Coping with stress among Aboriginal women and men with diabetes in Winnipeg, Canada

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Abstract

Many Aboriginal peoples are widely exposed to stress in their lives. This exposure to stress appears linked not only to their contemporary and immediate life circumstances (e.g., marginal economic and at-risk living conditions) but also to their historical, cultural, and political contexts. Recently, diabetes has become prevalent in many Aboriginal communities worldwide. The purpose of the present study was to gain a better understanding of the ways in which Aboriginal peoples with diabetes cope with stress. The study used a series of focus groups among First Nations and Métis women and men with diabetes in Winnipeg, Manitoba, Canada. Based on our cross-thematic analyses of the data, three overarching themes were identified: (1) individual and collective strengths of Aboriginal peoples with diabetes must be recognized and utilized to facilitate healing from or coping with the experience of stress and trauma; (2) healing must be accomplished holistically by maintaining balance or harmony among mind, body, and spirit; and (3) effective ways of coping with stress and healing from trauma potentially promote positive transformations for Aboriginal peoples and communities at both individual and collective levels. Also, sub-themes of stress-coping and healing that underlie and further describe the above three overarching themes emerged from the data. These include: (a) interdependence/connectedness, (b) spirituality/transcendence, (c) enculturation/facilitation of Aboriginal cultural identity, (d) self-control/self-determination/self-expression, and (e) the role of leisure as a means of coping with stress and healing from trauma. Accordingly, our deeper analyses resulted in the development of an emergent model of stress-coping and healing among Aboriginal peoples with diabetes, which is presented as a dynamic system in which the three overarching themes are embedded in the five specific themes of coping/healing. This evidence-based emergent model appears to provide some important insights into health policy and program planning for Aboriginal peoples with diabetes and their communities.

Introduction

Diabetes is prevalent in many Aboriginal communities worldwide (Young, Reading, Elias, & O’Neil, 2000; Rock, 2003). Due to health problems related to diabetes and other factors (e.g., unemployment, low income; Kraut, Walld, Tate, & Mustard, 2001), the lives of Aboriginal peoples with diabetes appear very stressful. Also, the literature suggests that there is a critical link between stress and diabetes (e.g., Daniel, Rowley, Herbert, O’Dea, & Green, 2001; Rock, 2003). Specifically, stress has been recognized as a key aetiology of Type 2 diabetes; that is, diabetes is not just another stressful problem in Aboriginal communities. Rather, stress is a direct risk factor or cause of diabetes and directly affects the management of diabetes among people already diagnosed with the disease through both physiological and behavioural mechanisms (International Diabetes Foundation, 2003).

It is important to emphasize that the changes wrought by colonization are considered a major factor for the alarming rise in diabetes incidence among Aboriginal peoples worldwide (Benyshek, Martin, & Johnson, 2001; Heffernan, 1995; McDermott, 1998; Rock, 2003). For example, in their study of the meanings of diabetes to Cree people, Boston and colleagues (Boston, Jordon, MacNamara, Kozolanka, Bobbish-Rondeau, & Iserhoff, 1997) found that Cree attributed the cause of diabetes to the “white man,” suggesting that the spread of diabetes is related to “the decline of bush life.” It is obviously necessary to give attention to broader cultural, socio-economic, historical, and political factors surrounding diabetes among Aboriginal peoples (Boston et al., 1997). For example, a couple of recent studies conducted on Aboriginal peoples with diabetes highlighted this notion.

First, Bruyere and Garro (2000) examined the ways in which First Nations people themselves understand diabetes in their native language in Opaskwayak Cree Nation, Manitoba. Narratives from the interviews suggested that “while health professionals tend to localize diabetes within individual bodies, the participants viewed diabetes as rooted in collective experience and in historical processes that have impinged on Aboriginal people and are beyond their control” (Bruyere & Garro, 2000, p. 28). Next, Sunday, Eyles, and Upshur (2001) investigated the occurrence and meanings of diabetes in two Anishnaabe communities on Manitoulin Island, Ontario. They found substantial differences in the descriptions of diabetes between the biomedical narratives of health care professionals and the community narratives of Aboriginal peoples. Health care professionals primarily attributed the high prevalence of diabetes among Aboriginal peoples to individual lifestyle factors—specifically, sedentary lifestyles and obesity, as well as to genetics. These health care professionals tended to blame the victims, emphasizing personal irresponsibility and the individuals’ lack of control over their lifestyles. In contrast, community members’ descriptions were much broader. Although genetics was identified as a primary causal factor (being described as an inherent quality and a sense of inevitability), these community members regarded its cause as a collective occurrence closely tied to larger notions of powerlessness. Also, community members study talked about the bodily manifestation of stress in the form of diabetes (Sunday et al., 2001). One member commented, “Your body gets quite eaten up unless you find ways of handling your stress.”

Despite the stressful nature of living with diabetes for Aboriginal peoples, many of them appear to have strengths and substantial potential to deal with stress, using appropriate coping strategies. For example, Sunday et al. (2001) found that “the occurrence of diabetes is helping to bring the community together” (p. 80). This finding was interpreted as having “teleological implications” (p. 80), being described by one participant—“It has a purpose that's why we have diabetes. I guess everything has a meaning, people, sickness, diseases. We’re brought closer together when we have problems.” Similarly, the majority of participants agreed that having diabetes has led to “renewed interest in tradition within the communities” (p. 80) and in valuing cultural knowledge and identity (Sunday et al., 2001). One participant elaborated this point,

“Everything that's been going on in the reserve they have to go back to that healing. Most people started to try and be more aware of their culture and trying to be part of their culture because we lost that a long time ago. I find that way the community is trying to get that back. In that way you’re learning more.”

