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Using Qualitative Research to Understand the
Sociocultural Origins of Diabetes among Cape Breton Mi'kmaq
Kim D Travers
Abstract
The highest prevalence rates of non-insulin-dependent diabetes mellitus
(NIDDM) documented for Canadian aboriginal populations occur among Indians
in the Atlantic region. Predictors of variation in prevalence among aboriginal
populations suggest the acculturation hypothesis: longer Euro-Canadian
influence on lifestyle is associated with increased prevalence of NIDDM.
The Mi'kmaq First Nation would have been among the first in Canada to
come into contact with Europeans. The lengthy history of contact has accompanied
changes in lifestyles consistent with risk factors for NIDDM. A better
understanding of the sociocultural origins of diabetes among aboriginal
populations can inform the development of policies and practices that
are culturally relevant to the prevention and management of NIDDM in native
communities. This paper describes the design, data collection strategies
and preliminary findings of an ongoing qualitative research project aimed
at developing such an understanding.
Key words:
Aboriginal health; diabetes mellitus, non-insulin-dependent; Nova Scotia;
qualitative research; social environment
Introduction
Epidemiologic evidence suggests that the prevalence of non-insulin-dependent
diabetes mellitus (NIDDM) is significantly higher among the aboriginal population
than that of the general Canadian population. For example, within Nova Scotia,
the crude prevalence of NIDDM among aboriginal persons was found to be 5.2%,
while the prevalence in those over age 40 was 25%.1 Although the prevalence
of diabetes in the non-native Atlantic Canadian population is unknown, the
prevalence of diabetes in the general population of Prince Edward Island
is 1.53%.2
A survey of the Canadian aboriginal population revealed the highest
crude prevalence (4.3%) and prevalence adjusted for age and sex (8.7%)
among Indians in the Atlantic region.3 However, genetics alone cannot
account for the variance in prevalence rates among aboriginal populations.
In fact, this survey found that the strongest predictor of variation in
diabetes prevalence among aboriginal populations was latitude, with prevalence
increasing along a north-south gradient. The authors postulated that higher
prevalence of NIDDM within native communities in more southern areas of
Canada may be associated with increased acculturation accompanying greater
Euro-Canadian influence on lifestyle.
The Mi'kmaq First Nation would have been among the first in Canada to
come into contact with Europeans. The lengthy history of contact has been
associated with increasing prevalence of NIDDM and has accompanied changes
in native lifestyles, particularly diet and exercise patterns. Reserve
settlement necessitated abandonment of traditional nomadic lifestyles,
making traditional hunting, fishing and gathering more difficult and less
productive.4 A decrease in physical activity and an increase in availability
of less nutritious alternatives to traditional foods are associated with
an increased prevalence of obesity. Since environmental determinants of
NIDDM include several lifestyle-related factors such as obesity, eating
and physical activity patterns,5 the impact of acculturation on NIDDM
prevalence becomes apparent.
A better understanding of the sociocultural origins of diabetes among
aboriginal populations such as the Mi'kmaq can inform the development
of policies and practices that are culturally relevant to the prevention
and management of NIDDM in native communities. A research project aimed
at developing such an understanding is currently proceeding in Cape Breton,
Nova Scotia.
Methods
Research Design
Previous research into sociocultural aspects of Mi'kmaq lifestyle related
to diabetes has been assessed using questionnaires. Typically, such questionnaires
are "expert"-designed and evaluated according to white, middle-class standards.
As such, this type of research may provide results inconsistent with aboriginal
people's experiences. For example, if a questionnaire revealed a majority
of negative responses to the question, "Do you worry about your diabetes?",
a non-native researcher or health professional may interpret this response
as apathy. This may be an inappropriate interpretation. In traditional Mi'kmaq
culture, "stress" or "worry" has no meaning. A negative response to this
question could mean "I pay attention to my diabetes, but it is a part of
my life, I take it day by day." This meaning is far different from the assumption
of apathy that a context-independent analysis of a questionnaire may reveal.
As such, research methods developed from a traditional perspective are inadequate
to develop the understanding that is the aim of this research.
Qualitative6 and participatory7 research strategies were chosen to study
the social problem of NIDDM in its natural context, to preserve the perspectives
of the Mi'kmaq people, to maintain the holistic nature of social problems
and to value the participation of the Mi'kmaq people. Although qualitative
and anthropologic research has been effectively used to explore Ojibwa
understanding of diabetes,8 no such research has been attempted with Mi'kmaqs.
Use of participatory research designs has not been documented.
Selection of Research Communities
A variety of research sites increases the richness of data available for
analysis and therefore can facilitate a more complete understanding. In
consultation with Medical Services Branch of Health Canada and the Union
of Nova Scotia Indians, two Mi'kmaq communities (Membertou and Wagmatcook)
were contacted through their respective band councils and participation
was negotiated. Although the two communities are in the same region of
Nova Scotia, they differ in that Membertou is located within an urban
centre, while Wagmatcook is more geographically isolated relative to other
M'ikmaq communities in the province.
Selection of Participants
The co-operation of local community health representatives and community
health nurses was essential to identifying members of each community with
NIDDM as potential research participants. Theoretical sampling,9 which
intentionally selects people with differing backgrounds (different sexes,
ages, education levels, employment status, duration of disease, experiences
with the health care system, etc.), was used so that a broad range of
experiences could be examined, thus maximizing the opportunity for discovering
categories of similarities and differences. Guided by the ongoing process
of categorizing during data analysis, sampling will continue until theoretical
saturation. Theoretical saturation is achieved when no new themes or issues
arise regarding a category of data, and when the categories are well established
and validated.9
Data Collection
Individual ethnographic interviews
Individuals are asked to participate in a series of 3-5 semi-structured
ethnographic interviews. All interviews are conducted within the participant's
home or workplace by the same trained Mi'kmaq researcher and are tape-recorded
for later transcription and analysis.
