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Although the impact of capacity building was not evaluated, the interviews with NSDP managers, supervisors, and interventionists indicated that the NHS program and associated capacity building activities helped increase their knowledge, skills, and capacity to provide better prevention services for the community. For example, the NSDP interventionists consistently expressed that the NHS program provided them better ways to educate and communicate with community members about healthy lifestyle. An interventionist remarked, “The program has a better idea of what is healthier for the public, how we can work with store managers and others to promote healthy lifestyle. We can ask store managers for setting up other things, not just for the healthy stores intervention. What we’re talking about was getting senior centers, the Department of Health clients for label reading, bringing them to the stores to do it.... (The trainings) have enlightened me. I got a lot of ideas, positive ways of educating people from them (the NHS academic team).”(NSDP interventionist, I7) Some the NSDP interventionists and supervisors reported that the interventionists taught their peers about the NHS educational sessions and shared NHS materials for their work. A NSDP supervisor also remarked on a potential incorporation of the NHS concepts of promoting healthy alternatives and healthy choices, “We can transfer these concepts into schools to begin to make an impact, such as meal planning, not only healthy choices but also healthy menu planning. People here have low income. What alternatives are there? We need to explore these alternatives.” (NSDP manager, M9) Many NSDP program managers and supervisors expressed that the NHS capacity workshops, esp. the evaluation workshop helped them realize the importance of data collection and evaluation. A program manager commented, “We do a pretty good job of counting things, how many presentations we did?

But we really don’t take a step back and take a look at how we affect or change our community or anything like that. And I’m trying to help people start thinking about the services that we provide in these terms.... (The evaluation workshop) really made me to stop and think about the services we provide, and what services we’re providing are appropriate. Are they effective? We need to ask these questions.” (NSDP manager, M4) In terms of institutionalization, our data indicates that the NHS program did not become part of the NSDP routine operations in the end of the round-one implementation.

At the practitioner level, three NSDP interventionists continued to implement the NHS interactive educational components in their service areas up to 2 years, but discontinued due to leadership turnover and changes in program priorities (Personal communication with the NHS field coordinator). However, there are some indications that the NSDP interventionists continued to use some of the NHS materials and concepts to educate community members to this day. For example, some interventionists still call the field coordinator to ask for certain materials.

In summary, there were indications that some components (esp. interactive educational sessions and intervention materials) of the NHS program were sustained in the setting, and the knowledge, skills, and capacity gained from the NHS capacity building activities may serve the NSDP for a longer time.

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To our knowledge, this is one of the first studies to examine the academiccommunity partnership process of translating a nutrition intervention trial to a locally implemented community program. Our findings support the four stage partnership development process proposed by Cargo & Mercer (2008) by naturally falling into the four consecutive stages: engagement, formalization, mobilization, and maintenance.

During the engagement stage, formative research and community workshops were conducted to engage various community stakeholders, to gain support for the program, and to facilitate community ownership and sustainability of the program. The formative research and community workshops also facilitated building trust and relationships with potential community partners and the identification of NSDP as a host organization for the program. The importance of assessing the setting in which an intervention was introduced, including organizational needs, capacity and readiness, and innovationorganizational fit has been recognized by many researchers (Fixsen et al., 2005; Feldstein & Glasgow, 2008; Greenhalgh et al., 2004; Kilbource, Neumann, Pincus, Bauer, & Stall, 2007; Rogers, 2003; Stith et al., 2006). In our study, having an extensive formative research phase and a field coordinator familiar with the host setting facilitated mutual understanding of needs and capacity of partners, establishing relationships and trust, and discovering potential for collaboration that would be mutually beneficial. Adapting the intervention to fit the host setting is a critical step for successful implementation (Meyer et al., 2012a). In our study, a planned adaptation was occurred prior to implementation through community workshops. Planned adaption can resolve the tension between the need for fidelity and adaptation (Lee, Altschul, & Mowbray, 2008).

Formalization occurred when a partnership agreement was established between the academic team and NSDP to share their resources and expertise. And capacity building was a key part of the partnership agreement to improve organizational capacity.

NSDP leaderships engaged in decisions on interventionist selection, program management, training and capacity building, which is critical to build ownership and commitment (Lantz, Viruell-Fuentes, Israel, Softley, & Guzman, 2001; Teufel-Shone, Siyuja, Watahomigie, & Irwin, 2006).

The mobilization stage consisted of staff selection and training, ongoing implementation support, capacity building and buy-in. There is strong evidence in the literature for the importance of training and ongoing technical assistance (Fixsen et al., 2005; Greenhalgh et al., 2004; Kilbource et al., 2007; Stith et al., 2006), and evidence indicates that the combination of training and ongoing support can enhance the quality of implementation (Miller, Yahne, Moyers, Martinez, & Pirritano, 2004; Sholomskas et al., 2005). In our study, ongoing support for implementation was accomplished through booster trainings, regular teleconferences, and field facilitation. Three integral parts of these support strategies were the monitoring of implementation progress, identifying problems and issues, and the provision of technical assistance and feedback along with the use of process data. Studies suggest that early monitoring of implementation can identify problems, and that timely provision of assistance and feedback can lead to significant improvement in implementation (DuFrene, Noell, Gilbertson, & Duhon, 2005;

Greenwood, Tapia, Abbott, & Walton, 2003).

