Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Monday, December 10, 2007

The Pathways Obesity Prevention in American Indian Schoolchildren Program: Wrong Path for Indian Country – Kristi A. Prellwitz

The rising rate of overweight and obese people in the United States has become a great concern over the last thirty years. Of particular interest is the growing number of overweight and obese children. An analysis of the data from the National Health and Nutrition Examination Study (NHANES) estimated that 17.1% of United States children (age 2-19 years) were overweight in 2003-2004 (1). This number dramatically increased from the early 1970s, when only 5% of children were overweight (2). No ethnic group is quite as affected as American Indians. Although national data for this group is limited, the estimated number of overweight American Indian children is between 25% and 46% (3, 4). This is of great importance as overweight children are more likely to be obese as adults and develop health problems, such as type II diabetes, which exists at high rates in American Indian populations (5).

A recent intervention to prevent overweight and obesity in American Indian schoolchildren is the Pathways Obesity Prevention in American Indian Schoolchildren Program. This full-scale study was developed after a three-year pilot study that tested for the feasibility of using the Pathways Program as an intervention (6). The program itself was designed to use culturally appropriate school curriculum for American Indian children in grades three thru five to promote healthy eating and physical activity (7). The cultural components included stories about American Indian children participating in healthy lifestyles, information about local and traditional food choices, and physical activity that included cultural games (6). In addition to the school-based components of curriculum, food services, and physical activity, the program tried to promote healthy living in other areas of life by including families in the intervention (7). Unfortunately, the Pathways Program has failed due to its strong emphasis on the use of Social Learning Theory, its failure to acknowledge the history and current social and economic factors affecting American Indians, and its inability to recognize the level of acculturation of the population.

Social Learning Theory Does Not Guarantee Proper Action

While it is important for American Indian populations to reduce the amount of obesity and complications associated with this health crisis, the Pathways Program falls short of this goal by basing its intervention on the Social Learning Theory. The study did show that the children had increased knowledge about healthy lifestyles and an increase in physical activity while in school, but the children did not have a reduction in average body weight or adiposity at follow-up (8). By using Albert Bandura’s Social Learning Theory, the program is unable to have an effect on weight change because of the theory’s key principle of vicarious learning through modeling (9). The intervention does not focus enough on the need for reinforcement of the behaviors that the children were to model.

Central to the Social Learning Theory is the idea that learning will occur through observation or modeling (10). The idea put forward is that the person will begin to imitate a reinforced behavior, not just gain knowledge about it. However, modeling did not work in the Pathways Program because of lack of reinforcement. At the beginning of the intervention, most children did not participate in the healthy behaviors that the program prescribed (8). Additionally, family members learned the behaviors as the children did when a child brought home a challenge sheet or when parents attended a family fun night (7). Therefore, few community members actually possessed these skills in the beginning. The hope was that by using American Indian storybook characters to model the intended behavior, the children would imitate the behavior. While storybook characters were a good initial model, the actual conditions in the environment are essential to behaviors continuing (10). A child rereading the book is not enough to reinforce the behavior; he must actually see other community members participating in the behavior in order to learn it. The changes in health behaviors the children accomplish in school may only be superficial or temporary and may stop if the children are unable to self-reinforce the behavior (11). While the children were able to understand cognitively what the program taught, they were unable to adopt the behaviors in their own lives without a good source of reinforcement from the community. Since an intervention using Social Learning Theory as a basis cannot guarantee adoption of taught behaviors, it is ineffective to use solely Social Learning Theory for an intervention influencing behavior (12).

Failure to Acknowledge Historical Effects on Social and Economic Status

For many groups, history continues to affect how members of a group experience life presently. Particularly when social standing does not change much over time, group members continue to experience social and economic situations similar to those of the past. By ignoring the history of American Indian people, the Pathways Program failed. While the focus of this intervention was school-based, it is apparent that components were supposed to change the overall lifestyle of children and their families (8). Therefore, an examination of the history and current social and economic status of American Indians is necessary to see if the American Indian family is able to adhere to the protocol prescribed or if it is simply out of its reach.

The American Indian history of oppression led to the economic and social disadvantages that American Indians experience today. Placement of American Indians on reservations and in boarding schools was the means of oppressing this group. The use of this combination was interesting. On the one hand, the reservations were places of poor land quality where seclusion of American Indians was to take place (13). On the other hand, boarding schools were places of assimilation for children where they would learn the ways of mainstream America (14). While the skills learned were appropriate based on the American standards, American Indians were unable to put these skills into practice because of lack of resources on reservations and the resistance of white settlers to accept American Indians into society (15). Because of the experience of being socially unaccepted, American Indians, in turn, were more reluctant to adopt programs developed by the white majority. The negative experiences of both institutions continue to affect the American Indians’ ability to survive, particularly socially and economically.

