«UNDERSTANDING THE PROCESS AND KEY FACTORS OF COMMUNITY IMPLEMENTATION OF A FOOD STORE-BASED NUTRITION INTERVENTION ON THE NAVAJO NATION by Muge Qi, ...»
that we needed to spend our time on what they felt nutritionists should be doing:
nutrition education, health care, and food demos.” (NSDP manager, M7) On the other hand, while the academic partners understood demanding schedules of intervention staff, they were concerned about the intensity of intervention delivery. As an academic partner explained, “The main concern has been the intensity of delivery of the intervention. The fact that the interventionists only delivered may be once a month or once every two or three weeks, when it should’ve been delivered weekly, that was the original scheme. … But you know in the end it was what could they do. Their schedules, their everything else that they were required to do for their jobs, this is how much they were able to dedicate.” (Academic partner, R1) Additional data collection and reporting requirements also presented a challenge.
The academic partners required intervention staff to complete an interventionist log designed to measure intervention implementation (esp. dose delivered, dose received, reach and fidelity). Additionally, in order to take the work relating the NHS program into staff monthly report to meet their performance standard, the host organization required intervention staff to record the name of program participants. However, due to a relatively large number of program participants in interactive educational sessions (on average, 70 per intervention session and supermarkets having more participants than smaller convenient stores), intervention staff often needed another person to complete the data collection. An intervention staff explained, “We’re required to record people’s name in order to get credit for our job...
when I was doing the healthy stores intervention, I was paying attention to the presentation, busy with my presentation. I just couldn’t record their names. Other people around, they just walked away before I recorded their names, no way to do that.” (NSDP interventionist, I1) An academic partner also expressed frustration with having incomplete interventionist logs, “They were required to fill out forms for each time they went out. Then they did it but they filled it out incorrectly a lot of times. Unfortunately it was very frustrating to me … they frequently didn’t do tick marking some of the sections where they were supposed to do it. So a lot of those data were not usable.”
(2) Obtaining buy-in from critical stakeholders While the decision to implement the healthy stores program was made by the top management of the host organization, it proved to be critical to engage field supervisors in all aspects of implementation and to have their full support. An academic partner remarked, “I really had hoped for much stronger implementation than actually done. Part of the reason (was) that people (intervention staff) didn’t feel supported by their supervisors to do this. … I think it remains a problem at the very end even to this point that those middle level folks didn’t buy in as much.” (Academic partner, R1) Several factors appeared to contribute to supervisors not being supportive of the program. First, there was lack of early involvement and regular communication.
Majority of supervisors did not get involved with the project from the beginning (esp. the development and planning phase), and a few supervisors were newly hired after implementation started. As a result, supervisors were not very familiar with the project and its goals. An academic partner remarked, “I think program managers and supervisors need a little handbook that explains why we do this program, what are its goals and objectives. We have it in the manual of procedure but that’s for interventionists. Supervisors should have that handbook to know what we are doing.” (Academic partner, R2) In addition, as the project was coordinated through the central administration and through conference calls with intervention staff, supervisors felt they were out of the loop. A supervisor (M10) stated, “As partners with the Healthy Stores Program, (the field coordinator) and (the program manager) in Window Rock should run smoothly, inform supervisors about what’s going on”.
Second, it was difficult to establish connections with the existing program objectives. Although the healthy stores activities were incorporated into the staff performance evaluation, it was considered by some supervisors as a ‘separate project’ or ‘additional responsibilities’ that were not in their written scope of work. As a supervisor (M2) explained, “Scope of work is our program objectives, what we’re supposed to do with the proposal. I’m not sure the healthy stores program is part of it”. A program manager agreed, “I think the way it was introduced to them as another program on top of what they’re doing… had some negative effects. That’s why supervisors were not supportive of the Healthy Stores Program, that’s why I’d like to see program managers to fully make use of their interventionists, provide their service.”
Furthermore, as mentioned in the previous paragraph, a lack of familiarity with the healthy stores program presented a challenge in making connections with existing program objectives. When asked the connections between the two programs, the program manager (M6) remarked, “I’m trying to remember if I’ve seen or read the Healthy Stores Program goals and objectives. I have to go back to see and compare with ours in the area of nutrition related activities.” Third, challenges existed in clearly communicating the values and benefits of the program for community. While the academic partners explicitly and repeatedly stated the specific goals and objectives of the project throughout the project period, some supervisors still expressed concern about the intention of the project and questioned the ‘real benefits’ of the project. As a supervisor stated, “I think they need to more clearly communicate what’s project doing, what’s the benefit to people here, or it’s just beneficial to people monitoring the project. … Hopefully, there is going be an in depth explanation of the project. I think most important to know real benefits of the project, or it’s just a study, just following certain individuals’ behavior, certain food eating.” (NSDP manager, M2) This supervisor also remarked on how academic language or terminology and Navajo culture and communication style (‘they say nothing even they don’t understand what people (experts) are talking’ as she put it) might influence on effective communication between the two partners. Some supervisors expressed they would support the program if it could show an impact on consumer behaviors. As a supervisor (M8) remarked, “I think if we can measure some impacts, I would certainly advocate for it, continue to work at stores”.
