A Qualitative Study of Hutterites' Perspective and Attitudes Toward Healthcare Providers.

As the U.S. becomes more diverse, so does the population presenting to healthcare providers. As a result, cultural competency has become a vital aspect of healthcare in the U.S. Providers need to understand not only how their treatments are appropriate for a specific cultural group, but also how they can most effectively communicate with and establish relationships with these patients. One of the distinct cultural groups living in South Dakota are the Hutterites. While members of the Hutterite colonies use mainstream medical facilities for their health care, there is little information about the preparation of mainstream healthcare providers for the culture of this group and how this preparation may impact the services they provide to Hutterites. The purpose of this phenomenological study was to understand Hutterites' experiences with healthcare providers. Individual interviews were conducted with eight adults from a local Hutterite colony who had experience with mainstream healthcare providers. The qualitative analysis of these interviews resulted in two major themes: issues of healthcare culture and use of medical services only when needed. Certain aspects of Hutterite culture should be acknowledged when they present for medical treatment.

Plasminogen activator inhibitor-1 is associated with leukocyte telomere length in American Indians: findings from the Strong Heart Family Study.

Essentials Plasminogen activator inhibitor-1 (PAI-1) advanced cellular senescence in experiment studies. No population study exists on the association between PAI-1 and biological aging in American Indians. We found cross-sectional and longitudinal associations between higher PAI-1 and shorter telomere length. Our findings suggest a pathway linking PAI-1 with biological aging beyond metabolic factors. SUMMARY: Background Plasminogen activator inhibitor-1 (PAI-1) promotes cellular aging both in vitro and in vivo. Telomere length is a marker of biological aging. Objectives To examine the cross-sectional and longitudinal associations between plasma PAI-1 and leukocyte telomere length in a large-scale epidemiological study of American Indians. Methods We measured leukocyte telomere length (LTL) and plasma PAI-1 in 2560 American Indians who were free of overt cardiovascular disease (CVD) and participated in the Strong Heart Family Study (SHFS) clinical examination in 2001-2003. LTL and PAI-1 were repeatedly measured in 475 participants who attended SHFS clinical visits in both 2001-2003 and 1998-1999. A generalized estimating equation model was used to examine the cross-sectional and longitudinal associations between PAI-1 and LTL, adjusting for known risk factors. Results A higher level of plasma PAI-1 was negatively associated with shorter age-adjusted LTL (ß = -0.023; 95% CI, -0.034 to -0.013). This association was attenuated (ß = -0.015; 95% CI, -0.029 to -0.002) after adjustments for demographics, study site, lifestyle (smoking, drinking and physical activity) and metabolic factors (obesity, blood pressure, fasting glucose, insulin, lipids and kidney function). Further adjustment for hsCRP did not change this association (ß = -0.015; 95% CI, -0.029 to -0.001). Longitudinal analysis revealed that change in plasma PAI-1 was also inversely associated with change in LTL after adjusting for demographics, follow-up years, lifestyle factors, changes in metabolic factors, baseline levels of PAI-1 and LTL (ß = -0.0005; 95% CI, -0.0009 to -0.0001). Conclusions A higher level of plasma PAI-1 was associated with shorter LTL in American Indians. This finding may suggest a potential role of PAI-1 in biological aging among American Indians.

A day of immersive physiology experiments increases knowledge and excitement towards physiology and scientific careers in Native American students.

