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«UNDERSTANDING THE PROCESS AND KEY FACTORS OF COMMUNITY IMPLEMENTATION OF A FOOD STORE-BASED NUTRITION INTERVENTION ON THE NAVAJO NATION by Muge Qi, ...»

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However, the departure of the program champion at an early stage of implementation affect the potential for cultivating unified support for implementation within the host organization (Goodman & Steckler, 1989). Moreover, we found that the implementation effort was facilitated by a local field coordinator, who was familiar with the local culture and practices and had prior working experiences with both the academic partners and the host organization on other research projects. Rycroft-Malone et al (2013) emphasize the need for appropriate facilitation by individuals with the appropriate roles, skills and knowledge to enhance the process of implementation. The type of facilitation and the role and skill of the facilitator that is required is determined by the “readiness" of individuals, team and context for implementation (Kitson et al., 2008).

Finding time for non-academic partners to support research and intervention activities while delivering services and programs was challenging (Cargo & Mercer, 2008). However, effective implementation requires adequate allocation of personnel and time (Fixsen et al., 2005; Greenhalgh et al., 2005). In this study, we found that it was difficult for existing staff of the host organization to implement the NHS program without compromising the intensity of intervention implementation. Academic community partnerships should find a way to assure adequate allocation of resources (time, staff, funding, cooperation) and bring about necessary organizational changes prior to the onset of implementation (Fixsen et al., 2005). In this study, we found differing data collection and reporting requirements also presented a challenge for the academiccommunity partnership. Champers & Azrin (2013) suggest creating a single data infrastructure that is useful for both research and practice.

The importance of fostering stakeholders’ buy-in and building a supportive organizational climate for effective implementation is well documented (Durlak & DuPre, 2008; Fixsen et al., 2005; Greenhalgh et al., 2005; Stith et al., 2006; Wandersman et al. 2008). As has been found in prior research, we found that buy-in of supervisors fell short due to a lack of their early involvement in the development and planning of the NHS program, failure to make connections with existing program objectives, and ineffective communication (Fixsen et al., 2005). Meyers et al (2012b) emphasized the need for communicating the perceived need for and perceived benefit of the innovation within the organization and for creating practices and policies that provide opportunities for stakeholder participation, foster shared decision making, enhance accountability and effective communication. Furthermore, use of academic language is a widely recognized barrier to effective communication between community and academic partners (Mitton, 2007). Hicks et al (2012) argued the importance of ‘the language of community benefit’ translating the research and its goals to connect with community benefit- and the need to tell ‘the whole story behind what we are doing’ for stakeholder buy-in.

It is important to have a clear implementation plan and to outline the roles, processes, and responsibilities of implementation team members (Meyers et al., 2012a).

In this study, we found that frequent manager turnover and a lack of clarity in their roles and responsibilities in the program weakened oversight and coordination of implementation. Organizational change and development is necessary for effective implementation of evidence-based programs (Fixsen et al., 2005). Our findings support this by showing how implementation was affected by inadequate planning and support for intervention staff (such as modification to job description, reporting and reimbursement requirements, and coordination from other partners) and resource allocation.

There are limitations to this study. First, the generalizability of findings from the present study is limited because this study was conducted only on the Navajo Nation and the particular context in which the implementation partnership occurred. However, many of our findings are consistent with findings in the literature, and most likely be applicable to the formation of other academic – community partnerships designed to translate public health intervention trials to sustainable, community implemented programs. Another important limitation is that we could not determine the relationship between different factors identified in this study and their relative contribution to the outcomes of the implementation effort.

This study has several strengths. First, this study was an integral part of the implementation partnership effort to learn factors that may have affected the partnership and implementation process and to inform future implementation efforts. Face-to-face individual interviews were conducted at the end of the first round of implementation by the first author, who was not directly involved in the implementation process, and created open avenues for constructive feedback from stakeholders in the host organization on the academic – community partnership and implementation process. The credibility of this study also increased as the preliminary findings from these interviews were presented to the host organization and included in a project report to the host organization.

Additionally, as noted above, we applied qualitative interviewing methods to understand factors that facilitated or hinder the partnership implementation process from multiple stakeholder perspectives.





In summary, this study described important factors that facilitated or hindered the academic - community partnership for the NHS program and contributes to the growing literature of partnership approaches to translate effective interventions to sustainable, community implemented programs. The findings have important implications for research and practice. As with other academic – community partnerships for research, collaborative partnerships for implementation research need to build on mutual trust and respect between academic – community partners, and need to engage and obtain full support from critical stakeholders. Academic partners should show commitment to program sustainability and be responsive to community partners’ interests in capacity development beyond implementation of a particular program. Community partners should proactively foster supportive organizational climate and program champions, and initiate necessary organizational change process to support front line practitioners and minimize foreseeable barriers to implement the program. Academic and community partners should recognize the important of having a clear implementation plan and engaging critical stakeholders and other agencies as part of the implementation team.

Field facilitation and additional trainings should be provided to ensure the quality of implementation by local interventionists. Further research is needed to understand the relationship between different factors identified in this study and their relative contribution to the outcomes of the implementation effort.

