Tribal Health Care Research Articles

Dr. Ravindra Kolhe and Dr. Smita Kolhe: The Pioneers of Improving Tribal Healthcare in Maharashtra, India.

Dr. Ravindra Kolhe and Dr. Smita Kolhe are the pioneers of improving tribal healthcare in Maharashtra, dedicating more than three and a half decades of their lives for the sake of the people in the remote Bairagarh village of the Melghat area. Their compassionate and resilient approach and a deep sense of social justice led to a dramatic improvement in maternal and child health with a noteworthy decline in the infant mortality rate. Apart from providing affordable healthcare services, the Kolhes have been pivotal in promoting sustainable agriculture to empower the local community to improve their livelihoods. Their relentless efforts have not only enhanced healthcare facilities in Bairagarh but also addressed broader social factors such as poverty, malnutrition, and infrastructure development. In recognition of their selfless service, the couple was awarded with the prestigious Padma Shri, the fourth-highest civilian award. This narrative review article highlights their profound impact on tribal healthcare in one of Maharashtra's most underdeveloped regions.

Implementing a Metabolism-informed approach for smoking cessation in an Alaska Tribal health system: study protocol for a single-arm implementation pilot trial

BackgroundIndividualized treatment for commercial tobacco smoking cessation, such as through the utilization of the nicotine metabolite ratio (NMR), offers potential clinical benefit. NMR is a metabolism-informed biomarker that can be used to guide medication selection. NMR testing is particularly promising for tobacco cessation efforts in populations with high rates of smoking, such as some Alaska Native and American Indian (AN/AI) communities. To date, no prior study has evaluated the implementation of NMR-guided tobacco cessation with AN/AI populations.MethodsThe present “QUIT” protocol is a two-phase study that will occur at Southcentral Foundation (SCF), an Alaska Native-owned health system, serving 70,000 AN/AI people, based in Anchorage, Alaska. In Phase one, qualitative interviews with customer-owners (patients), providers and administrators (n = 36) and a 10-participant beta-test will be used to refine a strategy to implement NMR testing in the health system. Phase two will involve a single-arm pilot trial (n = 50) and qualitative interviews throughout data collection (n = 48) to evaluate the implementation strategy and explore the real-world acceptability and feasibility of NMR testing to guide tobacco cessation with AN/AI populations.DiscussionThis study utilizes a community-based participatory approach to refine and implement a nicotine metabolism-informed smoking cessation program in a Tribal healthcare setting. The process and findings from this study will reflect the importance of customer-owner choice and honor the lived experience involved in quitting commercial tobacco. Pilot study data will inform the effect and sample sizes required for a future pragmatic trial of NMR-guided smoking cessation.Trial registrationThis study will be registered with clinicaltrials.gov after the beta test is complete and the final IRB protocol is approved.

Participatory action research to develop and implement multicomponent, multilevel strategies for implementing colorectal cancer screening interventions in American Indian communities in New Mexico

BackgroundDespite the effectiveness of colorectal cancer (CRC) screening, American Indians (AIs) have low screening rates in the US. Many AIs receive care at Indian Health Services, Tribal, and Urban Indian (I/T/U) healthcare facilities, where published evidence regarding the implementation of CRC screening interventions is lacking. To address this gap, the University of New Mexico Comprehensive Cancer Center and the Albuquerque Area Southwest Tribal Epidemiology Center collaborated with two tribally-operated healthcare facilities in New Mexico with the goal of improving CRC screening rates among New Mexico’s AI communities.MethodsGuided by the principles of Community Based Participatory Research, we engaged providers from the two tribal healthcare facilities and tribal community members through focus group (two focus groups with providers (n = 15) and four focus group and listening sessions with community members (n = 65)), to elicit perspectives on the feasibility and appropriateness of implementing The Guide to Community Preventive Services (The Community Guide) recommended evidence-based interventions (EBIs) and strategies for increasing CRC screening. Within each tribal healthcare facility, we engaged a Multisector Action Team (MAT) that participated in an implementation survey to document the extent to which their healthcare facilities were implementing EBIs and strategies, and an organizational readiness survey that queried whether their healthcare facilities could implement additional strategies to improve uptake of CRC screening.ResultsThe Community Guide recommended EBIs and strategies that received the most support as feasible and appropriate from community members included: one-on-one education from providers, reminders, small media, and interventions that reduced structural barriers. From the providers’ perspective, feasible and acceptable strategies included one-on-one education, patient and provider reminders, and provider assessment and feedback. Universally, providers mentioned the need for patient navigators who could provide culturally appropriate education about CRC and assist with transportation, and improved support for coordinating clinical follow-up after screening. The readiness survey highlighted overall readiness of the tribal facility, while the implementation survey highlighted that few strategies were being implemented.ConclusionsFindings from this study contribute to the limited literature around implementation research at tribal healthcare facilities and informed the selection of specific implementation strategies to promote the uptake of CRC screening in AI communities.

