Community Readiness Model for Prevention Planning: Addressing Childhood Obesity in American Indian Reservation Communities

Abstract

The Community Readiness Model (CRM) is a stage-matched assessment protocol to assess community readiness to address a public health issue.

To identify appropriate, culturally sensitive and community specific intervention strategies for preventing obesity in children, researchers and community members formed a partnership to address childhood obesity within one American Indian Reservation. The CRM guided 30 interviews in five communities to direct the team’s efforts in addressing obesity among children residing on the reservation. Interviews were scored across six dimensions on an anchored scale of one through nine; scores were then averaged to determine an overall readiness score for each community. A thematic analysis of interview responses aided in interpretation of the readiness scores and identified areas for prevention planning and intervention development.

The overall community readiness score for the communities was 2.9 (SD=0.5), which falls between 2 (Denial/ Resistance) and 3 (Vague Awareness) on the anchored rating scale. The thematic analysis resulted in a hierarchal classification scheme with six broad themes that corresponded to the CRM dimensions and 13 sub-themes.

The low readiness scores directed the team to implement corresponding strategies to increase awareness, while the thematic analysis suggested that action-based approaches might also be appropriate. The narrow range of scores suggest that community-wide assessments may be sufficient unless specific information is needed for each region of the community. The CRM may be an effective way to assess community readiness to address childhood obesity on an American Indian Reservation.

Introduction

Obesity risk is high among rural minority children, particularly among American Indians (AI) [1]. Rural residents have higher rates of poverty, fewer community resources, poorer access to healthy foods and physical activity (PA) opportunities, greater geographic dispersion, and more transportation challenges (e.g., lack of public transit, greater travel distance) than urban residents [2]. Rural communities also have unique strengths, including dense social networks, social ties of long duration, shared life experiences, and norms of neighborliness, self-help and reciprocity [3]. Possible explanations for enduring high rates of obesity among rural minority children include the lack of approaches that match the community’s level of interest in change and the paucity of community-identified solutions that build upon positive aspects of rural life. Such approaches could increase the impact of efforts to help children reduce obesity risk across contexts where they live, learn, and play [4].

The Tri-Ethnic Studies Center at Colorado State University developed the Community Readiness Model (CRM) to “better initiate the process of community change…and to develop effective, culturally-appropriate and community specific strategies for prevention and intervention” [5]. Initially developed to address HIV/AIDS prevention and intervention in AI communities, the developers suggest it can be adapted to address any public health issue. The CRM process uses a linear model to recommend stage-matched intervention strategies based on an overall community readiness score that is determined by scoring six key informant interviews [6].

The CRM is closely aligned with the Community-Based Participatory Research (CBPR) model, as it requires the inclusion of community members in the assessment of community needs and priorities to facilitate the development of appropriate and sustainable intervention strategies [7]. CBPR emphasizes the importance of establishing and maintaining partnerships between researchers, professionals and community members, which serves to facilitate the research process by identifying all members of the process as equal agents of change in the community. The CRM defines the issue in the context of the community’s needs and resources, and addresses the complexities involved with community change [8][9]. This strategy also can promote trust between the research team and the community by including community members at each stage of the process, which may increase community buy-in to the change efforts [10].

As summarized in a systematic review [11], the CRM has been used to assess the readiness of communities to address a range of public health issues such as obesity, drug abuse prevention, suicide, tobacco access, HIV/AIDS, and cancer, and partnership readiness among health care professionals [12][13]. The CRM lends itself to application in rural communities, where it may be logistically more difficult to engage community members due to small population sizes, large geographic areas, and difficulty locating large numbers of individuals with expertise on the topic. The model has been adapted to incorporate other methods of assessment, including focus groups [9], surveys, and other observations [14][15]. The incorporation of other methods of assessment has served to triangulate the findings from the key informant interviews and help direct intervention efforts [16].The CRM interview method has also been adapted to be implemented in alternative formats, such as surveys [17] and on-line assessments [18]. Community readiness ratings have been used as an evaluation tool [19], to select communities for implementing interventions, and to compare readiness across communities [20]. Nonetheless, the method is most frequently employed for program planning [11].

To identify appropriate, culturally sensitive and community specific intervention strategies for preventing obesity in children, researchers from a university, community members, and professionals from a tribal college and a tribal health department formed a partnership to address childhood obesity. One of the partnership’s first activities was to apply the CRM to conduct 30 interviews across five communities to direct the team’s efforts to address obesity among all children (AI and non-AI) residing on the reservation.

Methods

Advisory Board and Leadership Team

A 14-member Advisory Board provided overall strategic direction to the project, and recommended the use of the CRM as an initial step to assess readiness and capacity to address childhood obesity. The day-to-day activities of the project were coordinated by a five-member Leadership Team, which was comprised of a diabetes prevention specialist from the tribal health organization, a faculty member from a tribal college, and three faculty members from a nearby university. The research team also included two graduate students and one undergraduate student.

