Tribal Health Care System Research Articles

726-P: Medication Adherence among American Indians with Type 2 Diabetes—Assessing the Quality of Electronic Health Record Data within a Large Tribal Health Care System

Electronic health record (EHR) systems within tribal healthcare facilities offer a rich but underutilized data source about medication adherence and its potential to predict HbA1c. The purpose of this analysis was to describe data quality issues for medication events in a dataset extracted from a large tribal healthcare EHR system. This analysis was a critical step prior to conducting a study of medication adherence among American Indians with type 2 diabetes (T2D). The EHR dataset from 2017-2021 included 10,506 patients who were enrolled adult tribal citizens, had T2D, and had at least one health system encounter. Tribal pharmacy refill data were linked to the EHR data and included information such as prescription regimen (e.g., drug, dose, route of administration, quantity), date new medication prescribed, date picked up, and refill dates. Data quality indicators were: duplicate data, missing data (e.g., dispense and fill dates, RX number), and data inconsistent with eligibility criteria. The mean age of the sample was 60.2 ±13.4 years and 52% were female. Out of the 1,400,593 patient medication fill/refill events we excluded 64,015 medication events due to a) duplicate prescription fill data (n=112); b) no dispense date (n=1,081); c) no order date (n=0); d) no fill date (n=0); e) no RX number (n=0); f) missing number of days dispensed (n=0); g) missing drug (n=0); h) missing dose (n=0); and i) data extracted not meeting the eligibility criteria (n=62,822). The date the medication was prescribed was not extracted from the EHR. Discovering these results was labor intensive taking more than 6 months. This analysis revealed few data-related concerns. With the exception of one missing variable, the dataset includes high quality data from which we will calculate medication adherence among American Indians with T2D. Disclosure L.Scarton: None. T.N.Nelson: None. A.Devaughan circles: None. A.Legaspi: None. D.J.Wilkie: Other Relationship; eNursing llc. Funding National Institutes of Health (1R01NR020386-01)

Association of Medication Adherence With HbA1c Control Among American Indian Adults With Type 2 Diabetes Using Tribal Health Services.

To examine HbA1c levels and adherence to oral glucose-lowering medications and their association with future HbA1c levels among American Indian adults with type 2 diabetes (T2D) receiving medications at no cost from a tribal health care system. Tribal citizens with T2D who used Choctaw Nation Health Services Authority (CNHSA) and Pharmacies and had HbA1c data during 2017-2018 were included in this study. Medication adherence (proportion of days covered [PDC] ≥0.80) was calculated using 2017 CNHSA electronic health record data. Of the 74,000 tribal citizens living on tribal lands, 4,560 were eligible; 32% had HbA1c at or below target (≤7%), 36% were above target (>7 to ≤9%), and 32% were uncontrolled (>9%) in 2017. The percentage of patients with PDC ≥0.80 was 66% for those using biguanides, 72% for sulfonylureas, 75% for dipeptidyl peptidase 4 inhibitors, and 83% for sodium-glucose cotransporter 2 inhibitors. The proportion of patients with HbA1c at or below target increased slightly from 32% in 2017 to 42% in 2018. Higher average PDC in 2017 was associated with lower HbA1c levels in 2018 (β = -1.143; P < 0.001). Medication adherence was higher than that found in previous studies using self-report methods in American Indian populations, although a smaller proportion of patients had HbA1c at or below target relative to U.S. adults with T2D. Medication adherence was associated with improved HbA1c levels for most oral glucose-lowering medication classes. Future studies of American Indians should use both longitudinal prescription data from both electronic health records and pharmacy refills.

Tribal Healthcare System in Kerala during the Pandemic

In Kerala, 36 Scheduled Tribe communities live in various districts. Wayanad has 35 per cent of the state’s tribal population. Out of these 36 tribal groups, Wayanad has eight major and three minor tribal groups. With the outbreak of COVID, the Government of India ordered a lockdown in March 2020 to protect people from the spread of COVID. In Kerala and Wayanad district, State Government initiated COVID prevention activities and awareness all over the state. To prevent COVID, the district administration started the corona tribal cell and coordinated COVID-19 activities. The main objective of the cell is to coordinate tribal health care issues related to COVID and non-COVID diseases during the lockdown period and also coordinate food support for the tribal people. District administration had fully engaged in protecting tribal health during the COVID outbreak by preparing an action plan and evaluation method. The objective of the study is to understand the tribal situation during COVID. It covers the changes in their livelihood, the ups and downs in their personal and social life, and the problems and challenges they faced during this process. For this study, the highest tribal concentrated Block of Wayanad district Kalpetta was selected. The state government and the district authority supported the tribal peoples during the COVID-19 pandemic to reduce their grievances.