INTEGRATING TRADITIONAL INDIGENOUS PRACTICES AND MODERN MEDICINE FOR ENHANCED TRIBAL WELL-BEING

The Particularly Vulnerable Tribal Groups (PVTGs) of Tamil Nadu inhabit the remote hilly regions of the Nilgiris District, fostering a deep reliance on Traditional Medicine over the past decades. Advancements in healthcare systems like road accessibility and the Tribal Mobile Outreach Services (TMORS) have brought modern medicine to the doorstep. It is still a matter of fact to be analysed whether or not these services cater to the unique needs of the tribal communities. The realm of study surrounds the tribal hamlets of Kotagiri where a blend of traditional and modern medicine exists within the healthcare system. However, the absence of a formal integrated structure poses various challenges. The study utilises a qualitative method through interviews and observations. The study aims to assess the prevalence and utilisation of traditional medicine while examining the availability and feasibility of Modern medicine in the tribal communities. Furthermore, it seeks to explore the distinctive barriers and challenges in integrating traditional and modern medicine. The study proposes a strategy to enhance public health and address emergencies within the tribal community as the primary focus is on enhancing the tribal healthcare system to meet the distinctive needs with a tailored framework which contributes to a more effective and cohesive healthcare system. KEYWORDS: PVTGs, Traditional Medicine, Modern Medicine, Integrated Healthcare System, Public Health

Health Status Of Scheduled Tribes of 3 ITDA Spots of Kurnool District, Andhra Pradesh, India

Tribal populations are often at a heightened risk of under-nutrition due to socio-cultural and environmental factors impacting their food intake and health-seeking behavior. Limited access to nutritious food, inadequate healthcare services, and socio-economic marginalization exacerbate their vulnerability. This study focuses on assessing the health status of the Sugali tribes in 3 ITDA Spots of Kurnool District, Andhra Pradesh, India. The Sugali tribes constitute a significant portion of the tribal population facing various socio-economic challenges, including poverty, illiteracy, and lack of healthcare facilities. Objectives: The main objective of the study was to evaluate their health status, identify major health issues within the community, and analyze the availability of tribal healthcare facilities in the study area, the top ten diseases of the study area were also mentioned. To conduct the free mobile medical camps and promote the Unani System. Methodology: The study was carried out in 3 ITDA spots in the Kurnool district i.e. Bugganipalle Thanda, Goriman Konda Thanda, and Gooty Erragudi. The data was collected from the individuals, who attended the free mobile medical camps. Result: A total of 4507 individuals attended the OPDs of free mobile medical camps of 3 Selected ITDA spots. The top 10 diseases were also listed (Cough /Sual o surfa) Bronchitis, sardi wa zukam (catarrh and Coryza), warm i halaqa (pharyngitis), Humma (fever), Husr/ihtibas al Batn / Qabd (Constipation) were the common health problems of present Study area & the distribution of individuals was made by sex and age group. Conclusion: The chronic illness is less in the study area. Acute and common infections like Humma (fever), nazla wa zukam (Coryza and catarrh), sual o surfa (cough /Bronchitis) & warm i halaq (Pharyngitis) were commonly seen in 3 ITDA Spots.

Functionality of Tribal Health Care Centres of Himachal Pradesh: An Empirical Study

An effective regulatory system is a fundamental prerequisite for attracting and sustaining investment in Maternal and Child Health (MCH) services. This study aimed to assess the functionality of tribal health care centres of Himachal Pradesh with respect to Indian Public Health Standard. A quantitative cross sectional design was adopted. Data was collected from tribal Primary Health Centres and Sub-Centres of district Sirmour using modified observational checklist related to infrastructure, manpower and MCH services for monitoring Sub-centre and PHC by external mechanism given under Indian Public Health Standards. Data was analysed using SPSS Version 21. The result revealed that there was shortage of manpower and infrastructure facilities as per Indian Public Health Standards in selected health care centres for adequate distribution of MCH services. It is concluded that there is an urgent need to take State Governmental efforts for effective implementation of MCH services in tribal areas.

