Health and Healing the Ute Way: Perceptions of Diabetes Among the Uintah-Ouray

Generally stated, the purpose of the proposed research project is to evaluate perceptions of diabetes among the Uintah Ouray Utes in order to improve diabetic health care. In tandem with local initiatives, this study seeks to more fully understand native perceptions of diabetes and empirical translations of these perceptions in order to help develop an "innovative and effective community based educational plan" (Cesspooch 1999). This project, based upon Rapid Assessment Procedure (RAP), will consist of a descriptive and exploratory study to record these perceptions and their underlying cultural basis (Scrimshaw & Hurtado 1987, Beebe 1995). Following the premises of participatory action research, members of the Ute tribe will be implemented as consultants, collaborators and experts in the project design in order to increase efficiency and success of the proposed research project (Whyte 1990, Chrisman et. al. 1999).

It is commonly recognized that minority groups in the United States suffer from poorer health, with health indicators, such as infant and adult mortality rates, steadily growing worse (Loustaunau & Sobo 1997). Native Americans as a minority are no different when it comes to health care and in many cases, may be worse off. Diabetes is an especially pervasive health problem for Native Americans. The risk for developing Type II diabetes is five times greater in Native Americans than in Caucasians (Haffner 1998). Although the estimated national rate for diabetes is about 2%, Native American populations like the Cherokee and Seneca experience diabetes at a rate of approximately 14% and 20%, respectively (Woodcock 1974). The infamous Pima Indians of southern Arizona experience diabetes at an astounding rate of almost 50% (Ritenbaugh & Goodby 1998).

Diabetes is an equally pervasive problem for the Uintah Ouray Ute. In 1974, the Uintah Ouray Ute experienced diabetes at a rate of around 16.7% (Woodcock). Today, the tribe experiences diabetes at a rate of about 25% (Ebbert 1999). The difference between the two rates in magnitude and time readily suggests that diabetes is on the rise among this population. In concurrence with this assertion, diabetes was recently listed as the number one health concern for the tribe by a group of 40 members from the Uintah Ouray Indian Health Service (Cesspooch 1999).

The literature contains numerous examples of quantitative studies about diabetes among Native Americans--a single Internet search for diabetes research among the Pima produced 212 references alone. The majority of these studies, however, approach diabetes as a public health problem, reducing it to the organic level and treating it as a manifestation of genes and enzymes. Aside from the Pima example, researchers also typically treat Native Americans as a single unit, rather than as individual tribes. There is a relative absence of any qualitative studies that explore how a Ute diabetic or any other tribe-specific diabetic for that matter perceives his/her condition.

Qualitative studies that address culturally specific health behavior can affect ". . . patient compliance, satisfaction, comfort and attitude toward the medical establishment," all of which are important factors in improving healthcare among minorities such as the Uintah Ouray Ute (Loustaunau & Sobo 1997). Harwood was able to apply cultural knowledge of the "hot-cold theory of illness," popular among Latino populations, to improve doctor-patient interaction in his qualitative study of a Puerto Rican community (1998). The "hotcold theory of illness" requires that a "hot" condition, such as diarrhea, be treated with a "cold" remedy, such as milk of magnesia. Based upon this theory, Harwood encouraged physicians who prescribe a diuretic for Latino patients suffering from a common cold to prescribe a potassium-rich vitamin as well. Diuretics deplete the body of potassium, but the patient can usually eat bananas or oranges to replace lost potassium. However, Harwood noted that bananas and oranges are "cold" foods. A Latino patient would not adhere to this prescription but would take vitamins, which are "hot," to treat their cold, a "cold" condition. In the single qualitative study the writer was able to locate about a Native American tribe and diabetes, Tom-Orme was able to suggest culturally appropriate vocabulary to improve adherence among the Navajo in a nutrition education program (1988). Tom Orme found that the Navajo's perception of the word "diet" led them to believe that they would be required to follow a strict and inflexible eating pattern, and she suggested that medical practitioners use "meal plan" in place of "diet." "Meal plan" invoked a more positive image for the Navajo and better understanding of what the practitioner was trying to communicate.

Qualitative studies about minority health care are obviously an important but often overlooked resource in our effort to improve health care. The study proposed here and others like it offer a unique opportunity for practitioners and policy-makers to switch roles and listen, rather than giving answers. For the Uintah Ouray Ute, the opportunity to speak their minds about the services provided them and the disease they must inevitably deal with is especially important. In a system where they are often directed, they will finally be given the chance to offer input, input that can bring the changes in a health care system we so desperately need and want.

The following questions will be addressed:

1. How do the Ute perceive health and healing?

2. How do the Ute perceive diabetes?

3. How do they perceive current health care providers?

The parameters of this project will be limited to Ute Indians who are at risk for or suffering from Type II diabetes and live on the Uintah-Ouray Reservation. Risk will be determined by guidelines set forth by the American Diabetes Association (10 August 1999).

