Community Change Project Kent County, Michigan American Indians and Obesity

1. Community Change ProjectKent County, MichiganAmerican Indians and Obesity Hulwick, B. Johns, A. Marchenko, O. Ranstadler, L. Williams, S.

2. “The power of intuitive understanding will protect you from harm until the end of your days.” Lao-Tzu

3. One role of the public health nurse is to address underserved and at-risk populations to remedy health disparities.This PowerPointwill address the health disparity of obesity within the American Indian(AI) community of Kent County, Michigan. Introduction

4. Analysis: Statistics Nationwide epidemic: 35.7% of American adults and 17% of children are obese (Centers for Disease Control and Prevention [CDC], 2012a) State of Michigan: 30.9% of Michigan adults are obese (CDC, 2012b) Kent County, Michigan: 30% of adults are obese (Kent County Health Department, 2012) American Indian population nationwide: 39.6% of adults are obese (Office of Minority Health [OMH], 2012) According to the Kent County Needs Assessment of 2012, Kent County American Indian youth are most at risk for being obese.

5. Obesity: Contributing Factors Biological/Cultural Genetics “Thrifty gene” hypothesis (Neel, 1962) Lack of culturally relevant interventions (Brown, Harris, Harris, Parker, Ricci, & Noonan, 2010) Loss of cultural identity (Brown et al., 2010) AI lack of trust of governmental institutions (including healthcare) (U.S. Commission on Civil Rights, 2004) Lack of AI mental health practitioners (U.S. Department of Health and Human Services [USDHHS], 2001)

6. Obesity: Contributing Factors Social Determinants Sedentary lifestyle (Hodge, Cantrell, & Kim, 2011) Poverty (CDC, 2010) Poor eating habits/reduced access to healthy food (Kent County Health Department, 2011) Health care access/Services (Kent County Health Department, 2011) Education: AI adults are significantly more likely to have below basic health literacy compared to white counterparts (National Indian Health Board, n.d.). AI high school graduation rate is 64.2% (HealthyPeople 2020, 2012)

7. The Ecological Model “Based on the belief that all processes occurring within individual people and their environment should be viewed as interdependent. It suggests that behavior change in people needs to be considered in a broader social context, including developmental history, psychological characteristics, interpersonal relationships, physical environment, and culture” (Harkness & DeMarco, 2012, p. 79)

8. The Ecological Model (cont.) AI native land → European colonization → loss of cultural identity = social determinants: poverty lack of education mental illness lack of trust Westernization (USDHHS, 2001)

9. Existing Resources Kent County Health Department and website. Individual web resources include the following pages: Health Equity, Health Promotion, Health Education, Health Improvement and School Wellness (see https://www.accesskent.com) SEVA Foundation (SEVA.org) Gun Lake Band Health and Human Services Director: Phyllis Davis (Michigan Diabetes Prevention and Control Program, 2009; Match-E-Be-Nash-She-Wish Band of Pottawatomi: Gun Lake Tribe, 2004) Gun Lake Band Diabetes Outreach Worker: Carol Barker (Weick, 2009) Like the rest of the nation, Kent County resources do not address the complexity of the causes of AI health disparities and do not provide adequate service to this community.

10. What Other Disciplines are Involved? Schools Hospitals Social Services Community Mental Health Tribal governments

11. PROBLEM STATEMENT There is increased risk of obesity among the AI population in Kent County, Michigan related to genetic factors, reduced access to healthy food, lack of culturally relevant interventions, and loss of cultural identity, as demonstrated in the 2011 Kent County Health Needs Assessment and Health Profile.

12. Interventions Due to the AI mistrust of government institutions most effective interventions have been proven to come from within the tribal community (Tripp-Reimer, Choi, Kelley, Enslein, 2001). Interventions will be rooted in strengthening the collaboration between governmental institutions and minority populations based upon collaborative models proven to be effective (Trust for America’s Health, 2009).

13. Interventions: WHO AI or culturally competent…

14. Interventions:WHAT & HOW Assessment of Community Identify underserved “hidden” AI population Measurable goal: Commission report or supplement to next Kent County Health Assessment focusing on AI health disparities

15. Interventions:WHAT & HOW Provide training for cultural competency of Kent County public health workers Measurable goals: Attain cultural competency using Office of Minority Health benchmarks (2013) Study culturally relevant interventions and social/historic factors to address effects caused by loss of cultural identity

16. Interventions:WHAT & HOW Utilize existing Health Department web resources in context of culturally focused care, for e.g., Kent County Health Department webpages Health Equity, Health Promotion, Health Education, Health Improvement Measurable goals: Each of the web pages will address AI health disparities Provide culturally relevant education to AI population about nutrition, availability and location of healthy food sources and importance of physical activity

17. Interventions:WHERE & WHEN Where: Interventions will be mainly developed and implemented through the Kent County Health Department by improving the quality of the interactions between health care workers with the community. When: One year: Changes to the Kent County Health Department web pages to address AI community Five years: Education and training of Kent County Health Department health care workers and development of culturally relevant interventions Ten years: Reassessment of Kent County AI population within the framework of subsequent Kent County Health Assessment

18. Evalution: Quantitative Evaluation of the one-, five-, and ten-year goals for completion. One year: Meet with AI health liasons Carol Barker and Phyllis Davis for evaluation of changes to Kent County Health Department web pages. Incorporate survey in web page to ascertain the effectiveness of content from public site viewers. Five years: Submission of staff cultural competency certification to Kent County Health Department leadership. Submission to (at 2-year mark), implementation (at 3-year mark), and evaluation (at 5-year mark) of new culturally relevant interventions. Ten years: Review of Kent County Health Assessment data. Comparison of post-intervention data with current data to measure improvements in reports of access to healthy food, food choices, and activity level.

