Healthy Eating Determinants and Food Security Resource Opportunities: Urban-Dwelling American Indian and Alaska Native Older Adults Perspectives

Abstract

Objective:

To explore the perspectives of urban-dwelling American Indian and Alaska Native (AI/AN) older adults regarding determinants of healthy eating, food insecurity, and opportunities for an urban clinic to improve resources.

Methods:

Semistructured interviews (n = 24) with older adults (aged ≥ 60 years) at 1 urban AI/AN serving clinic. Telephone-based interviews were audio-recorded, professionally transcribed, and analyzed using thematic analysis.

Results:

Four overarching themes were revealed: (1) hunger-mitigating resources exist but do not necessarily lessen food insecurity; (2) multiple layers of challenges related to social determinants of health present barriers to healthy nutrition for AI/AN older adults; (3) unique facilitators rooted in AI/AN culture can help decrease food insecurity; and (4) many clinic-based opportunities for programs to improve food insecurity exist.

Conclusions and Implications:

Findings provide a foundation for urban-serving AI/AN clinics to develop healthy eating resources for their older adult patients. Greater benefit would result from resources that build on cultural strengths and address older adult-specific challenges to healthy eating.

INTRODUCTION

The Centers for Disease Control and Prevention describes the social determinants of health (SDH) as the conditions in which people live, learn, work, play, and that affect a wide range of health risks and outcomes.¹ Considering the SDH as they impact human health is often considered an upstream approach, or the causes of the causes. The US Healthy People 2030 initiative, outlined by the Department of Health and Human Services, emphasizes the importance of addressing SDH as they impact quality of life outcome and risks.² The Ecological (Socioecological) Perspective emphasizes the importance of the interaction between and interdependence of multiple levels and factors that influence health—within the context of the SDH.³ These levels include individual, interpersonal, organizational, community, and policy factors.³ Specific to American Indian and Alaska Natives (AI/AN), the National Institute on Minority Health and Health Disparities (NIMHD) has developed a research framework that delineates the domains of influence across all levels to reflect the historic and sociocultural influences experienced by AI/ANs across all ages and settings (eg, rural vs urban-dwelling).^4,5

It is well established that eating a healthful diet is a cornerstone to chronic disease prevention and management.^6,7 In the context of SDH and the ecological perspective, there are a myriad of factors that influence a person’s ability to eat a healthy diet.² The US Department of Agriculture defines food insecurity as a lack of consistent access to enough food for an active, healthy life.⁸ Food insecurity is inversely associated with diet quality in households that experience low income.⁹⁻¹¹ Management of nutrition-related chronic diseases such as hypertension, diabetes, heart disease, and obesity is negatively impacted by food insecurity because eating a healthy diet which is low in sodium, sugar, saturated fat, and high in fiber is key to successful chronic disease management.^12,13 According to data from the National Health and Nutrition Examination Survey, people who experience food insecurity were twice as likely to be obese than people without food insecurity.¹⁴ People with food insecurity are also more likely to have diabetes, even after adjusting for body mass index.^12,15 Food insecurity is also highly tied to disordered eating behaviors, especially binge eating, which can lead to higher weight and exacerbate all health conditions, including mental health.¹⁶⁻¹⁸ American Indians and Alaska Natives also experience a higher prevalence of food insecurity and poverty when compared to non-Native people.¹⁹⁻²³ As reflected in the adapted NIMHD research framework,⁴ food insecurity is exacerbated in AI/AN communities by contributors to barriers in physical and built environments, such as water insecurity,^24,25 loss of land, forced relocation, and environmental pollution, all which have devastated traditional healthy food practices.^8,26 These traditional healthy food practices such as hunting, gathering, and fishing have been destroyed by the lasting impacts of colonization and forced removal from traditional lands.²⁶ Urban-dwelling AI/AN adults experience different challenges to food insecurity than their rural-dwelling counterparts,²⁷ and there is scarce literature specific to food insecurity experiences among urban-dwelling, older AI/AN adults. The purpose of this study was to examine the perspectives of urban-dwelling older AI/AN adults regarding current resources to help with healthy eating, gaps in these resources, food insecurity, and recommendations to improve healthy eating resources for this priority population.