Methods will include the following:

1. One to two focus groups will be held, dependent upon initial response and sufficient funds. This focus group(s) will serve as a starting point for conceptualizing major issues and general ideas about diabetes from a sample of the population. Data collected from the focus group(s) will also serve to adjust inappropriate or irrelevant research topics and questions contained in existing surveys and interview guidelines (Coreil 1995, Beebe 1995, Stewart & Shamdasani 1990, Archly & Quandt 1999)).

2. Using rapid assessment procedures, an ethnographic survey will be conducted. Individuals recruited for this survey will be selected based upon their decision to volunteer and their qualities as they apply to the larger tribe. The survey will include forms designed to measure:

· knowledge and opinion of diabetes

· healing concepts and ethnomedical practices

· food consumption

Data collected in the survey will be similar to data collected from the focus group(s) in topic but differ in content with more detail-oriented information left unexplored in focus groups (Scrimshaw & Hurtado 1987, Schoenberg 1997).

3. In addition to the distributed survey, in-depth ethnographic study of the Ute culture will be performed with an undetermined number of key informants. This study will include participant observation in various community activities as well as association with informants and any family in day-to-day situations. This is to ensure that cultural practices the Ute themselves may not be conscious of are recorded and included in the project data (Spradley 1979).

The perceived outcomes of this project are two-fold. First, this project will aid the Uintah-Ouray tribe in treating diabetes. Diabetes is becoming a major concern for the tribe and was recently listed as the number one health concern for the Uintah-Ouray Ute. In an effort to facilitate better diabetic health care, reservation health and government officials have selected a number of priorities they wish to accomplish, one of them begin to develop an innovative and effective community-based educational plan (Cesspooch September 1999). The data gathered in this project will enable Ute officials to better tune their program to the needs and desires of their people and help improve adherence and efficiency.

Secondly, a paper detailing this project and its results will be publicly presented April 14,2000 at the O.C. Tanner Symposium, whose theme this year is "Body, Mind and Spirit: Culture and Health in America." This project is especially pertinent because it addresses dual goals of the symposium—integrating alternative options and improving healthcare. The paper will be presented with the help of Larry Cesspooch, Public Relations Director for the Uintah-Ouray Tribe and a Ute medicine man.

The following budget includes estimated costs required to implement the research design. Compensation for tribal members who participate in the proposed research project is necessary in order to follow culturally specific behavior that requires compensating an individual who has helped you, i.e. given you a gift. Other requests for monies to compensate assistants, moderators, etc. will help ensure that tribal members are utilized in the collection as well as the distribution of the data and will be vital in ensuring an open atmosphere while collecting the data.

References

American Diabetes Association. (10 August 1999). "Diabetes Risk Test." Located at http://www.diabetes.org/ada/risktest.asp.

Arcury,T.A.& Quandt, S.A. (1999). "Participant Recruitment for Qualitative Research: A Site-Based Approach to Community Research in Complex Societies." In Human Organization, Vol. 58, No. 2, pp. 128-133.

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Cesspooch, L. (1999). "Diabetes Number One Health Issue for U & O: Indian Health Service Program Planning for the Year 2000." In The Ute Bulletin, Vol. 32, No. 24., pp. 1,3.

Chrisman, N.J. et. al. (1999). "Community Partnership Research with the Yakama Indian Nation." In Human Organization, Vol. 58, No. 2, pp. 134-141.

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Ebbert, P. (2 October 1999). Personal Correspondence. Uintah-Ouray Indian Health Services: Ft. Duchesne, UT.

Hatcher, S.M. (1998) "Epidemiology at Type 2 Diabetes: Risk factors." In Diabetes Care, 21: C3-C6, Supplemental.

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Ritenbaugh, C. & Goodby, C. S. (1998). "Beyond the Thrifty Gene: Metabolic Implications of Prehistoric Migration into the New World." In Brown, P.J. (ed.), Understanding and Applying Medical Anthropology, pp.46-52. Mountain View, CA: Mayfield Publishing Comp.

Schoenberg, N.E. (1997). "A Convergence of Health Beliefs: An 'Ethnography of Adherence' of African-American Rural Elders with Hypertension." In Human Organization, Vol. 56, No. 2, pp. 174-181.

Scrimshaw, S.C.M. &; Hurtado, E. (1987). Rapid Assessment Procedures for Nutrition and Primary Health Care: Anthropological Approaches to Improving Programme Effectiveness. Los Angeles: UCLA Latin American Center Publications, University of California.

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Stewart, D.W. & Shamdasani, P. N. (1990). Focus Groups: Theory and Practice.. Sage Publications: Newbury Park.