Developing a culturally relevant physical activity guide for Alaska Native Head Start students in rural Alaska: the Got Neqpiaq? Study

ABSTRACT

Background: Concern was voiced by Elders, teachers, and parents that and playtime activities of the Head Start preschool programme were not aligned with the local Alaska Native culture in their communities.

Methods: The Alaska Native Tribal Health Consortium partnered with 12 Head Start preschool programmes, administered by Rural Alaska Community Action Program in rural Alaska, to explore with community members Alaska Native value-based solutions to the concerns they raised. Local input was gathered via focus groups, interviews, and surveys.

Results: We worked together with communities to create a physical activity guide specific to preschool-age children in the region. The guide includes activity descriptions, lesson plans, flash cards, and photos of traditional Alaska Native physical activities and games specific to the region. This manuscript details the community engagement process foundational to the physical activity guide’s adoption and implementation.

Conclusions: The processes by which the guide was developed were strength-based and participatory. Widespread community engagement and participation led to a guide that was readily adopted because the community had taken ownership of the content. The lessons learned have been invaluable in developing long-term community-based partnerships and in setting the precedent to further incorporate local/regional culture into rural Alaska Head Start programmes.

KEYWORDS:

• Head Start
• Alaska native
• physical activity
• community based participatory research
• engagement

Introduction

The Alaska Native Tribal Health Consortium (ANTHC) is a non-profit Tribal health organisation designed to meet the unique health needs of Alaska Native and American Indian people living in Alaska. It was established as a consortium of the 12 regional health organisations in Alaska and is the largest and most comprehensive Tribal health organisation in the United States. The researchers who initiated this study are housed in the Research Department with the Division of Community Health in ANTHC.

Photo 1. children ice-skating.

Head Start is a federally funded programme that prepares Alaska’s children and families with low incomes for school and life success through comprehensive services in early education and family well-being. Children benefit from educational services and healthcare support. Their lessons reinforce social skills, emotional wellbeing, language understanding, and cultural connectedness and identity. All families enrolled in Head Start receive medical, dental, mental health, and social services [1].

The Rural Alaska Community Action Program (RurAL CAP) is a statewide non-profit organisation working to improve the quality of life for low-income Alaskans. They operate Head Start programmes throughout Alaska including 12 preschools in Southwest Alaska.

There are several background factors that influenced this project. As researchers, clinicians, and epidemiologists, our initial concern was addressing childhood obesity. However, when we met with our community partners, we realised that we needed to adopt a broader lens. The community’s perspective was that children were not eating their traditional Native foods and they were spending too much time indoors. The project’s success depended upon merging these perspectives. Consequently, the scientific rationale for this project presented below was expanded so that it took into account both perspectives.

Scientific rationale

In 2020, Alaska Childhood Understanding Behaviors Survey conducted by the Center for Disease Control and Prevention reported a 38% prevalence of obesity among 3-year-olds statewide [2]. Additional data provided by the Rural Alaska Community Action Program, Inc. (RurAL CAP) documented as much as 68% of preschoolers in some remote rural communities were above the 85^th percentile for body mass index (BMI). These statistics are concerning because overweight children are at risk for adult obesity and associated chronic diseases, such as type 2 diabetes, hypertension, fatty liver disease, heart disease, and stroke [3–7].

The U.S. Department of Health and Human Services Head Start Performance Standards for Head Start (HS) programs nationwide recognise the importance of physical activity; however, there are no specific guidelines provided or activities recommended [8]. The American Academy of Pediatrics (AAP) recommends that children ages 3 to 5 years get a minimum of 60 minutes and up to several hours of daily unstructured physical activity [9]. The AAP also recommends that preschool children engage in at least 60 minutes of daily structured physical activity. However, one study found that less than half of Head Start preschool programmes meet these two recommendations [10].

