Beginning With the End in Mind: Contextual Considerations for Scaling-Out a Community-Based Intervention

A Mixed Method Evaluation of Practitioners' Perspectives on Implementation Strategies for Healthy Eating and Active Living Policy, Systems, and Environmental Changes

CONTEXT

The National Cooperative Extension System is a leader in delivering healthy eating and active living (HEAL) policy, systems, and environmental (PSE) changes; however, these interventions are challenging, and technical assistance efforts often misalign with implementation science concepts.

OBJECTIVE

The study objective was to understand the importance of implementation strategies and tailoring needs to support Louisiana Nutrition and Community Health (NCH) practitioners' delivery of rural HEAL PSE changes.

DESIGN

An explanatory sequential mixed method study design was used, including a survey to rank the importance of implementation strategies for HEAL PSE changes and a follow-up interview. A review of available implementation strategies (practice activities/resources) for Louisiana HEAL PSE changes was also conducted.

SETTING

This study occurred within Louisiana and focused on NCH practitioners' ongoing HEAL PSE change efforts throughout the state, with emphasis on rural community settings.

PARTICIPANTS

All NCH practitioners were eligible to participate. "Practitioners" included Extension NCH administrators and agents/educators directly delivering HEAL PSE changes.

MAIN OUTCOMES

The main quantitative outcome was the ranked importance of implementation strategies to support NCH practitioners' delivery of HEAL PSE changes. For explanatory interviews, perceptions of higher and lower ranked implementation strategies and tailoring opportunities were of interest. The alignment of available activities/resources with possible implementation strategies was also assessed.

RESULTS

Highly ranked implementation strategies focused on engaging dedicated community partners and community members and starting small to ensure success, generate buy-in, and demonstrate feasibility. Opportunities for capacity building in these areas were identified. A lower ranked implementation strategy, changing organizational structures, was considered less likely to occur but possibly necessary to improve job satisfaction, retention, and return on investment. Available activities/resources overlapped with a few available implementation strategies.

CONCLUSIONS

This study identified opportunities to use implementation science concepts to improve program support for NCH practitioners delivering complex HEAL PSE changes.

Supporting teams with designing for dissemination and sustainability: the design, development, and usability of a digital interactive platform

BACKGROUND

Designing for Dissemination and Sustainability (D4DS) principles and methods can support the development of research products (interventions, tools, findings) that match well with the needs and context of the intended audience and setting. D4DS principles and methods are not well-known or used during clinical and public health research; research teams would benefit from applying D4DS. This paper presents the development of a new digital platform for research teams to learn and apply a D4DS process to their work.

METHODS

A user-centered design (UCD) approach engaged users (n = 14) and an expert panel (n = 6) in an iterative design process from discovery to prototyping and testing. We led five design sessions using Zoom and Figma software over a 5-month period. Users (71% academics; 29% practitioners) participated in at least 2 sessions. Following design sessions, feedback from users was summarized and discussed to generate design decisions. A prototype was then built and heuristically tested with 11 users who were asked to complete multiple tasks within the platform while verbalizing their decision-making using the 'think aloud' procedure. The System Usability Scale (SUS) was administered at the end of each testing session. After refinements to the platform were made, usability was reassessed with 7 of 11 same users to examine changes.

RESULTS

The interactive digital platform (the D4DS Planner) has two main components: 1) the Education Hub (e.g., searchable platform with literature, videos, websites) and 2) the Action Planner. The Action Planner includes 7 interactive steps that walk users through a set of activities to generate a downloadable D4DS action plan for their project. Participants reported that the prototype tool was moderately usable (SUS = 66) but improved following refinements (SUS = 71).

CONCLUSIONS

This is a first of its kind tool that supports research teams in learning about and explicitly applying D4DS to their work. The use of this publicly available tool may increase the adoption, impact, and sustainment of a wide range of research products. The use of UCD yielded a tool that is easy to use. This tool's future use and impact will be evaluated with a broader sample of community partners and projects and the tool will continue to be refined and improved.

Advancing implementation science in community settings: the implementation strategies applied in communities (ISAC) compilation

BACKGROUND

Implementation strategies have predominantly been operationalized and studied in clinical settings. Implementation strategies are also needed to improve evidence-based intervention (EBI) integration in community settings, but there is a lack of systematic characterization of their use, which limits generalizability of findings. The goals of this study were to determine which implementation strategies are most used to deliver primary prevention EBIs in community settings, develop a compilation and pragmatic strategy selection process with accompanying guidance tools, and understand practitioners' preferences for dissemination.

