A Culture-Based Talking Circle Intervention for Native American Youth at Risk for Obesity

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Journal of Community Health Nursing
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A Culture-Based Talking Circle Intervention for
Native American Youth at Risk for Obesity
Melessa N. Kelley & John R. Lowe
To cite this article: Melessa N. Kelley & John R. Lowe (2018) A Culture-Based Talking Circle
Intervention for Native American Youth at Risk for Obesity, Journal of Community Health Nursing,
35:3, 102-117, DOI: 10.1080/07370016.2018.1475796
To link to this article: https://doi.org/10.1080/07370016.2018.1475796
Published online: 19 Jul 2018.
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A Culture-Based Talking Circle Intervention for Native American
Youth at Risk for Obesity
Melessa N. Kelley and John R. Lowe
College of Nursing, Center for Indigenous Nursing Research for Health Equity (INRHE), Florida State University,
Tallahassee, Florida
ABSTRACT
This community-based study explored the effectiveness of an after-school
cultural-based intervention for Native American youth at risk for obesity. A
standard health education after-school program served as the comparison
control condition. Cherokee self-reliance (cultural identity), perceived stress,
and obesity knowledge and related behaviors were the three outcome
measures evaluated at baseline and immediate post-intervention. Findings
revealed that participants who completed the cultural-based intervention
had better results on the three outcome measures in comparison to the
standard health education program.
Introduction
In the United States, obesity is reaching epidemic proportions, affecting one in six children or 12.7
million youth ages 2–19 (Ogden et al., 2016; World Health Organization, 2015). Without the reversal of
this rapidly growing trend, life expectancy for young people is likely to decrease to an all-time low
(Centers for Disease Control and Prevention, 2015). Even more alarming are the obesity rates for Native
American youth in comparison to the general United States (US) population (Centers for Disease
Control and Prevention, 2015). Findings from the National Health and Nutrition Examination Survey
(2015) indicated that Native American youth, ages 10–17 have higher prevalence rates of obesity (18%)
compared to the national average (12.2%) (Ogden, Carroll, Fryar, & Flegal, 2015). However, for the
purpose of this study, the age range selected included early adolescents ages 10–13 years old. According
to the World Health Organization (2013), early adolescence begins at the onset of the second decade of
life ages 10–13). Early adolescence, ages (10–13), is a crucial time for essential growth patterns involving
psychological, social, emotional, physical development, and behavior (Luby, Belden, Harmer, Tillman, &
Barch, 2016). Evidence suggests that the transition from early adolescence, ages 10–13, into adulthood is
a developmental stage where learned behaviors, such as dietary habits and physical activity can increase
or decrease one’s risk for obesity (Hueston, Cryan, & Nolan, 2017; Institute of Medicine, 2013).
Therefore, behavioral practices fostered during early adolescence can influence long-term health, even
into adulthood (Johnson, Riis, & Noble, 2016).
As a result of the higher prevalence rates of obesity, Native American youth are at increased risk
for obesity-related illnesses such as hypertension, high cholesterol, type II diabetes, and certain
cancers (Dennison et al., 2015; Marley & Metzger, 2015). Obesity is also associated with several
psychological problems including poor self-esteem, poor academic performance, increased stigma
and discrimination, and depression (Centers for Disease Control and Prevention, 2015). Studies have
demonstrated that overweight and obese youth are twice as likely to have a higher risk for obesity
into adulthood, suffering from premature death, and disability, and decreasing their life expectancy
CONTACT Melessa N. Kelley mnkelley@fsu.edu College of Nursing, Center for Indigenous Nursing Research for Health
Equity (INRHE), Florida State University, 102 Vivian M. Duxbury Hall, 98, Varsity Way, Tallahassee, Florida 32306.
© 2018 Taylor & Francis
JOURNAL OF COMMUNITY HEALTH NURSING
2018, VOL. 35, NO. 3, 102–117
https://doi.org/10.1080/07370016.2018.1475796

(Freedman, Dietz, Srinivasan, & Berenson, 2009; Freedman et al., 2005; World Health Organization,
2015). Therefore, interventions for youth at risk for obesity should begin as early as possible.
The historical events and struggles that Native Americans have endured for several hundreds of years
have impacted their current health status. Therefore, when examining the current obesity rates, it is
essential for researchers and scientists to review and understand how historical trauma has influenced
their current state of health. Historical trauma is defined as the cumulative effect of hundreds of years of
emotional, physical, and psychological injury experienced by populations, such as Native Americans,
over their lifespan and passed down from generation to generation (Kirmayer, Gone, & Moses, 2014).
