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1.  Use of Complementary Therapies for Health Promotion Among Older Adults 
This article describes the types of complementary therapies used by older adults for health promotion, and delineates the predisposing, enabling, and need factors associated with their use. One-hundred ninety-five African American and White participants (age 65+) completed a baseline interview and up to six sets of three daily follow-up interviews at monthly intervals. Complementary therapies for health promotion included home remedies, specific foods or beverages, herbs, supplements, vitamins, over-the-counter (OTC) medicine, prayer, exercise, and being active. Although gender, ethnicity, education, and trust in doctors were associated with the use of complementary therapies for health promotion, health information seeking was the predisposing factor most often associated. The enabling factors were also associated with their use. Health information seeking, which reflects a wellness lifestyle, had the most consistent associations with complementary therapy use for health promotion. This health self-management for health promotion may have positive effects on future medical expenditures.
PMCID: PMC4033702  PMID: 24652893
health promotion; disease prevention; complementary and alternative medicine; minoirty aging
2.  Caregiver Reports of Provider Recommended Frequency of Blood Glucose Monitoring and Actual Testing Frequency for Youth with Type 1 Diabetes 
To identify demographic, family and clinical characteristics associated with provider recommended frequency of blood glucose monitoring (BGM), actual frequency of BGM, and concordance between these categories in youth with type 1 diabetes (T1D) as reported by child’s caregiver.
Caregivers of 390 children 10–17 years were interviewed about their children’s providers’ recommendations for frequency of BGM and their child’s frequency of performance of BGM.
The majority (92%) of caregivers reported being told that their child should BGM ≥4 times per day and 78% reported their child checked that frequently. Caregivers of children who were younger, non-Hispanic White, from two-parent households, higher income households, and on insulin pumps were more likely to report being told by their provider to perform BGM ≥6 times per day and more likely to report that their child performed BGM ≥6 times per day. Younger children and those with private health insurance were more likely to adhere to reported recommendations. Children whose caregivers reported that their child met/exceeded their provider recommendations had lower A1c values than those who did not.
These findings may help clinicians identify subgroups of youth at-risk for poor diabetes management and provide further education in order to improve outcomes.
PMCID: PMC4519093  PMID: 21940061
Blood glucose monitoring; Adherence; Type 1 Diabetes; Youth
3.  Racial Differences in Knowledge, Attitudes, and Cancer Screening Practices among a Triracial Rural Population 
Cancer  2004;101(11):2650-2659.
Low-income, minority, and rural women face a greater burden with regard to cancer-related morbidity and mortality and are usually underrepresented in cancer control research. The Robeson County Outreach, Screening and Education Project sought to increase mammography use among low-income, minority, and rural women age > 40 years. The current article reports on racial disparities and barriers to screening, especially those related to knowledge, attitudes, and behaviors.
A baseline survey was administered to 897 women age > 40 years who lived in rural Robeson County in North Carolina. The sample consisted of three principal racial groups: whites, African Americans, and Native Americans. Survey comparisons were made among racial groups with respect to knowledge, attitudes, and behaviors regarding breast and cervical carcinoma screening.
Overall, Native American and African-American women had lower levels of knowledge, more inaccurate beliefs, and more barriers to screening compared with white women. Among the notable findings were that 43% of the patient population did not mention mammograms and 53% did not mention Pap smears as breast and cervical carcinoma screening tests, respectively; furthermore, compared with white women, significantly fewer African-American and Native American women mentioned these tests (P < 0.001). Sixty-seven percent of all women reported that a physician had never encouraged them to receive a mammogram, although 75% reported having received a regular checkup in the preceding year.
Although all low-income rural women experienced significant barriers to receiving cancer screening tests, these barriers were more common for minority women compared with white women. More research is needed to identify ways to overcome such barriers, especially among Native American women. The results of the current study have important implications with respect to the designing of interventions aimed at improving cancer screening for all women.
PMCID: PMC4465264  PMID: 15505784
racial differences; cancer screening; rural population; mammography
4.  Randomized Trial of an Intervention to Improve Mammography Utilization Among a Triracial Rural Population of Women 
Mammography is underused by certain groups of women, in particular poor and minority women. We developed a lay health advisor (LHA) intervention based on behavioral theories and tested whether it improved mammography attendance in Robeson County, NC, a rural, low-income, triracial (white, Native American, African American) population.
