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Characterizing the local food environment and grocery-store decision making among a large American Indian community in the north-central USA: qualitative results from the Healthy Foods Healthy Families Feasibility Study

  • Meagan C Brown (a1), Umit Shrestha (a2), Corrine Huber (a3), Lyle G Best (a3), Marcia O’Leary (a3), Barbara Howard (a4), Shirley Beresford (a5) and Amanda M Fretts (a5)...



Perceptions of social-contextual food environments and associated factors that influence food purchases are understudied in American Indian (AI) communities. The purpose of the present study was to: (i) understand the perceived local food environment; (ii) investigate social-contextual factors that influence family food-purchasing choices; and (iii) identify diet intervention strategies.


This qualitative study consisted of focus groups with primary household shoppers and key-informant interviews with food retailers, local government food assistance programme directors and a dietitian. An inductive, constant comparison approach was used to identify major themes.


A large AI reservation community in the north-central USA.


Four focus groups (n 31) and seven key-informant interviews were conducted in February and May 2016.


Perceptions of both the higher cost of healthy foods and limited access to these foods influenced the types of foods participants purchased. Dependence on government assistance programmes and the timing of benefits also contributed to the types of foods purchased. Participants described purchasing foods based on the dietary needs and preferences of their children. Suggestions for improving the purchase and consumption of healthy foods included: culturally relevant and family-centred cooking classes and workshops focused on monthly food budgeting. Participants also emphasized the importance of involving the entire community in healthy eating initiatives.


Cost and access were the major perceived barriers to healthy eating in this large rural AI community. Recommended interventions included: (i) family-friendly and culturally relevant cooking classes; (ii) healthy food-budgeting skills training; and (iii) approaches that engage the entire community.


