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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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Local health staff reported the stocking of promoted foods was challenging and inconsistent, a finding also reported in other studies in AI/AN and remote rural settings (Curran et al., 2005; Gardiner et al., 2013; Rosecrans et al., 2008). Only about one third of store managers reported adding some healthier snacks or healthier drinks that they had not previously stocked. All but one of these stores reporting adding healthier items were smaller stores, which may reflect the fact that the four participating supermarkets already had high availability of promoted foods. Our observational data also indicate no significant improvement in stocking of healthy foods in those smaller stores post intervention (Unpublished data). Small store managers reported lack of customer demand, lack of availability and increased cost of healthy foods from suppliers due to long transportation routes, as key challenges for stocking healthy foods. The economic recession that began in late 2008 and continued into 2009 may also have influenced customer demand for healthy foods (Bezruchka, 2009), as suggested by a supermarket manager in our study. Small stores located in remote rural areas face unique challenges in stocking perishable items like fruits and vegetables due to the time and costs associated with long transportation route (Bailey, 2010; Gittelsohn et al., 2006; Hudson, 2010; Mead, Gittelsohn, Kratzmann, Roache, & Sharma, 2010; Rosecrans et al., 2008). Gleason, Mogan, Bell, & Pooler (2011) reported difficulties faced by small stores in remote rural areas in obtaining the new WIC foods because suppliers refused to deliver them due to their remote location, or the foods when delivered were often near expiration. Emerging studies on implementation of the 2009 new WIC package suggest that small stores are able to adjust and adapt to the addition of healthy foods to their inventory (Andreyeva, Middleton, Long, Luedicke, & Schwartz, 2011; Gleason et al., 2011; Gittelsohn et al., 2012a). Most of the small stores in our study were WIC authorized vendors. It would have been interesting to learn how these stores responded to the changes. Lessons learned from these studies can inform small stores on the Navajo Nation to increase availability of healthy foods. Innovative strategies that fit the local context, for example, a Farm-toTable program connecting local farmers to small grocers may help address barriers associated with distance and cost of stocking perishable items (Setala et al., 2011).

Local health staff can play an important role in increasing community demand for healthy foods and facilitating stocking of healthy foods in small stores. Our findings suggest, however, there are limitations in utilizing local health staff as interventionists.

First, local health staff have full schedules with their regular duties and effort beyond that is difficult (see Chapter 5). Store managers reported in-store educational sessions happened sporadically, and felt local health staff needed to do more to persuade customers to change their behavior. Moreover, local health staff (mostly nutritionists) viewed their role in the program as nutrition educators to provide education for customers. This is primarily because the work related to the program was inclusive in their performance standard to get credit for their job (see Chapter 4). Another reason for local health staff to focus on nutrition education is their concern about “stepping on shoes” of store owners. Our findings indicate a difficult situation for local health staff attempting to have store managers stock promoted healthier options for the program while keeping good relationships with them. In addition, the lack of focus on stocking of healthy foods also attributes to limited oversight of implementation due to manager turnover and insufficient time for regular monitoring and feedback from program staff (see Chapter 4 and Chapter 5). Other food store-based programs suggest that close monitoring and timely feedback can improve program implementation (Curran et al., 2005). Still, having local health staff as interventionists is preferred from a sustainability perspective. As our evidence indicates, having local health staff as interventionists can enhance local buy-in. They are well known by community members (some local health staff were already familiar with participating store managers prior to implementation) through their regular job and already established credibility for their work. Store managers expressed positive feeling about the educational sessions provided by the local staff as part of the Special Diabetes Program. The lessons learned during the present study should be addressed in future community implementation efforts.

This study has several limitations. While we sought to understand the implementation of the NHS program from the perspectives of local health staff and store owners/managers, we did not interview community members/store customers.

Ultimately, community members are the end users of the program, and their perceptions about (and experience with) the program are crucial for the success of the program.

Additionally, due to resource and time constraints, we did not collect observational data regarding how the intervention was executed. This data would provide us information about other important aspects of implementation, such as quality, fidelity, dose, and reach of intervention implementation. The generalizability of findings from the present study is limited due to a relatively small numbers of stores participating in the study and the particular physical, social, and economic environments of the Navajo Nation where the participating stores are located.





In conclusion, local health staff were able to recruit and work together with store owners/managers to implement the NHS program, but there were challenges in delivering educational sessions with adequate intensity and having store owners stock healthier options. Our findings have important implications for future development and implementation of food store-based nutrition programs in rural American Indian contexts.

Future food store-based nutrition programs should pay attention to improving store owners/managers’ knowledge about the relationships between diet and health and actively engaging them in the design and planning of intervention approaches, implementation standards, as well as evaluation for the program. Local health staff can play an important role in implementing and sustaining food store-based nutrition programs. Additional efforts should be undertaken to incorporate food store intervention into existing health promotion activities and find innovative solutions to address both demand- and supply-side of healthy foods on the Navajo Nation.

