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ObjectiveAmerican Indian and Alaska Native peoples (AI/ANs) have a disproportionately high rate of obesity, but little is known about the social determinants of obesity among older AI/ANs. Thus, our study assessed social determinants of obesity in AI/ANs aged ≥ 50 years.DesignWe conducted a cross-sectional analysis using multivariate generalized linear mixed models to identify social determinants associated with the risk of being classified as obese (BMI ≥ 30.0 kg/m2). Analyses were conducted for the total study population and stratified by median county poverty level.SettingIndian Health Service (IHS) data for AI/ANs who used IHS services in FY2013.Participants27,696 AI/ANs aged ≥ 50 years without diabetes.ResultsMean BMI was 29.8 ± 6.6 with 43% classified as obese. Women were more likely to be obese than men, and younger ages were associated with higher obesity risk. While having Medicaid coverage was associated with lower odds of obesity, private health insurance was associated with higher odds. Living in areas with lower rates of educational attainment and longer drive times to primary care services were associated with higher odds of obesity. Those who lived in a county where a larger percentage of people had low access to a grocery store were significantly less likely to be obese.ConclusionsOur findings contribute to the understanding of social determinants of obesity among older AI/ANs and highlight the need to investigate AI/AN obesity, including longitudinal studies with a life course perspective to further examine social determinants of obesity in older AI/ANs.

BackgroundDiabetes, hypertension, and cardiovascular disease (CVD) are modifiable lifestyle-related cardiometabolic conditions associated with dementia. Yet, little is known regarding these associations among American Indian and Alaska Native (AI/AN) people. Thus, we examined the association of diabetes, hypertension, and CVD with all-cause dementia among AI/ANs aged 65 years and older.MethodThis was a cross-sectional analysis of the Indian Health Service Improving Health Care Delivery Data Project. Our study population was a 1:1 matched sample of 4 074 AI/ANs aged 65 years and older and Indian Health Service active users during fiscal year 2013. We employed International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes for all-cause dementia, hypertension, and CVD. Diabetes was measured with a validated algorithm to identify adults with diabetes that uses diagnoses, laboratory test results, and medication criteria.ResultsMultivariable analyses revealed that diabetes and CVD were associated with increased odds of all-cause dementia and hypertension was not. Cardiovascular disease types associated with all-cause dementia differed with cerebrovascular disease having the strongest association. Analyses stratified by gender revealed that diabetes and CVD were associated with increased odds of all-cause dementia for women and only CVD was associated with all-cause dementia for men.ConclusionsTraining and support of primary care clinicians, addressing cultural considerations, and ensuring inclusion of AI/ANs in research are steps that could help meet AI/AN people's needs. Our findings underscore to the importance of improved management and control of diabetes and CVD, which may lead to the prevention of dementia among older AI/ANs.

PurposeLittle is known about the association of psychosocial factors with health-related quality of life (HRQoL) among American Indians with type 2 diabetes (T2D). This study described functional social support, emotional support, coping, resilience, post-traumatic stress disorder, and HRQoL, among American Indians by diabetes status and, among those with diabetes, examined the association of these factors with HRQoL.MethodsUsing data from the Cherokee Nation Health Survey collected between 2017 and 2019, we evaluated differences in each measure of interest according to diabetes status, using t-test and Chi-squared tests of association. We used weighted multiple logistic regression to examine associations between multiple psychosocial factors and HRQoL among those with diabetes.ResultsCompared to individuals without diabetes, participants with diabetes rated their functional social support (4.62 vs. 4.56, respectively) and coping (2.65 vs. 2.61, respectively) slightly lower and were more likely to report ≥ 15 days of poor physical (14% vs. 26%, respectively) and mental health (14% vs. 17%, respectively) in the past month. Odds of reporting poor overall health increased more than sixfold for those who were dissatisfied/very dissatisfied with life (AOR = 6.70). Resilience scores reduced odds of reporting ≥ 15 days with poor physical health, while experiences of post-traumatic stress doubled these odds.ConclusionOur study yielded insights into the risk as well as protective factors associated with diabetes outcomes in a large sample of American Indians with T2D. Researchers should design pragmatic trials that deepen understanding of preventive as well as treatment leverage through greater attention to experiences that compromise HRQoL.