Historical trauma among Native Americans has resulted in disproportionate health disparities in
epidemic proportions, such as the current obesity rates (Satterfield, DeBruyn, Santos, Alonso, &
Frank, 2016). Studies have linked the phenomenon of historical trauma with multiple diseases support-
ing the view that one’s past often shapes and forms one’s current reality (Lowe, Liang, Henson, & Riggs,
2016; Weaver & Yellow Horse Brave Heart, 1999). The relatively rapid change in environment, diet, and
activity level perhaps are the most crucial factors blamed for the development of the disproportionate
health disparities such as obesity among Native Americans. Recognizing and understanding the pro-
found implications of history, culture, traditions, and health-related practices among Native Americans
are essential in order to reduce the disproportionate level of obesity (Fialkowski, Okoror, & Boushey,
2012). Efforts that focus solely on lifestyle interventions, such as diet and exercise, have demonstrated to
be ineffective for reducing obesity among Native Americans (Umstattd Meyer et al., 2016).
Prior to the 1970s, obesity and other health related conditions such as cardiovascular disease and
diabetes were practically unheard of among Native Americans (Styne, 2010). Over the last 30 years,
obesity has rapidly increased as one of the major public health concerns affecting Native Americans as
a result of abrupt lifestyle changes from a traditional lifestyle of farming, hunting, and regular daily
physical activity to a more sedentary lifestyle (Schell & Gallo, 2012). Over the last few decades, in
response to the increasing prevalence rates of obesity among youth worldwide, intervention programs
have been developed and evaluated but without successful, long-lasting results. Despite the increased
effort to develop and evaluate obesity prevention programs for youth, there has been very little
attention devoted to understanding and developing culturally effective approaches (Wilson et al.,
2015). Currently, there is scant research and a lack of cultural-based programs and approaches for
the prevention of obesity among Native American populations. As the Pathways Study (Caballero et al,
2003; Davis et al., 1999) was conducted, there has not been another documented successful interven-
tion program for the prevention of obesity among Native American youth. The Pathways Study was a
school-based obesity prevention program for Native American youth in the third through fifth grade
focused on physical activity and healthful eating behaviors, along with the incorporation of Native
American customs and practices. However, this particular study is over 15 years old and there has been
a gap in the literature since then. Thus, there is an urgent need for the development of culturally
appropriate interventions for Native American youth at risk for obesity to decrease the alarming
prevalence rates of obesity (Jernigan, Boe, Noonan, Carroll, & Buchwald, 2016).
One of the more promising approaches to reducing the gap in obesity rates among youth is
through group and community focused interventions. Evidence by Teufel-Shone et al. (2014)
suggests that developing interventions and programs based on the Native American worldview
that include cultural values, beliefs, and behaviors have the potential to create positive long-lasting
behavioral change. Currently, the majority of obesity prevention programs and intervention
approaches for Native Americans have been focused on individual behavior change, which is
reflective of a Western worldview or approach. However, obesity is more than just an individual
problem. According to Wang et al. (2013) and Stuart-Shor, Berra, Kamau, and Kumanyika (2012),
focusing on individual behavior change alone has not demonstrated effective results on reducing
obesity among youth. More community-based prevention programs within schools that integrate
Native American cultural values and beliefs are needed (Teufel-Shone et al., 2014). Successfully
addressing the obesity epidemic among youth will require a multi-level, multi-sector collaboration
that includes individuals, communities, local, public, state, and federal entities (Hollar et al., 2010).
JOURNAL OF COMMUNITY HEALTH NURSING 103

Many Native American communities have a long-standing history of incorporating oral traditions
such as storytelling or the talking circle into their daily routine as a way to teach about the culture and
traditional ways of life (Cesario, 2001). Therefore, for the purpose of this study, a cultural-tailored
talking circle approach was used as the delivery format for the intervention. Talking circles have been
used as a culturally appropriate format for delivering various health education programs that address
substance abuse, diabetes, and cancer (Hodge, Fredericks, & Rodriguez, 1996; Hodge, Pasqua,
Marquez, & Geishirt-Cantrell, 2002;Loweetal.,2016; Strickland, Chrisman, Yallup, & Squeoch,
1996). The talking circle is often referred to as a “sacred union”recognizing the Native American
way of life that serves as an important necessary function where everything is done in a circle (Lowe,
2008, p. 232). Everyone involved in the circle is considered equal and is valued as no more, or no less
than that of any other being in the circle.
The Cherokee Self-Reliance theoretical model (Figure 1) provided the theoretical underpinning
for this study (Lowe, 2002; Lowe et al., 2016). The Cherokee Self-Reliance theoretical model emerged
from several studies that explored the Keetoowah-Cherokee holistic worldview and way of life,
promoting well-being through the appreciation of one’s culture. The Cherokee Self-Reliance theore-
tical model is a composite of three categories that include (a) being responsible, (b) being disciplined,
and (c) being confident. Being responsible represents being responsible to care for self and others by
getting assistance, respecting self and others, and respecting the Creator. Being disciplined represents
Figure 1. Cherokee Self-Reliance model.
