Method of Developing a Culturally Tailored Diabetes Intervention for American Indians.

BACKGROUND: American Indians have the highest prevalence of type 2 diabetes compared with any other racial or ethnic group. OBJECTIVE: Developing a culturally tailored diabetes prevention and management intervention is one way to reduce diabetes-related health disparities among American Indian populations. The purpose of this article is to describe our approach for developing a diabetes prevention and management intervention study using Kolb's Experiential Learning Theory as the framework. METHODS: To ensure the intervention study was culturally meaningful and relevant we used community-based participatory principles by partnering with a team of nurse researchers, tribal diabetes educators, tribal leaders, and tribal community members who were involved in all aspects of the study process. We conducted seven focus groups predominantly in rural American Indian communities in Oklahoma. Using focus group findings, the team collaboratively designed and developed a multi-generational diabetes prevention and management intervention study. The intervention group sessions will focus on ways to prevent and manage diabetes while the control group sessions will focus on general health education topics that have been identified by the team as important and relevant. CONCLUSIONS: Family interventions that involve multiple generations and provide emotional and behavioral support to those with type 2 diabetes and family members at risk may provide our best chance at improving diabetes-related outcomes and reducing health disparities in this critical population.

Perceived Environments and Physical Activity Among American Indian Adults Living in Oklahoma: The THRIVE Study.

BACKGROUND: Obesity and chronic disease disproportionately affect American Indians (AI). Identifying barriers to physical activity (PA) may promote PA and healthier lifestyles. OBJECTIVE: To identify perceptions of the built environment and examine whether there is an association between environmental perceptions and self-reported PA in AI communities. METHODS: We conducted a survey among 459 AI adults (survey response of 91.4%) residing in Choctaw Nation and Chickasaw Nation, both located in primary rural areas, and we examined perceived PA environment and its association with PA adequacy (≥5 days/week). Participants provided self-report of PA frequency and duration (of ≥30 minutes per day), as well as the opportunity for exercise in indoor and outdoor, town center, and biking and school areas frequency and duration (of ≥30 minutes per day), and their opportunities for exercise in indoor, outdoor, town center, biking, and school areas. RESULTS: Of respondents, 29% met the recommendations of at least 150 minutes of exercise per week, and 56% were obese. The majority had indoor and outdoor exercise areas in their towns, but many did not use them. Higher town center built environment summary scores were associated with adequate PA (estimate = 0.43; p = 0.02). Not feeling like there were streets with marked crosswalks (odds ratio [OR], 0.25; 95% confidence interval [CI], 0.07-0.84) or being neutral/not sure about nice sidewalks (OR, 0.33; 95% CI, 0.13-0.78) were associated with lower odds of getting adequate PA, and not feeling like the town center had working streetlights was associated with higher odds of getting adequate PA (OR, 5.22; 95% CI, 1.34-21.01). CONCLUSIONS: We found that marked crosswalks and nice sidewalks in the town center were associated with getting adequate PA. This research, which identifies specific built environment factors that affect peoples' PA, may be used by tribal and local organizations to more effectively prioritize community interventions to improve PA and potentially the health of the community, specifically in regards to crosswalks and sidewalks.

Process Evaluation Tool Development and Fidelity of Healthy Retail Interventions in American Indian Tribally Owned Convenience Stores: the Tribal Health Resilience in Vulnerable Environments (THRIVE) Study.

BACKGROUND: The Tribal Health Resilience in Vulnerable Environments (THRIVE) study aimed to increase healthy food access in 2 rural American Indian communities. The intervention sought to increase fruit and vegetable availability, variety, and convenience through placement, promotion, and pricing of healthy foods and beverages in tribal convenience stores. OBJECTIVE: The aim of this study was to describe the development and implementation of the study process evaluation tool to assess intervention fidelity as part of this cluster-controlled trial. METHODS: Eight stores (2 intervention and 2 control stores per Nation) participated in the study, implemented from May 2016 to May 2017. A web-based survey tailored to store layouts and intervention components assessed how often intervention items were available, approximate quantity available, and whether placement of healthier food items and promotional materials were implemented as designed. After pilot testing the survey, tribal staff members implemented it to collect process evaluation data in the 8 stores during a period of 9-12 mo, assessing study implementation and potential changes in control stores. RESULTS: Promotional materials were available ≥75% of the time for most intervention locations. Fruit availability was similar in Nation A and Nation B intervention stores (79-100% compared with 70-100%), whereas fresh vegetable availability was higher in Nation B compared with Nation A (95-96% compared with 55-75%). Both control stores in Nation A and 1 control store in Nation B had moderate fruit and vegetable availability, ranging from 45% to 52%. No control stores in either Nation used intervention promotional materials. CONCLUSIONS: Process evaluation data indicate that the study was implemented with moderate to high fidelity. The development and implementation of the tool can inform future healthy retail interventions that aim to improve rural and tribal food environments.

Correction: Using financial incentives to promote physical activity in American Indian adolescents: A randomized controlled trial.

[This corrects the article DOI: 10.1371/journal.pone.0198390.].

