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Alabsi SM, Duval S, Sundberg M, Williams D, Luepker RV, Eder M, Van't Hof JR. Regular aspirin use among a sample of American Indians/Alaskan Natives in the Upper Midwest region of the United States. Prev Med Rep 2024; 37:102571. [PMID: 38222307 PMCID: PMC10784686 DOI: 10.1016/j.pmedr.2023.102571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 12/10/2023] [Accepted: 12/18/2023] [Indexed: 01/16/2024] Open
Abstract
Despite high prevalence of cardiovascular disease (CVD) and CVD risk factors among American Indian or Alaska Native adults (AI/AN), there is little information on aspirin use in this population. This survey-based study seeks to understand prevalence of aspirin use in a sample of AI/AN adults in the Upper Midwestern United States. In-person and telephone based surveys were conducted querying self-reported CVD and CVD risk factors, aspirin use, and aspirin related discussion with clinicians. A total of 237 AI/AN participants were included: mean age (SD) was 60.8 (8.4) years; 143 (60 %) were women; 59 (25 %) reported CVD history. CVD risk factors were common particularly smoking (37 %) and diabetes (37 %). Aspirin use was much higher among those with CVD (secondary prevention, 76 %) than those without (primary prevention, 33 %). Primary prevention aspirin use was significantly associated with age and all CVD risk factors in unadjusted analyses. After adjustment for demographics and CVD risk factors, only age (aRR 1.13 per 5 years, 95 % CI 1.02, 1.25) and diabetes (aRR 2.44, 95 % CI 1.52, 3.92) remained significantly associated with aspirin. Regardless of CVD status, a higher proportion of those taking aspirin reported a conversation about aspirin with their doctor compared to those not taking aspirin. Among participants with no CVD, those who had such a conversation were 2.6 times more likely to use aspirin than those who did not have a conversation (aRR 2.64, 95 % CI 1.58, 4.44). The findings of this study emphasize the importance of the patient-provider relationship for preventive therapy.
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Affiliation(s)
| | - Sue Duval
- Cardiovascular Division and Lillehei Heart Institute, Department of Medicine, University of Minnesota Medical School, Minneapolis MN, USA
| | - Michael Sundberg
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Donovan Williams
- Division of Geriatrics, Palliative and Primary Care, University of Minnesota Medical School, Minneapolis MN, USA
| | - Russell V. Luepker
- Cardiovascular Division and Lillehei Heart Institute, Department of Medicine, University of Minnesota Medical School, Minneapolis MN, USA
- University of Minnesota School of Public Health, Division of Epidemiology and Public Health, Minneapolis, MN, USA
| | - Milton Eder
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Jeremy R. Van't Hof
- Cardiovascular Division and Lillehei Heart Institute, Department of Medicine, University of Minnesota Medical School, Minneapolis MN, USA
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Reese JA, Guy C, Jay H, Ali T, Lee ET, Zhang Y. A community health promotion project: Amazing Race for Heart Health. FRONTIERS IN EPIDEMIOLOGY 2023; 3:1278672. [PMID: 38455940 PMCID: PMC10910991 DOI: 10.3389/fepid.2023.1278672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 12/06/2023] [Indexed: 03/09/2024]
Abstract
Introduction American Indians have higher rates of cardiovascular disease (CVD), likely due to disproportionate burden of diabetes and limited access to widespread CVD prevention programs such as Honoring the Gift of Heart Health (HGHH), a 10-week CVD risk factor awareness curriculum. Due to its length, HGHH may be difficult to complete; therefore, we aimed to evaluate a shortened CVD risk factor awareness program based on the HGHH educational materials for American Indians residing in southwest Oklahoma, entitled "The Amazing Race for Heart Health." Methods We conducted an interventional study where each participant served as their own control (n = 61), with pre- and post-intervention measurements. We included American Indians from seven tribal nations in southwest Oklahoma. At two interventional meetings we used educational materials and activities from HGHH focusing on nutrition, cholesterol, diabetes, hypertension, physical activity, and heart attack warning signs. McNemar's test was used to determine the effectiveness of the intervention on raising CVD risk factor awareness. Results When comparing the pre- and post-survey responses, the percentage of correct responses either stayed the same or increased. Knowledge improved in 11/25 (44%, p < 0.05) domains including the difference between good and bad cholesterol and types of physical activity that can prevent CVD. When considering diabetes, knowledge increased regarding the interaction between diabetes and cholesterol in the association with CVD. Discussion These results demonstrate that the "Amazing Race for Heart Health," a shortened CVD risk factor educational program based on the HGHH educational materials, was effective at increasing awareness regarding CVD risk factors.
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Affiliation(s)
- Jessica A. Reese
- Center for American Indian Health Research, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Carla Guy
- Center for American Indian Health Research, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Halana Jay
- Center for American Indian Health Research, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Tauqeer Ali
- Center for American Indian Health Research, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Elisa T. Lee
- Center for American Indian Health Research, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Ying Zhang
- Center for American Indian Health Research, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
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Sinclair K, Nguyen CJ, Wetherill MS, Nelson K, Jackson AM, Taniguchi T, Jernigan VBB, Buchwald D. Native opportunities to stop hypertension: study protocol for a randomized controlled trial among urban American Indian and Alaska Native adults with hypertension. Front Public Health 2023; 11:1117824. [PMID: 37333529 PMCID: PMC10272533 DOI: 10.3389/fpubh.2023.1117824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 05/11/2023] [Indexed: 06/20/2023] Open
Abstract
Introduction American Indian and Alaska Native (AI/AN) adults experience disproportionate cardiovascular disease (CVD) morbidity and mortality compared to other races, which may be partly attributable to higher burden of hypertension (HTN). Dietary Approaches to Stop Hypertension (DASH) is a high-impact therapeutic dietary intervention for primary and secondary prevention of CVD that can contribute to significant decreases in systolic blood pressure (BP). However, DASH-based interventions have not been tested with AI/AN adults, and unique social determinants of health warrant independent trials. This study will assess the effectiveness of a DASH-based intervention, called Native Opportunities to Stop Hypertension (NOSH), on systolic BP among AI/AN adults in three urban clinics. Methods NOSH is a randomized controlled trial to test the effectiveness of an adapted DASH intervention compared to a control condition. Participants will be aged ≥18 years old, self-identify as AI/AN, have physician-diagnosed HTN, and have elevated systolic BP (≥ 130 mmHg). The intervention includes eight weekly, tailored telenutrition counseling sessions with a registered dietitian on DASH eating goals. Intervention participants will be provided $30 weekly and will be encouraged to purchase DASH-aligned foods. Participants in the control group will receive printed educational materials with general information about a low-sodium diet and eight weekly $30 grocery orders. All participants will complete assessments at baseline, after the 8-week intervention, and again 12 weeks post-baseline. A sub-sample of intervention participants will complete an extended support pilot study with assessments at 6- and 9-months post-baseline. The primary outcome is systolic BP. Secondary outcomes include modifiable CVD risk factors, heart disease and stroke risk scores, and dietary intake. Discussion NOSH is among the first randomized controlled trials to test the impact of a diet-based intervention on HTN among urban AI/AN adults. If effective, NOSH has the potential to inform clinical strategies to reduce BP among AI/AN adults. Clinical trials registration https://clinicaltrials.gov/ct2/show/NCT02796313, Identifier NCT02796313.