Note: The model of Cherokee Self-Reliance is formed in a circle indicating the circular holistic worldview of
Cherokee culture. The outside circle is green, which symbolizes an oak wreath. The orange inner circle symbolizes
the sacred eternal fire. The live oak, the traditional principal hardwood timber of Cherokee people, was used to
kindle the sacred fire. In connection with this fire, the oak was a symbol of strength and everlasting life. These colors
are used in the seal of the Cherokee Nation. The three interlocking circles in the center of the model depict the
interrelatedness, intertwining, and interlacing of all of the categories and subcategories of the cultural domain of
Cherokee Self-Reliance. Source: Lowe (2002). Cherokee self-reliance. Journal of Transcultural Nursing, 13(4), 287-295.
104 M. N. KELLEY AND J. R. LOWE

creating and pursuing goals by taking the initiative in making decisions and taking healthy risks.
Being confident represents having a sense of identity and self-worth. Being true to one-self and being
connected are two cultural themes that cut across all three categories of the Cherokee Self-Reliance
theoretical model reflecting the identification and use of resources within the creation (Lowe, 2002;
Lowe et al., 2016; p. 1000).
The purpose of this study was to investigate the effectiveness of a cultural-tailored program
addressing Cherokee self-reliance (CSR-cultural identity), perceived stress, and obesity knowledge
and behavior on Native American youth at risk for obesity. Three outcome measures including
Cherokee self-reliance (CSR-cultural identity), perceived stress, and obesity knowledge and beha-
viors were evaluated at baseline and immediate post-intervention.
Cherokee self-reliance (CSR-cultural identity) was used as an outcome variable and in previous
studies has been demonstrated to be a valid outcome measure for youth ages 10–13 (Lowe et al.,
2016; Lowe, Liang, Riggs, & Henson, 2012). CSR relates to the mainstay and way of life that
influences the health of the Keetoowah-Cherokees. For Native Americans, having a strong sense of
self and knowing who one is symbolizes being proud of one’s heritage with strong intact values and
beliefs that are consistent with a Native American way of life (Lowe, 2002).
Stress was included as an outcome measure as it can lead to the development of obesity and other
health problems. Research by Haegerich and Tolan (2008) suggests school transition in youth ages
10–13 can increase perceived stress levels. Therefore, there is a need for the development of obesity
intervention programs that include stress reduction and healthy coping strategies among Native
American youth. Evidence by Pervanidou and Chrousos (2016) supports the psychological and
pathological link between stress and obesity. Unresolved daily stress can lead to chronic stress
causing a cascade of events in the body. Subsequently, untreated chronic stress can create a
hormonal imbalance causing the release of excessive cortisol, and insulin levels, placing one at
higher risk for health problems such as obesity.
General knowledge regarding obesity and behaviors such as dietary and physical activity
practices followed by youth ages 10–13 play an important role in growth and development. It is
also important to review general nutrition and health knowledge regarding obesity because knowl-
edge can serve as a prerequisite for intentional behavior changes related to health outcomes such
as obesity (Hueston et al., 2017).
Methods
This study consisted of a two-condition design to explore the feasibility of implementing a
cultural-based intervention, Keetoowah-Cherokee Talking Circle-Obesity (KCTC-O), compared
to a standard health education program (SE) during an after-school program for Native
American youth at risk for obesity. The United Keetoowah Band (UKB) of Cherokee Indian
Tribe in Oklahoma tribal administration pre-selected two after-school programs as the sites for
the study. An after-school program located within a rural public school was selected to serve as
the site for the KCTC-O intervention condition. An after-school program located at the UKB
tribal health facility served as the site for the SE control condition. Keetoowah-Cherokee
communities typically are self-contained communities with little interaction between each
other except for large tribal celebrations that usually occur annually. Therefore, to help reduce
the possibility of cross contamination between the two conditions, the sites were located 60 miles
in distance from each other.
Procedures
Prior to the recruitment process, the University Institutional Review Board (IRB), the school
administration, and the tribal administration provided study approval. After all approvals were
received, the tribal and school administration, and the after-school program directors initiated the
JOURNAL OF COMMUNITY HEALTH NURSING 105

recruitment process. The program directors at the after-school programs used the inclusion and
exclusion criteria to screen youth participants for eligibility for the study. The inclusion criteria
included all male and female youth, ages 10–13, who self-identified as Keetoowah-Cherokee and
enrolled at one of the after-school program sites. Exclusion criteria included Keetoowah-Cherokee
youth involved in other weight reduction programs, participating in a stress-reduction program,
and/or counseling sessions for behavior problems.
A flyer and introductory letter explaining the purpose of the study was provided to all eligible
UKB tribal youth by the program directors of the after-school programs to take home for review
with their parents/guardians. All eligible youth participants returned parental/guardian permission.
Additionally, signed parental/guardian consent and child assent and the ability to read and speak
English was required. Participation in the study was voluntary and youth participants were free to
withdraw at any time.
Prior to the implementation of the study, a power analysis was conducted using the G* Power 3
sampling program along with an ANOVA with repeated measures for between and within variables
priori power analysis with 80% power, an f effect size of 0.25, and a significance level of 0.05 (Faul,
Erdfelder, Lang, & Buchner, 2007). The power analysis determined a sample size of 49 participants
per condition was acceptable for this study. Therefore, to account for possible attrition, all eligible
students, 100 participants, were included.
