TY - JOUR
AU - Macaulay, Ann C
AB - Abstract Background Kahnawà:ke is a Kanien’kehá:ka (Mohawk) community in Quebec, Canada. In 1997, the community-controlled Kateri Memorial Hospital Centre in partnership with the Kahnawake Education Center, and the Kahnawake Schools Diabetes Prevention Project (KSDPP) developed an elementary school diabetes prevention health education program, aimed to increase knowledge of Type 2 diabetes, healthy eating and active lifestyles. Long-term goals for KSDPP community and school interventions are to decrease obesity and diabetes. Objectives To evaluate the Kateri Memorial Hospital Centre Health Education Program for Diabetes Prevention (HEP) and use key principles of knowledge translation to promote understanding of results to upgrade HEP content and improve delivery. Methods A KSDPP community-based participatory research team used mixed methods for evaluation, combining a cross-sectional survey for 23 teachers with interviews of two elementary school principals and three culturally appropriate Indigenous talking circles with HEP authors, teachers and parents. Questionnaire results were presented as descriptive statistics. The thematic textual analysis identified emerging themes from talking circles and interviews. Results Facilitators of HEP delivery were an acknowledgement of its importance; appreciation of prepared lesson plans for teachers; and KSDPP’s strong community presence. Barriers included reduced administrative support and instructional time due to competing academic demands; the need for increased Kanien’kehá:ka cultural content; and outdated resource materials. Recommendations included increasing teacher training, Kanien’kehá:ka cultural content and administrative support. Conclusion Community researchers undertook detailed knowledge translation activities of facilitators, barriers and recommendations with hospital and education centre administrators and Kahnawà:ke community to maximize uptake of findings before external dissemination of results. Aboriginal health/native populations, community medicine, prevention, school health education, talking circles Introduction Approximately 285 million people worldwide are affected by Type 2 diabetes and an estimated 7 million people will develop Type 2 diabetes annually, for a total of 438 million by 2030. Type 2 diabetes can reduce life expectancy by 5–10 years with an estimated 80% of people with diabetes dying from heart disease or stroke. Many Indigenous populations experience increased the prevalence of Type 2 diabetes, including those living in Canada where the Indigenous population is three to five times more likely than the general Canadian population to develop Type 2 diabetes (1). Worldwide there is a complex interplay between genetic and environmental factors with strong evidence that changes in nutrition and lifestyles play major roles in the development of obesity and Type 2 diabetes (1). There is a great need for diabetes primary prevention programs through public health interventions to increase personal knowledge and promote healthy eating and increased physical activity (1), to create supportive environments in both schools and community and to undertake planning in partnerships with the community to create culturally appropriate programs and promote community ownership (2). For school-based interventions the World Health Organization recommends wholistic, a settings-based approach that includes health curricula taught in classrooms, supportive school environments and links with family and community (3). Many school evaluations focus on student outcomes including increased knowledge (4), change in behaviours or anthropometric measurements (3), or the components that support curricula delivery (5,6). There is some evidence that the impact of the school-based curriculum has a positive health impact in Indigenous communities. The Sandy Lake school-based diabetes prevention intervention is known as one of the major diabetes prevention interventions for an Indigenous community in Canada. The 16-week intervention focused on knowledge and skills development related to healthy eating, physical activity and diabetes education for Indigenous children of age 7- to 14-year-old. Exposure to the intervention was significantly associated with being more knowledgeable about foods low in fat and having higher scores on the dietary self-efficacy, and curriculum knowledge scales while significantly reducing the mean plasma insulin levels (4). Additionally, the 3-year Zuni Diabetes Prevention Program was a cross-sectional design targeting high-school aged native American Indians which was designed to reduce the prevalence of diabetes risk factors by improving dietary habits, increasing physical activity and knowledge of diabetes risk factors (7). The program was evaluated by collecting data on physiological and behavioural change of high school students. The results have indicated a significant reduction in soft drink consumption and an increase in glucose/insulin ratios (7). Despite these promising initial results, there is a paucity of literature on the evaluation of health curricula content and on participatory knowledge translation of results. The Kahnawake Schools Diabetes Prevention Project Kahnawà:ke (‘on reserve’ population 7987 in February, 2017) is a Haudenosaunee (Iroquoian) Kanien’kehá:ka (Mohawk) community near Montreal, Canada which has enjoyed community control over health and education services since the late 1960s (8) The Kahnawake Schools Diabetes Prevention Project began in 1994 at the request of elders who, when local family physicians (including author ACM) documented that the prevalence of Type 2 diabetes was twice as high as the general population (9), wanted ‘to do something’ to prevent the onset of Type 2 diabetes in future generations. In Kahnawake, 12% of adults aged 45–64 years old have documented Type 2 diabetes, twice the rate of the general population of the same age (9). The Kahnawake Schools Diabetes Prevention Project is a community-based participatory research partnership (10) between Kahnawà:ke and researchers, where the community is represented through