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Community Change Project Kent County, Michigan American Indians and Obesity. Hulwick , B . Johns , A . Marchenko , O . Ranstadler , L . Williams , S. “The power of intuitive understanding will protect you from harm until the end of your days.” Lao-Tzu.

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Community change project kent county michigan american indians and obesity

Community Change ProjectKent County, MichiganAmerican Indians and Obesity

Hulwick, B.

Johns, A.

Marchenko, O.

Ranstadler, L.

Williams, S.

The power of intuitive understanding will protect you from harm until the end of your days lao tzu
“The power of intuitive understanding will protect you from harm until the end of your days.” Lao-Tzu

One role of the public health nurse is to address underserved and at-risk populations to remedy health disparities.This PowerPointwill address the health disparity of obesity within the American Indian(AI) community of Kent County, Michigan.


Analysis statistics
Analysis: underserved and at-risk Statistics

Nationwide epidemic: 35.7% of American adults and 17% of children are obese (Centers for Disease Control and Prevention [CDC], 2012a)

State of Michigan: 30.9% of Michigan adults are obese (CDC, 2012b)

Kent County, Michigan: 30% of adults are obese (Kent County Health Department, 2012)

American Indian population nationwide: 39.6% of adults are obese (Office of Minority Health [OMH], 2012)

According to the Kent County Needs Assessment of 2012, Kent County American Indian youth are most at risk for being obese.

Obesity contributing factors
Obesity: Contributing Factors underserved and at-risk


Genetics “Thrifty gene” hypothesis (Neel, 1962)

Lack of culturally relevant interventions

(Brown, Harris, Harris, Parker, Ricci, & Noonan, 2010)

Loss of cultural identity (Brown et al., 2010)

AI lack of trust of governmental institutions (including healthcare)

(U.S. Commission on Civil Rights, 2004)

Lack of AI mental health practitioners

(U.S. Department of Health and Human Services [USDHHS], 2001)

Obesity contributing factors1
Obesity: Contributing Factors underserved and at-risk

Social Determinants

Sedentary lifestyle (Hodge, Cantrell, & Kim, 2011)

Poverty (CDC, 2010)

Poor eating habits/reduced access to healthy food (Kent County Health Department, 2011)

Health care access/Services (Kent County Health Department, 2011)


AI adults are significantly more likely to have below basic health literacy compared to white counterparts (National Indian Health Board, n.d.).

AI high school graduation rate is 64.2% (HealthyPeople 2020, 2012)

The ecological model
The Ecological Model underserved and at-risk

“Based on the belief that all processes occurring within individual people and their environment should be viewed as interdependent. It suggests that behavior change in people needs to be considered in a broader social context, including developmental history, psychological characteristics, interpersonal relationships, physical environment, and culture” (Harkness & DeMarco, 2012, p. 79)

The ecological model cont
The Ecological Model underserved and at-risk (cont.)

AI native land →

European colonization →

loss of cultural identity =

social determinants:


lack of education

mental illness

lack of trust


(USDHHS, 2001)

Existing resources
Existing Resources underserved and at-risk

Kent County Health Department and website. Individual web resources include the following pages: Health Equity, Health Promotion, Health Education, Health Improvement and School Wellness (see

SEVA Foundation (

Gun Lake Band Health and Human Services Director: Phyllis Davis

(Michigan Diabetes Prevention and Control Program, 2009; Match-E-Be-Nash-She-Wish Band of Pottawatomi: Gun Lake Tribe, 2004)

Gun Lake Band Diabetes Outreach Worker: Carol Barker (Weick, 2009)

Like the rest of the nation, Kent County resources do not address the complexity of the causes of AI health disparities and do not provide adequate service to this community.

What other disciplines are involved
What Other Disciplines are Involved? underserved and at-risk



Social Services

Community Mental Health

Tribal governments

Problem statement
PROBLEM STATEMENT underserved and at-risk

There is increased risk of obesity among the AI population in Kent County, Michigan related to genetic factors, reduced access to healthy food, lack of culturally relevant interventions, and loss of cultural identity, as demonstrated in the 2011 Kent County Health Needs Assessment and Health Profile.

Interventions underserved and at-risk

Due to the AI mistrust of government institutions most effective interventions have been proven to come from within the tribal community (Tripp-Reimer, Choi, Kelley, Enslein, 2001).

Interventions will be rooted in strengthening the collaboration between governmental institutions and minority populations based upon collaborative models proven to be effective (Trust for America’s Health, 2009).

Interventions who
Interventions: WHO underserved and at-risk

AI or culturally competent…

Interventions what how
Interventions: underserved and at-risk WHAT & HOW

Assessment of Community

Identify underserved “hidden” AI population

Measurable goal:

Commission report or supplement to next Kent County Health Assessment focusing on AI health disparities

Interventions what how1
Interventions: underserved and at-risk WHAT & HOW

Provide training for cultural competency of Kent County public health workers

Measurable goals:

Attain cultural competency using Office of Minority Health benchmarks (2013)

Study culturally relevant interventions and social/historic factors to address effects caused by loss of cultural identity

Interventions what how2
Interventions: underserved and at-risk WHAT & HOW

Utilize existing Health Department web resources in context of culturally focused care, for e.g., Kent County Health Department webpages Health Equity, Health Promotion, Health Education, Health Improvement

Measurable goals:

Each of the web pages will address AI health disparities

Provide culturally relevant education to AI population about nutrition, availability and location of healthy food sources and importance of physical activity

Interventions where when
Interventions: underserved and at-risk WHERE & WHEN


Interventions will be mainly developed and implemented through the Kent County Health Department by improving the quality of the interactions between health care workers with the community.


