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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
2.  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
3.  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
4.  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
5.  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)
6.  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
7.  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
8.  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
9.  Mentoring Programs for Underrepresented Minority Faculty in Academic Medical Centers: A Systematic Review of the Literature 
Mentoring is critical for career advancement in academic medicine. However, underrepresented minority (URM) faculty often receive less mentoring than their nonminority peers. The authors conducted a comprehensive review of published mentoring programs designed for URM faculty to identify “promising practices.”
Databases (PubMed, PsycINFO, ERIC, PsychLit, Google Scholar, Dissertations Abstracts International, CINHAL, Sociological Abstracts) were searched for articles describing URM faculty mentoring programs. The RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance) formed the model for analyzing programs.
The search identified 73 citations. Abstract reviews led to retrieval of 38 full-text articles for assessment; 18 articles describing 13 programs were selected for review. The reach of these programs ranged from 7 to 128 participants. Most evaluated programs on the basis of the number of grant applications and manuscripts produced or satisfaction with program content. Programs offered a variety of training experiences, and adoption was relatively high, with minor changes made for implementing the intended content. Barriers included time-restricted funding, inadequate evaluation due to few participants, significant time commitments required from mentors, and difficulty in addressing institutional challenges faced by URM faculty. Program sustainability was a concern because programs were supported through external funds, with minimal institutional support.
Mentoring is an important part of academic medicine, particularly for URM faculty who often experience unique career challenges. Despite this need, relatively few publications exist to document mentoring programs for this population. Institutionally supported mentoring programs for URM faculty are needed, along with detailed plans for program sustainability.
PMCID: PMC3835658  PMID: 23425989
10.  Medical Skepticism and Complementary Therapy Use among Older Rural African-Americans and Whites 
Journal of health care for the poor and underserved  2013;24(2):10.1353/hpu.2013.0052.
This study documents demographic, health, and complementary therapy (CT) correlates of medical skepticism among rural older adults.
Older (≥65 years) African Americans and Whites in rural North Carolina (N=198) were interviewed. Medical skepticism was assessed using the four items from the Medical Expenditure Survey. Bivariate associations between medical skepticism and demographic and health characteristics and CT use were assessed, and independent effects on CT use.
Positive responses to medical skepticism questions ranged from 19.7% (can overcome illness without help) to 59.6% (believes own behavior determines their health). Medical skepticism indicators were associated with few demographic and health characteristics, and one CT category.
This study shows a high degree of medical skepticism among rural older adults, but limited associations with demographic and health characteristics and CT use. Further research is needed to understand relationships of attitudes towards conventional care and CT use in this population.
PMCID: PMC3830528  PMID: 23728044
Medical skepticism; complementary therapies; rural older adults; African Americans
11.  Patterns of Complementary Therapy Use for Symptom Management for Older Rural Adults with Diabetes 
Studies on complementary therapy use among adults with diabetes are limited by crude use measures and lack of specificity of use for treating diabetes. Data are from a study including baseline and repeated 3-day assessments of complementary therapy use among rural African American and White older (age ≥64) adults (n=71). Most commonly used complementary therapies for diabetes at baseline included prayer (88.7%), food/beverages (50.7%), herbs (11.3%) and home remedies (9.9%). In repeated measures (1131 interviews), prayer was used on 57.2% of days, followed by food/beverages (12.7%), herbs (3.4%) and home remedies (2.7%). 56.3% who reported praying did so on ≥5 reporting periods; other complementary therapy use was sporadic. These data show, with the exception of prayer and food/beverages, limited complementary therapy use for diabetes treatment among rural older adults, and less inconsistent use patterns of most complementary therapies. Further research is needed to understand the motivations and patterns of complementary therapy use for diabetes patients.
PMCID: PMC3826981  PMID: 24244893
Complementary Therapy Use; Diabetes Mellitus; Rural Older Adults
12.  The Association of Mental Conditions with Blood Glucose Levels in Older Adults with Diabetes 
Aging & mental health  2012;16(8):950-957.
People with diabetes must engage in several self-care activities to manage blood glucose; cognitive function and other affective disorders may affect self-care behaviors. We examined the executive function domain of cognition, depressive symptoms, and symptoms of generalized anxiety disorder (GAD) to determine which common mental conditions that can co-occur with diabetes are associated with blood glucose levels.
