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Cook&TillmanThesis 1

NATIVE FOOD SOVEREIGNTY: A BEST PRACTICE PROPOSAL TO PREVENT

DIABETES IN ADOLESCENT TOHONO AND PIMA INDIAN

By Douglas G. Cook & Tanya M. Tillman

A Project

Submitted in Partial Fulfillment

of the Requirements for the Degree of

Master of Science

in Nursing:

Northern Arizona University

August 2011

Approved:

______________________________

Linda Paul, Chair

______________________________

Karine Crow, Committee Member

______________________________

Vicki Black-Bishop, Committee Member




ABSTRACT

NATIVE FOOD SOVEREIGNTY: A BEST PRACTICE PROPOSAL TO PREVENT

DIABETES IN ADOLESCENT TOHONO AND PIMA INDIAN

Douglas Cook & Tanya Tillman




ACKNOWLEDGEMENT

We want to say thank you to our project committee chair Linda Paul and our

committee members Karine Crow and Vicki Black-Bishop for their guidance and

facilitation in the completion of our thesis project.




TABLE OF CONTENTS

List of Tables………………………………………………………………………………..6

List of Figures……………………………………………………………………………….7

List of Appendix…………………………………………………………………………….8

CHAPTER 1: THE RESEARCH PROBLEM AND PURPOSE

Background………………………………………………………………………….9

Significance of Problem……………………………………………………………10

Current Approaches to the Problem………………………………………………..12

Description of the Setting………………………………………………………….13

Population Affected by the Problem……………………………………………….13

Research Question…………………………….…………………………………...14

Conceptual or Theoretical Framework xx

CHAPTER 2: LITERATURE REVIEW

Evidence Based Practice and Standards of Care for Diabetes Mellitus

Body Mass Index and Diabetes

Diabetes in population adolescents

US verses Mexico population

Native Food Sovereignty………………………………..




Promotoras (mahkai and Himdag)…………………………………………

Summary………………………………………………………………..

CHAPTER 3: PROJECT DEVELOPMENT

Tohono Cultural Competencies

Available Resources

Nurse/Tohono healer

Western Medicine Advisory Role

Himdag Restoration Team

Hot Spots

Desired Cultural/physiologic Outcome

Summary

CHAPTER 4: IMPLEMENTATION

Implementation of proposed best practice

Center of Excellence Foundation

Evaluation protocol

5. CONCLUSION AND BENEFITS OF THE PROJECT.................................

Interpretation of Evaluation Findings

Limitations of the Study…………………………………………………….




Conclusions and Recommendations……………………………………..

REFERENCES…………………………………………………………………………..




LIST OF TABLES




LIST OF FIGURES




LIST OF APPENDIX



Cook&TillmanThesis10

CHAPTER 1

THE RESEARCH PROBLEM AND PURPOSE

Background

For centuries, the Tohono O’odham and Pima Indians successfully “lived with” the

Sonoran desert of present day Southern Arizona and Northern Mexico. Genetically and

culturally similar, the two bands of American Indian were able to coax enough calories

from the native plants and animals that shared this harsh desert habitat. The two bands

shared the foods grown by the Pima along the Gila River or gathered from the desert by the

Tohono. The diets of these two bands of desert people consisted of cultivated beans, native

seeds, desert plants, small-game animals, and deer. For years, the Tohono were known as

the “Papago”, a Spanish word that means “bean eater” which reflected the staple protein

source of the Tohono diet: tepary beans and mesquite bean pods (Underhill, 1979).

Digging miles of canal ditches to irrigate crops and crossing long distances of desert

to gather water and wild foods translated to a very high caloric energy expenditure lifestyle

for both the Pima and Tohono. Knowledge of how to live with the desert, rather than on the

desert, provided the tribes with foods to sustain the tribal communities (Tataranni, Harper,

Snitker, Parigi, Vozarova, et. al., 2003). The desert provided the “people” with a low fat,

low caloric diet. Dietary carbohydrates came from desert seeds and vegetation: prickly pear

cactus pads, cholla cactus pods (Underhill, 1979). Agave cactus and cultivated corn on the

Gila River supplemented the diet with some plant starch. To survive the Sonoran Desert

environment, the physiology of these desert dwellers adapted to a physically active lifestyle

and a low calorie/low fat diet. The same physiology that made it possible for the desert




people to survive and “live with” the Sonoran Desert now threatens the tribes with near

extinction from the ravages of obesity and non-insulin dependent diabetes (NIDDM).

