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Working towards a better understanding of type 2 diabetes care organization with First Nations communities: a qualitative assessment

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Background: Diabetes care is suboptimal in First Nations populations. Innovative and culturally-relevant approaches are needed to promote proactive organization of diabetes care for diabetes patients on-reserve in Canada. The Reorganizing the Approach to Diabetes care through the Application of Registries (RADAR) model is one strategy to improve care: an integrated disease registry and electronic health record for community healthcare workers with centralized care coordination. The aim of this study was to qualitatively assess the organization of type 2 diabetes care in participating communities in Alberta, Canada, at baseline prior to implementing RADAR. Methods: Using qualitative description, we purposefully sampled healthcare workers involved in diabetes care at each health center. We used the 5Rs framework (i.e., Recognize, Register, Resource, Relay, Recall) to inform the baseline assessment and conducted group interviews in 6 communities with 16 healthcare workers. Detailed notes were taken and validated by participants. Data was managed using ATLAS.ti 8 and analyzed using content analysis. Results: We found strong commitment and effort by local healthcare workers to support people living with type 2 diabetes in their communities. However, healthcare workers were limited in their ability to identify (i.e., recognize), track (i.e., register and relay) and manage (i.e., resource and recall) people with type 2 diabetes as proposed by the 5Rs framework. The organization of diabetes care was often reactive and dependent on patients' abilities to navigate the health system. Interestingly, participants talked about the 5Rs in relationship to one another, not in a linear or isolated manner. Conclusions: Overall, the organization of diabetes care in participating communities did not align with the recommended approach of the 5Rs framework. In addition, we propose "reimagining" the 5Rs to reflect the interdependence and mediation of components situated within human and financial resources. This will better equip healthcare workers to assess, plan and execute organized and proactive diabetes care. However, the onus on people living with type 2 diabetes to engage with healthcare services remains a concern. Trial registration: ISRCTN.com, ISRCTN14359671.
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R E S E A R C H Open Access
Working towards a better understanding of
type 2 diabetes care organization with First
Nations communities: a qualitative
assessment
Lisa A. Wozniak
1,2
, Jeffrey A. Johnson
1,2
and Dean T. Eurich
1,2*
Abstract
Background: Diabetes care is suboptimal in First Nations populations. Innovative and culturally-relevant approaches
are needed to promote proactive organization of diabetes care for diabetes patients on-reserve in Canada. The
Reorganizing the Approach to Diabetes care through the Application of Registries (RADAR) model is one strategy
to improve care: an integrated disease registry and electronic health record for community healthcare workers with
centralized care coordination. The aim of this study was to qualitatively assess the organization of type 2 diabetes
care in participating communities in Alberta, Canada, at baseline prior to implementing RADAR.
Methods: Using qualitative description, we purposefully sampled healthcare workers involved in diabetes care at
each health center. We used the 5Rs framework (i.e., Recognize, Register, Resource, Relay, Recall) to inform the
baseline assessment and conducted group interviews in 6 communities with 16 healthcare workers. Detailed notes
were taken and validated by participants. Data was managed using ATLAS.ti 8 and analyzed using content analysis.
Results: We found strong commitment and effort by local healthcare workers to support people living with type 2
diabetes in their communities. However, healthcare workers were limited in their ability to identify (i.e., recognize),
track (i.e., register and relay) and manage (i.e., resource and recall) people with type 2 diabetes as proposed by the
5Rs framework. The organization of diabetes care was often reactive and dependent on patientsabilities to
navigate the health system. Interestingly, participants talked about the 5Rs in relationship to one another, not in a
linear or isolated manner.
Conclusions: Overall, the organization of diabetes care in participating communities did not align with the
recommended approach of the 5Rs framework. In addition, we propose reimaginingthe 5Rs to reflect the
interdependence and mediation of components situated within human and financial resources. This will better
equip healthcare workers to assess, plan and execute organized and proactive diabetes care. However, the onus on
people living with type 2 diabetes to engage with healthcare services remains a concern.
Trial registration: ISRCTN.com, ISRCTN14359671.
