“Make Stories That Will Always Be There”: Eagle Books’ Appeal, Sustainability, and Contributions to Public Health, 2006–2022

Dawn Satterfield, PhD, MSN, RN¹; Lemyra DeBruyn, PhD¹; Teresa Lofton, PhD, MPH²; Carolee Dodge Francis, EdD³; Virginie Zoumenou, PhD, CNS⁴; Lorelei DeCora, RN, BSN⁵; Chelsea Wesner, MSW, MPH⁶ (View author affiliations)

Suggested citation for this article: Satterfield D, DeBruyn L, Lofton T, Francis CD, Zoumenou V, DeCora L, et al. “Make Stories That Will Always Be There”: Eagle Books’ Appeal, Sustainability, and Contributions to Public Health, 2006–2022. Prev Chronic Dis 2023;20:220315. DOI: http://dx.doi.org/10.5888/pcd20.220315.

PEER REVIEWED

Abstract

Purpose and Objectives

We aimed to determine why the Eagle Books, an illustrated series for American Indian and Alaska Native (AIAN) children to address type 2 diabetes, remain viable long after their release. We sought to answer 2 questions: Why did the books maintain popularity? What factors have sustained them?

Intervention Approach

Type 2 diabetes burgeoned in the US after World War II, compounding a long legacy of injustices for AIAN peoples. By the 1980s, their rates soared above those of White people. Concerned for future generations, Tribal Leaders suggested that the Centers for Disease Control and Prevention and Indian Health Service use traditional storytelling to teach children about staying healthy. Public health interventions are most effective when culture and history are integrated into health education, particularly stories to address a relatively new disease for AIAN peoples.

Evaluation Methods

From 2008 through 2013, we conducted a case study among 8 tribal communities to evaluate the uptake of the Eagle Books across Indian Country. To understand the Eagle Books’ sustained appeal, in 2022 we reanalyzed the original case study themes and analyzed for the first time themes that emerged from evaluation results in the Eagle Books’ program literature. These were programs that had independently evaluated their use of the Eagle Books and published their findings.

Results

Outcomes demonstrated continuous application of the Eagle Books in diverse community interventions, influencing children’s healthy choices. Community implementers described sustainability components, such as the books’ versatility, flexibility of use, and availability online and in print.

Implications for Public Health

Historical, social, economic, and environmental health determinants intersect with biological and behavioral factors to weave a complex web of causation for type 2 diabetes, beginning early in life. Compelling, colorful stories reflecting traditional wisdom and respect for Western and Indigenous science — through the eyes of a wise eagle, a clever rabbit, a tricky coyote, and kids in T-shirts and sneakers — can positively influence community health.

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Introduction

Children and adolescents in the US today face a greater risk than previous generations for type 2 diabetes and shortened lifespans, an unprecedented reversal in health (1). Case reports of American Indian and Alaska Native (AIAN) adolescents in the US and Canada with type 2 diabetes surfaced in the 1970s and 1980s, startling medical practitioners who had long considered it an adult disease. By the mid-90s, the epidemic of type 2 diabetes, characterized by insulin resistance and propelled by obesity, had affected children and adolescents in all US populations (2). From 1996 to 2004, type 2 diabetes prevalence among AIAN adolescents aged 15 to 19 years increased by 68% (3). In 2019, AIAN and African American children and adolescents aged 19 or younger had the highest type 2 diabetes rates compared with peers in other US populations (4), placing them at risk for complications such as chronic kidney disease while they are still young (5).

Collective factors, termed social determinants of health (SDOH), can predict physical and mental health outcomes. Socioeconomic status, including economic, educational, and occupational status, is strongly associated with diabetes risks and outcomes (6). For example, obesity prevalence was 18.9% among children and adolescents in the US aged 2 to 19 years in the lowest income group, 19.9% in the middle-income group, and 10.9% among those in the highest income group (7). Connectedness with “place,” which for many AIAN and other peoples encompasses loss of homeland and community (8) also impacts health.

