Research BriefFormative Assessment Using Social Marketing Principlesto Identify Health and Nutrition Perspectives of NativeAmerican Women Living within the Chickasaw NationBoundaries in OklahomaStephany Parker, PhD1,2; Toma Hunter, MS, RD, LD3; Chiquita Briley, PhD4;Sarah Miracle, MBA, RD, LD2; Janice Hermann, PhD, RD, LD1;Jean Van Delinder, PhD5; Joy Standridge, MPH, RD, LD6

1Departme2Chickasaw3Seminole4DepartmeUniversity5Departme6ChickasawAddress foSciences, O(405) 744-1�2011 SOdoi:10.1016

Journal of

ABSTRACT

Objective: To identify health product and promotion channels for development of a Chickasaw NationSupplemental Nutrition Assistance Education Program (SNAP-Ed) social marketing program.Methods: The study was qualitative and used social marketing principles to assess Native Americanwomen’s views of health and nutrition. Focus groups (n ¼ 8) and interviews (n ¼ 4) were conducted toidentify indigenous views of product, promotion, price, and place related to SNAP-Ed behavioral objec-tives.Results: The major theme identified for product was diabetes prevention. Participants (n¼ 42) indicateda preference for family-based education with promotion by elders, tribal leaders, and ‘‘everyday people.’’Participants identified tribe-specific community sites for program implementation at times conducive towork schedules.Conclusions and Implications: Culturally appropriate social marketing programs are necessary toaddress diabetes prevention with a focus on family, heritage, and tribal community. Additional researchis necessary to explore the role of elders and tribal leaders in diabetes prevention efforts.Key Words: Native American women, social marketing, focus groups, interviews, qualitative research,formative assessment (J Nutr Educ Behav. 2011;43:55-62.)

INTRODUCTION

Native Americans (NAs) experiencea disproportionate burden of manynutrition-related chronic diseases.1-4

Obesity rates are of concern amongNAs, as 42% of adults 18 years of ageand older were classified as obesecompared to the overall United Statespopulation, at 27% in 2008.5 The inci-dence of type 2 diabetes is increasingat faster rates among NA children

nt of Nutritional Sciences, OklahomNation Get Fresh! Nutrition Progr

Health Department, Hollywood, FLnt of Food Science, Nutrition a, Mississippi State, MSnt of Sociology, Oklahoma State UNation Nutrition Services, Ada, O

r correspondence: Stephany Parker,klahoma State University, Stillwate100; E-mail: steph.parker@okstate.edCIETY FOR NUTRITION EDUC/j.jneb.2010.07.002

Nutrition Education and Behav

and young adults than any other pop-ulation group, and the rate is over 2times the national average.1 Dispro-portionate rates of overweight, type2 diabetes, and cardiovascular diseaseamong NAs may be related to inade-quate understanding of indigenousviews of diet and physical activitybehaviors and failure to incorporateindigenous insight into nutritioneducation programs aimed at chronicdisease prevention.6-8

a State University, Stillwater, OKam, Ada, OK

nd Health Promotion, Mississippi State

niversity, Stillwater, OKKPhD, 301 HES, Department of Nutritionalr, OK 74078; Phone: (405) 744-6821; Fax:u or stephany.parker@chickasaw.net (S.P.)ATION

ior � Volume 43, Number 1, 2011

To understand nutrition andhealth disparities among NA popula-tions, social and cultural factors mustbe delineated. Better understandingof indigenous views of health andnutrition is necessary for the develop-ment of culturally meaningful educa-tion targeting dietary and physicalactivity behaviors.6,8-10 However, in-sufficient research has been con-ducted with diverse NA communitiesto understand how cultural viewsinfluence health behaviors.9,11 Todevelop nutrition education programsthat will be successful in eliminatinghealth disparities, it is necessary toconduct culturally and geographicallyrelevant, as well as economicallyrealistic research.10

The Supplemental Nutrition Assis-tance Education Program (SNAP-Ed)is a program with potential to reducenutrition-related health disparities.The SNAP-Ed program is offered toSupplemental Nutrition AssistanceProgram (SNAP) recipients, formerlyfood stamp recipients, and Food

55

56 Parker et al Journal of Nutrition Education and Behavior � Volume 43, Number 1, 2011

Distribution Program on Indian Reser-vation (FDPIR) recipients, who receivea monthly commodity food packageadministered locally by Indian TribalOrganizations.12 Supplemental Nutri-tion Assistance Education Programguidance recommends social market-ing strategies as a means of dissemi-nating nutrition education to FDPIRand SNAP participants.12

