«UNDERSTANDING THE PROCESS AND KEY FACTORS OF COMMUNITY IMPLEMENTATION OF A FOOD STORE-BASED NUTRITION INTERVENTION ON THE NAVAJO NATION by Muge Qi, ...»
Moreover, the extent and duration of field work that I was involved in with the NHS program increased the credibility of this study. I visited the research site multiple times during the early phases (i.e., the development and planning) of the NHS program and was involved in many aspects of the program, including attending community workshops and program meetings, writing workshop reports and meeting minutes, analyzing formative research data, assisting the trainings of interventionists and capacity building, as well as sitting in on meetings, such as the IRB meetings. These experiences provided me the opportunity to become familiar with the program as a whole and the research setting, and to know as well as to be known by the people (key stakeholders) who were closely involved in the program. Building on the existing relationships and trust, two key stakeholders were willing to provide extensive background information about the setting and it was extremely helpful for me to check against biases. Although I was not directly involved in the program, I was kept informed by the research team about its progress on a periodic basis. In fact, my disengagement during the intervention implementation and my primary role as an evaluator of the program served my neutrality and enhanced the frankness of responses in the course of the interviews with key stakeholders for this study.
Finally, the credibility of this study increased as this study was conducted as an integral part of the NHS program to inform future implementation efforts. This study created avenues for constructive feedback from stakeholders. The credibility of this study also increased as the preliminary findings of this study were shared with NSDP stakeholders and included in a project report (www.healthystores.org). The PI and field research coordinator, who were also participants in this study, peer reviewed the findings and these manuscripts.
7.3 IMPLICATIONS FOR THEORY Our findings support the four stage partnership process proposed by Cargo & Mercer (2008) by naturally falling into the four consecutive stages: engagement, formalization, mobilization, and maintenance. The findings also indicates that an effective (or ineffective) participatory partnership process can facilitate (or hinder) the host organization successfully moving through the stages of implementation. Our study identified key challenges as well as facilitating factors that affected the function of the participatory partnership, and has shown how these factors affected the outcomes of the implementation.
Moreover, we identified specific strategies used by the NHS partnership during the implementation process, many of which demonstrate the components in Meyers et al (2012a) Quality Implementation Framework (QIF). QIF was synthesized based on information from 25 implementation frameworks. The formative research and identification of a host organization found in this study can draw a parallel to the assessment step in QIF regarding the host setting, including organizational needs, innovation-organizational fit, and a capacity or readiness assessment. Adapting the intervention to fit the host setting is a critical step in the QIF and more specifically represented in this study as a planned adaptation through community workshops. Staff recruitment and pre-innovation training were accomplished in the NHS program through the collaboration between the research team and the host organization. The NHS program involved creating implementation teams and developing an implementation plan but in a less structured way. Indeed, there was a plan to create a Community Advisory Committee (CAC) to guide the implementation process and sustainability of the program. A number of people interested in being part of a CAC signed up during community workshops. But the original CAC plan was scrapped and focused on work with NSDP after a mutual agreement was reached between the research team and the host. This study also identified ongoing implementation support that consists of technical support, process evaluation, and supportive feedback mechanism, similar to the third phase of the QIF. Building general capacity and obtaining explicit buy-in from critical stakeholders were included in the QIF as pre-innovation steps, but in the NHS program these two elements occurred primarily during the intervention implementation. This study identified feedback and sustainability as the last step in the implementation process. Feedback is similar to the concept of learning from experience in the QIF, and represented in this study as gaining insights into the host organization’s experience with implementation and reporting back the results of the evaluation to the host organization.
7.4 IMPLICATIONS FOR PRACTICE Academic – community partnerships can be a viable approach to translate academic-derived intervention trials to sustainable, community-operated programs (Wallerstein & Duran, 2010). This study identified the process and strategies used by an academic - community partnership to implement and sustain a food store-based intervention, as well as facilitating factors and key challenges for the implementation partnership. This information can guide academic researchers and community practitioners in developing effective partnerships for community implementation of evidence-based interventions and help navigate more effectively the complex process of translation and implementation.
Future efforts to implement evidence-based nutrition programs through academic – community collaboration in American Indian contexts should apply the principles of community-based participatory research (Chino & DeBruyn, 2006; Israel et al., 1998) to established mutual trust and respect and facilitate the partnership implementation process.
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.