Trauma and chaotic conditions in childhood trigger physiologic stress, leading to neurologic regulatory responses that alter the brain’s pathways (9). Adverse childhood experiences (eg, witnessing violence, personally experiencing abuse or neglect) (10) correlate with obesity and type 2 diabetes across populations (11), including AIAN populations (12). Poverty contributes to conditions that can perpetuate adverse childhood experiences (eg, crowded housing, stress, and food insecurity). In 2020, two racial groups had poverty rates more than 10 percentage points higher than the national rate of 14.3%: AIAN (27.0%) and Black or African American (25.8%) (13). From 2000 to 2010, 25% of AIAN families were consistently food insecure, twice that of White families (14).

Stressors associated with colonization (eg, trauma, loss of lands, relocation to reservations, food insecurity, poverty), compounded across centuries, are linked to trends in obesity and type 2 diabetes in recent decades. As defined in 1998 by Brave Heart and DeBruyn, historical trauma is the collective, complex trauma inflicted on a group of people with a specific group identity or affiliation (eg, ethnicity, nationality, religious affiliation) (15). For generations of AIAN children, harsh conditions in boarding schools also contributed (16). “They taught us to be stingy,” said an elder removed from her home as a young child to attend boarding school. Competition for food to avoid hunger countered her cultural values of generosity and sharing (17).

Indigenous peoples’ survival and well-being has been supported by connectedness, the interrelated welfare of everyone and everything (18). Protective factors such as safe, stable, and nurturing relationships (10) can serve as buffers that mediate stressful and traumatic life events (19,20). Strengths-based health promotion efforts, including type 2 diabetes prevention programming, leverage protective factors to foster connectedness across environments and support the health and relational well-being of AIAN children and adolescents (20,21). Indigenous scholars note that historical and protective factors influence all levels of socioecological models, increasing a sense of belonging, self-esteem, self-efficacy, and health knowledge (1,18,21–24). For example, an Indigenous connectedness framework created by Ullrich (Figure 1) centers on child well-being in the context of intergenerational, environmental, family, and community connectedness, encompassed by spiritual and cultural connectedness (18). Stories, dance, music, and ceremony are common expressions of connectedness across Indigenous cultures.

Figure 1.
Indigenous connectedness framework for child well-being created by Ullrich (18). Reprinted with permission from the author. [A text version of this figure is available.]

Concerned for their people and future generations, tribal leaders and allies testified about the disproportionate prevalence of diabetes before Congress, which passed the Balanced Budget Act of 1997 (25). Under this legislation, lawmakers established the Special Diabetes Program for Indians in 1998, administered by the Indian Health Service (IHS). The Tribal Leaders Diabetes Committee (TLDC) guided tribally driven, culturally grounded programs designed to advance diabetes care and prevention (26). The Special Diabetes Program for Indians, with more than 300 programs nationwide, continues to demonstrate substantial improvements in health outcomes for AIAN people (27,28). The incidence of type 2 diabetes among AIAN adults decreased 5.2% from 15.4% in 2013 to 14.6% in 2017 (29). Overweight and obesity rates among AIAN children and adolescents aged 2 to 18 years, although high compared with their peers in other racial and ethnic groups, appear to have stabilized in recent years (30).

The IHS provided funds to the Centers for Disease Control and Prevention (CDC) through an interagency agreement, leading to the formation of CDC’s Division of Diabetes Translation Native Diabetes Wellness Program (NDWP) in 2004. The NDWP established principles of practice to inform the program’s work in Indian Country (Box).

The Diabetes Prevention Program (DPP), a landmark clinical trial to determine if treatment with lifestyle changes or medication can help prevent type 2 diabetes, was published in 2002 (31). AIAN adults living in the Southwest joined other volunteers with prediabetes for the study, supported by the National Institutes of Health, CDC, and IHS, confirming that type 2 diabetes can often be prevented with intensive lifestyle interventions (31). The Special Diabetes Program for Indians successfully replicated the DPP in tribal-based reservation and urban communities (32).

