Psychometric reliability, validity, and generalizability of 3MSE scores among American Indian adults: the Strong Heart Study.

OBJECTIVE: Modified Mini-Mental State Examination (3MSE) is often used to screen for dementia, but little is known about psychometric validity in American Indians. METHODS: We recruited 818 American Indians aged 65-95 for 3MSE examinations in 2010-2013; 403 returned for a repeat examination in 2017-2019. Analyses included standard psychometrics inferences for interpretation, generalizability, and extrapolation: factor analysis; internal consistency-reliability; test-retest score stability; multiple indicator multiple cause structural equation models. RESULTS: This cohort was mean age 73, majority female, mean 12 years education, and majority bilingual. The 4-factor and 2nd-order models fit best, with subfactors for orientation and visuo-construction (OVC), language and executive functioning (LEF), psychomotor and working memory (PMWM), verbal and episodic memory (VEM). Factor structure was supported for both research and clinical interpretation, and factor loadings were moderate to high. Scores were generally consistent over mean 7 years. Younger participants performed better in overall scores, but not in individual factors. Males performed better on OVC and LEF, females better on PMWM. Those with more education performed better on LEF and worse on OVC; the converse was true for bilinguals. All differences were significant, but small. CONCLUSION: These findings support use of 3MSE for individual interpretation in clinic and research among American Indians, with moderate consistency, stability, reliability over time. Observed extrapolations across age, sex, education, and bilingual groups suggest some important contextual differences may exist.

Sexual Assault, Psychological Distress, and Protective Factors in a Community Sample of Black, Latinx, and White Lesbian and Bisexual Women.

Intersectionality and minority stress frameworks were used to guide examination and comparisons of psychological distress (depression, anxiety, posttraumatic stress disorder symptoms) and protective factors (religiosity, spirituality, social support) among 673 Black, Latinx, and White lesbian and bisexual women with and without histories of sexual assault. Participants were from Wave 3 of the 21-year longitudinal Chicago Health and Life Experiences of Women (CHLEW) study. More than one-third (38%) of participants reported having experienced adolescent or adult sexual assault (i.e., rape or another form of sexual assault) since age 14. Confirmatory factor analysis, structural equation modeling, and multivariate analyses of covariance were used to analyze the data. Results revealed that levels of religiosity/spirituality and psychological distress varied by race/ethnicity and by sexual identity (i.e., Black lesbian, Black bisexual, Latinx lesbian, Latinx bisexual, White lesbian, White bisexual). Black lesbian women reported the highest level of religiosity/spirituality whereas White lesbian women reported the lowest level. White bisexual women reported the highest level of psychological distress whereas White lesbian women reported the lowest level. We found no significant differences in reports of sexual assault or in social support (i.e., significant other, family, friend, and total social support). However, White lesbian women had higher friend, significant other, and total social support relative to the other five groups of women with minoritized/marginalized sexual identities. Future work should examine whether religiosity, spirituality, and social support serve as protective factors that can be incorporated into mental health treatment for lesbian and bisexual who have experienced sexual assault to reduce psychological distress.

Testing gender and longitudinal measurement invariance of the SF-36 in American Indian older adults: The strong heart study.

Information about the equality of psychometric properties of the medical outcomes study (MOS) Short Form-36 (SF-36), a health status measure, across gender and across the lifespan for American Indian adults is lacking. We tested measurement invariance (configural, metric, scalar invariance) of the physical and mental components between gender and over time in a sample of 2,709 (1,054 men, 1,654 women) American Indian older adults at three time points, and across a 6-year time frame. Measurement invariance of a 2-factor higher-order model was demonstrated between gender at each time point. Tests of longitudinal invariance indicated longitudinal measurement invariance over time. Multiple-group latent means analysis indicated men had significantly higher physical and mental component latent means compared to women at each time point, and longitudinal latent means analysis found physical and mental component latent means decreased over time. The 2-factor higher-order model SF-36 is valid for American Indian older adults over a 6-year time frame. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Mid-Life Physical Activity and Late-Life Cognitive Performance among American Indians.