Social marketing is not merely ad-vertising, but rather a participant-ori-ented program-planning process thatapplies commercial marketing con-cepts and techniques to communicatebehavior change.13-15 Extensive for-mative assessment to understand thetarget audience segment’s concernsabout health and associated values,attitudes, opinions, and preferred pro-motional outlets is essential to plan-ning social marketing programs.13,14

Formative assessment to under-stand the 4 domains, or principles, ofbehavioral influence from the targetaudience’s perspective is essential.13,15

The4principles of socialmarketing areproduct, price, place, and promotion.Product refers to the desired behaviorthe audience will perform and associ-ated benefits the audience will re-ceive.15 Price refers to barriers theaudience members face in making thedesired behavior change.15 Place iswhere and when the target audiencewill perform the desired behavior andaccess program services.15 Promotionincludes materials, channels, and ac-tivities that will effectively reach theaudience to promote the benefits ofthe behavior change.15

The Chickasaw Nation Get Fresh!SNAP-Ed programmers viewed socialmarketing as a viable method forimproving the health of NA SNAP-Edfamilies living within the ChickasawNation boundaries. The purpose ofthis study was to conduct a formativeassessment to inform the develop-ment of a Chickasaw Nation SNAP-Ed social marketing program basedon health and nutrition perspectivesof NA SNAP-Ed–eligible women usingsocial marketing principles as a frame-work for understanding. The researchobjectives for the current study wereto: (1) identify a health product for fu-ture social marketing programming;(2) determine the price of undertakingbehavior changes related to the iden-tified product; (3) identify the mosteffective methods of communication

to influence behavioral change; and(4) identify a place to conduct healthinterventions and disseminate healthmessages.

Findings presented are results fromthe first step in developing a socialmarketing campaign and offer insightfor nutrition and health professionalsinterested in using similar formativeassessment methods when planningto develop campaigns with diverse au-diences. This research was approvedby the Institutional Review Board atOklahoma State University, and themanuscript was reviewed by theChickasaw Nation Institutional Re-view Board chair.

METHODS

The formative assessment design wasqualitative to gain an in-depth under-standing of indigenous views ofhealth and nutrition using the 4 prin-ciples of social marketing as a frame-work. Grier and Bryant’s definitionsof product, price, place, and promo-tion were adapted and used to developoperational definitions for each prin-ciple used in the current study.13 Fo-cus group methodology was used asthe primary formative assessmentmethod. To determine the healthproduct (social marketing focus),questions were asked related to healthconcerns, fruit and vegetable intake,body weight, and physical activity.

Participant Recruitment

Native American women were eligibleto participate in the study if they re-ceived SNAP or FDPIR benefits, livedwithin the Chickasaw Nation bound-aries, andhad1 ormore children livingin the home. The Chickasaw Nation’sjurisdictional territory includes 7,648square miles of south-central Okla-homa and encompasses all or parts of13 counties. Participants were re-cruited from 3 communities in whichestablished commodity food distribu-tion sites are located and SNAP-Ed isavailable. The researchers randomly se-lected NA women from a list of SNAPand FDPIR participants and recruitedthem by phone. Participants initiallyreceived $20 for participation in thestudy. To increase participation rates,the incentive was increased to $45.Participants were recruited for approx-

imately 3 months. Participant recruit-ment ceased when data saturationwas reached. The approximate partici-pant response rate was 63%.

Description of Focus GroupInterviews

Researchers identified focus groupmethodology as the best means of col-lecting formative data because it is inkeeping with the oral tradition of sto-rytelling, commonly used among NAsto teach and share information.8,11,16

Three principal investigators devel-oped focus group questions (Table)to identify the social marketing prin-ciples described previously. Focusgroup questions were developed usingKrueger's guidelines for structuredscripts.16 The principal investigatorshad extensive training in qualitativedata collection and analysis and in-cluded individuals with degrees in an-thropology, nutrition, sociology, ora combination thereof. The questionscript was first reviewed by 2 Chicka-saw Nation Nutrition Service man-agers to ensure compliance withChickasaw Nation program guidance.Additionally, to ensure participantunderstanding of the questions,SNAP-Ed specialists who commonlywork with the SNAP-Ed participantsreviewed the question script. Changesmade to the question script were re-lated primarily to culturally appropri-ate ways to refer to NAs in thisregion and ways to identify whatconstitutes community for NAs.

