The approach was based on Social Cognitve Theory13
, ecologic frameworks,14-16
consumer behavior models, along with various theories and concepts trying to explain politicial decision-making and public policy participation. illustrates the project’s evolution and identifies essential steps and key outcomes of the following five phases of the American Indian Healthy Eating Project.
Essential steps and key outcomes by phase of the American Indian Healthy Eating Project
Phase 1: Starting the Conversation
Using community-based participatory research,17,18
researchers at UNC established contacts in fall 2008 with members of the NC Commission of Indian Affairs (www.doa.state.nc.us/cia/
). The commission is a division of the NC Department of Administration created by the state’s General Assembly to advocate and assist its American Indian citizens. The commission suggested using Talking Circles (i.e., facilitated discussions commonly used among American Indian communities) to initiate conversations with tribal leaders.19
The NC American Indian Health Board (ncaihb.org/) was also a part of these initial discussions and helped develop a research ethics review process for the current study.
The modified Talking Circle was designed to initiate conversations about research ethics, as well as tribally led approaches to improving access to healthy, affordable foods within tribal communities. The one federally recognized tribe in the state opted out of the project, citing existing obesity prevention programs. The following seven state-recognized tribes invited us to host a modified Talking Circle and through these discussions agreed to participate in the American Indian Healthy Eating Project: Coharie Indian Tribe, Haliwa-Saponi Indian Tribe, Lumbee Tribe of NC, Occaneechi Band of the Saponi Nation, Meherrin Indian Tribe, Sappony, and Waccamaw Siouan Tribe.
Phase 2: Conducting Multidisciplinary Formative Research
Formative research was conducted by combining methodologies from public health, regional and urban planning, and public health law.
The project used modified Talking Circles, as well as key informant one-on-one interviews to build relationships and garner insights from tribal leaders and key stakeholders because a variety of qualitative approaches was a recommended approach to building trust and gathering input from American Indians.12
Qualitative research is also a recommended approach to gathering input on the local food environment, particularly from a variety of perspectives.20
Two community liaisons, along with community advisors from participating tribes, assisted with the development of the modified Talking Circle protocol. One community liaison faciliated all seven modified Talking Circles. This liaison, in addition to two additional community liaisons, recruited and faciliated all key informant interviews.
Tribal leaders were recruited for the Talking Circles and were identified by each tribe. The categories of key informants were chosen by community advisors, and the individuals recruited were identified by community advisors, tribal leaders, or responded to seeing a recruitment flyer. Common themes arising during the modified Talking Circle discussions included concerns about obesity among tribal youth, facilitators and barriers to purchasing and preparing affordable, healthy meals, and the role of the family, church, and tribal community in moving forward healthy-eating initatives.
Additional community insights were garnered from 40 key informants through one-on-one interviews with community and spiritual leaders (n=13); health professionals (n=8); Indian educators (n=10); food-sector professionals (n=5); and parents (n=4). Key informants who were also parents were asked about their insights on these issues as parents too, totaling 13 parent participants. The key informants added invaluable perspectives on how to utilize Native traditions and empower tribal leaders to improve access to healthy eating within tribal communities.
Food-environment assessments were conducted to identify the types and locations of all food retail outlets within each of the seven participating tribal communities.21
Information was gathered from secondary data sources (i.e., health county food-registry lists and state agriculture registry lists, Dun & Bradstreet,®
InfoUSA, and online Yellow Pages) and through a canvass by car of all primary roads within each of the communities. More than 1502 miles were canvassed; 711 food outlets were identified; evidence for validity of secondary food retail data sources was calculated; and inter-rater reliability of the methods was verified. The food landscapes of the tribal communities were characterized by country stores, gas stations with convenience stores, and fast-food restaurants.22
Two tribes had to travel more than 15 miles to reach the nearest full-service grocery store.
Public health law research
Informed by the qualitative and spatial preliminary findings, the American Indian Healthy Eating Project used methodologies from public health law research to identify the authority, as well as develop suggestions for feasible community changes that the participating tribes can implement to improve access to healthy, affordable foods within their tribal communities. Specifically, a systematic online collection and analysis of constitutions and websites of more than 500 tribes and urban Indian organizations in the U.S. was conducted. Three researchers coded with high agreement if and how constitutions, resolutions, and websites discussed food, nutrition, and health.
Preliminary findings indicate that tribal constitutions acknowledge the role of tribal government in health. For the more than 300 tribes with official websites, the health programs featured were the DHHS Indian Health Services and the U.S. Department of Agriculture Food Distribution Program on Indian Reservations. Some examples of obesity policies or resolutions were identified through website reviews such as Cherokee Nation’s Healthy Nation initiative (healthynation.cherokee.org/). To develop appropriate guidance for participating tribes, expertise was sought from several participating tribal leaders, Indian health law scholars, and relevant agencies that promulgate regulations regarding Indian health, home preservation and canning, farmers’ markets, and Pow Wow concessions (i.e., food sold at a special form of gathering of North American Native Americans).
Phase 3: Strengthening Partnerships and Tailoring Policy Options
To avoid historical and contemporary research ethics-related injustices experienced by American Indians,12, 23-25
the research and community partners worked informally and formally to regularly meet and discuss the data and how they should be disseminated to the participating tribes. Tribal leaders expressed their appreciation of the project’s frequent in-person and written communications. The participating tribes were generally led by volunteers who often had a full agenda of items to discuss at their Tribal Council meetings, so the project regularly created short project updates in written or oral form.
Through intermittent review of preliminary findings and of the proposed toolkit table of contents, several suggestions were provided by tribal liaisons and leaders in person, over the phone, and via e-mail that assisted the success of the dissemination of policy options within the tribal communities. For example, a number of tribes requested that the toolkits be visual, integrating pictures of and artwork by tribal members. A website was also regularly requested as a way to make accessible, for multiple people, the study results and suggested policy strategies.
During conversations with tribal leaders, the name of the project itself emerged to emphasize American Indian and healthy eating versus the original name that focused more on food access. Further, the tribes felt it was important to continue discussions with relevant community partners, especially spiritual and church leaders. Although the project’s main focus was healthy eating, to respond to frequent requests about ideas for promoting physical activity, the toolkit and project website provided ideas on improving active living in general and, more specifically, about creating or renovating places to be physically active within tribal communities.
Overall, tribal leaders expressed that they felt their opinions were valued since they were regularly asked for their opinions. More importantly, they felt their insights and ideas were reflected in the project as it evolved. The frequent engagement encouraged further interest and action on this project, along with other health endeavors among community partners and members.
Phase 4: Disseminating Community-Generated Ideas
A toolkit and web-based resources known as “Tools for Healthy Tribes” (americanindianhealthyeating.unc.edu/tools-for-healthy-tribes/) was created. The kit’s format and content was largely based on community insights on the local food environment and ways to stimulate action by their tribal leaders and at the grass-roots level, because community members felt dissemination should be leveraged to stimulate action, not just hand out information. Tribal leaders and members grew increasingly interested in the project as opportunities to disseminate the project’s process and products developed.
Leaders and members also appreciated the “empowering tone” and how dissemination materials focused on what tribes can do, rather than just describing a problem “they are all well aware of.” Showing the food-assessment results using maps was helpful but often not as interesting to community members who expressed that they “know where they eat and why.” Many leaders expressed more interest in hearing about low-cost, immediate approaches they can take to address both economic development and health.
Phase 5: Accelerating Action While Fostering Sustainability
Building awareness about the project and its potential within the seven participating tribes helped accelerate action while fostering sustainability. State-recognized tribes are not recognized by the federal government and thereby not permitted to participate in the DHHS Indian Health Services or the U.S. Department of Agriculture Food Distribution Program on Indian Reservations. Both of these programs increasingly provide opportunities, funding, and staff to focus on obesity prevention strategies. The support in data, technical assistance, as well as direct financial support of time, space, and staff, helped provide some critical funds to tribes to take action on healthy-eating strategies.
The Haliwa-Saponi Indian Tribe invested their grant support and additional grant funds awarded through another art project into their tribally owned and operated farmers’ market and started a community garden. These were great achievements considering state budget cuts at the time laid off the farmers’ market manager, who was instrumental in moving healthy-eating ideas forward. Finally, the American Indian Healthy Eating Project benefited from transitioning into Healthy, Native North Carolinians, a capacity-building project funded by Kate B. Reynolds Charitable Trust. This initiative directly supports the seven tribes, as well as the four urban Indian organizations in that state to develop, implement, and evaluate feasible and sustainable community changes regarding healthy eating and active living. This tribal government–state government–university collaborative project also provides support and technical assistance to strengthen capacity for meaningful, sustainable, and measurable changes.