the Kahnawake Schools Diabetes Prevention Project Community Advisory Board, consisting of volunteers from community organizations and the general population. The Kahnawake Schools Diabetes Prevention Project goals for the combined schools and community interventions are to promote healthy eating and active lifestyles by increasing knowledge on diabetes and changing the physical environment and social norms for the long-term goals of preventing obesity and diabetes (11). The Community Advisory Board meets monthly and oversees all intervention, research and training activities. As external health education programs were lacking for elementary school children that focussed on diabetes prevention, from 1994 to 1997 a nutritionist and two nurses from the Kateri Memorial Hospital Centre became the primary authors to draft the Kateri Memorial Hospital Centre Health Education Program for Diabetes Prevention (HEP). They then worked with teachers (many of whom are community members) from the Kahnawake Education Center and the Kahnawake Schools Diabetes Prevention Project intervention staff to finalize and implement this HEP. The HEP aim was to increase elementary school students’ knowledge of the body, Type 2 diabetes, healthy nutrition and fitness through a yearly program of ten 45-minute lessons for each Grade 1–6 using interactive and cooperative learning techniques incorporating story-telling, games, food tasting, experiments, puppet shows, and crafts. During Years 1 and 2, the nurses and the nutritionist delivered the HEP and mentored teachers. From Year 3 onward, teachers delivered the program themselves, with support from KSDPP staff (11). A nutrition policy to encourage only healthy foods in the schools was in existence in the Kahnawake Education Center from 1993. From 1995 to 1999, teachers were interviewed to explore their roles as health promoters. Results showed that the teachers’ role of HEP delivery, enforcing the nutrition policy, role modelling, encouraging healthy lifestyles pointed to a higher-order role which supports a wholistic approach to health (12). Several implementation and fidelity issues raised concerns about the HEP format to meet teachers’ needs (12), but resource constraints precluded action. In 2012, the Kahnawake Schools Diabetes Prevention Project secured resources for a new evaluation. The goals were to engage with teachers, principals and parents to (i) identify and understand facilitators and barriers to HEP delivery, (ii) to document recommendations for its revision and revival and (iii) to undertake detailed knowledge translation with the stakeholders. Methods The overall study was guided by a participatory research approach (13) that engaged the researchers and the Kahnawake Schools Diabetes Prevention Project Community Advisory Board in shared decision making throughout the project. The study team included an established community researcher who was previously a high school principal (AMc), a Masters student from the community (MP), an external Masters student (MK) and three academic researchers (GB, JS and ACM). The study adopted a sequential mixed methods design combining both qualitative and quantitative data collection (14). The methods for this project were grounded in deliberative democratic theory. The deliberative elements that are integrated into various public engagement methods are derived from the theory. A public engagement method is deliberative when the participants are informed about the relevant topic and are then encouraged to actively discuss a variety of viewpoints while weighing the merits of different positions to arrive at a considered judgement or to produce a set of recommendations (15,16). The quality of a deliberative process depends on four fundamental criteria (17). There must be equal participation in discussions, a respectful discourse, a consideration of what might be best for society or the community instead of just an individual and measuring the available evidence or positions presented in the deliberation to arrive at reasoned judgements or ideas (17,18). Although methods based on deliberative democratic theory are often employed to solicit the input of the general public, they are particularly useful for engaging people when the issues to be considered involve a small and/or very specific target population or setting (19) such as the Kahnawake Schools Diabetes Prevention Project. The deliberative engagement methods used were those already developed by Indigenous researchers as they were culturally appropriate for Kahnawà:ke, and had the added advantage of soliciting valid information using a very small number of participants. The participating community elementary schools were Kateri School (English speaking) and Karonhianonhnha tsi Ionteriwaienstahkwa (Mohawk language immersion) with a joint population of 430 children in Grades 1–6. Data collection (Table 1) began with one of three talking circles, co-facilitated by the Masters students, MP and MK. In a talking circle, participants sit in a circle and discuss the specified topic with each participant having the opportunity speak in turn sequentially around the circle without being interrupted. Participants have the option to remain silent during their turn, and discussion continues for as many cycles needed until all participants are satisfied with their contributions. Talking circles, otherwise known as sharing circles, are a culturally appropriate method increasingly being used in research by Indigenous researchers and involving Indigenous peoples (20). Talking circles are similar to focus groups and are a method of inquiry by way of ‘gathering stories’, and have also long been used as a healing method in which all participants’ stories are respectfully shared in a comfortable environment that emphasizes safety and confidentiality (21). Talking circles are based on respect for everyone present, active listening, learning and stating personal beliefs without arguing, debate or denigrating other opinions. Talking circles fit well with the consensus-building model of the Haudenosaunee and they also eliminate individuals from dominating the discussion as may