Supplemental Nutrition AssistanceEducation Program specialists (n ¼ 6)were trained as moderators and assis-tant moderators because of indige-nous connections to the populationand extensive experience in providingeducation in the communities understudy. To ensure consistency in datacollection, SNAP-Ed staff attendeda 1-day focus group training sessionconducted by 3 principal investiga-tors. Attendees were also trained inthe proper operation of OlympusDS2300 digital voice recorders (Olym-pus Imaging America Inc, Center Val-ley, PA, 2005-2008). Following thetraining session, each specialist con-ducted a mock focus group that wasobserved by principal investigators.The principal investigators discussedthe potential of each specialist and

Table. Key Focus Group Questions with Social Marketing Principles Identified

General health1. Tell me any major concerns you may have about the health of Native Americans. (PD)2. What would you like your children to know about health? (PD)3. What does it take for a Native American family to be healthy? (PD,PC)Body weight4. How would you describe the body weight of most Native American adults who you know? (PD)5. Some Native American adults have tried to lose weight, what are the reasons they want to lose weight? (PC)6. What do you think about the weight of most Native American children you know? (PD)Fruits and vegetables7. What are your family’s favorite fruits and vegetables? (PD)8. What needs to be done to make it easier for you and your family to eat more fruits and vegetables? (PM)9. Where do you get the fruits and vegetables that you and your family eat? (PL)Community10. Tell us about any people who you think could have an influence on improving the health of Native Americans. (PM)11. Who do you think Native American children will listen to? (PM)12. What would be fun ways for Native Americans families to learn about nutrition and health information? (PM)13. Where would be the best place for you and your family to get information about nutrition and health? (PL)

PC indicates price question; PD, product question; PL, place question; PM, promotion question.

Journal of Nutrition Education and Behavior � Volume 43, Number 1, 2011 Parker et al 57

assigned specialists asmoderators (n¼3) or assistant moderators (n ¼ 3).

Eight focus group interviews wereconducted in 3 communities in theChickasaw Nation boundaries whereSNAP-Ed programs were adminis-tered. Because of low participant re-sponse rate at some of the scheduledfocus groups, 2 individual and 2dyad interviews were conducted andtreated as focus groups for thepurposes of data analysis. Interviewsites were identified by moderatorsand assistant moderators who wereindigenous to the communities. Con-versations from the focus groups andinterviews were digitally recorded.Each interview lasted approximately1 hour. A principal investigator and/or a research assistant periodicallyconducted on-site quality checks offocus groups to ensure focus groupdata collection quality. The re-searchers conducted quality checksby passively listening to focus groupdiscussions, unless probing for addi-tional information was considerednecessary because the moderator didnot adequately probe.

Data Analysis

Professional transcriptionists tran-scribed the digital recordings in verba-tim format. A principal investigatorand research assistant analyzed verba-tim transcripts at a line-by-line leveland assigned initial codes.17 Initial cod-

ing consisted of reading each transcriptas a whole, then identifying relevantthemes discussed in-depth; discrep-ancies and interpretations were dis-cussed and agreed upon. If participantresponses were considered the resultof moderator leading, these responseswere excluded. Following initial cod-ing, researchers conducted focusedcoding.17 Focused coding involvedthe organization of themes and sub-themes into categories using socialmarketing principles of product, price,promotion, and place. The researchassistant organized the themes by so-cial marketing category and confirmedthe categorization with the principalinvestigator.

FINDINGS

A total of 42 women participated inthe study. The mean age of partici-pants was 36 � 14 years. The mostcommonly used public assistance pro-grams were the FDPIR (72%); SpecialSupplemental Nutrition Program forWomen, Infants, and Children(35%); Child Nutrition for Reduced/Free School Lunch/Breakfast (26%);and SNAP (23%).

Themes Identified for the HealthProduct and Health Benefits

To ascertain the best product for thesocial marketing intervention, partici-pants in the study were asked to share

their major health concerns. Partici-pants in all interviews expressedhealth concerns related to diabetes.Additional concerns expressed by par-ticipants included factors related toheart disease. Some participants men-tioned other health conditions, likecancer, kidney disease, and gallblad-der problems.

