Yéego Gardening! A Community Garden Intervention to Promote Health on the Navajo Nation

Process evaluation of the Yéego! Program to increase healthy eating and gardening among American Indian elementary school children

BACKGROUND

American Indian children are at increased risk for obesity and diabetes. School-based health promotion interventions are one approach to promoting healthy behaviors to reduce this risk, yet few studies have described their implementation and fidelity. We conducted a qualitative process evaluation of the Yéego! Healthy Eating and Gardening Program, a school-based intervention to promote healthy eating among Navajo elementary school children. The intervention included a yearlong integrated curriculum, as well as the construction and maintenance of a school-based garden.

METHODS

Our process evaluation included fidelity checklists completed by program staff and qualitative interviews with program staff and classroom teachers after the intervention was implemented. We used content analysis to identify themes.

RESULTS

We identified several themes related to evidence of delivery adherence, program satisfaction, and lessons learned about delivery. Intervention staff followed similar procedures to prepare for and deliver lessons, but timing, teaching styles, and school-level factors also impacted overall implementation fidelity. Teachers and students had positive perceptions of the program, especially lessons that were highly visual, experiential, and connected to Navajo culture and the surrounding community. Teachers and program staff identified ways to enhance the usability of the curriculum by narrowing the scope, relating content to student experiences, and aligning content with school curriculum standards.

CONCLUSIONS

The program was implemented with moderately high fidelity across contexts. We identified areas where modifications could improve engagement, acceptability, efficacy, and sustainability of the program. Our results have implications for the evaluation and dissemination of school-based health interventions to promote healthy eating among children, especially in American Indian communities.

Using environmental health dialogue in a Diné-centered approach for individualized results reporting in an environmental exposure study following the Gold King Mine Spill

BACKGROUND

On August 5, 2015, the Gold King Mine Spill (GKMS) resulted in 3 million gallons of acid mine drainage spilling into the San Juan River impacting the Diné Bikeyah (traditional homelands of the Navajo people). The Gold King Mine Spill Diné Exposure Project was formed to understand the impacts of the GKMS on the Diné (Navajo). Reporting individualized household results in an exposure study is becoming more common; however, materials are often developed with limited community input with knowledge flowing in one direction - from researcher to participant. In this study we examined the development, dissemination, and evaluation of individualized results materials.

METHODS

In August 2016, Navajo Nation Community Health Representatives (Navajo CHRs) sampled household water, dust, and soil, and resident blood and urine for lead and arsenic, respectively. From May-July 2017, iterative dialogue with a wide range of community partners and a community focus groups guided the development of a culturally-based dissemination process. In August 2017, Navajo CHRs reported individualized results and they surveyed the participants on the report-back process at that time.

RESULTS

All of the 63 Diné adults (100%) who participated in the exposure study received their results by a CHR in person and 42 (67%) completed an evaluation. Most of those participants (83%) were satisfied with the result packets. Respondents ranked the individual and overall household results as the most important information they received (69% and 57%, respectively), while information on metals exposures and their health effects were the least helpful.

CONCLUSIONS

Our project illustrates how a model of environmental health dialogue, defined by iterative, multidirectional communication among Indigenous community members, trusted Indigenous leaders, Indigenous researchers, non-Indigenous researchers, can improve reporting individualized study results. Findings can inform future research to encourage multi-directional environmental health dialogue to craft more culturally responsive and effective dissemination and communication materials.

Acceptability and Feasibility of Community Gardening Interventions for the Prevention of Non-Communicable Diseases among Indigenous Populations: A Scoping Review

Compared with non-Indigenous populations, Indigenous populations experience worse health across many outcomes, including non-communicable diseases, and they are three times more likely to live in extreme poverty. The objectives were to identify (1) the content, implementation, and duration of the intervention; (2) the evaluation designs used; (3) the outcomes reported; and (4) the enablers and the challenges. Using the PRISMA-ScR guidelines, a search of research databases and grey literature was conducted. Seven studies met the inclusion criteria. Papers reported on acceptability, nutrition knowledge, fruit and vegetable intake, self-efficacy, motivation, and preference concerning fruit and vegetable, diet, and gardening. No study measured all outcomes. All papers reported on acceptability, whether implicitly or explicitly. The evaluation used mostly pre- and post-intervention assessments. The effect of gardening on nutrition and gardening knowledge and fruit and vegetable intake was inconclusive, and was related to a general lack of robust evaluations. Applying the He Pikinga Waiora Framework, however, revealed strong evidence for community engagement, cultural centeredness, integrated knowledge translation and systems thinking in increasing the acceptability and feasibility of gardening in Indigenous communities. Despite environmental challenges, the evidence signaled that gardening was an acceptable intervention for the Indigenous communities.