INTRODUCTION: Research on factors associated with late-life cognitive performance in diverse racial/ethnic groups is increasingly important due to the growing size and racial diversity of the elder population. METHODS: Using data on American Indians (AIs) from the Strong Heart Study, we measured associations between mid-life physical activity (PA), assessed by a questionnaire or pedometer, and performance on tests of general cognitive function, phonemic fluency, verbal learning and memory, and processing speed. Cognitive tests were administered 7-21 years after PA measurements. To estimate associations, we used regression models with and without inverse-probability weights to account for potential attrition bias in the cohort. RESULTS: Questionnaire and pedometer measures of PA were positively associated with cognitive function. Participants in the top quartile of questionnaire-based PA had Modified Mini-Mental State examination scores 3.2 (95% CI: 1.5-4.9) points higher than participants in the lowest quartile. Phonemic fluency scores also trended higher for participants in the top compared to the bottom categories for both PA measures: top questionnaire quartile = 2.7 (95% CI: 0.6-4.8) points higher and top pedometry tertile = 6.7 (95% CI: 2.7-10.7) points higher. We observed no associations between PA and tests assessing verbal learning and memory, or processing speed. Weighted model results were similar, but less precise. CONCLUSIONS: In this cohort of AIs with relatively low levels of PA, positive associations between mid-life PA and late-life cognitive performance were dose-dependent and of modest clinical significance.

Social Support Protects Against Symptoms of Anxiety and Depression: Key Variations in Latinx and Non-Latinx White College Students.

Social support protects against perceived stress and its harmful effects on psychological well-being. College students in general are at high risk for mental health disorders, and Latinx college students face unique stressors placing them at greater risk of psychological distress. Social support may be a key construct in improving outcomes for college students; however, few studies have empirically tested whether the protective effect of social support is equivalent across racial/ethnic groups. Using a series of regression models, we investigated whether social support moderates the relationship between perceived stress and endorsement of depression and anxiety symptoms in Latinx (n = 265) and non-Latinx White college students (n = 216) and whether this moderating effect varied by group membership. Participants completed a series of questionnaires measuring social support, perceived stress, and depression and anxiety symptoms. The moderating effects of social support varied by group membership and outcomes (i.e., depression and anxiety). Social support moderated the relationship between perceived stress and depression symptoms for both Latinx and non-Latinx White students. However, social support only buffered the effect of perceived stress on anxiety symptom endorsement for Latinx college students. These findings suggest that social support does not function uniformly across racial/ethnic groups or the endorsement of depression and anxiety symptoms. Social support may be particularly important for Latinx students by providing a buffer between perceived stress and symptoms of anxiety.

El apoyo social protege contra el estrés y sus efectos en el bienestar psicológico. El riesgo de desarrollar trastornos psicológicos es elevado en estudiantes universitarios. Estudiantes universitarios Latinxs enfrentan situaciones relacionadas con identificatión de minoría que pueden contribuir a una elevación en el riesgo de desarrollar problemas psicológicos. Como tal, el apoyo social es un área clave para la preventión y mejoría del bienestar psicológico. Sin embargo, pocas investigaciones han comparado los efectos protectores del apoyo social a través de raza y etnia. Usamos una serie de modelos de regresión para investigar si el apoyo social modera la relación entre la percepción de estrés y el reporte de síntomas de depresión y ansiedad en estudiantes universitarios Latinxs y anglosajones. Además, investigamos si este efecto de moderación varia en dependencia de la membresía etnia. Participantes completaron una serie de cuestionarios midiendo variables de interés, incluyendo apoyo social, percepcicón de estrés, síntomas de depresión y ansiedad. El apoyo social modera la relación entre la percepcición de estrés y síntomas de depresión en los dos grupos étnicos, Latinxs y anglosajones. Sin embargo, para los síntomas de ansiedad, el efecto protector del apoyo social fue distinto para los estudiantes Latinxs. Estos resultados sugieren que la función del apoyo social no es uniforme a través de grupos étnicos o en términos de protectión contra diferentes problemas psicológicos. El apoyo social es particularmente importante para los estudiantes Latinxs en términos de proveer protectión contra síntomas de ansiedad en la presencia de la perceptión del estrés.

Racial/Ethnic Group Differences and Sociocultural Factors Associated With Implicit and Explicit Attitudes Toward Undocumented Latino Immigrants.