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Affiliation(s)
- Ka’imi Sinclair
- Institute for Research and Education to Advance Community Health, Washington State University, Seattle, WA, United States
| | - Cassandra J. Nguyen
- Nutrition Department at University of California, Davis, Davis, CA, United States
| | - Marianna S. Wetherill
- Department of Health Promotion Sciences, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Tulsa, OK, United States
| | - Katie Nelson
- Institute for Research and Education to Advance Community Health, Washington State University, Seattle, WA, United States
| | | | - Tori Taniguchi
- Center for Indigenous Health Research and Policy, Center for Health Sciences, Oklahoma State University, Tulsa, OK, United States
| | - Valarie Blue Bird Jernigan
- Center for Indigenous Health Research and Policy, Center for Health Sciences, Oklahoma State University, Tulsa, OK, United States
| | - Dedra Buchwald
- Institute for Research and Education to Advance Community Health, Washington State University, Seattle, WA, United States
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Moore KR, Schroeder EB, Goodrich GK, Manson SM, Malone AS, Pieper LE, Son-Stone L, Johnson D, Steiner JF. Racial and Ethnic Equity in Care for Hypertension and Diabetes in an Urban Indian Health Organization. J Racial Ethn Health Disparities 2023; 10:1319-1328. [PMID: 35503165 PMCID: PMC9630166 DOI: 10.1007/s40615-022-01317-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 04/20/2022] [Accepted: 04/25/2022] [Indexed: 11/30/2022]
Abstract
Approximately 70% of American Indian/Alaska Native (AI/AN) individuals reside in urban areas. Urban Indian Health Organizations (UIHOs) provide culturally engaged primary care for AI/AN patients and members of other racial and ethnic groups who have experienced disparities in diabetes and hypertension care, and are commonly affected by social and economic barriers to care. We assessed whether disparities were present between the racial and ethnic groups served by the largest UIHO in the USA. We developed retrospective cohorts of patients with hypertension or diabetes receiving primary care from this UIHO, measuring differences between AI/AN, Spanish-preferring Latinx, English-preferring Latinx, Black, and White patients in mean systolic blood pressure (SBP) and mean hemoglobin A1c (A1c) as primary outcomes. To assess processes of care, we also compared visit intensity, missed visits, and medication treatment intensity in regression models adjusted for sociodemographic and clinical characteristics. For hypertension (n = 2148), adjusted mean SBP ranged from 135.8 mm Hg among Whites to 141.3 mm Hg among Blacks (p = 0.06). For diabetes (n = 1211), adjusted A1c ranged from 7.7% among English-preferring Latinx to 8.7% among Blacks (p = 0.38). Care processes for both hypertension and diabetes varied across groups. No group consistently received lower-quality care. This UIHO provided care of comparable quality for hypertension and diabetes among urban-dwelling AI/ANs and members of other racial, ethnic, and language preference groups. Systematic assessments of care quality in UIHOs may help demonstrate the importance of their role in providing care and improve the quality of care.
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Affiliation(s)
- Kelly R Moore
- Centers for American Indian and Alaska Native Health, University of Colorado Anschutz Medical Campus, Mail Stop F800, 13055 East 17th Avenue, Aurora, CO, 80045, USA.
| | | | - Glenn K Goodrich
- Kaiser Permanente Colorado, Institute for Health Research, Aurora, CO, USA
| | - Spero M Manson
- Centers for American Indian and Alaska Native Health, University of Colorado Anschutz Medical Campus, Mail Stop F800, 13055 East 17th Avenue, Aurora, CO, 80045, USA
| | - Allen S Malone
- Kaiser Permanente Colorado, Institute for Health Research, Aurora, CO, USA
| | - Lisa E Pieper
- Kaiser Permanente Colorado, Institute for Health Research, Aurora, CO, USA
| | | | - David Johnson
- First Nations Community HealthSource, Albuquerque, NM, USA
| | - John F Steiner
- Kaiser Permanente Colorado, Institute for Health Research, Aurora, CO, USA
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Rusk AM, Kanj AN, Murad MH, Hassett LC, Kennedy CC. Smoking Cessation Interventions in Indigenous North Americans: A Meta-Narrative Systematic Review. Nicotine Tob Res 2023; 25:3-11. [PMID: 35869642 PMCID: PMC9717368 DOI: 10.1093/ntr/ntac181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 07/05/2022] [Accepted: 07/21/2022] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Indigenous North Americans have the highest cigarette smoking prevalence among all racial and ethnic groups in the United States. We seek to identify effective components of smoking cessation interventions in Indigenous people in the United States associated with favorable cessation outcomes. METHODS A review of literature studying smoking cessation interventions in Indigenous North Americans (American Indians and Alaska Natives) from January 2010 through August 2021 was completed. The primary objective of this study was to identify components of interventions associated with positive smoking cessation outcomes in Indigenous people. The studies identified were synthesized in a meta-narrative approach. RESULTS Ten studies out of 608 titles were included (6 randomized trials, 2 single-arm studies, 1 cohort study, and 1 prospective observational study). Five categories of smoking cessation interventions were identified; phone or web-based tools, culturally-tailored interventions, the inclusion of Indigenous study personnel, pharmaceutical cessation aids, and behavioral health interventions. Phone and web tools, cultural tailoring, and inclusion of Indigenous personnel conditions inconsistently influenced smoking cessation. Pharmaceutical aids were viewed favorably among participants. Individualized behavioral counseling sessions were effective at promoting smoking cessation, as was input from local communities in the planning and implementation phases of study. CONCLUSION A successful smoking cessation intervention in Indigenous North Americans includes Tribal or community input in intervention design and implementation; should provide individualized counseling sessions for participants, and offer access to validated smoking cessation tools including pharmacotherapy. IMPLICATIONS This study identifies a paucity of smoking interventions utilizing standard of care interventions in Indigenous North Americans. Standard of care interventions including individualized cessation counseling and pharmacotherapy were effective at promoting cessation. The use of novel culturally tailored cessation interventions was not more effective than existing evidence-based care with the exception of including Tribal and local community input in intervention implementation. Future smoking cessation interventions in Indigenous North Americans should prioritize the use of standard of care cessation interventions.
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Affiliation(s)
- Ann M Rusk
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
- The Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
- Respiratory Health Equity Clinical Research Laboratory at Mayo Clinic, Rochester, MN, USA
| | - Amjad N Kanj
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
- Respiratory Health Equity Clinical Research Laboratory at Mayo Clinic, Rochester, MN, USA
| | - Mohammad H Murad
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Cassie C Kennedy
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
- The Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
- Respiratory Health Equity Clinical Research Laboratory at Mayo Clinic, Rochester, MN, USA
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Camplain R, Teufel-Shone NI, Jiang L, Chang J, Manson SM. Change in physical activity, food choices and hemoglobin A1c among American Indians and Alaska Natives with type 2 diabetes. Prev Med Rep 2022; 29:101945. [PMID: 36161132 PMCID: PMC9502664 DOI: 10.1016/j.pmedr.2022.101945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 06/14/2022] [Accepted: 08/05/2022] [Indexed: 12/03/2022] Open
Abstract
At baseline, physically active participants with higher healthy food scores had lower HbA1c levels than non-active participants. Over the three-year period, women who increased physical activity and/or healthy food consumption had slightly decreased HbA1c. Changes in physical activity and HbA1c differed by gender.
The prevalence of diabetes among American Indian and Alaska Native (AI/AN) adults is the highest of all United States racial/ethnic groups. Health behaviors, including regular physical activity and healthy food choices, are important components in the management of diabetes. We estimated the cross-sectional association between physical activity and healthy food scores, separately, and combined (PAHF) with hemoglobin A1c (HbA1c) over three years of the Special Diabetes Program for Indians-Healthy Heart demonstration project (SDPI-HH) intervention. The relationship between physical activity and food choices was also examined. Among 3,039 SDPI-HH participants at baseline, those reporting being physically active and having high healthy food scores had statistically significant lower HbA1c (mean = 7.67 ± 2.01) compared to inactive participants with low healthy food scores (7.90 ± 1.92). Among the 1,150 SDPI-HH participants who attended the three-year follow-up visit, participants who increased physical activity, consumption of healthy foods, or both had a larger decrease in HbA1c (β = -0.29, P = 0.03) over the study period compared to participants with no improvement in physical activity or increase in consuming healthy foods. This association was statistically significant among women (β = -0.35, P = 0.04) but not among men (β = -0.08, P = 0.70). Our findings indicated that an increase in healthier behaviors, including physical activity and healthy food choices, was associated with a small improvement in HbA1c in the subset of women who participated in the SDPI-HH through the three-year follow up. Although the decrease in HbA1c was small, physical activity and healthy food choices are important behaviors to incorporate into everyday life among AI/AN adults, particularly those with diabetes.