Keywords: First Nations, Diabetes, Health services delivery, Qualitative description
© The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
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the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
* Correspondence: deurich@ualberta.ca
1
School of Public Health, University of Alberta, Edmonton, Alberta T6G 2E1,
Canada
2
Alliance for Canadian Health Outcomes Research in Diabetes, 2-040 Li Ka
Shing Centre for Health Research Innovation, University of Alberta,
Edmonton, Alberta T6G 2E1, Canada
Wozniak et al. Archives of Public Health (2020) 78:7
https://doi.org/10.1186/s13690-020-0391-8
Background
Diabetes rates have reached staggering proportions
among Indigenous peoples [1]. In Canada, the preva-
lence of diabetes is 35 times higher in First Nations
than in the general population [2]. First Nations people
experience a higher prevalence of diabetes-related com-
plications and mortality [2]. Canadian data shows the
mortality rate is 23 times higher for Aboriginal peoples
than the general population with diabetes [3]. These
concerns are exacerbated by suboptimal diabetes care,
particularly in remote settings where many First Nations
people live [2,46]. Applying the Chronic Care Model
[7] to diabetes care, with appropriate cultural context,
could lessen the impact of diabetes among First Nations.
The Chronic Care Model promotes proactive manage-
ment of diabetes at a population level through: team-
based approach; self-management support of patients;
decision support; clinical information systems; and re-
sources and policies [8,9]. When implemented in pri-
mary care settings, the model improves quality of care
and outcomes [8,10,11]. Diabetes Canada guidelines
recommend the 5Rs approach to organizing diabetes
care within a Chronic Care Model framework: Recognize
(assess risk factors and screen); Register (systematically
track patients); Resource (support self-management
through inter-professional teams); Relay (facilitate infor-
mation sharing); and Recall (timely review and reassess-
ment) [8]. Few First Nations communities have the
infrastructure, expertise, or resources to employ the 5Rs
for diabetes care. Innovative and culturally-relevant ap-
proaches are needed to promote the proactive
organization of diabetes care for people living with dia-
betes on-reserve in Canada [8,12].
The Reorganizing the Approach to Diabetes care
through the Application of Registries (RADAR) model
was developed in collaboration with First Nations com-
munities and OKAKI Health Intelligence Inc. (Calgary,
Canada) (OKAKI), a private sector company with more
than 10 years of experience working with First Nations
communities in Alberta, Canada. We are evaluating the
effectiveness of RADAR using a controlled trial study
protocol reported elsewhere [13]. Briefly, the RADAR
model uses centralized care coordinators (i.e., registered
nurses) to work with local healthcare workers in partici-
pating First Nations communities to: (1) populate an
electronic diabetes registry/electronic health record
(EHR) (e.g., demographics, clinical, lab information)
called the Community Assessment Response and Em-
powerment CARE software platform (CARE EHR);
and (2) assist, coordinate and monitor care at the
population-level (e.g. identify care gaps, coordinate refer-
rals) through the CARE EHR and telehealth approaches.
For this study, we aimed to qualitatively assess the
organization of type 2 diabetes (T2D) care in
participating First Nations communities at baseline prior
to implementing RADAR as little is known about how
T2D care is organized within the context of First Na-
tions communities in Alberta. This information is vital
to implementing quality improvement interventions like
RADAR and to contextualize the findings for the larger
controlled trial study. For example, we would not expect
a change in outcomes because of RADAR if T2D care
was organized in these communities using the 5Rs ap-
proach prior to implementing RADAR.
Methods
Study design
We used qualitative description [14,15] to elicit health-
care workersperceptions of the current organization of
T2D care in their communities. Qualitative description
is appropriate when the goal is to produce a summary of
a phenomenon, such as the organization of care. First
Nations leaders and community health managers in par-
ticipating communities reviewed and endorsed the pro-
ject. Approval was obtained from the University of
Albertas Health Research Ethics Board (Study ID
Pro00048714). All participating healthcare workers pro-
vided verbal consent. We followed the consolidated cri-
teria for reporting qualitative research (COREQ)in
reporting this study [16]. More detail is provided in an
additional file (Additional file 1).
