Felicia Schanche. Hodge, DrPH
Professor, School of Nursing
Professor, School of Public Health
Director, Center for American Indian/
Indigenous Research & Education
CAIIRE
University of California,
Los Angeles (UCLA)
Report on Diabetes Wellness
Study in So. Dakota & Nebraska
•
•
•
•
•
•
Requested to write the proposal
To coordinate the study
To conduct the data analysis
Hired local RNs and others to assist
Held focus groups to better understand
Held series of Talking Circles to educate,
empower, and to change attitude
Diabetes Wellness Study
• Funders:
National Institute of Health
National Institute of Nursing
Research (NINR)
• Dates:
1998 – 2003
• Principal Investigator: Felicia Hodge, DrPH
• Project Director: Lorelei DeCora
Improving Prevention Practices &
Diabetic Treatment Compliance
• Improve Knowledge • Change Attitudes
• Teach Skills
• Screening
Diabetes is Epidemic in
Indian Country
• Type 2 diabetes, once uncommon among
indigenous peoples of the North American
continent, is now at epidemic levels among
all tribes.
• Type 2 diabetes first diagnosed in 1945
among American Indians.
• Type 2 diabetes is now 3-6 times the national
average among some tribes.
A recent newsprint reports:
• Diabetes is principally a disorder of
metabolism. It is impossible to store fat
or become obese unless we consume
considerable amounts of dietary
carbohydrate: this is basic biochemistry.
• Diet, physical activity, and maintaining
healthy weight advised.
• Early screening is essential to reduce
threats of complications.
• The lack of early detection and
culturally-bound illness beliefs and
attitudes may add to diabetesrelated complications, such as
depression, heart disease,
blindness and amputations.
• Combination of depression and
fatalistic beliefs impacts diabetes
self-management and lifestyles
behaviors.
• The importance of early diabetes
detection through screenings and the
use of culturally appropriate tools
(Talking Circles) to aid in the
education, intervention and screenings
of diabetes increases knowledge about
the disease and improves healthy
lifestyle choices.
A Triple Problem
• The Triple Problem = Type 2 diabetes,
obesity, and cardiovascular disease.
• Very high carbohydrate, low-fat diet that
has been imposed upon our population
since the 1980s.
• Thus making it difficult to control blood
sugar, even with industrial doses of
insulin and certainly not with oral
hypoglycemic agents.
Co-morbid Conditions
• Cardiovascular Disease (CVD) is the
# 1 cause of death among AI/ANs.
• Obesity found to be among 82% in a
study of rural California Indians.
• Loss of limbs, eyesight and functionality
due to damaged blood vessels.
• Kidney failure, blindness, loss of toes,
limbs.
CHANGING LIFESTYLES
Sedentary lifestyles
Changed from high activity and labor
to low daily activity & unemployment
Poor nutrition
Changed from subsistence living
to high carb high processed foods
Diabetes Wellness Project
• Felicia Hodge, Principal Investigator
Lorelei DeCora, Project Director
• Screening, increasing knowledge, skills
• Intervention study (Talking Circles)
• Experimental Design N = 324
• Reservation Sites:
- Pine Ridge (Oglala Sioux)
- Rose Bud Sioux
- Yankton Sioux
- Winnebago
Project Phases
• Focus Groups
• Randomized
Intervention
- Winnebago
- Pine Ridge,
- Yankton
- Rosebud Sioux
• Data Analysis
•
•
Focus Groups Examined the
Cultural Constructs of Diabetes
- Etiology unknown
- A disease brought in from outside
- Belief that all Indians will get diabetes
- Cannot prevent onset of diabetes
- Once you get diabetes, there is nothing
to prevent it from getting worse
Fatalistic Beliefs
Talking Circle Interventions
• Based on Community
Participatory Research that
conceptualizes social capital as:
- Social Life Networks
- Norms (including reciprocity)
- Trust
- Respect
Talking Circle Sessions
•
•
•
•
Meet once a week for 1-2 hours
Meets for 8-12 weeks
Led by peer facilitator
Traditional foods (buffalo) served
• Curriculum: empowerment-self efficacy
Study Findings
•
•
•
•
INCREASE IN KNOWLEDGE
Especially the “at-risk” group
Younger groups
In diabetes knowledge, food fat,
fiber, nutrition and exercise.
• CHANGE IN ATTITUDE
• Reduction of fatalism (at-risk)
• Improvement in empowerment
Increased Knowledge Scores
• Knowledge scores increased
significantly at posttest (pre-post test)
as compared to control sites.
+ Diabetes knowledge
+ Fiber food knowledge
+ Fatty food knowledge
+ Exercise knowledge
Multiple regression data analysis
for knowledge vs. intervention
• Response
Adjusted for age and gender
(SE)
p-value
Total Knowledge
0.329 (0.076)
p<0.0001
Diabetes Knowledge
0.191 (0.064)
p=0.003
Fat food Knowledge
0.041 (0.017)
p=0.02
Fiber food Knowledge
0.045 (0.019)
p=0.018
Exercise Knowledge
0.045 (0.022)
p=0.04
Increase in Knowledge Scores
Compared to Control Groups
•
•
•
•
Increase in male K score (p=0.002)
Increase in female K score (p=0.001)
Increase in diabetic’s K score (p=0.02)
Increase in at-risk K score (p=0.0003)
• Further, multiple regression analysis
showed in overall K scores increased for
the Intervention group was significantly
higher (p=0.0002)
Predictors of K Change
• Younger age
• Obesity status
• Employment status
Were predictors for change in total
Knowledge Scores
Depression and Diabetes
• Depression rates are high
• Smoking rates are high
• Depression, smoking,
low empowerment and
low knowledge levels were
found in the population.