Intervention
Keetoowah-Cherokee talking circle-obesity intervention condition
The after-school program located within a rural public school was assigned to the KCTC-O intervention
condition, which included 45-min sessions, once per week, over a 7-week period, delivered in a talking
circle format. Fifty youth participants were recruited for the intervention condition and placed into
smaller groups of 10–12 participants. The KCTC-O talking circle sessions were conducted by a trained
Keetoowah-Cherokee interventionist knowledgeable about Keetoowah-Cherokee culture and cultural
identity and who completed the required Collaborative Institutional Training Initiative (CITI) training
and testing sessions. All sessions were conducted in a designated private room to ensure privacy and
confidentiality. The KCTC-O sessions were developed by tailoring an existing evidence-based Cherokee
Talking Circle (CTC) intervention in Table 1 designed to address at-risk behaviors among Cherokee
youth (Lowe, 2006). The core values of the Cherokee Self-Reliance theoretical model were also
integrated into the KCTC-O intervention (Lowe et al., 2016,2012).
Each talking circle session was tailored to discuss topics relevant to obesity risk among Native
Americans including Native American history, cultural values, and beliefs as well as the importance
Table 1. Session-by-session topic outline for the original Cherokee talking circle (CTC).
Session # Session Topic(s)
1 Group Introduction & Guidelines
2 Substance Abuse Education; Native American History & Substance Abuse
3 Recognition & Acknowledgment of Personal Substance Use Problems *Self-Monitoring of Substance Use;
Cherokee Traditions of Being Responsible, Being Disciplined & Being Confident
4 Identifying High-Risk Situations
5 Commitment Generation; Identifying Alternatives to Substance Use; Cherokee Traditional Activities
6 Commitment Generation; Alternatives to Use; Lifestyle Change
7 Coping with Stress; Cherokee Concept of Self
8 Relationship Building; Cherokee Life-Way of Right Relationships; Family Conflict Resolution; Cherokee Family
Structures/Roles
9 Abstinence Violation Effect; Practicing Resistance/Refusal; Review of Cherokee way of Being Disciplined
10 Social Support; Closing Ceremony
Source: Lowe (2006).
106 M. N. KELLEY AND J. R. LOWE

of how current stressors affect the health of Native Americans. Additionally, other topics discussed
in the sessions included the Keetoowah-Cherokee way of life, traditional diet and physical activity,
healthy coping strategies for stress reduction, and increased self-esteem. The three concepts of the
Cherokee Self-Reliance theoretical model served as foundational themes for each session.
Information regarding associated obesity risk factors among Native Americans was shared in an
open group talking circle discussion format. The youth participants were guided on how to
recognize, acknowledge, monitor, and evaluate their own personal obesity risks. This process allowed
participants to identify associated obesity risk factors and healthy alternatives to reduce obesity risk
along with the acknowledgment of the steps necessary to develop life-long healthy lifestyle changes.
Table 2 illustrates the topic outline and talking circle sessions.
Standard health education (SE) control condition
The tribal health facility after-school program was selected to serve as SE control condition where
the youth participants received 45-min classroom sessions, once per week, over a 7-week period.
Fifty youth participants were recruited and placed into smaller groups of 10–12. The sessions were
led by a tribal health educator who presented content from a health education curriculum designed
for the general population, non-specific to Native Americans. The topics presented in the SE
condition included basic concepts of health regarding, nutrition, exercise, diabetes, heart disease,
hygiene, substance abuse, and peer pressure/stress. Table 3 portrays the topic outline and standard
health education sessions.
Measures
Prior to implementation of the study, the program directors at both after-school programs
reviewed all instruments/measures for knowledge and age level appropriateness. Four measures
were used to collect data from youth participants in both conditions at baseline (pre-inter-
vention) and immediate post-intervention. The measures included the following: (a) the
Cherokee Self-Reliance Questionnaire (CSR-Questionnaire), (b) the Perceived Stress Scale
(PSS), and (c) the adapted Obesity Knowledge, and Behavior Survey (OKB-Survey). In addi-
tion, routine socio-demographic variables were recorded for each youth participant. Owing to
the short time frame of this study, BMI and weight were not measured, as it takes longer than
seven weeks to lose the 5–10% (0.5 lbs./week) of recommended weight loss for adolescents
(U.S. Preventive Services Task Force, 2015).
Table 2. Keetoowah-Cherokee talking circle—obesity (KCTC-O) session-by-session topic outline.
