Real-World Implementation of Community-Based Research in Navajo Nation

1. Real-World Implementation of Community-Based Research in Navajo Nation Lucinda L. Bryant PhD, Carmen George MS, Diana Cudeii BA, Nikola Toledo MPA, Vongphone Smith BA, David Quissell PhD, Judith Albino PhD University of Colorado Denver Navajo Nation Research Conference November 16, 2011

2. Field Staff

3. The Goal The highest quality and most effective health promotion research engages the community in all aspects of the research process, from selecting the topic to designing and conducting the project to analyzing data and disseminating results.

4. BUT In practice, implementation requires creative, often on-the-spot, responses to institutional and environmental constraints.

5. Community-Based Research

6. What is Community Based Participatory Research? “Community based participatory research [CBPR] in health is a collaborative approach to research that equitably involves all partners in the research process and recognizes the unique strengths that each brings. [It] begins with a research topic of importance to the community with the aim of combining knowledge and action for social change to improve community health and eliminate health disparities.” Source: W.K. Kellogg Foundation Community Health Scholars Program

7. Some CBPR Principles • The community is the “unit of identity” • CBPR builds on the community’s strengths and resources • CBPR involves collaborative partnerships in all phases of research • The integration of knowledge and action mutually benefits all partners • The CBPR process is cyclical and iterative • Findings and knowledge gained through CBPR must be disseminated to all partners Source: Israel, Schulz, Parker & Becker, 1998

8. So What?Participatory Conventional Research Source: Cornwall & Jewkes, 1995, p. 1669

9. Participatory Conventional Research

10. PREVENTING CARIES IN PRESCHOOLERS: Testing a Unique Service Delivery Model in American Indian Head Start Programs

11. Study Design • Setting: Navajo Nation Head Start • Design: Phase 4 cluster randomized trial • Unit of analysis: Head start classroom • Intervention: fluoride varnish + parent oral health promotion education + classroom activities, delivered by Community Oral Health Specialists (COHS) • Control: usual care • Sample: 26 intervention classrooms + 26 usual care classrooms • Timing: 2 years of intervention; 3 years of data collection

12. Study Hypothesis An intensive 2-year intervention delivered by COHS administering quarterly fluoride varnish and oral health promotion for parents/caregivers and for children in Head Start classrooms (Group 1), vs. the delivery of usual oral health care by dental providers in the community to children in Head Start classrooms (Group 2), will reduce the dmfs increment in the Group 1 children when compared to the Group 2 children and show improved parent/caregiver dental knowledge, attitudes, and behaviors

13. Community Oral Health Specialists • Innovative core of the intervention • Lay community members trained to deliver the intervention activities • From Navajo communities • Familiarity with local customs, geography and issues • Navajo language literacy • Passion for the well-being of children and families

14. Intervention Activities • Fluoride varnish 4 times per year • Oral health promotion activities each year • Parent/caregiver – child kick-off event • 3 additional parent events • 4 additional classroom events for children • All study participants (26 intervention and 26 usual care classrooms) • Toothbrushes and toothpaste for family • Inspection of child’s teeth

15. Outcomes of Interest • Number of decayed, missing , filled surfaces (dmfs) • Change in knowledge, attitudes, behaviors as assessed by computer-administered survey

16. We said there are environmental and institutional constraints

17. Nikola trying to get home from COHS training

18. Constraints • Physical and built environment • Geography and climate • Roads • Navajo Nation ←miles and miles and miles→ Denver • Institutional environment • Multiple “masters” • Recruitment and hiring of study personnel • Social environment • Social and cultural acceptance

20. Engaging the community to respond to constraints

21. From the Beginning • Obtain chapter, agency and nation level of support through sponsorship and resolutions • Support by all major IHS service units and health boards • Support by Navajo Nation Head Start Program and its five agency parent councils • Acceptance of the research program by Navajo Nation Human Research Review Board

22. Recruiting Navajo-based Personnel • Field staff (success), COHS (success), dental examiners and recorders (less success) • Methods • Local newspaper - Navajo Times • Local radio stations • Posting the positions at local chapter houses and employment fairs • Posting at specific locations in all 5 agencies such as local gas stations, groceries and employment centers

23. Recruiting Participants • Field staff visiting each Head Start classroom to meet teachers and to gain information about individual classrooms • COHS = primary enrollment staff • Cooperation from local chapters • Teachers, aides, bus drivers andcooks as cheerleaders

24. This research is supported by funding from the National Institute of Dental and Craniofacial Researchagreement #1U54DE019259-01 (Judith Albino PhD, Principal Investigator)