19. Evaluation: Qualitative “The power of intuitive understanding will protect you from harm until the end of your days.” Lao-Tzu The Ecological Model provides a framework for greater understanding of complex social factors, resulting in intuitive understanding and incorporation of the unknown into one’s consciousness. This brings qualitative improvement in the relationships and communication between cultures. Qualitative evaluation will include interview assessment of public healthcare workers and the AI community for knowledge and understanding of American Indian history and culture but the extent of true understanding cannot be measured.

20. References • American Psychiatric Association. (2010). Mental health disparities: American Indians and Alaska Natives. Retrieved from http://www.psychiatry.org/File%20Library/Mental%20IIlness/Lets%20Talk%20Facts/APA_American-Indians.pdf • Brown, B., Harris, K., Harris, J., Parker, M., & Noonan, C. (2010). Translating the diabetes prevention program for Northern Plains Indian youth through community-based participatory research methods. Diabetes Education, 36(6), 924-935. doi:10.1177/0145710382582 • CDC. (2010). Health disparities affecting minorities: American Indians and Alaska Natives. Retrieved from http://www.cdc.gov/minorityhealth/populations/REMP/definitions.html#AIAN • CDC. (2012a). Prevalence of Obesity in the United States, 2009-2010. Retrieved from http://www.cdc.gov/nchs/data/databriefs/db82.pdf •  CDC. (2012b). Michigan’s response to obesity. Retrieved July 17, 2013, from http://www.cdc.gov/obesity/stateprograms/fundedstates/michigan.html • Harkness, G., & DeMarco, R. (2012). Community and public health nursing practice: Evidence for practice. Philadelphia, PA: Wolters Kluwer/Lippincott, Williams & Wilkins.  • Healthy People 2020. (2012). Social determinants. Retrieved from http://healthypeople.gov/2020/LHI/socialDeterminants.aspx?tab=data • Hermann, J., Jackson, T., Miracle, S., Parker, S., & Robertson, D. (2010, June). Utilizing the socioecological model as a framework for understanding elder Native Americans’ views of Type 2 Diabetes for the development of an indigenous prevention plan. Native People’s Technical Assistance Office. Retrieved July 26, 2013, from http:/www.nptao.arizona.edu

21. References • Hodge, K., Cantrell, G., & Kim (2011). Health status and socioeconomic characteristics of the morbidly obese American Indians. Ethnicity and Disease, 21, 52-57. Retrieved from http://www.ishib.org/journal/21-1/ethn-21-01-52.pdf • Kent County Health Department (2011). 2011 community health needs assessment and health profile. Retrieved from http://assets1/mytrainsite.com/501187/kentcochna_final.pdf?r=1440 • Kent County Health Department (2013). accessKENT.com. Retrieved from https://www.accesskent.com/ • Koivusilta, L., Rimpela, A. & Vika, A. (2009). Health behaviors and health in adolescence as predictors of educational level in adulthood: a follow-up study from Finland. Social Science Medicine, 57(4), 577-593. doi:10.1300/J051v13n01_02 • Match-E-Be-Nash-She-Wish Band of Pottawatomi: Gun Lake Tribe. (2004). Health & human services director: Phyllis Davis. Retrieved July 23, 2013, from http://www.mbpi.org/hhs/healthandhuman.asp • Michigan Diabetes Prevention and Control Program. (2009). Plan for diabetes prevention and control in tribal communities. Retrieved from http://www.michigan/gov/documents/mdch/Tribal_Plan_rev_4-1-09_274987_7.pdf • National Indian Health Board. (n.d.). Healthy People 2020: Leading health indicators for American Indian/Alaska native populations. Retrieved July 17, 2013, from http://www.nihb.org/public_health/healthy_people_2020_social_determinants.php • Neel, J. (1962). Diabetes Mellitus: A “thrifty” genotype rendered detrimental by “progress”? American Journal of Human Genetics, 14(4), 353-362. • Office of Minority Health. (2012). Obesity and American Indians/Alaska Natives. Retrieved from http://minorityhealth.hhs.gov/templates/content/aspx?lvl=3&lvIID=537

22. References • Office of Minority Health. (2013). Educational materials/guide /PTTS/modules. Retrieved July 25, 2013, from http://minorityhealth.hhs.gov/templates/content/aspx?lvl=2&lvIID=107 • Seva Foundation. (2013). Retrieved July 15, 2013, from http://www.seva.org • Tripp-Reimer, T., Choi, E., Kelley, L., & Enslein. (2001). Cultural barriers to care: Inverting the problem. Diabetes Spectrum, 14(1), 13-22. doi:10.2337/diaspect.14.1.13 • Trust for America’s Health. (2009). Examples of successful community-based public health interventions (state-by-state). Retrieved from http://www.cahpf.org/GoDocUserFiles/601/TFAH_Examplesbystate1009.pdf • U.S. Department of Health & Human Services. (2001). Mental health: Culture, race, and ethnicity - A supplemental to mental health: A report of the Surgeon General. Retrieved from http://profiles/nlm/nih/gov/pf/retrieve/ResourceMetadata/NNBBS • U.S. Commission on Civil Rights. (2004, February). Native American health care disparities briefing. Retrieved from http://www.law.umaryland.edu/marshall/usccr/documents/nativeamericanhealthcareids.pdf • Weick, C. (2009, May 11). Gun Lake Tribe cares for ‘mind, body, spirit’. MLive.com. Retrieved from http://www.mlive.com/penaseeglobe/index.ssf/2009/05/gun_lake_tribe_cares_for_mind.html