We conducted a cross-sectional in-person survey of 563 rural older adults (age 60 years or older) with diabetes that included African Americans, American Indians, and Whites from eight counties in south-central North Carolina. Hemoglobin A1C (A1C) was measured from a finger-stick blood sample to assess blood glucose control. Executive function, depressive symptoms, and symptoms of GAD were assessed using established measures and scoring procedures. Separate multivariate linear regression models were used to examine the association of executive function, depressive symptoms, and symptoms of GAD with A1C.
Adjusting for potential confounders including age, gender, education, ethnicity, marital status, history of stroke, heart disease, hypertension, diabetes knowledge, and duration of diabetes, executive function was significantly associated with A1C levels: every one-unit increase in executive function was associated with a 0.23 lower A1C value (p = 0.02). Symptoms of depression and GAD were not associated with A1C levels.
Low executive function is potentially a barrier to self-care, the cornerstone of managing blood glucose levels. Training aids that compensate for cognitive impairments may be essential for achieving effective glucose control.
PMCID: PMC3434257  PMID: 22640032
A1C; cognitive function; depression; anxiety; aging
13.  Daily Symptom Management Practices for Arthritis Used by Older Adults 
Journal of aging and health  2011;24(4):598-615.
This article describes the daily self-management practices of older adults with arthritis and examines the association of symptom experience with the use of self-management behaviors.
197 African American and White participants completed a baseline interview and six sets of three follow-up daily-diary interviews at monthly intervals.
Arthritis was reported by 63.5%. Arthritis self-management reported included complementary therapies, over-the-counter (OTC) and prescription medications, foods or beverages, and home remedies. Odds of implementing these self-care practices were greater on days with joint pain, swelling, and stiffness. Although, 78.0% and 72.4% of all participants reported staying in bed or cutting back on activities in response to joint symptoms, these self-management activities were not associated with having arthritis.
Focusing on daily responses to symptoms demonstrates that older adults actively manage arthritis symptoms using a wide variety of measures, including complementary therapies.
PMCID: PMC3805964  PMID: 22173224
self-care; rural; complementary and alternative medicine; daily diary method
14.  “Culture” in Diabetes-Related Beliefs among Low- and High-Education African American, American Indian, and White Older Adults 
Ethnicity & disease  2012;22(4):466-472.
Racial and ethnic disparities in diabetes and subsequent complications are often attributed to culture; however, previous diabetes disparities research is restricted to in-depth ethnic-specific samples or to comparative study designs with limited belief assessment. The goal of this study is to improve understanding of the cultural basis for variation in diabetes beliefs.
Rural North Carolina
Older adults (aged 60+) with diabetes, equally divided by ethnicity (White, African American, American Indian) and gender (N=593).
Guided by Explanatory Models of Illness and Cultural Consensus research traditions, trained interviewers collected data using 38 items in four diabetes belief domains: causes, symptoms, consequences, and medical management. Items were obtained from the Common Sense Model of Diabetes Inventory (CSMDI).
Main Outcome
Beliefs about diabetes. Response options for each diabetes belief item were “agree,” “disagree” and “don’t know”. Collected data were analyzed using Anthropac (version 4.98) and Latent Gold (version 4.5) programs.
There is substantial similarity in diabetes beliefs among African Americans, American Indians, and Whites. Diabetes beliefs were most similar in the “symptoms” and “consequences” domains compared to beliefs pertaining to “causes” and “medical management.” Although some discrete beliefs differed by ethnicity, systematic differences by ethnicity were observed for specific educational groups.
Socioeconomic conditions influence diabetes beliefs rather than “ethnicity” per se.
PMCID: PMC3510461  PMID: 23140078
Diabetes Beliefs; Explanatory Models of Illness; Cultural Consensus; Ethnic Differences; Health Disparities
15.  Tools for Healthy Tribes 
American journal of preventive medicine  2012;43(3 Suppl 2):S123-S129.