Diabetes was identified as theprimary concern of participants in allinterviews. Participants discussed dia-betes as a stressful, normative experi-ence and conveyed family history ofthe disease, personal diagnosis, orconcern about themselves or theirchildren developing diabetes in thefuture. Diabetes, as a normative expe-rience, was conveyed by a participantwho stated that:

It [diabetes] is mostly in a lot of theIndians. They have it real bad. Idon’t know why. My grandparentshave always told me all of theirfriends and everybody they havetalked to and all of the familythat has grown up or that theyhave been with they have all haddiabetes. They have had real badsugar diabetes.

Participants also shared concernsabout diabetes developing in chil-dren, as expressed by a participantwho shared:

Had me and my son checked fordiabetes and we was both ok onit. But [Name]’s cousin is 3 years

58 Parker et al Journal of Nutrition Education and Behavior � Volume 43, Number 1, 2011

younger than him and he’s gota string high and high sugar levels.So I went and had him checked.

Participants conveyed the need fordiabetes screenings and diagnosis, asindicated by a participant who stated:

That could be a good idea that youcould give us about having more ofthose screenings for everything be-cause I’m a big fan of that becausethat’s what caused my husband’spre-diabetes [diagnosis] and he’sbeen that way for two years so theysaid he could not get it [diabetes] ifhe continues to do what he needs todo so those screenings are good.

Benefits of behavior change to ad-dress health concerns were discussedin terms of increased life span, im-proved ‘‘energy levels,’’ more favor-able appearance, and accountabilityto children. Success was also a positivemotivational factor, as expressed by 1participant who stated, ‘‘I know whenI lost weight I started it for appearancebut then I start losing weight and I feela lot better. Themore I lose the better Ifeel.’’ Being accountable for childhealth was viewed as a motivator tochange current weight, as expressedby an individual who stated:

I was really looking at myself thenlooking at my kids going down thesame road I was going down whenI was their age because I know Iwas a little chubby kid all throughelementary up to high school . . . Icould see my children on the roadto where I was. I looked at myselfthen looked at them and thoughtthere is no way I can put themthrough what I am going throughif I know I have the tools to changeit. Not only was I helping myself Isee it as I am doing this for me tohelp them.

Another participant was concernedabout her child’s weight and diabetesrisk when she commented:

One of my daughters has a verybad weight problem and my grand-daughter is 17 and she is alreadyoverweight. And I keep telling herto stop eating the junk food. Eatthe real stuff. But ya know I don’tknow what carbs you are supposedto eat with what. I have not yetbeen referred over there to the

diabetic clinic because my doctorseems to be underneath the impres-sion that he has told me.

Themes Identified for the Priceof Changing Health Behaviors

Many themes emerged as barriers tobehavior change among participants.Participants most commonly sharedfactors related to improved healthsuch as conflicting priorities and lackof support from others, which im-peded motivation to change.

A variety of conflicting prioritieswasmentioned as a barrier to makinghealthful changes. One participantstated, ‘‘Now because everybody isworking and going to school and no-body’s schedules are the same, it isjust like grab something and go,’’ in-dicating that there may be difficultyin balancing schedules because ofincreased work, school, and homedemands. Participants with childrenfelt that lack of child care was oftenan issue that made it harder to findtime to participate in educationalprograms and mentioned that inter-active family programs should bedeveloped to offset this barrier.When reflecting on what programswere needed, a participant shared:

More cooking classes with chil-dren. Letting the children volun-teering in the classes they have.And also I think, in my opinion, Ihave noticed there isn’t any cook-books coming out, new ones. Ithink we need those to teach ushow to cook with commodity[FDPIR] foods. Quick meals andthings that children can help youmake, or maybe kids’ meals thatwould be easy to make with thecommodity [FDPIR] foods.

Food access issues were commonlymentioned in terms of barriers to con-sumption of healthful food items.Issues such as food cost, availability,quality, andmarketingwerementionedby study participants. Food cost wasa primary deterrent discussed in termsof fruit and vegetable intake. Seasonalchanges in cost, as well as availabilityand quality of fruit, vegetables, andother healthful food items, were alsomentioned. One participant stated:

I think in the summer with me it[purchase of fruits] has to do with

the food prices. It seems like thefruits go up. They are higher inthe summer and they are not asgood as they used to be.

