The prevalence of type 2 diabetes among Native American populations is escalating, particularly in children and adolescents. Dietary factors appear to influence the development of diabetes, and therefore, are modifiable risk factors for primary prevention. Studies evaluating the dietary habits of Native American adolescents are sparse. Furthermore, studies examining the relationship between insulin and dietary factors have been limited to adult populations. The objective of this study was to describe dietary intake and food consumption patterns and examine dietary factors associated with fasting and 30-minute postprandial insulin levels among adolescents from the Zuni Pueblo, New Mexico. Dietary intake and plasma insulin concentration data were collected from Zuni male and female adolescents, 15--20 years of age, participating in the Zuni Diabetes Prevention Project (ZDPP). The ZDPP, a 4-year, cross-sectional, school-based intervention study was designed to reduced risk factors of type 2 diabetes among Zuni adolescents. Using 24-hr dietary recalls to estimate dietary intake, dietary data was collected during 1993-1994 (baseline) and spring of 1997 (3 years of intervention exposure). Modified glucose tolerance tests were conducted to measure plasma insulin concentrations. Baseline dietary data was adjusted to remove day-to-day variation and compared to national dietary guidelines. Logistic regression was conducted to examine associations between nutrient intake and insulin concentrations. Estimated daily fat intakes of Zuni adolescents exceeded recommendations, whereas, dietary fiber intakes did not achieve guidelines. Less than half of Zuni females met or exceeded dietary recommendations for most micronutrients. Less than 50% of Zuni males consumed recommended levels of vitamin A, folate, vitamin E, calcium, and magnesium. Zuni adolescents reported a diet low in nutrient-dense vegetables, high-fiber grains, and fruits. Sugared-beverages were a significant source of energy and total carbohydrate. Among Zuni males, dietary fat and protein intakes were significantly inversely associated with insulin levels. A negative association between dietary fat and insulin levels was not evident among females. Positive associations were observed for total carbohydrate intake in the unadjusted models. Our results suggest that diets higher in fat or protein compared to high-glycemic carbohydrates may be less deleterious in individuals with minimal hyperinsulinemia.

The purpose of this research was to evaluate the strategy of the military health service (MHS) to improve asthma outcomes through the use of clinical practice guidelines (CPGs). Outcomes were evaluated at the patient level and included inpatient/outpatient visits, prescriptions dispensed, number of exacerbations, number of beddays and direct cost of therapy. In addition, provider compliance to CPG recommendations was evaluated by measuring the proportion of subjects dispensed long-acting controller medications. A nonrandomized control-group before-after design with retrospective matched-pair DoD data was used for this research. The intervention used in this research was the formal asthma CPG-use process implemented by the Army in September of 2000. Compared to baseline measures, all outcomes improved significantly (p < 0.05) in the after period for both the subjects exposed, and not exposed, to the CPG-use process. Other than the improvement noted in the number of asthma exacerbations, which was greater in the exposed group than the non-exposed group (p < 0.001), there was no other difference between groups in the amount that outcomes improved. The proportion of subjects prescribed long-term controller medications increased significantly for subjects exposed to the CPG-use process (0.30 to 0.66, p < 0.001), and for those not exposed to the CPG-use process (0.30 to 0.66, p < 0.001). Although the findings of this research suggested that a formal CPG-use process to standardize asthma therapy was associated with decreased costs, this was not supported by results regarding the clinical outcomes. To further evaluate the effect of asthma CPGs on economic and clinical outcomes, additional research is needed.

Sleep disordered-breathing (SDB) including obstructive sleep apnea syndrome (OSAS) is increasingly recognized as an important cause of morbidity in children. Clinical symptoms of OSAS in children include snoring, nocturnal arousals, restlessness during sleep, enuresis, daytime sleepiness and hyperactivity. Evidence also suggests that the adverse effects of SDB include behavioral, learning, and personality problems. No large epidemiological study using polysomnography has been conducted to determine the prevalence and correlates of SDB in young children. The Tucson Children's Assessment of Sleep Apnea study (TuCASA) is a prospective cohort study designed to determine the prevalence of objectively documented SDB in pre-adolescent children and to investigate its relationship to symptoms, performance on neurobehavioral measures, and physiologic and anatomic risk factors. Hispanic and Caucasian children were recruited to participate in TuCASA by soliciting the cooperation of elementary schools in the Tucson Unified School District (TUSD). Through the use of a screening survey completed by parents, the TuCASA study has shown that children between 4-11 years of age with learning problems (LP) are more likely to have habitual snoring (SN) and excessive daytime sleepiness (EDS). Additionally, Hispanic children in this age group are more likely to have parental report of EDS, witnessed apnea (WA), and SN. Similar to studies in adults, girls 4-11 years of age are more likely to have parental report of daytime sleepiness than boys. Furthermore, the TuCASA study has demonstrated the feasibility of collecting high quality unattended multi-channel polysomnography in children ages 5 to 12 years. More importantly, the TuCASA study has documented the relationships between respiratory disturbance indices based on polysomnography and parental report of clinical symptoms of SDB in children ages 6-11. There are threshold values of respiratory disturbance index (RDI) associated with an increase in the prevalence of clinical symptoms of SDB. Until now, data linking objective indices of RDI severity to the presence of clinical symptoms have been lacking. Additionally, these findings contribute much needed information for determining clinically significant levels of RDI based on differing definitions of respiratory events. Therefore, these results represent an important step towards examining the natural history of SDB and the relationship between SDB severity and specific clinical outcomes in pre-adolescent children.