Underserved minority groups are disproportionately absent from the pursuit of careers in science, technology, engineering, and mathematics (STEM) fields. One such underserved population, Native Americans, are particularly underrepresented in STEM fields. Although recent advocacy and outreach designed toward increasing minority involvement in health care-related occupations have been mostly successful, little is known about the efficacy of outreach programs in increasing minority enthusiasm toward careers in traditional scientific professions. Furthermore, very little is known about outreach among Native American schools toward increasing involvement in STEM. We collaborated with tribal middle and high schools in South Dakota and Nebraska through a National Institutes of Health Science Education Partnership Award to hold a day-long physiology, activity-based event to increase both understanding of physiology and enthusiasm to scientific careers. We recruited volunteer biomedical scientists and trainees from the University of Nebraska Medical Center, Nebraska Wesleyan University, and University of South Dakota. To evaluate the effectiveness of the day of activities, 224 of the ~275-300 participating students completed both a pre- and postevent evaluation assessment. We observed increases in both students self-perceived knowledge of physiology and enthusiasm toward scientific career opportunities after the day of outreach activities. We conclude that activity-based learning opportunities in underserved populations are effective in increasing both knowledge of science and interest in scientific careers.

Variation in CYP2A6 and nicotine metabolism among two American Indian tribal groups differing in smoking patterns and risk for tobacco-related cancer.

OBJECTIVE: The Northern Plains (NP) and Southwest (SW) American Indian populations differ in their smoking patterns and lung cancer incidence. We aimed to compare CYP2A6 genetic variation and CYP2A6 enzyme activity (representative of the rate of nicotine metabolism) between the two tribal populations as these have previously been associated with differences in smoking, quitting, and lung cancer risk. PARTICIPANTS AND METHODS: American Indians (N=636) were recruited from two different tribal populations (NP in South Dakota, SW in Arizona) as part of a study carried out as part of the Collaborative to Improve Native Cancer Outcomes P50 Project. A questionnaire assessed smoking-related traits and demographics. Participants were genotyped for CYP2A6 genetic variants *1B, *2, *4, *7, *9, *12, *17, and *35. Plasma and/or saliva samples were used to measure nicotine's metabolites cotinine and 3'-hydroxycotinine and determine CYP2A6 activity (3'-hydroxycotinine/cotinine, i.e. the nicotine metabolite ratio, NMR). RESULTS: The overall frequency of genetically reduced nicotine metabolizers, those with CYP2A6 decrease-of-function or loss-of-function alleles, was lower in the NP compared with the SW (P=0.0006). The CYP2A6 genotype was associated with NMR in both tribal groups (NP, P<0.0001; SW, P=0.04). Notably, the rate of nicotine metabolism was higher in NP compared with SW smokers (P=0.03), and in comparison with other ethnic groups in the USA. Of the variables studied, the CYP2A6 genotype was the only variable to significantly independently influence NMR among smokers in both tribal populations (NP, P<0.001; SW, P=0.05). CONCLUSION: Unique CYP2A6 allelic patterns and rates of nicotine metabolism among these American Indian populations suggest different risks for smoking, and tobacco-related disease.

Response to an Online Version of a PRAMS-like Survey in South Dakota.

Objectives Increasing response rates for research surveys is challenging, especially in minority populations. A unique minority group in South Dakota is the American Indian (AI) representing about 9 % of the state's population and 15 % of the births. The purpose of this study was to determine race differences among White, AI, and Other Races (OR) in contact, participation, and response rates in the South Dakota Pregnancy Risk Assessment Monitoring System (SDPRAMS). We determined response rates of an online version and evaluated demographic characteristics associated with online response. Methods The SDPRAMS was sent to 1814 mothers randomly sampled from 2014 birth certificate files. Results The weighted response rate was 71.3 %, and varied significantly among the three races: 79.1 % for White race, 48.6 % for AI race, and 60.6 % for OR (p < 0.01). A higher percent of White mothers responded online than AI and OR (35, 25 and 26 %, respectively; p = 0.001); no difference between AI and OR. Online responders were more likely to be married, educated beyond high school and having annual incomes ≥$25,000 (p ≤ 0.01 for all), but only education (p < 0.001) and income (p = 0.05) remained significant in the logistic models. 26 % of White, 43 % of AI, and 46 % of OR online respondents used a smartphone to respond (p = 0.01). Conclusions Response rates differed among races. An online version of the PRAMS is a viable method of response to offer participants. Response to the online version via smartphone may increase response from minority populations, emphasizing the importance of mobile friendly formats.

