Advancing Diabetes Prevention and Control in American Indians and Alaska Natives.

As with many Indigenous populations globally, American Indians and Alaska Natives (AI/ANs) experience high rates of type 2 diabetes. Prevention efforts, ongoing medical care, patient self-management education, and support to prevent and reduce the risk of long-term complications must be developed to limit the impact of diabetes on individuals, families, and communities. Diabetes prevention and control require both individual- and community-level efforts as well as policies that attempt to mitigate contributing adverse socioeconomic factors. Congressional funding since 1998 continues to address the epidemic of diabetes in AI/AN groups with the Special Diabetes Program for Indians (SDPI), which has resulted in significant outcomes and key lessons that can inform new efforts to prevent diabetes in other populations and communities. The purpose of this review is to understand the context behind the epidemic of diabetes in AI/ANs, review the impact of the SDPI on prevention and control of diabetes as well as the translation of these strategies into clinical practice and their influence on health practice, and identify lessons learned for future efforts to address this ongoing challenge for AI/AN and other communities suffering from type 2 diabetes.

Twenty Years of Research into the Health Impacts of Native-themed Mascots: A Scoping Review.

Despite their recent high-profile removal by a handful of professional sports teams, Native-themed mascots continue to be a mainstay of professional, college, and youth athletics. To determine the extent of the literature on the health impacts on American Indians and Alaska Natives (AI/ANs) as a result of Native-themed mascots, we conducted a scoping review of primary research articles, utilizing the National Institute on Minority Health and Health Disparities (NIMHD) research framework as a guide to define health impacts broadly to include impacts on determinants of health and health disparities. Three databases were utilized, MEDLINE/PubMed, PsycINFO, and JSTOR, to identify the peer-reviewed literature for a twenty-year period that studied the health impacts of Native-themed mascots. We found 26 articles and books in the peer-reviewed literature and additional gray literature during the time period of 1999-2019. To better identify the relationship between Native-themed mascots and health impacts, we reviewed the articles by their focus on three groups: AI/ANs generally, AI/AN youth, and those that studied all races/ethnicities. The majority of research included in this review illustrates overall negative impacts of Native-themed mascots on health and its determinants that influence health and health disparities. Public health efforts should include review and replacement of harmful Native-themed mascots in professional and academic sports to avoid negative health impacts on AI/AN adults and youth.

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

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

An online diabetes nutrition education programme for American Indian and Alaska Native adults with type 2 diabetes: perspectives from key stakeholders.

OBJECTIVE: To explore stakeholder perspectives regarding online diabetes nutrition education for American Indians and Alaska Natives (AI/AN) with type 2 diabetes (T2D). DESIGN: Qualitative data were collected through focus groups and interviews. Focus group participants completed a brief demographic and internet use survey. SETTING: Focus groups and community participant interviews were conducted in diverse AI/AN communities. Interviews with nationally recognised content experts were held via teleconference. PARTICIPANTS: Eight focus groups were conducted with AI/AN adults with T2D (n 29) and their family members (n 22). Community participant interviews were conducted with eleven clinicians and healthcare administrators working in Native communities. Interviews with nine content experts included clinicians and researchers serving AI/AN. RESULTS: Qualitative content analysis used constant comparative method for coding and generating themes across transcripts. Descriptive statistics were computed from surveys. AI/AN adults access the internet primarily through smartphones, use the internet for many purposes and identify opportunities for online diabetes nutrition education. CONCLUSIONS: Online diabetes nutrition education may be feasible in Indian Country. These findings will inform the development of an eLearning diabetes nutrition education programme for AI/AN adults with T2D.

Holding Space for All of Us.

Negative experiences and misunderstanding are common in tribal-academic research partnerships. The Holding Space: A Guide for Partners in Tribal Research draws on the concepts of governance, trust, and culture to strengthen relationships, honor tribal sovereignty, counter histories of opportunistic research, and recognize all ways of knowing. We apply the Holding Space toolkit concepts to the All of Us Research Program and call on all research studies funded by the federal government to honor governance, trust, and culture in research partnerships with tribal nations.

The Holding Space: A Guide for Partners in Tribal Research.

