Part 3: Researching Multi-component, Community-wide Interventions

[ Table of Contents ]

The following cases highlight how researchers are partnering with communities to explore interventions that employ a number of strategies and work across multiple levels to effect community-wide change and improve the health of disadvantaged populations.

Working with Communities and the Private Sector in the Canadian Arctic

The Healthy Foods North project highlights a multilevel (individual, household, community and environment) intervention research project in Inuit and Inuvialuit communities in Nunavut and the Northwest Territories. Using a mixed-method approach to evaluate the impact of the intervention, this project demonstrates the value of partnering with community members, decision makers and private businesses and the value in implementing food store-based and community-based activities to support individual nutritional and lifestyle change.

Case 6 – The Healthy Foods North nutrition and lifestyle intervention program: a community- and evidence-based intervention program among Inuit and Inuvialuit communities in Arctic Canada

Sangita Sharma, Endowed Chair in Aboriginal Health and Professor of Aboriginal and Global Health Research, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB
Erin Mead, PhD student, Department of Health, Behavior, and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
Joel Gittelsohn, Professor, Center for Human Nutrition, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
Lindsay Beck, Community Health Science MSc student, University of Northern British Columbia, Prince George, BC
Cindy Roache, Department of Health and Social Services, Government of Nunavut (at the time of research)

Corresponding author: Sangita Sharma, gita.sharma@ualberta.ca

Introduction

Healthy Foods North (HFN) is a novel, multilevel health intervention program to address the growing public health and societal burden caused by the nutrition and lifestyle transition among Aboriginal Arctic populations in Canada (Sharma, 2010). The aims of the HFN nutrition and lifestyle intervention program are to reduce the risk of obesity and chronic disease, improve dietary adequacy and increase physical activity. Achieving good nutritional status and moderate to high levels of physical activity is important for the prevention of chronic diseases as well as infectious diseases that an immune system compromised by poor nutrition cannot easily prevent or cure. Previous interventions targeting Aboriginal Arctic populations often do not follow a population health intervention approach and largely consist of mass media programs that have been adapted from programs in southern Canada.

This innovative program was developed to address complex public health problems and their underlying factors. Through primary prevention, HFN aimed to reduce the disproportionately higher burden of many diseases among Inuit and Inuvialuit (Sharma, 2010), thus contributing to greater health equity. Support from the community for the program was key to ensuring both the development and implementation of the program was culturally appropriate, effective and sustainable. To obtain support, partnerships were created with community stakeholders, community members participated in the formative phase to develop the intervention, and community members were trained to implement research and intervention activities (Gittelsohn et al., 2010). As a result, Aboriginal peoples, organizations and communities may develop a more positive view of evidence-based research that contributes to improving health.

Project description and lessons learned

Healthy Foods North addresses six critical areas for health promotion in Arctic communities:

  1. Creating an evidence- and community-based, culturally appropriate, rigorously evaluated and sustainable intervention
  2. Providing up-to-date dietary, anthropometric and physical activity data, for example, evidence on which to base a program
  3. Creating population-specific methodologies for monitoring changes in diet
  4. Building local capacity for health promotion intervention development and evaluation with the communities
  5. Creating a bridge for partnership between the private sector (food retailers, airlines, shipping companies), communities, government and academia
  6. Sharing results at the community level in culturally appropriate formats (such as posters and presentations) and having community champions present results locally and nationally

HFN's formative research phase combined quantitative and qualitative methods to determine needs and preferences of the populations and to provide a context for understanding food and physical activity decision making (Sharma et al., 2009, Sharma et al., 2010, Gittelsohn et al., 2010). The intervention, its messages and materials were based on social cognitive theory and social ecology frameworks for behaviour change, collaborations between partners, 24-hour dietary recalls with randomly selected Inuit/Inuvialuit adults to characterize the diet, and in-depth interviews. We also held two-day participatory community workshops in the four Nunavut and Northwest Territories communities that would become the intervention communities (Gittelsohn et al., 2010). Selected via purposive sampling, workshop participants were community stakeholders, including elders, community leaders, community health program representatives, store managers and other community members. They identified the problem foods in their communities, healthier and appropriate alternatives, key messages and themes for the intervention, and avenues to deliver the messages.

Working at environmental, community, household and individual levels, HFN has two main components: food store-based activities and community-based activities (Sharma, Gittelsohn, Rosol & Beck, 2010). Store-based activities include increased stocking of healthy foods, interactive educational sessions (for example, food tasting), shelf labels, displays and posters. The messages conveyed in the sessions are reinforced through giveaways and handouts. Community-based activities include cooking classes, pedometer challenges, walking clubs, community feasts, radio stories and partnering with other local health programs. Local, trained community staff conducted all activities. The pilot intervention was implemented over 12 months from 2008-2009 in two Inuit communities in Nunavut and two Inuvialuit communities in the Northwest Territories.

Dietary, behavioural, physical activity and anthropometric data were collected from Inuit and Inuvialuit respondents pre- and post-intervention in the four intervention and two delayed-intervention communities to evaluate impact. Preliminary significant findings of the impact evaluation include decreased intake of energy and carbohydrate, increased density of select nutrient intake, and a 2.6 percent decrease in average body mass index after controlling for age, gender, socioeconomic status and intervention group assignment. These changes may be attributable to HFN's promotion to replace foods and beverages low in nutrients and high in fats and sugars with traditional foods, fruits, vegetables, and low-sugar beverages as well as facilitating an increase in physical activity. For example, preliminary significant findings from the impact evaluation indicate an increase in traditional meat consumption and decrease in high-fat, store-bought meat consumption. Self-efficacy and intentions to engage in healthier dietary behaviours also increased. From the formative phase through intervention evaluation, more than 700 people in the communities completed questionnaires or interviews (Sharma, 2010, Sharma et al., 2009, Sharma, Gittelsohn et al., 2010) and approximately 60 worked on the project.

One of the biggest challenges to implementing any research or intervention in the Arctic is the remoteness of the locations, which poses considerable logistical and personnel obstacles. In addition, many communities do not have health programs that foster partnerships across organizations, particularly with the private sector. In the case of HFN, initial researcher, community and government collaborations started to build essential partnerships, infrastructure and capacity for a multi-component, multilevel program four years before actual intervention implementation. A partnership with the private sector is a key factor for a program such as this, and the food retailers, as well as other organizations and businesses (for example, research institutes, airlines) were supportive and invested in the program. Our experiences highlight the need for comprehensive and consistent communication between all program stakeholders and partners throughout all phases of development, implementation and evaluation. Engaging stakeholders along the way helped to ensure expectations were being met and key lessons learned were being disseminated.

Implications for research, policy and practice

HFN acted as a bridge between directed research and evidence-based decision making. All partners of HFN played a vital role in its success: communities and Aboriginal organizations provide essential knowledge of societal values in relation to health and championing of the approach; academic partners provide essential expertise in research methods and intervention design; governments facilitate overall coordination of the project, particularly in engaging relevant partners from a policy perspective (that is, community health programmers); and the private sector, particularly food retailers, contribute essential expertise in the areas of Northern food transportation systems, in-store marketing and promotions, and product supply decision making.

At every stage of the program, results were shared with the partners and stakeholders, providing them with the opportunity to use data to improve health services and population health programming. For example, the preliminary evaluation results were presented to the federal and territorial governments. Communities were given the results on traditional food consumption and the important contributions these foods make to ensuring people receive sufficient nutrients, which was one of the communities' major priorities.

In addition, retailer, community member, government staff and academic partners presented HFN results at an international congress. Furthermore, community members and government partners had input into the research and intervention. For example, traditional values identified by the workshop participants were incorporated as family motifs and also formed the basis of entire phases in the intervention (that is, a country foods phase). The intervention staff were community members themselves and helped in the ongoing refinement of intervention activities. Extensively sharing results and information, as well as providing support among all project partners, is essential in celebrating success and keeping up the momentum. Results are currently being provided to the communities.

HFN has been incorporated into public health policy at the territorial and community levels, including the Nunavut Nutritional Framework For Action and Developing Healthy Communities: A Public Health Strategy for Nunavut and the NWT Foundation for Change Action Plan 2009-2012, with much more to be done with such positive results. By bringing together such diverse information and partners, HFN has the potential to act as a springboard to innovative health system decision making.

The HFN approach of involving all stakeholders in an open and innovative process can be generalized to a number of health systems and community settings, particularly in Aboriginal and remote and isolated communities. HFN started originally in Nunavut, and the Northwest Territories component was added with relative ease, highlighting the ability to utilize the framework and approach in new settings. The communications and community level activities were designed with extensive community input, and communities have subsequently asked to use the communications tools and overall program design to address other public health issues such as smoking. Valuable results, such as typical portion sizes for a variety of foods, will be available for clinicians to use for individual treatment, counseling and population health programming design. From an ethical perspective, HFN considered the broad sustainability of the program and the appropriateness, such as using foods that were readily available, easy to obtain and affordable.

Community stakeholders may have different priorities than researchers, which must be incorporated into program development and implementation. Community members serving as program staff and peer educators were a key element of success, though high turnover was a challenge indicating, perhaps, a need for more job flexibility. Members of the community played a significant role in moving research findings into practical and culturally relevant program development and implementation. By training community members to conduct research and intervention activities, academia shared knowledge with communities and other stakeholders, ultimately building capacity and hopefully strengthening the overall performance of the health care system from community, regional and territorial perspectives.

Given the strong focus on community involvement and the value attributed to Inuit and Inuvialuit culture and norms throughout the program's development, the evidence and lessons learned are potentially applicable to other Inuvialuit and Inuit communities. Moreover, the HFN program and research design can complement programs that tailor to specific community contexts, especially in Aboriginal communities. HFN may become a model of sustainable health promotion programming and population health intervention research that makes nutrition and lifestyle education culturally appropriate while improving Aboriginal health. Future population health intervention research initiatives have the potential not only to improve health at the local community level, but also to generate policy changes for broader population health.

For more information on the pre-intervention results, please refer to the publication.

Acknowledgements

Healthy Foods North (HFN) would like to express sincere thanks to all of the individuals, organizations, communities, hamlet councils, health committees and food shop managers that played an essential role in developing and implementing HFN in Nunavut and the Northwest Territories—especially Ms. Elsie De Roose, Ms. Renata Rosol, and the numerous members of the HFN teams in Nunavut and the Northwest Territories. We are grateful to the Aurora Research Institute and Beaufort Delta Health and Social Services Authority for their support. We thank all participants in the communities where this research was conducted, as well as the tirelessly dedicated project coordinators, community staff, research staff and invaluable supporters, without whose help this project would not have been possible. The project received funding or support from the American Diabetes Association Clinical Research Award Grant # 1-08-CR-57, Government of Nunavut Department of Health and Social Services, Government of the Northwest Territories Department of Health and Social Services, The Northwest Territories and Nunavut Public Health Association, Health Canada, and the Public Health Agency of Canada.

References

Gittelsohn, J., Roache, C., Kratzmann, M., Reid, R., Ogina, J., & Sharma, S. (2010). Participatory research for chronic disease prevention in Inuit communities. American Journal of Health Behavior 34 453-464.

Sharma, S. (2010). Assessing diet and lifestyle in the Canadian Arctic Inuit and Inuvialuit to inform a nutrition and physical activity intervention programme. Journal of Human Nutrition and Dietetics 23 (Suppl. 1) 5-17.

Sharma, S., Cao, X., Roache, C., Buchan, A., Reid, A., & Gittelsohn, J. (2010). Assessing dietary intake in a population undergoing a rapid transition in diet and lifestyle: the Arctic Inuit in Nunavut, Canada. British Journal of Nutrition 103 749-759.

Sharma, S., De Roose, E., Cao, X., Pokiak, A., Gittelsohn, J., & Corriveau, A. (2009). Dietary intake in a population undergoing a rapid transition in diet and lifestyle: The Inuvialuit in the Northwest Territories of Arctic Canada. CJPH 100 442-448.

Sharma, S., Gittelsohn, J., Rosol, R., & Beck, L. (2010). Addressing the public health burden caused by the nutrition transition through the Healthy Foods North nutrition and lifestyle intervention programme. Journal of Human Nutrition and Dietetics 23 (Suppl. 1) 120-127.

Partnering Across Research, Policy and Practice

The KidsFirst evaluation project showcases a partnership between researchers, program planners and government representatives developed to evaluate the effectiveness of an intervention for at-risk children. It demonstrates a mixed method and partnership approach to program evaluation and explores the value in an intervention that acts at individual, family and community levels to support changes in at-risk communities.

Case 7 – Early childhood intervention in the community… makes sense, but does it really work? Findings from our three-year collaborative study

Fleur Macqueen Smith, MA, University of Saskatchewan, Saskatoon, SK
Nazeem Muhajarine, PhD, University of Saskatchewan, Saskatoon, SK
Hongxia Shan, PhD, University of Saskatchewan, Saskatoon, SK
Darren Nickel, PhD, University of Saskatchewan, Saskatoon, SK
Healthy Children Research Team, Saskatchewan Population Health and Evaluation Research Unit, University of Saskatchewan, Saskatoon, SK, on behalf of the KidsFirst Evaluation Research Team*

Corresponding author: Fleur Macqueen Smith, fleur.macqueensmith@usask.ca

Introduction

KidsFirst is a provincial government population health intervention aimed at vulnerable children and their families that is administered locally in nine at-risk Saskatchewan communities. It uses intensive home visiting to build capacity in families, promote healthy child development and facilitate goal achievement for parents (such as returning to school or finding a job). KidsFirst also connects families with mental health and addiction services as well as early learning and childcare programs.

Our research team recently completed a three-year evaluation to determine the effectiveness of KidsFirst, using an integrated knowledge translation approach in which decision makers were engaged throughout the research process (select "KidsFirst" from the Projects menu on the left). This project is an example of community-based intervention research; it brought together researchers (from community health and epidemiology, social work, economics, political science and nursing), program managers from KidsFirst and government policy makers (from education, health, social services and First Nations and Métis relations) to ensure that the knowledge generated from evaluation was translated into program improvements.

KidsFirst addresses health equity by targeting families most in need to improve children's well being and family functioning. It also focuses and intervenes on upstream factors that determine child health and development, and strengthens the community as a whole. Our evaluation is of practical value both to the program and other early childhood intervention activities because it:

  1. focuses on child development in vulnerable families, a topic that has attracted worldwide attention (Keating & Hertzman, 1999)
  2. integrates findings from the application of multiple methods (Muhajarine et al., 2010)
  3. is driven by a clear framework, developed in collaboration with program staff (Muhajarine et al., 2010)

Project description and lessons learned

This project was initiated when the director of the government unit responsible for KidsFirst approached the principal investigator, Dr. Nazeem Muhajarine, as a result of his previous work in establishing program goals and objectives and his well-respected body of work in children's health research and knowledge translation. Subsequently, Dr. Muhajarine was able to secure external funding through a peer-reviewed process and assemble a team of researchers and decision makers to conduct the evaluation.

Between 2007 and 2010, the team used mixed methods to assess the program's effectiveness in helping participating families and communities make positive changes. The team started by constructing an evaluation framework collaboratively with program staff, and developing a background paper. It then conducted quantitative and qualitative studies to assess the short-term effects of the program and how these effects were produced. While the team developed the research questions in collaboration with program managers, researchers who had no control over program operation or design completed the methods and data interpretation. As well as receiving ethical approval from the University of Saskatchewan, the study also received approval from the health regions at each of the nine program sites.

For the quantitative study, the team analyzed routinely collected program data to assess family functioning and child health and development. It also employed a control group and analyzed vital statistics and health care utilization data representing adverse birth and health care outcomes. For the qualitative study, the team conducted 84 interviews and 27 focus groups with 242 adult program clients, program staff and government officials to reveal practices and processes contributing to positive child health outcomes.

Findings suggest that KidsFirst can help ensure that children in very vulnerable circumstances are nurtured by healthy, well-functioning families. Key activities included working with parents to enhance their knowledge and assertiveness; addressing families' basic needs such as helping them access food, transportation and services; and integrating families into their communities by connecting them to services, organizing social events and helping clients re-enter school or the job market. Program managers found that they served families better when they forged collaborative relationships with other organizations in their communities that worked with the same clients. Participants in the qualitative study reported that many parents have received mental health and addiction services because of KidsFirst.

Despite these successes, the team found that the program struggles to find sufficient human resources and staff capacity to serve the complex needs of some families. Typically, this problem arises with families that experience cyclical crises such as mental health and addiction issues, that cope with fetal alcohol spectrum disorder (their own and that of their children), and that are transient and homeless.

The geographical distances separating partners and the differing views that partners had of the research meant that a concerted effort was required for the academic researchers to maintain contact, constant diligence was needed to avoid misunderstanding, and good faith and discussion were essential to work through the issues that arose. It was also challenging to evaluate a program that did not have the infrastructure for systematic and continuous evaluation. Although considerable program data are continuously collected, there were issues with quality, reliability, completeness and relevance, leading the team to recommend a thorough review of existing data-collection procedures. The team also recommended that data would be more meaningful with the addition of audit and quality-control procedures (Muhajarine, Glacken, Cammer & Green, 2007).

Implications for research, policy and practice

Our experience demonstrates that community-based intervention research can be a unifying process, bringing together researchers, program managers and government policy makers. Effective population health intervention research is founded on the principle of collaboration among those who design and implement the programs, as such individuals can put the knowledge generated during an evaluation into policy and practice to improve the program. Ideal partners for this type of research are those who are committed to fully participating in the early phases of the study and are then committed to acting on the independent evidence produced.

Following a day-long meeting to jointly develop a program logic model and evaluation framework, researchers met every few months with program managers and staff from the government unit responsible for KidsFirst. In between these meetings, the principal investigator and research staff interacted regularly with these same partners by phone and email. Researchers also interacted in the early stages of the project with an advisory committee of government officials representing the four ministries involved in KidsFirst. A follow-up advisory committee meeting to discuss results and recommendations emerging from the research has yet to be held.

Throughout the evaluation, the team shared its findings through conference presentations and publications for provincial and national audiences. To facilitate the uptake of research findings, the team also produced a range of jointly authored reports including an evaluation framework, site profiles, home visiting literature review, quantitative and qualitative reports, summary of findings and recommendations, and site-specific reports. The team disseminated electronic and paper copies of these reports and posted them online. The team also distributed these reports to 90 stakeholders from across the province who attended a day-long meeting to discuss and provide feedback on project findings. After this meeting, the team revised the final reports based on the feedback we received and redistributed them. Additional knowledge transfer activities with specific sites are planned for the future as a result of additional funding we have received.

The team's findings suggest that program staff needed to achieve strong relationships with their clients before the clients would be receptive to new information, try new ways of parenting or interact with other members of the community. These findings were corroborated through a literature review of home visiting programs. The team believes these findings can be generalized to other kinds of intervention programs. With robust research evidence to support it, trust and relationship building should be considered an essential practice for community-based service providers who are working with vulnerable populations.

Despite the collaborative nature of the evaluation, and a high level of interaction with decision makers, it is difficult to know if this evaluation will promote large-scale policy change at the provincial level. It is more likely that community practices will change, and small-scale policy changes may be introduced. As researchers, the team was situated between community practitioners and advocates, who were managing the program on the ground, and government representatives with provincial responsibility, a situation that was occasionally challenging due to differing opinions about how the program should be implemented, managed and evaluated.

As is widely acknowledged, relationship building is integral to working effectively with decision makers. That said, researchers cannot compromise the strength and relevance of the research they conduct to appease decision makers; research needs to be both highly valid and highly policy relevant to have the best chance of improving policy and practice (Martens & Roos, 2005). Finally, the team's advice to others is to try not to get discouraged; while working this way is much harder than conducting researcher-driven studies, it can also be more energizing, and much more likely to make a difference.

Acknowledgements

*Members of the KidsFirst Evaluation Research Team include: Nazeem Muhajarine (PI), Gail Russell (Director, Early Childhood Development Unit, Ministry of Education, Saskatchewan), David Rosenbluth (Director of Evaluation, Ministry of Social Services), and SPHERU faculty members Angela Bowen, Jody Glacken, Kathryn Green,Bonnie Jeffery, Thomas McIntosh, Nazmi Sari, post-doctoral fellow Hongxia Shan, and research staff: Darren Nickel, Fleur Macqueen Smith, Robert Nesdole, Kristjana Loptson, Shainur Premji, Hayley Turnbull, Taban Leggett, Kathleen McMullin and Julia Hardy, and students Jillian Lunn, Karen Smith, Vince Terstappen, David Climenhaga, Brayden Sauve and Curtis Mang.

This evaluation was funded by the Canadian Population Health Initiative – Canadian Institute for Health Information (quantitative study), the Government of Saskatchewan (evaluation framework and qualitative study), MITACS, and the College of Medicine at the University of Saskatchewan (funding for research assistants).

References

Keating, D.P., Hertzman, C., (Eds.). (1999). Developmental health and the wealth of nations: Social, biological, and educational dynamics. New York, NY: Guilford Press.

Martens, P.J., & Roos, N.P. (2005). When health services researchers and policy makers interact: Tales from the tectonic plates. Healthcare Policy, 1(1), 72-84.

Muhajarine, N. et al. Saskatchewan KidsFirst Program Evaluations: Summary of Findings and Recommendations; Report of the Quantitative Study; Report of the Qualitative Study. Retrieved from the kidSKAN website.

Muhajarine, N., Glacken, J., Cammer, A., Green, K., & the KidsFirst Evaluation Team. (2007). KidsFirst program evaluation: Phase 1. Evaluation Framework. Retrieved from the kidSKAN website.

Empowering Communities to Support School Nutrition

This project involves collaboration between academic and First Nations communities to implement school-based nutrition interventions and improve access to quality healthy diets. It highlights the factors that support sustainable change in remote settings, including comprehensive program design and provision, supportive infrastructure such as modified school curricula and policies, greenhouse gardens, funding, and local champions and volunteers.

Case 8 – School nutrition programs in remote First Nations communities of the western James Bay region: impact, challenges and opportunities

Rhona Hanning, RD, PhD, Associate Professor, Department of Health Studies and Gerontology and Propel Centre for Population Health Impact, University of Waterloo, Waterloo, ON
Kelly Skinner, MSc, MPH, PhD Candidate, University of Waterloo, Waterloo, ON
Michelle Gates, RD, MSc, PhD Candidate, University of Waterloo, Waterloo, ON
Allison Gates, RD, MSc, PhD Candidate, University of Waterloo, Waterloo, ON
Len Tsuji, DDS, PhD, Professor, Department of Environment and Resource Studies, University of Waterloo, Waterloo, ON

Corresponding author: Rhona Hanning, rhanning@uwaterloo.ca

Introduction

Aboriginal Canadian children living in remote, northern First Nations communities are at high risk for unhealthy diets, due largely to low socioeconomic status and reduced access to healthy foods. The result can be malnutrition, which contributes to a high prevalence of obesity and chronic disease that can burden this population.

We attempted to obtain community-specific information about children's and adolescents' food intake to address this population health problem. We initially worked with the Western James Bay First Nations to tailor, validate and implement the University of Waterloo School Web-based Eating Behaviour Questionnaire. The results identified alarmingly high rates of obesity and low diet quality. To identify opportunities for change, we employed a collaborative, community-driven approach based on a foundation of trust, equity and respect among community and academic partners (Skinner, 2006). School nutrition programs were seen as a feasible and desirable intervention to improve the health of this vulnerable population.

Our objectives were to develop and implement three distinct, school-wide nutrition programs in Fort Albany, Kashechewan and Attawapiskat First Nations in Ontario and evaluate their impact on student food intake. We also wanted to describe what worked or could be improved from the perspectives of community stakeholders. Ultimately, the goal of the research was to empower community members and support sustained approaches to reduce inequities in nutrition and health in remote First Nations communities. Although the primary relevance of this work is for the communities involved, by underscoring the perceived program and community-level barriers, we hope also to influence key decision and policy makers to take appropriate action to reduce health inequities in Aboriginal communities.

Project description and lessons learned

Between 2004 and 2010, we developed and implemented programs based on social cognitive theory to improve students' diets. We provided healthy foods at school and, in some programs, through school food policy, student curriculum and parent/community education. Academic partners helped to plan the programs; provided seed funding; trained community assistants in program implementation, menu planning, food purchasing and grant writing; supported curriculum intervention; and coordinated program evaluations. Members from the school, health unit and the community-at-large were included on each community project advisory committee. However, Band Council involvement was generally at arms length (letters of support for funding applications, awareness of the project, receipt of school feedback reports). This participatory approach was fostered through the ongoing presence of academic partners and students in the communities.

Our project-related interactions with advisory committee members and their networks and workplaces further solidified community support. Long-term commitment and presence of the same researchers (that is, continuity) is of utmost importance when undertaking community-based research, especially in Aboriginal communities. Although we incorporated formal project knowledge exchange activities to further nurture this relationship, our informal interactions with community members during shopping and other daily activities was probably even more important than the formal interactions. Community support is not garnered in a day and must be nurtured over time.

We assessed changes in food and nutrient intakes for grade 6 to 10 students using the University of Waterloo School web-based Eating Behaviour Questionnaire, which incorporated a 24-hour recall adapted to include local traditional foods as well as photos for portion estimation, questions on food frequency and knowledge, self-efficacy and intention questions adapted from the Pro Children questionnaire (De Bourdeaudhuij et al., 2005). We assessed process and impact evaluations from case documentation, interviews and focus groups with students, teachers and community members, and analyzed them thematically. The study was approved by the Office of Research Ethics, University of Waterloo and passive parental consent for student participation was adopted at the request of project advisory committees in each community. There were no refusals in response to parent information letters; the reduced family burden of passive versus active consent likely supported the high response rates.

Results showed that programs varied from high functioning (comprehensive design, daily food provision, modified curricula and policies, and a greenhouse garden) enabled through sustained funding and a local champion, to low functioning (inconsistent provision of snacks) due to inadequate funding, poor infrastructure and a lack of volunteer support. During focus groups conducted post-program, community members expressed pride in their programs. Teachers remarked on improved classroom behavior on days when food was provided, including increased alertness, motivation and attentiveness. Students enjoyed the foods and interactive lessons and increased their exposure to and preferences for new food choices. Diet surveys showed that, in the short term, participants' intakes of food groups emphasized within the programs, and those foods' respective nutrients, were significantly increased. However, at long-term follow-up, significant improvements were not sustained in spite of students' improved knowledge (where curriculum was incorporated) and intentions to eat healthier. Moreover, overall diet quality remained dominantly within the 'needs improvement' range. The lack of sustained benefit related, in part, to reduced program integrity due to limited resources.

Implications for research, policy and practice

Our research adds to literature showing the prevalence of overweight and obesity as higher, and diet quality poorer, in Aboriginal children and adolescents than in the general population. It demonstrates that school nutrition programs can positively affect the eating behaviour of vulnerable children living in remote Ontario First Nations communities under ideal conditions and, ultimately, promote health equity. However, there are numerous barriers.

School nutrition programs in remote, isolated communities have high needs for resources, including funding, food, personnel and infrastructure if they are to have a sustained effect and reduce health inequities. While the research team provided seed funding and grant writing assistance, external grants were insufficient to meet high local food costs. Unlike in urban communities, fundraising is also insufficient, particularly because there are few local businesses with which to partner. Financial support provided through First Nations Band Councils was inconsistent due to competing priorities.