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Affiliation(s)
- Ricky Camplain
- Center for Health Equity Research, Northern Arizona University, Flagstaff, AZ, United States
- Department of Health Sciences, Northern Arizona University, Flagstaff, AZ, United States
- Corresponding author at: PO Box 4065, Northern Arizona University, Flagstaff 86011-4065, AZ.
| | - Nicolette I. Teufel-Shone
- Center for Health Equity Research, Northern Arizona University, Flagstaff, AZ, United States
- Department of Health Sciences, Northern Arizona University, Flagstaff, AZ, United States
| | - Luohua Jiang
- Department of Epidemiology, University of California, Irvine, CA, United States
| | - Jennifer Chang
- Department of Epidemiology, University of California, Irvine, CA, United States
| | - Spero M Manson
- Centers for American Indian and Alaska Native Health, University of Colorado Anschutz Medical Center, Aurora, CO, United States
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Fimbel L, Pitts M, Schure M, McCormick AKHG, Held S. Recruitment, retention, and intervention adherence for a chronic illness self-management intervention with the Apsáalooke Nation. PUBLIC HEALTH REVIEW 2022; 5:4786. [PMID: 35875172 PMCID: PMC9302479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Recruitment, retention, and adherence within health intervention research have been understudied in Indigenous communities, where well-known health disparities exist. The purpose of this paper is to describe planned versus actual recruitment, retention, and adherence strategies and the evaluation of retention and adherence strategies for a community-based research study of a Chronic Illness (CI) self-management intervention within an Indigenous community. A Community-Based Participatory Research (CBPR) approach was used to develop and implement Báa nnilah, a culturally consonant educational intervention to improve CI self-management. Reasons for participant adherence and retention were tracked and recorded over time. A post-intervention survey assessed barriers and facilitators to intervention adherence. Overall, recruitment, retention, and adherence methods were successful in enrolling and maintaining participation. Using a CBPR approach and culturally consonant strategies may assist in meeting recruitment goals and improving sustained participation of community members, thus impacting health disparities among Indigenous communities.
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Affiliation(s)
- Laurel Fimbel
- Montana State University, Department of Health and Human Development, Bozeman, Montana
| | - Mikayla Pitts
- Montana State University, Department of Health and Human Development, Bozeman, Montana
| | - Mark Schure
- Montana State University, Department of Health and Human Development, Bozeman, Montana
| | | | - Suzanne Held
- Montana State University, Department of Health and Human Development, Bozeman, Montana
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Kruse G, Lopez-Carmen VA, Jensen A, Hardie L, Sequist TD. The Indian Health Service and American Indian/Alaska Native Health Outcomes. Annu Rev Public Health 2022; 43:559-576. [PMID: 35081315 DOI: 10.1146/annurev-publhealth-052620-103633] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The Indian Health Service (IHS) has made huge strides in narrowing health disparities between American Indian and Alaska Native (AI/AN) populations and other racial and ethnic groups. Yet, health disparities experienced by AI/AN people persist, with deep historical roots combined with present-day challenges. Here we review the history of the IHS from colonization to the present-day system, highlight persistent disparities in AI/AN health and health care, and discuss six key present-day challenges: inadequate funding, limited human resources, challenges associated with transitioning services from federal to Tribal control through contracting and compacting, evolving federal and state programs, the need for culturally sensitive services, and the promise and challenges of health technology.
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Affiliation(s)
- Gina Kruse
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA;
- Harvard Medical School, Boston, Massachusetts, USA
| | | | - Anpotowin Jensen
- School of Engineering, Stanford University, Stanford, California, USA
| | - Lakotah Hardie
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA;
| | - Thomas D Sequist
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Quality and Patient Experience, Massachusetts General Brigham, Somerville, Massachusetts, USA
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Fort MP, Reid M, Russell J, Santos CJ, Running Bear U, Begay RL, Smith SL, Morrato EH, Manson SM. Diabetes Prevention and Care Capacity at Urban Indian Health Organizations. Front Public Health 2021; 9:740946. [PMID: 34900897 PMCID: PMC8661087 DOI: 10.3389/fpubh.2021.740946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 10/13/2021] [Indexed: 11/13/2022] Open
Abstract
American Indian and Alaska Native (AI/AN) people suffer a disproportionate burden of diabetes and cardiovascular disease. Urban Indian Health Organizations (UIHOs) are an important source of diabetes services for urban AI/AN people. Two evidence-based interventions-diabetes prevention (DP) and healthy heart (HH)-have been implemented and evaluated primarily in rural, reservation settings. This work examines the capacity, challenges and strengths of UIHOs in implementing diabetes programs. Methods: We applied an original survey, supplemented with publicly-available data, to assess eight organizational capacity domains, strengths and challenges of UIHOs with respect to diabetes prevention and care. We summarized and compared (Fisher's and Kruskal-Wallis exact tests) items in each organizational capacity domain for DP and HH implementers vs. non-implementers and conducted a thematic analysis of strengths and challenges. Results: Of the 33 UIHOs providing services in 2017, individuals from 30 sites (91% of UIHOs) replied to the survey. Eight UIHOs (27%) had participated in either DP (n = 6) or HH (n = 2). Implementers reported having more staff than non-implementers (117.0 vs. 53.5; p = 0.02). Implementers had larger budgets, ~$10 million of total revenue compared to $2.5 million for non-implementers (p = 0.01). UIHO strengths included: physical infrastructure, dedicated leadership and staff, and community relationships. Areas to strengthen included: staff training and retention, ensuring sufficient and consistent funding, and data infrastructure. Conclusions: Strengthening UIHOs across organizational capacity domains will be important for implementing evidence-based diabetes interventions, increasing their uptake, and sustaining these interventions for AI/AN people living in urban areas of the U.S.
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Affiliation(s)
- Meredith P Fort
- Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.,Department of Health Systems, Management and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Margaret Reid
- Department of Health Systems, Management and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Jenn Russell
- Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Cornelia J Santos
- Environmental Studies-Indigenous Sustainability Studies Program, Bemidji State University, Bemidji, MN, United States
| | - Ursula Running Bear
- Department of Population Health, School of Medicine and Health Sciences, University of North Dakota, Grand Forks, ND, United States
| | - Rene L Begay
- Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Savannah L Smith
- Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Elaine H Morrato
- Department of Health Systems, Management and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.,Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Chicago, IL, United States
| | - Spero M Manson
- Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.,Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.,Department of Psychiatry, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
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Maudrie TL, Colón-Ramos U, Harper KM, Jock BW, Gittelsohn J. A Scoping Review of the Use of Indigenous Food Sovereignty Principles for Intervention and Future Directions. Curr Dev Nutr 2021; 5:nzab093. [PMID: 34345758 PMCID: PMC8321882 DOI: 10.1093/cdn/nzab093] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 05/11/2021] [Accepted: 06/28/2021] [Indexed: 12/19/2022] Open
Abstract
Indigenous food sovereignty (IFS) represents a community-led movement with potential to reduce health inequities, but no scoping review of the impact of taking an IFS approach on intervention research has been conducted. This review sought to: 1) describe intervention studies that employ IFS principles, and 2) describe the impact of studies using IFS principles on food access, eating patterns, diet quality, physical activity, and health. Through a literature review, 4 IFS principles were identified: 1) community ownership, 2) inclusion of traditional food knowledge, 3) inclusion and promotion of cultural foods, and 4) environmental/intervention sustainability. Twenty intervention studies published between January 1, 2000 and February 5, 2020 were included. Most of the studies that scored high in IFS principles saw a positive impact on diet. This review found evidence supporting the value of IFS principles in the development, implementation, and evaluation of health interventions for Indigenous communities.