Session # Session Topic(s)
1 Group Introduction & Guidelines; Obesity Education; Native American History & Obesity Education
2 Recognition & Acknowledgment of Personal Obesity Risk *Self-Monitoring of Obesity Risk; Keetoowah-Cherokee
Traditions of Being Responsible, Being Disciplined, & Being Confident
3 Commitment Generation Identifying Associated Obesity Risk Factors; Identifying Alternatives to Obesity
Prevention; Keetoowah-Cherokee Traditional Activities (traditional foods and games)
4 Commitment Generation; Alternatives to Use; Healthy Lifestyle Changes
5 Coping with Stress, Self-Esteem, Body-Image; Social Support; Keetoowah-Cherokee Concept of Self
6 Relationship Building; Keetoowah-Cherokee Life-Way of Right Relationships; Family Conflict Resolution;
Keetoowah-Cherokee Family Structures/Roles
7 Discussion of the Keetoowah-Cherokee way of Being Disciplined; Completion of Cherokee Self-Reliance
questionnaire, Perceived Stress Scale Survey, and adapted obesity Knowledge, attitudes and behavior survey;
Closing Ceremony
Note. Due to time constraints, the KCTC-O was decreased to 7-sessions instead of the original 10-sessions.
JOURNAL OF COMMUNITY HEALTH NURSING 107

Cherokee self-reliance
Lowe’s(2003)24-item Cherokee Self Reliance Questionnaire (CSR-Questionnaire) was used to measure
cultural identity. The CSR-Questionnaire is a cultural derived instrument measuring self-reliance and its
defining qualities among Keetoowah-Cherokees. This instrument uses a five-point Likert scale (1–5)
varying from strongly disagree to strongly agree, and has an internal consistency coefficient of .84
(Lowe, 2006;Loweetal.,2016). The CSR-Questionnaire has a minimum score of 24 and a maximum
score of 120, with a higher score being reflective of an internalized sense of Cherokee self-reliance. The
CSR-Questionnaire scale reliability for both conditions at baseline and post-intervention demonstrated a
Cronbach’s alpha over .80, which is consistent with previous reports (Lowe, 2006;Loweetal.,2016,2012).
Perceived stress
Stress was assessed by using S. Cohen, Kamarck, and Mermelstein (1983)Perceived Stress Scale (PSS),
which is a 10-item self-reported instrument, using a 4-point Likert scale (0-4), ranging from never to
often. The PSS assesses the degree to which situations in one’s life are appraised as stressful and assesses
how unpredictable, uncontrollable, and overloaded participants find their lives. The PSS has a mini-
mum score of 0 and the maximum score of 40, with the lower score indicating a lower level of perceived
stress. The PSS demonstrated a Cronbach’s alpha over .88 at pre- and post-intervention for both
conditions, and in previous research, the PSS has demonstrated a Cronbach’s alpha at .82 with the
same age group (Hills, Andersen, & Byrne, 2011).
Obesity knowledge and behavior
The Obesity Knowledge and Behavior-Survey (OKB-Survey) was developed by adapting the Physical
Activity Questionnaire for Older Children (Kowalski, Crocker, & Donen, 2004) and the Nutrition and
Exercise Survey (Centers for Disease Control and Prevention, 2010). The OKB-Survey is a 13-item
self-reported instrument developed for use with this study, as currently there are no reliable measures
specific for Native American youth. The OKB-Survey was used to measure overall knowledge and
behavior and is divided into two sections. Section one addresses general knowledge questions in a yes or
no format regarding daily physical activity, eating habits, and stress. Section 2 uses a 4-point Likert scale
(0–4) ranging from never to very often to assess eating habits, physical activity levels, duration of physical
activity, and time spent on recreational activities such as video games, watching television, and on the
computeror internet overthe last seven days. On the OKB-Survey the minimum score achieved is 12 and
with a maximum possible score of 40. A higher score indicates better obesity knowledge, and behavior.
The OKB-Survey was tested for reliability and demonstrated a Cronbach’s alpha above .77 at pre- and
post-intervention for both conditions.
Table 3. Standard education health education curriculum for the SE sessions.
Session # Session Topic(s)
1 Nutrition: Components of a healthy diet; recommended daily servings of each food group; Importance of water
intake
2 Exercise: Importance and benefits of regular exercise; Intensity and duration of exercise for weight management
3 Diabetes Education: Signs and Symptoms of hypoglycemia and hyperglycemia; Components of a healthy
diabetic diet
4 Heart Disease; Hypertension; High Cholesterol; Importance of a heart healthy diet
5 Hygiene; Importance of personal and dental hygiene; Proper handwashing
6 Substance Use; Most common drugs; Alcohol use and abuse; substance abuse prevention; commercial tobacco
(including smokeless tobacco)
7 Peer Pressure and Stress; Healthy coping strategies and alternatives; Completion of Cherokee Self-Reliance
questionnaire, Perceived Stress Scale Survey, and adapted obesity Knowledge, attitudes and behavior survey;
Closing Ceremony
Note. Each SE session lasted 45 min and was delivered by the tribal health educator
108 M. N. KELLEY AND J. R. LOWE

Data analysis
Results
A convenience sample of 100 Keetoowah-Cherokee youth participants were recruited and
retained for the study. The socio-demographic variables were analyzed at baseline (pre-inter-
vention) and immediate post-intervention for both groups. Findings reported in the socio-
demographic section included females (n=55) and males (n=45) combined for both groups.
