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This dissertation is composed of seven chapters. Following this introduction, chapter 2 provides an overview of obesity, diet quality, food environment in American Indian communities and food store-based interventions to improve access to healthy foods. This chapter also summarizes research on the dissemination and implementation of evidence-based nutrition interventions in community settings. Chapter 3 describes the study design, data collection methods, and analytical approaches used.

Chapter 4 (Paper 1, target journal: American Journal of Preventive Medicine) presents the six key steps and strategies used by the collaborative partnership between Johns Hopkins University Center for Human Nutrition and Navajo Special Diabetes

Project to implement and sustain the NHS program. Chapter 5 (Paper 2, target journal:

American Journal of Public Health) examines factors that facilitated the academic community implementation partnership and barriers that hindered the partnership process. Chapter 6 (Paper 3, target journal: Health Promotion Practice) describes the implementation of the NHS program from the perspectives of local health staff (as interventionists) and store owners/managers, in terms of store recruitment, relationship building, and challenges in delivering the intervention. In addition, storeowners’ perceptions about the program, its implementation by local health staff, and program effectiveness are presented.

Finally, chapter 7 summarizes the main findings of the study and discusses study strengths and limitations. This chapter also provides suggestions for future practice, policy, and research.

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This chapter provides an overview of obesity, diet quality, food environment in American Indian (AI) communities, food store-based interventions to improve access to healthy foods, and research on dissemination and implementation of evidence-based nutrition interventions in community settings.

2.1 OBESITY IN AMERICAN INDIANS Obesity affects AI children and adults in a higher proportion than any other racial/ethnic group. Data from the Racial and Ethnic Approaches to Community Health (REACH) 2010 project shows obesity prevalence is 40.1% for AI men and 37.7% for AI women compared to that of Black (26.5% and 37.6%), Hispanics (26.6% and 28.4%) and Asian (2.7% and 3.1%) (Liao, Tucker, & Giles, 2003). AI children tend to become overweight in early childhood compared to all race national averages (CDC, 2005), and the high rate of overweight occurs as early as elementary school ages (Caballero et al., 2003; Neol, 2003; Zephier, Himes, Story, & Zhou, 2006). The high prevalence of obesity in AI is associated with increased rates of chronic diseases, such as type II diabetes, hypertension, cardiovascular disease and gallbladder disease (Compher, 2006; Slattery et al., 2010; Acton et al., 2002)..


Poor diet quality is widely recognized as one of the major causes of obesity among AI along with physical activity, genetic, psychosocial, and socioeconomic factors (USDHHS, 2007). There has been a dramatic shift in the AI diet in the past few generations from a traditional low-fat, high fiber diet to a high-fat and high-sugar Western diet that are associated with obesity development (Compher, 2006; Jackson, 1986). Traditional foods are relatively absent from the diet and a greater proportion of food is store-brought, processed and commercially prepared (Taylor, Keim, & Gilmore, 2005). Fruit and vegetable consumption is very low, and only a low proportion of the population meets recommendations for fruit, vegetable, dairy, and micronutrient consumption (Ballew et al. 1997; Costacou, Levin, & Mayer-Davis, 2000; Harnack, Sherwood, & Story, 1999; Sharma et al., 2007, 2010). Sweetened beverages are a leading source of energy intake among AI (Sharma et al., 2007; Wharton & Hampl, 2004).



There is limited literature on the food environment in AI communities. Findings from existing studies indicate that the retail food environment plays a key role in limiting access to and availability of healthy foods in AI settings (O’Connell, Buchwald, & Duncan, 2011; Odoms-Young, Zenk, Karpyn, & Ayala, 2012; Pareo-Tubbeh, Shorty, Bauer, & Agbolosoo, 2000). Most AI reservations are rural, and have limited access to diverse food outlets (Gittelsohn & Sharma, 2009). Large supermarkets are rare on most AI reservations, and most AI are dependent on convenience or gas-station stores, which primarily stock unhealthy snack foods and rarely carry fresh produce, and offer a range of ready-to-eat foods (Gittelsohn & Sharma, 2009; Gittelsohn & Rowan, 2011).