Participants- The Reservation

The AI reservation where the study was conducted is located in the Northwestern United States. In addition to its own tribal members, the reservation is also home for tribal members from over 200 AI tribes as well as non-AI individuals. Due to the history of research atrocities in AI communities [21][22] and at the request of the project Advisory Board, the researchers protected the privacy of the community by de-identifying the reservation and community locations in this manuscript.

The reservation is a diverse and complex setting encompassing more than 1.4 million acres spread over four rural counties. The reservation is large, geographically diverse, and sometimes difficult to traverse. Seasonal weather, such as freezing rain, heavy snow and flooding make travel a major undertaking. Access to support services in remote areas of the reservation is limited. The government and health care services are complex and serve residents living across a range of socio-economic levels. Although there are direct service clinics in nearly every community, public health organizations are often unable to allocate funds for prevention activities. Despite such complexities that exist on the reservation, residents and organizations were interested in working together to overcome rural health disparities, with an emphasis on childhood obesity prevention.

Participants- Five Communities

The Leadership Team initially identified eight geographically delineated communities on the reservation. The Advisory Board then selected five of these communities to conduct CRM interviews. To provide a comprehensive snapshot and explore potential variability in readiness across the reservation, the Board elected to include communities with small populations, communities that were located in geographically remote areas, and communities that were located at greater distances from the tribal government headquarters. These communities sometimes included a low number of youth and smaller percent AI.

The final selection of communities included representation from each geographic region of the reservation and a range of more-remote and less-remote communities. The following section provides an overview of the demographic characteristics of the communities. Specific data for each community are omitted to protect community anonymity. The geographic size of each community ranged from 0.38 to 6.6 square miles and the population ranged from 203 to 4488 individuals. The two most remote communities (Communities 3 and 4) had an average population of 374, while an average of 2871 individuals lived in the other communities (Communities 1, 2, and 5). The overall percentage of individuals living below the poverty level was 32% (range = 20.4% to 43.3%). The overall median age range was 26.5 to 57.2 years; the oldest people lived in one of the most remote communities (Community 3), while the youngest people lived in a less remote community (Community 1). Ethnicity/race varied across the communities. The percentage of AIs living in the communities ranged from 10% to 51%. There were differences across the communities in the number and type of schools and health care facilities. For example, two communities had medical centers and health clinics (Communities 2 and 5), one community had a health clinic (3), and two communities had no healthcare facilities (Communities 1 and 4). Three communities (Communities 2, 3 and 5) had K-12^th grade schools. The tribal college and tribal government headquarters were situated in one community (Community 1). A recreation lake that draws tourism is near Community 2. The two most remote communities (Communities 3 and 4) were on average 35 miles from other communities with a grocery store.

Participants- 30 Interviewees

Six interviews were conducted in each of the five communities, resulting in 30 key informant interviews. The process to identify key informants involved first selecting sectors, then selecting key informants from each sector. First out of the 11 sectors (i.e., school personnel, local businesses, community members) as outlined in the CRM [6], five sectors to be included for each community were randomly chosen using computer-generated random numbers. In addition, the sector of “community member” was always included, for a total of six sectors per community. Next members of the Advisory Board nominated two or more key informants from each sector. Interviewees were then randomly selected from among those nominated by the Advisory Board, again using computer-generated random numbers. Trained project staff contacted each selected key informant by telephone to schedule an interview. If the first key informant was unavailable, project staff invited another key informant identified by the Advisory Board from the same community sector. To protect the identity of respondents from small communities, we did not record the sector interviewees represented or instances when respondents were unavailable.

The six interviews in each community were conducted using questions from the Community Readiness Manual [6], which the Leadership Team modified to address the topic of childhood obesity. Staff conducted the interviews over a 9-month period and each interview lasted approximately 30 minutes. Interviews were conducted by members of the research team either in-person or, when it was more convenient for the respondent, by telephone. Most interviews were conducted in-person; the research team did not distinguish in the research records how the interviews were conducted. Verbal consent was obtained at the outset of each interview. The interviewer also provided each interviewee with the clinical definition of childhood obesity for context of the medical condition. Interviews were audio recorded and members of the research team transcribed the recordings for analysis. This research was approved by the Institutional Review Board at the tribal college located on the reservation where the study was conducted.

Measures and data analysis

Two-to-three coders who were members of the research team reviewed all transcripts and followed the standard anchored scoring protocol and procedures to score each interview for each of the six dimensions [6]. The six dimensions were: community efforts, community knowledge of efforts, leadership, community climate, knowledge about the issue, and resources. Each dimension was assigned a numeric score ranging from one to nine, with one indicating “no awareness” and nine indicating “high level of community ownership.” Scores for each interview were rounded down to the nearest whole number to ensure all criteria for the assigned stage were met. Coders discussed disagreements in coding until consensus was reached. Community-level scores were then generated by calculating the mean score across all interviews conducted in each community for the six dimensions, and for the community overall. Coders scored interviews after all interviews were completed for one community.

