Engaging Tribal Leaders in an American Indian Healthy Eating Project Through Modified Talking Circles
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Fam Community Health Vol. 34, No. 3, pp. 202–210 Copyright C 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Engaging Tribal Leaders in an American Indian Healthy Eating Project Through Modified Talking Circles Sheila Fleischhacker, PhD, JD; Maihan Vu, DrPH; Amy Ries, PhD; Ashley McPhail, BS Frequently used in the American Indian (AI) community and proven to be a valuable tool in health research, a Talking Circle is a method used by a group to discuss a topic in an egalitarian and nonconfrontational manner. Using community-based participatory research, a modified Talking Circle format was developed for engaging tribal leaders in an American Indian Healthy Eating Project in North Carolina. The culturally informed formative research approach enabled us to garner project support from 7 tribes, as well as insights on developing planning and policy strategies to improve access to healthy eating within each of the participating communities. Key words: American Indians, community engagement, food environment, Talking Circles Author Affiliation: Center for Health Promotion and MERICAN INDIANS (AIs)∗ endure a Disease Prevention (Drs Fleischhacker and Vu) and disproportionate risk of developing Department of Nutrition (Dr Ries), University of North A Carolina–Chapel Hill; and Cumberland County Health diet-related diseases of public health con- Department, Fayetteville, North Carolina cern, such as diabetes, obesity, and certain (Ms McPhail). cancers.1 Illustrative of these disparities, Type This project would not have been possible without the support from Coharie Tribe, Haliwa-Saponi In- 2 diabetes is considered a common disease dian Tribe, Lumbee Tribe, Meherrin Indian Tribe, for AI children older than 10 years.2 As Occaneechi Band of Saponi Nation, Sappony, and Wac- young as 4-year-olds, AI preschoolers in a re- camawSiouanTribe.WethanktheNorthCarolina Commission of Indian Affairs; specifically, Gregory cent cross-sectional, nationally representative Richardson, Missy Brayboy, and Dr Robin Cummings. study were found to have the highest preva- We greatly appreciate the time and thoughts shared by lence of obesity among 5 major racial/ethnic all Talking Circle participants. Our community liaisons and advisors were tremendous: Dr Ronny Bell, Tabatha groups (American Indian/Native Alaskan, Brewer, Sandra Bronner, Sherri Brooks, Randi Byrd, 31.2%; Hispanic, 22.0%; non-Hispanic black, Candice Collins, Dorothy Crowe, Vivette Jeffries-Logan, 20.8%; non-Hispanic white, 15.9%; and Asian, Dr Clara Sue Kidwell, Eric Locklear, Tony V. Locklear, 3 Faye Martin, Devonna Mountain, Julia Phipps, Marty 12.8%). The myriad of factors contributing Richardson, and John Scott-Richardson. Jason Evans to AI diet-related health disparities include crafted our Talking Stick. poverty; genetics; dietary changes over time; Support for this project was provided by Healthy Eat- and, in some cases, government policies.4,5 ing Research, a national program of the Robert Wood Johnson Foundation (RWJF) and a National Institute of Health (NIH) University of North Carolina Interdis- ∗Throughout this brief, the term, ,is ciplinary Obesity Training Grant (T 32 MH75854-03). American Indian The content is solely the responsibility of the authors used to describe both American Indians and Alaska Na- and does not necessarily represent the official views of tives. According to the US Census 2000, this collective cat- the RWJF or NIH. egorization includes individuals who self-identified that Correspondence: Sheila Fleischhacker, PhD, JD, Cen- they have origins in any of the original peoples of North ter for Health Promotion and Disease Prevention, Uni- and South America (including Central America). An esti- versity of North Carolina-Chapel Hill, Chapel Hill, NC mated 4.3 million individuals indicated this race/ethnicity 27599 (sheilafl[email protected]). category and this included 2.4 million people who only DOI: 10.1097/FCH.0b013e31821960bb reported American Indian and Alaska Native as their race. 202 Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Engaging Tribal Leaders in an American Indian Healthy Eating Project 203 Environmental and policy strategies can are in various stages of implementing, eval- promote healthy eating and reduce diet- uating, and sustaining interventions aiming to related health disparities.6-8 But research increase the availability and consumption of and practice has predominantly focused on healthy food and beverage items.24-26 Forma- understanding individual behavior change tive work indicated that some tribal members rather than evaluating environmental and traveled as far as 30 miles off the reservation