The purpose of this multifaceted research project was to explain and predict mental health outcomes through testing of a systems research organizing model using pre-existing behavioral health consumer-oriented data. Community Partnership of Southern Arizona provided the setting for the participation of its members in the statewide 2001 Mental Health Statistics Improvement Program Consumer Perception Survey. The sample for this study consisted of 214 adult member survey respondents. The Systems Research Organizing Model for Behavioral Health (SROM-BH) provided the conceptual framework for examining client risk adjustment characteristics and cost and access factors that interact with consumer participation processes to affect consumer perception of quality and health related quality of life. The American Academy of Nursing's Quality Health Outcomes Model and The University of Arizona Nursing Systems Core's System Research Organizing Model informed the development of the SROM-BH that extends this work through its adaptation for use within the context of behavioral health. Composite indices were developed for five model variables, implying that composites or latent variables can be developed from existing data when there is fastidious attention to theory and the conceptual definitions of the constructs. Eight hypothesized positive predictor and three unhypothesized negative predictor relationships were supported. Three hypothesized positive predictor relationships were not supported. Consumer participation in treatment planning, the intervention of interest in this study had an effect (either direct or indirect) on all five outcome variables. Reexamination of model relationships with a larger sample and continued testing of the survey instrument for psychometric performance is recommended. Further model testing using separate scales or methods is needed in order to reduce method effect and to determine the full strength of the findings. Use of structural equation modeling may offer a more precise test of the theoretical framework, strengthen support for instrument subscale construct validity through confirmatory factor analysis, and may provide an opportunity for analysis of recursive paths. Further development of recovery authentication, a concept developed as a result of this study, may contribute to a broadened understanding of opportunities to promote recovery and moderate the loss of self that is associated with mental illness.

Adolescent asthma symptom self-management choices frequently involve uncertain outcomes that include potential dangers such as trigger exposures or delays in treatments that can lead to increased morbidity or mortality. Nurses must understand factors that influence how adolescents make symptom decisions. The purpose of the investigation was to assess eight adolescent asthma symptom scenarios for use with the standard gamble technique (SGT) for making choices. The aims were to: (1) estimate the internal consistency and content validity of the scenarios; (2) estimate the relationship between measured risk preferences, age, and gender; and (3) describe adolescent responses to using the SGT. Thirty-six adolescents participated. Risk preferences or utilities elicited during face-to-face interviews with 31 adolescents were used to answer research questions. Data were analyzed using descriptive statistics, Cronbach's alpha, Kendall's tau correlations, and point biserial correlations. Content validity (CV) ratings from 36 adolescents were used to compute indexes and establish CV of the scenarios. Qualitative responses were analyzed using a modified case study strategy to further establish CV and assess using SGT with adolescents. The estimates of internal consistency reliability and relationships between utilities, age, and gender were limited by the non-normal distributions of utility and age data sets and small sample size. The standardized alpha was .70 for the eight-scenario composite. Eight significant inter-item correlations and seven significant item-total correlations were identified. One significant correlation between age and an individual scenario utility score was found. No significant relationships between age and mean utility scores or gender and the individual or mean utility scores were seen. The CV indexes support the relevancy of the content of the eight-scenario composite as evidenced by 94.5% of the adolescents rating the individual scenarios as CV for the domains and 92% for the risk areas. In addition, the adolescents rated 94% percent of the composites as CV. The qualitative responses support the quantitative data and describe the SGT as a method that adolescents can use. Future studies are needed with a larger sample to further examine the internal consistency of the scenarios and the relationships between age, gender, and utility scores measured with the SGT.