In 2000 and 2001, IHS, CDC, and TLDC held 8 listening sessions. More than 421 representatives from 171 tribes offered guidance on community-based approaches for diabetes prevention and care. A recurring theme was respect for traditional knowledge about protecting people’s health and appreciating the diversity of tribes. “Look to the culture. Our cultures are the source of health,” one representative said. Related to this was a deep concern for the health of children, who are considered sacred (33) in many AIAN cultures. “We need stories . . . it’s just the last decades where [diabetes] has run rampant. The stories aren’t there,” one representative explained. Another added, “Make it [a story] something that is there all the time” (CDC, unpublished report, Formative Research to Obtain Tribal Input on the National Diabetes Prevention Center. Westat, Inc, for CDC Division of Diabetes Translation, through CDC Health Communication Evaluation Services; 2000). Several representatives suggested a story about an eagle, told by Georgia Perez, a community health representative for Nambe Pueblo, incorporated into the Strong in Body and Spirit program. Told at the beginning of each session, the story facilitated open discussions. “It was as though walls of guilt, fear, anger, and denial came down, and people had new hope” (34). From 2002 through 2006, Through the Eyes of the Eagle, Knees Lifted High, Plate Full of Color, and Tricky Treats were written by Georgia Perez and illustrated by Patrick Rolo and Lisa A. Fifield. CDC supported the development of the series through a contract with Westat, Inc. The books feature children in sneakers and T-shirts, a wise eagle, a clever rabbit, and a wily coyote. The books were launched in 2006 at the Indian Pueblo Cultural Center in Albuquerque, New Mexico, and news media outlets covered the event (eg, Indian Country Today, Green Bay Gazette, USA Today). The development and implementation of Eagle Books programs and applications has spanned 2006 through 2022 (Figure 2).

High-resolution JPG for print

Figure 2.
A timeline of the development and implementation of Eagle Books, 2006–2022. [A text version of this figure is available.] Abbreviation: USDA SNAP-Ed, US Department of Agriculture Supplemental Nutrition Assistance Program–Education.

Responding to TLDC guidance, NIH concurrently established cooperative agreements with 8 tribal colleges and universities, and interagency agreements with CDC and IHS to create the K–12 Diabetes Education in Tribal Schools (DETS) curriculum (35,36). The K–4 curriculum included the Eagle Books. NDWP (D.S., L.D.B.) provided scientific review throughout the curriculum development.

In 2010, NDWP created novels for adolescents based on the original series (Figure 2). The children now aged 12 years and the animal characters returned with an expanded cast, including an elderly box turtle and a multicultural trickster rabbit. Written by Terry Lofton and illustrated by Patrick Rolo, these novels broadened the dialogue about type 2 diabetes prevention. Although not included in our evaluation, these books are part of Eagle Books’ continuity.

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Purpose and Objectives

Our study aimed to determine why the Eagle Books, an illustrated series created for AIAN children to address type 2 diabetes, remain viable 16 years after their launch. We sought to answer 2 questions: Why have Eagle Books maintained popularity? What factors sustained them?

The objectives of the Eagle Books were to 1) address the need for diabetes education for AIAN children, 2) create compelling, relevant stories about staying healthy and preventing type 2 diabetes, 3) promote traditional ways of knowing about healthy foods and physical activity through storytelling, and 4) portray vivid images and memorable characters to inspire healthy choices.

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Intervention Approach

We used 2 evaluation approaches. First, we reviewed the qualitative case study of the adoption of the Eagle Books for children in 8 diverse AIAN communities. Second, we performed an implementation evaluation to determine why and how the Eagle Books have remained popular in Indian Country and elsewhere.

Initial case study in 8 American Indian and Alaska Native communities

From 2008 through 2013, NDWP contracted with Westat to conduct a qualitative case study among AIAN communities to determine their uptake of the Eagle Books since 2006 (Teresa Lofton, PhD, et al, unpublished report, 2013. Uptake of the Eagle Books in Selected American Indian and Alaska Native Communities: Internal Report. Supported by the Native Diabetes Wellness Program, Division of Diabetes Translation, CDC. Task order contract no. 200-2007-20015). We chose sites to learn common patterns of use and unique local applications. Selection criteria included variation by culture, geographic region, population size, and whether communities had been exposed to federally funded promotion of the Eagle Books (DETS curriculum, Eagle Book campaign fairs and exhibits, diabetes talking circles) or had independently ordered at least 1,000 books. We wanted to understand how federal promotion influenced uptake and to identify contextual factors that affected the books’ use with or without support. Ultimately, we selected 8 locations — 4 locations had federal support and 4 locations were independent.

