Integrating community health representatives with health care systems: clinical outcomes among individuals with diabetes in Navajo Nation

Systems, Social, and Individual Factors Influencing Glycemic Control Among American Indian/Alaska Native Adults with Type 2 Diabetes: A Systematic Review

OBJECTIVES : American Indian/Alaska Native (AI/AN) peoples experience type 2 diabetes (T2DM) at double the rate of White Americans and have 2.3 times greater mortality. Glycemic control is a central goal of diabetes management and is associated with superior physical outcomes and quality of life. The purpose of this systematic review was to identify and synthesize all factors that influence glycemic control among AI/AN people with T2DM.

DESIGN

This is a systematic review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. PubMed, CINAHL, PsychInfo, Embase and Web of Science were searched using terms related to "type 2 diabetes" and "American Indian/Alaska Native" from 2008-2023.

RESULTS

Thirty-three studies were identified. Factors related to glycemic control were 1) healthcare interventions, 2) social determinants of health, 3) self-care behaviors, 4) mental health and psychological factors, and 5) genetic factors. Few factors were consistently associated with improved glycemic control. Multidisciplinary care models that integrate community members providing education/healthcare referrals, and medication adherence had the strongest signals with improved glycemic control. While some studies found relationships between glycemic control and diet, exercise and depression, others did not.

CONCLUSION

While more work is needed to understand influencers of glycemic control in this population, community health representatives, medication adherence and healthcare utilization should be leveraged to improve glycemic control. Future work among AI/AN people with T2DM should focus on how structural and societal factors, like health policy, built environment, and social environment, impact the performance of self-care behaviors and influence glycemic control.

Thoughts on the construction of public health informatization for community health archives grass roots management system

With the development of social economy and the continuous improvement of people's living standards, people expect to receive high-level medical services, and the requirements for medical care are also getting higher and higher. However, there are still objective problems such as rising medical costs, difficulty in seeking medical treatment, uneven distribution of medical resources, low efficiency of medical services, and uneven medical quality. This paper first analyzes the significance of public health informatization construction, focuses on the elements of public health informatization construction, and expounds the status quo of health informatization construction and the existing problems in community health informatization. Then, this paper expounds the construction of public health informatization based on the grass-roots management system of community health records, and discusses the construction of a health information platform centered on the health records of community residents. Afterwards, this paper proposes and studies the functions of the community medical information archives management system from three aspects: the composition of the community medical information archives management system, the problems of system management, and the development requirements of the system, and proposes an algorithm based on a decision tree model to enhance public health informology. Finally, on the basis of experiments and investigations, Internet technology and decision tree model algorithms are introduced into the public health information system construction of the community health archives system to build a new public health information system, and the satisfaction rate can be increased by 23%.

Effective primary care management of type 2 diabetes for indigenous populations: A systematic review

Background

Indigenous peoples in high income countries are disproportionately affected by Type 2 Diabetes. Socioeconomic disadvantages and inadequate access to appropriate healthcare are important contributors.

Objectives

This systematic review investigates effective designs of primary care management of Type 2 Diabetes for Indigenous adults in Australia, Canada, New Zealand, and the United States. Primary outcome was change in mean glycated haemoglobin. Secondary outcomes were diabetes-related hospital admission rates, treatment compliance, and change in weight or Body Mass Index.

Methods

Included studies were critically appraised using Joanna Briggs Institute appraisal checklists. A mixed-method systematic review was undertaken. Quantitative findings were compared by narrative synthesis, meta-aggregation of qualitative factors was performed.

Results

Seven studies were included. Three reported statistically significant reductions in means HbA1c following their intervention. Seven components of effective interventions were identified. These were: a need to reduce health system barriers to facilitate access to primary care (which the other six components work towards), an essential role for Indigenous community consultation in intervention planning and implementation, a need for primary care programs to account for and adapt to changes with time in barriers to primary care posed by the health system and community members, the key role of community-based health workers, Indigenous empowerment to facilitate community and self-management, benefit of short-intensive programs, and benefit of group-based programs.

Conclusions

This study synthesises a decade of data from communities with a high burden of Type 2 Diabetes and limited research regarding health system approaches to improve diabetes-related outcomes. Policymakers should consider applying the seven identified components of effective primary care interventions when designing primary care approaches to mitigate the impact of Type 2 Diabetes in Indigenous populations. More robust and culturally appropriate studies of Type 2 Diabetes management in Indigenous groups are needed.

Trail registration

Registered with PROSPERO (02/04/2021: CRD42021240098).