A total of 851 women who had not had a mammogram within the past year were randomly assigned to the LHA intervention (n = 433) or to a comparison arm (n = 418) during 1998–2002. Rates of mammography use after 12–14 months (as verified by medical record review) were compared using a chi-square test. Baseline and follow-up (at 12–14 months) surveys were used to obtain information on demographics, risk factors, and barriers, beliefs, and knowledge about mammography. Linear regression, Mantel–Haenszel statistics, and logistic regression were used to compare barriers, beliefs, and knowledge from baseline to follow-up and to identify baseline factors associated with mammography.
At follow-up, 42.5% of the women in the LHA group and 27.3% of those in the comparison group had had a mammogram in the previous 12 months (relative risk = 1.56, 95% confidence interval [CI] = 1.29 to 1.87). Compared with those in the comparison group, women in the LHA group displayed statistically significantly better belief scores (difference = 0.46 points on a 0–10 scale, 95% CI = 0.15 to 0.77) and reduced barriers at follow-up (difference = −0.77 points, 95% CI = −1.02 to −0.53), after adjusting for baseline scores.
LHA interventions can improve mammography utilization. Future studies are needed to assess strategies to disseminate effective LHA interventions to under-served populations.
PMCID: PMC4450352  PMID: 16954475
5.  An In-Depth Analysis of How Elders Seek and Disseminate Health Information 
This study documents older adults’ sources of health information, describes the purposes for health information seeking, and delineates gender and ethnic variation in health information seeking. Sixty-two African American and white adults age 65 and older completed qualitative interviews describing their use of complementary therapies. Interviews identified how individuals obtained and shared health information. Friends, not family, were the dominant source of health information. Participants ranged from active seekers to passive consumers of health information. Information seeking was common for benign symptoms. More women than men discuss health information with others. Friends are the primary source of health information for rural older adults. There is substantial passivity in the pursuit of health information. Identifying health information sources of rural older adults can support the dissemination of information to those who share it with others.
PMCID: PMC4449955  PMID: 24188253
Health information seeking; older adults; Rural; African American; health communication
6.  No association of dietary fiber intake with inflammation or arterial stiffness in youth with type 1 diabetes 
To examine the association of dietary fiber intake with inflammation and arterial stiffness among youth with type 1 diabetes (T1D) in the US.
Data are from youth ≥ 10 years old with clinically diagnosed T1D for ≥ 3 months and ≥ 1 positive diabetes autoantibody in the SEARCH for Diabetes in Youth Study. Fiber intake was assessed by food frequency questionnaire with measurement error (ME) accounted for by structural sub-models derived using additional 24-hour dietary recall data in a calibration sample and the respective exposure-disease model covariates. Markers of inflammation, measured at baseline, included IL-6 (n=1405), CRP (n=1387), and fibrinogen (n=1340); markers of arterial stiffness, measured approximately 19 months post-baseline, were available in a subset of participants and included augmentation index (n=180), pulse wave velocity (n=184), and brachial distensibility (n=177).
Mean (SD) T1D duration was 47.9 (43.2) months; 12.5% of participants were obese. Mean (SD) ME-adjusted fiber intake was 15 (2.8) g/day. In multivariable analyses, fiber intake was not associated with inflammation or arterial stiffness.
Among youth with T1D, fiber intake does not meet recommendations and is not associated with measures of systemic inflammation or vascular stiffness. Further research is needed to evaluate whether fiber is associated with these outcomes in older individuals with T1D or among individuals with higher intakes than those observed in the present study.
PMCID: PMC4011131  PMID: 24613131
type 1 diabetes; youth; dietary fiber; inflammation; arterial stiffness
7.  Unreliable Item or Inconsistent Person? A study of variation in health beliefs and belief- anchors to biomedical models 
Journal of health psychology  2013;20(8):1049-1059.