Adapting a cooking, food budgeting and nutrition intervention for a rural community of American Indians with type 2 diabetes in the North-Central United States

American Indian (AI) communities experience persistent diabetes-related disparities, yet few nutrition interventions are designed for AI with type 2 diabetes or address socio-contextual barriers to healthy eating. We describe our process of adapting the evidence-based Cooking Matters® program for use by AI adults with type 2 diabetes in a rural and resource-limited setting in the North-Central United States. We conducted three focus groups with AI adults with diabetes to (i) identify Cooking Matters® adaptations and (ii) gather feedback on appropriateness of the adapted intervention using Barrera and Castro's cultural adaptation framework. Transcripts were coded using an inductive, constant comparison approach. Queries of codes were reviewed to identify themes. Contextual considerations included limited access to grocery stores and transportation barriers, reliance on government food assistance and the intergenerational burden of diabetes. Adaptations to content and delivery included incorporating traditional and locally available foods; appealing to children or others in multigenerational households and prioritizing visual over written content. Our use of Barrera and Castro's framework adds rigor and structure to the cultural adaptation process and increases the likelihood of future intervention success. Other researchers may benefit from using this framework to guide the adaptation of evidence-based interventions in AI communities.

Food Insecurity and Associated Challenges to Healthy Eating Among American Indians and Alaska Natives With Type 2 Diabetes: Multiple Stakeholder Perspectives

Objective: To examine stakeholder perspectives on food insecurity and associated challenges to healthy eating among American Indian and Alaska Native (AI/AN) adults with type 2 diabetes (T2D). Methods: Focus groups and interviews were conducted with purposively selected stakeholders: AI/ANs with T2D, their family members, healthcare administrators, nutrition and diabetes educators, and national content experts on AI/AN health. Two coders analyzed transcripts using the constant-comparison method. Results: Key themes included (1) rural- and urban-dwelling AI/ANs experience different primary food security and associated challenges; (2) factors contributing to food insecurity extend beyond cost of healthy food; and (3) barriers to consuming fresh, healthy food include cost, preparation time, limited cooking knowledge, and challenges with gardening. Discussion: Resources for AI/ANs with T2D who experience food insecurity and associated challenges to healthy eating should be tailored based on urban versus rural location and should address cost and other barriers to consumption of fresh fruits and vegetables.

Can Community Gardens with Workshops Increase Gardening Behavior? A Navajo Wellness Collaboration

This project evaluated the potential efficacy of a community gardening intervention on the Navajo Nation to increase gardening and healthy eating behaviors, which are potentially important in preventing obesity and related health conditions. Rates of obesity are high among American Indians, including those living on Navajo Nation land. Eating fresh fruits and vegetables is part of healthy eating. However, availability and access to fresh fruits and vegetables are severely limited due to distance and cost. One way to increase both availability and consumption of fresh fruits and vegetables is through community gardening, yet many on the Navajo Nation have limited knowledge and capacity to garden.

METHODS

We used a quasi-experimental pre-post study design to estimate the effect of a community gardening intervention. Primary outcomes of interest were gardening frequency and fruit and vegetable consumption. Community gardens were constructed and planted in two communities on the Navajo Nation. In addition, a series of gardening workshops were held in each community. Community members were recruited to complete surveys at time points before and after the workshops. The time between baseline and follow-up was approximately one year.

RESULTS

We surveyed 169 participants at one time point at least, across both communities, and 25 of these participated in the gardening workshops. Within the 169, there was a cohort of 32 participants completing both baseline and follow-up surveys. For this cohort, interest in gardening increased from 78% to 97% (p=0.014), but none of the changes in gardening self-efficacy, knowledge or gardening frequency reached statistical significance. There were no measurable changes in reported fruit and vegetable consumption, self-efficacy or knowledge. Overall, the reported financial barriers to gardening increased from baseline to follow-up from 4.6 to 5.5 (p=0.035). Among those who completed follow-up, those who attended at least one workshop gardened more frequently than those who did not attend any workshops (21 times per month compared to 10 times per month (p=0.065).

CONCLUSION

Despite enthusiasm for the community garden in both the communities studied and the increased interest in gardening, workshop attendance and participant retention in the study were low. These factors limited our ability to evaluate the potential efficacy of the intervention on gardening and healthy eating behaviors. Nonetheless, we found some evidence that participating in gardening workshops may lead to increased gardening frequency. Future studies should augment the intervention to include explicit efforts to reduce barriers to long term engagement and extend intervention reach.

Characterizing the local food environment and grocery-store decision making among a large American Indian community in the north-central USA: qualitative results from the Healthy Foods Healthy Families Feasibility Study

OBJECTIVE

Perceptions of social-contextual food environments and associated factors that influence food purchases are understudied in American Indian (AI) communities. The purpose of the present study was to: (i) understand the perceived local food environment; (ii) investigate social-contextual factors that influence family food-purchasing choices; and (iii) identify diet intervention strategies.

DESIGN

This qualitative study consisted of focus groups with primary household shoppers and key-informant interviews with food retailers, local government food assistance programme directors and a dietitian. An inductive, constant comparison approach was used to identify major themes.

SETTING

A large AI reservation community in the north-central USA.

PARTICIPANTS

Four focus groups (n 31) and seven key-informant interviews were conducted in February and May 2016.