In the context of recent policies aimed at deterring immigration and criminalizing undocumented Latino immigrants, we examined factors predicting implicit and explicit attitudes toward this population. We hypothesized that more positive implicit and explicit attitudes toward undocumented Latino immigrants would be displayed by Latinxs (compared to non-Hispanic Whites) and by individuals having personal connections to undocumented immigrants or a high level of intercultural sensitivity. Latinx (n = 376) and non-Hispanic White (n = 214) college students (70% female, M age = 21) participated in this cross-sectional study and completed two Implicit Association Tests and measures of explicit attitudes, personal connections, and intercultural sensitivity. As predicted, Latinx participants held more positive implicit and explicit attitudes than non-Hispanic White participants. Intercultural sensitivity and personal connections to undocumented immigrants were associated with more positive explicit attitudes. Identifying factors that increase a sense of commonality and cultural sensitivity with undocumented Latino immigrants may be helpful in diminishing the profiling and criminalization of this community.

Gender differences in the assessment of depression in American Indian older adults: The Strong Heart Study.

The validation of the assessment of depression across ethnic groups is critical yet deficient for American Indian (AI) adults. Therefore, we assessed the psychometric properties of the Center for Epidemiological Studies-Depression (CES-D) in AI elders and tested differences in depression constructs between gender. Participants were 817 AI adults (68% women), mean age 73.2 years (SD = 6.1, range: 64-95) for women and 72.6 years (SD = 5.3, range: 65-90) for men., in the Cerebrovascular Disease and Its Consequences in AIs Study. We evaluated the factor structure of the 20-item and 12-item CES-D and tested measurement invariance between gender. Results demonstrated a poor fit for the 20-item CES-D and partial gender measurement invariance of the 12-item CES-D. AI female elders had significantly higher depression levels than AI male elders on the Depressed Affect subscale, the Somatic Symptoms subscale, and the Well-Being (reverse-coded) subscale. Further replication is needed, and we recommend future psychometric work with the 12-item CES-D with AI elders. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Macro- and meso-level contextual influences on health care inequities among American Indian elders.

BACKGROUND: American Indian elders, aged 55 years and older, represent a neglected segment of the United States (U.S.) health care system. This group 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 aging populations in the country. Despite the U.S. government's federal trust responsibility to meet American Indians' health-related needs through the Indian Health Service (IHS), elders are negatively affected by provider shortages, limited availability of health care services, and gaps in insurance. This qualitative study examines the perspectives of professional stakeholders involved in planning, delivery of, and advocating for services for this population to identify and analyze macro- and meso-level factors affecting access to and use of health care and insurance among American Indian elders at the micro level. METHODS: Between June 2016 and March 2017, we undertook in-depth qualitative interviews with 47 professional stakeholders in two states in the Southwest U.S., including health care providers, outreach workers, public-sector administrators, and tribal leaders. The interviews focused on perceptions of both policy- and practice-related factors that bear upon health care inequities impacting elders. We analyzed iteratively the interview transcripts, using both open and focused coding techniques, followed by a critical review of the findings by a Community Action Board comprising American Indian elders. RESULTS: Findings illuminated complex and multilevel contextual influences on health care inequities for elders, centering on (1) gaps in elder-oriented services; (2) benefits and limits of the Affordable Care Act (ACA); (2) invisibility of elders in national, state, and tribal policymaking; and (4) perceived threats to the IHS system and the federal trust responsibility. CONCLUSIONS: Findings point to recommendations to improve the prevention and treatment of illness among American Indian elders by meeting their unique health care and insurance needs. Policies and practices must target meso and macro levels of contextual influence. Although Medicaid expansion under the ACA enables providers of essential services to elders, including the IHS, to enhance care through increased reimbursements, future policy efforts must improve upon this funding situation and fulfill the federal trust responsibility.

The Underutilization of Community-based Participatory Research in Psychology: A Systematic Review.

Traditional non-participatory research methodologies have struggled to address the needs of multicultural populations in the United States (U.S.). Community-based participatory research (CBPR) is a research paradigm offering a unique opportunity for culturally appropriate research and improving health equity. CBPR is an equitable, strength-based approach involving all stakeholders throughout the research process. We investigate the field of psychology's utilization of CBPR as an approach for working with multicultural populations to collaboratively address relevant and impactful research questions. A total of 1912 CBPR-related articles, from 2004 to 2014, were identified using PsycINFO, PubMed, and CINAHL Complete databases. Of these, approximately 16% (n = 311) met our criteria for psychology-related CBPR articles accounting for a negligible amount (<1%) of peer-reviewed publications in mainstream psychological journals during the same time period. Among U.S. psychology-related CBPR articles, 86% focused on multicultural and marginalized populations. Prominent topics of investigation included physical health, mental and behavioral health, and theoretical or methodological articles. Features of publications, including authors' training, types of journals, study populations, and topics under investigation, were explored for all 1912 publications. Findings highlight an opportunity for further utilization of CBPR within psychology, with key implications for health equity. Recommendations for increasing CBPR uptake within the discipline are also offered.