Genome-wide linkage analysis of carotid artery lumen diameter: the strong heart family study.

BACKGROUND: A significant proportion of the variability in carotid artery lumen diameter is attributable to genetic factors. METHODS: Carotid ultrasonography and genotyping were performed in the 3300 American Indian participants in the Strong Heart Family Study (SHFS) to identify chromosomal regions harboring novel genes associated with inter-individual variation in carotid artery lumen diameter. Genome-wide linkage analysis was conducted using standard variance component linkage methods, implemented in SOLAR, based on multipoint identity-by-descent matrices. RESULTS: Genome-wide linkage analysis revealed a significant evidence for linkage for a locus for left carotid artery diastolic and systolic lumen diameters in Arizona SHFS participants on chromosome 7 at 120 cM (lod = 4.85 and 3.77, respectively, after sex and age adjustment, and lod = 3.12 and 2.72, respectively, after adjustment for sex, age, height, weight, systolic and diastolic blood pressure, diabetes mellitus and current smoking). Other regions with suggestive evidence of linkage for left carotid artery diastolic and systolic lumen diameter were found on chromosome 12 at 153 cM (lod = 2.20 and 2.60, respectively, after sex and age adjustment, and lod = 2.44 and 2.16, respectively, after full covariate adjustment) in Oklahoma SHFS participants; suggestive linkage for right carotid artery diastolic and systolic lumen diameter was found on chromosome 9 at 154 cM (lod = 2.72 and 3.19, respectively after sex and age adjustment, and lod = 2.36 and 2.21, respectively, after full covariate adjustment) in Oklahoma SHFS participants. CONCLUSION: We found significant evidence for loci influencing carotid artery lumen diameter on chromosome 7q and suggestive linkage on chromosomes 12q and 9q.

A common spinal muscular atrophy deletion mutation is present on a single founder haplotype in the US Hutterites.

Spinal muscular atrophy (SMA) is an autosomal recessive (AR) neuromuscular disease that is one of the most common lethal genetic disorders in children, with carrier frequencies as high as ∼1 in 35 in US Whites. As part of our genetic studies in the Hutterites from South Dakota, we identified a large 22 Mb run of homozygosity, spanning the SMA locus in an affected child, of which 10 Mb was also homozygous in three affected Hutterites from Montana, supporting a single founder origin for the mutation. We developed a haplotype-based method for identifying carriers of the SMN1 deletion that leveraged existing genome-wide SNP genotype data for ∼1400 Hutterites. In combination with two direct PCR-based assays, we identified 176 carriers of the SMN1 deletion, one asymptomatic homozygous adult and three carriers of a de novo deletion. This corresponds to a carrier frequency of one in eight (12.5%) in the South Dakota Hutterites, representing the highest carrier frequency reported to date for SMA and for an AR disease in the Hutterite population. Lastly, we show that 26 SNPs can be used to predict SMA carrier status in the Hutterites, with 99.86% specificity and 99.71% sensitivity.

"So long as I can read": farm women's reading experiences in Depression-era South Dakota.

During the Great Depression, with conditions grim, entertainment scarce, and educational opportunities limited, many South Dakota farm women relied on reading to fill emotional, social, and informational needs. To read to any degree, these rural women had to overcome multiple obstacles. Extensive reading (whether books, farm journals, or newspapers) was limited to those who had access to publications and could make time to read. The South Dakota Free Library Commission was valuable in circulating reading materials to the state's rural population. In the 1930s the commission collaborated with the USDA's Extension Service in a popular reading project geared toward South Dakota farm women. This "Reading in the Home" program greatly increased reading opportunities and motivations. Of particular interest to rural women were tales of pioneer life featuring strong protagonists. Through these stories, farm women found validation and encouragement to persevere. Reading also broadened horizons and challenged assumptions. For the depression-era farm woman, reading books and other materials provided recreation, instruction, and inspiration in a discouraging time.