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Affiliation(s)
- Tara L Maudrie
- Department of International Health, Center for Human Nutrition, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Uriyoán Colón-Ramos
- Department of Global Health, Department of Exercise and Nutrition Sciences, Milken Institute School of Public Health at The George Washington University, Washington, DC, USA
| | - Kaitlyn M Harper
- Department of International Health, Center for Human Nutrition, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Brittany W Jock
- School of Human Nutrition, Centre for Indigenous Peoples’ Nutrition and Environment (CINE), McGill University, Montreal, Quebec, Canada
| | - Joel Gittelsohn
- Department of International Health, Center for Human Nutrition, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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11
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O'Connell J, Reid M, Rockell J, Harty K, Perraillon M, Manson S. Patient Outcomes Associated With Utilization of Education, Case Management, and Advanced Practice Pharmacy Services by American Indian and Alaska Native Peoples With Diabetes. Med Care 2021; 59:477-486. [PMID: 33758159 PMCID: PMC8609964 DOI: 10.1097/mlr.0000000000001521] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The burden of diabetes is exceptionally high among American Indian and Alaska Native (AI/AN) peoples. The Indian Health Service (IHS) and Tribal health programs provide education, case management, and advanced practice pharmacy (ECP) services for AI/ANs with diabetes to improve their health outcomes. OBJECTIVE The objective of this study was to evaluate patient outcomes associated with ECP use by AI/AN adults with diabetes. RESEARCH DESIGN This observational study included the analysis of IHS data for fiscal years (FY) 2011-2013. Using propensity score models, we assessed FY2013 patient outcomes associated with FY2012 ECP use, controlling for FY2011 baseline characteristics. SUBJECTS AI/AN adults with diabetes who used IHS and Tribal health services (n=28,578). MEASURES We compared health status and hospital utilization outcomes for ECP users and nonusers. RESULTS Among adults with diabetes, ECP users, compared with nonusers, had lower odds of high systolic blood pressure [odds ratio (OR)=0.85, P<0.001] and high low-density lipoprotein cholesterol (OR=0.89, P<0.01). Among adults with diabetes absent cardiovascular disease (CVD) at baseline, 3 or more ECP visits, compared with no visits, was associated with lower odds of CVD onset (OR=0.79, P<0.05). Among adults with diabetes and CVD, any ECP use was associated with lower odds of end-stage renal disease onset (OR=0.60, P<0.05). ECP users had lower odds of 1 or more hospitalizations (OR=0.80, P<0.001). CONCLUSIONS Findings on positive patient outcomes associated with ECP use by adults with diabetes may inform IHS and Tribal policies, funding, and enhancements to ECP services to reduce disparities between AI/ANs and other populations in diabetes-related morbidity and mortality.
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Affiliation(s)
| | - Margaret Reid
- Department of Health Systems Management and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora
| | | | | | - Marcelo Perraillon
- Department of Health Systems Management and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora
| | - Spero Manson
- Centers for American Indian and Alaska Native Health
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O'Connell JM, Rockell JE, Ouellet JC, Yoder S, Lind KE, Wilson C, Friedson A, Manson SM. The Prevalence of Cardiovascular Disease and Other Comorbidities Among American Indian and Alaska Native Adults with Diabetes. EC ENDOCRINOLOGY AND METABOLIC RESEARCH 2021; 6:5-20. [PMID: 34766170 PMCID: PMC8580367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
AIMS American Indians and Alaska Native (AI/ANs) peoples experience significant health disparities compared to the U.S. general population. We report comorbidities among AI/ANs with diabetes to guide efforts to improve their health status. METHODS Drawing upon data for over 640,000 AI/ANs who used services funded by the Indian Health Service, we identified 43,518 adults with diabetes in fiscal year 2010. We reported the prevalence of comorbidities by age and cardiovascular disease (CVD) status. Generalized linear models were estimated to describe associations between CVD and other comorbidities. RESULTS Nearly 15% of AI/AN adults had diabetes. Hypertension, CVD and kidney disease were comorbid in 77.9%, 31.6%, and 13.3%, respectively. Nearly 25% exhibited a mental health disorder; 5.7%, an alcohol or drug use disorder. Among AI/ANs with diabetes absent CVD, 46.9% had 2 or more other chronic conditions; the percentage among adults with diabetes and CVD was 75.5%. Hypertension and tobacco use disorders were associated with a 71% (95% CI for prevalence ratio: 1.63 - 1.80) and 33% (1.28 - 1.37) higher prevalence of CVD, respectively, compared to adults without these conditions. CONCLUSION Detailed information on the morbidity burden of AI/ANs with diabetes may inform enhancements to strategies implemented to prevent and treat CVD and other comorbidities.
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Affiliation(s)
- Joan M O'Connell
- Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jennifer E Rockell
- Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Telligen, 7730 E Belleview Ave, Suite 300, Greenwood Village, CO, USA
| | - Judith C Ouellet
- Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Health and Behavioral Sciences, University of Colorado Denver, Denver, CO, USA
| | | | - Kimberly E Lind
- Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Mel & Enid Zuckerman College of Public Health, University of Arizona, USA
| | | | - Andrew Friedson
- Department of Economics, University of Colorado Denver, Denver, Colorado, USA
| | - Spero M Manson
- Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Merone L, McDermott R, Mein J, Clarke P, McDonald M. Primary Prevention of Cardiovascular Disease in Minority Indigenous Populations: A Systematic Review. Heart Lung Circ 2020; 29:1278-1291. [PMID: 32303469 DOI: 10.1016/j.hlc.2019.06.720] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 05/07/2019] [Accepted: 06/18/2019] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Cardiovascular disease (CVD) is the commonest cause of death across the globe; incidence and prevalence rates are increasing. Together, CVD and diabetes mellitus are responsible for a quarter of the health gap observed between Aboriginal Australians and Torres Strait Islanders, and non-Indigenous Australians. Numerous programs have been proposed and implemented to Close the Gap; ideally, these should be evidence-based. OBJECTIVE The aim of this review is to evaluate primary prevention measures and programs that aim to reduce CVD risk in minority Indigenous populations around the world. METHODS A search of PubMed, the Cochrane Library and the Elsevier Scopus Database was initially conducted using the terms "cardiovascular disease", "population groups", "primary prevention", "health services, indigenous", "indigenous health", "risk assessment" and "risk management". Results were then assessed per inclusion/exclusion criteria. A second reviewer independently evaluated the publications and review process to ensure agreement. RESULTS The initial search produced 37 publications; 19 met the inclusion criteria and were incorporated into a comparative table. Most were descriptive, mixed-methods, audit or intervention studies. Heterogeneity of study design prevented statistical analysis. CONCLUSION Addressing CVD risk in minority Indigenous populations is a multifactorial challenge; there is substantial room for improvement in routine risk assessment and management. Holistic approaches need to embrace local cultural perceptions of health and wellbeing. Validated risk reduction tools, individualised management plans, polypills and computer based decision support tools are promising to improve outcomes for those at risk.
