Physical Activity Intervention Adaptation: Recommendations from Rural American Indian Older Adults.

Preventive interventions are critical to improving health equity among American Indian (AI) populations, yet interventions that promote physical activity (PA) among AI populations are scarce. This research addresses the research-to-practice gap by informing the adaption and implementation process of evidence-based interventions (EBIs) among rural AI older adults. We used a community-based approach and an Indigenous-focused adaptation theoretical framework. Qualitative, semi-structured interviews elicited detailed information on preferences for PA intervention among rural AI older adults. We applied a collaborative directed content analysis strategy, and established trustworthiness and relevance using an inter-rater reliability process and member checking. We conducted 21 interviews, all participants identified as AI, the mean age was 66 years (SD = 7.6), and 57% were female. Themes characterized contextual and cultural intervention considerations for adapting and implementing evidence-based PA interventions in rural AI older adults. Key findings included an emphasis on social and community interaction, strategies for targeted engagement, preference for group format, pairing PA sessions with shared meals, and inclusiveness in the PA intervention across ability levels and age groups. This study identified opportunities for adaptation of PA-focused EBIs among rural AI older adults. Findings can be applied to support the adaptation and implementation of effective and relevant PA-focused preventive interventions among this population which is at high risk for chronic disease and health disparities.

A Systematic Review of Interventions to Increase Physical Activity Among American Indian and Alaska Native Older Adults.

BACKGROUND AND OBJECTIVES: Physical activity (PA) is a powerful protective factor known to reduce risk for chronic conditions across the life span. PA levels are lower among American Indians and Alaska Natives (AIANs) when compared with other racial/ethnic groups and decrease with age. This evidence justifies a synthesis of current intervention research to increase PA levels among AIANs. This systematic review examines completed interventions to increase PA among AIAN older adults and considers recommended practices for research with Indigenous communities. RESEARCH DESIGN AND METHODS: The systematic review was designed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement for systematic review protocols and reporting guidelines. Three electronic databases, PubMed, Web of Science, and PsycINFO, were searched for academic literature. Trials investigating interventions to increase PA among AIAN adults older than 50 years were eligible. The Quality Assessment Tool for Quantitative Studies was used to evaluate the quality of evidence. RESULTS: Three published trials were identified, including one group-level, clinic-based and two individual-level, home-based interventions. All were 6 weeks in duration, took place in urban areas, and used self-report PA measures. Findings indicated an overall increase in PA levels, improved PA-related outcomes, and improved psychosocial health among participants. None described community-engaged or culture-centered research strategies. DISCUSSION AND IMPLICATIONS: The narrow yet promising evidence represents a need for expanded research and a call to action for using culture-centered strategies. An advanced understanding of cultural and contextual aspects of PA may produce more impactful interventions, supporting health and mobility across the life span.

Assessing youth empowerment and co-design to advance Pasifika health: a qualitative research study in New Zealand.

OBJECTIVES: The Pasifika Prediabetes Youth Empowerment Programme (PPYEP) was a community-based research project that aimed to investigate empowerment and co-design modules to build the capacity of Pasifika youth to develop community interventions for preventing prediabetes. METHODS: This paper reports findings from a formative evaluation process of the programme using thematic analysis. It emphasises the adoption, perceptions and application of empowerment and co-design based on the youth and community providers' experiences. RESULTS: We found that the programme fostered a safe space, increased youth's knowledge about health and healthy lifestyles, developed their leadership and social change capacities, and provided a tool to develop and refine culturally centred prediabetes-prevention programmes. These themes emerged non-linearly and synergistically throughout the programme. CONCLUSIONS: Our research emphasises that empowerment and co-design are complementary in building youth capacity in community-based partnerships in health promotion. Implications for public health: Empowerment and co-design are effective tools to develop and implement culturally tailored health promotion programmes for Pasifika peoples. Future research is needed to explore the programme within different Pasifika contexts, health issues and Indigenous groups.

Uplifting the voices of rural American Indian older adults to improve understanding of physical activity behavior.

