Progress 07/01/02 to 06/30/05
Outputs
Introduction This final report summarizes work and analyses completed for the Apache Healthy Stores program through December 31, 2005. The AHS intervention was completed at the end of June 2004. As of December 31, we completed data collection on 184 of the original sample of 270 households, 68% follow-up (analyses presented here). Exposure to the AHS Program Respondents from intervention areas shopped significantly more at intervention stores than those living in the comparison areas. In addition, respondents living in intervention areas were significantly more likely to have attended a cooking demonstration, to have heard about the program on the radio, have seen an AHS program newspaper cartoon, and to have seen an AHS poster. Impact on psychosocial factors We examined evidence of the impact of the AHS program on psychosocial factors. All of the indicators indicate a trend towards a higher mean value in the intervention sample, although only one was statistically
significant. Food knowledge increased 0.79 points in the intervention sample, as compared to -0.25 points in the comparison sample (t-test, p=0.001). Food self-efficacy increased 2.6 points in intervention and 1.5 in comparison (p=0.25). Food intentions increased 1.2 points in intervention and increased 0.8 points in comparison (p=0.63). Impact on sales of promoted foods Supermarket sales data indicate an overall positive trend in sales of key promoted foods. Sales of cooking spray increased 244% at the intervention stores, and 149% at comparison stores. Sales of pretzels increased 150% in intervention stores and 131% at comparison stores. Sales of low sugar, high fiber cereals increased 18% in intervention stores, and decreased 1% in comparison stores. Impact on food consumption frequency Respondents living in the intervention areas were significantly more likely to increase their frequency of consumption of vegetables, lower sugar/higher fiber cereals, 2% milk and healthy beverages
than those living in comparison areas. The intervention sample also showed a non-significant increase in frequency of consumption of fruits and 1% or skim milk, and a decrease in frequency of consumption of unhealthy beverages and chips. Summary These preliminary results provide strong evidence of the success of the AHS program. Respondents from the intervention communities show a trend for higher food knowledge, self-efficacy and intentions associated with healthy food selection, preparation and consumption. Sales of promoted foods increased at a higher rate in supermarkets on the two Apache reservations (intervention) than in other supermarkets on American Indian reservations owned by the same chain. Food frequency data show that frequency of consumption of many promoted foods, including vegetables and lower sugar cereals increased significantly in intervention versus comparison respondents.
Impacts
The impact of the Apache Health Stores trial has been: 1) to demonstrate the effectiveness of a food store-centered program to increase food-related psychosocial factors (particularly knowledge), to improve the frequency of purchasing of healthy foods and to demonstrate an increase in the gram consumption of many promoted foods among adult American Indian community members; and 2) to demonstrate the impact of the program on food store sales, a crucial component of sustainability. The Apache Healthy Stores program supported by the USDA was an environmental intervention in food stores which led to increased availability of some healthy foods to the local population, and to promotion of these foods in a manner we hoped would encourage acceptance and sustained use through institutionalization. The program has served as a model for other investigators working to improve diet among Native North Americans - with the approach now being extended to other reservation-based
American Indian tribes in the United States. In addition, the results are applicable to other populations in the United States living in rural settings and to inner city urban populations which have reduced access to healthy foods in local stores.
Publications
- Curran S, Gittelsohn J, Anliker JA, Ethelbah B, Blake K, Sharma S and Caballero B (2005) Process evaluation of a store-based environmental obesity intervention on two American Indian reservations, Health Education Research, 20(6):719-29.
- Gittelsohn J, Anliker JA, Sharma S, Vastine AE, Caballero B and Ethelbah B (2006) Psychosocial determinants of food purchasing and preparation in American Indian households, Journal of Nutrition Education and Behavior, May-Jun;38(3):163-8.
- Sharma S, Cao X, Gittelsohn J, Ethelbah B, Anliker J, Caballero B. (2007) Dietary intake and development of a food frequency questionnaire to evaluate a nutrition intervention to reduce risk of chronic disease in American Indian populations, Public Health Nutrition, (in press).
- Sharma S, Cao X, Gittelsohn J, Ethelbah B, Anliker J, Caballero B. (2007) Nutritional composition of traditional Apache foods in Arizona. International Journal of Food Science and Nutrition (in press).
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Progress 10/01/03 to 09/30/04
Outputs
Introduction This report summarizes work and analyses completed for the Apache Healthy Stores program through September 30, 2004. The AHS intervention was completed at the end of June 2004. As of September 1, we completed data collection on 84 of the original sample of 270 households (analyses presented here). Since September 30, 2004 we have completed data collection on an additional 70+ households. In addition, we completed portion size weights and recipe data collection for the quantitative food frequency. Exposure to the AHS Program Respondents from the intervention areas shopped significantly more times at the intervention stores than those living in the comparison areas (18.1 vs 8.2). In addition, respondents living in intervention areas were significantly more likely to have attended a cooking demonstration (2.5 vs 1.0), have heard about the program on the radio (1.4 vs 0.4), have seen a AHS program newspaper cartoon (3.0 vs 0.6), and to have seen a AHS poster
(5.4 vs 1.8). Impact on psychosocial factors We examined evidence of the impact of the AHS program on psychosocial factors. All of the indicators indicate a trend towards a higher mean value in the intervention sample, although none are statistically significant. Food knowledge increased 0.82 points in the intervention sample, as compared to -0.18 points in the comparison sample (t-test, p=0.0625). Food self-efficacy increased 3.6 points in intervention and 2.9 in comparison (p=0.6603). Food intentions increased 1.0 points in intervention and decreased 0.1 points in comparison (p=0.3447). Impact on sales of promoted foods Analyses of supermarket sales data indicate an overall positive trend in sales of key promoted foods. Sales of cooking spray increased 244% at the intervention stores, and 149% at comparison stores. Sales of pretzels (promoted as an alternative to chips) increased 150% in intervention stores and 131% at comparison stores. Sales of low sugar, high fiber cereals
increased 18% in intervention stores, and decreased 1% in comparison stores. Impact on food consumption frequency Respondents living in the intervention areas were significantly more likely to increase their frequency of consumption of vegetables, lower sugar/higher fiber cereals, 2% milk and healthy beverages than those living in comparison areas. The intervention sample also showed a non-significant increase in frequency of consumption of fruits and 1% or skim milk, and a decrease in frequency of consumption of unhealthy beverages and chips. Summary These preliminary results provide strong evidence of the success of the AHS program. Respondents from the intervention communities show a trend for higher food knowledge, self-efficacy and intentions associated with healthy food selection, preparation and consumption. Sales of promoted foods increased at a higher rate in supermarkets on the two Apache reservations (intervention) than in other supermarkets on American Indian reservations
owned by the same chain. Food frequency data show that frequency of consumption of many promoted foods, including vegetables and lower sugar cereals increased significantly in intervention versus comparison respondents.