Westat assembled a team (T.L., lead evaluator) to conduct evaluation activities on site (C.D.F., L.D.C., and D.S., L.D.B., observers). Community-based and tribally driven participatory research (37) framed our approach, as these tribal partners had determined the most culturally appropriate uptake of the books in their communities.

Implementation evaluation framework

An implementation evaluation provided the best approach for the present study. We wanted to determine if the intervention, uptake of the Eagle Books, had been implemented in diverse settings and programs to address type 2 diabetes and had influenced children’s healthy food choices. We wanted to learn whether use of the Eagle Books had accomplished the original goals for their use, and if additional findings related to those goals. We were particularly interested in what happened after the Eagle Books case study was completed and what led to the books’ continued viability. Implementation evaluation covered these areas of inquiry to help us understand how sustainability occurred over 16 years.

Funding support for communications about Eagle Books (eg, newsletters and conferences) concluded in 2016. Programs continued to use the books in schools, communities, and culture camps (38). A small number of those programs conducted formal evaluations with similar (qualitative) or other (quantitative or both quantitative and qualitative) methods. Implementation evaluation can use both quantitative and qualitative measures to answer descriptive (who, what, where, when) questions and qualitative measures to explain how and why. Implementation evaluation helped frame the examination of what factors led to continued use of the Eagle Books and if themes from the first assessment still held.

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Evaluation Methods

Methods for the present study are based on the findings of the case study, which we reviewed and reanalyzed to answer our 2 research questions (Table 1). The review was sufficient to address the first question about popularity. To answer the second question about sustainability, 4 raters (T.L., D.S., C.W., L.D.B.) independently reanalyzed these data to identify the most important themes.

We knew of 3 Eagle Books evaluation studies. These included 1 of the 8 communities in the case study (41,42) and 2 programs that conducted independent evaluations, the DETS curriculum and the Jump-start on a Healthy Lifestyle program in Maryland (35,43). We reviewed the literature that described the 3 programs, comparing approaches, methods, and findings with the major themes. We listed the quantitative results that demonstrated significance in relation to Eagle Books’ use and impact. We described qualitative findings and extracted illustrative verbal descriptions from participants in the case study and other programs that supported, enhanced, and broadened our understanding of identified themes.

We conducted literature searches with Google using the terms “CDC Eagle Books program evaluation” and “CDC Eagle Books.” Our criteria included programs that had participant sample sizes large enough to determine significance and employed quantitative measures or, if qualitative, had used methods with a variety of participants, similar to the case study. We found no additional Eagle Books evaluations in the literature that met these criteria.

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Results

We identified 11 major themes that addressed Eagle Books’ popularity and why they are still in demand 16 years after launch. These themes include versatility and flexibility, cultural relevance, a relatable explanation of type 2 diabetes, colorful artwork, characters with whom children identify, relevance to diverse populations, and children as change agents (Table 2). Theme 1, versatility, includes subthemes that address sustainability: easy “as is” use; integration of books into existing programs; adaptation of the books for different genres, age groups, and diverse AIAN and other cultural groups; adjustment of books for very young readers; development of new programs for classroom, home, and Head Start; and stable, embedded use of Eagle Books across tribal and nontribal organizations and programs.

To illustrate application of these themes, we describe 5 programs that exemplify and promote Eagle Books sustainability and operationalize their popularity.

Whirling Thunder Eagle Books Program, Winnebago Tribe of Nebraska

In 2009, the Whirling Thunder Wellness Program collaborated with an Eagle Books champion and NDWP consultant (L.D.C.) to promote health and early literacy through the books. Whirling Thunder introduced the series to Head Start. Each family received the books and an animated video as the children were welcomed to the program (themes 7,8 [Table 2]).