Setting
The implementation of RADAR is a collaborative effort
with several First Nations communities from Treaty 6, 7
and 8 territories in Alberta, Canada. We restricted the
qualitative baseline assessment to 6 communities to bal-
ance the demands of rigor with feasibility and timeliness.
In addition, due to the staggered implementation of the
controlled trial study, the baseline assessment would
have taken several more years to complete if we included
all of the participating communities. The 6 selected
communities were diverse in context offering a range of
perspectives regarding the current organization of T2D
care. Health managers estimated that approximately 750
people with T2D reside in the 6 communities. The ma-
jority of care for people living in First Nations communi-
ties is delivered through federally funded, nurse-led
homecare, community health, and diabetes programs
[17]. Health services, including diabetes care, are primar-
ily delivered by local, on-reserve, healthcare workers
(e.g., registered nurses, licenced practical nurses, com-
munity health representatives) with limited access to pri-
mary care physicians and specialist services [18]. The 6
participating communities are situated approximately
30180 min from a major urban center, where the ma-
jority of diabetes specialist services are located.
Wozniak et al. Archives of Public Health (2020) 78:7 Page 2 of 8
At baseline, all communities had Alberta Netcare
(Netcare), a secure and confidential EHR that provides
healthcare workers with patientshealth information in-
cluding demographics, medications, laboratory test re-
sults, diagnostic images and reports, hospital discharge
summaries, and surgeries. The health centres imple-
mented the CARE EHR for their home care programs;
however, it was not being used specifically for diabetes
care.
Data collection
With the assistance of health managers, we identified
and purposefully sampled all healthcare workers in-
volved in diabetes care at each health center. To achieve
consensus regarding the organization of T2D care, re-
spondents in each community were invited to participate
in 1 group interview via telephone. A trained qualitative
researcher (LAW) conducted the interviews using a
semi-structured interview guide informed by the 5Rs
framework (Additional file 2). Interviews lasted approxi-
mately 90 min. Detailed notes were taken and validated
by participants for accuracy. All data were kept on a se-
cure server or in locked files in a secure office with privi-
leged access with only the research team having access
to the data.
Data analysis
We used content analysis [19] to examine the data [14].
LAW conducted the primary analyses using an inte-
grated approach. First, the data was coded using the 5Rs
framework. Then, we coded data not directly related to
the framework. Last, we applied an inductive approach
to identify emerging codes and concepts within, across,
and outside of the 5Rs. We reviewed code definitions
and emerging concepts at regular research team meet-
ings, and discussed discrepancies to reach consensus. All
data was managed with and queried using ATLAS.ti
Version 8 (Berlin, Germany, Scientific Software Develop-
ment GmbH) [20]. As described above, we drew on sev-
eral strategies to ensure reliability, including
methodological coherence, peer debriefing, and main-
taining an audit trail [21,22].
Results
We conducted 6 group interviews, with a total of 16 in-
dividuals, between November 2014 and July 2017. Types
of healthcare workers included: registered nurses (8); li-
cenced practical nurses (3); health managers (2); and
other (3) (i.e. community health representative, retinal
photographer, registered dietician). Types of programs
represented by participating healthcare workers in-
cluded: administration (3); home care (6); community
health (4); and diabetes program (3).
As demonstrated by their participation in RADAR, we
found strong commitment and effort by local healthcare
workers to support patients with T2D in their communi-
ties. However, healthcare workers reported being limited
in their ability to identify, track and manage people with
T2D. Below, we describe the organization of T2D care
prior to implementing RADAR by the processes of iden-
tifying (i.e., Recognize), tracking (i.e., Register and Relay),
and managing (i.e., Resource and Recall) of patients. We
provide a summary the organization of T2D care at
baseline by the 5Rs in Table 1.
Identify T2D patients (Recognize)
Prior to implementing RADAR, healthcare workers re-
ported limited screening to identify people with T2D.
