Journal of Rural Community Psychology Volume E6 Number 1 Spring 2003
Providing Culturally Appropriate Education
on Type 2 Diabetes to Rural American Indians:
Emotions and Racial Consciousness
Roxanne Struthers, Merrie Kaas, Doris L. Hill, Felicia Hodge,
Lorelei DeCora, & Betty Geishirt-Cantrell
Healthy and balanced emotions are an important aspect of well-being. Today, diabetes has a high prevalence in American Indian communities. Four Talking Circle facilitators were interviewed in a phenomenological research study to describe their experience of facilitating Talking Circles during a diabetes research intervention, Diabetes Wellness: American Indian Talking Circles. The Diabetes Wellness study provided a twelve week educational curriculum in a Talking Circle format to target prevention and effective maintenance of symptoms of Type 2 diabetes among American Indians adults on two rural Northern Plains reservations. Seven essential themes emerged from the phenomenological study data. This report describes one theme: expression of the emotional aspect of diabetes and three sub-themes that depict American Indian culture: connectedness, collective living, and transformation. Type 2 diabetes is a chronic disease that affects the emotional status of American Indians in rural communities. The notion of racial consciousness is discussed as a potential context from which Talking Circle facilitators can operate and Talking Circle participants respond. This viewpoint may be a useful cultural approach for lay personnel with an (emic) inside perspective like Talking Circle facilitators when working in areas like rural American Indian reservations.
Healthy and balanced emotions are an important aspect of well-being. Emotions can reflect the psychological well-being of the individual and may be adaptive or maladaptive. Stuart (2001) describes adaptive emotion as emotional responsiveness, when the individual has an openness and awareness of their feelings. In contrast, maladaptive emotion occurs when individuals suppresses his/her emotions and may actually deny or detachment themselves from their feelings. Insights into the emotional perceptions within a culture can assist the health care professional to gain an understanding of a culture's worldview.
Like all societies, American Indian people perceive their world through their culture. Various perspectives are unique to the American Indian worldview and a select few will be presented. A basic principle of American Indian culture is wholeness and interrelatedness (Pierotti & Wildcat, 1997). Everything is considered to have life, is interconnected (Cohen, 1998), intertwined; there is oneness in the universe and all actions and thoughts effect all of creation (Lowe, 2002; Struthers, 1999). Thus, American Indian individuals see themselves as part of all creation, living life as one system, and not in separate units that objectively relate to each other (Duran & Duran, 1995).
The holistic worldview of the American Indian believes a person's being is comprised of four aspects: mental, physical, emotional, and spiritual; and that life is circular (Figure 1). Within this perspective, the mental is the intellect, the physical is the body, the emotional is feelings, and the spiritual is the spirit. Each component is equal in significance. In this manner, the emotional aspect of a person has the same importance as the physical, mental, and spiritual. Thus, most American Indian people experience their being in the world as a totality of personality and not as separate systems within the person (Duran & Duran, 1995). Healthy means all components are in balance and/or harmony with nature, with the family, with the self, and the community. Therefore, if the emotional component, or feelings and emotions, of a person are out of balance, their whole being is ill or unhealthy (Avery, 1991).
Figure 1: From a broad American Indian perspective, the personís being consists of:
One illness that is prevalent in American Indian communities is Type 2 diabetes. Type 2 diabetes has reached epidemic proportions and is a major health concern for American Indians today (Bullock, 2001). Prior to the 1950s, Type 2 diabetes as a chronic illness in Native communities was a rare occurrence. In the published report of the Indian Health Service, Trends in Indian Health 1998-1999, diabetes mellitus was listed in the top five causes of death for American Indians. As an ethnic community, American Indians have a 249% greater chance of dying from this disease in comparison to all United States races (Indian Health Service, 2003b).
Chronic diseases such as Type 2 diabetes can have a major impact on emotions during the course of the disease process. The physical, mental or emotional reaction to the diagnosis of Type 2 diabetes and the ability to cope is impacted by the role of stress on the individual, family and community. Situational stressful events can create a state of disequilibrium. The circles of social/cultural understanding, transition and collective (community) strength demonstrate a harmonious interdependence that can promote psychological well-being (mental health) and coping abilities related to this disease. Social/cultural understanding is based on all aspects of the American Indian worldview; transition relates to the historical impact of colonialism and its devastating effects on the health of American Indians (Duran & Duran, 1995) and collective strength honors the role of the extended family, networks within indigenous communities (DuBray, 1998) and the importance of the continuation of tribal culture, values and beliefs.
