“Cause it’s family talking to you”: Children acting as change agents for adult food and physical activity behaviors in American Indian households in the Upper Midwestern United States

Abstract

This article presents research findings from the formative phase of OPREVENT, a pilot obesity prevention intervention trial for American Indian households on two reservations in the Upper Midwestern United States. We describe processes by which American Indian children acting as change agents influence adult food and physical activity behaviors on an Ojibwa and a Potawatomi reservation. This study borrows from Bronfenbrenner and Ceci’s socio-ecological model and extends Daniel’s resiliency theory for practice with vulnerable children. Using purposive sampling, we interviewed 168 community members, including 25 children between 6 and 13 years of age, using adult in-depth and paired-child interviews, household group interviews, focus groups, and community workshops. Results reveal that six American Indian children, 10–13 years old, were acting as change agents. We propose a socio-ecological conceptual framework to guide our understanding and application of a children as change agent approach for adult health behaviors which includes cultural identity (macro-system), institutional and community support (mezzo-system), family support through a secure base (micro-system), and children’s sense of belonging, self-esteem, self-efficacy, knowledge, and actions as change agents (intrapersonal factors). Resiliency and vulnerability are dynamic processes that intersect the multiple systems throughout children’s developmental stages to bolster their agency. We conclude with considerations for the OPREVENT pilot project and discuss future directions for developing a child as change agent theoretical framework for adult health behavior change.

Keywords

American Indian change agent children food physical activity

Background

Globally, children are acting as “change agents” to positively influence adult health behaviors in the household; understanding its socio-ecology among indigenous populations where childhood is constructed as central to the family structure may be crucial for addressing health disparities in these particularly vulnerable settings. A growing corpus of health sciences literature suggests that children are influential in an adult’s social environment through multiple modes and across diverse cultural settings in their home through communication and health behavior modeling (Gruber and Haldeman, 2009; James and James, 2008; Redmond, 2009; Schulman, 2006). Children have been reported as “active agents” or “change agents” (Davies, 2008; DeBoeck and Honwana, 2005; Smyth et al., 2011; Wihstutz, 2011) including a broad range of health areas such as informal caregiving (Smyth et al., 2011); parents’ diabetes self-management (Laroche et al., 2009); malaria, diarrhea, and personal hygiene (Onyango-Ouma et al., 2005); HIV counseling and testing (Kamo et al., 2008; Mwanga et al., 2007); and adult food and physical activity–related behaviors (Borys and Lafay, 2000). In cross-sectional studies, the presence of children in the household was associated with lower adult fat intake (Laroche et al., 2007), increased availability of fruits and vegetables in the household, and increased adult consumption of fruits and vegetables (Davis et al., 2002). However, there are no known prospective studies on children’s agency to advance our understanding of the biocultural processes and pathways by which children act as successful change agents for adult food and physical activity behaviors in vulnerable populations (Goodman and Leatherman, 1998).

Developing a child as change agent framework for vulnerable populations may be especially useful to effectively target modifiable health behaviors and reduce elevated risks for the rising global burden of chronic disease. Health behavior theories are often framed within the context of the mainstream populations in Western societies, leaving racial/ethnic and indigenous contexts largely understudied. To develop a child as change agent theory in the indigenous context requires sensitivity to local conceptualizations of childhood. In the social science literature, children are conceptualized as “competent social actors” (Christiansen, 2004; Holland et al., 2010; James et al., 1998; Vandenbroeck and De Bie, 2006) with agency to influence adult health behaviors. Childhood is a socially constructed and subjective phenomenon, possessing agency to act embedded within social structures that constrain or facilitate action (James and James, 2008). The existing theory has been developed largely within the Western cultural context where children are viewed as possessing less power than adults, though children are recognized as active agents (Bjerke, 2011; James et al., 1998). Since the 1960s, the fields of marketing and advertising have extensively studied children’s conceptualizations of economics and products and how they exert influence on parental purchase decisions at each cognitive and social developmental stage (John, 1999). Goh and Kuczynski (2009) extended this theory for multicultural contexts for children embedded within multigenerational networks. Sheper-Hughes and Sargent (1998) stressed the need to study children as fundamental to understanding social change.

Moreover, children living with vulnerabilities, such as socio-cultural stressors, have been noted as developing resilience to express agency (Zimmerman et al., 1998). Daniel and colleagues define vulnerable children as being “often from backgrounds where they or those close to them, have experience of mental illness, abuse …, criminal involvement, alcohol problems, poverty and, in some cases, damaged by war and other disasters” (Miller and Daniel, 2007). Children’s resiliency can be understood as, “both as an outcome, emotional well-being against the odds, and a process, adaptability in the face of adversity” (Miller and Daniel, 2007: 606).