Several models for health beliefs grounded in social theories have been extensively used in health-related research. However, the measurement of beliefs, especially the stability of beliefs, is still an understudied area. For example, reliability of an item designed to measure health belief is often confounded with response consistency at the person level, and the problem is often ignored in social research in medicine. To delineate discordant responses to the same item of belief in diabetes, which could be due to item unreliability or to respondent inconsistency, we applied contemporary measurement methods to an inventory of common sense beliefs about diabetes and tested the hypothesis that individuals whose health beliefs are congruent with a biomedical model are more consistent in their item responses. Approximately equal numbers of Whites, African Americans, and American Indians (total N=563) with diabetes were recruited into the study from rural areas in North Carolina. The Common Sense Model of Diabetes Inventory, which contained 31 items across six clinical domains, was administered to the participants at baseline and then one month later. Concordance between responses was analyzed using item response theory. Item-level analysis revealed that items in the domains of Causes of Diabetes and Medical Management of Diabetes were less reliable compared to items from other domains. Person-level analysis showed that respondents who held views congruent with the biomedical model were more consistent than people who did not. Item response theory facilitates a process to evaluate item unreliability and differences in distinguishing response consistency. People with diabetes who had beliefs regarding diabetes not congruent with the biomedical model tended to be less stable in their beliefs and should be more amenable to diabetes education and other interventions.
PMCID: PMC4004728  PMID: 24170016
diabetes; common sense model; reliability; concordance; response consistency; item response theory
8.  American-Indian diabetes mortality in the Great Plains Region 2002–2010 
To compare American-Indian and Caucasian mortality rates from diabetes among tribal Contract Health Service Delivery Areas (CHSDAs) in the Great Plains Region (GPR) and describe the disparities observed.
Research design and methods
Mortality data from the National Center for Vital Statistics and Seer*STAT were used to identify diabetes as the underlying cause of death for each decedent in the GPR from 2002 to 2010. Mortality data were abstracted and aggregated for American-Indians and Caucasians for 25 reservation CHSDAs in the GPR. Rate ratios (RR) with 95% CIs were used and SEER*Stat V.8.0.4 software calculated age-adjusted diabetes mortality rates.
Age-adjusted mortality rates for American-Indians were significantly higher than those for Caucasians during the 8-year period. In the GPR, American-Indians were 3.44 times more likely to die from diabetes than Caucasians. South Dakota had the highest RR (5.47 times that of Caucasians), and Iowa had the lowest RR, (1.1). Reservation CHSDA RR ranged from 1.78 to 10.25.
American-Indians in the GPR have higher diabetes mortality rates than Caucasians in the GPR. Mortality rates among American-Indians persist despite special programs and initiatives aimed at reducing diabetes in these populations. Effective and immediate efforts are needed to address premature diabetes mortality among American-Indians in the GPR.
PMCID: PMC4405614  PMID: 25926992
Mortality; Quantitative Methods; Native Americans
9.  Older Adults’ Use of Care Strategies in Response to General and Upper Respiratory Symptoms 
This study examined the use of complementary and medical treatments, both individually and in combination, to address common general and upper respiratory symptoms. Data for the analysis were collected from a series of 18 daily diary questionnaires administered to community-living older African American and white adults living in rural counties in North Carolina. Participants reported symptoms experienced on each diary day and the treatment strategies they used each day in response to the particular symptom(s). Older adults used diverse categories of strategies to treat symptoms; treatment strategies were used inconsistently across symptoms. Use of only complementary strategies, only medical conventional strategies, or both complementary and medical strategies to treat any one symptom rarely corresponded to the use of the same strategy to address other symptoms. Future research would benefit from analyzing how older adults use health care strategies across symptom categories.
PMCID: PMC4102662  PMID: 24652871
aging; complementary medicine; self-care; older adults; rural
10.  Prevalence of Type 1 and Type 2 Diabetes Among Children and Adolescents From 2001 to 2009 
JAMA  2014;311(17):1778-1786.
Despite concern about an “epidemic,” there are limited data on trends in prevalence of either type 1 or type 2 diabetes across US race and ethnic groups.
To estimate changes in the prevalence of type 1 and type 2 diabetes in US youth, by sex, age, and race/ethnicity between 2001 and 2009.
