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To address nutrition related questions of the NSDP interventionists, a community nutritionist from I.H.S. was invited for the trainings and helped to develop Frequently Asked Questions (FAQ) in the interventionist manual of procedures. Throughout the implementation, the NHS field coordinator also provided necessary support for the interventionists, such as helping recruit small stores, distributing intervention materials and giveaways to the intervention sites and sharing information among the interventionists.

Regular teleconference between the NHS academic team and the NSDP interventionists was a way to monitor and provide feedback on the implementation.

Teleconferences were scheduled biweekly during first two phases and monthly thereafter.

During these calls, the NSDP interventionists reported progress and problems related to implementation, and the academic team provided feedback and guidance. However, the interventionists irregularly attended these calls due to lack of access to a telephone at their workplace and conflicting schedules. It was felt that these calls were not sufficient for monitoring implementation and providing feedback. As a member (R1) of the NHS academic team described, “There’re so many people to report back. It was hard enough to get everybody on the calls much less get them to say ‘did you put up your posters yet’, much less get them to say ‘did you get them to stock low fat milk’. We just couldn’t get to that specific. There was never time to do that.” (Academic partner, R1) Another method for monitoring implementation was process evaluation. The interventionists administered a store visit log, which was designed to document details of each interactive educational session (cooking demonstrations and taste tests) they conducted in the intervention stores. The store visit log was slightly modified during the implementation to be more user-friendly and to be consistent with the NSDP recording system for internal use. For example, the age groups of program participants were expanded from 3 broad categories to 6 categories corresponding to the age groups on the NSDP report. The process data was compiled by the NHS academic team and presented during the booster trainings. The process data was used to discuss implementation progress and accomplishments, and to improve program implementation.

Capacity building and supervisor buy-in The NHS capacity building occurred both informally (unplanned) and formally (planned). Informally, bringing NSDP staff and staff from other health agencies (esp.

I.H.S) together in the community workshops and interventionist trainings had helped to enhance capacity of the NSDP staff and increased opportunities for communication and collaboration with other agencies. As a NSDP manager stated, “(The activities of the NHS program) will help our nutrition staff build their capacity for doing presentations, and actually having the background and the systems and the support not only from the nutrition staff but also from staff from Johns Hopkins and also with the partners from I.H.S, particularly nutrition staff.

Since they’re truly registered dietitians as opposed to our nutritionists not that they don’t know too many things but they don’t have a RD status. And they can learn quite a bit from RD staff from I.H.S, in terms of what they have done in their communities and possibly carry on other collaborative work that exists out there.”(NSDP manager, M4) Formally, five capacity building workshops were provided throughout the NHS intervention implementation. The target audiences for these capacity building workshops were the NSDP program managers and supervisors, although other staff were also invited to and attended the workshops. The topics of the capacity building were chosen by NSDP leaderships. These workshops included program evaluation, data analysis (two parts), research methods and protocol, and grant writing. The NHS academic team worked with NSDP administrators to make sure that these workshops were participatory and practical.

For example, during the evaluation workshop attendees discussed the importance of evaluation for their work, and then prioritized the established goals of NSDP to develop an evaluation plan and evaluation instruments. Data from the NSDP monthly reports were also used for demonstrations and practices during the data analysis workshops.

While the purpose of the NHS capacity building was to enhance knowledge and skills of NSDP managers and supervisors in the topics chosen, these trainings also served as a means of increasing communication within NSDP and building support for the NHS implementation. As a member of the NHS academic team explained, “The interventionists wanted the opportunities to bring their supervisors on board, because they felt lack of support from their supervisors. So how to use these opportunities to come together serve this additional function, although it served like a hidden function, like a hidden agenda to bring their supervisors there to build support, and that was another reason for the capacity building trainings. In some ways it wasn’t the content of the trainings, it was that opportunity to come together with the intervention people and supervisors and directors.” (Academic partner, R1) These capacity building workshops were logistically as well as strategically arranged following the booster trainings. However, not all of NSDP supervisors attended each capacity building workshop and booster training with their interventionists. Some supervisors remained unsupportive of the work related to the NHS program. An interventionist remarked, “I guess they gradually kicked in a little bit, although we had trainings together a lot. Some banned, some supported. They did not have a lot of interest in the program.” (NSDP interventionist, I4) (4) The maintenance stage: feedback, ongoing support, and sustainability Feedback on the NHS partnership and implementation was sought by interviewing NSDP managers, supervisors, and interventionists in the end of the NHS round-one implementation. Preliminary findings from these interviews as well as from the impact evaluation of the NHS program were shared with the NSDP managers, supervisors, and interventionists and lessons learned from the round-one implementation were discussed. Ways to sustain the NHS program were also discussed with the NSDP managers, supervisors, and interventionists, including possible future funding opportunities and potential inclusion in the NSDP strategic plan. The research findings and lessons learned were included in a project policy report with recommendations for how to improve the future implementation of the NHS program (http://healthystores.org).