This was often because healthcare workers presumed
that people were screened for T2D by physicians. When
people were screened for and diagnosed with T2D by
physicians, this information was not always relayed to
the healthcare workers expected to perform subsequent
diabetes care. When screening was conducted at the
health centers, it relied on patient self-referral to health
centres, including when patients were experiencing
symptoms or attending special events (e.g., health fairs,
Table 1 Summary of the organization of type 2 diabetes care
by the 5Rs at baseline
RECOGNIZE: Appropriately screen for & identify people with diabetes
Limited screening due to limited resources and patients screened
elsewhere by other providers
Used existing records/registries (e.g., chronic diseases lists, CARE EHR,
Physician EMR)
Relied on patient self-referral or engagement with healthcare system
REGISTER: Develop a means of tracking all patients with diabetes
Used patient charts or chronic diseases lists, paper-based and/or
electronic
Data entry in the context of limited resources was problematic
Relied on patient self-referral or engagement with healthcare system
RESOURCE: Support self-management through inter-professional teams
Differential access to diabetes-related providers and services, includ-
ing diabetes educators or programming
Limited ability to support patients in context of limited resources
Lack of collaborative care between healthcare providers
Relied on patient self-referral or engagement with healthcare system
RELAY: Information sharing between patient & healthcare team members
Used Netcare, CARE EHR, or Physician EMR
Facilitators: colocation of healthcare workers and providers; existing
relationships
Barriers: privacy concerns; limited access to data or data systems; or
incompatibility of Physician EMRs with CARE EHR resulting in data entry
RECALL: Remind caregivers & patients of timely review & reassessment
Used CARE EHR, patient chart review, or chronic diseases lists; patient
reminders
Barriers: patients not engaging with healthcare system (e.g., no
shows even when recalled); limited use of CARE EHR by all staff; time
consuming, not knowing who had T2D)
LEGEND: EMR Electronic Medical Record; T2D type 2 diabetes; EHR Electronic
Health Record
Wozniak et al. Archives of Public Health (2020) 78:7 Page 3 of 8
diabetes walks). In addition, limited financial and human
resources diminished healthcare workersability to
screen people who accessed their services.
Due to limited screening, healthcare workers primarily
identified people with T2D through: patient self-referral
after diagnosis by a physician; existing information
sources or registries, including Netcare, department- and
external program-based chronic diseases lists of patients
(i.e., paper- and/or electronic-based), the CARE EHR,
electronic medical records (EMRs), or databases (e.g.,
non-insured health benefits); and/or knowing the com-
munity or by word of mouth. Respondents recognized
the problematic nature of only identifying those having
T2D among people who accessed health services versus
those who did not. Reported patient-level barriers to
accessing health services included lack of transportation
and/or fear, denial or apathy about diabetes.
Track T2D patients (Register & Relay)
At baseline, healthcare workers primarily registered pa-
tients with T2D using patient charts, chronic diseases
lists (paper- and/or electronic-based), the CARE EHR
(narrative chart), and/or EMR. Of note, a diabetes regis-
try was being built within an EMR in 1 community as
part of a different quality improvement initiative. While
the CARE EHR was available prior to implementing
RADAR, its full capability was not used and limited to
the narrative chart and client admission/service tracking,
typically used only by home care staff.
Healthcare workers identified data entry as a barrier to
registering patients with T2D, including entering paper-
based data from records (e.g., patient charts and depart-
ment- or program-based lists) to the CARE EHR. The
burden of data entry was often situated in the context of
limited financial and human resources, including inad-
equate staffing levels and/or competing priorities (e.g.,
immunizations, flu clinics) and limited compatibility of
information systems (e.g. Physician EMRs with the
CARE EHR). Despite this, the move from a paper-based
to an electronic-based information system (i.e., the
CARE EHR) indicated a positive transition from register-
ing patients at an individual- to a panel-level. Regardless,
the strategies used to register patients with T2D still re-
lied on patient self-referral to healthcare services or were
focused on already managed patients (e.g., home care
patients), thus missing people who did not access these
services.