to policy factors.9 Despite this oversight, ev- access a diverse supply of affordable, healthy idence has been mounting over the last foods.26 Even less is known about the food en- 10 years demonstrating associations be- vironment for AIs living off reservations and tween diet-related health disparities and the outside of tribal areas—estimated to be as high local food environment.10-12 Various def- as 64% of the AI population.27 The US Census initions exist; but generally, community- Bureau noted when making this estimation level measures of the food environment in- that the number of AIs living off reservation clude food stores, restaurants, schools, and and in other rural and urban Indian communi- worksites.13 Besides the identification and ties is difficult to determine in part because of categorization of food outlets, measures of how reservations are defined and how the AI the food environment take into account the population is tracked. Another challenge for availability, accessibility, and affordability of understanding AI diet-related health dispari- healthy foods and beverages (eg, fruits and ties is the Indian Health Services (Pub. L. No. vegetables), along with exposure to calorie- 67-85, §13; Pub. L. No. 94-437; and Pub. L. dense, nutrient-poor foods and beverages (eg, No. 111-148, §10221) and the Food Distribu- sugar-sweetened beverages).14 Research ex- tion Program on Indian Reservations (Pub. L. amining associations between public health No. 93-86, §4(b); Pub. L. No. 106-171, §4; and and the food environment have found that Pub. L. No. 110-234, §4(b)) do not provide ser- greater proximity to chain grocery stores is vices to or data on AIs who are not members related to health outcomes, such as lower of federally recognized tribes. The US Con- body mass index and lower prevalence of stitution explicitly mentions the relationship obesity.15,16 Higher obesity prevalence has between the US federal government and In- been found in areas with increased access dian tribes (US Const., art. 1, §8). Through to convenience stores or smaller grocery this special government-to-government rela- stores.17 Compared with chain grocery sto- tionship, federally recognized tribes possess ries, smaller food outlets tend to stock less certain inherent rights of self-government and fruits and vegetables and more processed entitlement to federal benefits, services, and foods.18 Associations between obesity and protections (United States v Sandoval, 231 access to fast food restaurants has been US 28 (1913)). Under federal law and for their reported.19 Communities of lower socioeco- internal government purposes only, state gov- nomic status, with a higher proportion of eth- ernments can recognize Indian tribes (Indian nic minorities, or in rural settings may be at Arts and Crafts Act, 25 USC §305e (d)). The risk for living further away from chain grocery number of state-recognized tribes varies de- stores and closer to fast food restaurants and pending on source but at least 16 states have convenience stores.20-22 recognized tribes even though the federal No studies, to our knowledge, have sys- government has not.28 Therefore, little is temically conducted a rigorous assessment of known about the food environment within the food environment in AI settings, despite AI settings, especially for AIs living off reser- increased burdens of diet-related chronic vations and/or not members of federally rec- diseases and studies calling for increased ognized tribes. attention to context within AI settings.3,23 Re- Addressing these research gaps requires search is limited to 3 federally recognized employing more culturally and tribally spe- tribes in Arizona and New Mexico, which cific strategies and exploring the role of mixed Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 204 FAMILY &COMMUNITY HEALTH/JULY–SEPTEMBER 2011 method qualitative approaches.23 These rec- concentration of AIs east of the Mississippi ommendations came from the school-based AI river.29,30 In fact, more than 122 425 Ameri- obesity prevention program known as Path- can Indian/Alaskan Native individuals live in ways. After 9 years, the Pathways program North Carolina.31 American Indians live in reported positive changes in diet but found each of the state’s counties and three-fourths little impact on obesity. The Pathways investi- of North Carolina’s American Indian popula- gators noted great variability among the 7 par- tion is concentrated in 12 counties.29,30 Eight ticipating tribes’ access to resources, social state-recognized tribes and 4 urban organiza- norms, and rules about food and consump- tions live in North Carolina. The federal gov- tion within the household. Because of the ernment fully recognizes one of these 8 tribes variability of each participating tribes’ circum- and