METHODS

Purposive and snowball sampling was used to recruit community setting researchers and practitioners delivering primary prevention EBIs (nutrition, physical activity, tobacco prevention) in community settings: education, social services, city planning and transportation, workplaces, recreation/sport, faith-based, and other public health organizations. Semi-structured interviews were conducted using a guide based on the reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework. Participants were asked to describe barriers experienced and strategies used to overcome them within each RE-AIM dimension. Practitioners were also asked about preferred dissemination strategies, prompted by Diffusion of Innovations theory concepts of sources (who provides information) and channels (how information is provided). A rapid deductive approach was used to analyze findings with a coding matrix aligned with the interview guide.

RESULTS

Researchers (n = 10) and practitioners (n = 8) across all targeted settings and intervention outcomes completed interviews. Interviewees shared unique implementation strategies (N = 40) which were used to overcome barriers related to multiple RE-AIM dimensions, most commonly implementation (n = 29) and adoption (n = 27). Most frequently mentioned implementation strategies were conduct pragmatic evaluation (n = 31), provide training (n = 26), change adaptable program components (n = 26), and leverage funding sources (n = 21). Webinars (n = 6) and listservs/newsletters (n = 5) were the most mentioned dissemination channels; national public health organizations (n = 13) were the most mentioned sources.

CONCLUSIONS

Results reflect commonly used implementation strategies in community settings (e.g., training, technical assistance) and add novel strategies not reflected in current taxonomies. Dissemination preferences suggest the need to involve broad-reaching public health organizations. The resultant compilation (Implementation Strategies Applied in Communities) and strategy selection process provide resources to assist researchers and practitioners in applying strategies and improving EBI delivery in community settings.

Implementing evidence-based practices in rural settings: a scoping review of theories, models, and frameworks

Background

Rural healthcare has unique characteristics that affect the dissemination and implementation of evidence-based interventions. Numerous theories, models, and frameworks have been developed to guide implementation of healthcare interventions, though not specific to rural healthcare. The present scoping review sought to identify the theories, models, and frameworks most frequently applied to rural health and propose an approach to rural health research that harnesses selected constructs from these theories, models, and frameworks. This resulting synthesis can serve as a guide to researchers, policy makers, and clinicians seeking to employ commonly used theories, models, and frameworks to rural health.

Methods

We used the Scopus abstract indexing service to identify peer-reviewed literature citing one or more of theories, models, or frameworks used in dissemination and implementation research and including the word "rural" in the Title, Abstract, or Keywords. We screened the remaining titles and abstracts to ensure articles met additional inclusion criteria. We conducted a full review of the resulting 172 articles to ensure they identified one or more discrete theory, model, or framework applied to research or quality improvement projects. We extracted the theories, models, and frameworks and categorized these as process models, determinant frameworks, classic theories, or evaluation frameworks.

Results

We retained 61 articles of which 28 used RE-AIM, 11 used Community-Based Participatory Research (CBPR) framework, eight used the Consolidated Framework for Implementation Research (CFIR), and six used the integrated-Promoting Action on Research Implementation in Health Services (iPARIHS). Additional theories, models, and frameworks were cited in three or fewer reports in the literature. The 14 theories, models, and frameworks cited in the literature were categorized as seven process models, four determinant frameworks, one evaluation framework, and one classic theory.

Conclusions

The RE-AIM framework was the most frequently cited framework in the rural health literature, followed by CBPR, CFIR, and iPARIHS. A notable advantage of RE-AIM in rural healthcare settings is the focus on reach as a specified outcome, given the challenges of engaging a geographically diffuse and often isolated population. We present a rationale for combining the strengths of these theories, models, and frameworks to guide a research agenda specific to rural healthcare research.

Systematic Review Registration

https://osf.io/fn2cd/.

Supporting Teams with Designing for Dissemination and Sustainability: the Design, Development, and Usability of a Digital Interactive Platform

Background

The use of Designing for Dissemination and Sustainability (D4DS) principles and methods can support the development of research products (interventions, tools, findings) to match well with the needs and context of the intended audience and setting. D4DS principles and methods are not well-known or used during clinical and public health research; research teams would benefit from applying D4DS. This paper presents the development of a new digital platform for teams to learn and apply a D4DS process to their work.

