"We don't separate out these things. Everything is related": Partnerships with Indigenous Communities to Design, Implement, and Evaluate Multilevel Interventions to Reduce Health Disparities.

Multilevel interventions (MLIs) are appropriate to reduce health disparities among Indigenous peoples because of their ability to address these communities' diverse histories, dynamics, cultures, politics, and environments. Intervention science has highlighted the importance of context-sensitive MLIs in Indigenous communities that can prioritize Indigenous and local knowledge systems and emphasize the collective versus the individual. This paradigm shift away from individual-level focus interventions to community-level focus interventions underscores the need for community engagement and diverse partnerships in MLI design, implementation, and evaluation. In this paper, we discuss three case studies addressing how Indigenous partners collaborated with researchers in each stage of the design, implementation, and evaluation of MLIs to reduce health disparities impacting their communities. We highlight the following: (1) collaborations with multiple, diverse tribal partners to carry out MLIs which require iterative, consistent conversations over time; (2) inclusion of qualitative and Indigenous research methods in MLIs as a way to honor Indigenous and local knowledge systems as well as a way to understand a health disparity phenomenon in a community; and (3) relationship building, maintenance, and mutual respect among MLI partners to reconcile past research abuses, prevent extractive research practices, decolonize research processes, and generate co-created knowledge between Indigenous and academic communities.

Evaluation of a Synchronous, Online Diabetes Nutrition Education Program for American Indians and Alaska Natives With Type 2 Diabetes: Facilitators and Participants' Experiences.

OBJECTIVE: To explore the overall experiences of key players involved in a culturally adapted, online, synchronous diabetes nutrition education program across 5 reservation tribal and intertribal urban Indian clinics. METHODS: A multimethods design, including postclass surveys with Likert-scale and short-answer questions, was completed after each of the 5 classes. Participants (n = 54) and class facilitators/coordinators (n = 10) completed postclass surveys (n = 189 and 58, respectively). A subset of participants (n = 24) and all class facilitators/coordinators (n = 10) engaged in online focus groups after the conclusion of program implementation. Qualitative thematic methods and frequency distributions were used to analyze the data. RESULTS: Most participants reported that the classes were enjoyable (94%), culturally respectful (77%), and easily accessed online (68%). Qualitative themes included (1) class satisfaction, (2) class improvements, (3) preference for class facilitator, and (4) recommendations to improve recruitment and retention. CONCLUSIONS AND IMPLICATIONS: These findings will guide program modifications to provide improved diabetes nutrition education for American Indians and Alaska Natives adults with type 2 diabetes.