Using latent class analysis to operationalize a wholistic assessment of Inuit health and well-being.

Many indigenous cultures conceptualize health wholistically, whereby physical, mental, spiritual and relational dimensions of health are interconnected. Yet, quantitative approaches to studying Indigenous health remain anchored in western perspectives, that separate the dimensions of health. This paper aims to operationalize a wholistic indicator of health based on the IQI model of Inuit health. Variables from the 2017 Nunavik Health Survey (N = 1196) were selected based on their representativeness of IQI model. Exploratory Latent Class Analysis (LCA) was used to identify wholistic health profiles. Once participants assigned to their health profile, sociodemographic characteristics were compared across profiles, and multinomial regression models were used to examine the relationship between community-level social determinants of health and the profiles. The LCA revealed three health profiles, labelled as "excellent", "good" and "fair" based on the distribution of answers to the indicators. Nunavimmiut in "excellent" and "good" health were more likely to: rate their health positively; be over 30 years old; be in a relationship; and have participated or volunteered in community events. Nunavimmiut in "fair" health tended to report lower levels of community cohesion, family relationships, and emotional support. Intergrating culturally relevant models of health can support improved health status assessments and identify opportunities for health promotion.

Dietary Outcomes of a Multilevel, Multicomponent, Cluster Randomized Obesity Intervention in 6 Native American Communities in the Upper Midwest and Southwest United States.

Background: Impacts of colonization on dietary intake have led to high rates of obesity and noncommunicable diseases among Native American adults. Multilevel, multicomponent (MLMC) interventions may improve dietary intake. Objectives: To assess the impact of a MLMC obesity intervention, OPREVENT2 (Obesity Prevention and Evaluation of InterVention Effectiveness in NaTive North Americans 2; clinicaltrials.gov NCT02803853), on dietary intake in Native American adults in Intervention versus Comparison communities. Methods: A cluster-randomized controlled trial was performed among participants in 6 communities randomized to Intervention (n = 3 and Comparison (n = 3). Adults aged 18 to 75 were recruited from tribal communities in the Southwest and upper Midwest United States from September 2016 to May 2017 (n = 601). This analysis included participants who completed baseline and follow-up surveys (82% retention), reported dietary intake between 500 and 7000 kcal/d, and had no missing data for outcomes of interest (n = 446). The intervention was implemented from May 2017, to November 2018. OPREVENT2 integrated individual, environmental, social, and structural factors and was implemented in food stores, worksites, schools, and community media outlets in Intervention communities. Activities included taste tests, cooking demonstrations, and stocking healthier items in food stores and were reinforced by a social m)edia campaign, posters, brochures, and booklets focused on nutrition. Individual-level dietary intake among participating Native American adults was assessed via modified Block food-frequency questionnaire at preintervention and postintervention. Multilevel mixed-effects linear regression, with clustering at the community level, was performed. Results: Between-group effects were significant (P < 0.05) for intake of carbohydrates (-23 g/d), total fat (-9 g/d), saturated fats (-3 g/d), and monounsaturated fats (-4 g/d), with greater decreases in Intervention communities. Between-group effect for total sugar (-12 g/d in Intervention communities) was not statistically significant. Conclusions: This MLMC intervention was associated with significantly improved carbohydrate, total fat, and saturated fat intake among Native American adults. These changes are important for improving health within this population.

Journey to Promoting Structural Change for Chronic Disease Prevention: Examining the Processes for Developing Policy, Systems, and Environmental Supports in Native American Nations.