Medication Adherence and Cardiometabolic Control Indicators Among American Indian Adults Receiving Tribal Health Services: Protocol for a Longitudinal Electronic Health Records Study.

American Indian adults have the highest prevalence of type 2 diabetes (T2D) in any racial or ethnic group and experience high rates of comorbidities. Uncontrolled cardiometabolic risk factors-insulin resistance, resulting in impaired glucose tolerance, dyslipidemia, and hypertension-increase the risk of mortality. Mortality is significantly reduced by glucose- and lipid-lowering and antihypertensive medication adherence. Medication adherence is low among American Indian adults living in non-Indian Health Service health care settings. Virtually nothing is known about the nature and extent of medication adherence among reservation-dwelling American Indian adults who primarily receive their medications without cost from Indian Health Service or tribal facilities. Electronic health records (EHRs) offer a rich but underused data source regarding medication adherence and its potential to predict cardiometabolic control indicators (C-MCIs). With the support of the Choctaw Nation of Oklahoma (CNO), we address this oversight by using EHR data generated by this large, state-of-the-art tribal health care system to investigate C-MCIs. Our specific aims are to determine, using 2018 EHR data, the bivariate relationships between medication adherence and C-MCIs, demographics, and comorbidities and each C-MCI and demographics and comorbidities; develop machine learning models for predicting future C-MCIs from the previous year's medication adherence, demographics, comorbidities, and common laboratory tests; and identify facilitators of and barriers to medication adherence within the context of social determinants of health (SDOH), EHR-derived medication adherence, and C-MCIs. Drawing on the tribe's EHR (2018-2021) data for CNO patients with T2D, we will characterize the relationships among medication adherence (to glucose- and lipid-lowering and antihypertensive drugs) and C-MCIs (hemoglobin A1c ≤7%, low-density lipoprotein cholesterol <100 mg/dL, and systolic blood pressure <130 mm Hg); patient demographics (eg, age, sex, SDOH, and residence location); and comorbidities (eg, BMI ≥30, cardiovascular disease, and chronic kidney disease). We will also characterize the association of each C-MCI with demographics and comorbidities. Prescription and pharmacy refill data will be used to calculate the proportion of days covered with medications, a typical measure of medication adherence. Using machine learning techniques, we will develop prediction models for future (2019-2021) C-MCIs based on medication adherence, patient demographics, comorbidities, and common laboratory tests (eg, lipid panel) from the previous year. Finally, key informant interviews (N=90) will explore facilitators of and barriers to medication adherence within the context of local SDOH. Funding was obtained in early 2022. The University of Florida and CNO approved the institutional review board protocols and executed the data use agreements. Data extraction is in process. We expect to obtain results from aims 1 and 2 in 2024. Our findings will yield insights into improving medication adherence and C-MCIs among American Indian adults, consistent with CNO's State of the Nation's Health Report 2017 goal of reducing T2D and its complications. PRR1-10.2196/39193.

Measuring Attitudes About Alcohol Misuse and Dependence Among Alaska Native People Within a Tribal Health Care System.

Attitudes about alcohol misuse and dependence influence alcohol use and help-seeking behavior. Alaska Native and American Indian (AN/AI) people have higher rates of alcohol-related morbidity and mortality but engage in treatment at lower rates than the general population. No validated instruments exist to assess attitudes of AN/AI people about alcohol misuse and dependence to inform treatment and prevention efforts. This study aimed to develop an instrument to assess public attitudes among AN/AI people of alcohol misuse and dependence. This multiphase, mixed-methods study was conducted at Southcentral Foundation, a tribally owned health system serving 65,000 AN/AI people in Alaska. We conducted focus groups and interviews with health system users, providers, and leaders to adapt the Public Attitudes About Addiction Survey. The adapted instrument was piloted with 200 people. Cognitive interviews and exploratory and confirmatory factor analyses were used to refine the instrument, which were then administered to 777 AN/AI people. Initial exploratory factor analysis identified 5 factors, including 3 from the original Public Attitudes About Addiction Survey (moral, disease, nature), a combined psychology and sociology factor (psychosocial), and a new factor (environment). A final 4-factor model (psychosocial, moral, disease, nature) with 14 items had good fit with root mean square error of approximation (0.035; comparative fit index = 0.977; Tucker-Lewis index = 0.970; standardized root mean residual = 0.040) and loadings ranging from 0.41 to 0.80. This study developed the first instrument to assess AN/AI attitudes about alcohol misuse and dependence. This instrument has potential to inform alcohol-related treatment in AN/AI communities. Future research is warranted to adequately measure place-based contributors salient to AN/AI people.

