The Special Diabetes Program for Indians (SDPI) has led to decreased incidence of diabetes in tribal communities; however, there is room for program improvements. Additional program components should be considered to boost the effectiveness of tribally-driven SDPI programs; thus, further improving diabetes-related outcomes for American Indians and Alaska Natives (AIANs).

Generally, policies and practices are needed to decrease stress burden for AIANs at risk for diabetes and for those managing diabetes. This involves two broad strategies:

1. Reduce stressor exposures for AIANs

AIs with diabetes experience a broad range of stressors (Elm, Walls, & Aronson, 2019; Walls et al., 2017) and research shows that high level of stress is related to worse health amongst AIs with diabetes (i.e. dose-response relationship; Walls et al., 2017). Many stressors act as immediate barriers to adequate care for those managing diabetes. Examples include transportation challenges and discriminatory health care experiences (Elm, Walls, & Aronson, 2019). Other stressors, such as microaggressions are associated with distress among AIs with diabetes (Sittner et al., 2018). Other more “upstream” stressor exposures such as adverse childhood experiences are associated with risk for diabetes (Hughes, et al., 2017) and depressive symptoms, PTSD, and other mental health challenges – all of which contribute to risk for diabetes or poor diabetes management (Elm, et al., 2019; Aronson et al., 2018).

2. Buffer the effects of stressors on health for AIANs

Research has identified that for AIs with diabetes, social support and cultural involvement buffer the effects of adversity on health outcomes. Specific recommendations based on recent scientific literature are below and reflect the need to address “fundamental causes” (Link & Phelan, 1995) of diabetes risk and diabetes-related complications. Each new program component should involve rigorous evaluation from an independent academic evaluator when implemented.

Specific Recommendations

• Implement programming aimed at decreasing stress burden for AIANs, particularly those with diabetes, pre- diabetes, and obesity. Tribal health clinics should be provided with information about why this is important and receive incentives to implement new programming (e.g. in person community support groups, promotion of family support, internet support groups, etc.).
• Increase support to tribal clinics to systematically provide trauma-informed mental health screenings, referral, assessment, and treatment. All patients with obesity, pre-diabetes, diabetes should be screened for mood and anxiety disorders. Those who screen positive, should be referred to mental health clinicians who assess for a broad range of stressors in order to best estimate stress burden. Clinicians should be trained in treating complex trauma. Because there is a major shortage in mental health service providers in Indian Country, workforce development needs to be addressed (e.g. tele-mental health services may be helpful in addressing these needs; Elm, J., under review).
• Promote mental health for AIANs managing diabetes (Brockie, Elm, & Walls, 2018). Social support and opportunities for cultural involvement are relevant to the mental health of AIANs with diabetes.
• Development of AIANs programs should involve collaboration between practitioners, researchers and the AIAN community. Collaborations between these different perspectives can support the implementation of programs that are both culturally responsive and effective. See this case study discussing collaboration in an AIANs community.