Using an Ecological Perspective as a Framework for Understanding Native American Elders’ Views of Diabetes for the Development of an Indigenous Prevention Plan

Year: 2009

Research Center: American Indian Studies Program, The University of Arizona

Investigator: Parker, Stephany, Dwanna Robertson, Teresa Jackson, Sarah Miracle, and Janice Hermann

Institution: Oklahoma State University

Project Contact:
Stephany Parker
Oklahoma State University and the Chickasaw Nation Get Fresh! Program
301 HES, Department of Nutritional Sciences
Oklahoma State University
Stillwater, OK 74078
Phone: 405-744-6821


Type 2 diabetes is a growing concern for Native American adults and youth who exhibit diabetes prevalence rates at more than twice that of non-Hispanic Whites. The Centers for Disease Control and Prevention (CDC), Office of Minority Health Disparities (OMHD) reports that American Indians ages 10-19 have the highest prevalence of type 2 diabetes among people younger than 20.

Diabetes is a multifaceted problem that requires multifaceted solutions. Preliminary formative research indicated that diabetes is a major health concern for Native American families in Oklahoma. Native American participants indicated a preference for intergenerational health programs and identified elders as important change agents for health improvements. Previous research with Native American families supports the use of an ecological perspective as nutrition and health behaviors were frequently described as being affected by multiple levels of influence, including individual, interpersonal, and environmental factors.

The Social-Ecological Model offers a conceptual framework for understanding the health behaviors of Native Americans and can assist in developing plans for and evaluation of multiple-component nutrition and health programs. Furthermore, the results of previous research presented cogent reasons for using formative assessment approaches to investigate the role of elders as possible change agents for improved health among American Indian families. As such, the socioecological model was used in this study as the framework for evaluating Native American elders’ views of diabetes. The rationale underlying this investigation was that indigenous involvement is necessary to gain insight into the complex reasons for the disparate occurrence of diabetes among Native Americans.

The study design was qualitative and descriptive. Objectives of the study were to (1) frame diabetes from the perspective of elders who live in the Chickasaw Nation and (2) develop an indigenous plan for diabetes prevention using elders as agents of health change to address diabetes and improve overall health. Elders ages 60 or older who received Food Distribution Program on Indian Reservations (FDPIR) benefits from one site in Oklahoma were recruited to participate in the study. Elders participated in one or more of the four phases of research. In Phase I, seven focus groups were conducted to identify the individual sphere of influence. In this phase, five focus groups were conducted with elders who had diabetes and two groups were conducted with elders who did not have diabetes. In phase 2, storytelling video documentaries were used to identify interpersonal and community aspects of diabetes and included four elders diagnosed with diabetes and four elders who did not have diabetes. Phase 3 consisted of five focus group discussions to identify environmental aspects necessary for the prevention of type 2 diabetes. In Phase 4, investigators presented elders with seven possible prevention plans based on findings from the previous phases. In phase 4, three roundtable discussions were conducted with elders to identify the preferred prevention plans.

A total of 47 elders, with a mean age of 67 years, participated. Most participants (72 percent, n=34) were female, and approximately 60 percent (n=28) indicated that they had diabetes. Not only were elders commonly diagnosed with diabetes, but they also indicated strong familial ties to diabetes. At the individual and interpersonal levels, participants shared repeated traumatic loss, with family members and friends frequently being affected by the experience of type 2 diabetes. Devastating complications, such as limb loss and kidney failure, were associated with the diabetes experience.

Elders conveyed a sense of internalized blame and related diabetes to heredity, genetics, and upbringing. Elders shared that historical trauma brought about a shift in the way of living for Native American families that has led to the consumption of less healthful foods, declines in physical activity, and increased rates of diabetes. Elders conveyed a sense of contamination that has affected ways of living and food supply. Elders perceived the current food supply, including meat and produce, as being contaminated by food processing and handling procedures. Often elders conveyed a general sense of hopelessness surrounding diabetes prevention in younger generations because of the repeated loss, internalized blame, and historical trauma associated with the disease.

Partnerships and support were indicated as important environmental factors for the prevention of diabetes in younger generations. Most frequently tribal specific support was mentioned as central to prevention and included locations for programming, incentives for participation, and funding for diabetes prevention efforts. In addition to tribal support, family, religious, school, and community support were also cited as necessary for prevention. Elders most strongly favored diabetes prevention plans that were family, spiritual, and tribal based.

The results of this study indicate that diabetes prevention plans need to be developed that involve tribal members and address multiple levels of influence. The study also supports a need to redefine principles of practice related to diabetes prevention and to foster collaborative solution-based diabetes prevention strategies that acknowledge and address historical and generational trauma.

Direct inquiries about this study to the Project Contact listed above.