Social determinants of obesity in American Indian and Alaska Native peoples aged ≥ 50 years.

OBJECTIVE: American Indian and Alaska Native peoples (AI/ANs) have a disproportionately high rate of obesity, but little is known about the social determinants of obesity among older AI/ANs. Thus, our study assessed social determinants of obesity in AI/ANs aged ≥ 50 years. DESIGN: We conducted a cross-sectional analysis using multivariate generalized linear mixed models to identify social determinants associated with the risk of being classified as obese (BMI ≥ 30.0 kg/m2). Analyses were conducted for the total study population and stratified by median county poverty level. SETTING: Indian Health Service (IHS) data for AI/ANs who used IHS services in FY2013. PARTICIPANTS: 27,696 AI/ANs aged ≥ 50 years without diabetes. RESULTS: Mean BMI was 29.8 ± 6.6 with 43% classified as obese. Women were more likely to be obese than men, and younger ages were associated with higher obesity risk. While having Medicaid coverage was associated with lower odds of obesity, private health insurance was associated with higher odds. Living in areas with lower rates of educational attainment and longer drive times to primary care services were associated with higher odds of obesity. Those who lived in a county where a larger percentage of people had low access to a grocery store were significantly less likely to be obese. CONCLUSIONS: Our findings contribute to the understanding of social determinants of obesity among older AI/ANs and highlight the need to investigate AI/AN obesity, including longitudinal studies with a life course perspective to further examine social determinants of obesity in older AI/ANs.

Using the Health Literacy Universal Precautions Toolkit to Improve the Quality of Patient Materials.

Patient materials are often written above the reading level of most adults. Tool 11 of the Health Literacy Universal Precautions Toolkit ("Design Easy-to-Read Material") provides guidance on ensuring that written patient materials are easy to understand. As part of a pragmatic demonstration of the Toolkit, we examined how four primary care practices implemented Tool 11 and whether written materials improved as a result. We conducted interviews to learn about practices' implementation activities and assessed the readability, understandability, and actionability of patient education materials collected during pre- and postimplementation site visits. Interview data indicated that practices followed many action steps recommended in Tool 11, including training staff, assessing readability, and developing or revising materials, typically focusing on brief documents such as patient letters and information sheets. Many of the revised and newly developed documents had reading levels appropriate for most patients and--in the case of revised documents--better readability than the original materials. In contrast, the readability, understandability, and actionability of lengthier patient education materials were poor and did not improve over the 6-month implementation period. Findings guided revisions to Tool 11 and highlighted the importance of engaging multiple stakeholders in improving the quality of patient materials.

Reliability and Validity of Diabetes Nutrition Self-Efficacy and Behavior Measures for the "What Can I Eat" Diabetes Nutrition Education Program for American Indian and Alaska Native Adults With Type 2 Diabetes.

BACKGROUND: American Indian and Alaska Native (AI/AN) people have high rates of diabetes and limited access to nutrition education. The "What Can I Eat? Healthy Choices for People With Type 2 Diabetes" (WCIE) diabetes nutrition education program was culturally adapted for AI/AN adults. OBJECTIVE: This analysis was designed to evaluate the reliability and validity of items developed to measure diabetes nutrition self-efficacy (ie, confidence one can engage in specific behaviors) and diabetes nutrition behavior among participants in the WCIE program for AI/AN adults. DESIGN: This study was a secondary analysis of data from a randomized controlled trial designed to evaluate the WCIE program for AI/AN adults. Baseline data were used to assess the reliability and validity of the self-efficacy and behavior items, which were collected via survey. Due to COVID-19 safety protocols, the intervention was conducted via Zoom (Zoom Video Communications), and both survey and clinical data were collected at home by participants. PARTICIPANTS/SETTING: The study was conducted from January to December 2021 with 5 AI/AN-serving health care programs in Oklahoma, Illinois, North Carolina, California, and New York. AI/AN adults with type 2 diabetes who spoke English and had internet access were eligible. Sixty people participated. MAIN OUTCOME MEASURES: Analyses examined validity and reliability of diabetes nutrition self-efficacy and behavior items. STATISTICAL ANALYSIS PERFORMED: To test reliability, internal consistency and factor structures of the scales were examined. To evaluate convergent validity, Pearson correlations were computed to examine the association of the self-efficacy and behavior measures with each other and with clinical indicators (ie, body mass index, blood pressure, and hemoglobin A1c). RESULTS: Two self-efficacy factors were identified. Each showed strong internal consistency (Cronbach α ≥ 0.85; McDonald ω ≥ 0.88) and was directly associated with diabetes nutrition behavior (P < .001). The factor assessing Confidence in Using the Diabetes Plate was inversely associated with hemoglobin A1c (Pearson correlation = -0.32, P = .0243). The behavior measure capturing Healthy Nutrition Behavior showed strong internal consistency (α = 0.89; ω = 0.92) and was inversely associated with hemoglobin A1c (Pearson correlation = -0.38, P = .0057). CONCLUSIONS: Diabetes nutrition self-efficacy and behavior items developed for the WCIE program for AI/AN adults are valid and reliable. These items can facilitate rigorous and consistent evaluation of the AI/AN WCIE program.