Tribal Perspectives on Patient Navigation for Rural Native Veterans Using Veteran Health Administration Services.

American Indian and Alaska Native (Native) Veterans enrolled in theU.S. Department of Veterans Affairs(VA) benefits program are far less likely to access health care compared to other racial/ethnic groups, in part driven by challenges posed by often distant, complex, and culturally unresponsive health care that does not easily interface with the Indian Health Service (IHS) and local Tribal Health Care. To address this disparity, in 2020 the Veteran's Health Administration's (VHA) Office of Rural Health (ORH) initiated the development of a patient navigation program designed specifically for rural Native Veterans. There are no navigation programs for rural Native Veterans to guide development of such a program. Hence, the project team sought perspectives from rural Native Veterans, their families, and community advocates, (n = 34), via video and phone interviews about the role and functions of a Veteran patient navigator and personal characteristics best be suited for such a position. Participants believed a navigator program would be useful in assisting rural Native Veterans to access VHA care. They emphasized the importance of empathy, support, knowledge of local culture, and of Veteran experience within tribal communities, adeptness with VHA systems, and personnel consistency. These insights are critical to create a program capable of increasing rural Native Veteran access to VHA services.

Evaluating COVID-19 Response Within a Tribal Health Care Organization.

Health care organizations of all types have adapted in response to COVID-19. Responding to the pandemic has varied across organizations and there are few standardized frameworks from which to evaluate an organizational response. This article reports COVID-19 responses by a tribal health care organization using a synthesized evaluation framework that integrated the organizational values and allowed for timely implementation of responses during this COVID-19 public health emergency. The authors categorized each COVID-19 response into six domains, including leadership practices, patient engagement, operations management, teamwork and communication, public health, and external partnerships. Responses were analyzed by domain and across time. COVID-19 responses included medical alerts, modifying delivery of care, establishing testing and vaccination sites, additional benefits for employees, as well as new processes for communication between employees and senior leadership. COVID-19 responses were most frequently categorized into the operation management domain (80%). Many responses, especially those that considered patients, employees, and the community, also fit other domains. Operation management was the most frequent domain because the pandemic emerged rapidly and required swift, agile, action-oriented responses from the tribal health care organization. The majority of COVID-19 responses involved multiple, not single, domains. Our evaluation approach captured areas of importance to the tribal health organization and may be pertinent for other indigenous organizations and rural communities. It is especially important to consider tribal perspectives in response to COVID-19 because of the prior history with Western medicine and infectious diseases, and health care limitations experienced due to rurality.

Feedback on audit and action planning for dental caries control: a qualitative study to investigate the acceptability among interdisciplinary pediatric dental care teams.

American Indian and Alaska Native children suffer from the poorest oral health of all populational groups in the United States. Evidence-based practices (EBP) for caries control are well established, but systematically implementing such practices have proven difficult. Audit and feedback with goal setting, and action planning to implement these EBPs have not been tested or adapted for Alaska Native healthcare settings. The aim of this study was to investigate acceptability and perceived feasibility of an audit and feedback intervention for pediatric dental caries control among dental providers and patient stakeholders. The pilot program was implemented in two dental clinics from a tribal healthcare consortium in Alaska. Key-informant interviews were conducted to investigate the contextual, organizational, and behavioral facilitators and barriers to the implementation and expansion of the program. Interview transcripts were analyzed by two researchers using thematic analysis. Eight key informants were interviewed twice (during and after the intervention period), and one once, for a total of 17 interviews. Patient stakeholders were not interviewed due to COVID-19 pandemic clinic closures and social isolation mandates. Three principal themes emerged: a positive organizational climate and culture fostered the acceptability of the program, the positive impacts of the program observed in the pediatric dental teams and the organization, and the challenges to implement the program including understanding the data reports, trusting the accuracy of the data, and competing priorities. The intervention of audit and feedback with goal setting and action planning was well accepted and perceived as feasible by the study participants given the financial and human resources provided by the research project. This qualitative study can inform the design and evaluation of process-oriented implementation strategies geared towards decreasing health inequities and improving health outcomes, such as dental caries in American Indian and Alaska Native children and adolescents.