METHODS

Study Design

This study was framed by a constructivist epistemological approach which allowed themes to emerge that researchers might not have anticipated.²⁸ We used a semistructured moderator guide with probes to conduct individual telephone-based interviews. A total of 24 older urban-dwelling AI/AN adults (aged ≥ 60 years) participated in this study. Because of the safer at home guidelines during the coronavirus disease 2019 (COVID-19) pandemic, all interviews were conducted individually via telephone. Web-based interviews were not appropriate for this audience given concerns about internet connectivity, access to internet-connecting devices, and digital literacy of the priority audience. This study design was deemed appropriate by the collaborating clinic staff, who had been providing medical care visits via telephone to this patient population throughout the COVID-19 pandemic. The University of Colorado Institutional Review Board and the National Indian Health Service Institutional Review Board both approved this protocol as exempt, therefore an information sheet was used in lieu of a signed informed consent document.

Participants and Recruitment

Clinic staff utilized purposive sampling²⁹ to identify eligible participants. Participants who were aged ≥ 60 years, AI/AN, English-speaking, and who used the urban clinic for at least a portion of their health care services were invited to participate. Of note, positive screening for food insecurity was not an inclusion criterion for this study. Clinic staff called eligible participants using a standardized recruitment script, and if they were interested in participating in this study, their contact information was provided to the research staff who subsequently called each eligible participant, explained more about the study, and scheduled a telephone-based interview at a time when the participant would have approximately 1 hour available to converse. Before the scheduled interview, clinic staff mailed each participant an information sheet to their home address. Each participant received a $40.00 gift card for their time.

Data Collection

One trained qualitative researcher interviewed all participants in October, 2020. Recruitment and data collection were concluded when data saturation was reached.³⁰ This qualitative researcher used a call-recording application to record calls. The qualitative researcher used a semistructured interview guide, developed in collaboration with AI/AN researchers and AI/AN clinic-based collaborators, and reviewed by 2 members of the intended audience for readability and understandability. Per recommendation from AI/AN elders, because of the stigmatizing nature of food insecurity and other challenges to accessing healthful foods, we employed scenario-based questions for a portion of the interview.^31,32 The rationale for this approach was to decrease potential feelings of shame about personal experiences with food insecurity and engage participants who had not experienced food insecurity or other barriers to healthful eating related to SDH.³³ The moderator guide can be found in Table 1. Interviews ranged from 25−61 minutes with an average length of 37 minutes. The researcher took notes throughout the interview. Each participant completed a demographic survey which included questions on: age, marital status, household size, zip code, and the 2-item Hunger Vital Signs food insecurity screener.³⁴ Sex was determined by self-reported, close-ended questions with options: male, female, or other.

Table 1.

Moderator Guide Used for Qualitative Individual Interview Data Collection

Primary Interview Question	Probes	Rationale for Question
Tell me what healthy eating means to you.	Types of food, special diets, cooking methods, traditional food	Introduction, opening question to frame healthy eating
In your community or neighborhood, tell me about the types of places that someone can get food, such as groceries or other prepared food.	Community gardens, grocery store, corner market, food bank, farmers market, elder programs	Exploration of community-level determinants of healthy eating
Tell me about community food resources that are available for American Indian or Alaska Native elders.	Food bank, food pantry, Supplemental Nutrition Assistance Program, congregate meals	Exploration of community-level determinants of healthy eating, resources available, gaps in resources
An American Indian or Alaska Native elder has recently moved to Denver, CO and she’s struggling to afford enough groceries for her and her granddaughter. What suggestions do you have for her to help her with her household food needs?	Resources available, resources lacking, church-based, clinic-based, other American Indian or Alaska Native-serving organization, older adult-specific, food resources, non-food resources	Scenario-based question to reduce stigma, shame, and engage participants who have not personally experienced determinants to healthy eating or food insecurity
An American Indian or Alaska Native elder was recently told by a doctor that he has high blood pressure. His wife has diabetes. Money has been tight and he’s worried about being able to afford the healthy foods, like fresh fruits and vegetables, that the nutritionist recommended. What suggestions do you have to help this couple meet their household food needs?	Resources available, resources lacking, church-based, clinic-based, other American Indian-serving organization, older adult-specific, food resources, nonfood resources	Scenario-based question to reduce stigma, shame, and engage participants who have not personally experienced determinants to healthy eating or food insecurity
If we could create or improve any resource or program to help American Indian or Alaska Native elders in your community getting healthy food, what would it look like?	Improve existing resources, subsidized produce, grocery store vouchers, transportation, meal delivery, traditional food access	Recommendations for health care clinic
Please share anything else that you would like about healthy eating and American Indian or Alaska Native older adults.		Closing remarks, opportunity for participants to revisit previous topics or share participant-led topics

