Developing Diabetes Interventions in an Ojibwa-Cree Community in Northern Ontario: Linking Qualitative and Quantitative Data
Joel Gittelsohn, Stewart B Harris, Sara Whitehead, Thomas MS Wolever, Anthony JG Hanley, Annette Barnie, Louisa Kakegamic, Alexander Logan and Bernard Zinman

Abstract
Non-insulin-dependent diabetes mellitus is a leading cause of morbidity and mortality in North American aboriginal populations. While much research has focused on the pathogenesis and management of the disease, the development of effective primary prevention strategies is in its early stages. This paper presents a model for the use of formative research in the development of diabetes prevention interventions. A variety of qualitative and quantitative data was collected in the research community, an isolated Ojibwa-Cree reserve in Northern Ontario. Preliminary results were presented to the community, and both community members and investigators generated intervention ideas. A template was used to combine qualitative and quantitative data in problem definition, intervention, strategy development and obtaining community feedback. Two focal areas of intervention are presented as examples of this model: children’s consumption of fat and "added fat" consumption by adults. The overall intervention strategy will include a community-based arm (including interventions at the local grocery store and schools as well as a community education/media campaign) and an intensive intervention arm for high-risk individuals. The combination of qualitative and quantitative information can lead to socioculturally appropriate diabetes prevention interventions with good potential to be effective.

Keywords: Aboriginal health; diabetes mellitus, non-insulin-dependent; diet; food; health promotion; Ontario; primary prevention; qualitative research

Introduction

The Sandy Lake Health and Diabetes Project was initiated in 1992 to address this issue. The study’s objectives have already been discussed by Hanley et al. in the preceding article in this issue.10 This paper will focus on the third objective, the development of community-based intervention strategies to prevent diabetes and its complications, based on the formative qualitative and quantitative research.

Background

The linkage of qualitative and quantitative approaches has received increased attention over the past 20 years. It has been observed that the strengths and weaknesses of qualitative research complement those of quantitative research, and the reverse is also true.17 To date, the primary link has been the use of qualitative information to improve quantitative research. This has included the use of qualitative data to generate testable hypotheses and to design better quantitative instruments;18 the conduct of parallel streams of information-gathering that, when combined, yield increased confidence about research findings;19–21 and the use of qualitative data to assist in interpreting quantitative findings.22

Examples of the linkage of qualitative and quantitative methods for the design and implementation of health interventions include developing approaches for smoking prevention,23 developing effective AIDS risk reduction messages for use with commercial sex workers 24 and improving workplace conditions.20 Probably the most concerted set of efforts linking the two approaches has been in the development of a series of problem-focused "rapid assessment" manuals over the past eight years. Starting with the original Rapid Assessment Procedures manual developed by Scrimshaw and Hurtado in 1987,25 there have now been over 10 manuals produced on such topics as acute respiratory infections, women’s health, vitamin A, sexually transmitted diseases, malaria and water sanitation.26

In this paper, we present a model for linking qualitative and quantitative information to develop interventions targeted to prevent obesity and diabetes in an Ojibwa-Cree reserve. We will emphasize the contributions of formative data only. Certainly, there are other elements that enter into intervention design, such as review of the literature and our own personal experiences, but these will not be considered here.

Setting

The major supplier of food in the community is the Northern, a branch of retail chain that services many remote communities throughout Canada. The federal government’s Northern Food Mail Program partially subsidizes the transportation of perishable foods to these communities. In addition, there are a few small convenience stores that sell a wide range of canned foods, candy, snacks and fast foods (e.g. pizza, fried chicken). The community is considered a "dry reserve"; no alcohol is permitted on reserve land. The area has substantial wild food resources including moose, duck, geese, rabbit, beaver and fish, although hunting, fishing and consumption of these foods is seasonal and limited.

Although the community is remote, it is not lacking in modern technology. Most households have TVs and VCRs, many have satellite dishes and snowmobiles. The community has its own radio and community television stations. The two local schools currently have over 500 students enrolled from kindergarten to grade 12.

