Experiences With and Access to Evidence-Based Health Promotion Programs for Older American Indian, Alaska Native, and Native Hawaiian Peoples.

Evidence-based programs (EBPs) work effectively for participants whose characteristics match those of the EBP research participants. However, EBPs have been almost exclusively developed and evaluated for the general U.S. population with limited American Indian, Alaska Native, and Native Hawaiian (AI/AN/NH) community engagement. Thus, an AI/AN/NH Evidence-Based Program Advisory Council sought to identify AI/AN/NH peoples' experiences with and access to EBPs. We held 20 listening sessions with AI/AN/NH Elder services program staff (n = 118) and with AI/AN/NH Elders (n = 82) and conducted a self-administered online survey with Title VI Directors (n = 63). The six themes that emerged from the listening sessions with staff included misunderstanding community engagement, valuing fidelity over flexibility, lack of cultural awareness, assumptions about available infrastructure, unrealistic implementation timelines, and funding restrictions. Listening session themes with Elders included definitions of aging well, participation motivators, preferred activities, participation barriers, and unmet needs. Survey data indicated that programming of greatest interest for Elders as identified by Title VI Directors and staff included and/or addressed cultural activities (81%), socialization (75%), diabetes (73%), caregiving (68%), and nutrition (68%). Seventy-six percent of survey respondents had heard of EBPs and 24% indicated that EBPs were not being implemented in their community. The Advisory Council developed specific action steps with the goal of improving AI/AN/NH communities' access to culturally appropriate and feasible EBPs. The steps require collective action from federal agencies, national partners, EBP program developers and administrators, local organizations, and Elders to ensure EBPs are accessible and culturally appropriate for AI/AN/NH Elders.

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.

Diabetes and health-related quality of life among American Indians: the role of psychosocial factors.

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

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.

Identifying risk and protective factors related to depressive symptoms among Northern Plains American Indian women cancer survivors.

Cancer is the leading cause of death among American Indian and Alaska Native (AIAN) women, and depressive symptoms have been linked to higher mortality, but research on depressive symptoms among AIAN cancer patients has been scant. The purpose of this exploratory study was, using the Framework of Historical Oppression, Resilience, and Transcendence, to examine risk and protective factors related to depressive symptoms in American Indian (AI) women cancer survivors. We examined the relationships of adverse childhood experiences (ACE), perceived health status, resilience, and social support with depressive symptoms in Northern Plains AI women cancer survivors. We used a cross-sectional design with purposive sampling of 73 female cancer survivors (aged 18 years or older) between June 2014 and February 2015. Hierarchical multiple regression was used to test three sets of variables in relation to depressive symptoms: (1) sociodemographics, (2) risk factors (ACE and perceived health), and (3) protective factors (psychological resilience and social support). Approximately 47 percent of participants had probable depressive symptoms. Depressive symptoms were inversely associated with perceived health, psychological resilience, and social support. These results support bolstering existing social support among AI cancer patients and survivors as well as prevention and intervention efforts that strengthen resilience.

Lower body functioning and correlates among older American Indians: The Cerebrovascular Disease and Its Consequences in American Indians Study.