An Appraisal of Prevailing Issues in Rural Tribal Health Care System in India

Better health is one of the most important aspect of the overall development and progress of any country. In the context of India, tribals are an integral part, which are 8.6 percent of the total population of the country. Scarce public health care services in India and related issues are currently the most discussed topic with recent outbreak of Covid-19 affecting human life terribly and still persisting. Health care issue affects every individual in the society. In tribal areas health care issues become even more important because as it seems that this section of society is still comparatively in unprivileged condition and not properly exploited the benefits of development process.India's development cannot be imagined without improvement of rural and tribal health. This article highlights major issues prevailing in the rural tribal health care system of India, which arises many barriers to tribal health and the holistic development of the country. Based on the blending results of several multi-factual studies, it is known that there exist many issues prevailingin the rural tribal health care delivery system. Many issues are there which are responsible for poor and complex tribal health status among the tribes, such as, low awareness about health, different religious and cultural beliefs, unrealistic health practices, living in difficult and inaccessible areas, financial problems, various infectious diseases, nutritional deficiencies, and poor public health care facilities, etc. These issues have attracted renewed attention from physicians, health policy experts, various health agencies as well as the general public, particularly tribal societies, which are most affected by these issues. Keywords: Health Status; Health Infrastructure; Rural Health Care Services; Tribal Culture And Practices; Health Policy; Public Involvement And Awareness.

Tribal health care system of the gonds of Nuapada District of Odisha in India

The study of health care practices of the Gonds of Nuapada district of Odisha is one of significant aspects of the tribal health system of Odisha in Eastern India. As many as 62 types of Tribes are found in the state of Odisha, Among these, Gond is one of important tribes which noticed in the western part of Odisha. The Gond people of Nuapada are not conscious about their health and sanitation, for which they are facing different types diseases in their day to day life. The Gond community living in different eco-systems face heath and genetic problems of varying natural. Nothing is known about the health and nutritional status and also about the medico-genetic problems which are prevalent among the primitive section of the Gond tribe as no comprehensive study of this nature has yet been undertaken among these sections of the Gond tribe. The present study centers round this problem and its coverage is limited to two different sections of the Gond tribe, one residing in Sinapali village of Nuapada areas of Nuapada district and the other residing in Komna village of Boden areas of Nuapada district. &#x0D;

Using the electronic health record to identify suicide risk factors in an Alaska Native Health System.

Suicide rates are higher in some Alaska Native and American Indian communities than the general U.S. population. Screening for suicide risk typically requires self-report, but many people may not engage with conventional screening because of distrust or are reluctant to disclose thoughts of suicide. Resource-sensitive methods of detecting suicide risk are needed. This study identifies routinely collected electronic health record data to identify demographic, clinical, and utilization factors associated with suicide-related visits in a tribal health care system. In this retrospective, case-control study, cases were defined as any person with a suicide-related visit from 2012 to 2015. Cases and controls were matched by age, sex, and urban/rural residence. We used conditional logistic regression to estimate odds ratios, which were interpreted as prevalence ratios (PR) based on the rare outcome assumption. The dataset included 314 cases and 1,169 controls. In the year before the index visit, cases had higher prevalence of poisoning or overdose (PR = 13.4, 95% confidence interval [CI] [3.5, 51.7]), emergency department and urgent care visits (PR = 15.8, 95% CI [6.6, 38.1]), and hospitalizations (PR = 4.5, 95% CI [3.0, 6.8]). Electronic health records can be used to identify factors that are significantly associated with suicide risk among those who may not be flagged by screening. Risk detection through electronic health record assessment might increase clinical workload in the short term, but this change would be offset by downstream prevention of suicide-related events. Such efforts could improve suicide risk detection and help to improve suicide-related health disparities in Alaska Native and American Indian populations. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Community Perspectives on Communicating About Precision Medicine in an Alaska Native Tribal Health Care System.

