Tailoring a web-based weight maintenance intervention for Northern Plains American Indian public university students

Abstract

Objective:

High levels of obesity-related health disparities are common among US American Indian (AI) populations. AI public university students often face unique challenges that may contribute to weight gain and related consequences. Few weight maintenance interventions have been developed that meet the needs of AI public university students. The goal of this study was to determine how to tailor Project Y.E.A.H. (Young Americans Eating and Active for Health), a web-delivered, weight maintenance tool developed for college students to make it culturally relevant for AI public university students.

Methods:

Three mini focus groups (N = 15) and five in-depth interviews (N = 11) were conducted with self-identified AI college students on the campus of South Dakota State University. Participants were recruited with assistance from the American Indian Education and Cultural Center and through campus publicity. Recorded sessions were transcribed and multistep coding was used to assess the aesthetic appeal of the website and determine variations of certain health-related factors.

Results:

AI public university students have specific and culturally influenced aesthetic, food and physical activity exposures and preferences. AI students may perceive unique stressors compared to non-AI students and practise cultural forms of stress relief.

Conclusion:

Specific and culturally relevant psychographic information regarding AI college student preferences is needed for the development of effective weight maintenance tools.

Keywords

Educational technology US American Indians online USA weight maintenance

Introduction

About 1.7% of the US population or 5.2 million individuals self-identify as American Indian/Alaska Native (AI/AN), and over 2.1 million are under the age of 24 years. (Norris et al., 2012). The US AI population faces significantly greater rates of obesity and related health disparities compared to national standards (Jernigan et al., 2010). An Indian Health Services (IHS) report estimated that in 2011, 80% of AI/AN adults were either overweight or obese. High rates of obesity among young adults are associated with coexisting and future health complications. Obese AI/ANs under the age of 30 years are 70% more likely to have two or more physician-diagnosed medical conditions (Slattery et al., 2010). Although health disparities exist for the AI/AN population as a whole compared to national standards, health disparities also exist among AI/AN groups living in different geographic regions of the USA (Burrows et al., 2000). In particular, AIs living in the Northern Plains have a significantly greater prevalence of diabetes, coronary heart disease, myocardial infarction, smoking, obesity and heavy alcohol use compared to regional and national samples (Holm et al., 2010).

University students are at a high risk of weight gain (Crombie et al., 2009; Nelson et al., 2008; Racette et al., 2008) and related complications, which are often attributed to increased stressful life-transitions that negatively impact health-related behaviours (Crombie et al., 2009). AIs in the typical college age range (18–24 years) have greater rates of obesity (Slattery et al., 2010), hypertension and diabetes (Carter et al., 2000) than non-AIs in this age group, which have continued to climb over the years (Jernigan et al., 2010). This group has also been found to endure other harmful health-related consequences. As a whole, this age group of AIs drinks alcohol more heavily and experiences more negative life consequences related to drinking compared to students of other ethnicity (Cameron, 1999; Mullany et al., 2009). Young adult AIs also have the highest rates of smoking (Ward and Ridolfo, 2011), suicide mortality (Mullany et al., 2009) and post-secondary education dropout rates in the nation (Reddy, 1993).

The IHS (2011) has stated that ‘treating obesity and overweight is essential for preventing and treating diabetes, cardiovascular disease and many other chronic conditions that take a major toll on the lives of AI/AN’ (p. 9). Previous efforts to treat obesity and related conditions have stressed the importance of culturally tailored interventions for effective disease and obesity prevention among AIs (Mendenhall et al., 2012; Schmidt-Grimminger et al., 2013; Unger et al., 2008; Wilhelm et al., 2012; Wood et al., 2005). The success of former culturally tailored health interventions substantiates the need for more culturally tailored interventions. Few culturally tailored weight maintenance interventions have been developed for use among AI public university students in the USA.

Weight maintenance interventions for college-aged individuals are limited, but may be promising for early prevention of future health consequences. Project Y.E.A.H. (Young Adults Eating and Active for Health) was a theory-based, interactive, web-delivered weight maintenance intervention aimed to prevent excessive weight gain among college students (Kattelmann et al., 2014b). The website was developed using the community-based participatory research (CBPR) approach, which includes guidance from the target audience in the development process (Minkler and Wallerstein, 2011). The Y.E.A.H. study placed an emphasis on education about changeable behaviours for weight management, including healthful eating behaviours, physical activity and coping with stress (Kattelmann et al., 2014a, 2014b).

