The cost-efficacy of a healthy food box for managing hypertension within a native American population: a group randomized controlled trial.

BACKGROUND: Dietary interventions are used for the treatment of hypertension. We evaluated the cost-efficacy of delivering boxes of healthy, culturally tailored foods and checks that can only be spent on produce in a Native American population. METHODS: We conducted a group randomized controlled trial from 2018 to 2020 with N = 2 treatment counties and N = 2 control counties and a total of N = 160 Native American adults with baseline stage 1 or stage 2 hypertension. Participants in the intervention group received monthly boxes of food that adheres to the Dietary Approaches to Stop Hypertension diet as well as checks that could only be spent on produce for 6 months. We measured blood pressure and quality of life at baseline and at a 6-month follow-up in both intervention and control groups. We used ordered logistic regression to estimate the effect of treatment on probability of blood pressure improvements. We then conducted a cost-efficacy analysis. RESULTS: We found that treatment was effective in reducing blood pressure in women with stage 1 hypertension at baseline. Based on this finding, we also estimate that this intervention satisfies normative cost-effectiveness thresholds, even when lifetime treatment is needed to preserve the impact, so long as treatment is only continued in those who respond to treatment. CONCLUSIONS: Direct delivery of healthy foods and checks that can only be spent on produce are a potentially cost-effective intervention for the management of hypertension among Native American women with stage 1 hypertension. Further research is needed to understand why we found an impact only for this group.

The Cost-Efficacy of a Healthy Food Box for Managing Hypertension Within a Native American Population: The Chickasaw Healthy Eating Environment Research Study.

Background Dietary interventions are used for the treatment of hypertension. We evaluated the cost-efficacy of delivering boxes of healthy, culturally tailored foods and checks that can only be spent on produce in a Native American population. Methods We conducted a group randomized controlled trial from 2018-2020 with N = 2 treatment counties and N = 2 control counties and a total of N = 160 Native American adults with baseline stage 1 or stage 2 hypertension. Participants in the intervention group received monthly boxes of food that adheres to the Dietary Approaches to Stop Hypertension diet as well as checks that could only be spent on produce for 6 months. We measured blood pressure and quality of life at baseline and at a 6-month follow-up in both intervention and control groups. We used ordered logistic regression to estimate the effect of treatment on probability of blood pressure improvements. We then conducted a cost-efficacy analysis. Results We found that treatment was effective in women with stage 1 hypertension at baseline. Based on this finding, we also estimate that this intervention satisfies normative cost-effectiveness thresholds, even when lifetime treatment is needed to preserve the impact, so long as treatment is only continued in those who respond to treatment. Conclusions Direct delivery of healthy foods and checks that can only be spent on produce are a potentially cost-effective intervention for the management of hypertension among Native American women with stage 1 hypertension. Further research is needed to understand why we found an impact only for this group.

Perceived Environments and Physical Activity Among American Indian Adults Living in Oklahoma: The THRIVE Study.

BACKGROUND: Obesity and chronic disease disproportionately affect American Indians (AI). Identifying barriers to physical activity (PA) may promote PA and healthier lifestyles. OBJECTIVE: To identify perceptions of the built environment and examine whether there is an association between environmental perceptions and self-reported PA in AI communities. METHODS: We conducted a survey among 459 AI adults (survey response of 91.4%) residing in Choctaw Nation and Chickasaw Nation, both located in primary rural areas, and we examined perceived PA environment and its association with PA adequacy (≥5 days/week). Participants provided self-report of PA frequency and duration (of ≥30 minutes per day), as well as the opportunity for exercise in indoor and outdoor, town center, and biking and school areas frequency and duration (of ≥30 minutes per day), and their opportunities for exercise in indoor, outdoor, town center, biking, and school areas. RESULTS: Of respondents, 29% met the recommendations of at least 150 minutes of exercise per week, and 56% were obese. The majority had indoor and outdoor exercise areas in their towns, but many did not use them. Higher town center built environment summary scores were associated with adequate PA (estimate = 0.43; p = 0.02). Not feeling like there were streets with marked crosswalks (odds ratio [OR], 0.25; 95% confidence interval [CI], 0.07-0.84) or being neutral/not sure about nice sidewalks (OR, 0.33; 95% CI, 0.13-0.78) were associated with lower odds of getting adequate PA, and not feeling like the town center had working streetlights was associated with higher odds of getting adequate PA (OR, 5.22; 95% CI, 1.34-21.01). CONCLUSIONS: We found that marked crosswalks and nice sidewalks in the town center were associated with getting adequate PA. This research, which identifies specific built environment factors that affect peoples' PA, may be used by tribal and local organizations to more effectively prioritize community interventions to improve PA and potentially the health of the community, specifically in regards to crosswalks and sidewalks.

