Adapting a cooking, food budgeting and nutrition intervention for a rural community of American Indians with type 2 diabetes in the North-Central United States

Abstract

American Indian (AI) communities experience persistent diabetes-related disparities, yet few nutrition interventions are designed for AI with type 2 diabetes or address socio-contextual barriers to healthy eating. We describe our process of adapting the evidence-based Cooking Matters® program for use by AI adults with type 2 diabetes in a rural and resource-limited setting in the North-Central United States. We conducted three focus groups with AI adults with diabetes to (i) identify Cooking Matters® adaptations and (ii) gather feedback on appropriateness of the adapted intervention using Barrera and Castro’s cultural adaptation framework. Transcripts were coded using an inductive, constant comparison approach. Queries of codes were reviewed to identify themes. Contextual considerations included limited access to grocery stores and transportation barriers, reliance on government food assistance and the intergenerational burden of diabetes. Adaptations to content and delivery included incorporating traditional and locally available foods; appealing to children or others in multigenerational households and prioritizing visual over written content. Our use of Barrera and Castro’s framework adds rigor and structure to the cultural adaptation process and increases the likelihood of future intervention success. Other researchers may benefit from using this framework to guide the adaptation of evidence-based interventions in AI communities.

Introduction

The prevalence of type 2 diabetes among American Indians (AIs) is twice that of non-Hispanic Whites, and diabetes-related morbidity and mortality among AIs are the highest of any racial/ethnic group in the United States [1]. Diabetes among AI often begins early in life, with AI children having a nine times higher risk of being diagnosed than non-Hispanic Whites [2–4]. Findings from the Strong Heart Family Study, a study of cardiovascular diseases in 12 rural AI communities (including the study community described herein), indicated that most AIs did not achieve dietary recommendations, which can increase the risk for diabetes and related complications [5].

Diet quality, defined as the alignment of diet with dietary guidelines and diversity of foods within healthy food groups such as fruits and vegetables, among AIs is influenced by several interrelated socio-contextual factors [3, 6, 7]. Colonization and forced relocation of AI people to reservations in the 1800s resulted in the loss of land and disruption of traditional food systems [3]. Restricted access to resources and economic opportunities on reservations have also resulted in high poverty and unemployment rates [3]; persistent poverty is a fundamental driver of food insecurity and diet quality among AIs [8–11]. AIs are also more likely to live in rural regions when compared with other racial/ethnic groups [11], and access to healthy and affordable foods is limited in some rural communities due to long distances to food stores and/or limited availability of healthy foods at food stores [12–14]. These contextual factors result in high rates of food insecurity among AIs—a recent review found a weighted average prevalence of 57% among studies of rural-residing AIs, compared with a weighted average prevalence of 46% among all studies included in the review [15].

Most existing diabetes interventions adapted for AI communities focus on nutrition education and improving diet quality among those without type 2 diabetes [16–23]. Moreover, existing diabetes management interventions are typically clinically focused and do not address the underlying contextual factors that impact healthy eating, such as socioeconomic barriers to accessing and purchasing healthy foods [23]. Diabetes management interventions adapted for AIs with type 2 diabetes that address the underlying contextual barriers that impact healthy eating are needed in AI communities.

Cooking Matters® is an evidence-based nutrition intervention included in the United States Department of Agriculture Supplemental Nutrition Assistance Program—Education (USDA SNAP-Ed) Toolkit [24]. Cooking Matters® has evidence of effectiveness for improving food budgeting and cooking skills and healthy food consumption among low-income families [24, 25]. However, the intervention primarily targets non-AI populations and families living in urban or suburban areas [24, 25]. Prior meta-analyses of behavioral interventions suggest that culturally adapted interventions may be more effective in changing health-related behaviors than unadapted versions [26–28]. Furthermore, a review of AI population-focused interventions found that addressing the specific cultural, social, political and historical context of the study community was essential to evidence-based intervention success [28, 29]. We sought to adapt Cooking Matters® for AI with type 2 diabetes living in a rural reservation community in the North-Central United States using Barrera and Castro’s cultural adaptation framework to guide the adaptation process [30, 31].