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Affiliation(s)
- Lea Merone
- Centre for Chronic Disease Prevention, James Cook University, Brisbane, Qld, Australia; Apunipima Cape York Health Council, Bungalow, Qld, Australia.
| | - Robyn McDermott
- Centre for Chronic Disease Prevention, James Cook University, Brisbane, Qld, Australia; Apunipima Cape York Health Council, Bungalow, Qld, Australia; School of Population Health, University of South Australia, Adelaide, SA, Australia
| | - Jacki Mein
- Wuchopperen Health Service, Cairns, Qld, Australia
| | - Philip Clarke
- School of Population and Global Health, University of Melbourne, Melbourne, Vic, Australia
| | - Malcolm McDonald
- Centre for Chronic Disease Prevention, James Cook University, Brisbane, Qld, Australia; Wuchopperen Health Service, Cairns, Qld, Australia
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Breathett K, Sims M, Gross M, Jackson EA, Jones EJ, Navas-Acien A, Taylor H, Thomas KL, Howard BV. Cardiovascular Health in American Indians and Alaska Natives: A Scientific Statement From the American Heart Association. Circulation 2020; 141:e948-e959. [PMID: 32460555 PMCID: PMC7351358 DOI: 10.1161/cir.0000000000000773] [Citation(s) in RCA: 93] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cardiovascular disease (CVD) is the leading cause of death among American Indians and Alaska Natives. Over the past 50 years, the prevalence of CVD has been rising among American Indians and Alaska Natives. The objective of this statement is to summarize population-level risk factors and management techniques tailored for the American Indian and Alaska Native populations. METHODS PubMed/MEDLINE, the Centers for Disease Control and Prevention, and the annual Heart Disease and Stroke Statistics report from the American Heart Association were used to identify risk factors and interventions specific to American Indians and Alaska Natives. RESULTS Diabetes mellitus is a major contributor to disproportionately higher rates of coronary heart disease among American Indians and Alaska Natives compared with other racial and ethnic groups. Additional risk factors for CVD include low-density lipoprotein cholesterol levels, hypertension, renal disease, age, and sex. Smoking and exposure to toxic metals are risk factors for some subpopulations. A quarter of American Indians live below the federal poverty line, and thus, low socioeconomic status is an important social determinant of cardiovascular health. Community-based interventions have reduced CVD risk in American Indians and Alaska Natives. Underreporting of American Indian and Alaska Native race could underestimate the extent of CVD in this population. CONCLUSIONS Prevention and treatment of CVD in American Indians and Alaska Natives should focus on control of risk factors and community-based interventions that address social determinants of health, particularly among individuals with diabetes mellitus. Accurate reporting of race/ethnicity is encouraged to address race-specific risk factors.
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Trevisi L, Orav JE, Atwood S, Brown C, Curley C, King C, Muskett O, Sehn H, Nelson KA, Begay MG, Shin SS. Integrating community health representatives with health care systems: clinical outcomes among individuals with diabetes in Navajo Nation. Int J Equity Health 2019; 18:183. [PMID: 31771603 PMCID: PMC6880375 DOI: 10.1186/s12939-019-1097-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 11/18/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND We studied the impact of Community Outreach and Patient Empowerment (COPE) intervention to support Community Health Representatives (CHR) on the clinical outcomes of patients living with diabetes in the Navajo Nation extending into the States of Arizona, Utah, and New Mexico. The COPE intervention integrated CHRs into healthcare teams by providing a structured approach to referrals and home visits. METHODS We abstracted routine clinical data from the Indian Health Service's information system on individuals with diabetes mellitus seen at participating clinical sites from 2010 to 2014. We matched 173 COPE participants to 2880 patients with similar demographic and clinical characteristics who had not participated in COPE. We compared the changes in clinical outcomes between the two groups using linear mixed models. RESULTS Over the four years of the study, COPE patients had greater improvements in glycosylated hemoglobin (- 0.56%) than non-COPE participants (+ 0.07%) for a difference in differences of 0.63% (95% confidence interval (CI): 0.50, 0.76). Low-density lipoprotein fell more steeply in the COPE group (- 10.58 mg/dl) compared to the non-COPE group (- 3.18 mg/dl) for a difference in differences of 7.40 mg/dl (95%CI: 2.00, 12.80). Systolic blood pressure increased slightly more among COPE (2.06 mmHg) than non-COPE patients (0.61 mmHg). We noted no significant change for body mass index in either group. CONCLUSION Structured outreach by Community Health Representatives as part of an integrated care team was associated with improved glycemic and lipid levels in the target Navajo population. TRIAL REGISTRATION Trial registration: NCT03326206. Registered 31 October 2017 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/study/NCT03326206.
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Affiliation(s)
- Letizia Trevisi
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - John E Orav
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Sidney Atwood
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | - Christian Brown
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Cameron Curley
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | - Caroline King
- School of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Olivia Muskett
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Katrina A Nelson
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Sonya S Shin
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA.
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Pratte KA, Beals J, Johnson A, Bullock A, Manson SM, Jiang L. Recruitment and effectiveness by cohort in a case management intervention among American Indians and Alaska Natives with diabetes. Transl Behav Med 2019; 9:749-758. [PMID: 29982838 PMCID: PMC7184863 DOI: 10.1093/tbm/iby068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
In real-world settings, eligible populations and intervention effectiveness for a translational intervention likely vary across time. To determine the optimal strategies for effective large-scale implementation of evidence-based interventions, it is critical to investigate these potential variabilities. The purpose of this study is to evaluate whether patient characteristics and intervention effectiveness differed by year of enrollment in a multiyear evidence-based translational intervention. The Special Diabetes Program for Indians Healthy Heart (SDPI-HH) Demonstration Project is an intensive case management intervention designed to reduce cardiovascular disease risk among American Indians and Alaska Natives with diabetes. SDPI-HH participants recruited from 2006 through 2008 were included. Baseline characteristics were compared by year of enrollment. We also evaluated the differences in improvements in clinical and behavioral risk factors for cardiovascular disease among participants recruited in different years. The baseline characteristics of the three cohorts significantly differed in demographics, diabetes duration, health behaviors, level of motivation, and clinical measures. Improvements in 13 clinical and behavioral outcomes also differed by enrollment year with the 2006 cohort having the greatest number of significant improvements and the highest rates of participation and retention. Further investigation into the ways to modify the intensive case management model to address differences in levels of motivation and participation is warranted to improve the management of chronic disease in Indian health. Given the evolving nature of translational initiatives of this kind, our analysis results highlight the need to understand and adapt during the natural progression of health behavioral interventions.