Methods

A user-centered design (UCD) approach engaged users (n=14) and an expert panel (n=6) in an iterative design process from discovery to prototyping and testing. We led five design sessions using Zoom and Figma software over a 5-month period. Users (71% academics; 29% practitioners) participated in at least 2 sessions. Following design sessions, feedback from users were summarized and discussed to generate design decisions. A prototype was then built and heuristically tested with 11 users who were asked to complete multiple tasks within the platform while verbalizing their decision-making using the 'think aloud' procedure. The System Usability Scale (SUS) was administered at the end of each testing session. After refinements to the platform were made, usability was reassessed with 7 of 11 same users to examine changes.

Results

The interactive digital platform (the D4DS Planner) has two main components: 1) the Education Hub (e.g., searchable platform with literature, videos, websites) and 2) the Action Planner. The Action Planner includes 7 interactive steps that walk users through a set of activities to generate a downloadable D4DS action plan for their project. Participants reported that the prototype tool was moderately usable (SUS=66) but improved following refinements (SUS=71).

Conclusions

This is a first of its kind tool that supports research teams in learning about and explicitly applying D4DS to their work. The use of this publicly available tool may increase the adoption, impact, and sustainment of a wide range of research products. The use of UCD yielded a tool that is easy to use. The future use and impact of this tool will be evaluated, and the tool will continue to be refined and improved.

Healthy eating and active living policy, systems, and environmental changes in rural Louisiana: a contextual inquiry to inform implementation strategies

BACKGROUND

Healthy eating and active living policy, systems, and environmental (PSE) changes are implemented across the United States through Cooperative Extension. However, translating multisector PSE changes to practice in community settings is challenging and there is a lack of knowledge about barriers and facilitators to PSE changes among state Extension systems using standardized frameworks. Therefore, a research-to-practice partnership effort aimed to identify Louisiana Cooperative Extension Service Family and Consumer Science (LFCS) practitioners' barriers and facilitators to implementing PSE changes in rural Louisiana communities.

METHODS

A qualitative approach using the 2022 Consolidated Framework for Implementation Research (2022 CFIR) was used. Focus group discussions were conducted at five LFCS regional trainings between February and May 2022. All LFCS practitioners with any level of experience implementing healthy eating and active living PSE changes were eligible to participate, with emphasis on understanding efforts within more rural communities. Focus group discussions were audio-recorded and transcribed verbatim. Researchers analyzed qualitative data using the constant comparison method and 2022 CFIR domains and constructs including Inner Setting (LFCS organization), Outer Setting (rural Louisiana communities), Innovation (PSE changes), and Individuals (PSE change implementation actors/partners).

RESULTS

Across the five regions, LFCS practitioners (n = 40) described more barriers (n = 210) than facilitators (n = 100); findings were often coded with multiple 2022 CFIR domains. Reported Inner Setting barriers were lack of formal or informal information sharing and lack of access to knowledge and information. Outer Setting barriers included sustaining and initiating community partnerships and local environmental or political conditions. Individual barriers included a lack of time and expertise, and Innovation barriers included the complex nature of rural PSE changes. Facilitators were mentioned at multiple levels and included community partner buy-in and practitioners' motivation to implement PSE changes.

CONCLUSIONS

Implementation strategies are needed to build on organizational strengths and to overcome multi-level barriers to PSE change implementation among LFCS practitioners. The results from the in-depth contextual inquiry used could serve as a guide for future pragmatic assessment efforts among other state Extension systems or as a model for identifying barriers and facilitators and associated implementation strategies among other public health systems in the U.S. and abroad.

Preventing Falls Among Older Adults in Primary Care: A Mixed Methods Process Evaluation Using the RE-AIM Framework

BACKGROUND AND OBJECTIVES

Falls are a leading cause of injuries and injury deaths for older adults. The Centers for Disease Control and Prevention's Stopping Elderly Accidents Deaths and Injuries (STEADI) initiative, a multifactorial approach to fall prevention, was adapted for implementation within the primary care setting of a health system in upstate New York. The purpose of this article is to: (a) report process evaluation results for this implementation using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework and (b) examine the utility of RE-AIM for assessing barriers and facilitators.