Participants’ages ranged from 10 to 13 with a mean age of 11.5 years of age. Table 4 describes
detailed socio-demographic information for youth who participated in each condition. There
were no differences noted in the socio-demographic data results from baseline (pre-intervention)
to immediate post-intervention for either condition. The socio-demographic questionnaire also
included questions that assessed whether or not the youth participant’s family members were
overweight or obese and how many family members (immediate and extended family) were
overweight or obese. Forty-two percent of the youth participants for both conditions responded
yes (n=42) and 58% answered no (n=58) to their family members being overweight or obese.
Youth from both conditions reported having atleastonefamilymemberwhowasconsidered
overweight or obese (n=22), followed by two family members as overweight (n=18), and finally
three or more family members as overweight or obese (n=2).
The general linear model (GLM) analysis of variances (ANOVA) repeated measures procedure
for SPSS in Windows, version 22.0 (IBM Corp. Released, 2013) was used to compare the three
outcome variables within and between each condition (KCTC-O and SE) group as described in
Table 5. Youth who participated in the KCTC-O intervention condition demonstrated at baseline
(pre-intervention) CSR-Questionnaire mean scores of (M=88.42, SD=11.174) as compared to
baseline (pre-intervention) mean scores of the SE control condition (M=37.04, SD=8.028)
resulting in a mean difference of (MD= −51.380). At immediate post-intervention youth parti-
cipating in the KCTC-O intervention demonstrated significantly higher improvements in CSR
mean scores (M=100.90, SD=10.201) as compared to youth participating in the SE condition
(M=45.62, SD=7.754) with a mean difference of (MD=−55.280). These findings are depicted in
Figure 2, which shows how youth who participated in the KCTC-O intervention condition
demonstrated a larger increase in Cherokee self-reliance than youth who participated in the
SE control condition from baseline (pre-intervention) to post-intervention.
Youth participating in the KCTC-O intervention condition demonstrated baseline PSS
mean score results of (M=21.82, SD=5.283) compared to baseline PSS mean scores for the
SE control condition (M=21.04, SD=2.976) with a mean difference of (MD=−.780). At immedi-
ate post-intervention youth from the KCTC-O intervention condition demonstrated a signifi-
cant decrease in PSS (M=14.92, SD=5.428) as compared to youth of the SE condition
(M=20.60, SD=2.157) with a mean difference of (MD=5.980). Figure 3 depicts how youth
participants in the KCTC-O intervention condition sessions demonstrated lower levels of
perceived stress post the intervention sessions in comparison to the youth who participated
in the SE control condition sessions.
Youth from the KCTC-O intervention condition demonstrated baseline (pre-intervention)
OKB mean scores of (M=25.04, SD= 5.767) compared to the baseline OKB mean scores of the
SE control condition of (M=19.20, SD=1.841) resulting in a mean difference of (MD = −5.840).
Immediate post-intervention results revealed that youth among the KCTC-O intervention
condition demonstrated better improvements in OKB mean scores (M=28.10, SD=4.696)
as compared to the youth of the SE condition (M=19.80, SD=2.162) resulting in a mean
difference of (MD= −8.120). The findings as portrayed in Figure 4 reveal that youth who
participated in the KCTC-O condition sessions demonstrated better improvements in obesity
knowledge and behavior in comparison to youth participating in the SE control condition
sessions.
JOURNAL OF COMMUNITY HEALTH NURSING 109

Table 4. Demographics for the KCTC-O and SE conditions.
Total Sample KCTO-O Condition SE Condition
Demographic Variables n=100 n=50 n=50
Gender
Male 45 23 22
Female 55 27 28
Tribal Affiliation
Keetoowah 100 50 50
Grade in School
4
th
19 13 5
5
th
27 12 14
6
th
29 6 25
7
th
25 19 6
Family who lives with you
Mother/Father 81 35 46
Step parents 6 4 2
Grandparents 3 2 1
Aunt/Uncle 4 3 1
Other (foster) 6 6 0
Do you have family members who are obese?
Yes 42 23 19
No 58 27 31
# of obese family members if answered yes
0582731
1221012
218117
3220
Clubs/After-school Programs
Yes 27 21 6
No 73 29 44
Do you play sports?
Yes 84 47 37
No 16 3 13
# of sports played
016313
1461728
222149
311110
4 or more 5 5 0
Have you ever been on a diet program?
Yes 5 5 0
No 95 45 50
Currently receiving counseling?
Yes 0 0 0
No 100 50 50
Currently participating in a stress-reduction program?
Yes 0 0 0
No 100 50 50
Table 5. Mean statistics for each outcome variable by condition.
