Kahnawake Schools Diabetes Prevention Project Research Articles

School Travel Planning with the Kahnawake Schools Diabetes Prevention Project: Partnership Perspectives

Despite several studies examining the impact of school active transportation programming, there is limited understanding about undertaking the process of planning and evaluation from the perspective of community stakeholders. Most importantly, programming is rarely undertaken within an Indigenous context, which requires understanding of unique characteristics, culture, and needs. This study combined community-based participatory research with methods of ethnography within the Kahnawake Schools Diabetes Prevention Project in the Indigenous community of Kahnawake, Canada. This study fully engaged community members, built on pre-existing community and researcher strengths and increased the knowledge and understanding of active transportation to support schools in programming and implementation. In particular, this study, which may be relevant to other Indigenous and non-Indigenous communities, shed light on stakeholder perspectives of undertaking school active transportation program planning, which can inform the practice and provide support to others currently or planning to undertake similar projects.

Understanding community-based participatory research through a social movement framework: a case study of the Kahnawake Schools Diabetes Prevention Project

BackgroundA longstanding challenge of community-based participatory research (CBPR) has been to anchor evaluation and practice in a relevant theoretical framework of community change, which articulates specific and concrete evaluative benchmarks. Social movement theories provide a broad range of theoretical tools to understand and facilitate social change processes, such as those involved in CBPR. Social movement theories have the potential to provide a coherent representation of how mobilization and collective action is gradually developed and leads to systemic change in the context of CBPR. The current study builds on a social movement perspective to assess the processes and intermediate outcomes of a longstanding health promotion CBPR project with an Indigenous community, the Kahnawake Schools Diabetes Prevention Project (KDSPP).MethodsThis research uses a case study design layered on a movement-building evaluation framework, which allows progress to be tracked over time. Data collection strategies included document (scientific and organizational) review (n = 51) and talking circles with four important community stakeholder groups (n = 24).ResultsFindings provide an innovative and chronological perspective of the evolution of KSDPP as seen through a social movement lens, and identify intermediate outcomes associated with different dimensions of movement building achieved by the project over time (mobilization, leadership, vision and frames, alliance and partnerships, as well as advocacy and action strategies). It also points to areas of improvement for KSDPP in building its potential for action.ConclusionWhile this study’s results are directly relevant and applicable to the local context of KSDPP, they also highlight useful lessons and conclusions for the planning and evaluation of other long-standing and sustainable CBPR initiatives. The conceptual framework provides meaningful benchmarks to track evidence of progress in the context of CBPR. Findings from the study offer new ways of thinking about the evaluation of CBPR projects and their progress by drawing on frameworks that guide other forms of collective action.

Evaluating an Indigenous health curriculum for diabetes prevention: engaging the community through talking circles and knowledge translation of results.

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. 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. 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. 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. 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.

Active transportation to support diabetes prevention: Expanding school health promotion programming in an Indigenous community

BackgroundSchool-based physical activity (PA) interventions, including school active transportation (AT), provide opportunities to increase daily PA levels, improves fitness, and reduces risk of diseases, such as type 2 diabetes. Based on a community-identified need, the Kahnawake Schools Diabetes Prevention Project, within an Indigenous community, undertook school travel planning to contribute to PA programming for two elementary schools. MethodsUsing community-based participatory research, the Active & Safe Routes to School’s School Travel Planning (STP) process was undertaken in two schools with an STP-Committee comprised of community stakeholders and researchers. STP activities were adapted for local context including: school profile form, family survey, in-class travel survey, pedestrian-traffic observations, walkability checklist, and student mapping. ResultsSTP data were jointly collected, analyzed and interpreted by researchers and community. Traffic-pedestrian observations, walkability and parent surveys identified key pedestrian-traffic locations, helped develop safe/direct routes, and traffic calming strategies. In-class travel and mapping surveys identified a need and student desire to increase school AT. The STP-Committee translated findings into STP-action plans for two schools, which were implemented in 2014–2015 school year. ConclusionsCombining CBPR with STP merges community and researcher expertise. This project offered evidence-informed practice for active living promotions. Experience and findings could benefit Indigenous and non-Indigenous communities.

Using a participatory approach to the development of a school-based physical activity policy in an Indigenous community.