There is growing recognition that policymakers can promote access to healthy, affordable foods within neighborhoods, schools, childcare centers, and workplaces. Despite the disproportionate risk of obesity and type 2 diabetes among American Indian children and adults, comparatively little attention has been focused on the opportunities tribal policymakers have to implement policies or resolutions to promote access to healthy, affordable foods. This paper presents an approach for integrating formative research into an action-oriented strategy of developing and disseminating tribally led environmental and policy strategies to promote access to and consumption of healthy, affordable foods. This paper explains how the American Indian Healthy Eating Project evolved through five phases and discusses each phase’s essential steps involved, outcomes derived, and lessons learned.
Using community-based participatory research and informed by the Social Cognitve Theory and ecologic frameworks, the American Indian Healthy Eating Project was started in fall 2008 and has evolved through five phases: (1) starting the conversation; (2) conducting multidisciplinary formative research; (3) strengthening partnerships and tailoring policy options; (4) disseminating community-generated ideas; and (5) accelerating action while fostering sustainability. Collectively, these phases helped develop and disseminate Tools for Healthy Tribes—a toolkit used to raise awareness among participating tribal policymakers of their opportunities to improve access to healthy, affordable foods. Formal and informal strategies can engage tribal leaders in the development of culturally appropriate and tribe-specific sustainable strategies to improve such access, as well as empower tribal leaders to leverage their authority toward raising a healthier generation of American Indian children.
PMCID: PMC3431552  PMID: 22898161
16.  Cognitive function is a risk for health literacy in older adults with diabetes 
Cognitive impairment is common in older adults with diabetes, yet it is unclear to what extent cognitive function is associated with health literacy. We hypothesized that cognitive function, independent of education, is associated with health literacy.
The sample included 537 African American, American Indian, and White men and women 60 years or older. Measures of cognitive function included the Mini-Mental State Examination (MMSE), Verbal Fluency, Brief Attention, and Digit Span Backward tests. Health literacy was assessed using the S-TOFHLA.
Cognitive function was associated with health literacy, independent of education and other important confounders. Every unit increase in the MMSE, Digit Span Backward, Verbal Fluency or Brief Attention was associated with a 20% (p<.001), 34% (p<.001), 5% (p<.01), and 16% (p<.01) increase in the odds of having adequate health literacy, respectively.
These results suggest that cognitive function is associated with health literacy in older adults with diabetes. Because poor cognitive function may undermine health literacy, efforts to target older adults on improving health literacy should consider cognitive function as a risk factor.
PMCID: PMC3742688  PMID: 23806477
cognition; health literacy; diabetes
17.  Older Adults' Self-Management of Daily Symptoms: Complementary Therapies, Self-Care, and Medical Care 
Journal of aging and health  2011;24(4):569-597.
To describe older adults' use of complementary therapies, self-care practices, and medical care to treat daily symptoms and to delineate gender, ethnic, age, and education differences.
A total of 200 African American and White participants (age 65+) selected using a site-based procedure complete a baseline interview and up to six sets of three daily follow-up interviews at monthly intervals. The percent of older adults using a therapy and the frequency with which therapies are used are considered.
The use of complementary therapies to treat daily symptoms, though important, is substantially less than the use of self-care practices and medical care. Participants differed by age, ethnicity, and education in the use of therapies.
In considering the percentage of individuals who use a therapy and the frequency with which therapies are used, this analysis adds a new dimension to understanding how older adults manage daily symptoms. Older adults are selective in their use of health self-management.
PMCID: PMC3707926  PMID: 22187091
health self-management; complementary therapies; rural aging
18.  Dental Care Utilization among North Carolina Rural Older Adults 
This analysis delineates the predisposing, need, and enabling factors that are significantly associated with regular and recent dental care in a multi-ethnic sample of rural older adults.
A cross-sectional comprehensive oral health survey conducted with a random, multi-ethnic (African American, American Indian, white) sample of 635 community-dwelling adults aged 60 years and older was completed in two rural southern counties.
Almost no edentulous rural older adults received dental care. Slightly more than one-quarter (27.1%) of dentate rural older adults received regular dental care and slightly more than one-third (36.7%) received recent dental care. Predisposing (education) and enabling (regular place for dental care) factors associated with receiving regular and recent dental care among dentate participants point to greater resources being the driving force in receiving dental care. Contrary to expectations of the Behavioral Model of Health Services, those with the least need (e.g., better self-rated oral health) received regular dental care; this has been referred to as the Paradox of Dental Need.