At baseline, healthcare workers reported some degree
of relaying clinical information between members of the
healthcare teams (e.g., healthcare workers, physicians,
specialists, pharmacists, patients); however, this was
often done inconsistently. They reported using: informa-
tion systems, including Netcare, the CARE EHR, or
Physician EMRs; in-person communication when co-
located; telecommunication (i.e., telephone, fax, or mes-
saging); and/or established referral processes.
In contrast, there were examples of limited relaying of
clinical information among healthcare teams. Not being
co-located was reported as a barrier, with respondents
reporting limited opportunities to share information
with visiting physicians and specialists or staff housed in
separate buildings. Respondents explained that a lack of
awareness of and relationships between members of
healthcare teams was a barrier, particularly to sharing
clinical information with providers located outside of the
communities that led to gaps in coordinated care. For
example, despite being located in the same small com-
munity, healthcare workers at the health center and fam-
ily physicians in a separate clinic had never formally met
to discuss coordination of diabetes care until the
OKAKI/research team brought them together to discuss
implementing RADAR. During this face-to-face meeting,
physicians learned that retinal teleophthalmology was
available at their local health center. Until this point,
physicians had sent patients to an urban center (~ 3 h
travel) for a service available in the community. Add-
itional barriers to relaying clinical information included:
privacy issues, including the need for patient consent;
patients accessing multiple points of care; and limited
access to data (e.g., missing data) or information systems
(e.g., only registered nurses had access to EMR or
Netcare).
Manage T2D patients (Resource & Recall)
Healthcare workers reported differential access to
diabetes-related providers and programming by commu-
nity. Respondents in all communities reported the avail-
ability of nurses (i.e., registered nurses and/or licenced
practical nurses) and the following programs/ services:
home care, foot care, and medical transportation. Most
respondents reported some access to family physicians
(e.g., rotating physicians visiting the health center 2
days/week), pharmacists, or dieticians and the following
programs/services: laboratory services, diabetes pro-
graming, or retinal photography. It was less common for
patients in the communities to have access to commu-
nity health representatives, providers through primary
care networks, certified diabetes educators, or specialists
and the following programs/services: hospitals, medica-
tion review, or mental health services. We provide a de-
tailed summary of the available providers and services in
the communities as identified by respondents in
Additional file 3.
In addition, respondents identified patient- and
system-level barriers to the self-management of T2D. At
the patient-level, they perceived limited patient engage-
ment with healthcare services, including frequent no
showsfor appointments or tests. Rationales for patients
Wozniak et al. Archives of Public Health (2020) 78:7 Page 4 of 8
limited engagement included: fear or denial of T2D; lack
of transportation; or completing priorities, such as work.
At the system-level, respondents reported limited finan-
cial (i.e., funding, equipment) and human (i.e., staffing,
time, and expertise) resources as a barrier to healthcare
workers supporting patients with self-management.
Respondents varied in their opinions regarding the ap-
propriateness of care offered to support patients in self-
management. They described efforts to provide appro-
priate care to patients by healthcare workers (e.g., offer-
ing holistic care, tailoring programs to cultural or
community preferences, using preferred language of pa-
tients, or understanding food insecurity) or other pro-
viders (e.g., family physician was a community member
or visiting specialists had experience working with Indi-
genous communities). Respondents in 1 community de-
scribed educating other providers on culturally
sensitivecare. Regardless of these positive examples, re-
spondents identified barriers to appropriate care includ-
ing: lack of trust among some patients to share
information about their culture, current context, or ideas
about their care with providers; lack of understanding
among providers of the context faced by patients (e.g.,
food insecurity or barriers to accessing care and man-
aging their health), often leading to a judgemental atti-
tude; or lack of traditional medicine offered in
conjunction with other treatments.