American Indians, especially those on reservations, continue to suffer. The Oglala Sioux of the Pine Ridge Indian Reservation, one group included in the Pathways Program, experience many challenges of living on reservation land. On the reservation, American Indians continue to be suspicious of the American school system. Suspicion causes American Indians to have the highest high school dropout rate with less that 50% of American Indians graduating from high school (12). Lack of education makes it difficult for American Indians to support themselves. Estimates of the median income on the Pine Ridge Reservation are only between $2,600 and $3,500 annually (16). Furthermore, there is an unemployment rate 0f 45%, a backlog of substandard housing (including 4% of families being without housing), and lack of transportation (both public and private) (17). Modern conveniences of telephones, electricity, plumbing, and running water are lacking in some parts of the reservation (18).

These factors may help to explain why American Indian families cannot follow the healthy eating habits prescribed by the Pathways program. Mistrust of the school system is likely to make it difficult for families to accept the Pathways message. Even when American Indians desire to follow the program, there are obstacles. It is obviously difficult for these families to get from one location to the next, particularly those living outside towns and lacking a car to reach the nearest towns. The towns that are near the reservation all have populations less than 5,000 people (17). Even if the families are able to travel to these towns, it is unlikely they have the same variety of foods that are available in a larger city. Furthermore, since the American Indian income is considerably lower than that of the general population, it may be beyond difficult to choose healthier, more expensive foods over cheaper, less nutritious foods. While students and their parents were taught and could understand healthy eating habits, it may be too difficult to implement this knowledge into action, especially when the decision is between keeping food on the table (healthy or not) and providing other necessities, like electricity or gas.

Focus on Tradition Interventions versus a Bicultural Approach

The culture of American Indians is considerably different in comparison to other minority groups that have undergone assimilation in the United States. Unlike these groups, which tend to remove themselves from their country of origin over time, American Indians practice biculturism, in which they seek and maintain connections with both cultures (19). American Indian children often connect to traditional culture, but the majority culture of the United States still influences them. The Pathways Program failed by focusing solely on traditional elements of American Indian culture. Even though traditional interventions have worked, it is necessary that investigators begin to look at all cultural influences, both traditional and non-traditional (20).

While it was advantageous for Pathways to address traditional norms, they failed to account for differing levels of acculturation between the various tribes and even between participants of the program (20). Examining the level of acculturation of a particular tribe is necessary to determine if a purely traditional model is appropriate. In some tribes, traditional activities no longer are passed down through the generations (21). If children in the Pathways Program did not relate to an activity for either of the above reasons, the stories and physical activity skills learned may have felt inappropriate. The children that could not relate would not have a reason to reinforce these behaviors.

As acculturation strengthens, the media has influenced more American Indian children, particularly through television. Like any other American child, American Indian children enjoy watching television. Sociologists and anthropologists believe that exposure to the media is a powerful way for American Indians to be assimilated into the dominant culture (22). Beyond using for pleasure, American Indian families turn to television (84%) as a way to relieve stress, compared to talking to friends and family (76%), praying or meditating (64%), and exercising (67%) (23). When families use the television for pleasure or for coping, American Indian children see the messages of the dominant culture. Particularly, they see the way other Americans eat through advertisements for high fat, high calorie foods. This food promotion directly links to the eating habits of children (24). Therefore, addressing television use (and potentially other mainstream influences), is important to the success of a program. Just as it is necessary to use traditional techniques to which American Indians can relate, it is also necessary to apply techniques that work in the majority culture when appropriate.

Concluding Remarks

The Pathways Program was an inappropriate attempt to reduce obesity and being overweight in American Indian children. Social Learning Theory posits vicarious learning through modeling. Students may learn the behaviors modeled for them, but without reinforcement, they are likely to forget the behaviors and imitate the actions they see around them. The intervention also failed to acknowledge the importance of historical and social information about the study participants. The intervention may have taught both children and their parents new information about health, but it should have made sure there were ways to put the knowledge into practice. Finally, by not emphasizing a bicultural model, the intervention did not adequately take into account the totality of influences that American Indian children experience from the majority culture. These majority culture influences may play as large or an even larger role in health behaviors.

A more appropriate approach would address underlying factors that might affect a participant’s ability to follow the prescribed intervention. Since American Indians are a creative group, it might be effective to combine Social Learning Theory with other theories or ideas. For example, teach children a skill and let them expand on it. This might involve teaching dance steps and allowing them to create their own dance. By attaching ownership, the children become inclined to continue the behavior. Instead of just teaching a behavior, a better way to get children and their families to eat healthily may have been to give food vouchers to families to redeem healthy foods or bringing food stands to families that are far from grocery stores. Additionally, accurately determining the level of acculturation is necessary, particularly in American Indian tribes, where the level of acculturation can vary by and within a tribe. This will affect the accuracy of the intervention. By considering details prospectively, an intervention has the ability to succeed. Using this front-end approach acknowledges areas where there are barriers and removes them before an intervention hits a dead end.


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