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Communication Strategy for Lowering the Obesity Rate of Pima Children
MPH 588
Diana Pinney
September 2013
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Communication Strategy for Lowering the Obesity Rate of Pima Children
Who Are the Pima?
The target audience for this communication strategy are the Pima Indian children
of the Gila River Reservation in Arizona, and their parents. Archaeologically linked to the
Hohokam of Mexico, the Pima have lived in the Sonoran desert near the Gila River in
southwestern Arizona for 2,000 years (NIDDK, 2007). Historically, the Pima organized
irrigation, which provided them with yields of wheat, beans, squash, and cotton. Today, their
agriculture has turned small scale (necessitated by a water rights battle), and has turned to that of
economically viable modern convenience.
The Spanish missionary, Marcos de Niza, made contact with the Pima in 1539.
Rebellions occurred in the late 1600s to the mid 1700s in response to Spanish mining, forts,
ranches, and the eventual European farmers who found this land highly advantageous. Holding
with the continuity of most Native American history, the Pima were pushed onto a reservation
incomparable in size to the 3.5 million acres they were used to subsisting on. The Pima
population exceeded the carrying capacity of this land and some migrated from the Gila River
area to the Salt River area forming another population (NIDDK, 2007). The Gila River
population is the one discussed here.
The Pima’s Present Health Status
Type II diabetes (or non-insulin dependent diabetes mellitus [NIDDM]) is more prevalent
in some populations than others, most notably the Pima Indians of the American southwest.
Fifty percent of Pima adults have diabetes (NIDDK, 2011). With the destruction of their farming
practices, the Pima subsistence changed from beans and squash to a high sugar and high fat laden
diet that this group’s metabolic systems were not used to handling. The Pima were forced by
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colonialism to give up traditional subsistence and participate in a market economy (NIDDK,
2007). As their shared historical characteristics show, the high rate of type II diabetes can be
linked to this interruption of their traditional life ways, and an increasing prevalence of obesity
(NIDDK, 2007).
Knowler, Saad, Pettit, Nelson, and Bennett (1993) found that type II diabetes “is a very
common and serious disease in many American Indian tribes” (p. 216). Knowler et al., (1993)
also found that the Pima Indians of Arizona have “the highest recorded prevalence and incidence
of NIDDM of any geographically defined population” (p. 216).
What Action Should They Take?
In order to decrease diabetes, the prevalence of obesity in the Pima population
must be addressed. It is the goal of this campaign to lower the obesity rate of the Pima
population (most notably children) and in turn, the prevalence of diabetes. In order to address the
goal of lowering the obesity rate of the Pima, knowledge objectives of instilling the importance
of healthy eating habits and an appreciation of historic lifeways should be fulfilled. Methods to
create a less obese population involve a healthier diet, but more specifically, a diet that is tailored
to represent more historical and traditional Pima subsistence. In order to create the desire for a
healthier lifestyle, knowledge objectives would also be aimed at children, but most importantly
their parents, with the expectation that parents influence their children and want them to be
happy, healthy, and lives long fulfilling lives.
Behavior objectives would be aimed at increasing the physical activity of children
and encouraging the build up of infrastructure to make the prospect of healthy eating habits seem
less daunting.
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Barriers.
As discussed earlier, the issue of obesity could be addressed by facilitating a
return to a diet more similar to the historical Pima diet, or by encouraging healthier eating in
general. This behavior change of lowering obesity by returning to more traditional lifeways has
many competitors, most notably, ingrained cultural habits of food choices, poverty, and low
literacy levels.
In order to keep type II diabetes in check, patients are counseled to eat less calories and
lose weight (Gohdes, 1988). According to Gohdes (1988), there are many reasons why diet
counseling is difficult. One reason is, “the usual diet prescription has been unrelated to patients’
cultural and economic status” (p. 189). Also, “diet has been presented in ways that are difficult
for low-literacy learners to understand and implement” (p. 189). Unfortunately, “Arizona has one
of the highest drop out rates in the nation…and 50% of all high school students cannot read at
grade level” (Literacy Connects, 2013). Children in Arizona have a higher chance than the
national average of living in poverty, and half of illiterate adults also live in poverty (Literacy
Connects, 2013). Over half (51%) of Native Americans living on reservations in 1989 were
below the poverty level (Story et al., 1999).
Poor socioeconomic situations also negatively influence health and health choices
(MacGregor, 2010). Not only is the Pima’s current diet drastically different from their traditional
one, but pre-made foods have created less work time and increased sedentariness (MacGregor,
2010). Culture influences diet, and economics also determine food choices. High caloric,
processed foods are cheaper than fruits and vegetables (Gohdes, 1988).