BackgroundDiabetes, hypertension, and cardiovascular disease (CVD) are modifiable lifestyle-related cardiometabolic conditions associated with dementia. Yet, little is known regarding these associations among American Indian and Alaska Native (AI/AN) peoples. Thus, we examined the association of diabetes, hypertension, and cardiovascular disease (CVD) with all-cause dementia among AI/ANs aged ≥ 65 years.MethodsThis was a cross-sectional analysis of the Indian Health Service Improving Health Care Delivery Data Project. Our study population was a 1:1 matched sample of 4,074 AI/ANs aged ≥ 65 years and Indian Health Service active users during fiscal year 2013. We employed international Classification of Diseases 9th Revision Clinical Modification (ICD-9) diagnostic codes for all-cause dementia, hypertension, and CVD. Diabetes was measured with a validated algorithm to identify adults with diabetes that uses diagnoses, laboratory test results, and medication criteria.ResultsMultivariable analyses revealed that diabetes and CVD were associated with increased odds of all-cause dementia and hypertension was not. CVD types associated with all-cause dementia differed with cerebrovascular disease having the strongest association. Analyses stratified by gender revealed that diabetes and CVD were associated with increased odds of all-cause dementia for women and only CVD was associated with all-cause dementia for men.ConclusionsTraining and support of primary care clinicians, addressing cultural considerations, and ensuring inclusion of AI/ANs in research are steps that could help meet AI/AN peoples' needs. Our findings underscore to the importance of improved management and control of diabetes and CVD, which may lead to the prevention of dementia among older AI/ANs.

We examined the association of resilience with measures of mental and physical health in a sample of older American Indians (AIs). A validated scale measuring resilience was administered to 185 noninstitutionalized AIs aged greater than or equal to 55 years. Unadjusted analyses revealed that higher levels of resilience were associated with lower levels of depressive symptomatology and chronic pain, and with higher levels of mental and physical health. Resilience remained significantly associated with depressive symptomatology after controlling for demographic and other health measures. Our findings suggest that resilience among older AIs has important implications for some aspects of mental and physical health. (Contains 3 tables.)

The purpose of our study was to describe research attitudes of undergraduate social work students and to identify individual characteristics associated with positive research attitudes. Our data were collected in the spring semester of 2016 through an online survey at a midsize state university with 170 study participants. Research attitudes were measured with the Attitudes Toward Research Scale and the Kirk-Rosenblatt Research Inventory. We found that although respondents appreciated the value of research and its application to social work, negative emotions of anxiety and stress persisted. Older age, completion of prior research course work, prior research exposure, knowing what evidence-based practice means, and acceptance into the BSW program were associated with more positive attitudes toward research.

This article describes the collective experience of a multidisciplinary network of researchers, practitioners, and program evaluators who support appropriate research and evaluation methods in working with Native peoples. Our experience underlines the critical importance of culture in understanding and conducting research with the diverse populations of American Indians and Alaska Natives, and documents the need for community-based, collaborative, participatory action research. We discuss the major findings of the first American Indian Research and Program Evaluation Methodology national symposium, and articulate a set of 20 guiding principles for conducting research and program evaluation. (Contains 6 footnotes.)

Mobility, broadly defined as movement in all of its forms from ambulation to transportation, is critical to supporting optimal aging. This article describes two projects to develop a framework and a set of priority actions designed to promote mobility among community-dwelling older adults. Project 1 involved a concept-mapping process to solicit and organize action items into domains from a broad group of stakeholders to create the framework. Concept mapping uses qualitative group processes with multivariate statistical analysis to represent the ideas visually through maps. A snowball technique was used to identify stakeholders (n = 211). A 12-member steering committee developed a focus prompt, "One specific action that can lead to positive change in mobility for older adults in the United States is..." Project 2 included a Delphi technique (n = 43) with three iterations to prioritize four to six items using results from the concept mapping rating process. Project 1 resulted in 102 items across nine domains (Research to Practice, Independence and Engagement, Built Environment and Safety, Transportation, Policy, Housing and Accessibility, Community Supports, Training, and Coordinated Action). The number of items ranged from 6 to 18 per domain. Project 2 resulted in agreement on four items that reflect the importance of promoting environmental strategies through collaborative initiatives aimed at planning and best practices focusing on environmental enhancements or transit, training of professionals, and integration of mobility into state and local public health plans. These findings can be applied to support coordinated, multidisciplinary research and practice to promote mobility among older adults.

