Community involvement in design, implementation and evaluation of nutrition interventions to reduce chronic diseases in indigenous populations in the U.S.: a systematic review

Jinan Banna, Andrea Bersamin, Jinan Banna, Andrea Bersamin

Abstract

Background: Indigenous peoples of the United States disproportionately experience chronic diseases associated with poor nutrition, including obesity and diabetes. While chronic disease related health disparities among Indigenous people are well documented, it is unknown whether interventions adequately address these health disparities. In addition, it is unknown whether and to what extent interventions are culturally adapted or tailored to the unique culture, worldview and nutrition environments of Indigenous people. The aim of this review was to identify and characterize nutrition interventions conducted with Indigenous populations in the US, and to determine whether and to what degree communities are involved in intervention design, implementation and evaluation.

Methods: Peer-reviewed articles were identified using MEDLINE. Articles included were published in English in a refereed journal between 2000 and 2015, reported on a diet-related intervention in Indigenous populations in the US, and reported outcome data. Data extracted were program objectives and activities, target population, geographic region, formative research to inform design and evaluation, partnership, capacity building, involvement of the local food system, and outcomes. Narrative synthesis of intervention characteristics and the degree and type of community involvement was performed.

Results: Of 1060 records identified, 49 studies were included. Overall, interventions were successful in producing changes in knowledge, behavior or health (79%). Interventions mostly targeted adults in the Western region and used a pre-test, post-test design. Involvement of communities in intervention design, implementation, and evaluation varied from not at all to involvement at all stages. Of programs reporting significant changes in outcomes, more than half used at least three strategies to engage communities. However, formative research to inform the evaluation was not performed to a great degree, and fewer than half of the programs identified described involvement of the local food system.

Conclusions: The extent of use of strategies to promote community engagement in programs reporting significant outcomes is notable. In planning interventions in Indigenous groups, researchers should consider ways to involve the community in intervention design, execution and evaluation. There is a particular need for studies focused on Indigenous youth in diverse regions of the US to further address diet-related chronic conditions.

Conflict of interest statement

JB is an Associate Professor in the Department of Human Nutrition, Food and Animal Sciences at the University of Hawai’i at Mānoa. She has an interest in obesity prevention and health promotion in diverse populations. Much of her current work centers on nutrition education and development of tools to evaluate nutrition education programs aimed at promoting healthy eating. Her previous work at the University of California, Davis involved the development of two tools, a food behavior checklist and physical activity questionnaire, to be used in the low-income Spanish-speaking community in the U.S. to evaluate nutrition education interventions.

AB is an Associate Professor at the Center for Alaska Native Health Research, Insitute of Arctic Biology at the University of Alaska Fairbanks. Her research interests are in the role of nutrition and physical activity in the development and prevention of chronic diseases, determinants of dietary and physical activity patterns, development and evaluation of theory-based interventions, and minority health, particularly in indigenous populations.

Not applicable.

Not applicable.

The authors declare that they have no competing interests.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Flow Diagram Illustrating Selection of Studies for Systematic Review of Community Involvement in Design, Implementation and Evaluation of Nutrition Interventions in Indigenous Populations in the U.S