2.4 FOOD STORE-BASED INTERVENTIONS In the U.S., a number of studies have shown that the availability of retail food stores (e.g., supermarkets and grocery stores) that offer a quantity of affordable healthy food in ‘neighborhoods’ (definitions and boundaries vary among studies) is associated with healthy eating (e.g., higher intake of fruits and vegetables) and lower rates of obesity among residents (Black & Macinko, 2007; Larson, Story, & Nelson, 2009; Sallis & Glanz, 2009; Story et al., 2008). Some studies have observed that communities of color, low income, and minorities in the U.S tend to have less access to supermarkets and more access to smaller stores that offer no or limited selections of healthy food (Black & Macinko, 2007; Larson et al. 2009; Sallis & Glanz, 2009; Story et al., 2008; Treuhaft & Karpyn, 2010). Thus, retail food stores in underserved communities have become important venues for environmental interventions to improve the availability of, access to, and purchasing of healthy food (Sallis & Glanz, 2009; Glanz & Yaroch, 2004; Gittelsohn et al., 2012b; Seymour et al., 2004).

Store-based environmental approaches to improve the availability of and access

to healthy food in underserved communities consist of two primary approaches:

developing new supermarkets/grocery stores and improving the selection and quality of food in existing smaller stores. Each approach has unique benefits and challenges (Flournoy & Treuhaft, 2005). Although strategies, such as offering financial incentives (e.g., tax credits, grant and loan programs) and using zoning regulations (e.g., “as of right” and “conditional use permits”), have been identified to be promising (IOM & NRC, 2009; Karpyn et al., 2010), developing new supermarkets involve a lengthy, complex process and may not be feasible in many communities (Bolen & Hecht, 2003; Flournoy & Treuhaft, 2005; IOM & NRC, 2009). Improving the availability of healthy food through existing smaller neighborhood stores can be a viable approach in communities (i.e., low income, inner-city and rural communities), with no or limited access to supermarkets and grocery stores (Bodor, Ulmer, Dunaway, Farley, & Rose, 2010;

Flournoy & Treuhaft, 2005; IOM & NRC, 2009).

To improve access to healthy food choices through existing smaller stores, there are several promising strategies, such as offering financial incentives, connecting with small business development, linking with wholesale distributors and local farmers, and providing training, technical assistance and other forms of marketing and promotion support (Flournoy & Treuhaft, 2005; Gittelsohn et al., 2012b). While promising, working with existing neighborhood stores faces many challenges that may vary from store to store, community to community, and rural areas versus urban areas (Flournoy & Treuhaft, 2005; Gittelsohn & Sharma, 2009). The limited literature shows the feasibility of some strategies (e.g., offering financial incentives and providing training and technical assistance for store owners) in underserved communities, and modest success of such strategies (often in combination with point-of-purchase information and community social marketing) in store sales or neighborhood purchase of promoted healthy food items (Bodor et al. 2010; Burtness, 2009; IOM & NRC, 2009; Gittelsohn et al., 2012b).

There are four types of food store-based interventions: (1) provision of Pointof-Purchase (POP) information, (2) reduced prices and coupons, (3) increased availability, variety, and convenience of healthier foods, and (4) promotion and advertising (Escaron et al., 2013; Glanz & Yaroch, 2004). POP information includes shelf labels and/or signage that specifies healthy food choices based on established criteria, and is often combined with food demonstrations, taste testing, and other printed materials (such as posters, brochures, and/or fliers). Reduced prices and coupons involves reducing price and providing coupons for healthy food choices and/or fruits and vegetables.

Interventions based on increased availability, variety, and convenience aim to provide more healthy food choices through various venues. Promotion and advertising strategies use newspaper inserts, multimedia advertising, games, posters, and other communication media to announce and encourage consumption of healthy choices. There is strong support for the feasibility of these approaches (Glanz & Yaroch, 2004).There is also evidence demonstrating the increased effectiveness combining these strategies (Escaron et al., 2013). These combinations include POP information and promotion and advertising; POP information, increased on increased availability of healthy foods, and promotion and advertising; POP information, pricing, increased availability of healthy foods.

