One month later, Clyde visits Dr. Nyrit for the second time. Dr. Nyrit has been thinking about her early experiences at the reserve and how she should proceed. (See “Reflective exercise 2” below). Clyde talks to his cousin Sandy about his visit to the physician.
“I can’t stand salad. I take the lettuce out of my hamburger, I hate it so much. I will eat salad from time to time, but don’t count on me to eat it four times a day … But I could eat bread everyday … Or molasses. Sometimes I’d like to have something fatty, with home-made bread and then some sugar, brown sugar.”
Social suffering and diabetes
Why is diabetes so much more common among Indigenous people? Sandy brings up two of the frequently mentioned theories: genetic predisposition and change in lifestyle. A change in lifestyle refers to more than a change in diet and exercise, although those certainly play a role. There is a compelling body of evidence suggesting that social suffering may be an important component. This term primarily refers to loss: loss of cultural identity, loss of heritage language, loss of homeland, loss of meaningful work, loss of respect and loss of hope. Such losses are thought to cause chronic stress in individuals, leading to metabolic abnormalities that result in hyperglycemia. The implications of this relation of social determinants of health to biological disease are that a change in diet and exercise — even an attempt to return to a previous hunter-gatherer lifestyle — may not result in glycemic control. We will further examine the implications of trying to institute lifestyle change in “Reflective exercise 2” below.
Other theories about the epidemiology of type 2 diabetes invoke genetic predisposition. Amy had gestational diabetes, which is also more common in Indigenous women than in non-Indigenous women. Experts are still unsure whether this, and low birth weight as a predisposition to develop diabetes, is genetic, environmentally-induced, or multifactorial.
Read the following articles for more information about socio-economic disparities, health inequities and diabetes in Indigenous peoples:
- “The embodiment of inequity: Health disparities in Aboriginal Canada” by N. Adelson.
- “Stress-coping among Aboriginal individuals with diabetes in an urban Canadian city: From woundedness to resilience” by Y. Iwasaki and J. Bartlett.
- “Native ethics and rules of behavior” by C. Brant.
- “Listening to native patients: Changes in physicians’ understanding and behaviour” by L. Kelly and J.B. Brown.
- “Patient and caregiver perspectives of health provision practices for First Nations and Métis women with gestational diabetes mellitus accessing care in Winnipeg, Manitoba” by H. Tait Neufeld.
- “Globalization, coca-colonization and the chronic disease epidemic: Can the Doomsday scenario be averted?” by P. Zimmet.
Reflective exercise 2
Preventive medicine and behaviour change
Counselling patients about health maintenance and disease prevention is one of the most important tasks of any physician, especially those in primary care.
As noted in the article by Elder (J.P. Elder,1999): “Primary care providers have traditionally relied on persuading patients to change through ‘informational power’ (sharing facts about health and illness) and ‘expert power’ (using professional credentials at least implicitly to impress patients with the potential effectiveness of the prescribed behavior change).” These tactics often fail, leaving both patient and physician frustrated and unsatisfied. Why?
Often, the physician tries to do too much, too soon. Without some knowledge of a patient’s life situation, values and beliefs, flooding them with information is fruitless. This is illustrated in this case as all the physicians try to deal with the difficult issue of diabetes in Indigenous people. The principles of behaviour modification apply to all patients, however.
In this exercise there are four video scenarios illustrating different ways in which a physician might approach behaviour modification in a patient with diabetes.
First, read: “Theories and intervention approaches to health-behavior change in primary care” by J.P. Elder, G.X. Ayala and S. Harris.
In each scenario, Dr. Nyrit is trying to utilize one or more of the models of behaviour change. Each option could potentially lead to a change in Clyde’s relationship to his diabetes. As you watch the scenarios, consider the following questions:
- What was the quantity of information exchanged?
- What was the quality of information exchanged?
- Did Dr. Nyrit use the “informational” or “expert power” approach, or something else?
Watch all four scenarios. Select the one you feel is the best choice. After making your selection, read the commentary related to each option.
Dr. Nyrit visits the reserve the next month and asks to see Clyde again.
Clyde is the fourth patient with new onset diabetes that Dr. Nyrit has seen in the past month. Having heard that the community is important in the health of Indigenous patients, she decides to speak to the local chief about her concerns.
Commentary on option 1
In this option, Dr. Nyrit attempts to use the Stages of Change model, one of the behaviour modification techniques discussed by Elder. This model has several stages:
It reminds us that patients are unlikely to change unhealthy behaviour if they have not even thought about it. Unhealthy is, after all, a point of view. The patient has to feel that the change is not only a good idea for them, but that it is possible to undertake. In this scenario, Clyde seems to react angrily when Dr. Nyrit suggests lifestyle changes. Why do you think this happens?
- He does not like her because she is a “white physician.”
- He has thought about making changes, but knows it is impossible and that makes him angry.
- He does not want to make changes in his life, and resents her interference.
- He thinks that making changes will not make any difference to his health.
- Her ignorance of his situation alienates him (“walk to the bush — it’s too far!”).
- Clyde cannot read well enough to understand the pamphlets, and is ashamed to admit it.