(3) Overseeing implementation The NHS program was overseen by a central office administrator (program manager) of the host organization in coordination with the academic partners. Due to frequent turnover of central office administrators and a lack of clarity in their roles and responsibilities in the program, oversight of implementation was less than optimal. As an academic partner (R2) stated, “Changes in personnel really affected our program. They had three turnovers of program managers....We had agreement with the first manager, but he was gone.
After that there was no agreement. But the next one felt other program pushed on them that just assigned already. They probably felt don’t know how to do it.”
A program manager remarked on a lack of documented roles and responsibilities for the program, “I don’t know what authority does this person have, when, where does this person make decision on, even in the field how to make sure to get staff involved.
Something in written should have been drafted when the program was initiated.”
In addition, a lack of understanding of the program objectives and mechanism also affected effective oversight of implementation by succeeding program managers. As an intervention staff (I1) remarked, “If they had been there from the beginning to understand the program, they would have pushed a little more. Not as much as (the first program manager) knows what’s happening.” One of the program managers (M4) said, “Unfortunately I just didn’t have any time to go into any detail about the program mechanism things like that.” Furthermore, necessary structural and procedural support for intervention staff was not in place prior to the onset of implementation. First, job descriptions were not undated to include NHS related activities. Because of this, some supervisors were not supportive of their intervention staff spending time on the NHS program. Second, the work related to the NHS program was not incorporated into the standard reporting system until later on and there was a lack of clarity in compiling different reporting formats. A supervisor described challenges in compiling monthly reports, “The (reporting) formats were different. …They didn’t know how to handle it.
They’re just kind of deal with it when it came. Nobody knew; no written thing how
Thirdly, there was lacking of coordination and building support from other community partners. As a supervisor stated, “I wish I was far more collaborative with WIC, Health Education Program, not just Special Diabetes Program trying to implement the Healthy Stores Program, probably involving other education programs in cost sharing, taking turns.”
Lastly, resource allocation and budgeting was also a challenge for the partnership.
Intervention staff reported challenges in not having purchase orders for food items for intervention activities and in getting reimbursed by the tribe for the travel related to implementation. A program manager (M6) said, “These types of items were not considered when we put up budget together” Prior to the onset of implementation. The academic partners also had issues with planning and resource. As an academic partner explained, “It would have been hard to do more than they did, because they ran out of our intervention promotional items so quickly. I had sort of thought it would be at the same level as sort of Apache experience, where you go to a store after a couple of hours may be you keep thirty or forty people, may be fifty sixty. They would get a hundred fifty people. I would’ve given them what I thought was the entire supply of, water bottles for the entire phase, then they would run out in one session. So part of it my own planning and resource issue is that we just didn’t have enough of the giveaways for people.” (Academic partner, R1)
This is one of the first studies to examine the factors associated with implementation partnerships between academic researchers and community-based organizations. Academic – community partnerships can be a viable approach to translate public health intervention trials to sustainable, community implemented programs (Wallerstein & Duran, 2010). We identified several factors that help guide academic researchers and community practitioners in developing effective partnerships and navigate more effectively the complex process of translation and implementation.
Establishing and maintaining the needed trust and respect are essential for academic – community partnership efforts (Cargo & Mercer, 2008; Israel et al., 1998).
The challenge of lack of trust between academic researchers and marginalized, underserved, and vulnerable populations is identified strongly within community based participatory research (CBPR) initiatives (Wallerstein et al., 2008). In the present study, we found the prior experiences of the academic partners with American Indian communities helped to build a trusting relationship with the Navajo Nation and the host organization. In addition, having an extensive formative research phase and community engagement process also fostered mutual understanding and trusting relationship within the partnership (see Chapter 4). Furthermore, the academic partners’ commitment to program sustainability and long term collaboration was conducive to the development and maintenance of mutual trust necessary for collaborative implementation.
Capacity development is essential for academic – community partnership efforts (Israel, et al. 2005), and building and maintaining an adequate level of capacity is critical to ensure effective implementation (Meyers et al., 2012a; Wandersman et al., 2008).
Capacity development is consistent with the principles of CBPR (Israel et al. 1998) and cultural values and traditions of American Indians (Chino & DeBruyn, 2006). Flaspohler, Duffy, Wandersman, Stillman, & Maras (2008) emphasized the need for two types of capacity development for quality implementation: innovation-specific capacity and general capacity that enables the organization to function better in a number of its activities. In this study, we found that the academic- community partnership valued the importance of capacity development “as much as the program was implemented”.
Trainings were provided by the academic partners to develop general capacity of the host organization in addition to implementation-specific trainings.
The presence of program champions has been long recognized as important to foster internal support and buy-in (Durlak & DuPre, 2008; Fixsen et al., 2005;
Greenhalgh et al., 2004; Sandlers et al., 2005; Stith et al., 2006). In this study, we found a program champion was identified early on, who played an important role in garnering support for the program within the host organization and promoting the program to other partners, as well as inspired and led intervention staff to implement the program.