This article extends Daniel’s (2003) conceptual framework to identify extrinsic and intrinsic factors critical to children’s resiliency, or coping processes, essential for change agency. Daniel (2003) discusses protective extrinsic factors such as secure attachments in the family, having supportive social structures beyond the family, and institutional support influence children’s resilience, expressed as having a sense of belonging and security, self-esteem, and self-efficacy (Daniel, 2003; Daniel and Wassell, 2002). We can surmise from Daniel’s framework that vulnerable children who have extrinsic and intrinsic protective factors may be better equipped to act as change agents.

In an indigenous context, American Indian (AI) children experience and exhibit ongoing processes of vulnerability related to the multiple losses from colonization (Moore, 2010; Stevens et al., 2003). Common ecological stressors of daily life include the fractured social structures that resulted from historical trauma and displacement, high unemployment and poverty (Cornell and Kalt, 2000), food insecurity (Pardilla et al., 2014), and a high prevalence of physical and mental health and abuse problems (Barnes et al., 2010; Jernigan et al., 2010; Centers for Disease Control and Prevention [CDC], 2012; Legha and Novins, 2012). These vulnerabilities are interrelated and act on multiple levels to counterbalance the resiliency factors that impact children’s well-being (LaFromboise et al., 2006). Children are taught to engage in self-care and to be self-sufficient earlier in some AI cultures than average non-Native US children, and are taught to assist with household chores, food preparation and family care, and help bring harmony and balance to their households (Glover, 2001; Nichols and Keltner, 2005).

In this article, we reveal findings from our pre-intervention formative research, a large community-based randomized controlled trial for adult obesity prevention targeting schools, households, food stores, worksites, and media campaigns in five AI communities in the US Midwest called the Obesity Prevention Research and Evaluation of InterVention Effectiveness in NaTive North Americans (OPREVENT) Project. This article presents processes and pathways by which children act as change agents for adult food and physical activity–related behaviors in their households for the purpose of informing the development of the trial in two of our participating communities in the Midwest region. We extend Daniel’s resilience theory by the additional cultural context of AI communities and by discussing children’s developmental stages for their readiness to be change agents (Piaget, 1964). We address the following research questions:

What are the key characteristics of change agency among children for adult food and physical activity–related health behaviors in AI households?

What are the implications for child as change agent approach for adult food and physical activity–related health behaviors in AI households?

Methods and methodology

Materials developed for this study are based on previous research in AI communities (Gittelsohn et al., 2012; Gittelsohn and Rowan, 2011). Data are drawn from 8 months of formative research in the US Midwest using multiple qualitative research methods in order to understand the local context of food and physical activity, identify social and environmental factors to focus upon, understand the social determinants of health, and identify resources necessary to implement interventions (Gittelsohn et al., 1999). A socio-ecological approach was taken and influenced by an overarching ecological perspective, and theories on children by Sheper-Hughes and Sargent (1998), Bronfenbrenner and Ceci (1994), and Daniel (2003). Findings guided the development of a novel child as change agent component of OPREVENT.

Site and sample

The Ojibwa and Potawatomi communities are located 120 miles apart in the Upper Midwest, with at least one gas/convenient store, a small grocery store, and at least one school. The Ojibwa reservation is located about 60 miles from a university town where households travel to shop for groceries, health care, eating out, and other major amenities. The Ojibwa reservation has dual land bases in the Upper Midwest. The Potawatomi reservation is located 20 miles west of a major town where households travel for groceries, health care, eating out, and other major amenities. Both reservations are located in some of the most socioeconomically disadvantaged Counties in this region.

Methods

An Ojibwa and a Potawatomi community in the Upper Midwest were recruited through formal invitations; subsequently, tribal resolutions were obtained in-person by the research team. Each tribal council assigned a health department employee as the study coordinator, who provided us with client rosters for study recruitment. We recruited adult caregivers and their child and four households to voluntarily participate in the formative phase of this study a priori to understand bio-ecological issues related to children acting as change agents. We recruited children by first recruiting their caregivers and gaining their consents before gaining children’s assent. Because of the unavoidable asymmetry of power between children and adults, we recognize that adults can at any time override children’s rights for research participation (James and James, 2008, 2004). Formative research involved qualitative research methods (Crabtree and Miller, 1999) and took place from July 2010 to April 2011 with the first author immersing herself in fieldwork. Adults gave their consent and children gave their assent and were compensated with a US$10 gift card. We interviewed a total of 168 participants (including 25 children) across the two sites using in-depth interviews with adults (school officials, health officials, caregivers, and worksite officials), focus groups (FGs) (school officials, caregivers, and worksite officials), household group interviews, community workshops, and paired-child interviews.

