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During the formative research phase, food stores were identified across the Navajo Nation and availability of healthy foods was documented using a food source survey. The Navajo Nation was divided into 10 store regions on the basis of the presence of a supermarket. The 10 store regions were randomized into intervention (Round 1 implementation) and comparison (Round 2 implementation) areas. The intervention areas included 5 supermarkets and 10 smaller stores nearby the 5 supermarkets. The corporate management of the Bashas’ supermarket chain established a memorandum of understanding with the university team and permitted its individual stores on the Navajo Nation to participate in the project. Top management of the chain convenience stores was contacted by interventionists when corporate approval was needed for participation of individual stores. In each region, the main grocery store and a few smaller stores housed the intervention.

The intervention was implemented by trained nutritionists/health staff of Navajo Special Diabetes Project (NSDP), a community health organization funded under the Special Diabetes Program for Indians (SDPI) (Community-directed) Grant Program for diabetes prevention and treatment services. Johns Hopkins University provided intervention materials, giveaways, periodic additional trainings and oversight. Each interventionist was assigned 1–2 stores and conducted a 1–2-h interactive session at each store 2–4 times during each phase lasting 6-10 weeks. The interactive sessions included demonstrating healthier cooking methods, taste testing healthy foods, giving away promotional items, and responding to questions from store customers. The interventionists’ additional duties were to create and maintain relationships with food stores, work with stores to stock key promoted healthier foods, and set up media materials such as educational displays, posters, and shelf labels. Radio announcements of key messages were recorded and played regularly in both Navajo and English (Gittelsohn et al., 2013).

6.3.2 Participants and Procedures Study participants were NHS local interventionists (10) and program manager (1) and intervention store owners or managers (13). At the time when this study was conducted, of 15 stores recruited for the NHS program, one store was closed for business.

The manager of a chain convenience store owned by a private company was not given permission to participate in the interview by their top manager. A total of 21 people were interviewed at their workplaces. Signed consent was obtained from all participants. A semi-structured interview guide was used to ensure that key areas were addressed in the limited time available to the participants. Topics covered included: store recruitment, intervention implementation, barriers to implementation, coordination with interventionists, program impact on customers and stores.

There was no audio-recording of interviews, out of respect for local culture and participants’ preferences. The researcher wrote down interview responses, and made every effort to capture actual phrases and sentences used by participants. The duration of interviews ranged from 10 minutes to 1 hour 45 minutes, but most of the interviews with store managers lasted 15 – 20 minutes and with interventionists lasted about 1 hour.

Interviews took place during the last phase of the NHS program, from March 25 to May 15, 2009.

Program documents were reviewed to understand the experiences and perceptions of study participants in the program context, and to corroborate information from interviews, as well as to provide background detail for the study. These documents included program meeting and teleconference minutes, formative research reports, the interventionist manual of procedures, progress updates and reports, and journal articles.

This study was approved by both the Johns Hopkins University Institutional Review Board (IRB) and the Navajo Nation Human Research Review Board (NNHRRB).

6.3.3 Data Analysis The template approach (Crabtree & Miller, 1999; King, 1998) was used to analyze textual data (from interviews and documents). A list of pre-determined codes derived from the literature, interview guide, and initial reading of interview responses and program documents were used to analyze the data and modified through careful reading and rereading of the data. A research assistant with a qualitative data analysis background helped check the accuracy and clarity of the coding template by independently coding a subset of data. Coded segments of text were entered into the appropriate data charts created for each code in the final version of the coding template using NVIVO 8.

Themes that were of direct relevance to the main research questions and of great importance to participants were prioritized, and representative, contextually rich quotes were identified to aid the understanding of specific points of interpretation.

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Findings that described store recruitment and relationship building between local health staff (interventionists) and store owners/managers are presented first, followed by a description of challenges in implementing the food store – based intervention by comparing and contrasting between storeowner/manager and interventionist accounts, and lastly a description of storeowners’ perceptions about the program, its implementation and effectiveness.

6.4.1 Store Recruitment and Relationship Building There were concerns and trust issues in recruiting stores for the program.

Interventionists reported they felt uncertain about approaching food stores managers initially about the healthy stores program. As an interventionist described, “I guess my concern was the store managers, owners, whether they accept the program or not. We’re just stepping on their toes. I thought that might be a conflict. We’re trying to promote healthy foods but they might worry about getting rid of unhealthy snacks that they’re making the most money of.” (Interventionist,

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In fact, this concern did not appear to be an issue for most of the store managers that participated in the program. Most of the store managers expressed that they welcomed interventionists because they felt the healthy stores program would be beneficial to their customers and community in combating diabetes. They acknowledged that a lot of Navajo people have diabetes and that diabetes has affected their families and employees. Two of the store managers, who had shown great support for the program according to the interventionists, emphasized the importance of having the program based on their experiences and knowledge about diet and health.

“I knew about diabetes ten years back, and how diabetes affected Navajo people.