Impact of a Healthy Retail Intervention on Fruits and Vegetables and Total Sales in Tribally Owned Convenience Stores: Findings From the THRIVE Study.

BACKGROUND: Healthy retail interventions are a recommended intervention strategy to address diet-related diseases, such as obesity and diabetes; however, retail managers are concerned about their bottom line. This study's aim was to assess the impact of a healthy retail intervention on fruits and vegetables (FV) sales, as well as total sales, in tribally owned convenience stores where grocery stores are scarce. METHOD: We analyzed weekly sales data over the first 6 months of a healthy retail intervention. We assessed the proportion of sales from two FV baskets. The FV basket included all fresh, canned, and dried FV sold at stores; while the fruits, vegetables, and salads (FVS) basket included all FV items as well as all salads sold. We compared mean weekly sales rates in intervention and control stores over the 6-month period using generalized estimating equations models to account for repeated measures. RESULTS: Mean weekly FV basket sales rates were higher in intervention stores than control stores in both Nations. Mean weekly FVS baskets sales were significantly higher in intervention stores than control stores in one Nation and were higher, but not statistically significant, in intervention stores in the other Nation. Total sales remained steady throughout the intervention period. CONCLUSIONS: The THRIVE (Tribal Health and Resilience in Vulnerable Environments) intervention increased FV sales without negatively affecting total sales. Policy and Practice Implications. Healthy retail interventions in tribal convenience stores, where many Native Americans living in rural areas shop due to scarcity of grocery stores, could improve diet-related disparities without reducing total sales.

Process Evaluation Tool Development and Fidelity of Healthy Retail Interventions in American Indian Tribally Owned Convenience Stores: the Tribal Health Resilience in Vulnerable Environments (THRIVE) Study.

BACKGROUND: The Tribal Health Resilience in Vulnerable Environments (THRIVE) study aimed to increase healthy food access in 2 rural American Indian communities. The intervention sought to increase fruit and vegetable availability, variety, and convenience through placement, promotion, and pricing of healthy foods and beverages in tribal convenience stores. OBJECTIVE: The aim of this study was to describe the development and implementation of the study process evaluation tool to assess intervention fidelity as part of this cluster-controlled trial. METHODS: Eight stores (2 intervention and 2 control stores per Nation) participated in the study, implemented from May 2016 to May 2017. A web-based survey tailored to store layouts and intervention components assessed how often intervention items were available, approximate quantity available, and whether placement of healthier food items and promotional materials were implemented as designed. After pilot testing the survey, tribal staff members implemented it to collect process evaluation data in the 8 stores during a period of 9-12 mo, assessing study implementation and potential changes in control stores. RESULTS: Promotional materials were available ≥75% of the time for most intervention locations. Fruit availability was similar in Nation A and Nation B intervention stores (79-100% compared with 70-100%), whereas fresh vegetable availability was higher in Nation B compared with Nation A (95-96% compared with 55-75%). Both control stores in Nation A and 1 control store in Nation B had moderate fruit and vegetable availability, ranging from 45% to 52%. No control stores in either Nation used intervention promotional materials. CONCLUSIONS: Process evaluation data indicate that the study was implemented with moderate to high fidelity. The development and implementation of the tool can inform future healthy retail interventions that aim to improve rural and tribal food environments.

A Nutrition Environment Measure to Assess Tribal Convenience Stores: The THRIVE Study.