Interviewing techniques

Data collection procedures

The first and second authors developed interview guides prior to the fieldwork based on our previous studies (Gittelsohn et al., 2012; Gittelsohn and Rowan, 2011). The caregiver in-depth interviews and FGs began with open-ended questions such as “Tell me about your community”, and asked caregivers to describe household food and physical activities, daily routines, community health needs, and their conceptualization of a “healthy” family and a “healthy” child. We also gleaned recommendations for intervention activities. The first author interviewed child participants in a quiet room at the tribal health department, worksite, school, a community site, or their private home. Consent and assent forms were read aloud and time was given to the respondents to raise any questions. Children were interviewed in pairs (with another child or with a caregiver) by request. Paired-child interviews took 20–45 minutes and household group interviews took 2–2.5 hours. The first author conducted household group interviews with three Ojibwa and one Potawatomi household, involving trust and rapport building with the household members, adults, and children, through repeated invited visits with a note-taker present. The household group interviews entailed participant observation with the first author participating in meal planning and preparations, Maple tree tapping, and socializing among intergenerational household members. The first author also engaged in participant observation in harvest feasts, ceremonies, powwows, school, and health department events throughout her fieldwork. The Johns Hopkins Bloomberg School of Public Health and Indian Health Service Institutional Review Boards and the tribal councils approved the study.

Qualitative data analysis

Interviews were transcribed, reviewed, and analyzed with Atlas.ti version 6.2 software program. As Anishinaabe tribes, Ojibwa and Potawatomi communities share cultural contexts, which support combining the data for analysis. The first and second authors engaged in thematic content analysis by creating an emic codebook from themes that emerged from a set of three interview transcripts from each community. The codebooks were compared, differences were resolved, and the final codebook was approved by the principal investigator (J.G.). Interviews were analyzed iteratively for emerging themes and salience related to the child as change agent theory. Themes were compared through cross-case analysis to avoid generalizations and to capture the complexity and richness of the data.

Results

Participant characteristics

We analyzed transcripts of 168 adult and children (including household group interviews) (Table 1). There were 25 children between 6 and 13 years of age (n = 18 Ojibwa, n = 7 Potawatomi), including 14 girls and 11 boys. Of these, 17 (n = 17) child participants had siblings, 4 (n = 4) lived in extended families, 12 (n = 12) lived with parents who are married, and 2 (n = 2) children lived with extended family members and/or foster parents. In this article, we focus upon the narratives of six children between 10 and 13 years of age (including one child from a household group interview) and six adults aged 27–38 years, whose names were changed to protect their identity.

Table 1.

Pre-intervention formative research methods and sampling for child as change agents in American Indian households in the Upper Midwestern United States.

Type of interview^a	Ojibwa (n)	Potawatomi (n)
School FG	5	9
Parent FG	4	13
Worksite FG	10	–
Household groups (HG)	19	2
School official IDI	5	4
Caregiver IDI	21	4
Child IDI	14	10
Worksite IDI	6	2
Health official IDI	3	4
Community workshops^b	2	2
Total/community participants	102	66

FG: focus groups; HG: household groups; IDI: in-depth interviews.

n: number of workshops.

Children acting as change agents: The proposed framework

In this article, we propose a conceptual framework for AI children acting as change agents (Figure 1). On the macro-system level, having a strong cultural identity provides resiliency to children who act as change agents amid multiple vulnerabilities and adversities. On the mezzo-system level, children gain support from their family networks, community support systems, and tribal and local institutions. On a micro-system (i.e. household) level, they have secure bonds with family members and engage in food and physical activity–related activities with their family. On an intrapersonal level, children acting as change agents have a sense of belonging and self-esteem and self-efficacy related to change agency, have a command of health knowledge to convey it to their caregivers, and are currently actions as change agents. Using in-depth studies of six child participants 10 and 13 years of age, we discuss the shifting vulnerabilities and resiliency of AI children within these multiple influencing systems as active agents, and how six children negotiated their roles as change agents.

Figure 1.

Proposed conceptual framework for a children acting as change agent approach for adult food and physical activity in American Indian households.

Cultural identity and resiliency

The six children shared how having a strong sense of pride in their Native cultural identity fosters resiliency against the harmful aspects of the world around them. Adults mentioned the importance of revitalizing indigenous ways and customs in today’s politico-cultural climate. Children are cherished, protected, and celebrated in the Anishinaabe cultures of the Ojibwa and Potawatomi communities. Agency is nurtured from an early age of children who are embedded in local extended social structures (Sheper-Hughes and Sargent, 1998). Each child described their reservation as “one large family” where there are strong intergenerational bonds and reinforcement of traditional roots. Hannah, a 13-year-old girl, stated proudly, “I am related to everyone on the reservation, except for one family”. Also, when describing where their extended family members lived, all 25 children stated that they had at least one extended family member living nearby, most within walking distance from their homes.

Several adults relayed how AI children negotiated their identity and customs within the context of social support from extended family networks on the reservation and the centrality of children in family life. Sarah, a 30-year-old single mother, discussed how children can celebrate their cultural identities—simultaneously as being part of a family and as a Native person:

The nice thing about intergenerational relationship is that children are able to celebrate their traditions, but give a new light on it. I see that a lot in our community. Our children are revered. They are the light of the family.