After the interviews were scored for all five communities, a thematic analysis was performed to aid in interpretation of the readiness scores and to identify specific areas for prevention planning and intervention development. The analysis was aided by the software NVivo12 (QSR International, Cambridge, MA). One coder prepared the transcripts by grouping respondent’s sequential sentences that were similar in content. Typically, the groupings represented one thought or point made in response to an interviewer’s question or comment; these groupings of text were treated as blocks that could be assigned one or more codes. The analysis then involved one coder identifying broad themes and sub-themes through a careful read of the transcripts, followed by identifying emergent common themes. Once a complete list of themes was identified, all transcripts were re-reviewed to identify instances of new themes identified. This process resulted in a hierarchal classification scheme with six broad themes that corresponded to the CRM dimensions and 13 sub-themes (Table 2). Reliability was assessed by using an independent coder to apply the coding scheme to 10% of the coded interview text. Agreement was reached 72 out of 74 times, resulting in a 97% agreement rate.

Table 2.

Thematic categories, brief definitions of themes, and the number of blocks of text that were scored in each category. Main themes are listed in bold and sub-themes are italicized.

Theme	Brief definition	Number of text blocks*
Existing community efforts	Any description of existing community efforts, including programs and policies. Descriptions include the efforts, how long they have been in place, who can access them, and interviewee perspectives on the efforts. This theme also encompasses strengths or weaknesses of existing efforts.	213
Strengths and description of existing efforts	Strengths and detailed descriptions of efforts, like longevity and inclusivity. When a strength was described in the context of other weaknesses, or a program was described as weak, the text was coded under this theme.	180
Barriers	Weaknesses of the existing efforts.	29
Opportunities to overcome barriers	Opinions and ideas of how to improve existing community efforts.	16
Community knowledge about prevention	Amount of awareness and quality of awareness had by the community regarding the prevention efforts that are currently being made.	60
Leadership	Opinions and value systems of the leaders of the community, according to the interviewee. Generally, how leaders approached the issue of childhood obesity within the context of their community; for example, if they support it and/or value it, and how open they are to further work on the issue.	92
Support from leaders	Actions or activities undertaken by community leaders that demonstrated support for prevention activities; perspectives on receptiveness for increased or continued support.	61
Priority	Priority of childhood obesity as a community issue (as demonstrated or expressed by leaders); rated from low priority to high priority by numerical value 1 to 10.	30
Community climate	Tendencies, energy, attitude, patterns, and overall wellbeing of the community.	118
Community involvement	Support for/involvement in community prevention efforts, extent of support/involvement, and why.	31
Community attitude	Descriptions of community conditions that may impact community attitude on the issue of childhood obesity.	64
Knowledge about the issue	Knowledge available in the community regarding the problem and the accessibility of the information.	120
Available information	Type of information available, including local data.	65
Ways to access information	How community members gain access to available data.	31
Resources		90
Community generosity	Volunteering time, money, and physical resources to address childhood obesity.	30
Action plans	Action plans or proposals to address childhood obesity.	30
Evaluation efforts	Evaluation of efforts that were currently underway to address childhood obesity.	30

^*Blocks of text could be included in more than one category

Results

Table 1 shows the readiness scores for each of the six dimensions across all communities, and mean scores and standard deviations for each community. The overall mean community readiness score for the reservation was 2.9 (SD=0.5), which corresponds to readiness stage between Denial/Resistance and Vague Awareness. Table 2 shows the classification scheme resulting from the thematic analysis, along with brief definitions and the number of blocks of text that were scored in each category. A higher number of text blocks indicates that content contained in the category was discussed more frequently. The following sections summarize the community readiness scores by dimension and uses thematic analysis findings to inform and provide context to the scores.

Table 1:

Mean Community Readiness Scores by Community and Overall

Dimensions	Communities					Overall Mean	SD
	1	2	3	4	5
Community Efforts	5	5.8	2.8	2.5	6.8	4.6	1.9
Community Knowledge of Efforts	3.2	2.8	2.8	2.8	3.2	3.0	0.2
Leadership	2.5	2.1	3.8	2.3	2.9	2.7	0.7
Community Climate	2.7	3.1	3.3	2.4	2.7	2.8	0.4
Knowledge About the Issue	2.3	3	2	2.3	2.5	2.4	0.4
Resources for Prevention Efforts	2.9	3.9	2	2	3.8	2.9	0.9
Overall Score	3.11	3.4	2.8	2.4	3.6	2.9	0.5

^*Scores reported are on a scale of 1 – 9, with 1 being the lowest and 9 being the highest

SD=Standard Deviation

Dimension 1: Existing Community Efforts

Across the communities, the dimension of community efforts had the highest average score (M = 4.6, SD=1.9), which corresponded to the stage between Preplanning and Preparation. Communities 1, 2 and 5 had average scores of 5 (Preparations Stage) and above, whereas Communities 3 and 4 had average scores between 2 (Denial/Resistance) and 3 (Vague Awareness). Three sub-themes identified through the qualitative analysis and are described below.

