Evaluating Community-Based Translational Interventions Using Historical Controls: Propensity Score vs. Disease Risk Score Approach.

Many community-based translations of evidence-based interventions are designed as one-arm studies due to ethical and other considerations. Evaluating the impacts of such programs is challenging. Here, we examine the effectiveness of the lifestyle intervention implemented by the Special Diabetes Program for Indians Diabetes Prevention (SDPI-DP) demonstration project, a translational lifestyle intervention among American Indian and Alaska Native communities. Data from the landmark Diabetes Prevention Program placebo group was used as a historical control. We compared the use of propensity score (PS) and disease risk score (DRS) matching to adjust for potential confounder imbalance between groups. The unadjusted hazard ratio (HR) for diabetes risk was 0.35 for SDPI-DP lifestyle intervention vs. control. However, when relevant diabetes risk factors were considered, the adjusted HR estimates were attenuated toward 1, ranging from 0.56 (95% CI 0.44-0.71) to 0.69 (95% CI 0.56-0.96). The differences in estimated HRs using the PS and DRS approaches were relatively small but DRS matching resulted in more participants being matched and smaller standard errors of effect estimates. Carefully employed, publicly available randomized clinical trial data can be used as a historical control to evaluate the intervention effectiveness of one-arm community translational initiatives. It is critical to use a proper statistical method to balance the distributions of potential confounders between comparison groups in this kind of evaluations.

Neighborhood characteristics and lifestyle intervention outcomes: Results from the Special Diabetes Program for Indians.

Growing evidence reveals various neighborhood conditions are associated with the risk of developing type 2 diabetes. It is unknown, however, whether the effectiveness of diabetes prevention interventions is also influenced by neighborhood characteristics. The purpose of the current study is to examine the impact of neighborhood characteristics on the outcomes of a lifestyle intervention to prevent diabetes in American Indians and Alaska Natives (AI/ANs). Year 2000 US Census Tract data were linked with those from the Special Diabetes Program for Indians Diabetes Prevention Program (SDPI-DP), an evidence-based lifestyle intervention implemented in 36 AI/AN grantee sites across the US. A total of 3394 participants started the intervention between 01/01/2006 and 07/31/2009 and were followed by 07/31/2016. In 2016-2017, data analyses were conducted to evaluate the relationships of neighborhood characteristics with intervention outcomes, controlling for individual level socioeconomic status. AI/ANs from sites located in neighborhoods with higher median household income had 38% lower risk of developing diabetes than those from sites with lower neighborhood income (adjusted hazard ratio = 0.65, 95% CI: 0.47-0.90). Further, those from sites with higher neighborhood concentrations of AI/ANs achieved less BMI reduction and physical activity increase. Meanwhile, participants from sites with higher neighborhood level of vehicle occupancy made more improvement in BMI and diet. Lifestyle intervention effectiveness was not optimal when the intervention was implemented at sites with disadvantaged neighborhood characteristics. Meaningful improvements in socioeconomic and other neighborhood disadvantages of vulnerable populations could be important in stemming the global epidemic of diabetes.

Food choices and distress in reservation-based American Indians and Alaska Natives with type 2 diabetes.

OBJECTIVE: To examine the association between food choice and distress in a large national sample of American Indians/Alaska Natives (AI/AN) with type 2 diabetes. DESIGN: Participants completed a sociodemographic survey, an FFQ and the Kessler-6 Distress Scale. Foods were identified as 'healthy' or 'unhealthy' using a classification grounded in the health education provided by the programme case managers; healthy and unhealthy food scores were calculated using reported intake frequencies. Pearson's correlation coefficients for distress and food scores were calculated for all participants and by gender. Multiple linear regression models stratified by gender assessed the association between distress and food scores, controlling for sociodemographics and duration of type 2 diabetes. SETTING: Rural AI reservations and AN villages. SUBJECTS: AI/AN (n 2484) with type 2 diabetes. RESULTS: Both males (34·9 %) and females (65·1 %) had higher healthy food scores than unhealthy scores. In bivariate analysis, distress level had a significant negative correlation with healthy food scores among female participants, but the association was not significant among males. Significant positive correlations between distress and unhealthy food scores were found in both genders. In the final multivariate models, healthy food scores were not significantly related to distress; however, unhealthy food scores showed significant positive relationships with distress for both genders (females: ß=0·078, P=0·0007; males: ß=0·139, P<0·0001). CONCLUSIONS: Health professionals working with AI/AN diagnosed with type 2 diabetes should offer food choice strategies during difficult times and recognize that males may be more likely than females to select unhealthy foods when distressed.