Method

Study setting and overview

The study community is one of the larger AI communities in the United States and is classified as a food desert by the USDA Economic Research Service [32]. Employment opportunities in the community are limited, and the reservation is located in two of the lowest-income counties in the United States with per capita incomes of about $9000 and $7500, respectively [33].

The current study evolved from an ongoing partnership with the study community via the Strong Heart Study, the largest longitudinal study of AI health in the United States [34]. Many of the investigators have been working with the community since 1988 to identify major risk factors for cardiometabolic diseases among AIs in the community (See Fig. 1 for timeline and evolution of partnership). In response to Strong Heart Study findings, the community voiced a desire to shift from observational research to research focused on interventions to reduce cardiometabolic disease morbidity and mortality risk. This resulted in the Cooking for Health study (and the formative Healthy Food, Healthy Families study that preceded Cooking for Health), which aims to develop and test a distance-learning-based culturally adapted healthy food budgeting, purchasing and cooking intervention adapted from Cooking Matters® for AI adults with type 2 diabetes who reside in the study community [12, 35, 36].

Fig. 1.

 

Cooking for Health Research Collaboration Timeline.

The present adaptation study design was informed by Barrera and Castro’s cultural adaptation framework [30, 31]. We opted to use this framework due to our prior success in using this framework in other cultural adaptations and the consensus this framework has in its overarching elements with other adaptation models and frameworks [31, 37]. The framework comprises a multistage approach for adapting evidence-based interventions composed of (i) gathering information and conducting formative research about the intended population; (ii) designing preliminary adaptations; (iii) assessing preliminary adaptations; (iv) refining adaptations and (v) implementing and testing the intervention [30, 31]. This manuscript describes our process and findings for Steps 1–3. Intervention implementation is ongoing, with a target completion date of September 2023.

Study sample

We conducted three focus groups to gather community insight on potential changes to Cooking Matters® content and delivery needed for the implementation of the curriculum on the reservation. AI men and women aged 18–60 years with self-reported diagnosed type 2 diabetes who resided on the reservation and who reported doing most of the cooking and shopping for their household were eligible to participate in the focus groups. Individuals who were pregnant, on dialysis, cognitively impaired or had a history of bariatric surgery were excluded from participation since these conditions may influence food choices. Additionally, only one eligible individual per household was allowed to participate in the focus groups.

Focus group participants were recruited by study staff at the Missouri Breaks Industries Research Inc. (MBIRI) with assistance from the Tribal Adult Diabetes Program. The MBIRI is an AI-owned research firm located in the study community that has managed several extensive research studies over the past 20 years. MBIRI is the field center of the Strong Heart Study. To identify a diverse sample of participants across the reservation, we used multiple recruitment strategies including paper flyers posted at local businesses and distributed at the local Indian Health Services hospital, Facebook announcements and word-of-mouth. Study staff obtained written informed consent from all study participants on-site prior to the start of the focus groups. The Institutional Review Board at the University of Washington, the Indian Health Services and the tribal health board approved all study procedures. All study procedures were in accord with the Helsinki Declaration of 1975 as revised in 1983. The tribal health board approved the final version of this manuscript.

Data collection and analysis

Two focus groups (focus group 1: n = 6; focus group 2: n = 8) were conducted in October 2018, and one focus group (n = 3) was conducted in October 2019. We decided in advance to have three focus groups. The number of focus groups was determined based on staff capacity to host the groups and our previous work where three groups were sufficient to capture prominent themes around the topic of interest [12]. The first sets of focus groups were designed to solicit input on intervention curriculum topics and necessary adaptations to Cooking Matters® needed for the target community. These focus groups included a pile sort activity where participants were asked to group potential topics into green (definitely interested), yellow (possibly interested) and red (not interested) categories. As previous pilot work identified the need for an asynchronous video intervention format due to transportation barriers and the lack of a suitable teaching kitchen in the community [11], in the focus groups, participants also provided feedback on an example video lesson, binder with paper materials and potential cooking tools to provide to participants as part of the intervention curriculum. The 2019 focus group was designed to obtain more specific feedback on implementation in response to the adaptations made from the first set of focus groups, including feedback on the readability and clarity of preliminary intervention materials. In this last focus group, participants were provided with examples of the intervention website, two video lessons, an example welcome kit with cooking tools and tablets with example data collection forms and asked to provide feedback. Participants in all three focus groups were also asked to provide input on strategies and incentives that would maximize community participation (e.g. monthly newsletters, potential monthly raffle items and welcome kit). Focus group guides were organized by topic, including engagement, exploration and exit questions (Table I). Focus groups lasted ∼1 h, and all participants were compensated $25 for their time. Focus group recordings were transcribed verbatim by a trained transcriptionist and checked for accuracy by the focus group facilitators.