Impact of targeted health promotion on cardiovascular knowledge among American Indians and Alaska Natives.

The National Heart, Lung, and Blood Institute developed the Honoring the Gift of Heart Health (HGHH) curriculum to promote cardiovascular knowledge and heart-healthy lifestyles among American Indians and Alaska Natives (AI/ANs). Using data from a small randomized trial designed to reduce diabetes and cardiovascular disease (CVD) risk among overweight/obese AI/ANs, we evaluated the impact of an adapted HGHH curriculum on cardiovascular knowledge. We also assessed whether the curriculum was effective across levels of health literacy (defined as the 'capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions'). We examined change in knowledge from baseline to 3 months for two groups: HGHH (N = 89) and control (N = 50). Compared with controls, HGHH participants showed significant improvement in heart attack knowledge and marginally significant improvement in stroke and general CVD knowledge. HGHH participants attending ≥1 class showed significantly greater improvement than controls on all three measures. Although HGHH participants with inadequate health literacy had worse heart attack and stroke knowledge at baseline and 3 months than did participants with adequate skills, the degree of improvement in knowledge did not differ by health literacy level. HGHH appears to improve cardiovascular knowledge among AI/ANs across health literacy levels.

Food Insecurity and Associated Challenges to Healthy Eating Among American Indians and Alaska Natives With Type 2 Diabetes: Multiple Stakeholder Perspectives.

Objective: To examine stakeholder perspectives on food insecurity and associated challenges to healthy eating among American Indian and Alaska Native (AI/AN) adults with type 2 diabetes (T2D). Methods: Focus groups and interviews were conducted with purposively selected stakeholders: AI/ANs with T2D, their family members, healthcare administrators, nutrition and diabetes educators, and national content experts on AI/AN health. Two coders analyzed transcripts using the constant-comparison method. Results: Key themes included (1) rural- and urban-dwelling AI/ANs experience different primary food security and associated challenges; (2) factors contributing to food insecurity extend beyond cost of healthy food; and (3) barriers to consuming fresh, healthy food include cost, preparation time, limited cooking knowledge, and challenges with gardening. Discussion: Resources for AI/ANs with T2D who experience food insecurity and associated challenges to healthy eating should be tailored based on urban versus rural location and should address cost and other barriers to consumption of fresh fruits and vegetables.

Technology-based Health Education Resources for Indigenous Adults: A Scoping Review.

Indigenous peoples experience a disparate burden of chronic diseases and lower access to health education resources compared with other populations. Technology can increase access to health education resources, potentially reducing health inequities in these vulnerable populations. Although many Indigenous communities have limited access to the Internet, this barrier is decreasing as tribes and Indigenous-serving organizations work to improve TechQuity. Using Arksey and O'Malley's framework, we conducted a scoping literature review to identify technology-based health education interventions designed for Indigenous adults. We searched multiple databases, limiting papers to those written in English, describing interventions for participants 18 years of age or older, and published between 1999-2020. The review yielded 229 articles, nine of which met eligibility criteria. Findings suggest a paucity of technology-based health education interventions designed for Indigenous peoples and limited testing of the existing resources. Future health disparity research should focus on development and rigorous testing of such interventions.