Asthma in American Indian adults: the Strong Heart Study.

BACKGROUND: Despite growing recognition that asthma is an important cause of morbidity among American Indians, there has been no systematic study of this disease in older adults who are likely to be at high risk of complications related to asthma. Characterization of the impact of asthma among American Indian adults is necessary in order to design appropriate clinical and preventive measures. METHODS: A sample of participants in the third examination of the Strong Heart Study, a multicenter, population-based, prospective study of cardiovascular disease in American Indians, completed a standardized respiratory questionnaire, performed spirometry, and underwent allergen skin testing. Participants were > or = 50 years old. RESULTS: Of 3,197 participants in the third examination, 6.3% had physician-diagnosed asthma and 4.3% had probable asthma. Women had a higher prevalence of physician-diagnosed asthma than men (8.2% vs 3.2%). Of the 435 participants reported in the asthma substudy, morbidity related to asthma was high: among those with physician-diagnosed asthma: 97% reported trouble breathing and 52% had severe persistent disease. The mean FEV(1) in those with physician-diagnosed asthma was 61.3% of predicted, and 67.2% reported a history of emergency department visits and/or hospitalizations in the last year, yet only 3% were receiving regular inhaled corticosteroids. CONCLUSIONS: The prevalence of asthma among older American Indians residing in three separate geographic areas of the United States was similar to rates in other ethnic groups. Asthma was associated with low lung function, significant morbidity and health-care utilization, yet medications for pulmonary disease were underutilized by this population.

Prediction of coronary heart disease in a population with high prevalence of diabetes and albuminuria: the Strong Heart Study.

BACKGROUND: The present article presents equations for the prediction of coronary heart disease (CHD) in a population with high rates of diabetes and albuminuria, derived from data collected in the Strong Heart Study, a longitudinal study of cardiovascular disease in 13 American Indian tribes and communities in Arizona, North and South Dakota, and Oklahoma. METHODS AND RESULTS: Participants of the Strong Heart Study were examined initially in 1989-1991 and were monitored with additional examinations and mortality and morbidity surveillance. CHD outcome data through December 2001 showed that age, gender, total cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein cholesterol, smoking, diabetes, hypertension, and albuminuria were significant CHD risk factors. Hazard ratios for ages 65 to 75 years, hypertension, LDL cholesterol > or = 160 mg/dL, diabetes, and macroalbuminuria were 2.58, 2.01, 2.44, 1.66, and 2.11 in men and 2.03, 1.69, 2.17, 2.26, and 2.69 in women, compared with ages 45 to 54 years, normal blood pressure, LDL cholesterol <100 mg/dL, no diabetes, and no albuminuria. Prediction equations for CHD and a risk calculator were derived by gender with the use of Cox proportional hazards model and the significant risk factors. The equations provided good discrimination ability, as indicated by a c statistic of 0.70 for men and 0.73 for women. Results from bootstrapping methods indicated good internal validation and calibration. CONCLUSIONS: A "risk calculator" has been developed and placed on the Strong Heart Study Web site, which provides predicted risk of CHD in 10 years with input of these risk factors. This may be valuable for diverse populations with high rates of diabetes and albuminuria.

Rural versus nonrural differences in BMC, volumetric BMD, and bone size: a population-based cross-sectional study.

