摘要：Objectives. To assess a healthy retail intervention in Tribal convenience stores in Oklahoma. Methods. We adapted healthy retail strategies to the context of 8 Tribally owned stores. We assessed individual- and store-level outcomes in a cluster-controlled intervention trial (April 2016–June 2017). We measured fruit and vegetable intake, store environment perceptions, and purchases before and after the intervention among a cohort of 1637 Native American shoppers. We used mixed-effects linear regression to estimate pre- to postintervention changes in and between groups. Results. We followed 74% of participants (n = 1204) 9 to 12 months. Intervention and control participants perceived healthier stores after intervention. Higher shopping frequency was related to purchases of fruits, vegetables, and healthy items. Conclusions. Intervention exposure was associated with healthy purchasing but not fruit and vegetable intake. Research is needed to further assess impacts of environmental interventions on intake. Public Health Implications. As the first healthy retail intervention in Tribally owned stores, our results contribute evidence for environmental and policy interventions to address obesity in Tribal Nations. Multicomponent interventions, led by Tribal leaders from diverse sectors, are needed to create healthy environments and sustainable improvements in Native American health. Community food environments with few or no supermarkets and numerous fast food and convenience stores are associated with obesity. 1–3 Native Americans are more likely to be obese than are Whites and have rates of diabetes and hypertension that exceed those of the US general population. 4 However, few studies have examined the food environments of Native American communities, which include rural, reservation, and urban communities. A study of 2 Southwestern reservations found that supermarkets were scarce and Native Americans were dependent on convenience stores that stocked unhealthy foods and no produce. 5 Other studies of rural and reservation communities found poor access, high cost, and poor quality of fresh produce as barriers to vegetable and fruit consumption. 6,7 Urban-dwelling Native Americans also appear to encounter barriers to healthy eating. Although research is limited, a study by Dammann and Smith found that Native Americans living in the inner city had poor access to grocery stores and shopped at corner stores, purchasing only essential items at inflated prices. 8 Interventions to improve community food environments are recommended to address obesity. 9,10 Encouraging supermarkets to locate in low-income communities is helpful, but a more feasible approach is to implement “healthy makeovers” in existing stores to improve healthy food access. 11,12 Although results are mixed, recent systematic reviews conclude that healthy retail interventions encourage customers to buy and eat healthy foods, particularly interventions that combine lowering prices with easy access and engaging promotion strategies. 13,14 To our knowledge, only 2 published studies, both in reservations, have tested the efficacy of healthy retail interventions in Native American communities. 15,16 These studies included cooking demonstrations, taste tests, and education. The interventions increased knowledge and healthy food purchasing and, in the second trial, noted a trend toward lower body mass index among intervention group participants although results were not significant. 16 The study cites the absence of convenience store participation as a limitation to broader intervention reach. 16 Although both studies generated important knowledge, the diversity of Native American communities requires that healthy retail interventions be adapted for community context. 17 Tribal Health and Resilience in Vulnerable Environments (THRIVE) is a 5-year participatory research study to improve Tribal food environments by implementing healthy makeovers in rural Tribally owned convenience stores in the Chickasaw and Choctaw Nations of Oklahoma. The study is grounded in social cognitive theory, which posits that behavior change is influenced by the interaction of personal, behavioral, and environmental factors. 18 To our knowledge, this is the first healthy retail intervention study to be implemented in Tribally owned convenience stores. The Chickasaw and Choctaw Nations, once reservations, are now classified by the US government as Tribal Jurisdictional Areas and are among the largest sovereign indigenous Nations in the United States. 19 The Nations together constitute one quarter of the state of Oklahoma’s population and have a combined population of more than 70 000 Native Americans residing in the Tribal boundaries. 19 The poverty rate for all residents in the Chickasaw and Choctaw Nations is 15.3% and 20.7%, respectively, 19 and both Nations have high rates of diabetes (25%), obesity (56%), and hypertension (48%). 20 Access to healthy foods is limited; 56% of Native Americans report inadequate food quantity. 21 More than half (56%) of Tribal members travel more than 20 miles round trip to purchase groceries 22 (this is a food desert indicator 23 ), and 65% shop for food at a convenience store once or more per week. 22 The THRIVE study is led by a steering committee comprising university health researchers, Tribal employees (most of whom are also Tribal citizens), and leaders from the health, commerce, and government sectors of both Nations. The steering committee guided and implemented all aspects of the study. 22 We present the primary results from the healthy retail intervention trial. Data are available on request from the Chickasaw and Choctaw Nations. The survey materials (Appendices A and B) and data analysis code (Appendix C) are available as supplements to the online version of this article at http://www.ajph.org . When presenting study data, the names of the Tribes are not identified, per Tribal preference..