The bidirectional influences between children and elders were described as children learning about customs and values from elders through storytelling and learning cultural skills such as dancing, singing, or drumming; in turn, elders gained a renewed sense of inspiration from the grandchildren who re-interpret their cultural identities through these gained customs and skills. Many elders lost much of their cultural identity while being forced to attend boarding schools in their youth. Michael, a 38-year-old father of five children, who is now deceased, spoke of this intergenerational inspiration:

A lot of elders in our community have been treated very badly and they don’t grasp our culture. Its been beaten out of them, taken out of them. To see young ones dance and drum and learning the language inspires them. The more and more they see the youth coming out in their community, the more they’re inspired to learn about the language, maybe the stories. To learn some songs that they remember inspires them to come out ‘cause they know there are some receptive youth out there.

Through co-constructing their Native identity and family roles, the children demonstrated resiliency amid harmful environments and motivation to engage in healthy, positive behaviors. Strong cultural identity appeared to spur intergenerational interaction and reverence for traditions.

The six children appeared to develop resilience as they negotiated their daily lives in their bicultural environments, learning in schools beside non-Native children, and learning from non-Native teachers and in their own native communities. They appeared to be consciously redefining their identity through simultaneous acculturation and enculturation in their complex, modern environments. Hannah spoke about Native history and her cultural identity, reflecting her high self-esteem:

Last year we did family history reports and she [grandma] said how far the reservation has gotten from getting electricity and having houses. And my grandpa was taken from his parents, when he was really young, the Indian Removal Act. She’s been trying to help me trace back people. All we known from my great grandpa’s side of my family is my great grandpa on my mom’s side. She tries to teach me about Sitting Bull and Chiefs, and she got a book and they made a three-hour documentary of it. And she got that for us. She’s been trying to take us to powwows and she got us beautiful regalia. Mine’s about the Trail of Tears and has like tears and the Chief, which is on horse.

The children exhibited agency in terms of duties and roles in their households. Several female caregivers stated that older girls were raised to express the traditional gendered role as nurturers, while boys were raised to express the traditional gendered role as protectors of their younger siblings. Donna, a 12-year-old girl, spoke about babysitting as a family responsibility she took seriously:

I have newborn to 6 year old cousins. They like to be running and hyper. Sometimes when their parents are working or they need a babysitter for a couple hours, I babysit probably about 3–4 times a week. I sometimes do it with my sister [name] and sometimes with my eldest sister. Other times I do it alone.

When asked about his siblings’ and parents’ health in a household group interview, Frank, an 11-year-old boy, spoke of protecting his sisters. He stated,

Sometimes with kids, I watch the kids. When I babysit, I get something from fridge or get pizza. I help folding laundry, yard work with my daddy. And chores at mom’s work every once in a while.

On a separate occasion in a paired-child interview, Frank spoke about what it meant for him to be the oldest child, expressing his desire to safeguard his three younger sisters:

I ask my parents if I can have a balanced meal and sometimes my mom will already make it, and to keep the girls from eating too much junk food.

Caregivers, teachers, and health officials expressed the importance of having a secure bond to a family member to help with developing their agency and resiliency.

Leading by example and speaking up

The six children were already acting as change agents in a range of ways by sharing knowledge they gained from school, engaging in healthy behaviors, and by speaking up and encouraging their caregivers to do the same. Across all children, girls predominantly discussed their agency in the context of adult food related behaviors in the present, while boys tended to describe their agency for physical activity and projections for the future. All children spoke about learning about food and physical activity from their schools and teachers. For instance, two paired-child interviewees mentioned learning about the food pyramid. Laura, a 12-year-old girl, stated,

My health teacher gave us a food pyramid, we did cut outs and go over a food plan at [school]. Once a month we get health classes.

Melissa, a 35-year-old teacher, described the nutrition lessons under the State model for elementary school standards:

We looked at it [MyPyramid], we brainstormed foods, and I said they can bring snacks but they have to be from the food pyramid…I gave the list of foods, in order to limit caffeine and sugar consumption foods need to be from MyPyramid and this is the list that the class came up with, and then I screened the snacks…That is one way children were able to influence their homes.

Complementing these children’s and teacher’s perspectives, Kate, a 27-year-old single mother of three children, stated,

I would eat what they eat versus saying you eat what I eat…They’re in control, I’m seeing. In school they have a lot of programs that they go through where they talk about the kids’ pyramid. And then they took out the vending machines at the school. And only the middle and high school kids are allowed to go there. They took out the pop machines. And so they come home with that or they come home with what they are supposed to be eating less of and what they are supposed to be eating more of.

Additionally, knowledge of “healthy” and “unhealthy” foods lead some older girls to speak up about their concerns for adult caregivers’ health through “nagging” or giving helpful reminders about choosing healthy over unhealthy foods in their company. Stephanie, a 10-year-old girl, spoke about giving reminders for her mother and grandmother about food:

We went to [restaurant], me and my grandma did. And she had a lot of sweet and I said, “Grandma, you’re diabetic. Why are you having so many sweets?”, ‘cause I wanted to remind them so they don’t get their sugar up really high and would have to take a lot of insulin.

