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«UNDERSTANDING THE PROCESS AND KEY FACTORS OF COMMUNITY IMPLEMENTATION OF A FOOD STORE-BASED NUTRITION INTERVENTION ON THE NAVAJO NATION by Muge Qi, ...»

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The Navajo Healthy Stores (NHS) program was a store-based intervention on the Navajo Nation developed through extensive formative research and a community engagement process, based on a previous intervention trial (Curran et al., 2005; Vastine et al., 2005). NHS was implemented by a collaborative partnership between Johns Hopkins Center for Human Nutrition and 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. NSDP provided personnel and resources to carry out NHS intervention activities, and the university provided intervention materials, giveaways, trainings, technical assistance, and program evaluation. 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 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 (Gittelsohn et al., 2013).

The purpose of this study was to examine the experiences of the academic team and NSDP staff members with the NHS program and identify key factors that have affected the implementation partnership. Specifically, we conducted a qualitative study to understand (1) how and what factors have facilitated the partnership effort to implement and sustain the program, and 2) how and what factors have hindered the partnership effort to implement and sustain the program.

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The Navajo Nation encompasses 24,078 square miles in northern Arizona, New Mexico, and southern Utah, and is the largest Indian Reservation in the US (NDOH, 2004). Most of the population lives in rural isolated homesteads of several related households surround by dry land. A few of the towns on the reservation have large grocery stores but the majority of them have a trading post or convenience store. Thus, the NHS program planned to utilize the available environmental resources by conducting interventions in grocery stores, trading posts, and convenience stores.

5.3.2 Participants and Procedures Participants for this study were the members of the NHS academic team and NSDP, who were either decision makers or involved in the implementation of the NHS program. They included the NHS principal investigator (PI), the NHS field coordinator, NSDP program managers, supervisors, and interventionists. A total of 24 individuals were interviewed by the researcher in a private office at their workplaces. Signed consent was obtained from all participants. A semi-structured interview guide was used during the interviews. Topics covered included: program initiation, intervention adaptation, implementation, sustainability, program facilitators, barriers, and impacts.

There was no audio-taping of interviews with local stakeholders because of participants’ preferences to remain completely anonymous, and because of time constraints to obtain the Navajo Nation Human Research Review Board (NNHRRB) approval for audio-recording at the time this study was conducted. The researcher wrote done interview responses, and made every effort to capture actual phrases and sentences used by the participants. The duration of interviews ranged from 30 minutes to 2 hours, but most of the interviews lasted about 1 hour. The interviews took place from March 25 to May 15, 2009. This study was approved by both the Johns Hopkins University Institutional Review Board (IRB) and the Navajo Nation Human Research Review Board (NNHRRB).

Program documents were reviewed to reveal the complexity of partnership development and implementation process and to understand the experiences and perceptions of study participants in the program context. These documents included program meeting and teleconference 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.

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Data were analyzed thematically, using the template approach (Crabtree & Miller, 1999; King, 2004). With guidance from the research questions and the interview guide, the researcher constructed a coding template through careful reading and rereading of the interview responses. These preliminary codes were revised multiple times by the researcher working back and forth between the data and the coding template. The accuracy and clarity of the coding template was checked twice with a research assistant who had a qualitative data analysis background by independently coding four set of interview responses each time. Some adjustments were made to the codding on the basis of their discussions as well as a detailed rereading of the full set of interview responses to produce the final version of the analytical template. Themes that were of direct relevance to the study questions was presented below.

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Findings that describe factors that facilitated the academic - community implementation partnership are presented first, followed by a description of challenges or barriers that hindered the partnership process.





5.4.1 Facilitating Factors (1) Trust in the academic partners’ experience and commitment to sustainability Experiences of the academic partners with other tribes helped to develop a trusting relationship with the Navajo Nation and the host organization. The principal investigator (PI) of the project had nearly 20 years of working experience with American Indian communities and had successfully conducted store-based interventions in multiple settings. A program manager recalled, “Johns Hopkins experiences with other tribes were very helpful to convince the Navajo Nation to participate. … He (PI) covered the Apache Healthy Stores program. He mentioned the programs in Marshall Island, tribes from Canada, and also a couple of other 6 to 7 programs in the South or Midwest. I remember specifically Marshall Islands’ Spam diet observations and changes in behaviors, modification of behaviors that was the selling point for me.” (NSDP manager,

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Furthermore, the partnership was facilitated by the academic partners’ commitment to program sustainability and long term collaboration. A supervisor remarked on the academic partners’ effort to ensure successful implementation, “I’ve had meetings with them. They’re always trying to figure out how to improve the program. … I don’t know if they did it themselves, but they sort of knew what’s going on in the field. They sort of have people to tell them. But they did share some experiences from other tribes. I guess you just learn as it goes.... All and all, they’re trying to correct them when we’re running into problems. Overall we’re able to learn, overcome problems.” (NSDP supervisor, M1) As the goal of the collaborative partnership was to establish a self-sustained healthy stores program, the academic partners committed to providing continuous training to the host organization beyond the project funding period. As an academic partner stated, “I’ll go out again as soon as I get another grant. So advantages of my getting a grant, even it’s unrelated to this work, is that it means if I get another grant work with Navajo, it means I’ll keep going out there, I can keep supporting the activities and efforts, and that’s what I’d like to do.” (Academic partner, R1) (2) Being responsive to the partner’s interests in capacity development An important facilitating factor for the implementation partnership was addressing specific needs of the host organization beyond program implementation.

