1. PURPOSE
The purpose of thisanalysiswasto furtherexplore the foodenvironmentof the FortDefiance Indian
Hospital Board,Incorporated(FDIHB,Inc.) Service Unit. The investigatorsexploredthe barriersto
selectingnutritiousfoodandthe availabilityof freshfruitsandvegetables.
METHODS
Data was cross analyzedfromthe UnitedStates CensusBureau2011 AmericanCommunitySurvey5-
yearestimatesand locationof establishmentsthatsell food,specificallylarge grocerystoresand
conveniencesstores. Due tothe highpercentage of peoplelivinginpovertyinthe chaptercommunities,
the investigatorschoose tosearchdatarelevanttofinancial resourcesusedtopurchase food. Thus,the
data fromthe U.S.Censusfocusedonthe percentage of people thatreceiveSupplemental Nutrition
Assistance Program(SNAP/EBT) benefits.
RESULTS
Chaptercommunitieswiththe highest percentage of SNAPbenefitsare locatedthe furthestfroma
grocerystore and are locatedlessthan5 milesfroma convenience store. Therefore,itisappropriate to
assume thatthe purchasingbehaviorof people inthe communitywill be favorable forfoodsthatare
offeredinthe convenience store because theyare easilyaccessible. Accessiblywasidentifiedasa
barrierto propernutritiousfoodconsumption. These accessibilitybarriersincludedprice,
transportation,andfoodstorage issues.The percapitaincome of the communitymembers inthe
FDIHB, Inc.Service Unit isfar belowthe State andNational averagesthusleadingtoahighpercentage of
people relyingonfederal,state,andtribal foodprograms. The investigatorsfocusedon the
Supplemental NutritionAssistance Program, afederal subsidizedfoodprogramotherwiseknownas
foodstamps,intheiranalysis. Studies inrural low-incomeareashave shownthatredemptionratesfor
SNAPbenefitsare higheratconveniencestoresthanlarge grocerystores,whichusuallyoffer more fresh
fruitsandvegetables.1
Therefore,the FDIHB,Inc.service areacommunitymemberswouldlikelyspend
theirSNAPbenefitsatlocal convenience storesthanatlarge grocerystores. Thisleadsto people
purchasingfoodthatis nothealthyor nutritious,limitingtheirpotential tobe healthy.
CONCLUSION
In orderfor programsto make a directpositive impactonthe healthof the FDIHB,Inc. communitiesan
increasedeffortinmakingnutritiousfoodavailable tothe rural low-incomecommunitiesisneeded.
Interventionsaimedatcreatinghealthycommunities needtokeepinmindthe foodenvironmentof the
FDIHB, Inc.service areacommunitiesandadjustprogrammingtospecificallytailortheirprevention
education. Manyof the communitymemberscandistinguishhealthyfoodfromnon-healthyfood,but
are unable toaccessthe healthyfood. Therefore,anincreasedeffortinprovidingaccessshouldbe a
guidingfocusforprogramsin the FDIHB,Inc. service area.

2. NUTRITION IS IMPORTANT TO OVERALL HEALTH
Accordingto Webster’sdictionarythe definitionof medicineis,“the science andartdealingwiththe
maintenance of healthyandthe prevention,alleviation, orcure of disease”,therefore foodcanbe seen
as medicine as itmaintains,prevents,andeventreatsdisease. The importance of foodtoour healthis
vital forour overall well-being. The foodwe eatgivesourbodiesthe informationandmaterials needed
to functional properly. If we don’tgive ourbodiesthe rightinformation,ourmetabolic processessuffer
and our healthdeclines.2
The nutrientsin foodenable the cellsinourbodiestoperformtheirnecessaryfunctions, “Nutrientsare
the nourishingsubstancesinfoodthatare essential forgrowth,developmentandmaintenance of body
functions. Essentially, thismeans thatif anutrientisnot present,aspectsof functionandhumanhealth
decline. Whennutrientintake doesnotregularlymeetthe nutrientneedsdictatedbycell activity,the
metabolicprocessesslowdownorevenstop”.3
Therefore, nutrientsgive ourbodiesinstructionsabouthow to function. Withoutnutrientsourbodies
do notknowhow to functionproperly,whichleadstodysfunction,orinotherwords,diseaseandill
health. Foodshouldbe lookedatasa wayto create healthand reduce disease by helpingthe body
maintainfunction.
