«UNDERSTANDING THE PROCESS AND KEY FACTORS OF COMMUNITY IMPLEMENTATION OF A FOOD STORE-BASED NUTRITION INTERVENTION ON THE NAVAJO NATION by Muge Qi, ...»
UNDERSTANDING THE PROCESS AND KEY FACTORS OF
COMMUNITY IMPLEMENTATION OF A FOOD STORE-BASED
NUTRITION INTERVENTION ON THE NAVAJO NATION
Muge Qi, MHS
A dissertation submitted to Johns Hopkins University in conformity with the
requirements for the degree of Doctor of Philosophy
© 2014 Muge Qi
All Rights Reserved
The prevalence of obesity is significantly higher among American Indians (AI) than in other racial/ethnic groups and is associated with increased rates of diabetes, hypertension, and cardiovascular disease. In rural AI settings, accessibility, availability and variety of healthful foods are limited. Changing the food environment in these AI communities may be a feasible way to impact diet quality and reduce obesity and chronic disease risk. The Navajo Healthy Stores (NHS) program was a food store-based intervention implemented through an academic–community partnership to improve dietary patterns on the Navajo Nation and to reduce risk for obesity. This dissertation describes the partnership process and key factors affecting the implementation and sustainability of the NHS program.
A qualitative study was conducted using a combination of semi-structured interviews with key stakeholders and a review of program documents. We found that the academic-community partnership for implementation of the NHS program evolved through an engagement, formalization, mobilization, and maintenance process, but there were important challenges needed to address in order to successfully move through the stages of implementation. Key challenges faced by the partnership included fitting into local health staff job schedule, obtaining buy-in from critical stakeholders, and overseeing implementation within the host organization. We also identified important facilitating factors for the partnership effort, including trust in the academic partners’ experience and commitment to sustainability, being responsive to the partner’s interests in capacity development, having a program champion, and having a dedicated and ii experienced field coordinator. Our study also found that local health staff was able to work with store owners/managers to implement the NHS intervention, but there were challenges in delivering intervention activities with adequate intensity and having store owners to stock healthier options. Small store managers reported lack of customer demand, lack of availability and increased cost of healthy foods from suppliers due to long transportation route as key challenges for stocking healthy foods.
The findings of this study help guide academic researchers and community practitioners in developing effective partnerships for community implementation of evidence-based nutrition interventions.
Joel Gittelsohn, PhD Professor, International Health
Laura Caulfield, PhD Professor, International Health Janice Bowie, PhD Associate Professor, Health Behavior & Society Sara Bleich, PhD Associate Professor, Health Policy & Management Caitlin Kennedy, PhD (alternate) Assistant Professor, International Health Roni Neff, PhD (alternate) Assistant Scientist, Environmental Health & Science
This endeavor would not have been possible without people who provided tremendous support and encouraged me through this long process. I am especially grateful to my advisor, Dr. Gittelsohn, for his guidance, encouragement, and patience that were essential to the completion of this PhD. I would like to thank my committee members, including Drs. Janice Bowie, Laura Caulfield, Sara Bleich, Caitlin Kennedy, Roni Neff, and Kate Clegg-Smith for their valuable input and kind words. Special thanks go to Drs. Terry Brown and Joanne Katz for providing me with the support I needed. I would also like to thank the U.S. Department of Agriculture and the Center for a Livable Future and the Director, Dr. Robert Lawrence, for providing generous financial support for this work.
Special recognition goes to Marla Pardilla, who provided valuable support in the field and facilitated my work. And to my friends, faculty, staff here at JHSPH, including Drs. Keith West, Youfa Wang, Parul Christian, Rolf Klemm, Carol Buckley, Rhonda Skinner, Peggy Bremer, Tom Durkin, and many others, who provided guidance and support throughout this process I offer the utmost appreciation. Most importantly I thank my family who has supported and helped me to go through this journey. Without their ultimate love, care, and encouragement, everything I’ve done would not be possible.