Case patients were ascertained in 4 geographic areas and 1 managed health care plan. The study population was determined by the 2001 and 2009 bridged-race intercensal population estimates for geographic sites and membership counts for the health plan.
Prevalence (per 1000) of physician-diagnosed type 1 diabetes in youth aged 0 through 19 years and type 2 diabetes in youth aged 10 through 19 years.
In 2001, 4958 of 3.3 million youth were diagnosed with type 1 diabetes for a prevalence of 1.48 per 1000 (95% CI, 1.44–1.52). In 2009, 6666 of 3.4 million youth were diagnosed with type 1 diabetes for a prevalence of 1.93 per 1000 (95% CI, 1.88–1.97). In 2009, the highest prevalence of type 1 diabetes was 2.55 per 1000 among white youth (95% CI, 2.48–2.62) and the lowest was 0.35 per 1000 in American Indian youth (95% CI, 0.26–0.47) and type 1 diabetes increased between 2001 and 2009 in all sex, age, and race/ethnic subgroups except for those with the lowest prevalence (age 0–4 years and American Indians). Adjusted for completeness of ascertainment, there was a 21.1% (95% CI, 15.6%–27.0%) increase in type 1 diabetes over 8 years. In 2001, 588 of 1.7 million youth were diagnosed with type 2 diabetes for a prevalence of 0.34 per 1000 (95% CI, 0.31–0.37). In 2009, 819 of 1.8 million were diagnosed with type 2 diabetes for a prevalence of 0.46 per 1000 (95% CI, 0.43–0.49). In 2009, the prevalence of type 2 diabetes was 1.20 per 1000 among American Indian youth (95% CI, 0.96–1.51); 1.06 per 1000 among black youth (95% CI, 0.93–1.22); 0.79 per 1000 among Hispanic youth (95% CI, 0.70–0.88); and 0.17 per 1000 among white youth (95% CI, 0.15–0.20). Significant increases occurred between 2001 and 2009 in both sexes, all age-groups, and in white, Hispanic, and black youth, with no significant changes for Asian Pacific Islanders and American Indians. Adjusted for completeness of ascertainment, there was a 30.5% (95% CI, 17.3%–45.1%) overall increase in type 2 diabetes.
Between 2001 and 2009 in 5 areas of the United States, the prevalence of both type 1 and type 2 diabetes among children and adolescents increased. Further studies are required to determine the causes of these increases.
PMCID: PMC4368900  PMID: 24794371
11.  Relative validity and reliability of a food frequency questionnaire in youth with type 1 diabetes 
Public health nutrition  2014;18(3):428-437.
To evaluate the relative validity and reliability of the SEARCH food frequency questionnaire (FFQ) that was modified from the Block Kids Questionnaire.
Study participants completed the 85-item FFQ twice plus three 24-hour dietary recalls within one month. We estimated correlations between frequencies obtained from participants with true usual intake for food groups and nutrients, using a two-part model for episodically-consumed foods and measurement error adjustment.
The multi-center SEARCH for Diabetes in Youth Nutrition Ancillary Study.
A subgroup of 172 participants aged 10 - 24 years with type 1 diabetes.
The mean correlations adjusted for measurement error of food groups and nutrients between FFQ and true usual intake were 0.41 and 0.38, respectively, with 57% of the food groups and 70% of the nutrients exhibiting correlations >0.35. Correlations were high for low-fat dairy (0.80), sugar-sweetened beverages (0.54), cholesterol (0.59) and saturated fat (0.51), while correlations were poor for high fiber bread and cereal (0.16) and folate (0.11). Reliability of FFQ intake based on two FFQ administrations was also reasonable with 54% of Pearson correlation coefficients ≥ 0.5. Reliability was high for low fat dairy (0.7), vegetables (0.6), carbohydrates, fiber, folate and vitamin C (all 0.5), but less than desirable for low fat poultry and high fiber bread, cereal, rice and pasta (0.2-0.3).
While there is some room for improvement, our findings suggest that the SEARCH FFQ performs quite well for the assessment of many nutrients and food groups in a sample of youth with type 1 diabetes.