OBJECTIVE: To examine HbA1c levels and adherence to oral glucose-lowering medications and their association with future HbA1c levels among American Indian adults with type 2 diabetes (T2D) receiving medications at no cost from a tribal health care system. RESEARCH DESIGN AND METHODS: Tribal citizens with T2D who used Choctaw Nation Health Services Authority (CNHSA) and Pharmacies and had HbA1c data during 2017–2018 were included in this study. Medication adherence (proportion of days covered [PDC] ≥0.80) was calculated using 2017 CNHSA electronic health record data. RESULTS: Of the 74,000 tribal citizens living on tribal lands, 4,560 were eligible; 32% had HbA1c at or below target (≤7%), 36% were above target (>7 to ≤9%), and 32% were uncontrolled (>9%) in 2017. The percentage of patients with PDC ≥0.80 was 66% for those using biguanides, 72% for sulfonylureas, 75% for dipeptidyl peptidase 4 inhibitors, and 83% for sodium–glucose cotransporter 2 inhibitors. The proportion of patients with HbA1c at or below target increased slightly from 32% in 2017 to 42% in 2018. Higher average PDC in 2017 was associated with lower HbA1c levels in 2018 (β = −1.143; P < 0.001). CONCLUSIONS: Medication adherence was higher than that found in previous studies using self-report methods in American Indian populations, although a smaller proportion of patients had HbA1c at or below target relative to U.S. adults with T2D. Medication adherence was associated with improved HbA1c levels for most oral glucose-lowering medication classes. Future studies of American Indians should use both longitudinal prescription data from both electronic health records and pharmacy refills. [ABSTRACT FROM AUTHOR]

Models for community-based participatory research (CBPR) urge academic investigators to collaborate with communities to identify and pursue research questions, processes, and outcomes valuable to both partners. The tribal participatory research (TPR) conceptual model suggests modifications to CBPR to fit the special needs of American Indian communities. This paper draws upon authors' collaboration with one American Indian tribe to recommend theoretical revision and practical strategies for conducting gerontological research in tribal communities. We rated the TPR model as a strong, specialized adaptation of participatory research principles. Although the need for some TPR mechanisms may vary, our experience recommends incorporating dissemination as a central TPR mechanism. Researchers and communities can expect well-crafted collaborative projects to generate particular types of positive project outcomes for both partners, but should prepare for both predictable and unique challenges.

Purpose: With a sample of American Indian adults, we estimated the prevalence of adult caregiving, assessed the demographic and cultural profile of caregivers, and examined the association between cultural factors and being a caregiver. This is the first such study conducted with American Indians. Design and Methods: Data came from a cross-sectional study of 5,207 American Indian adults residing on 2 closely related Lakota Sioux reservations in the Northern Plains and one American Indian community in the Southwest. Cultural factors included measures of cultural identity and traditional healing practices. Results: Seventeen percent of our sample reported being caregivers. In both the Northern Plains and Southwest, caregiving was positively correlated with younger age, being a woman, larger household size, attending and participating in Native events, and endorsement of traditional healing practices. In both regions, attendance and participation in Native events and engagement in traditional healing practices were associated with increased odds of caregiving after adjusting for covariates. Only in the Northern Plains did we find that speaking some Native language at home was associated with increased odds of being a caregiver. Examination of interaction terms indicated some sex differences in the association between cultural factors and caregiving in the Northern Plains but not in the Southwest. Implications: Our findings indicate that greater cultural identity and engagement in traditional healing practices are related to caregiving in American Indian populations. Caregiving research, intervention efforts, and caregiving programs and services in Native communities should pay special attention to the dynamics of culture and caregiving.

Purpose: Self-perceptions of health vary depending on one's social and cultural context. Rural residents have been characterized as having a distinct culture, and health differences by residence have been well documented. While there is evidence of poor health among rural older adults, little research has examined how they perceive and define health. Qualitative methods may help capture these lay meanings of health. The purpose of our study was to use a qualitative approach to examine what perceptions community-dwelling rural older adults have regarding their health. Methods: The study involved thirteen 90-minute focus groups and short self-administered surveys with community-dwelling persons aged 60 years or older residing in 6 rural West Virginia communities. A total of 101 participants were asked questions about their personal definitions of health. With professional transcribed tapes from the focus group discussions, we used a systematic text analysis approach. Findings: Discussions included 4 themes on the meaning of health: (1) health as a value, (2) dimensions of life, (3) holistic nature of health, and (4) health care use and adherence. Conclusion: Our results expand on previous studies and demonstrate that health is a subjective, multidimensional construct deeply embedded in the everyday experience of rural older adults. We found that older adults' perceptions about health contain components which most medical professionals would not take into account. Health care providers may consider supplementing traditional medical approaches with a more contextually sensitive recognition of rural elders' desired health goals and outcomes. (Contains 1 table and 1 figure.)

Purpose: Research suggests that men and women often differ in knowledge and beliefs about causes and treatments of a variety of diseases. This study examines gender differences in views about cognitive health and behaviors that have been associated with its maintenance, focusing on older adults living in rural areas. Design and Methods: We conducted 6 focus groups in rural West Virginia. Participants included 37 women and 30 men, aged 55 years and older. Results: Men and women held similar views of cognitive decline, as well as largely similar views about causes of Alzheimer's disease (AD). However, women were more concerned about developing AD than were men. Gender differences were also noted with respect to healthy lifestyle beliefs, including diet, leisure-time physical activity, and strategies to maintain cognitive health. Implications: Findings illustrate the importance of considering gender with respect to health beliefs, health behaviors, and health promotion, and emphasize the need to develop interventions designed for specific populations. Results highlight a critical need to translate research findings to the community.

Context: Many rural elders experience limited access to health care. The majority of what we know about this issue has been based upon quantitative studies, yet qualitative studies might offer additional insight into individual perceptions of health care access. Purpose: To examine what barriers rural elders report when accessing needed health care, including how they cope with the high cost of prescription medication. Methods: During Spring 2001, thirteen 90-minute focus groups were conducted in 6 rural West Virginia communities. A total of 101 participants, aged 60 years and older, were asked several culminating questions about their perceptions of health care access. Findings: Five categories of barriers to health care emerged from the discussions: transportation difficulties, limited health care supply, lack of quality health care, social isolation, and financial constraints. In addition, 6 diverse coping strategies for dealing with the cost of prescription medication were discussed. They included: reducing dosage or doing without, limiting other expenses, relying on family assistance, supplementing with alternative medicine, shopping around for cheapest prices, and using the Veteran's Administration. Conclusions: Overall, rural older adults encounter various barriers to accessing needed health care. Qualitative methodology allows rural elders to have a voice to expound on their experiences. Research can contribute valuable information to shape policy by providing a forum where older adults can express their concerns about the current health care delivery system.

Context: Many rural elders experience limited access to health care. The majority of what we know about this issue has been based upon quantitative studies, yet qualitative studies might offer additional insight into individual perceptions of health care access. Purpose: To examine what barriers rural elders report when accessing needed health care, including how they cope with the high cost of prescription medication. Methods: During Spring 2001, thirteen 90-minute focus groups were conducted in 6 rural West Virginia communities. A total of 101 participants, aged 60 years and older, were asked several culminating questions about their perceptions of health care access. Findings: Five categories of barriers to health care emerged from the discussions: transportation difficulties, limited health care supply, lack of quality health care, social isolation, and financial constraints. In addition, 6 diverse coping strategies for dealing with the cost of prescription medication were discussed. They included: reducing dosage or doing without, limiting other expenses, relying on family assistance, supplementing with alternative medicine, shopping around for cheapest prices, and using the Veteran?s Administration. Conclusions: Overall, rural older adults encounter various barriers to accessing needed health care. Qualitative methodology allows rural elders to have a voice to expound on their experiences. Research can contribute valuable information to shape policy by providing a forum where older adults can express their concerns about the current health care delivery system.