Empowerment-based support program for vulnerable populations living with diabetes, obesity or high blood pressure: a scoping review

BACKGROUND

The management of chronic diseases such as diabetes, obesity and high blood pressure is a major global health challenge, particularly among the most disadvantaged populations. Beyond the biomedical management of these diseases, comprehensive support that takes into account the peoples' economic and social situation is fundamental. The objective of this scoping review is to create an inventory and an analysis of the different types of support for these chronic diseases among disadvantaged, immigrant or minority populations to contribute to a better definition and characterization of what should be global support for these vulnerable populations suffering from these diseases.

METHODS

A search of PubMed, PsycINFO, Sages Journals and Web of Science was conducted (between March and May 2021) for articles published between January 2000 and May 2021. Articles were selected after screening titles, abstracts and full texts according to our 5 inclusion criteria.

RESULTS

We included 16 articles. The diabetes, obesity and high blood pressure support programs described in these articles operate to improve physical and mental health and access to care. The approaches of these interventions are focused on the training and participation of people and the implementation of support actions adapted to the person. The majority of these interventions have a real attachment to the community.

CONCLUSIONS

This review of the literature shows that support for people with chronic diseases such as diabetes, obesity or high blood pressure is based on three pillars: empowerment, peer mediation and holistic and tailor-made support for the individual. The empowerment approach, which considers the capacities and resources of individuals and whose goal is to strengthen their ability to act on their health, appears to be entirely suited to the support of these chronic diseases. This review underlines the importance of moving away from a biomedical approach to a holistic approach truly focused on the person, their capacities and their needs.

Diné Navajo Resilience to the COVID-19 pandemic

OBJECTIVE

To date, there are no studies of COVID-19 cases and deaths in the Navajo Nation, US. The primary objective of this manuscript is to understand whether counties with a higher proportion of Navajo (Diné) population also had higher cases and deaths of COVID-19 and whether these dropped with vaccination.

METHOD

We undertook a cross-sectional analysis of county level data from March 16, 2020-May 11, 2021. Data were obtained from public repositories and the US Census for the Navajo Nation, including northeastern Arizona, southeastern Utah, and northwestern New Mexico. The primary outcome measure is the number of individuals with confirmed cases or deaths of COVID-19. A secondary outcome was COVID-19 vaccinations.

RESULTS

The 11 counties in Navajo Nation have a wide variation in the percent Navajo population, the resources available (ICU beds and occupancy), and COVID-19 outcomes. Overall, there was a substantial increase in the number of cases from March 16 -July 16, 2020 (the height of the pandemic) with a doubling time of 10.12 days on Navajo Nation. The percent Navajo population was a strong predictor of COVID-19 cases and deaths per million population. COVID-19 vaccinations were inversely associated with COVID-19 cases and deaths in these counties.

CONCLUSIONS

The COVID-19 pandemic on the Navajo Nation is a story of resilience. Navajo Nation was one of the hardest hit areas of the United States, with peak cases and deaths due to COVID-19. With an aggressive vaccination effort, these cases and deaths were strikingly curtailed, showing the resilience of the Navajo (Diné) people.

The Indian Health Service and American Indian/Alaska Native Health Outcomes

The Indian Health Service (IHS) has made huge strides in narrowing health disparities between American Indian and Alaska Native (AI/AN) populations and other racial and ethnic groups. Yet, health disparities experienced by AI/AN people persist, with deep historical roots combined with present-day challenges. Here we review the history of the IHS from colonization to the present-day system, highlight persistent disparities in AI/AN health and health care, and discuss six key present-day challenges: inadequate funding, limited human resources, challenges associated with transitioning services from federal to Tribal control through contracting and compacting, evolving federal and state programs, the need for culturally sensitive services, and the promise and challenges of health technology.

Community Outreach for Navajo People Living with Diabetes: Who Benefits Most?

INTRODUCTION

The Community Outreach and Patient Empowerment (COPE) intervention provides integrated outreach through community health representatives (CHRs) to people living with diabetes in Navajo Nation. The aim of this study was to identify groups for whom the intervention had the greatest effect on glycated hemoglobin A_1c (HbA_1c).

METHODS

We analyzed de-identified data extracted from routine health records dated from December 1, 2010, through August 31, 2014, to compare net change in HbA_1c among COPE patients and non-COPE patients. We used linear mixed models to assess whether the intervention was modified by age, sex, preferred language, having a primary care provider, baseline HbA_1c, or having a mental health condition.