Strengths and descriptions of existing efforts

The thematic analysis showed that school-based and afterschool programs to promote exercise, playgrounds, healthy school lunch, and gardening were consistently identified as programs, policies and efforts to address childhood obesity. For example, a member of Community 4 described one innovative afterschool activity: “We have Fit Kids club, so the kids are encouraged to run and if they meet their goals, they get a new pair of tennis shoes.” Generally, these programs were available to all school aged children and had been in place for several years. Transportation to and from activities was frequently mentioned as a strength when it was available. Some community members described local gardening efforts. A member of Community 4 said: “ …I’d say the community gardens would be our example that we have for [addressing childhood] obesity.”

Members of Communities 1, 2 and 5 mentioned a plethora of programs and community areas to promote healthy weight among children and some placed these efforts in the broader context of overall family health. A member of Community 1 described the extensive community resources available:

“We have playgrounds, basketball courts, we have a gym that is semi-accessible to the community, we have an interesting walking trail along the highway, we have quite a bit of open space, we have about 3 baseball diamonds, a fitness center/gym that’s college sponsored (physically). Program wise we are the hub of [the tribal] nation, we have a lot of programs like DHRD, Social Services, the college in general… Prevention is so broad that being healthy, mentally, physically, spiritually, emotionally is something that the tribe addresses. So, I think there is a lot of them and I would put childhood obesity in there with them, just because of its wholeness, wellness and that’s part of it.”

A member of Community 2 discussed many changes in the school lunch program:

“We’re offering snacks [at school] three days a week for students K-6^th …they are offered fresh fruits and vegetables…at lunchtime…we offer a full salad bar with lots of fresh fruits and vegetables, we’re [also] serving whole grains. We are not providing any margarine or butter or high fat mayonnaises.…and we try to encourage the students to eat healthy and choose healthy food options.”

Some communities were working on school wellness policies. A member of Community 5 said: “Right now we are working on a wellness policy and that should go before the school board in the next couple weeks… …that deals with anything from food consumption [to] P.E., what is offered to the kids in the area.”

While respondents in the smaller, more remote communities were typically aware of at least one effort, they could not identify multiple efforts to address childhood obesity, and many noted the extreme lack of opportunity. For example, a member of Community 3 expressed concern about the lack of activities in the summer:

“ … we have no programs, it’s kind of sad, they have an after school program, I think it’s only through the school year, there is nothing in the summertime, the kids don’t have a program here, no place to hang out, there’s nothing here [community name], It’s sad, ‘cause that’s when kids get into trouble.”

Barriers

Across communities, barriers included lack of programs that are interesting to youth and the limited reach of programs throughout the community. In the words of a member of Community 3: “I don’t think they are reaching as many kids as they could. It’s open and it’s up to the kids to come, but they don’t all come in and take advantage of it.” Members of Communities 1, 2, and 5 also discussed lack of parental involvement, competing activities (e.g., electronics), and cost (i.e., costs to the programs sponsoring events, and out of pocket expenses for parents). A member of Community 1 articulated a number of these barriers, along with uncertainty as to how to address them:

“When you throw an event together and you get lack of attendance, I think that’s a weakness. You know it’s good, everybody knows it’s good but you can’t get people from their couch to the event. And there are so many different reasons why they are not attending-- sports, babysitter, I don’t have no gas … something’s blocking them from physically getting in their car and going to that event. So, that’s a weakness. I don’t know how to address it…”

A member of Community 2 further addressed funding issues with programming by stating:

“…some of the challenges that come with them [programs] are of course is funding. I’m guessing that you heard with everyone that funding is the hard part…certainly I think there’s the desire, the passion…to implement these programs and to help drive them but I do think that funding is probably the biggest challenge that we‘ll have.”

Opportunities to overcome barriers

Interviewees discussed strategies to improve community efforts to reduce obesity. Increased options for physical activities were suggested to increase youth interest—such as running, biking, soccer, obstacle courses, and jungle gyms. A member of Community 1 suggested activities that were highly motivating: “all children would benefit from the program if there was a program to get people motivated. Bike program, or something, to get the kids out of the house.” Returning to daily physical education and recess at schools was also suggested, as were school-based gardens.

Interviewees suggested family-based strategies such as games at the grocery store, family modeling, and returning to traditional foods and activities such as hunting, gathering and family gardens. A member of Community 2 described traditional activities:

“I think they have to go back to the old ways…traditional foods. Lotta deer meet or berries, or roots….Parents need to take their kids hunting so they ‘ll know how to prepare meat that is leaner and better for them. And take them out to gather, get their roots, their berries, apples you know. God, we picked all the fruits around here when I was young, well I still do. I think we got to go back to traditional stuff and it starts with the parents and the grandparents…”

A member of Community 5 emphasized the importance of family and teachers as role models and said:

“Parents, grandparents, aunts/uncles, brothers/sisters, and nieces/nephews get involved with your kids - that is the important part. Teach them right, give them self-esteem.…to be proud of who [they] are and if they are obese or overweight work with them help them… Parents and relatives have to set the example.”

