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2.5.1 Interventions and Target Audiences The dissemination and implementation of seven distinct interventions was examined in eight studies, including two studies that examined one intervention under two different settings at different time points (Heath & Coleman, 2003; Hoelscher et al., 2001). Of these seven distinct interventions, four were academic-derived interventions (Harvey-Berino et al., 1998; Heath & Coleman, 2003; Hoelscher et al., 2001; Patterson et al., 1998; Wiecha et al., 2004), and three were developed and disseminated in partnership with provincial, state or regional agencies or organizations (Nanney et al., 2007; Naylor et al., 2010; Olson, Devine, & Frongillo, 1993). The dissemination and implementation of academic-derived interventions was initiated either by the research teams after the completion of efficacy trials (Patterson et al., 1998; Wiecha et al., 2004), or in response to the demands from state agencies or local organizations (Harvey-Berino et al., 1998;

Heath & Coleman, 2003; Hoelscher et al., 2001). The majority of the interventions (5 out of 7) were school-based programs or curriculums. Only two of the eight studies examined the dissemination and implementation of an intervention in minority populations or communities (Heath & Coleman, 2003; Naylor et al., 2010).

2.5.2 Dissemination and Implementation Strategies and Theoretical Models Main dissemination and implementation strategies reported in these studies include training, technical assistance, or consultation from the original research team, financial support, and provision of program protocols and materials. These strategies were applied in various combinations in different studies. One study also reported developing implementation plans through an action committee and allowing flexibility to fit specific organizational needs (Heath & Coleman, 2003). Two studies used community-participatory research approach (CBPR) (Naylor et al., 2010; Wiecha et al., 2004). Six of the eight studies reported that Diffusion of Innovation Theory (Roger,

2003) guided the dissemination efforts, and only one study described in detail how the theory guided specific dissemination strategies (Hoelscher et al., 2001). Two studies did not mention any theoretical guidance for dissemination and implementation.

2.5.3 Implementation and Sustainability Six studies reported the level of implementation, indicated by either the number or the percentage of target audiences that actually used program materials, or the percentage of meeting the intended intervention activity goals (dose delivered or dose exposed). Various degrees of implementation success were observed. One study evaluated the effects of different strategies on implementation (implementation with or without external training support, and implementation with or without grocery store link) (Harvey-Berino et al., 1998). Most studies examined factors associated with dissemination and implementation, including the characteristics of the interventions and the adopters and the availability of adequate training, resources and financial support.

Only two studies reported the findings from outcome evaluations (Coleman et al., 2005;

Devine, Olson, & Frongillo, 1992). Although positive findings were reported for individual level outcomes, such as nutrition attitudes and behavior and body weight, the response rates were low in both studies. Sustainability of intervention was reported in only one study (Wiecha et al., 2004).

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In summary, previous research on the dissemination and implementation of evidence-based nutrition interventions in community settings was primarily guided by diffusion theory, used a top-down approach to dissemination and implementation, and focused on school-based interventions. Diffusion of Innovation theory (Roger, 2003) explains the process by which an innovation is adopted by the target audience, and has successfully guided variable- and dissemination- focused studies (Dearing, 2008).

However, the application of diffusion theory has been limited in implementation research (Green et al., 2009). This may explain why data on implementation is cross-sectional and limited, but factors, such as the characteristics of the interventions and the adopters have been examined extensively in prior research. There is a need to incorporate constructs from other related theories or models that focus more on implementation and sustainability (Tabak et al., 2012). To our knowledge, only two studies have examined the dissemination and implementation of evidence-based nutrition interventions in minority population or communities, despite the prevalence of obesity and chronic disease is disproportionately higher in racial and ethnic minority populations (Kumanyika & Grier, 2006; O’Connell et al., 2010; Ogden et al., 2006; Wang & Beydoun, 2007).

Only two studies reported using Community-based Participatory Research (CBPR) approach. The full potential of CBPR for dissemination and implementation of evidencebased interventions has yet to be explored (Glasgow et al., 2012; Wallerstein & Duran, 2010), and may be particularly effective for working with minority and underserved populations (Cargo & Mercer, 2008; Scarinei et al., 2007; Wallerstein et al., 2008).

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 frameworks derived from participatory research and by examining stages of implementation process.

Table 2.1.

Summary of research on the dissemination and implementation of evidence-based nutrition interventions in community settings

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This dissertation describes the process and key factors of community implementation of a food store-based nutrition intervention on the Navajo Nation through an academic-community partnership. In this chapter, I describe the study design and setting, data collection procedures and data analysis methods.

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The Navajo Healthy Stores (NHS) program was designed to improve dietary patterns on the Navajo Nation and to reduce risk for obesity by improving the availability of healthy foods in local stores and promoting the purchase, preparation and consumption of healthy food alternatives in local stores (Gittelsohn, Kim, He, & Pardilla, 2013). The program was developed through extensive formative research and a community engagement process, based on a previous intervention trial (Curran et al., 2005; Vastine et al., 2005). The overall intervention approach was a locally implemented and sustained intervention through a collaboration with Navajo Special Diabetes Project (NSDP), a community-based health organization funded under the Special Diabetes Program for Indians (SDPI) Community-directed Grant Program.

