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Textual data were analyzed thematically, using the template approach (Crabtree & Miller, 1999; King, 2004). With guidance from the fieldwork, literature review, and interview guides, the researcher constructed a coding template through careful reading and rereading of textual data from the documents and interviews. These preliminary codes were revised multiple times working back and forth between the data and the coding template. Then, the researcher and a research assistant independently coded four sets of interview responses, and compared coding, discussed discrepancies. Several changes were made to the coding template. Again, the researcher and the research assistant coded another four interview notes independently, which resulted in further refinements to the coding template. Minor adjustments were made to the template on the basis of a detailed rereading of the textual data from the documents and interviews to produce the final version of the analytical template. Coded segments of text were entered into the appropriate data charts using NVIVO 8. The researcher prioritized themes that were of direct relevance to the main research questions of this study and of great importance to participants by reviewing the data charts. Representative, contextually rich quotes were identified to aid the understanding of specific points of interpretation.

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The implementation partnership for the NHS program naturally went through the four partnership stages: engagement, formalization, mobilization, and maintenance.

Relevant components, activities, key challenges, and outcomes of NHS implementation partnership process are presented in Table 4.1 and discussed below.

4.4.1 Partnership Stages (1) The engagement stage: formative research, community workshops, relationship building A key approach to engage community stakeholders and gain support for the NHS program was conducting formative research on the local food environment and eating behaviors, which demonstrated a need for food store-based interventions. The formative research engaged community members, health staff, and store managers, who provided important information on promoting healthy eating in the community to guide the development of the NHS intervention. Community workshops were another key approach used to engage various community stakeholders during the development of the NHS intervention approach based on the findings from the Apache Healthy Stores (AHS) intervention trial and to facilitate community ownership and the sustainability of the program. A total of 13 community workshops were held across the Navajo Nation. These workshops brought together a diverse group of people, including representatives from local health and human service organizations and local stores, as well as community members. On average approximately 20 people attended each workshop, ranging from 4 to 27 participants.

Importantly, the formative research and community workshops facilitated building trust and relationships with potential community partners and the identification of NSDP as a host organization for the program. During the formative research, the NHS field coordinator, who had prior working experiences with NSDP on other research projects and already familiar with NSDP managers and staff, introduced the program to NSDP through the senior nutritionist that oversaw NSDP nutrition activities. The timing was fortuitous, as at the time NSDP already had a plan to work with grocery stores on healthy foods and had started working with a few supermarkets on nutrition education and cooking demonstrations. The NHS program presented an opportunity for enhancing nutrition services for the community and would help to achieve established program goals. As a member of the NHS academic team described, “When I spoke to the (Navajo Special Diabetes) Program early on, they said what you’re doing with the healthy store intervention is one piece of what we should be doing. So they felt it should be naturally part of their program activities.”

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NSDP leaderships showed great enthusiasm for the NHS program and contributed to arranging 3 community workshops, disseminating the program to the community and local partners, and recruiting community members, community leaders, local store managers and health staff for the community workshops. NSDP staff, esp., nutritionists attended these workshops and contributed to the development and refinement of the intervention approach and materials. Initial meetings between the NHS academic team and the NSDP leaderships focused on understanding needs of each other and how collaboration could potentially address these needs. The academic team emphasized implementing a self-sustained healthy stores program on the Navajo Nation and transferring the ownership of the NHS program to the local community. From the academic team’s perspective, the key to the sustainability of the NHS program was to train local staff and incorporate the NHS intervention activities within existing health promotion programs. NSDP wanted to enhance nutrition education activities through developing evidence-based projects. As a NSDP manager (M5) stated, “The whole country has moved to evidence-based projects and this is one way to develop it”.

Therefore, it appeared a good match between the needs of the NHS program and NSDP.

However, both the formative research and community workshops were unable to engage and obtain support from some important stakeholders, such as local leaders (e.g., chapter council members), organizational decision makers (i.e., of health and human service organizations), small store managers, local fresh food producers, representatives from the division of community development, and local media representatives (newspapers and radio stations) that would have played important roles in the implementation and sustainability of the NHS program. A NSDP supervisor, whose nutritionist left for a new position in the early stage of the NHS intervention implementation remarked, “It was felt that we didn’t get any coordination from the top. It would have been nice to get (I.H.S.) community health nutritionists’ help. … Their boss didn’t allow his staff to help with the teaching, although they did have a community nutritionist. She showed up at the Window Rock trainings, but was not able to show up at our field sites to teach us.” (NSDP manager, M10) Initially, it was intended to create a Community Advisory Committee (CAC) to guide the implementation process and sustainability of the NHS program. A number of people interested in being part of the CAC signed up during the community workshops.

However, the original CAC plan was scrapped and the NHS academic team focused on working with NSDP. As a member of the NHS academic team explained, “We probably focused on the Special Diabetes Program pretty quickly. … The story was there was probably dozens of important stakeholders and the question became ‘who can you work with?’ I think it seemed that the Special Diabetes Program had enough going on a ground level. They can actually get stuff done.”

