Community governance of the Kahnawake Schools Diabetes Prevention Project,Kahnawake Territory,Mohawk Nation,Canada

Health promotion emphasizes the importance of community ownership in the governance of community-based programmes, yet little research has been conducted in this area. This study examined perceptions of community ownership among project partners taking responsibility for decision-making related to the Kahnawake Schools Diabetes Prevention Project (KSDPP). Project partners were surveyed cross-sectionally at 18 months (T1) and 60 months (T2) into the project. The perceived influence of each project partner was assessed at T1 and T2 for three domains: (i) KSDPP activities; (ii) KSDPP operations; and (iii) Community Advisory Board (CAB) activities. Project staff were perceived to have the greatest influence on KSDPP activities, KSDPP operations and CAB activities at both T1 and T2. High mean scores of perceived influence for CAB members and community researchers, however, suggests that project decision-making was a shared responsibility among multiple community partners. Although academic researcher influence was consistently low, they were satisfied with their level of influence. This was unlike community affiliates, who were less satisfied with their lower level of influence. In keeping with Kanien'kehaka (Mohawk) culture, the findings suggest a participatory democracy or shared decision-making as the primary mode of governance of KSDPP.     

Implementing participatory intervention and research in communities: lessons from the Kahnawake Schools Diabetes Prevention Project in Canada

Community public health interventions based on citizen and community participation are increasingly discussed as promising avenues for the reduction of health inequalities and the promotion of social justice. However, very few authors have provided explicit principles and guidelines for planning and implementing such interventions, especially when they are linked with research. Traditional approaches to public health programming emphasise expert knowledge, advanced detailed planning, and the separation of research from intervention. Despite the usefulness of these approaches for evaluating targeted narrow-focused interventions, they may not be appropriate in community health promotion, especially in Aboriginal communities. Using the experience of the Kahnawake Schools Diabetes Prevention Project, in Canada, this paper elaborates four principles as basic components for an implementation model of community programmes. The principles are: (1) the integration of community people and researchers as equal partners in every phase of the project, (2) the structural and functional integration of the intervention and evaluation research components, (3) having a flexible agenda responsive to demands from the broader environment, and (4) the creation of a project that represents learning opportunities for all those involved. The emerging implementation model for community interventions, as exemplified by this project, is one that conceives a programme as a dynamic social space, the contours and vision of which are defined through an ongoing negotiation process.     

Identification of Barriers and Facilitators of Healthy Food Choices Among Children Aged 6 to 12 Years: From the Kahnawake Schools Diabetes Prevention Project

This study aimed to identify barriers and facilitators of healthy food choices among children aged 6 to 12 years in Kahnawake, and help orienting Kahnawake School Diabetes Prevention Project (KSDPP) to improve the diet of the children. A series of four focus groups with a total of 15 people was conducted with mothers of children enrolled in one of the two intervention schools. Comments were analyzed verbatim by content analysis.

Results showed that cost, time, taste, season of the year, pressure from family and friends, and health concerns within the family can be both barriers and facilitators of healthy eating for the children. However, KSDPP is a facilitator.     

Identification of Barriers and Facilitators of Healthy Food Choices Among Children Aged 6 to 12 Years: From the Kahnawake Schools Diabetes Prevention Project

This study aimed to identify barriers and facilitators of healthy food choices among children aged 6 to 12 years in Kahnawake, and help orienting Kahnawake School Diabetes Prevention Project (KSDPP) to improve the diet of the children. A series of four focus groups with a total of 15 people was conducted with mothers of children enrolled in one of the two intervention schools. Comments were analyzed verbatim by content analysis.

Results showed that cost, time, taste, season of the year, pressure from family and friends, and health concerns within the family can be both barriers and facilitators of healthy eating for the children. However, KSDPP is a facilitator.     

Comparison of the dietary intakes of two different groups of children (grades 4 to 6) before and after the Kahnawake Schools Diabetes Prevention Project

The diet of Mohawk children (grades 4 through 6) was assessed using 24-hour recalls after 4 years' participation in the Kahnawake Schools Diabetes Prevention Project. Analysis compared mean intakes of energy, fat, and sucrose, and proportions of children consuming each food. No significant difference was found in the mean intake of energy, fat, and sucrose. There was a significant decrease in the frequency of consumption of high-fat foods (P<.05) and fruits (P<.001), and a significant increase in the energy contribution of white sugar (P<.05). Results illustrate the complexity of food choices and suggest that specific nutrition education targets need to reflect newly available food-items.     

Disease management interventions II: What else is in the black box?