Table I.

Adaptation and refinement focus group questions

Initial adaptation focus groups	Refinement focus group
Engagement questions
Please go around the room and introduce yourself and tell us what your favorite thing to cook is? If you cook regularly, what resources do you use to find recipes to make for your family?	Please go around the room and introduce yourself and tell us what your favorite thing to cook is?
Exploration questions
[After sorting intervention topics into green, yellow and red pile categories]: What did you put in your green pile and why? What did you put in your red pile and why? Are there other topics that were not included that you would be interested in? [After review of binder materials] What do you like about the layout and content of the binder? What do you not like about the layout and content of the binder? [After review of example intervention video] What did you learn while watching the video? What was helpful about the video? What information was missing from the video that you would like to know? What kinds of foods or recipes would you be interested in learning how to cook using these types of videos? What could we include in a video that represents or relates to [tribe name] culture and traditions? Do you foresee any problems watching videos and doing an online survey that includes 3–5 questions each month? [After review of potential cooking tools that might be provided to participants to help them cook recipes] What tools or equipment were missing from the list that you think might be useful?	[After distributing iPads, showing participants how to access website and monthly modules and watching two intervention videos]: What do you like about the layout of the website? What do not you like about the layout of the website? Can you foresee any problems that participants in the Cooking for Health study may have when watching these videos? If so, please explain If you were a participant in the Cooking for Health Study, where would you typically watch the videos [e.g. at home, here at Missouri Breaks, at the Adult Diabetes Program Office in (reservation town center), or at a field clinic]? If watching at home, would you use a tablet, phone, laptop or desktop computer? [After showing example of surveys to be completed by participants on iPad] What do you like about using the iPad to complete the surveys? Do you foresee any challenges or problems in using the iPad? [After review of intervention data collection procedures] If you were a Cooking for Health study participant, would you be willing to participate in a one hour interview? Why or why not? If you were a Cooking for Health study participant, would you prefer the interview to be done in-person (here at Missouri Breaks) or over the phone? Why? If you were a Cooking for Health study participant, would you like to receive text message reminders about study visits or reminders to send in postcards by text? Why or why not? [After showing intervention ‘welcome kit’ with participant cooking tools; raffle items and postcards for raffle entries] In addition to raffles and gift cards, are there other things that we should consider adding keep participants motivated to participate for 12 months/1 year? Are Facebook and Facebook Messenger groups something you would participate in? Why or why not?
Exit questions
[After review of potential raffle options] Are there other items you think we should include? Besides a monthly raffle, what else would keep you motivated to participate in the study (i.e. complete the monthly lessons/watch videos)?	We hope that everyone who participates in the Cooking for Health Study can commit to the one hour per month requirement for the full year/12 months. If you were to participate, what are some reasons you might stop participating before the end of the study? Based on what you learned today about the Cooking for Health study, is this a study that you would be willing to participate in? Why or why not?

The study team consists of public health researchers, practitioners and community-based staff who are also tribal members. The analytic team in particular consisted of the Principal Investigator who is Mi’kmaq and an enrolled member of Eel Ground First Nation who has been working on projects related to nutrition and AI health for 17 years; a Co-I who is a Latina woman with 10 years of experience working on nutrition-related projects with AI populations; the lead analyst who is a mixed race (Black/white) woman who has been working on Cooking for Health-related projects for 5 years and community-based food security programs for 13 years; and a co-analyst who is a white woman who has been working on Cooking for Health-related projects for 3 years and in global health research for 8 years. Study findings were shared and interpreted with larger team that included the site PI who led the Cooking for Health study for 5 years, administered the Healthy Foods Healthy Families Feasibility study and has 23 years’ prior experience developing and delivering nutrition and health-related programs for the AI population, a family physician practiced medicine in AI communities from 1977 to 2013 and has been conducting epidemiologic research in these same communities from 2000 to present, and a consultant who is a white woman with 15 years of experience working on behavioral interventions to increase healthy food choices in diverse populations.