Data Analysis

All recorded interviews were transcribed verbatim by a professional transcription company. Transcripts were checked for accuracy in their entirety and deidentified using [NAME] in place of participant name or other family members referenced by the participant during the interview. Next, deidentified transcripts were uploaded to a qualitative data analysis program, Atlas.ti (Mac version 8.1.1, ATLAS.ti Scientific Software Development GmbH). The research team used Atlas.ti to digitalize and increase transparency in the analytic process.³⁵ The first round of coding included inductive free coding, in which no predetermined codebook was used.³⁶ On the basis of this first round of coding, the lead qualitative researcher consulted with AI/AN clinical partners to review inductive codes, and develop a codebook on the basis of the inductive codes and the moderator guide. Codes derived from the moderator guide were considered deductive (a priori) and used in the second round of coding. During the second round of coding, the lead qualitative researcher reviewed all transcripts with the agreed on codebook (including inductive and deductive codes). After this round of coding, the lead qualitative researcher consulted with the AI/AN clinical partners to debrief, summarize and collapse codes, and strategize development of categories. For example, codes “no personal car” and “relied on borrowed vehicle” were collapsed and combined as “no personal vehicle” as the coders defined them identically. As another example, codes “no personal car,” “neighbors helped with transit,” “unsafe public transit,” and “distrust ride share program” were placed in the category “transportation barriers.”³⁶ Ultimately, the categories revealed 4 overarching themes in this thematic analysis.³⁷ The analysis and findings follow the consolidated criteria for reporting qualitative research guidelines, which is a 32-item checklist meant to guide rigorous and systematic reporting of qualitative research.³⁸

The descriptive characteristics of the participants were estimated using proportions for categorical measures and means and ranges for continuous measures (version 15.1, Stata/SE for Windows, StataCorp LLC, 2017). The 2-item Hunger Vital Signs food insecurity questions on each questionnaire were pooled so that an affirmative response to either question indicated positive for food insecurity.³⁴ To examine bivariate associations between participant characteristics and food insecurity, cross tabulations were estimated and differences were evaluated using Fisher’s exact tests. For bivariate analysis single, divorced, widowed, and separated were collapsed together to reflect those not married or cohabiting.

RESULTS

Participant Characteristics

Twenty-four AI/AN participants completed the demographic survey and food insecurity screener questions. Participants were mostly female (79%) and the mean age was 68 years. More than one-third (38%) were either married or cohabiting. Household size ranged from 1 to 6 members, with an average size of 2.6 members. Just 21% of households included members aged > 18 years, whereas 63% included additional members > 65 years. Three quarters (75%) of the participants screened positive for household-level food insecurity in the past year using the 2 screening questions.³⁴ Women were more likely than men to report food insecurity (90% vs 20.0%: P < 0.01). Although 93% of those who were single, divorced, separated, or widowed reported being food insecure, just 44% of those who were cohabiting or married reported food insecurity in the past year (P < 0.01). Details on participant characteristics can be found in Table 2.

Table 2.

