The StrongWomen-Healthy Hearts program in Pennsylvania: RE-AIM analysis

Implementation of an Evidence-Based, Tai Ji Quan Fall Prevention Program in Rural West Virginia Churches: A RE-AIM Evaluation

This study implemented a 16-week Tai Ji Quan: Moving for Better Balance® intervention for older adults in churches in hard-to-reach, medically underserved, rural communities, and evaluated the process using the RE-AIM Framework. Community-dwelling adults, aged 55 years, or older, were eligible. Data (N = 237) were collected at baseline, 16 weeks, and 32 weeks on falls efficacy, depression, physical/mental health-related quality of life, aerobic activity, gait speed, mobility, balance, and leg strength. Generalized/linear mixed models determined if outcomes improved. Eighteen churches sponsored 16 classes. Church adoption was 94%, instructor adoption was 86%, reach was 90%, and fidelity was good/fair. All outcomes improved except physical health-related quality of life and gait speed. Thirty-six percent of participants, 28% of churches, and 37% of instructors continued Tai Ji Quan: Moving for Better Balance at 32 weeks. Compared with two prior RE-AIM evaluations, adoption and reach rates, improvements in outcomes, and satisfaction were comparable; attendance, program completion, and continuation rates were lower.

Evaluating the Application of the RE-AIM Planning and Evaluation Framework: An Updated Systematic Review and Exploration of Pragmatic Application

Background

RE-AIM is one of the most widely applied frameworks to plan and evaluate the implementation of public health and health behavior change interventions. The objective of this review is to provide an updated synthesis of use of the RE-AIM (Reach Effectiveness Adoption Implementation and Maintenance) planning and evaluation framework and explore pragmatic use (i.e., partial application of the framework) and how this is reported.

Methods

Systematic review. MEDLINE (R) and PsycINFO were searched, via the Ovid interface, between January 2011 and December 2017. Studies that applied RE-AIM as a planning and/or evaluation framework were included.

Results

One hundred fifty-seven articles met inclusion criteria. One hundred forty-nine reported using RE-AIM for evaluation, three for planning and five for planning and evaluation. Reach was the most frequently reported dimension (92.9%), followed by implementation (90.3%), adoption (89.7%), effectiveness (84.5%), and maintenance (77.4%). One hundred forty-seven/one hundred fifty-seven articles originated from high-income economy countries. Within a sub-set analysis (10% of included articles), 9/15 articles evaluated all dimensions. Of the 6/15 articles that did not evaluate all dimensions, five provided no justification for pragmatic application.

Conclusions

RE-AIM has gained increased use in recent years and there is evidence that it is being applied pragmatically. However, the rationale for pragmatic use is often not reported.

Systematic Review Registration

PROSPERO (CRD42017054616).

Development and Implementation of the How to Talk to Your Doctor HANDbook Health Literacy Program in Rural Counties

Background:

Improvements in health literacy are unlikely without intervention in community settings. However, interventions appropriate for delivery in these settings are lacking, limiting reach to rural adults who are disproportionately affected by low health literacy and poor health outcomes. The How to Talk to Your Doctor (HTTTYD) HANDbook Program was developed through a research-practice partnership to educate rural residents to effectively advocate and participate in their own health care.

Brief Description of Activity:

We describe development of the HTTTYD HANDbook Program delivered through the Cooperative Extension Service to educate adults who are eligible for Medicaid and have low health literacy. HTTTYD HANDbook implementation is described using the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework (and specifically the reach, adoption, implementation, and maintenance dimensions).

Implementation:

The HTTTYD HANDbook was developed using health literacy best practices with user-centered design, and it was field tested with community members with varying levels of health literacy. Reach, adoption, implementation, and maintenance of the HTTTYD HANDbook were assessed by tracking distribution of HTTTYD HANDbook Program materials, return submission of evaluation and tracking instruments, adherence to program and data collection/submission protocols, and program continuation.