For analysis, the two analysts, the study PI and a study Co-I worked together to develop a set of a priori codes for analyses based on the content of the focus group guides. The two analysts independently coded the first transcript using Atlas.ti and met to review for consistency and adjust the codebook along with the PI and Co-I. The two analysts then independently coded the remaining two transcripts and afterward came together with the PI and Co-I to review coding, discuss the transcripts and finalize the codebook. Following coding, the two analysts collaboratively reviewed the coded segments for each code and identified themes within each code as well as cross-cutting themes that arose during the review using memos and based on the Barrera and Castro framework. These themes were then reviewed, discussed and finalized with the PI and Co-I before being presented to the full study team for inclusion in the final manuscript, as well as for use in intervention adaptation.

Results

Participant demographics

Characteristics of focus group participants (n = 17) are described in Table II. Most (82%) of the participants were female, and about half (47%) were 40–49 years old. Multigenerational households are typical in the study community, and 65% of participants reported that three or more adults reside in their household. Only one participant reported having no children living in the household. In our sample, 94% of participants with income data had total household incomes of less than $48 001 per year.

Table II.

Focus group participant demographics¹

Variable	Freq.	Percentage
Sex
Male	3	17.6
Female	14	82.3
Age
30–39	2	11.8
40–49	8	47.1
50–59	7	41.2
Number of adults in household
1	1	5.9
2–4	13	76.4
5–6	3	17.6
Number of children in household
0	1	5.9
1–3	7	41.2
4–6	7	41.2
7–9	2	11.8
Level of education
High school graduate or General Education Development (GED)	3	17.6
Some college	4	23.5
2 year college degree	4	23.5
4 year college degree	4	23.5
Some postgraduate work	2	11.8
Household income
0–$1000/month (0–$12 000/year)	4	5.9
$1001–$2500/month ($12 001–$30 000/year	3	17.6
$2501–$4000/month ($30 001–$48 000/year)	8	23.5
$5001–$6000/month ($60 001–$72 000/year)	1	5.9
Do not know/Did not response	1	5.9
Food preparation
Participant is main food preparer in household	9	52.9
Participant is not main food preparer in household	3	17.6
Participant equally shares food preparation with others	5	29.4
Food shopping
Main food shopper in household	12	70.6
Not main food shopper in household	1	5.9
Equally share food shopping with others	4	23.5
Percentage of time participant decides what to cook or have for a meal
None of the time	0	0.0
<25% of the time	3	17.6
25–50% of the time	7	41.2
51–75% of the time	2	11.8
>75% of the time	5	29.4
Percentage of time participant does the actual cooking
None of the time	0	0.0
<25% of the time	6	35.3
25–50% of the time	4	23.5
51–75% of the time	2	11.8
>75% of the time	5	29.4
How far is participant from the closest grocery story
<5 miles	14	82.4
5–10 miles	0	0.0
11–25 miles	0	0.0
>25 miles	3	17.6

¹Some percentages do not add up 100% due to rounding.

We identified three major ‘contextual factors’ to address when adapting Cooking Matters® content for this rural reservation community: (i) perceived limited supermarket availability and transportation hinders access to healthy, high-quality foods; (ii) many community members rely on either the Food Distribution Program on Indian Reservations (FDPIR) or Supplemental Nutrition Assistance Program (SNAP) for food assistance and (iii) high intergenerational burden of diabetes negatively impacts the mental health of family members with and without diabetes. Participants also identified three ‘additional content and delivery adaptations’ needed to make Cooking Matters® relevant for this community of AI adults with type 2 diabetes and their families: (i) focus on traditional AI and locally available foods; (ii) incorporate foods that appeal to children or others in multigenerational households and (iii) prioritize visual instruction over written content.