Whirling Thunder developed an Eagle Books program, 4 in-class sessions for grades 1 through 6 with new outdoor games based on the characters, classroom discussion that engaged shy students at risk for type 2 diabetes, and reinforcement of messages (eg, “sometimes” and “everyday” foods) (themes 1, 4, 5, 9 [Table 2]). In 2011, the Winnebago Tribal Council passed a resolution to continue Eagle Books in their curriculum for prekindergarten through third grade (Figure 2).

A TLDC member in 2004 and Winnebago Tribal Council member (L.D.C.) developed Eagle Books Talking Circles, an adaptation of the books for educating adults about children’s health needs. This activity became part of the many she developed and presented as part of NDWP’s 2008 partnership with the Seva Foundation to fund diabetes talking circles in AIAN communities. She conducted 148 talking circles and promotional events that included booths at health fairs and pow-wows, presentations at regional and national conferences, and book distribution to families, schools, libraries, and health departments. She understands children’s power: “One aspect of Native communities is all-powerful — that’s our children. No one can get Indian communities to change faster than their children” (theme 11 [Table 2]).

Over the years, local newspapers have reported on Eagle Books events. In spring 2022, The Winnebago Times newsletter praised a skit performed by third graders based on Plate Full of Color and the US Department of Agriculture’s (USDA’s) My Native Plate (44).

Through the Eyes of the Eagle: Illustrating Healthy Living for Children Exhibit, Arizona State Museum and Tohono O’odham Community Action

In 2008, Lisa Falk, associate director of education at the Arizona State Museum (ASM), visited the exhibit Through the Eyes of the Eagle: Illustrating Healthy Living, at the National Museum of the American Indian. Falk was impressed by the extraordinary artwork that addressed a serious health issue in her community (theme 4 [Table 2]). To bring the exhibit to Tucson, she built a partnership of 9 community organizations and university departments to support an expanded version of the tour (theme 1 [Table 2]). Her goal was to promote understanding of type 2 diabetes that spoke to art, history, culture, and community health (theme 10 [Table 2]). Tohono O’odham Community Action joined the partnership to represent the Tribe’s struggle with type 2 diabetes and efforts to revitalize their agricultural and athletic traditions.

Falk (ASM) and Terrol Dew Johnson (Tohono O’odham Community Action) co-curated the exhibit, which featured O’odham historical and contemporary items relating to sport and foodways spanning 13,000 years. Concurrently, ASM partnered with the Ha:San Preparatory School and faculty to develop a comic book adaptation of the Eagle Books for middle and high school students. Falk and Ryan Huna Smith (Chemehuevi/Navajo) co-wrote the comic, It’s Up 2 You!, set in the Southwest. The comic includes a wise tribal elder and a skateboarder who encourages her friends to eat healthy and be physically active. Students narrated a video of It’s Up to You! in English, O’odham, and Spanish (theme 1 [Table 2]).

Healthy Celebration Day opened the exhibit with more than 60 activities, including a 5K run, cultural dances, storytelling, food tasting, and local tribal games. Four years in development, the exhibit was on display from October 2011 to January 2012; more than 6,000 visitors attended.

When the exhibit closed, ASM added exhibit objects to its permanent collection. The 2013 edition of Sites of Conscience devoted 10 pages to the exhibit as a collaboration that addressed the critical issue of diabetes through community planning and participation. Currently, Falk delivers a lecture on the Eagle Books’ exhibit to each new class of museology students at ASM, and the museum’s website posts the comic and a diabetes quiz for download.

Eagle Adventure Program

Eagle Adventure was the outcome of formative research conducted by staff from the Chickasaw Nation Nutrition Services Get Fresh! Program and the Department of Nutritional Sciences at Oklahoma State University to assess the health needs of local tribal families and elders from 2006 through 2008. Their findings identified type 2 diabetes as a primary concern, with elders emphasizing the need for child education that includes storytelling and intergenerational interaction (theme 2 [Table 2]).