PMCID: PMC4353637  PMID: 24679679
Food frequency questionnaire validation; reliability; youth; diabetes mellitus
12.  Patterns and Stability over Time of Older Adults’ Diabetes-related Beliefs 
We sought to identify coherent profiles of diabetes beliefs within discrete domains (ie causes, symptoms, consequences, self management, and medical management), and delineate consistency of belief profiles over one month.
Diabetes beliefs of rural-dwelling older adults were assessed with the Common Sense Model of Diabetes Inventory at baseline (N = 593) and one month later (N = 563).
A discrete number of belief patterns were identified in each belief domain using latent class analysis. Belief patterns varied by the extent to which more popular or folk notions of diabetes encroached on biomedical understandings of the disease. Belief patterns were generally stable over time.
A manageable number of belief patterns can be identified and used to strengthen patient-centered care and, potentially, enhance diabetes management.
PMCID: PMC4190851  PMID: 25309938
Common Sense Model of Illness; diabetes beliefs; type 2 diabetes; older adultst
13.  Peripheral Neuropathy in Adolescents and Young Adults With Type 1 and Type 2 Diabetes From the SEARCH for Diabetes in Youth Follow-up Cohort 
Diabetes Care  2013;36(12):3903-3908.
To estimate the prevalence of and risk factors for diabetic peripheral neuropathy (DPN) in a pilot study among youth participating in the SEARCH for Diabetes in Youth study.
DPN was assessed using the Michigan Neuropathy Screening Instrument (MNSI) (examination for foot abnormalities, distal vibration perception, and ankle reflexes). An MNSI exam (MNSIE) score >2 is diagnostic for DPN.
The MNSIE was completed in 399 subjects, including 329 youth with type 1 diabetes (mean age 15.7 ± 4.3 years, duration 6.2 ± 0.9 years) and 70 with type 2 diabetes (mean age 21.6 ± 4.1 years, duration 7.6 ± 1.8 years). Glycated hemoglobin (A1C) was similar in both groups (8.8 ± 1.8% for type 1 vs. 8.5 ± 2.9% for type 2). The prevalence of DPN was significantly higher in youth with type 2 compared with those with type 1 diabetes (25.7 vs. 8.2%; P < 0.0001). In unadjusted analyses, diabetes type, older age, longer duration of diabetes, increased waist circumference, elevated blood pressure, lower HDL cholesterol, and presence of microalbuminuria (urinary albumin-to-creatinine ratio >30 mg/g) were associated with DPN. The association between diabetes type and DPN remained significant after adjustment for age and sex (odds ratio 2.29 [95% CI 1.05–5.02], P = 0.03).
DPN prevalence among youth with type 2 diabetes approached rates reported in adult populations with diabetes. Our findings suggest not only that youth with diabetes are at risk for DPN but also that many already show measurable signs of DPN.
PMCID: PMC3836139  PMID: 24144652
14.  Self-Reported Sleep Difficulties and Self-Care Strategies Among Rural Older Adults 
This study examined the use of self-care strategies to address difficulty sleeping among community-dwelling older adults. Data were collected from a series of 18 questionnaires administered to 195 rural African American and white older adults in North Carolina. Participants reported whether they had experienced difficulty sleeping and strategies used to respond to the symptom. The most widely used strategies included ignoring the symptom, staying in bed or resting, and praying. Herb and supplement use were not reported. Ethnicity, income, and education were associated with use of specific self-care strategies for sleep. This variation suggests that older adults may draw on cultural understandings to interpret the significance of difficulty sleeping and influence their use of self-care strategies, including complementary and alternative medicine use. This information may enable health care providers to communicate with the older patients about sleep difficulty strategies to minimize sleep problems.
PMCID: PMC4240534  PMID: 24647377
older adults; sleep; self-care
15.  Older Adults’ Fears about Diabetes: Using Common Sense Models of Disease to Understand Fear Origins and Implications for Self-Management 
This study examines older adults’ fears of diabetes complications and their effects on self-management practices. Existing models of diabetes self-management posit that patients’ actions are grounded in disease beliefs and experience, but there is little supporting evidence. In-depth qualitative interviews were conducted with a community-based sample of 74 African American, American Indian, and white older adults with diabetes. Analysis uses Leventhal’s Common Sense Model of Diabetes to link fears to early experience and current self-management. Sixty-three identified fears focused on complications that could limit carrying out normal activities: amputation, blindness, low blood glucose and coma, and disease progression to insulin use and dialysis. Most focused self-management on actions to prevent specific complications, rather than on managing the disease as a whole. Early experiences focused attention on the inevitability of complications and the limited ability of patients to prevent them. Addressing older adults’ fears about diabetes may improve their diabetes self-management practices.