- How might Dr. Nyrit find out which of the above are going on in this conversation?
- Do you think Dr. Nyrit should acknowledge Clyde’s emotion?
Visit Stages of Changes for additional information.
“A critical examination of the application of the Transtheoretical Model’s stages of change to dietary behaviours,” explains some of the reasons why this, or any model, is not as simple to use as it first seems.
Commentary on option 2
The people around us, and who matter to us, play an important role in our decision making. Dr. Nyrit understands this and tries to enlist Amy’s help, which she is eager to give. However, the physician again reveals her ignorance of the social and environmental situation in which her patient lives. Her response to information about the barriers to change is: “Well, we’ll have to work on that.” She is approaching the situation from a biomedical point of view. Clyde and Amy see it as “being Indigenous,” and “people go away and don’t come back.” Amy recognizes that she does not have the skills to cook proper meals, but Dr. Nyrit is unable to acknowledge that and help her with realistic suggestions. Amy also brings up the importance of the community. People will talk if you do something unusual, like take a walk. We might say: “So what?” But in a culture in which the community, not the individual, is the unit of importance, this is a significant barrier.
Thus, although enlisting social support is crucial for Clyde, Dr. Nyrit is unlikely to succeed in helping Clyde and Amy manage his diabetes in this option.
Commentary on option 3
We observed in “Reflective exercise 1” that communicating with Indigenous patients takes time, patience and an understanding of their cultural values. Note in this option the difference in information exchange. Dr. Nyrit speaks more slowly and asks Clyde questions about his language, family and community. She expresses an interest in learning some Mohawk words, and Clyde responds in his native language (but actually using a derogatory term). Note that he is not unwilling to talk, and as the interview proceeds, he interacts more with Dr. Nyrit. This is the beginning of a therapeutic alliance.
Which way does the information flow this time: from physician to patient or from patient to physician? The interview does take more time, but at the end, Clyde seems willing to at least consider thinking about managing his diabetes, and Dr. Nyrit promises a definite follow-up. Will Clyde return? Is it more likely than in options 1 and 2? Also, if a therapeutic alliance has been formed, then the strategies employed in options 1 and 2 might be more successful.
Which of the behaviour modification models do you think is being applied in this option?
Which, if any, of the eight personal factors needed in behaviour change have been discussed? (See Elder.)
Commentary on option 4
In this option, Dr. Nyrit seems to understand, and attempts to influence, the socio-economic and environmental barriers to health promotion and disease prevention. But does she really understand the situation on the reserve? Is changing the type of food in the northern store the issue? What about building a hockey rink? These are good ideas, but are they realistic?
With the best of intentions, she again uses the expert, clinical voice: “People aren’t making healthy choices.” The band chief responds with a seemingly unrelated statement about logging and building a store. What is his point, and which of them knows more about the fundamental causes of poor health in this community?
To the chief, who has been asked to come to the physician’s office and who has been given a lecture about the problems on his reserve, this option may look like medical arrogance.
Finally, how should Dr. Nyrit respond to his question about Clyde, given the importance of community in this culture?
Read this article for more information about the health policy issues in lifestyle changes and diabetes. While written from an American point of view, it does bring up some of the issues in the broader health system that may impact local and individual behaviour.
The case continues
Clyde is put on oral hypoglycemic medication and is encouraged by the physicians and the community health worker to follow a diet and exercise program. He asks about a job at the school and is told there is no money to hire anyone. While Amy has a part-time job, Clyde is at home with the younger children. He muses on his situation.
This window into Clyde’s perspective on his diabetes brings up a number of points.
Knowledge of diabetes
Clyde clearly knows about the importance of maintaining a normal blood glucose level. He understands the role of medication and the necessity of taking it regularly, even if he feels no different.
Clyde recognizes the importance of diet and exercise in controlling his diabetes, but he is also aware of the barriers to any changes he might try to make in his life. He has no control over the lack of jobs and the cost of food. Such lack of control over one’s life may lead to a sense of hopelessness and even depression, which is thought to be more common in diabetics than the general population.
Eating together is an important part of First Nations culture. Clyde is isolated from his siblings and relatives at home, as the only one needing a special diet. He cannot talk to his friends, as they tease him for being different. Clyde’s question is important: “If we all have it, why can’t we talk about it?”
In the past, the Canadian government made concerted efforts to prevent Indigenous people from using traditional medicine and healing ceremonies. The sweat lodge was outlawed, along with other cultural ceremonies like the Sun Dance, the Potlatch and the Shaking Tent. It was felt that the medical value was negligible, and that the holistic and spiritual aspects of these ceremonies should be suppressed in favour of Christianity.
Many Indigenous people lost knowledge of their cultural heritage. However, while it was driven underground, elders and other leaders kept the knowledge alive. Now that there is recognition of Indigenous self-determination, these same elders are helping their people reclaim these practices. Many Indigenous patients, like Clyde, access both western and traditional medicine with no sense of dissonance, although it can cause some problems.
- Now that you have heard Clyde’s thoughts, go back and look at “Reflective exercise 2.”
- Would you change your choice of action?
- Can you think of another course of action that you might take if you were in Dr. Nyrit’s place?