Knowing that her dad has heart disease, and she herself was recently diagnosed as obese by her physician, Anna, a 12-year-old girl, spoke about negotiating healthier fast food purchasing with her father, expressing her self-efficacy as a change agent:

My sister would make him go to McDonalds. And he would go most of the time. Usually me and him go to town we never get McDonalds. We go to Subway. I tell dad, “Dad, we should go to Subway ‘cause I’m hungry”. We go there ‘cause it’s healthier, ‘cause it’s not a bunch of salty or fatty foods. At Subway they have vegetables that you can eat on wheat bread or Italian bread. If I didn’t say I want to go to subway, he would go to [local fast food restaurant].

Anna expressed her knowledge of healthy foods and her vigilance as a change agent for her father’s diet:

Sometimes I would remind my dad. He would have one really big plate and he would want one more. I would remind him not to do that. “Dad if you want to lose weight you probably shouldn’t do that. Just drink something”.

Most boys described being presently active with other male members of their extended family networks such as their fathers, uncles, and older male siblings, with activities such as ice fishing and snowmobiling in the wintertime and basketball and riding bikes in the summertime. The six children, including Frank, an 11-year-old boy, were conscious of the significance of family in AI cultures, recognizing that they had an advantage as change agents in their households:

[I’m] interested in doing it [promoting health in the household] because that would help most of the parents living in [town] and people would be eating less junk food and more healthy foods. I think coming from kids, it means more ‘cause it’s family talking to you about it and, [that] too, your kids.

Diane, a 37-year-old mother of two children, supported children’s direction actions as change agents, and stated,

I think kids should be able to say something to their parents. My daughter says, mom, you’re getting your surgery. You shouldn’t be eating that stuff. I say, I know, you’re right. So we try to shop better. We all shop together. They remind me to eat healthier and buy healthier foods. They pick out all the fruits and vegetables. We try out new vegetable and fruit every shopping week.

Some of the children who were already acting as change agents were also engaging in physical activity with their caregivers. Alexa, a 31-year-old married mother of five children, stated how her 10-year-old daughter, Samantha, would go to yoga and dance with her and they would be active together:

This one (pointing to her daughter on the couch) will do dance and different activities. She’ll do dance and yoga and she’ll do workouts with me. With her it’s kind of a social thing too.

Vulnerability and agency

Children have never before faced health risks of developing type 2 diabetes and shortened lifespan compared to previous generations in the United States, regardless of race/ethnicity. Ojibwa and Potawatomi children, not unlike many AI and ethnic minority children, face ongoing and emerging social vulnerability. Teachers, nurses, and health officials noted that children’s welfare was being threatened by the rising childhood obesity and pre-mature type 2 diabetes epidemic, as well as associated mental health risks from being bullied because of being overweight or obese. Anna later described how she was confronting bullying in school:

I’m trying to accomplish not being an obese teenager or adult ‘cause I just don’t wanna go through that my whole life of being a chubby kid and I wanna be different. People here actually call me fat, but I know that I’m not fat. And they may tell me that I’m overweight and that’s not healthy but they don’t know me and I actually eat healthy… When people say bad names, I say, “Well, I may be overweight but, at least I’m beautiful”.

Anna also described her own fear of diabetes in the context of living with a parent and other family members who were diabetic and her own struggles with weight control. She simultaneously expressed her acute awareness and knowledge about diabetes:

I’m trying really hard to lose weight because if I don’t lose weight or I gain more weight, then I have a big chance of getting diabetes. My mom and my dad and my doctor told me… And I really don’t want to go through that when my dad has diabetes and diabetes has been running in my family for a long time. And I don’t want to get it.

Discussion

Children acting as change agents: The proposed framework

Pre-intervention formative research findings suggest that there are four interrelated systems of children acting as change agents in Midwestern AI households, visualized in Figure 1 as macro-system (cultural identity); mezzo-system (institutional/community support); micro-system (secure bonds in the family network); and intrapersonal level (cognitive developmental stage, self-esteem, self-efficacy, knowledge, and actions as change agents [leading by example, speaking up]).

In summary, on a macro-system level, the six children were acting as change agents, exhibiting enculturation (Zimmerman et al., 1998) through learning from their communities and households about their language, values, and engaging in cultural traditions such as powwows and ceremonies. Yet, these children face chronic and multiple vulnerable processes early on and never before encountered by any generation, including poverty, epidemic levels of diet-related illnesses, stigma from childhood obesity, and bullying at school, that resulted in some heightened fears about personal risk of diabetes. On a mezzo-system level, local and tribal institutions, such as schools and health departments, were working to reinforce positive health messages and dispel heightened fears among young children. On a micro-system level, strong family bonds oriented the six children to develop and negotiate their agency by responding to stressful environments with resilience. On an intrapersonal level, the six children were leading by example and speaking up—sharing their knowledge gained from school, elders, and community with their household members and became catalysts for action.