TABLE OF CONTENTS
LIST OF TABLES
LIST OF FIGURES
CHAPTER 1. INTRODUCTION
1.1 PROBLEM STATEMENT
1.2 SUMMARY OF DISSERTATION CHAPTERS
CHAPTER 2. LITERATURE REVIEW
2.1 OBESITY IN AMERICAN INDIANS
2.2 DIET QUALITY IN AMERICAN INDIANS
2.3 FOOD ENVIRONMENTS IN AMERICAN INDIAN COMMUNITIES............... 7
2.4 FOOD STORE-BASED INTERVENTIONS
2.5 RESEARCH ON DISSEMINATION AND IMPLEMENTATION OF
EVIDENCE-BASED NUTRITION INTERVENTIONS IN COMMUNITYSETTINGS
2.5.1 Interventions and Target Audiences
2.5.2 Dissemination and Implementation Strategies and Theoretical Models.......... 14 2.5.3 Implementation and Sustainability
2.5.4 Gaps in the Literature
CHAPTER 3. METHODS
3.1 STUDY OVERVIEW
3.2 STUDY DESIGN AND SETTING
3.3 DATA COLLECTION METHODS
3.3.2 Semi-Structured Interviews
3.3.3 Document Review
3.4 DATA MANAGEMENT AND ENTRY
3.5 DATA ANALYSIS
3.6 ETHICAL APPROVAL
CHAPTER 4: IMPLEMENTATION PARTNERSHIP PROCESS FOR A STOREBASED NUTRITION INTERVENTION ON THE NAVAJO NATION (PAPER 1).... 37
4.2.1 Navajo Healthy Stores Program
4.3.1 Conceptual Framework
4.3.2 Study Design and Data Collection
4.3.3 Data Analysis
4.4.1 Partnership Stages
4.4.2 Partnership Outcomes
CHAPTER 5: FACTORS AFFECTING AN ACADEMIC – COMMUNITY
PARTNERSHIP FOR IMPLEMENTATION OF A STORE –BASED NUTRITIONINTERVENTION (PAPER 2)
5.3.1 Study Setting
5.3.2 Participants and Procedures
5.3.3 Data Analysis
5.4.1 Facilitating Factors
5.4.2 Challenges or Barriers
CHAPTER 6: THE PERSPECTIVES OF LOCAL HEALTH STAFF AND STORE
OWNERS ON IMPLEMENTATION OF A STORE-BASED NUTRITIONINTERVENTION (PAPER 3)
6.3.1 Study Setting
6.3.2 Participants and Procedures
6.3.3 Data Analysis
6.4.1 Store Recruitment and Relationship Building
6.4.2 Implementation Challenges
6.4.3 Store Owners/Managers’ Perceptions
CHAPTER 7: CONCLUSION
7.1 SUMMARY OF FINDINGS
7.2 STRENGTHS AND LIMITATIONS
7.3 IMPLICATIONS FOR THEORY
7.4 IMPLICATIONS FOR PRACTICE
7.5 IMPLICATIONS FOR POLICY
7.6 IMPLICATIONS FOR FUTURE RESEARCH AND METHODOLOTY.......... 141 APPENDIX A-D
APPENDIX A: CONSENT FORM
APPENDIX B: INTERVIEW GUIDE – INTERVENTIONIST
APPENDIX C: LIST OF DOCUMENTS REVIEWED
APPENDIX D: THE FINAL CODING TEMPLATE
CHAPTER 2 Table 2.1.
Summary of research on the dissemination and implementation of evidencebased nutrition interventions in community settings…………………………………….17 CHAPTER 3 Table 3.1.
Type and number of NHS participating stores by intervention store area........33 Table 3.2. Study participants by affiliation (# of participants)…………………………..34 CHAPTER 4 Table 4.1. Components, activities, key challenges, and outcomes of NHS implementation partnership process………………………………………………………………............ 72 Table 4.2. Comparisons of intervention phases between the AHS and NHS programs....74 Table 4.3. Comparisons of intervention contents between the AHS and NHS programs, according to related phase …………………………………………………………….....75 Table 4.4. Actual vs. planned intervention implementation of the NHS program............80
CHAPTER 3 Figure 3.1.
