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 Community 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

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. Process Participatory Research Conventional Research What is the research for? ActionUnderstanding with perhaps action later Who is the research for?Local peopleInstitutional, personal, and professional interests Whose knowledge counts? Local people’sScientists’ What influences the topic choice? Local prioritiesFunding 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

9. Process Participatory Research Conventional Research Problem identification?Local peopleResearcher Data collection?Local peopleResearcher, enumerator Interpretation?Local concepts & frameworks Disciplinary concepts and frameworks Analysis?Local peopleResearcher Presentation of findings?Local access & utilityTo other academics or funders Action on findings?Integral to the processSeparate and may not happen Who takes action?Local people, with or w/o external support External agencies Who owns the results?SharedResearcher What is emphasized?ProcessOutcomes Participatory Conventional Research

10. TESTING A UNIQUE SERVICE DELIVERY MODEL IN AMERICAN INDIAN HEAD START PROGRAMS PREVENTING CARIES IN PRESCHOOLERS:

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 and cooks as cheerleaders

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