To furtherthe importance of food,manyNavajotraditionsandceremoniesare builtonthe oral intake
of medicine toprevent,heal,andmaintainhealth. Asstatedabove,foodismedicine,andthisof
upmostimportance inmanyNavajoceremonies. The medicinesinvolvedwithhealingviaNavajo
ceremoniesare developedfromingredientslocatedwithinthe Navajofoursacredmountains,the
Navajohomelandforhundredsof years. Navajoswere abletoadaptand thentake advantage of the
landwhere theylived. Navajoshave understood the importanceanddirectconnectionof foodand
healthforhundredsof years. Foodintake isvital tolivingahealthylife.
NEW WESTERN LIFESTYLE
In the past Navajoshadaccessto and knew how to cultivate the landfornutritiousfoodthatwould
sustaintheirbodies. Today,manyof those wayshave beenlosttothe modernfoodsupplychain, such
as groceryand convenience store food buyingbehaviors. Inrare instancesthere are still some families
that live off of the landto plant,harvest,andeatfoodthat has beengrownonNavajoland. However,
manyof the familiesthatlive onthe reservationrelyonfederal foodprogramstopurchase foodand
evenreceive food. The lifestyle of the Navajo people haschangeddrasticallywithinthe pastone
hundredyears. Today’sNavajo people canbe saidtostill be adaptingtothischange, and withmost
change,there are rough transitions. The roughtransitionsof this lifestylechange come inthe formof
disease,sickness,andunbalanceddiet. The healthof a Navajolivingonthe reservationiscontingenton
the availabilityof nutritiousfood similartothose thathave sustainedthe tribe forhundredsof years.

3. NO ACCESS
Studiesshow thatpeople livinginrural areas,suchas the NavajoNationhave loweraccessto
supermarketsandlarge grocerystores. Froma studypublishedinthe Rural DevelopmentPerspectives
Journal, “Poorhouseholdsinrural areas relymore onsmallergrocerystoresandsupermarketsthando
metroarea households,andtheymayface higheraverage foodpricesandreducedaccesstofoodas a
result”.1
Afteranalyzingfoodstampredemptiondata,poorhouseholdsspent76.7percentof food
stampsin supermarketsnationwide,but rural supermarketsaccountedforjust58.9 percentof all rural
foodstampredemptions.1
Specificallyinlow-income rural areas,like manycommunitiesonthe Navajo
reservation,supermarketsaccountedforonly52.8 percentof total redemptions.1
Thisindicatesthat
47.2 percentof foodstamps giventopeople wholivedinlow income rural areas were redeemedatnon-
supermarkets,suchasconvenience stores, tradingposts,orotherstoreseligible toreceivefoodstamp
payments. This furthersupportsthe dataretrieved showingcommunitieswiththe highestproportionof
foodstampslive the furthestfrom alarge grocery store,butclosesttoconvenience stores thus
increasingthe opportunityforSNAPbenefitstobe usedatconvenience stores. The proportionof food
stampsredeemedatnon-supermarketgrocerystoresmaybe higherforthe FDIHB, Inc. service asthere
are additional barriers thathinderlarge grocery store access. These barriersinclude price,
transportation,andfoodstorage issues.
