Using document analysis methods and implementation science frameworks to conduct a process evaluation of the community asthma program on the Navajo Nation

Background: Asthma affects approximately 8.2% of United States school-aged children, with a significantly higher prevalence among socioeconomically disadvantaged minority children. Among Diné (Navajo) children living on the Navajo Nation, asthma rates exceed 20%. The community asthma program (CAP) was developed in partnership with the Navajo Nation following a year-long community engagement process. CAP is a 7-year, multicomponent, evidence-based intervention designed to improve asthma management within Indian Health Service facilities and Diné K-12 schools. Purpose: This study evaluates CAP’s implementation processes and outcomes using document analysis, guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) and Consolidated Framework for Implementation Research (CFIR) frameworks. We describe our data sources, coding methods, and their contributions to understanding implementation, as well as discuss strengths, limitations, and implications for process evaluation. Methods: CAP research documents were collected from the 2017 community engagement period through the intervention’s conclusion in 2023. When COVID-19 limited access to implementation settings, additional data sources, including email correspondence and meeting minutes, were analyzed using document analysis to examine activities, experiences, and attitudes related to CAP implementation. Results: Multiple data sources, including RE-AIM forms, staff interviews, and research team documents, identified key process indicators and explanatory factors. While these sources provided valuable context, system- and provider-level fidelity indicators are needed to fully assess intervention reach and quality. Conclusions Findings underscore the importance of collecting process data throughout implementation and leveraging diverse data sources to capture the local implementation context comprehensively. Clinical Trial Information: The Clinical Trials Registration # NCT03377647.