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Understanding how these factors influence each other is important when identifying
competition to lowering obesity rates; poverty is related to literacy, which is related to
implementing diet programs that prevent obesity and diabetes.
Eating habits are cultural and have continuity through generations and as stated earlier,
over recent generations the Pima diet has changed from subsistence farming to modern
convenience (Gohdes, 1988). It has been found that sister tribe of the Arizona Pima, the Pima of
Mexico are leading a more ‘traditional’ life and have less obesity and type II diabetes than the
Pima of the Southwest (Ravussin, et al., 1994).
There is also some evidence that the genes of the Pima leave them susceptible to quickly
gaining weight from sugar-laden foods (Hanson et al., 1998). According to Story et al., (1999)
the Pima’s diet of one hundred years ago “consisted of about 70-80% carbohydrate, 8-12% fat,
and 12-18% protein; the current Pima diet consists of about 47% carbohydrate, 35% fat, 15%
protein, and 3% alcohol” (p. 751). Fruits and vegetables are eaten less (the basis of Pima
traditional diet) while an increase of fats used for cooking and consumption in commodity food
is significantly higher (Story et al., 1999). Data taken of 1,704 elementary school aged Native
American children from a study by Grier and Kumanyika (2006) shows that in communities in
New Mexico, the obesity rate is 26.8% for boys and 30.5% for girls. Over the years, this rate has
been climbing and is much higher than national averages (Grier & Kumanyika, 2006).
“The traditional Pima diet changed rapidly from naturally grown produce to
commercially processed foods, and physical activity decreased tremendously” (Ravussin, 1993,
p. 234). Pima adolescents drink twice as many soft drinks as compared to the national average,
and fatty foods are often chosen for their low price and extended shelf life (Story et al., 1999). It
has also been found that Pima youths spend more time watching television than white children
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who also play more sports (Story et al., 1999). According to Krueter, et al. (2006), “the social
environment in which individuals live influences behavior.”
Choices made generation-to-generation affect a culture, and these choices are made based
on the economic and social environment. The Pima face many competitors in regard to the food
choices in their environment. Not only are these choices now part of their shared culture, but
public policy has also provided an environment for the loss of traditional subsistence patterns to
more easily take hold. In order to help bolster the Pima’s destroyed traditional lifeways and assist
their entrance into the market economy, “the United States government influenced Pima food
choices as national government food distribution programs began supplying them with American
staples such as eggs, lard, cheese, fruit juices, and pasta” (Manahan et al., 1994. p. 415).
The Pima value highly good cooking and the sharing of sweet and fried foods. They
welcome guests into their homes with these staples and use them at cultural gatherings and
ceremonies (Smith-Morris, 2004). Effectively, unhealthy foods have not only become a dietary
staple, but a symbol of their cultural identity. The Pima see exercise as “foreign” and
“impractical” (Smith-Morris, 2004, p. 39). The Pima also do not share the very Western value of
individuality or individual responsibility because theirs is a kinship-based society (Smith-Morris,
2004). This lifeway manifests itself within a society in the sharing of subsistence habits and
foodstuffs, income, and transportation (Smith-Morris, 2004). Most important to understand of
Pima core values is that “Pimas who remain this dependent upon and connected to kin networks
will have a fairly consistent problem with treatment plans that assume individual responsibility
for disease prevention and treatment” (Smith-Morris, 2004, p. 39).
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What is the Benefit to the Pima of Lowering the Obesity Rate in Children?
The Pima are an insular kinship based society that finds great value in its togetherness
and community support. Increased exercise by children, widespread knowledge of diabetes and
its causes, and healthier eating habits would benefit the Pima group as a whole. The benefits of
culturally appropriate nutritional counseling aimed at the younger generation (that is linked to
traditional lifeways), and increased activity in children are obvious. If children become more
connected with their historical subsistence, eat more appropriately for their metabolism and
constitution, and exercise more, benefits to the Pima include increased health, longevity,
productivity, and ultimately the stability of a vibrant culture. If the youngest generation was the
healthiest, instead of having the most potential to be ill, then their community would only
continue growing healthier. The benefits of these desired behaviors, from the perspective of the
Pima is a healthier path for the people, which has long-term benefits for the whole of their
society.
Support for this benefit.
The barriers for this behavior change, as discussed earlier are cultural mistrust of
Westernized ideals regarding exercise. Culture and socioeconomics also influence the role that
food and food choices play in the Pima society. The prospect of this increased population health
and vitality translates to the strength of Pima kinship bonds, and speaks to the power of their
shared identity.