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)

Exploring factors associated with parent-reported early childhood caries with Alaska's childhood understanding behaviors survey data.

Early Childhood Caries (ECC) can negatively impact the lives of young children, despite being preventable. The purpose of this study was to utilize available data in Alaska to describe changes in parent reports of ECC, and identify factors related to ECC. The Childhood Understanding Behaviors Survey (CUBS) is a population-based survey of parents of 3-year-old children and was utilized to describe changes in: parent-reported ECC among children with a dental visit, access to and or utilization of dental care, and consumption of three or more cups of sweetened beverages between 2009-2011 and 2016-2019. Logistic regression modeling was used to explore factors associated with parent-reported ECC among children with a dental visit. Over time, a significantly smaller proportions of parents whose 3-year-old child had seen a dental professional reported ECC. Additionally, a smaller proportion of parents reported three or more cups of sweetened beverage consumption by their child, while larger proportions had seen a dental professional by age 3. Factors associated with parent-reported ECC included consumption of three or more cups of sweetened beverages, and enrollment in Medicaid or Tribal health care insurance, while protective factors included a parent earning a college degree, and military insurance. Although at the statewide level, improvements were observed in parent-reported measures over time, regional disparities were apparent. Social and economic factors as well as excessive consumption of sweetened beverages appear to play important roles in ECC. CUBS data can help identify trends in ECC within Alaska.

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.

Indigenous Peoples and the Justice40 Screening Tool: Lessons from EJSCREEN

The Biden-Harris administration has focused considerably on environmental justice (EJ), including the Justice40 Initiative and renewed White House Council on Native American Affairs. This work has included financial investments in Tribal economies, prioritizing Tribal health care, and major Tribal infrastructure investments as part of current passed bills and active proposed legislation. The Justice40 Initiative aims at delivering at least 40% of the benefits of federal investments in climate and energy to disadvantaged communities, including many Tribes. The recent White House Tribal Nations Summit Progress Report discusses Justice40 and its potential benefits related to climate, energy, transportation, housing, pollution, and infrastructure. The report leaves open the question of how Tribes will benefit from Justice40. Currently, the White House Council on Environmental Quality is developing a new Climate and Economic Justice Screening Tool for identifying disadvantaged communities who qualify for Justice40 investments. Executive Order 14008 references how this new screening tool should be based on lessons learned from EJSCREEN. For Tribes, however, EJSCREEN does not adequately represent infrastructure and other EJ needs relevant to the goals outlined in Justice40. In this article, we will discuss issues with EJSCREEN that must be addressed in the forthcoming screening tool that was released in prototype form for public comment on February 18, 2022. Major gaps in EJSCREEN include ones in data regarding mining, energy extraction, cultural landscapes, meaningful spatial boundaries, and qualitative data in general, as well as the fundamental issue of engaging with Tribes. These concerns must be addressed if Tribes are to be accurately represented by the tool such that they may fully benefit from Justice40 investments. However, there may be ethics and sovereignty issues that will make some data unavailable at the national scale, or shortages in the United States and Tribal capacity to coordinate the formation of data sets.

The Cultural Adaption of a Sobriety Support App for Alaska Native and American Indian People: Qualitative Feasibility and Acceptability Study.

Despite high rates of alcohol abstinence, Alaska Native and American Indian (ANAI) people experience a disproportionate burden of alcohol-related morbidity and mortality. Multiple barriers to treatment exist for this population, including a lack of culturally relevant resources; limited access to or delays in receiving treatment; and privacy concerns. Many ANAI people in the state of Alaska, United States, live in sparsely populated rural areas, where treatment access and privacy concerns regarding peer-support programs may be particularly challenging. In addition, prior research demonstrates that many ANAI people prefer a self-management approach to sobriety, rather than formal treatment. Taken together, these factors suggest a potential role for a culturally adapted smartphone app to support ANAI people interested in changing their behavior regarding alcohol use. This study was the first phase of a feasibility and acceptability study of a culturally tailored version of an off-the-shelf smartphone app to aid ANAI people in managing or reducing their use of alcohol. The aim of this qualitative needs assessment was to gather insights and preferences from ANAI people and health care providers serving ANAI people to guide feature development, content selection, and cultural adaptation before a pilot test of the smartphone app with ANAI people. From October 2018 to September 2019, we conducted semistructured interviews with 24 ANAI patients aged ≥21 years and 8 providers in a tribal health care organization in south-central Alaska. Participants generally endorsed the usefulness of a smartphone app for alcohol self-management. They cited anonymity, 24/7 access, peer support, and patient choice as key attributes of an app. The desired cultural adaptations included ANAI- and land-themed design elements, cultural content (eg, stories from elders), and spiritual resources. Participants considered an app especially useful for rural-dwelling ANAI people, as well as those who lack timely access to treatment services or prefer to work toward managing their alcohol use outside the clinical setting. This needs assessment identified key features, content, and cultural adaptations that are being implemented in the next phase of the study. In future work, we will determine the extent to which these changes can be accommodated in a commercially available app, the feasibility of implementation, and the acceptability of the culturally adapted version of the app among ANAI users.