Prior to implementing RADAR, respondents reported
variable use of strategies for recall. Strategies used to re-
mind healthcare workers to review and reassess client
targets included: use of information systems, such as the
CARE EHR or Physician EMR; patient chart review on a
regular basis or prior to scheduled client appointments;
and/or the use of manual chronic diseases lists of pa-
tients due for care specific to departments (e.g., foot
care, retinal photography, or immunizations). While the
CARE EHR was identified as a tool for recall, respon-
dents identified barriers including use by home care staff
but not by all healthcare workers. Thus, only some
members of a patients care team captured information
needed in the CARE EHR for healthcare workers to
know who to recall and for what service. Lastly, a few re-
spondents recognized that they used no systematic
means of recall for healthcare workers.
Techniques used to recall patients consisted mainly of
patient reminders for scheduled appointments either in-
person or by telephone or mail. Respondents reported
recalling patients to book overdue appointments or
when lab values were outside of normal range; however,
this was often limited to home care patients. Respon-
dents in 1 community identified access to clinical infor-
mation (e.g., lab values through Netcare) as a facilitator
to recalling patients. Regardless, respondents identified
several barriers to recalling patients. First, the onus was
on patients to make appointments or walk-into
needed healthcare services, rather than being proactively
recalled. This is troubling as respondents identified
patient-level barriers to accessing care even when
recalled, including: no showsor missed appointments
often because they lacked transportation; no phone to
receive reminder calls; and/or changing contact informa-
tion. Additional barriers to recalling patients included
the time-consuming nature of the activity (i.e., resources
needed) or not knowing who had diabetes because pa-
tients sought diabetes care elsewhere.
Discussion
Overall, we found that healthcare workers in the partici-
pating First Nations communities were limited in their
ability to systematically identify, track, and manage pa-
tients with T2D prior to implementing RADAR. These
challenges are not unique to the healthcare workers in
these communities. Across settings and health care pro-
fessions, T2D can remain undiagnosed for many years
[23], indicating the lack of screening to identify asymp-
tomatic individuals. Furthermore, our previous study de-
scribing the development and use of diabetes registries
in primary care networks in Alberta revealed similar is-
sues to those reported here, including: the use of existing
registries to recognize patients with T2D rather than
proactively screen; relying on patient self-referral thereby
limiting reach to patients engaged with the healthcare
system; and limited relay of, or access to, clinical infor-
mation [24].
We found that care was often reactive and dependent
on patientsabilities to engage with and navigate the
health system. This is particularly troubling given the
patient-level barriers to accessing care. It is unclear
whether limited patient engagement with healthcare ser-
vices was a result of limited access to services or health
behaviours, including the conscious or unconscious deci-
sion not to access services, or a combination of both.
For example, historical trauma makes it likely that First
Nations people avoid healthcare services [25]. Due to
the inequitable diabetes care received by Indigenous
peoples, including access to providers and programs,
there have been calls for cultural mentorship to increase
the knowledge of non-Indigenous providers of the social
and historical context influencing patients healthcare de-
cisions, and moving beyond cultural competency to un-
derstanding culture as a relational and fluid process [26].
Lastly, we found that healthcare workers discussed the
5Rs of organizing care in relationship to one another,
not in a linear or isolated manner. They situated the 5Rs
in the context of relationships with other healthcare pro-
viders and the availability of sufficient financial and hu-
man resources. Thus, while the definitions of the 5Rs
are distinct, they represent connected and overlapping
Wozniak et al. Archives of Public Health (2020) 78:7 Page 5 of 8
processes situated in a broader context, particularly rela-
tionships and resources. Based on these results, we
propose reimagining the 5Rs to 6Rs: replace the existing
term Resourcewith Relationshipsand reflect the
interdependence and mediation of components with
dotted lines with all components situated within the 6th
RofResources(e.g., financial & HR) (Fig. 1).
The RADAR model has the potential to address most
of the challenges to organizing diabetes care as reported
in this qualitative study by operationalizing a 6Rs ap-
proach: Recognize, Register, Relay, Recall, Relationships,
and Resources. In addition, RADAR can facilitate a
community-based team approach to diabetes care that is
culturally relevant and aligned with recommendations to
improve diabetes care for First Nations peoples [1,13].