Background: Obesity and chronic disease rates continue to be disproportionally high among Native Americans (NAs) compared with the US general population. Policy, systems, and environmental (PSE) changes can address the root causes of these health inequalities by supporting access to healthy food and physical activity resources. Objective: We aim to describe the actors and processes involved in developing PSE changes supporting obesity prevention in NA Nations. Methods: As part of the Obesity Prevention Research and Evaluation of InterVention Effectiveness in NaTive North Americans 2 (OPREVENT2) trial (ClinicalTrials.gov registration: NCT02803853), we collected 46 in-depth interviews, 1 modified Talking Circle, 2 workshops, and 14 observations in 3 NA communities in the Midwest and Southwest regions of the United States. Participants included Tribal government representatives/staff, health staff/board members, store managers/staff, and school administrators/staff. We used a Grounded Theory analysis protocol to develop themes and conceptual framework based on our data. Results: Health staff members were influential in identifying and developing PSE changes when there was a strong relationship between the Tribal Council and health department leaders. We found that Tribal Council members looked to health staff for their expertise and were involved in the approval and endorsement of PSE changes. Tribal grant writers worked across departments to leverage existing initiatives, funding, and approvals to achieve PSE changes. Participants emphasized that community engagement was a necessary input for developing PSE changes, suggesting an important role for grassroots collaboration with community members and staff. Relevant contextual factors impacting the PSE change development included historical trauma, perspectives of policy, and "tribal politics". Conclusions: This article is the first to produce a conceptual framework using 3 different NA communities, which is an important gap to be addressed if structural changes are to be explored and enacted to promote NA health. The journey to change for these NA Nations provides insights for promoting future PSE change among NA Nations and communities.

"We've Already Endured the Trauma, Who is Going to Either End that Cycle or Continue to Feed It?": The Influence of Family and Legal Systems on Native American Women's Intimate Partner Violence Experiences.

Native American (NA) women experience higher rates of intimate partner violence (IPV) compared to other U.S. racial/ethnic groups, yet previous research has not sufficiently examined the complex determinants shaping their IPV experiences. This research explores the interplay of family networks and legal systems influencing NA women's IPV experiences. Data were collected through in-depth individual and group interviews with 42 NA survivors and 41 health/social service providers from July 2016 to June 2017 in NA communities from three different U.S. regions. We used Grounded Theory to develop emergent themes from the data, focusing on system-level risk and protective factors of women's of IPV experiences. In terms of family systems, participants indicated that NA communities were comprised of highly influential and interwoven family systems, making them powerful sources of support for both survivors and their partners who use violence. Participants described how intergenerational violence exposures contributed to the normalization of violence. In terms of legal systems, participants described inconsistent consequences for abusers of NA women, insufficient protection from legal systems, and manipulation of jurisdictional complexities. Interactions between family and legal systems influenced decision-making and outcomes. Family and community-based approaches, and the incorporation of traditional language and cultures, are needed to promote healing. Our findings reflect the complex ways that family and legal systems shape NA women's IPV experiences. Results provide insight into how NA women interact with and navigate these systems when experiencing IPV and how these systems impact decision-making and the ability to be safe from IPV. Research is needed to advance understanding of the inter-relationships between intergenerational trauma, family systems, and legal systems on IPV survivors' mental health and wellness. To make meaningful change, further research examining IPV from an interdisciplinary perspective that explores the interplay of social determinants of health inequities is needed.

Dismantling the status quo: promoting policies for health, well-being and equity: an IUHPE2022 prelude.

The next international gathering of the global health promotion family will be in Montreal, in May 2022. The 24th IUHPE conference is themed 'Promoting policies for health, well-being and equity'. Conference organizers have decided to transcend the 'usual suspects' rhetoric and frame a conference program that truly challenges these key notions for health promotion. In this contribution, members of the Canadian National and Global Scientific Committees reflect on the state of play and the opportunities ahead. We propose three themes as follows: (a) breaking news (the promise and opportunities for disruptions and tipping points, whether from pandemic health challenges, climate change, geopolitical shifts, social unrest or technological promise); (b) breaking free (from world-views that favor only market solutions, divisions between North and South, toward emancipatory decolonizing practices and knowledge systems); and (c) breaking through (disciplines, silos, boundaries and identities engrained in our practices and understandings for innovation.).

A multi-level, multi-component obesity intervention (Obesity Prevention and Evaluation of InterVention Effectiveness in NaTive North Americans) decreases soda intake in Native American adults.