Despite reports of lower fracture risk among rural versus urban populations, few studies have investigated rural versus urban differences in bone mineral content (BMC) and bone mineral density (BMD). Population differences in cross-sectional bone geometry and understanding lifestyle factors responsible for these differences may reveal insights into the reason for differences in fracture risk. We hypothesized that if lifestyle differences in bone mass, size, and geometry are a result of muscle strength, activity, or dietary differences, Hutterite and rural populations should have greater bone mass compared to nonrural populations. The study population consisted of 1189 individuals: 504 rural Hutterites (188 men), 349 rural individuals (>75% life farming, 184 men), and 336 nonrural individuals (never lived on farm, 134 men) aged 20 to 66 years. BMC, bone area, and areal BMD (aBMD) of the total body (TB), hip, femoral neck (FN), and spine by DXA; volumetric BMD (vBMD) and bone geometry at the 4% and 20% radius; polar stress strain index (pSSI), a measure of bone strength, at the 20% pQCT site; and strength, 7-day activity recall, and 24-h diet recall were collected and compared among groups. Hutterite women and men had greater grip strength compared to rural and nonrural populations (both, P <0.001). Rural women had greater activity versus Hutterite and nonrural (P <0.001), while both Hutterite and rural men had greater activity than nonrural (P <0.001). Hutterite and rural populations tended to have greater BMC and areal size than the nonrural population, while Hutterites had greater BMC and areal size than rural population at some (TB, FN for females only), but not all (proximal hip), sites. Cortical vBMD was inversely associated with periosteal circumference at the 20% radius in women (r=-0.25, P <0.001) and men (r=-0.28, P <0.001) and was higher in nonrural versus Hutterite and rural men. Hutterite and rural women and men had greater pSSI at the 20% radius compared to nonrural; inclusion of strength measurements explained population differences among women, but not men. Lifestyle differences did not explain population differences in BMC, aBMD, vBMD, or bone size.

Relationships between bone mass and circulating leptin concentrations in Hutterites.

A limited number of previous studies have shown inverse associations between bone mass or density and circulating leptin in humans. Relationships between bone mass and circulating leptin in Hutterites, who have elevated bone density, are unknown. Knowledge gained from studies in mice suggests that Hutterites exhibit traits consistent with a deficiency in circulating leptin or in leptin signaling. We examined relationships between whole body (WB) and regional (lumbar, total hip, femoral neck, trochanter) bone mineral content (BMC) by dual energy X-ray absorptiometry and circulating leptin in 249 Hutterites (137 female) ages 20-55 years and 72 similarly aged non-Hutterites (37 female). We tested the hypothesis that (1) Hutterites will have low circulating leptin concentrations for a given amount of body fat compared to non-Hutterites, and (2) controlling for body fat, there will be an inverse relationship between BMC and circulating leptin among Hutterites. Hutterites had higher BMC than non-Hutterites at all skeletal sites after adjusting for site-specific bone area, age, and sex (P

Differences in echocardiographic findings and systemic hemodynamics among non-diabetic American Indians in different regions: The Strong Heart Study.

PURPOSE: This study was undertaken to determine whether differences in left ventricular (LV) and systemic hemodynamic findings exist between American Indians in different regions that might contribute to known differences in cardiovascular morbidity rates among American Indians. METHODS: We compared echocardiography results in 290 non-diabetic Strong Heart Study (SHS) participants in Arizona, 595 in Oklahoma and 572 in North/South Dakota (ND/SD). RESULTS: Participants in the 3 regions were similar in age and gender but those in Arizona had the highest body mass indices and lowest heart rates while those in ND/SD had the lowest diastolic blood pressures (BP). In analyses that adjusted for significant covariates, ND/SD participants had larger aortic (Ao) anular, Ao root, and LV chamber size as well as higher cardiac output and lower peripheral resistance, whereas Arizona participants had increased LV wall thickness and mass and reduced LV myocardial contractility. These findings may contribute to the known high rates of cardiovascular events in ND/SD Indians and to the proportionately higher rate of cardiovascular death than of non-fatal cardiovascular events that has been recently documented in Arizona Indians. CONCLUSIONS: Application of echocardiography to non-diabetic SHS participants reveals that LV chamber and arterial size are larger in ND/SD Indians and that LV wall thicknesses and mass are higher and LV myocardial contractility lower in Arizona Indians, possibly contributing to the higher than expected rates of cardiovascular morbidity and mortality among Indians in Arizona.