This study is part of a larger community-based participatory research (CBPR) project to develop, implement, and evaluate the physical activity component of a school-based wellness policy. The policy intervention is being carried out by community stakeholders and academic researchers within the Kahnawake Schools Diabetes Prevention Project, a well-established health promotion organization in the Indigenous community of Kahnawake, Quebec. We explored how a group of stakeholders develop a school physical activity policy in a participatory manner, and examined factors serving as facilitators and barriers to the development process. This case study was guided by an interpretive description approach and draws upon data from documentary analysis and participant observation. A CBPR approach allowed academic researchers and community stakeholders to codevelop a physical activity policy that is both evidence-based and contextually appropriate. The development process was influenced by a variety of barriers and facilitators including working within existing structures, securing appropriate stakeholders, and school contextual factors. This research offers a process framework that others developing school-based wellness policies may use with appropriate modifications based on local environments.

Evaluation of an Elementary School Diabetes Prevention Curriculum in a Mohawk Community

The Kahnawake Schools Diabetes Prevention Project (KSDPP), a community-based participatory research project at Kahnawake Mohawk Territory, Quebec, evaluated the Kateri Memorial Hospital Centre (KMHC) Health Education Program (HEP) for Diabetes Prevention for the years 2010 to 2012 at 2 elementary schools. The project goal was to understand how the HEP continued to be delivered since its inception in 1994. The project objectives were to identify the relevance and accuracy of the curriculum content; to identify the cultural appropriateness of the content and instructional methodology, and the successes and challenges of the implementation methodology; to identify facilitators and barriers of the HEP delivery; and to understand the overall effectiveness of the curriculum. Qualitative and quantitative data collection included individual interviews with principals; teacher questionnaires; talking circles with teachers and with key informants (authors); and a curriculum review of the content, instructional methodology and cultural appropriateness. The results indicated that participants and evaluators perceived the HEP as important to the children to increase knowledge regarding health behaviours to prevent type 2 diabetes. The strengths of the curriculum included factors involving a positive school environment and certain aspects of delivery and curriculum content. Weaknesses included lack of administrative support, instructional time and time management issues, a lack of Mohawk cultural representation, and outdated or missing resource materials. Recommendations addressed curriculum content, cultural integration, methodology development and administrative support to revitalize the curriculum and delivery. Knowledge transfer activities include discussions with local stakeholders (hospital, schools and KSDPP) with follow up strategizing to implement the recommendations.

Community Based Early Intervention for the Prevention of Type 2 Diabetes: A Case Report of the Kahnawake Schools Diabetes Prevention Project

Type 2 diabetes (T2D) is a chronic metabolic disorder that is predominately associated with lifestyle changes including reduced physical activity, poor nutrition and obesity. Despite major medical advances in the treatment of T2D, its prevalence is still increasing at an alarming rate. Accordingly, better management and prevention strategies are urgently needed to prevent the development and progression of this disease. In the last decade there have been considerable efforts to improve public health through alternative research paradigms. Community-Based Participatory Research (CBPR) is one such process by which researchers form an equal and transparent partnership with the community with the final goal of creating empowerment and societal change to facilitate action and provide solutions to promote health and well-being. One CBPR program, the Kahnawake Schools Diabetes Prevention Project (KSDPP), was initiated to promote increased physical activity and healthier eating habits among school children based on the Mohawk’s “Living in Balance” philosophy. Utilizing CBPR principles, KSDPP engaged researchers and the community in all stages of the research processes. This project was community driven from the beginning and was independent of any external institutional change agent to facilitate community action and the implementation of strategies to find solutions. Although the project has been instrumental in community empowerment and societal change, several challenges remain. Accordingly, understanding the unique social, environmental and historical context that shapes lifestyle and risk factors for T2D in Native populations will help to understand the unique nature of this disease in these groups.