Another participant talked about “his transformation following his diagnosis with diabetes from a state of cultural alienation to one of cultural belonging” (Sunday et al., 2001, p. 80).

Sunday et al.'s study (2001) provided important evidence for the potential that rekindling cultural values and traditions in Aboriginal communities helps people effectively deal with diabetes, by positively transforming those suffering from diabetes, those around them, and their communities. Furthermore, on the basis of their study of a rural Aboriginal population in British Columbia, Daniel, O’Dea, Rowley, McDermott and Kelly (1999) recommended the use of culturally relevant empowerment-oriented diabetes management strategies to promote mastery and life quality among Aboriginal peoples with diabetes.

Although not specifically focusing on issues surrounding diabetes, the literature on coping or healing for Aboriginal peoples in general provides some important insights into potential coping or healing strategies/mechanisms that may prove useful and effective in dealing with stress/trauma for Aboriginal peoples with diabetes. For example, as described by Restoule (2000), community healing is a grassroots approach that has gained much support in Aboriginal communities across Canada. This approach is based on the concept of holistic health to improve the overall health of individuals, families, and Aboriginal communities based on their needs and resources. This community healing approach suggests that healing is a process to deal with the underlying causes of health problems, as opposed to past interventions that have primarily targeted the symptoms of health problems. Generally, this approach emphasizes two things: improving the overall health of Aboriginal peoples and promoting positive Aboriginal cultural identity (Restoule, 2000).

Similarly, it has been reported that culturally relevant gatherings and symbolic healing rituals facilitated by Aboriginal peoples and communities themselves are important to establish reconnection to cultural values and traditions and gain a sense of rejuvenations and cultural pride (Adelson, 2000; McCormick, 2000). Furthermore, some researchers emphasized the importance of identifying and utilizing Aboriginal peoples’ strengths within their communities (Van-Uchelen, Davidson, Quressette, Brasfield, & Demerais, 1997), for example, by facilitating interdependence, connectedness, and spiritual coping (McCormick, 1997; Walters & Simoni, 2002) and by emphasizing community development and local control to promote cultural continuity and renewal (Chandler & Lalonde, 1998; Kirmayer, Brass, & Tait, 2000). In their qualitative study on First Nations peoples in Saskatchewan, Canada, who are survivors of residential schools, Hanson and Hampton (2000) suggested that community-based health initiatives which focus on traditional sources of strengths (e.g., sharing, respect, spirituality, humour, compassion, and cultural pride) within First Nations communities, would be most effective in promoting healing from trauma.

The purpose of the present study was to examine the ways in which Aboriginal peoples with diabetes cope with stress, using a sample from an urban western Canadian city. A series of focus groups was conducted to gain an understanding of stress-coping strategies from their perspectives. Generally, there appear to be common ideologies, shared histories, and specific health-related issues that constitute the Aboriginal viewpoint. However, it is important to give attention to the diversity of Aboriginal peoples with respect to, for instance, cultural differences such as languages and values/attitudes (Kirmayer et al., 2000; Renfrey & Dionne, 2001). Thus, in this study the composition of focus groups differed based on cultural group-classifications in the Aboriginal population. Specifically, study participants represented two of the three major Aboriginal groups in Canada—First Nations and Métis peoples.1

Furthermore, it has been suggested that it is important to recognize gender issues within a multicultural context in Aboriginal research (Malone, 2000). In applying this idea to Aboriginal stress and coping research, it is crucial to recognize gender differences in the sources or causes of stress in women's and men's lives. According to Wise, Carmichael, Belar, Jordan, and Berlant (2001), who describe ethnic minority women's health from a cultural perspective, key “crosscutting factors” are that “these women are often the sole support of families with a poverty-level income,” and that they have “the potential for increased exposure to sexism and racism in society” (p. 464). Therefore, gender, ethnicity, and poverty “place minority women at ‘triple jeopardy’ when it comes to health status” (p. 464). Consequently, in the present study, the composition of focus groups was based also on gender of the participants to allow for gender-based analysis.

Section snippets

Methods

Grounded in a qualitative framework, focus groups were employed. Focus groups are considered an effective method for obtaining in-depth information about a concept or issue, and learning about people's experiences (Madriz, 2000; Krueger, 1994). Instead of being directed by predetermined hypotheses or controlled by existing measures, focus groups enable participants to express themselves, in their own words, in an open and flexible process (Krueger & Casey, 2000). Furthermore, because focus

Common stress-coping themes

Based on our analyses of the focus group data, several key themes are identified that capture the essence or core meanings of coping or healing strategies used by the participants.

Interdependence/connectedness: One common theme concerns social aspects of coping/healing that facilitate a sense of interdependence and connectedness. First Nations women with diabetes emphasized the importance of social support provided by their friends and significant others who face similar life circumstances and

Discussion

To begin this discussion section, it must be noted that our attempt here is not to generalize our findings, given the very specific nature of the sample used—i.e., participants living in an urban Canadian city who responded to posters displayed at a Aboriginal health centre and voluntarily agreed to be involved in a focus group. However, major strengths of our study are that (a) both First Nations and Métis people were represented, (b) both women and men participated, and most importantly, (c)

Conclusion

The findings from this study seem to have important implications for understanding coping with stress and healing from trauma among Aboriginal peoples with diabetes. From a broad perspective, first, individual and collective strengths of Aboriginal peoples with diabetes must be identified and utilized to facilitate healing from or coping with the experience of stress and trauma. This proactive approach appears more appropriate than focusing on deficits and trying to “fix problems” from a

Acknowledgements

The study was supported by the Social Sciences and Humanities Research Council of Canada (SSHRC), Strategic Program, Research Development Initiative (RDI) Grants.

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