References

    1. Anderson SE, Whitaker RC. Prevalence of obesity among US preschool children in different racial and ethnic groups. Arch Pediatr Adolesc Med. 2009;163(4):344–348. doi: 10.1001/archpediatrics.2009.18.
    1. Schoenborn CA, Adams PF, Peregoy JA. Health behaviors of adults: United States, 2008-2010. Vital Health Stat 10. 2013;(257):1–184.
    1. Jernigan VB, Duran B, Ahn D, Winkleby M. Changing patterns in health behaviors and risk factors related to cardiovascular disease among American Indians and Alaska natives. Am J Public Health. 2010;100(4):677–683. doi: 10.2105/AJPH.2009.164285.
    1. Madsen KA, Weedn AE, Crawford PB. Disparities in peaks, plateaus, and declines in prevalence of high BMI among adolescents. Pediatrics. 2010;126(3):434–442. doi: 10.1542/peds.2009-3411.
    1. Blackwell DL, Lucas JW, Clarke TC. Summary health statistics for U.S. adults: National Health Interview Survey, 2012. Vital Health Stat 10. 2014;(260):1–161.
    1. Rasmus SM. Indigenizing CBPR: evaluation of a community-based and participatory research process implementation of the Elluam Tungiinun (towards wellness) program in Alaska. Am J Community Psychol. 2014;54(1–2):170–179. doi: 10.1007/s10464-014-9653-3.
    1. Teufel-Shone NI. Promising strategies for obesity prevention and treatment within American Indian communities. J Transcult Nurs. 2006;17(3):224–229. doi: 10.1177/1043659606288378.
    1. Egeland GM, Harrison GG, Kuhnlein HV, Erasmus B, Spigelski D, Burlingame B. Indigenous peoples' food systems and well-being: interventions and policies for healthy communities. 2013. Health disparities: promoting Indigenous Peoples' health through traditional food systems and self-determination; pp. 9–22.
    1. Story M, Hannan PJ, Fulkerson JA, Rock BH, Smyth M, Arcan C, Himes JH. Bright start: description and main outcomes from a group-randomized obesity prevention trial in American Indian children. Obesity. 2012;20(11):2241–2249. doi: 10.1038/oby.2012.89.
    1. Ritenbaugh C, Teufel-Shone NI, Aickin MG, Joe JR, Poirier S, Dillingham DC, Johnson D, Henning S, Cole SM, Cockerham D. A lifestyle intervention improves plasma insulin levels among native American high school youth. Prev Med. 2003;36(3):309–319. doi: 10.1016/S0091-7435(02)00015-4.
    1. Gilliland SS, Azen SP, Perez GE, Carter JS. Strong in body and spirit: lifestyle intervention for native American adults with diabetes in New Mexico. Diabetes Care. 2002;25(1):78–83. doi: 10.2337/diacare.25.1.78.
    1. Weaver HN, Jackson KF. Healthy living in two worlds: testing a wellness curriculum for urban native youth. Child Adolesc Social Work J. 2010;27(3):231–244. doi: 10.1007/s10560-010-0197-6.
    1. Murphy S, Wilson C. Breastfeeding promotion: a rational and achievable target for a type 2 diabetes prevention intervention in native American communities. J Hum Lact. 2008;24(2):193–198. doi: 10.1177/0890334408317434.
    1. Mau MK, Keawe'aimoku Kaholokula J, West MR, Leake A, Efird JT, Rose C, Palakiko DM, Yoshimura S, Kekauoha PB, Gomes H. Translating diabetes prevention into native Hawaiian and Pacific islander communities: the PILI 'Ohana pilot project. Prog Community Health Partnersh. 2010;4(1):7–16. doi: 10.1353/cpr.0.0111.
    1. Harvey-Berino J, Rourke J. Obesity prevention in preschool native-american children: a pilot study using home visiting. Obes Res. 2003;11(5):606–611. doi: 10.1038/oby.2003.87.
    1. Rinderknecht K, Smith C. Social cognitive theory in an after-school nutrition intervention for urban native American youth. J Nutr Educ Behav. 2004;36(6):298–304. doi: 10.1016/S1499-4046(06)60398-9.
    1. Hill TG, Briant KJ, Bowen D, Boerner V, Vu T, Lopez K, Vinson E. Evaluation of Cancer 101: an educational program for native settings. J Cancer Educ. 2010;25(3):329–336. doi: 10.1007/s13187-010-0046-5.