Moreover, children’s cognitive developmental stage is identified as a critical determinant of their change agency, such that 10 years and older children expressed a capacity to think abstractly about health (self, family, and community) and their potential role as change agents in their households (John, 1999; Piaget, 1964). Intersecting across multiple systems, translating children’s knowledge to change agency may be moderated by the competing and simultaneous cultural resiliency and social vulnerabilities within which children’s lives are embedded. Personal attributes such as having self-esteem, being motivated to care, concerned for household members, and having self-efficacy for change agency were present among these six children. These children’s actions as change agents included leading by example and speaking up, reminding adults about healthier options for food, requesting healthier foods, encouraging caregivers to be physically active, caring for their younger siblings and elders alike, and helping with household responsibilities.

Existing literature supports, on a macro-system level, that AI children are raised with cultural values of self-reliance and interdependence (Duran and Duran, 1995; Red Horse, 1980). Embedded within their socio-cultural structures, these children were negotiating their identities and adapting to their obesogenic landscapes (Lesane-Brown et al., 2010; Liebler, 2010), which, in turn, may be producing them as promising change agents (Legha and Novins, 2012; Zimmerman et al., 1998). Children’s participation in community development as change agents reinforced their cultural identity and agency (James and James, 2008). The six children who were already acting as change agents appeared to be more resilient across all three socio-ecological levels—intrapersonal traits, familial, and extra-familial, supporting Daniel and colleagues’ theory (Daniel, 2003). At the intersection of micro-system and intrapersonal levels lie children’s socialized valuation of their family’s health and application of their knowledge and skills towards behaving as change agents for their household.

Limitations of this study include exploring change agency in children up to age 13 years only and primarily focusing upon girls and women. Also, this study was designed, developed, and implemented under normative research ethics views on children’s assent as dependent upon adult’s consent (Miller and Nelson, 2006). We made a conscientious effort to treat children as subjects and important players in the development of a household-centered obesity prevention pilot intervention. Children’s and adults’ suggestions were incorporated into the intervention material development, paying attention to their everyday lived experiences of children (Mayall, 2002), particularly from the context of the social structures within which they are embedded and active such as their families, communities, and institutions. Also, this study explored children as change agents in two “brotherhood” tribes with similar cultural contexts. We feel that the themes draw on contexts common to other indigenous communities, such as trauma, high prevalence of health problems, and poverty (Hecht, 2012; Miles and Hurdle, 2003). Finally, as a non-Native and female interviewer, girls opened up more freely to the first author, while boys were more reserved and spoke less unless prompted more by caregivers who were present at the interview. The first author was sensitive to the inherent asymmetry of power with the children, and worked to create a supportive and nurturing interview environment for the children.

This study has key implications for theory and practice. From a definitional standpoint, childhood needs to be viewed as a social sphere that every adult must pass through, which is shaped by the local cultural context and is changed through time and historic events (James and James, 2008; Qvortrup, 1994). From a research ethics stance, the research process ought to be inclusive of treating children as subjects rather than objects (Verhellen, 1994). We interviewed children seated within the dominant research framework, where children’s assent hinges upon caregivers’ consent. In future publications, we plan to address these ethical issues related to children’s assent in health sciences research (Miller and Nelson, 2006; Ungar, 2006; United Nation’s Children’s Fund [UNICEF], 2012). In light of Daniel’s (2003) resilience theory, interventions like OPREVENT will need to be sensitive to her five suggested strategies, including (1) reducing children’s vulnerabilities and risks; (2) reducing the number of stressors; (3) increasing available resources in children’s tribal and local communities; (4) mobilizing protective processes, such as familial and community support systems; and (5) fostering resiliency processes that enhance children’s cultural identity. Strengths of this study include methodological triangulation such as member checking of the thematic content analysis with the research team, key community stakeholders at community workshops, teachers and research team members at ongoing school/family working groups to inform the OPREVENT project.

In conclusion, this study was the first of its kind to explore how six Ojibwa and Potawatomi children were already acting as change agents for adult caregivers’ food and physical activity–related health behaviors in the contemporary indigenous cultural context. These findings informed the development of OPREVENT school-based curriculum and program planning and evaluation tools to pilot a child as change agent approach for adult lifestyle behavior change. Future research is needed to study the relevance of a child as change agent approach for lifestyle-related adult health behaviors across diverse cultures and public health problems.

Footnotes

Acknowledgements

We wish to express our greatest appreciation to the Ojibwa and Potawatomi community members for their participation in this study. Thanks to our fieldwork teams for their hardwork and commitment. With gratitude to the two anonymous reviewers at Childhood journal for their insightful direction, and Barrett Brenton and our friends for their constructive feedback and encouragement. This article is dedicated to our families.

Funding

This work was supported by the US Department of Agriculture (NIDA Grant #2010-85215-20666); and the Sommer Scholarship of the Johns Hopkins Bloomberg School of Public Health for the first author’s doctoral program. This article is a product of the first author’s dissertation project.