Despite the large sample population recruited for Project Y.E.A.H., only 0.7% of the study participants (N = 1,630) identified themselves as AI/AN. Consequently, this project was designed to determine how to tailor the previously implemented web-based health maintenance tool, Project Y.E.A.H., to the preferences of Northern Plains AI public university students.

Methods

This project was approved by the South Dakota State University Institutional Review Board. The Y.E.A.H. application was created with the ability to be tailored for a non-university setting or to be used to enhance the reach of needed populations not included in the original Y.E.A.H. study (Walsh et al., 2014). Following the methods used in the development of Project Y.E.A.H., focus groups and in-depth interviews with AI college students were used to evaluate the original format of the Project Y.E.A.H. web tool. Open-ended focus group and interview questions were developed according to standards set by Krueger and Casey (2000). Questions were reviewed and edited by university marketing faculty and approved for use by the leaders of the American Indian Education and Cultural Center (AIECC) on campus. Oral consent was obtained from all participants prior to participation.

Self-identified AI college students (N = 23) were recruited over a period of five non-consecutive months through word-of-mouth, informational flyers, recruitment presentations and referral from leaders associated with the AIECC on campus. Participation criteria included enrolment in a university and self-identified AI descent. AI university enrolment at the beginning of this study was 159 students.

The project was divided into two phases: (1) focus groups were used to independently assess the functionality of the website and (2) in-depth interviews were used to assess the cultural acceptability. Phase 1 was delivered in the fall semester of 2012, and phase 2 was delivered in the spring semester. Two separate sets of open-ended questions were delivered, one at each phase, by a trained moderator. Participants were given a small stipend to compensate their time.

Phase 1 ‘focus group’ questions assessed the website’s aesthetic appeal, navigational ease, language relevance and suggestions for change. Participants were shown all pages of the website on an overhead projector two times, the first time without providing feedback and the second time while prompted to answer focus group questions. Questions ranged from ‘What do you think about the graphics of this site?’ to ‘How does the navigation of this site compare to others that you use?’ After conducting three focus groups using questions querying for functionality, noticeable repetition of major themes and lack of culturally specific information cued researchers to move on to phase 2 questions querying for cultural acceptability.

Phase 2 ‘cultural acceptability’ questions assessed certain health-related factors that were addressed on the website. Questions regarding food, physical activity, support preferences, stressors and time management were delivered through a series of in-depth interviews. To facilitate this process, the actual website was not displayed; however, information collected directly from the site was used to generate questions and provide printed examples from the website. Students were asked to answer phase 2 questions from an individual perspective and then from a cultural perspective. For example, individual questions included, ‘Are the types of foods you usually eat included on this website?’ (corresponding list of examples provided) and ‘What are some stress relief methods that you practise?’ Cultural perspective questions were, ‘What types of cultural foods do you eat (if any)?’ and ‘What are some of the stress relief methods that you would consider to be important in your culture?’ Examples of randomly selected images from the website were also printed and shown to participants. Participants were asked to explain whether the images related to them and why or why not.

All interviews and focus groups were audio-recorded and transcribed verbatim. Transcripts were coded using a multistep coding method adapted from the Family Education Diabetes Series (Mendenhall et al., 2012). Three trained researchers read through all transcripts one time to gain familiarity with the conversation. They then read through each of them again making note of any major categories, themes and subthemes. The developed themes were grouped, then compared and used to develop an agreed-upon code. Three researchers individually coded each transcript line-by-line. Coded transcripts were compared and discrepancies in coding were resolved by an outside researcher.

Results

In all, 15 AI students (groups of 6, 4 and 5) were recruited to complete phase 1 ‘functionality’ focus groups. The mean age was 22.4 ± 1.8 years and 73% were female. Eleven AI students were recruited to participate in phase 2 ‘cultural acceptability’ in-depth interviews. The mean age was 23.0 ± 3.2 years and 64% were female. Student status in school ranged from freshmen to second year graduate student.

Results querying for functionality provided suggestions to improve appearance, functionality and value of the website (Table 1). Overall, students felt that the current appearance of the site could use renovation. Many students felt that the website seemed dark and lacking in colour. Other students felt that the fonts were plain and boring; one participant said, ‘it looks like you’re reading a term paper’. Participants also felt that the site had a lot of empty space and an odd layout. When asked about the graphics, one student stated that the current graphics ‘wouldn’t capture my interest’. Another suggested ‘make them relate more to the words’.

Table 1.

Suggestions to improve functionality of a web-based weight maintenance programme (N = 15).