Another participant shared that shewas successfully ‘‘dieting’’ and eatingmore healthfully until:

Our income changed because I hadto quit my job to go to school. Istarted eating this food from thecommodities [FDPIR]. I had tomix in noodles to make it stretchfarther to make a meal out of itand I have stopped losing weightsince I have had to do that. Ofcourse it is not just that but I thinkthat it plays a part in it.

Although impressions were suchthat overall food options have im-proved at FDPIR sites, some referredto FDPIR food as causing currentweight and health problems in NAsand leading to a shift away from con-sumption of traditional food. This no-tion was best stated by an individualwho shared:

The flour that our ancestors ate . . .if they would give that out asa commodity [FDPIR food] andtake away that stuff that cameabout, no offense anybody butwhen the white men came aboutthey brought in their stuff . . . youwould think that they would haveseen to it to that this would bechanged a long time ago. Notkeep giving us the same stuff thatis killing us.

Themes Identified forPromotion of Nutrition andHealth Information

Participants mentioned a variety of dis-tribution channels, including publicfigures, media outlets, and printedmaterials. Although participants some-times felt there was a lack of communi-cation regarding existing programs,there was a general level of satisfactionand pride with services offered, asshared by an individual who stated:

They [Chickasaw Nation leaders]have worked so hard and spent somuch money, time, and effort tocreate these things. You know tobetter our people. I feel like it makes

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me proud to be able to say that Iam Chickasaw and I can do thisbecause all of the Governors beforeand all of the people that haveworked for these things they haveworked hard and put in a lot of ef-fort so that we can have the thingsthat are being offered.

Another participant also com-mented:

We [who receive services from theChickasaw Nation] have lots ofplaces to do the things [educationalprograms]. The Chickasaw Nationoffers to a wide variety of ages andeverything.

Indigenous communication was com-monly cited as a means of promotinghealth and nutrition information.Learning through the stories of elderssuch as ‘‘grandparents’’ or ‘‘teachers’’was mentioned by many participantsas a way to promote change amongNA youth. Grandparents were com-monly caregivers for children, as ex-pressed by a participant who stated,‘‘We’re at work most of the day andmy grandma’s got the kids so shekeeps them maintained.’’ Elders werehighly respected and regarded as im-portant to pass on nutrition andhealth information. A participantstated, ‘‘Even as young children to in-teract with older people I think makesa big difference in the way they seethings. And hear stories and thingslike that.’’

Participants preferred everyday peo-ple as important role models whowere similar to themselves and ap-proachable for promotion of healthbehavior change. A participant statedthat she envisioned:

Those that have changed orbenefited from changing theireating habits or how healthythey are. Even as a family. Ithink my biggest role model wouldhave to be other people that havedone it.

Another participant mentioned that:

There are good role models outthere. Like that new ChickasawNation commercial they [Nation]have got coming out things likethat, all have role models andstuff. That does give an impactoccasionally.

Participants also mentioned theimportance of promotion of goodhealth by tribal leaders. The respectparticipants have for the tribal leaderswas evident in a statement from a par-ticipant who shared, ‘‘Well they listenmore to the chief of the tribe thanthey would just anybody.’’ The Chick-asaw Nation governor was mentionedas important for promoting improvedhealth. A participant shared:

When Governor [name] talks peo-ple tend to listen to what he hasto say. He will say ‘I am a represen-tative for whoever within thenative tribal government. Theywill listen to what you have to say.’

Printed materials were suggested toreach audiences. Advertising in theform of ‘‘flyers’’ and ‘‘posters’’was sug-gested, because some participantswere unaware of existing tribal nutri-tion and health programs and service.Some participants felt they could getmore fromhandouts with how-to stepsthat would ‘‘show you how to dostuff.’’ Television as a means to reachpeople was also discussed by partici-pants to increase awareness about theChickasaw Nation’s programs andservices. Participants also recommen-ded the Chickasaw Times and somesuggested ‘‘bulletins’’ to inform indi-viduals about health programs andservices.

Themes Identified for Place toDisseminate Nutrition andHealth Information

Participants discussed the importanceof delivering educational programs atconvenient times. Participants sharedthat optimal locations might includecommunity places, Chickasaw Nationprogram sites, and programs inschools for children.