OBJECTIVE: To evaluate the impact of a multi-level, multi-component (MLMC) adult obesity intervention on beverage intake in Native American adults living in five geographically and culturally diverse tribal communities. DESIGN: A 14-month, community-randomised, MLMC design was utilised, with three communities randomised to Intervention and two communities randomised to Comparison. FFQ were administered pre- and post-interventions, and difference-in-differences (DiD) analysis was used to assess intervention impact on beverage intake. SETTING: The intervention took place within food stores, worksites, schools and selected media outlets located in the five communities. Key activities included working with store owners to stock healthy beverages, display and dispersal of educational materials, support of policies that discouraged unhealthy beverage consumption at worksites and schools and taste tests. PARTICIPANTS: Data were collected from 422 respondents between the ages of 18 and 75 living in the five communities pre-intervention; of those, 299 completed post-intervention surveys. Only respondents completing both pre- and post-intervention surveys were included in the current analysis. RESULTS: The DiD for daily servings of regular, sugar-sweetened soda from pre- to post-intervention was significant, indicating a significant decrease in Intervention communities (P < 0·05). No other changes to beverage intake were observed. CONCLUSIONS: Large, MLMC obesity interventions can successfully reduce the intake of regular, sugar-sweetened soda in Native American adults. This is important within modern food environments where sugar-sweetened beverages are a primary source of added sugars in Native American diets.

A Scoping Review of the Use of Indigenous Food Sovereignty Principles for Intervention and Future Directions.

Indigenous food sovereignty (IFS) represents a community-led movement with potential to reduce health inequities, but no scoping review of the impact of taking an IFS approach on intervention research has been conducted. This review sought to: 1) describe intervention studies that employ IFS principles, and 2) describe the impact of studies using IFS principles on food access, eating patterns, diet quality, physical activity, and health. Through a literature review, 4 IFS principles were identified: 1) community ownership, 2) inclusion of traditional food knowledge, 3) inclusion and promotion of cultural foods, and 4) environmental/intervention sustainability. Twenty intervention studies published between January 1, 2000 and February 5, 2020 were included. Most of the studies that scored high in IFS principles saw a positive impact on diet. This review found evidence supporting the value of IFS principles in the development, implementation, and evaluation of health interventions for Indigenous communities.

Sociodemographic and Psychosocial Factors Associated With Diet Quality in 6 Rural Native American Communities.

OBJECTIVE: To identify psychosocial and household environmental factors related to diet quality among Native Americans (NA). DESIGN: Analysis of baseline data from a community-randomized obesity prevention trial. SETTING: Six rural NA communities in the Midwest and the Southwestern US. PARTICIPANTS: A total of 580 tribal members, aged 18-75 years old (mean 45 years), 74% female, self-identified as the main household food purchaser. VARIABLES MEASURED: Diet quality (Healthy Eating Index-2015 [HEI]) was derived from a semiquantitative food frequency questionnaire. Sociodemographic, psychosocial, and home food environment factors were assessed via interviewer-administered questionnaires. ANALYSIS: One-way ANOVA, linear regression models, and 2-tailed t tests compared HEI scores among sociodemographic categories. Multiple linear regression models assessed the relationship between psychosocial factors, home food environment, and HEI. RESULTS: Prevalence of obesity was 59%. Mean HEI-2015 score was 49.3 (SD = 8.1). Average HEI scores were 3.0 points lower in smokers than nonsmokers (P < 0.001), and 2.2 points higher in females than males (P < 0.01). Higher self-efficacy (ß = 0.97; P < 0.001) and healthier eating intentions (ß = 0.78; P < 0.001) were positively associated with HEI. Healthier household food patterns score was associated with higher HEI (ß = 0.48; P < 0.01). CONCLUSIONS AND IMPLICATIONS: Psychosocial factors were associated with diet quality, a finding that supports the use of social-cognitive intervention approaches in rural NA communities in the Midwest and Southwest, and warrants evaluation in other locations. There remains a need to elucidate the association between the Food Distribution Program on Indian Reservations and diet quality.

Individual- and household-level factors associated with fruit, vegetable, and dietary fiber adequacy among Native American adults in 6 reservation communities.