As stated, emotions that surround Type 2 diabetes and their management have far reaching implications for American Indian individuals, their family and community. Culturally appropriate, innovative interventions to provide education on Type 2 diabetes have been developed and implemented in a research project Diabetes Wellness: American Indian Talking Circles. In relation to health care, racial consciousness can be utilized to understand the complex history of a group, ameliorate health disparities, and assist in self-appraisal of one's attitudes and biases towards a select group (Watts, 2003). Racial consciousness is a concept from which American Indian community personnel who led the Talking Circles intervention can operate and American Indian (Native) participants can respond.
To counteract the epidemic prevalence and its effects of Type 2 diabetes among American Indian adults, a research project, Diabetes Wellness: American Indian Talking Circles, utilized a Talking Circle format as a culturally appropriate intervention on the Pine Ridge Reservation in South Dakota and the Winnebago Reservation in Nebraska. The Talking Circle project encompassed a twelve-week educational curriculum that targeted prevention and effective maintenance of symptoms of Type 2 diabetes among adult American Indians residing on the selected rural reservations. The Talking Circle is an ancient American Indian cultural technique still used today across tribes to conduct a group process. Thompson (as cited in Varcarolis, 2002) proposes that a group is comprised of individuals coming together who share a reason, interest or concern; in this instance, the reason was Type 2 diabetes. The Talking Circle cultural practice allows members to experience the emotions of others, develop and maintain trust, promote active listening, and give respect to members of the community. Hodge and Stubbs (1999) and Hodge, Pasqua, Marquez, and Geishirt-Cantrell (2002) have modeled and tested the Talking Circle method in research intervention projects, demonstrating the effectiveness of this method among American Indians.
Each Talking Circle has a facilitator that guides and maintains the process of the Talking Circle. In this research project, the Talking Circle facilitator were four American Indian community members trained by the research staff in the goals of the research project, Talking Circle facilitation, and the medical aspects of Type 2 diabetes. The facilitators were interviewed in a phenomenological qualitative research study that was a minority supplement to the larger R01 Diabetes Wellness: American Indian Talking Circles. The purpose of this paper is to describe what four American Indian Talking Circle facilitators reported about their experience discussing the emotional aspects of Type 2 diabetes with American Indian Talking Circle participants from two rural reservations.
This research study describes the experience of four Talking Circle facilitators of the Diabetes Wellness: American Indian Talking Circles project. Interviews were conducted with the facilitators on their reservations: the Pine Ridge Reservation in South Dakota and the Winnebago Reservation in Nebraska. The taped interviews were conducted in person, on-site at the respective reservations, and were restricted to the facilitator and the interviewer. The facilitators were all female, aged 31 to 48, who described themselves as members of the community and personally effected by Type 2 diabetes. Interviews questions were open-ended and allowed the facilitators to freely discuss the process of the Talking Circle. The interviews took from one to two hours, elicited the stories of guiding sixteen separate Talking Circles in 2000 and 2001.
The interview transcripts were analyzed using phenomenological techniques taken from Colaizzi (1978), van Manen (1990), and Rose (1988). The analysis included the following steps: a) audio tapes were listened to while reading the verbatim transcripts; b) seven essential themes emerged from the data; c) supporting statements for the seven essential themes were extracted from the first transcript; d) this process (step a to c) was repeated for the other transcripts to compare and contrast research participant's descriptions and to eliminate redundancies; e) the research participants received a written summary of the findings and were contacted by phone to set up a face-to-face meeting to clarify and validate the essential themes; f) participant comments were integrated into the final draft; g) this draft was distributed to two facilitators for further critique, and h) further suggestions were integrated into the final product that describes the experience of being a facilitator for the Diabetes Wellness: American Indian Talking Circles research project. The major finding from these interviews reported in this article is: expression of the emotional aspect of Type 2 diabetes. Other essential themes derived from the interviews are described elsewhere (Struthers, Hodge, De Cora, & Geishirt-Cantrell, 2003).