The research team explored program products and models that would address these needs. The Eagle Books were free, available, and culturally appropriate; there were no restrictions on use; the art was spectacular; appeal would probably extend to mixed ethnicity classrooms; and the messages aligned with USDA standards (themes 2, 4, 10 [Table 2]).

The team was awarded a USDA Supplemental Nutrition Assistance Program–Education (SNAP-Ed) Wave 1 demonstration project in 2008 to develop, pilot, and evaluate an Eagle Books school-based program in grades 1 through 3. The pilot design included developing a live play, 4 classroom sessions based on each book, and take-home materials (Nestwork) that brought families and elders into the program (theme 1 [Table 2]). The classroom sessions featured nutritional messages and physical activities that included dancing, nutrition games, and a healthy harvest activity (themes 4, 5 [Table 2]).

To develop the pilot components, the team had to reach out across many departments in tribal government and locate schools willing to participate (theme 1 [Table 2]). The pilot program, named Eagle Adventure, was implemented in spring 2010, and the program was deployed in the fall.

Since its launch, the program has spread beyond Chickasaw Nation’s tribal jurisdiction, reaching more than 6,000 students throughout Oklahoma. Eagle Adventure components remain unchanged, although staff continue to create additional activities and materials. Evaluation results demonstrated significant intentions for healthy eating and physical activity choices (Table 3). In 2019, Eagle Adventure was accepted into the USDA’s SNAP-Ed toolkit, a collection of evidence-based programs.

In 2017, the Eagle Adventure team reorganized as Oklahoma Tribal Engagement Partners (OKTEP) (theme 1 [Table 2]). They added team members, and new tribal partners adopted the program. CDC remains a partner for program sustainability, providing books to support ongoing needs. Currently, 9 tribes offer Eagle Adventure.

“Health Is Life in Balance”: DETS

Responding to TLDC guidance to develop a culturally relevant type 2 diabetes health education curriculum for AIAN children, the National Institute of Diabetes and Digestive and Kidney Diseases established cooperative agreements with 8 tribal colleges and universities and interagency agreements with IHS and CDC. DETS is a supplement for science, social science, and health education lessons in kindergarten through 12th grade designed to meet national science education standards and include AIAN traditions (theme 2 [Table 2]) (35,36).

DETS K–4 explores health and foods, healthy life in balance, diabetes as imbalance, and harvesting Mother Earth. Tribal college and university education specialists tasked with developing these lessons described the Eagle Books as having a “wow” factor. They believed that, integrated into the curriculum, the books’ beautiful imagery, character emotion, and easy-to-understand explanation of diabetes would create excitement and effective messaging in the classroom (themes 1, 3, 4, 5 [Table 2]). As expected, most children reported liking the books, drawn to the colorful illustrations, and the fun-to-read messages (Table 3) (35,36).

When DETS rolled out across Indian Country in 2008, Eagle Books had their first widespread distribution (Figure 2). The K–4 program was well-liked in schools. However, state school policies and budget cuts made it challenging to use the curriculum in some communities. Nevertheless, DETS began spreading as educators adjusted and adapted the lesson plans for informal use in schools and integration into Head Start programs (Theme 1 [Table 2]). Six of the case study communities were using DETS. In Alaska, community educators delivered DETS directly to schools as well as to families in which children were home schooled. Amazed at the popularity of DETS and Eagle Books, these educators observed a principal, dressed in a Mr. Eagle costume, reading a book to a class. Later, children participated in a DETS balance activity. The curriculum is available online from the IHS diabetes catalog.