Depression is being diagnosed worldwide at rapidly increasing rates. The World Health Organization has identified depression as the second leading cause of disability worldwide. Women are diagnosed with depression at twice the rate of men. Although much research has been conducted on depression in women, there is very little research on depression in lesbians. The impact of living within a heteronormative society upon lesbians' experiences of depression is unknown. The purpose of this study was to explore lesbians' subjective experiences of depression. Critical ethnographic methods were used to study the ways that lesbians construct their experiences of depression. Twelve self-identified lesbians participated in up to three in-depth interviews conducted over an eight month period. Social constructionism and critical theories underpinned the study's methodology. Thematic analysis led to a schema of themes, domains, and categories that described the participants' experiences. The analysis found no commonalities across the narratives linking being a lesbian with experiences of depression. However, many patterns did emerge describing the ways that the participants construct their experiences of depression. Four themes were identified: Being depressed: Describing the experience, The roots of depression: Emotional dissonance, Managing depression: Desire for relief, and Explaining depression: Needing to know why . The dominant discourses of depression forwarded by psychiatry and psychology have penetrated the popular culture and shaped the participants' understandings of their feelings of depression. These discourses assist in the maintenance of social hegemonies. Further analysis of the study themes led to the discovery that experiences of depression are class-mediated, with study outliers offering glimpses into alternative class-based constructions of depression. The participants shared a number of constructs in formulations of their sexuality. Lesbian identity and radical-cultural feminist discourses underpinned the participants' narratives of identity. Class privilege was identified as significant in these women's abilities to comfortably negotiate their marginalized sexuality within a heteronormative society. Implications of the study for nursing practice, education and research include the formulation of new understandings of lesbianism and sexuality. Findings indicate future depression research must explore of the ways social class influences experiences and perceptions of depression.

Objective. To describe patient variables associated with adherence to Highly Active Antiretroviral Therapies (HAART) in the Tucson VA HIV Clinic. Methods. A cross-sectional study of sixty-seven HIV-infected veterans on HAART regimens (two protease inhibitors or three or more antiretroviral medications) examined theorized patient, patient-provider and regimen predictors related to: HIV RNA viral load, one-month monitored adherence of one antiretroviral medication within the HAART regimen via Medication Event Monitoring System cap percent therapeutic coverage (%TC-ADH), and self-reported adherence (SR-ADH). Sixty-seven subjects completed self-report, and sixty MEMS Cap data. Results. Subjects were male, white (78%), gay (54%) and/or intravenous drug using (31%), and educated (70% completed high school). Forty-three percent had an AIDS diagnosis, and antiretroviral history averaged five years. Thirty-five of sixty-seven (52%) had an HIV RNA ≤50 copies (undetectable). Forty-one of sixty (68%) had %TC-ADH ≥90%, and 41/67 (62%) had 100% SR-ADH over the previous 7 days. %TC-ADH and SR-ADH were correlated (r = .56 p < .0001). SR-ADH ≥90% was associated with an undetectable viral load (OR 3.3, CI 1.2-9.2). There was a trend toward an association between MEMS-ADH as a continuous variable and log viral load (P = 0.074). %TC-ADH ≥90% was not associated with viral suppression (OR 1.2, CI .39-3.5). Disruption of pilltaking by activities of daily living was associated with a six-fold increased risk of viral load >50 copies (OR 5.9, CI 1.4-24.8). Belief in one's ability to take medication as ordered (OR 32 CI 4.4-234) was highly associated with SR-ADH ≥90%. Employment was associated with lower odds of SR-ADH ≥90% (OR 0.12, CI .02-.67). Non-white subjects had lower odds of %TC-ADH ≥90% (OR 0.18, CI .04-.93). A 10-point higher score on the HIV-MOS energy/fatigue scale (OR 1.46, CI 1.04-2.4), and belief in ability to take medication as ordered (OR 2.5, CI 1.20-5.0), were associated with greater odds of %TC-ADH ≥90%. Conclusions. SR-ADH was associated with HIV RNA viral load. Less than 62% of patients adhered at ≥90% based upon SR and %TC-ADH. Disruption of medication-taking by activities of daily living, and poor self-efficacy may negatively affect adherence. Assessment of patient beliefs in their ability to take medications as ordered may be a clinically useful adherence screening question.

