Challenges to the provision of diabetes care in first nations communities: results from a national survey of healthcare providers in Canada.

BACKGROUND: Aboriginal peoples globally, and First Nations peoples in Canada particularly, suffer from high rates of type 2 diabetes and related complications compared with the general population. Research into the unique barriers faced by healthcare providers working in on-reserve First Nations communities is essential for developing effective quality improvement strategies. METHODS: In Phase I of this two-phased study, semi-structured interviews and focus groups were held with 24 healthcare providers in the Sioux Lookout Zone in north-western Ontario. A follow-up survey was conducted in Phase II as part of a larger project, the Canadian First Nations Diabetes Clinical Management and Epidemiologic (CIRCLE) study. The survey was completed with 244 healthcare providers in 19 First Nations communities in 7 Canadian provinces, representing three isolation levels (isolated, semi-isolated, non-isolated). Interviews, focus groups and survey questions all related to barriers to providing optimal diabetes care in First Nations communities. RESULTS: the key factors emerging from interviews and focus group discussions were at the patient, provider, and systemic level. Survey results indicated that, across three isolation levels, healthcare providers' perceived patient factors as having the largest impact on diabetes care. However, physicians and nurses were more likely to rank patient factors as having a large impact on care than community health representatives (CHRs) and physicians were significantly less likely to rank patient-provider communication as having a large impact than CHRs. CONCLUSIONS: Addressing patient factors was considered the highest impact strategy for improving diabetes care. While this may reflect "patient blaming," it also suggests that self-management strategies may be well-suited for this context. Program planning should focus on training programs for CHRs, who provide a unique link between patients and clinical services. Research incorporating patient perspectives is needed to complete this picture and inform quality improvement initiatives.

Major gaps in diabetes clinical care among Canada's First Nations: results of the CIRCLE study.

AIMS: The aim of this cross-sectional study was to document the clinical management of type 2 diabetes and related complications in Canada's First Nations. METHODS: Patients were randomly selected from 19 communities. Data from charts from consenting patients were collected. RESULTS: Of 885 patients, 63.3% were female, mean age was 54.9 years and mean duration of T2DM was 11.2 years. Mean A1C was 8.2%; 61.1% of patients had an A1C >7.0%; mean LDL was 2.4 mmol/L; 92.6% had dyslipidemia; mean systolic BP was 132 mm Hg; mean diastolic BP was 76 mm Hg; 92.0% had hypertension. Lipid-lowering medications were prescribed to 62.9% of those with dyslipidemia and an LDL-C >2.0 mmol/L. Of hypertensive patients, 15.8% were not on an antihypertensive agent. For vascular protection, 55.1% were on a statin, 72.1% on an ACE inhibitor or ARB, and 64.5% on an anticoagulant. Smoking was documented in 39.4%, 92.1% were overweight/obese; 55.1% had chronic kidney disease, and 13.3% had coronary artery disease. CONCLUSIONS: Major care gaps were revealed, with most patients not achieving glycemic, lipid and BP targets. Over half of this relatively young cohort had established microvascular disease. Macrovascular disease rates may increase dramatically due to the high prevalence of risk factors.

Lessons learned in using community-based participatory research to build a national diabetes collaborative in Canada.

BACKGROUND: Using community-based participatory research (CBPR) principles, the Canadian First Nations Diabetes Clinical Management Epidemiologic (CIRCLE) study documents the current clinical management of type 2 diabetes (T2DM) and complications in 19 partnering First Nations (FN) communities. OBJECTIVES: To outline the lessons learned in developing and fostering community health partnerships, and demonstrate the feasibility of using CBPR in multisite research at a national level. METHODS: Investigators developed investigator-FN community partnerships from seven Canadian provinces, and research assistants were hired from each community to facilitate data collection. Research assistants randomly selected patients from each community's diabetes registry, and audited the charts of consenting patients from 2006 to 2009 for diabetes indicators in accordance with national diabetes guidelines. LESSONS LEARNED: Lessons learned in using CBPR on a national scale are outlined by highlighting challenges and facilitating factors associated with (1) building collaborative relationships, (2) culture and ethics, (3) collaboration and partnership, and (4) innovative avenues of data management and dissemination. Lessons learned include the need for a flexible research agenda, clear and mutually agreed upon roles, partnership from all community levels including Elders, regional coordinators managing several sites, and wide-scale dissemination methods. CONCLUSION: The CIRCLE national CBPR multisite collaborative is unprecedented in Canada, and provides a feasible model for other studies. Using CBPR on a national scale exacerbates challenges commonly faced with single-site or multisite research, but the benefits provided in developing partnerships based on mutual trust and goals makes it of great importance.