Characteristics of Individuals Who Participated in Individual Interviews (n = 24)

Characteristics	n	%
Sex
Male	5	21
Female	19	79
Mean age (range)	68.2	(67–83)
Marital status
Single	5	21
Married/cohabiting	9	38
Widowed	2	8
Divorced/separated	8	33
Household composition
Mean household size (range)	2.6	(1–6)
Households with members < 18 y	5	21
Households with members > 65 y	15	63
Food insecure past year
Never	6	25
Sometimes/often	18	75

Qualitative Findings

Four salient themes emerged across these interviews. First, programs to reduce hunger exist in the urban area, but they might not be enough to decrease food insecurity and improve access to healthy food. Second, older AI/AN adults face multiple challenges related to SDH which impact their ability to eat a healthy diet. Third, the social and cultural value placed on sharing and supporting one another by AI/ANs can help improve healthy food access for older adults. Finally, there are many opportunities for AI/AN serving organizations to improve healthy food resources for older adults in this urban area.

Programs to improve food access exist in the urban area, but they may not be enough to decrease food insecurity or improve access to healthy food.

Participants discussed many programs and resources in the urban area aimed to improve food access. For example, participants shared that many food banks and pantries were available and had even increased in number because of COVID-19. They noted these food banks and pantries were often generous in the amount of food offered, but largely these foods were not healthy as stated by this participant:

They do the best they can, but most of it is high in salt like canned stuff or has white flour and sugar like pasta, donuts, and bread. I know I shouldn’t eat that stuff so when that’s all they [food pantry] [have], I’ll give it to my neighbors.

Participants noted they had been eating less fresh food, largely because food pantries do not offer these foods, or that among those that do offer fresh foods, the food supplies often go bad quite quickly. Participants noted there are public transit resources for older adults but voiced multiple concerns about using these resources during the COVID-19 pandemic. Participants suggested some of the public transit resources have unpredictable schedules, and often the public transit routes still require a rider to walk a distance to get to/from a designated stop which is especially challenging when carrying groceries. Participants discussed other food-aide resources such as the commodity food program offered through one of the AI/AN serving organizations in town and the Supplemental Nutrition Assistance Program (SNAP). Multiple concerns arose during discussions about the commodity food program—namely the lack of fresh foods offered, high number of processed foods, and mismanagement and poor communication by the organization providing this service. Participants did note that this organization was likely understaffed and underfunded, but voiced concerns about unpredictable food box distribution claiming, “you just never know if you’re on the list, so you can’t rely on it really.” They shared that SNAP benefits are often not enough to eat healthfully, and several who used SNAP benefits suggested they altered their diet to make the benefits last longer. Some of these examples include purchasing less or no fresh food because of concerns of food waste and eating more shelf-stable foods such as canned soups, though most participants recognized these are not healthy choices, as evidenced here:

You do what you can. I’ve never gone hungry. I’ll just eat the canned stuff, I can make meals out of canned soup. Even in hard times, I can get that. I mean, yes, there is so much salt in there and preservatives − but that’s better than going hungry right? No one wants that.

Older AI/AN adults face multiple challenges related to SDH which impact their ability to eat a healthy diet.

Participants noted that though many people are struggling because of the COVID-19 pandemic, older adults are disproportionately impacted by the negative implications of SDH. They discussed issues with lack of transportation and physical ability to carry groceries for older adults, such as exemplified here:

I’d walk 5 blocks and do my shopping and then carry it home. Transportation and then this neighborhood that I’m in now, it’s a food desert. It’s also a challenge when you’re older and having to carry it or figure a way to put it in a backpack or some kind of a way to carry it home.

They also discussed implications of living on a fixed income, the cost of many medication copayments, and the rising prices of fresh food as financial concerns related to healthful eating. One participant shared that “I would say, it’s limited finances, fixed income. That’s the biggest thing that stops me from eating the way I know I am supposed to.”

Participants indicated health concerns associated with older adults such as compromised eyesight, dentition, chronic pain which stymies the ability to stand and cook meals in the kitchen, and mental health issues such as depression, especially related to the social isolation of the COVID-19 pandemic.