BACKGROUND: More than six million American Indians live in the United States, and an estimated 1.6 million will be aged ≥65 years old by 2050 tripling in numbers since 2012. Physical functioning and related factors in this population are poorly understood. Our study aimed to assess lower body functioning and identify the prevalence and correlates of "good" functioning in a multi-tribe, community-based sample of older American Indians. METHODS: Assessments used the Short Physical Performance Battery (SPPB). "Good" lower body functioning was defined as a total SPPB score of ≥10. Potential correlates included demographic characteristics, study site, anthropometrics, cognitive functioning, depressive symptomatology, grip strength, hypertension, diabetes mellitus, heart disease, prior stroke, smoking, alcohol use, and over-the-counter medication use for arthritis or pain. Data were collected between 2010 and 2013 by the Cerebrovascular Disease and Its Consequences in American Indians Study from community-dwelling adults aged ≥60 years (n = 818). RESULTS: The sample's mean age was 73 ± 5.9 years. After adjustment for age and study site, average SPPB scores were 7.0 (95% CI, 6.8, 7.3) in women and 7.8 (95% CI, 7.5, 8.2) in men. Only 25% of the sample were classified with "good" lower body functioning. When treating lower body functioning as a continuous measure and adjusting for age, gender, and study site, the correlates of better functioning that we identified were younger age, male gender, married status, higher levels of education, higher annual household income, Southern Plains study site, lower waist-hip ratio, better cognitive functioning, stronger grip strength, lower levels of depressive symptomatology, alcohol consumption, and the absence of hypertension, diabetes mellitus, and heart disease. In our fully adjusted models, correlates of "good" lower body functioning were younger age, higher annual household income, better cognitive functioning, stronger grip, and the absence of diabetes mellitus and heart disease. CONCLUSIONS: These results suggest that "good" lower body functioning is uncommon in this population, whereas its correlates are similar to those found in studies of other older adult populations. Future efforts should include the development or cultural tailoring of interventions to improve lower body functioning in older American Indians.

Lifetime Trauma and Depressive Symptomatology Among Older American Indians: The Native Elder Care Study.

We examined the association between lifetime traumatic events with or without trauma response symptoms and depressive symptomatology in American Indians aged ≥ 55 years from a tribe in the Southeastern US (N = 362). Twenty-three percent of the sample experienced a traumatic event without trauma-response symptoms, whereas 14% experienced a traumatic event with at least one trauma-response symptom. After adjustment for sociodemographic characteristics and social support, participants who experienced a traumatic event with one or more trauma-response symptoms had higher odds of clinically relevant depressive symptomatology compared to (1) those who never experienced a traumatic event [odds ratio (OR) 3.2, p < 0.05], (2) and those who experienced a traumatic event without further symptoms (OR 3.7, p < 0.05). Our results suggest that mental health providers who serve older American Indians should consider the experience of traumatic events followed with response symptoms as a potential risk factor for further disruptions in psychological functioning.

Older American Indians' Perspectives on Health, Arthritis, and Physical Activity: Implications for Adapting Evidence-Based Interventions, Oregon, 2013.

INTRODUCTION: Despite the high prevalence of arthritis and physical disability among older American Indians, few evidence-based interventions that improve arthritis self-management via physical activity have been adapted for use in this population. The purpose of this study was to identify beliefs about health, arthritis, and physical activity among older American Indians living in a rural area in Oregon to help select and adapt an arthritis self-management program. METHODS: In partnership with a tribal health program, we conducted surveys, a focus group, and individual interviews with older American Indians with arthritis. Our sample comprised 6 focus group participants and 18 interviewees. The 24 participants were aged 48 to 82 years, of whom 67% were women. Forms B and C of the Multidimensional Health Locus of Control (MHLC) instrument, modified for arthritis, measured MHLC. RESULTS: The concepts of health, arthritis, and physical activity overlapped in that health was a holistic concept informed by cultural teachings that included living a healthy lifestyle, socializing, and being functionally independent. Arthritis inhibited health and healthy behaviors. Participants identified barriers such as unreliable transportation and recruiting challenges that would make existing interventions challenging to implement in this setting. The Doctor subscale had the highest MHLC (mean = 4.4 [standard deviation (SD), 1.0]), followed by the Internal subscale (3.9 [SD, 1.4]) and the Other People subscale (2.8 [SD, 1.1]). CONCLUSIONS: Existing evidence-based programs for arthritis should be adapted to address implementation factors, such as access to transportation, and incorporate cultural values that emphasize holistic wellness and social interconnectedness. Culturally sensitive programs that build on indigenous values and practices to promote active coping strategies for older American Indians with arthritis are needed.

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.

Community as a source of health in three racial/ethnic communities in Oregon: a qualitative study.