Mental health burden in a national sample of American Indian and Alaska Native adults: differences between multiple-race and single-race subgroups.

PURPOSE: Research on American Indian and Alaska Native (AIAN) mental health disparities is based largely on either tribal populations or national samples of adults that do not account for multiracial AIANs, even though over 40% of AIANs identify with multiple racial groups. The present investigation extends this research by assessing mental health status in a national sample of multiracial AIAN adults relative to adults who identify exclusively as either AIAN or White. METHODS: 2012 BRFSS data were used to conduct multinomial logistic regression analyses comparing mental health outcomes among respondents who identified as either AIAN and one or more other races (AIAN-MR), AIAN-Single Race (AIAN-SR), or White-SR. RESULTS: After demographic adjustment, the AIAN-MR group reported a higher lifetime prevalence of diagnosed depressive disorder, more days of poor mental health, and more frequent mental distress compared to both the AIAN-SR and White-SR groups. AIAN-MR individuals also had higher levels of Kessler 6 (K6) non-specific psychological distress compared to White-SR individuals but not AIAN-SR adults. Differences between AIAN-SR and White-SR adults were found in days of poor mental health, frequent mental distress, and total K6 scores. CONCLUSIONS: These findings help gauge the magnitude of mental health disparities in the U.S. AIAN population and pinpoint AIAN subgroups for whom mental health is particularly problematic. As such, they raise concerns about restrictions that limit the identification of national survey respondents who report multiple race designations. Such restrictions will thwart efforts to understand the causal mechanisms and pathways leading to mental distress among AIAN individuals.

Self-Efficacy About Sexual Risk/Protective Behaviors: Intervention Impact Trajectories Among American Indian Youth.

For adolescents, normative development encompasses learning to negotiate challenges of sexual situations; of special importance are skills to prevent early pregnancy, HIV, and other sexually transmitted diseases. Disparities in sexual risk among American Indian youth point to the importance of intervening to attenuate this risk. This study explored the impact of Circle of Life (COL), an HIV prevention intervention based on social cognitive theory, on trajectories of self-efficacy (refusing sex, avoiding sexual situations) among 635 students from 13 middle schools on one American Indian reservation. COL countered a normative decline of refusal self-efficacy among girls receiving the intervention by age 13, while girls participating at age 14 or older, girls in the comparison group, and all boys showed continuing declines.

Psychiatric disorders and mental health treatment in American Indians and Alaska Natives: results of the National Epidemiologic Survey on Alcohol and Related Conditions.

PURPOSE: To examine the prevalence of common psychiatric disorders and associated treatment-seeking, stratified by gender, among American Indians/Alaska Natives and non-Hispanic whites in the United States. Lifetime and 12-month rates are estimated, both unadjusted and adjusted for sociodemographic correlates. METHOD: Analyses were conducted with the American Indians/Alaska Native (n = 701) and Non-Hispanic white (n = 24,507) samples in the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions [(NESARC) n = 43,093]. RESULTS: Overall, 70 % of the American Indian/Alaska Native men and 63 % of the women met criteria for at least one Diagnostic and Statistical Manual-IV lifetime disorder, compared to 62 and 53 % of Non-Hispanic white men and women, respectively. Adjusting for sociodemographic correlates attenuated the differences found. Nearly half of American Indians/Alaska Natives had a psychiatric disorder in the previous year; again, sociodemographic adjustments explained some of the differences found. Overall, the comparisons to non-Hispanic whites showed differences were more common among American Indian/Alaska Native women than men. Among those with a disorder, American Indian/Alaska Native women had greater odds of treatment-seeking for 12-month anxiety disorders. CONCLUSION: As the first study to provide national estimates, by gender, of the prevalence and treatment of a broad range of psychiatric disorders among American Indians/Alaska Natives, a pattern of higher prevalence of psychiatric disorder was found relative to Non-Hispanic whites. Such differences were more common among women than men. Prevalence may be overestimated due to cultural limitations in measurement. Unmeasured risk factors, some specific to American Indians/Alaska Natives, may also partially explain these results.

Longitudinal Patterns of Stages of Change for Exercise and Lifestyle Intervention Outcomes: An Application of Latent Class Analysis with Distal Outcomes.