BACKGROUND: Although a community-based participatory research (CBPR) approach is desired by American Indian/Alaska Native (AI/AN) tribes, many researchers and tribes experience challenges in research partnerships. The aim of this project was to develop and disseminate an evidence-based training toolkit to help strengthen tribal-academic research partnerships. Our prior research found that governance, trust, and culture were essential pillars for successful community academic partnerships. METHODS: This article describes the development and evaluation of the new Holding Space: A Guide for Partners in Tribal Research toolkit, which contains a Holding Space Discussion Guide and the Tribal Research Future Game, which are delivered in a training format for participants in tribal- academic research partnerships. RESULTS: Results indicate that Holding Space is a useful tool for facilitating conversations and openly reflecting on practices within partnerships and may also be appropriate for a broader audience. CONCLUSIONS: Future work includes further effectiveness studies as well as research focused on dissemination and implementation.

Toward Health Equity: A National Study of Promising Practices in Community-Based Participatory Research.

OBJECTIVES: In the first nationwide study of community- academic research partnerships, we identified contextual and partnership practices that were significantly correlated with successful partnership outcomes guided by a community-based participatory research (CBPR) conceptual model. METHODS: Data collection included three stages: 294 community-engaged research (CEnR) projects in 2009 identified from federally funded grant databases; 200 (68.0%) principal investigators (PI) completed a key informant survey that included measures of power/resource sharing and structural characteristics of projects; 312 (77.2% of invited) community partners and 138 PI (69.0% of invited) responded to a survey including research context, process, and outcome measures. RESULTS: Context and process correlates accounted for 21% to 67% of the variance in the specific outcomes. Seven categories of research partnership practices were positively associated with successful synergy, capacity, and health outcomes: power sharing, partnership capacity, bridging social capital, shared values, community involvement in research, mutuality, and ethical management. CONCLUSIONS: Through empirical testing of an innovative, multidisciplinary CBPR model, key context and process practices were identified that confirm the positive impact of partnership evaluation and self-reflection on research outcomes. Further, these findings provide academic and other key stakeholders with real-world practical recommendations to engage agencies, groups, and individuals who suffer most from inequities and may have unrecognized or indigenous knowledge, experience, and leadership to contribute to health and social research and to the creation of paths to wellness.

Power Dynamics in Community-Based Participatory Research: A Multiple-Case Study Analysis of Partnering Contexts, Histories, and Practices.

Community-based participatory research has a long-term commitment to principles of equity and justice with decades of research showcasing the added value of power-sharing and participatory involvement of community members for achieving health, community capacity, policy, and social justice outcomes. Missing, however, has been a clear articulation of how power operates within partnership practices and the impact of these practices on outcomes. The National Institutes of Health-funded Research for Improved Health study (2009-2013), having surveyed 200 partnerships, then conducted seven in-depth case studies to better understand which partnership practices can best build from community histories of organizing to address inequities. The diverse case studies represented multiple ethnic-racial and other marginalized populations, health issues, and urban and rural areas and regions. Cross-cutting analyses of the qualitative results focus on how oppressive and emancipatory forms of power operate within partnerships in response to oppressive conditions or emancipatory histories of advocacy within communities. The analysis of power was conducted within each of the four domains of the community-based participatory research conceptual model, starting from how contexts shape partnering processes to impact short-term intervention and research outputs, and contribute to outcomes. Similarities and differences in how partnerships leveraged and addressed their unique contexts and histories are presented, with both structural and relational practices that intentionally addressed power relations. These results demonstrate how community members draw from their resilience and strengths to combat histories of injustice and oppression, using partnership principles and practices toward multilevel outcomes that honor community knowledge and leadership, and seek shared power, policy, and community transformation changes, thereby advancing health equity.

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.

Assessing the Everyday Discrimination Scale among American Indians and Alaska Natives.

The Everyday Discrimination Scale (EDS) has been used widely as a measure of subjective experiences of discrimination. The usefulness of this measure for assessments of perceived experiences of discrimination by American Indian and Alaska Native (AI/AN) peoples has not been explored. Data derived from the Special Diabetes Program for Indians--Healthy Heart Demonstration Project (SDPI-HH), a large-scale initiative to reduce cardiovascular risk among AI/ANs with Type 2 diabetes. Participants (N = 3,039) completed a self-report survey that included the EDS and measures of convergent and divergent validity. Missing data were estimated by multiple imputation techniques. Reliability estimates for the EDS were calculated, yielding a single factor with high internal consistency (α = .92). Younger, more educated respondents reported greater perceived discrimination; retired or widowed respondents reported less. Convergent validity was evidenced by levels of distress, anger, and hostility, which increased as the level of perceived discrimination increased (all p < .001). Divergent validity was evidenced by the absence of an association between EDS and resilient coping. Resilient coping and insulin-specific diabetes knowledge were not significantly associated with perceived discrimination (p = .61 and 0.16, respectively). However, general diabetes-related health knowledge was significantly associated with perceived discrimination (p = .02). The EDS is a promising measure for assessing perceived experiences of discrimination among those AI/ANs who participated in the SDPI-HH.