Background:Precision medicine seeks to better tailor medical care to the needs of individual patients, but there are challenges involved in communicating to patients, health care providers, and health system leaders about this novel and complex approach to research and clinical care. These challenges may be exacerbated for Alaska Native and American Indian (ANAI) people, whose experiences of unethical research practices have left some ANAI communities hesitant to engage in research that involves extensive data-sharing and diminished control over the terms of data management and who may have distinct, culturally-informed communication needs and preferences. There is need for communication research to support Tribal health organizations and ANAI people as they consider implementation of and participation in precision medicine. To address that need, this study characterizes the informational needs and communication preferences of patients, providers, and leaders at an Alaska Native Tribal health organization.Methods:We conducted 46 individual, semi-structured interviews to explore perspectives on precision medicine and related communication needs among patients, providers, and leaders of a Tribal health organization. Analysis involved team-based coding to identify a priori and emergent themes, followed by identification and recoding of content relevant to precision medicine informational needs and communication preferences.Results:Patients, providers, and leaders were described as both sources and recipients of information about precision medicine. Information deemed essential for making decisions about whether to participate in or implement a precision medicine program included information about the clinical and research applications of precision medicine, benefits and risks, health system costs and impacts, and data management practices. Preferred communication channels included digital and non-digital informational materials, as well as in-person learning opportunities for individuals and groups. Participants also describe contextual factors and barriers that influenced the acceptability and effectiveness of approaches to health communication.Conclusion:Results can inform approaches to communicating information about precision medicine to stakeholders within Tribal and other health care systems considering implementation of precision medicine in clinical or research contexts.

Community–clinic linkages: qualitative provider perspectives on partnering with community health representatives in Navajo Nation

ObjectiveTo understand providers’ opinions about the Community Outreach and Patient Empowerment (COPE) Project designed to strengthen Navajo Community Health Representative (CHR) outreach to individuals living with diabetes.DesignThis was a qualitative...

Health care utilisation changes among Alaska Native adults after participation in an indigenous community programme to address adverse life experiences: a propensity score-matched analysis

ABSTRACT The aim of this study was to investigate whether participation in Family Wellness Warriors Initiative (FWWI), an Alaska Native program that addresses adverse life experiences, is associated with changes in health care utilisation. The study method was a propensity score-matched cohort analysis using retrospective electronic health record data from Southcentral Foundation, a tribal health care system, from 2012 to 2017. Ninety p\\articipants in FWWI trainings were identified as the intervention cohort and were propensity matched with 90 people who participated in other emotional wellness-related interventions. The primary outcome was the number of total health system visits. Secondary outcomes included emergency department (ED) visits, substance-use visits and visits with somatisation potential. After adjustment for covariates, FWWI participants showed a 36% reduction in total system visits (incidence rate ratio 0.64, 95% CI 0.49–0.84) and a 70% reduction in substance use visits (incidence rate ratio 0.30, 95% CI 0.10–0.93) when compared to the control. FWWI participants showed a 40% reduction in ED visits (incidence rate ratio 0.60, 95%CI 0.35–1.02) when compared to the control that was borderline significant. No significant differences were found for visits with somatisation potential (incidence rate ratio 1.25, 95% CI 0.79–1.99).

Organizational Readiness to Implement System Changes in an Alaskan Tribal Dental Care Organization.

Tribal health care systems are striving to implement internal changes to improve dental care access and delivery and reduce health inequities for American Indian and Alaska Native children. Within similar systems, organizational readiness to implement change has been associated with adoption of system-level changes and affected by organizational factors, including culture, resources, and structure. The objectives of this study were to assess organizational readiness to implement changes related to delivery of evidence-based dental care within a tribal health care organization and determine workforce- and perceived work environment-related factors associated with readiness. A 92-item questionnaire was completed online by 78 employees, including dental providers, dental assistants, and support staff (88% response rate). The questionnaire queried readiness for implementation (Organizational Readiness for Implementing Change), organizational context and resources, workforce issues, organizational functioning, and demographics. Average scores for the change commitment and change efficacy domains (readiness for implementation) were 3.93 (SD = .75) and 3.85 (SD = .80), respectively, where the maximum best score was 5. Perceived quality of management, a facet of organizational functioning, was the only significant predictor of readiness to implement change (B = .727, SE = .181, P < .0002) when all other variables were accounted for. Results suggest that when staff members (including dentists, dental therapists, hygienists, assistants, and support staff) from a tribal health care organization perceive management to be high quality, they are more supportive of organizational changes that promote evidence-based practices. Readiness-for-change scores indicate an organization capable of institutional adoption of new policies and procedures. In this case, use of more effective management strategies may be one of the changes most critical for enhancing institutional behaviors to improve population health and reduce health inequities. The results of this study can be used by clinicians and other leaders implementing changes within dental care organizations. To promote organizational readiness for change and, ultimately, more expedient and efficient adoption of system-level changes by stakeholders, consideration should be given to organizational functioning generally and quality of management practices specifically.

Text message reminders increased colorectal cancer screening in a randomized trial with Alaska Native and American Indian people.