BACKGROUND: A 2011 report by the Oregon Health Authority and the Department of Human Services documented disparities in its Latino and American Indian populations on multiple individual-level health indicators. However, research is lacking on the social contexts in which Latinos and American Indians in Oregon live and how these environments influence the health of communities as a whole. To help fill this gap, this study sought to contextualize the social environments that influence the health of Latinos and American Indian residents in three Oregon communities. METHODS: Guided by an ecological framework, we conducted one-time semi-structured qualitative interviews with 26 study participants to identify the prominent health-related issues in the communities and to examine the factors that study participants perceived as enabling or inhibiting healthy lifestyles of community residents. We used a grounded theory approach to perform content and thematic analyses of the data. RESULTS: Study participants identified preventable chronic conditions, such as diabetes, obesity, and hypertension, as the most pressing health concerns in their communities. Results showed that traditional and cultural activities and strong family and community cohesion were viewed as facilitators of good community health. Poverty, safety concerns, insufficient community resources, and discrimination were perceived as barriers to community health. Three themes emerged from the thematic analyses: social connectedness is integral to health; trauma has an ongoing negative impact on health; and invisibility of residents in the community underlies poor health. CONCLUSIONS: This study's findings provide insight to the social contexts which operate in the lives of some Latinos and American Indians in Oregon. While participants identified community-level factors as important to health, they focused more on the social connections of individuals to each other and the relationships that residents have with their communities at-large. Our findings may also help to explain how the intra- and inter-personal levels, the community/institutional level, and the macro level/public policy contexts can serve to influence health in these communities. For example, trauma and invisibility are not routinely examined in community health assessment and improvement planning activities; nonetheless, these factors appear to be at play affecting the health of residents.

Prostate Cancer Screening Among American Indians and Alaska Natives: The Health and Retirement Survey, 1996-2008.

INTRODUCTION: Among US men, prostate cancer is the leading malignancy diagnosed and the second leading cause of cancer death. Disparities in cancer screening rates exist between American Indians/Alaska Natives and other racial/ethnic groups. Our study objectives were to examine prostate screening at 5 time points over a 12-year period among American Indian/Alaska Native men aged 50 to 75 years, and to compare their screening rates to African American men and white men in the same age group. METHODS: We analyzed Health and Retirement Study data for 1996, 1998, 2000, 2004, and 2008. Prostate screening was measured by self-report of receipt of a prostate examination within the previous 2 years. Age-adjusted prevalence was estimated for each year. We used regression with generalized estimating equations to compare prostate screening prevalence by year and race. RESULTS: Our analytic sample included 119 American Indian/Alaska Native men (n = 333 observations), 1,359 African American men (n = 3,704 observations), and 8,226 white men (n = 24,292 observations). From 1996 to 2008, prostate screening rates changed for each group: from 57.0% to 55.7% among American Indians/Alaska Natives, from 62.0% to 71.2% among African Americans, and from 68.6% to 71.3% among whites. Although the disparity between whites and African Americans shrank over time, it was virtually unchanged between whites and American Indians/Alaska Natives. CONCLUSION: As of 2008, American Indians/Alaska Natives were less likely than African Americans and whites to report a prostate examination within the previous 2 years. Prevalence trends indicated a modest increase in prostate cancer screening among African Americans and whites, while rates remained substantially lower for American Indians/Alaska Natives.

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.

Cultural identity and patient trust among older American Indians.

