Abstract

American Indian/Alaska Native (AI/AN) adults experience higher rates of type 2 diabetes and worse glycemic control than non-Hispanic White Americans. Despite the importance of medication adherence for T2DM management, there is only one study in the last 15 years examining the relationship between medication adherence and A1C among AI/ANs. Furthermore, T2DM research among AI/ANs has largely been conducted within Indian Health Service and Tribal healthcare systems, though most AI/ANs live outside of reservations, meaning many use commercial health systems. The purpose of this dissertation is twofold. We sought to first understand the experience of AI/AN people accessing T2DM in a commercial system, and second to identify and understand factors driving T2DM medication adherence, and the subsequent effect on glycemic control within the context of a commercial health system.

This dissertation consists of a systematic review of predictors of glycemic control among AI/AN people with T2DM, a qualitative study investigating the experience of AI/AN people within a commercial healthcare system receiving T2DM care, and a cross-sectional quantitative study of potential drivers of medication adherence and their relationship with glycemic control. Studies were conducted within a large, non-profit commercial health system in the Western United States. Participants of the studies were AI/AN adults, aged 18-65 with T2DM and an A1C measured in the previous year.

For our qualitative study, we conducted fifteen semi-structured in-depth interviews about experiences accessing the healthcare system for T2DM care. The following themes were identified: difficulty navigating health system bureaucracy, smart phones facilitating access to care, positive relationships with healthcare providers and a variable desire for cultural care accommodation.

The quantitative study gathered data from participant surveys and electronic health records. Potential predictors were defined using the World Health Organization Medication Adherence Model. Outcomes were medication adherence, measured as proportion of days covered (PDC), and glycemic control, measured as A1C. Among all predictors investigated, self-efficacy is the only significant driver of PDC. Furthermore, PDC was associated with superior glycemic control. It is important that clinicians evaluate medication adherence in routine clinical care, and leverage interventions that improve self-efficacy so patients can optimize both adherence and glycemic control.

Notes

This work was funded by a 2024 DAISY Foundation Health Equity Grant for Research and EBP, Addressing Social Determinants of Health

Author Details

Leandra Bitterfeld, PhD, RN

Years of experience: 8 years

Areas of expertise: research, pediatrics, health equity, health policy, medication adherence

Sigma Membership

Non-member

Type

Dissertation

Format Type

Text-based Document

Study Design/Type

Other

Research Approach

Mixed/Multi Method Research

Keywords:

Social Determinants of Health, American Indian, Alaska Native, Indigenous Peoples, Native Americans, Type 2 Diabetes, Medication Adherence

Advisor

Christine T. Rael

Degree

PhD

Degree Grantor

University of Colorado

Degree Year

2025

Rights Holder

All rights reserved by the author(s) and/or publisher(s) listed in this item record unless relinquished in whole or part by a rights notation or a Creative Commons License present in this item record. All permission requests should be directed accordingly and not to the Sigma Repository. All submitting authors or publishers have affirmed that when using material in their work where they do not own copyright, they have obtained permission of the copyright holder prior to submission and the rights holder has been acknowledged as necessary.

Review Type

None: Degree-based Submission

Acquisition

Self-submission

Date of Issue

2025-12-16

Funder(s)

The DAISY Foundation

Full Text of Presentation

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