Improving appearance	Functionality	Value
Add relevant graphics Use consistent layout Fit contents to page Reduce negative space Brighten Add more colour Add texture Change logo	Keep in text links Keep links to credible websites Add scrolling Add table of contents/navigation bar Keep links within parent site Make buttons less obvious Do not link to PDFs that contain writing only	Keep easy to understand, informative language Keep more new/unfamiliar topics Keep quizzes Eliminate educational language Eliminate questions as titles Eliminate general information Cut down contents/eliminate repetition Add games Add blogs/forums Add personalisation Eliminate password requirement

Students appreciated hyperlinks within the text of the website, stating, ‘you can read through it, and if you want to check on it you can’. They especially liked links to credible websites such as www.cdc.gov. They were not fond of the current navigation of the site and thought improvements could be made by adding a scrolling feature, a table of contents and smaller ‘next’ and ‘back’ buttons to avoid ‘making the user feel like a dummy’.

Participants valued the easy-to-understand, informative language, the new or unfamiliar topics and the quizzes. One participant stated, ‘I really liked the quizzes’. Almost all participants suggested reducing the amount of information either by eliminating repetition of topics or by reducing the amount of general information provided. One participant stated, ‘A lot of people already understand that to be healthier you have to eat more fruits and vegetables’. Students did not like the password requirement for getting onto the site; one student stated, ‘If they (website) ask (me) to sign up for it or register, I think “no”’.

Other suggestions for improvement included providing recipe ideas, adding blogs, incorporating games and adding interaction. One student stated, ‘I know friends of mine who want to eat healthier are looking for … recipes’. Another popular idea was to provide an option for personalisation of information based on participant goals and preferences; one student thought that ‘The information should be for each individual’s type of health’. To increase accessibility to the site, one student suggested linking the site to Facebook, and another suggested turning it into an application.

Phase 2 questions were developed with the intention of uncovering more cultural information based on prompts that asked specifically about important components of the AI culture. The major themes identified were (1) Food, (2) Physical Activity, (3) Social Support, (4) Stressors and Stress Relief, (5) Time Management, (6) Symbolism (Table 2).

Table 2.

Major themes and supporting quotes to assess cultural relevance of the web-based weight maintenance tool for American Indian (AI) university students (N = 11).

Major theme/description	Supporting quotes
Food – AI college students do not eat traditional cultural foods on a daily basis; however, cultural factors are expressed in their food choices and should be considered when providing food suggestions	‘Out West (West River South Dakota) we eat a lot more buffalo … and a lot more soup that uses whatever grows out there … a lot of corn’.
	‘Traditional (foods) … our grandmothers teach us, and we learn through ceremony … it’s a process, we don’t just cook it, we pray with it … it’s different’.
Physical activity – Activities with cultural significance present an opportunity for inspiring more physical activity among AI college students	‘Horse riding isn’t required by our culture, but we are a horse culture so a lot of people do’.
	‘Basketball is huge, number one’.
	‘Softball is really big in Native communities, especially in ours’.
	‘Powwow dancing … walking and running … are important in my tribe’.
Social Support – AI college students have mixed levels of preference for support during pursuit of goals, but most liked the idea of online social interaction with an expert	‘I would much rather be working on my own … I don’t like putting my business out there for everybody’.
	‘I guess, naturally, at home, the community would just kind of automatically support you … I think the reason behind that is because everybody knows everybody so there is a better support system’.
Stressors and Stress Relief – AI college students cited stressors both listed and not listed on the website and tend to practise both traditional and cultural methods of stress relief	Stressors:
	‘Mine would be family, finances and food … trying to figure out what to feed my family’.
	‘Finance, work and school’.
	‘I tend to worry a lot about my family at home … schoolwork … managing my time’.
	Stress Relief:
	‘I do beadwork. I hang out with friends and laugh a lot’.
	‘Exercise, meditate … sleep … dance, sing … with my girls’.
	‘I try to meditate … sweat and go to ceremony, but I can’t do it over here’.
Time Management – Time management is an important issue for AI college students; college can be a difficult transition for students who come from more relaxed environments where time is perceived differently	‘When I first started college, it was hard for me to adjust. I was used to running on Indian time; I’d be a little late to things’.
	‘For some Native American students, depending on their background, that transition of time might be a hard adjustment or that the idea of time might be different’.
	‘In a public university, it’s rude to be late, but back home it would be rude to leave that person you are talking with. It might be difficult to make that transition at college’.
Symbolism – AI college students relate to images that depict typical college settings, but are inspired by symbols and realistic images that represent AIs in a natural environment	‘They (the current images) relate to us in the sense that we’re in college; you know we should have the same image that they (non-Natives) do, but we don’t … those pictures … seem very stiff, whereas, if you were to run into any of us on a given day, we would be very laid back and relaxed’.
	‘Star quilts … or the four colours, I mean, every Native American knows what that is and can relate’.