There are many evidence-based interventions focused on increasing physical activity in preschool settings; however, none have focused on Alaska Native (AN) children [11–14]. The AN cultures have a rich history of traditionally active lifestyles filled with Native sports, dancing, and subsistence activities. These traditional activities are valued by many communities because of their relevance in maintaining their connections to the land, culture, community, traditions, and personal identity [15].

Cultural and community influences are significant determinants in children’s health and development. When children identify personally and culturally with lessons being taught, they are more likely to attain mastery of the lesson in addition to other positive outcomes, including coping skills, self-esteem, and optimism [16,17]. The Alaska Native (AN) Elders and parents who participated in the study focus group discussions concurred, insisting that preschool age lessons and activities should focus on developing cultural awareness and teaching important traditional values, skills, and healthy lifestyle habits [18]. Recognising the need for activity-promoting programmes that are culturally-driven, connected to community values and lifestyles, this project team embarked upon developing the first culturally resonant physical activity guide for HS children ages 3-to-5 years old living in 12 communities located in the remote rural Yukon-Kuskokwim region of Alaska. Although this paper details this community-based participatory process specific to the development of a physical activity guide for preschool Alaska Native children, we believe this process could easily be adopted in addressing larger health concerns in a community setting.

Methods

Project background

Researchers at the Alaska Native Tribal Health Consortium (ANTHC) partnered with RurAL CAP and the Head Start preschool programmes in 12 AN communities in the Yukon-Kuskokwim region to understand and address community concerns about preschool health and education. This partnership resulted in the implementation of the Got Neqpiaq? study. Neqpiaq is the Yup’ik word for “real food” which addresses a primary outcome of the study and is described elsewhere in depth [19]. Briefly, Got Neqpiaq? had three aims: (1) increase the proportion of nutrient-dense foods consumed, both traditional and non-traditional, (2) decrease consumption of sugar-sweetened beverages, and (3) reduce the proportion of AN children who are ≥ 95^th percentile for height/weight See Figure 1.

Figure 1. The Physical activity guide development process.

The Got Neqpiaq? study emphasised the inclusion of traditional foods in HS menus to provide healthy food choices to decrease overweight prevalence. Traditional foods in this region of Alaska includes land mammals, marine mammals and fish, sea, pond, and tundra greens, birds, and berries. The study also emphasised increased physical activity among children as a way to promote health and as a way to connect to their Yup’ik culture. This need for outdoor and indoor play was also recognised and articulated by community members and HS teachers. Thus, a physical activity guide was an important step in addressing community concerns and in standardising physical activity levels among participating HS programmes.

Considering the strong relationship between childhood dietary and physical activity habits and with subsequent adult food choices, activity levels, and overall health [20,21], the focus of this part of the project was to develop a physical activity guide for HS preschool teachers which provided them the structure for implementing and standardising physical activity into the school day in a manner that was culturally-based and consistent with their Yup’ik values.

Theoretical background

The project team adopted a community-based participatory research CBPR) approach, based on the nine principles proposed by La Veaux and Christopher when working with Tribal communities [22]. This approach recognises Tribal sovereignty, builds on the strength of communities, recognises the importance of community-defined problems, adopts a cyclical and iterative process to mutually develop solutions, and utilises indigenous ways of knowing. These principles were incorporated into our every interaction with our community partners. When we first began the study, we met in person with Tribal leaders in each community. This accomplished two things: It provided validation for us to do the study in the community and it gave us their permission to be in their community and meet with their community members.

The ANTHC researchers initially focused on childhood obesity in the region. This approach was restructured by communities in two major ways: 1) Instead of a focusing on obesity, the community wanted to address childhood wellness; and 2) The community regarded physical activity as a way to achieve child wellness. The participatory research process was greatly enhanced by listening to and adopting the community definition of the issues and their solutions. This also allowed the issues to be reframed as solutions and strength-based. The subsequent course of action by which we re-planned the study objectives was highly interactive and mutually beneficial. The most important outcome of this process was that the community took ownership of the implementing the solutions.