The importance of building organizational capacity and fostering a supportive organizational climate is well documented (Durlak & DuPre, 2008; Fixsen et al., 2005;

Greenhalgh et al., 2005; Wandersman et al., 2008). Interestingly, we found that NHS capacity building trainings also served as a mean of building support for the intervention implementation within NSDP. Capacity building workshops were logistically as well as strategically arranged next to booster trainings. However, some supervisors remained unsupportive of the work related to the NHS program.

The maintenance stage involved reflecting on the NHS implementation experiences and discussed lessons learned, sharing research results with NSDP, providing training and materials for the next round of implementation, and exploring ways to sustain the program within NSDP. In terms of Shediac-Rizkallah & Bone’s (1998) three dimensions of sustainability, our findings indicates that some components (esp.

interactive educational sessions and intervention materials) of the NHS program were sustained in the setting, and the knowledge, skills, and capacity gained from the NHS capacity building activities may potentially serve NSDP for a longer time. There is a need to evaluate the maintenance of program effects gained during the NHS round-one implementation.

Finally, our findings suggest that there were some key challenges needed to address as the academic-community partnership moved along the stages of implementation. These challenges included engaging and gaining support from important community stakeholders, buy-in at the administrative level, clarity of direction and management of program, ensuring compatibility of program management with the organizational structure, ensuring necessary structural and procedural support in place, ensuring sufficient and timely monitoring and feedback on implementation, overcoming leadership turnover, securing funding, and gaining unanimous support within the host organization. A close examination of these factors revealed that the interactions among these factors had a significant impact on the function and outcomes of the partnership implementation effort (see Chapter 5).

There are limitations to this study. This study serves as one case study understanding the process of translating an academic-derived food store-based intervention trial to a sustainable, community-operated intervention. Therefore, the generalizability of the findings to other settings is limited. Additionally, this study focused on the partnership between the host organization (NSDP) and NHS academic team, while food stores were also important partners in the NHS implementation effort.

However, given that the NSDP served as a host organization for the NHS program to deliver intervention activities and active engagement of NSDP leaders and staff throughout, this study was warranted to examine closely the partnership with NSDP alone and understand why it was crucial for program success. We examined store owners/managers’ perspectives on the program and its implementation in Chapter 6 of this dissertation.

In summary, this study has shown that the academic-community partnership for implementation of the NHS program evolved through an engagement, formalization, mobilization, and maintenance process, but there were important challenges needed to address in order to successfully move through the stages of implementation This study contributes to the growing literature of implementation science by demonstrating the process and strategies used by an academic-community partnership to implement an environmental nutrition intervention in a systematic fashion. Future efforts to implement evidence-based nutrition interventions through an academic – community collaboration in American Indian contexts should apply the principles of community-based participatory research (Chino & DeBruyn, 2006; Israel, Schulz, Parker, & Becker, 1998) to established mutual trust and respect and facilitate the implementation process.

Figure 4.1.

Conceptual framework for stages of academic-community implementation partnerships

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AHS, Apache Healthy Stores; NHS, Navajo Healthy Stores Table 4.3. Comparisons of intervention contents between the AHS and NHS programs, according to related phase

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The retail food environment plays a key role in limiting access to and availability of healthy foods in AI settings. Changing the food environment in these AI communities may be a feasible way to impact diet quality and reduce obesity and chronic disease risk.

The Navajo Healthy Stores (NHS) program was a food store-based intervention on the Navajo Nation and implemented by a collaborative partnership between Johns Hopkins Center for Human Nutrition and Navajo Special Diabetes Program (NSDP). The purpose of this study was to examine the partners’ experiences with implementing the NHS program and identify key factors that have affected the implementation partnership. A qualitative study was conducted using a combination of semi-structured interviews with 24 key stakeholders and program document review as primary sources of data. We identified four important facilitating factors and three key challenges for the implementation partnership. Facilitating factors include trust in the academic partners’ experience and commitment to sustainability, being responsive to the partner’s interests in capacity development, having a program champion, and having a dedicated and experienced field coordinator. Challenges for the partnership include fitting into staff job schedule, obtaining buy-in from critical stakeholders, and overseeing implementation.

Understanding key factors that affect the implementation partnership can help guide academic researchers and community practitioners in developing implementation partnerships and navigate more effectively the complex process of implementation.

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Obesity affects American Indian (AI) children and adults in a higher proportion than any other racial/ethnic group (Liao et al., 2003; Slattery et al., 2010). Poor diet quality is widely recognized as one of the major causes of obesity among AI (USDHHS, 2007). The retail food environment plays a key role in limiting access to and availability of healthy foods in AI settings (O’Connell et al., 2011; Odoms-Young et al., 2012; PareoTubbeh et al., 2000). Most AI reservations are rural, and have limited access to diverse food outlets (Gittelsohn & Sharma, 2009). Large supermarkets are rare on most AI reservations, and most AI are dependent on convenience or gas-station stores, which primarily stock unhealthy snack foods and rarely carry fresh produce, and offer a range of ready-to-eat foods (Gittelsohn & Sharma, 2009; Gittelsohn & Rowan, 2011). Changing the food environment in these AI communities may be a feasible way to impact diet quality and reduce obesity and chronic disease risk. Food store-based intervention trials have shown potential to improve availability and consumption of healthy foods and to reduce obesity and related chronic conditions in underserved populations (Curran et al., 2005; Escaron et al., 2013; Gittelsohn et al., 2012b; Ho et al., 2008; Rosecrans et al., 2008; Vastine et al., 2005).

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