This study utilized baseline data collected in 2017 from the OPREVENT2 trial, which included 540 Native Americans in six Midwest and Southwest reservation communities. The objective was to identify correlates of fruit, vegetable, and dietary fiber adequacy among participants 18-75 years old who self-identified as the main food purchaser or preparer in their household. Mean daily servings of fruits and vegetables and grams of dietary fiber were quantified based on a 30-day semi-quantitative food frequency questionnaire. Participants consumed an average of 0.5 (±0.4) cup-equivalent servings of fruit, 2.5 (±1.8) cup-equivalent servings of vegetables, and 15.5 (±8.9) grams of fiber per day. <2% of the study population met the 2015-2020 Dietary Guidelines for Americans recommendations for fruit consumption, while 12 and 42% met recommendations for dietary fiber and vegetable consumption, respectively. Females had a prevalence ratio 1.4 times greater than males for adequate intakes of vegetables (p = 0.008) and over 6 times greater for dietary fiber (p < 0.001). Participants over the age of 30 were about twice as likely to meet dietary fiber recommendations (p = 0.031) compared to those 30 years and younger. Participants receiving food assistance from the USDA's Food Distribution Program on Indian Reservations (FDPIR) were nearly twice as likely as non-FDPIR recipients to meet recommendations for dietary fiber (p = 0.008). These findings can help guide the development of targeted interventions to improve diet quality; however, further work is needed to understand and address underlying reasons for low fruit consumption in these rural reservation communities.

Dietary Intake of Upper Midwest and Southwest Native American Adults.

Limited information on current dietary patterns of Native American (NA) adults exists. This paper describes the dietary intake of 582 NA adults, aged 19-75 years, living in six communities in New Mexico and Wisconsin in 2016-2017 and compares macronutrient and micronutrient intakes, estimated via a semi-quantitative 30-day Block Food Frequency Questionnaire, among different age and sex groups. NA adults consumed a diet high in % energy from total fat, saturated fat, added sugars, and sodium. A general trend of lower micronutrient intakes with increasing age was observed. Health professionals can apply this information to develop effective and culturally relevant nutrition interventions. Abbreviations: NA = Native American; CVD = Cardiovascular diseases; IOM = Institute of Medicine; IRB = Institutional Review Board; AIQ = Adult Impact Questionnaire; FFQ = Food Frequency Questionnaire; NHANES = National Health and Nutrition Examination Survey; NHNS: Navajo Health and Nutrition Survey.

Latent Class Analysis Offers Insight into the Complex Food Environments of Native American Communities: Findings from the Randomly Selected OPREVENT2 Trial Baseline Sample.

Native Americans (NAs) experience a high burden of obesity and diabetes, yet previous research has not holistically described the unique food environments of NA communities. The objective of this paper is to describe the subgroups and demographic characteristics related to NA household food environments. Surveys collected food getting, food assistance, and sociodemographic variables from randomly selected adults from three NA communities (n = 300) in the Midwest and Southwest. Exploratory latent class analysis (LCA) identified the appropriate number of subgroups based on indicator responses. After assigning participants to classes, demographic differences were examined using bivariate analyses. NA household food environments could be described using two subgroups ("lower" and "higher access household food environments"). The "lower access" group had significantly higher age, smaller household size, and fewer children per household than the "higher access" group, while body mass index (BMI) did not significantly vary. This is the first LCA of NA household food environments and highlights the need for approaches that characterize the complexity of these environments. Findings demonstrate that NA household food environments can be described by developing subgroups based on patterns of market and traditional food getting, and food assistance utilization. Understanding NA household food environments could identify tailored individual and community-level approaches to promoting healthy eating for NA Nations.

OPREVENT (Obesity Prevention and Evaluation of InterVention Effectiveness in NaTive North Americans): Design of a Multilevel, Multicomponent Obesity Intervention for Native American Adults and Households.