One year: Changes to the Kent County Health Department web pages to address AI community

Five years: Education and training of Kent County Health Department health care workers and development of culturally relevant interventions

Ten years: Reassessment of Kent County AI population within the framework of subsequent Kent County Health Assessment

Evalution quantitative
Evalution underserved and at-risk : Quantitative

Evaluation of the one-, five-, and ten-year goals for completion.

One year:

Meet with AI health liasons Carol Barker and Phyllis Davis for evaluation of changes to Kent County Health Department web pages.

Incorporate survey in web page to ascertain the effectiveness of content from public site viewers.

Five years:

Submission of staff cultural competency certification to Kent County Health Department leadership.

Submission to (at 2-year mark), implementation (at 3-year mark), and evaluation (at 5-year mark) of new culturally relevant interventions.

Ten years:

Review of Kent County Health Assessment data. Comparison of post-intervention data with current data to measure improvements in reports of access to healthy food, food choices, and activity level.

Evaluation qualitative
Evaluation: Qualitative underserved and at-risk

“The power of intuitive understanding will protect you from harm until the end of your days.” Lao-Tzu

The Ecological Model provides a framework for

greater understanding of complex social factors,

resulting in intuitive understanding and incorporation

of the unknown into one’s consciousness. This brings

qualitative improvement in the relationships and

communication between cultures.

Qualitative evaluation will include interview assessment

of public healthcare workers and the AI community for

knowledge and understanding of American Indian history

and culture but the extent of true understanding cannot be measured.

References underserved and at-risk

  • American Psychiatric Association. (2010). Mental health disparities: American Indians and Alaska Natives. Retrieved from

  • Brown, B., Harris, K., Harris, J., Parker, M., & Noonan, C. (2010). Translating the diabetes prevention program for Northern Plains Indian youth through community-based participatory research methods. Diabetes Education, 36(6), 924-935. doi:10.1177/0145710382582

  • CDC. (2010). Health disparities affecting minorities: American Indians and Alaska Natives. Retrieved from

  • CDC. (2012a). Prevalence of Obesity in the United States, 2009-2010. Retrieved from

  •  CDC. (2012b). Michigan’s response to obesity. Retrieved July 17, 2013, from

  • Harkness, G., & DeMarco, R. (2012). Community and public health nursing practice: Evidence for practice. Philadelphia, PA: Wolters Kluwer/Lippincott, Williams & Wilkins. 

  • Healthy People 2020. (2012). Social determinants. Retrieved from

  • Hermann, J., Jackson, T., Miracle, S., Parker, S., & Robertson, D. (2010, June). Utilizing the socioecological model as a framework for understanding elder Native Americans’ views of Type 2 Diabetes for the development of an indigenous prevention plan. Native People’s Technical Assistance Office. Retrieved July 26, 2013, from http:/

References underserved and at-risk

  • Hodge, K., Cantrell, G., & Kim (2011). Health status and socioeconomic characteristics of the morbidly obese American Indians. Ethnicity and Disease, 21, 52-57. Retrieved from

  • Kent County Health Department (2011). 2011 community health needs assessment and health profile. Retrieved from http://assets1/

  • Kent County Health Department (2013). Retrieved from

  • Koivusilta, L., Rimpela, A. & Vika, A. (2009). Health behaviors and health in adolescence as predictors of educational level in adulthood: a follow-up study from Finland. Social Science Medicine, 57(4), 577-593. doi:10.1300/J051v13n01_02

  • Match-E-Be-Nash-She-Wish Band of Pottawatomi: Gun Lake Tribe. (2004). Health & human services director: Phyllis Davis. Retrieved July 23, 2013, from

  • Michigan Diabetes Prevention and Control Program. (2009). Plan for diabetes prevention and control in tribal communities. Retrieved from http://www.michigan/gov/documents/mdch/Tribal_Plan_rev_4-1-09_274987_7.pdf

  • National Indian Health Board. (n.d.). Healthy People 2020: Leading health indicators for American Indian/Alaska native populations. Retrieved July 17, 2013, from

  • Neel, J. (1962). Diabetes Mellitus: A “thrifty” genotype rendered detrimental by “progress”? American Journal of Human Genetics, 14(4), 353-362.

  • Office of Minority Health. (2012). Obesity and American Indians/Alaska Natives. Retrieved from

References underserved and at-risk

  • Office of Minority Health. (2013). Educational materials/guide /PTTS/modules. Retrieved July 25, 2013, from

  • Seva Foundation. (2013). Retrieved July 15, 2013, from

  • Tripp-Reimer, T., Choi, E., Kelley, L., & Enslein. (2001). Cultural barriers to care: Inverting the problem. Diabetes Spectrum, 14(1), 13-22. doi:10.2337/diaspect.14.1.13

  • Trust for America’s Health. (2009). Examples of successful community-based public health interventions (state-by-state). Retrieved from

  • U.S. Department of Health & Human Services. (2001). Mental health: Culture, race, and ethnicity - A supplemental to mental health: A report of the Surgeon General. Retrieved from http://profiles/nlm/nih/gov/pf/retrieve/ResourceMetadata/NNBBS

  • U.S. Commission on Civil Rights. (2004, February). Native American health care disparities briefing. Retrieved from

  • Weick, C. (2009, May 11). Gun Lake Tribe cares for ‘mind, body, spirit’. Retrieved from