KCTC-O Condition SE Condition
Variables MSDnMSDn
Cherokee Self-Reliance
Pre 88.42 11.174 50 37.04 8.028 50
Post 100.90 10.201 50 45.62 7.754 50
Perceived Stress
Pre 21.82 5.283 50 21.04 2.976 50
Post 14.92 5.428 50 20.60 2.157 50
Obesity Knowledge and Behavior
Pre 25.04 5.767 50 19.20 1.841 50
Post 28.10 4.696 50 19.98 2.162 50
Note. There was no missing data for all 50 participants from both groups.
110 M. N. KELLEY AND J. R. LOWE

Discussion
To our knowledge, this was the first community-based study that explored the effectiveness of a 7-week
after-school cultural-based intervention for Keetoowah-Cherokee youth ages 10-13 at risk for obesity as
compared to a standard health education program evaluating Cherokee self-reliance (cultural identity),
perceived stress, and obesity knowledge and behavior. The design utilized pre-selection of two very
distinct and separate UKB tribal communities for condition assignment. This pre-selection process
helped to avoid cross-contamination of the participants involved in the study. The KCTC-O intervention
condition was implemented in an isolated, rural, and Keetoowah-Cherokee traditional enculturated
community location. The SE control condition was implemented in a more assimilated western world-
view community location. This may have influenced the mean score results on all of the measures. For
example, results for the CSR-Questionnaire and the PSS demonstrated significant improvements from
TIME
0
20
40
60
80
100
120
POST 7 WEEKSBASELINE
MIN SCORE 24 -MAX SCORE 120
GROUP
KCTC-O SE
Figure 2. The comparison of Cherokee self-reliance scores between group and time.
TIME
0
5
10
15
20
25
30
35
40
POST 7 WEEKSBASELINE
SCORE MIN 0 -MAX 40
GROUP
KCTC-O SE
Figure 3. The comparison of perceived stress scores between group and time.
JOURNAL OF COMMUNITY HEALTH NURSING 111

baseline (pre-intervention) to post-intervention for the KCTC-O intervention condition participants as
compared to the SE control condition participants. The results are consistent with the findings from
previous studies that demonstrated strong sense of family, community, and holding true to one’s cultural
traditions and values can serve as a protective factor and buffer against stress and other health risks
(Neblett, Rivas-Drake, & Umaña, 2012; Stratford & Murphy, 2015). The results also are consistent with
previous intervention studies utilizing the talking circle to address the prevention of substance use and
associated risk behaviors among Native American youth (Lowe, 2006;Loweetal.,2016,2012; Schinke,
Tepavac, & Cole, 2000; Stratford & Murphy, 2015).
Perceived stress mean scores were noted to be lower at immediate post-intervention among the
KCTC-O participants in comparison to the SE participants. This could be attributed to the KCTC-O
participants’reported involvement in sports and daily physical activity. Forty-seven of the KCTC-O
participants compared to 37 of the SE participants reported participation in some type of sports
activity. Youth who participate in sports and exercise regularly have been found in other studies to
report lower stress levels, and increases in self-esteem (Eime, Young, Harvey, Charity, & Payne, 2013;
Fleming, 2017; Mayo Clinic, 2015). This finding should be explored in further detail in future
studies.
The talking circle format provided an appropriate setting for the KCTC-O intervention because it
is a coming together and a place where sharing of information is done in a respectful manner.
Cherokee Self-Reliance theoretical concepts, which describe the holistic worldview, values, beliefs,
and behaviors within Keetoowah-Cherokee culture, were integrated into the KCTC-O sessions.
Unlike the KCTC-O, the SE sessions utilized a health education curriculum presented in a classroom
setting. Keetoowah-Cherokee cultural values were not integrated in the curriculum. The significantly
higher Cherokee self-reliance scores among the KCTC-O participants reflect the impact of the use of
a cultural-based intervention (Scholl, 2006).
Findings related to obesity knowledge and behavior demonstrated more of a change or
improvement in the KCTC-O intervention condition group than compared to the SE control
condition group from baseline (pre-intervention) to immediate (post-intervention). The study
occurred over a limited time of seven weeks, which may not have been enough time to
demonstrate significant improvements in knowledge internalization and behavior. The holistic
thinkingprocessofNativeAmericansmayalsoexplainslowertrendstowardchangesinobesity
knowledge and behavior among the participants. Native Americans often process new informa-
tion in a circular manner as compared to cultures that rely on linear thinking. This involves a
TIME
0
5
10
15
20
25
30
35
40
POST 7 WEEKSBASELINE
MIN SCORE 12 -MAX SCORE 40
GROUP
KCTC-O SE
Figure 4. The comparison of obesity knowledge and behavior scores between group and time.
112 M. N. KELLEY AND J. R. LOWE

particular subject of being perceived in its entirety without being broken into parts. Circular
thought processes are not linear or sequential but involve movement from concept to concept.
This is especially true concerning information about health because of the impact on Native
American communities. As a result, the internalization of the information and changes in
thinking and behavior may not occur and be evident immediately until some time has elapsed
since first receiving new information (Lowe et al., 2012).