    1. LaFrance J, Nichols R, Kirkhart KE. Culture writes the script: on the centrality of context in indigenous evaluation. N Dir Eval. 2012;2012(135):59–74. doi: 10.1002/ev.20027.
    1. Banna JC, Vera Becerra LE, Kaiser LL, Townsend MS. Using qualitative methods to improve questionnaires for Spanish speakers: assessing face validity of a food behavior checklist. J Am Diet Assoc. 2010;110(1):80–90. doi: 10.1016/j.jada.2009.10.002.
    1. Townsend MS. Evaluating food stamp nutrition education: process for development and validation of evaluation measures. J Nutr Educ Behav. 2006;38(1):18–24. doi: 10.1016/j.jneb.2005.11.008.
    1. Kuhnlein HV, Burlingame B, Erasmus B, Spigelski D. Indigenous peoples' food systems and well-being: interventions and policies for healthy communities. 2013. Why do indigenous Peoples' food and nutrition interventions for health promotion and policy need special consideration? pp. 3–8.
    1. Bersamin A, Zidenberg-Cherr S, Stern JS, Luick BR. Nutrient intakes are associated with adherence to a traditional diet among Yup'ik Eskimos living in remote Alaska native communities: the CANHR study. Int J Circumpolar Health. 2007;66(1):62–70. doi: 10.3402/ijch.v66i1.18228.
    1. Blaisdell R. Historical and cultural aspects of native Hawaiian health. Honolulu: University of Hawaii Press; 1989.
    1. Turner NJ, Plotkin M, Kuhnlein HV, Erasmus B, Spigelski D, Burlingame B. Global environmental challenges to the integrity of Indigenous Peoples' food systems. In: Communities Ipfsaw-biapfh, editor. Indigenous peoples' food systems & well-being: interventions & policies for healthy communities; 2013. p. 23–38.
    1. Egeland GM, Johnson-Down L, Cao ZR, Sheikh N, Weiler H. Food insecurity and nutrition transition combine to affect nutrient intakes in Canadian arctic communities. J Nutr. 2011;141(9):1746–1753. doi: 10.3945/jn.111.139006.
    1. Johnson-Down LM, Egeland GM. How is nutrition transition affecting dietary adequacy in Eeyouch (Cree) adults of northern Quebec, Canada? Appl Physiol Nutr Metab. 2013;38(3):300–305. doi: 10.1139/apnm-2012-0167.
    1. Reeds J, Mansuri S, Mamakeesick M, Harris SB, Zinman B, Gittelsohn J, Wolever TM, Connelly PW, Hanley A. Dietary patterns and type 2 diabetes mellitus in a first nations community. Can J Diabetes. 2016;40(4):304–310. doi: 10.1016/j.jcjd.2016.05.001.
    1. Williams DE, Knowler WC, Smith CJ, Hanson RL, Roumain J, Saremi A, Kriska AM, Bennett PH, Nelson RG. The effect of Indian or Anglo dietary preference on the incidence of diabetes in pima Indians. Diabetes Care. 2001;24(5):811–816. doi: 10.2337/diacare.24.5.811.
    1. Asian and Pacific Islander American Health Forum: Native Hawaiian and Pacific Islander Health Disparities; 2010. Available at: .
    1. Jolly SE, Howard BV, Umans JG. Cardiovascular Disease Among Alaska Native Peoples. Curr Cardiovasc Risk Rep. 2013;7(6):438–45.
    1. Ogden CL, Carroll MD, Fryar CD, Flegal KM. Prevalence of Obesity Among Adults and Youth: United States, 2011-2014. NCHS Data Brief. 2015;(219):1–8.
    1. United States Department of Agriculture Center for Nutrition Policy and Promotion. Diet Quality of Children Age 2–17 Years as Measured by the Healthy Eating index-2010. Nutrition Insight 52. 2013.
    1. Institute of Medicine Committee on Prevention of Obesity in C, Youth: The National Academies Collection: Reports funded by National Institutes of Health. In: Preventing Childhood Obesity: Health in the Balance. edn. Edited by Koplan JP, Liverman CT, Kraak VI. Washington (DC): National Academies Press (US) National Academy of Sciences.; 2005.
    1. Willett W. Nutritional epidemiology. 3. New York: Oxford University Press; 2013.
