The Cherokee Choices/REACH 2010 program includes three main components: elementary school mentoring, worksite wellness for adults, and church-based health promotion. A social marketing component, including television advertisements and a television documentary series, supports the three components. The program is based on core American Indian values to maximize improvements to lifestyle behaviors and reduce risk of chronic disease.
During the first year of the program, team members conducted formative research, created coalitions, and developed an action plan. The formative research included in-depth interviews, a series of focus groups, and a review of epidemiological data. The focus groups collected information on the community's perceptions of diabetes and related health issues and their ideas and opinions for the program's design and initiatives. The research emphasized the prevention of type 2 diabetes, particularly among children. Recognizing that successful interventions for children need to include parents, the team identified the elementary school, worksites, and local churches as gateways for the intervention components. Evaluation of Cherokee Choices is based on the following REACH 2010 evaluation criteria: 1) targeted action, 2) community and systems change, and 3) change among change agents.
Meetings with tribal agencies and community groups facilitated planning and capacity building, which led to development of the community action plan. The plan embraced strategies to 1) engage individuals interested in a school intervention for children, 2) target tribal employees interested in losing weight and improving health, and 3) create opportunities for increased physical activity and nutritional information among church members.
Elementary school mentoring program
This program was conducted at Cherokee Elementary School. The school is the one elementary school in the community, and it is operated by the EBCI. It includes grades kindergarten through six and has approximately 600 students. A team of four paid community mentors who met education and experience criteria worked with elementary school children and staff to increase awareness of diabetes as a serious health issue, promote physical activity and enhance knowledge about good nutrition during the school day and after school, teach stress-management techniques and coping skills, develop teachers as healthy role models through faculty fitness activities, and encourage healthy choices and general well-being with an overall objective to reduce the risk of diabetes. The mentors developed lesson plans that they implemented in the classroom to enhance self-esteem, cultural pride, conflict resolution, emotional well-being, and health knowledge. The mentors participated during class time, lunch, and recess. In addition, they developed a weekly after-school program to enhance teamwork and cultural awareness and increase physical activity.
The school component collected quantitative and qualitative data to contextualize responses and issues raised during the mentoring process. Students participated in an annual survey on issues of self-concept, perceived stress, cultural awareness, peer relations, and eating habits. Quantitative survey data were entered into SPSS 13.0 (SPSS Inc, Chicago, Ill) for analysis. The mentors also maintained daily logs in which they recorded interactions and exchanges between mentors and students. The narratives were entered into Atlas.ti (Atlas.ti Scientific Software Development GmbH, Berlin, Germany) a qualitative software program that systematically codes and catalogs for analyses. Mentors and program evaluation staff discussed patterns and themes that emerged from interviews to plan future program initiatives.
Worksite wellness for adults
The worksite wellness program involved teams of tribal workers who were challenged to increase time spent in physical activity and participate in weekly educational and support activities. Tribal offices competed for prizes earned by attendance at healthy cooking demonstrations, classes on exercise techniques, nutritional assessments, supermarket tours, and stress-management workshops in addition to meeting physical activity and dietary change goals. Nutritionists, dietitians, and fitness workers conducted activities. Data were collected at baseline and follow up. Participants described their eating and physical activity habits through initial personal interviews conducted by Cherokee Choices program staff. Clinical measurements were taken at the local diabetes clinic. Measures included fasting blood glucose, blood pressure, and fasting lipid panel (total cholesterol, high-density lipoprotein, low-density lipoprotein, and triglycerides). Measurement of height, weight, and body fat percentage was recorded within a week of program enrollment. Body fat was measured with a Futrex–6100XL body-fat analyzer (Spencer Medical Inc, Rancho Santa Margarita, Calif), which can measure between 3% and 45% of body fat. Follow-up measures and interviews on goal attainment were conducted every 6 months. Data were entered into SPSS 13.0 (SPSS Inc, Chicago, Ill).
With this baseline information, services were developed and conducted at worksites. In addition, Cherokee Choices became active in health policy change with support from program managers, supervisors, and the EBCI chief, who attends many Cherokee Choices functions and celebrations.
The first group of worksite wellness participants began in June 2002 with two teams. During the next 2 years, seven more teams were formed for three additional 4-month challenges. More teams were added to waiting lists. A leader was selected for each team; the role of the team leader was to keep a record of weekly exercise minutes and participation in educational and support activities. Assessment data were entered into Access and ultimately translated into SPSS 12.0 (SPSS Inc, Chicago, Ill) for final analyses. Data collection methods include scheduled interviews, informal interviews, and client histories. Of 86 individuals who participated in the program for at least 1 year from June 2002 to June 2005, all but one continued to participate in the worksite program. Others joined the maintenance program for at least 1 year.
Church wellness program
Nutritionists, dietitians, and fitness workers helped members of five churches participate in activities to improve diet and food preparation, raise awareness of tribal health-related services, and increase physical activity such as walking. The churches provided venues for healthy cooking demonstrations, exercise classes, and stress management lessons. Each church selected a team leader, and exercise classes were conducted in small group sessions. In addition, from November 2004 through April 2005, five churches participated in the Walk to Jerusalem, in which congregations organized walking groups and recorded their time and mileage walked. The goal of the program was to walk the equivalent distance from Cherokee, NC, to Jerusalem (approximately 8500 miles); progress was tracked on a map displayed prominently in each church. Each church member was given a pedometer to keep track of mileage, and incentives such as exercise videos, cookbooks, and weights were provided. Each participant filled out a preintervention and postintervention survey. Data included demographic information and queries on health, exercise time per week, and self-reports of daily water and fruit and vegetable intake.