PMCID: PMC4212900  PMID: 25364096
Rural; qualitative methods; common sense model
16.  Sleep Problems, Suicidality and Depression among American Indian Youth 
Study background
Mental health and sleep problems are important public health concerns among adolescents yet little is known about the relationship between sleep, depressive symptoms, and suicidality among American Indian youth.
This study examined the impact of sleep and other factors on depressive symptoms and suicidality among Lumbee American Indian adolescents (N=80) ages 11–18.
At the bivariate level, sleepiness, was associated with depression but not with suicidality. Time in bed (TIB) was not associated with depression, but more TIB decreased the likelihood of suicidality. Higher levels of depressive symptoms were associated with increased likelihood of suicidality. At the multivariate level, sleepiness, suicidality, and self-esteem were associated with depression. TIB and depressive symptoms were the only variables associated with suicidality.
In working with American Indian youth, it may be helpful to consider sleep patterns as part of a comprehensive assessment process for youth who have or are at risk for depression and suicide.
PMCID: PMC4191909  PMID: 25309936
Depression; Suicide; Sleep problems; Adolescents; American indians
17.  Correlates of Physician Trust Among Rural Older Adults with Diabetes 
To examine the demographic, health and diabetes management correlates of physicians trust in a rural, multi-ethnic population with diabetes.
563 older (≥60 years) African American, American Indian and White adults completed in-home surveys, including the 11-item General Trust in Physicians Scale.
Higher trust scores were seen among: older (≥75) participants (p < .01), those with fewer (<3) chronic health conditions (p < .01), and those who adhered to physical activity (p < .05) and dilated eye exam (p < .01) guidelines; the latter remained significant (eye exam, p = .019) or approached significance (physical activity, p = .051) after adjustment for potential confounders.
Physician trust may influence patient adherence to diabetes management recommendations. Efforts should be made to build trust in the patient-provider relationship to enhance patient outcomes.
PMCID: PMC3761406  PMID: 23985289
physician trust; diabetes self-management; rural older adults; ethnic minority populations
Although bullying has been linked to suicide among youth, little is known about bullying in American Indians, a population at high risk for suicide. Qualitative data from focus groups with Lumbee Indian youth (N = 31, 16 males, 15 females, 12–17 years of age) and in-depth interviews with gatekeepers in the Lumbee community revealed that bullying is common, and is perceived to contribute to depression and suicide. Youth expressed powerlessness to overcome bullying. Survey data (N = 79, 32 males, 47 females, 11–18 years of age) showed that bullied youth (11.5%) had lower self-esteem and higher levels of depressive symptoms. Interventions are needed to address this behavior that contributes to poor psychosocial health in Lumbee youth.
PMCID: PMC4094365  PMID: 24788918
19.  Diabetes Self-Management Education Patterns in a US Population-based Cohort of Youth with Type 1 Diabetes 
The Diabetes educator  2013;40(1):29-39.
The purpose of this study is to describe: 1) the receipt of diabetes self-management education (DSME) in a large, diverse cohort of US youth with type 1 diabetes (T1DM); 2) the segregation of self-reported DSME variables into domains; and 3) the demographic and clinical characteristics of youth who receive DSME.
Data are from the US population-based cohort, SEARCH for Diabetes in Youth. A cross-sectional analysis was employed using data from 1273 youth < 20 years of age at time of diagnosis of T1DM. Clusters of 19 self-reported DSME variables were derived using factor analysis and their associations with demographic and clinical characteristics were evaluated using polytomous logistic regression.
