Although diabetes prevention and control efforts have increased in American Indian and Alaskan Native (AIAN) communities, AIAN people continue to experience disproportionality higher rates of diabetes-related morbidity and mortality (1). Diabetes is the fourth leading cause of death for the Navajo Nation (2), and is the seventh leading cause of death for the United States in general (US). The age-adjusted diabetes mortality rate for the Diné (Navajo) population is more than double (2.29 times higher) the US population rate (3). Poor glucose management may lead to diabetes complications and premature death, including vision loss, kidney failure, heart disease, limb amputation, and death (3–5). Promising approaches to diabetes management include nationally recognized guidance for self-care, medication management, diabetes education, regular check-ups, and ongoing support (6). The purpose of this study was to culturally adapt a standard diabetes education program originally designed to broadly address DM education needs for AIAN populations collectively. This cultural adapted program is designed specifically for Diné community members diagnosed with type 2 diabetes.

Cultural adaptation has been defined broadly as a modification of an evidence-based intervention by changing the curriculum's language and context in such a way that it is compatible with the client's cultural patterns, meanings, and values (7). To some, cultural adaptation is achieved by making surface-level adaptation such as changing the visual content or by adding AIAN created artwork (8). Deep-level cultural adaptation, on the other hand, has deeper levels of meaningfulness and includes adapting the language, metaphors, content, concepts, goals, methods, and framework to meet the needs of Indigenous communities (8). To optimize the impact of diabetes education for AIAN populations, deep-level cultural adaptations must be considered (9).

In 1997, in an effort to provide culturally competent health programs, Congress established the Special Diabetes Program for Indians (SDPI) to treat and prevent diabetes in AIAN communities (10). Currently 404 Indian Health Service (IHS), tribal and urban Indian health programs across the US receive SDPI funding (10). SDPI grantees recognize that culture and health are intertwined and inseparable concepts. They propose culturally adapted interventions are more acceptable, better understood, and more effective (11). For example, SDPI interventions that include AIAN language, traditional food demonstrations, and cultural activities (11) have demonstrated reduction in diabetes complications such as amputations and kidney failure (10, 12).

Despite well-intentioned efforts to culturally adapt and tailor health education curricula, diabetes programs have inadvertently created a “one size fits all” adaptation approach to health education programs (13) that is commonly used to prevent and manage diabetes among AIAN communities (14). Emergent research, however, suggests that AIAN community members prefer tailored and culturally adapted diabetes education programs that reflect their own cultures. The Native American Diabetes Project (NADP) conducted a participant satisfaction questionnaire regarding cultural competency with eight tribal communities (15). Results revealed that community input in co-developing the diabetes education sessions was an important factor in participant satisfaction and retention in the diabetes education series (15). Griffin et al. (15) highlighted that storytelling, a traditional communication strategy, was recommended by participants as a way to communicate information and provide diabetes education (15). Moreover, participants suggested that more culturally specific components, such as traditional foods, teachings and games could enhance participant satisfaction with educational sessions (15). Roubideaux found that 95% of participants preferred diabetes education materials relevant to their specific tribe or culture (16).

Several studies have shown a high prevalence (16.5%) of diabetes among the Diné (17) and 22.9% for adults (18) and an incidence rate of 2.78 per 1,000 for youth (19). Studies implicate the need for effective culturally relevant education for the Diné (20, 21) however, none of the prior diabetes prevention projects included tailored, deep-level, tribe-specific health information or cultural enhancement of diabetes education that were designed specifically for Diné communities. Efforts to apply surface-level cultural adaptations to the standard AIAN diabetes education curriculum may further perpetuate high program drop-out and may have limited effectiveness in promoting optimal diabetes self-management or glucose control in Diné communities. The purpose of this research was to use a community-based participatory research (CBPR) approach to engage Diné cultural experts and healers, to gain insights about cultural world views and Indigenous knowledge for the purpose of adapting an evidence-based diabetes management intervention for Diné adults diagnosed with Type 2 diabetes.

