Purpose: Nutrition interventions for hypertension (HTN), such as the Dietary Approaches to Stop Hypertension (DASH) eating plan, fail to consider barriers to obtaining and utilizing fruits and vegetables (F/V). A paucity in the literature exists regarding acceptability of nutrition interventions for Hispanic/Latine communities. This project aims to determine the effect improved access to a culturally-appropriate, medically-tailored foods has on Hispanic/Latine individuals with HTN via an iterative process: 1) conceptualization of culturally-appropriate F/V for a "DASH box" using a patient/provider survey, 2) formative DASH box development utilizing individual interviews seeking box content feedback, and 3) free living pilot trial including DASH box intervention to determine effects on cardiometabolic markers.
Methods: Using community-based participatory research methods, F/V preferences indicated in 50 surveys supported the conceptualization of six boxes, including F/V, herbs, and staple foods to support DASH eating plan adherence. Boxes were displayed during 15 interviews gathering feedback on acceptability. Themes were assessed using the Framework Method and finalized via consensus building. A 28-day open trial enrolling 21 participants (12 females, 9 males) collected pre- and post- measurements of blood pressure (BP), weight, waist circumference, and skin carotenoid levels while receiving weekly DASH boxes and diet education.
Results: Thematic analysis determined participants prefer fresh F/V, use staple items to compliment F/V, and experience barriers (time, money, transportation) to accessing or using F/V. After the 28-day intervention, there was a significant improvement in systolic BP (mean difference of -4.1土7.8 mmHg, p=0.01), diastolic BP (-3.7土6.4 mmHg, p=0.004), and waist circumference (-0.8土1.1 inches, p=0.003). While mean difference in weight (-1.2土4.8 lbs, p=0.26) and skin carotenoid levels (26.7土74.1, p=0.06) changed, results were not significant.
Conclusions: Attention should be paid to the voices of communities to develop culturally-appropriate nutrition interventions for chronic disease management and supporting populations with high food insecurity. This research provides formative contributions regarding culturally-appropriate interventions for chronic disease management, suggesting tailored DASH boxes may be effective in lowering BP for Hispanic/Latine individuals with HTN.

Purpose: Despite the well-documented benefits of lifelong physical activity (PA) and its benefits during pregnancy, a majority of women do not meet the recommended PA guidelines. Doulas, despite being recognized for improving birthing experiences, little is known about their perspective on PA promotion. Therefore, the purpose of this research is to better understand doulas' perspectives on providing PA education and counseling during pregnancy.

Methods: This was a qualitative phenomenological study. A purposive sampling method was used to recruit doulas across Nebraska. A semi-structured interview guide was developed based on the Theory of Planned Behavior. Data were analyzed using a directed content analysis approach. Member checking and audit trail were performed to ensure the validity and reliability of the data.

Results/Findings: A total of 12 doulas with a mean age of 34.40 ± 5.79 years participated in the study. The sample included labor and birth doulas (75%), postpartum doulas (16.6%), and miscarriage doulas (8.3%). While almost all doulas knew about the benefits of PA, they rarely offered PA education and counseling to women. Participants mentioned that there were barriers to providing PA education and counseling for both doulas and pregnant women. For doulas, barriers included a lack of knowledge of PA guidelines and the COVID-19 pandemic. For pregnant women, barriers included pregnancy-related symptoms, cultural barriers, lack of knowledge related to PA, and environmental barriers. Doulas felt there was a need for education and training on PA for doulas to improve their knowledge and promotion of PA with women during consultations. They also advocated for tailored PA programs for pregnant women depending on their physiological and psychological needs.

Conclusions: Doulas lacked knowledge of PA guidelines during pregnancy and were not often provided with such education and counseling. The study emphasizes the need to improve doulas' knowledge of PA guidelines, provide resources, and foster a supportive environment for promoting PA during pregnancy. Future efforts should focus on interventions and training programs to empower doulas in effectively supporting pregnant women’s PA.

Purpose: In Puerto Rico (PR), more than 85% of food is imported. PR’s food system has been continuously impacted by natural disasters, most notably by Hurricane María in 2017. We used Community-Based System Dynamics (CBSD) to develop a shared understanding of the systemic barriers to local food production and understand how to promote a more resilient and robust agricultural economy.

Methods: We conducted a Group Model Building (GMB) Workshop in San Juan, PR bringing together diverse stakeholders to develop a shared understanding of how local food consumption has dropped over time. We recruited 26 stakeholders from the private sector, civil society, food production, academia, local communities, and local government and agencies to participate in the workshop. CBSD framed the GMB and its subsequent causal loop diagram (CLD). We synthesized the information from the workshop, data collected from in-depth interviews, and two 2.5-hour member-checking meetings to generate a comprehensive CLD.

Results: The stakeholders identified 6 subsystems: (1) demographic change and rural disinvestment, (2) climate change and farm sector adaptive capacity, (3) agricultural economy, (4) food culture, (5) nutrition security and health, and (6) governance and public policy. Four reinforcing and four balancing loops were identified across the system. For each balancing loop, we identified potential lever points that could be effective in intervening within the system. One example was based on the balancing loop: the rising rate of ecological degradation in agricultural areas increases ecological consciousness which, in turn, emphasizes the importance of implementing regenerative agricultural practices. Due to barriers preventing farmers from transitioning to regenerative agriculture, to strengthen this balancing loop, we propose investing in regenerative practice capacity by providing technological assistance and financing to farmers.