Nearly all participants reported receiving DSME content consistent with ‘survival skills’ (e.g., target blood glucose and what to do for low or high blood glucose), yet gaps in continuing education were identified [e.g., fewer than half of participants reported receiving specific medical nutrition therapy (MNT) recommendations]. Five DSME clusters were explored: Receipt of Specific MNT Recommendations, Receipt of Diabetes Information Resources, Receipt of Clinic Visit Information, Receipt of Specific Diabetes Information, and Met with Educator or Nutritionist. Factor scores were significantly associated with demographic and clinical characteristics, including race/ethnicity, socioeconomic status, and diabetes self-management practices.
Health care providers should work together to address reported gaps in DSME in order to improve patient care.
PMCID: PMC4076934  PMID: 24248833
20.  Attitudes of Older Adults Regarding Disclosure of Complementary Therapy Use to Conventional Physicians 
Many older adults use complementary therapies in health self-management but do not disclose this use to their physicians. This paper examines factors affecting disclosure of complementary therapy use, and it considers ethnic and gender differences in disclosure. It is based on a systematic qualitative analysis of in-depth interviews conducted with 62 African American and White adults aged 65 and older. Twenty-three of the 39 older adults who acknowledge using complementary therapies disclose this to their physicians. Themes leading to disclosure are believing that physicians are supportive and the importance of sharing information. Themes for not disclosing complementary therapy use include physicians’ negative views, complementary therapy use affecting physicians’ incomes, and the need to protect cultural knowledge. African American women were least likely to disclose use. Disclosure by elders to their physicians is a complex decision process. Medical encounters, including decisions regarding information to disclose, are embedded in broader social structures.
PMCID: PMC4076141  PMID: 24991082
Complementary therapies; patient-provider communication; minority aging
21.  Traditional and Commercial Herb Use in Health Self-Management among Rural Multiethnic Older Adults 
This study analyzes the role of traditional and commercial herbs in older adults’ health self-management based on Leventhal’s Self-Regulatory Model conceptual framework. Sixty-two African American and white adults age 65 and older completed qualitative interviews describing the forms of herbs currently being used, sources of information about them, interpretations of health (acute symptoms or chronic conditions) that lead to their use, and the initiation and suspension of use. Traditional herbs are native to the region or have been traditionally cultivated; usually taken raw or boiled to produce tea; and used for treating mild symptoms. Commercial herbs are prepared as pills, extracts, or teas; they are purchased at local stores or ordered by catalog or internet; and used for health promotion, illness prevention or treatment of chronic conditions. Herbs are widely used among older adults; this analysis differentiates the types of herbs they use and their reasons for herbs use.
PMCID: PMC4076146  PMID: 24991081
Complementary therapies; herbal remedies; rural aging; minority aging
22.  Relationship Between Nonprescribed Therapy Use for Illness Prevention and Health Promotion and Health-Related Quality of Life 
This study describes the nonprescribed therapy use (prayer, over-the-counter medications [OTC's], home remedies, vitamins, herbs and supplements, and exercise) for health promotion among rural elders. It also delineates the association of such therapy use with physical and mental health-related quality of life (HRQoL).
The sample (N = 200) consisted of African American and White elders from south-central North Carolina. Participants completed baseline interviews and repeated measures of nonprescribed therapy use over a 6-month follow-up.
Prayer had the highest percentage (80.7%) of use for health promotion followed by OTC (54.3%); vitamins only (49.3%); herbs and supplements (40.5%); exercise (31.9%); and home remedies (5.2%). Exercise was significantly associated with better physical HRQoL (p < .05). However, elders who used nonprescribed therapies had poorer mental HRQoL than nonusers, adjusting for potential confounders.
This analysis suggests that use of some nonprescribed therapies for health promotion is associated with poorer mental HRQoL.
PMCID: PMC4059179  PMID: 24781966
nonprescribed therapy use; health-related quality of life (HRQoL)
23.  Assessment of a Short Diabetes Knowledge Instrument for Older and Minority Adults 
The Diabetes educator  2013;40(1):68-76.
The purpose of the study was to assess the performance of a short diabetes knowledge instrument (SDKI) in a large multi-ethnic sample of older adults with diabetes and to identify possible modifications to improve its ability to document diabetes knowledge.