RESEARCH DESIGN AND METHODS

This evaluation used mixed methods. Qualitative evaluation involved semistructured interviews with key stakeholders and intercept interviews with health care providers and clinic staff. Quantitative methods utilized surveys with clinic staff. Process evaluation tools were developed based on the AIM dimensions of the RE-AIM framework. The study was conducted over a 2-month period, approximately 18 months postimplementation, and complements previously published results of the program's reach and effectiveness.

RESULTS

Primary barriers by RE-AIM construct included competing organizational priorities (Adoption), competing patient care demands (Implementation), and staff turnover (Maintenance). Primary facilitators included having a physician champion (Adoption), preparing and training staff (Implementation), and communicating about STEADI and recognizing accomplishments (Maintenance).

DISCUSSION AND IMPLICATIONS

Results revealed a high degree of concordance between qualitative and quantitative analyses. The framework supported assessments of various stakeholders, multiple organizational levels, and the sequence of practice change activities. Mixed methods yielded rich data to inform future implementations of STEADI-based fall prevention.

Impact of a public open-access community-based physical activity and fall prevention program on physical performance in older adults

BACKGROUND

In older adults, physical activity (PA) is important in maintaining physical performance. Data on the effectiveness of public open-access community-based programs on physical performance and fall prevention are scarce.

METHODS

Prospective observational controlled study in community centers providing an open-access public prevention program. Retirees aged ≥60 years who chose to participate in weekly PA workshops for 3 months were compared to those who chose the cognitive stimulation (CS) workshops. Collected data: handgrip strength, five times sit-to-stand, single-leg stance, Timed Up and Go tests, gait speed, short physical performance battery (SPPB) and frailty status at baseline (M0) and at 3 months (M3). The proportion of participants reporting a history of falls was assessed at baseline and using follow-up telephone interviews (F-Up).

RESULTS

Two hundred eighty-eight participants (age 73.8 years, 87% women) were included. The sit-to-stand test, single-leg stance and SPPB scores improved significantly between M0 and M3 in both groups. A greater SPPB increase was observed in the PA than in the CS group (+0.39 vs. +0.32 points, P = 0.02) after adjustment for age, sex, number of sessions attended, fall history and SPPB at baseline. During F-Up (median 22 months), the proportion of participants reporting at least one fall decreased from 55% to 31% (P = 0.01) in the PA group and from 27% to 19% (P = 0.12) in the CS group.

CONCLUSION

In a public open-access community-based program participants improved physical performance and reduced fall incidence when participating in the PA or the CS workshops. Older adults may benefit most from multifaceted prevention programs.

Dissemination in Extension: Health Specialists' Information Sources and Channels for Health Promotion Programming

In the National Cooperative Extension System (herein: Extension), state-level specialists serve as key intermediaries between research, educators, and the community members they serve. There is a need to understand information seeking and sharing practices (i.e., dissemination) among specialists to increase the adoption of evidence-based health promotion programs. Specialists (N = 94) across 47 states were identified and invited to participate in this mixed methods study. A one-way ANOVA with Bonferroni corrections was used to analyze survey data. Data collected through semi-structured interviews were analyzed using an immersion crystallization approach. Forty-seven health specialists completed the survey representing 31 eligible states (65%) and were predominately female (89%), Caucasian (70%), had a doctorate (62%), and were employed within Extension for 10.2 + 9.7 years. The information sources used most frequently were academic journals and other specialists, and most used email and online meetings to communicate. Qualitative findings support the use of other specialists as a primary source of information and indicate specialists' desire for an on-demand, bi-directional, online national repository of Extension programs. This repository would facilitate the dissemination of evidence-based programming across the system and reduce program duplication as well as information burden on county-based educators.

Using implementation strategies in community settings: an introduction to the Expert Recommendations for Implementing Change (ERIC) compilation and future directions

In this commentary, we introduce public health practitioners and researchers to implementation science through an established compilation of implementation strategies. We provide terminology and examples for community settings so public health practitioners and researchers can use implementation strategies and document efforts using standard terminology. We also discuss the need for future work to determine the extent to which these implementation strategies work and are most useful in community settings, and ultimately, how health behaviors are impacted. We intend this commentary to serve as a dissemination strategy for implementation strategies and to contribute to knowledge in the growing field of implementation science in community settings.