The prevalence of NIDDM and impaired glucose tolerance in Sandy Lake is high; based on our study, roughly 16% of the study population over the age of 10 have diabetes, and another 10% have impaired glucose tolerance.

Methods

A wide variety of both qualitative and quantitative data was gathered through the course of the project. Table 1 gives an idea of the range of methods used in conducting the formative qualitative research. These methods consisted of key informant interviews, systematic interview techniques such as free listing and pile sorts, direct observations and review of existing written materials. Themes explored included commonly eaten foods, beliefs about foods, leisure and other activities, and health and illness beliefs. Both children and adults participated as informants and respondents. Results of this data collection and specific details of the methodology have been presented in detail elsewhere.27

Quantitative data were gathered at both the individual and the household level over 20 months (July 1993–March 1995). These data were collected to obtain basic community information on obesity and diabetes prevalence as well as associated risk factors in this setting. For individuals aged 10 or older, a structured survey was performed that included the following components: sociodemographics, health beliefs and knowledge, food frequency (usual food intake over the past three months), 24-hour dietary recall, substance use, activity recall, concepts of body image and a family tree for history of diabetes. Physical examination included anthropometry and assessment of body composition by bioelectrical impedance assessment (BIA). Serum was drawn for laboratory investigations of fasting glucose, oral glucose tolerance test, lipids, creatinine, urea, etc. A 73% participation rate was achieved by testing 728 (out of 1018 eligible) individuals above the age of 10 years.

At the household level, information was collected about household demographics, economic status and food preparation practices from a sample of 250 households. A detailed description of these methods is presented earlier in this issue.10

Model For Developing Interventions Using Qualitative and Quantitative Information

The final steps in intervention development are pre-testing the interventions and obtaining community feedback about their appropriateness and effectiveness. This process is currently under way in the community. Following further refinement, a community-wide strategy will be implemented.

Making a Worksheet
Figure 2 provides a basic template for incorporating qualitative and quantitative research results. The data are initially used to define specific problems, which may be viewed as identifying specific risk behaviours and population subgroups of greatest concern. In formulating an intervention, the data are used to help select the appropriate medium, choose the language and phrasing of the message and identify target groups. Finally, community input and feedback about the appropriateness and effectiveness of the intervention are sought using group techniques.

Applications of the Model

Example 1: Children’s Consumption of Fat

a) Problem definition
The first example addresses the issue of fat consumption by children in the community. Several components of the qualitative data led to the definition of this problem. Direct observations were conducted at the Northern’s delicatessen counter during lunch hours, where many school children go to purchase their lunch. Most of the foods purchased are high in fat, such as pizza pops and nachos. In a separate free listing exercise, local third and fourth grade children listed six high-fat foods in the top ten most commonly mentioned foods, including hamburgers, cereal, pizza pops, pizza, (fried) chicken and chips. In listing what foods they most commonly ate for lunch at home, children named hamburgers, French fries, wieners, soup and French toast.

Parents frequently emphasized the poor eating habits of their children, and their own healthier preference for food from the bush, like fish and moose meat.

The quantitative data supports and complements the findings of the qualitative data analysis. Based on the results of the food frequency survey, children were significantly more likely than adults to report frequent (three or more times per week) consumption of Klik (a canned meat product with 82% of total calories from fat), chips, (whole) milk, pop, chocolate and cookies.

In addition, body composition assessment by BIA supports the finding that obesity prevention in children may be important. The BIA results showed average percent body fat in 10–19-year-old males to be 21.0 (SD = 1.0); and in 10–19-year-old females, 36.7 (SD = 1.1). Both of these averages are well above mean reference values for this age group, especially for females.

b) Intervention strategy
The interventions being developed to address this issue have two components: one based in the schools, the other at the Northern Store. In the schools, the project will work with teachers and parents to develop a health and nutrition curriculum. At the Northern Store, we will work with an existing store-based health education project. Icons will be supplied to label food choices as healthy or unhealthy, and lower fat choices (e.g. lower fat pizza pops) will be made available. Some of the messages will advise children to "choose lower fat foods" and that "foods with a lot of fat can be unhealthy."