• Improved in the study group
•
•
Percent Depression and
Substance Abuse Reported
• Depression
• Smoking cigs
• Tx for alcohol
and drugs
#1
21.4
62.3
22.5
#2
#3 #4
14.3 8.8 28.6
37.5 73.2 52.9
20.9 22.3 27.0
Diabetes Wellness –Fatalistic Attitude
• “I will probably get diabetes
at some time in my life.”
• “There is nothing I can do
to prevent getting diabetes.”
• “There is nothing that can
be done to prevent diabetes
from getting worse.”
•
•
Fatalistic
Attitudes
70%
60%
50%
40%
30%
20%
10%
0%
TRT - pre
TRT - post
Control - pre
Control - post
I will get
diabetes
Can do
Can't
nothing prevent
about it diabetes
I will get diabetes
Female/Male “at risk” Participants
70%
60%
TRT - pre
TRT - post
Control - pre
Control - post
50%
40%
30%
20%
10%
0%
FEMALES
p<.001
MALES
Can do nothing to prevent
diabetes Female/Male“at risk”
Participants
35%
30%
25%
20%
15%
10%
5%
0%
TRT - pre
TRT - post
Control - pre
Control - post
FEMALES
P=.02
MALES
Once you get diabetes, there is
nothing to prevent getting worse
30%
25%
20%
TRT - pre
TRT - post
Control - pre
Control - post
15%
10%
5%
0%
FEMALES
MALES
Findings
• Statistically significant increase in levels
of knowledge
• Statistically significant increase in
screening
• Statistically significant reduction of
fatalistic beliefs
• Reduction of watching TV
• Increased attention to diet, physical
activity.
Talking Circles
• Talking Circles Intervention had significant
results in reducing fatalistic attitudes toward
diabetes.
• Significant difference between pre-posttest
scores seen in females.
• Reduction in other chronic health conditions
were not as significant – need more time?
RECOMMENDATIONS:
• Reduce Obesity:
- by reducing carb
- increasing exercise
- screening for diabetes
- screening for co-morbid conditions
* sores that heal slowly* vision
problems* numbness*depression
- improve screening in depression
OBJECTIVES: Session 2
• Collect the Dietary Recall Log
• Watch the Diabetes Wellness video
• Look at people’s perceptions of diabetes
• Learn diabetes myths from fact
34
MYTHS OF DIABETES
• Diabetes has always been with us, is in all
of our families, and is inevitable in our lives.
• Nothing that we can do can influence our
chances of getting diabetes or help control
our disease once we get diabetes.
35
MYTHS OF DIABETES
• If one must take insulin for diabetes, they
will have a poorer outcome than those that
don’t.
• Once a person develops a complication from
diabetes, there is nothing that can be done.
• Diabetes only affects the body, and
not the mind.
36
SECTION II: DIABETES
SESSION 2: DIABETES – Perceptions
MAIN POINTS
•Know myths from facts on diabetes.
•Begin the process of challenging a fatalistic perspective on
diabetes.
•Begin the process of promoting empowerment and having the
ability to
overcome diabetes.
MATERIALS:
•Sign-in sheet
•Traditional story
•Paper
•Pens
•Diabetes Wellness Video
•Curriculum Flip Chart
•Myths of Diabetes Handouts
•Refreshments
ACTIVITIES:
•Welcome circle members as they arrive. Have them sign in.
•You or ask circle member to say traditional prayer for circle and food.
•Read traditional story.
•Inclusion exercise:
Star exercise: Hand out a piece of paper and pen to each person. Ask
them to draw a five-pointed star on the paper. Tell them that they will be
asked to write something on the point of each star that they will be asked
to share.
Point 1. Favorite Food
Point 2. A famous person with whom they would like to visit.
Point 3. Something they like to do in their free time.
Point 4. Something they hope to learn in the Talking Circles.
Point 5. Why they decided to participate in the Talking Circles.
Describe Objectives for Session 2 from flip chart.
OBJECTIVES: FLIP CHART
•Collect the dietary recall log.
•Watch the Diabetes Wellness Video.
•Look at people’s perceptions of diabetes.
•Learn diabetes myths from fact.
Collect Food Diaries.
Show Diabetes Wellness Video.
Ask members for comments on the video and their beliefs about
diabetes.
Distribute Dr. Lehmann’s Myths of Diabetes handout. Review myths
and facts using the flip chart. Promote group discussion on myths and
facts.
Diabetes has always been with us, is in all of our families, and is inevitable
in our lives. (FALSE)
Nothing that we can do can influence our changes of getting diabetes or
help control our disease once we get diabetes. (FALSE)
Diabetes usually shows symptoms when it first starts in the body. (FALSE)
If I must take insulin for diabetes, I will have a poorer outcome than
someone who doesn’t. (FALSE)
Giving myself a shot of insulin is extremely painful. (FALSE)
Once a person develops a complication from diabetes, there is nothing that
can be done. (FALSE)
Diabetes only affects the body, not the mind. (FALSE)
•Review Objectives for Session 2 from flip chart to be sure they were all
completed.
•Thank circle members for their participation, attendance and commitment.
Refreshments
To download the Diabetes
Talking Circle Materials
http://www.seva.org/dtc
To receive a FREE copy of the
video, curriculum, cookbook,
measurement and publications
Contact:
www.fhodge@sonnet.ucla.edu