Results:

Overall reach into the population was 6 per 10,000; about 25% were Medicaid recipients and 28.2% had low health literacy. Most participants were age 65 years or older. Of the 72 counties with program access, 52.7% requested HTTTYD HANDbook Program materials; 31% adopted the program, but only 30% of these counties adhered to program implementation and data collection protocols. Reach and adoption were higher among rural counties, and rural counties were more likely than nonrural counties to maintain the HTTTYD HANDbook Program.

Lessons Learned:

The HTTTYD HANDbook Program addresses barriers to engagement in patient-provider communication for rural, low-income community members. Programs can be implemented in community settings through established local organizations, such as county extension offices, to increase access for rural adults. Implementation barriers included staff turnover and transportation of program materials. Online facilitator training availability had little impact on adherence to program protocols. Organizational context and established procedures for program delivery and evaluation should be considered in adoption decisions and integrated into implementation protocols. [HLRP: Health Literacy Research and Practice. 2019;3(3):e205–e215.]

Plain Language Summary:

The How to Talk to Your Doctor HANDbook Program was created with people from the community to help patients prepare for doctor visits. The How to Talk to Your Doctor HANDbook Program helps patients to overcome barriers to talking to their doctor so that they can better understand how to get healthy and stay healthy.

An integrated community health worker intervention in rural Nepal: a type 2 hybrid effectiveness-implementation study protocol

Background

Evidence-based medicines, technologies, and protocols exist to prevent many of the annual 300,000 maternal, 2.7 million neonatal, and 9 million child deaths, but they are not being effectively implemented and utilized in rural areas. Nepal, one of South Asia’s poorest countries with over 80% of its population living in rural areas, exemplifies this challenge. Community health workers are an important cadre in low-income countries where human resources for health and health care infrastructure are limited. As local women, they are uniquely positioned to understand and successfully navigate barriers to health care access. Recent case studies of large community health worker programs have highlighted the importance of training, both initial and ongoing, and accountability through structured management, salaries, and ongoing monitoring and evaluation. A gap in the evidence regarding whether such community health worker systems can change health outcomes, as well as be sustainably adopted at scale, remains. In this study, we plan to evaluate a community health worker system delivering an evidence-based integrated reproductive, maternal, newborn, and child health intervention as it is scaled up in rural Nepal.

Methods

We will conduct a type 2 hybrid effectiveness-implementation study to test both the effect of an integrated reproductive, maternal, newborn, and child health intervention and the implementation process via a professional community health worker system. The intervention integrates five evidence-based approaches: (1) home-based antenatal care and post-natal care counseling and care coordination; (2) continuous surveillance of all reproductive age women, pregnancies, and children under age 2 years via a mobile application; (3) Community-Based Integrated Management of Newborn and Childhood Illness; (4) group antenatal and postnatal care; and 5) the Balanced Counseling Strategy to post-partum contraception. We will evaluate effectiveness using a pre-post quasi-experimental design with stepped implementation and implementation using the RE-AIM framework.

Discussion

This is the first hybrid effectiveness-implementation study of an integrated reproductive, maternal, newborn, and child health intervention in rural Nepal that we are aware of. As Nepal takes steps towards achieving the Sustainable Development Goals, the data from this three-year study will be useful in the detailed planning of a professionalized community health worker cadre delivering evidence-based reproductive, maternal, newborn, and child health interventions to the country’s rural population.

Trial registration

ClinicalTrials.gov Identifier: NCT03371186, registered 04 December 2017, retrospectively registered.

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0741-x) contains supplementary material, which is available to authorized users.

Long-Term Body Weight Maintenance among StrongWomen-Healthy Hearts Program Participants

Background. The repeated loss and regain of body weight, referred to as weight cycling, may be associated with negative health complications. Given today's obesity epidemic and related interventions to address obesity, it is increasingly important to understand contexts and factors associated with weight loss maintenance. This study examined BMI among individuals who had previously participated in a 12-week, evidence-based, nationally disseminated nutrition and physical activity program designed for overweight and obese middle-aged and older women. Methods. Data were collected using follow-up surveys. Complete height and weight data were available for baseline, 12-week program completion (post-program) and follow-up (approximately 3 years later) for 154 women (response rate = 27.5%; BMI characteristics did not differ between responders and nonresponders). Results. Mean BMI decreased significantly from baseline to post-program (−0.5, P < 0.001) and post-program to follow-up (−0.7, P < 0.001). Seventy-five percent of survey respondents maintained or decreased BMI post-program to follow-up. Self-efficacy and social support for healthy eating behaviors (but not physical activity) were associated with BMI maintenance or additional weight loss. Conclusions. These findings support the durability of weight loss following participation in a relatively short-term intervention.

