Disparities in chronic disease risk factors and health status between American Indian/Alaska Native and White elders: findings from a telephone survey, 2001 and 2002

Urgent versus elective surgical disparities among American Indian and Alaska Native patients

BACKGROUND

American Indian and Alaska Native (AIAN) health issues are understudied despite documentation of lower-than-average life expectancy. Urgent surgery is associated with higher rates of postsurgical complications and postoperative death. We assess whether American Indian and Alaska Native (AIAN) patients in Washington State are at greater risk of requiring urgent rather than elective surgery compared with non-Hispanic Whites (NHW).

METHODS

We accessed data for the period 2009-2014 from the Washington State Comprehensive Hospital Abstract Reporting System (CHARS) database, which captures all statewide hospital admissions, to examine three common surgeries that are performed both urgently and electively: hip replacements, aortic valve replacements, and spinal fusions. We extracted patient race, age, insurance status, comorbidity, admission type, and procedures performed. We then constructed multivariable logistic regression models to identify factors associated with use of urgent surgical care.

RESULTS

AIAN patients had lower mean age at surgery for all three surgeries compared with NHW patients. AIAN patients were at higher risk for urgent surgery for hip replacements (OR = 1.49, 95% CI 1.19-1.88), spinal fusions (OR = 1.39, 95% CI 1.04-1.87), and aortic valve replacements (OR = 2.06, 95% CI 1.12-3.80).

CONCLUSION

AIAN patients were more likely to undergo urgent hip replacement, spinal fusion, and aortic valve replacement than NHW patients. AIAN patients underwent urgent surgery at younger ages. Medicaid insurance conferred higher risks for urgent surgery across all surgeries studied. Further research is warranted to more clearly identify the factors contributing to disparities among AIAN patients undergoing urgent surgery.

Alzheimer's disease and its related dementias in US Native Americans: A major public health concern

Alzheimer's disease (AD) and Alzheimer's related dementias (ADRD) are growing public health concerns in aged populations of all ethnic and racial groups. AD and ADRD are caused by multiple factors, such as genetic mutations, modifiable and non-modifiable risk factors, and lifestyle. Studies of postmortem brains have revealed multiple cellular changes implicated in AD and ADRD, including the accumulation of amyloid beta and phosphorylated tau, synaptic damage, inflammatory responses, hormonal imbalance, mitochondrial abnormalities, and neuronal loss. These changes occur in both early-onset familial and late-onset sporadic forms. Two-thirds of women and one-third of men are at life time risk for AD. A small proportion of total AD cases are caused by genetic mutations in amyloid precursor protein, presenilin 1, and presenilin 1 genes, and the APOE4 allele is a risk factor. Tremendous research on AD/ADRD, and other comorbidities such as diabetes, obesity, hypertension, and cancer has been done on almost all ethnic groups, however, very little biomedical research done on US Native Americans. AD/ADRD prevalence is high among all ethnic groups. In addition, US Native Americans have poorer access to healthcare and medical services and are less likely to receive a diagnosis once they begin to exhibit symptoms, which presents difficulties in treating Alzheimer's and other dementias. One in five US Native American people who are 45 years of age or older report having memory issues. Further, the impact of caregivers and other healthcare aspects on US Native Americans is not yet. In the current article, we discuss the history of Native Americans of United States (US) and health disparities, occurrence, and prevalence of AD/ADRD, and shedding light on the culturally sensitive caregiving practices in US Native Americans. This article is the first to discuss biomedical research and healthcare disparities in US Native Americans with a focus on AD and ADRD, we also discuss why US Native Americans are reluctant to participate in biomedical research.

COVID-19 Among Non-Hispanic American Indian and Alaska Native People Residing in Urban Areas Before and After Vaccine Rollout-Selected States and Counties, United States, January 2020-October 2021

Objectives. To evaluate COVID-19 disparities among non-Hispanic American Indian/Alaska Native (AI/AN) and non-Hispanic White persons in urban areas. Methods. Using COVID-19 case surveillance data, we calculated cumulative incidence rates and risk ratios (RRs) among non-Hispanic AI/AN and non-Hispanic White persons living in select urban counties in the United States by age and sex during January 22, 2020, to October 19, 2021. We separated cases into prevaccine (January 22, 2020-April 4, 2021) and postvaccine (April 5, 2021-October 19, 2021) periods. Results. Overall in urban areas, the COVID-19 age-adjusted rate among non-Hispanic AI/AN persons (n = 47 431) was 1.66 (95% confidence interval [CI] = 1.36, 2.01) times that of non-Hispanic White persons (n = 2 301 911). The COVID-19 prevaccine age-adjusted rate was higher (8227 per 100 000; 95% CI = 6283, 10 770) than was the postvaccine rate (3703 per 100 000; 95% CI = 3235, 4240) among non-Hispanic AI/AN compared with among non-Hispanic White persons (2819 per 100 000; 95% CI = 2527, 3144; RR = 1.31; 95% CI = 1.17, 1.48). Conclusions. This study highlights disparities in COVID-19 between non-Hispanic AI/AN and non-Hispanic White persons in urban areas. These findings suggest that COVID-19 vaccination and other public health efforts among urban AI/AN communities can reduce COVID-19 disparities in urban AI/AN populations. (Am J Public Health. 2022;112(10):1489-1497. https://doi.org/10.2105/AJPH.2022.306966).

Consistent Honor, Persistent Disadvantage: American Indian and Alaska Native Veteran Health in the National Survey of Veterans

Objective: To examine self-rated health and activities of daily living (ADLs) limitations among American Indian and Alaska Native (AI/AN) veterans relative to white veterans. Methods: We use the 2010 National Survey of Veterans and limit the sample to veterans who identify as AI/AN or non-Hispanic white. We calculated descriptive statistics, confidence intervals, and used logistic regression. Results: AI/AN veterans are younger, have lower levels of income, and have higher levels of exposure to combat and environmental hazards compared to white veterans. We found that AI/AN veterans are significantly more likely to report fair/poor health controlling for socioeconomic status and experience an ADL controlling for age, health behaviors, socioeconomic status, and military factors. Discussion: The results indicate that AI/AN veterans are a disadvantaged population in terms of their health and disability compared to white veterans. AI/AN veterans may require additional support from family members and/or Veteran Affairs to address ADLs.

Loneliness and sleep in the American Indian Blackfeet community

BACKGROUND

Sleep is largely understudied in American Indians (AIs), even though sleep is implicated in the chronic diseases which disproportionately affect AI communities.

OBJECTIVE

To investigate relationships between daily self-reported loneliness and sleep as measured with actigraphy.

METHODS

In a sample of 98 Blackfeet adults living on the Blackfeet reservation in Montana, we used Ecological Momentary Assessment and actigraphy over a week-long period to investigate relationships between loneliness and sleep. Loneliness was measured daily using the Short Loneliness Scale and actigraphy was used to measure total sleep time, sleep onset latency (SOL), wake after sleep onset (WASO), and sleep efficiency (SE).

RESULTS

Using a series of generalized linear mixed-effects models controlling for demographic characteristics, anxiety and depressive symptoms, and adverse childhood experiences, we found that those who were lonelier had higher WASO and SOL, and lower SE relative to those who were less lonely. Within-subject effects indicate that participants who were lonelier for a given day relative to their own weekly average had higher WASO that night relative to their own weekly average.