In rural American Indian (AI) communities, where supermarkets are rare, tribally owned and operated convenience stores are an important food source. Food environment measures for these settings are needed to understand and address the significant diet-related disparities among AIs. Through a tribal-university partnership that included tribal health and commerce representatives from two Native Nations in rural southeastern Oklahoma, we developed the Nutrition Environment Measures Survey for Tribal Convenience Stores (NEMS-TCS) to inform the development and evaluation of a healthy food retail intervention. The NEMS-TCS assessed four scored domains of the rural convenience store food environment-food availability, pricing, quality, and placement-and included 11 food categories that emphasized ready-to-eat food items. Trained raters administered the NEMS-TCS using a sample of 18 rural convenience stores (primarily ranging between 2,400 and 3,600 square feet). We assessed interrater reliability with kappa statistics for dichotomized variables and intraclass correlation coefficients (ICC) for continuous variables. NEMS-TCS demonstrated high inter-rater reliability for all food categories (>85% agreement), subscores (ICC = 0.73-1.00), and the total score (ICC = 0.99). The NEMS-TCS responds to recent calls for reliable measures for rural food environments and may be valuable for studying food environments of large convenience stores in other Native Nations as well as other rural settings.

Diabetes and Obesity Associated with Poor Food Environments in American Indian Communities: the Tribal Health and Resilience in Vulnerable Environments (THRIVE) Study.

BACKGROUND: American Indians (AIs) have significantly higher rates of diet-related chronic diseases than other racial/ethnic groups, and many live in environments with limited access to healthy food. OBJECTIVE: As part of the Tribal Resilience in Vulnerable Environments (THRIVE) study, we examined the relations between the perceived food environment, utilization of food retailers, fruit and vegetable intake, and chronic diseases, including obesity, hypertension, and type 2 diabetes among AI adults. METHODS: Through a community-based participatory research partnership, we surveyed a cross-sectional sample of 513 AIs living within the Chickasaw Nation and the Choctaw Nation of Oklahoma. RESULTS: Only 57% of participants reported that it was easy to purchase fruits and vegetables in their town, and fewer (35%) reported that available fruits and vegetables were of high quality. Additionally, over half (56%) reported traveling ≥20 miles round trip to shop for food. Few participants met the recommended daily intake for fruit (44%) or vegetables (25%). Obesity (55%), hypertension (49%), and diabetes (25%) were commonly reported. Obesity was significantly higher among participants who reported that the price of fruits and vegetables were cost-prohibitive (prevalence proportion ratio (PPR): 1.24; 95% CI: 1.02, 1.50) and those who shopped frequently for food at nontraditional food retailers, such as Dollar Stores (PPR: 1.35; 95% CI: 1.08, 1.69) and small markets (PPR: 1.38; 95% CI: 1.02, 1.86). Diabetes was significantly higher among participants who frequently shopped at convenience stores/gas stations (PPR: 2.26; 95% CI: 1.22, 4.19). CONCLUSIONS: Our study found that the use of nontraditional food retailers, including convenience stores, gas stations, and Dollar Stores, as a regular source of food was associated with obesity and diabetes. These results underscore the importance of interventions to improve rural Tribal food environments. Healthy retail interventions in nontraditional retail settings, such as those implemented through the THRIVE study, may contribute to reducing AI health disparities.

A Healthy Retail Intervention in Native American Convenience Stores: The THRIVE Community-Based Participatory Research Study.

Objectives. To assess a healthy retail intervention in Tribal convenience stores in Oklahoma.Methods. We adapted healthy retail strategies to the context of 8 Tribally owned stores. We assessed individual- and store-level outcomes in a cluster-controlled intervention trial (April 2016-June 2017). We measured fruit and vegetable intake, store environment perceptions, and purchases before and after the intervention among a cohort of 1637 Native American shoppers. We used mixed-effects linear regression to estimate pre- to postintervention changes in and between groups.Results. We followed 74% of participants (n = 1204) 9 to 12 months. Intervention and control participants perceived healthier stores after intervention. Higher shopping frequency was related to purchases of fruits, vegetables, and healthy items.Conclusions. Intervention exposure was associated with healthy purchasing but not fruit and vegetable intake. Research is needed to further assess impacts of environmental interventions on intake.Public Health Implications. As the first healthy retail intervention in Tribally owned stores, our results contribute evidence for environmental and policy interventions to address obesity in Tribal Nations. Multicomponent interventions, led by Tribal leaders from diverse sectors, are needed to create healthy environments and sustainable improvements in Native American health.

Social Support and Physical Activity Among American Indians in Oklahoma: Results From a Community-based Participatory Research Study.