Ancillary words that did not alter the meaning of the quotes have been eliminated to improve flow and understanding.

In regard to food habits, students reported eating traditional foods only on special occasions, but most students would like to see traditional recipes available online. One student stated,

Papa (dried meat) is … actually more of a traditional food. It’s usually, the meat from … buffalo or deer or it’s dried and then they usually put berries … sometimes they put corn in it … It’s really good, but I just don’t know how to make it.

Soups, as well as meat-based meals, were frequently mentioned as daily foods. Cultural foods mentioned throughout the discussion included wojapi, tripe, tipsina, papa, menugo soup, wasna, buffalo, fry bread, corn, beans, wild game and wild rice. Many students noted that they were lactose intolerant, which was prompted after seeing multiple lactose-containing foods on the site. One student’s comment was, ‘I don’t drink milk … I’m lactose intolerant … a lot of Natives are’, and another stated, ‘many US American Indians are lactose intolerant’.

When prompted about personal physical activity choices, activities mentioned most frequently were those that were already suggested on the website. Basketball was found to be the most popular, followed by baseball/softball and walking/running. When asked about important physical activities in their communities or in their culture, both male and female students indicated that basketball was an important sport for AI communities. The comment, ‘Playing basketball is always a huge thing on reservations’, was a common sentiment among participants. Other culturally important physical activities included pow wow dancing, horseback riding/rodeo, running/walking, canoeing, baseball/softball, lacrosse and archery.

When further questioned about pow wow dancing, participants indicated that pow wow dancing was often practised by people at home in preparation for a pow wow or Wacipi, but could be a good form of exercise. Pow wow dancing is usually not taught in a group setting; one student claimed to learn via YouTube. Regardless of their participation or lack of participation in formal pow wow dancing, many felt that it was an important physical activity for AIs.

When questioned about the type of support they preferred when pursuing health-related goals, there were a variety of responses. Some students said they preferred community support: ‘Yes community versus individual (support) really helps’. Others preferred doing things individually: ‘I don’t know something that personal, you usually want to do it yourself’. Some felt that having both types of support was helpful; ‘I guess a little bit of both’.

When asked about opportunities for social interaction on websites promoting weight maintenance, almost all participants said they would like the opportunity for interaction with a credible source or an expert. One comment was, ‘I think having an expert discussion board would be good just because people aren’t sure where to start’.

When asked about top 3 sources of stress, the most commonly mentioned were school, work, finances and family/relationships. All of these sources of stress were already listed on the website. Sources of stress not listed on the website included the high cost of healthcare, cooking for a family, taking care of children and being homesick.

Stress relief methods mentioned by participants that were also listed on the website included exercising, reading, talking with friends/family, praying, watching television, listening to music, sleeping and playing with children. Cultural stress relief methods were also mentioned, including attending ceremony, visiting a sweat lodge, beading, meditating and doing quillwork. Barriers to participating in preferred stress relief methods were also mentioned: ‘There is one (stress reliever) I would like to do, but it’s not really around here, go to sweat’.

All students agreed that the perception of time is different for many AIs. One participant noted, ‘Traditionally how time was perceived … wasn’t like a clock with numbers. It was just like when the sun came up, you came up and did all you could while the sun was up’. Participants reported that the idea of time is much more relaxed on the reservation than it is on a college campus. One student commented,

I went to a boarding school on the reservation and they were pretty lenient about it (time) because they are all US American Indians mostly, too, and they all understand like … we would say ‘oh we’re running on Indian time’ … it’s definitely hard but you get used to it ‘cause you have to’. Several students brought up the term ‘Indian time’, which tended to refer to being a bit late to things, being generous with time, or seeing time as relative. Alternatively, one student stated, ‘I feel like I do run late sometimes but it’s not because of Indian time or it’s not because of my culture, it’s because I’m late’.