Contextual factors

Perceived limited supermarket availability and transportation hinders access to healthy and high-quality foods

Focus group participants described that a lack of access to healthy, affordable, high-quality fresh fruits and vegetables in the community was a major barrier to healthy eating and achieving optimal control of blood sugar. In 2016, 30 businesses sold food within a 90-mile radius of the reservation’s town center: 16 convenience stores, 3 dollar/discount stores, 10 small grocery stores and 1 supermarket (supermarket was 89 miles from the reservation’s town center) [35]. Participants described the limited produce available at local stores as expensive and of poor quality (e.g. bruised, spoiled and overripe), which dis-incentivized purchasing.

But the other thing I think, too, is that in this area, especially like down where we live…when we go in, and we look at the produce, many times it’s not even worth it to buy…It’s like we’ve—the hunter-gatherer in us is now hunting for the gathering stuff—Focus group 1, Participant 3

Trips to the supermarket (89 miles away) occurred only occasionally to stock up on foods that were too expensive or unavailable locally. While the majority of focus group participants reported residing <5 miles from one of the 10 small grocery stores, many still described challenges in getting to the grocery store due to the lack of public transportation and unreliable car access (e.g. relied on rides from others, the car was broken down and did not have money to fix).

Because up here, a lot of people don’t have the transportation to get off the reservation, and so like [local grocer]…they don’t have the diabetic foods…We need to get that food up here, so we don’t have to drive 90 miles away—Focus Group 2, Participant 2

Reliance on FDPIR and SNAP limits access to healthy foods

Many participants described relying on either the FDPIR (commonly referred to as commodity foods by participants) or SNAP for food assistance. The FDPIR is a government program started in the 1960s to address food insecurity and undernutrition among low-income AIs who reside on reservations and serves as an alternative to SNAP in these communities [38]. Historically, foods distributed as part of the FDPIR were primarily shelf-stable items (e.g. flour, canned meat and canned vegetables with added salt) with poor nutritional value. However, the program has made vast improvements since its inception and now includes fresh fruits, vegetables and traditional meats, such as buffalo. Despite these improvements, individuals who participate in the FDPIR described specific challenges to healthy eating. FDPIR recipients receive one allotment once each month and generally do not have much choice in which foods they receive, making meal planning difficult. Similar to the local grocery stores, participants also mentioned that the quality of fresh produce from FDPIR was highly variable. Furthermore, since most fresh fruits and vegetables spoil within 1–2 weeks, participants mostly ate fresh produce only in the first half of the month. Some focus group participants who utilized the FDPIR reported traveling to grocery stores to spend their limited income on fresh foods as this was the only way to ensure a healthy diet composed of whole foods throughout the entire month.

A lot of times [we] get whatever we can through [commodity foods] and it’s not always—you know, you’ve got to hit right on—the right day…When the truck comes in. And even then, it’s only once a month—Focus group 1, Participant 3

In contrast to the monthly distribution of food via FDPIR, SNAP recipients receive a monthly monetary benefit on a debit card to use for food purchases throughout the month. SNAP dollars can be used to purchase foods available in participating convenience stores, grocery stores and supermarkets, except for hot prepared foods, such as hot dogs or rotisserie chicken, available at some stores [39]. For SNAP recipients, barriers to healthy eating included (i) difficulty budgeting SNAP dollars to last for an entire month and (ii) meal planning to counter the appeal of convenient but less healthy, processed foods. Participants mentioned that work and family responsibilities led them to spend their SNAP dollars on easy-to-prepare (but less healthy) convenience foods (e.g. chips and soda). To counter this, participants expressed an interest in learning how to prepare quick and low-cost healthy meals.

I would throw in saving money using a budget and shopping list and meal planning, because it seems like whenever I go to the store, we just buy what is really convenient right away and get going—Focus group 2, Participant 5

High intergenerational burden of diabetes negatively impacts the mental health of family members with and without diabetes

The prevalence of type 2 diabetes is high in the community. Participants reported that, like themselves, many of their family members (e.g. parents, grandparents, siblings and other relatives) also have diabetes. Many participants expressed concern that developing type 2 diabetes feels inevitable in their community. This feeling that diabetes is not preventable—and that even children will be destined to develop diabetes—had adverse effects on community members’ mental health and willingness to make changes to manage their diabetes.