happen in a focus group. The talking circles were chosen as a culturally appropriate deliberative stakeholder engagement method (22). Table 1. Order of data collection Method  Participants  Talking circle 1  Two of three HEP authors, one former KSDPP intervention facilitator (N = 3)  Consultation  Two teachers and one principal with cultural expertise who had delivered or supervised the HEP  Master’s nutrition student reviewed HEP for scientific content  Individual interviews  Principals at each of two elementary schools (N = 2)  Survey/questionnaire  Teachers from 2 elementary schools (N = 23)  Talking circle 2  Teachers for follow up to teacher survey (N = 4)  Talking circle 3  Volunteer parents (N = 2)  Method  Participants  Talking circle 1  Two of three HEP authors, one former KSDPP intervention facilitator (N = 3)  Consultation  Two teachers and one principal with cultural expertise who had delivered or supervised the HEP  Master’s nutrition student reviewed HEP for scientific content  Individual interviews  Principals at each of two elementary schools (N = 2)  Survey/questionnaire  Teachers from 2 elementary schools (N = 23)  Talking circle 2  Teachers for follow up to teacher survey (N = 4)  Talking circle 3  Volunteer parents (N = 2)  View Large The initial participants were two of the HEP authors and one former Kahnawake Schools Diabetes Prevention Project intervention facilitator—to understand the development and initial HEP delivery. Next, MP interviewed the principal of each school to understand how the HEP was supported and delivered and to gather recommendations for HEP revision. Information from these initial qualitative stages helped to inform the development of questionnaires by MK. The original questions were derived from the literature using studies that evaluated health education curricula (23,24). The adapted questions were pilot tested with recently retired teachers who were not eligible to be a part of the study, but had sufficient knowledge on the health education curriculum to test the questionnaire. The questions, instructions and responses were checked for relevancy and appropriateness. The final questionnaires were distributed to all teachers in both schools who were responsible for HEP teaching in 2010–2011 and 2011–2012 to understand their perceptions on (i) level of administrative support and resources available to teachers; (ii) HEP delivery such as the time allocated and the associated workload; (iii) appropriateness of the HEP in terms of culture, language and age-related content and (iv) importance of the HEP and the personal satisfaction gained from teaching it. Most questions (Table 1) were rated on a 5-point Likert scale, from Strongly Agree through Strongly Disagree, with space for additional comments. Basic descriptive statistics (means and percentages) were applied to responses. The teachers were also asked how many years they had delivered the HEP and if they would be willing to join a talking circle. The final component consisted of two separate talking circles held with (i) teachers and (ii) parents to engage and explore the facilitators and barriers that have contributed to the HEP delivery, and to seek recommendations for HEP revision. Four teachers representing both schools volunteered for the talking circle. Five parents volunteered following a notice sent out by the schools, but only two parents—one from each school—arrived to participate. The talking circles began with a brief presentation on the HEP and lasted 60–90 minutes. Questions included ‘Can you think of facilitators and barriers to HEP delivery?’ and ‘What are your specific suggestions for improving the HEP?’ With individual permission, the interviews and talking circles were recorded, and transcribed. Researchers MP, with previous experience, and MK analyzed the transcripts using inductive thematic analysis. Both researchers coded the transcripts individually and then codes were refined by their collaborative contributions. Themes were generated and reviewed by the academic researchers, a thematic map was constructed, and relevant quotations were selected to support the themes. In addition, a Masters nutrition student reviewed the HEP for scientific content and three former school educators, chosen for their teaching expertise and detailed knowledge of Kanien’kehá:ka culture, language and teaching approaches, were contracted to review the HEP and provide comments on both the cultural appropriateness of the content and the delivery methods. Throughout the project, the study team presented to the wider Kahnawake Schools Diabetes Prevention Project research team and the Community Advisory Board at their respective monthly meetings to update everyone on progress, and allow for discussion and interpretation of preliminary findings and recommendations for the next stages. Results For the quantitative component, there were 30 eligible teachers from the two schools. Of the 23 teachers who completed the questionnaire (77%), 17 reported the number of lessons they taught for the year 2010–2011: 2 out of 17 (12%) teachers taught all 10 lessons and 5 (29%) taught less than 4 lessons. For 2011–2012, 16 teachers reported the number of lessons they taught: none taught all 10 lessons and 6 (37.5%) taught less than 4 lessons. Table 2 reports the percentage of all the teachers who agreed with each survey question. Twenty (84%) teachers perceived the HEP program as important and 15 (65%) teachers incorporated some HEP content into the regular academic lessons and 11 (45%) teachers had a positive attitude towards the program content. Fifteen (61%) had negative views on the methods of delivery; these included having insufficient time and the burden of the associated workload. Their level of training and administrative support was perceived positively by only 8 (33%) teachers. Table 2. Level of teachers’ agreement with general survey items Survey item  Strongly Agree and Agree combined (%)  Meana  The level of training I received to teach the program is sufficient  17.4  2.7  The teacher guide and resources available to teach the program are user friendly  26.1  2.8  The teacher guide and