The success of any disease management (DM) program ultimately depends upon the ability and willingness of participants to change and maintain desired health behaviors. To achieve those results, DM program administrators have several issues to consider, including the type of behavioral change desired, the scope of intervention that the organization is willing and capable of implementing, and whether the appropriate support structures are available to ensure successful achievement of program goals. An understanding of these issues will assist program designers in selecting the appropriate change models. This paper serves as an extension of our prior paper in which eight core psychosocial behavioral change models were described. Here, five more recently developed theory-based approaches are introduced, providing readers with up-to-date information in this area.     

Outcomes of a Latino Community-Based Intervention for the Prevention of Diabetes: The Lawrence Latino Diabetes Prevention Project

Objectives. We tested the effectiveness of a community-based, literacy-sensitive, and culturally tailored lifestyle intervention on weight loss and diabetes risk reduction among low-income, Spanish-speaking Latinos at increased diabetes risk.Methods. Three hundred twelve participants from Lawrence, Massachusetts, were randomly assigned to lifestyle intervention care (IC) or usual care (UC) between 2004 and 2007. The intervention was implemented by trained Spanish-speaking individuals from the community. Each participant was followed for 1 year.Results. The participants’ mean age was 52 years; 59% had less than a high school education. The 1-year retention rate was 94%. Compared with the UC group, the IC group had a modest but significant weight reduction (−2.5 vs 0.63 lb; P = .04) and a clinically meaningful reduction in hemoglobin A1c (−0.10% vs −0.04%; P = .009). Likewise, insulin resistance improved significantly in the IC compared with the UC group. The IC group also had greater reductions in percentage of calories from total and saturated fat.Conclusions. We developed an inexpensive, culturally sensitive diabetes prevention program that resulted in weight loss, improved HbA1c, and improved insulin resistance in a high-risk Latino population.Type 2 diabetes is a serious disorder with many complications and is characterized by insulin resistance and relative insulin deficiency. The prevalence of diabetes in Latino Americans is 1.5 times that in non-Latino Whites.1 Between 1988 to 1994 and 2005 to 2006, the prevalence of diabetes increased from 9.6% to 12.6% in the adult Latino population.2,3 Prediabetes, as defined by impaired glucose tolerance or impaired fasting blood glucose, is often present 5 or more years before the development of type 2 diabetes.4 Several randomized clinical trials have shown that it is possible to prevent or delay the progression of the prediabetic state to clinical type 2 diabetes.5–7The Diabetes Prevention Program (DPP) demonstrated that a lifestyle intervention incorporating dietary modification and increased physical activity produced an average weight loss of 5.6 kilograms at 1 year and by 4 years reduced the incidence of diabetes by 58% versus usual care.7 However, the intervention was intensive and costly, beginning with a 16-session curriculum that was delivered individually over 24 weeks and continuing with a number of follow-up individual and group sessions. The total intervention cost over the first year was $1399 per participant. The participants, although representing diverse American subpopulations, were generally well-educated, literate in English, and of average socioeconomic status.The effectiveness of the DPP lifestyle intervention delivered in a lower cost, lower intensity format to high-risk populations is not known. We hypothesized that a community-based, culturally tailored, literacy-sensitive lifestyle intervention delivered in a primarily group-based format would facilitate weight loss and reduce the risk of type 2 diabetes among low-income Latinos at elevated risk of developing diabetes.     

Minimal-contact physical activity interventions in women: a pilot study

OBJECTIVE: To examine the impact of 3 minimal-contact lifestyle interventions on physical activity in women. METHODS: Fifty female volunteers were randomly assigned to one of 3 lifestyle physical activity interventions for 8 weeks. Subjects wore an accelerometer for a week at baseline and postintervention to objectively monitor their physical activity. RESULTS: Participants significantly increased their physical activity from baseline to postintervention; however, there was no significant difference in physical activity among the 3 intervention groups. CONCLUSIONS: Results of this pilot study support the use of minimal-contact lifestyle interventions to promote physical activity in women.     

Should implementation intentions interventions be implemented in obesity prevention: the impact of if-then plans on daily physical activity in Dutch adults

Background  

Forming implementation intentions (specifying when, where and how to act) has been proposed as a potentially effective and inexpensive intervention, but has mainly been studied in controlled settings for straightforward behaviors.     

Website-delivered physical activity interventions a review of the literature

BACKGROUND: Evidence-based physical activity interventions that can be delivered to large numbers of adults at an acceptable cost are a public health priority; website-delivered programs have this potential. The purpose of this study was to systematically review the research findings and outcomes of website-delivered physical activity interventions and to identify relationships of intervention attributes with behavioral outcomes. METHODS: A structured search of PubMed, Medline, PsycInfo, and Web of Science was conducted for intervention studies published up to July 2006. Studies included in the review were those that (1) used websites or e-mail, (2) had physical activity behavior as an outcome measure, (3) had randomized controlled or quasi-experimental designs, (4) targeted adults, and (5) were published in English. RESULTS: Of the fifteen studies reviewed, improvement in physical activity was reported in eight. Better outcomes were identified when interventions had more than five contacts with participants and when the time to follow-up was short (6 months, 40%) follow-up. There were no clear associations of outcomes with other intervention attributes. CONCLUSIONS: A little over half of the controlled trials of website-delivered physical activity interventions have reported positive behavioral outcomes. However, intervention effects were short lived, and there was limited evidence of maintenance of physical activity changes. Research is needed to identify elements that can improve behavioral outcomes, the maintenance of change and the engagement and retention of participants; larger and more representative study samples are also needed.     