CONCLUSIONS

Our findings provide initial preliminary evidence suggesting that loneliness may be a psychosocial factor which contributes to poor sleep in AI communities.

The Ramapough Lunaape Nation: Facing Health Impacts Associated with Proximity to a Superfund Site

This study aimed to evaluate self-reported exposure to the Ringwood Mines/Landfill Superfund Site in relation to chronic health outcomes among members of the Ramapough Lunaape Turtle Clan nation and other local residents of Ringwood, New Jersey. Community surveys on personal exposure to the nearby Superfund site, self-reported health conditions, and demographics were conducted with 187 members of the Ramapough Lunaape Turtle Clan Nation and non-Native Americans residing in Ringwood, New Jersey from December 2015 to October 2016. Multiple logistic regression was performed to assess the association between ethnicity and a Superfund site exposure score developed for this study, as well as between exposure score and several chronic health conditions. Native Americans were 13.84 times (OR 13.84; 95% CI 4.32, 44.37) more likely to face exposure opportunities to Superfund sites as compared to non-Native Americans in the same New Jersey borough. For the entire surveyed cohort, increased Superfund site exposure routes was significantly associated with bronchitis (OR 4.10; 95% CI 1.18, 14.23). When the analyses were restricted to Native Americans, the association between self-reported Superfund site exposure and bronchitis remained significant (OR 17.42; 95% CI 1.99, 152.45). Moreover, the association between greater exposure score and asthma in this same population also reached statistical significance (OR 6.16; 95% CI 1.38, 27.49). This pilot study demonstrated a significant association between being a Ringwood resident of Native American ethnicity and self-declared opportunities for Superfund site exposure. It also showed a strong association between self-reported Superfund site exposure and the prevalence of bronchitis and asthma.

American Indian Alcohol Use from a Sex-Specific Wellness Approach: Exploring Its Associated Physical, Behavioral, and Mental Risk and Protective Factors

PURPOSE

The top causes of death for American Indians (AIs), including heart and liver disease, are associated with alcohol use. Using the culturally based Framework of Historical Oppression, Resilience, and Transcendence (FHORT), the purpose of this article was to examine AI alcohol use from a sex-specific wellness approach, exploring its associated physical, behavioral, and mental risk and protective factors.

METHOD

Data were drawn from a cross-sectional survey with 479 AI adults in South Dakota. We employed a series of multiple hierarchical regression analyses to assess the associations of demographic (sex, age, marital status, income, and educational attainment), physical (Body Mass Index and cardiovascular risk), behavioral (smoking and health self-efficacy) and mental (depressive symptoms) factors with alcohol use.

RESULTS

Results indicated that surveyed males tended to drink three times that of females, and depressive symptoms were associated with higher levels of alcohol use.

DISCUSSION

This study highlights the need to examine AI alcohol use with sex in mind.

Health outcomes in a national sample of American Indian and Alaska Native adults: Differences between multiple-race and single-race subgroups

OBJECTIVES

To determine differences among multi-race (MR) American Indian and Alaska Natives (AIAN), single race (SR) AIANs, and SR-Whites on multiple health outcomes. We tested the following hypotheses: MR-AIANs will have worse health outcomes than SR-AIANs; SR-AIANs will have worse health outcomes than SR-Whites; MR-AIANs will have worse health outcomes than SR-Whites.

METHODS

Behavioral Risk Factor Surveillance System data were used to examine general health, risk behaviors, access to health care, and diagnosed chronic health conditions. Those identifying as SR-White, SR-AIAN, and MR-AIAN were included in multinomial logistic regression models.

RESULTS

Compared to SR-AIANs, MR-AIANs had more activity limitations, a greater likelihood of experiencing cost as a barrier to health care and were more likely to be at increased risk and diagnosed with more chronic health conditions. Both SR and MR-AIANs have worse health than SR-Whites; MR-AIANs appear to be at increased risk for poor health.

CONCLUSIONS

The current study examined access to health care and nine chronic health conditions, neither of which have been considered in prior work. MR AIANs are at increased risk compared to SR groups. These observations beg for further inquire into the mechanisms underlying these differences including stress related to identify, access to care, and discrimination. Findings support the continued need to address health disparities among AIANs regardless of SR or MR identification.

Type 2 diabetes management among older American Indians: beliefs, attitudes, and practices

Objective: The purpose of this study was to examine beliefs, attitudes, and practices of older American Indians regarding their type 2 diabetes mellitus (T2DM) management. T2DM is one of the leading causes of morbidity and mortality among American Indians. American Indians are more than twice as likely to have T2DM and have over three times a T2DM mortality rate as Whites. Design: Study participants were older members of a federally recognized tribe who had T2DM. A low-inference qualitative descriptive design was used. Data were collected through semi-structured in-depth qualitative interviews with a mixed inductive, deductive, and reflexive analytic team process. Results: Our study sample included 28 participants with a mean age of 73.0 ± 6.4 years of whom 16 (57%) were women. Participants' mean self-confidence score of successful T2DM management was 8.0 ± 1.7 on a scale from 1 to 10 with 10 representing the greatest amount of confidence. Participants' mean HbA1c was 7.3% ± 1.5%. Overall, participants discussed T2DM management within five themes: 1) sociocultural factors, 2) causes and consequences, 3) cognitive and affective assessment, 4) diet and exercise, and 5) medical management. Conclusions: It is important to be aware of the beliefs and attitudes of patients. Lay understandings can help identify factors underlying health and illness behaviors including motivations to maintain healthy behaviors or to change unhealthy behaviors. Such information can be helpful for health educators and health promotion program staff to ensure their efforts are effective and in alignment with patients' realities.

Reliability, construct validity, and measurement invariance of the PROMIS Physical Function 8b-Adult Short Form v2.0

PURPOSE

The National Institutes of Health established the Patient-Reported Outcomes Measurement Information System (PROMIS) to assess health across various chronic illnesses. The standardized PROMIS measures have been used to assess symptoms in studies that included Native American participants, although the psychometric properties of these measures have not been assessed among a solely Native American population. This study aimed to assess the reliability, construct validity, and measurement invariance of a widely used PROMIS Physical Function survey among Native Americans residing on or near the Apsáalooke (Crow) Reservation who were living with chronic illnesses.

METHODS

Participants aged 24 to 82 years and living with at least one chronic illness were recruited for a community-based participatory research project. Baseline data were used for the current study (N = 210). The 8-item PROMIS Physical Function 8b-Adult Short Form v2.0 was used to assess the function of upper and lower extremities, central core regions, and the ability to complete daily activities on a 5-point Likert scale.

RESULTS

Results indicated that the above PROMIS survey had high internal consistency (Cronbach's α = 0.95) and split-half (r = 0.92, p < 0.001) reliabilities. Confirmatory factor analyses supported construct validity among females of the above population and when the two sex groups were combined. Results also indicated that corresponding thresholds and factor loadings were invariant across male and female groups.