Expression of the emotional aspect of diabetes
Among its many functions, the facilitators stated the Talking Circle provided a forum for participants to discuss and process emotions surrounding diabetes. The four facilitators identified and discussed several emotions that surfaced during the twelve-week sessions. Reaction to the initial diagnosis of diabetes may vary, ranging from denial, anger, and depression. "Some people stay in the denial part, some stay mad, some are angry" when they find out they have diabetes. Others go into a "kind of depression over their diagnosis." Some feel like it is a "punishment of something" for some reason or look for an explanation for the onset of diabetes. Facilitators reported that Native diabetics often feel isolated and recognize many obstacles and barriers to obtaining help. There is a generalized helplessness or lack of knowledge as to resources or steps to take to obtain care. A second major emotion expressed was in relation to living with Type 2 diabetes. These included: "the real pain; the real emotional part of being a diabetic, the ups and downs." All of these emotions caused added stress, distress, feelings of loss, and discouragement to Native participants who were diagnosed and living with Type 2 diabetes.
Sub-themes of expression of the emotional aspect of diabetes
Facilitators reported that diabetes was a very sensitive discussion topic. The facilitators provided much discussion during the interviews related to Native participant emotions, as well as their own emotion from being personally effected by Type 2 diabetes. The emotional responses that occurred during the Talking Circles were expressed within the cultural context of three sub-themes: connectedness, collective living, and transformation.
Connectedness is a fundamental focal point of American Indian culture and thus an important part of the American Indian value system. Connectedness occurs through the dynamics of relationship. These relationships exist between everything and every person within the creation/universe (Lowe, 2002). Facilitators described the relationship of emotional response to Type 2 diabetes and connectedness in several examples. One facilitator stated there were lots of emotions, feelings, and many tears in the Talking Circle. "I was getting to the point where I just want to sit there and bawl (cry) just the fact that you can loose your life from this (diabetes) if you don't change. You know, you can not only lose your life but you can lose your sight, lose your legs, you know, everything."
Facilitators described the Talking Circle participants as connected; they are people who live on these rural reservations and are familiar; they know each other. "Almost everyone is related, some way or another, on this reservation so, when someone talks about (their dad, their brother) you know that person. You were there, you seen it You're part of the experience and then it's real close and you have to recall that and sit there and listen to them and try not to bawl (cry) as hard as they are because crying happens almost every week in a talking circle There's always something that hits hard and it's very emotional. Just recalling this is choking me up. You know their story and you also know you don't want that for other people." Consequently, the facilitators dealt incessantly with grief, loss, and suffering related to Type 2 diabetes when facilitating the Talking Circles.
The American Indian culture views birth and death as part of the circle of life. Type 2 diabetes makes apparent the reality of impending death. A facilitator who had Type 2 diabetes herself recounted the following: "I always tell my kids (who are in grade-school) 'one of these days, tomorrow is going to come without mama'. But it's like that for everybody, I let them know. For everybody. It's just not because mama's a diabetic, but it's life...That's the way it was meant to be. But I say, 'You'll have to remember all the good things mama used to do. All the good things that we did.' And carry on too." You are part of a beautiful culture and within that culture, we are responsible to live onward, contribute in a meaningful way, and do the best of one's ability. That is what is done after our loved ones transition to the spirit world.
Clearly, because of this sense of connectedness, Native participants were able to discuss their emotional responses to living with Type 2 diabetes; and this sense of connectedness allowed the facilitators to understand these emotional experiences. All the facilitators noted that people "connected in the Talking Circle" and that is important in the American Indian culture. This connectedness reflects an intuitive awareness of others that recognizes the oneness and intertwining of all actions and thoughts of those present. The facilitators and the participants bonded and relationships were formed. In view of that, connection, a fundamental American Indian concept was supported in the Talking Circles.
Collective living, or doing what is best for the good of the group, is also integral to the American Indian culture (DuBray, 1998). This type of thinking can be said to be opposite of autonomy, or what is considered best for each person (individualism). Examples of collective living that took place in the Talking Circle are provided. Taken as a whole, Type 2 diabetes has far-reaching implications for the continuity of American Indian tribes. Without gaining a cultural understanding of the consequential outcomes of Type 2 diabetes in American Indian communities, the continued loss of language, traditional practices, elders, and life ways could occur.
In a previous employment position, one facilitator had access to data that showed high mortality in her tribe. Male tribal members, for the most part, did not live past the age of 50 years. "It's still that way and diabetes is knocking out a lot of our men at younger ages. It's very rare to become an elder in our tribe that leaves us a limited number of elders to learn from." This statement is substantial, for in American Indian tribes the elders have accumulated knowledge through many, many years and are relied upon to pass on traditions and culture. "When they are not there or there are just a few of them, it affects everybody it really has a huge effect. Huge, very huge because of the importance as Indian people we put on the elders."