Finally, participants shared that in addition to the added SDH impacting older adults, specifically as AI/AN older adults, another unique determinant of health is the historical and cultural context and trauma related to loss of access to traditional foods, and loss of traditional food acquisition methods. They also discussed that AI/AN older adults face added mental health challenges related to the trauma of colonization and systemic racism. Here is an excerpt of 1 participant’s story:

Now, you also have to keep in mind I was… A lot of my generation and myself was forced into missionary school. And my parents could be imprisoned if they get me out of school. (…) I was totally institutionalized from 4 years old. First to sixth grade, were allowed no contact with our parents, as they [the missionary school] indoctrinated us. (…) And we were malnourished. Because the food they fed us there, there was no nutritional value to that food. (…) And so, I spent a good portion of my life living in this missionary school. And again, survival mode. And again, you ate what was put in front of you. And that’s all you had. So you ate it. And so, I guess what I’m not trying to give you my hard-luck story, I’m just trying to tell you a lot of the factors that affect my generation.

The social and cultural value placed on sharing and supporting one another by AI/ANs can help improve healthy food access for older adults.

In response to the scenario-based questions, almost all interviewees said they would personally help and share their food/resources with another AI/AN family who was struggling. This was an almost universal initial response to scenario-based questions as exemplified here:

I would give what I have, that’s what we do, we always share food. My mother did this growing up, and I would always share what I have even now, when I have little.

In addition to responding to the scenario-based questions that participants would share their personal resources, they also discussed sharing with their neighbors, family, and friends on a regular basis. Finally, participants discussed the importance of sharing information with one another. A common concern about food resources was that many do not know what is available. For example, 1 participant said:

But education is key, because you need to know where your resources are and how you can contact those resources. So I tell everyone I know when I come across a good deal at the store or when a food bank has good supply.

There are many opportunities for AI/AN serving organizations to improve healthy food resources for older adults in this urban area.

Participants expressed many ideas of how healthy food resources could be improved for older adults. First, they strongly suggested improving communication on existing resources. They noted that people simply do not know what resources are available, especially if they are experiencing food insecurity for the first time (such as during the COVID-19 pandemic).

Regarding the format of this improved communication, participants also had many suggestions such as the following:

One of the things that I always felt I needed to be able to do more (…) [was] just to give out information. Not everybody has computers and stuff. There’s a lot of information out there that people just don’t get. It needs to be mailed and phone calls, too, just calling people to tell them what is out there.

Participants thought that gift cards for grocery stores would be better than food boxes, as a means to preserve food sovereignty and respect differences in taste and preferences, as indicated here:

Ideally, if I could get vouchers or gift cards where you can shop as you need it, that’s even better. So you have choice, that gives me dignity to choose what is healthy for me and respect my preferences, especially for elders.

Participants recommended resources to mitigate transportation barriers such as a transportation service exclusively for AI/AN older adults to take them to medical appointments and grocery shopping and meal or food delivery services for either hot prepared meals or grocery delivery. In addition, participants suggested help with non-food related expenses to free up their own resources for purchasing healthy food.

Together, these 4 themes exemplify the key findings across all 24 interviews and build the foundation for development of elder-centered healthy eating resources.

DISCUSSION

The purpose of this study was to examine the perspectives of urban-dwelling older AI/AN adults regarding current resources to help with healthy eating, gaps in these resources, food insecurity, and recommendations to improve healthy eating resources. The themes presented from these findings are supported by conceptual frameworks and existing literature.

All 4 themes are directly related to SDH and exemplify the need to consider upstream and multiple levels of influence across domains that challenge healthy eating among AI/AN older adults. Food insecurity is a key SDH for older adults.³⁹ According to a Feeding America Report, among all older adults aged ≥ 60 years, 7.8% were food insecure in 2018.⁴⁰ Feeding America⁴⁰ and The National Council on Aging⁴¹ indicate that racial and ethnic minority groups of older adults are disproportionately affected by food insecurity. Older adults often have added challenges to healthful eating including a fixed income, multiple medications or medical appointments which require copayments,⁴² issues with mobility,⁴³ and comorbidities which exacerbate food insecurity,⁴⁴ among others. Because food insecurity may or may not coexist with hunger, defined as the physiological sensation caused by lack of food,⁴⁵ it is prudent to consider the psychological ramifications of experiencing food insecurity, especially for the most disproportionately affected older adults.