BACKGROUND: Patients' trust in healthcare providers and institutions has been identified as a likely contributor to racial-ethnic health disparities. The likely influence of patients' cultural characteristics on trust is widely acknowledged but inadequately explored. OBJECTIVE: To compare levels of patients' trust in primary care provider (interpersonal trust) with trust in healthcare organizations (institutional trust) among older American Indians (AIs), and determine associations with cultural identity. DESIGN: Patient survey administered following primary care visits. PARTICIPANTS: Two-hundred and nineteen American Indian patients ≥ 50 years receiving care for a non-acute condition at two clinics operated by the Cherokee Nation in northeastern Oklahoma. MAIN MEASURES: Self-reported sociodemographic and cultural characteristics. Trust was measured using three questions about interpersonal trust and one measure of institutional trust; responses ranged from strongly agree to strongly disagree. Finding substantial variation only in institutional trust, we used logistic generalized estimating equations to examine relationships of patient cultural identity with institutional trust. KEY RESULTS: Ninety-five percent of patients reported trusting their individual provider, while only 46 % reported trusting their healthcare institution. Patients who strongly self-identified with an AI cultural identity had significantly lower institutional trust compared to those self-identifying less strongly (OR: 0.6, 95 % CI: 0.4, 0.9). CONCLUSIONS: Interpersonal and institutional trust represent distinct dimensions of patients' experience of care that may show important relationships to patients' cultural characteristics. Strategies for addressing low institutional trust may have special relevance for patients who identify strongly with AI culture.

Testing a Culturally Tailored Advance Care Planning Intervention (MY WAY) for an American Indian Tribe: Protocol for a Quasi-Experimental Waitlist Control Design.

BACKGROUND: American Indian and Alaska Native peoples experience poor end-of-life care, including more hospitalizations and lower use of hospice and do-not-resuscitate orders. Although advance care planning (ACP) can improve end-of-life care, ACP rates are disproportionately low in American Indians and Alaska Natives. OBJECTIVE: We culturally tailored and delivered an existing evidence-based ACP program for an American Indian tribal community. Here, we present the protocol for assessing the intervention's feasibility and efficacy. METHODS: We measured feasibility via participant recruitment, participants' evaluation (acceptability, appropriateness, comprehension, and satisfaction), and intervention fidelity. Recruitment was measured with participant screening, eligibility, enrollment, and retention. Participant's evaluation of the intervention was measured with surveys. Fidelity was measured with direct observation and the Make Your Wishes About You (MY WAY) Fidelity Checklist Tool. To assess the intervention's efficacy, we used a quasi-experimental waitlist control design with 2 cohorts who were surveyed each on three separate occasions. The intervention's efficacy was assessed by the following: ACP barriers and facilitators as well as ACP self-efficacy, readiness, and completion. RESULTS: A total of 166 participants were screened for eligibility; 11 were deemed ineligible, and 155 participants were enrolled in the study. Of those enrolled, 113 completed the intervention and will be included in subsequent analyses. We finalized data collection in January 2023, and analyses are underway. Study enrollment was successful, and we expect that participants will report high levels of acceptability, appropriateness, comprehension, and satisfaction with the intervention. We expect that the intervention was implemented with fidelity and will demonstrate decreases in ACP barriers and increases in ACP facilitators, self-efficacy, readiness, and completion. CONCLUSIONS: Enrolling over twice as many participants as we had hoped suggests that members of this tribal community are willing to engage in end-of-life ACP. We were able to implement a waitlist study design to show that a culturally tailored ACP program for a tribal community is feasible. TRIAL REGISTRATION: ClinicalTrials.gov NCT05304117; https://clinicaltrials.gov/study/NCT05304117. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/50654.

Association of Medication Adherence With HbA1c Control Among American Indian Adults With Type 2 Diabetes Using Tribal Health Services.

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

Community readiness for adopting a physical activity program for people with arthritis in West Virginia.