Head start setting

Rural Alaska Community Action Program (RurAL CAP) manages 12 HS preschool programmes in the southwest Yukon-Kuskokwim region. Each RurAL CAP HS (HS henceforth) preschool class is scheduled between four and six hours, four days a week, depending on the community. The total population of these 12 communities ranged from 423 to 1367 persons with the average being 676. Teachers in these programmes are predominantly Alaska Native (AN) community members, many of whom have had their own children enrolled in their local HS. These 12 HS programmes are administered by RurAL CAP, which employs teachers, cooks, and facility staff locally, and closely monitors classes to ensure they are aligned with programme goals, objectives, and activities and federal regulations.

Project Team

The physical activity guide project team was made up of an ANTHC research lead, an ANTHC registered dietician (RD), and the RurAL CAP RD. The ANTHC RD was well versed in child physical activity planning. She had formerly been the RD for RurAL CAP’s HS programmes and was familiar with each of the community programmes and settings as well as the indoor space and outside environmental limitations. Both the ANTHC research lead and the two RDs had many years of experience working with AN families and Tribal leaders in the participating region.

The project team sought input from AN Elders, HS teachers, HS parents, and storekeepers in the 12 communities by holding focus group discussions and interviews [18,23,24]. Focus group participants were self-selected and were felt to be a representative subset of the community. Interviews were held with key informants in the community and included Elders and Tribal leaders.

In addition to community input, the project team sought guidance from RurAL CAP programme directors, child development coordinators, and the health coordinator for the 12 HS programme sites to ensure HS programme alignment and invite suggestions. Suggestions included the following points: (1) teach fundamental movement skills (e.g. jumping, balance, throwing, kicking, catching), (2) incorporate required learning objectives in key development areas when possible (e.g. social-emotional, language, maths, literacy and cognitive), and (3) ensure gross motor skills activities meet one or more of the core HS physical development objectives (i.e. improved movement, balance, and object manipulation). The RurAL CAP education department suggested a minimum of 30 activities be included to enhance choices and recommended individual activities be placed on separate, laminated, 3-hole punched 8 × 10 inch cards for easy removal from and replacement in a physical activity binder.

Activity guide development process

A common theme among the discussions and interviews with the community was the high value placed on teaching young children a healthy traditional way of life, which included more traditional foods and more culturally relevant physical activities. Based on the input from these discussions, the project team incorporated the following key concepts: (1) educate children from a cultural perspective; (2) incorporate physical movement activities throughout the day; (3) encourage opportunities for the children to learn from community Elders; and (4) introduce HS children to the cultural activities related to hunting, fishing, and gathering traditional foods in their community.

Incorporating the needs and recommendations from the community, the RurAL CAP education team, and professional guidelines, the ANTHC RD initiated the development process with an original draft of 38 unique physical activities. The activities were created to support cultural responsiveness, a strength-based approach grounded in respect and appreciation for the role of culture in children’s learning and development [25].

When selecting activities, it was important to acknowledge and incorporate the HS preschool and community environments. Most national physical activity curricula contain references to objects or practices unfamiliar to children in the 12 participating AN communities, and do not reflect Yup’ik culture or take into consideration the remote Alaskan environment. While it can be appropriate to introduce objects and practices not seen in a child’s immediate environment, it is just as important to include familiar objects and cultural practices. Programme coordinators also emphasised that activities be easily adaptable to indoor performance due to potentially inclement weather and limited outdoor play space. Furthermore, many HS buildings had restricted indoor space, so indoor activities or games, such as tag, would not work for many sites.