Research Design and Methods
A sample of 593 African American, American Indian, and white female and male adults 60 years and older, with diabetes diagnosed at least two years prior, was recruited from eight North Carolina counties. All completed an interview that included a 16-item questionnaire to assess diabetes knowledge. A subsample of 46 completed the questionnaire a second time at a subsequent interview. Item-response analysis was used to refine the instrument to well-performing items. The instrument consisting of the remaining items was subjected to analyses to assess validity and test-retest reliability.
Three items were removed after item-response analysis. Scores for the resulting instrument were lower among minority and older participants, as well as those with lower educational attainment and income. Scores for test-retest were highly correlated.
The SDKI (13 item questionnaire) appears to be a valid and reliable instrument to evaluate knowledge about diabetes. Assessment in a multi-ethnic sample of older adults suggests that this instrument can be used to measure diabetes knowledge in diverse populations. Further evaluation is needed to determine whether or not this instrument can detect changes in knowledge resulting from diabetes education or other interventions.
PMCID: PMC3946961  PMID: 24163359
24.  Lessons Learned in Community Research Through The Native Proverbs 31 Health Project 
American Indian women have high rates of cardiovascular disease largely because of their high prevalence of hypertension, diabetes, and obesity. This population has high rates of cardiovascular disease-related behaviors, including physical inactivity, harmful tobacco use, and a diet that promotes heart disease. Culturally appropriate interventions are needed to establish health behavior change to reduce cardiovascular disease risk.
Community Context
This study was conducted in Robeson County, North Carolina, the traditional homeland of the Lumbee Indian tribe. The study’s goal was to develop, deliver, and evaluate a community-based, culturally appropriate cardiovascular disease program for American Indian women and girls.
Formative research, including focus groups, church assessments, and literature reviews, were conducted for intervention development. Weekly classes during a 4-month period in 4 Lumbee churches (64 women and 11 girls in 2 primary intervention churches; 82 women and 8 girls in 2 delayed intervention churches) were led by community lay health educators. Topics included nutrition, physical activity, and tobacco use cessation and were coupled with messages from the Proverbs 31 passage, which describes the virtuous, godly woman. Surveys collected at the beginning and end of the program measured programmatic effects and change in body mass index.
Churches were very receptive to the program. However, limitations included slow rise in attendance, scheduling conflicts for individuals and church calendars, and resistance to change in cultural traditions.
Churches are resources in developing and implementing health promotion programs in Christian populations. Through church partnerships, interventions can be tailored to suit the needs of targeted groups.
PMCID: PMC3992295  PMID: 24742392
25.  Metabolic and Inflammatory Links to Depression in Youth With Diabetes 
Diabetes Care  2012;35(12):2443-2446.
Youth with diabetes are at increased risk for depression. The objectives of this study were to provide preliminary evidence that this at-risk status for depression is associated with metabolic and inflammatory markers and to inform future, more stringent examinations of the directionality of these associations.
Data from SEARCH for Diabetes in Youth (SEARCH), an observational study of U.S. children diagnosed with diabetes at <20 years of age, were used for these analyses. SEARCH participants were drawn from four geographically defined populations in Ohio, Washington, South Carolina, and Colorado; health plan enrollees in Hawaii and California; and Indian Health Service beneficiaries from four Native American populations. Participants were 2,359 youth with diabetes from the 2001 prevalent and 2002–2004 incident SEARCH cohorts. Depression was measured with the Center for Epidemiologic Studies Depression scale. Eight metabolic and inflammatory markers were measured: adiponectin, leptin, C-reactive protein, serum amyloid A, apolipoprotein B (apoB), lipoprotein A, interleukin-6, and LDL.
Six of eight markers were significantly (P < 0.006) associated with depression in youth with diabetes in bivariate analyses. In general, higher levels of depression were associated with indicators of worse metabolic or inflammatory functioning. In regression models stratified by diabetes type and accounting for demographic and clinical characteristics, only higher levels of apoB remained associated with higher levels of depression in youth with type 1 diabetes.
These data suggest that depression reported by youth with diabetes is partially associated with metabolic abnormalities and systemic inflammation.
PMCID: PMC3507554  PMID: 23033243

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