Adoption of a Tai Chi Intervention, Tai Ji Quan: Moving for Better Balance, for Fall Prevention by Rural Faith-Based Organizations, 2013-2014

BACKGROUND

Translating evidence-based, community-delivered, fall-prevention exercise programs into new settings is a public health priority.

COMMUNITY CONTEXT

Older adults (aged ≥65 y) are at high risk for falls. We conducted a community engagement project in West Virginia to evaluate the adoption of a tai chi exercise program, Tai Ji Quan: Moving for Better Balance, by rural faith-based organizations (FBOs) and exercise instructors by recruiting 20 FBOs and 20 or more exercise instructors and by obtaining input from key stakeholders (representatives of FBOs, community representatives, exercise instructors) regarding potential barriers and facilitators to program adoption.

METHODS

We used both multistage, purposeful random sampling and snowball sampling to recruit FBOs and exercise instructors in 7 West Virginia counties. Two forums were held with stakeholders to identify barriers and facilitators to program adoption. We calculated separate adoption rates for organizations and exercise instructors.

OUTCOME

It took up to 3 months to recruit each FBO with an adoption rate of 94%. We made 289 telephone calls, sent 193 emails and 215 letters, distributed brochures and flyers to 69 FBOs, held 118 meetings, and made 20 trips over a period of 31 days (8,933 miles traveled). Nineteen of 22 trained exercise instructors started classes, an instructor adoption rate of 86%. Key issues regarding adoption were the age requirement for participants, trust, education, and competing priorities.

INTERPRETATION

Although we had recruitment challenges, our adoption rates were similar to or higher than those reported in other studies, and the objectives of the community engagement project were met. Clustering the FBOs and having them located closer geographically to our location may have reduced our resource use, and using a recruitment coordinator from the local community may have enabled us to gain the trust of congregants and clergy support.

Interventions to Improve HPV Vaccine Uptake: A Systematic Review

CONTEXT

The human papillomavirus (HPV) vaccine is a safe, effective cancer prevention method that is underutilized in the United States. Despite increased understanding of barriers to vaccination, rates remain low. Globally, developed and developing nations have achieved high rates of vaccination.

OBJECTIVE

Identification of effective strategies is necessary to optimize uptake of the HPV vaccine. We systematically reviewed the literature for national and international interventions that have successfully increased HPV vaccine uptake.

DATA SOURCES

We used a standardized protocol to search for articles published between January 1, 2006, and April 30, 2015, in 3 electronic databases: PubMed, Scopus, and Embase.

STUDY SELECTION

We identified interventions designed to increase HPV vaccine uptake among adolescents and young adults aged 11 to 26 years. All study designs were acceptable. Only articles that included postintervention vaccination rates were included.

DATA EXTRACTION

Two authors independently reviewed each article for data extraction and quality assessment. Interventions were classified according to the Community Preventive Service Task Force guide.

RESULTS

Results were reported according to the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. Fifty-one articles met eligibility criteria: 2 informational interventions, 18 behavioral interventions, and 31 environmental interventions. Factors associated with HPV vaccine uptake were increased vaccine availability, decreased financial barriers, and interventions targeting both providers and patients.

LIMITATIONS

Lack of consistent RE-AIM metric reporting, limiting our ability to assess intervention validity and quality.

CONCLUSIONS

Population-based vaccination strategies that increased vaccine availability reached the greatest number of adolescents and were most successful in achieving high rates of vaccination.

Using a Mixed-Methods RE-AIM Framework to Evaluate Community Health Programs for Older Latinas

OBJECTIVE

This study used the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework to evaluate a promotora-led community health program designed for Latinas ages 50 and older that sought to improve physical activity, nutrition, and stress management.