Global complication rates of type 2 diabetes in Indigenous peoples: A comprehensive review.

INTRODUCTION AND OBJECTIVE: The world's Indigenous peoples are experiencing an unprecedented epidemic of type 2 diabetes [T2DM] but little has been published describing the complications burden. The objective of this paper was to conduct a systematic review of T2DM complications in Indigenous populations worldwide. METHODS: A literature review was conducted using PubMed and EMBASE to examine available complications data. Country, Indigenous population, authors, publication year, total sample size, Indigenous sample size, age, methodology, and prevalence of nephropathy, end-stage renal disease, retinopathy, neuropathy, lower extremity amputations, cardiovascular disease, hospitalizations and mortality due to diabetes were recorded. RESULTS: One-hundred and eleven studies were selected. Results revealed a disproportionate burden of disease complications among all Indigenous peoples regardless of their geographic location. Complication rates were seen to vary widely across Indigenous groups. DISCUSSION: Gaps were found in the published literature on complications among Indigenous populations, especially those living in underdeveloped countries. These gaps may be in part due to the challenges caused by varying operational practices, research methodologies, and definitions of the term Indigenous, making documentation of rates among these peoples problematic. Comprehensive surveillance applying standardized definitions and methodologies is needed to design targeted prevention and disease management strategies for Indigenous peoples with T2DM.

Testing for episodic-like memory in rats in the absence of time of day cues: replication of Babb and Crystal.

Two experiments were performed to look for evidence of episodic-like memory in rats. On each of a series of trials on an eight-arm radial maze, rats in two groups entered four open arms in Phase 1, with reward pellets on three arms and a favored reward (chocolate in Experiment 1 and cheese in Experiment 2) on the remaining arm. Phase 2 retention tests were given 30 min or 4 h after Phase 1, with all eight arms open. The four arms not entered in Phase 1 all contained reward pellets, and the three arms that contained pellets in Phase 1 were empty. In the replenish short group, the favored reward was replenished at the same location where it was found in Phase 1 at the 30 min retention interval but was absent (Experiment 1) or degraded (Experiment 2) at the 4 h retention interval. In the replenish long group, the favored reward was replenished at the 4 h retention interval but not at the 30 min retention interval. Over a number of daily trials that randomly mixed short and long delays, rats in both experiments learned to return earlier to the arm containing the favored reward at the retention interval when it was replenished than at the retention interval when it was absent or degraded. These results replicate earlier findings [Babb, S.J., Crystal, J.D., 2005, Discrimination of what, when, and where: implications for episodic-like memory in rats. Learn. Mot., 36, 177-189] and provide evidence of episodic-like memory in rats.

Anticipation of future events in squirrel monkeys (Saimiri sciureus) and rats (Rattus norvegicus): tests of the Bischof-Kohler hypothesis.

The Bischof-Kohler hypothesis holds that nonhuman animals cannot anticipate a future event and take appropriate action when that event involves satisfaction of a need not currently experienced. Tests of the Bischof-Kohler hypothesis were performed with squirrel monkeys (Saimiri sciureus) and rats (Rattus norvegicus). In experimental trials with both species, a nonthirsty animal had its water bottle removed and then chose between a smaller and larger quantity of food. Consumption of the food induced thirst. Choice of the smaller quantity led to the return of the water bottle sooner than choice of the larger quantity. Monkeys reversed their baseline preference for the larger quantity of food when the experimental contingencies were introduced, but rats continued to prefer the larger amount. Although the rat findings support the Bischof-Kohler hypothesis, the monkey findings challenge it.

Can squirrel monkeys (Saimiri sciureus) plan for the future? Studies of temporal myopia in food choice.

In seven experiments, 2 squirrel monkeys were given choices between arrays of food that varied in the quantity offered. In Experiments 1-5, the monkeys were offered choices between quantities of the same food that varied in a 2:1 ratio. The squirrel monkeys failed to show the temporal myopia effect or a decrease in preference for the larger quantity as the absolute number of food items offered increased. Even when given choices of 8 versus 16 peanuts and 10 versus 20 peanuts, both monkeys significantly preferred the larger quantity. An examination of the monkeys' rates of consumption indicated that 20 peanuts were consumed over a 1- to 2-h period, with eating bouts separated by periods of nonconsumption. In Experiments 6A, 6B, and 7, food was either pilfered or replenished 15 min after an initial choice, so that choice of the smaller quantity led to more total food in the long run. These manipulations caused both monkeys to reduce choice of the larger quantity, relative to baseline choice. The results suggest that squirrel monkeys anticipated the future consequences of their choices.