Diabetes and Obesity Associated with Poor Food Environments in American Indian Communities: the Tribal Health and Resilience in Vulnerable Environments (THRIVE) Study.

BACKGROUND: American Indians (AIs) have significantly higher rates of diet-related chronic diseases than other racial/ethnic groups, and many live in environments with limited access to healthy food. OBJECTIVE: As part of the Tribal Resilience in Vulnerable Environments (THRIVE) study, we examined the relations between the perceived food environment, utilization of food retailers, fruit and vegetable intake, and chronic diseases, including obesity, hypertension, and type 2 diabetes among AI adults. METHODS: Through a community-based participatory research partnership, we surveyed a cross-sectional sample of 513 AIs living within the Chickasaw Nation and the Choctaw Nation of Oklahoma. RESULTS: Only 57% of participants reported that it was easy to purchase fruits and vegetables in their town, and fewer (35%) reported that available fruits and vegetables were of high quality. Additionally, over half (56%) reported traveling ≥20 miles round trip to shop for food. Few participants met the recommended daily intake for fruit (44%) or vegetables (25%). Obesity (55%), hypertension (49%), and diabetes (25%) were commonly reported. Obesity was significantly higher among participants who reported that the price of fruits and vegetables were cost-prohibitive (prevalence proportion ratio (PPR): 1.24; 95% CI: 1.02, 1.50) and those who shopped frequently for food at nontraditional food retailers, such as Dollar Stores (PPR: 1.35; 95% CI: 1.08, 1.69) and small markets (PPR: 1.38; 95% CI: 1.02, 1.86). Diabetes was significantly higher among participants who frequently shopped at convenience stores/gas stations (PPR: 2.26; 95% CI: 1.22, 4.19). CONCLUSIONS: Our study found that the use of nontraditional food retailers, including convenience stores, gas stations, and Dollar Stores, as a regular source of food was associated with obesity and diabetes. These results underscore the importance of interventions to improve rural Tribal food environments. Healthy retail interventions in nontraditional retail settings, such as those implemented through the THRIVE study, may contribute to reducing AI health disparities.

Collaborative implementation of a community-based exercise intervention with a partnering rural American Indian community.

BACKGROUND: The prevalence and socioeconomic burden of childhood obesity and diabetes has increased rapidly in the United States in the last 30 years. American Indians have the highest prevalence of type 2 diabetes among newly diagnosed youth in the country. Contributing factors include environmental, behavioral, and genetic components. Some American Indian tribal communities have explored innovative ways to combat this epidemic including collaborations with academic centers on community-based research. METHOD: From 2012 to 2017, the University of Oklahoma Health Science Center and the Choctaw Nation of Oklahoma partnered on a National Institutes of Health-funded project to determine if financial incentives would elicit an increase in physical activity in Native youth. This was a community-based behavioral intervention for overweight or obese American Indian youth ages 11-20 living in a rural community at risk for developing diabetes. RESULTS: Tribal leaders and staff identified culturally appropriate strategies to aid implementation of the trial in their community. Their identified implementation strategies helped standardize the study in order to maintain study integrity. The mutually agreed strategies included co-review of the study by tribal and University research review boards (but designation of the Choctaw Nation review board as the "Board of Record"), training of community-based staff on research ethics and literacy, standardization of the informed consent process by videotaping all study information, creation of a viable and culturally appropriate timeline for study implementation, adapting tribal wellness center operations to accommodate youth, and development of effective two-way communication through training sessions, on-site coordination, and bi-monthly conference calls. CONCLUSION: In an effort to partner collectively on a randomized clinical research trial to combat childhood diabetes, tribal leaders and staff implemented strategies that resulted in a culturally appropriate and organized community-based behavioral intervention research project.

Social Support and Physical Activity Among American Indians in Oklahoma: Results From a Community-based Participatory Research Study.

PURPOSE: Little is known about the contribution of social support to physical activity (PA) behavior among American Indians (AIs). This community-based participatory research study examined the prevalence of and associations between different types of PA social support and PA among AIs in rural Oklahoma. METHODS: Our tribal-academic partnership surveyed AI adults (N = 513) living within the tribal jurisdictional areas of 2 tribal nations. We used the Physical Activity Social Support (PASS) scale to assess 3 types of PA social support and Poisson regression to investigate associations between PASS types and self-reported PA behavior. FINDINGS: Over a third of participants perceived high levels of PA social support from friends (37%), family (35%), and overall (34%), yet only 29% reported regular PA (ie, 150 minutes or more weekly). Participants who exercised with pets/other were significantly more likely to achieve regular PA than those who exercised alone (PR 2.0, 95% CI: 1.4-2.9). Although not significant, compared with those reporting no/low support, participants with high friend PASS (PR 1.2, 95%: CI 0.9-1.6), medium family PASS (PR 1.2, 95% CI: 0.9-1.7), and overall PASS (PR 1.1, 95% CI: 0.8-1.6) were more likely to report regular PA. CONCLUSIONS: The majority of participants did not meet current recommendations for PA behavior, which underscores the ongoing need for PA effective interventions among AIs living in rural areas. Results suggest that exercising with pets/other could be an important factor for future intervention. Further research is needed to elucidate determinants of PA and test interventions to increase PA among AIs.