    1. Baranowski T, Perry CL, Parcel GS, Glanz K, Rimer BK, Lewis FM. Health Behavior and Health Education: Theory, Research, and Practice. 3. San Francisco: Jossey-Bass; 2002. How Individuals, Environments, and Health Behavior Interact; pp. 165–184.
    1. Arcan C, Hannan PJ, Himes JH, Fulkerson JA, Rock BH, Smyth M, Story M. Intervention effects on kindergarten and first-grade teachers' classroom food practices and food-related beliefs in American Indian reservation schools. J Acad Nutr Diet. 2013;113(8):1076–1083. doi: 10.1016/j.jand.2013.04.019.
    1. Bachar JJ, Lefler LJ, Reed L, McCoy T, Bailey R, Bell R. Cherokee choices: a diabetes prevention program for American Indians. Prev Chronic Dis. 2006;3(3):A103.
    1. Wagner EH, Wickizer TM, Cheadle A, Psaty BM, Koepsell TD, Diehr P, Curry SJ, Von Korff M, Anderman C, Beery WL, et al. The Kaiser Family Foundation Community health promotion grants program: findings from an outcome evaluation. Health Serv Res. 2000;35(3):561–589.
    1. Beckham S, Bradley S, Washburn A, Taumua T. Diabetes management: utilizing community health workers in a Hawaiian/Samoan population. J Health Care Poor Underserved. 2008;19(2):416–427. doi: 10.1353/hpu.0.0012.
    1. Mayer-Davis EJ, Sparks KC, Hirst K, Costacou T, Lovejoy JC, Regensteiner JG, Hoskin MA, Kriska AM, Bray GA. Dietary intake in the diabetes prevention program cohort: baseline and 1-year post randomization. Ann Epidemiol. 2004;14(10):763–772. doi: 10.1016/j.annepidem.2004.02.004.
    1. Wing RR, Hamman RF, Bray GA, Delahanty L, Edelstein SL, Hill JO, Horton ES, Hoskin MA, Kriska A, Lachin J, et al. Achieving weight and activity goals among diabetes prevention program lifestyle participants. Obes Res. 2004;12(9):1426–1434. doi: 10.1038/oby.2004.179.
    1. Mendenhall TJ, Berge JM, Harper P, GreenCrow B, LittleWalker N, WhiteEagle S, BrownOwl S. The family education diabetes series (FEDS): community-based participatory research with a midwestern American Indian community. Nurs Inq. 2010;17(4):359–372. doi: 10.1111/j.1440-1800.2010.00508.x.
    1. Buller DB, Woodall WG, Zimmerman DE, Slater MD, Heimendinger J, Waters E, Hines JM, Starling R, Hau B, Burris-Woodall P, et al. Randomized trial on the 5 a day, the Rio Grande way website, a web-based program to improve fruit and vegetable consumption in rural communities. J Health Commun. 2008;13(3):230–249. doi: 10.1080/10810730801985285.
    1. Bradley S, Beckham S, Washburn A. The Hawai'i community resource obesity project: results from the lifestyle enhancement program. Hawaii Med J. 2009;68(4):80–84.
    1. Gittelsohn J, Vijayadeva V, Davison N, Ramirez V, Cheung LW, Murphy S, Novotny R. A food store intervention trial improves caregiver psychosocial factors and children's dietary intake in Hawaii. Obesity (Silver Spring, Md) 2010;18(Suppl 1):S84–S90. doi: 10.1038/oby.2009.436.
    1. Carrel A, Meinen A, Garry C, Storandt R. Effects of nutrition education and exercise in obese children: the Ho-Chunk Youth Fitness Program. WMJ. 2005;104(5):44–7.
    1. Brown B, Noonan C, Harris KJ, Parker M, Gaskill S, Ricci C, Cobbs G, Gress S. Developing and piloting the journey to native youth health program in Northern Plains Indian communities. Diabetes Educ. 2013;39(1):109–118. doi: 10.1177/0145721712465343.
    1. Gellert KS, Aubert RE, Mikami JS. Ke 'Ano Ola: Moloka'i's community-based healthy lifestyle modification program. Am J Public Health. 2010;100(5):779–783. doi: 10.2105/AJPH.2009.176222.
    1. Benyshek DC, Chino M, Dodge-Francis C, Begay TO, Jin H, Giordano C. Prevention of type 2 diabetes in urban American Indian/Alaskan native communities: the life in BALANCE pilot study. J Diabetes Mellitus. 2013;3(4):184–191. doi: 10.4236/jdm.2013.34028.
    1. Kattelmann KK, Conti K, Ren C. The medicine wheel nutrition intervention: a diabetes education study with the Cheyenne River Sioux tribe. J Am Diet Assoc. 2009;109(9):1532–1539. doi: 10.1016/j.jada.2009.06.362.