Stages of change measure an individual's readiness to alter a health behavior. This study examined the latent longitudinal patterns of stages of change (SoC) for regular exercise over time among individuals participating in a lifestyle intervention project. It also investigated the association between the longitudinal patterns of SoC and intervention outcomes using a new statistical method to assess the relationship between latent class membership and distal outcomes. We analyzed data from the Special Diabetes Program for Indians Diabetes Prevention Program, a lifestyle intervention program to prevent diabetes among American Indians and Alaska Natives. Latent class analysis (LCA) was conducted to identify the longitudinal patterns of SoC for regular exercise reported at three time points. LCA with distal outcomes was performed to investigate the associations between latent class membership and behavioral changes after the intervention. The parameters and standard errors of the LCA with distal outcomes models were estimated using an improved three-step approach. Three latent classes were identified: Pre-action, Transition, and Maintenance classes. The Transition class, where stage progression occurred, had the greatest improvements in physical activity and weight outcomes at both time points post-baseline among female participants. It also had the largest improvements in weight outcomes among male participants. Furthermore, the Pre-action class had more attenuation in the improvements they had achieved initially than the other two classes. These findings suggest the potential importance of motivating participants to modify their readiness for behavioral change in future lifestyle interventions.

Derivation and Evaluation of a Risk-Scoring Tool to Predict Participant Attrition in a Lifestyle Intervention Project.

Participant attrition in clinical trials and community-based interventions is a serious, common, and costly problem. In order to develop a simple predictive scoring system that can quantify the risk of participant attrition in a lifestyle intervention project, we analyzed data from the Special Diabetes Program for Indians Diabetes Prevention Program (SDPI-DP), an evidence-based lifestyle intervention to prevent diabetes in 36 American Indian and Alaska Native communities. SDPI-DP participants were randomly divided into a derivation cohort (n = 1600) and a validation cohort (n = 801). Logistic regressions were used to develop a scoring system from the derivation cohort. The discriminatory power and calibration properties of the system were assessed using the validation cohort. Seven independent factors predicted program attrition: gender, age, household income, comorbidity, chronic pain, site's user population size, and average age of site staff. Six factors predicted long-term attrition: gender, age, marital status, chronic pain, site's user population size, and average age of site staff. Each model exhibited moderate to fair discriminatory power (C statistic in the validation set: 0.70 for program attrition, and 0.66 for long-term attrition) and excellent calibration. The resulting scoring system offers a low-technology approach to identify participants at elevated risk for attrition in future similar behavioral modification intervention projects, which may inform appropriate allocation of retention resources. This approach also serves as a model for other efforts to prevent participant attrition.

Gender differences among Alaska Native people seeking alcohol withdrawal treatment.

BACKGROUND: Few studies focus on gender differences among patients who utilize detoxification services; even fewer focus on detoxification for Alaska Native people. This analysis focused on gender differences at admission among a sample of Alaska Native patients seeking alcohol withdrawal treatment. METHODS: The sample included 383 adult Alaska Native patients admitted to an inpatient alcohol detoxification unit during 2006 and 2007. Logistic regression was used to estimate unadjusted and adjusted associations with gender. RESULTS: Women were 88% more likely to have stable housing than men (odds ratio [OR] = 1.88, 95% confidence interval [CI] = 1.15, 3.05, P = .01). Women were 87% less likely to be seasonal workers (OR = 0.13, 95% CI = 0.03, 0.48, P = .003) and 50% less likely than men to be seeking employment (OR = 0.50, 95% CI = 0.29, 0.84, P = .01) at admission. Women had more than 5 times the odds of having children in the home at admission (OR = 5.64, 95% CI = 3.03, 10.56, P < .001) and almost 3 times the odds of experiencing physical abuse than men (OR = 2.96, 95% CI = 1.31, 6.66, P = .01). Additionally, women were 50% less likely to accept a referral to substance abuse treatment following detoxification (OR = 0.50, 95% CI = 0.30, 0.83, P = .01). CONCLUSIONS: The study found significant differences based upon gender. For instance, women are in need of services that accommodate women with children and services that address histories of physical abuse. Conversely, men are in need of housing and employment opportunities. Post detoxification follow-up, case management, and transition to care should include gender as a factor in treatment planning.

Demographic characteristics and food choices of participants in the Special Diabetes Program for American Indians Diabetes Prevention Demonstration Project.

