Real-World Implementation of Community-Based Research in

Navajo NationLucinda 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 ConferenceNovember 16, 2011

Field StaffCommunity Oral Health Specialists (COHS)

• Stella Begay• Helen Curley • Nicole Garcia• Tracy Goldtooth

• Rose Lee• Lolita Spencer• Cerise Watson

Field Office

• Carmen George (Field Staff Director)• Nikola Toledo (Field Data Coordinator -- & Interim COHS)• Diana Cudeii (Community Liaison)

Dental Examiners and Dental Data Collectors

• Michelle Hodge• Nicole Hodge• Nikolas Johs• Alexandria Kalinowski

• Lisa Lavorgna• Sue McIntosh• Raj Shah

With special thanks to the approximately 500 Head Start families and the teachers and staff from 52 Navajo Nation Head Start classrooms

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.

BUT

In practice, implementation requires creative, often on-the-spot, responses to

institutional and environmental constraints.

COMMUNITY-BASED RESEARCH

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

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

ProcessParticipatory Research

Conventional Research

What is the research for?

Action Understanding with perhaps action later

Who is the research for? Local people Institutional, personal, and professional interests

Whose knowledge counts?

Local people’s Scientists’

What influences the topic choice?

Local priorities Funding priorities, institutional & professional interests

Methodology chosen for?

Empowerment, mutual learning

Disciplinary conventions, “objectivity,” “truth”

So What?Participatory Conventional Research

Source: Cornwall & Jewkes, 1995, p. 1669

ProcessParticipatory Research

Conventional Research

Problem identification? Local people Researcher

Data collection? Local people Researcher, enumeratorInterpretation? Local concepts &

frameworksDisciplinary concepts and

frameworks

Analysis? Local people ResearcherPresentation of findings? Local access & utility To other academics or

fundersAction on findings? Integral to the process Separate and may not

happenWho takes action? Local people, with or

w/o external supportExternal agencies

Who owns the results? Shared ResearcherWhat is emphasized? Process Outcomes

Participatory Conventional Research

TESTING A UNIQUE SERVICE DELIVERY MODEL IN AMERICAN INDIAN HEAD START PROGRAMS

PREVENTING CARIES IN PRESCHOOLERS:

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

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

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

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

Outcomes of Interest

• Number of decayed, missing , filled surfaces (dmfs)

• Change in knowledge, attitudes, behaviors as assessed by computer-administered survey

WE SAID THERE ARE ENVIRONMENTAL AND INSTITUTIONAL CONSTRAINTS

Nikola trying to get home from COHS training

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

Stella Begay 1. Chichiltah 2. Pinedale 1 & 2 Tracy Goldtooth 1. Cameron 2. Tuba City 1 3. Shonto 1 & 2 New COHS 1. Whippoorwill 2. Pinon 1 & 2 Rose Lee 1. Steamboat 2. Greasewood 3. Dilkon 4. Nazlini Helen Curley 1. Sweetwater 2. Nenahnezad 1 & 2 Lolita Spencer 1. Carson 2. Red Lake 3. Sanostee Nicole Garcia 1. Tohatchi 2. Red Rock 1 & 2 Cerise Watson 1. Cow Springs 2. Round Rock 1 & 2

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ENGAGING THE COMMUNITY TO RESPOND TO CONSTRAINTS

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

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

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 and

cooks as cheerleaders

This research is supported by funding from the

National Institute of Dental and Craniofacial Research

agreement #1U54DE019259-01 (Judith Albino PhD, Principal

Investigator)