Johns Hopkins University Press
Abstract

Indigenous peoples experience a disparate burden of chronic diseases and lower access to health education resources compared with other populations. Technology can increase access to health education resources, potentially reducing health inequities in these vulnerable populations. Although many Indigenous communities have limited access to the Internet, this barrier is decreasing as tribes and Indigenous-serving organizations work to improve TechQuity. Using Arksey and O'Malley's framework, we conducted a scoping literature review to identify technology-based health education interventions designed for Indigenous adults. We searched multiple databases, limiting papers to those written in English, describing interventions for participants 18 years of age or older, and published between 1999–2020. The review yielded 229 articles, nine of which met eligibility criteria. Findings suggest a paucity of technology-based health education interventions designed for Indigenous peoples and limited testing of the existing resources. Future health disparity research should focus on development and rigorous testing of such interventions.

Key words

Indigenous, technology-based health education, scoping review [End Page 318]

Indigenous peoples across the world are disparately affected by chronic diseases such as diabetes,1 obesity,2 and cardiovascular disease.3,4 Furthermore, Indigenous populations experience limited access to health education resources and support.513 Many of the chronic diseases that Indigenous people experience can be effectively prevented and managed with health education.1417 In the United States and North America, Indigenous peoples, including American Indians, Alaska Natives, and Native Hawaiians, experience inequitable access to quality clinical health education services from health care professionals because of barriers such as transportation, lack of child and elder care, and limited availability of culturally responsive health care opportunities for those who live in urban areas.18 Health care systems that serve Indigenous peoples in multiple countries are widely acknowledged to be underfunded.1922

As supported by the Social Ecological Framework, an individual's health is influenced by individual factors, such as health-related knowledge and behavior, as well as factors at the interpersonal, organizational, community, and policy levels.23 Indigenous peoples are disproportionately affected by health disparities due largely to community-level determinants of health.24,25 For example, limited access to healthful food, safe places to engage in physical activity, clean water and air, and high-quality housing challenge Indigenous peoples' ability to prevent and manage chronic disease.2629 Limited access to health care services and health education resources may play a pivotal role in the health of Indigenous people.6,2022 Further, though the United Nations has declared access to the Internet a human right,30 Indigenous peoples often experience limited access to reliable Internet service as a community-level barrier associated with health inequities.

Use of telehealth, defined as a synchronous modality using telephone or video conferencing technology to provide health care and health education remotely, has grown over the last several years among Indigenous communities.3136 Given the effects of COVID-19 social-distancing recommendations on group-based health education classes, never before has there been such a compelling need to offer technology-based, distance/remote, online health education resources, especially for at-risk adults. Health care providers are increasingly relying on technology-based health care and education services to comply with social distancing safety guidelines. COVID-19 has affected Indigenous communities in the U.S. at disparate rates,37 and many of the adults who live in these communities have pre-existing health conditions that increase their susceptibility to the devastating consequences of COVID-19 infection.38 In order to better serve Indigenous communities with evidence-based and research-tested health education interventions, it is crucial to consider improving and expanding on innovative technology-based interventions for Indigenous communities.

Technology has the potential to make health education resources more widely available.3941 Access to the Internet was once considered a barrier to the feasibility of online health education resources for Indigenous peoples in the United States. However, American Indians and Alaska Natives (AI/AN) have increasing access to the Internet through low-cost Internet-accessing devices (e.g., smartphones and tablets), expanding public WiFi availability (e.g., clinics, libraries, retail stores), more affordable data plans,42 and concerted efforts among Indigenous-serving organizations to improve this access.43 In some AI/AN communities, efforts are being made to overcome persistent [End Page 319] telecommunication barriers through the extension of broadband networks and coverage to traditionally underserviced areas.44 Data suggest that approximately half of AI/ANs now have broadband access,45 and the majority of these individuals connect primarily through smartphones and live in urban areas.46 Yet, the digital divide continues to affect AI/ANs who live in rural reservation areas that do not provide broadband access.47 Specifically, 41% of American Indians living on tribal lands lack broadband access, and 68% of those living in rural areas of tribal lands lack broadband access.48 A 2017 report suggests only 24% of Indigenous peoples in Canada have Internet access,49 and other studies indicate that Indigenous Australians also lag behind non-Indigenous Australians in access to the Internet.50,51 It is difficult to accurately report Internet access among Native Hawaiians as these data are often aggregated with Pacific Islanders and even more broadly with Asian Americans. In Hawaii, 84% of households have broadband Internet access, but this is significantly lower among those households with less household income, and Native Hawaiians are disproportionately represented among low-income households.52 Trends suggest that access to the Internet and Internet-accessing devices is likely to improve in Indigenous communities just as it has among people who live in developing nations in general.53

Use of online health education programs tailored for Indigenous adults is a relatively new area of research. However, needs assessments and qualitative exploration of Indigenous adults' opinions of the feasibility of technology-based health education programs are promising. Research indicates that accessing health information is a key reason that AI/ANs use the Internet, suggesting that Native people might find technology-based health education resources to be acceptable.47 In a small mixed-methods needs assessment conducted at four geographically diverse American Indian sites (n=48), researchers found over 60% of American Indian adults use the Internet every day, with 64% of them reporting that they connect primarily through their smartphones.46

Further, Indigenous adults across the world have specific ideas concerning how these resources and programs could be culturally tailored to serve their communities and which technological tools would best meet their needs.31,36,5460 Building on findings from these needs assessments, some innovative researchers and communities have collaborated to develop, implement, and evaluate technology-based health education interventions for Indigenous communities.

A scoping review methodology is best suited to answer the research question "What is known about the topic of technology-based health education interventions for Indigenous adults?"61 and doing so was the purpose of this review.62 Specifically, we sought to identify health education interventions that have been developed for and tested with Indigenous populations. Because the literature in this area is sparse, we included papers focusing on Indigenous peoples around the world, including AI/ANs, Native Hawaiians, First Nations (Canada), and Indigenous Australians and New Zealanders. Given the lack of outcomes literature on technology-based health education interventions for Indigenous adults, in this scoping review, we identify and evaluate the acceptability, feasibility, uptake, and efficacy of these interventions for Indigenous adults. [End Page 320]

Methods

Methods used for this scoping review follow the Arksey and O'Malley Methodological Framework.62 Stage four of this five-stage scoping review process includes charting the data, which describes a technique used to synthesize and interpret findings, much like a narrative analytical process used in qualitative research.62 For this reason, our study team employed three trained qualitative researchers who led this study.

Data sources and article identification

A comprehensive literature search was performed by a master's-trained medical librarian in May 2019 and refreshed in October 2020. The medical librarian, a co-author on this paper, met with the first author on six occasions to establish a search strategy, including identification of search terms, and they conversed via email to further refine the search. Relevant publications were identified by searching the following databases: Ovid MEDLINE (including Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE® Daily, and Versions® 1946 to present), Embase (via Elsevier, Embase.com, 1947 to present), CINAHL (Cumulative Index to Nursing and Allied Health Literature via EBSCOhost, 1981 to present), PsycINFO (via Ovid, 1806 to present), and Web of Science Core Collection (via Clarivate Analytics, including Science Citation Index Expanded and Social Sciences Citation Index, 1974 to present).The total search results from all databases were imported into EndNote X8 (Clarivate Analytics, Boston) and the de-duplication function was used to remove duplicate results. As suggested in the Arksey and O'Malley Framework,62 the search was first conducted with a broad range of synonyms as agreed upon by the research team. The initial search strategy included the following terms, and related search terms: Indigenous, adults, technology, nutrition education, and type 2 diabetes. This initial search included nutrition education and type 2 diabetes as the original intent of the researchers was to determine what technology-based nutrition education resources were available for Indigenous adults with type 2 diabetes. However, this narrower search strategy did not produce enough published papers to warrant a scoping review analysis. Therefore, we expanded our search strategy by removing the term type 2 diabetes and broadening nutrition education to health education.

Screening and eligibility

Papers were screened in several phases. First, we conducted a manual search of all records to remove duplications that had not been removed using the previously mentioned automated de-duplication function. Next, two researchers reviewed all titles and abstracts and removed those records for which the full text was not available and those that did not meet the inclusion criteria. These two researchers met biweekly for four months, reviewing abstracts and discussing eligibility for inclusion in the review. To be eligible for full review records had to be published in the English language, involve human subjects research, be published from January 1999 through October 2020, and include Indigenous adults 18 years old or older. Additionally, eligible papers had to be focused on adult and family-based studies. We excluded studies that focused only on children, as children often have access to the Internet and Internet-accessing devices (e.g., tablets, laptops) at school, and we were specifically interested in outside-of-school programming and access. As further eligibility criteria for this scoping review, family-based studies were required to include health education and behavior focused on the adult family members, as opposed to programs [End Page 321] only focusing on children. Eligible papers for full review also were required to include interventions that used technology-based health education, and so we omitted studies that only used technology as a means of recruitment into the study. For example, interventions that were entirely in-person but used social media for recruitment were not included. Finally, we did not include health education resources that were intended to be "reminder" or "one touch" resources such as text messages to encourage engagement in colorectal cancer screening63 as we were specifically interested in longer health education intervention studies.

Data management

We used a Microsoft Excel 2020 (version 16.4) spreadsheet and Mendeley Reference Manager 2008 (version 1.19.4) to manage the references identified through the literature search. The medical librarian initially provided search output in EndNote X8 (Clarivate Analytics, Boston), but per preference of the first author, these records were imported into Mendeley Reference Manager for all subsequent analysis.

Data abstraction

Data were abstracted by two independent researchers using the customized Microsoft Excel file capturing information about the following domains: title, publication year, first author, priority population, type of paper, study design, age of participants, education component (yes/no), technology (type), theoretical framework. Two researchers discussed results on a bi-weekly basis and conferred about discrepancies as they arose. If eligibility of a record was unclear, additional researchers were consulted.

Data analysis

Reseachers with expertise in qualitative methods used qualitative content analysis strategies, including both deductive (a priori) and inductive coding.64 One researcher coded all manuscripts and conferred with the collaborating researchers regarding codebook, categories, and overarching themes. The overarching themes across all included records suggest the most prominent similiarites across these technology-based health education interventions for Indigenous adults.

Results

After de-duplication (both automated via EndNote and manual during initial review), 229 records were obtained using the search strategy described above and were reviewed by two researchers. These two researchers reviewed all titles and abstracts and removed those records which were only an abstract (n=7) and those that did not meet the inclusion criteria (n=180). Records describing interventions in which technology was only used in the recruitment phase of the health education intervention for Indigenous adults were removed (n=3). Records that did not involve interventions were removed (n=30). Therefore, a total of 9 records were included in this full scoping review synthesis (Figure 1).

Numeric results

Technology-based health interventions included in this scoping review are detailed in Table 1. Articles in this scoping review focused on technology-based health education interventions developed or tested with Indigenous adults. Of the nine articles included in this review, two included Native Hawaiians,65,66 one Alaska Natives,67 three included Native peoples from a variety of rural American Indian tribes,6870 one included First Nations and Inuit peoples from Canada,71 one included Indigenous peoples from the Aboriginal Torres Strait in Australia,72 and one included Māori and Pasifika from New Zealand.73 The focus of the health education interventions [End Page 322]

Figure 1. PRISMA-ScR flow diagram of selected articles included in this scoping review.
Click for larger view
View full resolution
Figure 1.

PRISMA-ScR flow diagram of selected articles included in this scoping review.

described in these papers included: physical activity (1);65 nutrition (3);67,70,72 pre/post-natal physical activity and health (2);65,67 both nutrition and physical activity (4);66,68,69,73 and weight management (6).65,66,6870,72 Note that numbers total more than nine as some studies focused on more than one health education topic (e.g., both physical activity and weight management). Details on the health topics covered, chronic disease focus, and technology employed can be found in Table 2.

Two of the studies enrolled women only, as they were focused on pre/post-natal [End Page 323]

Table 1. DETAILED SUMMARY OF STUDY CHARACTERISTICS
Click for larger view
View full resolution
Table 1.

DETAILED SUMMARY OF STUDY CHARACTERISTICS

[End Page 329]

Table 2. DESCRIPTION OF HEALTH TOPICS COVERED, CHRONIC DISEASE FOCUS, TECHNOLOGY EMPLOYED, AND EXPECTED OUTCOMES OF STUDIES INCLUDED IN THIS SCOPING REVIEW.
Click for larger view
View full resolution
Table 2.

DESCRIPTION OF HEALTH TOPICS COVERED, CHRONIC DISEASE FOCUS, TECHNOLOGY EMPLOYED, AND EXPECTED OUTCOMES OF STUDIES INCLUDED IN THIS SCOPING REVIEW.

[End Page 331]

care.65,67 Although all articles focused on health education for adults, as was required by inclusion criteria for this scoping review, four studies extended health education to families, specifically with children in the home.6769,71 Two of these studies collected outcomes data on children as well as adults, or plan to do so.68,69 All of these studies met criteria for inclusion because they focused on health education and behavior for adults as well as children. No studies were included if the health education or behavior outcomes were focused on children only.

Types of technology utilized varied across identified studies. Technology used included: telephone,65 website,65,70 social media,68,69,72 radio,72 television,67,72 CD-ROM,71 DVD,66 text messaging,69 application (apps),73 or combinations of these. Three studies used more than one form of technology in their intervention.65,69,72 In two of the studies, technology was only used in one component of the intervention, while other parts involved in-person education and support.68,69 Only three of the studies mentioned prevalence of access to the Internet among the priority audience;65,68,70 however, five of these studies did not use Internet-based technology, and Internet access may not have been relevant for their work. Of the nine interventions described, eight were designed specifically for Native peoples. The one study that was not culturally tailored to Indigenous peoples was intended for rural communities, and American Indians constituted 9% of the study sample. Therefore, this paper was included in the scoping review.70 Two of the studies specified that their selected technology (social media, television, and/or radio) was intended to serve the whole community, as an effort to address the importance of community-level involvement.

Three interventions revealed positive health and behavior change results including: increased physical activity among postpartum women after engaging in a telephonic and web-based intervention,65 improved diet patterns in families with more fruit and vegetable intake after a multi-level intervention with American Indian families,69 and no difference in weight loss between DVD vs. in-person weight loss counseling for Native Hawaiian adults, suggesting DVD-based weight management education and support was just as beneficial as in-person education and support.66 Three studies did not show any positive results from their technology-based health intervention and cited various reasons. One suggested that social media should be used in collaboration with a more comprehensive intervention to reduce sugar-sweetened beverage intake among Aboriginal and Torres Strait Islander adults;72 one suggested that a website alone is likely not rigorous enough to improve fruit and vegetable intake among rural-living American Indian adults in southwestern U.S.;70 and one cited low engagement in the application (app) among participants.73 One of the intervention studies included did not have outcome results available at the time of this scoping review68 and one presented only qualitative results from the intervention suggesting that Inuit adults from Canada would be more likely to accept a technology-based (CD-ROM) healthy family and pregnancy intervention if it is specifically tailored to their community.71 Finally, two intervention studies encountered challenges with evaluation and data collection and suggested their findings were positive regarding the use of technology-based health education, but they needed additional resources to effectively evaluate the programs.67,70

Qualitative results

Five key themes emerged across the nine studies. These included [End Page 332] 1) culturally tailoring technology-based health education interventions for Native communities is important; 2) technology supports learning style preferences and access for many Indigenous adults; 3) programs must be personally tailored and interactive for optimal engagement; 4) evaluation of technology-based health education is challenging; and 5) future needs for research in this area include rigorous evaluation and use of Internet-based opportunities.

Culturally tailoring technology-based health education interventions for Native communities is important

All nine studies included in this scoping review emphasized the importance of culturally tailoring the technology for the priority audience.6573 This included using community-based participatory research strategies, involving members of the priority audience in technology-based program development, featuring actors and images from the community, including elders as public health messengers as much as possible,67,7073 and being aware of Internet-accessing capability and Internet-accessing devices available to the community in general.65,70

Technology supports learning style preference and access for many Indigenous adults

Findings from this scoping review suggested that the inherent audio and visual nature of technology-based learning suits the learning style preference of their priority audience.67,71 Further, especially for busy families, technology was noted to offer asynchronous alternatives to time-and-location-specific classroom-based learning.65,67,69 Finally, among the studies that focused exclusively on rural-living Indigenous adults, it was noted that technology may offer expanded services to those who otherwise experience barriers to attending in-person health education related to transportation and distance to travel.6770

Programs must be personally tailored and interactive for optimal engagement

In one study, personalized telephone calls positively augmented the website-based intervention as the calls provided motivational-interviewing focused personalized support aimed at increasing physical activity.65 Results from studies where the technology was passive and not prescriptive in any way (e.g., optional website, Facebook, other social media) suggested that there was very low engagement in these technology-based resources. This likely contributed to small to no measurable changes in outcomes.6870 One study did feature an application (app) that included lifestyle tracking as an interactive component, but still yielded no significant changes in healthy-behavior adherence compared with controls.73

There are challenges to rigorous evaluation of technology-based health education programs

Challenges in evaluating these programs focused on difficulties with tracking engagement in the technology-based portions of the program.6870,72 Results of one study suggested evaluation was a challenge due to low response rates to pre-post evaluation questions, but that collaborating community members suggested quantitative pre-post evaluation was not the best measure of the program's success. These individuals suggested wider community acceptance and excitement is a better measure of program success.67 For one study a CD-ROM-based health education tool was used, which focused on healthy pregnancy and family health. However, investigators noted that since participants were required to come in person to view the CD-ROM at the study site and had help navigating the CD-ROM, they were unsure how confident participants would be in using this technology at home.71 [End Page 333]

Further research is needed to rigorously evaluate technology-based health education programs for Indigenous adults and expand use of Internet-based opportunities

Three papers described studies that offered non-Internet-based technology interventions. Results suggested that expanding their work to Internet-based portals would be a logical and recommended next step.65,66,71 Researchers suggested that cost-and time-effectiveness of asynchronous health education was encouraging for large-scale dissemination,65,66 and that technology-based interventions should be explored to expand reach to rural areas.67,68,70,71 The results of three studies that featured more passive technology-based health education (e.g., self-directed website or application [app] only) suggested that social media and websites would likely be more effective as part of a more comprehensive health education intervention with a community-level focus, but recommended further research to explore this possibility.70,72,73

Discussion

Given the small number of studies included in this scoping review, it is apparent there is a paucity of published research examining technology-based health education interventions for Indigenous adults. Of the interventions included in this review that had resources available to conduct rigorous outcome evaluation, three cited positive health behavior changes, such as improved nutrition and physical activity among Indigenous adults who participated.65,66,69 As supported by the literature, technology-based weight management,76 healthy eating,77,78 and physical activity promotion79,80 interventions can be as effective as in-person interventions, and may have particular appeal to adults with variable work and child care schedules.

Of the nine studies included in this scoping review, six included Internet-based technology65,6870,72,73 and, of those, only three mentioned access to the Internet as a limitation or reason their intervention wasn't as successful as planned.65,68,70 These three studies focused on rural areas of the United States and noted that slow (or no) Internet access may have been a barrier for their participants. However, at least three of the research groups involved in these papers,73,81, along with others, have conducted in-depth needs assessments with members of their partner communities. These qualitative and survey-based needs assessments strongly suggest that Indigenous adults have interest in technology-based health education resources, confidence to use (or learn how to use) these resources, and desire to be involved in development of such resources.54,55,5759,73,82 In two needs assessment studies, Indigenous adults were resistant to technology-based health education and support—one specific to AI/AN cancer survivors who strongly preferred face-to-face support36 and one in which AI/AN veterans were resistant to remote-access health education/support but eventually warmed to the idea as their concerns were addressed.31 As with all health education programs and resources, engaging the intended Indigenous community early in program development will increase the program's acceptability and usability among the priority audience.27,83,84 The Theoretical Framework of Acceptability supports the importance of exploring the attitudes and perceptions of members of the collaborating community to preemptively assess how health care interventions may work within any given community.85 An important [End Page 334] qualitative finding from this scoping review suggests the importance of including key stakeholders in the development of technology-based health education interventions. This finding is strongly supported by community-based participatory research principles83 as well as literature on co-designing mHealth programs for the most effective user engagement.86,87

These findings document potential for technology-based learning, suggesting that it might match the preferred learning style (visual and audible) of many Indigenous adults.67 Technology-based learning is supported by Adult Learning and eLearning Theories.88 Adult Learning Theory suggests that adults tend to be visual learners and prefer self-paced and interactive learning opportunities.88 Screen-based technology (e.g., computer, smartphones) is inherently visual and has many interactive learning opportunities.88,89 As with other studies90,91 these scoping review findings indicate that participants would benefit from "anytime-anyplace" learning opportunities given barriers to attending traditional health education classes. This was particularly noted for post-partum women65,67 and workplace education.66 For busy parents and working adults, asynchronous learning can support unpredictable schedules and self-directed learning as supported by Adult Learning Theory.88

Another key finding from this scoping review included challenges related to rigorous evaluation of technology-based health interventions specific to those offered online and remotely. For example, it was difficult to examine engagement in a nutrition education website,70 and challenging to determine reach from social media-based interventions.68,69 However, two latter interventions included technology only as a supportive feature or smaller component of larger multi-level (e.g., community-level) interventions and very likely the researchers focused their rigorous evaluation efforts on other components of their interventions. This offers an opportunity to consider enhancing community-level evaluation of technology-based health education programs.92 Among health education research with non-Indigenous communities, rigorous evaluation of technology-based health interventions is possible, given the appropriate resources.78,9395 Several research groups across the country are collecting formative and process evaluation data on innovative technology-based health education resources for Indigenous communities. These innovative programs include: a website for AI/AN adults with posttraumatic stress disorder,96 mobile health and cardiovascular disease management,33 eHealth and breast-feeding promotion,54 application for healthy living support for pregnant Indigenous Canadian women,97 smoking cessation,83,98 suicide prevention,99 and a text messaging intervention to promote child health in a rural American Indian reservation,100 among others. Further, the observed challenges with program evaluation may be addressed by using Indigenous evaluation frameworks, which may measure technology-based health education program success and outcomes in a way that is more culturally relevant to the priority audience.101103

Limitations

There are several key limitations to this scoping review. First, given that we limited our search to English-language only, we may have missed studies addressing other Indigenous groups (e.g., Indigenous peoples of Central and South America) or other intervention approaches (e.g., text messaging, which is a common mode of communication in African interventions). Second, because of the rapid rate at which [End Page 335] technology evolves, some studies included in this review may be dated. For example, many affordable digital devices (e.g., smartphones and tablets) currently available do not have DVD or CD-ROM ports and therefore this technology may not be adaptable for present-day widespread dissemination in their current form.

Conclusion

The United States' Healthy People 2030, released in August 2020, more strongly emphasizes addressing social determinants as key objectives than did Healthy People 2020.104 For decades, Healthy People objectives have focused on health promotion and disease prevention measures as tools to benchmark national progress and reduce health disparities. A subset of key objectives in Healthy People 2030 focus on the COVID-19 pandemic and health-related inequities. One of these key objectives includes increasing broadband Internet access. Reliable, high-speed connections have become essential for people to use the Internet for work, study, health care, and deliverable goods during the pandemic.105

The work summarized here suggests that use of technology may aid in reducing health disparities experienced by Indigenous communities. As exemplified by the work summaries in this scoping review, there is much diversity among Indigenous communities and this diversity must be reflected, by design, in online health education resources. The COVID-19 pandemic has forever changed the way everyone will engage in remote-access resources and activities (health, school, work, worship). Research in the area of technology and remote-access health education will expand greatly given the dramatic changes to education, health care, and social support in the COVID-19 era, and awareness of the current and potential growing disparities between those who do and do not have reliable Internet access is of upmost importance to the public and community health professionals. Certainly, the COVID-19 pandemic has revealed the benefits of reliable access to the Internet and the importance of this access to support achieving equity for the most vulnerable communities. As supported by guidance from the United States' Healthy People 2030,106 improvements in Internet access for Indigenous communities is essential to improve equity and access to culturally relevant,35 technology-based, online, remote-access health education resources. Next steps in this work include development, implementation, and evaluation of technology-based health education interventions for Indigenous peoples and advocacy to improve access to these resources.

Financial Support:

This study was supported by the American Diabetes Association grant #4-18-SMC-01 (PI: Moore) and the Native Elder Research Center, Resource Centers for Minority Aging Research, National Institutes on Aging, grant #P30 AG15292 (PI: Manson)

Sarah Stotz, Luciana E. Hebert, Angela G. Brega, Steven Lockhart, J. Neil Henderson, Yvette Roubideaux, Kristen DeSanto, and Kelly R. Moore

SARAH STOTZ, ANGELA G. BREGA, and KELLY R. MOORE are affiliated with the Centers for American Indian and Alaska Native Health at the Colorado School of Public Health at The University of Colorado Anschutz Medical Campus. LUCIANA E. HEBERT is affiliated with the Institute for Research and Education Advancing Community Health (IREACH) at the Elson S. Floyd College of Medicine at Washington State University. STEVEN LOCKHART is affiliated with the Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS) at the Children's Hospital Colorado at The University of Colorado Anschutz Medical Campus. J. NEIL HENDERSON is affiliated with the Memory Keepers Medical Discovery Team at the Department of Family Medicine and Biobehavioral Health at The University of Minnesota Medical School. YVETTE ROUBIDEAUX is affiliated with the National Congress of American Indians. Kristen DeSanto is affiliated with The University of Colorado Medical Campus.

Please address all correspondence to Sarah Stotz, University of Colorado, Colorado School of Public Health, Nighthorse Campbell Native Health Building, 13055 East 17th Avenue, Aurora, CO 80045; email: Sarah.stotz@cuanschutz.edu; phone: 858-232-3545.