References

Barnes

Adams

Powell-Griner

(2010) Health characteristics of the American Indian or Alaska Native adult population: United States, 2004–2008. National Health Statistics Report 20, 9 March. Washington, DC: U.S. Department of Health and Human Services.

Bjerke

(2011) “It’s the way they do it”: Expressions of agency in child-adult relations at home and school. Children and Society 25: 93–103.

Borys

Lafay

(2000) Nutritional information for children to modify the food habits of the whole family. Revue Médicale de la Suisse Romande 92(11): 918–923.

Bronfenbrenner

Ceci

(1994) Nature-nurture reconceptualization in development perspective: A bioecological model. Psychological Review 101: 568–586.

Centers for Disease Control and Prevention (CDC) (2012) U.S. Centers for Disease Control and Prevention. National Center for Health Statistics. American Indian Health Statistics. Available at: http://www.cdc.gov/nchs/data/nhsr/nhsr020.pdf (accessed 12 December 2013).

Christiansen

(2004) Children’s participation in ethnographic research: Issues of power and representation. Children and Society 18: 165–176.

Cornell

Kalt

(2000) Where’s the glue? Institutional and cultural foundations of American Indian economic development. Journal of Socio-Economics 29(5): 443–470.

Crabtree

Miller

(1999) Doing Qualitative Research. 2nd ed. Thousand Oaks, CA: SAGE.

Daniel

(2003) The value of resilience as a concept for practice in residential settings. Scottish Journal of Residential Child Care 2(1): 6–15.

10.

Daniel

Wassell

(2002) The School Years: Assessing and Promoting Resilience in Vulnerable Children. Philadelphia, PA: Jessica Kingsley Publishers.

11.

Davies

(2008) A childish culture? Shared understandings, agency and intervention: An anthropological study of street children in northwest Kenya. Childhood 15(3): 309–330.

12.

Davis

. (2002) Using children as change agents in increased fruit and vegetable consumption among lower-income African American adults: Process evaluation results of the Bringing It Home Program. In: Steckler

Linnan

(eds) Process Evaluation in Public Health Interventions. San Francisco: Jossey-Bass.

13.

DeBoeck

Honwana

(2005) Children and youth in Africa: Agency, identity, and place. In: Honwana

DeBoeck

(eds) Makers and Breakers: Children and Youth in Postcolonial Africa. Oxford: James Currey, pp. 1–18.

14.

Duran

(1995) Native American Postcolonial Psychology. Albany: State University of New York Press.

15.

Gittelsohn

Rowan

(2011) Preventing diabetes and obesity in American Indian communities: The potential for environmental interventions. American Journal of Clinical Nutrition 93(5 Suppl.): 1179S–1183S.

16.

Gittelsohn

Evans

Story

. (1999) Multisite formative assessment for the pathways study to prevent obesity in American Indian school children. American Journal of Clinical Nutrition 69(4 Suppl.): 767S–772S.

17.

Gittelsohn

Rowan

Gadhoke

(2012) Interventions in small food stores to change the food environment, improve diet, and reduce risk of chronic disease. Preventing Chronic Disease 9: E59.

18.

Glover

(2001) Parenting in Native American families. In: Webb

(ed.) Culturally Diverse Parent-Child and Family Relationships: A Guide for Social Workers and Other Practitioners. New York: Columbia University Press, pp. 205–234.

19.

Goh

ECL

Kuczynski

(2009) Agency and power of single children in multi-generational families in urban Xiamen, China. Culture and Psychology 15: 506–532.

20.

Goodman

Leatherman

(1998) Building a New Biocultural Synthesis: Political-Economic Perspectives on Human Biology. Ann Arbor, MI: University of Michigan Press.

21.

Gruber

Haldeman

(2009) Using the family to combat childhood and adult obesity. Preventing Chronic Disease 6(3): 1–10.

22.

Hecht

(2012) The struggle of being Toba in contemporary Argentina: Processes of ethnic identification of indigenous children in contexts of language shift. Childhood 19(3): 346–359.

23.

Holland

Renold

Ross

. (2010) Power, agency, and participatory agendas: A critical exploration of young people’s engagement in participative qualitative research. Childhood 17: 360–375.

24.

James

(2004) Constructing Childhood: Theory, Policy and Social Practice. London: Palgrave Macmillan.

25.

James

(2008) Key Concepts in Childhood Studies. London: SAGE.

26.

James

Jenks

Prout

(1998) Theorizing Childhood. Cambridge: Polity Press.

27.

Jernigan

Duran

Ahn

. (2010) Changing patterns of health behaviors and risk factors related to cardiovascular disease among American Indian and Alaska Natives. American Journal of Public Health 100: 677–683.

28.

John

DRJ

(1999) Consumer socialization of children: A retrospective look at twenty-five years of research. Journal of Consumer Research 26(3): 183–213.

29.

Kamo

Carlson

Brennan

. (2008) Young citizens as health agents: Use of drama in promoting community efficacy for HIV/AIDS. American Journal of Public Health 98: 201–204.