Diabetes runs rampant in my family, and I’ve had to take care of an auntie, I took care of her son. Um, my mother—and if people that—like me, that experienced that, excuse me if I get emotional, but all of the things that happen, losing limbs, kidneys, hearts, and how people pass away from that, I really think that we need to share that with our children…They‘ve got to know the truth. Because they’re going to deal with it—Focus group 2, Participant 5

Participants described the emotional stress they experienced while juggling their own health struggles (including managing blood sugar, preparing and eating healthy foods) while also caregiving for family members with diabetes-related complications, such as retinopathy, neuropathy and nephropathy. A few participants described watching family members become depressed after developing diabetes-related health complications; the depression led to a downward spiral—uncontrolled depression contributed to worse diabetes management, which resulted in dangerously high HbA1c levels and the development of cardiovascular disease. In addition, watching numerous family members endure serious complications from diabetes triggered anxiety in some participants—a reminder of what could happen to them or their children in the future if blood sugar is not adequately controlled.

And—and, um, another thing with diabetes is like we go into this depression—and we’re just like, I don’t want to do it anymore. You know? Then I—then something has to wake me up, and I say, no, I’m going to do it again. (Participant 7, Focus Group 2)

Additional content and delivery adaptations

Focus on traditional AI and locally available foods

In addition to the contextual factors described above, participants described the importance of including traditional foods in the intervention curriculum, including lessons on the history and meaning of traditional foods and healthy recipes for common foods available locally. Many participants felt that traditional diets are healthier than modern American/Western diets and that learning about how to prepare traditional foods would be a well-received intervention strategy.

When I lived with my grandparents…my grandpa would cook, or my grandma, and everything was…wild game. We didn’t hardly use salt. I didn’t see that. My grandparents, they never had diabetes. And then my mom did, but she…just ate partial game. And then me, anything, got diabetes—Focus group 1, Participant 1

Developing content that promotes a healthy diet for the entire family, including multigenerational households and children

Focus group participants highlighted the importance of including healthy recipes in the curriculum that will appeal to children or other family members in the household. A few participants mentioned that their children and/or household members were reluctant to try new or healthy foods in their multigenerational household. As a result, offering healthy recipes that will not spike blood sugar, but that family members without diabetes will also enjoy eating, is a priority. Participants also described the importance of being a role model for their children and modeling healthy eating to prevent diabetes in future generations.

Participant: Most of this stuff, whenever I’m thinking about it…it’s mostly teaching my kids, because…they all need to know how to cook and take care of themselves. Mine are at an age where they really need to be learning those things…So when I‘m looking at this, I’m not just for myself, but…it’s becoming more of a lifestyle of healthy cooking and eating. And so for me …it’s like what do I need to be able to not just do it for myself, but for my family—Focus Group 1, Participant 3

Focus on visuals rather than text

We showed participants examples of potential written intervention materials (e.g. an example lesson on vegetables; an example study newsletter) and a sample video of a recipe (e.g. a video led by a community member with step-by-step instruction on how to prepare baked sweet potato fries) to gather feedback about these elements. Participants generally liked the content, design and clarity of the example paper materials and video. Participants also liked that a traditional song was included in the video and asked for more traditional words to be included in written materials. In addition, because many participants learned to cook through oral tradition or demonstration rather than by following a recipe on paper, participants felt that videos were appropriate for delivering the intervention. Finally, participants noted that the initial written materials needed to include more pictures and visuals to be more appealing and accurately reflect how many people in the community prefer to learn.

Native Americans, they’re visual. More pictures, and then make it look yummy, and then probably the words need to be really big. (Participant 4, Focus Group 1)

Discussion

The purpose of this study was to gather the input necessary to adapt the Cooking Matters® curriculum for a population of AI adults with type 2 diabetes residing in a rural and resource-limited setting. Using the cultural adaptation framework developed by Barrera and Castro, we identified changes to the Cooking Matters® curriculum necessary to reflect the needs, strengths and values of the intended study population and community [30]. These adaptations include (i) a greater focus on food budgeting and meal planning for multigenerational families with minimal budgets, including how to most effectively use FDPIR or SNAP; (ii) incorporation of healthy, culturally relevant and locally available foods into curriculum and recipes; (iii) optimal diet for management of type 2 diabetes; (iv) proper storage of fresh and frozen foods to improve shelf-life and ensure participants can consume high-quality foods regularly and (v) use of visuals over written instruction (See Fig. 2 for the depiction of links between contextual factors and intervention adaptations).