Project MOVE: A randomized controlled trial of interventions for initiating and maintaining physical activity in depressed individuals

ObjectiveTo test interventions for increasing aerobic exercise in depressed individuals.MethodsWe conducted a 3-arm randomized controlled trial aimed at increasing minutes of moderate-to-vigorous physical activity (MVPA) in depressed adults (N = 242). Each successive arm included an added component that might serve to increase and maintain physical activity. Arms were: 1) Brief advice (BA) to aerobic exercise; 2) BA + supervised and home-based aerobic exercise (SHE) + health education (HE); and 3) BA + SHE + cognitive-behavioral sessions focused on increasing and maintaining aerobic exercise (CBEX). HE was intended to serve as a control for CBEX. Assessments were conducted at baseline, Month 1.5, end of intervention (Month 3), Month 6, and Month 9. The primary outcome of MVPA was assessed via accelerometry. Secondary outcomes included self-reported MVPA, depression severity, and other aspects of mood and affect.ResultsAt 3 months (the pre-designated primary outcome timepoint), the simple effect of treatment was statistically significant (F_{2, 569.0} = 4.17, p = .016), with BA + SHE + CBEX being superior to BA. We did not observe differences between BA + SHE + HE and either of the other arms. There were no statistically significant differences between treatment groups at 6- or 9-months. Treatment effects were not statistically significant for secondary outcomes.ConclusionsSupervised and home-based exercise, when combined with a cognitive-behavioral exercise intervention, is effective in increasing aerobic exercise in depressed adults in the short-term, although the impact diminishes post-intervention period.Trial registrationclinicaltrials.gov NCT02691845.     

Effectiveness of physical activity interventions for older adults: a review

OBJECTIVE: This review evaluates the effectiveness of physical activity interventions among older adults. METHODS: Computerized searches were performed to identify randomized controlled trials. Studies were included if: (1) the study population consisted of older adults (average sample population age of > or =50 years and minimum age of 40 years); (2) the intervention consisted of an exercise program or was aimed at promoting physical activity; and (3) reported on participation (i.e., adherence/compliance) or changes in level of physical activity (e.g., pre-post test measures and group comparisons). RESULTS: The 38 studies included 57 physical activity interventions. Three types of interventions were identified: home-based, group-based, and educational. In the short-term, both home-based interventions and group-based interventions achieved high rates of participation (means of 90% and 84%, respectively). Participation declined the longer the duration of the intervention. Participation in education interventions varied widely (range of 35% to 96%). Both group-based interventions and education interventions were effective in increasing physical activity levels in the short-term. Information on long-term effectiveness was either absent or showed no difference of physical activity level between the study groups. CONCLUSIONS: Home-based, group-based, and educational physical activity interventions can result in increased physical activity, but changes are small and short-lived. Participation rates of home-based and group-based interventions were comparable, and both seemed to be unrelated to type or frequency of physical activity. The beneficial effect of behavioral reinforcement strategies was not evident. Comparative studies evaluating the effectiveness of diverse interventions are needed to identify the interventions most likely to succeed in the initiation and maintenance of physical activity.     

Opening the black box of quality improvement collaboratives: an Actor-Network theory approach

Background  

Quality improvement collaboratives are often labeled as black boxes because effect studies usually do not describe exactly how the results were obtained. In this article we propose a way of opening such a black box, by taking up a dynamic perspective based on Actor-Network Theory. We thereby analyze how the problematisation process and the measurement practices are constructed. Findings from this analysis may have consequences for future evaluation studies of collaboratives.     

Evaluation of physical activity reporting in community Diabetes Prevention Program lifestyle intervention efforts: A systematic review

IntroductionThe Diabetes Prevention Program (DPP) lifestyle intervention has been translated to community settings using the DPP goals of 7% weight loss and 150 min of moderate physical activity (PA) per week. Given that PA is a primary lifestyle goal and has been linked to improvements in metabolic health in the DPP, it is important to understand the role that PA plays in translation effort success. The purpose of this review is to thoroughly evaluate the reporting of PA methodology and results in DPP-based translations in order to guide future prevention efforts.MethodsPubMed and Ovid databases were searched to identify peer-reviewed original research articles on DPP-based translations for adults at-risk for developing diabetes or cardiovascular disease, limited to English language publications from January 2002–March 2015.Results72 original research articles describing 57 translation studies met eligibility criteria. All 57 study interventions included a PA goal, 47 studies (82%) collected participant PA information, and 34 (60%) provided PA results.ConclusionsDespite PA being a primary intervention goal, PA methodology and results are under-reported in published DPP translation studies. This absence and inconsistency in reporting PA needs addressed in order to fully understand translation efforts' impact on participant health.     