Significance of the Problem

The Pima/Tohono Indians have one of the highest obesity rates of any cultural

group in the world (Schulz, Bennett, Ravussin, Kidd, Esparza, et al., 2006). As in many

other obese populations, increased rates of IDDM correlates with an increase in body mass

index (BMI). At the turn of the 20th

century, the Pima continued to practice subsistence

agriculture and the Tohono continued to hunt and harvest desert foods as these populations

had done for centuries. Literature reveals the presence of NIDDM at that time was either

non-existent or unrecognized; the truth was most likely the former, although the latter

would probably have been true had the population suffered from the disease. In the 1930s,

water from the Gila and other desert water sheds and water tables were tapped and diverted

to irrigate non-Indian farms and quench the thirst of the growing populations of Phoenix

and Tucson (Pavkov, Hanson, Knowler, Bennett, Krakoff, et. al., 2007).

To survive, the Pima and Tohono began to transition away from their native diet to

a higher caloric/fat Western diet. In 1930, 21 Pima were diagnosed with diabetes, which

correlated to the incidence in the general US population. Unfortunately, obesity and the

incidence of diabetes in the Pima trended upward until both greatly overshadowed other

populations by the 1950s. In 1965, systematic diabetes screening became part of a

longitudinal study of the Pima shortly after obesity and diabetes were identified as the

population’s major health issues (Pavkov, et. al., 2007). Today, the Pima are one of the

most obese populations in the world and suffer a rate of NIDDM that is five times higher

than that of the general population (Schulz, et al., 2006). The longitudinal evidence that




lifestyle and diet. Healthcare providers must turn to tactics that celebrate and encourage the

cultural strengths of the desert and river people in order to return the people to health.

Modern conveniences and an endangered culture now threaten the survival of one of the

most resilient and hearty populations the world has known. In her 1930 biography, Chona,

a 90 year-old Tohono woman articulated the answer, “Wheat flour makes me sick! I think

it has no strength. But when I am weak, when I am tired, my grandchildren make me gruel

out of the wild seeds. That is food!” (Underhill, 1979).

Current Approaches to the Problem

The arms brought to bear in the fight against obesity and NIDDM is the latest

evidence-based nutrition principles and treatment modalities as outlined by the American

Diabetic Association. However, the message to reduce caloric and carbohydrate intake has

been repeated time and time again with little to no effect, along with increasing physical

activity. The traditional approach to the issue of obesity has had limited success in reducing

BMI and the risk for developing diabetes. This lack of success at preventing obesity and

diabetes has forced the hand of medicine to one of treatment. The addition of medicines to

the fight is an approach fraught with compliance issues and the number of Pima that require

renal dialysis remains steady (American Diabetes Association, 2002).

Fortunately, non-medical interest groups, a revitalization of popularity of American

Indian culture, and the infusion of casino monies augment medical strategies to encourage

lifestyle changes. The Native Seeds Search is a non-profit organization that has led a

grassroots effort to protect, preserve, and propagate native Sonoran food crops and to

encourage Native Peoples to eat Native foods (Native Seed Search on-line, 2010). The

Tohono O’odham employed casino revenues to build a cultural center and museum. The




Tohono O’odham Community Action (TOCA) is a community-based organization that

strives to restore cultural and physical health to the desert people. One of the main

principles of TOCA is the concept of “Native Food Sovereignty” (TOCA on-line, 2010).

Native Food Sovereignty is referred to as returning to traditional diet. Medical

interventions have realized only moderate success in treating the effects of diabetes and

little success in preventing the disease. The next step is to integrate and marry medical,

nursing, cultural, and community strategies to empower the Tohono culture to cure itself.

Description of the Setting

The Tohono O’odham Nation consists of four geographic locations in Southern

Arizona that includes the main reservation, the San Xavier District, the San Lucy District,

and Florence Village. The nation covers more than 2.7 million acres and is home to 24,000

people. The Pima make up two main communities on Arizona’s Gila and Salt Rivers.

Approximately 11,000 Pima live on the 550,000-acre Gila River Reservation while the

53,000-acre Salt River – Maricopa Indian Community is home to approximately 7,200

people that consist of Pima and the culturally distinct Maricopa Indian (Curtis, 2003).