Addressing Health Inequities: An Exploratory Assessment of Extension Educators' Perceptions of Program Demand for Diverse Communities

Land grant universities are a key provider of community-based health promotion programs through the Cooperative Extension Service. However, Extension's current approach to addressing systemic social determinants of health is incomplete and inconsistent. The purpose of this study was to explore Extension health educators' perceptions of demand for health promotion programming targeting audiences most likely to experience health inequities. Health educators within 2 state Extension systems were invited to complete an online survey based on a capacity building model. Survey questions included rating perceptions of demand for programming for health disparate populations: low-income; Black and African American; Hispanic, Latino/a, Latinx; persons with disabilities; immigrants and refugees; and lesbian, gay, bisexual, and transgender. Analysis of variance and Bonferroni post hoc testing was used to determine differences in perceived demand between populations. Ninety-six educators completed the survey. Perceived demand for low-income population programming was significantly higher than for other populations. Perceived programming demand for immigrants and refugees and lesbian, gay, bisexual, and transgender people was significantly lower than for other populations. Individual and organizational-level factors, including racism and Extension's historical scope, likely contribute to the results. Engaging historically excluded Extension audiences requires time and resources to improve the Extension system and educator capacity for relationship building, trust building, and communication.

Effects of lifestyle interventions on weight amongst Pasifika communities: A systematic review and meta-analysis

BACKGROUND

Pasifika populations experience high incidence and prevalence of obesity and T2DM. However, no international review of lifestyle intervention studies amongst Pasifika communities exists. This study seeks to identify the effect and translatability of lifestyle strategies on weight amongst Pasifika populations.

METHODS

Lifestyle studies involving ≥90% adult Pasifika participants measuring weight change were eligible for inclusion. Database searching was carried out up to December 2021. Databases searched were MEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCOhost) and ProQuest Central. Risk of bias was assessed using RoB2 (RCTs) and the National Heart, Lung and Blood Institute (NHLBI) quality assessment tool. Meta-analysis and meta-regression used a bivariate random-effects model. Strategies were coded against pre-identified components of the newly proposed Cultural and Sustainability Assessment of Intervention (CSAI) framework.

FINDINGS

Twenty-three studies (n = 4258 participants) met inclusion and exclusion criteria. Thirty-two lifestyle strategies targeting weight loss (WL) and 7 targeting weight maintenance (WM) were extracted. Meta-analysis estimates small but significant effect of -0.26 standard deviations (95% CI -0.51 to -0.02), with RCTs demonstrating a non-significant effect of -0.23 standard deviations (95% CI -0.49 to 0.035). Culturally relevant strategies included community and peer support facilitators and team-based activities. The CSAI identified 14 out of 23 studies with low cultural competency and sustainability scores (<60%).

INTERPRETATION

Qualitative and quantitative analysis show tailored lifestyle interventions has had an estimated small but beneficial effect on WL amongst Pasifika communities. Potential for tailored interventions design to incorporate psychosocial and behavioural considerations. The CSAI has the potential for systematically identifying cultural and sustainability components of efficacy in interventions.

FUNDING

This review was funded under Western Sydney University's Postgraduate Research Scholarship.

Development and Feasibility of an Online Brief Emotion Regulation Training (BERT) Program for Emerging Adults

Mental wellness is a critical component of healthy development in emerging adulthood and serves to protect against stress and promote resilience against psychopathology. Emotion regulation is a key mechanism for effective prevention because of its role in socio-emotional competence and its transdiagnostic significance for psychopathology. In this feasibility study, a brief, time and cost-effective emotion regulation training program for emerging adults (BERT) was developed and tested using the RE-AIM framework. Importantly, building interventions within the context of an implementation framework, such as the RE-AIM framework, enhances the chances that an intervention will be able to scale out and scale up. First, the brainwriting premortem method was utilized to refine program content, conducting focus groups a priori to identify potential program failures prior to program implementation. Undergraduate students (n = 12) attended four focus groups presenting initial program content. Four clinicians were also interviewed to determine program barriers. Qualitative analyses aggregated participant feedback to identify compliments, changes, and concerns about BERT and critical feedback was immediately implemented prior to initial testing. BERT was rooted in cognitive-behavioral practices and informed by the Gross model of emotion regulation. The 5-week program was then examined in a college sample (N = 42) to evaluate implementation (low attrition, high content engagement, favorable attitudes, low incidence of technical errors, costs), reach (enrollment and completion demographics comparable to the population in which recruitment took place), and efficacy (positive change in emotion regulation pre- to post-program). Of the recruited participants, 36 remained in the study where 27 completed at least 80% of program content. Repeated-measures ANOVAs exhibited significant improvements in emotion regulation, psychological distress, and negative affectivity, suggesting promising initial efficacy. Initial data provide support for feasibility and a future randomized control trial. BERT has potential significance for promoting healthy development as its brief electronic format reduced barriers and the program development process incorporated stakeholder feedback at multiple levels to inform better implementation and dissemination.