Community Capacity as an “Inside Job”: Evolution of Perceived Ownership within a University-Aboriginal Community Partnership

PURPOSE. To assess the evolution of perceived ownership of a university-Aboriginal community partnership across three project stages. DESIGN. Survey administration to project partners during project formalization (1996-T1), mobilization (1999-T2), and maintenance (2004-T3). SETTING. Aboriginal community of Kahnawake, outside Montreal, Quebec, Canada. PARTICIPANTS. Partners involved in influencing decision making in the Kahnawake Schools Diabetes Prevention Project (KSDPP). MEASURE AND ANALYSIS . A measure of perceived primary ownership subjected to linear trend analysis. RESULTS. KSDPP staff were perceived as primary owner at T1 and shared ownership with Community Advisory Board (CAB) members at T2 and T3. Trend tests indicated greater perceived ownership between T1 and T3 for CAB (χ(2)(1) = 12.3, p < .0001) and declining KSDPP staff (χ(2)(1) = 10.5, p < .001) ownership over time. Academic partners were never perceived as primary owners. CONCLUSION. This project was community driven from the beginning. It was not dependent on an external academic change agent to activate the community and develop the community's capacity to plan and implement a solution. It still took several years for the grassroots CAB to take responsibility from KSDPP staff, thus indicating the need for sustained funding to build grassroots community capacity.

Can the democratic ideal of participatory research be achieved? An inside look at an academic-indigenous community partnership

Democratic or equal participation in decision making is an ideal that community and academic stakeholders engaged in participatory research strive to achieve. This ideal, however, may compete with indigenous peoples' right to self-determination. Study objectives were to assess the perceived influence of multiple community (indigenous) and academic stakeholders engaged in the Kahnawake Schools Diabetes Prevention Project (KSDPP) across six domains of project decision making and to test the hypothesis that KSDPP would be directed by community stakeholders. Self-report surveys were completed by 51 stakeholders comprising the KSDPP Community Advisory Board (CAB), KSDPP staff, academic researchers and supervisory board members. KSDPP staff were perceived to share similar levels of influence with (i) CAB on maintaining partnership ethics and CAB activities and (ii) academic researchers on research and dissemination activities. KSDPP staff were perceived to carry significantly more influence than other stakeholders on decisions related to annual activities, program operations and intervention activities. CAB and staff were the perceived owners of KSDPP. The strong community leadership aligns KSDPP with a model of community-directed research and suggests that equitable participation-distinct from democratic or equal participation-is reflected by indigenous community partners exerting greater influence than academic partners in decision making.

Community-Based Participatory Research: Lessons From Sharing Results With the Community: Kahnawake Schools Diabetes Prevention Project

Kahnawake Schools Diabetes Prevention Project (KSDPP) is an ongoing, community-based participatory research project with an Aboriginal community in Canada, promoting healthy lifestyles to prevent type 2 diabetes. To document lessons learned from sharing results with the community, and analyzing feedback from attendees. In 2004, a researcher-community team delivered 16 sessions of a contextualized presentation of data collected from 1994 to 2002. The team documented the resulting questions and discussions, attendees completed anonymous questionnaires including open-ended questions, and presenters summarized their impressions. One hundred eighty-one people attended the presentations and question/discussion periods were summarized. One hundred sixty-two (82%) of attendees (87% female), completed the questionnaires; 99% understood the presentations and 142 (88%) stated they intended to improve their lifestyles. Qualitative analysis of discussions and open-ended comments categorized attendees' comments about KSDPP, the 1994 through 2002 results, the community, and lifestyle habits. Lessons learned included the time needed to develop and make the presentations, the importance of using community knowledge to guide the experience, ways of attracting an audience, difficulty of reaching men, use of feedback from those attending the presentations, and the need to plan prospectively for analyzing attendee feedback. Community feedback was used to improve interventions and finalize interpretation of the results.

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.

Understanding the social context of school health promotion program implementation

PurposeAlthough implementation fidelity is an important component in the evaluation of school health promotion programs, it assumes that teaching is the most relevant teacher role. To understand the social context of program implementation, a qualitative study was undertaken with the aim of identifying the schoolteacher's role in implementing the objectives of the Kahnawake Schools Diabetes Prevention Project (KSDPP), a locally governed Kanienke:háka (Mohawk) community‐based diabetes prevention program.Design/methodology/approachProspective semi‐structured interviews were conducted cross‐sectionally with 30 teachers, two administrators and one physical education teacher across four intervention years. Interviews were analysed retrospectively using qualitative thematic analysis.FindingsIn implementing KSDPP objectives teachers adopted, to varying degrees, the roles of teaching the health education curriculum, enforcing the school nutrition policy, role modelling healthy lifestyles, and encouraging healthy lifestyles. Taken together, these roles point to a high‐order role of teachers taking responsibility for enabling healthy lifestyles in their children, which is congruent with a wholistic approach to health. Study findings suggest that children in different classrooms were exposed to a different intervention dose based on the extent to which teachers applied each role.Research limitations/implicationsThe findings suggest that the current conceptualisation of implementation fidelity should be expanded to account for the influence of the social context (i.e. teachers' roles) on the implementation of health promotion program objectives.Originality/valueConsistent with an ecological approach to intervention, teachers would benefit from interventions that predispose, enable, and reinforce their capacity to adopt and apply health promotion roles.

