Centering the Strengths of American Indian Culture, Families and Communities to Overcome Type 2 Diabetes.

Type 2 diabetes (T2D) is a critical Indigenous health inequity rooted in experiences of colonization and marginalization including disproportionate exposure to stressors, disruption of traditional family and food systems, and attacks on cultural practices that have led to more sedentary lifestyles. Thus, an important step in redressing inequities is building awareness of and interventions attuned to unique Indigenous contexts influencing T2D and Indigenous culture as a pathway to community wellbeing. Using a dynamic, stage-based model of intervention development and evaluation, we detail the creation and evolution of a family-based, culturally centered T2D preventive intervention: Together on Diabetes (later Together Overcoming Diabetes) (TOD). The TOD program was built by and for Indigenous communities via community-based participatory research and has been implemented across diverse cultural contexts. The TOD curriculum approaches health through a holistic lens of spiritual, mental, physical and emotional wellness. Preliminary evidence suggests TOD is effective in reducing diabetes risk factors including lowering BMI and depressive symptoms, and the program is viewed favorably by participants and community members. We discuss lessons learned regarding collaborative intervention development and adaptation across Indigenous cultures, as well as future directions for TOD.

Assessment of feasibility and outcomes of a salivary cortisol collection protocol in five American Indian communities.

We evaluated the feasibility and outcomes of administering a naturalistic saliva collection procedure and assessment in American Indian (Indigenous) communities. We focus on Indigenous adults living with type 2 diabetes given the "epidemic" of the disease disproportionately impacting many tribal groups. Data are from community-based participatory research (CBPR) involving 5 tribal communities. Participants were randomly selected from tribal clinic records. The sample includes 188 adults living with type 2 diabetes (56% female; age range = 18-77 years; M age = 46.3 years). Participants provided a total of 748 saliva samples, representing 4 samples/participant on a single day with instructions for collection at 4 time points: upon waking, 1 h after waking, 2 h after waking, and at 8 PM. Saliva sample times were recorded by participants on paper and electronically via placement in a Medication Event Monitoring System (MEMS®) bottle. Overall, 67% of samples were completed within 10 min of protocol instructions and 91% of participants provided at least one useable sample (79% provided four useable samples). Noncompliance, behavioral and environmental factors were not robustly associated with deviations in observed cortisol indices. Results suggest that home-based, community interviewer-involved protocols yields valid data with high compliance. The success of this study was facilitated by exemplary efforts of tribal community-based interviewers and our overall CBPR approach.Lay summaryAuthentic efforts for tribal community partnerships in research are critical to successfully implementing biological assessments with American Indians given legacies of research misconduct and mistrustOur Community-Based Participatory Research with 5 tribes yielded high participant compliance to a home-based salivary cortisol collection protocolLack of compliance to salivary cortisol protocol and medication usage were not consistently associated with observed cortisol indices.

Stress Exposure and Physical, Mental, and Behavioral Health among American Indian Adults with Type 2 Diabetes.

American Indian (AI) communities experience disproportionate exposure to stressors and health inequities including type 2 diabetes. Yet, we know little about the role of psychosocial stressors for AI diabetes-related health outcomes. We investigated associations between a range of stressors and psychological, behavioral, and physical health for AIs with diabetes. This community-based participatory research with 5 AI tribes includes 192 AI adult type 2 diabetes patients recruited from clinical records at tribal clinics. Data are from computer-assisted interviews and medical charts. We found consistent bivariate relationships between chronic to discrete stressors and mental and behavioral health outcomes; several remained even after accounting for participant age, gender, and income. Fewer stressors were linked to physical health. We also document a dose-response relationship between stress accumulation and worse health. Findings underscore the importance of considering a broad range of stressors for comprehensive assessment of stress burden and diabetes. Policies and practices aimed at reducing stress exposure and promoting tools for stress management may be mechanisms for optimal health for AI diabetes patients.