American Indian (AI) older adults experience pronounced health disparities and demonstrate one of the lowest levels of physical activity (PA) among racial and ethnic groups. Nearly half of AI older adults live in rural areas, indicating distinct challenges to participation in PA. Research to identify factors influencing PA in this population is missing from the literature, yet is critical to informing culturally relevant PA intervention development and implementation. The purpose was to identify barriers to and facilitators of PA among rural AI older adults using the ecological model and qualitative methods. A community-based approach was used to conduct semi-structured interviews with rural AI older adults. Interview questions were based on a multi-level ecological model. Content analysis was performed, using an iterative coding process to identify findings. The mean age of participants (n = 21) was 66 years. Barriers to and facilitators of PA were identified across ecological model levels. Barriers included factors such as caregiving and community responsibilities, lack of acceptable areas for walking, and overall lack of community-level support for older adult health. Facilitators included a personal connection to the land and ancestors through PA, multigenerational participation, and supportive tribal policies. This study addressed a gap in the literature by identifying barriers to and facilitators of PA among rural AI older adults, which can inform PA intervention development. With barriers and facilitators identified by AI older adults themselves, the voices of those directly affected are uplifted to shape efforts toward addressing longstanding health disparities through relevant public health interventions.

Pasifika Prediabetes Youth Empowerment Programme: learnings from a youth-led community-based intervention study.

AIM: Using a co-design approach, we describe exploratory findings of a community-based intervention to mobilise Pasifika communities into action, with the intent of reducing the risk factors of prediabetes. METHOD: A group of 25 Pasifika youth aged 15-24 years from two distinctive Pasifika communities in New Zealand were trained to lead a small-scale, community-based intervention programme (among 29 participants) over the course of eight weeks. The intervention, which targeted adults aged 25-44 years who were overweight or obese, employed both an empowerment-based programme and a co-design approach to motivate community members to participate in a physical-activity-based intervention programme. RESULTS: Findings show significant reductions in total body weight and waist circumference, as well as improved physical activity. CONCLUSIONS: The strength of this intervention was evident in the innovative approach of utilising Pasifika-youth-led and co-designed approaches to motivate communities into healthier lifestyles. The approaches used in this project could be utilised in a primary healthcare setting as a community-wide strategy to reduce diabetes risk, particularly among Pasifika peoples.

Lessons Learned in Conducting Community Participatory School-Based Health Research on an American Indian Reservation.

BACKGROUND: Describing lessons learned from using a community-based participatory research (CBPR) approach to conduct school-based child health research in a tribal community is an important contribution to the literature. OBJECTIVES: To identify how CBPR principles shaped the process of conducting a school-based child health intervention, and to describe lessons learned. METHODS: The study evaluates how CBPR principles guided a mixed-methods, school-based child health intervention to increase physical activity (PA). RESULTS: Nine key lessons are identified, associated with CBPR principles. CONCLUSIONS: This information can help researchers understand how to successfully navigate the challenges and opportunities of conducting CBPR-guided research in the context of a small, short-term project, including leadership turnover, multiple Institutional Review Board (IRB)s, and study design approaches amidst schools policy changes. Collectively, understanding the lessons learned through the perspective of CBPR principles may help others conduct meaningful research with schools and children in tribal communities.

Group Gardening in a Native American Community: A Collaborative Approach.

Background. There is increasing awareness of the potential health benefits derived from gardening activities. Gardening practices are gaining momentum in Native American (NA) communities, yet no efforts have applied a community-based participatory research approach within a social-ecological model to understand opportunities and barriers for group gardening on an American Indian reservation. Objectives. The primary objective of this study was to identify influences across social-ecological levels that promote or hinder the implementation of community gardens and use of locally grown foods on the reservation; a secondary objective was to assess the feasibility of implementing a group gardening program for NA adults and potential of collecting health outcome measures. Method. Community members and academicians collaborated to develop and implement this study. The study (1) conducted interviews with key stakeholders to identify influences across social-ecological levels that promote or hinder the implementation of community gardens and using locally produced food and (2) assessed the physical and psychological well-being of NA adults participating in a group gardening feasibility study. Results. Major factors influencing using locally grown food and community gardens that emerged from nine interviews included knowledge/experience, self-efficacy, Elders, traditional ways, community values, generational gaps, and local tribal policies. Twenty NA adults with prediabetes or diabetes participated in the feasibility study. The Profile of Mood States Inventory showed consistently positive change in score for participants in the group gardening program versus the comparison group. Conclusions. This study identified key influences for growing locally grown food, and approaches for implementing group gardening programs for NA adults.

