Process evaluation of a store-based environmental obesity intervention on two American Indian Reservations.

Obesity and other diet-related chronic diseases are widespread in American Indian communities. Inadequate access to healthy food on many reservations has led to a high-fat, high-sugar diet. The purpose of this paper is to report on the results of the process evaluation of a food store-based program to improve diet on two American Indian reservations. Process data were collected from 11 intervention stores to document the implementation of the Apache Healthy Stores (AHS) program. Process evaluation instruments recorded the stocking of promoted foods, presence of in-store communication materials, implementation of and participation in the cooking demonstrations and taste tests, and the transmission of mass-media messages. At the store level, the program was implemented with a high level of dose and reach, and a moderate to high level of fidelity. At the community level, the AHS program was implemented with a moderate degree of fidelity and dose. At the individual level, the cooking demonstrations and taste tests reached a large number of community members with a high dose. Implementing the AHS program on multiple levels (store, community, individual) was challenging, and differed between levels. Overall, improvements were seen from start to finish as program staff monitored, documented and responded to barriers to implementation. Process data will be tied to outcomes and will be useful for the planning of future store-based programs.