INTRODUCTION: The health benefits of physical activity are well established in older adults with arthritis. Despite these benefits, many older adults with arthritis are not active enough to maintain health; therefore, increasing physical activity in adults with arthritis is a public health priority. The purpose of this study was to use the Community Readiness Model to assess readiness for adopting a physical activity program for people with arthritis in 8 counties in West Virginia. METHODS: During 2007 and 2008, we conducted a telephone survey among 94 key informants who could provide insight into their community's efforts to promote physical activity among older adults with arthritis. We matched survey scores with 1 of 9 stages of readiness, ranging from 1 (no awareness) to 9 (high level of community ownership). RESULTS: The survey placed the counties in stage 3 (vague awareness), indicating recognition of the need for more physical activity programming; community efforts were not focused and leadership was minimal. The interviews suggested that culturally sensitive, well-promoted free or low-cost programs conducted by community volunteers may be keys to success in West Virginia. CONCLUSION: Information derived from our survey can be used to match intervention strategies for promoting physical activity among people with arthritis to communities in West Virginia according to their level of readiness.

Loneliness, depression, social support, and quality of life in older chronically ill Appalachians.

This study's purpose was to describe loneliness and to examine the relationships between loneliness, depression, social support, and QOL in chronically ill, older Appalachians. In-person interviews were conducted with a convenience sample of 60 older, chronically ill, community-dwelling, and rural adults. Those with dementia or active grief were excluded. The UCLA Loneliness Scale (Russell, Peplau, & Cutrona, 1985), Geriatric Depression Scale (Shiekh & Yesavage, 1986), Katz ADL scale (Katz, Down, & Cash, 1970), MOS Social Support Scale (Sherbourne & Stewart, 1991), and a visual analog scale for Quality of Life (Spitzer et al., 1981) scale were used. Diagnoses were obtained through chart reviews. SPSS was used for data analyses. The majority of the 65% female sample (M age = 75 years) were married and impoverished. Participants' number of chronic illnesses averaged more than 3. Over 88% of participants reported at least 1 area of functional impairment. Loneliness was prevalent with UCLA loneliness scores indicating moderate to high loneliness, ranging from 39 to 62 (possible scores were 20-80). Higher loneliness scores correlated with depression, lower Qol, and lower social support, particularly lower emotional support. This study provides evidence that loneliness is a significant problem for older chronically ill Appalachian adults and that it may be related to low emotional support. Further, it provides evidence that this population may be significantly lonely and may not self-identify as lonely. Screening for loneliness and designing interventions that target the emotional aspects of loneliness could be important in this population.

Nephrology and Palliative Care Providers' Beliefs in Engaging American Indian Patients in Palliative Care Conversations.

Background: American Indians with chronic kidney disease are twice as likely to develop end-stage renal disease. Palliative care is underused by American Indian patients, although studies show it is not due to an unwillingness to engage in conversations about end of life. Objectives: The aim of our study was to explore the experiences and beliefs of Nephrology and palliative care providers of one tribal community with respect to engaging patients and family members in palliative care. Design: Using an interview guide, individual, in-depth interviews were conducted between March and August 2019 with eligible participants. We used constant comparative analysis of interview transcripts. Setting and Subjects: Our study sample included eight participants, including four Nephrology providers and four palliative care providers. Results: We identified five themes, including (1) providers' stereotypes, (2) patients' mistrust of providers, (3) patients' end-of-life preferences, (4) available community resources, and (5) patients' family dynamics. Negative stereotypes were present in every theme, although most participants did not acknowledge the role stereotypes played in establishing trust and building therapeutic relationships conducive to end-of-life discussions. Conclusion: Providers serving American Indian patients with kidney disease should consider training in trauma informed care and cultural sensitivity. Negative stereotypes of American Indian patients may impact provider's ability to build trust, a key component of end-of-life conversations, and contribute to misperceptions related to family dynamics, end-of-life preferences, and available community resources.

Social Support and Diabetes Management Among Older American Indians.