Convenient timing was mentionedas important for future programs. Par-ticipants shared that programs are of-ten offered at times ‘‘you can’t makebecause children are getting out ofschool.’’ Many participants felt that‘‘evening classes’’ or ‘‘weekend’’ pro-grams would be a better timing optionfor people with busy schedules andalso mentioned that programs shouldbe available for families. A participantwho felt timing was an issue with

program attendance stated:

If this class [focus group] hadn’tbeen offered at 6 o’clock I wouldn’thave been able to come . . . it justhappened to fall on the day that Ididn’t have to do work until 8. I re-ally couldn’t do anything duringthe day. . . . Maybe things shouldbe offered at various times andmore than just once.

Going to a program during traditionalwork hours was perceived as less im-portant than earning a living, as a par-ticipant stated, ‘‘because people donot want to take off of work and losemoney to come and learn.’’

Participants frequently indicateda preference for Chickasaw Nation-specific sites for programs. Many partic-ipants mentioned Chickasaw Nationprogram sites with which they werefamiliar, such as the Special Supple-mental Nutrition Program forWomen, Infants, and Children clinic,Food Distribution Center, WellnessCenter, and Family Life Center. A par-ticipant commented that programsshould be:

Right here [Chickasaw NationFamily Life Center]. . . . I havebeen to the cooking class here andit is great. The food is nutritionaland they [SNAP-Ed specialists]tell different recipes and hand outthe recipes with the nutritionguides.

Although Chickasaw Nation siteswere commonlymentioned, some par-ticipants shared community locationssuch as ‘‘the health department,’’‘‘library,’’ ‘‘Web sites,’’ ‘‘schools,’’ and‘‘department of human services.’’ Par-ticipants generally felt children shouldreceive nutrition education in theschool environment and be offeredmore healthful food options at school.

DISCUSSION

A primary objective of the researchwas to identify a health product forthe development of a social marketingcampaign. Diabetes prevention wasidentified as the health product forthe focus of the future campaign be-cause diabetes was the most frequenthealth concern mentioned by theaudience segment in this study. Con-sistent with previous research, NA

60 Parker et al Journal of Nutrition Education and Behavior � Volume 43, Number 1, 2011

women in the current study con-nected to diabetes as a stressful, nor-mative and somewhat unavoidableexperience that is related to genet-ics.18,19 Brave Heart and Debruyn re-ported that ‘‘present generations ofAmerican Indians face repeatedtraumatic losses of relatives and com-munity members’’ to a host ofhealth-related issues.20 The loss offamily and friends to diabetes is be-coming more common among NApopulations. Participants in the cur-rent study reported repeated exposureto diabetes through the experiences offriends, family members, and childrenover time. To address the possibletrauma and loss associated with themagnitude of diabetes among NAfamilies, it is important to incorporateindigenous community input and col-laboratively work to alter social expec-tations that diabetes is inevitable.

Participants in the current studydemonstrated a great sense of pridein family, NA heritage, and servicesoffered by the Chickasaw Nation. Ca-nales and Geller describe Connectingto Nativeness as the

degree of connecting along a range,from women who did not perceiveof themselves as Native in termsof their interactions with othersand beliefs about and participationin traditional practices

to others who were ‘‘immersed in cul-tural practices after Connecting to Na-tiveness through family members,Native leaders, courses, or their ownself-exploration.’’21 The investigatorsin the current study find Canalesand Geller’s construct applicable toNA views of health in the currentstudy and infer the importance ofmaking connections to NA heritagewhen developing social marketingprograms targeting diabetes preven-tion. The Cherokee Choices diabetesprevention social marketing forma-tive assessment findings implicatedthe importance of making connec-tions to family, spirituality, and tradi-tion.22 Cherokee Choices focus groupparticipants similarly appreciated theopportunity to share diabetes experi-ences, which they felt imparted a com-mensurate feeling that they were notalone in the diabetes experience.22

Participants in the present study re-ported that the price of making life-

style changes was rooted primarily inmultiple household responsibilitiesand family-based priorities. Multipleresponsibilities and work schedulesoften imposed time constraints onmeal preparation and physical activ-ity. Participants also discussed barriersto changing current behaviors, be-cause accessing healthful food at anaffordable price was viewed as unat-tainable by most. Pierre et al reportedsimilar findings in Native Canadianmothers, whose perceived barriers tocooking healthful meals included thehigh cost of food, lack of time, andunfamiliarity with healthful foodand recipes.23 Thompson et al also re-ported that less intensive culturallyinfluenced lifestyle interventionsresulted in improved dietary intakein a sample of urban American Indianwomen.24 Because barriers to makinglifestyle changes were reportedlyabundant, social marketing programsshould focus on small steps to im-proving nutritional health based onformative assessments of what isconsidered achievable by families.