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Affiliation(s)
- Katherine A Pratte
- Department of Epidemiology, University of California Irvine, School of Medicine, Irvine, CA, USA
| | - Janette Beals
- Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Ann Johnson
- Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Ann Bullock
- Division of Diabetes Treatment and Prevention, Indian Health Service, Rockville, MD, USA
| | - Spero M Manson
- Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Luohua Jiang
- Department of Epidemiology, University of California Irvine, School of Medicine, Irvine, CA, USA
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Schroeder EB, Moore K, Manson SM, Baldwin MA, Goodrich GK, Malone AS, Pieper LE, Xu S, Fort MM, Johnson D, Son-Stone L, Steiner JF. An Interactive Voice Response and Text Message Intervention to Improve Blood Pressure Control Among Individuals With Hypertension Receiving Care at an Urban Indian Health Organization: Protocol and Baseline Characteristics of a Pragmatic Randomized Controlled Trial. JMIR Res Protoc 2019; 8:e11794. [PMID: 30938688 PMCID: PMC6465973 DOI: 10.2196/11794] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 01/15/2019] [Accepted: 01/22/2019] [Indexed: 01/09/2023] Open
Abstract
Background Efficient and effective strategies for treating chronic health conditions such as hypertension are particularly needed for under-resourced clinics such as Urban Indian Health Organizations (UIHOs). Objective The objective of the Controlling Blood Pressure Trial is to assess the impact of an interactive voice response and text message (IVR-T) intervention compared with usual care among individuals with hypertension receiving care at a UIHO in Albuquerque, New Mexico. This manuscript presents the baseline characteristics of individuals enrolled in the trial and compares their characteristics with those in the hypertension registry who did not enroll in the trial. Methods A hypertension registry developed from the clinic’s electronic health record was used for recruitment. Potentially eligible participants were contacted by letter and then by phone. Those who expressed interest completed an in-person baseline visit that included a baseline survey and blood pressure measurement using standardized procedures. Individuals randomized to the intervention group could opt to receive either automated text messages or automated phone calls in either English or Spanish. The messages include reminders of upcoming appointments at First Nations Community HealthSource, requests to reschedule recently missed appointments, monthly reminders to refill medications, and weekly motivational messages to encourage self-care, appointment keeping, and medication taking for hypertension. Individuals in the IVR-T arm could opt to nominate a care partner to also receive notices of upcoming and missed appointments. Individuals in the IVR-T arm were also offered a home blood pressure monitor. Follow-up visits will be conducted at 6 months and 12 months. Results Over a 9.5-month period from April 2017 to January 2018, 295 participants were enrolled from a recruitment list of 1497 individuals. The enrolled cohort had a mean age of 53 years, was 25.1% (74/295) American Indian or Alaska Native and 51.9% (153/295) Hispanic, and 39.0% (115/295) had a baseline blood pressure greater than or equal to 140/90 mmHg. Overall, the differences between those enrolled in the trial and patients with hypertension who were ineligible, those who could not be reached, or those who chose not to enroll were minimal. Enrolled individuals had a slightly lower blood pressure (129/77 mmHg vs 132/79 mmHg; P=.04 for systolic blood pressure and P=.01 for diastolic blood pressure), were more likely to self-pay for their care (26% vs 10%; P<.001), and had a more recent primary care visit (164 days vs 231 days; P<.001). The enrolled cohort reported a high prevalence of poor health, low socioeconomic status, and high levels of basic material needs. Conclusions The Controlling Blood Pressure Trial has successfully enrolled a representative sample of individuals receiving health care at a UIHO. Trial follow-up will conclude in February 2019. Trial Registration ClinicalTrials.gov NCT03135405; http://clinicaltrials.gov/ct2/show/NCT03135405 (Archived by WebCite http://www.webcitation.org/76H2B4SO6) International Registered Report Identifier (IRRID) DERR1-10.2196/11794
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Affiliation(s)
- Emily B Schroeder
- Kaiser Permanente Colorado, Institute for Health Research, Aurora, CO, United States.,Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Kelly Moore
- Centers for American Indian and Alaska Native Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Spero M Manson
- Centers for American Indian and Alaska Native Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Megan A Baldwin
- Kaiser Permanente Colorado, Institute for Health Research, Aurora, CO, United States
| | - Glenn K Goodrich
- Kaiser Permanente Colorado, Institute for Health Research, Aurora, CO, United States
| | - Allen S Malone
- Kaiser Permanente Colorado, Institute for Health Research, Aurora, CO, United States
| | - Lisa E Pieper
- Kaiser Permanente Colorado, Institute for Health Research, Aurora, CO, United States
| | - Stanley Xu
- Kaiser Permanente Colorado, Institute for Health Research, Aurora, CO, United States
| | - Meredith M Fort
- Centers for American Indian and Alaska Native Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - David Johnson
- First Nations Community HealthSource, Albuquerque, NM, United States
| | - Linda Son-Stone
- First Nations Community HealthSource, Albuquerque, NM, United States
| | - John F Steiner
- Kaiser Permanente Colorado, Institute for Health Research, Aurora, CO, United States.,Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
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Banna J, Bersamin A. Community involvement in design, implementation and evaluation of nutrition interventions to reduce chronic diseases in indigenous populations in the U.S.: a systematic review. Int J Equity Health 2018; 17:116. [PMID: 30103753 PMCID: PMC6090789 DOI: 10.1186/s12939-018-0829-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 07/24/2018] [Indexed: 11/19/2022] Open
Abstract
Background Indigenous peoples of the United States disproportionately experience chronic diseases associated with poor nutrition, including obesity and diabetes. While chronic disease related health disparities among Indigenous people are well documented, it is unknown whether interventions adequately address these health disparities. In addition, it is unknown whether and to what extent interventions are culturally adapted or tailored to the unique culture, worldview and nutrition environments of Indigenous people. The aim of this review was to identify and characterize nutrition interventions conducted with Indigenous populations in the US, and to determine whether and to what degree communities are involved in intervention design, implementation and evaluation. Methods Peer-reviewed articles were identified using MEDLINE. Articles included were published in English in a refereed journal between 2000 and 2015, reported on a diet-related intervention in Indigenous populations in the US, and reported outcome data. Data extracted were program objectives and activities, target population, geographic region, formative research to inform design and evaluation, partnership, capacity building, involvement of the local food system, and outcomes. Narrative synthesis of intervention characteristics and the degree and type of community involvement was performed. Results Of 1060 records identified, 49 studies were included. Overall, interventions were successful in producing changes in knowledge, behavior or health (79%). Interventions mostly targeted adults in the Western region and used a pre-test, post-test design. Involvement of communities in intervention design, implementation, and evaluation varied from not at all to involvement at all stages. Of programs reporting significant changes in outcomes, more than half used at least three strategies to engage communities. However, formative research to inform the evaluation was not performed to a great degree, and fewer than half of the programs identified described involvement of the local food system. Conclusions The extent of use of strategies to promote community engagement in programs reporting significant outcomes is notable. In planning interventions in Indigenous groups, researchers should consider ways to involve the community in intervention design, execution and evaluation. There is a particular need for studies focused on Indigenous youth in diverse regions of the US to further address diet-related chronic conditions.
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Affiliation(s)
- Jinan Banna
- Department of Human Nutrition, Food and Animal Sciences at the University of Hawai'i at Mānoa, Honolulu, USA.
| | - Andrea Bersamin
- Center for Alaska Native Health Research, Institute of Arctic Biology at the University of Alaska Fairbanks, Fairbanks, USA
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Gonzales KL, Garcia GE, Jacob MM, Muller C, Nelson L, Manson SM. Patient-provider relationship and perceived provider weight bias among American Indians and Alaska Natives. Obes Sci Pract 2018; 4:76-84. [PMID: 29479467 PMCID: PMC5818742 DOI: 10.1002/osp4.135] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 08/21/2017] [Accepted: 08/29/2017] [Indexed: 12/25/2022] Open
Abstract
Objective The objective of this study was to examine patient-provider relationships among American Indians and Alaska Native (AI/AN) patients by examining associations between patient activation, perceived provider weight bias and working alliance. Patient activation is generally defined as having the knowledge, skills and confidence to manage one's health. Methods Among a sample of 87 AI/AN adults presenting for general medical care at an urban clinic in the north-west region of the USA, ordinary least squares regression analysis was completed to examine associations. Results Better working alliance scores were associated with increased patient activation, while perceived provider weight bias was associated with reduced patient activation. In addition, those with class II obesity had decreased patient activation. Conclusion These findings point to the importance of a positive patient-provider relationship in AI/ANs. Optimal patient engagement and subsequent health outcomes warrant additional consideration of patients' perceptions of provider weight bias within the context of health promotion and interventions.