PURPOSE: Little is known about the contribution of social support to physical activity (PA) behavior among American Indians (AIs). This community-based participatory research study examined the prevalence of and associations between different types of PA social support and PA among AIs in rural Oklahoma. METHODS: Our tribal-academic partnership surveyed AI adults (N = 513) living within the tribal jurisdictional areas of 2 tribal nations. We used the Physical Activity Social Support (PASS) scale to assess 3 types of PA social support and Poisson regression to investigate associations between PASS types and self-reported PA behavior. FINDINGS: Over a third of participants perceived high levels of PA social support from friends (37%), family (35%), and overall (34%), yet only 29% reported regular PA (ie, 150 minutes or more weekly). Participants who exercised with pets/other were significantly more likely to achieve regular PA than those who exercised alone (PR 2.0, 95% CI: 1.4-2.9). Although not significant, compared with those reporting no/low support, participants with high friend PASS (PR 1.2, 95%: CI 0.9-1.6), medium family PASS (PR 1.2, 95% CI: 0.9-1.7), and overall PASS (PR 1.1, 95% CI: 0.8-1.6) were more likely to report regular PA. CONCLUSIONS: The majority of participants did not meet current recommendations for PA behavior, which underscores the ongoing need for PA effective interventions among AIs living in rural areas. Results suggest that exercising with pets/other could be an important factor for future intervention. Further research is needed to elucidate determinants of PA and test interventions to increase PA among AIs.

Using community-based participatory research to develop healthy retail strategies in Native American-owned convenience stores: The THRIVE study.

In rural Native American communities, access to healthy foods is limited and diet-related disparities are significant. Tribally owned and operated convenience stores, small food stores that sell ready-to-eat foods and snacks primarily high in fat and sugar, serve as the primary and, in some areas, the only food stores. The Tribal Health and Resilience in Vulnerable Environments or "THRIVE" study, implemented between 2013 and 2018, is the first healthy retail intervention study implemented in tribally owned and operated convenience stores. THRIVE aims to increase vegetable and fruit intake among Native Americans living within the Chickasaw and Choctaw Nation of Oklahoma. The study comprises three phases: 1) formative research assessing tribal community food environments and associated health outcomes; 2) intervention development to assess convenience stores and tailor healthy retail product, pricing, promotion, and placement strategies; and 3) intervention implementation and evaluation. In this paper we share the participatory research process employed by our tribal-university partnership to develop this healthy retail intervention within the unique contexts of tribal convenience stores. We summarize our methods to engage tribal leaders across diverse health, government, and commerce sectors and adapt and localize intervention strategies that test the ability of tribal nations to increase fruit and vegetable purchasing and consumption among tribal members. Study processes will assist in developing a literature base for policy and environmental strategies that intervene broadly to improve Native community food environments and eliminate diet-related disparities among Native Americans.

Food choice considerations among American Indians living in rural Oklahoma: The THRIVE study.

In rural American Indian (AI) communities, access to affordable, healthy foods is often limited. Understanding AI food choice considerations when selecting foods, such as sensory appeal, cost, or health, is an important yet understudied topic for eliminating persistent AI health disparities. In partnership with the Chickasaw Nation and Choctaw Nation of Oklahoma, we administered a modified version of the Food Choice Values (FCV) Questionnaire to a cross-sectional sample of 83 AI patrons shopping at tribally-owned convenience stores ≥3 times per week. The FCV Questionnaire uses 25 items to assess eight FCV subscales related to buying and eating food, including sensory appeal; safety; accessibility; convenience; health/weight control; organic; tradition; and comfort. We compared mean scores for each FCV subscale by demographic groups using t-tests and ANOVA. We used confirmatory factor analysis (CFA) to examine how well the data from this population fit FCV subscale constructs. We then used cluster analysis, MANOVA, and discriminant analysis to characterize distinct segments of the population based on patterns of FCV endorsement. Appeal, safety, and access FCVs were most strongly endorsed across the sample. Prioritization of FCVs varied by age, gender, income, and education. Our cluster analysis identified four groups, or segments, each with distinct patterns of FCV endorsement: limited endorsement of any FCVs (23.3%); safety and sensory appeal (32.9%); health/weight control (17.8%); and broad endorsement of FCVs (26.0%). These groups varied by age and employment status. Findings from this analysis informed the design and implementation of a healthy retail intervention comprised of new healthful foods and beverages, product placement and marketing strategies within four tribally-owned and operated convenience stores. Public health interventions aimed at reducing nutrition-related disparities in rural AI populations may benefit from assessing food choice considerations.