OBJECTIVE: American Indians and Alaska Natives (AI/ANs) suffer a disproportionate burden of diabetes. Identifying food choices of AI/ANs at risk of type 2 diabetes, living in both rural and urban settings, is critical to the development of culturally relevant, evidence-based education strategies designed to reduce morbidity and mortality in this population. DESIGN: At baseline, 3135 AI/AN adults participating in the Special Diabetes Program for American Indians Diabetes Prevention Demonstration Project (SDPI-DP) completed a socio-demographic survey and a 27-item food frequency questionnaire (FFQ). The primary dietary behavior goal of SDPI-DP education sessions and lifestyle coaching is changes in food choices, i.e., increased fruits, vegetables and whole grains, decreased high sugar beverages, red meat, and processed foods. Subsequently, program assessment focuses on changes in food types. Foods were delineated using a 'healthy' and 'unhealthy' classification as defined by the educators advising participants. Urban and rural differences were examined using χ(2) tests and two sample t-tests. Multiple linear regressions and linear mixed models were used to assess the association between socio-demographic factors and food choice. RESULTS: Retired participants, those living in urban areas and with high income and education selected healthy foods most frequently. Young males, those with low income and education consumed unhealthy foods most frequently. Selection of unhealthy foods did not differ by urban and rural setting. CONCLUSIONS: The ubiquitous nature of unhealthy food choices makes them hard to avoid. Food choice differences by gender, age, income, and setting suggest that nutrition education should more effectively target and meets the needs of young AI/AN males.

Changes in Food Choices of Participants in the Special Diabetes Program for Indians-Diabetes Prevention Demonstration Project, 2006-2010.

INTRODUCTION: American Indians/Alaska Natives (AI/ANs) have a disproportionately high rate of type 2 diabetes. Changing food choices plays a key role in preventing diabetes. This study documented changes in the food choices of AI/ANs with diagnosed prediabetes who participated in a diabetes prevention program. METHODS: The Special Diabetes Program for Indians-Diabetes Prevention Demonstration Project implemented the evidence-based Diabetes Prevention Program (DPP) lifestyle intervention in 36 health care programs nationwide, engaging 80 AI/AN communities. At baseline, at 30 days post-curriculum, and at the first annual assessment, participants completed a sociodemographic survey and 27-item food frequency questionnaire and underwent a medical examination assessing fasting blood glucose (FBG), blood pressure, body mass index (BMI), low-density lipoprotein [LDL], high-density lipoprotein [HDL], and triglycerides. Multiple linear regressions were used to assess the relationship between temporal changes in food choice and other diabetes risk factors. RESULTS: From January 2006 to July 2010, baseline, post-curriculum, and first annual assessments were completed by 3,135 (100%), 2,046 (65%), and 1,480 (47%) participants, respectively. An increase in healthy food choices was associated initially with reduced bodyweight, BMI, FBG, and LDL and increased physical activity. At first annual assessment, the associations persisted between healthy food choices and bodyweight, BMI, and physical activity. CONCLUSION: AI/AN adults from various tribal and urban communities participating in this preventive intervention made sustained changes in food choices and had reductions in diabetes risk factors. The outcomes demonstrate the feasibility and effectiveness of translating the DPP lifestyle intervention to community-based settings.

Participant and site characteristics related to participant retention in a diabetes prevention translational project.

Using multilevel analysis, this study investigated participant and site characteristics associated with participant retention in a multisite diabetes prevention translational project among American Indian and Alaska Native (AI/AN) people. We analyzed data from the Special Diabetes Program for Indians Diabetes Prevention Program (SDPI-DP), a lifestyle intervention to prevent diabetes implemented in 36 AI/AN grantee sites. A total of 2,553 participants were recruited and started the intervention between January 1, 2006 and July 31, 2008. They were offered the 16-session Lifestyle Balance Curriculum from the Diabetes Prevention Program (DPP) in the first 16-24 weeks of intervention. Generalized estimating equation models and proportional hazards models with robust standard error estimates were used to evaluate the relationships of participant and site characteristics with retention. As of July 31, 2009, about 50 % of SDPI-DP participants were lost to follow-up. Those who were younger, male, with lower household income, no family support person, and more baseline chronic pain were at higher risk for both short-term and long-term retention failure (i.e., not completing all 16 DPP sessions and loss to follow-up, respectively). Sites with large user populations and younger staff had lower likelihood of retaining participants successfully. Other site characteristics related to higher risk for retention failure included staff rating of participant disinterest in SDPI-DP and barriers to participant transportation and child/elder care. Future translational initiatives need to pay attention to both participant- and site-level factors in order to maximize participant retention.