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(2) The formalization stage: partnership agreement A partnership agreement was reached between the NHS academic team and the NSDP leaderships to implement and sustain the NHS program. The two partners agreed to share their resources and expertise by NSDP providing interventionists and program management and the academic team providing materials, giveaways, trainings, technical assistance, and program evaluation. Capacity building was also a key part of the agreement to improve NSDP capacity and support NSDP beyond NHS related activities as needed (see Mobilization for details). A member of the NHS academic team explained, “Part of the setup was to provide capacity building activities. And I think they (management) were excited about that possibility to have that happened… that something (the program director) and (the senior nutritionist) really emphasized something that they wanted to learn. Because it would help to evaluate their program and so forth.” (Academic partner, R1) Specific aspects of the implementation were discussed with the NSDP leaderships, including implementation timeline, staff designation, program management, training, capacity building, program monitoring, performance evaluation, data collection, and reporting. To ensure a successful transition of the NHS program ownership, the plan was the academic team would diminish involvement and support for Round-2 implementation. While consensus was reached between the partners on these aspects of the implementation, they were not developed into a document for future reference. This became problematic when there was frequent manager turnover. A NSDP program manager (M6) remarked, “There’s no written outline that states what’s supposed to happen. The word ‘oversee’ itself didn’t say what had to take place.” The decision to implement the NHS program was a top-down decision, but not without some opposition in the NSDP central administration. A NSDP manager (M7) explained, “The concerns were that we’re pulling our nutritionists from completing their stated goals and objectives with our contract with the Indian Health Service...

that we needed to spend our time on what they felt nutritionists should be doing:

nutrition education, health care, and food demos.” (NSDP manager, M7) “There were a couple of times heated debates”, another NSDP manager (M5) said “after that the program moved forward”. However, the concern about pulling the NSDP nutritionists from completing their regular duties remained during the NHS round-one implementation. A majority of the NSDP field supervisors did not get involved in the early stages of the partnership (i.e., the development and planning of the program), and felt out of the loop for the most part as the NHS program was coordinated through the central administration.

(3) The mobilization stage:

Staff selection and training To begin the intervention implementation, the NSDP leaderships selected nutritionists and other health staff with experience in delivering nutrition interventions as interventionists. The interventionists were paired to assist each other and to lighten workload for each other. The senior nutritionist was designated to oversee the implementation and to coordinate with the NHS academic team. However, such personnel arrangement for the implementation was found to be at odds with the NSDP organizational structure as the planning and supervision of field activities took place at the service area level. The interventionists were required to work within their designated service area, due to shortage of staff and limited travel mileages. As a result, most of the interventionists were discouraged by their field supervisors and unable to work in pairs for the most part of the round-one implementation. As an interventionist remarked, “I was told to do it by myself by my supervisor. We were put in pairs to do the healthy stores intervention, but our supervisors said ‘No. We have our own staff, you utilize your staff’.” (NSDP interventionist, I1) A two-day comprehensive training was provided for the NSDP interventionists, which focused on skills and information needed to conduct the NHS program. The duties and responsibilities of interventionists were clearly stated in the interventionist manual of procedures and were reviewed during the training. The NSDP interventionists were trained on the goals, objectives, intervention strategies/approaches and implementation standards of the NHS program. The training demonstrated how to implement the NHS intervention activities, including working with participating stores to make healthier alternatives available, conducting interactive educational sessions (cooking demos and taste tests) with customers, putting up print materials (educational displays, posters, shelf labels) in stores, arranging radio announcements with local radio stations, and reporting a store visit log. The training included role playing interactive sessions with the interventionist trainees and drafting scripts for radio announcements. Participants shared their experiences working with local stores and in the community and discussed implementation-related questions and concerns.

While the nutritionists were well-prepared for the implementation at the practitioner level through the training, this was not true at the administrative level.

Necessary structural and procedural changes, including job description and reporting system, were not in place to support for the interventionists. Although these changes would, as a member of the NHS academic team stated “take more build up before it could be done”, it appeared to be critical for the NSDP supervisors to “justify” the interventionist work related to the NHS program. Additionally, although NSDP took the responsibility of purchasing food items locally for the intervention activities, NSDP could only set aside a limited amount of funds due to restrictions on the I.H.S funding and a Purchase Order was not in place when the implementation started. Consequently, the interventionists sometimes did not have these items on time and or in sufficient quantity during the round-one implementation.

Implementation support: booster training, regular teleconference, field coordination, process evaluation Prior to each intervention phase, a refresher training (or booster training) was provided for the interventionists. These trainings were intended to review implementation progress, to discuss issues and address problems encountered in the previous phase, as well as to plan for the upcoming phase. During these trainings, the interventionists shared experiences among each other and the academic team provided guidance to the questions and concerns that the interventionists brought up. NSDP managers as well as supervisors were invited to the trainings to discuss issues needed to address. An interventionist described, “We always had meetings, got together with (the PI and field coordinator). We invited our supervisors to make sure this was our priority. … (The meetings were) really getting us together to discuss problems and work on them.” (NSDP

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