Population Affected by the Problem

The Tohono O’odham and Pima Indians have lived on the Sonoran Desert in

present Sonora Arizona and Mexico for centuries. Today the two tribes are geographically

and politically separate, but continue to share close genetic, religious, and cultural

similarities. The two tribes are in fact, two bands of the Uto-Aztecan language family of

American Indians, which includes the Shoshone, Paiute, and Comanche. Archaeological

evidence shows that this language band of American Indians located to the present day

Western United States via a Northward migration from Latin America. The Uto-Aztecan




language family of American Indian remains genetically and culturally independent from

the Athabaskan language family of American Indians (the Navajo, several bands of

Apache, and many others) who came to inhabit many of the same lands following a

Southward migration from Canada (Curtis, 2003).

The two tribes of Uto-Aztecan Indians that came to call Southern Arizona home

think of themselves as one people. In fact, the word O’odham translates to “people”. Both

tribes historically referred to the Pima, who settled in the Gila River valley and adopted an

agricultural culture, as the Akimel O’odham, which translates to “river people”. The word

Tohono translates to “desert” and reflects the more nomadic lifestyle (moving to co-locate

with seasonal water sources and food) of the people who practiced a hunting/gathering

existence in the Desert Islands of the Sonoran desert foothills (Underhill, 1979).

Pima/Tohono culture incorporates Himdag, which translates to “our path” (Woods,

Blaine, & Francisco, 2002). Himdag provides an assessment of the individual’s critical

balance between mental, physical, and spiritual health it (Martinez, G. A. (2005). Himdag

is a gift that cannot be claimed by any other Indian Tribe or Nation and it demands respect

for those that hold it (Martinez, G. A. (2005). The concept represents the pathway

(holistic/lifelong journey), which preserves the member’s strength, affords protection, and

fosters wellness for the Tohono people. The concept represents much more than culture as

it incorporates everything that makes the individual unique as an individual and a member

of the greater Tohono Nation (heritage, history, values, traditions, customs, beliefs, and

language). Also used as a verb, Himdag means to “be able to walk”. The concept

integrates values, language, arts, kinship, games, the environment, mobility, and medicinal

plants in a force that connects the individual to self and the tribe (Martinez, G. A. (2005).




Research Question

Will changing to a culturally traditional diet (I) be as effective as other interventions

(C) for glycemic control (O) (hemoglobin A1C 5.7-6.4) in Pima/Tohono O’odham

adolescents (P) diagnosed with Pre-diabetes?

Conceptual or Theoretical Framework:

It is well established that obesity and diabetes remains America’s major health

concern. The US Surgeon General made the first call to action against these maladies

nearly a decade ago. Today’s US Surgeon General has joined the First Lady, the National

Institutes of Health, and the Secretary of the US Department of Health and Human Services

(HHS) in putting plans to combat obesity and improving nutrition at the top of our Nation’s

health care strategy (OPHS Press Office, 2010). Obesity and diabetes touches every

community. Both have reached epidemic proportions in most American ethnic groups.

Unfortunately, epidemiologic reviews of American populations reveals that the Tohono and

Pima Indian communities in Arizona have the highest rates of obesity and Type 2 diabetes

of any population in the world (Schulz, Bennett, Ravussin, Kidd, Esparza, et al., 2006). The

literature is replete with studies that confirm that exercise and a low caloric/low fat diet is

effective in controlling obesity. In turn, controlling obesity in a population is the single

most effective strategy in reducing type 2 diabetes in that population. The need to modify

behavior to control obesity and promote exercise is greatly magnified in the Tohono/Pima

population.

Therapeutic/Integrative/Complementary Health Strategies: The proposed health

strategy could not be simpler, which focuses on behavior modification to promote

nutritional sovereignty and increased physical activity. The decline in nutritional health of




the Tohono paralleled the abandonment of the native diet and adoption of Western culture

that threw Himdag out of balance for the people.

The proposed strategy is to reduce and slide medical Western intervention to a

subservient/advisory role as a tool for the people to restore Himdag. In the traditional

Tohono way, people would walk and run to great the rising sun each morning. This act

was exercise, but it was viewed as Himdag…not exercise. Helping individuals, families,

and the community reclaim traditional physical activities (singing, walking, running,

playing games) will increase physical activity. Helping the people reclaim the native diet

will put them in-line with the American Diabetes Association’s recommendation for a high

fiber, low caloric diet rich in vegetables and lean protein sources (American Diabetes

Association, 2002).