The limited availability of healthy food in community stores was a huge constraint. The only school to consistently meet policy guidelines for acceptable healthy foods and beverages chartered an airplane to deliver outside food. In a remote setting, the logistics of obtaining, storing, preparing and serving sufficient quantities of healthy food for up to 400 students can be incredibly challenging.

Most school nutrition programs do not provide funds for personnel, so volunteer coordinators are required. Only one of the three communities had a long-standing school nutrition champion and in that community a high functioning program has evolved over years. In the two other communities, it was more difficult to identify a school nutrition program volunteer and, when one was identified, that person was not consistently available. Although these schools were very supportive, they often struggled with staffing needs and could not meet program demands.

These schools operated out of portable classrooms; facilities for food and beverage preparation, delivery and storage were minimal and, in some cases, non-existent. Yet even suboptimal programs are perceived to offer benefit for many children who come to school hungry.

Programs and materials must be tailored to meet the needs of specific populations. In the community where an educational component was initiated, curriculum needed to be adapted to children's learning styles, which favoured interactive lessons such as food preparation or taste testing. In addition, lessons had to accommodate limited learning resources, a wide range of literacy levels in students, students with special needs, and variable school attendance related to absenteeism and community-level challenges (for example, flooding and H1N1). Although findings from one community can inform new projects and programs, the individual nature of each First Nations community, even among those in close proximity, means that separate relationships must be forged, and interventions and methods tailored to each community.

Research and knowledge translation are enhanced by active participation of research partners and community members. Our research benefitted from close, long-standing relationships between the research team and First Nations communities. However, this aspect of our research has also been challenging due to the high cost of transportation to remote communities and the expense of long visits. We used numerous knowledge translation strategies, including written and electronic reports sent to the First Nations Band Council, Health Unit and school, community newsletters, and radio and newspaper articles. The dissemination strategies achieving the best reach and visibility have been in-person meetings and healthy community feasts. At one such feast prepared by the research team and local students, more than 12 percent of the community attended and readily participated in brief surveys to evaluate parental perceptions of the school nutrition program and in a raffle for healthy foods that are not always locally accessible.

From our experience, the keys to success in First Nations school nutrition interventions are sustained and sufficient funding, consistent volunteer support or paid personnel (preferably a local program champion), adequate facilities to prepare, store and distribute food, and consistent access to healthy food. Despite the challenges and barriers that we have described, students, teachers and parents valued the programs. There is great potential for school nutrition programs to positively impact the dietary intake and health of First Nations children. These programs continue to address approaches to assess and improve the situation regarding food insecurity. The work also includes school-based intervention and support for sustainable access to healthy and traditional foods. The authors hope these research findings will help support local needs and spur systemic action to address inequities.

Acknowledgements

We acknowledge with gratitude the students of Fort Albany, Kashechewan and Attawapiskat First Nations and the support of George Combden, Bob Salvisburg, Joan Metatawabin, Ruby Edwards-Wheesk and Stella Wesley. Funding was provided through the Canadian Institutes of Health Research, Rx & D, Danone Institute of Canada, the Canadian Foundation for Dietetic Research and the Heart and Stroke Foundation of Ontario.

References

Skinner, K., Hanning, R.M. & Tsuji, L.J.S. (2006). Barriers and supports for healthy eating and physical activity for First Nation youths in northern Canada. International Journal of Circumpolar Health 65(2) 148-61.

Hanning, R.M., Royall, D., Toews, J., Blashill, L., Wegener, J. & Driezen, P. (2009). Web-based food behaviour questionnaire: Validation with grades six to eight students. Canadian Journal of Dietetic Practice and Research 70(4)172-8.

De Bourdeaudhuij, I., Klepp, K.-I., Due, P., Perez Rodrigo, C., de Almeida, M.D.V. Wind, M et al. (2005). Reliability and validity of a questionnaire to measure personal, social and environmental correlates of fruit and vegetable intake in 10-11-year-old children in five European countries. Public Health Nutrition 8(2) 189-200.

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