Objective: Greater understanding how relationships that can facilitate or impede type 2 diabetes (T2D) management and control among older American Indian people is an overlooked, yet urgently needed strategy. Thus, we examined social support among older American Indian people in relation to their T2D management. Methods: During the fall 2015, we conducted qualitative interviews with 28 participants aged ≥ 60 years who were members of a federally-recognized tribe. Drawing upon the buffering and direct effects theoretical models of how social support affects health, we examined transcribed audio recordings of the interviews with a systematic text analysis approach. We used a low-inference qualitative descriptive design to provide a situated understanding of participants' life experiences using their naturalistic expressions. Results: The mean age of our participants was 73.0 ± 6.4 years with a mean HbA1c of 7.3 ± 1.5. Main social support sources were family, clinicians/formal services, community/culture, and spiritual/God. All four common social support types were represented, namely emotional, instrumental, informational, and appraisal support with most being instrumental in nature. A prominent gender difference was seen with respect to men receiving more instrumental support family/friends support than women. Discussion: Value orientations among American Indian people often reflect extended social systems and interdependence. A deeper understanding is needed of how social relationships can be better leveraged to aid in effective T2D management among older American Indian people. The development and implementation of evidence-based social network interventions with an assets-based orientation that build upon the cultural value of reciprocity hold promise to improve T2D outcomes of older American Indian people.

Medication Adherence and Cardiometabolic Control Indicators Among American Indian Adults Receiving Tribal Health Services: Protocol for a Longitudinal Electronic Health Records Study.

BACKGROUND: American Indian adults have the highest prevalence of type 2 diabetes (T2D) in any racial or ethnic group and experience high rates of comorbidities. Uncontrolled cardiometabolic risk factors-insulin resistance, resulting in impaired glucose tolerance, dyslipidemia, and hypertension-increase the risk of mortality. Mortality is significantly reduced by glucose- and lipid-lowering and antihypertensive medication adherence. Medication adherence is low among American Indian adults living in non-Indian Health Service health care settings. Virtually nothing is known about the nature and extent of medication adherence among reservation-dwelling American Indian adults who primarily receive their medications without cost from Indian Health Service or tribal facilities. Electronic health records (EHRs) offer a rich but underused data source regarding medication adherence and its potential to predict cardiometabolic control indicators (C-MCIs). With the support of the Choctaw Nation of Oklahoma (CNO), we address this oversight by using EHR data generated by this large, state-of-the-art tribal health care system to investigate C-MCIs. OBJECTIVE: Our specific aims are to determine, using 2018 EHR data, the bivariate relationships between medication adherence and C-MCIs, demographics, and comorbidities and each C-MCI and demographics and comorbidities; develop machine learning models for predicting future C-MCIs from the previous year's medication adherence, demographics, comorbidities, and common laboratory tests; and identify facilitators of and barriers to medication adherence within the context of social determinants of health (SDOH), EHR-derived medication adherence, and C-MCIs. METHODS: Drawing on the tribe's EHR (2018-2021) data for CNO patients with T2D, we will characterize the relationships among medication adherence (to glucose- and lipid-lowering and antihypertensive drugs) and C-MCIs (hemoglobin A1c ≤7%, low-density lipoprotein cholesterol <100 mg/dL, and systolic blood pressure <130 mm Hg); patient demographics (eg, age, sex, SDOH, and residence location); and comorbidities (eg, BMI ≥30, cardiovascular disease, and chronic kidney disease). We will also characterize the association of each C-MCI with demographics and comorbidities. Prescription and pharmacy refill data will be used to calculate the proportion of days covered with medications, a typical measure of medication adherence. Using machine learning techniques, we will develop prediction models for future (2019-2021) C-MCIs based on medication adherence, patient demographics, comorbidities, and common laboratory tests (eg, lipid panel) from the previous year. Finally, key informant interviews (N=90) will explore facilitators of and barriers to medication adherence within the context of local SDOH. RESULTS: Funding was obtained in early 2022. The University of Florida and CNO approved the institutional review board protocols and executed the data use agreements. Data extraction is in process. We expect to obtain results from aims 1 and 2 in 2024. CONCLUSIONS: Our findings will yield insights into improving medication adherence and C-MCIs among American Indian adults, consistent with CNO's State of the Nation's Health Report 2017 goal of reducing T2D and its complications. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/39193.