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.

Psychosocial Predictors of Weight Loss among American Indian and Alaska Native Participants in a Diabetes Prevention Translational Project.

The association of psychosocial factors (psychological distress, coping skills, family support, trauma exposure, and spirituality) with initial weight and weight loss among American Indians and Alaska Natives (AI/ANs) in a diabetes prevention translational project was investigated. Participants (n = 3,135) were confirmed as prediabetic and subsequently enrolled in the Special Diabetes Program for Indians Diabetes Prevention (SDPI-DP) demonstration project implemented at 36 Indian health care programs. Measures were obtained at baseline and after completing a 16-session educational curriculum focusing on weight loss through behavioral changes. At baseline, psychological distress and negative family support were linked to greater weight, whereas cultural spirituality was correlated with lower weight. Furthermore, psychological distress and negative family support predicted less weight loss, and positive family support predicted greater weight loss, over the course of the intervention. These bivariate relationships between psychosocial factors and weight remained statistically significant within a multivariate model, after controlling for sociodemographic characteristics. Conversely, coping skills and trauma exposure were not significantly associated with baseline weight or change in weight. These findings demonstrate the influence of psychosocial factors on weight loss in AI/AN communities and have substantial implications for incorporating adjunctive intervention components.

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.

Socioeconomic Disparities in Weight and Behavioral Outcomes Among American Indian and Alaska Native Participants of a Translational Lifestyle Intervention Project.

OBJECTIVE: To investigate possible socioeconomic disparities in weight and behavioral outcomes among American Indian and Alaska Native (AI/AN) participants in a translational diabetes prevention project. RESEARCH DESIGN AND METHODS: We analyzed data from the Special Diabetes Program for Indians Diabetes Prevention (SDPI-DP) Program, an evidence-based lifestyle intervention to prevent diabetes in 36 AI/AN grantee sites. A total of 2,553 participants started the 16-session Lifestyle Balance Curriculum between 1 January 2006 and 31 July 2008. Linear mixed models were used to evaluate the relationships of participant and staff socioeconomic characteristics with weight and behavioral outcomes at the end of the curriculum. RESULTS: A strong, graded association existed between lower household income and less BMI reduction, which remained significant after adjusting for other socioeconomic characteristics. Compared with others, participants with annual income <$15,000 also had less improvement in physical activity and unhealthy food consumption in bivariate models, but the relationships were only marginally significant in multivariate regressions. Furthermore, grantee sites with fewer professionally prepared staff were less successful at improving participant BMI and healthy food consumption than the other sites. The strong association between income and BMI reduction was reduced by 20-30% in the models with changes in diet variables but was unrelated to changes in physical activity. CONCLUSIONS: Significant socioeconomic disparities exist in weight outcomes of lifestyle intervention at both participant and site staff levels. Helping low-income participants choose more affordable healthy foods and increasing the proportion of professionally trained staff might be practical ways to maximize the effectiveness of lifestyle interventions implemented in "real-world" settings.

Serious Psychological Distress and Diabetes Management among American Indians and Alaska Natives.

OBJECTIVE: Our study examined associations between serious psychological distress and blood glucose level (HbA1c) and body mass index (BMI) among American Indian and Alaska Native (AI/AN) participants in a cardiovascular disease prevention program. DESIGN: Using linear regression, we assessed the relationships between serious psychological distress and HbA1c and BMI at baseline and one year later. SETTING, PARTICIPANTS, AND INTERVENTION: AI/AN participants were aged 18 years, diagnosed with type 2 diabetes, and enrolled in the Special Diabetes Project for Indians Healthy Heart Project. MAIN OUTCOME MEASURES: Outcomes were percentage of HbA1c and BMI, measured at enrollment and first annual exam. Both outcomes were continuous measures in all analyses. RESULTS: Serious psychological distress was associated at baseline with increased HbA1c in the unadjusted and adjusted models (adjusted b = .17%, P < 0.01). Serious psychological distress also was associated at baseline with increased BMI (.635 kg/m2, P = .01) and at one year with increased BMI (0.174 kg/m2, P = .01) in the unadjusted model. After adjustment for demographic and health characteristics, these relationships were no longer significant. CONCLUSIONS: Cross-sectional baseline findings are consistent with existing literature. One-year findings suggest need for further inquiry into mediators of psychological distress and examination of additional diabetes-specific health outcomes. Additional years of observation may be needed to disentangle relationships between serious psychological distress and BMI.

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.

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.

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.