IproposetrainingyoungTohonoadultsaslayhealthcoaches.Thetraining

objectiveistorestoreHimdagandcurriculumdevelopmentwillbeleadbytheelder

Tohonoandmahkai;Westernmedicalexpertswillberelegatedtoanadvisoryrole.

Westernmedicinecanrelegateitsresources(IndianHealthServiceresources)toan

epidemiologictooltoidentifyhotspotsofobesityanddiabeteswithinthecommunity

andtotrackclinicalchanges(improvement/declinesinobesity/diseaserates).A

Tohonoteamthatconsistsofmahkiandlayhealthcoachwillmaintainclosecontact

withidentifiedpatientstohelpthemrestoreHimdag.Supportiveresourcesinclude

theNativeSeedsSearch,anon-profitorganizationthathasledagrassrootseffortto

protect,preserve,andpropagatenativeSonoranfoodcropsandtoencourageNative

PeoplestoeatNativefoods(NativeSeedSearchon-line,2010).TheTohonoO’odham

employedcasinorevenuestobuildaculturalcenterandmuseum.TheTohono




O’odhamCommunityAction(TOCA)isacommunity-basedorganizationthatstrives

torestoreculturalandphysicalhealthtothedesertpeople.Oneofthemainprinciples

ofTOCAistheconceptof“NativeFoodSovereignty”(TOCAon-line,2010).Other

resourcesinthecommunitythatcanbeutilizedarethecommunitycollege,hospital,

andseveraloutpatientclinicsmanagedbytheIndianHealthServices(UnitedStates

PublicHealthService).IproposethisprogrambebaseoutofTohono O'odham

Community CollegeinSells,Arizona.




CHAPTER 2

LITERATURE REVIEW

A literature review focused on the central clinical question: Will changing to a

culturally traditional diet (I) be as effective as other interventions (C) for glycemic control

(O) (hemoglobin A1C 5.7-6.4) in Tohono O’odham adolescents (P) diagnosed with Pre-

diabetes. The literature survey employed a Medline and Cline Library database search of

full-text English language articles published within the last 10 years. Key search terms

included: Type 2 diabetes; glycemic control; Tohono O’odham, Pima Indian native diet;

and behavior modification. Database title hits and abstract reviews were reviewed for

relevance to the key search terms. Applicable articles were retrieved and integrated in a

synthesis table to facilitate information recall utility.

Evidence Based Practice and Standards of Care for Diabetes Mellitus

Body Mass Index and Diabetes

Schulz, Bennett, Ravussin, Kidd, Kidd, Esparza, et al. (2006) conducted research

that demonstrated an environmental component to obesity (measured by BMI) and type-2

diabetes (diagnosed by OGTT) in the Pima Indian. This correlation descriptive study

assessed and compared data that measured the incidence of obesity and type-2 diabetes in

genetically similar populations (Pima Indian) that are subject to different environmental

conditions (population living in the United States and population living in Mexico). The

study established a type-2 diabetes rate of 5.6% in Mexican Pima males and 8.5% in

Mexican Pima females (statistically similar to incidence in non-Pima Mexicans). The

incidence of diabetes in the studied US Pima male population was 34.2%, and 40.8% in the

US Pima female population. Although genetically similar, the two populations of Pima




Indian have a significantly different incidence of diabetes. The study concludes the

correlation between the higher physical activity level and lower dietary energy intake in the

Mexican Pima with the lower incidence of type-2 diabetes. The study suggests a striking

example of environmental factors (diet and exercise) and the incidence of diabetes. The

study provides solid evidence in the efficacy of preventing the disease in the Pima Indian

by controlling obesity and increasing physical activity level.