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Affiliation(s)
- K. L. Gonzales
- Oregon Health Sciences University‐Portland State University School of Public HealthPortland State UniversityPortlandORUSA
| | - G. E. Garcia
- Department of SociologyPortland State UniversityPortlandORUSA
| | - M. M. Jacob
- Department of Education Studies, College of EducationUniversity of OregonEugeneORUSA
| | - C. Muller
- Initiative for Research and Education to Advance Community HealthWashington State UniversitySeattleWAUSA
| | - L. Nelson
- Initiative for Research and Education to Advance Community HealthWashington State UniversitySeattleWAUSA
| | - S. M. Manson
- Centers for American Indian and Alaska Native HealthUniversity of Colorado DenverAuroraCOUSA
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Poudel A, Zhou JY, Story D, Li L. Diabetes and Associated Cardiovascular Complications in American Indians/Alaskan Natives: A Review of Risks and Prevention Strategies. J Diabetes Res 2018; 2018:2742565. [PMID: 30302343 PMCID: PMC6158951 DOI: 10.1155/2018/2742565] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 08/12/2018] [Indexed: 12/22/2022] Open
Abstract
UNLABELLED Diabetes mellitus (DM) is the seventh leading cause of death in the United States and the leading cause of death in the U.S. American Indian/Alaskan Natives (AI/ANs), who comprise only 2% of the total population. The AI/AN population has a high prevalence of DM in adults aged 20 years or older and is developing DM at a younger age than the general U.S. POPULATION DM is a major risk factor for cardiovascular disease (CVD), and mortality from CVD is higher in AI/ANs than the general population, as is the prevalence of stroke and 1-year poststroke mortality for both genders when compared to non-Hispanic whites. A genome-wide scan found a number of chromosome linkages in the AI/AN population that suggest that genetic factors may contribute to their high risk of DM and CVD. Importantly, studies also suggest that in addition to race/ethnicity, cultural norms and historic conditions play important roles in the prevalence of DM and CVD in this population. Therefore, multiple factors should be taken into consideration when establishing prevention programs to decrease the prevalence of obesity, diabetes, and CVD incidence among adults and children in the AI/AN population. Prevention programs should focus on behavioral risk factors and lifestyle changes like encouraging smoking cessation, healthy diet, and increased physical activity while taking into consideration cultural, economic, and geographic factors.
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Affiliation(s)
- Anil Poudel
- Department of Physician Assistant, College of Health Professions, Central Michigan University, MI 48859, USA
| | - Joseph Yi Zhou
- College of Medicine, Central Michigan University, MI 48859, USA
| | - Darren Story
- Program in Neuroscience, Central Michigan University, MI 48859, USA
| | - Lixin Li
- Department of Physician Assistant, College of Health Professions, Central Michigan University, MI 48859, USA
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Philip J, Ryman TK, Hopkins SE, O'Brien DM, Bersamin A, Pomeroy J, Thummel KE, Austin MA, Boyer BB, Dombrowski K. Bi-cultural dynamics for risk and protective factors for cardiometabolic health in an Alaska Native (Yup'ik) population. PLoS One 2017; 12:e0183451. [PMID: 29091709 PMCID: PMC5665420 DOI: 10.1371/journal.pone.0183451] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 08/06/2017] [Indexed: 11/17/2022] Open
Abstract
Alaska Native people experience disparities in mortality from heart disease and stroke. This work attempts to better understand the relationships between socioeconomic, behavioral, and cardiometabolic risk factors among Yup'ik people of southwestern Alaska, with a focus on the role of the socioeconomic, and cultural components. Using a cross-sectional sample of 486 Yup'ik adults, we fitted a Partial Least Squares Path Model (PLS-PM) to assess the associations between components, including demographic factors [age and gender], socioeconomic factors [education, economic status, Yup'ik culture, and Western culture], behavioral factors [diet, cigarette smoking and smokeless tobacco use, and physical activity], and cardiometabolic risk factors [adiposity, triglyceride-HDL and LDL lipids, glycemia, and blood pressure]. We found relatively mild associations of education and economic status with cardiometabolic risk factors, in contrast with studies in other populations. The socioeconomic factor and participation in Yup'ik culture had potentially protective associations with adiposity, triglyceride-HDL lipids, and blood pressure, whereas participation in Western culture had a protective association with blood pressure. We also found a moderating effect of participation in Western culture on the relationships between Yup'ik culture participation and both blood pressure and LDL lipids, indicating a potentially beneficial additional effect of bi-culturalism. Our results suggest that reinforcing protective effects of both Yup'ik and Western cultures could be useful for interventions aimed at reducing cardiometabolic health disparities.
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Affiliation(s)
- Jacques Philip
- Center for Alaska Native Health Research, University of Alaska Fairbanks, Fairbanks, Alaska, United States of America
| | - Tove K. Ryman
- Bill and Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Scarlett E. Hopkins
- Center for Alaska Native Health Research, University of Alaska Fairbanks, Fairbanks, Alaska, United States of America
| | - Diane M. O'Brien
- Center for Alaska Native Health Research, University of Alaska Fairbanks, Fairbanks, Alaska, United States of America
| | - Andrea Bersamin
- Center for Alaska Native Health Research, University of Alaska Fairbanks, Fairbanks, Alaska, United States of America
| | - Jeremy Pomeroy
- Marshfield Clinic Research Institute, Marshfield, Wisconsin, United States of America
| | - Kenneth E. Thummel
- Department of Pharmaceutics, University of Washington, Seattle, Washington, United States of America
| | - Melissa A. Austin
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington, United States of America
| | - Bert B. Boyer
- Center for Alaska Native Health Research, University of Alaska Fairbanks, Fairbanks, Alaska, United States of America
| | - Kirk Dombrowski
- Department of Sociology, University of Nebraska, Lincoln, Nebraska, United States of America
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22
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Mohammed SA, Udell W. American Indians/Alaska Natives and Cardiovascular Disease: Outcomes, Interventions, and Areas of Opportunity. CURRENT CARDIOVASCULAR RISK REPORTS 2017. [DOI: 10.1007/s12170-017-0526-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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23
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Walter KN, Wagner JA, Cengiz E, Tamborlane WV, Petry NM. Substance Use Disorders among Patients with Type 2 Diabetes: a Dangerous but Understudied Combination. Curr Diab Rep 2017; 17:2. [PMID: 28101793 DOI: 10.1007/s11892-017-0832-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW This paper reviews research on substance use and disorders (SUDs) among adults with diabetes. It describes epidemiological data on SUDs in persons with type 2 diabetes, overviews effects of substance use on diabetes outcomes, and discusses treatments for SUDs in patients with diabetes. RECENT FINDINGS Rates of current smoking range from 10 to 26% and alcohol use disorders are 0-5%. Rates of illicit SUDs are 3-4%, but there are no population-based studies using nationally representative samples. Smoking increases the risk for long-term diabetes complications and premature death. Alcohol and illicit drug use can also impact long-term diabetes complications by impairing glucose homeostasis and adversely influencing self-management behaviors. There is mixed evidence about psychosocial smoking cessation interventions in adults with diabetes and little on alcohol and illicit SUD interventions. Limited data exist on pharmacotherapies for SUDs in this population, but a recent study suggests that varenicline is safe and effective for treating smoking in patients with diabetes. Substance use is an understudied problem in type 2 diabetes, and addressing substance use holds potential for improving outcomes. Additional large population-based epidemiological studies in those with type 2 diabetes are needed, particularly for alcohol and illicit SUDs. Longitudinal studies should be conducted to better understand the time course of diabetes onset and outcomes in relation to SUDs. Randomized controlled trials are needed to assess safety and efficacy of promising psychosocial and pharmacological interventions.
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Affiliation(s)
- Kimberly N Walter
- University of Connecticut School of Medicine (MC 3944), 263 Farmington Ave., Farmington, CT, 06030-3944, USA
| | - Julie A Wagner
- University of Connecticut School of Dental Medicine, 263 Farmington Ave., Farmington, CT, USA
| | - Eda Cengiz
- Yale University School of Medicine, PO Box 208064, New Haven, CT, USA
| | | | - Nancy M Petry
- University of Connecticut School of Medicine (MC 3944), 263 Farmington Ave., Farmington, CT, 06030-3944, USA.