This dissertation was a substudy within the larger NHS intervention study which aimed to understand how such academic – community partnerships can enhance (or potentially detract from) the community implementation and sustainability of nutrition interventions. The aims of this substudy were to access the partnership process involved in the design, implementation, evaluation and continuance of the NHS program and to identify key factors affecting the partnership process. I explored three key aspects, each

guided by specific research questions:

1. To examine the academic-community implementation partnership process:

1.1 How was the implementation partnership formed and how did it evolve?

1.2 What were strategies used by the partnership to implement and sustain the

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1.3 What were key challenges for the implementation partnership?

2. To identify key factors affecting the academic-community partnership effort:

2.1 How and what factors have facilitated the partnership effort to implement

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3. To understand challenges in community implementation of the program from the

perspectives of local health staff and food store owners:

3.1 What challenges were faced by local health staff in recruiting food stores

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This study used a qualitative approach, which offers a means of investigating a process in a naturalistic setting and access to experiences and perceptions of others (Merriam, 1992; Morse & Field, 1995; Patton, 2001; Weiss, 1994), therefore, was well suited for this study. A combination of fieldwork, semi-structured interviews and document review was used to understand the partnership process and key factors from the perspectives of academic partners, local health staff, and store owners of participating stores on the Navajo Nation.

The Navajo Nation is the largest federally recognized American Indian (AI) tribe in the United States, spanning 27,000 square miles across New Mexico, Arizona, and Utah (Figure 3.1), with an estimated on reservation population of over 250,000 individuals (NDOH, 2004). The Nation is divided into 5 agencies (similar to counties) that consist of 110 chapters (similar to towns, the smallest administrative units on the Navajo Nation). Most of the Navajo Nation is remote and rural, and much of the population lives on isolated homesteads of several related households (Pareo-Tubbeh et al., 2000). Geographic remoteness, lack of infrastructure (e.g., electricity, paved roads, telecommunication, and transportation), and limited cash resources have been major obstacles for Navajo economic development, access to the delivery of health care (NDOH, 2004). Poverty and unemployment rates are high, at 42.9% and 54.1% respectively (NDED, 2006). Food insecurity rates on the Navajo Nation are the highest reported to date in the USA and are likely attributable to the extremely high rates of poverty and unemployment (Pardilla, Prasad, Suratkar, & Gittelsohn, 2012).

The lack of retail outlets is one of the major economic problems on the Navajo Nation, resulting in leakage of Navajo dollars (NDOH, 2004). According to a reservationwide food source survey conducted as part of the formative research of the NHS program in 2007, there are only 9 supermarkets on the reservation in the small towns where a shopping center is located. Most retail food stores are small grocery stores or convenience gas station stores that are scattered about the rural areas of the Navajo Nation. There are also several trading posts and a few flea market 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, piñon nuts, and soft drinks, among others. Thus, the NHS program planned to utilize the available environmental resources by conducting interventions in grocery stores, trading post, and convenience stores (Gittelsohn et al., 2013). Among participating stores in this study, 4 stores were Bashas’ stores (an Arizonabased, family owned grocery chain), one was a City Market store, and 8 convenience stores or gas stations, and 2 were trading post. These stores scattered across 5 Navajo agencies (Table 3.1).

Navajo Special Diabetes Project (NSDP) is one of the 14 tribal health programs provided by the Navajo Division of Health (http://www.nndoh.org). NSDP was created in 1999 and funded under the Special Diabetes Program for Indians (SDPI) Communitydirected Grant Program “to promote healthy lifestyle and develop strategies to reduce and prevent diabetes affecting the Navajo people” (www.nnsdp.org). NSDP provides primary, secondary, and tertiary prevention services to a wide range of target population, including school-aged children, adult at risk of diabetes, newly diagnosed diabetic patients, pregnant women and elderly. Primary activities include preventive education, raising awareness of diabetes, community screenings for early detection and referrals for more extensive testing and treatment, promoting the importance of physical activities and proper nutrition, diet and foods to combat diabetes (NSDP interim report, 2009). Serving a large, scattered population in a remote, rural reservation poses a unique challenge for the NSDP in preventing and treating diabetes with limited funding (less than 10% of the total budgets go to support program activities).

NSDP has established a reservation-wide program, consisting of eight service areas located throughout the Navajo Nation with the central administration located in the Capital - Window Rock, Arizona. A program manager provides oversight and direction to the program, and eight program supervisors provide guidance and support to the respective service area office. There were 99 FTE positions, such as senior community health workers (17), health education technicians (15), fitness specialists (7), nutritionists (6), and nutrition education technicians (2), among others. A majority of the NSDP staff members are bilingual (Navajo/English). Because the NSDP is responsible for diabetes prevention and community nutrition, the NHS academic team identified NSDP as a logical partner to work with on the program. Participants in this study were NSDP nutritionists and community health workers (as interventionists) and their supervisors/ program managers.

3.3 DATA COLLECTION METHODS This study used a combination of fieldwork, semi-structured interviews and program documents as primary sources of data.

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