Impact of a Diabetes Prevention Program on Body Size, Physical Activity, and Diet Among Kanien'kehá:ka (Mohawk) Children 6 to 11 Years Old: 8-Year Results From the Kahnawake Schools Diabetes Prevention Project

Report the 8-year impact on body size, physical activity, and diet of a community-based diabetes prevention program for elementary-school children in a Kanien'keha:ka (Mohawk) community in Canada. Follow-up (1994-1996) of subjects in the intervention and comparison community and repeat cross-sectional measurements in the intervention community alone from 1994 to 2002. Measures included triceps and subscapular skinfold thicknesses, body mass index (BMI), weekly number of 15-minute episodes of physical activity, run/walk test times, television watching, and consumption of sugared foods, fatty foods, and fruits and vegetables. The longitudinal data of 1994-1996 showed some early positive effects of the program on skinfold thickness but not on BMI, physical activity, fitness, or diet. Repeat cross-sectional measures from 1994 to 2002 showed increases in skinfold thickness and BMI. Physical activity, fitness, and television watching showed favorable trends from 1994 to 1999 that were not sustained in 2002. Key high-fat and high-sugar foods consumption decreased, as did consumption of fruits and vegetables. Although early results showed some successes in reducing risk factors for type 2 diabetes, these benefits were not maintained over 8 years.

Unpacking the Black Box: A Deconstruction of the Programming Approach and Physical Activity Interventions Implemented in the Kahnawake Schools Diabetes Prevention Project

An ecological lens was used to deconstruct the programming approach and unpack physical activity interventions implemented through the Kahnawake Schools Diabetes Prevention Project. Despite a surge of interest in ecologically based health promotion programming, optimal combinations of interventions and programming approaches to promote community physical activity involvement have not been systematically studied. The authors obtained physical activity intervention descriptions through archive retrieval and face-to-face interviews with intervention staff. Programming approach, intervention targets, strategies for change, and delivery settings were assessed by applying the intervention analysis procedure to intervention descriptions. A complex intervention package was found containing a host of multitarget, multisetting intervention strategies designed and implemented through dynamic exchanges between a diversity of community partners. This study provides a first step toward better understanding community intervention packages and programming strategies for promoting physical activity involvement within a community setting.

Legitimizing diabetes as a community health issue: a case analysis of an Aboriginal community in Canada

The Kahnawake Schools Diabetes Prevention Project (KSDPP) is an ongoing participatory research and intervention project aimed at the primary prevention of type 2 diabetes. Formally initiated in 1994 with strong community support, KSDPP provides a fertile opportunity to learn about how a community came to identify the need for preventive action on a health problem such as diabetes. The purpose of our study was to describe the various conditions in the community of Kahnawake, which gave rise to its mobilization for the prevention of type 2 diabetes. Qualitative data consisted of 12 individual interviews and one focus group with key community members and health professionals living and/or working in the community of Kahnawake, along with historically relevant documents. The data collection and analysis procedures of the grounded theory method were applied. Results describe a preceding phase to formal KSDPP implementation, triggered by returning research results on the community prevalence of type 2 diabetes. This phase of 'legitimizing diabetes as a community health issue' is characterized by a shift in the perceived preventability of diabetes among community members; from a problem that was to be lived with to a problem that was to be prevented. The shift in perceptions was facilitated by the context in the community, described by structural developments, cognitive and relational elements. In addition to reaffirming the critical importance of utilizing lay knowledge during the planning of a health promotion intervention, our study has uncovered some of the key conditions through which individuals in the community came to participate in the identification and planning of a diabetes prevention project.