Telephone interventions for physical activity and dietary behavior change: a systematic review

BACKGROUND: Given the epidemic of lifestyle-related chronic diseases, building the evidence base for physical activity and dietary behavior change interventions with a wide population reach is of critical importance. For this purpose, telephone counseling interventions have considerable potential. PURPOSE: To systematically review the literature on interventions for physical activity and dietary behavior change in which a telephone was the primary method of intervention delivery, with a focus on both internal and external validity. METHODS: A structured search of PubMed, Medline, and PsycInfo was conducted for studies published in English from 1965 to January 2006. Studies targeted primary or secondary prevention in adults, used randomized designs, and included physical activity and/or dietary behavior outcomes. RESULTS: Twenty-six studies were reviewed, including 16 on physical activity, six on dietary behavior, and four on physical activity plus dietary behavior. Twenty of 26 studies reported significant behavioral improvements. Positive outcomes were reported for 69% of physical activity studies, 83% of dietary behavior studies, and 75% of studies addressing both outcomes. Factors associated with positive outcomes appear to be the length of intervention and the number of calls, with interventions lasting 6 to 12 months and those including 12 or more calls producing the most favorable outcomes. Data on the representativeness of participants, implementation of calls, and costs were reported much less frequently. CONCLUSIONS: There is now a solid evidence base supporting the efficacy of physical activity and dietary behavior change interventions in which the telephone is the primary intervention method. Thus, research studies on broader dissemination are necessary, and should address questions relevant to the translation of this body of work into population health practice.     

The effectiveness of physical activity interventions in socio-economically disadvantaged communities: a systematic review

Objective

Interventions to increase levels of physical activity (PA) in socio-economically disadvantaged communities are needed but little is known about their effectiveness. This review examines the effectiveness of interventions designed to increase PA in these communities and the theoretical frameworks and components used.

Methods

Five databases were searched for papers published in English between January 2000 and December 2010 that reported outcomes of PA interventions in socio-economically disadvantaged communities. Studies targeting individuals with pre-existing disease and not reporting a measure of free-living PA were excluded. Two reviewers independently extracted data and evaluated quality of evidence against pre-defined criteria.

Results

Of 478 publications identified, 27 were included. We found that group-based interventions were effective for adults but not for children; evidence for the effectiveness of interventions targeting individuals was insufficient; limited evidence suggested that community-wide interventions produced small changes in PA. Interventions underpinned by any theoretical framework, compared to none, were more likely to be effective. Several effective interventions included education, PA and social support components.

Conclusion

Compared to other approaches, multi-component adult group-based interventions with theoretical frameworks are most effective in increasing PA in socio-economically disadvantaged communities. More robust evaluations of interventions targeting individuals in these ‘hard-to-reach’ communities are required.     

Environmental interventions for eating and physical activity: a randomized controlled trial in middle schools

BACKGROUND: Our objective was to evaluate the effects of environmental, policy, and social marketing interventions on physical activity and fat intake of middle school students on campus. DESIGN: Twenty-four middle schools were randomly assigned to intervention or control conditions. Baseline measures were collected in spring 1997, and interventions were conducted during the 1997-1998 and 1998-1999 school years SETTING/PARTICIPATION: The schools had mean enrollments of 1109, with 44.5% nonwhite students.Over 2 years, physical activity interventions were designed to increase physical activity in physical education classes and throughout the school day. Nutrition interventions were designed to provide and market low-fat foods at all school food sources, including cafeteria breakfasts and lunches, a la carte sources, school stores, and bag lunches. School staff and students were engaged in policy change efforts, but there was no classroom health education. MAIN OUTCOMES MEASURES: Primary outcomes were measured by direct observation and existing records. RESULTS: Randomized regression models (N =24 schools) revealed a significant intervention effect for physical activity for the total group (p <0.009) and boys (p <0.001), but not girls (p <0.40). The intervention was not effective for total fat (p <0.91) or saturated fat (p <0.79). Survey data indicated that the interventions reduced reported body mass index for boys (p <0.05). CONCLUSIONS: Environmental and policy interventions were effective in increasing physical activity at school among boys but not girls. The interventions were not effective in reducing fat intake at school. School environmental and policy interventions have the potential to improve health behavior of the student population, but barriers to full implementation need to be better understood and overcome.