30.

LaFromboise

Hoyt

Whitbeck

(2006) Family, community, and school influences on resilience among American Indian adolescents in the Upper Midwest. Journal of Community Psychology 34(2): 193–206.

31.

Laroche

Davis

Forman

. (2009) Children’s roles in parents’ diabetes self-management. American Journal of Preventive Medicine 37(Suppl. 1): S251–S261.

32.

Laroche

Hofer

Davis

(2007) Adult fat intake associated with the presence of children in households: Findings from NHANES III. Journal of the American Board of Family Medicine 20: 9–15.

33.

Legha

Novins

(2012) The role of culture in substance abuse treatment programs for American Indian and Alaska Native communities. Psychiatric Services 63(7): 686–692.

34.

Lesane-Brown

Brown

Tanner-Smith

. (2010) Negotiating boundaries: Frequency of young children’s socialization to their ethnic/racial heritage. Journal of Cross-Cultural Psychology 41: 457–464.

35.

Liebler

(2010) Homelands and indigenous identities in a multiracial era. Social Science Research 39: 596–609.

36.

Mayall

(2002) Towards a Sociology of Childhood: Thinking from Children’s Lives. Buckingham: Open University Press.

37.

Miles

Hurdle

(2003) Resiliency factors related to substance use/resistance: Perceptions of Native adolescents of the Southwest. Journal of Sociology and Social Welfare 30(4): 80–94.

38.

Miller

Daniel

(2007) Competent to cope, worthy of happiness? How the duality of self-esteem can inform a resilience-based classroom environment. School Psychology International 28: 605–622.

39.

Miller

Nelson

(2006) A developmental approach to child assent for nontherapeutic research. Journal of Pediatrics 149: S25–S30.

40.

Moore

(2010) Youth-onset type 2 diabetes among American Indians and Alaska Natives. Journal of Public Health Management Practice 16(5): 388–393.

41.

Mwanga

Jensen

Magnussen

. (2007) School children as health change agents in Magu, Tanzania. Health Promotion International 23(1): 16–23.

42.

Nichols

Keltner

(2005) Indian family adjustment to children with disabilities. American Indian Alaskan Native Mental Health Research 12(10): 22–48.

43.

Onyango-Ouma

Aagaard-Hansen

Jensen

(2005) The potential of schoolchildren as health change agents in rural western Kenya. Social Science & Medicine 61: 1711–1722.

44.

Pardilla

Prasad

Suratkar

. (2014) High levels of household food insecurity on the Navajo Nation. Public Health Nutrition 17: 58–65.

45.

Piaget

(1964) Part I: Cognitive development in children: Piaget development and learning. Journal of Research in Science Training 2(3): 176–186.

46.

Qvortrup

(1994) Childhood matters: An introduction. In: Qvortrup

Mardy

Sgritta

.(eds) Childhood Matters: Social Theory, Practice and Politics. Aldershot: Avebury, pp. 1–24.

47.

Red Horse

(1980) Family structure and value orientation in American Indians. Social Casework 61(8): 462–467.

48.

Redmond

(2009) Children as actors: How does the child perspectives literature treat agency in the context of poverty? Social Policy and Society 8(4): 541–550.

49.

Schulman

(2006) Terms of engagement: Aligning youth, adults, and organizations toward social change. Journal of Public Health Management Practice November(Suppl. 1): S26–S31.

50.

Sheper-Hughes

Sargent

(1998) Small Wars: The Cultural Politics of Childhood. Berkeley, CA: University of California Press.

51.

Smyth

Cass

Hill

(2011) Children and young people as active agents in care-giving: Agency and constraint. Children Youth Services Review 33: 509–514.

52.

Stevens

Story

Ring

. (2003) The impact of the pathways intervention on psychosocial variables related to diet and physical activity in American Indian school children. Preventive Medicine 37: S70–S79.

53.

Ungar

Joffe

Kodish

(2006) Children are not small adults: Documentation of assent for research involving children. Journal of Pediatrics 149: S31–S33.

54.

United Nation’s Children’s Fund (UNICEF) (2012) Empowering Climate Ambassadors at the Children’s Climate Forum as agents of change. Available at: http://www.unicef.org/infobycountry/denmark_51984.html (accessed 12 December 2013).

55.

Vandenbroeck

De Bie

(2006) Children’s agency and educational norms: A tensed negotiation. Childhood 13: 127–143.

56.

Verhellen

(2006) Convention on the Rights of the Child. Leuven: Garant.

57.

Wihstutz

(2011) Working vulnerability: Agency of caring children and children’s rights. Childhood 18(4): 447–459.

58.

Zimmerman

Ramirez

Washienko

. (1998) Chapter 10: Enculturation hypothesis. Exploring direct and protective effects among Native American youth. In: McCubbin

Thompson

. (eds) Resiliency in Native American and Immigrant Families. Thousand Oaks, CA: SAGE, pp. 199–220.