This can be achieved by combining information systems
and centralized care coordination to strengthen commu-
nity capacity; it has been proposed that telehealth, while
not a specific element of the Chronic Care Model, could
facilitate components of the model [8]. For example, a
centralized RN care coordinator, partnered with each
community, can facilitate central registration (Register)
of patients with T2D by populating the CARE EHR with
specific diabetes measures, compiling information from
multiple sources with the support of data entry clerks
(Resources). They could support the relaying of clinical
information (Relay) by supporting relationship-building
between local healthcare workers and providers as well
as addressing privacy concerns to ensure that those re-
sponsible for diabetes care have access to the informa-
tion they need to support patients in self-management
(Relationships). In addition, the RN care coordinators
can support healthcare workers in recalling patients (Re-
call) who are not meeting targets or scheduled for regu-
lar appointments and coordinate care within (e.g.,
promote awareness of existing services) and outside of
(e.g., specialty care) the community (Relationships). In-
deed, centralized RN care coordinators represent essen-
tial human resources (Resources) for local healthcare
workers, working to increase their capacity (i.e., know-
ledge and confidence) in delivering diabetes care to their
patients.
While the onus remains on individuals to engage with
the healthcare system, there are opportunities to system-
atically screen for T2D (Recognize) in this primary care
setting as part of RADAR. This aligns with the clinical
practice guidelines to screen more frequently in special
populations with additional risk factors for diabetes [27].
Indeed, previous studies demonstrate that screening in
rural or remote communities is possible when done ap-
propriately (i.e., with respect, resources, and follow-up),
including in Alberta [2,28]. There is the potential for
RADAR to expand, and be implemented by community
outreach teams, taking the onus off of people to engage
in traditional healthcare settings and potentially increas-
ing the number of people recognized and offered coordi-
nated diabetes care.
Regardless of access to centralized RN care coordinators,
local healthcare workers are best positioned to provide ap-
propriate direct patient care based on their existing rela-
tionships and understanding of the context of each
community. For example, authors of a systematic review of
telediabetes services found that the involvement of Indigen-
ous health workers was an enabler, in part due to their role
in communicating in local language and understanding of
the community [29]. This approach is likely better than
having RNs parachutein to the communities to provide
direct patient care. This aligns with Diabetes Canadasrec-
ommendation that the management of diabetes in Aborigi-
nal peoples should follow the same clinical practice
guidelines as those for the general population, with respect
and sensitivity to language, cultural history, and traditional
ways of knowing, using a holistic approach [2].
Fig. 1 Reimagining the organization of diabetes care. ID: Identify.
Info: Information. $: Financial resources. HR: Human resources
Wozniak et al. Archives of Public Health (2020) 78:7 Page 6 of 8
Our results should be interpreted in light of several limi-
tations. Although we sampled a diversity of healthcare
workers with knowledge of the organization of diabetes
care in their health centres, our sample size was small.
Also, while participating communities were diverse, our
findings are based on the experiences of healthcare
workers from 6 voluntary health centres that may not be
representative of other health centres on-reserves. There
is limited transferability of our results beyond the present
context (i.e. sample and setting). Regardless, the strengths
of this work include its qualitative descriptive approach
and adding to the current literature by describing the
organization of diabetes care in First Nations communities
in Alberta. Further, this baseline assessment of T2D care
prior to implementing RADAR will inform our overall
evaluation of its effectiveness [13].
Conclusions
Overall, we found that healthcare workers in the participat-
ing First Nations communities were limited in their ability
to systematically identify, track, and manage patients with
T2D. RADAR has the potential to address some of these is-
sues. In addition, our reimagining of the 5Rs to 6Rs based
on the results of this study may equip local healthcare
workers to plan and execute organized diabetes care in
their communities. It recognizes the interconnectedness of
components and emphasizes relationships among health-
care providers to organize T2D care within the context of
sufficient resources. Further, RADAR can support First Na-
tions community capacity to organize T2D care. The model
addresses many challenges identified at baseline through its
electronic registry/EHR support and access to a centralized
care coordinator. This model may be applied by organiza-
tions to improve the delivery of diabetes care. Regardless of
the operationalization of a 6Rs approach through RADAR,
the onus on T2D patients to engage with healthcare ser-
vices remains a concern.