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.

Cancer statistics for American Indian and Alaska Native individuals, 2022: Including increasing disparities in early onset colorectal cancer.

American Indian and Alaska Native (AIAN) individuals are diverse culturally and geographically but share a high prevalence of chronic illness, largely because of obstacles to high-quality health care. The authors comprehensively examined cancer incidence and mortality among non-Hispanic AIAN individuals, compared with non-Hispanic White individuals for context, using population-based data from the National Cancer Institute, the Centers for Disease Control and Prevention, and the North American Association of Central Cancer Registries. Overall cancer rates among AIAN individuals were 2% higher than among White individuals for incidence (2014 through 2018, confined to Purchased/Referred Care Delivery Area counties to reduce racial misclassification) but 18% higher for mortality (2015 through 2019). However, disparities varied widely by cancer type and geographic region. For example, breast and prostate cancer mortality rates are 8% and 31% higher, respectively, in AIAN individuals than in White individuals despite lower incidence and the availability of early detection tests for these cancers. The burden among AIAN individuals is highest for infection-related cancers (liver, stomach, and cervix), for kidney cancer, and for colorectal cancer among indigenous Alaskans (91.3 vs. 35.5 cases per 100,000 for White Alaskans), who have the highest rates in the world. Steep increases for early onset colorectal cancer, from 18.8 cases per 100,000 Native Alaskans aged 20-49 years during 1998 through 2002 to 34.8 cases per 100,000 during 2014 through 2018, exacerbated this disparity. Death rates for infection-related cancers (liver, stomach, and cervix), as well as kidney cancer, were approximately two-fold higher among AIAN individuals compared with White individuals. These findings highlight the need for more effective strategies to reduce the prevalence of chronic oncogenic infections and improve access to high-quality cancer screening and treatment for AIAN individuals. Mitigating the disparate burden will require expanded financial support of tribal health care as well as increased collaboration and engagement with this marginalized population.

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.

Patterns of Healthcare Use and Mortality After Alzheimer's Disease or Related Dementia Diagnosis Among Alaska Native Patients: Results of a Cluster Analysis in a Tribal Healthcare Setting.

Background:Alaska Native and American Indian (AN/AI) people represent a rapidly aging population with disproportionate burdens of Alzheimer’s disease and related dementias (ADRD) risk factors.Objective:To characterize healthcare service use patterns and mortality in the years following ADRD diagnosis for patients in an Alaska Native Tribal health system.Methods:The study sample included all AN/AI patients aged 55 or older with an ADRD diagnosis who were seen between 2012–2018 (n = 407). We used cluster analysis to identify distinct patterns of healthcare use for primary care, emergency and urgent care, inpatient hospital stays, and selected specialty care. We compared demographic and clinical factors between clusters and used regression to compare mortality.Results:We identified five clusters of healthcare service use patterns after ADRD diagnosis: 1) people who use a low amount of all services (n = 107), 2) people who use a high amount of all services (n = 60), 3) people who use a high amount of primary and specialty care (n = 105), 4) people who use a high amount of specialty care (n = 65), and 5) people who use a high amount of emergency and urgent care (n = 70). The cluster with the highest use had the greatest proportion of comorbidities and had a 2.3-fold increased risk of mortality compared to the cluster with the lowest healthcare service use.Conclusion:Results indicate that those receiving the most services had the greatest healthcare-related needs and increased mortality. Future research could isolate factors that predict service use following ADRD diagnosis and identify other differential health risks.

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.