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Store-based intervention trials to improve dietary quality and reduce risk for obesity in underserved communities (i.e., low income, ethnic minority, inner-city and rural communities) have shown some success in increasing the availability and sale of healthy foods, the purchase and consumption of those foods, and consumer knowledge (Escarton et al., 2013; Gittelsohn et al., 2012a; Glanz & Yaroch, 2004). Often these trials have applied multipronged strategies (food provision, infrastructure change, and health communication) along with community engagement to increase both supply and demand for healthy foods. It is expected that implementing and sustaining effective store-based environmental interventions at the local level can produce impact at the population level in obesity and chronic disease over the long term (CDC, 2009).

Research on translating nutrition intervention trials to locally implemented community interventions is scarce (Ciliska et al., 2005; Rabin et al., 2009). Participatory partnership approaches that value local perspectives, stakeholder input, and community resources are essential for successfully implementing evidence-based interventions in relevant settings and populations (Cargo & Mercer, 2008; Glasgow et al., 2012).

Wallerstein and Duran (2010) demonstrate the potential of community participatory research approaches for addressing core challenges in the translation of intervention trials to real-world community programs. However, little is known about how the participatory partnership for implementation develops and how it affects the process of evidence-based intervention implementation.

4.2.1 Navajo Healthy Stores Program The Navajo Healthy Stores (NHS) program was a food store-based intervention designed to improve dietary patterns on the Navajo Nation and to reduce risk for obesity by increasing the availability, purchase, and consumption of healthy foods, based on the findings from a previous intervention trial (Curran et al., 2005; Vastine et al., 2005). An academic team from the Johns Hopkins University School of Public Health (JHSPH) partnered with the Navajo Special Diabetes Project (NSDP), a community health organization funded under the Special Diabetes Program for Indians (SDPI) (Community-directed) Grant Program for diabetes prevention and treatment services. The NHS program had four overlapping phases: planning and formative research, intervention development, implementation, outcome evaluation. An approximately 20-month long planning and formative research phase included obtaining approvals from the Navajo Nation Human Research Review Board (NNHRRB) and Navajo agencies and generating local planning data. The formative research focused on identifying food sources and availability of healthy foods, commonly consumed foods and food shopping habits on the Navajo Nation, programs or activities related to healthy eating in stores and in the community (Sharma et al., 2009).

The NHS program was developed with the aid of 13 1-2 day long community workshops in the formative planning stage. The workshop discussions generated a series of key foods and behaviors for promotion, using a brainstorming and prioritizing process (Gittelsohn et al., 2010a). A series of messages and ideas were developed to promote healthy food choices, preparation, and consumption. The NHS program consisted of a six-phase intervention, each phase lasting 6-10 weeks focused on different foods and behaviors for promotion, with interactive sessions at local retail food stores through cooking demonstrations and taste testing of healthier food alternatives for community members. The NHS intervention was planned to implement in two rounds (round-one implementation and round-2 implementation) for the purpose of evaluation. Ten large store areas on the Navajo Nation were identified and randomized into intervention areas and control/delayed intervention areas. For round-one implementation, 15 stores in the intervention areas were targeted, including Basha’s Stores, a City Market in Shiprock, and various smaller stores within 30 miles of larger stores. For round-two implementation, the intervention would expand to stores in five control areas.

The overall NHS intervention approach was a locally implemented and sustained intervention. The intervention was carried out by NSDP nutritionists/health workers. The NHS academic team provided periodic additional trainings and oversight. The interventionists were assigned 1-2 stores for their work on the project and conducted a 1hour interactive session at each store 2-4 times per month. The interactive sessions included demonstrating healthier cooking methods, taste testing healthy foods, giving away promotional items, and responding to questions from store customers. The interventionists’ additional duties were to create and maintain relationships with food stores, work with stores to stock key promoted healthier foods, and set up media materials such as educational displays, posters, and shelf labels. Radio announcements of key messages were recorded and played regularly in both Navajo and English.

The NHS program was evaluated with a pre-post prospective longitudinal cohort study of a randomly selected sample of consumers divided into intervention and comparison groups, with measurements at baseline prior to the beginning of the roundone implementation and 15-20 months later after the round-one implementation.

Intervention impact was examined by analyzing pre-post differences by intervention group and by intervention exposure level. When intervention and comparison groups were compared, only Body Mass Index (BMI) showed a trend towards impact of the intervention. However, greater exposure to the intervention was associated with significantly reduced BMI, and improved healthy food intentions, healthy cooking methods, and healthy food getting (Gittelsohn et al., 2013). To our knowledge, this is one of the first such community-based trials to show impact on weight status among adult AI.

The purpose of this study was to identify the process and strategies used by the academic - community partnership to implement the NHS program. Specifically we conducted a qualitative study guided by a conceptual framework to address the following research questions: (1) How was the implementation partnership formed and how did it evolve? (2) What were strategies used by the partnership to implement and sustain the program? (3) What were key challenges for the implementation partnership?