If American Indian communities don't have any elders, where will tribal people go for traditional knowledge? This void of elders may be viewed as depriving the next generation. One facilitator described this as "devastating to watch because in our tribe, the men are the leaders. They are the ones that are to step up and lead the rest of us to where we're supposed to be...That's the male's position." Without a doubt, if elders are not able to pass on tribal knowledge because they are ill or deceased, it is a "threat to the whole tribe," to the usual life way that American Indian people have collectively lived for centuries.
Another facilitator who lost several of her family members to diabetes reported diabetes has a tremendous effect on her life. "It is real fresh in my mind...In my feelings and everything. It is always there Things are always happening with it." Thus, diabetes is communally and collectively present in the body, the mind, the emotions, and the spirit.
Any holistic approach developed for education or interventions would need to acknowledge the cultural understanding and impact of Type 2 diabetes to the community and potential psychological responses such as depression, anxiety, loss of hope, grief and loss. As a chronic illness, Type 2 diabetes is traumatizing to relationships within the community. This disease victimizes members to the point of feeling powerless, vulnerable and establishes a sense of fear surrounding the disease. Talking Circles offer a therapeutic approach for addressing concerns, emotions and feelings within a cultural context. Lowe (2002) might describe it as an "oneness of spirit that is created and a way for the exchange of healing life-energy" (p.9).
Transformation, or change during one's life, is viewed as a commonplace phenomenon in American Indian culture and is also part of the natural occurring circle of life. Transformation was seen as a way for the facilitators to manage the emotions experienced and discussed by the Native participants. The facilitators also experienced some of these same emotions. One facilitator has Type 2 diabetes and described the Talking Circles as "reliving my past everyday. All the hurt you went through, all the anger. You have to learn how to control all of that being a facilitator."
One facilitator felt that there was no space allowed in our health care system for the emotional process that has to take place when diabetes is diagnosed. Instead, "We immediately get a referral to the dietician (nutritionist) to tell us what to eat; to the foot doctor who tells us what is going to happen to our feet if we don't take care of our feet now that we are diabetic." Negating the feelings of being overwhelmed and distressed disallows the necessary transformation from a previous state of health to living with and managing a chronic illness.
The Talking Circle provided an opportunity for genuine healing. The facilitators reported that Native participants described a feeling of relief upon leaving the Talking Circle because participants felt at ease of being able to talk, unload something, relate to it and process feelings during the dialogue. One facilitator reported that in the Talking Circle, "people reach a point where they are ready to release what they have been holding in a release of the pain a release of grief it is safe to release what they're carrying." With this relief, Native participants experienced transformation, and were then able to further "learn about diabetes."
A program that recognizes the holistic intertwining of the components of the being: the mind, body, feelings and spirit; and integrates important American Indian concepts such as connectedness, collective living, and transformation, is necessary to influence the epidemic of Type 2 diabetes in American Indian communities. The framework of racial consciousness can be utilized to provide culturally appropriate health care services on rural American Indians reservations.
Integrating racial consciousness as a context for Talking Circle facilitators
An explanation of racial consciousness will be provided as a feasible context from which Talking Circle facilitators can operate and Native participants respond. The milieu in communities like rural American Indian reservations is different in that racial consciousness and disparities have a role in the creation of community health status.
One may belong to several groups. Racial consciousness was first described in social science literature. In a broad sense, Banton (1988) states racial consciousness reflects contact between people who can be distinguished by their physical appearance. Racial consciousness is increased in societies in which appearance is used as a basis for discontinuous social classification; a fair complexion has usually been preferred over a dark one (Banton, 1988). Even so, racial consciousness is not easily defined because it involves a distillation of personal experience (Banton, 1988) and is an individual's interpretation of how his or her life is affected by the way others assign him or her to a racial category. This appointment allows very little freedom of choice, so the assignment to a specific group appears permanent and involuntary (Banton, 1997). In another form, it is the individual's tendency to assign others to racial categories.
Racial consciousness is greatest when: a) an identification of "us" and "them" is evoked (Banton, 1997, p. 66), b) there is a question of who has power and group control over economic resources, and c) differences are so significant they are maintained for some time (Banton, 1988). As a result, the subordinated peoples view themselves as oppressed, this may evoke solidarity (Banton, 1997), and those appointed to a particular grouping share like experiences.