Many participants felt that time management was a very important skill, stating things such as ‘I think it’s really important. If you want to finish college, you’ve got to make deadlines’, and ‘I guess it’s a little more important, and it’s harder to manage time than in high school. I have a lot more free time than I did’. Many thought that, depending on student backgrounds and community and/or family expectations in regard to how time is shared, transitioning to college may be more difficult for AI students. ‘I’m not speaking for all Natives, but even just like how abstract people can view time and how much of your time you can share’. She mentioned her own community’s expectation of sharing time: ‘ … if your community is like, we need you to do this. I was raised to be like, okay then you have to do that, so I think there’s that expectation of the time you give’.

Study participants also evaluated website images. When randomly selected photos from the website were shown, participants related to university-related photos including eating in a cafeteria, working out and studying. Most students, however, did not find photos on the site to represent their diversity. They responded to the images with statements such as ‘The only thing I relate to is the studying, cooking, and there’s one image of a salad, and as for a reason why … is because, I mean, there is some ethnicity in the photos but not US American Indians’ and ‘Many of these people on here are not too diverse’.

Students thought relaxed photos of AIs would be the most inspiring and relevant graphics for attracting other AI students. ‘With the images … catch Natives doing community events, maybe serving food, ’cause all the women serve food or maybe a picture of a chow line … playing basketball, riding horse’. Students joked about unrealistic pictures of overly eager AI students holding books and smiling, encouraging them to ‘come be a nursing student at our school’. Participants, especially those who have grown up with health issues in their families, also recommended keeping the images realistic. One student said, ‘If you have grown up with a lot of diabetes prevention (campaigns), sometimes they can come off a little … cheesy. We want something that’s a little more realistic’. Cheesy signs they mentioned included those that use AI symbols improperly.

Participants were asked to give recommendations for altering the website in order to make it more relevant to AIs. Colours of the medicine wheel, dream catchers and circles were all noted as being culturally relevant symbols that would resonate with most AIs. Statements included,

What stands out to me are the four colors, you know black, red, yellow, white, and I think that would draw a lot of Natives’ eyes … you know your headline or your name/title could have something with those colors or something with a circular design, ’cause that’s a symbol’.

If it has like a Native looking design it catches my attention.

Discussion

Qualitative research is of particular value in the design of health interventions and can be especially responsive to the needs of the AI population (Mendenhall et al., 2012; Minkler and Wallerstein, 2011). The objective of this study was to determine how to tailor the original Project Y.E.A.H. website for cultural relevancy to AI public university students. The discussions provide helpful information about factors that should be considered when developing or tailoring websites for use among Northern Plains AI public university students.

The finding that most college students do not eat traditional Native American foods on a daily basis is consistent with the findings of Stluka and Gengler (2004). Most students were aware of traditional foods and reported eating them mainly at special events and family holidays. This pattern has also been reported in previous studies (DeGonzague et al., 1999). Although most students welcomed the idea of Native American recipes on the website, one participant did mention that it may be disrespectful to some elders; therefore, approval from an elder may be necessary for making decisions in regard to this portion of the design. The lactose intolerance of many AIs brought forward an important issue for developing food-related suggestions that might be recommended on a website for this population. The discussion that many AIs are lactose intolerant is consistent with previous findings finding that most AIs lack the enzyme to digest lactose (Bertron et al., 1999). One study estimated that around 74% of AIs were lactose maldigesters (Newcomer et al., 1977). It is important to include recipes that contain a limited number of lactose-containing food items to better serve the AI student population. Further research should also be done to uncover other possible AI food intolerances prior to making food suggestions.

Research has shown that strategies to increase physical activity need to be culturally relevant for each racial or ethnic group (Van Duyn et al., 2007). Promotion of popular activities on a website has the potential to encourage more participation in physical activity among this group and reduce obesity. The popularity of basketball among AI communities was apparent in this study. This is consistent with findings of the Pathways study involving AI children, which also found basketball to be the most common physical activity of participants, followed by running/walking (Davis et al., 1999; Gittelsohn et al., 1998). These findings suggest that the participation of basketball among AI communities begins at an early age and presents an opportunity for providing culturally relevant physical activity recommendations. However, it is important to note that another study among adolescent AIs suggested that the overemphasis and expenditure on basketball in some communities might also limit individuals who are not interested in basketball from participating in other activities (Brown et al., 2010). Other cultural activities that could be emphasised in future web-based interventions include softball/baseball, running/walking and pow wow dancing.