Reaching Older People With a Digital Fall Prevention Intervention in a Swedish Municipality Context-an Observational Study

Background

There is robust evidence that falls in old age can be prevented by exercise programs that include balance training, functional exercises, and strength training. For the interventions to have a population health impact, outreach to the population of focus with suitable interventions is needed. While digital interventions are promising there is limited knowledge on the characteristics of who is reached. The aim of this study was to describe the recruitment process, estimate reach rate at the population level and to describe participants characteristics and representativeness in a digital fall prevention intervention study.

Methods

In a municipality-based observational study, reach of a digital fall prevention intervention was evaluated. The intervention included a digital exercise programme (Safe Step) and optional supportive strategies, complemented with a range of recruitment strategies to optimize reach. Recruitment during a period of 6 months was open to people 70 years or older who had experienced a fall or a decline in balance the past year. Reach was based on data from the baseline questionnaire including health and demographic characteristics of participants. Representativeness was estimated by comparing participants to a sample of older people from the Swedish National Public Health Survey.

Results

The recruitment rate was 4.7% (n = 173) in relation to the estimated population of focus (n = 3,706). Most participants signed up within the first month of the intervention (n = 131). The intervention attracted primarily women, older people with high education, individuals who used the internet or digital applications almost every day and those perceiving their balance as fair or poor. Safe step participants lived more commonly alone and had higher education and better walking ability in comparison to the Swedish National Public Health Survey.

Conclusions

With a range of recruitment strategies most participants were recruited to a digital fall intervention during the first month. The intervention attracted primarily highly educated women who frequently used the internet or smart technologies. In addition to digital fall prevention interventions, a higher diversity of intervention types (digital and non-digital) is more likely to reach a larger group of older people with different needs.

Clinical Trial Registration

ClinicalTrials.gov, NCT04161625 (Retrospectively registered), https://clinicaltrials.gov/ct2/show/NCT04161625.

Implementation Strategies to Support Built Environment Approaches in Community Settings

BACKGROUND

Built environment approaches are recommended to improve population physical activity levels. Implementation strategies are needed to improve uptake, but little is known about effective strategies to translate research to practice in community settings.

PURPOSE

Inform implementation strategies through understanding delivery agents' perceptions of (1) built environment approaches, (2) a toolkit developed to support implementation, and (3) other required implementation strategies.

METHOD

A toolkit was developed to detail the process of partnering to change the built environment and provide examples of built environment approaches (e.g., walking paths, traffic calming). Data were collected through focus groups (N = 3) with Extension Agents (n = 46) in 2020. The semi-structured focus group script was based on the Consolidated Framework for Implementation Research and the Technology Acceptance model. Rapid content analysis techniques and a deductive, grounded theory approach were used to interpret the data. Results. Focus groups generated meaning units coded into themes of perceptions of the intervention (subthemes: barriers, resources needed, and facilitators) and perceptions of the toolkit (subthemes: components to add, positive perceptions, and helpful components). The most common resources needed were coalition guidance and funding.

CONCLUSION

Agents experience barriers and facilitators to implementing built environment approaches and have specific needs for support. Based on the results, we created implementation strategies: (1) Places for Physical Activity toolkit, (2) Coalition Coaching, and (3) Mini-Grants. Future work is needed to investigate the effectiveness of these implementation strategies.