resources available to teach the program are complete  22.7  2.5  The school administrators such as the principal offer support for the health education program  30.0  2.8  I feel confident teaching the program  47.8  3.5  I have enough knowledge to deliver the health education program  60.9  3.5  I understand the need to teach the program  82.6  4.1  I have incorporated the health education program into academic lessons  65.2  3.6  I have followed the lessons as guided by the program  47.8  3.1  The language of the program content is appropriate for teacher usage  56.5  3.2  The program content is age-appropriate for students  30.4  2.7  The program content incorporates Kanien’kéhaka Traditions  21.7  2.6  The time (45 minutes/lesson) allocated for the program delivery is sufficient  34.8  2.9  I have sufficient time to deliver the program during school hours  21.7  2.6  Program delivery disrupts regular classroom activities  26.1  3.1  Program delivery increased my workload as an educator  52.1  3.4  The program is useful for students  65.2  3.6  I gain personal satisfaction in delivering the health education program  39.1  3.2  Survey item  Strongly Agree and Agree combined (%)  Meana  The level of training I received to teach the program is sufficient  17.4  2.7  The teacher guide and resources available to teach the program are user friendly  26.1  2.8  The teacher guide and resources available to teach the program are complete  22.7  2.5  The school administrators such as the principal offer support for the health education program  30.0  2.8  I feel confident teaching the program  47.8  3.5  I have enough knowledge to deliver the health education program  60.9  3.5  I understand the need to teach the program  82.6  4.1  I have incorporated the health education program into academic lessons  65.2  3.6  I have followed the lessons as guided by the program  47.8  3.1  The language of the program content is appropriate for teacher usage  56.5  3.2  The program content is age-appropriate for students  30.4  2.7  The program content incorporates Kanien’kéhaka Traditions  21.7  2.6  The time (45 minutes/lesson) allocated for the program delivery is sufficient  34.8  2.9  I have sufficient time to deliver the program during school hours  21.7  2.6  Program delivery disrupts regular classroom activities  26.1  3.1  Program delivery increased my workload as an educator  52.1  3.4  The program is useful for students  65.2  3.6  I gain personal satisfaction in delivering the health education program  39.1  3.2  a>3 reports agreement with a statement, <3 signifies disagreement and 3 is neutral. View Large The number of years teaching the health education curriculum was divided into three categories (1–5, 6–10 and 11–15). Three teachers had less than 5 years of experience, six teachers had between 6 and 10 years of experience and seven teachers had above 10 years of experience. When the responses were compiled by years of teaching experience, 71% of those will less experience (1–5 years) had a negative perception on delivery, 88% were dissatisfied with the content and 89% were dissatisfied with the level of support. Of those with the longest teaching experience (11–15 years), only 39% had a negative perception on delivery, 45% were dissatisfied with the content and 53% were dissatisfied with the level of support. Qualitative component The analysis of the talking circles and semi-structured interviews identified barriers, facilitators (Table 3) and recommendations for the HEP (Table 4). The four major barriers for the HEP included organizational issues, challenges with the delivery of the program, lack of cultural appropriateness and problems identified in the contents. The facilitators included organizational factors, delivery and program content and the overall importance of the program. The recommendations addressed targeted support for delivery of the HEP, organizational factors, ideas for improvement of the content including cultural adaptations and incorporation into other health programs. Table 3. Teachers’ responses: lists of barriers and facilitators of the health education program Barriers  Organizational  • Lack of administrative and training support  • Lack of sufficient resources  • Ongoing changes associated with each school  • Financial constraints  Delivery  • Other priorities  • Lack of time  Cultural appropriateness  • Insufficiency of Kanien’kehá:ka cultural representation  Program content  • Difficulty in integrating contents into academics  • Language of program  • Outdated material  • Repetition of material from grade to grade  • Not age appropriate  • Lack of parental education  Facilitators  Organizational  • Kahnawake Schools Diabetes Prevention Project’s established presence in community  • Organizational structures (health teachers at one school)  Delivery  • Integration of material into academics  • Prepared lessons  Program content  • Acknowledge importance of program for diabetes prevention  • Appreciation of prepared lessons  Barriers  Organizational  • Lack of administrative and training support  • Lack of sufficient resources  • Ongoing changes associated with each school  • Financial constraints  Delivery  • Other priorities  • Lack of time  Cultural appropriateness  • Insufficiency of Kanien’kehá:ka cultural representation  Program content  • Difficulty in integrating contents into academics  • Language of program  • Outdated material  • Repetition of material from grade to grade  • Not age appropriate  • Lack of parental education  Facilitators  Organizational  • Kahnawake Schools Diabetes Prevention Project’s established presence in community  • Organizational structures (health teachers at one school)  Delivery  • Integration of material into academics  • Prepared lessons  Program content  • Acknowledge importance of program for diabetes prevention  • Appreciation of prepared lessons  View Large Table 4. Recommendations for the Kateri Memorial Hospital Center Health Education Program in Diabetes Prevention Recommendations   Support  • Administration  • Training (professional development, label reading)  • Financial (hire more health teachers)  • Parental education  • Community (Kahnawake Education Center, KSDPP, and other organizations)  • Sense of ownership  Organizational  • Outdoor and physical activity  • Designate one classroom with designated health teacher(s)  Program content  • Less complex lessons  • Shorter lessons  • More interactive/fun activities  • Incorporate innovative and up-to-date technology (websites, links, games)  • Update program content (with accompanying worksheets, diagrams, pictures, posters)  • Use contemporary appropriate terms (change native to Indigenous)  • Replenish toolbox at the beginning of each school year/revive tracking mechanism  Cultural  • Increase Kanien’kehá:ka cultural teachings  • Incorporate wholistic teachings (i.e. in natural setting)  • Increase Kanien’kéha:ka language  Other  • Development of comprehensive health program for Kahnawake elementary schools  Recommendations   Support  • Administration  • Training (professional development, label reading)  • Financial (hire more health teachers)  • Parental education  • Community (Kahnawake Education Center, KSDPP, and other organizations)  • Sense of ownership  Organizational  • Outdoor and physical activity  • Designate one classroom with designated health teacher(s)  Program content  • Less complex lessons  • Shorter lessons  • More interactive/fun activities  • Incorporate innovative and up-to-date technology (websites, links, games)  • Update program content (with accompanying worksheets, diagrams, pictures, posters)  • Use contemporary appropriate terms (change native to Indigenous)  • Replenish toolbox at the beginning of each school year/revive tracking mechanism  Cultural  • Increase Kanien’kehá:ka cultural teachings  • Incorporate wholistic teachings (i.e. in natural setting)  • Increase Kanien’kéha:ka language  Other  • Development of comprehensive health program for Kahnawake elementary schools  View Large Themes for barriers The first major theme identified as a barrier was expressed by participants as the need for better organizational support for delivery of the program. This included training in the delivery of the program. During the development and early implementation stages, the HEP was supported by Kahnawake Education Center and the Kahnawake Schools Diabetes Prevention Project through in-service training and regular monitoring with the intention that classroom teachers would assume HEP delivery. We always insisted the teacher stayed in the room. So that’s how the capacity building happened. The teacher observed the program being taught for two years. (Interview, HEP author) Since then HEP support has unintentionally steadily decreased. Currently, teachers ‘feel they are left on their own’, and ‘require administrative support’. One participant commented that ‘professional development, training is needed’. Along with organizational issues, less resources, financial constraints and ongoing changes at the schools emerged as barriers to the HEP delivery. A second major them identified as a barrier was the methods of delivery where there was not sufficient time and other school topics took priority. Since the HEP development, many changes have occurred including the addition of a new mathematics program, a French immersion program in one school, administration changes and new teachers. With increased focus on core academic programming, health education instruction has become less of a teaching priority. There was a big push at the beginning and then later things changed, there was downsizing and different priorities, different things happened and it [the health education program] was not so closely followed. (Talking Circle, HEP Author) Teachers also reported that changes in staff and principals ‘brought in all kinds of new strategies’ that affected the HEP delivery. Cultural appropriateness in terms of cultural representation was a third barrier identified for use of the HEP. Many participants said that the HEP lessons need updating with increased Kanien’kehá:ka cultural and language teachings. One of the consultants contracted to review the cultural content stated: As Kanien’kehá:ka identity is connected with the natural world, it emphasizes being healthy on a wholistic level such as physically, emotionally, and spiritually. It is deemed appropriate to educate children more on this identity while teaching the health education curriculum – if you are Kanien’kehá:ka, you are healthy. (Kanien’kehá:ka consultant) Additionally, it was suggested that the HEP should include the history of the recent development of diabetes amongst Indigenous peoples to promote a better understanding of preventing the disease. The final barrier identified was the need for revision and update of the curriculum. Originally, the authors planned that each lesson could be delivered in 45 minutes. Nevertheless, teachers reported that 45 minutes did not represent the actual length that it took to cover the lesson materials. It looks like it should take 45 minutes but it really doesn’t because you’re dealing with kids. Things look good on paper but when you start dealing with kids, they take you somewhere else, so it does take longer than anticipated. (Talking Circle, Teachers) The authors also planned that the HEP content was flexible to divide each lesson into shorter length lessons, or to be integrated into other subjects. Teachers indicated that integration was not appropriate for all contents. Some things you can integrate, like if you’re doing measurements, like math you can integrate measuring intestines and things like that but you can’t always do it. (Talking Circle, Teachers) The HEP Content was developed using existing guidelines and resources including the Canadian Diabetes Association Clinical Care Guidelines and the Canada Food Guide. Since then, the guidelines have evolved, health promotion materials are accessible on the internet and there is increased community focus on Indigenous foods. As one of the authors of the program, I feel that in order for it to be used it has to be updated, it has to become contemporary, most of the information [fitness, lifestyle and diabetes] is still exactly perfect, it just needs to