Establishing appropriate support systems based on the preferences of intervention, individuals may help improve the ability for participants to maintain health. Previous research with AIs has established community support as an important aspect for health interventions involving substance abuse (Novins et al., 2012), diabetes (Parker et al., 2011) and obesity (Heath et al., 1991). The success of the Family Education Diabetes Series was also attributed to the sense of community that participants felt during the programme (Mendenhall et al., 2010). Although a consensus was not reached in regard to individual versus group support preferences while pursuing health goals in this study, most students felt that the availability of interaction with an expert would be very helpful. Implications of a previous study with college students emphasised that young adults need to learn about credible health websites; they suggested that expert recommendations and credible online resources should be distributed among college students (Kim et al., 2011).

Time perception and definition have often been found to differ between the AI population and dominant society. In traditional AI culture, time was measured by natural events; less emphasis was placed on saving time and planning and more on living day-to-day (Horejsi and Pablo, 1993). Indian Time has been defined as ‘a traditional Native American perception of time that progresses through events rather than minutes on a clock (Verbos et al., 2011)’. Many participants of this study mentioned this difference and thought that transitioning to a public university schedule could cause a potential challenge for AIs, affecting their ability to practise proper time management. Education and guidance on time management should be emphasised in interventions involving AI students due to the cultural variation of the definition of time and the negative effects that poor time management can have on health behaviour.

Perceived stress among college students is often associated with negative health outcomes. Rocha-Singh (1994) concluded that college students perceive multiple dimensions of stress including academic, financial, familial, personal and environmental. Perceived stress of college students is often academic stress (Rocha-Singh, 1994). Stressors mentioned in this study generally fell within these broad domains. However, it may be of interest for future interventions to recognise the stress related to caring for children that was felt by some participants in this study. Three female interview participants mentioned stress related to mothering a child. In the USA, the AI/AN teenage birth rate is two to three times the rate of non-Hispanic White teenagers (Wingo et al., 2012), suggesting that more AI/AN college students may be responsible for caring for children. This factor should be considered when developing relevant and accommodating interventions for this group.

In the discussion of stress relief methods, students recognised their utilisation of sweat or ceremony for stress relief. They also made note of their current inability to practise that stress relief method at a public university, due to the fact that there are no sweat lodges available in the area. In one college study, researchers found that those with limited internal or external coping resources are at risk of academic failure and higher dropout rates (Ratanasiripong et al., 2010). It is important to recognise the lack of traditional resources that AI students may have for successfully practising stress management at a public university and understand the possible implications this may have on health behaviour.

Certain colours and symbols carry cultural relevance for many AIs (Dapice, 2006). Comments from this study provide a powerful suggestion as to how to capture this audience. However, students also noted the importance of realistic images and symbols, which in this case should not be developed without input from the target audience. Medicine Wheel colours, star quilts, dream catchers and circles are all commonly used symbols in AI interventions, but developers need to be cautious because these common symbols may be ignored due to overuse or be used in the wrong context. The suggestion for capturing the attention of this group is to provide realistic images depicting AIs in their natural and relaxed settings.

Due to rapid advances in technology and the amount of time that is required to conduct a research study, development of an up-to-date website that meets the preferences of young individuals can be hard to achieve. This limitation may be overcome by developing partnerships with entities that are current with the rapidly advancing technology used by this generation. Small sample population, limited geographic distribution and homogeneity of the study participants limit the ability to generalise the information obtained in this study.

When developing online weight maintenance interventions for Northern Plains AI public university students, it is important to understand and consider certain cultural aspects that may alter the study design. AI public university students may relate to some common cultural foods, physical activities, time perceptions, support preferences, stress relief methods, images, symbols and colours. However, when developing materials to engage AI college students, the following issues may usefully be taken into account.

Awareness of high rates of lactose intolerance and current food practices will help when providing food recommendations. Encouraging or providing opportunities for cultural physical activities such as basketball, softball/baseball, running/walking and pow wow dancing may inspire higher levels of participation. AI students may desire online interaction with a health expert and links to evidenced-based health information. Providing opportunities and support for cultural stress relief methods such as ceremony or sweat lodges will help to combat unique stressors faced by this population. Offering time management classes or workshops may be helpful for those students transitioning from a background in which time was not based on a clock. Ensuring that AI colours, symbols and designs are used tastefully and correctly will enhance the credibility of the material. Overall, using thoughts, opinions and ideas derived from AI health intervention participants may be the best method of creating the most culturally appropriate forms of online health maintenance intervention.

Footnotes

Acknowledgements

The authors wish to thank the faculty of the American Indian Education and Cultural Center on the campus of South Dakota State University for their support and cooperation with this project. The data reported on here were collected as part of a graduate thesis research project.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the USDA National Institute for Food and Agriculture under Grant 2009-55215-05460.

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