PRICE
Rural householdface supermarketpricesabout4percenthigherthansuburbanarea supermarkets,
where pricesare the lowest.1
Pricesare likelytobe lower insupermarketsbecause supermarketscan
take advantage of scale economies. So,supermarketshave lowerstore marginscomparedtoother
smallerstores. Itislikelythatthe price difference maybe higherforrural convenience storeslocatedin
the low-income areas due totheirsmall economies. Small convenientstoresonthe Navajoreservation
charge higherpricesastheyare the onlyoptionforfoodavailability. Since the federal government
subsidizes the costof food there islikelylittle regardfor costand increased emphasisonfulfilling
hunger.
It takesproperplanningtopractice propernutritional foodintake,butthe conveniencestore model is
one basedon instantgratificationandsatisfaction. Thus,makingiteasy forlow income community
members togo to a convenience store locatedafew milesandpurchase foodthatwill instantlyfulfill
theirhunger.
REDUCED MOBILITY
Low-income householdsreliedonsmallersupermarketsandgrocerystoressomewhatmore thandidall
households.1
The differencesinspendingatlarge retailersbetweenall householdsandlow-income
householdsare consistentwithreducedmobilityamong the poorinrural regions.1
All chaptercommunitiesinthe FDIHB,Inc.service unitare below the ArizonaandUnitedStatesper
capita income levels.4

4. Significantlylowerincome levelshinderthe abilitytotravel tolarge grocerystores for freshfruitsand
vegetables.Low-incomehouseholdsare lesslikelytotravel becausetheydonotownor have access to
transportation ortheycannot affordthe cost of transportation. Many of the low-income households
live infederallysubsidizedhousingmade available throughthe NavajoHousingAuthority (NHA). In
mostcommunities,thesehousesare locatedveryclose toconvenience storesallowingindividualsto
walkto the store whenneeded.
FOOD STORAGE ISSUES
Personal storage
For people notlivinginNHA housingthere isanotherbarriertoaccessingfreshfruitsandvegetables,
foodstorage. In rare instanceselectricityisavailabletoeverycommunitymember,butdue tothe rural
locationof residentsonthe NavajoNation,electricityisnotanoption. Therefore,if the people livingoff
the electrical gridhave anopportunitytogo to a large grocerystore theydonot have the meansto
store any freshfruitor vegetablespurchased. Theycannotpurchase foodthathas to be storedina
refrigerator. Thisisa majorbarrierfor the elderpopulationastheyare usuallythe individualsthat
choose to continue tolive infarrural areas.
Store storage
In additiontocreatinga barrierforindividual families,foodstorage alsoaffectsthe storeowners. Food
distributiontrucksdonotcome on a dailybasisdue to the rural area and the cost of transportation. So
whenstoreownersstocktheirshelvestheyorderfoodthatwill lastforlongperiodsof time. These foods
have increased preservativestokeep afreshflavorandare usually the productswithhighcalories. A
majorityof these foodsare SNAPeligibleandcanpurchase withSNAPbenefits. These foodsare often
marketedasa snack,butfor many people,they actastheirfull meal. Itiscommonfor individualsto
purchase large,unhealthy,preservative heavy,highcalorie,packagedchipstoreplace ahome cooked
meal. For storeownersthisiswhere theyare able tomake a profit. Convenience storessell foodsthat
people canpurchase withSNAP,butare alsohave a longshelf life.
METHODS
Data Collectionand Analysis
A quantitative crossanalysiswasmade betweenthree sources,the Census’AmericanCommunity
Survey, USDA’sSNAPauthorizedretailers map, andcommunity member’sidentificationof store type.
The informationgatheredfromthe Census’2011 5-yearAmericanCommunitySurveyshowedthe
percentage of people receivingSNAPbenefitsbychaptercommunity. The resultsare showninTable 1
below:

5. Table 1: Percentage ReceivingSNAP BenefitsbyChapterCommunity4
Thiswas then cross analyzed withthe SNAPauthorizedretailersby community. Table 2isa listof the
SNAPauthorizedretailersinthe chaptercommunities.
Table 2: SNAPauthorizedretailersandlocation
Store Name Address City State Zip
Speedy's Convenience inc - Lupton
017 I-40 exit 359 Grants Rd Lupton AZ 86508
Klagetoh Express 512 Hwy 191 Ganado AZ 86505
Red Mesa Express 530 Pine springs rd & hwy 66 Sanders AZ 86512
Family Dollar 7905 Hwy 191 Sanders AZ 86512
Sawmill Express 527 Indian Hwy 7 Fort Defiance AZ 86504
GiantFour Corners 108 Navajo Route 12 Fort Defiance AZ 86504
State Line General Store I-40 Grants Rd exit Lupton AZ 86508
Mustang 7203 1/4 mileoff I-40 on Hwy 191 Sanders AZ 86515
Mustang 7601 Hwy 264 St Michaels AZ 86511
Painted Hills TradingPost 1/2 mileS I-40 at Sanders exit Sanders AZ 86512
Red Mesa TradingCompany #508 Navajo Highway #15 Lwr.Greasewood AZ 86505
Giant7252 Hwy 264 Ganado AZ 86505
Steamboat TradingPost #502
Hwy 264 (20 miles west of
Ganado) Ganado AZ 86505
BurnsideJunction Mart Chevron Hwy 191 & Hwy 264 Ganado AZ 86505
Mora's Grocery Se corner Hwy 191 & 264 Ganado AZ 86505
Chapter Community Percentage Receiving SNAP/Food
Stamps
Cornfields 28.2
Crystal 16.1
Fort Defiance 20.4
Ganado 19.5
Greasewood 34.2
Houck 31.8
Kinlichee 31.1
Klagetoh 30.4
Lupton 25.5
Nahat’a Dziil (Sanders) 17.9
Oak Springs 9.6
Red Lake 33.8
St. Michaels 14.0
Sawmill 28.0
Steamboat 39.5
Wide Ruins 39.3

6. Unknown Convenience Store I40 & Houck exit #348 Houck AZ 86506
Navajo PineMarket Route 12 Navajo NM 87328
Navajo Conoco Route 12 and Sheperd Springs Navajo NM 87328
Lowe's Shop n Save 24 State Road 12 Hwy 264 Window Rock AZ 86515
Window Rock Fina Route 264 Window Rock AZ 86515
Window Rock Chevron Hwy 264 and RT 12 Window Rock AZ 86515
Bashas DineMarket 35 Hwy 264 and RT 12 Window Rock AZ 86515
Thenthisinformationwas cross-analyzedwithcommunity members’ knowledge of whetherthisstore
was a large grocerystore or a conveniencestore. The resultsare below inTable 3.
Table 3: SNAPauthorizedtype of store
Store name
Large Grocery Store or
Convenience Store Chapter Community
Speedy's Convenience inc - Lupton 017 Convenience store Lupton
Klagetoh Express 512 Convenience store Klagetoh
Red Mesa Express 530 Convenience store Nahat'a dziil
Family Dollar 7905 Convenience store Nahat'a dziil
Sawmill Express 527 Convenience store Sawmill
GiantFour Corners 108 Convenience store Fort Defiance
State Line General Store Convenience store Lupton
Mustang 7203 Convenience store Nahat'a dziil
Mustang 7601 Convenience store St. Michaels
Painted Hills TradingPost Convenience store Nahat'a dziil
Red Mesa TradingCompany #508 Convenience store Greasewood
Giant7252 Convenience store Ganado
Steamboat TradingPost #502 Convenience store Steamboat
BurnsideJunction Mart Chevron Convenience store Ganado
Mora's Grocery Convenience store Nahat'a dziil
Unknown Convenience Store Convenience store Houck
Navajo PineMarket Large Grocery store Red Lake
Navajo Conoco Convenience store Red Lake
Lowe's Shop n Save 24 Large Grocery store St. Michaels
Window Rock Fina Convenience store St. Michaels
Window Rock Chevron Large Grocery store St. Michaels
Bashas DineMarket 35 Large Grocery store St. Michaels

7. RESULTS
The resultsare displayinTable 4 and Table 5. Crossanalysisfromtwodata sources show that the
communities receivingthe highestproportionof SNAPbenefitsare the furthestdistance fromagrocery
store. Theyare alsothe nearestto a convenience store. Studieshave shownthatSNAPredemption
ratesare higherat conveniencestoresspecificallyamonglow-incomerural populations1
,muchlike the
NavajoChaptercommunities. Manyof the small rural communitiesdonothave accessto a large
grocerystore. Of the 16 chapter communitiesthatthe FDIHB, Inc. serves,only3are withinfive milesof
a large grocery store (St. Michaels,Nahat’aDziil,andRedLake). The average roundtripto and froma
large grocerystore is49.6 milesornearlyan hourat 57.5 minutes. Whereas,the average roundtripto
and froma convenience store is5.67 milesor10.8 minutes (See table on nextpage forbreakdown). The
likelihoodof afamilyspendingtheirSNAPbenefitsata convenience store isincreasedwitheachmile
and minute because of the lowincome constraintsmentioned inthe introductionsection.
DISCUSSION
Many timespeople blameanindividual fornotbeingable tolive ahealthylifestyle,butfromthisstudy
and more to come,data isshowingthatenvironmentplaysahuge role inpeople’sbehavior,especially
healthbehavior. The programsonthe NavajoNation,specificallyFDIHB,Inc.service areaare doinga
great jobeducatingcommunitymembersaboutthe importance of anutritiousdiet. Thishasproduced
healthknowledgeableindividualsable todistinguishhealthyfoodfromunhealthyfood. However,they
are unable topractice theirfoodselection skillsbecause theyare notprovidedthe access. Inorder for
directresultstobe seena change of environmentneedstobe a priorityforhealthpromotionprograms.
Partnershipsneedtobe extendedtothe private sector,specificallythe grocerystore ownersand
conveniencestore ownerstoencourage themto increase accesstohealthyfoods. HealthPromotion
professionals shouldthinkoutside the box todevelopinnovative,creative,relevant,focused and
responsive interventions tohelppositivelychange the foodenvironment.
In additiontoadvocatingforfoodenvironmentchange,furtherstudiesneedtoaddressfood
environmentand itsdirectlinktohealthwithinthe FDIHB,Inc.service area. One studythatthe author
wouldencourage istoconduct a chart review of residentsthatlive furthestfromaconvenience store to
answerthe followingquestions: Are people livingfurthestfromgrocerystoresmore sick? Do they
come to the hospital more often? Dotheysuffermore from chronicdiseases causedbyunhealthyfood
consumption?These are questionsthatwouldhelptoimprovethe foodenvironmentatthe same time
showthe importance of environmentandits impacton overall health.
Furtherstudiesshouldalsofocusonthe grocerystores. Anotherstudycouldbe conductedto
investigatethe foodofferingsateachof the four large grocerystoreswithinthe FDIHB,Inc.service area.
Lastly,policymakersneedtokeepinmindthe relationshipbetween environmentandhealth. Leaders
shouldmake decisionsthatare data driven,suchas thisanalysis. In conclusion,amore healthyfood
offeringandaccessisneededinNavajocommunitiestocontinue onthe Journey to Hozho.

8. Table 4: Chaptercommunitylocationfromlarge grocery store.
Community
SNAP
Percentage
Miles from
nearest grocery
store
Miles
Round
Trip
Travel
time
(minutes)
Travel Time
Round Trip
(minutes) Location SNAP Grocery Store
Steamboat 39.5 44.9 89.8 45 90 Chinle,AZ Bashas'
Wide Ruins 39.3 50.2 100.4 51 101 Window Rock, AZ Lowe's / Bashas'
Greasewood 34.2 52.5 105 68 136 Chinle,AZ Bashas'
St. Michaels 33.8 2.7 5.4 5 10 Window Rock, AZ Lowe's / Bashas'
Houck 31.8 33.4 66.8 31 62 Gallup,NM Wal-Mart/ Safeway
Kinllichee 31.1 23.4 46.8 33 66 Window Rock, AZ Lowe's / Bashas'
Klagetoh 30.4 43.1 86.2 44 88 Window Rock, AZ Lowe's / Bashas'
Cornfields 28.2 40.1 80.2 47 94 Chinle,AZ Bashas'
Sawmill 28 20.3 40.6 36 72 Window Rock, AZ Lowe's / Bashas'
Lupton 25.5 22.2 44.4 21 41 Gallup,NM Wal-Mart/ Safeway
Ft. Defiance 20.4 6.9 13.8 10 20 Window Rock, AZ Lowe's / Bashas'
Ganado 19.5 28.4 56.8 29 58 Window Rock, AZ Lowe's / Bashas'
Oak/PineSprings 17.9 14.9 29.8 17 34 Window Rock, AZ Lowe's / Bashas'
Crystal 16.1 11.9 23.8 20 40 Navajo,NM Navajo PineMarket
Nahat'a Dziil (Sanders) 14 1 2 2 4 Sanders,AZ Mora's Grocery
Red Lake 9.6 1 2 2 4 Navajo,NM Navajo PineMarket
Average 26.20625 24.80625 49.6125 28.8125 57.5

9. Table 5: Chaptercommunity locationfromconvenience store
Community
SNAP
Percentage
Miles from
nearest
convenience
store
Miles
Round
Trip
Travel
time
(minutes)
Travel
Time
Round
Trip
(minutes) Location SNAP Convenience Store
Steamboat 39.5 1 2 2 4 Steamboat, AZ Steamboat Trading
Wide Ruins 39.3 7.9 15.8 12 24 Klagetoh, AZ Klagetoh Express
Greasewood 34.2 1 2 2 4 Greasewood, AZ Red Mesa TradingCo.
St. Michaels 33.8 1 2 2 4 St. Michaels,AZ Mustang 7601
Houck 31.8 1 2 2 4 Houck, AZ Gas Station
Kinllichee 31.1 8.8 17.6 18 36 Ganado, AZ Giant7252
Klagetoh 30.4 1 2 2 4 Klagetoh, AZ Klagetoh Express
Cornfields 28.2 9.4 18.8 17 34 Burnside,AZ BurnsideJunction Mart Chevron
Sawmill 28 1 2 2 4 Sawmill,AZ Sawmill Express 527
Lupton 25.5 1 2 2 4 Lupton, AZ Speedy's Convenience
Ft. Defiance 20.4 1 2 2 4 Fort Defiance, AZ GiantFour Corners
Ganado 19.5 1 2 2 4 Ganado, AZ Giant7252
Oak/PineSprings 17.9 12.3 14.6 16 32 Lupton, AZ Speedy's Convenience
Crystal 16.1 1 2 2 4 Navajo,NM Navajo Conoco
Nahat'a Dziil (Sanders) 14 1 2 2 4 Sanders,AZ Mustang 7203
Red Lake 9.6 1 2 2 4 Navajo,NM Conoco
Average 26.20625 3.15 5.675 5.4375 10.875

10. REFERENCES:
1. Kaufman,P.Rural Poor Have Less Accessto Supermarkets,Large GroceryStores. Rural
DevelopmentPerspectives.13(3),pp. 19-25.
2. Universityof Minnesota CenterforSpiritualityandHealing. Taking chargeof yourhealth and
wellbeing.July03, 2013. http://www.takingcharge.csh.umn.edu/explore-healing-practices/food-
medicine/how-does-food-impact-health.AccessedFebruary02,2014.
3. Wardlaw,G., & Insel,P. Perspectivesin Nutrition. MarylandHeights,MO:Mosby; 1990.
4. U.S. CensusBureau,2007-2011 AmericanCommunitySurvey