Another support for this benefit would be to find another population that has lowered
their obesity and diabetes rates by changing their eating habits and exercising more. This
population could be one that the Pima would connect with on a cultural level, such as a tight knit
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cultural group, or one that shares the history of subjugation that the Pima have experienced since
contact with cultures outside of theirs.
In short, if the Pima were to eat healthier, more fresh foods that mimic their historical
subsistence patterns and support their children in increased physical activity, they will grow
stronger and healthier physically, but also in their collective bonds.
Openings and Channels to Convey this Message
Because of the structure of their close-knit society, the best place and situation to convey
messaging or actionable items to the Pima would be community areas such as a tribal center,
library, or in community health centers. In Pima County, there are many organizations working
towards preserving and improving the cultural heritage and health of its inhabitants. One is the
Pima County Health Department. While this institution and the information it disseminates may
be trusted because of its official nature, it is still an inherently Western construct. There are also
arts councils and cultural centers that may touch at the heart of this culture with more ease.
Organizations that have the backing, support, and participation of tribal elders would be the most
effective channel to convey the message of the health benefits of more traditionally wholesome
eating habits and increased childhood physical activity.
This messaging may also be conveyed in local television commercials, or publications, or
town hall meeting style gatherings. Without being able to perform thorough formative research
to know if this would be effective or appropriate, the author would also suggest a guest speaker
from a trusted community agency could be given some time to speak or inform at a tribal
gathering. This speaker could hand out materials that were actionable information with the
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branding and images of the campaign to establish a connection or continuity with any
forthcoming participation by the individuals present for this presentation.
What Images Should Communications Convey?
Once trusted sources that are invested in participating in this health communication are
identified, images should be chosen that not only reflect the goals of the campaign, but also
commune will with their established branding, if any. In this way, the messaging for this
campaign will be even more recognizable and trustworthy, and may even ‘catch the eye’ of
individuals who would not have noticed it otherwise. The images these health communications
should portray a sense of respect for one’s body. Images should also instill a sense of
togetherness, or community. For example, a graphic of some figures holding hands in a circle, or
encircling the parent organization’s logo would be an effective visual image. The images
representing this campaign should not have any qualities that could make them seem
overbearing, pushy, or too inclined towards Western values as this population mistrusts Western
influence. The images should espouse only the value of health to the Pima and their shared
history and culture.
Behavior Change Theory
The behavior change theory most applicable to increasing childhood activity and healthy
eating habits amount the Pima is the Health Belief Model. This model seems to have the most
breadth within it to work for the Pima. The health situation the Pima are in is endemic and only
getting worse. This model posits that behavior is based on the individual or population’s value of
an outcome (Models of Health Behavior, 2013). This model seems very apt to use to consider the
Pima’s present health behaviors and outlook because it does not suggest that people to not value
health, it suggests that people may value their current behavior more than the effort it takes to
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change it. For the Pima, everything seems stacked against them. Since their first interaction with
cultures outside of theirs, they have been becoming more unhealthy. Today, the very construct of
their environment exacerbates their declining health, including the most important construct; the
fabric of their kinship based social structure. In order to make any inroads in health
interventions, a program must recognize the lack of self efficacy inherent in this population, start
from the ground up to help them understand the value of the belief that they are strong enough,
and strong together, and can make a change.
This model also considers how the target population sees potential for increases in their
health based on the change they make in their health behavior (Models of Health Behavior,
2013).
This is a community where 50% of the population has diabetes, is currently subsisting in
an unhealthy environment, and is not easily swayed by outside influence or suggestions on
changing their current behavior for the deeply entrenched cultural reasons discussed earlier. Self
efficacy seems extremely low, and perhaps many individuals feel helpless regarding their current
health situation which is influenced by many factors within the socioeconomic realm. The Pima
have been studied for many decades with many health intervention models built to in crease their
wellbeing, but their situation is still getting worse. This fact causes one to think that the Pima
have no faith in the outcome of many interventions, because none of the have lowered the
diabetes rate thus far. This is an important factor to address when considering which model to
use. For so many years the Pima health has been declining after so many ‘ologists’ and programs
have tried to intervene on its decline, so why would they believe anything else would work?
Addressing this distrust or lack of belief that a change in health behavior will help them is a
necessary facet of any program that purports to do just that.
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References
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Grier, S., and Kumanuika, S. (2006). Targeting interventions for ethnic minority and lowincome populations. The Future of Children, 16 (1), 187-207. Retrieved from
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Hanson, R., Ehm, M. G., Pettitt, D. J., Prochazka, M, Thompson, D. B., Timberlake,
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