Parental Ethnic Identity and Its Influence on Children's Oral Health in American Indian Families.

OBJECTIVES: To examine the relationship between ethnic identity and oral health knowledge, beliefs, behavior, and outcomes in American Indian families. METHODS: Secondary data were analyzed for 579 parent-child dyads in a randomized controlled trial aimed at reducing early childhood caries in a Northern Plains tribal community. Data included demographic characteristics; parental ethnic identity; oral health knowledge, beliefs, and behavior; and parental/pediatric oral health outcomes. Ethnic identity was assessed using two measures: perceived importance of tribal identity and tribal language proficiency. We examined the association of baseline ethnic identity with baseline and longitudinal oral health measures. RESULTS: At baseline, importance of tribal identity was significantly associated with several oral health beliefs, and one's locus of control measure (external-chance). Baseline scores on importance of tribal identity were also associated with one's oral heath belief (perceived severity), the same locus of control measure, and oral health knowledge and behavior over the three years of study follow up. Tribal language proficiency was not associated with any study measures at baseline, although it was associated with parental oral health status over the three years. CONCLUSIONS: Ethnic identity was associated with a range of oral health constructs expected to influence American Indian children's oral health.

Health Literacy and Parental Oral Health Knowledge, Beliefs, Behavior, and Status Among Parents of American Indian Newborns.

OBJECTIVE: To examine the relationship between health literacy (HL) and parental oral health knowledge, beliefs, behavior, and self-reported oral health status (OHS) among parents of American Indian (AI) children. METHODS: This analysis used baseline data from a randomized controlled trial that tested an oral health intervention with parents of AI newborns. Participants were recruited in parent-child dyads (N = 579). Parents completed items assessing sociodemographic characteristics, HL, and parental oral health knowledge, beliefs, behavior, and self-reported OHS. We examined the correlation of HL with each oral health construct, controlling for parent age and income. RESULTS: On average, parents felt quite confident in their HL skills, performed well on questions assessing parental oral health knowledge, and endorsed beliefs likely to encourage positive parental oral health behaviors (e.g., confidence that one can successfully engage in such behaviors). Parents with more limited HL had significantly less knowledge, perceived cavities to be less severe, perceived more barriers and fewer benefits to recommended oral health behaviors, were less confident they could engage in these behaviors, and were more likely to believe their children's oral health was under the control of the dentist or a matter of chance (P values < 0.001). Limited HL was not associated with behavior (P > 0.05) but was linked to worse self-reported OHS (P = 0.040). CONCLUSIONS: HL was associated with parental oral health knowledge, beliefs, and self-reported OHS. Oral health education interventions targeting AI families should facilitate development of knowledge and positive oral health beliefs among parents with more limited HL skills.

The slow pace of interactive video telemedicine adoption: the perspective of telemedicine program administrators on physician participation.

We conducted semistructured interviews with telemedicine program administrators as part of a national survey of physicians and managers regarding attitudes toward, and knowledge of, telemedicine. Telemedicine administrators were interviewed regarding factors affecting physician adoption of interactive video (IAV) telemedicine. The seven networks with which these managers were affiliated represented "traditional" telemedicine programs, primarily providing specialty teleconsultation via IAV. These programs were located in different geographic regions, and included both consulting and referring sites. We include data only for well-established networks for which multiple administrators responded. Data were analyzed using standard qualitative research methods. We conclude that reimbursement issues are important determinants of the rate of adoption, but that by themselves they do not fully account for the slow diffusion of IAV telemedicine. Likewise, appeals to physicians as rational decision-makers are necessary but insufficient means of increasing the volume of telemedicine within a network. Telemedicine networks and administrators that have been effective in persuading physicians to practice telemedicine or to refer patients demonstrate an emphasis on aggressive recruitment of physicians who will be involved actively in one or the other role. Most efforts to encourage physicians to adopt telemedicine, however, have focused on the supply of specialists, rather than stimulating demand among primary care providers who have patients to refer. Habit was identified as an important, albeit overlooked, factor explaining physician adoption of telemedicine.