Where did these ideas come from? Portions of the qualitative data suggested working on the school curriculum. Pile sort exercises found that, as early as the second and third grade, children categorize some foods as "junk foods" and feel they are unhealthy. Children also recognize sweet foods as unhealthy. Thus, children in Sandy Lake already have a sense of the healthiness and unhealthiness of food. Currently there is no health or nutrition curriculum until ninth grade. However, there is strong teacher interest to begin one in earlier grades.

Changes in the foods available at the Northern’s delicatessen will likely have some impact as well. Parents report that children prefer "junk foods" to bush foods: "They used to eat Indian foods when they were small, but they don’t really like it now. Now they only like French fries, Klik, beef stew, ... canned food." Thus, children do exercise choice in the selection of food in their environment, particularly when they are on their own, getting food during the school lunch period.

Differences in the eating habits of children and adults in the community will help us target interventions to children. While children eat significantly more snack foods, adults report eating eggs, lard, hot cereal, soup, potatoes (not French fries or chips) and tea significantly more often than children. We will use this information to develop age-specific, food-specific messages.

Community input and feedback about these interventions will be sought in the summer and fall of 1995.

Example 2: Added Fat Consumption

a) Problem definition
Another important problem identified through the formative research is that of "added fat consumption." This term is used for the fat added to commonly consumed foods, such as putting butter on bread and bannock or adding evaporated milk to tea.
The qualitative information that led us to this problem came from several sources, including pile sorts. In this exercise, local adult respondents were asked to group 35 different commonly consumed foods into three piles: a) healthy; b) unhealthy; and c) not healthy, not unhealthy. Many respondents put grain-based foods into a "not healthy, not unhealthy" pile. Foods like bannock, tea and bread were felt to be neutral in their effect on the body, with some informants remarking, "These don’t do anything," or "You can eat as much as you want." However, direct observation showed that people in the community commonly put large amounts of butter or lard on bread and bannock, and evaporated milk in their tea. These foods are therefore not as dietarily "neutral" as people might believe.

The quantitative food frequency data were helpful in confirming the importance of the issue of added fat consumption. Most of the frequently (3+ times/week) consumed foods were store-bought foods such as tea (94%), white bread (90%), butter/lard (80%), evaporated milk (73%) and pop (64%). The majority of the 10 most frequently consumed foods on the list are either high in fat or are commonly consumed with added fat. The least frequently consumed foods tended to be wild foods, available only during specific seasons. For example, only 16% of the population reported eating moose three or more times a week.

The following added fats were consumed daily by the given percentages of the population: evaporated milk, 67%; lard or butter, 66%; margarine, 48%. The corresponding figures for foods to which fat is added are bannock, 43%; white bread, 79%; tea, 90%.

b) Intervention strategy
The intervention strategy planned to address the issue of added fat consumption will be a broad-based community education program, including the creative use of a variety of community mass media strategies to pass on the message to "use less added fat." These messages will be addressed to community members of all ages and will be delivered in both English and Oji-Cree.

Our health education messages will focus on those specific foods that contribute the most added fat to the diet. Out of over 300 different foods consumed in the community, only 20 foods accounted for 77.1% of total fat consumption (grams). Four of these foods consumed as added fat—lard, evaporated milk, butter and margarine— account for 14% of the total amount of fat consumed. The single highest source of fat in the diet, bannock (11.6% of the total amount of fat consumed), is also commonly eaten with added fat. Efforts to reduce the amount of fat in the diet will focus on reducing the amount of lard and butter eaten on bannock, replacing whole evaporated milk with 2% evaporated milk and encouraging people to try bannock recipes with reduced fat. We anticipate a reduction of total fat intake by 5–10% in individuals by intervening with these foods alone.

The qualitative information suggesting a community-wide mass media intervention strategy included multiple observations that radios are commonly left on all day long, tuned to the community station. Most community announcements are made on radio, which is seen as a source of "service, information and help." Local television is another means of communication for special community events, such as funerals and fund-raising activities. These community media are effective ways of reaching a broad spectrum of the population on a regular basis. The quantitative data support the use of these media, as our questionnaire of material possessions revealed that 100% of homes have working radios, 99.2% have televisions and 78.7% have VCRs. Of course, health education messages to reduce the amount of added fat will also be communicated and reinforced in many other ways through other components of the intervention plan, including activities such as home visiting and health fairs.