be updated, 15 years is a long time. (Talking Circle, HEP Author) Some of the program content was deemed repetitive, with approximately the same information being covered from grade to grade. I have been hearing for years how it’s just a repetition, like at grade five and six you are just adding, maybe one different component, but the lessons are primarily the same. (Individual Interview, Principal) Parents, however, believed that repetition was necessary for children’s learning process and could help them better remember the important facts on diabetes. Themes for facilitators Several positive topics emerged as facilitators for the HEP program (Table 3). All participants agreed on the importance of the HEP, and some parents commented that health education at school had a positive influence on their children’s behaviour. By him being aware about the foods that he eats, he’s more conscious of it. He makes me more conscious of it too. My son comes home with information, papers, recipes; it has all these healthy ingredients. (Talking Circle, Parents) Many teachers saw the importance of increasing student interest and engagement in health education, and have developed their own teaching materials using the Internet and updated technology. Every material I find on the internet, I have to adapt it, and then I have to look at the kids, what are the kids interested in, how can I make it exciting? I use music a lot. (Talking Circle, Teachers) Others believe that for some HEP aspects, children still need tactile activities using senses: You could do stuff on the computer, but you’d need the three dimensional heart, some of those things have to do with your touching, and I wouldn’t take that away to a computer because the whole idea is you want to encourage movement. (Talking Circle, HEP Author) Box 1. Knowledge translation activities Step 1. Discussed the results with the full KSDPP Research Team and KSDPP Community Advisory Board. Step 2. Community researcher MP compiled a detailed written report of results and recommendations for the funding agency and the main stakeholders at KMHC and KEC, before co-authoring a lay summary for the community newspaper with MK. Step 3. Community researchers (MP and AMc) embarked on detailed community knowledge translation activities. Step 4. MP and AMc undertook detailed discussions with KMHC and KEC senior administrators to address the knowledge-to-action gap. Step 5. MP undertook in-depth interviews with all stakeholders (KEC administrators, principals, teachers, KSDPP staff, KMHC staff and HEP authors) to better understand their views on this study’s recommendations. Step 6. MP engaged Grades 5/6 students in a photovoice project to understand their concepts of healthy lifestyles, and discussed their photographs in a talking circle. Step 7. MP’s results will provide additional guidance for HEP revival and implementation within the new proposed comprehensive health curriculum and form the basis for her doctoral thesis. Themes for recommendations for changes There were several themes that emerged from the analyses on recommendations for HEP renewal or revival that touched on the topics identified as barriers and facilitators, namely issues of support, organizational factors, program content, cultural adaptation and the possibility of a more comprehensive health education program. For the topic of support, the school principals and teachers believed that parents should receive more interventions than are currently available, with educational materials and visual representations such as graphs, pictures and diagrams along with the facts to reinforce the importance of preventing Type 2 diabetes. Well it all goes back to the parents … I think there has to be more workshops for you know, meeting with parents to get them 100% on board … (Individual interview, Principal) Although students learned what was healthy/not healthy, it didn’t necessarily translate or affect their choices. In the end it is the parents that buy the groceries, and dictate eating choices. (Talking Circle, Teachers) For the content, many teachers perceived that the HEP was basically developed externally and then adopted by the schools, resulting in a decreased sense of ownership by the teachers: The lessons need to be made by teachers. (Talking Circle, Teachers) In addition, teachers recommended reinstituting in-service training because if they were completely knowledgeable about diabetes, and its outcomes, they would be more engaged in HEP teaching. One of the things I think is that more of us need more professional development in these areas. When you are trying to implement health, you have to understand how certain things affect the body. (Individual Interview, Principal) Other specific recommendations on how to adapt the program content and increase cultural appropriateness are summarized in Table 4. Discussion The study results demonstrate that since the HEP’s inception in 1997, it is still viewed by the principals, teachers and parents as a positive intervention, yet is not being fully implemented for various reasons. The facilitators for successful delivery included teachers beliefs of the value of the HEP and appreciation of prepared lessons, the potential for integrating some content into academic lessons and the strong presence of the Kahnawake Schools Diabetes Prevention Project in the community that has also been documented in other Kahnawake Schools Diabetes Prevention Projects (25). The barriers to delivery included decreased administrative support, lack of time, other competing academic requirements and the need for more parental education, all of which have been previously noted elsewhere (26). Findings also demonstrated that teachers who had taught the HEP for a longer period of time had more positive views on the HEP content, its delivery and the level of support provided, due to the training they had received in the early years. Some parents felt that it made a positive impact on the children and their resulting choices of foods. Many findings are similar to other authors who have documented the need for active and engaged leadership from school principals (5,6), professional development for teachers (6) and school/family/community partnerships (6). Some study participants recommended including HEP in comprehensive health education, as does the WHO (3) and Centers Disease Control and Prevention (CDC) (27). Not surprisingly, after 15 years, recommendations included updating the scientific content and use of the internet and technology. What is unique is the community’s readiness to incorporate more cultural teachings into health education which reflects ongoing self-determination efforts of revitalization and renewal of Indigenous ways of knowing (8), not only in Kahnawà:ke, but throughout North America. As one participant commented, ‘if you are Kanien’kehá:ka, you are healthy’. This points to the community’s vision of linking a health education program with a Kanien’kehá:ka identity of being healthy physically, mentally, spiritually and emotionally. Another suggestion was to designate one classroom for HEP delivery with designated health teachers. Health delivery already varies in the two schools: one school has dedicated health teachers whereas in the other school homeroom teachers are responsible for HEP delivery. Results, however, have been combined from the two schools at the direction of the Kahnawake Combined Schools Committee (the local school board), to prevent comparisons between the two schools. While there is a general consensus in the literature about the suitability of generalist classroom teachers to implement health education curricula for elementary school children, some experts advocate for specialized teachers to teach adolescents (28). Knowledge translation The Kahnawake Schools Diabetes Prevention Project Code of Research Ethics states that dissemination must occur within Kahnawake before any external dissemination (http://www.ksdpp.org/elder/code_ethics.php). Figure 1 outlines the knowledge translation activities for the project. Detailed activities were purposively undertaken by the community researchers knowing that the credibility of the messenger is paramount and people trust those they know (28). As a result of the knowledge translation activities, the Kateri Memorial Hospital Centre supported the HEP authors to update HEP scientific content with current national recommendations. In the schools, the Kahnawake Schools Diabetes Prevention Project facilitated the knowledge translation process through the School Wellness Committee, established in 2013 whose goal is to develop and support school healthy activities and healthy lifestyle policies. The Kahnawake Education Center recently launched plans to engage in strategic planning with parents, families, and the community to develop a new overall health program to integrate all aspects of health and safety, that will include the revised HEP and teacher training. This echoes the goals of WHO (3) and the CDC (27) for comprehensive school health and safety education to increase knowledge and essential health skills to value a healthy lifestyle. Strengths and limitations The significant strengths of this study were the engagement of the community and the use of culturally appropriate qualitative methods in the form of talking circles and the very detailed knowledge translation activities to address the knowledge to action gap. The small numbers of teachers and parents in the talking circles is indicative of the many competing demands on time for community members. We also did not ask students for their opinions, so their perspective is not included in our findings. This will be important to address in the next steps of the research process as well as extending the research to assess the impact on diabetes prevalence. Conclusion Consistent with an ecological approach to interventions, with teachers often assuming leadership promoting school health, it is essential to better understand their needs in terms of program content and delivery. Culturally appropriate evaluation of the HEP in Kahnawà:ke using questionnaires finalized with community input and talking circles as a form of deliberative enquiry revealed its strengths and areas for improvements. The detailed participatory knowledge translation of the results to all relevant community stakeholders in health and education was time-consuming, but promoted maximum use of the results and significant researcher and community capacity building and provides an example of detailed knowledge translation from a community-based participatory research project. Declaration Funding: We thank the Regional Evaluation and Innovation Fund of the Quebec Region Aboriginal Diabetes Initiative (ADI), Health Canada for funding. The first author was supported by the Fonds de Recherche en Santé, Quebec Master’s training award. Ethical approval: This study was first approved by the Kahnawake Schools Diabetes Prevention Project Community Advisory Board and then the McGill University Faculty of Medicine Institutional Review Board in accordance with the Kahnawake Schools Diabetes Prevention Project Code of Research Ethics (http://www.ksdpp.org/elder/code_ethics.php). Conflict of interest: none. Acknowledgements The authors thank all the participants, the community of Kahnawà:ke, and the Kahnawake Schools Diabetes Prevention Project Research Team and Community Advisory Board for assistance in planning and implementing this study (www.ksdpp.org). References 1. Schulze MB, Hu FB. Primary prevention of diabetes: what can be done and how much can be prevented? Annu Rev Public Health  2005; 26: 445– 67. Google Scholar CrossRef Search ADS PubMed  2. Rice K, Te Hiwi B, Zwarenstein Met al.  ; FORGE AHEAD program team. Best practices for the prevention and management of diabetes and obesity-related chronic disease among indigenous peoples in Canada: a review. Can J Diabetes  2016; 40: 216– 25. Google Scholar CrossRef Search ADS PubMed  3. Langford R, Bonell CP, Jones HEet al.   The WHO Health Promoting School Framework for Improving the Health and Well-Being of Students and Their Academic Achievement . Vol. 8. Langford R (ed). Chichester, UK: John Wiley & Sons, Ltd, 1996. 