«UNDERSTANDING THE PROCESS AND KEY FACTORS OF COMMUNITY IMPLEMENTATION OF A FOOD STORE-BASED NUTRITION INTERVENTION ON THE NAVAJO NATION by Muge Qi, ...»
Some incentives might encourage that change.” (Convenience store owner, S 5) “The chapter (similar to towns, the smallest administrative units on the Navajo Nation) asked us to put more healthy stuff, but they’re still buying all that unhealthy stuff. … If you look at Navajo people, compared to Flagstaff they are more obese than some other towns, not just Flagstaff. I don’t know it’s because we sell unhealthy foods. They know there’re other choices. People (from health department) come out and set booths and educate them healthy options.” (Convenience store manager, S13) Some store managers attributed the perceived and actual cost of healthier choices to low customer demand for healthy foods. A supermarket manager expressed that healthy foods are expensive for a lot of local people, “Especially the way economy it is today, things get expensive. People don’t have enough money to eat healthy. I can’t do it myself sometimes. A lot of times foods less healthy less expensive; healthy foods are a lot expensive. A lot of people can’t afford it.” (Supermarket manager, S8) The other key concern store managers had was the availability of healthier options from suppliers and cost of stocking healthier options, which might relate to inconsistent stocking of promoted food items observed by interventionists.
6.4.3 Store Owners/Managers’ Perceptions The following section presents store owners/managers’ perceptions about the Navajo Healthy Stores program, its implementation by local health staff, and program effectiveness.
(1) Perceptions about the program Store managers consistently perceived the program as an educational program on healthy eating that targeted their customers. A supermarket manager (S11) felt the program was “just like every other program (done by the Navajo Health Department), giving information (to customers).” Some store managers commented positively on the intervention materials (i.e., shelf labels, flyers), citing that helped their customers make healthy choices. A convenience store manager (S1) remarked on the potential impact of shelf labels on her store, “If they (customers) don’t see it (shelf labels), (they would say) ‘oh, they don’t have any healthy choices here’.” Most of the store managers perceived the program was neither good nor bad for their business. A store owner remarked, “(The program was) simply making them (customers) aware of the benefits of selecting healthier items instead of unhealthy items. That knowledge allowed them to make simple choices like that. … (It had) no negative impact on my business...
actually it’s kind of a positive thing happened … something different probably some extra interests (to customers), anything out of ordinary is interesting here.” (Convenience store owner, S5) A supermarket manager expressed that the program helped his store by increasing sales of sampled foods by interventionists, “We sold the products sampled and all ingredients whatever she used to make it on the table. We saw a rising sale on the aisles she did sampling afterward. We hit people at the time she was here, but not people who came later because they’re not the same people. It helped us.” (Supermarket manager, S12) Some store managers mentioned that they and their employees had also benefited from the program personally in terms of improving their knowledge about healthy eating.
“I realized after they set up booth (and) educated them diet Pepsi was better than regular one, one of my staff started taking diet pepsi rather than regular one.”(Convenience store manager, S 10) (2) Perceptions about intervention implementation by local health staff In general, store managers perceived that the interventionists from the NSDP did a good job of implementing the program. They felt customers (as well as themselves) liked and learned from the educational sessions. A store manager expressed his positive feeling about the educational sessions provided by interventionists as part of the NSDP, “The training was great, not just good. If we could hit one person we accomplish our job. If we hit more people, that’s good. I like the Special Diabetes Program, I always do.... The program in itself, especially in last few years it’s a great tool for our people to have, to reduce what makes people have diabetes and death. You don’t realize how much diabetes hurt until you see it yourself. That needs more training. I like the cooking demonstrations myself.” (Supermarket manager, S12) However, store managers also perceived that only some of their customers were interested in the educational sessions. As a convenience store manager (S4) remarked, “People came and I told them go talk to this lady. Some listened; the rest just waved their hands back to the door again.” Some store managers felt their customers were shy about participating in educational sessions.