Another factor that may have influenced the results, relates to the intervention and standard
education sessions not being delivered in consecutive weeks. After week five, a two-week holiday
break occurred for both groups. This is a time when many Native American families usually
celebrate with food and may have served as a confounding variable. The OKB-Survey included
questions related to changes in eating and exercise habits and activity within the last seven days. At
pre-intervention, the majority of the KCTC-O participants reported everyday activity and better food
habits within the last seven days. In contrast, some of the same participants reported a decline in
physical activity and food habits within the last seven days on the immediate post-intervention
survey administered after the holiday break.
The OKB-Survey also included questions that may have resulted in unrealistic expectations of
behavioral changes regarding healthy food choices and dietary resources for this population. There
are limited available food choices for the isolated and rural tribal community where the KCTC-O
intervention was implemented. Often, rural Native American communities face numerous barriers
including higher poverty levels, less access to nutritious foods, fewer safe places for regular physical
activity, and other limited resources. The OKB-Survey could have included questions that assessed
participant’s thoughts and suggestions for how to improve healthier food options and resources
within their community. Previous studies have tested strategies for improving healthy food choices
in rural, isolated, and lower socioeconomic tribal communities. For example, results from a study
involving community gardens suggest that improvements can occur for food access by providing a
foundation for healthier food options (Teig et al., 2009). Instituting community gardens can serve as
a policy strategy for tribal leaders and governments as an approach for the risk of obesity (Castro,
Samuels, & Harman, 2013).
Limitations of the study
There were limitations to this study. Evaluating the KCTC-O intervention effectiveness with youth
from one tribe decreased the generalizability of the study. This two-condition design served as an
exploratory study, which is critical before preparing for future studies that will include cross-tribal,
cross-sectional, cross-age, and multi-tribal sites to study the impact of a culturally appropriate
obesity intervention for Native American youth. Participant weights and Body Mass Index (BMI)
were not measured owing to the short time frame of the intervention. In addition, the long-term
effects and benefits of the implementation of the intervention were not assessed. Additionally, the
OKB-Survey may need to be revised to ensure the use of Likert scale responses to all questions. The
instrument included items with yes and no response options.
Implications for school nursing within the community setting
The results of this study have implications for community health nursing and related disciplines. As
youth spend the majority of their time during the day in a school setting including after-school
programs, the school setting within the community presents opportunities for reducing the risk for
obesity. School-based programs for youth at risk for obesity within tribal communities can be
instrumental in implementing policy changes that affect available healthy food choices, physical
education, class curricula, and the acceptability of healthy behaviors. Therefore, community health
nurses are in a perfect position to assist with the facilitation of obesity prevention type programs.
They can play a critical role for establishing safe and supportive environments within tribal
JOURNAL OF COMMUNITY HEALTH NURSING 113

communities for cultural specific obesity prevention programs (Hunt, Barrios, Telljohann,
& Mazyck, 2015). There is a critical need to develop and implement school-based and commu-
nity-level education and intervention programs within tribal communities for youth at risk for
obesity. Schools should have culturally specific educational programs within tribal communities that
address youth who are at risk for obesity. Utilization of Native American cultural appropriate
models, such as the talking circle, can be developed by nurses to implement obesity education in
school systems.
Recommendations for future research
Future Native American youth talking circle obesityrisk prevention studies that utilize rigorous
designs, such as randomized control trials havethepotentialtoprovidegreaterinformation
about the effectiveness and efficacy of cultural specific interventions. Additional data collection
points should be included to assess the longevity and sustainability of the overall impact of
interventions that utilize a talking circle approach. Longitudinal designs could demonstrate the
long-term benefits and impact of implementing culturally specific talking circle obesity preven-
tion programs within tribal communities. The inclusion of larger sample sizes with longer
intervention durations would allow for more rigorous analytical strategies and approaches. The
use of weight and BMI measurements can also be used to further assess for changes and impact
of obesity interventions. Additionally, testing the talking circle youth obesity prevention program
among other Native American tribal communities can provide information regarding general-
izability of the intervention.
Summary
In conclusion, some reports indicate youth obesity rates are leveling off among the general popula-
tion in the United States. However, obesity rates continue to increase in epidemic proportions
among Native American youth (Centers for Disease Control and Prevention, 2015). Therefore,
Native American youth should be considered as a target population for prevention strategies.
Although there has been increased efforts to develop and evaluate obesity programs for youth in
general, very little attention has been devoted to the understanding and development of culturally
effective approaches for Native American youth.
There is a critical need for more robust research that addresses obesity risk prevention among
Native American youth populations. School-based programs within communities have been found
to be appropriate and opportunistic environments for the delivery of programs that focus on
obesity risk prevention (Brand et al., 2014). Thus, school-based programs can be a driving force to
increase awareness and knowledge of obesity risk among youth within tribal communities
(Afterschool Alliance, 2015).
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of
this article. This study was partially supported by a Graduate Research and Inquiry Program (GRIP) grant from the
Graduate College at Florida Atlantic University.
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