Fig. 2.

Links between contextual factors identified by participants and intervention adaptations.

The original Cooking Matters® intervention has repeatedly demonstrated its ability to improve healthy food consumption among low-income families with limited food budgets [24, 25]. In many ways, the core elements of this evidence-based intervention—its purpose and general target population—fit the study community well. However, Cooking Matters® was designed with urban and suburban settings in mind and does not reflect the context of this rural and extremely resource-limited AI community. For instance, in both settings, convenience stores and small grocers with limited healthy food options are the predominant food retailers [24, 25, 35, 40, 41]. However, it is common for families to travel long distances once a month to stock up on groceries in the study community. Therefore, additional instruction on safely buying and storing fresh, frozen and canned (without added salt) healthy foods in bulk is a necessary contextual adaptation to support participants’ ability to eat healthy foods throughout the month. These adaptations to Cooking Matters® helped address the underlying contextual factors impacting healthy eating in this community.

Findings from prior interventions developed for AI populations have emphasized the importance of using community-based approaches and integrating historical, social and political contexts and cultural traditions, beliefs and values when adapting evidence-based interventions [28, 29]. Several successful nutrition education programs culturally adapted for AIs exist, including interventions that are part of the Special Diabetes Program for Indians [23, 42]. Community-engaged and participatory methods are common in the development and adaptation of community-based nutrition interventions to improve healthy eating behaviors among AI [43–46]. Similar to our findings, adaptations of these interventions often incorporate cultural elements, practices and values specific to a region or tribe into program materials [44–46]. However, traditionally the core elements of these interventions for AIs focus on promoting healthy diets without addressing the underlying contextual factors that influence dietary behaviors, such as lack of access to fresh foods. Furthermore, many of these programs focus on diabetes prevention; nutrition interventions for AIs already diagnosed with type 2 diabetes are not common outside of clinical settings [23]. Our work extends upon these prior interventions by understanding and identifying adaptations to a nutrition intervention based on the broader contextual factors that shape eating behaviors among AIs with type 2 diabetes and their families.

Some of our findings mirror those found in work by Stotz et al. regarding barriers and facilitators to healthy eating among AI/Alaskan Native adults with type 2 diabetes [47, 48]. Similar to our findings, in their formative work addressing socioeconomic barriers to healthy eating was a priority for participants, including eating healthy on a budget and in areas with limited access to healthy foods [47, 48]. Their participants also frequently mentioned the mental health impacts of living with type 2 diabetes [47]. Findings from one of these studies were used to adapt an American Diabetes Association intervention, ‘What Can I Eat? Healthy Choices for People with Type 2 Diabetes’, across four AI/Alaskan Native communities [47]. Our findings lend further support for adapting existing evidence-based interventions to address the unique social contexts and socioeconomic barriers in reservation communities. Furthermore, our findings extend their work in several ways. First, while Stotz et al. included images of Native people from the different tribal groups included in the study, we were able to include additional culture elements (songs, language and imagery) as we were working with only one study community [47]. Second, in Stotz et al., the modules addressing socioeconomic barriers were added on to the end of the existing intervention as optional lessons, whereas we adapted the entire Cooking Matters® curriculum to address contextual barriers to healthy eating such as food budgeting and meal planning when using FDPIR or SNAP [47]. Finally, methodologically speaking, our work articulates an established framework through which adaptation can occur and be made relevant for rural and resource-limited reservation contexts [47].

A limitation of this study is the small sample size. Additional participants may have yielded distinct or more nuanced findings. However, despite the small sample size, the study team felt saturation was reached as participant responses were consistent across the three focus groups and aligned with pilot study conversations with other community members and stakeholders involved in developing and implementing the intervention, increasing our confidence in the findings [12, 35]. Additionally, most participants reported living <5 miles from the town center in our sample. Their perspectives about barriers and facilitators to eating healthy may differ from individuals who live in more remote areas of the reservation as there is a grocery store in the town center. However, in our study many participants still struggled to access the local store regularly as they did not have access to a car, and public transit does not exist for the general population. Furthermore, the 10 small grocery stores on or around the reservation are spread out geographically, so even individuals who reside further from the town center likely have similar access to similarly sized and stocked grocery stores within driving distance of their home.

