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.

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 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.