Structure, culture, and agency: Framing a child as change agent approach for adult obesity prevention in American Indian households

BACKGROUND: Despite growing research on the obesogenic environment, majority of interventions that focus on individual behavior change and environmental change observe limited success. The social environment plays a key role in the development and prevention of obesity and related chronic diseases among American Indian/Alaska Native (AI/AN) populations. There is an urgent need to further study the role of social environmental factors such as the household, family members including children, and social support, in order to have greater success for preventing obesity. This is the first study of its kind to understand the role of child influence and household social factors upon adult diet and physical activity habits in American Indians across two regions in the United States. Study findings have important implications for the development and design of comprehensive obesity prevention interventions across American Indian populations and for a broader multicultural context.;METHODS: This dissertation project borrows for the Socio-ecological Model, anthropological and microeconomic theories guiding principles, and specific constructs from Social Cognitive Theory and Theory of Planned Behavior to describe the dynamic relationship between structure, culture, and agency. Methods include qualitative research (formative assessment) and quantitative research methods (survey design), to explore the role of macro-system, mezzo-system, and micro-system factors upon adult food and physical activity habits. Regional differences, socio-demographics, household environment, social support, child influence, and adult psychosocial factors were evaluated.;RESULTS: AI/AN household members, adults and children, are engaging in health strategies to reduce their risk of obesity and diabetes. Health knowledge and motivation and commitment for making health behavior changes, in the form of food shopping, food preparation, and physical activity habits, are substantial. Children are already acting as change agents within American Indian households. Children mediate the influence of the region of residence and adult healthy food getting habits. Adult health attitudes mediate the influence of the region of residence on adult healthy food preparation methods. Adult food self-efficacy mediates the relationship between child influence and adult healthy food getting habits.;DISCUSSION: Taking a socio-ecological approach to understand the role of household health strategies and the social environment of adults for obesity prevention is necessary. Specifically, socio-ecological framework and Social Cognitive Theory and Theory of Planned Behavior constructs explain some of the key relationships between regional differences, child influence, adult psychosocial factors, and adult diet and physical activity behaviors. However, there is a need to further study the role of social and relational factors, including the role of children in adult psychosocial and behavioral factors to improve obesity prevention efforts for populations that are family-centered such as American Indian cultures.;CONCLUSIONS: Traditionally, adult caregivers have been viewed in public health as the change agents and the source of influence of change. However, this study contributes to a growing corpus of evidence that children influence adults' psychosocial factors and food and physical activity related health behaviors. This study contributes towards an important paradigm shift in public health interventions involving children as change agents for adult health behaviors. This study proposed a social ecological framework for approaching child as change agents for food and physical activity. The themes identified in this study include cultural resiliency and structural vulnerability, institutional support, community sense, household factors, and the child-adult relational factors to describe households undergoing food and physical activity changes. Within this framework, this study has identified children's attributes and actions, and resiliency and vulnerability. Future research is necessary to measure the impact of children upon adult food and physical activity behaviors. A scoring system should be developed to measure the primary dimensions of children's change agency. A scoring system for children's agency will be beneficial household-focused food and physical activity programs for adult obesity prevention. This research may also be relevant for other health issues among AI/AN, indigenous, and other ethnic populations.