With the semi-structured interview format, a list of topics is predetermined,
but the interviewer has the flexibility to change ordering and wording
of questions to suit the respondent and situation.10 Interviews progress
from description of everyday lifestyle practices to exploration of values,
beliefs, perceived barriers and resources that shape actions.
Observation
The purposes of observation11 are primarily to add naturalistic depth
to the interview data and to provide an internal validity check from a
second source of ethnographic data for corroboration. Various degrees
of participation are associated with observations. For example, observations
of the participants' household facilities and of the reserve and surrounding
areas involve little or no participation, whereas the M'ikmaq researcher
has accompanied some respondents to diabetes education clinics and participated
as their guest. Observations are recorded in detailed field notes.
Community meetings/interviews
In a second, "community phase" of the research, interested members of
the community (not necessarily with diabetes) are recruited through communication
channels traditional within each community. Participants in community
meetings share their experiences related to health and lifestyle, and
reflect upon critical issues raised during individual interviews and observation.
This phase of study has several purposes: to enrich the individual data
with a broader range of perspectives and experiences, to promote an emphasis
on primary prevention of diabetes by incorporating prediagnosis experiences
into the research process, to enlist the participation of the Mi'kmaq
communities in the process of data analysis in order to ensure that findings
are culturally relevant and to provide a forum for transmitting findings
back to the Mi'kmaq communities for potential action.
Data Analysis
Data analysis proceeds concurrently with data collection. Naturally occurring
commonalities and differences in experiences and perceptions are categorized
thematically.12 Initial analysis is inductive, that is, it moves from
the particular (the experiences of the research participants) to the general
(those unifying themes and issues that appear to account for the observed
commonalities and differences). Then, using logical analysis, the data
are compared to the themes for a logical "fit." This process is similar
to the constant comparative method.13
Members of the Mi'kmaq communities assist and guide the analysis through
the community meetings. Such collaboration is essential to "check" for
the potential of imposing culturally inappropriate analyses on the participants'
experiences and to ensure that the analyses are accessible and relevant
to the participating communities.
Progress to Date
To date, we have completed series of individual interviews with
10 Mi'kmaq people in Membertou, the urban community, and have facilitated
four community meetings at monthly intervals. Observations and interviews
are currently under way in Wagmatcook. The following summarizes some of
the preliminary themes arising from the data.
Policy
During interviews and community meetings in Membertou, the elders spoke
of the changes in their eating habits over their lifetimes. Their description
of how the forced relocation of Membertou in the 1920s influenced eating
and lifestyle provided an example of the influence of policy, specifically
land claims, on risk factors for NIDDM. Membertou's original location
on the banks of the Sydney River was fertile for agriculture and made
for easy access to water for fishing as a source of traditional food.
The reserve was forcibly relocated away from the river to a swampy area
accessible by only one road. For the first time, the reserve offered absolutely
no opportunity for fishing, hunting or agriculture. People were made totally
dependent upon the market for food with the move; they remain so dependent.
The Market Economy
The expressed lack of access to traditional sources of food and the resulting
necessary reliance on store-bought foods is indicative of how money has
become a necessary precondition for nourishment and health. Many participants
expressed concern about the cost of purchasing nutritious foods on their
fixed incomes. With respect to food shopping, Membertou Band members have
an advantage as the urban location means ready access to supermarkets
with variety and lower prices. However, in the more isolated community,
although there is a larger community with two grocery stores within 15
kilometres, such a trip requires access to reliable transportation. Although
most study participants can make arrangements for travel to grocery stores,
they may be occasionally reliant upon reserve stores for food, making
it impossible to consume a healthy diet. The reserve stores stock primarily
high turnover foods such as soda pop, candy bars and high-fat snack foods.
Fruits and vegetables are notably absent, or if they are available, only
in a limited number of canned varieties. Fresh meats are also not available.
Protein choices are limited to peanut butter and processed meats such
as wieners and bologna.
Health Care
Regardless of whether or not they were following a diabetes care plan,
most participants were aware of what they should be doing to control their
diabetes. Generally, those with more formal education in white society
were better able to integrate the concepts presented in standard hospital-based
diabetes education programs. However, some people were finding it more
difficult to change their lifestyle than others, the reasons for which
were partially related to the nature of their experiences with the health
care system. For example, some participants found the diabetes education
offered in hospital-based clinics to be culturally irrelevant.
Implications
By helping health professionals to understand the experiences of the Mi'kmaq
people, qualitative research can assist in making professional practice
more sensitive to their needs. By supporting Mi'kmaq people in analyzing
their situations, qualitative research can enable them to take social action
through community development to address the problem of NIDDM in their communities.
For example, community meeting participants in Membertou are exploring the
following as potential short-term solutions.
- Store owners in Membertou are investigating the feasibility of stocking
healthier foods at reasonable prices.
- Elder women are considering hosting community kitchens where younger
band members can learn to prepare traditional foods, socialize and share
the cost and time associated with meal preparation.
In the long term, qualitative research can inform community-initiated policy
change by helping communities and policy makers understand how policies
are felt by the Mi'kmaq people.
Acknowledgements
This research was supported by grant #6603-1433-ND from the
National Health Research and Development Program (NHRDP) of Health Canada.
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Author Reference
Kim D Travers, Department of Human Ecology, Mount Saint Vincent University,
Halifax, Nova Scotia B3M 2J6 This paper presents further methodological
information from an oral presentation made at the 3rd International Conference
on Diabetes and Indigenous Peoples: "Theory, Reality and Hope," held in
Winnipeg, Manitoba, May 26-30, 1995.
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