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NOVEMBER / DECEMBER 2014 :: 75(6)
Improving Population Health in North Carolina

Population health examines the health outcomes of groups and the disparities in health among subgroups. This issue of the NCMJ illustrates population health efforts in the areas of obesity prevention, tobacco cessation, and clean water. Articles in this issue also discuss community health needs assessments, integrated health improvement, social determinants of health, and the Healthy North Carolina 2020 program.


Advancing Native Health in North Carolina Through Tribally Led Community Changes

Sheila Fleischhacker, Randi Byrd, Amy Locklear Hertel

N C Med J. 2014;75(6):409-411.PDF | TABLE OF CONTENTS

American Indian children have a disproportionately high risk of developing obesity and type 2 diabetes [1-3]. Indeed, the prevalence of obesity among American Indian 4-year-olds (31.2%) was the highest of all 5 major race/ethnic groups examined in a recent study; this rate was almost double the rate for non-Hispanic whites (15.9%) and Asians (12.8%) [4]. The multifactorial origins of these health disparities are present very early in life and include genetics, environment, and policy factors that influence dietary and activity behaviors and challenges in accessing health care [5-9].

Targeting environmental and policy factors could potentially improve health equity among American Indians. To date, focusing on individual characteristics and behaviors while neglecting to modify the environmental and policy contexts in which American Indians live has yielded little progress [10, 11]. Nevertheless, comparatively few studies have rigorously evaluated the health impacts of tribally led policy, systems, or environmental changes that aim to promote active living or healthy eating [12]. A recent article presenting 3 case studies of intervention trials [13] concluded there are critical knowledge gaps regarding which institutional and multilevel approaches are most culturally and contextually appropriate for the prevention of chronic disease among American Indians.

To advance research and begin to address health disparities, the American Indian Healthy Eating Project (AIHEP) was created in the fall of 2008 using community-based participatory research. The aim was to develop land use planning and policy strategies for improving access to healthy, affordable foods in 7 American Indian communities in North Carolina. More than 122,000 American Indian/Alaskan Native individuals reside in North Carolina, making this the 7th largest American Indian population in the nation [14]. Overall, American Indians in the state face significantly worse health outcomes than white North Carolinians [15]. AIHEP was supported in part by the National Institutes of Health and Healthy Eating Research, a national program of the Robert Wood Johnson Foundation. The project was based on social cognitive theory [16], ecologic frameworks [17-19], and consumer behavior models and took into account various theories and concepts that attempt to explain political decision making and public policy participation.

As our group has described elsewhere [20], AIHEP evolved through 5 phases: starting conversations, conducting multidisciplinary formative research, strengthening partnerships and tailoring policy options, disseminating community-generated ideas, and accelerating action while fostering sustainability. These phases helped us develop and disseminate Tools for Healthy Tribes [21]—a toolkit created in partnership with the 7 participating tribes—that was designed to increase awareness of tribally led environmental and policy strategies for raising a healthier generation of American Indian children. AIHEP was one of the first studies to rigorously examine the food environment of American Indians living off reservations and to systematically explore with tribal leaders their potential to use changes in policy, systems, and the environment to promote healthy eating. Data were not collected on in-store food availability, access to physical activity resources, or health outcomes.

Building on the momentum established through AIHEP and with the support of the Kate B. Reynolds Charitable Trust, a 3-prong capacity-building approach known as Healthy, Native North Carolinians was undertaken to accelerate tribally led community changes. The first prong of the program was to expand the capacity of tribal leaders and community stakeholders to develop, implement, and evaluate sustainable community changes that promote active living and healthy eating. The second prong was to foster connections between tribal governments and community stakeholders who are interested in community changes related to active living and healthy eating. The third prong was to create a model program that American Indian tribal leaders could use to develop the capacity for this type of community change. For our purposes, tribally led community changes were self-determined changes in policy, systems, or the environment, initiated by tribal leaders, that promote active living or healthy eating through ongoing, repeated, long-term, strategic, and/or comprehensive planning.