Supplementary information
Supplementary information accompanies this paper at https://doi.org/10.
1186/s13690-020-0391-8.
Additional file 1: Consolidated criteria for reporting qualitative studies
(COREQ): 32-item checklist. We provide more detail on reporting this
study using the consolidated criteria for reporting qualitative research
(COREQ) checklist.
Additional file 2: Interview guide informed by the 5Rs framework. We
provide the semi-structured interview guide informed by the 5Rs framework.
Additional file 3: Summary of available providers and services in
communities identified by respondents. We provide a detailed summary
the available providers and services in the communities as identified by
respondents.
Abbreviations
CARE EHR: Community Assessment Response and Empowerment CARE
software platform; COREQ: consolidated criteria for reporting qualitative
research; EHR: Electronic health record; EMR: Electronic medical record;
Netcare: Alberta Netcare electronic health record; OKAKI: OKAKI Health
Intelligence Inc. (Calgary, Canada); RADAR: Reorganizing the approach to
diabetes through the application of registries; T2D: Type 2 diabetes
Acknowledgements
We thank our First Nations partners for their ongoing and generous support.
We recognize that this work was implemented in the traditional territories of
our Treaty 6, 7, and 8 First Nations partners. We thank OKAKI Health
Intelligence Inc. for their support and participation in the evaluation of
RADAR. In addition, we acknowledge the significant contribution of Dr.
Sumit (Me2) R. Majumdar, who recently passed away, to the study design.
Lastly, we thank Allison Soprovich for providing feedback on early drafts of
this manuscript.
Authorscontributions
DTE conceived the study, its protocols, received ethics approval and funding.
JAJ actively contributed to the study design. LAW led the qualitative
research design, data collection, and data analysis. All authors read and
approved the final manuscript.
Funding
This work was supported by the Canadian Institutes of Health Research
(eHIPP # 143562), Alberta Innovates (#201500876), and the Lawson
Foundation (GRT 201438) (to DTE).
Availability of data and materials
The dataset supporting the conclusions of this article are not publicly
available due to confidentiality but are available from the corresponding
author on reasonable request.
Ethics approval and consent to participate
Ethics approval was obtained from the University of Albertas Health
Research Ethics Board (Study ID Pro00048714). All participating healthcare
providers provided verbal consent.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Received: 8 July 2019 Accepted: 14 January 2020
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... These issues are compounded by suboptimal diabetes care, particularly in rural or remote settings where many First Nations people live [2,[4][5][6]. In Canada, diabetes care in First Nations communities is delivered through federally-funded nurse-led homecare, community health, and diabetes programs with limited access to primary care physicians and specialists [7] Additionally, healthcare providers in some First Nations communities in Alberta feel limited in their ability to identify, track, and manage patients with type 2 diabetes; therefore, care was typically reactive and dependent on patients' abilities to navigate the health system [8]. Clearly, there is a need for innovative and culturallyrelevant approaches to promote systematic and proactive organization of diabetes care for First Nations people living with diabetes on-reserve in Canada [9,10]. ...
... Tools, like Mapping the System, can be used to help understand participants' values as well as potential losses and benefits as a result of implementing a new model, process, or intervention [35]. In the case of RADAR, targeted messaging for community leaders and health centre staff, might include reframing diabetes care from reactive and episodic to proactive and preventative [8]. Messaging could capitalize on health directors' and local HCPs' focus on traditional public health, such as immunizations, to prevent disease and reframe diabetes care similarly as prevention of chronic disease [37]. ...
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... (33) In the case of RADAR, targeted messaging for community leaders and health centre staff, might include reframing diabetes care from reactive and episodic to proactive and preventative. (8) Messaging could capitalize on health directors' and local HCPs' focus on traditional public health, such as immunizations, to prevent disease and reframe diabetes care similarly as prevention of chronic disease. (35) To increase its potential to achieve outcomes, the spread (i.e. ...
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