Self-rated health (SRH) predicts service use, morbidity, and mortality. Additionally, SRH has been associated with indices of psychological well-being. The main focus of the study was to investigate important differences among the lower spectrum of SRH (ie, fair and poor) on indices of well-being. In-person interviews collected data from 207 (M age = 75.8) older rural adults. Data were used to examine differences between those reporting poor, fair, and good or excellent SRH on measures of demographics, and physical and psychological health. Significant differences emerged between levels of SRH in relation to measures of physical and psychological health. Specifically, individuals with poor SRH were significantly more likely to have (1) illnesses, (2) problems with basic and cognitive tasks of daily living, and (3) depressed affect than individuals reporting good or excellent health. Individuals with poor SRH were significantly more likely to have problems with basic and cognitive tasks of daily living than individuals with fair SRH. No significant differences were found between people reporting fair and good or excellent SRH on illnesses and depressed affect. Results suggest that future research should investigate the expansion of the lower-end of the SRH measure to more accurately assess SRH among vulnerable, rural older adults. Such efforts would better inform health care providers, practitioners, and policy makers in rural areas as to how SRH affects the well-being of vulnerable older adults.

Making geriatric education available to rural faculty/preceptors, students, and practitioners presents many challenges. Often the only options considered for educating those in the health professions about geriatrics are either traditional face-to-face courses or distance education programs. The purpose of this paper was to examine the use of Web-based modules or courses and other distance learning technology in concert with traditional learning modalities. The Mountain State Geriatric Education Center explored the use of a multi-modal approach within a high-touch, high-tech framework. Our findings indicate the following: it is important to start where participants are ready to begin; flexibility and variety are needed; soliciting evaluative feedback from participants is valuable; there is a need to integrate distance learning with more traditional modalities; and a high-tech, high-touch approach provides a format which participants find acceptable, accessible, and attractive. This assertion does not rule out the use of technology for distance education but rather encourages educators to take advantage of a wide range of modalities, traditional and technological, to reach rural practitioners, faculty, and students. (Contains 1 table.)

Context: Of 2.4 million American Indians, approximately 60% are eligible to receive Indian Health Service (IHS) benefits, leaving many to seek care elsewhere. It is unknown if their quality of care, health behaviors, and health status vary by source of care, as demonstrated for other populations. Purpose: The purpose of this study was to determine whether preventive services, health behaviors, and number of health conditions vary as a function of having non-IHS public versus private physicians as sources of usual care. Methods: 1,177 Lumbee Indians, who are ineligible to receive IHS services, completed a telephone interview that included information on receipt of preventive measures, tobacco use, physical activity, breast self-examination, and medical conditions. Frequencies, chi-squares, t tests, odds ratios, and confidence intervals were used to compare variables by source of care. Findings: 939 respondents (80%) had a private and 210 (18%) a public health clinic physician as their usual source of care; 28 (2%) reported having neither. Logistic regression analyses, restricted to the 1,149 participants who reported either a private or public source of care, revealed no differences in receipt of preventive services or health status by usual source of care. Smokeless tobacco use was less common among persons using private than public providers. Conclusions: Lumbees whose usual source of care was a public clinic physician did not differ in receipt of preventive services or in health status compared to their counterparts who received care from a private physician. More targeted research into health similarities and differences arising from access to public and private sources of care is warranted.

In a needs assessment of 84 rural health care professionals (44.1% physicians, 15.5% pharmacists, 14.3% nurses, 26.1% other), 39% considered their geriatrics knowledge above average. They were interested in learning more about Alzheimer's/dementia, medication use, and adverse effects. Preferred methods were videotapes, CD-ROM, and an interdisciplinary approach. (Contains 30 references.) (SK)

Purpose: Research suggests that men and women often differ in knowledge and beliefs about causes and treatments of a variety of diseases. This study examines gender differences in views about cognitive health and behaviors that have been associated with its maintenance, focusing on older adults living in rural areas. Design and Methods: We conducted 6 focus groups in rural West Virginia. Participants included 37 women and 30 men, aged 55 years and older. Results: Men and women held similar views of cognitive decline, as well as largely similar views about causes of Alzheimer's disease (AD). However, women were more concerned about developing AD than were men. Gender differences were also noted with respect to healthy lifestyle beliefs, including diet, leisure-time physical activity, and strategies to maintain cognitive health. Implications: Findings illustrate the importance of considering gender with respect to health beliefs, health behaviors, and health promotion, and emphasize the need to develop interventions designed for specific populations. Results highlight a critical need to translate research findings to the community. Key Words: Knowledge, Cognitive decline, Health beliefs, Healthy lifestyle, Rural, Qualitative