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24
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Scott DM, Strand M, Undem T, Anderson G, Clarens A, Liu X. Assessment of pharmacists' delivery of public health services in rural and urban areas in Iowa and North Dakota. Pharm Pract (Granada) 2016; 14:836. [PMID: 28042356 PMCID: PMC5184378 DOI: 10.18549/pharmpract.2016.04.836] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 11/22/2016] [Indexed: 11/29/2022] Open
Abstract
Background: The profession of pharmacy is expanding its involvement in public health, but few studies have examined pharmacists’ delivery of public health services. Objective: To assess Iowa and North Dakota pharmacists’ practices, frequency of public health service delivery, level of involvement in achieving the essential services of public health, and barriers to expansion of public health services in rural and urban areas. Methods: This study implemented an on-line survey sent to all pharmacists currently practicing pharmacy in Iowa and North Dakota. Results: Overall, 602 valid responses were analyzed, 297 in rural areas and 305 in urban areas. Three practice settings (chain stores [169, 28.2%], independent community pharmacies [162, 27.0%], and hospital pharmacies [156, 26.0%]) comprised 81.2% of the sample. Both chain and independent community pharmacists were more commonly located in rural areas than in urban areas (P<0.05). For some public health services, pharmacists in rural areas reported higher frequency of delivery than did pharmacists in urban areas (P < .05) that included: medication therapy management, immunizations, tobacco counseling, and medication take-back programs. For some essential services, pharmacists (particularly independents) in rural areas reported more frequent delivery than did pharmacists in urban areas (P < .05), these included: evaluate the services the pharmacy provides, partner with the community to identify and help solve health problems, and conduct needs assessments to identify health risks in my community. Conclusion: Rural pharmacists more frequently deliver public health services than urban in both Iowa and North Dakota. These findings should be interpreted to be primarily due to differences in the role of the rural pharmacist and the quest for certain opportunities that rural pharmacists are seeking.
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Affiliation(s)
- David M Scott
- Departments of Pharmacy Practice and Public Health, School of Pharmacy, College of Health Professions, North Dakota State University . Fargo, ND ( United States ).
| | - Mark Strand
- Departments of Pharmacy Practice and Public Health, School of Pharmacy, College of Health Professions, North Dakota State University . Fargo, ND ( United States ).
| | - Teri Undem
- Advanced Pharmacy Practice Experience (APPE), College of Health Professions, North Dakota State University . Fargo, ND ( United States ).
| | - Gabrielle Anderson
- School of Pharmacy, College of Health Professions, North Dakota State University . Fargo, ND ( United States ).
| | - Andrea Clarens
- School of Pharmacy, College of Health Professions, North Dakota State University . Fargo, ND ( United States ).
| | - Xiyuan Liu
- Department of Statistics, College of Math and Science, North Dakota State University . Fargo, ND ( United States ).
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25
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Gibbs HD, Pacheco C, Yeh HW, Daley C, Greiner KA, Choi WS. Accuracy of Weight Perception Among American Indian Tribal College Students. Am J Prev Med 2016; 51:e139-e144. [PMID: 27450725 PMCID: PMC5067191 DOI: 10.1016/j.amepre.2016.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 05/20/2016] [Accepted: 06/01/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION National data indicate a higher prevalence of obesity among American Indian (AI) populations and greater disparity of morbidity and mortality among younger age groups compared with other ethnicities. Diet and physical activity are important obesity preventive behaviors, but no published data exist that describe these behaviors in relation to obesity in AI young adults at tribal colleges. Study purposes were to: (1) identify fruit and vegetable intake and physical activity practices of AI young adults from three U.S. tribal colleges according to BMI categories; (2) identify the accuracy of body weight perceptions; and (3) identify predictor variables for weight misperception. METHODS In this observational study during 2011-2014, a total of 1,256 participants were recruited from three participating U.S. tribal colleges to complete an online survey addressing issues related to diet, physical activity, and weight perception. Reported height and weight were used to calculate BMI categories, and differences between BMI categories were examined. Gender differences related to accuracy of weight perception by BMI categories were also examined. Analyses were conducted in 2016. RESULTS Based on self-reported height and weight, 68% of the sample was overweight or obese (BMI ≥25) and mean BMI was 28.9 (SD=6.9). Most did not meet recommendations for fruit intake (78.7%), vegetable intake (96.6%), or physical activity (65.6%). More than half (53.7%%) who were overweight/obese underestimated their weight category. Men more often underestimated their weight category (54.2%) than women (35.1%). CONCLUSIONS Interventions are needed to improve weight-related lifestyle behaviors of AI tribal college students.
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Affiliation(s)
- Heather D Gibbs
- Department of Dietetics and Nutrition, University of Kansas Medical Center, Kansas City, Kansas
| | - Christina Pacheco
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Hung-Wen Yeh
- Department of Biostatistics, University of Kansas Medical Center, Kansas City, Kansas
| | - Christine Daley
- Department of Preventive Medicine and Public Health, University of Kansas Medical Center, Kansas City, Kansas
| | - K Allen Greiner
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Won S Choi
- Department of Preventive Medicine and Public Health, University of Kansas Medical Center, Kansas City, Kansas.
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Haw JS, Tantry S, Vellanki P, Pasquel FJ. National Strategies to Decrease the Burden of Diabetes and Its Complications. Curr Diab Rep 2015; 15:65. [PMID: 26255260 DOI: 10.1007/s11892-015-0637-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Comparative results from national strategies for diabetes care and prevention are needed to understand the impact and barriers encountered during the implementation process. Long-term outcomes are limited, but results on intermediate outcomes and processes of diabetes care measures are available from translational research studies. In this narrative review, we highlight programs with nationwide reach, targeting various ethnic, racial, and socioeconomic populations with diabetes. We describe the implementation strategies, the impact on clinical outcomes, specific barriers, and cost-effectiveness results of national efforts aimed at improving diabetes care and prevention in the USA.
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Affiliation(s)
- J Sonya Haw
- Division of Endocrinology, Emory University School of Medicine, 49 Jesse Hill Dr SE, FOB Rm 439, Atlanta, GA, 30303, USA,
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A Home-Based Educational Intervention Improves Patient Activation Measures and Diabetes Health Indicators among Zuni Indians. PLoS One 2015; 10:e0125820. [PMID: 25954817 PMCID: PMC4425648 DOI: 10.1371/journal.pone.0125820] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 03/17/2015] [Indexed: 12/31/2022] Open
Abstract
Introduction One in three people will be diagnosed with diabetes by 2050, and the proportion will likely be higher among Native Americans. Diabetes control is currently suboptimal in underserved populations despite a plethora of new therapies. Patient empowerment is a key determinant of diabetes control, but such empowerment can be difficult to achieve due to resource limitation and cultural, language and health literacy barriers. We describe a home-based educational intervention using Community Health Representatives (CHRs), leading to improvement in Patient Activation Measures scores and clinical indicators of diabetes control. Methods Sixty participants with type 2 diabetes (T2D) completed a baseline evaluation including physical exam, Point of Care (POC) testing, and the Patient Activation Measure (PAM) survey. Participants then underwent a one hour group didactic session led by Community Health Representatives (CHRs) who subsequently carried out monthly home-based educational interventions to encourage healthy lifestyles, including diet, exercise, and alcohol and cigarette avoidance until follow up at 6 months, when clinical phenotyping and the PAM survey were repeated. Results PAM scores were increased by at least one level in 35 (58%) participants, while 24 participants who started at higher baseline score did not change. Six months after intervention, mean levels of A1C decreased by 0.7 ± 1.2%; fasting blood glucose decreased by 24.0 ± 38.0 mg/dl; BMI decreased by 1.5 ± 2.1 kg/m2; total cholesterol decreased by 12.0± 28.0 mg/dl; and triglycerides decreased by 52.0 ± 71.0 mg/dl. All of these changes were statistically significant (p<0.05). Conclusion This six month, CHR led and community-oriented educational intervention helps inform standards of practice for the management of diabetes, engages diabetic populations in their own care, and reduces health disparities for the underserved population of Zuni Indians. Trial Registration ClinicalTrials.gov NCT02339311
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