Alaska Native and American Indian people (AN/AIs) have a high incidence of colorectal cancer (CRC) and CRC-related mortality. Screening can prevent death from CRC, but screening rates are low in racially and ethnically diverse populations. The authors conducted a randomized controlled trial using text messaging to increase CRC screening among unscreened AN/AIs in a tribal health care system in Anchorage, Alaska. The intervention entailed up to 3 text messages sent 1 month apart. The authors randomized 2386 AN/AIs aged 40 to 75 years who were eligible for CRC screening to the intervention or usual-care control conditions. Screening status was ascertained from electronic health records 3 months and 6 months after the last text message. Hazard ratios (HRs) were estimated to evaluate the effectiveness of the intervention, stratified by age and sex. The intervention increased CRC screening for AN/AIs aged 50 to 75 years (HR, 1.42; 95% confidence interval [95% CI], 0.97-2.09) and aged 40 to 49 years (HR, 1.24; 95% CI, 0.95-1.62). Within both age groups, the HRs were higher for women (HR, 1.69 [95% CI, 1.02-2.80] and HR, 1.37 [95% CI, 1.01-1.88]) compared with men (HR, 1.09 [95% CI, 0.59-1.99] and HR, 0.90 [95% CI, 0.54-1.53]). Interaction analysis yielded P values of .55 and .09, respectively, for age and sex. A simple text messaging intervention was found to increase CRC screening rates in AN/AIs, a group with high CRC morbidity and mortality. Text messaging may be a cost-effective means of reducing CRC screening disparities in AN/AIs and other populations. Cancer 2017;123:1382-1389. © 2016 American Cancer Society.

Health ownership in American indigenous communities

Although the Indian Health Service (IHS) has adequately stifled acute infectious diseases that once devastated American Indian and Alaska Native (AIAN) communities, this system of health provision has become obsolete in the face of chronically debilitating illnesses. Presently, AIAN communities suffer disproportionally from chronic diseases that demand adequate, long-term health maintenance such as hepatitis, renal failure, and diabetes to name a few. A number of research endeavors have sought to define this problem in the literature, but few have proposed adequate mechanisms to alleviate the disparity. The objective of this study was to examine the efficacy of both the Indian Health Service (IHS) and the relative few tribal healthcare systems (PL 93-638) respectively in their sociopolitical contexts, to determine their utility among a financially lame IHS. Domestic and international indigenous health systems were compared through analysis of the current literature on community and indigenous health. Informal interviews were carried out with indigenous practitioners, community members, and political figures to determine how AIAN communities were receiving PL 93-638 programs. Although the IHS has adequately stifled the acute infectious diseases that once devastated AIAN communities, this system of health provision has become obsolete in the face of chronically debilitating illnesses. A number of research endeavors have sought to define this problem in the literature, but few have proposed adequate mechanisms to alleviate the disparity. International indigenous health systems are noted to have a greater component of community involvement in the successful administration of health services. Reinstating notions of ownership in multiple paradigms, along with novel approaches to empowerment is requisite to creating viable solutions to the unique health circumstances in Native America. This article demonstrates the importance and need of more qualitative data to better characterize how PL 93-638 healthcare delivery is actually experienced by AIAN patients.

Cardiometabolic Risk, Knowledge, Risk Perception, and Self‐Efficacy among American Indian Women with Previous Gestational Diabetes

To describe cardiometabolic risk among a sample of American Indian women with previous gestational diabetes and describe the women's knowledge, risk perception for type 2 diabetes and cardiovascular disease, and self-efficacy beliefs related to preventing these diseases. Mixed methods, cross-sectional, exploratory, descriptive. Four campuses within one American Indian tribal health care system in a southwestern state. A purposeful sample of 22 self-identified American Indian women with a history of gestational diabetes. Qualitative interview data were subjected to content analysis, and descriptive statistics were used to analyze quantitative questionnaire data and biophysiologic data. The majority of participants (13 of 21) were classified as having metabolic syndrome, and 13 of 18 women were found to be insulin resistant. In general, the women had high levels of knowledge related to type 2 diabetes and cardiovascular disease and high risk perception, but low self-efficacy related to preventing cardiometabolic disease. The overarching theme from the in-depth interviews, struggling to change lifestyle behaviors while doubting prevention is possible, encompassed four categories that provided further illumination into participants' risk perceptions and self-efficacy beliefs: concerns, control, beliefs/attitudes, and prevention. High levels of knowledge and risk perception do not necessarily promote increased self-efficacy to prevent cardiometabolic disease among American Indian women with previous gestational diabetes. Findings indicate the need to further explore women's self-efficacy beliefs in the context of American Indian culture prior to developing interventions aimed at increasing self-efficacy to prevent or delay type 2 diabetes and cardiovascular disease. Women with previous gestational diabetes are at increased risk for developing cardiovascular disease, independent of a diagnosis of type 2 diabetes.