The success of interventions focusing on changing the food store environment depends largely on engaging store owners/managers. Storeowners’ views on the opportunities and barriers for increasing the supply of healthy foods are critical to developing effective intervention strategies (Flournoy & Treuhaft, 2005; Gittelsohn et al., 2006, 2010b; Larson et al., 2013; Public Health Law & Policy, 2009; Song et al., 2012).

Furthermore, store owners can provide important insights about implementation successes and challenges that are crucial for successful outcomes and program sustainability (Adams et al., 2012; Dannefer, Williams, Baronberg, & Silver, 2012;

Gardiner et al., 2013; Gittelsohn et al., 2012a; O’Loughlin, Ledoux, Barnett, & Paradis, 1996; Rosecrans et al., 2008; Song et al., 2011). Effective communication and skillful coordination between program staff and store owners are essential for engaging store owners and sustaining their participation (Gardiner et al., 2013; Song et al., 2011).

The majority of small-store intervention trials to date have been conducted in lowincome, urban settings (Gittelsohn et al., 2012b). A few food store interventions have been conducted in AI communities. The Zhiwaapenewin Akino’Maagewin (Ho et al., 2008; Rosecrans et al., 2008) and Apache Healthy Stores (Curran et al., 2005; Vastine, Gittelsohn, Ethelbah, Anliker, & Caballero, 2005) programs showed positive changes in individual knowledge, and the frequency of healthy food acquisition. Changing the food environment in AI communities may be a feasible way to improve diet quality and reduce obesity and chronic disease risk (Gittelsohn & Rowan, 2011).

In summary, retail food stores in underserved communities have become important venues to improve the availability of and access to healthy foods and to promote healthy food choices (Flournoy & Treuhaft, 2005; Glanz & Yaroch, 2004; Sallis & Glanz, 2009; Seymour et al., 2004). There is sufficient evidence demonstrating effectiveness of store-based interventions in improving food-related behaviors through a combination of demand- and supply-side strategies (Escaron et al., 2013; Gittelsohn et al., 2012b). However, implementing and sustaining multi-component store-based interventions in the real world is challenging and requires continuing evaluation and surveillance to ensure the intervention effectiveness (Glanz & Yaroch, 2004).




Systematic reviews of population- and community-based nutrition interventions indicate that nutrition interventions can achieve modest positive changes (e.g. in reducing fat intake and increasing fruits and vegetables intake) in the general population in the short term (Bowen & Beresford, 2002; Ciliska et al., 2000; Seymour et al., 2004;

Thorogood, Simera, Dowler, Summerbell, & Brunner, 2007; WHO, 2009). It is expected that wide-scale dissemination and implementation of effective nutrition interventions can produce population-level impacts in the long term (Thorogood et al., 2007). However, research on the dissemination and implementation of effective nutrition interventions in community settings is scarce. Dissemination may be defined as a planned process of actively spreading evidence-based interventions to a target audience or other key stakeholders via determined channels. Implementation is defined as the process of putting to use or integrating evidence-based interventions within a setting by undertaking a specific set of activities (Fixsen et al., 2005; Rabin et al., 2008). The process of implementation can be categorized into four stages: exploration and adoption, program installation, implementation, and sustainability (Fixsen et al., 2005).

A review of dissemination and implementation of nutrition interventions for cancer prevention among adults identified only seven distinct studies, published between 1980 and 2002, even though all primary studies were eligible for inclusion regardless of study designs (Ciliska et al., 2005). Of those seven studies, only one study examined the dissemination of a nutrition intervention in community settings (Patterson et al., 1998).

In a complementary review updated with studies published between 2002 and 2008 and interventions for children and adolescents, Rabin et al (2010) identified five additional studies on the dissemination and implementation of nutrition interventions in community settings. The researcher also identified two additional studies (Harvey-Berino, Ewing, Flynn, & Wick, 1998; Naylor et al., 2010) that were not included in these two reviews.

The main components related to dissemination and implementation were summarized in Table 2.1 and discussed below.

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