Case management to reduce cardiovascular disease risk in American Indians and Alaska Natives with diabetes: results from the Special Diabetes Program for Indians Healthy Heart Demonstration Project.

OBJECTIVES: We evaluated cardiovascular disease (CVD) risk factors in American Indians/Alaska Natives (AI/ANs) with diabetes in the Special Diabetes Program for Indians Healthy Heart (SDPI-HH) Demonstration Project. METHODS: Multidisciplinary teams implemented an intensive case management intervention among 30 health care programs serving 138 tribes. The project recruited 3373 participants, with and without current CVD, between 2006 and 2009. We examined data collected at baseline and 1 year later to determine whether improvements occurred in CVD risk factors and in Framingham coronary heart disease (CHD) risk scores, aspirin use, and smoking status. RESULTS: A1c levels decreased an average of 0.2% (P < .001). Systolic and diastolic blood pressure, low-density lipoprotein (LDL) cholesterol, and triglyceride levels decreased, with the largest significant reduction in LDL cholesterol (∆ = -5.29 mg/dL; P < .001). Average Framingham CHD risk scores also decreased significantly. Aspirin therapy increased significantly, and smoking decreased. Participants with more case management visits had significantly greater reductions in LDL cholesterol and A1c values. CONCLUSIONS: SDPI-HH successfully translated an intensive case management intervention. Creative retention strategies and an improved understanding of organizational challenges are needed for future Indian health translational efforts.

Religio-Spiritual Participation in Two American Indian Populations.

Following a previous investigation of religio-spiritual beliefs in American Indians, this article examined prevalence and correlates of religio-spiritual participation in two tribes in the Southwest and Northern Plains (N = 3,084). Analysis suggested a "religious profile" characterized by strong participation across three traditions: aboriginal, Christian, and Native American Church. However, sociodemographic variables that have reliably predicted participation in the general American population, notably gender and age, frequently failed to achieve significance in multivariate analyses for each tradition. Religio-spiritual participation was strongly and significantly related to belief salience for all traditions. Findings suggest that correlates of religious participation may be unique among American Indians, consistent with their distinctive religious profile. Results promise to inform researchers' efforts to understand and theorize about religio-spiritual behavior. They also provide tribal communities with practical information that might assist them in harnessing social networks to confront collective challenges through community-based participatory research collaborations.

Lifetime prevalence of posttraumatic stress disorder in two American Indian reservation populations.

Posttraumatic stress disorder (PTSD) has been found to be more common among American Indian populations than among other Americans. A complex diagnosis, the assessment methods for PTSD have varied across epidemiological studies, especially in terms of the trauma criteria. Here, we examined data from the American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project (AI-SUPERPFP) to estimate the lifetime prevalence of PTSD in two culturally distinct American Indian reservation communities, using two formulas for calculating PTSD prevalence. The AI-SUPERPFP was a cross-sectional probability sample survey conducted between 1997 and 2000. Southwest (n = 1,446) and Northern Plains (n = 1,638) tribal members living on or near their reservations, aged 15-57 years at time of interview, were randomly sampled from tribal rolls. PTSD estimates were derived based on both the single worst and 3 worst traumas. Prevalence estimates varied by ascertainment method: single worst trauma (lifetime: 5.9% to 14.8%) versus 3 worst traumas (lifetime, 8.9% to 19.5%). Use of the 3-worst-event approach increased prevalence by 28.3% over the single-event method. PTSD was prevalent in these tribal communities. These results also serve to underscore the need to better understand the implications for PTSD prevalence with the current focus on a single worst event.

Trauma and conditional risk of posttraumatic stress disorder in two American Indian reservation communities.

PURPOSE: To determine conditional risk of posttraumatic stress disorder (PTSD) in two culturally distinct American Indian reservation communities. METHOD: Data derived from the American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project, a cross-sectional population-based survey that was completed between 1997 and 2000. This study focused on 1,967 participants meeting the DSM-IV criteria for trauma exposure. Traumas were grouped into interpersonal, non-interpersonal, witnessed, and "trauma to close others" categories. Analyses examined distribution of worst traumas, conditional rates of PTSD following exposure, and distributions of PTSD cases deriving from these events. Bivariate and multivariate logistic regressions estimated associations of lifetime PTSD with trauma type. RESULTS: Overall, 15.9 % of those exposed to DSM-IV trauma qualified for lifetime PTSD, a rate comparable to similar US studies. Women were more likely to develop PTSD than were men. The majority (60 %) of cases of PTSD among women derived from interpersonal trauma exposure (in particular, sexual and physical abuse); among men, cases were more evenly distributed across trauma categories. CONCLUSIONS: Previous research has demonstrated higher rates of both trauma exposure and PTSD in American Indian samples compared to other Americans. This study shows that conditional rates of PTSD are similar to those reported elsewhere, suggesting that the elevated prevalence of this disorder in American Indian populations is largely due to higher rates of trauma exposure.

