Water (in)security and American Indian health: social and environmental justice implications for policy, practice, and research

Relationship Between Food Insecurity and Healthy Eating Behavior for Gestational Diabetes Risk Reduction Among American Indian and Alaska Native Adolescent and Young Adult Females: A Qualitative Exploration

OBJECTIVE

To understand the perspectives of key informant experts regarding the relationship between food insecurity and gestational diabetes mellitus risk reduction behaviors among young American Indian and Alaska Native females.

METHODS

Participants were adult key informants with expertise in food/nutrition and health within Tribal communities (N = 58) across the US. Data were collected through 1:1 interviews using a semistructured moderator guide and analyzed using thematic content analysis methods.

RESULTS

Three themes included (1) diet and nutrition habits are formed through intergenerational food preferences and are driven by lasting implications of colonization; (2) young people are influenced by what their peers eat and the food environment, including outside of the home; and (3) the methods used to understand household food insecurity and nutrition habits in the parent study were likely limited.

CONCLUSIONS AND IMPLICATIONS

Findings provide guidance as to where nutrition education and interventions may best support young Native females.

Relationship between food insecurity and a gestational diabetes risk reduction intervention: outcomes among American Indian and Alaska Native adolescent and young adult females

American Indian and Alaska Natives (AI/ANs) are disproportionately impacted by gestational diabetes mellitus (GDM), subsequent type 2 diabetes, and food insecurity. It is prudent to decrease risk of GDM prior to pregnancy to decrease the intergenerational cycle of diabetes in AI/AN communities. The purpose of this project is to describe and examine food insecurity, healthy eating self-efficacy, and healthy eating behaviors among AI/AN females (12-24 years old) as related to GDM risk reduction. Methods included: secondary analysis of healthy eating self-efficacy and behaviors, and household-level food insecurity measures from an randomized controlled trial that tested the effect of engagement in a GDM risk reduction educational intervention on knowledge, behavior, and self-efficacy for GDM risk reduction from baseline to 3-month follow-up. Participants were AI/AN daughters (12-24 years old) and their mothers (N = 149 dyads). Researchers found that more than one-third (38.1%) reported food insecurity. At baseline food insecurity was associated with higher levels of eating vegetables and fruit for the full sample (p = .045) and cohabitating dyads (p = .002). By 3 months healthy eating self-efficacy (p = .048) and limiting snacking between meals (p = .031) improved more in the control group than the intervention group only for cohabitating dyads. For the full sample, the intervention group had increases in times eating vegetables (p = .022) and fruit (p = .015), whereas the control group had declines. In the full sample, food insecurity did not moderate the group by time interaction for self-efficacy for healthy eating (p ≥ .05) but did moderate the group by time interaction for times drinking soda (p = .004) and days eating breakfast (p = .013). For cohabitating dyads, food insecurity did moderate self-efficacy for eating 3 meals a day (p = .024) and days eating breakfast (p = .012). These results suggest food insecurity is an important factor regarding the efficacy of interventions designed to reduce GDM risk and offer unique insight on "upstream causes" of GDM health disparities among AI/AN communities.

Respecting tribal voices in the development of a gestational diabetes risk reduction preconception counseling program for American Indian/Alaska Native adolescent females: a qualitative study

BACKGROUND

American Indians and Alaska Natives (AI/AN) are disproportionately affected by adolescent obesity, adolescent pregnancy and gestational diabetes mellitus (GDM). GDM is associated with increased risk for perinatal death, obesity, and subsequent type 2 diabetes (T2D) for the offspring. Moreover, mothers with GDM are also at increased risk for T2D post-partum. Yet few lifestyle interventions exist to reduce GDM risk prior to pregnancy. We describe the process of adapting an existing validated preconception counseling intervention for AI/AN adolescent girls at-risk for GDM and their mothers. Perspectives and recommendations were gathered from a diverse array of stakeholders to assure the new program called Stopping GDM was culturally responsive and developed with tribal voices and perspectives represented.

METHODS

We conducted focus groups and individual interviews with multiple AI/AN stakeholders (n = 55). Focus groups and interviews were digitally recorded, transcribed verbatim, and analyzed using a thematic content approach to construct cross-cutting themes across the focus groups and interviews.

RESULTS

Four key themes emerged reflecting issues important to planning a reproductive health intervention: 1) Limited awareness, knowledge, and health education resources about GDM; 2) The importance of acknowledging traditional AI/AN values and the diversity of traditions and culture among AI/AN tribes; 3) The need to cultivate healthy decision-making skills and empower girls to make safe and healthy choices; and 4) Lack of communication about reproductive health between AI/AN mothers and daughters and between AI/AN women and health care professionals.

CONCLUSION

Findings have been used to inform the cultural tailoring and adaptation of an existing preconception counseling program, originally designed for non-AI/AN adolescent girls with diabetes, for AI/AN adolescents at-risk for GDM in future pregnancies.