Depression Symptoms and Cognitive Test Performance in Older American Indians: The Strong Heart Study.

BACKGROUND: American Indians have excess risk of depression, which can contribute to cerebrovascular and cognitive disability, with effects on memory, processing speed, executive function, and visuospatial ability. However, studies examining depression and cognition in American Indians are limited; this study aims to report associations of depression with general cognition, verbal fluency and memory, and processing speed. DESIGN: Cohort study. SETTING: The Cerebrovascular Disease and its Consequences in American Indians study was an ancillary examination of Strong Heart Study participants from 3 U.S. regions. PARTICIPANTS: All eligible were included in this analysis (N=818). MEASUREMENTS: Participants completed evaluations for depressive symptomology, cognition, and physical function-including Center for Epidemiologic Studies Depression (CESD), Modified Mini-Mental State Examination (3MSE), Wechsler Adult Intelligence Scale-Fourth Edition coding (WAIS), Controlled Oral Word Association (COWA), California Verbal and Learning Test, Halstead finger tapping, grip strength, and Short Physical Performance Battery (SPPB) tests. Linear mixed models were adjusted for site, age, sex, education, income, marital status, alcohol, smoking, diabetes, hypertension, obesity, cholesterol, stroke, infarct, and hemorrhage. RESULTS: Symptoms of depression were common, with 20% (N=138) endorsing CES-D scores of 16+. More depressive symptoms were associated with older age, female sex, lower education, lower income, non-married status, not using alcohol, not smoking, hypertension, diabetes, and stroke. In adjusted analyses, processing speed (WAIS: ß -0.13, 95%CI -0.25, -0.03), general cognition (3MSE: ß -0.10, 95%CI -0.17, -0.03), verbal fluency (COWA: ß -0.10, 95%CI -0.19, -0.01), and motor function (SPPB: ß -0.05, 95%CI -0.07, -0.03) were significantly associated with more symptoms of depression. CONCLUSION: These findings maybe informative for health disparities populations, especially those with depressive risk. Clinicians may require particular training in cultural humility. Future studies should validate use of the CES-D scale in this population; longitudinal studies may focus on causal mechanisms and potential secondary prevention, such as social support. J Am Geriatr Soc 68:1739-1747, 2020.

Measurement invariance of neuropsychological measures of cognitive aging across race/ethnicity by sex/gender groups.

OBJECTIVE: The purpose of this study was to evaluate the measurement invariance of a neuropsychological battery across race/ethnicity by sex/gender subgroups over repeated measurements. METHOD: Participants were 6,057 non-Hispanic White (NHW), Black, and Hispanic men and women in the Washington/Hamilton Heights Inwood Columbia Aging Project (WHICAP) who were administered neuropsychological tests of memory, language, and visuospatial abilities at 18 to 24-month intervals for up to 25 years. Invariance analyses were conducted on the three-factor model across sex/gender, racial/ethnic, and sex/gender by racial/ethnic subgroups, as well as across five assessment timepoints. RESULTS: The three-factor model demonstrated full measurement invariance across sex/gender groups and over repeated measurements. However, partial measurement invariance (invariant factor structure and factor loadings but nonequivalent observed score intercepts) for the language domain was exhibited across racial/ethnic and sex/gender by racial/ethnic subgroups. CONCLUSION: Establishing measurement invariance is essential for valid interpretation of group differences in cognitive test performance. Findings from the current study highlight the need for continued examination of sex/gender by racial/ethnic differences in measurement properties of assessment tools, as well as expanded research on sex/gender variability across other understudied racial/ethnic groups. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Cognitive Correlates of MRI-defined Cerebral Vascular Injury and Atrophy in Elderly American Indians: The Strong Heart Study.