Thearle, Bunt, Knowler, and Krakoff (2009) conducted a correlation descriptive

study that established a strong correlation between childhood factors found in 76 Pima

Indian youths and the onset of type-2 diabetes in adulthood. Childhood factors studied

included waist circumference, body mass index (BMI), systolic blood pressure (sBP),

diastolic blood pressure (dBP), fasting glucose, and 2-hr oral glucose tolerance test

(OGTT) data collected during routine wellness exams. Type-2 diabetes was diagnosed

using criteria of acute insulin response (AIR), which was determined by intravenous

glucose tolerance test, and insulin action (M ), which was measured by fasting plasma

glucose levels following alternating intravenous infusions of glucose and insulin. An oral

glucose tolerance test (OGTT) excluded diabetics from study enrollment. The longitudinal

data revealed that insulin secretion and insulin action have deteriorated before impaired

glucose regulation manifests. The data revealed that 2-hr OGTT, waist circumference, and

BMI were the strongest predictors while sBP, dBP were relatively weak factors for the

prediction of type-2 diabetes. This study supports the correlation (co-vary) of childhood

obesity (independent variable) and the onset of type-2 diabetes in adulthood for the Pima

Indian population. This study further supports the premise of the clinical question of

preventing type-2 diabetes by controlling childhood obesity.




Diabetes in population adolescents

Pavkov, Hanson, Knowler, Bennett, Krakoff, & Nelson (2007) examined Type 2

diabetes incidence trends in the Pima Indian between 1965 and 2003. This non-

experimental descriptive study followed 8,236 Pima Indians (≥ 5 years of age) over three

13-year time periods and employed two physiological criteria to define diabetes: 1) 2-h

plasma glucose concentration ≥ 200 mg/dl, and 2) hypoglycemic treatment. The study

participants did not initially meet either criterion for the disease and were followed over

time to see if they would later exhibit the pre-determined criteria during a subsequent

wellness examination. The longitudinal data revealed that of the 8,236 non-diabetic study

participants, 1,005 would develop the disease on follow-up. Interestingly, the study

revealed different disease incident trends among different age groups. Over the course of

the study, the body mass index (BMI) in the population increased by 19%, but the research

disclosed that the incidence of Type 2 diabetes increased in the 5-14 year group, decreased

in the 25-34 year group, and remained stable in all other age groups. This study clearly

showed that the trend of rising incidence of the disease is limited to the population’s youth

who exhibited a six-fold increase over the course of the study. The study is useful in that it

re-enforces the importance of interventions directed at diabetes prevention in the Pima

Indian youth.

US verses Mexico population

Native Food Sovereignty




Brett and Davison (2010) drew upon Theory of Planned Behavior (TPB) and the

Trans-theoretical Model (TTM) to examine the link between fostering behavioral change in

adolescents to adopt a plant-based diet (PBD). This cross-sectional study followed 204

college students from a large public university in the northeastern United States. The

researchers defined a PBD as a diet dominated by fresh or minimally processed plant foods.

The PBD is not a vegetarian diet, but merely follows a limited consumption of meat, eggs,

and dairy. The study employed surveys to determine the participants’ readiness for change

and assigned the participant to one of the five stages of change outlined by the TTM (pre-

contemplation, contemplation, preparation, action, and maintenance). Measurement scales

measured TPB; participant attitude for following a PBD was measured using a 4-item scale

(“bad” to “good”, “harmful” to “beneficial“ “unpleasant” to “pleasant”). The study

demonstrated that an individual’s decision to follow a PBD is different than simply adding

more fruits and vegetables to the diet. This difference is in-line to making a lifestyle

change. Stages of change were not found to be a significant predictor of adopting a PBD.

However, attitude was found to be a strong predictor of behavioral change in adopting a

PBD. The research findings relevant to the clinical question are the importance of attitude,

subjective norms, and perceived behavioral control in readiness to adopt a BPD. This study

can provide direction in facilitating change in the Pima/Tohono adolescent population.

Williams, Knowler, Smith, Hanson, and Roumain, et al., (2001), examined the

correlation between a Western diet and the development of type-2 diabetes in the Pima

Indian. This correlation descriptive study collected survey data from 162 Pima Indians who

were asked to identify their diet as “Indian”, “Anglo” or “Mixed”. The study also contained

a longitudinal component where non-diabetic participants were later diagnosed with that




disease. The results revealed that study subjects with a higher intake of complex

carbohydrates, dietary fiber, insoluble fiber, and vegetable proteins were from the Indian

versus the Anglo or mixed diets. Adjusted for age and sex, the data showed that the risk of

developing diabetes was 2.5 times higher in the Anglo-diet group, and 1.3 times higher in

the mixed-diet group, than in the Indian-diet group. The study suggests a correlation

between higher incidences of type-2 diabetes in Pima Indian populations that follow an

Anglo-based diet. This study supports the premise of the clinical question and supports a

return to a traditionally native diet to decrease the incidence of diabetes in the Pima Indian.