Intervention Characteristics Considered in Health Educators' Adoption Decision-Making Process

It is well known that perceptions of intervention characteristics (e.g., cost, source, evidence strength and quality) are a critical link from dissemination to implementation. What is less known is the process by which researchers understand the characteristics most valued by key intermediaries (i.e., real-world decision-makers), particularly in the federal system of Cooperative Extension. In Extension, university-based specialists are available to assist county-based agents in program selection, delivery, and evaluation. For this work, a sequential explanatory mixed-methods design was used to conduct surveys and semi-structured interviews, informed by the Diffusion of Innovations theory and Consolidated Framework for Implementation Research. Educators and specialists were recruited across 47 states to identify characteristics of health promotion interventions that facilitate the adoption decision-making process. Analysis of intervention attribute importance survey data was conducted through a one-way ANOVA with Bonferroni post hoc test to determine individual variable differences between responses. Interviews underwent a conventional content analysis. In total, 121 educators and 47 specialists from 33 states completed the survey. Eighteen educators and 10 specialists completed interviews. Educators and specialists valued components such as the community need for the intervention, and potential reach compared with other components including previous delivery settings and external funding of the intervention (p < .05). Qualitative data indicated divergence between educators and specialists; educators valued understanding the intervention cost (time and training) and specialists valued the evidence base and external funding available. Intervention developers should communicate information valued by different stakeholders to improve the adoption of evidence-based interventions.

Health Educator Participation in Virtual Micro-Credentialing Increases Physical Activity in Public Health Competencies

Background: Physical activity is an important component of leading a healthy life. Public health is one of the nine major sectors for disseminating information about physical activity and increasing the physical activity of the general public.

Purpose: Increase competency among Cooperative Extension agents (i.e., public health workers) on selecting, delivering, and evaluating physical activity programs through a theory-based online training program.

Methods: Cooperative Extension agents from two states were invited to participate via statewide listservs. Participants were invited to attend sessions, complete competency checks, and between-session assignments each week. The study was conducted using a video conferencing platform. The intervention was 9 weeks from June to July 2020 and had 130 participants. Pre- and post-program surveys included physical activity competencies and validated scales for flourishing and physical activity status. Data for competencies pre and post were analyzed using the Wilcoxon signed rank test, p < 0.01. Physical activity and flourishing pre and post were compared using t-tests, p < 0.05.

Results: Physical activity in public health competency increased significantly (p < 0.00) as did agents' personal physical activity levels (p < 0.05). Changes in flourishing were not significant (p < 0.09) but trended in the hypothesized direction.

Conclusions: The online competency-based training program significantly improved Cooperative Extension agents' knowledge of physical activity guidelines and physical activity program implementation. Future work is needed related to the scalability of the training program.

"Replanning" a Statewide Walking Program Through the Iterative Use of the Reach, Effectiveness, Adoption, Implementation, and Maintenance Framework

BACKGROUND

Interventions undergo adaptations when moving from efficacy to effectiveness trials. What happens beyond these initial steps-that is, when the "research" is over-is often unknown. The degree to which implementation quality remains high and impacts remain robust is underreported as these data are often less valued by community entities. Comprehensive and iterative evaluation is recommended to ensure robust outcomes over time.

METHODS

The reach, effectiveness, adoption, implementation, and maintenance framework was used within an assess, plan, do, evaluate, report process to determine the degree to which a statewide physical activity promotion program aligned with evidence-based core components, assess who was reached and impacts on physical activity behaviors, and make decisions for future iterations.

RESULTS

Walk Across Arkansas was adopted by a majority of delivery agents and was effective at increasing physical activity levels postprogram, but those effects were not maintained after 6 months. Future decisions included recruitment strategies to reach a more diverse population and a blueprint document to reduce program drift.

CONCLUSIONS

This article details the process of "replanning" a community-based physical activity intervention to understand public health impact and make decisions for future iterations. Pragmatic reach, effectiveness, adoption, implementation, and maintenance questions were useful throughout the assess, plan, do, evaluate, report process.

Understanding and applying the RE-AIM framework: Clarifications and resources

INTRODUCTION

Understanding, categorizing, and using implementation science theories, models, and frameworks is a complex undertaking. The issues involved are even more challenging given the large number of frameworks and that some of them evolve significantly over time. As a consequence, researchers and practitioners may be unintentionally mischaracterizing frameworks or basing actions and conclusions on outdated versions of a framework.

METHODS

This paper addresses how the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework has been described, summarizes how the model has evolved over time, and identifies and corrects several misconceptions.