Dimension Two: Community Knowledge of Efforts

Across the five communities, the dimension of community knowledge of efforts had a mean readiness score of 3.0 (SD=0.2), which corresponded to the stage of Vague Awareness. As suggested by the standard deviation, there was little variability across communities. No distinct sub-themes emerged.

Some found that providing an overall rating from 1 to 10 on the quantity of the community’s knowledge of obesity prevention efforts, programs, and policies was difficult. Respondents noted their own lack of awareness (“I couldn’t even guess”) or observed variety within their community. While many respondents said that members of the community do not know much about the efforts, a few said the community was well-informed. For example, a member of Community 1 said “I would imagine that they know a lot. We target everyone, we send out information through media—Facebook—word of mouth and posters. We put information up so everyone is aware of the activities that are happening.” Another member of Community 1 noted the community was well-informed about some things, but not others: “there are certain efforts that are really well-known…[other] hard core efforts aren’t prevalent yet… because they just started and people don’t know about it yet.”

Cost was noted as a barrier to community-wide communication, as was members only knowing about efforts if their family members were involved in them. A member of Community 1 stated:

“ …some of the reasons that some of the people aren’t receiving the message [about the program] is money…you can only advertise maybe once or twice, it’s so expensive in the newspapers, radio ads, everything costs money. To even print brochures cost money. Advertisement and media…people want to know more, but they‘re just not getting the information or sometimes the information doesn’t get to them.”

In addition, many reported that those directly connected with the schools and afterschool programs had a higher level of knowledge compared to others in the community; in the words of a member of Community 2: “I think the community that has students going to the schools are very much aware of what’s going on, I would hope. But the community members that don’t have students in the school district are probably unaware of the efforts that are being made.”

Dimension Three: Leadership

Across the communities, the dimension of leadership had an average readiness score of 2.7 (SD=0.7), which corresponded between the stage of Denial/Resistance and Vague Awareness. The community with the largest population (Community 2) had the lowest score (2.1). Interestingly the small rural Community 3, which scored lower on the dimension of community efforts, scored highest (3.8) on the dimension of leadership. The two sub-themes identified were (1) support from leaders and (2) priority.

Support from leaders

Interviewees indicated that some leaders provided direct support by doing tangible activities, like supervising gyms so that they can remain open after school hours. Others reported that some leaders actively promoted healthy alternatives. For example, a member of Community 5 noted: “the leaders, they will have events. They are trying to do more fundraisers to fund walks. Things like that instead of trying to sell candy bars.”

Others who were interviewed commented that some leaders served as role models by attending or participating in sports and community events, especially in the schools. A member of Community 4 highlighted the school principal’s efforts: “Our school principal is very fit and active… So he promotes that.” Similarly, the teachers in Community 5 also model healthy activities: “ the teachers will go out walking after school so that shows the kids to be out and active.”

Most of those interviewed thought that the community leaders were generally supportive of efforts to address childhood obesity, or they would be if information was provided to the leaders on the problem or potential solutions. A member of Community 2 thought that leaders would be supportive “… once they understand, you know, the severity of the issue.” Likewise, leaders were more likely to be supportive if effective interventions were proposed. For example, a member of Community 1 noted “I’m pretty sure they would [support childhood obesity prevention efforts] as long as someone told them how to go about it.” A member of Community 4 also stressed the importance of interventions that were initiated by others: “I suppose if somebody started something, then you would have the leaders supporting it.”

Priority

Participants described that busy schedules prevented leaders from prioritizing efforts to address obesity. In the words of a leader in Community 3 “We need a lot of motivation around here to get things done, I’m one of the worst ones. I belong to a lot of committees [and] we run a big ranch so it takes me away lot. So, I can’t be one hundred percent involved because I’m getting pulled in every way.” A member of Community 1 commented on the plethora of community issues that vie for the leaders’ limited time: “our leadership is paying attention to our dam, water issues, our drug issues that we are facing. They’re all important but childhood obesity is pushed to the back because it’s getting attention, but not enough.” Some interviewees noticed that addressing obesity was a higher priority in certain community sectors, such as schools, where food services, gardens, and wellness policies were described. A member of Community 4 noted “In the school, it’s a high priority. They do care. In the community, I couldn’t say. From what I’ve seen, not so much.”

Like leaders, families also had immediate, pressing issues that diverted their attention from focusing on childhood health. A member of Community 4 described some of the serious economic challenges faced by families: “There are other things that are more important. There are quite a few families that are out of work, having a hard time meeting the bills that they have, getting food. Just basic things are hard.”