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1. Galloway, JM (2005) Cardiovascular health among American Indians and Alaska Natives. Am J Prev Med 29, 1117.
2. Centers for Disease Control and Prevention (2017) Summary Health Statistics: National Health Interview Survey: 2015. (accessed May 2019).
3. Caballero, B, Himes, JH, Lohman, T et al. (2003) Body composition and overweight prevalence in 1704 schoolchildren from 7 American Indian communities. Am J Clin Nutr 78, 308312.
4. Must, A, Jacques, PF, Dallal, GE et al. (1992) Long-term morbidity and mortality of overweight adolescents: a follow-up of the Harvard Growth Study of 1922 to 1935. N Engl J Med 327, 13501355.
5. Power, C, Lake, JK & Cole, TJ (1997) Measurement and long-term health risks of child and adolescent fatness. Int J Obes Relat Metab Disord 21, 507526.
6. Centers for Disease Control and Prevention (2018) About chronic diseases. (accessed December 2018).
7. Centers for Disease Control and Prevention (2015) Chronic diseases: the leading causes of death and disability in the United States. (accessed December 2018).
8. Fretts, AM, Howard, BV, McKnight, B et al. (2014) Life’s simple 7 and incidence of diabetes among American Indians: the Strong Heart Family Study. Diabetes Care 37, 22402245.
9. McLeroy, KR, Bibeau, D, Steckler, A et al. (1988) An ecological perspective on health promotion programs. Health Educ Q 15, 351377.
10. Byers, T (1996) Nutrition and cancer among American Indians and Alaska Natives. Cancer 78, 16121616.
11. Cobb, N, Espey, D & King, J (2014) Health behaviors and risk factors among American Indians and Alaska Natives, 2000–2010. Am J Public Health 104, Suppl. 3, S481S489.
12. McCloskey, J & Chee, MJT (2006) An Ethnographic Study of the Factors Affecting the Nutritional Patterns of Navajo Women and Their Children in the WIC Program. (accessed May 2019).
13. Nord, M, Coleman-Jensen, A & Gregory, CA (2014) Prevalence of US Food Insecurity is Related to Changes in Unemployment, Inflation, and the Price of Food. Economic Research Report no. ERR-167. (accessed December 2018).
14. Bauer, KW, Widome, R, Himes, JH et al. (2012) High food insecurity and its correlates among families living on a rural American Indian reservation. Am J Public Health 102, 13461352.
15. Jernigan, VBB, Huyser, KR, Valdes, J et al. (2017) Food insecurity among American Indians and Alaska Natives: a national profile using the current population survey–food security supplement. J Hunger Environ Nutr 12, 110.
16. Halpern, P & Regier, J (2007) Obesity and American Indians/Alaska Natives. (accessed December 2018).
17. Chodur, GM, Shen, Y, Kodish, S et al. (2016) Food environments around American Indian reservations: a mixed methods study. PLoS One 11, e0161132.
18. O’Connell, M, Buchwald, DS & Duncan, GE (2011) Food access and cost in American Indian communities in Washington State. J Am Diet Assoc 111, 13751379.
19. DiSantis, KI, Grier, SA, Odoms-Young, A et al. (2013) What ‘price’ means when buying food: insights from a multisite qualitative study with black Americans. Am J Public Health 103, 516522.
20. Glanz, K, Hewitt, AM & Rudd, J (1992) Consumer behavior and nutrition education: an integrative review. J Nutr Educ Behav 24, 267277.
21. Thow, AM, Downs, S & Jan, S (2014) A systematic review of the effectiveness of food taxes and subsidies to improve diets: understanding the recent evidence. Nutr Rev 72, 551565.
22. Rozin, P, Scott, S, Dingley, M et al. (2011) Nudge to nobesity I: minor changes in accessibility decrease food intake. Judgm Decis Mak 6, 323332.
23. Marteau, TM, Hollands, GJ & Fletcher, PC (2012) Changing human behavior to prevent disease: the importance of targeting automatic processes. Science 337, 14921495.
24. Fretts, AM, Huber, C, Best, LG et al. (2018) Availability and cost of healthy foods in a large American Indian community in the north-central United States. Prev Chronic Dis 15, E03.
25. Bernard, HR (2018) Research Methods in Anthropology: Qualitative and Quantitative Approaches, 6th ed. Lanham, MD: Rowman & Littlefield.
26. Glaser, BG, Strauss, AL & Strutzel, E (1968) The discovery of grounded theory; strategies for qualitative research. Nurs Res 17, 364.
27. National Cancer Institute, Division of Cancer Control & Population Sciences (2018) Qualitative Methods in Implementation Science. (accessed December 2018).
28. Armstrong, D, Gosling, A, Weinman, J et al. (1997) The place of inter-rater reliability in qualitative research: an empirical study. Sociology 31, 597606.
29. US Department of Agriculture, Economic Research Service (2017) Food access research atlas. (accessed August 2017).
31. Glanz, K, Sallis, JF, Saelens, BE et al. (2007) Nutrition Environment Measures Survey in stores (NEMS-S): development and evaluation. Am J Prev Med 32, 282289.