Regular and recent dental care are infrequent among rural older adults. Those not receiving dental care are those who most need care. Community access to dental care and the ability of older adults to pay for dental care must be addressed by public health policy to improve the health and quality of life of older adults in rural communities.
PMCID: PMC3429793  PMID: 22536828
dental care utilization; aging; gerontology; rural health; minority health; public health policy
19.  The Relationship between Cognitive Function and Non-Prescribed Therapy Use in Older Adults 
Aging & mental health  2012;16(5):648-658.
To examine the association of cognitive function with use of non-prescribed therapies for managing acute and chronic conditions, and to determine whether use of non-prescribed therapies changes over time in relation to baseline cognitive function.
200 community-dwelling adults aged 65 and older were recruited from three counties in south central North Carolina. Repeated measures of daily symptoms and treatment were collected on three consecutive days at intervals of at least one month. The Mini-Mental State Examination (MMSE), the primary cognitive measure, was collected as part of the baseline survey. Data were collected on the daily use of common non-prescribed therapies (use of prayer, ignore symptoms, over-the-counter remedies, food and beverage therapies, home remedies, and vitamin, herb, or supplements) on each of the three days of the follow-up interviews for up to six consecutive months.
Older adults with poorer cognitive function were more likely to pray and ignore symptoms on days that they experienced acute symptoms. Poorer cognitive function was associated with increased use of home remedies for treating symptoms related to existing chronic conditions.
Cognitive function may play a role in why older patients use some non-prescribed therapies in response to acute and chronic conditions.
PMCID: PMC3346852  PMID: 22304694
cognitive function; self health management; health services
20.  Gender and Health Lifestyle: An In-Depth Exploration of Self-Care Activities in Later Life 
Evaluate similarities and differences in the self-care domain of health lifestyle among older, rural dwelling women and men.
Qualitative analysis of in-depth interview data from 62 community-dwelling older (M = 74.3 years) African and European American women and men.
Both older women and men rely heavily on over-the-counter (OTC) medications and home remedies self-care; professional health care is typically sought when self-care is not effective. However, relative to men, women were more knowledgeable about different approaches to self-care, especially home remedies, they used a wider range of self-care activities, and they placed greater priority on self-care over professional health care.
The structure of older women’s and men’s self-care domain of health lifestyle is similar. However, there are subtle differences in health lifestyle that are likely embedded in gendered role behavior and may contribute to women’s greater health complaints.
PMCID: PMC3693089  PMID: 21632439
21.  Ethnic Variation in Oral Health and Social Integration among Older Rural Adults 
This analysis examines the associations of oral health with social integration among ethnically diverse (African American, American Indian, white) rural older adults. Data are from a cross-sectional survey of 635 randomly selected community-dwelling adults aged 60+. Measures include self-rated oral health, number of teeth, number of oral health problems, social engagement, and social network size. Minority elders have poorer oral health than do white older adults. Most rural elders have substantial social engagement and social networks. Better oral health (greater number of teeth) is directly associated with social engagement, while the relationship of oral health to social network size is complex. The association of oral health with social engagement does not differ by ethnicity. Poorer oral health is associated with less social integration among African American, American Indian and white elders. More research on the ways oral health affects the lives of older adults is warranted.
PMCID: PMC3685432  PMID: 23788829
Oral health disparities; social engagement; social network; rural aging
22.  Daily Use of Complementary and Other Therapies for Symptoms among Older Adults: Study Design and Illustrative Results 
Journal of aging and health  2010;23(1):52-69.
This paper describes research designed to specify complementary therapies used among older adults by obtaining daily use data and the specific purposes for use.
Two-hundred African American and white participants completed a baseline interview and up to six sets of three daily-diary interviews at monthly intervals.
Participants provided retrospective information on complementary therapy use, and information on the use of therapies for specific symptoms experienced across 3,070 person days. Retrospective information indicated that most participants used complementary therapies (e.g., 85.0% used home remedies in the past year). The use of complementary or other therapies and the number of days the therapies were used varied for specific symptoms. For example, home remedies were used on 86 (9.1%) of the 944 person days for which joint pain was reported.