Four Diné male healers and one female cultural expert were interviewed for a total of five cultural expert and/or healer participants. Four participants were Diné healers knowledgeable about cultural teachings. One participant did not identify as a healer but was affiliated with the healer association as a cultural expert. Key themes from the data included the importance of the concepts and behaviors of discipline, positivity, and mindfulness—each attribute of Hózhó as outlined in the HRM, which were identified to be important aspects of wellness behaviors. When asked about health, participants discussed traditional Diné teachings and cultural activities that promote holistic health.

Participants also spoke about the importance and fundamental teachings of living in Hózhó, the ultimate state of health and wellness for the Diné. One healer explained, “As Diné we have a purpose for everything we do, so…we should think about what we put in our bodies and how we treat our bodies. How we think about things is important when we talk about Hózhó.”

Another healer said,

Three reoccurring culturally informed health promotion and self-management themes arose from the transcripts and were used to guide the development of DH:

Theme 1: T'óó bikiinígo (translation—eating just enough). Some messages were central to healthy eating, e.g., being mindful of portion sizes is important to prevent overindulgence and wastefulness. Overindulgence is not the traditional way of eating for the Diné. One healer said,

Wasting traditional food is disrespectful to the Diné people, it shows poor values. A healer explained,

Further, participants discussed key practices around food preparation were discussed (e.g., praying and having good thoughts while cooking). “Eating food that has been made by the fire in a hogan is the best medicine, because homemade chiyaan (food) is made with prayer and good thoughts…so when you eat it, you should feel better,” said a Diné healer.

Theme 2: T'aa hwo ajiteego. (Translation—It is up to you to accomplish things in your life, no one is going to do it for you). For the Diné people, self-discipline is needed in every aspect of life from dawn to dusk (28). One strict disciplinary teaching is to offer a morning prayer and run in the east direction. The Diné believe that when a person adheres to this teaching, the individual will be blessed with a good life, including good health and wellness. A Diné healer said,

All participants emphasized that this teaching is essential to living in Hózhó; self-discipline is needed to establish good physical, mental, and spiritual health.

Theme 3: Role of mindfulness is fundamental to health and wellbeing in the Diné culture. The Diné are told to have strong respect of the self through discipline and mindfulness (28). For the Diné, mindfulness means that all actions must have a purpose. They believe that the Holy People are watching over them, therefore they must carry themselves in a mindful, positive and respectful manner. Negative thoughts and behaviors are strongly discouraged. Doing so brings disharmony and imbalance. A healer explained,

Healers also explained the Diné belief in the holistic connection of the mind, body, spirit to Mother Earth and all living things i.e., plants, animals, the elements.

A key strategy to increasing diabetes education attendance and retention rates for AIANs is to implement culturally grounded, tribe-specific curriculums into community-based health programs (10). The main findings of this study include (1) CBPR approaches are feasible to inform development and adaptation of health programs in AIAN communities and (2) Indigenous health research practices and qualitative methods can be applied to strengthen existing curriculum, as in this case, in the form of the DH supplemental curriculum.

Researchers used CBPR to ensure that the results of the study can be used for action and sustained by the community (22, 25). In this study, several steps were essential to ensure that the Diabetes Program could implement and sustain the DH. First, the lead author established a relationship with the program before writing the study proposal. Establishing a reciprocal relationship with the community early in research is important in CBPR, especially in tribal communities. The diabetes program staff took initiative in all phases of the study by writing letters of support, attending leadership meetings, helping obtain IRB approvals from the university and tribe and co-developing the curriculum. Second, the lead author applied Indigenous health research practices and Diné values of k'é (i.e., personal conduct and kinship) to establish respect and build positive relationships with Diné leaders and community members (23, 24). Second, in addition to the program's contribution in the curriculum development, other key stakeholders, such as cultural experts and healers were actively involved. The integration of the Diné healers' and cultural expert's Indigenous knowledge certified and validated the cultural rigor that was used to inform the adapted DH content. This process used in the development of the DH supplement curriculum exemplifies consideration and respect for the integration and inclusion of Indigenous knowledge for the purpose of gathering information in a culturally appropriate and meaningful way (31).