As discussed in Healthy, Native North Carolinians: Advancing Native Health through Community Changes, Capacity Building, and Collaborations [22], 7 American Indian tribes and 3 urban Indian organizations in North Carolina collaborated with partners in state government, academia, and the community to create self-determined plans of action. These plans generally integrated a variety of community changes aiming to foster active living and healthy eating; for example, 8 tribes and urban Indian organizations started or expanded community gardens; 3 tribes built or expanded walking trails; and the Sappony started an annual trail race, which they have sustained over the past 3 years. All participants in Healthy, Native North Carolinians also made efforts to improve access to healthy foods and beverages during their community events; for example, the Waccamaw Siouan Tribe started offering healthy concessions at their sporting events, and the Haliwa-Saponi Indian Tribe sold fruit cups at their powwow. More than 20 tribal leaders grew in their capacity to develop, implement, evaluate, and sustain such community changes, and more than 238 individuals and organizations engaged with Healthy, Native North Carolinians. Participating tribal leaders said that their participation contributed to increased civic engagement among members of their communities, facilitated cross-community collaborations, and enhanced statewide recognition of their role in raising a healthier generation of American Indian children.

The Kate B. Reynolds Charitable Trust recently renewed its support for Healthy, Native North Carolinians for another 2 years. With this support, the American Indian Center at the University of North Carolina at Chapel Hill (, in collaboration with participating tribal communities and partnering academic, government, and community organizations, has now leveraged more than half a million dollars to create meaningful ways of reducing the prevalence of obesity among Native American youth by shaping the communities in which these children and their families live, pray, study, eat, and play.

This article was written on behalf of the American Indian Healthy Eating Project and the Healthy Native North Carolinians Network. These projects would not have been possible without the support of tribal leaders and liaisons from the Coharie Indian Tribe, the Cumberland County Association for Indian People, the Guilford Native American Association, the Haliwa-Saponi Indian Tribe, the Lumbee Tribe of North Carolina, the Meherrin Indian Nation, the Occaneechi Band of the Saponi Nation, the Sappony, the Triangle Native American Society, and the Waccamaw Siouan Tribe. We also acknowledge the invaluable contributions of the North Carolina Commission of Indian Affairs, with special thanks to Gregory Richardson, Missy Brayboy, and Kimberly Hammonds; the North Carolina American Indian Health Board, with special thanks to Robin Cummings and Edgar Villanueva; and team members, partners, and advisers of the American Indian Healthy Eating Project and Healthy, Native North Carolinians. We also greatly appreciate the time and thoughts shared by all modified Talking Circle participants and key informants.

Financial support. Support for the American Indian Healthy Eating Project was provided in part by Healthy Eating Research, a national program of the Robert Wood Johnson Foundation (ID #66958), and in part by a National Institutes of Health (NIH) University of North Carolina Interdisciplinary Obesity Training Grant (T 32 MH75854-03). Support for Healthy, Native North Carolinians was and continues to be made possible in part by the Kate B. Reynolds Charitable Trust. The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the US Department of Health & Human Services or any of its agencies, the Robert Wood Johnson Foundation, or the Kate B. Reynolds Charitable Trust.

Potential conflicts of interest. All authors have no relevant conflicts of interest.

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21. The American Indian Healthy Eating Project (AIHEP) in partnership with 7 American Indian tribes in North Carolina. Tools for Healthy Tribes. Chapel Hill, NC: AIHEP; 2011. Accessed July 18, 2014.

22. Healthy, Native North Carolinians. Healthy, Native North Carolinians: Advancing Native Health through Community Changes, Capacity Building, and Collaborations. Chapel Hill, NC: American Indian Healthy Eating Project; 2013. Accessed July 16, 2014.

Sheila Fleischhacker, PhD, JD senior public health and science policy advisor, Division of Nutrition Research Coordination, US Department of Health & Human Services, National Institutes of Health, Bethesda, Maryland.
Randi Byrd, BA community engagement coordinator, American Indian Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
Amy Locklear Hertel, JD, MSW director, American Indian Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Address correspondence to Dr. Sheila Fleischhacker, National Institutes of Health, Division of Nutrition Research Coordination, 2 Democracy Plaza, Rm 635, 6707 Democracy Blvd, MSC 5461, Bethesda, MD 20892 (