The daily-diary design provides detailed information for delineating how elders include complementary and other therapies in their health self-management.
PMCID: PMC3657707  PMID: 20937796
Health self-management; complementary therapies; rural aging
23.  The Association of Health and Functional Status with Private and Public Religious Practice among Rural, Ethnically Diverse Older Adults with Diabetes 
This analysis describes the association of health and functional status with private and public religious practice among ethnically diverse (African American, Native American, white) rural older adults with diabetes.
Data were collected using a population-based, cross-sectional, stratified, random sample survey of 701 community-dwelling elders with diabetes in two rural North Carolina counties. Outcome measures were private religious practice, church attendance, religious support provided, and religious support received. Correlates included religiosity, health and functional status, and personal characteristics. Statistical significance was assessed using multiple linear regression and logistic regression models.
These rural elders had high levels of religious belief, and private and public religious practice. Religiosity was associated with private and public religious practice. Health and functional status were not associated with private religious practice, but they were associated with public religious practice, such that those with limited functional status participated less in public religious practice. Ethnicity was associated with private religious practice: African Americans had higher levels of private religious practice than Native Americans or whites, while Native Americans had higher levels than whites.
Variation in private religious practice among rural older adults is related to personal characteristics and religiosity, while public religious practice is related to physical health, functional status and religiosity. Declining health may affect the social integration of rural older adults by limiting their ability to participate in a dominant social institution.
PMCID: PMC3653177  PMID: 17565525
rural aging; minority aging; chronic disease; diabetes; religious participation; religiosity; social integration
24.  Performance of Health Literacy Tests Among Older Adults with Diabetes 
Knowing a patient’s health literacy can help clinicians and researchers anticipate a patient’s ability to understand complex health regimens and deliver better patient-centered instructions and information. Poor health literacy has been linked with lower ability to function adequately in health care systems.
We evaluated and compared three measures of health literacy and performance among older patients with diabetes.
Cross-sectional study utilizing in-person interviews conducted in participants’ homes.
A tri-ethnic sample (n = 563) of African American, American Indian, and white older adults with diabetes from eight counties in south-central North Carolina.
Participants completed interviews and health literacy assessments using the Short-Form Test of Functional Health Literacy in Adults (S-TOFHLA), the Rapid Estimates of Adult Literacy in Medicine Short-Form (REALM-SF), or the Newest Vital Signs (NVS). Scores for reading comprehension and numeracy were calculated.
Over 90% completed the S-TOFHLA numeracy and approximately 85% completed the S-TOFHLA reading and REALM-SF. Only 73% completed the NVS. The correlation of S-TOFHLA total scores with REALM-SF and NVS were 0.48 and 0.54, respectively. Age, gender, ethnic, educational and income differences in health literacy emerged for several instruments, but the pattern of results across the instruments was highly variable.
A large segment of older adults is unable to complete short-form assessments of health literacy. Among those who were able to complete assessments, the REALM-SF and NVS performed comparably, but their relatively low convergence with the S-TOFHLA raises questions about instrument selection when studying health literacy of older adults.
PMCID: PMC3326106  PMID: 22095571
health literacy; older adults; diabetes
25.  Social Integration and Diabetes Management among Rural Older Adults 
Journal of aging and health  2012;24(6):899-922.
To describe diabetes management behaviors and social integration among older adults, and delineate the associations of social integration with diabetes management behaviors.
Interview data from 563 African American, American Indian and white participants (age 60+) from eight south central North Carolina counties selected using a site-based procedure. Statistical analysis comprises descriptive statistics, bivariate analysis, and multivariate analysis.
Participants had high levels of social integration and largely adhered to diabetes management behaviors (glucose monitoring, checking feet, maintaining diet, formal exercise program, health provider monitoring A1C and examining feet). Social integration was associated with several behaviors; social network size, particularly other relatives seen and spoken with on the telephone, was associated with provider A1C monitoring and foot examinations.
Social integration had small but significant associations with diabetes management behaviors. This analysis suggests specific mechanisms for how social integration influences the effect of disease on disability.
PMCID: PMC3636064  PMID: 22764154
Diabetes management; social integration; social engagement; social network; disablement process

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