Promotoras (mahkai and Himdag)

Summary




CHAPTER 3

PROJECT DEVELOPMENT

Tohono Cultural Competencies

Available Resources

Nurse/Tohono healer

Western Medicine Advisory Role

Himdag Restoration Team

Hot Spots

Desired Cultural/physiologic Outcome

Summary




CHAPTER 4

IMPLEMENTATION

Implementation of proposed best practice

Center of Excellence Foundation

Evaluation protocol




CHAPTER 5

CONCLUSION AND BENEFITS OF THE PROJECT

Interpretation of Evaluation Findings

Limitations of the Study

Conclusions and Recommendations




REFERENCES

American Diabetes Association (2002). Evidence-based nutrition principles and

recommendations for the treatment and prevention of diabetes and related

complications. Diabetes Care, 25 (1), 202-212.

Martinez, G. A. (2005). My Desert Encounter with Himdag. Tribal College Journal , 17(2),

54. Retrieved from EBSCOhost .

Native Seeds Search on-line, 2010, http://www.nativeseeds.org

Northwestern University Library, Edward S. Curtis's "The North American Indian," 2003.

http://digital.library.northwestern.edu/curtis/

Office of the Surgeon General Press Release, 28 Jan 2010, HHS Secretary and Surgeon

General Join First Lady to Announce Plans to Combat Overweight and Obesity and

Support Healthy Choices, retrieved on 20 Feb 2010 from

http://www.hhs.gov/news/press/2010pres/01/20100128c.html

Pavkov, M., Hanson, R., Knowler, W., Bennett, P., Krakoff, J., & Nelson, R. (2007).

Changing patterns of type 2 diabetes incidence among Pima Indians. Diabetes Care,

30(7), 1758-1763. Retrieved from CINAHL Plus with Full Text database.

Schulz, L., Bennett, P., Ravussin, E., Kidd, J., Kidd, K., Esparza, J., et al. (2006). Effects of

traditional and Western environments on prevalence of type 2 diabetes in Pima

Indians in Mexico and the U.S. Diabetes Care, 29(8), 1866-1871. Retrieved from

CINAHL Plus with Full Text database.




Tataranni, P. A., Harper, I. T., Snitker, S., Parigi, A. D., Vozarova, B., Bunt, J., Bogardus,

C., & Ravussin, E. (Dec 2003). Body weight gain in free-living Pima Indians: effect

of energy intake vs expenditure. (Paper). International Journal of Obesity, 27, 12.

p. 1578. Retrieved February 15, 2010, from Academic OneFile via Gale:

http://libproxy.nau.edu:2124/gtx/start.do?prodId=AONE&userGroupName=nauniv

Thearle, M.S., Bunt, J.C., Knowler, W.C., and Krakoff, J., (2009). Childhood predictors of

adult acute insulin response and insulin action. Diabetes Care, 32 (5), 938-943.

Retrieved from CINAHL Plus with Full Text database

Tohono O’odham Community Action (TOCA) on-line,

http://www.tocaonline.org/About_TOCA/About_TOCA.html

Underhill, R. M. (1979). The Papago and Pima Indians of Arizona. Palmer Lake,

Colorado: The Filter Press

Underhill, R. M. (1979). Papago woman. Long Grove, Illinois: Waveland Press, Inc.

Williams, D. E., et al (2000). Indian or Anglo Dietary Preferences and the Incidence of

Diabetes in Pima Indians. Diabetes 49.5 (2000): A39. Academic OneFile. Web. 15

Mar. 2010.

Woods, T., Blaine, K., & Francisco, L. (2002). O'odham Himdag as a Source of Strength

and Wellness Among the Tohono O'odham of Southern Arizona and Northern Sonora,

Mexico. Journal of Sociology & Social Welfare, 29(1), 35. Retrieved from EBSCOhost .

Wyker, B. A., & Davison, K. K., (2010). Behavioral change theories can inform the

prediction of young adults’ adoption of a plant-based diet. Journal of Nutrition




Education and Behavior, 22 (6), 1-10, Retrieved from CINAHL Plus with Full Text

database.

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