METHOD

A mixed-methods evaluation approach was administered at participant and organizational levels with a focus on the efficacy, adoption, implementation, and maintenance components of the RE-AIM theoretical model.

RESULTS

The program was shown to be effective at improving participants' eating behaviors, increasing their physical activity levels, and lowering their depressive symptoms. Promotoras felt motivated and sufficiently prepared to deliver the program. Some implementation challenges were reported. More child care opportunities and an increased focus on mental well-being were suggested.

DISCUSSION

The promotora delivery model has promise for program sustainability with both promotoras and participants alike expressing interest in leading future programs.

Strong Hearts, healthy communities: a rural community-based cardiovascular disease prevention program

BACKGROUND

Cardiovascular disease is the leading cause of death in the United States and places substantial burden on the health care system. Rural populations, especially women, have considerably higher rates of cardiovascular disease, influenced by poverty, environmental factors, access to health care, and social and cultural attitudes and norms.

METHODS/DESIGN

This community-based study will be a two-arm randomized controlled efficacy trial comparing a multi-level, community program (Strong Hearts, Healthy Communities) with a minimal intervention control program (Strong Hearts, Healthy Women). Strong Hearts, Healthy Communities was developed by integrating content from three evidence-based programs and was informed by extensive formative research (e.g. community assessments, focus groups, and key informant interviews). Classes will meet twice weekly for one hour for 24 weeks and focus on individual-level skill building and behavior change; social and civic engagement are also core programmatic elements. Strong Hearts, Healthy Women will meet monthly for hour-long sessions over the 24 weeks covering similar content in a general, condensed format. Overweight, sedentary women 40 years of age and older from rural, medically underserved communities (12 in Montana and 4 in New York) will be recruited; sites, pair-matched based on rurality, will be randomized to full or minimal intervention. Data will be collected at baseline, midpoint, intervention completion, and six-month, one-year, and eighteen months post-intervention. The primary outcome is change in body weight; secondary outcomes include physiologic, anthropometric, behavioral, and psychosocial variables. In the full intervention, engagement of participants' friends and family members in partnered activities and community events is an intervention target, hypothesizing that there will be a reciprocal influence of physical activity and diet behavior between participants and their social network. Family members and/or friends will be invited to complete baseline and follow-up questionnaires about their health behaviors and environment, height and weight, and attitudes and beliefs.

DISCUSSION

Strong Hearts, Healthy Communities aims to reduce cardiovascular disease morbidity and mortality, improve quality of life, and reduce cardiovascular disease-related health care burden in underserved rural communities. If successful, the long-term goal is for the program to be nationally disseminated, providing a feasible model to reduce cardiovascular disease in rural settings.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02499731 Registered on July 1, 2015.

National Dissemination of StrongWomen-Healthy Hearts: A Community-Based Program to Reduce Risk of Cardiovascular Disease Among Midlife and Older Women

OBJECTIVES

We describe the national dissemination of an evidence-based community cardiovascular disease prevention program for midlife and older women using the RE-AIM (reach effectiveness adoption implementation maintenance) framework and share key lessons learned during translation.

METHODS

In a 2010 to 2014 collaboration between the StrongWomen program and the National Extension Association of Family and Consumer Sciences, we assessed reach, adoption, implementation, and maintenance using survey methods, and we assessed effectiveness using a pretest-posttest within-participants design, with weight change as the primary outcome.

RESULTS

Overall reach into the population was 15 per 10,000. Of 85 trained leaders, 41 (48%) adopted the program. During the 12-week intervention, weight decreased by 0.5 kilograms, fruit and vegetable intake increased by 2.1 servings per day, and physical activity increased by 1238 metabolic equivalent (MET)-minutes per week (all P < .001). Average fidelity score was 4.7 (out of possible 5). Eleven of 41 adopting leaders (27%) maintained the program.

CONCLUSIONS

The StrongWomen-Healthy Hearts program can be implemented with high fidelity in a variety of settings while remaining effective. These data provide direction for program modification to improve impact as dissemination continues.