OBJECTIVE: American Indians experience substantial health disparities relative to the US population, including vascular brain aging. Poorer cognitive test performance has been associated with cranial magnetic resonance imaging findings in aging community populations, but no study has investigated these associations in elderly American Indians. METHODS: We examined 786 American Indians aged 64 years and older from the Cerebrovascular Disease and its Consequences in American Indians study (2010-2013). Cranial magnetic resonance images were scored for cortical and subcortical infarcts, hemorrhages, severity of white matter disease, sulcal widening, ventricle enlargement, and volumetric estimates for white matter hyperintensities (WMHs), hippocampus, and brain. Participants completed demographic, medical history, and neuropsychological assessments including testing for general cognitive functioning, verbal learning and memory, processing speed, phonemic fluency, and executive function. RESULTS: Processing speed was independently associated with the presence of any infarcts, white matter disease, and hippocampal and brain volumes, independent of socioeconomic, language, education, and clinical factors. Other significant associations included general cognitive functioning with hippocampal volume. Nonsignificant, marginal associations included general cognition with WMH and brain volume; verbal memory with hippocampal volume; verbal fluency and executive function with brain volume; and processing speed with ventricle enlargement. CONCLUSIONS: Brain-cognition associations found in this study of elderly American Indians are similar to those found in other racial/ethnic populations, with processing speed comprising an especially strong correlate of cerebrovascular disease. These findings may assist future efforts to define opportunities for disease prevention, to conduct research on diagnostic and normative standards, and to guide clinical evaluation of this underserved and overburdened population.

Sex/gender differences in cognitive trajectories vary as a function of race/ethnicity.

INTRODUCTION: The present study sought to determine whether cognitive trajectories differ between men and women across and within racial/ethnic groups. METHODS: Participants were 5258 non-Hispanic White (NHW), Black, and Hispanic men and women in the Washington/Hamilton Heights-Inwood Columbia Aging Project who were administered neuropsychological tests of memory, language, and visuospatial abilities at 18- to 24-month intervals for up to 25 years. Multiple-group latent growth curve modeling examined trajectories across sex/gender by race/ethnicity. RESULTS: After adjusting for age and education, the largest baseline differences were between NHW men and Hispanic women on visuospatial and language, and between NHW women and Black men on memory. Memory and visuospatial decline was steeper for Black women compared with Hispanic men and NHW women, respectively. DISCUSSION: This study takes an important first step in understanding interactions between race/ethnicity and sex/gender on cognitive trajectories by demonstrating variability in sex/gender differences across race/ethnicity.

The associations among sociocultural factors and neuropsychological functioning in older American Indians: The Strong Heart Study.

OBJECTIVE: Valid neuropsychological assessment is critical to the accurate diagnosis and effective treatment of diverse populations. American Indians and Alaska Natives experience substantial health disparities relative to the general U.S. POPULATION: Given the dearth of studies on neuropsychological health in this population, we aimed to characterize neuropsychological performance among older American Indians with respect to age, sex, education, income, and language use. METHOD: From 2010 to 2014, we recruited 818 American Indians aged 60 and older from the Cerebrovascular Disease and Its Consequences in American Indians Study, who comprised all of the surviving members of a cardiovascular study (Strong Heart Study). This cohort from 11 tribes resided on or near their home reservations in three geographic regions (Northern Plains, Southern Plains, and Southwest). Using a cross-sectional design investigating potential vascular brain injury, we administered a brief, targeted neuropsychological and motor function assessments. RESULTS: Higher scores on neuropsychological tests were associated with younger age, female sex, more education, higher income, and less Native American language use. Similar associations were found for the motor tests, although men had higher scores on both motor function tests. After accounting for other sociocultural and health factors, age, sex, education, income, and Native American language use all had significant associations to the test scores. CONCLUSIONS: Our findings may be used to guide research and inform clinical practice. The development of future normative studies for older American Indians will be more culturally appropriate when sociocultural factors are included. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Type 2 diabetes and later cognitive function in older American Indians: The Strong Heart Study.