4. Saksvig BI, Gittelsohn J, Harris SB, Hanley AJ, Valente TW, Zinman B. A pilot school-based healthy eating and physical activity intervention improves diet, food knowledge, and self-efficacy for native Canadian children. J Nutr  2005; 135: 2392– 8. Google Scholar CrossRef Search ADS PubMed  5. Rasberry CN, Slade S, Lohrmann DKet al.   Lessons learned from the whole child and coordinated school health approaches. J Sch Health  2015; 85: 759– 65. Google Scholar CrossRef Search ADS PubMed  6. Valois RF, Lewallen TC, Slade S, Tasco AN. The ASCD Healthy School Communities project: formative evaluation results. Health Educ  2015; 115: 269– 84. Google Scholar CrossRef Search ADS   7. Teufel NI, Ritenbaugh CK. Development of a primary prevention program: insight gained in the Zuni Diabetes Prevention Program. Clin Pediatr (Phila)  1998; 37: 131– 41. Google Scholar CrossRef Search ADS PubMed  8. Kirmayer LJ, Dandeneau S, Marshall Eet al.   Toward an ecology of stories: Indigenous perspectives on resilience. In: Ungar M (ed). The Social Ecology of Resilience . New York, NY: Springer, 2012, pp. 399– 414. Google Scholar CrossRef Search ADS   9. Montour LT, Macaulay AC, Adelson N. Diabetes mellitus in Mohawks of Kahnawake, PQ: a clinical and epidemiologic description. CMAJ  1989; 141: 549– 52. Google Scholar PubMed  10. Cargo M, Mercer SL. The value and challenges of participatory research: strengthening its practice. Annu Rev Public Health  2008; 29: 325– 50. Google Scholar CrossRef Search ADS PubMed  11. Macaulay AC, Paradis G, Potvin Let al.   The Kahnawake Schools Diabetes Prevention Project: intervention, evaluation, and baseline results of a diabetes primary prevention program with a native community in Canada. Prev Med  1997; 26: 779– 90. Google Scholar CrossRef Search ADS PubMed  12. Cargo M, Salsberg J, Delormier Tet al.   Understanding the social context of school health promotion program implementation. Health Educ  2013; 106: 85– 97. Google Scholar CrossRef Search ADS   13. Jagosh J, Macaulay AC, Pluye Pet al.   Uncovering the benefits of participatory research: implications of a realist review for health research and practice. Milbank Q  2012; 90: 311– 46. Google Scholar CrossRef Search ADS PubMed  14. Creswell JW, Plano Clark VL. Designing and Conducting Mixed Methods Research . Thousand Oaks, CA: SAGE, 2011. 15. Abelson J, Forest PG, Eyles Jet al.   Deliberations about deliberative methods: issues in the design and evaluation of public participation processes. Soc Sci Med  2003; 57: 239– 51. Google Scholar CrossRef Search ADS PubMed  16. Fishkin JS. When the People Speak: Deliberative Democracy and Public Consultation . Oxford: Oxford University Press, 2009. 17. De Vries R, Stanczyk A, Wall IFet al.   Assessing the quality of democratic deliberation: a case study of public deliberation on the ethics of surrogate consent for research. Soc Sci Med  2010; 70: 1896– 903. Google Scholar CrossRef Search ADS PubMed  18. De Vries R, Stanczyk AE, Ryan KAet al.   A framework for assessing the quality of democratic deliberation: enhancing deliberation as a tool for bioethics. J Empir Res Hum Res Ethics  2011; 6: 3– 17. Google Scholar CrossRef Search ADS PubMed  19. O’Doherty K, Gauvin FP, Grogan Cet al.   Implementing a public deliberative forum. Hastings Cent Rep  2012; 42: 20– 3. Google Scholar CrossRef Search ADS PubMed  20. Lavallée LF. Practical application of an indigenous research framework and two qualitative indigenous research methods: sharing circles and anishnaabe symbol-based reflection. Int J Qual Methods  2009; 8: 21– 40. Google Scholar CrossRef Search ADS   21. Struthers R, Hodge FS, Geishirt-Cantrell Bet al.   Participant experiences of talking circles on type 2 diabetes in two Northern Plains American Indian Tribes. Qual Health Res  2003; 13: 1094– 115. Google Scholar CrossRef Search ADS PubMed  22. Corradetti C, Bartlett G. Public deliberation and the role of stakeholders as a new frontier in the governance of science: the British Columbia biobank deliberation and the DePGx project. In: Mascalzoni D (ed). Ethics, Law and Governance of Biobanking. Vol 14. The International Library of Ethics, Law and Technology . Dordrecht: Springer Netherlands, 2015, pp. 241– 60. 23. Caballero B, Clay T, Davis SMet al.  ; Pathways Study Research Group. Pathways: a school-based, randomized controlled trial for the prevention of obesity in American Indian schoolchildren. Am J Clin Nutr  2003; 78: 1030– 8. Google Scholar PubMed  24. Steckler A, Ethelbah B, Martin CJet al.   Pathways process evaluation results: a school-based prevention trial to promote healthful diet and physical activity in American Indian third, fourth, and fifth grade students. Prev Med  2003; 37: S80– 90. Google Scholar CrossRef Search ADS PubMed  25. Salsberg J, Macridis S, Garcia Bengoechea E, Macaulay AC, Moore S; KSDPP School Travel Planning Committee. Engagement strategies that foster community self-determination in participatory research: insider ownership through outsider championship. Fam Pract  2017; 34: 336– 40. Google Scholar CrossRef Search ADS PubMed  26. Totura CM, Figueroa HL, Wharton C, Marsiglia FF. Assessing implementation of evidence-based childhood obesity prevention strategies in schools. Prev Med Rep  2015; 2: 347– 54. Google Scholar CrossRef Search ADS PubMed  27. CDC. Whole School, Whole Community, Whole Child (WSCC) . cdc.gov. PubMed PubMed  28. Salsberg J, Macaulay AC, Parry D. Guide to integrated knowledge translation research. In: Graham ID, Tetroe JM, Pearson A (eds). Turning Knowledge into Action: Practical Guidance on How to Do Integrated Knowledge Translation Research . Book 21 in the Synthesis Science in Healthcare book series. Philadelphia, PA: Wolters Kluwer-Joanna Briggs Institute, 2014. © The Author(s) 2017. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
TI - Evaluating an Indigenous health curriculum for diabetes prevention: engaging the community through talking circles and knowledge translation of results
JF - Family Practice
DO - 10.1093/fampra/cmx068
DA - 2018-02-01
UR - https://www.deepdyve.com/lp/oxford-university-press/evaluating-an-indigenous-health-curriculum-for-diabetes-prevention-47LnlKmC53
SP - 80
EP - 87
VL - 35
IS - 1
DP - DeepDyve
ER -