As described above, the 12 communities in this study are located in a remote areas of Alaska and are not connected to a road system. Objects that might be considered normal in more urban areas, are often not seen in these communities. For example, a child would not see a firetruck or police car but would be familiar with a four-wheeler or snow machine. On the other hand, there are common objects in these remote rural Alaska communities that would be atypical in other places, such as ice roads, fish wheels, smokehouses for drying fish, snow machines, and dog sled teams. There are also Yup’ik traditional practices that are an important part of a child’s life, such as berry picking and fishing. Thus, the activities included in this physical activity guide were designed to reflect local environments and included activity variations if a teacher wanted to further adapt the activity to reflect their unique community.

The communities and project team agreed to implement a 30-minute minimum requirement for structured physical activity during each school day. This was in accordance with the AAP recommendation of 30 minutes of structured play for half-day preschool programmes [9]. Each activity in the physical activity guide was designed to take approximately 15 minutes for each class to perform, so HS teachers could easily select two physical activities for their lesson plans each day. Each activity card included a list of materials needed, the steps to performing the activity, and a brief description of how the activity contributed to learning and physical development goals. All activities were designed to be used in an indoor classroom setting.

Upon review by the RurAL CAP programme coordinators, several changes in terminology were recommended to make activities more relevant to preschoolers. For example, “Snowball Fight” was changed to “Snowball Toss”, “Simon Says” was changed to “Aunty Says” and “Stop/Go” was changed to “Ice Statues”. Other changes were made to use vocabulary more familiar to the teaching staff and the local community.

The initial draft of the physical activity guide was sent to the RC HS teachers in each of the 12 YK communities in April 2019. HS teachers were invited to test the different activities in their classrooms and provide feedback concerning the children’s and teacher’s likes, dislikes, and ideas for change. Due to the limited time left in the school year, each community was asked to test a specific set of the activities so that all activities were tested. To make the draft more culturally relevant to these Yup’ik communities, the project team encouraged HS teachers to photograph children (whose parents had signed photo release waivers) participating in the activities during class. Importantly, the team invited teachers to share their comments and any adjustments they had made to the draft as they were teaching that could be helpful to include in the next draft. All photos and draft ideas were submitted to the RurAL CAP RD for review and presentation to the project team. The project team also requested teachers volunteer their ideas for tracking the physical activities on a daily and weekly basis.

Results

After the 6-week pilot of the activity guide, the HS teachers in the study communities described their experiences with leading the different activities. The teachers’ and children’s response to the activities were positive, and teachers readily shared their class activity photos and provided thoughts and ideas for several additional activities and adaptations. Each teacher provided their comments and photos via email and all of their feedback was incorporated in some way. For example, one teacher adapted the berry picking activity to make it reflect the more traditional way of berry picking in her community. This adaptation, as well as many others, was included in the final version.

Ninety percent of the teachers commented that they appreciated that the physical activity guide provided suggestions for how they could incorporate regular physical activity into the classroom. Related comments included appreciation that the lesson plans promoted traditional activities and cultural values. Half of the teachers stated that having a guide led to higher levels of engagement by children during structured play. All of the teachers stated that children were excited to try the new activities and that they enjoyed playing games in new ways. These outcomes were additionally captured in a review of programme adherence to Head Start standards [7]. There was a significant increase from baseline in structured physical play as well teacher documentation of play times (unpublished Head Start data).

During the summer of 2019, the RurAL CAP RD reviewed all activity quotes, ideas, and photographs submitted, matching them to their corresponding activities. Applicable photos and ideas shared by HS teachers were included in the final guide approved by RurAL CAP. A revised edition of the physical activity guide was mailed to each site at the beginning of the 2019–2020 school year. Upon receipt, teachers remarked that there was much excitement over seeing Yup’ik children performing the in-school physical activities. More importantly, teachers liked the guide served as a curriculum with lesson plans and activity descriptions that were adapted to their community values.

Discussion

Requested by community Elders and members to enrich the HS programming so that it was more culturally relevant, the Got Neqpiaq? study team developed a culturally responsive physical activity guide with 12 HS programmes using a participatory community based process. Through this process, the HS physical activity programme was standardised according to national recommendations and was adapted to the local community values, culture, and lifestyles.