RESULTS

Age, having a primary care provider, and baseline HbA_1c significantly modified HbA_1c levels. Among patients aged 64 or younger, COPE participation was associated with a net decrease in HbA_1c of 0.77%; among patients aged 65 or older, the net decrease was 0.49% (P = .03). COPE participation was associated with a steeper decrease in HbA_1c among patients without a primary care physician (net decrease, 0.99%) than among patients with a primary care provider (net decrease, 0.57%) (P = .03). COPE patients with a baseline HbA_1c >9% had a net decrease of 0.70%, while those with a baseline HbA_1c ≤9% had a net decrease of 0.34% (P = .01). We found no significant differences based on sex, preferred language, or having a mental health condition.

CONCLUSION

Findings suggest that the COPE intervention was robust and equitable, benefiting all groups living with diabetes in Navajo Nation, but conferring the greatest benefit on the most vulnerable.

Community-based outreach associated with increased health utilization among Navajo individuals living with diabetes: a matched cohort study

Background

Navajo community members face high rates of diabetes mellitus and other chronic diseases. The Navajo Community Health Representative Outreach Program collaborated with healthcare providers and academic partners to implement structured and coordinated outreach to patients living with diabetes. The intervention, called Community Outreach and Patient Empowerment or COPE, provides home-based health coaching and community-clinic linkages to promote self-management and engagement in healthcare services among patients living with diabetes. The purpose of this study was to evaluate how outreach by Navajo Community Health Representatives (“COPE Program”) affected utilization of health care services among patients living with diabetes.

Methods

De-identified data from 2010 to 2014 were abstracted from electronic health records at participating health facilities. In this observational cohort study, 173 cases were matched to 2880 controls. Healthcare utilization was measured as the number of times per quarter services were accessed by the patient. Changes in utilization over 4 years were modeled using a difference-in-differences approach, comparing the trajectory of COPE patients’ utilization before versus after enrollment with that of the control group. The model was estimated using generalized linear mixed models for count outcomes, controlling for clustering at the patient level and the service unit level.

Results

COPE enrollees showed a 2.5% per patient per quarter (pppq) greater increase in total utilization (p = 0.001) of healthcare services than non-COPE enrollees; a 3.2% greater increase in primary care visits (p = 0.024); a 6.3% greater increase in utilization of counseling and behavioral health services (p = 0.013); and a 9.0% greater increase in pharmacy visits (p <  0.001). We found no statistically significant differences in utilization trends of inpatient, emergency room, specialty outpatient, dental, laboratory, radiology, or community encounter services among COPE participants versus control.

Conclusions

A structured intervention consisting of Community Health Representative outreach and coordination with clinic-based providers was associated with a modest increase in health care utilization, including primary care and counseling services, among Navajo patients living with diabetes. Community health workers may provide an important linkage to enable patients to access and engage in clinic-based health care.

Trial registration

NCT03326206, registered 10/31/2017, retrospectively registered.

Qualitative evaluation of a community health representative program on patient experiences in Navajo Nation

BACKGROUND

Community Health Representatives (CHRs) overcome health disparities in Native communities by delivering home care, health education, and community health promotion. The Navajo CHR Program partners with the non-profit Community Outreach and Patient Empowerment (COPE), to provide home-based outreach to Navajo clients living with diabetes. COPE has created an intervention (COPE intervention) focusing on multiple levels of improved care including trainings for CHRs on Motivational Interviewing and providing CHRs with culturally-appropriate education materials. The objective of this research is to understand the participant perspective of the CHR-COPE collaborative outreach through exploring patient-reported outcomes (PROs) of clients who consent to receiving the COPE intervention (COPE clients) using a qualitative methods evaluation.

METHODS

Seven COPE clients were selected to participate in semi-structured interviews one year after finishing COPE to explore their perspective and experiences. Qualitative interviews were recorded, transcribed, and coded to identify themes.

RESULTS

Clients revealed that health education delivered by CHRs facilitated lifestyle changes by helping them understand key health indicators and setting achievable goals through the use of accessible material and encouragement. Clients felt comfortable with CHRs who respected traditional practices and made regular visits. Clients also appreciated when CHRs educated their family members, who in turn were better able to support the client in their health management. Finally, CHRs who implemented the COPE intervention helped patients who were unable to regularly see a primary care doctor for critical care and support in their disease management.

CONCLUSION

The COPE-CHR collaboration facilitated trusting client-CHR relationships and allowed clients to better understand their diagnoses. Further investment in materials that respect traditional practices and aim to educate clients' families may foster these relationships and improve health outcomes.

TRIAL REGISTRATION

clinicaltrials.gov: NCT03326206. Registered 9/26/2017 (retrospectively registered).