Food Insecurity and Chronic Diseases Among American Indians in Rural Oklahoma: The THRIVE Study.

OBJECTIVES: To examine food insecurity and cardiovascular disease-related health outcomes among American Indians (AIs) in rural Oklahoma. METHODS: We surveyed a cross-sectional sample of 513 AI adults to assess food insecurity domains (i.e., food quality and quantity) and obesity, diabetes, and hypertension. RESULTS: Among AIs surveyed, 56% reported inadequate food quantity and 62% reported inadequate food quality. The unadjusted prevalence of diabetes (28.4% vs 18.4%), obesity (60.0% vs 48.3%), and hypertension (54.1% vs 41.6%) was higher among participants with inadequate food quantity than among those with adequate food quantity. These associations did not reach statistical significance after adjustment for age, gender, study site, education, and income. The unadjusted prevalence of obesity (60.7% vs 45.8%), diabetes (27.3% vs 18.8%), and hypertension (52.5% vs 42.5%) was higher among those with inadequate food quality than among those with adequate food quality, even after adjustment for age, gender, study site, education, and income. CONCLUSIONS: Tribal, federal, and state policymakers, as well as businesses and nonprofit organizations, must collaboratively take aggressive action to address food insecurity and its underlying causes, including improving tribal food environments, reducing barriers to healthy foods, and increasing living wages.

Cardiovascular Disease Risk Factors and Health Outcomes Among American Indians in Oklahoma: the THRIVE Study.

INTRODUCTION: Limited available data document higher prevalences of cardiovascular disease (CVD) risk factors and health outcomes among American Indians (AIs) compared to other racial/ethnic groups. METHODS: As part of a randomized control trial to improve tribal food and physical activity environments, our tribal-academic partnership surveyed a cross-sectional sample of American Indian adults (n = 513) to assess the prevalence of type 2 diabetes, obesity, hypertension, tobacco use, physical activity, and vegetable and fruit intake. Surveys were collected from April through May 2015. We used logistic regression to examine the association between CVD-related risk factors and health outcomes. RESULTS: The prevalence of CVD-related outcomes was high, ranging from 25% for diabetes to 75% for low vegetable intake. The prevalence of diabetes, obesity, and hypertension tended to be higher among participants with any tobacco use compared to no tobacco use, but findings were not statistically significant. The prevalence of diabetes (prevalence ratio 2.1, 95% CI 1.4-3.2) and obesity (prevalence ratio 1.5, 95% CI 1.2-1.8) was higher among participants with low physical activity levels compared to recommended physical activity levels. CONCLUSIONS: CVD risk factors and health outcomes persist among American Indians even as some risks (e.g., smoking) appear to be stabilizing or even declining in the general US population. Efforts to include American Indians in national health surveys, implement broad reaching environmental and policy interventions, and address the social determinants of health are critical to the elimination of these disparities.

Formative assessment using social marketing principles to identify health and nutrition perspectives of Native American women living within the Chickasaw Nation boundaries in Oklahoma.

OBJECTIVE: To identify health product and promotion channels for development of a Chickasaw Nation Supplemental Nutrition Assistance Education Program (SNAP-Ed) social marketing program. METHODS: The study was qualitative and used social marketing principles to assess Native American women's views of health and nutrition. Focus groups (n = 8) and interviews (n = 4) were conducted to identify indigenous views of product, promotion, price, and place related to SNAP-Ed behavioral objectives. RESULTS: The major theme identified for product was diabetes prevention. Participants (n = 42) indicated a preference for family-based education with promotion by elders, tribal leaders, and "everyday people." Participants identified tribe-specific community sites for program implementation at times conducive to work schedules. CONCLUSIONS AND IMPLICATIONS: Culturally appropriate social marketing programs are necessary to address diabetes prevention with a focus on family, heritage, and tribal community. Additional research is necessary to explore the role of elders and tribal leaders in diabetes prevention efforts.