Study setting: Navajo Nation map …………………………………………..35 Figure 3.2. Flow diagram of qualitative data analysis…………………………………...36 CHAPTER 4 Figure 4.1.
Conceptual framework for stages of academic-community implementation partnerships ……………………………………………………………………………...71
Growing research on the relationship between food environments, dietary intake, and obesity risk suggests a need for effective strategies to improve food environments in various settings (Sallis & Glanz, 2009; Story, Kaphingst, Robinson-O'Brien, & Glanz, 2008). In recent years, retail food stores in underserved communities have become important venues to improve the availability of and access to healthy foods and to promote healthy food choices (Flournoy & Treuhaft, 2005; Glanz & Yaroch, 2004; Sallis & Glanz, 2009; Seymour, Yaroch, Serdula, Blanck, & Khan, 2004). There is sufficient evidence for effectiveness of store-based interventions in improving food-related behaviors through the combination of demand- and supply-side strategies (Escaron, Meinen, Nitzke, & Martinez-Donate, 2013; Gittelsohn et al., 2012b). It is expected that the wide-spread dissemination and implementation of effective store-based environmental interventions at the local level can produce public health impact on obesity and chronic disease prevention over the long term (CDC, 2009).
However, research on the dissemination and implementation of effective nutrition interventions in community settings is scarce. Dissemination defined as a planned process of actively spreading evidence-based interventions to the target audience via determined channels, and implementation is defined as the process of putting to use or integrating evidence-based interventions within a setting by undertaking a specific set of activities (Fixsen, Naoom, Blase, Friedman, & Wallace, 2005; Rabin, Brownson, Haire-Joshu, Kreuter, & Weaver, 2008). The process of implementation can be categorized into four stages: exploration and adoption, program installation, implementation, and sustainability (Fixsen et al., 2005). Previous research on the dissemination and implementation of evidence-based nutrition interventions in community settings (A) was primarily guided by diffusion theory, (B) primarily used a top-down approach to dissemination and implementation, and (C) focused on school-based interventions (Ciliska et al., 2005;
Rabin, Glasgow, Kerner, Klump, & Brownson, 2010). Diffusion of Innovation theory (Roger, 2003) explains the process by which an innovation is adopted by the target audience, and has served well in variable- and dissemination- focused studies (Dearing, 2008). However, the application of diffusion theory has been limited in research on implementation that place greater attention on the process and how-to-knowledge as well as users of evidence-based interventions (Green, Ottoson, Garcia, & Hiatt, 2009; Tabak, Khoong, Chambers, & Brownson, 2012). Despite the prevalence of obesity and chronic disease is disproportionately higher in racial and ethnic minority populations (Kumanyika & Grier, 2006; O’Connell, Yi, Wilson, Manson, & Acton, 2010; Ogden et al., 2006;
Wang & Beydoun, 2007), previous studies rarely examined the dissemination and implementation of evidence-based nutrition interventions in minority population or communities. Participatory research approach, in particular Community-based Participatory Research (CBPR) have been considered as an effective approach for working with minority and underserved populations (Cargo & Mercer, 2008; Stacciarini, Shattell, Coady, & Wiens, 2007; Wallerstein et al., 2008). However, the potential of CBPR for dissemination and implementation of evidence-based interventions has yet to be explored (Glasgow, Green, Taylor, & Stange, 2012; Wallerstein & Duran, 2010).
This dissertation aimed to address these gaps in the literature by examining the implementation process of a store-based nutrition intervention on the Navajo Nation guided by the frameworks or models of participatory research and stages of implementation process. The goal of this dissertation was to understand the process and key factors of community implementation of a food store-based nutrition intervention through an academic-community partnership. The specific aims of this study and research
questions to be addressed are as follows:
1. To examine the academic-community implementation partnership process:
1.3 What were key challenges for the implementation partnership?
2. To identify key factors affecting the academic-community partnership effort:
3. To understand challenges in community implementation of the program from
the perspectives of local health staff and food store owners: