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OPREVENT2 was a multilevel, multicomponent (MLMC) adult obesity prevention that sought to improve access and demand for healthier food and physical activity opportunities in six Native American communities in the Southwest and Midwest. OPREVENT2 worked with worksites, food stores, schools (grades 2-6), through social media and mailings, and with a local community action committee (CAC), in each of the three intervention communities, and was implemented in six phases. We conducted a process evaluation to assess implementation of each intervention component in terms of reach, dose delivered and fidelity. Implementation of each component was classified as high, medium or low according to set standards, and reported back at the end of each phase, allowing for improvements. The school and worksite components were implemented with high reach, dose delivered and fidelity, with improvement over time. The school program had only moderate reach and dose delivered, as did the social media component. The CAC achieved high reach and dose delivered. Overall, study reach and dose delivered reached a high implementation level, whereas fidelity was medium. Great challenges exist in the consistent implementation of MLMC interventions. The detailed process evaluation of the OPREVENT2 trial allowed us to carefully assess the relative strengths and limitations of each intervention component., (© The Author(s) 2020. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Obesity and other nutrition-related chronic disease rates are high in American Indian (AI) populations, and an urgent need exists to identify evidence-based strategies for prevention and treatment. Multi-level, multi-component (MLMC) interventions are needed, but there are significant knowledge gaps on how to deliver these types of interventions in low-income rural AI communities., Methods: OPREVENT2 is a MLMC intervention targeting AI adults living in six rural reservations in New Mexico and Wisconsin. Aiming to prevent and reduce obesity in adults by working at multiple levels of the food and physical activity (PA) environments, OPREVENT2 focuses on evidence-based strategies known to increase access to, demand for, and consumption of healthier foods and beverages, and increase worksite and home-based opportunities for PA. OPREVENT2 works to create systems-level change by partnering with tribal stakeholders, multiple levels of the food and PA environment (food stores, worksites, schools), and the social environment (children as change agents, families, social media). Extensive evaluation will be conducted at each level of the intervention to assess effectiveness via process and impact measures., Discussion: Novel aspects of OPREVENT2 include: active engagement with stakeholders at many levels (policy, institutional, and at multiple levels of the food and PA system); use of community-based strategies to engage policymakers and other key stakeholders (community workshops, action committees); emphasis on both the built environment (intervening with retail food sources) and the social environment. This paper describes the design of the intervention and the evaluation plan of the OPREVENT2., Trial Registration: Clinical Trial Registration: NCT02803853 (June 10, 2016).

This article reveals women caregivers' perceptions and coping strategies to improve households' food and physical activity habits. Results emerged from the pre-intervention formative research phase of a multi-site, multi-level obesity prevention pilot intervention on American Indian (AI) reservations. Using purposive sampling, 250 adults and children participated in qualitative research. Results reveal that having local institutional support was a key structural facilitator. 'Family connectedness' emerged as a key relational facilitator. Hegemony of systems, food deserts, transportation, and weather were key structural barriers; Childcare needs and time constraints were key relational barriers. Women's coping strategies included planning ahead, maximizing, apportioning, tempting healthy, and social support. Findings informed the development and implementation of a novel obesity prevention pilot intervention tailored for each participating AI community addressing culturally relevant messages, institutional policies, and programs. We conclude with future consideration for comparative, ethnicity-based, class-based, and gender-specific studies on women's coping strategies for household health behaviors.

The relationship between dietary patterns and chronic disease is underexplored in indigenous populations. We assessed diets of 424 American Indian (AI) adults living in 5 rural AI communities. We identified four food patterns. Increased prevalence for cardiovascular disease was highly associated with the consumption of unhealthy snacks and high fat-food patterns (OR 3.6, CI=1.06, 12.3; and OR 6.0, CI=1.63, 22.1), respectively. Moreover, the food-consumption pattern appeared to be different by community setting (p<.05). We recommend culturally appropriate community-intervention programs to promote healthy behavior and to prevent diet-related chronic diseases in this high-risk population.

The prevalence of obesity is significantly higher among American Indians (AIs) and is associated with increased rates of diabetes, hypertension, and cardiovascular disease. We implemented a 14-mo intervention trial (Navajo Healthy Stores) on the Navajo Nation that sought to increase availability of healthier foods in local food stores and to promote these foods at the point of purchase and through community media. We divided the Navajo Nation into 10 store regions, half of which were randomized to intervention and half to comparison. We evaluated the program by using a pre-post sample of systematically sampled adult Navajo consumers (baseline, n = 276; postintervention, n = 145). Intervention impact was examined by analyzing pre-post differences by intervention group and by intervention exposure level. When intervention and comparison groups were compared, only body mass index (BMI) showed a trend toward impact of the intervention (P = 0.06). However, greater exposure to the intervention was associated with significantly reduced BMI (P ≤ 0.05) and improved healthy food intentions (P ≤ 0.01), healthy cooking methods (P ≤ 0.05), and healthy food getting (P ≤ 0.01). With increasing exposure, the odds of improving overweight or obese status was 5.02 (95% CI: 1.48, 16.99; P ≤ 0.01) times the odds of maintaining or worsening overweight or obese status. In summary, a food store intervention was associated with reduced overweight/obesity and improved obesity-related psychosocial and behavioral factors among those persons most exposed to the intervention on an AI reservation.

Background: Pathways was a large-scale, multisite, 3-year, study testing a school-based intervention designed to lower percent body fat in American Indian children., Methods: At the 21 intervention schools process evaluation data were collected for training of school personnel; implementation of the classroom and physical activity curricula; implementation of the project's food service guidelines in the school cafeterias; adult participation in the family events; and, students' perceived exposure to the Pathways interventions., Results: Students received about 93% of the classroom curriculum lessons. The minimum requirement of physical education being taught three times per week for at least 30 minutes duration was achieved by the fifth grade. The implementation of the food service behavioral guidelines increased from 51% in the third grade to 87% in the fifth grade. The family events had lower than anticipated adult participation. The participation rates were 45% during the third grade, and 41 and 63% during the fourth and fifth grades, respectively. There was a significant difference between intervention and control students' perceived exposure to Pathways type interventions., Conclusion: The Pathways interventions were successfully implemented with good reach, high extent, and fidelity.