Using Novel Telemedicine Interventions to Tackle the Diabetes Epidemic Crippling the Navajo Nation in the Southwestern United States

Posted on by BUJPH
A stethoscope on a southwestern landscape

Illustration by Nikitha Bhimireddy
Article by Wesley Peng

Diabetes is a treatable and preventable disease, but it is still the fourth leading cause of death in the Navajo Nation.1 It is one of the leading factors contributing to disability-adjusted life-years (DALYs), and the prevalence has been on the rise ever since 1965.2 In the Navajo Nation, the percentage of individuals with either prediabetes or diabetes has skyrocketed to nearly 50% in 2020 as opposed to the national average of just 9.4%. This increase in the prevalence of diabetes has been especially dramatic over the last decade, with costs now accounting for nearly 37% of all adult treatment expenses within the Indian Health Service.3 Even with a high proportion of cost allocated to diabetes treatment, it still remains poorly managed, and its prevalence does not seem to be decreasing anytime soon.4,5 With the problem of diabetes only becoming worse, finding initiatives to tackle diabetes must be of utmost priority in the Navajo Nation.

 

Causes of High Diabetes Prevalence

One of the main challenges in managing diabetes for the Navajo Nation comes from the fact that it is remotely situated and its health system is heavily under-resourced.6,7 The Navajo Nation reservation mainly sits in rural Northeast Arizona, with the nearest major hospital system located around 208 miles away. Instead, the population relies on the Navajo Area Indian Health Service (NAIHS). In an area that is over 27,000 square miles, the NAIHS houses only 5 main service units.8,9 Not only are services far away, but the NAIHS also faces a chronic shortage of physicians, especially when it comes to primary care physicians (PCPs). PCPs are the main providers of diabetes management, and the Navajo Nation is well below the 1:3000 PCP per capita threshold that designates a region as a PCP shortage area.10,11 This problem has been further exacerbated during the pandemic as more physicians move away from the Navajo Nation. A lack of both health infrastructure and staffing means that individuals often need to travel long distances, at times over 50 miles, to receive basic diabetes care.12,13 Further, if it is already hard to get to one diabetes appointment, it becomes nearly impossible to consistently access care in a system that is far away and overburdened. Studies have attributed this lack of access to physicians as a major reason for poor diabetes management.1 Diabetes management in the Navajo Nation has improved with increased access to care through community health outreach. However, these programs were only temporary and lacked consistent funding.

The second major problem that leads to this high prevalence of diabetes is the lack of health literacy in the Navajo Nation.14 Many individuals often do not understand when or where to get their treatment, resulting in their diabetes deteriorating before they seek or receive care. Many Native people are also unaware of the major risk factors leading to diabetes, including physical activity, diet, and weight.15 In recent years, Navajo natives, especially children, have adopted a more Western diet in lieu of their traditional, more healthy diets like boiled mutton and corn.16-18 This shift is due to not only limited environmental resources, but also comes about as the adverse effect of cultural assimilation.17 These unhealthy habits have led to increased obesity and lethargy. Attempts at trying to solve this problem include enforcing a 2% “unhealthy food” tax within the Navajo Nation.19 However, these efforts have not been significantly fruitful in changing behavior and still do not tackle the fundamental challenge of poor health literacy surrounding diabetes.

 

How Telemedicine Addresses The Diabetes Epidemic

This is where telemedicine, a low-cost alternative, can be a helpful intervention to combat the diabetes epidemic, as it has been shown to provide consistently high-quality, high-value primary care while tackling both disease management and prevention.20,21 Telemedicine provides better continuity of care for individuals of all ages and particularly those that come from underserved backgrounds, which fits the demographics of the Navajo Nation. Not only does telemedicine improve access to care by eliminating distance barriers and providing availability to providers, but it has also been shown to improve health literacy.