When (the interventionist) came, I didn’t think twice. Eating healthy, it saves your life. … All my employees have or know someone who had diabetes (that) either took their lives or took their limbs. When the program came, no issue involved.” (Supermarket manager, S12) “I got family members who had cancer, diabetes, and their doctors told (me) about it (healthy eating). … Twenty percent of Navajo have diabetes, that’s one in five people. They don’t realize picking up soda that’s slowly killing ourselves. A lot of people are getting social security, significant amount of food stamps and compensating on junk foods. They line up for pop, juice and candy. … People here drink a lot of energy drinks. It would be good to show customers the down side of it, how our body reacts to it.” (Convenience store manager, S4) However, according to the program manager, who was in charge of store recruitment, some convenience store managers were hesitated to participate in the program because of “lack of trust” and “worried about losing customer money.” The program manager also reported challenges in convincing the top manager of a convenience store chain owned by a private company that had over 40 stores throughout the Navajo Nation. He remarked, “District managers were very willing to meet with them (interventionists). They wanted to participate and increase local availability of healthy foods. But CEO very hesitated”.

Communication between interventionists and store managers also presented a challenge when the program was introduced. A supermarket manager reported interventionists failed to introduce themselves as part of the program, “I didn’t know people came to the store first time. They didn’t introduce themselves as part of the program. …. I asked who they were. People came up before, set up tables and targeted on healthy items.” (Supermarket manager, S11) One of the interventionists who worked with that supermarket remarked, “We went to the store, talked to the store managers, told them how we would do (the program), putting up posters, low fat low sugar shelf labels. They felt that they didn’t know what we’re talking about … until we told them the memo (the Memorandum of Understanding between the university and the supermarket corporate office).” (Interventionist, I9) Other interventionists also remarked on the importance of having a memo or a written confirmation from the top managers of chain stores to show to store managers.

An interventionist (I4) said, “If you just step in there, they don’t remember who you are.” This seemed to be particularly true when stores had several managers.

Despite these initial challenges, interventionists reported they were able to establish good relationships with most of the store managers during implementation. As an interventionist remarked, “We established good relationships with them but not getting in their way, although you know talking with them about what we needed to make available to customers, especially small convenience stores it’s kind of hard.” (Interventionist,

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This remark seemed to reflect a difficult situation of interventionists attempting to have store managers stock promoted healthier options for the program while keeping good relationships with them. A convenience store manager (S3) remarked, “They (interventionists) had something on shelves, put healthy labels. They never told me don’t sell this or order this.” Most of the store managers felt the program ran smoothly, and commended interventionists as friendly, nice, easy to have, and very organized.

Interventionists reported some store managers were very supportive, providing help to set up tables and donating foods for cooking demonstration.

6.4.2 Implementation Challenges

Challenges in implementation are presented below by program components:

interactive educational sessions (cooking demonstrations and taste testing with customers) and stocking healthier options.

(1) Challenges in setting up educational sessions A key challenge faced by interventionists in increasing demand for healthy foods through point-of-purchase educational sessions was setting up educational booths where promoted foods were located and when many customers presented in stores.

Interventionists reported some stores had little space and narrow aisles, and they were allowed to set up an educational booth only in a designated area in these stores. Store managers of several smaller stores mentioned having interventionists on a busy day was a little inconvenient. As a convenience store owner (S5) said, “The only negative I’d think of was the space taking up on a busy day.” An interventionist (I4) reported, “The store manager told me, it’s a busy day why don’t you come up these days”. Store managers’ preference for having interventionists on a not so busy day appeared to be at odds with interventionists’ tendency to visit stores on a busy day (i.e., the first of the month) when they could educate many customers. As another convenience store manager (S7) remarked, “Only thing I kind of see this and I don’t know if anything changes like that, sometime when she came here, there were many customers here. But I don’t know if she or I can change when customers come...To me she came when we’re very busy. Sometimes I felt bad. We’re busy when she could teach a lot of people....

Sometimes we didn’t have a lot of customers for her to educate.” (Convenience

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(2) Challenges in stocking healthier options Only about one third of store managers reported adding some healthier snacks or healthier drinks that they had not previously stocked. A convenience store manager reported not stocking any additional healthier options for the program, because his store already carried a lot of healthy foods based on the WIC requirements. According to interventionists, requesting managers of smaller stores to stock promoted food items, i.e., fresh produce, was challenging, and stocking of these items was inconsistent. An interventionist (I4) remarked, “(A convenience store manager) said focusing on fresh produce, may be like 88% of that could goes to waste. They would loose money, so they hardly put them on shelves.” Store managers expressed two key concerns about stocking healthier options that they had not previously stocked. One of the concerns related to customer receptivity and demand for healthier options. As two store managers commented, “It’s not good (for the business) if it’s healthy but people don’t buy. … It’s difficult to get people try new things, often people are reluctant to try new foods.

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