    1. Burden RW, Kumar RN, Phillips DL, Borrego ME, Galloway JM. Hyperlipidemia in native Americans: evaluation of lipid management through a cardiovascular risk reduction program. J Am Pharm Assoc. 2002;42(4):652–655.
    1. Mau MK, Glanz K, Severino R, Grove JS, Johnson B, Curb JD. Mediators of lifestyle behavior change in native Hawaiians: initial findings from the native Hawaiian diabetes intervention program. Diabetes Care. 2001;24(10):1770–1775. doi: 10.2337/diacare.24.10.1770.
    1. Gittelsohn J, Kim EM, He S, Pardilla M. A food store-based environmental intervention is associated with reduced BMI and improved psychosocial factors and food-related behaviors on the Navajo nation. J Nutr. 2013;143(9):1494–1500. doi: 10.3945/jn.112.165266.
    1. Sinclair KA, Makahi EK, Shea-Solatorio C, Yoshimura SR, Townsend CK, Kaholokula JK. Outcomes from a diabetes self-management intervention for native Hawaiians and Pacific people: Partners in Care. Ann Behav Med. 2013;45(1):24–32. doi: 10.1007/s12160-012-9422-1.
    1. Caballero B, Clay T, Davis SM, Ethelbah B, Rock BH, Lohman T, Norman J, Story M, Stone EJ, Stephenson L, et al. Pathways: a school-based, randomized controlled trial for the prevention of obesity in American Indian schoolchildren. Am J Clin Nutr. 2003;78(5):1030–1038. doi: 10.1093/ajcn/78.5.1030.
    1. Gittelsohn J, Evans M, Helitzer D, Anliker J, Story M, Metcalfe L, Davis S, Iron CP. Formative research in a school-based obesity prevention program for native American school children (Pathways) Health Educ Res. 1998;13(2):251–65. doi: 10.1093/her/13.2.251.
    1. Cunningham-Sabo L, Snyder MP, Anliker J, Thompson J, Weber JL, Thomas O, Ring K, Stewart D, Platero H, Nielsen L. Impact of the Pathways food service intervention on breakfast served in American-Indian schools. Prev Med. 2003;37(6 Pt 2):S46–54. doi: 10.1016/j.ypmed.2003.08.007.
    1. Davis SM, Clay T, Smyth M, Gittelsohn J, Arviso V, Flint-Wagner H, Rock BH, Brice RA, Metcalfe L, Stewart D, et al. Pathways curriculum and family interventions to promote healthful eating and physical activity in American Indian schoolchildren. Prev Med. 2003;37(6 Pt 2):S24–S34. doi: 10.1016/j.ypmed.2003.08.011.
    1. Himes JH, Ring K, Gittelsohn J, Cunningham-Sabo L, Weber J, Thompson J, Harnack L, Suchindran C. Impact of the Pathways intervention on dietary intakes of American Indian schoolchildren. Prev Med. 2003;37(6 Pt 2):S55–61. doi: 10.1016/j.ypmed.2003.08.003.
    1. Stevens J, Story M, Ring K, Murray DM, Cornell CE, Juhaeri GJ. The impact of the Pathways intervention on psychosocial variables related to diet and physical activity in American Indian schoolchildren. Prev Med. 2003;37(6 Pt 2):S70–9. doi: 10.1016/j.ypmed.2003.08.012.
    1. Stevens J, Cornell CE, Story M, French SA, Levin S, Becenti A, Gittelsohn J, Going SB, Reid R. Development of a questionnaire to assess knowledge, attitudes, and behaviors in American Indian children. Am J Clin Nutr. 1999;69(4 Suppl):773s–781s. doi: 10.1093/ajcn/69.4.773S.
    1. Stone EJ, Norman JE, Davis SM, Stewart D, Clay TE, Caballero B, Lohman TG, Murray DM. Design, implementation, and quality control in the Pathways American-Indian multicenter trial. Prev Med. 2003;37(6 Pt 2):S13–23. doi: 10.1016/j.ypmed.2003.08.006.
    1. Story M, Snyder MP, Anliker J, Weber JL, Cunningham-Sabo L, Stone EJ, Chamberlain A, Ethelbah B, Suchindran C, Ring K. Changes in the nutrient content of school lunches: results from the Pathways study. Prev Med. 2003;37(6 Pt 2):S35–45. doi: 10.1016/j.ypmed.2003.08.009.
    1. Kaholokula JK, Wilson RE, Townsend CK, Zhang GX, Chen J, Yoshimura SR, Dillard A, Yokota JW, Palakiko DM, Gamiao S, et al. Translating the diabetes prevention program in native Hawaiian and Pacific islander communities: the PILI 'Ohana project. Transl Behav Med. 2014;4(2):149–159. doi: 10.1007/s13142-013-0244-x.