Although cell and animal studies support an association between nonmelanoma skin cancer and dietary fat, few studies have assessed this relationship among humans. This study assessed the relationship among participants in a five-year chemoprevention trial completed at the Arizona Cancer Center. This design allowed efficient investigation into the association of dietary fat with development of skin basal (BCC) and squamous cell carcinoma (SCC) among high risk individuals. Three manuscripts were written to examine the dietary characteristics of the study population, factors associated with basal and squamous cell skin cancer occurrence, and the association of dietary fat and other dietary components with skin cancer incidence. The hypothesis was that dietary fat, and linoleic acid in particular, would increase the risk of SCC occurrence. Using a semi-quantitative food frequency questionnaire, usual dietary intake of the volunteers, aged 51 to 85 years, was generally consistent with intakes reported by other studies. However, more than half of the participants consumed less than the recommended levels of vitamin D, folate, calcium, and dairy and grain foods. Among participants randomly assigned to the control intervention with no prior history of skin cancer, the incidence of BCC and SCC was 3629 and 2671 per 100,000 person-years, respectively. Only age independently predicted BCC incidence, while male gender, naturally red hair color, years of residency in Arizona as an adult, and age predicted SCC incidence. Dietary fat was not associated with the development of BCC among these high risk individuals. Estimated daily intake of total fat and oleic acid were weakly associated with SCC occurrence (p = 0.09 and p = 0.06) and linoleic acid was not associated. Neither total dietary fat nor any specific fatty acid were associated with reduction in time to first occurrence or total number of skin cancers. Dietary vitamin C and vitamin E, antioxidants that could potentially reduce cellular protein damage from the oxidative compounds formed by ultraviolet penetration, were also not associated with BCC or SCC development.

In this series of studies, three issues were addressed. First, the prevalence of undiagnosed diabetes (high fasting blood glucose with no prior diagnosis of diabetes) and how different they are from the diagnosed diabetes in risk factors. Second, the prevalence and risk factors of overweight and obesity were described in the general population. Finally, an evaluation of the relationship between obesity and type 2 diabetes were made in Saudi adult men and women. Our study population came from a national cross sectional survey which included 3271 males and females, age 30-70 years old. All participants completed a specifically designed questionnaire, and a comprehensive physical examination which included blood pressure and anthropometric measurements. Fasting serum samples were analyzed for glucose and blood lipids. A number of compelling findings have resulted from this research. First, the prevalence of diabetes is high with 30% of men and 25% of women diabetics. Undiagnosed diabetes presents a substantial problem; they constitute 41% of the total diabetic population and 11% of the total population. Undiagnosed diabetics are however, similar to diagnosed diabetes with uncontrolled fasting blood glucose level and many of the associated risk factors. Second, the prevalence of obesity is also high with 49.15% in women and 29.94% in men identified as obese and an additional 31.55% of females and 41.91% of males identified as overweight. Third, in this study population, 12% are obese diabetics and in the diabetic population 43% are obese diabetics. Diabetes appears to have a harmful effect on blood lipids, which seem to worsen when diabetes is combined with obesity. Based on these findings, obesity and diabetes appear to have created very serious complications and prevalent health problems in adult Saudi population between the age of 30-70 years old. Because about half of the population are under 18 years old, there is a very good chance for the government to successfully implement education and health programs to prevent and control these two conditions from becoming an epidemic in future generations.

Rural Hispanic communities in America face socioeconomic barriers that are costly in terms of morbidity and mortality. Explication of the community qualities that influence healthcare utilization of rural Hispanic populations is critical to overcoming these socioeconomic barriers. Yet, empirical support for community concepts and relational links to explain healthcare utilization in rural Hispanic communities have not been addressed in the nursing literature. This study sought to improve understanding of the inner workings and coping mechanisms within the community. The study was a secondary analysis of data sets obtained from a larger study entitled Comprehensive Multi-Level Practice Model for Rural Hispanics (CMLNP). The original study was conducted in four rural communities in the southwest region of the United States. The primary purpose of the current study was to explore and describe conceptual meanings of community, community health issues, and community health beliefs from interviews conducted in two rural, primarily Hispanic communities. Thematic content analysis explored the relationships between themes that emerged from interviews and lexical variables from computer analysis. The themes most frequently shared among informants in interviews reflected a strong belief in caring for one another, which was evidenced in their volunteerism and perception of community as family. Barriers to health care included transportation, multigenerational acquiescence, and community dependency. Computerized language analysis of texts demonstrated low complexity and variety scores. Language scores indicating ambivalence, tenacity, denial and motion were higher than the normal range. There was evidence of relational links between theoretical concepts and health service utilization. Themes from interviews were closely related to services provided, health education topics, and nursing diagnoses during clinical encounters. Assessment and screening, case management, and skilled care services were the most frequently used health care services. Predominant health education topics in each town concerned specific medical conditions, preventive health care, medications, and anticipatory guidance. Nursing diagnoses were related to themes concerning Graying, Substance Abuse, and Community Knowledge Development. The study explored underlying mechanisms influencing utilization of healthcare services in rural, Hispanic communities, confirming theoretical perspectives. Confirmation came through the stories of community residents who demonstrated where health lies in the context of their lives.