CONCLUSIONS

The above PROMIS measure had good psychometric properties in females and when the two sex groups were combined among Native American adults living on or near the Apsáalooke reservation with chronic illnesses. Thresholds and factor loadings appeared to be invariant by sex. Future studies with a larger sample size among males and more studies on the psychometric properties of other PROMIS measures among Native American populations are needed.

Environmental Risk Perceptions and Community Health: Arsenic, Air Pollution, and Threats to Traditional Values of the Hopi Tribe

American Indian and Alaska Native populations experience chronic disparities in a wide range of health outcomes, many of which are associated with disproportionate exposures to environmental health hazards. In the American Southwest, many indigenous tribes experience challenges in securing access to sustainable and safe sources of drinking water, limiting air pollution emissions on and off tribal lands, and cleaning up hazardous contaminants left over from a legacy of natural resource extraction. To better understand how households perceive the risk of exposure to potential environmental health risks, we conducted six focus groups organized by age and geographic location on the Hopi reservation. Focus group participants (n = 41) were asked to reflect on changes in their natural and manmade environment and how their health might be influenced by any potential changes. By investigating these environmental risk perceptions, we were able to identify arsenic in drinking water and indoor air quality as significant exposures of concern. These risk perceptions were frequently anchored in personal and familial experiences with health problems such as cancer and asthma. Older focus group participants identified ongoing shifts away from tradition and cultural practices as increasing environmental health risks. Similar to other communities economically dependent on the extraction of natural resources, focus group participants described the need for behavioral modifications regarding environmental health risks rather than eliminating the sources of potential health risks entirely. Our results suggest the need for including traditional values and practices in future interventions to reduce environmental health risks.

American Indian young adults display diminished cardiovascular and cortisol responses to acute psychological stress

American Indian adults are at an increased risk for cardiovascular disease compared with non-Hispanic white adults. Scant research exists examining the underlying physiological and psychological mechanisms associated with these risks. This study aimed to examine possible psychological and physiological stress-related mechanisms related to cardiovascular disease risk in healthy American Indian and non-Hispanic white adults. Forty American Indian (60% female, Mean age = 19.93, SD = 2.08 years) and 45 non-Hispanic white (70% female, Mean age = 20.18, SD = 2.22 years) participants attended an in-person laboratory session. Salivary cortisol and cardiovascular activity were measured before (baseline), during, and after exposure to a 10-minute mental arithmetic task. Compared to non-Hispanic white participants, American Indian had diminished salivary cortisol (p < .001), blood pressure (p's < .001), and heart rate (p = .041) responses to acute psychological stress. These effects could not be accounted for by differences in task performance or self-reported engagement. Previous research has shown that exaggerated responses to stress are associated with increased risk of cardiovascular disease. However, diminished responses to stress are associated with early childhood stress and future adverse behaviors (e.g., addiction, obesity). Diminished reactivity may influence behaviors that can impact future development of cardiovascular disease in American Indian populations.

Cardiovascular Health among U.S. Indigenous Peoples: A Holistic and Sex-Specific Systematic Review

PURPOSE

The purpose of this systematic review is to examine mental, sociocultural, behavioral, and physical risk and protective factors related to cardiovascular disease (CVD) and related outcomes among U.S. Indigenous peoples.

METHODS

A total of 51 articles met the inclusion criteria of research focusing factors for CVD among U.S. Indigenous peoples (Mental n= 15; Sociocultural, n =17; Behavioral/Physical, n =19).

RESULTS

This review reveals clear risks for CVD, which tended to be elevated for females. Mental health problems (depression, anxiety, PTSD/trauma, alcohol and other drug (AOD) abuse) were clearly associated with CVD, along with enculturation, social support, and the social environment-including discrimination and trauma. Poor diet and obesity, diabetes, hypertension, cholesterol were behavioral or physical factors.

DISCUSSION

Overall, identified research was limited and in beginning stages, lacking more information on etiology of the interconnections across sex and the mental, sociocultural, and behavioral determinants of CVD.

The effect of facilities management of common areas on the environment domain of quality of life or older people in private buildings

Purpose

The world was facing significant aging challenges. Aging in place has long been advocated which reflected the preference of older people to stay in their own home as long as possible. A huge amount of older people resided in private buildings that consist of both indoor settings (i.e. individual unit flats) and outdoor settings (i.e. common areas like lobby and corridor). The effect of indoor environment on the quality of life of the older people has been investigated, while this paper aims to examine the different effect of common areas environment for the older people.

Design/methodology/approach

A questionnaire survey was administered among over 300 older people living in private buildings. Multiple statistical techniques, including reliability test, correlation coefficient and multiple regression models, were used to analyze the collected data to determine the interactions between facilities management of the common areas in private buildings and the environment domain of quality of life for older people.

Findings

The final results were concluded based on the congruence of all the statistical results, which covered the identification of facilities management factors in common areas of private buildings that could influence the environment domain of quality of life for older people, including overall environment, health-care accessibility, information acquisition and transportation aspects; the overall environment was positively predicted by space and security in common areas of private building; health-care accessibility was positively affected by space, barrier-free facilities and recreational facilities; the information acquisition was only positively predicted by security; transportation was positively predicted by distance and recreational facilities; and building services of common areas in private buildings had no effect on the environment domain of quality of life for older people.

Originality/value

Practical recommendations have been made to improve the facilities management of common areas in private buildings to ensure the quality of life for older people, including provision of walking assistance, motion or infrared controlled systems and so on. This study contributed to enhance current understanding of the interactions between the older people and their living environment.

"Improving Native American elder access to and use of health care through effective health system navigation"

BACKGROUND

Public insurance reforms of the past two decades have failed to substantively address the healthcare needs of American Indians in general, let alone the particular needs of American Indian elders, ages 55 years and older. Historically, this population is more likely to be uninsured and to suffer from greater morbidities, poorer health outcomes and quality of life, and lower life expectancies compared to all other United States aging populations, representing a neglected group within the healthcare system. Despite the pervasive belief that the Indian Health Service will address all their health-related needs, American Indian elders are negatively affected by gaps in insurance and lack of access to health care. While the 2010 Patient Protection and Affordable Care Act included provisions to ameliorate disparities for American Indians, its future is uncertain. In this context, American Indian elders with variable health literacy must navigate a complex and unstable healthcare system, regardless of where they seek care.

METHODS

This community-driven study features a mixed-method, participatory design to examine help-seeking behavior and healthcare experiences of American Indian elders in New Mexico, in order to develop and evaluate a tailored intervention to enhance knowledge of, access to, and use of insurance and available services to reduce healthcare disparities. This study includes qualitative and quantitative interviews combined with concept mapping and focus groups with American Indian elders and other key stakeholders.

DISCUSSION

The information gathered will generate new practical knowledge, grounded in actual perspectives of American Indian elders and other relevant stakeholders, to improve healthcare practices and policies for a population that has been largely excluded from national and state discussions of healthcare reform. Study data will inform development and evaluation of culturally tailored programming to enhance understanding and facilitate negotiation of the changing landscape of health care by American Indian elders. This work will fill a gap in research on public insurance initiatives, which do not typically focus on this population, and will offer a replicable model for enhancing the effects of such initiatives on other underserved groups affected by healthcare inequities.

TRIAL REGISTRATION

This protocol does not include the collection of health outcome data. Clinicaltrials.gov, NCT03550404 . Registered June 6, 2018.