Utilizing a qualitative approach to develop and inform a cultural curriculum is important for identifying health-protective and strength-based wisdom in AIAN communities. A qualitative voice enriches the curriculum and adds depth, richness, and meaning to the educational content. The Native American Diabetes Project (NADP) also used a qualitative approach to design culturally relevant education materials. In the NAPD, the community was an integral part of the project; they participated in the interviews, focus groups and community advisory board (32). A unique feature of our study was the rich cultural context and experience tribal scholars brought to the table. The Diné cultural experts' and lead author's cultural knowledge were imperative to understanding the depth and strength of the health messages. The qualitative approaches used in this study can guide the development and implementation of culturally-based, tribe-specific health education model tailored for AIAN populations, which can then be implemented for the Diné individuals diagnosed and living with diabetes. Outcomes of culturally informed and adapted health promotion programs should be studied further for outcomes and effectiveness within each tribal community that receives an adapted curriculum.

The study has a few limitations. First, there were only a handful of key informant interviews conducted due to time constraints and competing commitments such as work, expectations of both professional careers, and/or commitments to patient appointments for healing ceremonies. Despite the recruitment of five participants (n = 5), however, data saturation was achieved. Second, only one female participated in the key informant interviews. The Diné people are a matrilineal culture, therefore more insight from female healers could add to the curriculum, especially in regard to traditional food ways and healthy eating. Third, the community partners were not initially involved in the analysis of data, due to the training required to analyze qualitative data. In the hopes of mediating this limitation, the CAB and DH (many with expert cultural knowledge) working groups played vital roles in identifying culturally appropriate health messages for the curriculum.

A significant strength in this project was how the collective wealth and richness of authentic cultural knowledge shared by healers, CAB members and the diabetes program team members contributed to the study. Their willingness to share, learn and collaborate with the lead author on this study required additional work and time, but their dedication to properly honoring Indigenous health research was integral to developing a culturally grounded curriculum. This study could be used to guide the development and implementation of other culturally-based and tribe-specific health interventions for AIAN populations. Most important, the robustly tailored program will need to be tested to determine the impact on program enrollment, engagement, recidivism, and clinically relevant health outcomes such as diabetes self-management and glucose control. Lastly, the DH is not meant to serve as an independent diabetes curriculum, it is a supplemental curriculum that should be used in conjunction with a standard diabetes education curriculum specifically for the Diné people. The CAB members felt strongly about keeping and integrating the DH supplement in the existing DM program because it added authenticity and meaningfulness that countered the existing predominantly western based or mainstream diabetes education program.

Culturally safe and meaningful engagement with cultural leaders, along with the use of qualitative research methods can inform deep-level cultural adaptations essential to developing robust diabetes education programs at the individual tribe level. Such work can illuminate cultural relevance and may be important in identifying culturally related factors that influence engagement and completion as well as health outcomes for participants in AIAN diabetes education programs. We recommend qualitative CBPR approaches and Indigenous research practices used here to guide the development and implementation of culturally tailored tribe-specific educational model that has been informed by the Diné cultural teachings.

The datasets presented in this article are not readily available because the data belongs to the Navajo Nation, according to the Navajo Research Act and longstanding IRB policy.

The studies involving human participants were reviewed and approved by Navajo Nation Human Research Review Board. The patients/participants provided their written informed consent to participate in this study.

JW wrote the manuscript and made revisions to manuscript as part of her dissertation. CT, MK-J and SS provided comments on drafts and helped with final edits. All authors contributed to the article and approved the submitted version.

Author AE was employed by Tuba City Regional Health Care Corporation. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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