    1. Kaholokula JK, Kekauoha P, Dillard A, Yoshimura S, Palakiko DM, Hughes C, Townsend CK. The PILI 'Ohana project: a community-academic partnership to achieve metabolic health equity in Hawai'i. Hawai'i J Med Public Health. 2014;73(12 Suppl 3):29–33.
    1. Richards J, Mousseau A. Community-based participatory research to improve preconception health among Northern Plains American Indian adolescent women. Am Indian Alsk Native Ment Health Res. 2012;19(1):154–185. doi: 10.5820/aian.1901.2012.154.
    1. Jiang L, Manson SM, Beals J, Henderson WG, Huang H, Acton KJ, Roubideaux Y. Translating the diabetes prevention program into American Indian and Alaska native communities: results from the special diabetes program for Indians diabetes prevention demonstration project. Diabetes Care. 2013;36(7):2027–2034. doi: 10.2337/dc12-1250.
    1. Moore K, Jiang L, Manson SM, Beals J, Henderson W, Pratte K, Acton KJ, Roubideaux Y. Case management to reduce cardiovascular disease risk in American Indians and Alaska natives with diabetes: results from the special diabetes program for Indians healthy heart demonstration project. Am J Public Health. 2014;104(11):e158–e164. doi: 10.2105/AJPH.2014.302108.
    1. Jernigan VB. Community-based participatory research with native American communities: the chronic disease self-management program. Health Promot Pract. 2010;11(6):888–899. doi: 10.1177/1524839909333374.
    1. Howard BV, Roman MJ, Devereux RB, Fleg JL, Galloway JM, Henderson JA, Howard WJ, Lee ET, Mete M, Poolaw B, et al. Effect of lower targets for blood pressure and LDL cholesterol on atherosclerosis in diabetes: the SANDS randomized trial. JAMA. 2008;299(14):1678–1689. doi: 10.1001/jama.299.14.1678.
    1. Russell M, Fleg JL, Galloway WJ, Henderson JA, Howard J, Lee ET, Poolaw B, Ratner RE, Roman MJ, Silverman A, et al. Examination of lower targets for low-density lipoprotein cholesterol and blood pressure in diabetes--the stop atherosclerosis in native diabetics study (SANDS) Am Heart J. 2006;152(5):867–875. doi: 10.1016/j.ahj.2006.05.021.
    1. Karanja N, Lutz T, Ritenbaugh C, Maupome G, Jones J, Becker T, Aickin M. The TOTS community intervention to prevent overweight in American Indian toddlers beginning at birth: a feasibility and efficacy study. J Community Health. 2010;35(6):667–675. doi: 10.1007/s10900-010-9270-5.
    1. Leslie JH. Uli'eo Koa program: incorporating a traditional Hawaiian dietary component. Pacific health dialog. 2001;8(2):401–406.
    1. Witmer JM, Hensel MR, Holck PS, Ammerman AS, Will JC. Heart disease prevention for Alaska native women: a review of pilot study findings. J Women's Health. 2004;13(5):569–578. doi: 10.1089/1540999041280981.
    1. DeWeese AD, Kmiecik NE, Chiriboga ED, Foran JA. Efficacy of risk-based, culturally sensitive Ogaa (walleye) consumption advice for Anishinaabe tribal members in the Great Lakes region. Risk Anal. 2009;29(5):729–742. doi: 10.1111/j.1539-6924.2008.01198.x.
    1. Driscoll D, Sorensen A, Deerhake M. A multidisciplinary approach to promoting healthy subsistence fish consumption in culturally distinct communities. Health Promot Pract. 2012;13(2):245–251. doi: 10.1177/1524839910380156.
    1. Smith J, George VA, Easton PS. Home-grown television: a way to promote better nutrition in a native Alaskan community. J Nutr Educ. 2001;33(1):59–60. doi: 10.1016/S1499-4046(06)60013-4.
    1. Thompson JL, Allen P, Helitzer DL, Qualls C, Whyte AN, Wolfe VK, Herman CJ. Reducing diabetes risk in American Indian women. Am J Prev Med. 2008;34(3):192–201. doi: 10.1016/j.amepre.2007.11.014.

Source: PubMed

Sponsorer og samarbejdspartnere

Medicinske tilstande

Narkotikainterventioner

3
Abonner