Education, Income, and Employment and Prevalence of Chronic Disease Among American Indian/Alaska Native Elders

INTRODUCTION

Chronic disease studies have omitted analyses of the American Indian/Alaska Native (AI/AN) population, relied on small samples of AI/ANs, or focused on a single disease among AI/ANs. We measured the influence of income, employment status, and education level on the prevalence of chronic disease among 14,632 AI/AN elders from 2011 through 2014.

METHODS

We conducted a national survey of AI/AN elders (≥55 y) to identify health and social needs. Using these data, we computed cross-tabulations for each independent variable (annual personal income, employment status, education level), 2 covariates (age, sex), and presence of any chronic disease. We also compared differences in values and used a binary logistic regression model to control for age and sex.

RESULTS

Most AI/AN elders (89.7%) had been diagnosed with at least one chronic disease. AI/AN elders were also more than twice as likely to have diabetes and more likely to have arthritis. AI/AN elders with middle-to-low income levels and who were unemployed were more likely to have a chronic disease than were high-income and employed AI/AN elders.

CONCLUSION

Addressing disparities in chronic disease prevalence requires focus on more than access to and cost of health care. Economic development and job creation for all age cohorts in tribal communities may decrease the prevalence of long-term chronic diseases and may improve the financial status of the tribe. An opportunity exists to address health disparities through social and economic equity among tribal populations.

Physical Activity and Cardiovascular Disease Among Older Adults: The Case of Race and Ethnicity

The goals of this study were (1) to test the relative contribution of light intensity and moderate-to-vigorous intensity physical activity (MVPA) to cardiovascular disease (CVD) risk in older adults, and (2) to examine the influence of ethnicity. We used pooled data from the 2003-2004 and 2005-2006 waves of the National Health and Nutritional Examination Survey (NHANES). The sample consisted of 1,171 non-Hispanic White, non-Hispanic Black, and Mexican American adults aged 65 and older. Using ordinary least squares regression, we showed no statistically significant relationship between lower CVD risk with light intensity activity. However, greater minutes of MVPA was associated with lower CVD risk. Mexican Americans had statistically significantly higher risk for CVD compared to non-Hispanic Whites after controlling for physical activity. Mexican Americans remain an at-risk group for CVD. Regardless of race or ethnicity, physical activity recommendations among elders should be for at least moderate intensity activity for a more favorable CVD outcome.

HIV care and treatment of American Indians/Alaska natives with diagnosed HIV infection - 27 states and the District of Columbia, 2012

The objective of this study was to measure linkage to care, retention in care, and suppressed viral load (VL) among American Indians/Alaska Natives (AIs/ANs) aged ≥13 years with diagnosed HIV infection. We used national HIV case surveillance data to measure linkage to care, defined as ≥1 CD4 or VL test ≤1 month after HIV diagnosis during 2013; retention in care, defined as ≥2 CD4 or VL tests ≥3 months apart during 2012; and suppressed VL, defined as <200 copies/mL at the most recent VL test during 2012. In 2013, 74.1% of AIs/ANs were linked to care. At year-end 2012, 46.9% of AIs/ANs were retained in care and 45.1% were virally suppressed. A lower percentage of females (41.3%), compared with males (46.5), were virally suppressed. By age group, the lowest percentage of virally suppressed AIs/ANs (37.5%) were aged 13-34 years. To improve individual health and to prevent HIV among AIs/ANs, outcomes must improve - particularly for female AIs/ANs and for AIs/ANs aged 13-34 years. Screening for HIV infection in accordance with Centers for Disease Control and Prevention's testing recommendations can lead to improvements along the continuum of HIV care.

Prevalence and Risk for Negative Disability Outcomes Between American Indians-Alaskan Natives and Other Race-Ethnic Groups in the Southwestern United States

In the USA, some race-ethnic minorities are unjustly relegated to the margins of society. As a consequence, these groups are more frequently found to have risk profiles associated with adverse health than individuals from the majority group (non-Hispanic Whites). Limited research has been devoted to investigating how American Indians and Alaska Natives (AIANs) differ from other race-ethnic minorities and the majority group with regard to prevalence and risk for self-care, independent living, and ambulatory disabilities. Our investigation attempts to quantify both of these tracks by accounting for race-ethnic and poverty status. Our cross-sectional analysis used nationally representative data from the American Community Survey (ACS) 5-year (2009-2013) Public Use Microdata Sample (PUMS) file to address this literature gap. We selected survey participants from the four states with the largest concentration of AIANs in the USA (Arizona, California, New Mexico, and Oklahoma). We used information on 2,428,233 individuals to generalize prevalence of and risk for disability to 49,994,332 individuals in the Southwest US. We found disability (self-reported) prevalence differed between our six race-ethnic groups in statistically significant and complex ways. Population-weighted logistic regression analyses adjusting for age, sex, and citizenship found AIANs have a higher risk for disability than non-Hispanic Whites, non-Hispanic Asians, and Hispanics. In order to impact public health and build a more equitable society, efforts should continue to identify health disparities. Researchers should continue to advance conceptual frameworks on plausible causal mechanisms between markers of social stratification and disablement processes.

Determinants of Health-Related Quality of Life Among Older American Indians and Alaska Natives

During the past decade, health-related quality of life (HRQoL) has been recognized in both clinical and community health research as an important health outcome and a needed supplement to conventional health outcomes. The authors provide a profile of HRQoL and examine its determinants among American Indians and Alaska Natives aged 50 or older. Multivariate analyses of cross-sectional survey data from the 1996-1998 Centers for Disease Control Behavioral Risk Factor Surveillance System were conducted. Thirty-four percent of the sample reported fair or poor self-rated health. The mean number of poor health days in the past month ranged from 4 to 6 on different measures. Age, sex, education, annual household income, employment status, hypertension, and obesity were associated with aspects of HRQoL. Further research aimed at eliminating health disparities among this population should focus on identifying additional indicators of poor HRQoL and on understanding variables that mediate the relationship between disease and HRQoL.

Differences in Functional Disability of Rural American Indian and White Older Adults With Comorbid Diabetes

This study examines racial/ethnic differences in functional disability among a sample of rural older adults with comorbid diabetes. In 2002, interviews were conducted with 62 rural American Indian and 64 White community-dwelling persons aged 65 years or older. Examination of disability levels by group suggested that functional disability for Whites was concentrated in the lower levels (1-2 limitations), whereas disability for American Indians was concentrated in the higher levels (3 or more limitations). Adjusted prevalence rates indicated that American Indian older adults were significantly more likely than Whites to require assistance with dressing, walking, bathing, and shopping. Conversely, for reaching the toilet in time, Whites were significantly more likely than American Indians to report a limitation. Results of this study, coupled with previous literature, suggest that American Indians are more functionally disabled than other racial/ethnic groups and have a marked need for future long-term care.

Association of depressive symptomatology with receipt of informal caregiving among older American Indians: the native elder care study

OBJECTIVE

Our study objectives were to identify the primary sources of informal caregiving and to examine the association of depressive symptomatology with receipt of informal caregiving among a sample of community-dwelling older American Indians.

DESIGN

We conducted a cross-sectional study of older American Indians.