Impacts
The impact of the Apache Health Stores trial will be: 1) to demonstrate the effectiveness of a food store-centered program to increase food-related psychosocial factors (knowledge, self-efficacy, intentions), and the purchasing, preparation and consumption of healthy foods among American Indian community members; and 2) to demonstrate the impact of the program on food store sales, a crucial component of sustainability. The Apache Healthy Stores program is an environmental intervention in food stores which provides for significant changes in the types of foods made available to the local population, and promotion of these foods in a manner which will encourage acceptance and sustained use through institutionalization. The results of this intervention trial may be directly extended to other reservation-based American Indian tribes in the United States. In addition, the results will be applicable to other populations in the United States living in rural settings and to
inner city urban populations which have reduced access to healthy foods in local stores.
Publications
- Vastine, A.E., Gittelsohn, J., Ethelbah, B., Anliker, J., and Caballero, B. (2005) Formative research and stakeholder participation in intervention development. Am J Health Behavior, 29(1): 57-69.
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Progress 10/01/02 to 09/30/03
Outputs
Obesity disproportionately affects American Indians resulting in chronic disease rates many times higher than national averages. The Apache Healthy Stores (AHS) Project aims to reduce these high rates of obesity and chronic disease risk among by implementing an environmental store-based intervention to increase the availability of healthy food options and promote them at the point of purchase. The AHS study design allocated eleven stores in two areas on the two reservations to implement the intervention and ten stores in two other areas to serve as comparisons. The intervention impact on store healthier food ordering, sales, and promotion will be assessed. Additionally, we will examine changes in consumer purchasing, preparation, consumption, and self-efficacy, a pretest/posttest, prospective longitudinal study of 300 respondents is being conducted. In June 2003 a two-day training session was held by project staff and attended by tribal health representatives, a store
manager, and AHS staff. The intervention officially began on June 16, 2003 with a Kickoff Event. Phase 1 promoted healthy snacks was extended to two and a half months while Phase 2 (healthy breakfasts) lasted close to two months. We are currently completing Phase 3 which supports the use of cooking spray. To evaluate the AHS Intervention we have developed a Customer Impact Questionnaire (CIQ) (SES, food purchasing, food preparation, intentions, self-efficacy, food security, health beliefs, quantitative food frequency (FFQ)) to be conducted pre and post intervention; a Customer Exposure form to be conducted post intervention, a Store Evaluation Questionnaire (Store characteristics, unit food sales, outcome expectations, etc.) to be conducted pre, interim and post intervention, and Process Evaluation instruments to be conducted during the implementation. Baseline data collection took place from February-August 2003. The CIQ was completed on a sample of 270 persons, the FFQ on 225, and
the store evaluation form on all but 2 of the reservation stores. Process evaluation results to date reveal good intervention implementation. Promoted foods, shelf labels, and posters were the primary intervention components evaluated in the store visit form. On average, promoted foods have been correctly labeled 70-85% of the time (depending on phase). The cooking demonstration and taste test process evaluation form assesses the duration of the activities, customer participation, and food and flyer distribution. Each demo has had an average of 16 visitors, with food samples and flyers being given out. By the end of phase 2, over 300 persons had been reached by the food demonstrations. The Apache Healthy Stores program is at its halfway point and appears to have been successful in impacting awareness and knowledge, and encouraging the trial of healthier foods. We have learned that the stocking of promoted foods by intervention stores can be inhibited by factors such as tribal finances
or store remoteness. Encouraging stores to carry the promoted food items can thus take more time than the phase allows for and requires constant encouragement by and support.
Impacts
The impact of this intervention trial is three-fold: 1) we will demonstrate the effectiveness of a food store-centered program to increase sales of healthy foods and improve the diets of American Indian adults; 2) we will provide a model for such a store-centered program which is both effective and sustainable; and 3) we will provide accurate and precise data on the diet of adult American Indians (from baseline FFQ data), which will permit comparison of their intakes with current DRIs and FGP recommendations -- in a population where these data are not readily available.
Publications
- Ethelbah, B., Gittelsohn J., Vastine A., Caballero B., Anliker J., Noel J., Kessay S. (2003). The Apache Healthy Stores program: Results of the formative research. The FASEB Journal, v17(4): A708.
- Vastine, A., Gittelsohn J., Ethelbah B., Anliker J., Caballero B. (2003). Development and content of a food store-based intervention targeting American Indians. The FASEB Journal, v17(4): A710.
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