In terms of promotion, partici-pants in the current study commonlyidentified intergenerational activitiesas a means of positively influencinghealth. Furthermore, participantsidentified tribal leaders and elders asimportant individuals to promotebehavior change. Participants wereconcerned with improving the healthof their entire family and felt nutri-tion education should be offered infun, family-friendly, and interactiveformats to promote healthful eatingand physical activity. The importanceof family with an emphasis on elderswas also mentioned as an effectiveway to share information, as elderswere seen as role models in the familyand community. Results from thePathways study,10 as well as theauthors’ previous research,25 implythat family-based programming iscentral to improved health amongNA families. The Pathways study forimproved health among NA school-children also revealed the essentialityof developing intervention strategiesthat provide opportunities for socialinteraction and social support aroundhealthful eating and physical activitybehaviors.10

In terms of place, participants in-dicated familiarity with current pro-

grams offered by the ChickasawNation and expressed that programsshould be offered at places wherecurrent services are already in exis-tence. Time of day was expressed asan important factor to consider forprogram offerings. Sherwood, Har-nack, and Story also found time ofday and convenient location werecentral to a weight management pro-gram in urban NA.26 Individuals inthe present study found programtime of day to be in contrast withpersonal availability for program at-tendance. It is compelling for nutri-tion and health programs to beoffered at nontraditional hours, asmany people are at work during thetraditional 9-to-5 hours of operation.Development of culturally appropri-ate programs at times convenientfor working people may be centralto future program attendance andimproved health.

This study has important limita-tions. First, newly trained moderatorsconducted the focus groups. Second,the methodology of focus groupswas intended as the only studymethod. However, the respondentrate was low on a few occasions,and individual or dyad interviewswere conducted instead of focusgroups. Third, the results from thestudy cannot be generalized to allNA communities because of culturaland regional differences, the smallnumber of participants, and qualita-tive nature of the study.

IMPLICATIONS FORRESEARCH ANDPRACTICE

Formative assessment to identify in-digenous views is essential prior tothe development of social marketingand nutrition education programsfor diverse populations. Results fromthis study suggest that there isa need to develop culturally appropri-ate social marketing programs that ad-dress and build on strong familial,community, and tribal support net-works rather than targeting behaviorchange at the individual level. Socialmarketing programs that identifydiabetes prevention as the productshould involve tribal ‘‘communitymobilization, empowerment, and

Journal of Nutrition Education and Behavior � Volume 43, Number 1, 2011 Parker et al 61

capacity-building models as a meansof developing locally responsive pro-gramming.’’27 Additional researchshould be conducted with elders andtribal leaders to identify views of theirrole in community mobilization andcapacity building related to diabetesprevention, because they were identi-fied as important agents of change forimproved health.

It is important to note that socialmarketing programs for NA audiencesshould not be limited to printcampaigns alone. Family-based pro-gramming for NA audiences is recom-mended to provide opportunities forparticipants to come together andshare experiences, which is in keepingwith the oral traditions of NA popula-tions. Because of the magnitude andburden of the diabetes experience inNA communities, future researchshould also explore traumatic inter-generational experiences related to di-abetes, as well as address and identifythe possible ‘‘failure of institutionalsystems, policies, and perspectives’’as opposed to faulting ‘‘the victimsof those disparities.’’27

ACKNOWLEDGMENTS

The study was funded in part by theUnited States Department of Agricul-ture Supplemental Nutrition Assis-tance Program. Participant incentiveswere provided by the ChickasawNation and start-up funds from theCollege of Human Environmental Sci-ences at Oklahoma State University.The researchers would like to thankChickasaw Nation Get Fresh! em-ployees Kathy Bean, Melissa Church,Leslie Cook, Carla Eidson, Neva Harjo-chee, Alicson Scott, and Jennifer Spie-gel and Oklahoma State Universityresearch assistants Teresa Jacksonand Sandra Peterson for their help inmaking the current research projectpossible. Additionally, the researchersthank the women who willingly andgraciously shared their life experi-ences and opinions. Finally, the re-searchers would like to thank theChickasaw Nation Institutional Re-view Board for review of this manu-script. Portions of this study wereincluded as part of TomaHunter’s the-sis to fulfill the requirement of MS de-gree in nutrition at Oklahoma StateUniversity.

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