All systems are interrelated: Multilevel interventions with indigenous communities

Prevalence of indoor air pollutants from First Nation homes in North Central British Columbia, Canada

Poor indoor air quality poses significant health risks. This study addresses the gap in knowledge regarding the prevalence of indoor air pollutants in remote and rural First Nation communities in north-central British Columbia, Canada. Dust samples from 75 homes were collected and analysed for house dust mites, pet allergens, mould antigens, and bacterial endotoxins. Indoor air quality parameters, including carbon monoxide, carbon dioxide, particulate matter, temperature, and humidity, were measured. A detailed questionnaire on household characteristics and potential pollutant sources was administered. Homes exhibited exposure to multiple pollutants, with wood stove smoke identified as a primary source. Felis domesticus (cat allergen) and Canis familiaris (dog allergen) were prevalent, with detectable levels in 64% and 60% of homes, respectively. Bacterial endotoxins were present in all households. One-third of homes exceeded recommended thresholds for 3 or more pollutants. This study provides critical insights into the prevalence and magnitude of indoor air pollutants, contributing to a broader initiative to characterise respiratory health in First Nations communities. While many homes in First Nations communities had acceptable air quality, one-third of homes exceeded thresholds for 3 or more pollutants. The results can guide ongoing community efforts to address housing concerns and advocate for increased federal funding.

Relationship Between Food Insecurity and Healthy Eating Behavior for Gestational Diabetes Risk Reduction Among American Indian and Alaska Native Adolescent and Young Adult Females: A Qualitative Exploration

OBJECTIVE

To understand the perspectives of key informant experts regarding the relationship between food insecurity and gestational diabetes mellitus risk reduction behaviors among young American Indian and Alaska Native females.

METHODS

Participants were adult key informants with expertise in food/nutrition and health within Tribal communities (N = 58) across the US. Data were collected through 1:1 interviews using a semistructured moderator guide and analyzed using thematic content analysis methods.

RESULTS

Three themes included (1) diet and nutrition habits are formed through intergenerational food preferences and are driven by lasting implications of colonization; (2) young people are influenced by what their peers eat and the food environment, including outside of the home; and (3) the methods used to understand household food insecurity and nutrition habits in the parent study were likely limited.

CONCLUSIONS AND IMPLICATIONS

Findings provide guidance as to where nutrition education and interventions may best support young Native females.

Multilevel Interventions Targeting Obesity: State of the Science and Future Directions

A seminal report, released in 2001 by the Institute of Medicine, spurred research on the design, implementation, and evaluation of multilevel interventions targeting obesity and related behaviors. By addressing social and environmental factors that support positive health behavior change, interventions that include multiple levels of influence (e.g., individual, social, structural) aim to bolster effectiveness and, ultimately, public health impact. With more than 20 years of multilevel obesity intervention research to draw from, this review was informed by published reviews (n = 51) and identified intervention trials (n = 103), inclusive of all ages and countries, to elucidate key learnings about the state of the science. This review provides a critical appraisal of the scientific literature related to multilevel obesity interventions and includes a description of their effectiveness on adiposity outcomes and prominent characteristics (e.g., population, setting, levels). Key objectives for future research are recommended to advance innovations to improve population health and reduce obesity.

A Hybrid Pragmatic and Factorial Cluster Randomized Controlled Trial for an Anti-racist, Multilevel Intervention to Improve Mental Health Equity in High Schools

Systemic racism is pervasive in US society and disproportionately limits opportunities for education, work, and health for historically marginalized and minoritized racial and ethnic groups, making it an urgent issue of social justice. Because systemic racism is a social determinant of health prevalent across multiple social and institutional structures, it requires multilevel intervention approaches using effective designs and analytic methods to measure and evaluate outcomes. Racism is a fundamental cause of poor health outcomes, including mental health outcomes; thus, mental health services and programs that address racism and discrimination are key to promoting positive mental health of racial and ethnic minority youth. While multilevel interventions are well-suited for improving outcomes like youth mental health disparities, their evaluation poses unique methodological challenges, requiring specialized design and analytic approaches. There has been limited methodological guidance provided to researchers on how to test multilevel interventions using approaches that balance methodological rigor, practicality, and acceptability across stakeholder groups, especially within communities most affected by systemic racism. This paper addresses this gap by providing an example of how to rigorously evaluate a hypothetical, theoretically based, multilevel intervention promoting mental health equity in three US school systems using an anti-racist approach intervening at the macro- (i.e., school system), meso- (i.e., school), and micro- (i.e., family and student) levels to improve mental health in adolescents. We describe the design, sample size considerations, and analytic methods to comprehensively evaluate its effectiveness while exploring the extent to which the components interact synergistically to improve outcomes. The methodological approach proposed can be adapted to other multilevel interventions that include strategies addressing macro-, meso-, and micro-levels of influence.

"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.