Future development and implementation of food store-based nutrition programs in rural American Indian contexts should consider bringing local health staff and food store owners together to ensure both the demand- and supply-sides issues related to healthy foods are addressed in a coordinated manner. Further, intervention strategies (such as monetary incentives, nutrition education training, business training) targeting store owners/managers should be developed to help ensure stocking of healthy foods. These strategies should include nutrition education components to increase store owners’ knowledge about the relationships between diet and health (i.e., diet-related health problems, such as diabetes and obesity that affect their community). Local health staff can deliver these nutrition education components as part of existing health promotion activities. Moreover, food store-based nutrition programs should create an effective mechanism for continuous monitoring and evaluation to increase accountability, allow for early identification of potential problems, and provide supportive feedback in a timely manner. Additional efforts should be undertaken to build trusting relationships between local health staff and store owners, and to actively engage store owners in the design and planning of intervention approaches, implementation standards, as well as evaluation for the program. Finally, future food store-based nutrition programs in rural American Indian contexts should find innovative solutions, such as a Farm-to-Table program connecting local farmers to small grocers to help address barriers associated with distance and cost of stocking perishable items.
7.5 IMPLICATIONS FOR POLICY Given that nearly the entire Navajo Nation is a food desert (USDA, 2012) and challenges exist for stocking healthy foods in small food stores in this setting, policy initiatives initiated by tribal leadership are necessary to support long-term changes in food retail environment. Tribal leadership can model upon Healthier Food Retail (HFR) initiatives at state- or federal- level (CDC, 2011), or connect healthy food initiatives to tribal agricultural policies or other community development policies to create greater support for improving the food store environment. Local health practitioners and community health organizations, such as Navajo Special Diabetes Program can support initiation of such policy initiatives by sharing information about the NHS program, formative research and outcome evaluation findings, as well as their experiences working with store owners/managers, and help policy makers move toward greater support for expansion of the NHS program.
An important challenge for the academic – community partnership relates to funding, particularly inadequate research funding to continue the NHS program for a longer period and funding regulation or reimbursement policy regarding the use of existing organizational resources to cover the costs associated with implementation of the program. Thus, it is critical to develop funding policies for research and health promotion that are conducive to implementation and sustainability of evidence-based nutrition programs in community settings. Such funding policies should allow adequate resources for extra costs, effort, equipment, manuals, materials, recruiting, access to expertise, retraining for new organizational roles, associated with implementation (Fixsen et al., 2005), as well as continuity of funding for a longer period to ensure sustainability of the program in the community.
7.6 IMPLICATIONS FOR FUTURE RESEARCH AND
METHODOLOTYStudy academic - community partnership approaches to implement and sustain food store-based interventions in other settings: this study serves as one case study conducted to understand the process and challenges of translating an academicderived food store-based intervention trial into a sustainable, community-operated intervention. More studies are needed in other American Indian contexts and in other community contexts to add on information to this new area of study. Future studies can apply the process and strategies identified in this study to evaluate whether they are applicable to other food-store based programs in other settings.
Collect observational data on implementation and qualitative data from community members: without having data regarding how the intervention was executed, little can be evaluated with regard to other important aspects of implementation, such as quality, fidelity, dose, and reach of intervention implementation. The information can corroborate qualitative data on implementation, and any discrepancies warrant further examination. Future studies should collect qualitative data on 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 and understanding of the process and challenges of program implementation.
Expand formative research by exploring the formation of linkages and partnerships with local fresh produce suppliers and producers: small stores located in remote rural areas on the Navajo Nation face unique challenges in stocking perishable items like fruits and vegetables due to time and cost associated with long transportation route. Formative research could be used to identify and possibly provide a map of local food producers, and explore the potential for linking small stores with local fresh produce suppliers and producers. Additionally, future studies should also explore how WIC vendors on the Navajo Nation responded to the new WIC packages. This information is valuable to share with non WIC vendors and may encourage them to stock healthy foods.
Use planned adaptation and store-specific implementation plan: The implementation strategies for the NHS program included a planned adaptation of a previous intervention trial through community workshops prior to intervention delivery.
Local health staff members who served as interventionists were actively involved in this process. Planned adaptation can resolve the tension between the need for fidelity and adaptation (Lee, et al. 2008). However, the NHS program was not able to engage small store owners in the development and planning process. While there are common challenges to stocking healthy foods, stores are likely to differ with respect to concerns, capacity and barriers for stocking healthy foods. Future studies should work closely with stores to develop implementation plans that takes consideration the range of unique circumstances found by stores.
Johns Hopkins University Bloomberg School of Public Health Title of Research Project Expanding and sustaining a successful food-store based program to improve diet and reduce risk for obesity and other chronic diseases in American Indians: Local organization interviews (Form G) [phase 4].
Explanation of Research Project:
Hello, my name is ________________________, and I am an evaluator with the Healthy Stores Program. As you know, the main goal of the program is to prevent some of the common health programs in American Indian communities, like diabetes, obesity, heart disease, and hypertension. We are doing this by working with local stores and the Special Diabetes Program to help make sure healthy and affordable food choices are available to people here, that they know about their benefits and how to prepare them.