Community input and feedback concerning these strategies will be sought in the summer and fall of 1995.

Overall Intervention Strategy

Community-based Strategy
The community-based arm of the intervention strategy will emphasize three areas.

• THE NORTHERN: Interventions will include increasing the selection of low-fat foods available, organizing shopping tours with information about healthier food choices, setting up information displays about nutritional content of foods, labelling foods with icons according to fat content and demonstrating recipes. These interventions will be conducted in partnership with the Northern, which is initiating its own program to promote healthful eating using many of the same elements.
• SCHOOL: School children currently have limited opportunities for a nutritious lunch since neither school has a cafeteria. Most of the children obtain their lunches through fast food outlets in the area, including the school snack store (The Pit Stop). Grades 4, 5 and 6 will be targeted since our formative work indicates that children begin to show increased control over their own diets at this point. A health and nutrition curriculum will be introduced to the students that will focus on healthier food choices and increased physical activity. In addition, there will be improved access to low-fat foods at the Pit Stop. Through the local school board, parents will be advised of these changes and will be encouraged to participate to provide healthier lunch/snack options.
• COMMUNITY EDUCATION: A major effort to educate the community about healthier lifestyle choices will be undertaken by using the local media. Radio programs will regularly feature broadcasts such as nutrition tips, presentations by elder storytellers and the popular "Dr Diabetes" phone-in shows hosted by the project investigators. The community also houses a local TV studio that will be used to broadcast TV programs demonstrating traditional cooking recipes, traditional activities, interviews and educational videos. Presentations at major community events such as Treaty Days, the Annual Health Fair and feasts will include games and contests, crafts and healthy food stalls. In addition, one-to-one education will be provided through a series of home visits to interested households. These home visits will include nutrition education sessions, low-fat cooking demonstrations and a physical activity component.

The high-risk individuals are defined as those at risk for developing diabetes, i.e. individuals with impaired glucose tolerance and/or significant obesity (body mass index >27) and hyperinsulinemia (highest 20th percentile) who are between 20 and 50 years of age. This group at risk was identified during the previous survey. The intensive lifestyle intervention group will receive enhanced and individualized diet and exercise education, motivational support and increased exercise training from qualified community-based physical activity leaders (PALS) recruited and trained locally. The PALS will have regular and frequent contact with these individuals in order to optimize lifestyle changes.

Overall, this strategy will help to determine if a community approach to lifestyle intervention can be successfully implemented in an aboriginal setting.

Conclusions

Acknowledgements

This project was funded by grants from the National Institute of Health (91-DK-01) and the Ontario Ministry of Health (#04307).

References

2. Long TP. The prevalence of clinically treated diabetes among Zuni Reservation residents. Am J Public Health 1978;68:901–2.

3. Knowler WC, Pettitt DJ, Savage PJ, Bennett PH. Diabetes in Pima Indians: contributions of obesity and parental diabetes. Am J Epidemiol 1981;113:144–56.

4. Szathmary EJE. Diabetes in arctic and subarctic populations undergoing acculturation. Collegium Anthropologicum (Zagreb) 1986;10:145–58.

5. Neel JV. Diabetes mellitus: a thrifty genotype rendered detrimental by ‘progress’? Am J Hum Genet 1962;14:353–62.

6. Knowler WC, Pettitt D, Bennett PH, Williams RC. Diabetes mellitus in the Pima Indians: genetic and evolutionary considerations. Am J Phys Anthropol 1983;62:107–14.

7. Ritenbaugh C, Goodby C. Beyond the thrifty gene: metabolic implications of prehistoric migration into the new world. Medical Anthropology: Cross Cultural Studies in Health and Illness 1989;11(3):227–36.