Historical points of view may be important in relation to racial consciousness. A contemporary example is the outcome by which Europeans established themselves in the New World in the sixteenth century. The Europeans looked very different in physical appearance from the Natives and also differed in their expectations of work, literacy and knowledge in technical areas such as firearms (Banton, 1988). Consequently, an attitude of 'us' and 'them' was swiftly generated. Even so, factors like race and discrimination are just beginning to be studied by researchers in the health care arena. Williams, Neighbors, and Jackson (2003) examined community studies and found that discrimination is associated with multiple indicators of poorer physical health and, especially, mental health status.
More recently, Watts (2003) explained racial consciousness within a broad etic (outsider) perspective and defined the concept in relation to the provision of health care. She noted that racial consciousness constituted: a) understanding the complex historical journey of a particular racial group; b) knowledge of disparities in health which may facilitate or inhibit optimum levels of care for these individuals, their families and communities; and c) self appraisal of one's attitudes, feelings, beliefs, and biases towards a select group. The following discussion will focus on Watts (2003) explanation of racial consciousness related to health care.
For this report, the select group is American Indians and the health care providers are lay personnel who were trained as Talking Circle facilitators. Given a description of racial consciousness, it is optimistic to state the facilitators employed the concept of racial consciousness from an emic (inside) perspective to craft and effectively guide and lead the Talking Circles to meet the native participant's needs and desires. This situation afforded the opportunity for emotions related to Type 2 diabetes to be expressed within a culturally appropriate holistic milieu created by the facilitators.
Shared ways of knowing are culturally shaped and provides insights into a culture's perspective of health and illness (Turton, 1997). In the experience of the Talking Circle, comfort was obtained utilizing a group approach and there was a shared sense of belonging, community identity within the group, and a deep-seated understanding of the complex historical journey of the American Indian. The intergenerational and intercultural ties of the community became the psychological and emotional resources for expressing feelings, finding support, coping, grieving and celebrating successes. Self-disclosure within a group helps an individual share fears and concerns, promotes acceptance and provides a therapeutic process for promoting psychological well-being. This sharing, based upon collective living within the American Indian cultural context, led to emotional bonding, which enhanced connectedness and exposed opportunities for further transformation.
For the Winnebago American Indians, their history includes a long journey that included being forced out of Northeastern Wisconsin, their original homeland, and into Northeastern Iowa. Many Winnebago people kept returning to Wisconsin, or just plain refused to leave when ordered. As a result, Winnebago people today live in two separate locations. Some live scattered in ten counties in Wisconsin where they have tribal land. Others live in Nebraska, on a reservation formed in 1865 when the United States government purchased 40,000 acres from the Omaha Indians to provide the Winnebago with a reservation (Winnebago History, 2003).
The Oglala people who currently live on the Pine Ridge Reservation originally resided in north central Minnesota. White encroachment forced them to South Dakota where they discovered their spiritual center, the Black Hills. In 1868, the United States government formed the Great Sioux Reservation and in 1889 decreased the size of the reservation when they confiscated the Black Hills. In 1890, over 300 residents were pointlessly slaughtered by the United States government troops near Wounded Knee Creek on the Pine Ridge Reservation (Reservation Profiles, 2003). Today, one can visit the mass grave and envision and feel the hurt that transpired for the ancestors on that day.
Like many other tribal nations, the Winnebago and Pine Ridge people have experienced forced relocation, war, disease, starvation, and strong acts of forced assimilation to White culture (Struthers & Lowe, 2003). The World Health Organization (1999) recognizes the traumas and dislocations indigenous peoples have experienced and agrees it affects mental health issues. Several times during the interviews, facilitators talked about their tribal history and related it to Type 2 diabetes. Examples include: "What has been done to us by the dominant society over the last 500 years has been terrible." Another stated, "I think a part of this (diabetes) epidemic started because of the trauma of the starvation period (that our people went through) due to being chased around by the military and being moved out of where our lands were." One facilitator said, "I compare diabetes to the smallpox. You know, the blankets that were sent over to our people back then and our immune system was clean then," so the disease swept through our people. Another described, in the Talking Circle, "When our people talk about the culture, a lot of people are angry, and they start getting mad at the non-Indian society, the hurt they caused us, the things they did."