Community Readiness Model for Prevention Planning: Addressing Childhood Obesity in American Indian Reservation Communities.

INTRODUCTION: The community readiness model (CRM) is a stage-matched assessment protocol to assess community readiness to address a public health issue. To identify appropriate, culturally sensitive, and community-specific intervention strategies for preventing obesity in children, researchers, and community members formed a partnership to address childhood obesity within one American Indian Reservation. METHODS: The CRM guided 30 interviews in five communities to direct the team's efforts in addressing obesity among children residing on the reservation. Interviews were scored across six dimensions on an anchored scale of one through nine; scores were then averaged to determine an overall readiness score for each community. A thematic analysis of interview responses aided in interpretation of the readiness scores and identified areas for prevention planning and intervention development. RESULTS: The overall community readiness score for the communities was 2.9 (SD = 0.5), which falls between 2 (denial/resistance) and 3 (vague awareness) on the anchored rating scale. The thematic analysis resulted in a hierarchal classification scheme with six broad themes that corresponded to the CRM dimensions and 13 sub-themes. DISCUSSION: The low readiness scores directed the team to implement corresponding strategies to increase awareness, while the thematic analysis suggested that action-based approaches might also be appropriate. The narrow range of scores suggest that community-wide assessments may be sufficient unless specific information is needed for each region of the community. The CRM may be an effective way to assess community readiness to address childhood obesity on an American Indian Reservation.

Rural Parent Support of Child Health Behavior in the Home Environment: A Qualitative Study on an American Indian Reservation.

Background. Obesity rates are disproportionately high among rural and American Indian (AI) children. Health behaviors contributing to child obesity are influenced by parents at home. Engaging parents remains a challenge, particularly among low-income and ethnic minority families. Aims. The aim of this study was to learn how AI parents living on a rural AI reservation support and engage with their children's nutrition and physical activity behaviors at home. Methods. Parents with children ages 6 to 12 years living on one, rural AI reservation participated. Focus groups and interviews were conducted, using a 14-question moderator's guide. A systematic, iterative content analysis was applied to the transcripts. Results. Twenty-five parents (52% AI or Alaska Native) participated in 3 focus groups (n = 17) and interviews (n = 8). Themes related to enhancers included role modeling and whole family and child-initiated activities. Barriers included resources, child safety concerns, driving distances, and competing family priorities. Themes related to strategies for change included opportunities for peer learning from other local families, creating fun, program support for all supplies and incentives, and incorporation of storytelling and multicultural activities. Discussion. This study advances knowledge to promote parental engagement with child health behavior in the home, including unique themes of inclusiveness, culture-focused, and intergenerational activities. Conclusion. Results may inform interventions seeking to engage parents living in rural and AI reservation communities in home-based child behavior change efforts.

Feasibility and outcomes of an out-of-school and home-based obesity prevention pilot study for rural children on an American Indian reservation.