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.

Geographical access and the substitution of traditional healing for biomedical services in 2 American Indian tribes.

OBJECTIVES: American Indians who live in rural reservation communities face substantial geographic barriers to care that may limit their use of health services and contribute to their well-documented health disparities. The purpose of this study was to examine the impact of geographical access to care on the use of services for physical and mental health problems and to explore American Indians' use of traditional healing services in relation to use of biomedical services. METHODS: We analyzed survey data collected from 2 tribes (Southwest and Northern Plains). Geographical access to the closest biomedical service was measured using a Geographic Information System, including road travel distance, elevation gain, and reservation boundary crossing. RESULTS: Use of biomedical services was unaffected by geographical access for Northern Plains tribal members with mental health problems and for Southwest tribal members with physical or mental health problems. For members of the Northern Plains tribe with physical health problems, travel distance (P=0.007) and elevation gain (P=0.029) significantly predicted a lower likelihood of service use. The use of traditional healing was unrelated to biomedical service use for members of the Northern Plains tribe with physical or mental health problems and for members of the Southwest tribe with physical health problems. For members of the Southwest tribe with mental health problems, the use of biomedical services increased the likelihood of using traditional healing services. CONCLUSIONS: Findings suggest that biomedical services are geographically accessible to most tribal members and that tribal members are not substituting traditional healing for biomedical treatments because of poor geographical access.

Special diabetes program for Indians: reliability and validity of brief measures of print literacy and numeracy.

OBJECTIVES: Health literacy is associated with health knowledge, behavior, and outcomes. Availability of valid measures of health literacy that require minimal time and resources to administer may provide a valuable resource for researchers and healthcare providers. We investigated the psychometric properties of brief, written tests of two components of health literacy--print literacy and numeracy--among American Indians and Alaska Natives. DESIGN: Secondary analysis of baseline data from the Special Diabetes Program for Indians Healthy Heart Project. SETTING: Thirty health care programs participate in the project. They span 13 states and include Indian Health Service hospitals/clinics/service units as well as tribal and urban Indian health care programs. PARTICIPANTS: 3,033 American Indian and Alaska Native adults with diabetes. MAIN OUTCOME MEASURES: Internal consistency was investigated for the print literacy items. Construct validity analyses examined the expected association of print literacy and numeracy with demographic characteristics and four measures of disease knowledge. RESULTS: The print literacy items demonstrated acceptable internal consistency. Print literacy and numeracy were more limited among older people and those with lower income and education. Both measures were strong predictors of disease knowledge. CONCLUSIONS: Results support the value of the brief tests of print literacy and numeracy, and represent the first examination of the performance of health literacy measures in the American Indian and Alaska Native population.

Latent class analysis of stages of change for multiple health behaviors: results from the Special Diabetes Program for Indians Diabetes Prevention Program.

This study sought to identify latent subgroups among American Indian and Alaska Native (AI/AN) patients with pre-diabetes based on their stages of change for multiple health behaviors. We analyzed baseline data from participants of the Special Diabetes Program for Indians Diabetes Prevention (SDPI-DP) Program, a lifestyle intervention program to prevent diabetes among AI/ANs. A total of 3,135 participants completed baseline questionnaires assessing stages of change for multiple health behaviors, specifically exercise, healthy eating, and weight loss. Latent class analysis was used to identify subgroups of people based on their answers to stages of change questions. Covariates were added to the latent class analyses to investigate how class membership was related to sociodemographic, behavioral, and psychosocial factors. Three classes were identified based on the distributions of the stages of change variables: Contemplation, Preparation, and Action/Maintenance classes. Male and retired participants were more likely to be in more advanced stages. Those who exercised more, ate healthier diets, and weighed less were significantly more likely to be in the Action/Maintenance class. Further, the participants who had higher self-efficacy, stronger family support, and better health-related quality of life had higher odds of being in the Action/Maintenance class. In conclusion, we found that stages of change for multiple behaviors can be summarized by a three-class model in this sample. Investigating the relationships between latent classes and intervention outcomes represents important next steps to extend the findings of the current study.