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This chapter will summarize the key findings of the dissertation research, discuss the strengths and limitations of the study, and make recommendations for future research, policy and practice.

–  –  –

The first paper describes the process and strategies used by the collaborative partnership between Johns Hopkins University Center for Human Nutrition and Navajo Special Diabetes Program to implement and sustain the Navajo Healthy Stores (NHS) program. Our findings indicate 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. This paper demonstrates that the use of a combination of different theories or theoretical constructs can enhance the understanding of the complex process of implementation and partnership development in a more systematic way, and help identify challenges needed to address.

The second paper examines the academic – community partners’ experiences with the NHS program and identifies key factors that have affected the implementation partnership. We identified four important facilitating factors and three key challenges for the implementation partnership. Facilitating factors include trust in the academic partners’ experience and commitment to sustainability, being responsive to the community partner’s interests in capacity development, having a program champion, and having a dedicated and experienced field coordinator. Challenges for the partnership include fitting into staff job schedule, obtaining buy-in from critical stakeholders, and overseeing implementation. The findings demonstrate that the successful translation of academic-derived intervention trials to sustainable, community implemented programs will need long-term commitment of academic – community implementation partnerships.

The third paper describes the implementation of the NHS program from the perspectives of local health staff (as interventionists) and store owners/managers, in terms of store recruitment, relationship building, and challenges in delivering the intervention.

In addition, storeowners’ perceptions about the program, its implementation by local health staff, and program effectiveness are described. We found that local health staff members were able to recruit small stores and maintain good relationships with store owners/managers, but there were challenges in delivering educational sessions with adequate intensity and having store owners 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 routed as key challenges for stocking healthy foods. Store managers commonly perceived the program as an educational program on healthy eating that targets their customers, expressed positive feelings about intervention implementation by local health staff as part of the Navajo Special Diabetes Program, but felt local health staff needed to do more to have significant effects on changing customers’ behaviors. Additional efforts should be undertaken to incorporate the NHS intervention into existing community health promotion activities and find innovative solutions to address both the demand- and supply-side of healthy foods on the Navajo Nation.

–  –  –

A strength of this study was the relevance and novelty of the topic under investigation. Previous research on the dissemination and implementation of evidencebased nutrition interventions in community settings focused on school-based interventions for general population, was primarily guided by diffusion theory and primarily used a top-down approach to dissemination and implementation (Ciliska et al., 2005; Rabin et al., 2009). This dissertation aimed to address these gaps in the literature by examining the implementation process of a store-based nutrition intervention on an AI reservation guided by the frameworks or models of participatory research and stages of implementation process.

Another strength of this study was the use of qualitative methods, which grounded the research in the local context and enabled access to experiences and perceptions of those directly involved in the program. This study also incorporated multiple stages of fieldwork over a 1.5-year period, including field visits during the development and initiation of the NHS program and the early phases of intervention implementation and in the end of the intervention implementation. Additionally, the use of multiple data sources, including program documents and interviews with key stakeholders allowed for triangulation of the data as well as understanding of the implementation from the perspectives of researchers, practitioners, and store owners.

There were limitations to this study. Because this study was conducted only on the Navajo Nation, the generalizability of findings to other settings is limited. Further, we could not determine the relationship between various factors identified in this study and their relative contribution to the outcomes of the implementation effort. While the researcher attempted to understand the partnership process and factors affecting the implementation of the NHS program from the perspectives of various stakeholders, she did not interview community members/store customers. Ultimately, community members are the end users of the program, and their perceptions about (and experience with) the program are crucial for its success. The NHS exposure data from store customers can provide additional information on the program implementation. Additionally, due to resource and time constraints, the researcher did not collect observational data regarding intervention execution. These data would provide us useful information about other important aspects of implementation, including the quality, fidelity, dose, and reach of the intervention implementation.

Another limitation of this study was that we did not audio-record the interviews, because of participants’ preferences to remain completely anonymous, and because of time constraints to obtain the NNHRRB approval for audio-recording at the time this study was conducted. I wrote down interview responses with permission, and made every effort to capture actual words or sentences used by interviewees. For instances, when I was not able to get down fully what an interviewee said about something that seemed particularly important, he/she was politely asked to repeat it. Further, I quickly reviewed the written responses immediately following the interview, and asked interviewees for clarification if I found something was missing or incomplete. In the earlier stage of the field work, the field coordinator helped check the completeness and accuracy of written responses taken immediately after an interview with her, and the results were very satisfactory. Prior to conducting this study, I worked in a similar (organizational and cultural) setting (San Carlos Apache Indian reservation) for six months. During this period, I had the opportunity to conduct many interviews with staff from the local Diabetes Prevention Program and direct observations of program related activities. These experiences allowed me to build skills for conducting qualitative interviews and writing down interviewee responses. Also, the prior field experience provided me well the opportunity to become familiar with American Indian culture and ways of communication. This, in turn, allowed me to be more culturally sensitive when interacting with local people and conducting interviews.



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