RESULTS

Perceptions of both the higher cost of healthy foods and limited access to these foods influenced the types of foods participants purchased. Dependence on government assistance programmes and the timing of benefits also contributed to the types of foods purchased. Participants described purchasing foods based on the dietary needs and preferences of their children. Suggestions for improving the purchase and consumption of healthy foods included: culturally relevant and family-centred cooking classes and workshops focused on monthly food budgeting. Participants also emphasized the importance of involving the entire community in healthy eating initiatives.

CONCLUSIONS

Cost and access were the major perceived barriers to healthy eating in this large rural AI community. Recommended interventions included: (i) family-friendly and culturally relevant cooking classes; (ii) healthy food-budgeting skills training; and (iii) approaches that engage the entire community.

Community Readiness Model for Prevention Planning: Addressing Childhood Obesity in American Indian Reservation Communities

INTRODUCTION

The community readiness model (CRM) is a stage-matched assessment protocol to assess community readiness to address a public health issue. To identify appropriate, culturally sensitive, and community-specific intervention strategies for preventing obesity in children, researchers, and community members formed a partnership to address childhood obesity within one American Indian Reservation.

METHODS

The CRM guided 30 interviews in five communities to direct the team's efforts in addressing obesity among children residing on the reservation. Interviews were scored across six dimensions on an anchored scale of one through nine; scores were then averaged to determine an overall readiness score for each community. A thematic analysis of interview responses aided in interpretation of the readiness scores and identified areas for prevention planning and intervention development.

RESULTS

The overall community readiness score for the communities was 2.9 (SD = 0.5), which falls between 2 (denial/resistance) and 3 (vague awareness) on the anchored rating scale. The thematic analysis resulted in a hierarchal classification scheme with six broad themes that corresponded to the CRM dimensions and 13 sub-themes.

DISCUSSION

The low readiness scores directed the team to implement corresponding strategies to increase awareness, while the thematic analysis suggested that action-based approaches might also be appropriate. The narrow range of scores suggest that community-wide assessments may be sufficient unless specific information is needed for each region of the community. The CRM may be an effective way to assess community readiness to address childhood obesity on an American Indian Reservation.

Metal(loid)s in Cucurbita pepo in a Uranium Mining Impacted Area in Northwestern New Mexico, USA

More than 500 unreclaimed mines and associated waste sites exist on the Navajo Nation reservation as a result of uranium (U) mining from the 1940s through the 1980s. For this study, the impact of U-mine waste on a common, locally grown crop food was examined. The goal of this site-specific study was to determine metal(loid) concentration levels of arsenic (As), cadmium (Cd), cesium (Cs), molybdenum (Mo), lead (Pb), thorium (Th), U, vanadium (V) and selenium (Se) in Cucurbita pepo Linnaeus (squash), irrigation water, and soil using inductively coupled plasma-mass spectrometry. The concentrations of metal(loid)s were greatest in roots > leaves > edible fruit (p < 0.05), respectively. There were significant differences between metal(loid)s in squash crop plot usage (<5 years versus >30 years) for V (p = 0.001), As (p < 0.001), U (p = 0.002), Cs (p = 0.012), Th (p = 0.040), Mo (p = 0.047), and Cd (p = 0.042). Lead and Cd crop irrigation water concentrations exceeded the United States Environmental Protection Agency (USEPA) Maximum Contaminant Levels for drinking water for those metals. Edible squash concentration levels were 0.116 mg/kg of As, 0.248 mg/kg of Pb, 0.020 mg/kg of Cd, and 0.006 mg/kg of U. Calculated human ingestion of edible squash did not exceed Provisional Tolerable Weekly Intake or Tolerable Upper Limit levels from intake based solely on squash consumption. There does not appear to be a food-ingestion risk from metal(loid)s solely from consumption of squash. Safer access and emphasis on consuming regulated water was highlighted. Food intake recommendations were provided. Continued monitoring, surveillance, and further research are recommended.

Group Gardening in a Native American Community: A Collaborative Approach

Background. There is increasing awareness of the potential health benefits derived from gardening activities. Gardening practices are gaining momentum in Native American (NA) communities, yet no efforts have applied a community-based participatory research approach within a social-ecological model to understand opportunities and barriers for group gardening on an American Indian reservation. Objectives. The primary objective of this study was to identify influences across social-ecological levels that promote or hinder the implementation of community gardens and use of locally grown foods on the reservation; a secondary objective was to assess the feasibility of implementing a group gardening program for NA adults and potential of collecting health outcome measures. Method. Community members and academicians collaborated to develop and implement this study. The study (1) conducted interviews with key stakeholders to identify influences across social-ecological levels that promote or hinder the implementation of community gardens and using locally produced food and (2) assessed the physical and psychological well-being of NA adults participating in a group gardening feasibility study. Results. Major factors influencing using locally grown food and community gardens that emerged from nine interviews included knowledge/experience, self-efficacy, Elders, traditional ways, community values, generational gaps, and local tribal policies. Twenty NA adults with prediabetes or diabetes participated in the feasibility study. The Profile of Mood States Inventory showed consistently positive change in score for participants in the group gardening program versus the comparison group. Conclusions. This study identified key influences for growing locally grown food, and approaches for implementing group gardening programs for NA adults.