References

1. Centers for Disease Control and Prevention (CDC). National Diabetes Statistics Report 2020—estimates of diabetes and its burden in the United States. Atlants, GA: CDC, 2020. Available at: https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf.
2. US Department of Health and Human Services Office of Minority Health. Obesity and American Indians/Alaska Natives. Rockville, MD: US Department of Health and Human Services Office of Minority Health, 2020. Available at: https://www.minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=40.
3. Deen JF, Adams AK, Fretts A, et al. Cardiovascular disease in American Indian and Alaska native youth: Unique risk factors and areas of scholarly need. J Am Heart Assoc. 2017 Oct 24;6(10):e007576 https://doi.org/10.1161/JAHA.117.007576 PMid:29066451
4. US Department of Health and Human Services Office of Minority Health. Heart Disease and American Indians/Alaska Natives. Rockville, MD: US Department of Health and Human Services Office of Minority Health, 2020. Available at: https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=34.
5. Mitchell FM. Reframing diabetes in American Indian communities: a social determinants of health perspective. Heal Soc Work. 2012 May;37(2):71–9. https://doi.org/10.1093/hsw/hls013 PMid:23029974
6. Warne D, Wescott S. Social determinants of American Indian nutritional health. Curr Dev Nutr. 2019 May 23;3(Suppl 2):12–8.
7. Stanley LR, Swaim RC, Kaholokula JK, et al. The imperative for research to promote health equity in Indigenous communities. Prev Sci. 2020 Jan;21(suppl 1):13–21. https://doi.org/10.1007/s11121-017-0850-9 PMid:29110278
8. Pirisi A. Country in focus: health disparities in Indigenous Canadians. Lancet Diabetes Endocrinol. 2015 May;3(5):319. https://doi.org/10.1016/S2213-8587(15)00080-7
9. Paradies Y, Ben J, Denson N, et al. Racism as a determinant of health: a systematic review and meta-analysis. PLoS One. 2015 Sep 23;10(9):e0138511. https://doi.org/10.1371/journal.pone.0138511 PMid:26398658
10. Ellison-Loschmann L, Pearce N. Improving access to health care among New Zealand's Maori population. Am J Public Health. 2006 Apr;96(4):612–7. https://doi.org/10.2105/AJPH.2005.070680 PMid:16507721
11. Graham R, Masters-Awatere B. Experiences of Māori of Aotearoa New Zealand's public health system: a systematic review of two decades of published qualitative research. Aust N Z J Public Health. 2020 April 20;44(3):193–200. https://doi.org/10.1111/1753-6405.12971 PMid:32311187
12. Yu CHY, Zinman B. Type 2 diabetes and impaired glucose tolerance in aboriginal populations: a global perspective. Diabetes Res Clin Pract. 2007 Nov;78(2):159–70. https://doi.org/10.1016/j.diabres.2007.03.022 PMid:17493702
13. Schiller J, Lucas J, Ward B, et al. Summary health statistics for US adults: national health interview survey. Vital Health Stat 10. 2012 Jan; (252):1–207.
14. American Diabetes Association. Standards of Medical Care in Diabetes—2020. Diabetes Care. 2020 Jan; 43(Supplement 1):S1–2. https://doi.org/10.2337/dc20-Sint
15. American Diabetes Association. Lifestyle management: standards of medical care in diabetes. Diabetes Care. 2019 Jan;42(Suppl 1):S46–60. https://doi.org/10.2337/dc19-S005 PMid:30559231
16. Raynor HA, Champagne CM. Position of the academy of nutrition and dietetics: interventions for the treatment of overweight and obesity in adults. J Acad Nutr Diet. 2016 Jan;116(1):129–47. https://doi.org/10.1016/j.jand.2015.10.031 PMid:26718656
17. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. Circulation. 2019 Sep 10; 140(11):e596–e646. https://doi.org/10.1161/CIR.0000000000000678
18. Committee on American Indian/Alaska Native Women's Health, Committee on Health Care for Underserved Women. Committee opinion no. 515: Health Care for Urban American Indian and Alaska Native Women. Obstet Gynecol. 2012 Jan;119(1):201–5. https://doi.org/10.1097/01.AOG.0000410162.34363.0b PMid:22183240
19. Warne D, Frizzell LB. American Indian health policy: historical trends and contemporary issues. Am J Public Health. 2014 Jun;104(Suppl 3):S263–7. https://doi.org/10.2105/AJPH.2013.301682 PMid:24754649
20. Davy C, Harfield S, McArthur A, et al. Access to primary health care services for Indigenous peoples: a framework synthesis. Int J Equity Health. 2016 Sep 30;15(1):163. https://doi.org/10.1186/s12939-016-0450-5 PMid:27716235
21. Horrill T, McMillan DE, Schultz A, et al. Understanding access to healthcare among Indigenous peoples: a comparative analysis of biomedical and postcolonial perspectives. Nurs Inq. 2018 Jul;25(3):e12237. https://doi.org/10.1111/nin.12237 PMid:29575412
22. Li J. Cultural barriers lead to inequitable healthcare access for aboriginal Australians and Torres Strait Islanders. Chinese Nurs Res. 2017 Dec;4(4):207–10. https://doi.org/10.1016/j.cnre.2017.10.009
23. Stokols D. Translating social ecological theory into guidelines for community health promotion. Am J Health Promot. 1996 Mar–Apr;10(4):282–98. https://doi.org/10.4278/0890-1171-10.4.282 PMid:10159709
24. Center for Disease Control and Prevention (CDC). CDC Health Disparities and Inequalities Report—United States, 2013. MMWR Morb Mortal Wkly Rep. 2013 Nov 22;62(3):1–186.
25. Bauer UE, Plescia M. Addressing disparities in the health of American Indian and Alaska Native people: the importance of improved public health data. Am J Public Health. 2014 Jun;104 Suppl 3(Suppl 3):S255–7. https://doi.org/10.2105/AJPH.2013.301602 PMid:24754654
26. Jernigan VBB, Peercy MT, Branam D, et al. Beyond health equity: achieving wellness within American Indian and Alaska Native communities. Am J Public Health. 2015 Jul;105 Suppl 3(Suppl 3):S376–9. https://doi.org/10.2105/AJPH.2014.302447 PMid:25905823
27. Jernigan VBB, Salvatore AL, Styne DM, et al. Addressing food insecurity in a Native American reservation using community-based participatory research. Health Educ Res. 2012 Aug;27(4):645–55. https://doi.org/10.1093/her/cyr089 PMid:21994709
28. Mitchell FM. Water (in)security and American Indian health: social and environmental justice implications for policy, practice, and research. Public Health. 2019 Nov;176:98–105. https://doi.org/10.1016/j.puhe.2018.10.010 PMid:30661805
29. Satterfield D, DeBruyn L, Santos M, et al. Health promotion and diabetes prevention in American Indian and Alaska Native communities—Traditional foods project, 2008–2014. Mmwr. 2016 Feb 12;65(1):4–10. https://doi.org/10.15585/mmwr.su6501a3 PMid:26916637
30. The United Nations General Assembly. Promotion and protection of all human rights, civil, political, economic, social and cultural rights, including the right to development. New York, NY: The United Nations General Assembly, 2011. Available at: https://www.un.org/development/desa/disabilities/promotion-and-protectionof-all-human-rights-civil-political-economic-social-and-cultural-rights-including-the-right-to-development.html.
31. Brooks E, Manson SM, Bair B, et al. The diffusion of telehealth in rural American Indian communities: A retrospective survey of key stakeholders. Telemed J E Health. 2012 Jan–Feb;18(1):60–6. https://doi.org/10.1089/tmj.2011.0076 PMid:22082106
32. Xu D, Jenkins A, Ryan C, et al. Health-related behaviours in a remote Indigenous population with Type 2 diabetes: a Central Australian primary care survey in the telehealth eye and associated medical eervices network [TEAMSnet] project. Diabet Med. 2019 Dec;36(12):1659–70. https://doi.org/10.1111/dme.14099 PMid:31385331
33. Wali S, Hussain-Shamsy N, Ross H, et al. Investigating the use of mobile health interventions in vulnerable populations for cardiovascular disease management: scoping review. J Med Internet Res. 2019 Oct 7;7(10):e14275. https://doi.org/10.2196/14275 PMid:31593547
34. Dawson AZ, Walker RJ, Campbell JA, et al. Telehealth and indigenous populations around the world: a systematic review on current modalities for physical and mental health. Mhealth. 2020 Jul 5;6:30. https://doi.org/10.21037/mhealth.2019.12.03 PMid:32632368
35. Cueva K, Cueva M, Revels L, et al. A framework for culturally relevant online learning: lessons from Alaska's tribal health workers. J Cancer Educ. 2019 Aug;34(4):647–53. https://doi.org/10.1007/s13187-018-1350-8 PMid:29569143
36. Harris R, Van Dyke ER, Ton TGN, et al. Assessing needs for cancer education and support in American Indian and Alaska Native communities in the northwestern United States. Health Promot Pract. 2016 Nov;17(6):891–8. https://doi.org/10.1177/1524839915611869 PMid:26507742
37. Hatcher SM, Agnew-Brune C, Anderson M, et al. COVID-19 Among American Indian and Alaska Native persons—23 states, January 31–July 3, 2020. MMWR Morb Mortal Wkly Rep. 2020 Aug 28;69(34):1166–9.
38. Kakol M, Upson D, Sood A. Susceptibility of southwestern American Indian tribes to Coronavirus Disease 2019 (COVID-19). J Rural Heal. 2021 Jan;37(1):197–9. https://doi.org/10.1111/jrh.12451 PMid:32304251
39. Ortega-Navas M. The use of new technologies as a tool for the promotion of health education. Procedia—Soc Behav Sci. 2017 Feb;237:23–9. https://doi.org/10.1016/j.sbspro.2017.02.006
40. Kratzke C, Cox C. Smartphone technology and apps: Rapidly changing health promotion. Int Electron J Health Educ. 2012;15:72–82.
41. Free C, Phillips G, Galli L, et al. The effectiveness of mobile-health technology-based health behaviour change or disease management interventions for health care consumers: a systematic review. PLoS Med. 2013;10(1):e1001362. https://doi.org/10.1371/journal.pmed.1001362 PMid:23349621
42. Perrin A, Duggan M. Americans' internet access 2000–2015. Washington, DC: Pew Research Center, 2015. Available at: http://www.pewinternet.org/2015/06/26/americans-internet-access-2000-2015/.
43. American Indian policy institute. Digital divide. Phoenix, AZ: Arizona State University, 2020. Available at: https://aipi.asu.edu/content/digital-divide.
44. US Department of the Interior. National Tribal Broadband Summit. Washington, DC: US Department of the Interior. Available at: https://www.doi.gov/tribalbroadband.
45. US Census Bureau. 2013–2017 American Community Survey five-year estimates. American Community Survey. Washington, DC: US Census Bureau, 2018. Available at: https://www.census.gov/programs-surveys/acs/technical-documentation/table-and-geography-changes/2017/5-year.html.
46. Stotz S, Brega AG, Lockhart S, et al. An online diabetes nutrition education programme for American Indian and Alaska Native adults with type 2 diabetes: perspectives from key stakeholders. Public Health Nutr. 2020 Jul 17;1–11. https://doi.org/10.1017/S1368980020001743 PMid:32677608
47. Filippi M, Pacheco C, McClosky C, et al. Internet use for health information among American Indians: facilitators and inhibitors. J Health Dispar Res Pract. 2014;7(3):4.
48. Federal Communications Commission. 2016 Broadband Access Report. Washington DC; Federal Communications Commission, 2016. Available at: https://docs.fcc.gov/public/attachments/FCC-16-6A1.pdf.
49. Candian Radio-television and Telecommunications Commission. Communications Monitoring Report 2018. Ontario, Canada: Canadian Radio-television and Telecommunications Commission, 2018. Available at: https://crtc.gc.ca/eng/publications/reports/policymonitoring/2018/.
50. Rennie E, Thomas J, Wilson C. Aboriginal and Torres Strait islander people and digital inclusion: what is the evidence and where is it? Commun Res Pract. 2019;5(2):105–20. https://doi.org/10.1080/22041451.2019.1601148
51. Rice ES, Haynes E, Royce P, Thompson SC. Social media and digital technology use among Indigenous young people in Australia: A literature review. Int J Equity Health. 2016 May 25;15(81). https://doi.org/10.1186/s12939-016-0366-0 PMid:27225519
52. United States Census Bureau. Quick Facts Hawaii. Washington, DC: US Census Bureau, 2020. Available at: https://www.census.gov/quickfacts/HI.
53. Pew Research Center. Internet seen as positive influence on education but negative influence on morality in emerging and developing nations. Washington, DC: Pew Research Center, 2015. Available at: https://www.pewresearch.org/global/2015/03/19/internet-seen-as-positive-influence-on-education-but-negative-influence-on-morality-in-emerging-and-developing-nations/.
54. Abbass-Dick J, Brolly M, Huizinga J, et al. Designing an eHealth breastfeeding resource with indigenous families using a participatory design. J Transcult Nurs. 2018 Sep;29(5):480–8. https://doi.org/10.1177/1043659617731818 PMid:29308703
55. Power JM, Braun KL, Bersamin A. Exploring the potential for technology-based nutrition education among WIC recipients in remote Alaska Native communities. J Nutr Educ Behav. Jul–Aug 2017;49(7 Suppl 2):S186–91.e1. https://doi.org/10.1016/j.jneb.2016.11.003 PMid:28689556
56. Buller DB, Woodall WG, Zimmerman DE, et al. Formative research activities to provide web-based nutrition education to adults in the upper Rio Grande Valley. Fam Community Health. 2001 Oct;24(3):1–12. https://doi.org/10.1097/00003727-200110000-00003 PMid:11563940
57. Cueva K, Revels L, Kuhnley R, et al. Co-creating a culturally responsive distance education cancer course with, and for, Alaska's community health workers: motivations from a survey of key stakeholders. J Cancer Educ. 2017 Sep;32(3):426–31. https://doi.org/10.1007/s13187-015-0961-6 PMid:26666680
58. Gibson KL, Coulson H, Miles R, et al. Conversations on telemental health: listening to remote and rural First Nations communities. Rural Remote Health. 2011;11(2):1656.
59. Gorman JR, Clapp JD, Calac D, et al. Creating a culturally appropriate web-based behavioral intervention for American Indian/Alaska native women in Southern California: The healthy women healthy Native nation study. Am Indian Alaska Nativ Ment Heal Res. 2013;20(1):1–15. https://doi.org/10.5820/aian.2001.2013.1 PMid:23529767
60. Geana M, Makoskey-Daley C, Nazir N, et al. Use of online health information resources by American Indians and Alaska Natives. J Health Commun. 2012 Aug;17(7):820–35. https://doi.org/10.1080/10810730.2011.650831 PMid:22642739
61. Tricco AC, Lillie E, Zarin W, et al. PRISMA extension for scoping reviews (PRISMAScR): checklist and explanation. Ann Intern Med. 2018 Oct 2;169(7):467–73. https://doi.org/10.7326/M18-0850 PMid:30178033
62. Arksey H, O'Malley L. Scoping studies: Towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19–32. https://doi.org/10.1080/1364557032000119616
63. Muller CJ, Robinson RF, Smith JJ, et al. Text message reminders increased colorectal cancer screening in a randomized trial with Alaska Native and American Indian people. Cancer. 2017 Apr 15;123(8):1382–9. https://doi.org/10.1002/cncr.30499 PMid:28001304
64. Vaismoradi M, Turunen H, Bondas T. Content analysis and thematic analysis: Implications for conducting a qualitative descriptive study. Nurs Heal Sci. 2013 Sep;15(3):398–405. https://doi.org/10.1111/nhs.12048 PMid:23480423
65. Albright CL, Steffen AD, Wilkens LR, et al. Effectiveness of a 12-month randomized clinical trial to increase physical activity in multiethnic postpartum women: results from Hawaii's N Mikimiki Project. Prev Med. 2014 Dec;69:214–23. https://doi.org/10.1016/j.ypmed.2014.09.019 PMid:25285751
66. Townsend-Ing C, Miyamoto R, Fang R, et al. Comparing weight loss–maintenance outcomes of a worksite-based lifestyle program delivered via DVD and face-to-face: a randomized trial. Heal Educ Behav. 2018 Aug;45(4):569–80. https://doi.org/10.1177/1090198118757824 PMid:29504468
67. Smith J, George VA, Easton PS. Home-grown television: a way to promote better nutrition in a Native Alaskan community. J Nutr Educ Behav. 2001 Jan–Feb;33(1):59–60. https://doi.org/10.1016/S1499-4046(06)60013-4
68. Gittelsohn J, Jock B, Poirier L, et al. Implementation of a multilevel, multicomponent intervention for obesity control in Native American communities (OPREVENT2): challenges and lessons learned. Health Educ Res. 2020 Jun 1;35(3):228–42. https://doi.org/10.1093/her/cyaa012 PMid:32413105
69. Tomayko EJ, Prince RJ, Cronin KA, et al. The healthy children, strong families 2 (HCSF2) randomized controlled trial improved healthy behaviors in American Indian families with young children. Curr Dev Nutr. 2018 Nov 16;3(Suppl 2):53–62. https://doi.org/10.1093/cdn/nzy087 PMid:31453428
70. Buller D, Woodall WG, Zimmerman D, et al. Randomized trial on the 5 a Day, the Rio Grande Way website, A web-based Program to improve fruit and vegetable consumption in rural communities. J Health Commun. 2008 Apr–May;13(3):230–49. https://doi.org/10.1080/10810730801985285 PMid:18569356
71. McShane KE, Smylie JK, Hastings PD, et al. Evaluation of the acceptability of a CD-Rom as a health promotion tool for Inuit in Ottawa. Int J Circumpolar Health. 2013 May 23;72:20573 https://doi.org/10.3402/ijch.v72i0.20573 PMid:23717816
72. Browne J, MacDonald C, Egan M, et al. You wouldn't eat 16 teaspoons of sugar—so why drink it? Aboriginal and Torres Strait Islander responses to the LiveLighter sugary drink campaign. Heal Promot J Aust. 2019 Apr;30(2):212–8. https://doi.org/10.1002/hpja.196 PMid:30144362
73. Mhurchu CN, Morenga L Te, Tupai-firestone R, et al. A co-designed mHealth programme to support healthy lifestyles in Māori and Pasifika peoples in New Zealand (OL @-OR @): a cluster-randomised controlled trial. Lancet Digit Heal. 2019;1(6): e298–307. https://doi.org/10.1016/S2589-7500(19)30130-X
74. Australian Institute of Health and Welfare. The active Australia survey: A guide and manual for implementation, analysis, and reporting. Canberra, Australia: Australian Institute of Health and Welfare, 2003. Available at: https://www.aihw.gov.au/reports/physical-activity/active-australia-survey/summary.
75. Khaw KT, Wareham N, Bingham S, et al. Combined impact of health behaviours and mortality in men and women: The EPIC-Norfolk prospective population study. PLoS Med. 2008 Jan 8;5(1):0039–47. https://doi.org/10.1371/journal.pmed.0050012 PMid:18184033
76. Blomfield RL, Collins CE, Hutchesson MJ, et al. Impact of self-help weight loss resources with or without online support on the dietary intake of overweight and obese men: the SHED-IT randomised controlled trial. Obes Res Clin Pract. 2014;8(5): e476–87. https://doi.org/10.1016/j.orcp.2013.09.004 PMid:25263837
77. Au LE, Whaley S, Gurzo K, et al. If you build it they will come: satisfaction of WIC participants with online and traditional in-person nutrition education. J Nutr Educ Behav. 2016;48(5):336–42.e1. https://doi.org/10.1016/j.jneb.2016.02.011 PMid:27017051
78. Lohse B, Belue R, Smith S, et al. About Eating: An online program with evidence of increased food resource management skills for low-income women. J Nutr Educ Behav. 2015 May–Jun;47(3):265–72. https://doi.org/10.1016/j.jneb.2015.01.006 PMid:25744780
79. Griffin JB, Struempler B, Funderburk K, et al. My Quest, an intervention using text messaging to improve dietary and physical activity behaviors and promote weight loss in low-income women. J Nutr Educ Behav. 2018 Jan;50(1):11–8.e1. https://doi.org/10.1016/j.jneb.2017.09.007 PMid:29325657
80. Dunn C, Whetstone L, Kolasa K, et al. Using synchronous distance-education technology to deliver a weight management intervention. J Nutr Educ Behav. 2014 Nov–Dec;46(6):602–9. https://doi.org/10.1016/j.jneb.2014.06.001 PMid:25052936
81. Gittelsohn J, Jock B, Redmond L, et al. OPREVENT2: Design of a multi-institutional intervention for obesity control and prevention for American Indian adults. BMC Public Health. 2017 Jan 23;17(1):105. https://doi.org/10.1186/s12889-017-4018-0 PMid:28114926
82. Dotson JAW, Nelson LA, Young SL, et al. Use of cell phones and computers for health promotion and tobacco cessation by American Indian college students in Montana. Rural Remote Health. 2017 Jan–Mar;17(1):4014. https://doi.org/10.22605/RRH4014 PMid:28328231
83. Holkup PA, Tripp-Reimer T, Salois EM, et al. Community-based participatory re-search: An approach to intervention research with a Native American community. Adv Nurs Sci. 2004 Jul–Sep;27(3):162–75. https://doi.org/10.1097/00012272-200407000-00002 PMid:15455579
84. Chung-Do JJ, Look MA, Mabellos T, et al. Engaging Pacific Islanders in research: community recommendations. Prog Community Heal Partnersh. Spring 2016;10(1):63–71. https://doi.org/10.1353/cpr.2016.0002 PMid:27018355
85. Sekhon M, Cartwright M, Francis JJ. Acceptability of healthcare interventions: an overview of reviews and development of a theoretical framework. BMC Health Serv Res. 2017 Jan 26;17(1):88. https://doi.org/10.1186/s12913-017-2031-8 PMid:28126032
86. Jones L, Jacklin K, O'Connell ME. Development and use of health-related technologies in Indigenous communities: critical review. J Med Internet Res. 2017 Jul 20;19(7):e256. https://doi.org/10.2196/jmir.7520 PMid:28729237
87. Eyles H, Jull A, Dobson R, et al. Co-design of mHealth delivered interventions: a systematic review to assess key methods and processes. Curr Nutr Rep. 2016;5(3):160–7. https://doi.org/10.1007/s13668-016-0165-7
88. Knowles M, Holton III E, Swanson R. The adult learner, 8th ed. London, England: Routledge, 2015. https://doi.org/10.4324/9781315816951
89. Sharples M, Taylor J, Vavoula G. Towards a theory of mobile learning. United Kingdom, 2005. Available at: https://www.researchgate.net/publication/228346088_Towards_a_theory_of_mobile_learning.
90. Rainie L, Fox S. Just-in-time information through mobile connections arguments. Washington, DC: Pew Research Center, 2012. Available at: https://www.pewresearch.org/internet/2012/05/07/just-in-time-information-through-mobile-connections/.
91. Bull SS, Levine DK, Black SR, et al. Social media-delivered sexual health intervention: a cluster randomized controlled trial. Am J Prev Med. 2012 Nov;43(5):467–74. https://doi.org/10.1016/j.amepre.2012.07.022 PMid:23079168
92. Ruggiero CF, Poirier L, Trude ACB, et al. Implementation of B'more healthy communities for kids: Process evaluation of a multi-level, multi-component obesity prevention intervention. Health Educ Res. 2018 Dec 1;33(6):458–72. https://doi.org/10.1093/her/cyy031 PMid:30202959
93. Stotz S, Lee JS, Hall J. A mixed-methods formative evaluation using low-income Georgians' experiences with a smartphone-based eLearning nutrition education programme. Public Health Nutr. 2018 Dec;21(17):3271–80. https://doi.org/10.1017/S1368980018001933 PMid:30101733
94. Au LE, Whaley S, Gurzo K, et al. Evaluation of online and In-person nutrition education related to salt knowledge and behaviors among Special Supplemental Nutrition Program for Women, Infants, and Children participants. J Acad Nutr Diet. 2017 Sep;117(9):1384–95. https://doi.org/10.1016/j.jand.2016.12.013 PMid:28196620
95. Au LE, Whaley S, Rosen NJ, et al. Online and in-person nutrition education improves breakfast knowledge, attitudes, and behaviors: a randomized trial of participants in the Special Supplemental Nutrition Program for Women, Infants, and Children. J Acad Nutr Diet. 2016 Mar;116(3):490–500. https://doi.org/10.1016/j.jand.2015.10.012 PMid:26669795
96. Hiratsuka VY, Moore L, Avey JP, et al. An internet-based therapeutic tool for American Indian/Alaska native adults with posttraumatic stress disorder: user testing and developmental feasibility study. JMIR Form Res. 2019 Nov 13;3(4). https://doi.org/10.2196/13682 PMid:31719027
97. Darroch FE, Giles AR. Conception of a resource: development of a physical activity and healthy living resource with and for pregnant urban First Nations and Métis women in Ottawa, Canada. Qual Res Sport Exerc Heal. 2017;9(2):157–69. https://doi.org/10.1080/2159676X.2016.1246471
98. Gould GS, Bovill M, Pollock L, et al. Feasibility and acceptability of Indigenous Counselling and Nicotine (ICAN) QUIT in Pregnancy multicomponent implementation intervention and study design for Australian Indigenous pregnant women: A pilot cluster randomised step-wedge trial. Addict Behav. 2019 Mar;90:176–90. https://doi.org/10.1016/j.addbeh.2018.10.036 PMid:30412909
99. Kerr B, Stephens D, Pham D, et al. Assessing the usability, appeal, and impact of a web-based training for adults responding to concerning posts on social media: pilot suicide prevention st udy. JMIR Ment Heal. 2020 Jan;7(1):e14949. https://doi.org/10.2196/14949 PMid:31958066
100. Brown B, Harris K, Dybdal L, et al. Feasibility of text messaging to promote child health in a rural community on an American Indian reservation. Health Education Journal. 2019 Feb; 78(5):001789691882462. https://doi.org/10.1177/0017896918824624
101. Lokuge K, Thurber K, Calabria B, et al. Indigenous health program evaluation design and methods in Australia: a systematic review of the evidence. Aust N Z J Public Health. 2017 Oct;41(5):480–2. https://doi.org/10.1111/1753-6405.12704 PMid:28749539
102. LaFrance J, Nichols R. Reframing evaluation: defining an indigenous evaluation framework. Can J Progr Eval. 2008;23(2):13–31.
103. Chouinard JA, Cousins JB. Culturally competent evaluation for aboriginal communities: a review of the empirical literature. J Multidiscip Eval. 2007;4(8):40–57.
104. US Department of Health and Human Services. Healthy People 2030. Washington, D.C.: US Department of Health and Human Services, 2020. Available at: https://health.gov/our-work/healthy-people-2030.
105. Barna M. Healthy People 2030 charts new course for nation: newest edition shares 355 measurable, streamlined objectives. The Nation's Health. 2020 Oct;50(8):1–8. Available at: https://thenationshealth.aphapublications.org/content/50/8.

Share