Obesity prevalence is high in Native American (NA) adults, and there is a critical need to establish and implement evidence-based social, behavioral, and policy interventions that are theoretically informed. The use of multilevel, multicomponent (MLMC) interventions has been shown to be an effective strategy for comprehensive health behavior change; however, there is little guidance available in the literature to facilitate implementation in this underserved and understudied population. To decrease obesity and related comorbidities in NA adults, an MLMC intervention called OPREVENT (Obesity Prevention and Evaluation of InterVention Effectiveness in NaTive North Americans) was implemented in 5 rural NA communities to modify the food-purchasing environment, improve diet, and increase physical activity (PA). Five NA communities across the Upper Midwest and Southwest United States were randomly assigned to Immediate (n = 3) or Delayed (n = 2) Intervention. OPREVENT was implemented in Immediate Intervention community food stores, worksites, schools, and media over 1 y. A community-randomized controlled trial was used to evaluate intervention impact in adults at the individual and institutional levels, with individual-level data being collected on diet, PA, and psychosocial variables at baseline and follow-up; and institutional-level data being collected on food stores, worksites, and schools, media, and process measures. The OPREVENT intervention was one of the first MLMC obesity interventions in this population and provides evidence-based practices for future program development. The purpose of this article is to describe the design, implementation, and evaluation of OPREVENT. This trial was registered at isrctn.com as ISRCTN76144389.

OPREVENT2: Design of a multi-institutional intervention for obesity control and prevention for American Indian adults.

BACKGROUND: Obesity and other nutrition-related chronic disease rates are high in American Indian (AI) populations, and an urgent need exists to identify evidence-based strategies for prevention and treatment. Multi-level, multi-component (MLMC) interventions are needed, but there are significant knowledge gaps on how to deliver these types of interventions in low-income rural AI communities. METHODS: OPREVENT2 is a MLMC intervention targeting AI adults living in six rural reservations in New Mexico and Wisconsin. Aiming to prevent and reduce obesity in adults by working at multiple levels of the food and physical activity (PA) environments, OPREVENT2 focuses on evidence-based strategies known to increase access to, demand for, and consumption of healthier foods and beverages, and increase worksite and home-based opportunities for PA. OPREVENT2 works to create systems-level change by partnering with tribal stakeholders, multiple levels of the food and PA environment (food stores, worksites, schools), and the social environment (children as change agents, families, social media). Extensive evaluation will be conducted at each level of the intervention to assess effectiveness via process and impact measures. DISCUSSION: Novel aspects of OPREVENT2 include: active engagement with stakeholders at many levels (policy, institutional, and at multiple levels of the food and PA system); use of community-based strategies to engage policymakers and other key stakeholders (community workshops, action committees); emphasis on both the built environment (intervening with retail food sources) and the social environment. This paper describes the design of the intervention and the evaluation plan of the OPREVENT2. TRIAL REGISTRATION: Clinical Trial Registration: NCT02803853 (June 10, 2016).

Food Environments around American Indian Reservations: A Mixed Methods Study.

OBJECTIVES: To describe the food environments experienced by American Indians living on tribal lands in California. METHODS: Geocoded statewide food business data were used to define and categorize existing food vendors into healthy, unhealthy, and intermediate composite categories. Distance to and density of each of the composite food vendor categories for tribal lands and nontribal lands were compared using multivariate linear regression. Quantitative results were concurrently triangulated with qualitative data from in-depth interviews with tribal members (n = 24). RESULTS: After adjusting for census tract-level urbanicity and per capita income, results indicate there were significantly fewer healthy food outlets per square mile for tribal areas compared to non-tribal areas. Density of unhealthy outlets was not significantly different for tribal versus non-tribal areas. Tribal members perceived their food environment negatively and reported barriers to the acquisition of healthy food. CONCLUSIONS: Urbanicity and per capita income do not completely account for disparities in food environments among American Indians tribal lands compared to nontribal lands. This disparity in access to healthy food may present a barrier to acting on the intention to consume healthy food.

Patterns of Food Consumption are Associated with Obesity, Self-Reported Diabetes and Cardiovascular Disease in Five American Indian Communities.

The relationship between dietary patterns and chronic disease is underexplored in indigenous populations. We assessed diets of 424 American Indian (AI) adults living in 5 rural AI communities. We identified four food patterns. Increased prevalence for cardiovascular disease was highly associated with the consumption of unhealthy snacks and high fat-food patterns (OR 3.6, CI=1.06, 12.3; and OR 6.0, CI=1.63, 22.1), respectively. Moreover, the food-consumption pattern appeared to be different by community setting (p<.05). We recommend culturally appropriate community-intervention programs to promote healthy behavior and to prevent diet-related chronic diseases in this high-risk population.