32. Chino, M, Haff, DR & Dodge Francis, C (2009) Patterns of commodity food use among American Indians. Pimatisiwin: J Aborig Indig Community Health 7, 279289.
33. Finegold, K, Pindus, N, Levy, D et al. (2009) Tribal food assistance: a comparison of the Food Distribution Program on Indian Reservations (FDPIR) and the Supplemental Nutrition Assistance Program (SNAP). (accessed December 2018).
34. Finegold, K, Pindus, NM, Wherry, L et al. (2005) Background Report on the Use and Impact of Food Assistance Programs on Indian Reservations. (accessed December 2018).
35. Whiting, EF & Ward, CJA (2010) Food provisioning strategies, food insecurity, and stress in an economically vulnerable community: the Northern Cheyenne case. Agric Hum Values 27, 489504.
36. Dillinger, TL, Jett, SC, Macri, MJ et al. (1999) Feast or famine? Supplemental food programs and their impacts on two American Indian communities in California. Int J Food Sci Nutr 50, 173187.
37. Smith, TA, Berning, JP, Yang, X, et al. (2016) The effects of benefit timing and income fungibility on food purchasing decisions among SNAP households. Am J Agric Econ 98, 564580.
38. Castner, L & Henke, J (2011) Benefit redemption patterns in the Supplemental Nutrition Assistance Program. (accessed December 2018).
39. Richards, MR & Sindelar, JL (2013) Rewarding healthy food choices in SNAP: behavioral economic applications. Milbank Q 91, 395412.
40. US Department of Agriculture (2018) Commodity Supplemental Food Program. (accessed December 2018).
41. Jobe, JB, Adams, AK, Henderson, JA et al. (2012) Community-responsive interventions to reduce cardiovascular risk in American Indians. J Prim Prev 33, 153159.
42. Wiedman, D (2005) American Indian diets and nutritional research: implications of the Strong Heart Dietary Study, phase II, for cardiovascular disease and diabetes. J Am Diet Assoc 105, 18741880.
43. Teufel-Shone, NI, Jiang, L, Beals, J et al. (2015) Changes in food choices of participants in the Special Diabetes Program for Indians–Diabetes Prevention Demonstration Project, 2006–2010. Prev Chronic Dis 12, E193.
44. Indian Health Service, Special Diabetes Program for Indians (2014) Changing the Course of Diabetes: Turning Hope into Reality. (accessed December 2018).
45. Witmer, JM, Hensel, MR, Holck, PS et al. (2004) Heart disease prevention for Alaska Native women: a review of pilot study findings. J Womens Health (Larchmt) 13, 569578.
46. Thompson, JL, Allen, P, Helitzer, DL et al. (2008) Reducing diabetes risk in American Indian women. Am J Prev Med 34, 192201.
47. Narayan, KM, Hoskin, M, Kozak, D et al. (1998) Randomized clinical trial of lifestyle interventions in Pima Indians: a pilot study. Diabet Med 15, 6672.
48. Heath, GW, Wilson, RH, Smith, J et al. (1991) Community-based exercise and weight control: diabetes risk reduction and glycemic control in Zuni Indians. Am J Clin Nutr 53, 6 Suppl., 1642S1646S.
49. Curran, S, Gittelsohn, J, Anliker, J et al. (2005) Process evaluation of a store-based environmental obesity intervention on two American Indian Reservations. Health Educ Res 20, 719729.
50. Gittelsohn, J, Anliker, JA, Ethelbah, B et al. (2005) A food store intervention to reduce obesity in two American Indian communities: impact on food choices and psychosocial indicators. FASEB J 19, A1021.
51. Pargee, D, Lara-Albers, E & Puckett, K (1999) Building on tradition: promoting physical activity with American Indian community coalitions. J Health Educ 30, Suppl. 2, S37S42.
52. Jiang, L, Huang, H, Johnson, A et al. (2015) Socioeconomic disparities in weight and behavioral outcomes among American Indian and Alaska Native participants of a translational lifestyle intervention project. Diabetes Care 38, 20902099.
53. Polacsek, M, Moran, A, Thorndike, AN et al. (2017) A supermarket double-dollar incentive program increases purchases of fresh fruits and vegetables among low-income families with children: the Healthy Double Study. J Nutr Educ Behav 50, 217228.
54. Olsho, LE, Payne, GH, Walker, DK et al. (2015) Impacts of a farmers’ market incentive programme on fruit and vegetable access, purchase and consumption. Public Health Nutr 18, 27122721.
55. Ornelas, IJ, Deschenie, D, Jim, J et al. (2017) Yéego Gardening! A community garden intervention to promote health on the Navajo Nation. Prog Community Health Partnersh 11, 417425.
56. Carney, PA, Hamada, JL, Rdesinski, R et al. (2012) Impact of a community gardening project on vegetable intake, food security and family relationships: a community-based participatory research study. J Community Health 37, 874881.
57. Armstrong, DL (2000) A community diabetes education and gardening project to improve diabetes care in a Northwest American Indian tribe. Diabetes Educ 26, 113120.



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