Jump-start on a Healthy Lifestyle, a Head Start Program

Jump-start on a Healthy Lifestyle, Head Start Program, is a University of Maryland Eastern Shore Extension program that partners with Head Start Centers and summer camps in the tri-county area of the Lower Eastern Shore of Maryland. The program promotes health, including preventing obesity, in children from low-income families. Virginie Zoumenou, University of Maryland Eastern Shore Extension, received 2 USDA grants to develop an Eagle Books–based Jump-start program (2010–2017) that served African American families (theme 10 [Table 2]). Zoumenou et al published an article describing the development and testing of components in 4 phases (43). The evaluation included students in prekindergarten through third grade in the tri-county area of the Lower Eastern Shore. Program adaptations included teachers reading Eagle Books in short excerpts for prekindergarten, shortening book length, and introducing gardening to reinforce nutritional messages (grades 1–3) (themes 1,4 [Table 2]). Zoumenou also developed songs, music, dance, and magic tricks to create classroom enthusiasm. Qualitative results showed that children remembered character names, the stories, and shared stories with their families (theme 11 [Table 2]). Quantitative results demonstrated that book messages and gardening significantly increased children’s healthy food choices, physical activity, and knowledge of diabetes (Table 3).

NDWP did not know if the popularity of the Eagle Books, designed for AIAN communities, would cross cultural groups. Zoumenou et al suggested the stories are relevant for African Americans, whose story traditions also preserve history, mores, and cultural information, consistent with griot practices of West African storytellers (43).

Zoumenou et al noted other commonalities (43). African Americans and AIAN people share high rates of diabetes and a long history of oppression. The consequent histories of disenfranchisement continue to result in devastating health inequities for both populations. When Mr. Eagle gives hope that diabetes can be prevented, children may also understand that history does not determine their destiny.

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Implications for Public Health

We sought to answer 2 questions: Why have the Eagle Books maintained their appeal, and what factors sustain them? Our findings suggest that Eagle Books’ appeal is due to culturally relevant storylines, relatable characters, the emotional power and beauty of the artwork, and respectful messaging of traditional health knowledge set in current times. The stories have meaning for a wider audience than in Indian Country alone, demonstrating respect, wisdom, humor, peer support, and hope. (theme 10 [Table 2]).

An important element of remembered stories is identification with story characters (45). Many children identified with the Eagle Books’ child characters because they looked like them. These and other children were equally drawn to the colorful artwork and imagery, regardless of age, race, or ethnicity.

We had hoped to create stories that would “always be there,” guided by tribal leaders and representatives. We did not project the application of the Eagle Books’ stories for 16 years. In public health, we tend to create shorter-lived, conventional communications. Although the sustainability of public health interventions is inherently valued, sustained applications of effective messaging with measurable outcomes are not common (40,46).

The Eagle Books’ availability, including access to online versions (47), was a sustaining factor. Many children, parents, and teachers still prefer the feel of a book in hand, especially books for young children (Figure 3). The books were widely distributed — shared at events, or on request mailed to all 50 states, more than 200 tribal communities, the 6 US Affiliated Pacific Islands, Puerto Rico, and the US Virgin Islands, CDC distributed almost 6,000 sets of books annually from 2016 through 2021. The Canadian Diabetes Association tailored and printed the series. South Dakota State University Extension, through a cooperative agreement with CDC’s Racial and Ethnic Approaches in Community Health program, led talking circles and worked with native speakers to translate the series into Lakota and Dakota languages (48).

Figure 3.
Child reading Tricky Treats.
[A text version of this figure is available.]

The Eagle Books inspired CDC’s National Center for Injury Prevention and Control to develop the Star Collection stories, published in 2020. The Friendship Makers and Stars that Connect Us, written and illustrated by Marisa Erven, highlight protective factors of safe, stable, and nurturing relationships (49). In 2021, OKTEP, in collaboration with CDC and the CDC Foundation, created a coloring book, Community Protectors: Children Help Communities Stay Safe from COVID-19, featuring original Eagle Books’ characters, illustrated by Patrick Rolo and written by James Wallace (Figure 2).

Partnerships and political infrastructures with tribal leaders and allies advocating for diabetes prevention and care are 2 of 9 domains identified as critical for program sustainability (40,46). Program evaluation, another sustainability domain, began informally when Eagle Books launched in 2006 and continues, including the recent studies (34,41–43) that confirm changes in children’s intent for healthy choices (Table 3).

In entrusting local and national partners to create paths for better health outcomes through storytelling, tribal leaders lent powerful support, grounded by traditional ecologic knowledge, to “what works,” as advised during early listening sessions. In cultures where words carry the power to shape reality, stories have the power to empower a vision of hope and strength for the future in an indirect, nonthreatening way (34).