CHAPTER 6: THE PERSPECTIVES OF LOCAL HEALTH

STAFF AND STORE OWNERS ON IMPLEMENTATION

OF A STORE-BASED NUTRITION INTERVENTION

(PAPER 3)

–  –  –

The Navajo Healthy Stores (NHS) program was a food store intervention to increase the availability, purchase and consumption of healthy foods on the Navajo Nation. The overall NHS intervention approach was a locally implemented and sustained intervention that was carried out by NSDP nutritionists/health workers. The purpose of this paper was to understand the community implementation of the NHS program from the perspectives of local health staff and food store owners/ managers. A qualitative study was conducted using semi-structured interviews with store owners/managers and local health staff and program document review. We found local health staff was able to recruit and work with store owners/managers to implement the intervention, but there were challenges in delivering educational sessions with adequate intensity and having store owners to stock healthier options. Key challenges for small stores to stock healthy foods included lack of customer demand, lack of availability and increased cost of healthy foods from suppliers due to long transportation route. Additional efforts should be undertaken to incorporate food store interventions into existing community health promotion activities and find innovative solutions to address both demand- and supplyside of healthy foods on the Navajo Nation.

6.2 INTRODUCTION Small-store intervention trials demonstrates consistent improvement in the availability and sale of healthy foods, consumer knowledge, and the purchase and consumption of those foods (Gittelsohn et al., 2012b). While promising, working with existing small neighborhood stores faces many challenges that may vary from store to store, community to community, rural area to urban area (Flournoy & Treuhaft, 2005;

Gittelsohn & Sharma, 2009). Storeowners’ views on the opportunities and barriers for increasing healthy food supply are critical to develop effective intervention strategies (Flournoy & Treuhaft, 2005; Gittelsohn et al., 2006, 2010b; Larson et al., 2013; Public Health Law & Policy, 2009; Song et al., 2012). Furthermore, store owners can provide important insights about implementation successes and challenges that are crucial for successful outcomes and program sustainability (Adams et al., 2012; Dannefer et al., 2012; Gardiner et al., 2013; Gittelsohn et al., 2012a; O’Loughlin et al., 1996; Rosecrans et al., 2008; Song et al., 2011). The success of interventions focusing on changing the food store environment depends largely on engaging store owners/managers. Effective communication and skillful coordination between program staff and store owners are essential for engaging store owners and sustaining their participation (Gardiner et al., 2013; Song et al., 2011).

As food store interventions advance from feasibility trials to community implementation, there is a need to understand implementation successes and challenges from program staff and store owners’ perspectives to help identify particular strengths and weaknesses that occurred during implementation and guide future program development and implementation efforts. This paper sought to understand challenges in community implementation of a food store-based nutrition program from the perspectives of local health staff and food store owners/ managers. Specifically, we conducted semistructured interviews with local health staff and food store owners/managers and document review to address the following research questions. (1) What were the challenges faced by local health staff in recruiting food stores and working with store owners? (2) What were the challenges faced by store owners in participating in the program? (3) What were storeowners’ perceptions about the program, its implementation by local health staff, and program effectiveness?

–  –  –

The Navajo Nation is the largest reservation in the U.S., covering the corners of three states: Arizona, New Mexico, and Utah. Most of the Navajo Nation is extremely remote and rural, and lack of infrastructure (e.g., electricity, paved roads, telecommunication, and transportation) (NDOH, 2004). The US Department of Agriculture Food Desert Locator shows that nearly the entire Navajo Nation is a food desert (USDA, 2012). There are only 9 supermarkets on the reservation in the small towns where a shopping center is located. There are also several trading posts and a few flea markets that sell limited food items. Across the reservation, there are many food vendors that sell a variety of prepared foods, such as fry bread, blue corn bread, piki bread, tamales, Navajo tortillas, corn meal, Indian tacos, hamburgers, pinon nuts, and soft drinks, among others.

The Navajo Healthy Stores program The Navajo Healthy Stores (NHS) program was a food store intervention to improve dietary patterns on the Navajo Nation and to reduce risk for obesity by increasing the availability, purchase and consumption of healthy foods. The design of the NHS intervention was based on a previously intervention trial (Apache Healthy Stores, Curran et al., 2005; Vastine et al., 2005), and involved extensive formative research and a community engagement process (see Chapter 3 for more details). The intervention consisted of six phases, with each phase focusing on different foods and behaviors for promotion. The themes of six phases were (1) healthy beverages and breads, (2) healthy cooking methods, (3) healthier luncheon meat/eat in moderation (4) better healthier meals, (5) healthier snacks and desserts, and (6) planning ahead/ healthy and affordable meals.

The NHS intervention attempted to address both supply- and demand- sides of healthy foods. Three main components of the intervention included stocking healthier alternatives (low in fat/sugar, high in fiber), in-store and mass media communication, and interactive educational sessions (cooking demonstrations and taste tests). A list of healthier alternatives for commonly consumed foods was developed and divided into two categories: ‘all possible’ and ‘minimum standards’ promoted foods. The ‘all possible’ category included all foods that the NHS program hoped the participating stores would stock during each phase. The ‘minimum standard’ category included the foods required for the stores to stock within a phase. In-store intervention materials (shelf labels, posters, educational displays, flyers, recipe cards) and mass media strategies (the publication of newspaper articles and the broadcast of radio announcements) were used to promote the program and communicate key behavioral messages each phase. In-store cooking demonstrations and taste tests were used to highlight the promoted foods and cooking methods for each phase and to engage customers.



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