BACKGROUND: Children living in rural areas are at higher risk for obesity compared to urban children, and Native American (NA) children have the highest prevalence of overweight/obesity for all races combined. Out-of-school programs (OOSPs) are a promising setting to improve children's health. Parents are important in supporting their child's obesity-related behaviors, yet it remains unclear what combination and dose of parent engagement strategies is feasible and optimal. This study's primary objective was to assess the feasibility of an OOSP and home-based obesity prevention intervention for rural NA and non-NA children. METHODS: This was an 11-week, two group, randomized feasibility study. Participants were children and their parents at one OOSP on a rural American Indian reservation. Children, ages 6-9, were randomized to receive the Generations Health (GH) intervention or comparison condition. The GH group received daily activities focused on physical activity (PA), nutrition, sleep, and reducing TV/screen time, and frequently engaged parents. The comparison group received usual OOSP activities. To assess intervention feasibility, we measured recruitment and participation rates and program satisfaction. We assessed pre- to posttest changes in body composition, PA and sleep patterns, dietary intake and Healthy Eating Index-2010 (HEI-2010) scores, TV/screen time, and nutrition knowledge. We report recruitment and participation rates as percentages and participants' program satisfaction as means. Two-tailed paired t tests and 95% confidence intervals were used to detect changes in behavioral and health outcome variables. RESULTS: Forty-six children met age eligibility criteria; following screening, 52% (24/46) met the inclusion criteria and 96% (23/24) were randomized to the study. Overall, 91% of the children participated in the intervention and 100% participated in at least some of the posttest assessments. Parents reported high program satisfaction (mean rating of 4, on a 1-5 scale). Our outcome measure for child adiposity, zBMI, was reduced by 0.15 in the GH group, but increased by 0.13 in the comparison condition. Meaningful changes were evident for total kilocalories, HEI-2010 scores, PA, TV/screen time, and nutrition knowledge. CONCLUSIONS: High recruitment, participation and program satisfaction and positive health and behavioral outcomes at 11 weeks provide encouraging indications of the feasibility and potential effectiveness of the intervention. TRIAL REGISTRATION: ISRCTN24274245.

Building Capacity to Increase Health Promotion Funding to American Indian Communities: Recommendations From Community Members.

Foundations and government agencies have historically played a critical role in supporting community-based health promotion programs. Increased access to health promotion funding may help address significant health issues existing within American Indian (AI) communities, such as childhood obesity, type 2 diabetes, and cardiovascular disease. Understanding the capacity of AI communities to successfully apply for and receive funding may serve to increase resources for health promotion efforts within AI communities in Montana. This exploratory qualitative study completed 17 semistructured interviews across three AI reservations in the state of Montana. Dimensions of community capacity within the context of the funding application process and partnership with funding agencies were identified, including resources, leadership, community need, networks, and relationship with the funding agency. Dimensions of AI community capacity were then used to suggest capacity-building strategies for improved partnership between AI communities in Montana and the funding agencies.

Assessing Barriers and Enhancers to Increasing Physical Activity during the School Day in Children on an American Indian Reservation: A Qualitative Research Study.

OBJECTIVE: We attempted to determine factors that enhance or limit physical activity (PA) in children living on an American Indian (AI) reservation. METHODS: Six audio-recorded focus groups (FGs) were conducted. Each group included 6 - 8 participants (N = 42) with 3 grade specific FGs (4th - 6th grade students) and 3 adult FGs. RESULTS: FG analysis identified 4 main barriers to PA: school environment; community and school resources; electronic devices; and the role of parents and family. Analysis revealed 3 main strategies to increase PA: structured/non-competitive activities; structured/competitive activities; and increasing school and community-wide capacity. CONCLUSION: The results from this study provide a school health perspective on the 4-day school week.

Experiential Perceptions of Relactation: A Phenomenological Study.

BACKGROUND: Relactation is the process of re-establishing a breast milk supply that has diminished or ceased. OBJECTIVE: This study aimed to explore the lived experiences of women living in Montana who chose to attempt relactation. METHODS: A phenomenological approach was used to understand the lived experiences of 10 women in Montana who attempted relactation. In-depth interviews were conducted, and a 21-item categorical and open-ended demographic and experiential questionnaire was completed. RESULTS: An overarching theme that could have affected the initial breastfeeding experience, and furthered the need for relactation, was having a difficult baby. Examples of being difficult included colic, latching issues, or a lack of bonding felt by the participant. CONCLUSION: When asked about the experience of relactation, participants reflected on the emotional aspects of the process rather than the physical process. The most common feelings expressed were rejection, anger, stress, and failure. Future studies could examine what factors are present with women who continue nursing versus factors that are absent in women who discontinue nursing difficult babies, which could help prevent the need for relactation.

Community-identified strategies to increase physical activity during elementary school recess on an American Indian reservation: A pilot study.

The aim of this study was to determine the effect of an 8-week recess intervention on physical activity levels in children attending elementary school on an American Indian reservation during fall 2013. Physical activity was measured with direct observation in three zones on the playground. Lines were painted on existing pavement in zone 1. Zone 2 had permanent playground equipment and was unchanged. Zone 3 contained fields where bi-weekly facilitators led activities and provided equipment. Pre- to post-changes during recess in sedentary, moderate physical activity, moderate-to-vigorous, and vigorous physical activities were compared within zones. Females physical activity increased in Zone 1 (moderate: 100% increase; moderate-to-vigorous: 83%; vigorous: 74%, p < 0.01 for all) and Zone 3 (moderate: 54% increase, p < 0.01; moderate-to-vigorous: 48%, p < 0.01; vigorous: 40%, p < 0.05). Male sedentary activity decreased in Zone 2 (161%, p < 0.01). Physical activity changes in Zone 3 were not dependent upon the presence of a facilitator. Simple and low-cost strategies were effective at increasing recess physical activity in females. The findings also suggest that providing children games that are led by a facilitator is not necessary to increase physical activity as long as proper equipment is provided.

Daily flaxseed consumption improves glycemic control in obese men and women with pre-diabetes: a randomized study.

The study hypothesis was that fasting glucose, insulin, fructosamine, C-reactive protein, and interleukin-6 decrease and adiponectin increases with daily flaxseed consumption in overweight or obese individuals with pre-diabetes. In this randomized, cross-over study overweight or obese men and postmenopausal women (n = 25) with pre-diabetes consumed 0, 13, or 26 g ground flaxseed for 12 weeks. Glucose, insulin, homeostatic model assessment (HOMA-IR), and normalized percent of α-linolenic fatty acid (ALA) were significantly different by treatment (multiple analysis of variance, P = .036, P = .013, P = .008, P = .024 respectively). Paired t tests showed glucose decreased on the 13 g intervention compared to the 0 g period [13 g = -2.10 ± 1.66 mg/L (mean ± SEM), 0 g = 9.22 ± 4.44 mg/L, P = .036]. Insulin decreased on the 13 g intervention but not the 26 g (P = .021) and 0 g (P = .013) periods (13 g = -2.12 ± 1.00 mU/L, 26 g = 0.67 ± 0.84 mU/L, 0 g = 1.20 ± 1.16 mU/L). HOMA-IR decreased on the 13 g period but not on the 26 g (P = .012) and 0 g (P = .008) periods (13 g = -0.71 ± 0.31, 26 g = 0.27 ± 0.24, 0 g = 0.51 ± 0.35). The α-linolenic fatty acid decrease for the 0 g period was different than the 13 g (P = .024) and 26 g (P = .000) periods (13 g = 0.20 ± 0.04, 26 g = 0.35 ± 0.07, 0 g = -0.01 ± 0.07). Fructosamine, high sensitivity C-reactive protein, adiponectin, and high-sensitivity interleukin-6 had no significant differences. Flaxseed intake decreased glucose and insulin and improved insulin sensitivity as part of a habitual diet in overweight or obese individuals with pre-diabetes.

Developing and piloting the Journey to Native Youth Health program in Northern Plains Indian communities.

PURPOSE: The purpose of this study was to develop a lifestyle change program for Native American youth by modifying the Diabetes Prevention Program (DPP) and assess implementation indicators and short term behavioral and physiological outcomes of the intervention among a small pilot sample. METHODS: Community members and project staff modified the original DPP to be developmentally and culturally appropriate for youth targeting healthy weight maintenance, lowering fat intake, and increasing physical activity. Modifications included incorporating cultural aspects and delivering the program in small groups led by community members. Sixty-four Native American youth, aged 10-14 years old were recruited from 2 Montana Indian reservations to participate in the project, titled "Journey to Native Youth Health." Participants were randomized to the Journey DPP or a health-oriented comparison condition. Pretest and posttest measures included body mass index (BMI), dietary intake, physical activity (PA), and nutrition knowledge, attitudes and beliefs (KAB). RESULTS: The target number of participants was recruited and 84% completed the program and final measures. Changes favoring the Journey DPP group were observed on measures of PA, KAB, and kilocalories from fat consumed. As expected given the short (3-month) duration of treatment, there was no overall effect on BMI at end of treatment. Among youth who were overweight or obese at baseline, however, the Journey DPP had lower BMI growth. CONCLUSIONS: Results suggest the Journey DPP is feasible to implement and has the potential to impact behaviors and weight gain associated with risk for type-2 diabetes in Native American youth.

Parental influence on obesity in Northern Plains American Indian youth.

Little is known regarding American Indian (AI) parental influence on children's diet and physical activity (PA), or if this influence is associated with childhood weight. We compared AI parents' diet, PA, and support for these behaviors with the child's body mass index. Scores for parental support of positive PA and diet were higher among parents of overweight/obese children. Parent PA and nutrition behaviors were in a similar, but not significant, direction with respect to child body mass index. Findings suggest that future research is needed to determine what parental, societal, or community variables influence AI children to engage in healthy eating and PA, especially if they are overweight or obese, and the age at which these variables would have the most impact on these behaviors.

Translating the diabetes prevention program for Northern Plains Indian youth through community-based participatory research methods.

PURPOSE: The purpose of this study was to use a community-based participatory research (CBPR) approach to translate the original Diabetes Prevention Program (DPP) to be age and culturally specific for American Indian (AI) youth. METHODS: Tribally enrolled members on 2 Montana Indian reservations conducted focus groups and interviews to discuss community members' perspectives of factors that encouraged or were barriers to healthy diet and exercise behaviors in AI youth. In total, 31 community members, aged 10 to 68 years old, participated in 4 focus groups and 14 individual interviews. Participants were self-identified as elder, cultural expert, tribal health worker, educator, parent/guardian, youth, or school food service worker. Researchers analyzed transcripts based on inductive methods of grounded theory. RESULTS: Data analysis revealed translating the DPP to youth was contingent on the lessons incorporating cultural strategies for healthy behaviors in youth such as berry picking, gardening, horseback riding, and dancing; improving knowledge and access to healthy foods and physical activity for youth and their parents; having interactive, hands-on learning activities for healthy lifestyles in the DPP lessons; using a group format and tribal members to deliver the DPP lessons; and having tribal elders talk to youth about the importance of adopting healthy behaviors when they are young. CONCLUSIONS: A CBPR approach engaged community members to identify strategies inherent in their culture, tradition, and environment that could effectively translate the DPP to Montana Indian youth living in rural reservation communities.

Acanthosis nigricans among Northern Plains American Indian children.

The purpose of this study is to present cross-sectional and prospective data on acanthosis nigricans (AN) prevalence in the context of other risk factors for diabetes including high body mass index (BMI), abnormal blood pressure (BP), physical inactivity and family history of diabetes among Northern Plains American Indian (AI) children. Standardized health measures were collected in 2,520 K-12th-grade AI students for AN, BMI, and BP. Data were also collected on family history of diabetes and physical activity. Approximately, 9.7% of the participants were positive for AN. AN was associated with high BMI, abnormal BP, and diabetes family history. Sports participation was inversely associated with AN. Among children measured the prior year, relative risk (and 95% confidence interval [CI]) for obesity and incident AN was 9.8 (4.2-23.0) compared to normal weight. These findings suggest there is utility in measuring this marker of insulin resistance in this at-risk population.

Variability in childhood asthma and body mass index across Northern Plains American Indian communities.

OBJECTIVE: There are sparse data on the variability in childhood asthma across different Native American communities and the corresponding associations with known risk factors such as high body mass index and family history. The purpose of this study is to evaluate cross-sectional data on childhood asthma prevalence, body mass index, and other descriptive variables among Native Americans in five rural Northern Plains Indian reservation communities. METHODS: A school-based screening program was conducted on four Northern Plains Indian Reservations. The 1852 children (96% Native American, 4th through 12th grades) were screened for asthma status, body mass index (BMI), and family history. RESULTS: Approximately 9.5% of students reported current asthma. Current asthma varied significantly across the four reservation sites, ranging from 5.7% to 12.6%. Current asthma was also positively associated with BMI and family history of asthma. CONCLUSIONS: The intertribal differences in asthma prevalence noted here emphasize the need for further understanding the intertribal environmental, social, and behavioral factors that are associated with childhood asthma and obesity. Such knowledge can help inform disease prevention or disease management strategies that encompass the unique characteristics of tribal communities and culture.