Focused telemedicine that improves PCP access can significantly improve diabetes outcomes in the rural Navajo Nation. With chronic diabetes management focused on evaluative and management (E&M) services instead of procedural services, telemedicine is positioned perfectly to address chronic diabetes. Though there are some in-person tests for diabetes such as an HgbA1C (hemoglobin A1C) test, these tests can often be performed with home test kits and results can be interpreted over the phone.22 Many studies have shown a significant improvement in continuity of care of up to 50% for diabetes management with the use of telemedicine.20,23-25 Meanwhile, other studies indicate a 15% reduction in baseline HgbA1C levels with telemedicine. Moreover, a well-designed telemedicine system can compensate for the acute shortages of physicians, especially as we see the PCP-per-capita ratio dipping to record lows in the Navajo Nation.26,27 It can efficiently provide diabetes management services to many patients since visits can be shorter, and this allows existing physicians to have a greater bandwidth.28,29 Meanwhile, physicians can care for their patients at any geographical location, including across state lines. This way, the Navajo Nation can access physicians in neighboring states such as Arizona, Utah, Colorado, and New Mexico.30 This new influx of PCP availability will allow for quality care of diabetes at a significantly lower cost than traditional visits.31

Finally, health literacy can dramatically improve when providers include the topic in these new PCP telemedicine visits which can address both disease management and prevention.32 For example, health education integrated into telemedicine can improve disease recognition, symptom management, and appointment cadence.31 Through teaching about risk factors such as a healthy diet, exercise, and weight loss, doctors can instill significant behavioral changes to address diabetes risk factors. Studies have shown an uptake of preventative behaviors with the adoption of telemedicine in rural areas, which may greatly abate the issue of diabetes in the Navajo Nation.33

 

Conclusion and Implications

Overall, PCP-focused telemedicine that includes diabetes management and preventative health literacy measures will vastly benefit the Navajo Nation in tackling the diabetes epidemic. Investment and continual funding of telemedicine should prove fruitful, and further studies should be implemented to analyze the effect. Ultimately, similar practices can and should be implemented in other Native reservations across the nation that face a similarly disproportionate burden of diabetes.

 

References

  1. Trevisi, Letizia, et al. “Peer Reviewed: Community Outreach for Navajo People Living with Diabetes: Who Benefits Most?.” Preventing Chronic Disease17 (2020).
  2. Sugarman, Jonathan R., et al. “The changing epidemiology of diabetes mellitus among Navajo Indians.” Western Journal of Medicine153.2 (1990): 140.
  3. Trevisi, Letizia, et al. “Integrating community health representatives with health care systems: clinical outcomes among individuals with diabetes in Navajo Nation.” International journal for equity in health18.1 (2019): 1-9.
  4. Anderson, Erik S., et al. “Nontargeted Diabetes Screening in a Navajo Nation Emergency Department.” American Journal of Public Health109.2 (2019): 270-272.
  5. Parkhurst, Nicholet A. Deschine, Kimberly R. Huyser, and Aggie J. Yellow Horse. “Historical environmental racism, structural inequalities, and Dik’os Ntsaaígíí-19 (COVID-19) on Navajo Nation.” Journal of Indigenous Social Development9.3 (2020): 127-140.
  6. Wang, Haoying. “Why the Navajo Nation was hit so hard by coronavirus: Understanding the disproportionate impact of the COVID-19 pandemic.” Applied Geography134 (2021): 102526.
  7. English, Kevin C., et al. “Intermediate outcomes of a tribal community public health infrastructure assessment.” Ethnicity and Disease14.3; SUPP/1 (2004): S1-61.
  8. Indian Health Service (IHS). Navajo Area. (n.d.). Retrieved November 2, 2022, from

https://www.ihs.gov/navajo/

  1. Kim, Catherine. “Recruitment and retention in the Navajo area Indian health service.” Western Journal of Medicine173.4 (2000): 240.
  2. Johnson, William G., et al. “The Arizona Physician Workforce Study.”
  3. Johnson, William G., et al. “The Arizona Physician Workforce Study: Part II.”
  4. Kovich, Heather. “Rural matters—coronavirus and the Navajo nation.” New England Journal of Medicine383.2 (2020): 105-107.
  5. Hindman, Amy. “Going the Distance: Bringing Cancer Care to the Navajo Nation.” Oncology Issues34.5 (2019): 46-51.
  6. Brega, Angela G., et al. “Special diabetes program for Indians: reliability and validity of brief measures of print literacy and numeracy.” Ethnicity & disease22.2 (2012): 207-214.
  7. Petry, Clive J. “Gestational diabetes: risk factors and recent advances in its genetics and treatment.” British Journal of Nutrition104.6 (2010): 775-787.
  8. Wolfe, Wendy S., Charles W. Weber, and Katherine Dahozy Arviso. “Use and nutrient composition of traditional Navajo foods.” Ecology of food and nutrition17.4 (1985): 323-344.
  9. Gittelsohn, Joel, et al. “A food store–based environmental intervention is associated with reduced BMI and improved psychosocial factors and food-related behaviors on the Navajo Nation.” The Journal of nutrition143.9 (2013): 1494-1500.
  10. Oski, Jane. “A recipe for change on the Navajo Nation: Community-based strategies to address obesity in Native American youth.” Childhood Obesity6.5 (2010): 237-239.
  11. Yazzie, Del, et al. “Peer Reviewed: The Navajo Nation Healthy Diné Nation Act: A Two Percent Tax on Foods of Minimal-to-No Nutritious Value, 2015–2019.” Preventing Chronic Disease17 (2020).
  12. Shah, D. A., Sall, D., Peng, W., Sharer, R., Essary, A. C., & Radhakrishnan, P. (2022). Exploring the role of telehealth in providing equitable healthcare to the vulnerable patient population during COVID-19. Journal of Telemedicine and Telecare, 1357633X221113711.
  13. McConnochie, Kenneth M. “Webside manner: a key to high-quality primary care telemedicine for all.” Telemedicine and e-Health25.11 (2019): 1007-1011.
  14. Odom JM, Stancil M, Nelson B, et al. Improving Diabetes Control Through Remote Glucose Monitoring in a Diabetes Self-Management Program for Employees of a Health System. Clin Diabetes. 2019;37(3):203-210. doi:10.2337/cd18-0056
  15. Chu, Cherry, et al. “Rural telemedicine use before and during the COVID-19 pandemic: repeated cross-sectional study.” Journal of medical Internet research23.4 (2021): e26960.
  16. Alfiyyah, Arifah, Dumilah Ayuningtyas, and Agus Rahmanto. “Telemedicine and electronic health record implementation in rural area: a literature review.” Journal of Indonesian Health Policy and Administration7.2 (2022): 221-228.
  17. Rush, Kathy L., et al. “Rural use of health service and telemedicine during COVID-19: The role of access and eHealth literacy.” Health informatics journal27.2 (2021): 14604582211020064.
  18. Committee on Pediatric Workforce, et al. “The use of telemedicine to address access and physician workforce shortages.” Pediatrics136.1 (2015): 202-209.
  19. Batsis, John A., Sarah N. Pletcher, and James E. Stahl. “Telemedicine and primary care obesity management in rural areas–innovative approach for older adults?.” BMC geriatrics17.1 (2017): 1-9.
  20. McDonnell, Marie E. “Telemedicine in complex diabetes management.” Current diabetes reports18.7 (2018):1-9.
  21. Meingast M, Roosta T, Sastry S. Security and privacy issues with health care information

technology. Conf Proc IEEE Eng Med Biol Soc. 2006; 2006:5453-5458. doi:10.1109/IEMBS.2006.260060.

  1. King, Caroline, et al. “Identifying risk factors for 30-day readmission events among American Indian patients with diabetes in the Four Corners region of the southwest from 2009 to 2016.” PLoS One13.8 (2018): e0195476.
  2. Atmojo, Joko Tri, et al. “Telemedicine, cost effectiveness, and patients satisfaction: a systematic review.” J Health Policy Manag5.2 (2020): 103-107.
  3. Ye, Siqin, et al. “Telemedicine expansion during the COVID-19 pandemic and the potential for technology-driven disparities.” Journal of general internal medicine36.1 (2021): 256-258.
  4. Nouri, Sarah, et al. “Addressing equity in telemedicine for chronic disease management during the Covid-19 pandemic.” NEJM Catalyst Innovations in Care Delivery1.3 (2020).

 

Nikitha Bhimireddy Wesley Peng