It was also commonly perceived by store managers that educational sessions happened sporadically in their stores. Most of them expressed they would like interventionists to continue the work and do it more often in their stores to persuade many customers to change their behavior. As a store manager remarked, “I think they need to do it more often, so the word would be out. The more you spell it, the more it gets out… people will start listening. Do it more often, not just once every 3 or 4 months.” (Convenience store manager, S13) Some store managers felt that interventionists were overloaded, and it would take more people to do it often. A supermarket manager remarked, “I think the nutritionist was overloaded. She was running around. She was all over the reservation from here to other parts of the reservation and came back here again.” (Supermarket manager, S12) There were a few complaints about the use of intervention materials by interventionists. A supermarket manager reported their store did not receive the big ‘healthy store’ banner that was presented in other participating supermarkets as being part of the healthy stores program, and the posters on the windows became worn. A convenience store manager remarked that the interventionists did not provide enough information about shelf labels and flyers that would have helped to inform their customers about healthy options they had. Another store manager expressed her dissatisfaction with the use of pamphlets with older illiterate customers, “A lot of times they had their pamphlets. You know many grandparents are not educated, give them pamphlets they can’t read. I haven’t seen anyone teaching eating healthy… Grandparents have radios, inform them that way or they can tell them if they’re going to do sampling. They can tell them in store, present to them, show to them here the place where they pick (the healthy options).” (Supermarket manager, S8, discontinued the program halfway) (3) Perceptions about program effectiveness Most of the store managers perceived that some of their customers started buying healthier items that were low in sugar or fat after the healthy stores program started. A convenience store manager described a slight shift in customer purchasing behavior because of the program, “I saw people stand there, looked at spam, soda. Now they look at apples, fruits and vegetables. …I see sales go up for water, cooking spray and whole wheat bread, and light spam.” (Convenience store manager, S4) Some store managers perceived that the program had no obvious impact on their customers. A convenience store manager remarked that the program had little impact because it only reached small numbers of customers that shopped at her store. Another convenience store owner expressed that he was not sure how the program was effective because “it’s difficult to measure” and “hard to quantify the results.”
This is one of the first studies to examine the implementation of a food storebased nutrition program from the perspectives of both local health staff and store owners/managers. The findings presented in this paper provide key insight into community implementation of food store-based nutrition programs to improve diet quality in underserved communities.
As has been found in prior research, we found that store owners participated in the program because they perceived the program as beneficial to their customers and community (Song et al., 2011). Most of the store owners explicitly expressed how diabetes has affected their families, employees, and community, and felt the program could help compact diabetes. Our findings also indicate that store owners are more likely to support the program if they have more knowledge about the relationship between diet and health. Thus, nutrition education training to help store owners understand the importance of stocking of healthy foods should consider including information on the relationships between diet and health, particularly diet-related health problems (e.g., diabetes) that affect their community(Song et al., 2011).
The findings suggest the importance of having a written agreement from the top managers of chain stores. Chain food stores often make centralized decisions about product selection, price, promotion, as well as nutrition related activities, and have centralized supply and distribution of products (Hawkes, 2008). All four Bashas’ store managers referred to the approval of their corporate office as the main reason for their participation in the program. Most of the store managers of convenience store chains needed permission from their top managers to participate in the program. From the local health staff’s perspective, having written confirmation from the top not only helped recruit stores, but also helped inform store managers when they were present in the stores to do intervention activities (at least initially).
Store managers commonly perceived the program as an educational program on healthy eating, but not as a food environment change intervention. There are several plausible explanations for this. First, there was a lack of involvement of store owners/managers in the design and planning stage of the program. Although store managers across the Navajo Nation were invited to intervention development and planning workshops through community flyers and local health organization newsletters, only five store managers (all from supermarkets) participated in these workshops. And because of randomization of stores to intervention and comparison areas, only one of those five stores was assigned to the intervention. It would have been better if store managers were involved in the program in the beginning to understand the goals, intervention approaches, implementation standards, as well as evaluation methods for the program. Also, store owners/managers’ input at this stage is crucial to develop effective intervention and implementation strategies (Gittelsohn et al., 2006, 2010b; Song et al., 2012). Second, local health staff (as interventionists) focused implementation on educational sessions with store customers, as discussed more detail below. Third, no intervention strategy targeted store owners/managers. Prior research suggests the potential of intervention strategies, such as monetary incentives, nutrition education training, business training (e.g., stocking and handling fresh produce) for store owners to help ensure stocking of healthy foods in small stores (Gittelsohn et al., 2012b; Song et al., 2011).