From these survey findings, most of these participants (75%) screened positive for household-level food insecurity even though food insecurity was not a stated inclusion criterion for study participation. This number is far higher than national estimates (14%) for food insecurity during COVID-19 among older adults.⁴⁶ Although many participants in this study shared they had not frequently experienced hunger, available food resources still left them food insecure and eating less fresh food or eating highly processed food as unhealthy coping mechanisms to avoid hunger. Navigating unpredictable transportation may exacerbate mental health conditions related to anxiety about food security.⁴⁷ Furthermore, as supported by the NIMHD research framework, participants described specific levels of influence that challenge their ability to eat healthfully such as: at the individual-level (eg, comorbidities and chronic disease), at the community-level (eg, transportation), and at the societal-level (eg, implications of trauma related to colonization).^4,5

The recommendations regarding resources the urban Indian clinic (of which all participants were active patients) could do to help improve healthy eating among AI/AN older adults also reflected these multiple levels of influence and SDH that challenge healthy eating. Participants recognized there are existing resources in this urban area, but wanted clearer communication on available resources, how to access these resources, and how other people—specifically those who have multiple barriers to healthful eating—could use them. Building collective capacity across existing resources in this urban area is a clear next step supported by these findings. Coordinating healthy food resources with clinical partners is also a promising approach to improve food insecurity.⁴⁸⁻⁵¹ Finally, participants talked about the importance of maintaining choice with what foods they purchase, which is important to most adults,⁵² but was particularly moving in the context of historical loss of traditional foods and traditional food acquisition habits for the AI/AN older adults in this study who shared their personal experiences with colonization and systemic efforts to erase cultural identity among AI/ANs such as missionary and boarding schools.

A profound finding in this study was the participants’ enthusiastic willingness to help fellow AI/ANs who were experiencing hardships related to healthy eating. These urban-dwelling AI/AN participants created community through such organizations as the Urban Indian Health Clinic and Indian community centers. Not only did almost all participants share their first course of action as a response to the scenario-based questions would be to personally help the AI/AN family presented in the scenario, but almost all indicated they shared food with their extended family and community long before the COVID-19 pandemic. Participants explained in detail how sharing food is a core cultural value among all AI/ANs regardless of Tribe. Resilience among AI/AN elders is rooted in connection to Tribal community connectivity and cultural values, in both urban and rural-dwelling AI/ANs.^53,54 Healthy eating resources are most beneficial if they build on this inherent strength among AI/AN communities.^55,56

The primary limitation to this study is that there was only 1 coder.³⁶ However, to mitigate this limitation, the coder did consult with coauthors (2 of whom are AI/AN) during weekly debriefing conversations throughout the data collection and analysis period.

IMPLICATIONS FOR RESEARCH AND PRACTICE

Older adults who have multiple chronic health conditions, live on limited or fixed income, and who are from communities that are impacted by racism are disproportionately affected by health disparities related to multilevel SDH. It is important for nutrition interventionists to recognize the multiple layers of influence, many of which are not directly food or nutrition related, when creating programs and resources to support older adults. The findings from this study are supported by both theory and the literature and provide a foundation for organizations who serve urban-dwelling AI/ANs, or other historically disadvantaged communities, to develop community member-centered, strengths-based resources for these individuals. Building collective capacity across existing food security resources in this urban area is a logical next step.⁴⁸⁻⁵¹ Furthermore, next steps include leveraging existing community food security resources and using community participatory based research methods^57,58 to develop, implement, and evaluate a clinic-based, food security resource specifically tailored for AI/AN urban-dwelling older adults.