Finally, some interviewees commented on the lack of a coordinated effort to address obesity within their own community and across the reservation. The fragmentation was sometimes attributed to not having a designated group that organizes efforts. A member of Community 1 describes the duplication and lack of efficiency that can result: “There are so many groups that are trying to do good things, but some are doing the same things. They are not working together sometimes. … The leadership might be one of our downfalls because we don’t have a large group trying to put it together.” Noting a lack of cooperation, a member of Community 2 said their community suffered from “cliquish stuff” In contrast, some described examples of effective coordinated efforts: “The tribe itself has begun to put in place a diabetes program. I know it started out in [one community] and it’s going really well. They plan to do that in [a nearby community], too. They will combine it with the Boys and Girls Club. It’s collaboration.” (member of Community 1).

Dimension Four: Community Climate

The dimension of community climate included topics of community support for childhood obesity prevention efforts, and community conditions that may impact climate for addressing childhood obesity. This dimension had a mean readiness score of 2.8 (SD=0.4), which approaches the stage of Vague Awareness. There was little variability across communities on the readiness scores for community climate. Three sub-themes identified through the qualitative analysis and are described below.

Community involvement

As indicated by the low readiness score, most respondents suggested that the community was not very supportive or involved in obesity prevention efforts. In the words of a member of Community 1, “There are a few people who support and do efforts to help, and there’s a lot that don’t.” Similar to the dimension of existing community efforts, people who knew about or were connected with schools, sports, afterschool (e.g., Boys and Girls Clubs) and summer programs were more likely to be involved in the efforts. A member of Community 2 said: “School is pretty involved and from the city perspective not very involved, and from a community perspective I’m also going to say not very involved, because you don’t hear a lot about it.”

Community attitude

Interviewees provided a variety of responses as they described both their community and potential conditions influencing community attitude on childhood obesity. Some interviewees highlighted the positive aspects of their community (e.g., “unique and diverse,” “scenic,” “salt of the earth good kind people,” “peaceful,” “close knit community,” “great diabetic care for older people,” “walking trails”). However, comments also included negative aspects that might contribute to the low readiness score related to community climate. Lack of information about obesity, limited efforts and poverty were cited as problems, including by a member of Community 1: “Within the community, I don’t think that it is a high concern because there have been limited efforts in addressing it” Some described their community as “fractured”. A member of Community 4 elaborated on the lack of physical cohesion: “It’s a small community but it’s scattered out. There’s not really a central location for the community anymore.” A member of Community 3 talked about the relationship between poverty and obesity by saying, “.…we are the number one poorest community in the state. People grow up on commodities, or the welfare program, the food bank….and those people tend to go more towards the obese…”

Dimension Five: Knowledge about the Issue

Community knowledge about childhood obesity had the lowest mean readiness score (Mean=2.4, SD=0.4) out of all the dimensions. The lowest readiness score was 2 in Community 3, which corresponds to the stage of Denial/Resistance, while the highest score was 3 in Community 2, which corresponds to the stage of Vague Awareness. The qualitative analysis identified two sub-themes, described below.

Available information

As reflected in the low readiness score, many interviewees described low knowledge levels about childhood obesity in the community, and that local data were nonexistent. A member of Community 1 said: “[there isn’t] a childhood obesity tagline or specific poster or billboard or anything that directly says they want to stop Childhood obesity. There’s [substance abuse] prevention information but not childhood obesity information.” Some mentioned that the information provided as part of the interview (i.e., growth charts) was thus far the only resource made available to them: “The information you are giving us now, I’m going to share that, we will say this is a start right here, this is step one.” (Community 4).

Community members who were described by others as knowledgeable about childhood obesity included school personnel (especially those in school food service), medical professionals, and tribal health staff. Other resources included the tribal college library, summer feeding programs, WIC, individual program newsletters, agricultural extension programs, and the Job Corps.

Ways to access information

Most interviewees did not know where they could access information about childhood obesity in their own community. An exception was one member of Community 3 who said “food service will usually come out with pamphlets, and you can probably get some through the office too.”

Resources for finding information in communities included the internet and Facebook. For example, a member of Community 2 said “I do not know but I would think that you could go online and do a search and get some sort of statistics regarding the problem.” Others suggested talking with people from other communities, using the school or tribal college library, or asking teachers, Boys and Girls Club staff, WIC employees, and medical professionals. In the words of a member of Community 5: “Ask the Boys and Girls Club, schools, hospitals and dietitians they got all the information, but you got to go out and get it. Write them an email, call them.”

Dimension Six: Resources for Prevention Efforts

Resources for prevention efforts had an overall score of 2.9 (SD=0.9), which approached the stage of Vague Awareness. The qualitative analysis identified three sub-themes.

Community generosity

Interviewees in all communities described examples of how the community supports improvement efforts, such as building a fence around the garden, Bison Stampede fun runs, volunteers from the business sector, and a local foundation that provides financial support. Space for meetings was described as readily available in all communities: “Spaces like the Community Center and gyms and places like that and the Native Senior Citizen Center” (Community 5). Many indicated that it’s important that someone initiate the efforts, and let the community know what is needed to make the efforts successful.