This seemed to be very important for NSDP program managers and supervisors to support the continuation of the NHS program. As a program manager stated, “Impacts have been made are expected, knowing the completed projects. How it’s measured with our program, are we effective or just running around talking about diabetes? … I feel supervisors should learn that. Once they learned that they are more interested in doing the program knowing it really benefits people.” (NSDP

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Still, there was no unanimous support for the NHS round-two implementation at the administrative level. Some supervisors remained concerned about the NHS program was taking interventionists away from their established scope of work. As a supervisor remarked, “I heard a couple of staff saying ‘I don’t know how much the Healthy Stores program takes away from our scope of work’. … This is my question as well… it should be in the written scope of work as a part of the Special Diabetes Project.”

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A training was provided to the NSDP interventionists for the round-two implementation. Intervention materials were provided to initiate the implementation and at the NSDP request thereafter. Additionally, an orientation and training was provided specifically for NSDP managers and supervisors at the request of NSDP leadership. The purpose of this orientation training was to address the concern about pulling the NSDP interventionists from completing their regular duties that raised and remained during the NHS round-one implementation. The orientation training addressed this concern by demonstrating how the specific components of the NHS program could help meet the NSDP goals and objectives for their new grant cycle. The NHS academic team also offered suggestions on how to coordinate future work through incorporating the NHS work with the NSDP new objectives.

However, it proved to be challenging to make the NHS round-two implementation happen, due to NSDP leadership turnover and funding issues. As a supervisor commented, “In the last meeting, (the PI) has indicated that they won’t provide as much as they did in the round-one. That made me question, where would the things they provided come from? If the program doesn’t have the money to support this, do we really need to continue this program? I think that commitment we need. (The program director) did indicate the Special Diabetes Project will support the program, but he left. Will that be still there?” (NSDP manager, M9) 4.4.2 Partnership Outcomes (1) Significant adaptation of the intervention content The formative research and community workshops resulted in significant adaptation of the AHS intervention to the Navajo setting. The main intervention components (stocking of healthier alternatives in local stores, point-of-purchase interactive educational sessions, and mass media promotion) and structure (six-phased intervention) of the AHS intervention were maintained, but the content of the intervention (themes, messages, specific foods and behaviors for promotion, print materials) was modified according to formative research findings and community input (Table 4.2, Table 4.3). A NSDP program manager described the process of material revisions as, “There were exchanges of some of the posters and materials. She (a graphic designer from the academic team) gave some information and some of us gave comments, suggestions back and forth several times. It might appear minor but small changes made the program a lot more better, culturally sensitive. A lot more care, better to understand on the part of participants.” (NSDP manager,

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(2) Limited execution of the intervention components The NSDP interventionists completed the entire six-phase of the NHS program over a one-year period. However, the execution of the NHS intervention components was limited (Table 4.4). The interventionists were unable to recruit enough small stores surrounding the five supermarkets in the intervention areas, primarily because small store owners were not interested in the program and the top manager of the Red Mesa stores, which are the major chain of small stores on the Navajo Nation, was unwilling to cooperate. The actual interactive educational sessions in each store happened less frequently than planned, and declined during the later phases of the intervention. But the biggest disappointment seemed to be not getting small stores to stock healthier food options for the program. A member of the NHS academic team expressed, “We didn’t have a big intervention component in small stores, there wasn’t much changing of the food environment. In other words, there wasn’t much work by these interventionists with the small stores to get them stock the foods. … I don’t think we were successful in that respect. I think the program was delivered as essentially an education program in the stores, but not as a food environment change. So I think in future work we really need to work with these food stores to get them to stock the foods.” (Academic partner, R1) The community components of the NHS program, in particular radio announcements rarely happened. But some of the interventionists reported they had been using the NHS materials to do nutrition education in community settings, such as schools, senior centers, and worksites. However, this could create another intervention execution issue concerning potential contamination of different geographic areas of the Navajo Nation as some of the interventionists came from the NHS control areas, and/or their service areas overlapped the control areas.

(3) The extent of program sustainability The degree of NHS sustainability as a result of the implementation partnership is discussed below according to Shediac-Rizkallah & Bone’s (1998) three dimensions of sustainability: maintenance of health benefits, capacity building, and institutionalization.

The evaluation of the effectiveness of the NHS program on store customers showed that higher exposure to the NHS intervention was associated significantly improved healthy food intentions, healthy cooking methods, and healthy food getting, and significantly reduced BMI (body mass index) (for more detail see Gittelsohn et al., 2013). However, follow-up evaluations are needed to see if the improved psychological and behavioral outcomes and weight status of these customers is maintained over a longer period of time.

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