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4.3.1 Conceptual Framework Figure 4.1 depicts the conceptual framework developed for this study. Academic – community partnership approaches, in particular community-based participatory research (CBPR) approach can play an important role in successful implementation of evidence-based interventions by incorporating local partners’ real-world knowledge and experiences with researchers’ expertise in evidence-based interventions and effective support strategies (Cargo & Mercer, 2008; Glasgow et al., 2012; Lindamer et al., 2009;

Wallerstein & Duran, 2010). According to Cargo and Mercer (2008), participatory research approaches have seven core elements: mutual respect, trust, capacity building, empowerment, ownership, accountability, and sustainability, which undergird partnership efforts for the development and implementation of an evidence-based intervention.

Implementation is a process, by which an evidence-based intervention is put to use or integrated within a setting (Rabin et al., 2010). The process of implementation can be categorized into four stages: exploration and adoption, program installation, implementation, and sustainability (Fixsen et al., 2005). The purpose of exploration is to assess the match between the evidence-based intervention and the needs of the potential host community/organization and to make a decision to adopt (or not). After a decision is made to implement the intervention, an organizational change process begins to put in place structural supports necessary to initiate the intervention (program installation).

During the initial stage of implementation, the focus is on increasing staff skill and organizational capacity and on fostering supportive organizational culture. Full implementation occurs when the intervention is fully operational and becomes an “accepted practice” within the setting. Sustainability of an implementation site begins during the exploration stage and continues thereafter for the long-term survival and continued effectiveness of the intervention.

Corresponding to these four stages of implementation, participatory partnerships for implementation of an evidence-based intervention develop and evolve in four consecutive stages: engagement, formalization, mobilization, and maintenance (Cargo & Mercer, 2008). The engagement stage facilitates identification and understanding of a potential host community/organization and development of relationships and trust.

Formalization occurs when a formal agreement is established with the host organization, outlining the role, responsibilities, and expectations for the partnership. Mobilization involves preparing the organization, supporting systems, and staff for implementation of the intervention. Maintenance is needed to ensure sustainability of the partnership, capacity building, and the intervention. This conceptual framework hypothesizes that an effective (or ineffective) participatory partnership process can facilitate (or hinder) the host organization successfully moving through the stages of implementation. This conceptual framework also acknowledges that multi-level factors affect the implementation process (Greenhalgh, Robert, Macfarlane, Bate, & Kyriakidou, 2005;

Durlak & DuPre, 2008). Guided by this conceptual framework, this study aimed to understand how the participatory partnership for the NHS program developed and what key challenges were for the partnership moving through the stages of implementation.

Because the main study, in which this substudy was nested, was guided by Shediac-Rizkallah & Bone’s (1998) three dimensions of sustainability, this substudy also qualitatively explored the extent to which the three dimensions of sustainability were achieved as a result of the academic-community implementation partnership. ShediacRizkallah & Bone (1998) theorized that program sustainability has three dimensions: (1) maintenance of health benefits of the program (program effectiveness), (2) continuing of program benefits through an organizational structure (institutionalization), and (3) building capacity of the recipient community (capacity-building) (Shediac-Rizkallah & Bone, 1998). Maintenance of health benefits is at the heart of sustainability for health promotion programs. Often health promotion programs do not immediately produce measurable health outcomes. Behavioral changes must be sustained over a long period of time before any significant decrease in actual morbidity or mortality can occur and be measured (Puska et al., 1985). Institutionalization refers to long-term survival of a program within an organizational structure (Steckler & Goodman, 1989). When institutionalization occurs the program becomes part of the organization’s routine operations and loses its separate identity (Goodman, McLeroy, Steckler, & Hoyle, 1993;

Yin, 1981). Capacity-building refers to sustainability in communities. It represents a process of strengthening the problem-solving capability of communities not only to address the current health problems but to tackle new or other health issues (Green, 1989;

Hawe, Noort, King, & Jordens, 1997; Shediac-Rizkallah & Bone, 1998).

4.3.2 Study Design and Data Collection This study used a qualitative approach using a combination of semi-structured interviews and program documents as primary sources of data. This study was approved by both the Johns Hopkins University Institutional Review Board (IRB) and the Navajo Nation Human Research Review Board (NNHRRB).

Semi-structured interviews Semi-structured interviews were conducted to understand the experiences of individuals as part of the NSDP and NHS academic team. A total of 24 individuals, who had been closely involved in the partnership development and implementation of the NHS program were identified based on the researcher’s fieldwork experience with the NHS program. These individuals included the NHS principal investigator, field research coordinator, NSDP managers, supervisors, and interventionists. Interviews were conducted by the researcher at participants’ workplaces. An interview guide was used during interviews. Topics covered included: project initiation, intervention adaptation, implementation, sustainability, program facilitators, barriers, and impacts. There was no audio-recording of interviews with local stakeholders 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. The researcher wrote down interview responses with permission, and made every effort to capture actual phrases and sentences used by participants. Signed consent was obtained from all participants. The duration of interviews ranged from 30 minutes to 2 hours, but most of the interviews lasted about 1 hour.

Documents review Program documents were reviewed to reveal the complexity of partnership and implementation process and to understand the experiences and perceptions of study participants in the program context. These documents included program meeting and conference call minutes, formative research reports, community workshop reports, the interventionist manual of procedures, presentation slides for training and capacity building workshops, progress updates and reports, and journal articles. Documents pertained to the development, implementation and evaluation of the previous food storebased intervention trial was also reviewed to explore the degree of intervention adaption to the Navajo setting. Additionally, available documents of the NSDP were also reviewed for relevant information.

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