The positive benefits of physical activity are well studied and recommendations for activity in the classroom should be considered standard in early child education settings [26,27]. Regular, structured physical activity in preschools is important in developing motor skills and brain plasticity in early childhood. In a study where children were placed in either a control group preschool, or a preschool that utilised a structured 24-week physical activity curriculum, children in the group with structured activity significantly improved their psychomotor profiles versus the control group [25]. When developing an early childhood health-related curriculum, it is essential that it is culturally driven and culturally responsive. When students are able to connect with their cultural identity during lessons, they are more likely to engage and their pride, confidence, and self-esteem are more likely to increase [28]. The Got Neqpiaq? team developed this guide using a process of assessing community perceptions and needs, consulting with child development experts, developing culturally responsive activities, pilot testing the initial draft, and providing multiple opportunities for community and teacher feedback, pictures, and quotes to be incorporated into the final version draft.

Throughout project development and pilot testing, there were multiple feedback loops to create a culturally grounded curriculum. Preliminary interviews with Elders, HS teachers, and parents, and the RurAL CAP HS education team provided a foundation to begin guide its development. Edits from the child-development team provided strength in supporting early childhood education needs. The pilot test implementing and tracking activities, and feedback from teachers provided additional ideas and enriched the final version.

In review, the project team acknowledged that there was little opportunity offered the local community HS teachers to provide activity ideas for the initial draft. Involvement of the teachers earlier in the design and development process may have provided an even stronger sense of cultural relevance and project ownership during the pilot. After seeing the unexpectedly high interest in providing feedback to the guide, this important principle was recognised; it is essential that local teachers, who are well versed in the community and cultural environments of their students be involved at every stage of development. We realised that the local expertise was essential in the development of the guide and invaluable in its eventual adoption. Recognition of the importance of this guiding principle provides a foundation for all culturally-driven partnerships. It is our strong recommendation that all partners are engaged early in all aspects of a study. Community ways have tremendous bearing on the success of an intervention. Unrecognised, community ways can derail the best designed study. Recognised and integrated, community ways will embrace a study as their own. The culturally and community driven development process described in this paper provided greatly needed community insight to RurAL CAP HS teachers and the Got Neqpiaq? research team on foundational principles for developing successful health education interventions. By developing relationships and addressing the values and needs of community leaders, teachers, and parents prior to interventions being developed, interventions can better meet individual, cultural, and community needs. Involving community members in each step of development produces more opportunities to learn from, better portray, and celebrate the values and depth of a culture. Promoting healthy behaviours with a locally relevant physical activity guide that reflects the shared values and cultural identity of the students and their community is key to successful programme implementation, sustained engagement in physical activities, and healthy adherence to physical activity into adulthood.

Ethics statement

This portion of the Got Neqpiaq? study was conducted using a community-based participatory approach. RurAL CAP and Head Start programme staff provided feedback voluntarily and anonymously as employees of RurAL CAP. No personal information was collected. Parents of all children whose photographs were included in the final edition of the physical activity guide signed photo release forms waiving the requirement for signed parent consent. Got Neqpiaq? was approved by the Indian Health Service Alaska Area Institutional Review Board (protocol # 2017-10-047) and by the Alaska Native Tribal Health Consortium and the Yukon Kuskokwim Health Corporation boards of directors.

Geolocation information

The coordinates for the study’s hub community is: 60.79548521760368, −161.77003883063355

Acknowledgments

Quyana (“thank you”) to the Head Start families and staff, the Yup’ik Elders, and AN members of the 12 participating Y-K communities who provided input on local traditions and suggestions for vocabulary words, activities, artwork, and revisions to this guide.

Disclosure statement

We confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome.

Additional information

Funding

This work was supported by the This study was supported by the NIH National Institute of Nursing Research under Award Number 1R01NR015417.