8. Dowse GK, Zimmet PZ, Gareeboo H, Alberti KGMM, Tuomilchto J, Finch CF, et al. Abdominal obesity and physical inactivity are risk factors for NIDDM and impaired glucose tolerance in Indian, Creole, and Chinese Mauritians. Diabetes Care 1991;14:271–82.

9. Kriska AM, LaPorte R, Pettitt D, Charles M, Nelson R, Kuller L, et al. The association of physical activity with obesity, fat distribution and glucose intolerance in Pima Indians. Diabetologia 1993;36:863–9.

10. Hanley AJG, Harris SB, Barnie A, Gittlesohn J, Wolever TMS, Logan A, et al. The Sandy Lake Health and Diabetes Project: design, methods and lessons learned. Chronic Dis Can 1995;16(4):149–56.

11. Atkin CK, Freimuth V. Formative evaluation research in campaign design. In: Rice RE, Atkin CK, eds. Public communication campaigns. 2nd ed. Newbury Park (CA): Sage, 1991.

12. Gittelsohn J, Bentley ME, Pelto PJ, Nag M, Harrison A, Landman LT, eds. Listening to women talk about their health: issues and evidence from India. New Delhi: Har-Anand Publications, 1994.

13. Helitzer-Allen D, Kendall C, Wirima J. The role of ethnographic research in malaria control: an example from Malawi. Res Sociol Health Care 1993;10:269–86.

14. Helitzer-Allen D, Zukoski A, Newes G, Doniger A. Applying an ecological framework to understand factors contributing to early initiation of sexual activity and social desirability of teen pregnancy: a case study in Monroe County, New York. Health Education Research: Theory and Practice. In press.

15. Lloyd LS, Winch P, Ortega-Canto J, Kendall C. The design of a community-based health education intervention for the control of aedes aegypti. Am J Trop Med Hyg 1994;50(4):401–11.

16. Young TK. The health of native Americans: towards a biocultural epidemiology. New York: Oxford University Press, 1994.

17. Steckler A, McLeroy K, Goodman R, Bird S, McCormick L. Toward integrating qualitative and quantitative methods: an introduction. Health Educ Q 1992;19(1):1–9.

18. Coreil J, Augustin A, Holt E, Halsey NA. Use of ethnographic research for instrument development in a case control study of immunization use in Haiti. Int J Epidemiol 1989;18 Suppl 2:S33–7.

19. Helitzer-Allen D, Kendall C. Explaining differences between qualitative and quantitative data: a study of chemoprophylaxis during pregnancy. Health Educ Q 1992;19(1):41–54.

20. Hugentobler MK, Israel BA, Schurman SJ. An action research approach to workplace health: integrating methods. Health Educ Q 1992;19(1):55–76.

21. Jick T. Mixing qualitative and quantitative methods: triangulation in action. Adm Sci Q 1979;24(4):602–11.

22. Buchanan DR. An uneasy alliance: combining qualitative and quantitative research methods. Health Educ Q 1992;19(1):117–35.

23. de Vries H, Weijts W, Dijkstra M, Kok G. The utilization of qualitative and quantitative data for health education program planning, implementation and evaluation: a spiral approach. Health Educ Q 1992;19(1):101–15.

24. Dorfman LE, Derish PA, Cohen JB. Hey girlfriend: an evaluation of AIDS prevention among women in the sex industry. Health Educ Q 1992;19(1):25–40.

25. Scrimshaw SCM, Hurtado E. Rapid assessment procedures for nutrition and primary health care. Los Angeles: University of California at Los Angeles, Latin American Center Publications; 1987.

26. Manderson L, Aaby P. An epidemic in the field? Rapid assessment procedures and health research. Soc Sci Med 1992;35(7):839–50.

27. Gittelsohn J, Harris SB, Burris K, Kakegamic L, Landman L, Sharma A, et al. Use of ethnographic methods for applied research on diabetes among Ojibway-Cree Indians in Northern Ontario. Health Educ Q. In press.

Author References

Based on a paper presented at the 3rd International Conference on Diabetes and Indigenous Peoples: "Theory, Reality and Hope," held in Winnipeg, Manitoba, May 26–30, 1995.