Conclusion: The complex nature of the challenges facing local food production and consumption in Puerto Rico, underlines the necessity for action. The scope of factors and areas of expertise demonstrate the need for cross-sectoral collaboration and community involvement to effectively intervene in the system. Our work has revealed a willingness to address this issue and demonstrated that the cohesion and integration of efforts is the key to viable solutions.

Purpose: Food insecurity, defined as insufficient access to enough nutritious food, is disproportionately prevalent among American Indian and Alaska Native individuals in the US. Some Indian Health Services (IHS) facilities screen patients for food insecurity by asking if their food did not last or if they had worries about food. However, screening may be stigmatizing. The purpose of this project was to develop and evaluate alternative culturally informed questions among IHS patients.
Methods: The mixed methods sequential exploratory study included a qualitative phase and a quantitative phase. During the first phase, participants were interviewed about their impressions of the existing food insecurity screener and alternative culturally informed questions. After analyzing interviews, culturally informed questions were refined, and a second sample was recruited for the quantitative phase. During this phase, respondents completed a survey that included the existing food insecurity screener and the culturally informed questions to assess equivalent-form reliability. This project was reviewed by the Navajo Nation Human Research Review Board and the University of Washington IRB.
Results/findings: Interview participants (n=25) reported high risk of food insecurity (60%) based on existing screening questions. Interviewees felt screening was important, but the existing food security screener might be confusing and produce shame. Interviewees provided insights that were used to update the alternative culturally informed questions. Survey participants (n=97) reported high risk of food insecurity (70%) based on existing screening questions. Responses to culturally informed questions were similar for respondents considered food insecure or food secure, with a few exceptions. When responses to the culturally informed questions were classified as potentially food insecure, the Pearson correlation between potential food insecurity and food insecurity based on the existing screener was of weak to moderate strength (0.3).
Conclusions: The equivalent-form reliability analyses indicated the existing and alternate screeners were not strongly associated, suggesting the questions may be gathering data related to two unique underlying concepts. The qualitative data and consistent high quantitative prevalence of food insecurity in both phases of the study provide evidence of rampant food insecurity issues, highlighting the importance that actions be taken to ensure food security among Navajo Nation residents.

Purpose: Indigenous Nations are regaining control over their health and well-being to reduce health inequities. Training programs that guide Indigenous community stakeholders to mobilize for collective health promotion action are promising approaches for addressing health inequities.
The Community Mobilization Training (CMT) developed by the Kahnawake Schools Diabetes Prevention Program is an example of a training program that guides Indigenous stakeholders in the mobilization of their community towards health promotion. Because it is essential to develop health promotion programs that support mobilization of Indigenous communities, understanding ways to account for context and trigger the essential mechanisms are needed to optimize community mobilization. It is therefore essential to understand how, why, for whom and under which circumstances CMT produces its outcomes. The aim is to present an initial program theory explaining CMT outcomes in Indigenous communities that have received this training.
Methods: A realist-informed evaluation was carried out. To uncover tacit theories specific to the CMT program, individual semi-structured interviews were conducted with research team members who were involved in the CMT in the six communities where it was deployed. A group interview was also conducted with the investigators involved in CMT implementation. An iterative analysis process was used to generate Context-Mechanism-Outcome configurations for developing the CMT initial program theory.
Results/findings: Participating community members were aware of the burden of type 2 diabetes faced by their communities and motivated to make the necessary changes to promote health. In some communities, however, it was difficult to balance long-term health promotion activities with urgent and time-sensitive community needs. Considering that the CMT program integrates traditional knowledges and is sensitive to the culture of each community, it generated a great interest among participants in improving the collective mobilization of their community in health promotion. The CMT also enabled relationships and discussions between organizations within communities for health promotion. In addition, the presence of a community champion helps to maintain CMT outcomes after the program has been delivered.
Conclusion : By being rooted in traditional knowledges, the CMT program facilitates community mobilization for health promotion in Indigenous communities.

Purpose: First Nations communities regularly engage in various sports, cultural and land-based activities. However, due to various intrinsic, systemic and structural barriers, individuals noted through the Health Evaluation conducted by Carrier Sekani Family Services (CSFS), a First Nations-led healthcare society, the need for improved physical activity. As such, this project supports increased emphasis in communities and the calls to action made at all governmental levels. While initiatives have been made, there is still little access to programs appropriate for those with chronic conditions. To understand the current experience to being active in the community, this project determined the values of, and barriers and facilitators to, physical activity in rural and remote northern British Columbia First Nations communities, specifically among individuals with chronic conditions. This project is a partnership between the University of British Columbia and CSFS.
Methods: This qualitative study is a subset of a larger mixed-methods, community-based participatory action project. Semi-structured interviews with an optional Photovoice component were conducted with a subset of participants who previously completed a survey in the first phase of this project. Eligible participants included those 12+ years old, experiencing at least one chronic condition, and a member of a First Nation receiving services from CSFS. Using NVivo, verbatim transcripts were analyzed using reflexive thematic analysis.
Results: Out of the 215 survey responses, 28 interviews were conducted with participants across two communities. Preliminary findings suggest that physical activity aligns with cultural values, specifically the benefits to health and well-being through land-based activity. Restoring historical ways of life may reduce barriers to physical activity, including barriers arising from physical and mental health concerns. Tailoring future programming to the community’s needs, such as changes to infrastructure, may help facilitate physical activity.
Conclusion: To improve programming, service providers must ensure that their offerings reflect the values of community members, minimize barriers they experience and support factors that they have identified as facilitators. These results will enable CSFS to create specific strategies on physical activity programming that will be appropriate for those with chronic conditions.
Financial Support: This research is supported by the Canadian Institutes of Health Research.