Financial resources were noted as a limitation. A member of the medical community in Community 5 made the point that it is easier to get people’s time than money: “especially the professionals in health care, I think we do a lot of donating time … again money is, like everywhere else, an issue. But I do think the community is very supportive of those efforts.” Many community members do not have financial resources to spare. An interviewee noted that Community 1 was “… not the best source for financial collection. I think many of our families struggle and if you look at tribal college students, they can hardly feed themselves, much less make ends meet with food and kiddos.”

Actions plans/proposals

Generally, interviewees were not aware of any action plans to address childhood obesity in their community. Some mentioned that the project conducting these interviews was the exception and a “perfect example” of community action planning. The only other action plans mentioned each by one person in Community 5 included a plan from the tribal health diabetes program and the required school lunch changes.

Evaluation efforts

Since few identified systematic efforts to address childhood obesity, it was not surprising that most interviewees indicated that they were unaware of plans to evaluate these efforts. The project sponsoring the interviews was again mentioned as one that was spearheading evaluation plans. Also mentioned each by one person were health fairs in Community 2 and school health screenings in Community 5.

Discussion

The Community Readiness Model (CRM) was developed to provide a simple guide to assess the readiness of a community to address a public health issue. This process engages community members as key informants in the interview process and as agents of change in the development of intervention strategies.

Low readiness scores: Awareness and action-oriented strategies

The application of the CRM in the current project identified that each of the communities received an overall community readiness score of around 3 (Vague Awareness) or below, which corresponds to stage-matched strategies aimed at increasing awareness and education about childhood obesity. Others using the CRM, but not all [11], have also reported low scores on the community readiness scale. For example, Freirichs and colleagues [23] found the baseline community readiness score for obesity prevention for urban Latino youth in Omaha, Nebraska to be a 3 (Vague Awareness), and the post-study community readiness score to be a 5 (Preparation) over a period of 2.5 years. Similarly, Ogilvie et al. [12] found the overall community readiness score to reduce inhalant use among rural and Alaska Native communities in Alaska increased to a 3 (Vague Awareness) from a 2 (Denial/ Resistance) over the study period of 20 months. Paltzer and colleagues [24] found all communities (N= 21) in their statewide study on alcohol abuse in Wisconsin to be at or below an overall community readiness score of a 4 (Pre-planning) with a mean increase of community readiness of less than one complete readiness stage over a three year study period in which they implemented environmental and policy-based strategies.

While the project had initially planned to implement action-oriented interventions to reduce obesity among AI and non-AI youth, the readiness scores directed the Leadership Team toward targeted activities to increase awareness of the prevalence and consequences of childhood obesity on the reservation. In response, the Leadership Team was guided by the suggestions of interviewees in approaches to raising awareness. One strategy produced three multi-media digital stories that engaged youth and families on the reservation to “tell” their story about healthy lifestyles and behaviors associated with preventing obesity and chronic disease. The digital stories featured AI and non-AI role models and were disseminated at the tribal college, local health clinics, and are publicly available through YouTube [25]. The project also developed and implemented a texting platform for parents of pre-school children on the reservation to improve parent knowledge of key behaviors related to obesity risk (e.g., intake of sugary drinks, sleep), and small steps and resources to improve behavior among children. The text-based intervention allowed parents who lived in the outlying areas with few youths the opportunity to participate in an intervention that was convenient to access remotely. The outcomes were encouraging; parents found the text messages useful [26]. The project also developed educational materials that were presented at local events (e.g., health fairs, family nights) including bookmarks and posters that showed national and local obesity statistics, recommendations for simple ways to get kids active, and contact information for the project.

The project also provided an important opportunity to communicate with key community stakeholders. As mentioned by those who were interviewed, the discussion itself raised awareness of the problem of childhood obesity and sensitized community members to the lack of action taken to address this important health concern. Also, the project created community-specific data summaries in the form of handouts that were distributed throughout the community and to Advisory Board members. These data were also presented verbally and with visual presentations to community organization leaders, and at a tribal health department wellness committee meeting.

Although the low readiness scores indicated awareness strategies were most appropriate, the comments from the interviews suggested that, under the right conditions, community members and leaders were ready to act to improve childhood health. Interviewees said, both directly and through examples, that when community members knew (1) the seriousness of the problem and (2) effective strategies to address childhood obesity, people would be ready to act. The concurrence of low readiness scores with community members’ interest in taking action may point to a limitation of the CRM—the CRM may not provide a comprehensive assessment of a community’s readiness to address a community problem. The simplicity of the numeric ratings may mask the actual variability in readiness that exists in communities. Further, the stage-matched interventions that are recommended by low numeric ratings do not include interventions that capitalize on the motivation, interest, and commitment that some community members already have to address community problems directly and immediately.