The adapted Cooking Matters® curriculum (called Cooking for Health) is currently being tested in a randomized controlled trial to test the adapted intervention’s effectiveness at improving diet quality and health outcomes in AI adults with diabetes [36]. Our ability to utilize community-engaged methods to make this intervention relevant for the study community is predicated on over three decades of relationship building with the tribe via the Strong Health Study [5, 12, 35, 36]. We believe this longstanding relationship with the community to be a major strength, which if effective, may improve the long-term sustainability of the intervention. For instance, the intervention videos developed as a result of the present study can be played at home, negating the need to travel to a central location. The videos are also designed to be asynchronous and downloaded, allowing participants to play the video at a convenient time and without requiring an internet connection. The study community is also involved in both implementation and evaluation—we are working closely with the Tribal Adult Diabetes Program and other local health programs to assist with recruitment and data collection, and all study staff are also community members [36]. We will be working with the study community to collect implementation and evaluation data on the adapted intervention, and future iterations of the intervention will be designed in partnership with the community.

Healthy eating and high-quality diets are critical to successful type 2 diabetes management and reduction in risk of diabetes-related complications, morbidity and mortality [49]. While educational interventions that address contextual barriers to healthy eating using culturally adapted content are essential to improving diet quality, additional multilevel strategies that address structural factors and the impact of colonization and forced relocation are critical to reducing the burden of diabetes among AI and promoting health equity. Based on our work with the study community, including the present study, examples of these interventions include changing the FDPIR program to allow twice-monthly pickup to maximize intake of whole fresh foods, allowing simultaneous enrollment in FDPIR and SNAP, increasing the monthly SNAP dollar amount allotted to households or working with food distributors and store owners to maximize variety and quality of healthy foods available an affordable prices [5, 12, 35]. While these more structural-level changes can face additional resistance and barriers to implementation, they are not unprecedented—FDPIR began offering traditional foods in 2008 and continues to make changes to ensure consistent provision of these traditional foods, as well as transfer control of purchasing to tribal organizations [50, 51]. Nationally, SNAP benefit amounts were temporarily increased in 2020 in response to the coronavirus (COVID-19) pandemic; in October 2021, US Congress made a 40-cents per-person per-meal increase permanent [52].

Regardless of the strategy, using community-engaged methods to identify and address these underlying contextual factors will continue to be a key component to reducing the burden of diabetes among AI and promoting health equity. Our use of Barrera and Castro’s framework—an established method for the cultural adaptation of existing interventions—to ground our study findings adds additional rigor and structure to the adaptation process and increases the likelihood of future intervention success [30, 31]. Qualitative research can help inform the context in which an intervention will be implemented and the specific intervention materials used. Other researchers may benefit from using this framework to guide the cultural adaptation of other evidence-based interventions in AI communities.

Additionally, working with the local community to adapt and implement the intervention can support shared responsibility and ownership of the study and facilitate continued partnership. If Cooking for Health is successful, the study team and Tribal Health Committee plan to work together to identify possible ways to continue the intervention, including potential broad adoption of the program for community members with diabetes through the Adult Diabetes Program or other local health programs. We also believe some of the core elements of Cooking for Health (e.g. use of videos, focus on healthy food preparation and storage) could be adapted for other rural and underserved settings. If successful, we plan to create a ‘toolbox’ with all study materials for use by other tribal communities interested in the intervention, maximizing the impact of this intervention on food security and diabetes in AI communities.

Funding

National Institute of Minority Health and Health Disparities at the National Institutes of Health (R01MD011596); National Heart, Lung, and Blood Institute postdoctoral fellowship (T32HL702842 to M.C.B., in part). The funders had no input or involvement in study design, collection, management, analysis and interpretation of data, writing and decision to submit for publication.

Conflict of interest statement

None declared.