“Stories are universal,” Zoumenou et al reminds us (43). Relatable characters enlivened by story and images can transcend cultures and bring people together. In public health, well-told stories — culturally relevant, respectfully integrating traditional knowledge with sound Western science — are a powerful tool to relay indelible messages connecting people, history, culture, hope, and health. Storyteller N. Scott Momaday deepens our understanding of stories, language, and the power of words: “Language is considered sacred and to be used in ways that count for good. Words are to be taken seriously and remembered . . . the risk of loss is constant, and language is never to be taken for granted” (50).

AIAN communities exemplify “communities of memory,” in which members share a sense of belonging, kinship, cultural identity, connectedness, and history, with understanding of the intrinsic meaning of these values for their people (51). The power of stories to create hope for the future, told and retold over generations, is time-tested.

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Acknowledgments

The generosity of diverse and dedicated partners across tribes, agencies, programs, and academic institutions has made this work not only rewarding but possible. We could never name all who have and continue to contribute to this work in support of the well-being of future generations. We especially thank the IHS Tribal Leaders Diabetes Committee for their guidance and encouragement throughout the development and sharing of the Eagle Books. They were the books’ first champions. We also want to acknowledge those who have journeyed to the Spirit World. Your shoulders were strong. You held us up.

Specific champions include, but are not limited to, Kelly Acton, Lynn Aho, Aiko Allen, Larry Alonso, Chester Antone, Dave Baldridge, Lawrence Barker, Arianna Baros, Shirley Baros, Steph Bliss, Tammy Brown, Kelly Hitchcock Bundy, Brady Garcia, Carl Casperson, Rachel Ciccarone, Marilyn Cuch, Veronica Davidson, John Eagle Shield, Melinda Frank, Jill Fox, Shayna Heller, Mary Hindelang, Teresa Jackson, Bree Maldonado, Sarah Miracle, Kavitha Muthuswamy, Stephany Parker, Erica Reed-Gross, Ursula O’Hara, Michelle “Micha” Rinaldi, Marjorie Santos, Delight Satter, Becky Schlais, Louise Shaw, Arlene Sherman, Stephen Smith, Darlene Thomas, Reycita Trancosa, Lorraine Valdez, and Melva Zerkoune.

Financial support for the Eagle Books was provided by CDC’s Division of Diabetes Translation, in part through an interoffice agreement between CDC and the Indian Health Service.

C.D.F. is an enrolled member of the Oneida Nation; L.D.C. is an enrolled member of the Winnebago Tribe of Nebraska, and C.W. is an enrolled member of the Choctaw Nation of Oklahoma.

The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of CDC or the Agency for Toxic Substances and Disease Registry. No copyrighted tools or instruments were used in this research without permission.

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Author Information

Corresponding Author: Dawn Satterfield, PhD, MSN, RN, Native Diabetes Wellness Program, Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA 30341 (dxs9@cdc.gov).

Author Affiliations: ¹Native Diabetes Wellness Program, Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia. ²Westat, Inc, Atlanta, Georgia. ³School of Human Ecology, University of Wisconsin-Madison. ⁴University of Maryland Eastern Shore Extension, Princess Anne, Maryland. ⁵Winnebago Tribe of Nebraska, Winnebago, Nebraska. ⁶Center for American Indian and Alaska Native Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado.

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Tables

Abbreviations: AIAN, American Indian or Alaska Native; NDWP, Native Diabetes Wellness Program.

Abbreviations: DETS, Diabetes Education in Tribal Schools; SNAP-Ed, US Department of Agriculture Supplemental Nutrition Assistance Program–Education; USDA, US Department of Agriculture.
^a Chickasaw Nation Get Fresh! and partners, including Oklahoma State University, began development of Eagle Adventure in 2008.
^b The partnership expanded to include additional Oklahoma tribes after reorganizing in 2017 as Oklahoma Tribal Engagement Partners.
^c Food and physical activity desirability reflects the social desirability (culturally relevant and meaningful) of foods and physical activities presented in the Eagle Play.

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