It is possible that, for the current project, the rurality of the reservation contributed to this juxtaposition of low readiness scores and interest in taking action. Changes may be more feasible in small rural versus large urban communities because, in rural communities, the bureaucratic barriers to change are more surmountable, there are fewer numbers of institutions and gatekeepers, and community members often know local decision-makers and are sometimes the decision-makers themselves [27][28].

Thus, the team also engaged in activities focused on alleviating conditions related to childhood obesity. For example, food insecurity that comes from the intense poverty discussed by those interviewed led the project team to explore action steps to increase access to healthy foods. The project team hosted a series of meetings that engaged local leaders, agricultural experts, and community members to discuss strengthening food sovereignty and access to locally sourced foods on the reservation. Topics discussed at these meetings included ways to establish and maintain more community garden plots on the reservation, ways to engage youth and families in food preservation (e.g., preparing dry meat from local game and bison, preserving local foods for winter) and promoting monthly gatherings that celebrating local food and traditional agricultural practices. Similar efforts have been promoted in some AI communities, and have focused on growing and preserving healthy foods [29] and strengthening food sovereignty [30]. The comments interviewees made regarding interest in gardening mirrored other gardening efforts in the Bemidji tribe area in Wisconsin [31], on the Navajo reservation [32], and a reservation in North Central Montana [33].

The comments from interviewees also prompted the project team to partner with local extension staff to develop and implement structured gardening sessions for children and their families enrolled in a summer program. The gardening sessions included hands-on activities for children in growing and tasting fruits and vegetables, preparing snacks and meals using locally sourced low-cost foods, and making healthy meals together with family [34].

Schools were mentioned frequently as a natural a place to expand childhood obesity prevention efforts. Although schools provide opportunities for students to learn about and practice healthy eating and PA behaviors, programs are most likely to be sustained if they (1) fit into the current school structure; (2) receive buy-in by teachers; and (3) require minimal additional funds or staff time [35]. Demand for schools to improve the academic achievement of children has led to decreased amounts of time for PE and nutrition education, recess, lunch and other components of school-based health promotion [36]. Teachers and school leaders are already stretched and may not have the resources to address issues that require collaborative action across the community. Interviewees identified other points of connections in the community that could be activated for preventing childhood obesity, such as medical clinics, after school and summer programs, and libraries. These “other parts” of the public sector have a role to play in increasing opportunities for PA, promoting healthy food and drink choices, and supporting children to make better behavioral choices [37] [38] [39].

Narrow Range of Scores

The Leadership Team was surprised by the low readiness scores and the narrow range of scores across the five communities. The Leadership Team had expected variation between and across communities that would require different intervention approaches; however, variation in community readiness scores was low. One reason for this may be similar levels of knowledge and access to childhood obesity prevention resources across the geographically defined rural communities. Community Efforts was the singular dimension that demonstrated wide variability in the readiness scores. The lower scores in Communities 3 and 4 may have been due to the small population size, where the small number of children could not support multiple on-site youth programs.

Other studies, but not all [40], found similarly narrow ranges in overall readiness scores. For example, Ogilvie and colleagues [12] found the average community readiness score to be a 2.9, with individual community readiness baseline scores at 3.0, 2.9, 3.0 and 2.7. Paltzer, Black and Moberg [24] also found that a statewide assessment of community substance abuse coalitions (n =21) in Wisconsin scored at or below the community readiness stage of 4 (Preplanning). These narrow community readiness scores suggest that community-wide assessments may be sufficient unless specific information is needed for each region of the community.

Summary

The Leadership Team identified several strengths of the CRM, particularly that the interviews provided useful data to return to the community. The interviews also helped to identify available resources and key people on the reservation to help organize and lead child health efforts in their respective communities. The CRM process also brought other issues of critical importance related to childhood obesity, such as food access and insecurity, to the attention of the Leadership Team, Advisory Board, and community members.

CRM may be particularly valuable when used in conjunction with other methods of data collection, such as a thematic analysis of interview responses, focus groups, and surveys, to verify the results and identify appropriate and sustainable intervention strategies. Nonetheless, the CRM has face validity, especially among community leaders. It is a valuable tool to assist researchers in initiating and engaging in a dialogue with community members and leaders about addressing a public health issue, and it facilitates collaborative problem solving at multiple levels.

The findings in this study have limitations that are common to studies employing qualitative research methods. The findings do not reflect the views of all members of the reservation and the results may not be generalizable to other rural or reservation communities. However, the CRM process may have advantages that outweigh these disadvantages when starting a new community partnership to address health issues. The process of conducting the recommended six key informant interviews may be less time consuming than other data collection methods, the scoring method is systematized, and the qualitative interview questions allow for the interviewees to communicate rich details. The CRM key informant interview questions are easily adaptable and can be used to address many public health issues. As with the CBPR approach, CRM allows for balance between the scientific research and the needs of communities, which is necessary in addressing complex public health issues like childhood obesity.