It is the knowing of this history that binds American Indians together in a like type experience and enfolds them into indigenous oneness (Lowe & Struthers, 2001). Thus, sharing experiences and processing the emotions that accompany the historical journey encompasses a deep cultural understanding. This cultural understanding translates to the necessity of cultural knowledge for all professionals as they interact with the American Indian population. Terms, such as emotional need, must be understood from the American Indian cultural worldview in order to impact their mental health. Cultural insensitivity to the needs of ethnic communities may lead to under utilization of health care and mental health services. Kim-Goodwin, Clarke, & Barton (2001) emphasize that positive health outcomes for the individual, family or community can occur if there is integration between culture, community and the health care system. They further propose that cultural knowledge is a necessary component of cultural sensitivity.
The facilitators possess intimate knowledge related to disparities in health that facilitate or inhibit optimum levels of care for reservation individuals, their families and the community. On these rural reservations health care is provided by the United States government-run Indian Health Service (IHS). The severely under funded Indian Health Service had 1,387,982 active user beneficiaries as of September 30, 2001. Individuals who receive healthcare from the Indian Health Service are allotted $1,384 by the United States government, while a person on a Federal Employee Health Plan is allotted is allotted $3,582 (Indian Health Service, 2003a). While the Indian Health Service does the best job possible under the circumstances, health care in the reservation is far less than optimal. Thus, health disparities are evident in that Type 2 diabetes is an epidemic in the population.
On the other hand, the facilitators knew their communities intimately, possessed cultural wisdom, and combined these strengths to facilitate education on Type 2 diabetes. Noted assets included understanding who would be uncomfortable in a certain group due to the carrying forth of old wounds and traumatic events in a small rural community. Thus, the facilitator would ask that person to join a more congenial Talking Circle. Also, the facilitators utilized the American Indian culture throughout the educational curriculum to enhance the presentation of ways to prevent and effectively maintain symptoms of Type 2 diabetes.
Lastly, racial consciousness encompasses a self-appraisal of one's attitudes, feelings, beliefs, and biases towards a select group. In this instance, the group is American Indians. The Facilitators were American Indian themselves and were familiar with their communities, its members, and the culture. Thus, they had first hand knowledge related to attitudes, feelings, beliefs and biases that were targeted toward American Indian persons by others. As well, self-appraisal was evident through quotes from each of the facilitators as they preformed their work. The facilitators were "proud of work," performed their jobs with "much thought," and felt it was the "right thing to do" for themselves, their families, and their communities.
All four Talking Circle facilitators stated that emotions are difficult and that the emotional aspect of Type 2 diabetes needs further investigation. American Indian reservations and the epidemic of Type 2 diabetes call for holistic culturally appropriate strategies such as Talking Circles to provide education on this paramount topic and to provide a group setting where sharing can happen in a comfortable, safe environment. As a result, interventions like the Talking Circle can provide a milieu for coming together, discussing delicate topics like emotions within a group context, and thus enhance the letting go of feelings related to diagnosis of, and living with, Type 2 diabetes. It is thought that the notion of incorporating a concept like racial consciousness adds to the success of a venture such as this on American Indian reservations where health disparities are high; community members yearn for a therapeutic milieu that recognizes and comprehends their historical journey as a people and as a tribe; and community facilitators can use self-reflection towards their constituents in a positive, helping fashion. In this way, important cultural themes such as connectedness, collective living, and transformation can be honored and healthy emotions can be achieved.
All cultures are enmeshed in racial consciousness. Culture is important and has an influence on how one perceives the world, how one views others, as well as those like themselves, and is an important factor in the provision of health care, treatment and healing (DuBray & Sanders, 1999). Psychological health and illness is best understood from the cultural meanings and worldview shared by a group such as the American Indian community. For the practitioner, cultural knowledge leads to cultural sensitivity and culturally appropriate interactions and interventions. This creates a therapeutic relationship between the practitioner and the community. Culture is as much a structure as economics or politics; it is rooted in institutions such as families and communities (West, 1993). This in turn affects individual, family, or a community response to a crisis, such as a chronic illness (DuBray, 1998) like Type 2 diabetes.
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This research study was funded as a Minority Supplement to Diabetes Wellness: American Indian Talking Circles 3 RO1 NR04722-04S1 (Dr. Felicia Hodge, PI) from the National Institute of Health, National Institute of Nursing Research (2000-2002).