PARTICIPANTS

Community-dwelling adults aged 55 years and older who are members of a federally recognized American Indian tribe in the Southeast United States.

MEASUREMENTS

We collected information on the participant's primary caregiver, number of informal care hours received in the past week, depressive symptomatology, demographic characteristics, physical health status, and assistance need.

RESULTS

Daughters, spouses, and sons were the most common informal primary caregivers with distinct differences by sex of those receiving care. Compared with participants with lower levels, those with a high level of depressive symptomatology received substantially greater hours of informal care (33.4 versus 11.5 hours per week).

CONCLUSION

Older American Indians with higher levels of depressive symptomatology received more informal caregiving than those with lower depressive symptomatology. The burden of caregiving of older adults is primarily shouldered by spouses and children with those who care for older adults with depressive symptomatology likely experiencing an even greater burden of care.

Stressors, Coping Resources, and Depressive Symptoms among Rural American Indian Older Adults

The purpose of this study was to examine the associations of physical health stressors and coping resources with depressive symptoms among American Indian older adults age 50 years or older. The study used a convenience sample of 227 rural American Indian older adults. A hierarchical multiple regression tested three sets of predictors on depressive symptoms: (a) sociodemographics, (b) physical health stressors (functional disability and chronic medical conditions), and (c) coping resources (social support and spirituality). Most participants reported little difficulty in performing daily activities (e.g., eating, dressing, traveling, and managing money), while presenting over two types of chronic medical conditions. Depressive symptoms were predicted by higher scores on perceived social support and lower scores on functional disability; women and those having no health insurance also had higher levels of depressive symptoms. Findings suggest that social work practitioners should engage family and community support, advocate for access to adequate health care, and attend to women's unique circumstances and needs when working with American Indian older adults.

An Examination of the Disablement Process Among Older American Indians: The Native Elder Care Study

PURPOSE OF THE STUDY

Older American Indians disproportionately suffer from poorer physical and mental health and have greater disability compared to their racial and ethnic counterparts. The purpose of this study was to examine the disablement process among older American Indians.

DESIGN AND METHODS

Data analyzed were from the Native Elder Care Study, which included in-person interviews with 505 community-dwelling American Indians aged ≥55 years. We used structural equation modeling to examine the contributive direct and indirect effects of health, demographic, and psychosocial risk factors on disability.

RESULTS

Pathology had direct and indirect effects through social support and depressive symptoms on chronic pain intensity. Pathology also had direct and indirect effects on disability. Chronic pain intensity was a significant mediator between pathology and functional limitations. With contributive effects of older age and female sex, greater functional limitations were associated with increased disability.

IMPLICATIONS

Our results support the theorized main pathway of the Disablement Process Model with our sample of older American Indians. Our findings support the importance of taking into account intra and extraindividual factors in assessing the prevalence and incidence of disability for older American Indians.

Correlates of social support in older American Indians: the Native Elder Care Study

OBJECTIVES

This study examined social support and identified demographic and health correlates among American Indians aged 55 years and older.

METHODS

Data were derived from the Native Elder Care Study, a cross-sectional study of 505 community-dwelling American Indians aged ≥55 years. Social support was assessed using the Medical Outcomes Study Social Support Survey measure (MOS-SSS) of which psychometric properties were examined through factor analyses. Logistic regression analyses were used to identify associations between age, sex, educational attainment, marital status, depressive symptomatology, lower body physical functioning, and chronic pain and social support.

RESULTS

Study participants reported higher levels of affectionate and positive interaction social support (88.2% and 81.8%, respectively) than overall (75.9%) and emotional (69.0%) domains. Increased age, being married/partnered, and female sex were associated with high social support in the final model. Decreased depressive symptomatology was associated with high overall, affectionate, and positive interaction support, and decreased chronic pain with affectionate support. The count of chronic conditions and functional disability were not associated with social support.

CONCLUSIONS

Overall, we found high levels of social support for both men and women in this population, with the oldest adults in our study exhibiting the highest levels of social support. Strong cultural values of caring for older adults and a historical tradition of community cooperation may explain this finding. Future public health efforts may be able to leverage social support to reduce health disparities and improve mental and physical functioning.

Construct validity of the SF-12 among American Indian and Alaska Native people using two known scoring methods

OBJECTIVE

This study evaluated the construct validity of the 12-Item Short Form Survey Instrument (SF-12) in a cohort of American Indian and Alaska Native (AIAN) people. We evaluated two scoring methods to determine their utility in this population.

METHODS

Participants (N = 11,127) were aged 18 and older, self-identified as AIAN, and had complete SF-12 interview data. Physical and mental health summary scores were calculated using traditional SF-12 (PCS12 and MCS12) and RAND-12 (PHC and MHC) scoring methods.

RESULTS

Women scored lower than men on the PHC, PCS12, MHC, and MCS12, as did those with more medical conditions versus none. Those aged 55 and older scored lower on the PHC and PCS12 than younger people. There was no difference in the mean MCS12 score by age and for those 31-55 and aged older than 55 for the MHC.

CONCLUSIONS

This study demonstrates the construct validity of the PCS12/MCS12 and PHC/MHC in a cohort of AIAN people.

Gambling with our health: smoke-free policy would not reduce tribal casino patronage

BACKGROUND

Tribal sovereignty exempts tribal casinos from statewide smoking bans.

PURPOSE

To conduct a tribally-led assessment to identify the characteristics of casino patrons at Lake of the Torches Resort Casino in Lac du Flambeau WI and their preferences for a smoke-free casino.

METHODS

A survey was administered from April to August 2011 to a stratified random sample of 957 members of the casino players club to assess their preferences for a smoke-free casino. These members were categorized into three groups: those who reported being likely to (1) visit more; (2) visit less; or (3) visit the same if the casino prohibited smoking. They were characterized by age, education, sex, race/ethnicity, annual income, players club level, and reasons for visiting the casino. Statistical analyses were conducted on weighted data in October to December 2011. Weighted logistic regression was calculated to control for potential confounding of patron characteristics.

RESULTS

Of the 957 surveyed patrons, 520 (54%) patrons were likely to visit more; 173 (18%) patrons to visit less; and 264 (28%) patrons were indifferent to the smoke-free status. Patrons more likely to prefer a smoke-free casino tended to be white, elderly, middle class and above, and visit the casino restaurants. Patrons within the lower tiers of the players club, almost half of the players club members, also showed a higher preference for a smoke-free casino.

CONCLUSIONS

This tribal casino would likely realize increased patronage associated with smoke-free status while also contributing to improved health for casino workers and patrons.

Culturally-Tailored Smoking Cessation for Adult American Indian Smokers: A Clinical Trial

This collaborative, community-engaged project developed and tested a Culturally-Tailored Treatment (CTT) for American Indian/Alaska Native (AI/AN) smokers in the Menominee tribal community. One hundred three adult AI/AN smokers were randomized to receive either Standard Treatment (n= 53) or CTT (n = 50) for smoking cessation. Both treatment conditions included 12 weeks of varenicline and four individual counseling sessions but differed in terms of cultural tailoring of the counseling. The primary outcome was 7-day biochemically-confirmed point-prevalence abstinence (PPA) at the 6-month end-of-study visit. Both intention-to-treat (ITT) and responder-only analyses were conducted. There were no statistically significant group differences in 7-day PPA. The overall ITT abstinence rate at 6 months was 20%; the responder-only rate was 42%. The current study represents the first randomized smoking cessation clinical trial testing a culturally-tailored smoking cessation intervention designed for a specific AI/AN tribal community that combined FDA-approved cessation medication (varenicline) and innovative cultural intervention components.

