Understanding the Impact of Food Assistance Program Use on Food-Related Psychosocial Factors and Behaviors Among American Indians

Year: 2009

Research Center: American Indian Studies Program, The University of Arizona

Investigator: Gittelsohn, Joel, Muge Qi, and Sonali Suratkar

Institution: Johns Hopkins University

Project Contact:
Joel Gittelsohn
Johns Hopkins University
Bloomberg School of Public Health
615 North Wolfe Street
Baltimore, MD 21205-2179
Phone: 410-955-3927


Food assistance programs, including the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), the Food Stamp Program (FSP)—now the Supplemental Nutrition Assistance Program (SNAP)—and the Food Distribution Program on Indian Reservations (FDPIR), aim to ensure low-income American Indian households an adequate, nutritious food supply. Many low-income American Indian households on reservations rely heavily on food assistance programs to meet their nutritional needs. However, limited accessibility, availability, and affordability of healthy foods on American Indian reservations may constrain food purchasing and consumption. While food assistance program participation helps in promoting food security and increases food purchasing power of low-income households, its impact on food-related psychosocial factors, food behaviors, and diet quality of low-income American Indian households is unclear.

The goals of this study were to (1) examine the impact of patterns of food assistance program use on other aspects of food acquisition and use; (2) examine relationships between food assistance program use and dietary quality among American Indian food assistance program participants; and (3) develop culturally appropriate nutrition-intervention components for the Healthy Stores programs that support food assistance program use, including healthier cooking methods.

The research was conducted on three American Indian reservations: the San Carlos and White Mountain Apache Tribes and the Navajo Nation. Surveys on random samples of adult tribal members (baseline: Apache, n=342; Navajo, n=284) were conducted and a Healthy Stores intervention was implemented in all three settings. Data collection instruments included an Adult Impact Questionnaire (AIQ), which included questions on sociodemographics, food assistance use, food purchasing, food preparation, food security, and psychosocial factors. A second instrument used was a quantitative food frequency questionnaire that recalled dietary intake of more than 100 foods over the past 30 days. The study followed up with a post-intervention evaluation on the Navajo Nation only (n=121 respondents), which included an instrument to assess exposure to intervention components.

The Apache Study: Of 342 Apache respondents, 83 percent were the main food preparers and shoppers, 93 percent were female, 40 percent were married, and 29 percent were employed full time. The mean age of the sample was 41.5 (standard deviation (SD)=13), and mean household size was 5.0 (SD=2.3). At the time of data collection, 24 percent of participants were from households that participated in only the FSP, 9 percent from households that participated in only the FDPIR, and 6 percent from households that participated in only WIC during the last 12 months. In addition, 25 percent of participants were from households that participated in both the FSP and WIC (FSP+WIC) and 3 percent from households that participated in both WIC and the FDPIR (WIC+FDPIR). Household participation in only the FSP was negatively associated with the frequency of getting healthy alternative foods (beta=-7.56, p=0.0002) and with the frequency of getting fruits and vegetables (beta=-6.76, p=0.0521). The frequency of American Indian households that participated in only the FSP getting healthy alternative foods or fruits and vegetables was about 7.6 times and 6.8 times, respectively, lower during the last 30 days than that of households that did not participate in any food assistance program. Food-related knowledge of respondents who participated in only the FSP was significantly lower than the knowledge of households that did not participate in any food assistance program (beta=-1.305, p=0.0038).

The study did not find significant associations between types of food assistance program participation and frequency of getting unhealthy foods, healthy food preparation and prepared food purchasing, and food-related self-efficacy and intention. Further analyses indicated that households that participated in WIC (either alone or in combination with the FSP) do better than households that participated in only the FSP in terms of frequency of getting healthy alternative foods and getting prepared foods, and that main food preparers and shoppers in these households had higher food-related knowledge. WIC-only households had a greater frequency of purchasing prepared foods. These findings were incorporated into the Apache Healthy Foods intervention.

Results of Navajo Baseline Data: Of the baseline Navajo respondents, 77 percent were female with a mean age of 46.6 (SD=17.1). The mean household size was 4.2 (SD=2.3), and a major proportion (34.1 percent) were married. Navajo respondents reported high levels of chronic disease both among themselves and their immediate families. Over 10 percent of respondents reported that they had heart disease, 22.2 percent reported diabetes, and 28.3 percent reported high blood pressure. The sample of Navajo adults had very high rates of obesity, with 86 percent of the sample either overweight or obese.

Navajo households reported extremely high levels of food insecurity. More than three-quarters of all Navajo households studied had some level of food insecurity, with more than a quarter of all households reporting child hunger, the most severe form of food insecurity. Respondents who were more obese tended to have greater knowledge of healthier food choices and were better able to read food labels. Respondents who were more obese also reported using healthier cooking methods and obtaining unhealthy foods less frequently. The baseline findings demonstrated that the Navajo Healthy Stores (NHS) program would have to rely on more than just straightforward education as a means of changing behavior and reducing risk for obesity and diabetes.

Results of Baseline Navajo Data by Food Assistance Program Participation: A third of the baseline Navajo sample was on WIC and /or food stamps (10.6 percent on WIC only, 13.6 percent on FSP only, and 9.9 percent on FSP+WIC), while 18.3 percent received commodity foods, 20.5 percent ate at the senior center (part of the Nutrition Services Incentive Program), and 8.8 percent used Food Bank/Navajo Way. A higher proportion of food-insecure households were participating in either one or more of the food assistance programs (FSP, WIC, commodity foods, food bank/Navajo Way, or senior center) compared with their food-secure counterparts. Of the psychosocial factors, only healthy eating self-efficacy seemed to be significantly lower (p=0.03) in participants of the FSP and commodity food programs, after controlling for age, sex, socioeconomic status, and other sociodemographic characteristics. Food knowledge scores were also lower in those eating at senior center/food bank/Navajo Way, but these lower scores were not significant (p=0.07 to 0.08). Those receiving commodity foods showed a trend toward higher food-getting frequency scores after adjustment (p=0.11), while those receiving food stamps tended to have worse healthy cooking scores (p<0.01). On the other hand, those on food stamps had a greater frequency of vegetable consumption (p<0.05).

Results of Navajo Post-Intervention Data: No impact of the NHS intervention was observed in terms of the primary psychosocial and behavioral outcomes by treatment group. Few significant differences were observed between the intervention and comparison group respondents in terms of level of exposure to specific intervention components. This finding is unlike previous findings in similar intervention trials with the Apache and First Nations, where significant exposure differences were found between intervention and comparison respondents. In all likelihood, respondents from comparison areas were not significantly less exposed to the intervention. The entire sample of respondents was pooled to examine the manner in which their outcomes varied by level of exposure. Those respondents most exposed to the intervention were much more likely to have visited an intervention store in the past 30 days.

When divided into quartiles by level of exposure, many trends were found where greater exposure was associated with changes in the individual outcomes in the direction expected, including a statistically significant improvement in food intentions. People who were more exposed to the intervention tended to show trends toward greater improvements in food-related knowledge, self-efficacy, and intentions. Respondents who were more exposed to the intervention also showed greater changes in behaviors, including healthy cooking methods and frequency in getting healthy foods. In conclusion, a point of purchase (POP) intervention in American Indian food stores appears to be associated with psychosocial and behavioral improvements. POP and environmental changes to improve food access may be an effective way to complement food assistance program efforts.

Direct inquiries about this study to the Project Contact listed above.