During the planning stage of the project, the leadership of the host organization explicitly expressed their interests in evaluating program activities and improving organizational capacity in collaboration with the academic partners. As an academic partner explained, “(They’re) for the possibility of providing some evaluation, and both of them seeing from Indian Health Services is that there’s going be a real big demand, and still is a big demand for evaluation work, and to evaluate their program and so forth … and part of the set up was to provide capacity building activities. And I think they were excited about that possibility to have that happened.” (Academic

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Five capacity building workshops were provided throughout implementation by the academic partners as requested by the host organization. A program manager (M7) commented on the impact of these trainings on their program, “Johns Hopkins University strengthened our nutrition goals by education, by training, by assisting how to evaluate our activities”. The academic partner explained the importance of being responsive to the needs for capacity development to the partnership, “I think all those trainings and capacity building that’s something that even though you may be look back in your original proposal was there, in my mind I don’t know if I really thought it was going to be as important or central as it actually was. In some ways when you think about the work of the project, that was more the work of the project than the implementation of the program in some ways. That was as important that those things happened as much as the program itself was implemented.” (Academic partner, R1)

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Another important facilitating factor for the partnership was the presence of a program champion, who was motivated to develop an evidence-based project through the academic – community partnership. In the early stages of the project, the senior nutritionist at the central administration played an important role in garnering support for the project within the host organization and promoting the program to other partners. As he described his role as, “I think the first task was to sell the concept to the staff; next, to formally understand the university and the program. My role was coordinating between the university and our office, disseminating information on all materials, instruments to be used, scheduling activities, and expanding the program to other partners, i.e., small stores. Some activities that’s necessary to get the project done.” (NSDP

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According to an academic partner (R1), he was “operationally supportive in a sense that he had a lot of enthusiasm, wanted to get things going” and “the one who really spearheaded, made the effort to make the collaboration work.” When the implementation began, he inspired and led intervention staff to implement the program, as well as reassured they were doing a good job and felt supported. An intervention staff (I1) remarked, “(he) was all for it. He was our supervisor at that time. He wanted to let us go out there to do the stuff.” However, he left the host organization for a new position in the middle of implementation and his responsibilities were assigned to another manager subsequently. An academic partner remarked on the importance of his role, “He went around to the stores. He would go out with the interventionists, nutritionists, made sure they deliver the program and he was really supportive.

And they loved it. That was first four or five or six months or whatever. And then he left and things changed. And then (the field coordinator) had to really step in and provide a lot of that support. So I think program champions are really important.” (Academic partner, R1) (4) Having a dedicated and experienced field coordinator The partnership was also greatly facilitated by hiring a local field coordinator, who was familiar with the local culture and practices, spoke Navajo, and had prior working experiences with both the academic partners and the host organization on other research projects. An academic partner explained the importance of having the field coordinator, “It’s always difficult to make things happen if you’re not there and if you’re not able to speak the language. And I think those demonstrate some big challenges regardless. So I mean I think there may be some sort of traditional kind of relationships that still cause some issues. But that’s why it is so important to have someone like (the field coordinator), who is Navajo speaking and who is the member of the tribe. And who’s there able to put in time, energy and effort to manage these relationships.” (Academic partner, R1) While the field coordinator initially served as a liaison between the university and the host organization, gradually she played a more active role in implementation and supporting intervention staff. As she described her role, “I helped to move the process along, like coordinating phases, made sure they got supplies and materials go to next phases, and helped to share information among interventionists. They called me (and said) ‘I can’t work because I’m out of posters, flyers, incentives’. I made sure to have the incentives for them to do the intervention, made sure (the program director and manager) got information. I emailed them a lot to update intervention progress, informed (the PI) everyday problem issues, and eliminated adverse events. I resolved it immediately so it won’t become a big problem.” (Academic partner, R2)

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As the healthy stores program was implemented by existing staff (primarily nutritionists) of the host organization, it was challenging to fit the intervention activities in their job schedules. As an intervention staff described, “We’re told to do the healthy stores intervention on a weekly basis. We had to do our job what we scheduled to do. I had to balance what’s the best time to do the intervention. I actually had to do a lot of time management just to fit it in my daily schedule.”(NSDP interventionist, I10) The time element concerned both field supervisors and the academic partners. On one hand, supervisors expressed their concern about taking away intervention staff from their established scope of work. A program manager remarked, “The concerns were that we’re pulling our nutritionists from completing their stated goals and objectives with our contract with the Indian Health Service...



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