Enculturation, perceived stress, and physical activity: implications for metabolic risk among the Yup'ik--the Center for Alaska Native Health Research Study

OBJECTIVES

American Indians and Alaska Natives (ANs) report among the lowest levels of physical activity in the USA, but there is very little systematic research examining the determinants of physical activity patterns in these populations. This study investigated the relationships between enculturation (or cultural traditionality), psychosocial stress, and physical activity in a community-based sample of Yup'ik women and men living in rural AN communities. Associations between these variables and several metabolic risk factors were also examined.

DESIGN

A sample of 488 Yup'ik participants (284 women and 204 men) from six villages in the Yukon-Kuskokwim Delta region completed a wellness survey and an array of physiological assessments [e.g., body mass index (BMI), blood pressure]. A subset of 179 participants also completed a 3-day pedometer assessment of physical activity.

RESULTS

Multivariate linear regression models indicated that participants who were more enculturated (i.e., living more of a traditional lifestyle) and who experienced lower levels of psychosocial stress were significantly more physically active. In turn, both lower levels of psychosocial stress and higher levels of physical activity were associated with lower BMI, lower percent body fat, and lower waist circumference.

CONCLUSIONS

Findings underscore the importance of gaining a culturally specific understanding of physical activity patterns in indigenous groups in order to inform effective health promotion strategies.

Trends and disparities in stroke mortality by region for American Indians and Alaska Natives

OBJECTIVES

We evaluated trends and disparities in stroke death rates for American Indians and Alaska Natives (AI/ANs) and White people by Indian Health Service region.

METHODS

We identified stroke deaths among AI/AN persons and Whites (adults aged 35 years or older) using National Vital Statistics System data for 1990 to 2009. We used linkages with Indian Health Service patient registration data to adjust for misclassification of race for AI/AN persons. Analyses excluded Hispanics and focused on Contract Health Service Delivery Area (CHSDA) counties.

RESULTS

Stroke death rates among AI/AN individuals were higher than among Whites for both men and women in CHSDA counties and were highest in the youngest age groups. Rates and AI/AN:White rate ratios varied by region, with the highest in Alaska and the lowest in the Southwest. Stroke death rates among AI/AN persons decreased in all regions beginning in 2001.

CONCLUSIONS

Although stroke death rates among AI/AN populations have decreased over time, rates are still higher for AI/AN persons than for Whites. Interventions that address reducing stroke risk factors, increasing awareness of stroke symptoms, and increasing access to specialty care for stroke may be more successful at reducing disparities in stroke death rates.

Health behaviors and risk factors among American Indians and Alaska Natives, 2000-2010

OBJECTIVES

We provided contextual risk factor information for a special supplement on causes of death among American Indians and Alaska Natives (AI/ANs). We analyzed 11 years of Behavioral Risk Factor Surveillance System (BRFSS) data for AI/AN respondents in the United States.

METHODS

We combined BRFSS data from 2000 to 2010 to determine the prevalence of selected risk factors for AI/AN and White respondents residing in Indian Health Service Contract Health Service Delivery Area counties. Regional prevalence estimates for AI/AN respondents were compared with the estimates for White respondents for all regions combined; respondents of Hispanic origin were excluded.

RESULTS

With some regional exceptions, AI/AN people had high prevalence estimates of tobacco use, obesity, and physical inactivity, and low prevalence estimates of fruit and vegetable consumption, cancer screening, and seatbelt use.

CONCLUSIONS

These behavioral risk factors were consistent with observed patterns of mortality and chronic disease among AI/AN persons. All are amenable to public health intervention.

Beyond black and white: race/ethnicity and health status among older adults

OBJECTIVES

This study examined physical and mental health, health symptoms, sensory and functional limitations, risk factors, and multimorbidity among older Medicare managed care members to assess disparities associated with race/ethnicity.

STUDY DESIGN AND METHODS

We used data on 236,289 older adults from 208 Medicare plans who completed the 2012 Medicare Health Outcomes Survey to compare 14 health indicators across non-Hispanic whites, blacks, American Indians/Alaskan Natives, Asians, Native Hawaiians/Pacific Islanders, multiracial individuals, and Hispanics. Logistic regression models that clustered on the plan estimated the risk of indicators of adverse health and functional status.

RESULTS

Even after controlling for key patient sociodemographic factors, race/ethnicity was significantly associated with most adverse health indicators. Except for Asians, all racial/ethnic minority groups were significantly more likely than whites to report poor mental health status, presence of most health symptoms, sensory limitations, and activities-of-daily-living disability. Important differences were observed across racial and ethnic groups.

CONCLUSIONS

Despite some exceptions, elders of racial/ethnic minority background are generally at higher risk than non-Hispanic whites for a broad range of adverse health and functional outcomes that are not routinely assessed. Limitations include bias related to self-reported data and respondent recall. Future research should consider ethnic subgroup variations; employing newer techniques to improve estimates for smaller groups; and prioritizing and identifying opportunities for care improvement of diverse enrollee groups by considering specific needs. To improve the health status of the elderly, service delivery targeting the needs of specific population groups, coupled with culturally appropriate care for racial/ ethnic minorities, should also be considered.

Systematic review of health disparities for cardiovascular diseases and associated factors among American Indian and Alaska Native populations

BACKGROUND

American Indians and Alaska Native (AI/AN) populations experience significant health disparities compared to non-Hispanic white populations. Cardiovascular disease and related risk factors are increasingly recognized as growing indicators of global health disparities. However, comparative reports on disparities among this constellation of diseases for AI/AN populations have not been systematically reviewed.

OBJECTIVES

We performed a literature review on the prevalence of diabetes, metabolic syndrome, dyslipidemia, obesity, hypertension, and cardiovascular disease; and associated morbidity and mortality among AI/AN.

DATA SOURCES

A total of 203 articles were reviewed, of which 31 met study criteria for inclusion. Searches were performed on PUBMED, MEDLINE, the CDC MMWR, and the Indian Health Services.

STUDY ELIGIBILITY CRITERIA

Published literature that were published within the last fifteen years and provided direct comparisons between AI/AN to non-AI/AN populations were included.

STUDY APPRAISAL AND SYNTHESIS METHODS

We abstracted data on study design, data source, AI/AN population, comparison group, and. outcome measures. A descriptive synthesis of primary findings is included.

RESULTS

Rates of obesity, diabetes, cardiovascular disease, and metabolic syndrome are clearly higher for AI/AN populations. Hypertension and hyperlipidemia differences are more equivocal. Our analysis also revealed that there are likely regional and gender differences in the degree of disparities observed.

LIMITATIONS

Studies using BRFSS telephone surveys administered in English may underestimate disparities. Many AI/AN do not have telephones and/or speak English. Regional variability makes national surveys difficult to interpret. Finally, studies using self-reported data may not be accurate.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Profound health disparities in cardiovascular diseases and associated risk factors for AI/AN populations persist, perhaps due to low socioeconomic status and access to quality healthcare. Successful programs will address social determinants and increase healthcare access. Community-based outreach to bring health services to the most vulnerable may also be very helpful in this effort.

SYSTEMATIC REVIEW REGISTRATION NUMBER

N/A.

Characteristics of American Indian light smokers

INTRODUCTION

American Indians (AI) have the highest smoking rates of any racial/ethnic group in the U.S. and have more difficulty quitting smoking. Little is known about the smoking characteristics of AI smokers. The present study compared the demographic and smoking characteristics of light (≤10 cigarettes per day; N=206) and moderate/heavy (11+ cigarettes per day; N=86) AI smokers participating in a cross-sectional survey about smoking and health.

METHODS

Multiple methods were used to recruit participants in attendance at powwows, health and career fairs, and conferences. A total of 998 AI (76% cooperation rate) completed a survey assessing general health, sociodemographics, traditional and commercial tobacco use, knowledge and attitudes related to cancer, source of health information and care and other health-related behaviors.

RESULTS

AI light smokers were younger and less likely to be married or living with a partner compared to moderate/heavy smokers. AI light smokers were less dependent on smoking and more likely to have home smoking restrictions. There were no differences with respect to number of quit attempts in the past year or the average length of their most recent quit attempt by light vs. moderate/heavy smoking. In addition, a similar proportion of light and heavy smokers reported using tobacco for traditional purposes such as ceremonial, spiritual and prayer.

CONCLUSIONS

These findings highlight important differences between AI light and heavier smokers. Differences related to smoking characteristics such as level of dependence and home smoking restrictions have important implications for the treatment of AI smokers.

[Degree of physical activity and metabolic syndrome: a cross-sectional study among the Khisêdjê group in the Xingu Indigenous Park, Brazil]

This study aimed to verify the existence of an association between degree of physical activity and presence of metabolic syndrome in the Khisêdjê indigenous group. The authors evaluated 170 individuals 20 years or older, based on demographic data, physical examination, and laboratory tests. The data were analyzed with the chi-square test (p < 0.05), crude and adjusted prevalence ratios (point and 95% confidence intervals), and Student's t-test. Satisfactory results were observed in relation to cardiorespiratory endurance, flexibility, bending of arms and trunk, and measurement of physical activity according to the number of steps/day. Prevalence of metabolic syndrome was 27.8% and was higher in women, the 39-49-year and ≥ 50-year age groups, and in individuals with lower performance on the cardiorespiratory endurance test, horizontal impulse, and number of steps/day. The results indicate the need for greater surveillance in the control and prevention of risk factors for metabolic syndrome.

Excess frequent insufficient sleep in American Indians/Alaska natives

OBJECTIVE

Frequent insufficient sleep, defined as ≥14 days/past 30 days in which an adult did not get enough rest or sleep, is associated with adverse mental and physical health outcomes. Little is known about the prevalence of frequent insufficient sleep among American Indians/Alaska Natives (AI/AN).

METHODS

We assessed racial/ethnic differences in the prevalence of frequent insufficient sleep from the combined 2009-2010 Behavioral Risk Factor Surveillance Survey among 810,168 respondents who self-identified as non-Hispanic white (NHW, n = 671,448), non-Hispanic black (NHB, n = 67,685), Hispanic (n = 59,528), or AI/AN (n = 11,507).

RESULTS

We found significantly higher unadjusted prevalences (95% CI) of frequent insufficient sleep among AI/AN (34.2% [32.1-36.4]) compared to NHW (27.4% [27.1-27.6]). However, the age-adjusted excess prevalence of frequent insufficient sleep in AI/AN compared to NHW was decreased but remained significant with the addition of sex, education, and employment status; this latter relationship was further attenuated by the separate additions of obesity and lifestyle indicators, but was no longer significant with the addition of frequent mental distress to the model (PR  =  1.05; 95% CI : 0.99-1.13). This is the first report of a high prevalence of frequent insufficient sleep among AI/AN. These results further suggest that investigation of sleep health interventions addressing frequent mental distress may benefit AI/AN populations.

Disparities in health status and health care access and use among older American Indians and Alaska Natives and non-Hispanic Whites in California

OBJECTIVES

The present study compared the characteristics of health status and health care access and use among older American Indians and Alaska Natives (AIANs) to those of non-Hispanic Whites (NHWs).

METHODS

Data were drawn from the 2009 California Health Interview Survey, with a total of 17,156 adults aged 60 and older (198 AIANs and 16,958 NHWs) analyzed.

RESULTS

Older AIANs reported poorer physical and mental health than did NHWs. AIANs were less likely than NHWs to see a medical doctor and have a usual source of medical care and were more likely than NHWs to delay getting needed medical care and report difficulty understanding the doctor at their last visit.

DISCUSSION

These findings highlight the vulnerability and unmet health care needs of older AIANs. More research on the older AIAN population is clearly needed to document their health care needs in order to better inform efforts to reduce health disparities.

Psychometric Properties of the Connor-Davidson Resilience Scale With Older American Indians: The Native Elder Care Study

Resilience is a term that refers to a person's ability to successfully adapt to adversity. Resilience research has been relatively limited with older adults, particularly with older American Indians. Also, none of the resilience measures have been validated in older American Indians. This study's objective was to assess the psychometric properties of the full 25-item and abbreviated 10-item versions of Connor-Davidson Resilience Scale (CD-RISC) with a sample of older American Indians. Both CD-RISC versions performed similarly in the study sample compared with what has been reported in other populations. The full version demonstrated adequate internal consistency and convergent and divergent validity, but a meaningful factor structure was not confirmed. The abbreviated version showed good internal consistency and convergent and divergent validity and appeared to have a stable one-factor solution. These findings lend greater support to the use of the abbreviated version than the full version of the CD-RISC with older American Indians.

Theory and practice in participatory research: lessons from the Native Elder Care Study

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.

Cancer-related disparities and opportunities for intervention in Northern Plains American Indian communities

OBJECTIVES

We examined behavioral trends associated with cancer risk and cancer screening use from 1997 through 2006 among American Indians/Alaska Natives (AI/ANs) in the Northern Plains region (North Dakota, South Dakota, Nebraska, and Iowa) of the United States. We also examined disparities between that population and non-Hispanic white (NHW) people in the Northern Plains and AI/ANs in other regions.

METHODS

We analyzed Behavioral Risk Factor Surveillance System data from the Centers for Disease Control and Prevention for 1997-2000 and 2003-2006. We used age-adjusted Wald Chi-square tests to test the difference between these two periods for AI/ANs and the difference between AI/ANs and NHW people during 2003-2006.

RESULTS

There was no statistically significant improvement among AI/ANs in the Northern Plains region for behaviors associated with cancer risk or cancer screening use, and there was a significant increase in the obesity rate. The prevalence of binge drinking, obesity, and smoking among AI/ANs in the Northern Plains was significantly higher than among NHW people in the same region and among AI/AN populations in other regions. Although the percentage of cancer screening use was similar for all three groups, the use of sigmoidoscopy/colonoscopy was significantly lower among the Northern Plains AI/ANs than among NHW people.

CONCLUSION

These results indicate a need for increased efforts to close the gaps in cancer health disparities between AI/ANs and the general population. Future efforts should focus not only on individual-level changes, but also on system-level changes to build infrastructure to promote healthy living and to increase access to cancer screening.

Comorbidity among older American Indians: the native elder care study

Comorbidity is a growing challenge and the older adult population is most at risk of developing comorbid conditions. Comorbidity is associated with increased risk of mortality, increased hospitalizations, increased doctor visits, increased prescription medications, nursing home placement, poorer mental health, and physical disability. American Indians experience some of the highest rates of chronic conditions, but to date there have been only two published studies on the subject of comorbidity in this population. With a community-based sample of 505 American Indians aged 55 years or older, this study identified the most prevalent chronic conditions, described comorbidity, and identified socio-demographic, functional limitations, and psychosocial correlates of comorbidity. Results indicated that older American Indians experience higher rates of hypertension, diabetes, back pain, and vision loss compared to national statistics of older adults. Two-thirds of the sample experienced some degree of comorbidity according to the scale used. Older age, poorer physical functioning, more depressive symptomatology, and lower personal mastery were all correlates of higher comorbidity scores. Despite medical advances increasing life expectancy, morbidity and mortality statistics suggest that the health of older American Indians lags behind the majority population. These findings highlight the importance of supporting chronic care and management services for the older American Indian population.

Smoking-cessation strategies for American Indians: should smoking-cessation treatment include a prescription for a complete home smoking ban?

BACKGROUND

The prevalence of cigarette smoking is particularly high among American Indian communities in the Upper Midwest.

PURPOSE

To evaluate the predictors of smoking cessation among a population-based sample of American Indians in the Upper Midwest during a quit attempt aided with nicotine replacement therapy (NRT).

METHODS

This study used the subsample of American Indian adults (n = 291, response rate = 55.4%) from a cohort study of smokers engaging in an aided NRT quit attempt. Eligible participants filled an NRT prescription between July 2005 and September 2006 through the Minnesota Health Care Programs (e.g., Medicaid). Administrative records and follow-up survey data were used to assess outcomes approximately 8 months after the NRT fill date. This analysis was conducted in 2009-2010.

RESULTS

Approximately 33% of American Indian respondents trying to quit smoking reported complete home smoking bans. Adoption of a complete home smoking ban and greater perceived advantages of NRT were cross-sectionally associated with 7-day smoking abstinence in univariate and multivariate analyses. Consistent with previous research, older age was a significant predictor of 7-day abstinence. Having a history of clinician-diagnosed anxiety in the past year was associated with decreased likelihood of 7-day abstinence in the unadjusted analysis, but not significant in multivariate analyses.

CONCLUSIONS

Results of this study suggest potential modifiable targets of interventions for future research to help American Indians quit smoking: (1) improved delivery of behavioral interventions to increase the intensity of smoking cessation treatment; (2) promotion and adoption of complete home smoking bans; and (3) education to increase awareness of the benefits of NRT.

Peritonitis and exit site infections in First Nations patients on peritoneal dialysis

BACKGROUND AND OBJECTIVES

First Nations (FN) patients on peritoneal dialysis experience poor outcomes. Whether discrepancies exist regarding the microbiology, rate of infections, and outcomes between FN and non-FN peoples remains unknown. Design, setting, participants, & measures: All adult peritoneal dialysis patients (n = 727) from 1997 to 2007 residing in Manitoba, Canada, were included. Parametric and nonparametric tests were used as necessary. Negative binomial regression was used to determine the relationship of rates of exit site infections (ESIs) and peritonitis between FN and non-FN peoples.

RESULTS

A total of 161 FN and 566 non-FN subjects were included in the analyses. The unadjusted relative rates of peritonitis and ESIs in FN subjects were 132.7 and 86.0/100 patient-years compared with 87.8 and 78.2/100 patient-years in non-FN populations, respectively. FN subjects were more likely to have culture-negative peritonitis (36.5 versus 20.8%, P < 0.0001) and Staphylococcus ESIs (54.1 versus 32.9%, P < 0.0001). The crude and adjusted rates of peritonitis were higher in FN subjects for total episodes and culture-negative and gram-negative peritonitis. Catheter removal because of peritonitis was similar in both groups (42.9 versus 38.1% for FN and non-FN subjects, respectively; P = 0.261).

CONCLUSIONS

FN patients experience higher rates of peritonitis and similar rates of ESIs compared with non-FN patients. Interventions to improve outcomes and prevent infections should specifically be targeted to the FN population.

American Indian/Alaska Native uninsurance disparities: a comparison of 3 surveys

OBJECTIVES

We examined whether 3 nationally representative data sources produce consistent estimates of disparities and rates of uninsurance among the American Indian/Alaska Native (AIAN) population and to demonstrate how choice of data source impacts study conclusions.

METHODS

We estimated all-year and point-in-time uninsurance rates for AIANs and non-Hispanic Whites younger than 65 years using 3 surveys: Current Population Survey (CPS), National Health Interview Survey (NHIS), and Medical Expenditure Panel Survey (MEPS).

RESULTS

Sociodemographic differences across surveys suggest that national samples produce differing estimates of the AIAN population. AIAN all-year uninsurance rates varied across surveys (3%-23% for children and 18%-35% for adults). Measures of disparity also differed by survey. For all-year uninsurance, the unadjusted rate for AIAN children was 2.9 times higher than the rate for White children with the CPS, but there were no significant disparities with the NHIS or MEPS. Compared with White adults, AIAN adults had unadjusted rate ratios of 2.5 with the CPS and 2.2 with the NHIS or MEPS.

CONCLUSIONS

Different data sources produce substantially different estimates for the same population. Consequently, conclusions about health care disparities may be influenced by the data source used.

Associations among body mass index, waist circumference, and health indicators in American Indian and Alaska Native adults

PURPOSE

Little is known about obesity-related health issues among American Indian and Alaska Native (AIAN) populations.

APPROACH

A large cohort of AIAN people was assembled to evaluate factors associated with health.

SETTING

The study was conducted in Alaska and on the Navajo Nation.

PARTICIPANTS

A total of 11,293 AIAN people were included.

METHODS

We present data for body mass index (BMI, kg/m2) and waist circumference (cm) to evaluate obesity-related health factors.

RESULTS

Overall, 32.4% of the population were overweight (BMI 25-29.9 kg/m2), 47.1% were obese (BMI > or = 30 kg/m2), and 21.4% were very obese (BMI, > or = 35 kg/m2). A waist circumference greater than 102 cm for men and greater than 88 cm for women was observed for 41.7% of men and 78.3% of women. Obese people were more likely to perceive their health as fair/poor than nonobese participants (prevalence ratio [PR], 1.91; 95% CI, 1.71-2.14). Participants younger than 30 years were three times more likely to perceive their health as being fair or poor when their BMI results were 35 or greater compared with those whose BMI results were less than 25 kg/m2. A larger BMI was associated with having multiple medical conditions, fewer hours of vigorous activity, and more hours of television watching.

CONCLUSIONS

Given the high rates of obesity in AIAN populations and the association of obesity with other health conditions, it is important to reduce obesity among AIAN people.