Development of the Physical Activity Interactive Recall (PAIR) for Aboriginal children

BackgroundAboriginal children in Canada are at increased risk for type 2 diabetes. Given that physical inactivity is an important modifiable risk factor for type 2 diabetes, prevention efforts targeting Aboriginal children include interventions to enhance physical activity involvement. These types of interventions require adequate assessment of physical activity patterns to identify determinants, detect trends, and evaluate progress towards intervention goals. The purpose of this study was to develop a culturally appropriate interactive computer program to self-report physical activity for Kanien'kehá:ka (Mohawk) children that could be administered in a group setting. This was an ancillary study of the ongoing Kahnawake Schools Diabetes Prevention Project (KSDPP).MethodsDuring Phase I, focus groups were conducted to understand how children describe and graphically depict type, intensity and duration of physical activity. Sixty-six students (40 girls, 26 boys, mean age = 8.8 years, SD = 1.8) from four elementary schools in three eastern Canadian Kanien'kehá:ka communities participated in 15 focus groups. Children were asked to discuss and draw about physical activity. Content analysis of focus groups informed the development of a school-day and non-school-day version of the physical activity interactive recall (PAIR). In Phase II, pilot-tests were conducted in two waves with 17 and 28 children respectively to assess the content validity of PAIR. Observation, videotaping, and interviews were conducted to obtain children's feedback on PAIR content and format.ResultsChildren's representations of activity type and activity intensity were used to compile a total of 30 different physical activity and 14 non-physical activity response choices with accompanying intensity options. Findings from the pilot tests revealed that Kanien'kehá:ka children between nine and 13 years old could answer PAIR without assistance. Content validity of PAIR was judged to be adequate. PAIR was judged to be comprehensive, acceptable, and enjoyable by the children.ConclusionsResults indicate that PAIR may be acceptable to children between nine and 13 years old, with most in this age range able to complete PAIR without assistance. The flexibility of its programming makes PAIR an easily adaptable tool to accommodate diverse populations, different seasons, and changing trends in physical activity involvement.

Kahnawake Schools Diabetes Prevention Project

The Kahnawake Schools Diabetes Prevention Project Center for Research and Training — funded — by the Canadian Institutes of Health Research- is offering scholarships for Masters, Doctoral and Post-Doctoral candidates interested in undertaking research in the area of community prevention of type 2 diabetes. The KSDPP Center is a partnership between the Kanien’keha’ka of Kahnawake Territory, located in Kahnawake, Quebec, Canada, with McGill University and the Université de Montréal. The KSDPP Center is an expansion of the Kahnawake Schools Diabetes Prevention Project (KSDPP), which since 1994 has developed and implemented a school-based and community-based diabetes prevention program to promote healthy lifestyles by incorporating the principles of participatory research and community ownership of the project.

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.

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.

The Kahnawake Schools Diabetes Prevention Project: Intervention, Evaluation, and Baseline Results of a Diabetes Primary Prevention Program with a Native Community in Canada

Objectives.Kahnawake Schools Diabetes Prevention Project is a 3-year community-based, primary prevention program for non-insulin-dependent diabetes mellitus in a Mohawk community near Montreal, Canada. Objectives are to improve healthy eating and encourage more physical activity among elementary school children.Methods.Intervention incorporates behavior change theory, Native learning styles, the Ottawa Charter for Health Promotion, and a health promotion planning model. Evaluation uses a mixed longitudinal and cross-sectional design to measure obesity, fitness, eating habits, and physical activity of elementary school children in the experimental and comparison communities. Intermediate variables are self-efficacy and perceived parental support. Process evaluation provides feedback to the intervention.Results.During 3 years, 63 distinct interventions that included a Health Education Program reinforced by school events, a new Community Advisory Board, a recreation path, and community-based activities promoting healthy lifestyles were implemented. Baseline consent rates were 87 and 71% in the experimental and comparison schools. As expected, anthropometric data increase with age. Between 9 and 10 years there are increased weight, height, BMI, and skinfold thicknesses; decreased fitness; and increased television watching.Conclusions.Implementing a Native community-based diabetes prevention program is feasible through participatory research that incorporates Native culture and local expertise.