Using financial incentives to promote physical activity in American Indian adolescents: A randomized controlled trial.

American Indians (AI) have high prevalence of diabetes in youth and may benefit from increasing physical activity as a strategy to improve metabolic health. We tested whether financial incentives would elicit greater frequency and/or duration of exercise in AI youth at high risk for developing diabetes. Overweight/obese AI boys and girls, 11-20 years old, were instructed to exercise on 3 days/week for 48 weeks at a tribal wellness center. The program was divided into three, 16-week-long phases to test different financial incentive strategies. Within each phase participants were randomly assigned to one of two groups that received different payments for exercise. Phase 1 was designed to test whether the size of the incentive would affect exercise frequency. In Phase 1, the number of exercise sessions did not differ between the group receiving a modest fixed-value payment per exercise session and the group receiving enhanced incentives to exercise more frequently (26 ± 3 versus 28 ± 2 sessions, respectively, p = 0.568). In Phase 2, the provision of an enhanced financial incentive to increase exercise duration resulted longer sessions, as the incentivized and standard payment groups exercised 38 ± 2 versus 29 ± 1 minutes per session (p = 0.002), respectively. In Phase 3, the effect of reducing the incentives on maintenance of exercise behaviors was inconclusive due to high participant withdrawal. Aerobic fitness increased 10% during Phase 1 but was unchanged thereafter. Insulin sensitivity and body composition were unchanged during the study. In conclusion, enhanced financial incentives increased the duration of exercise sessions, but had minimal effects on exercise participation. These results indicate that financial incentives hold promise in motivating previously sedentary, overweight/obese adolescents to exercise longer, but motivating them to sustain an exercise program remains the major challenge. TRIAL REGISTRATION: ClinicalTrials.gov NCT01848353.

Food choice considerations among American Indians living in rural Oklahoma: The THRIVE study.

In rural American Indian (AI) communities, access to affordable, healthy foods is often limited. Understanding AI food choice considerations when selecting foods, such as sensory appeal, cost, or health, is an important yet understudied topic for eliminating persistent AI health disparities. In partnership with the Chickasaw Nation and Choctaw Nation of Oklahoma, we administered a modified version of the Food Choice Values (FCV) Questionnaire to a cross-sectional sample of 83 AI patrons shopping at tribally-owned convenience stores ≥3 times per week. The FCV Questionnaire uses 25 items to assess eight FCV subscales related to buying and eating food, including sensory appeal; safety; accessibility; convenience; health/weight control; organic; tradition; and comfort. We compared mean scores for each FCV subscale by demographic groups using t-tests and ANOVA. We used confirmatory factor analysis (CFA) to examine how well the data from this population fit FCV subscale constructs. We then used cluster analysis, MANOVA, and discriminant analysis to characterize distinct segments of the population based on patterns of FCV endorsement. Appeal, safety, and access FCVs were most strongly endorsed across the sample. Prioritization of FCVs varied by age, gender, income, and education. Our cluster analysis identified four groups, or segments, each with distinct patterns of FCV endorsement: limited endorsement of any FCVs (23.3%); safety and sensory appeal (32.9%); health/weight control (17.8%); and broad endorsement of FCVs (26.0%). These groups varied by age and employment status. Findings from this analysis informed the design and implementation of a healthy retail intervention comprised of new healthful foods and beverages, product placement and marketing strategies within four tribally-owned and operated convenience stores. Public health interventions aimed at reducing nutrition-related disparities in rural AI populations may benefit from assessing food choice considerations.

Choctaw Nation Youth Sun Exposure Survey.

The incidence of skin cancer is rising among American Indians (AI) but the prevalence of harmful ultraviolet light (UVL) exposures among AI youth is unknown. In 2013, UVL exposures, protective behaviors, and attitudes toward tanning were assessed among 129 AI and Non-Hispanic (NHW) students in grades 8-12 in Southeastern Oklahoma. Sunburn was reported by more than half the AI students and most of the NHW students. One-third of AI students reported never using sunscreen, compared to less than one-fifth of NHW students, but racial differences were mitigated by propensity to burn. Less than 10% of students never covered their shoulders when outside. Girls, regardless of race, wore hats much less often than boys. Regardless of race or sex, more than one-fourth of students never stayed in the shade, and more than one-tenth never wore sunglasses. The prevalence of outdoor tanning did not differ by race, but more than three-fourths of girls engaged in this activity compared to less than half the boys. Indoor tanning was reported by 45% of the girls, compared to 20% of girls nationwide, with no difference by race. Nearly 10% of boys tanned indoors. Among girls, 18% reported more than ten indoor tanning sessions. Over one-quarter of participants agreed that tanning makes people look more attractive, with no significant difference by race or sex. Investigations of UVL exposures should include AI youth, who have not been represented in previous studies but whose harmful UVL exposures, including indoor tanning, may place them at risk of skin cancer.