OBJECTIVES: Insulin resistance is a substantial health issue for American Indians, with type 2 diabetes overrepresented in this population as compared with non-Hispanic whites. Insulin resistance and its related conditions in turn increase risk for dementia and cognitive impairment. The aim of the current study was to determine whether type 2 diabetes and insulin resistance at midlife was associated with later-life cognitive testing in a large sample of older American Indians, aged 65 and older. METHODS: American Indian participants who underwent both fasting blood draw as part of the Strong Heart Study and had subsequent cognitive testing as part of the later adjunct Cerebrovascular Disease and its Consequences in American Indians study were included (n = 790). Regression models examined type 2 diabetes and impaired fasting glucose and subsequent cognitive test performance as part of a longitudinal study design. The relationship between a continuous measure of insulin resistance and later cognitive test performance was assessed using generalized estimating equations. RESULTS: Controlling for demographic and clinical factors, verbal fluency and processing speed/working memory were significantly negatively associated with having type 2 diabetes and with insulin resistance, but not with impaired fasting glucose. CONCLUSION: In this sample of American Indians, type 2 diabetes at midlife was associated with subsequent lower performance on measures of executive function. These results may have important implications for future implementation of diagnostic and intervention services in this population.

Normative data for Farsi-speaking Iranians in the United States on measures of executive functioning.

As the Farsi-speaking Iranian population continues to grow in the United States, examination of their cognitive performance is an imperative first step to providing this group with culturally competent services. Thirty-six healthy primarily Farsi-speaking Iranian adults completed Farsi-translated and adapted versions of three frequently used measures of executive/subcortical functioning: Wisconsin Card Sorting Test (WCST), Trail Making Test (TMT), and Color Trails Test (CTT). Participants' performance on each measure was compared to published normative data resulting in 0-85% of cognitively and medically healthy individuals being classified as impaired depending on the executive/subcortical test score examined, with the highest impairment rates for specific WCST outcome scores. These findings raise questions for the use of published norms with Farsi-speaking Iranians residing in the US. The present study provided normative data from this group of Farsi-speaking Iranians on the Farsi-translated and adapted versions of the WCST, TMT, and CTT.

Linguistic factors associated with phonemic fluency performance in a sample of bilingual Hispanic undergraduate students.

Research has demonstrated that bilingualism impacts neuropsychological performance, but the findings on its effects on verbal fluency have been mixed. This study compared the verbal fluency performance of non-Hispanic White monolingual speakers with a Hispanic bilingual population. Ninety-nine Spanish-English bilingual Hispanic and thirty English-speaking monolingual non-Hispanic White undergraduates completed the Controlled Oral Word Association Test (COWAT). Students also completed a general cognitive and English reading measure. Bilingual students completed an in-depth language questionnaire to gauge language dominance, age of acquisition of second language (AoA), and first language learned. Results revealed that both language dominance and AoA influence phonemic fluency performance in bilingual Hispanics. English-dominant and balanced bilingual students performed similarly to monolingual students. Spanish-dominant bilingual students scored lower than monolinguals or the other bilingual groups. Bilingual students with early AoA (<7 years) performed on par with monolingual students. Late AoA bilinguals performed significantly lower than early AoA bilinguals. Results illustrate the clinical importance of obtaining a full linguistic history of bilingual clients in order to accurately interpret verbal fluency performance, as this is essential for proper diagnoses and treatments.

Health literacy, sociodemographic factors, and cognitive training in the active study of older adults.

OBJECTIVE: Health literacy is critical for understanding information from health-care providers and correct use of medications and includes the capacity to filter other information in navigating health care systems. Older adults with low health literacy exhibit more chronic health conditions, worse physical functioning, and poorer mental health. This study examined the relationship between sociodemographic variables and health literacy, and the impact of cognitive training on change in health literacy over 10 years in older adults. METHODS: Participants (N = 2,802) aged 65 years and older completed assessments, including reading and numeracy health literacy items, as part of the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) study. We evaluated baseline sociodemographic variables and change in health literacy over a 10-year period in individuals exposed to cognitive training in reasoning, processing speed, memory, or a no-contact control condition. RESULTS: Age, sex, race, education level, and general cognitive functioning at baseline were all associated with baseline health literacy in older adults. Predictors of change in health literacy over the 10-year follow-up were age, race, education level, general cognitive functioning, and neighborhood income; disparities in health literacy because of race attenuated over time, while the effect of age increased over time. Health literacy was generally stable across the ACTIVE intervention groups over 10 years. CONCLUSIONS: The present study showed important disparities in health literacy level and change over 10 years. Cognitive training did not significantly impact health literacy, suggesting that alternative approaches are needed to reduce the disparities.

"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.

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.