Implementing a Community-Led Arsenic Mitigation Intervention for Private Well Users in American Indian Communities: A Qualitative Evaluation of the Strong Heart Water Study Program

Arsenic is a naturally occurring toxicant in groundwater, which increases cancer and cardiovascular disease risk. American Indian populations are disproportionately exposed to arsenic in drinking water. The Strong Heart Water Study (SHWS), through a community-centered approach for intervention development and implementation, delivered an arsenic mitigation program for private well users in American Indian communities. The SHWS program comprised community-led water arsenic testing, point-of-use arsenic filter installation, and a mobile health program to promote sustained filter use and maintenance (i.e., changing the filter cartridge). Half of enrolled households received additional in-person behavior change communication and videos. Our objectives for this study were to assess successes, barriers, and facilitators in the implementation, use, and maintenance of the program among implementers and recipients. We conducted 45 semi-structured interviews with implementers and SHWS program recipients. We analyzed barriers and facilitators using the Consolidated Framework for Implementation Research and the Risks, Attitudes, Norms, Abilities, and Self-regulation model. At the implementer level, facilitators included building rapport and trust between implementers and participating households. Barriers included the remoteness of households, coordinating with community plumbers for arsenic filter installation, and difficulty securing a local supplier for replacement filter cartridges. At the recipient level, facilitators included knowledge of the arsenic health risks, perceived effectiveness of the filter, and visual cues to promote habit formation. Barriers included attitudes towards water taste and temperature and inability to procure or install replacement filter cartridges. This study offers insights into the successes and challenges of implementing an arsenic mitigation program tailored to American Indian households, which can inform future programs in partnership with these and potentially similar affected communities. Our study suggests that building credibility and trust between implementers and participants is important for the success of arsenic mitigation programs.

Metal(loid)s in Common Medicinal Plants in a Uranium Mining-Impacted Area in Northwestern New Mexico, USA

The objective of this study was to determine uranium (U) and other metal(loid) concentrations (As, Cd, Cs, Pb, Mo, Se, Th, and V) in eight species of plants that are commonly used for medicinal purposes on Diné (Navajo) lands in northwestern New Mexico. The study setting was a prime target for U mining, where more than 500 unreclaimed abandoned U mines and structures remain. The plants were located within 3.2 km of abandoned U mines and structures. Plant biota samples (N = 32) and corresponding soil sources were collected. The samples were analyzed using Inductively Coupled Plasma−Mass Spectrometry. In general, the study findings showed that metal(loid)s were concentrated greatest in soil > root > aboveground plant parts, respectively. Several medicinal plant samples were found to exceed the World Health Organization Raw Medicinal Plant Permissible Level for As and Cd; however, using the calculated human intake data, Reference Dietary Intakes, Recommended Dietary Allowances, and tolerable Upper Limits, the levels were not exceeded for those with established food intake or ingestion guidelines. There does not appear to be a dietary food rise of metal(loid) ingestion based solely on the eight medicinal plants examined. Food intake recommendations informed by research are needed for those who may be more sensitive to metal(loid) exposure. Further research is needed to identify research gaps and continued surveillance and monitoring are recommended for mining-impacted communities.

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

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.

Our Relationship to Water and Experience of Water Insecurity among Apsáalooke (Crow Indian) People, Montana

Affordable access to safe drinking water is essential to community health, yet there is limited understanding of water insecurity among Native Americans. Therefore, the focus of this paper is to describe Apsáalooke (Crow Indian) tribal members' experiences with water insecurity. For Apsáalooke people, local rivers and springs are still vitally important for traditional cultural activities. We interviewed 30 Native American adults living on the Crow Reservation in Southeastern Montana. Participants answered six open-ended interview questions about their water access, costs of obtaining water and changes in their domestic and traditional water uses. Participants emphasized how the use of water has changed over time and described the complex challenges associated with addressing water insecurity in their community, including the importance of considering the spiritual and cultural impacts of water insecurity on health. Water insecurity is a growing global problem and more attention and efforts are needed to find appropriate and affordable solutions.

Water and mental health

There is a well‐established connection among water quality, sanitation, and physical health. The potentially important relationship between water and mental health is considerably less studied. Reviewing evidence from ethnography, geography, folklore, indigenous studies, rural medicine, drought research, and large‐n statistical studies, we argue there is now good theoretical rationale and growing evidence of water insecurity as a possible driver of mental ill‐health. Furthermore, some nascent evidence suggests that emotionally meaningful interactions with water might improve mental health outcomes. Leveraging these literatures, we address the many ways in which mental health outcomes are conceptualized and operationalized in water research, including as emotional distress, perceived stress, depressive symptoms, anxiety symptoms, somatic symptoms, and quality of life. We outline arguments supporting seven possible (and likely interlocking) mechanisms that could explain such a relationship: (a) material deprivation and related uncertainty, (b) shame of social failure, (c) worry about health threats, (d) loss of connections to people and places, (e) frustration around opportunity losses and restricted autonomy, (f) interpersonal conflict and intimate partner violence, and (g) institutional injustice or unfairness. However, we explain that as most existing studies are ethnographic, qualitative, or cross‐sectional, a causal relationship between water and mental ill‐health is yet to be confirmed empirically. More research on this topic is needed, particularly given that poorly understood connections may create barriers to achieving Sustainable Development Goals 3 (health) and 6 (water). We further suggest that tracking mental health indicators may provide unique and as‐yet underappreciated insights into the efficacy of water projects and other development interventions.

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