RESULTS

We address 13 specific areas where misconceptions have been noted concerning the use of RE-AIM and summarize current guidance on these issues. We also discuss key changes to RE-AIM over the past 20 years, including the evolution to Pragmatic Robust Implementation and Sustainability Model, and provide resources for potential users to guide application of the framework.

CONCLUSIONS

RE-AIM and many other theories and frameworks have evolved, been misunderstood, and sometimes been misapplied. To some degree, this is inevitable, but we conclude by suggesting some actions that reviewers, framework developers, and those selecting or applying frameworks can do to prevent or alleviate these problems.

Assess, Plan, Do, Evaluate, and Report: Iterative Cycle to Remove Academic Control of a Community-Based Physical Activity Program

PURPOSE AND OBJECTIVES

Responsive methods and measures are needed to bridge research to practice and address public health issues, such as older adults' need for multicomponent physical activity. The objective of this study was to detail the longitudinal, quasi-experimental work that spans 5 years to describe outcomes across RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) dimensions of integrating a physical activity intervention for older adults into the Cooperative Extension System through the assess, plan, do, evaluate, report (APDER) cycle.

INTERVENTION APPROACH

The participant-level intervention is Lifelong Improvements through Fitness Together (LIFT), an 8-week, group dynamics-based, strength-training program with 16 in-person sessions. The implementation intervention applies the iterative APDER cycle based on feedback for each dimension of RE-AIM. Each year, the APDER cycle was used to embed data collection procedures at the instructor and participant level to reveal the next evolution of the program.

EVALUATION METHODS

Each evolution of LIFT was measured through a pretest and posttest quasi-experimental design. Data were collected on each RE-AIM dimension through participant surveys and functional fitness assessments, number and representativeness of trainees, and process evaluation.

RESULTS

Overall, LIFT was expanded to 4 states with 275 instructors, reaching 816 older adults; consistently improved functional fitness outcome measures; demonstrated strong program adherence; and was seen as feasible and enjoyable by instructors and participants. LIFT is now undergoing adaptations for virtual delivery as well as updating the exercise protocol to introduce yoga postures that target flexibility and balance.

IMPLICATIONS FOR PUBLIC HEALTH

Overall, ongoing adaptations were necessary to ensure the program continued to fit the mission, values, and resources of the delivery system. Public health implications to support the need for ongoing adaptation include embedding pragmatic measures of adaptations and RE-AIM into standard evaluation pathways and using iterative APDER cycles.

Red, Yellow, and Green Light Changes: Adaptations to Extension Health Promotion Programs

Extension professionals have high autonomy to adapt the programs they deliver. However, fidelity is typically not reported, so it is unknown what adaptations are made. It is also unknown whether agents have the necessary training to adapt programs while maintaining fidelity to the core components. The purpose of this study was to determine (1) adaptations that Extension agents and specialists are making to programs they deliver, (2) the reasons for making these adaptations, (3) timing of adaptations, and (4) Extension agents' and specialists' understanding of the adaptation process. Extension agents and specialists nationwide were invited to complete a survey which queried about adaptations based on the traffic light model, adaptome, and adaptation taxonomy. Specifically, the traffic light model assigns a color for adaptations: tailoring language or pictures (green), adding/substituting activities or session sequence (yellow), or deleting lessons and decreasing timeline or session length (red). Responses were received from 98 agents and 24 specialists. Most agents and specialists reported making green (85% and 79%, respectively), yellow (89% and 75%), and red light changes (81% and 58%). Agents were significantly more likely than specialists to change the age appropriateness of lessons or activities, respond to individual client needs, substitute activities, delete lessons or activities, decrease the length and/or number of sessions, and shorten the program timeline. Within green light changes, each of those that could increase cultural appropriateness (tailoring language, scenarios, and pictures) were reported by less than 50% of agents and specialists. Of the most common adaptations reported, the primary reasons for these decisions were difficulty retaining or engaging participants and lack of time/competing demands on time. Most adaptations were made before the program was delivered. Agents rated their confidence level in the program adaptation process as somewhat confident to confident. Dissemination and implementation strategies to improve program adaptation within Extension are needed, including participatory approaches, training on the adaptation process, bi-directional evidence-based program repositories, and organizational-level changes.

Southwest Harvest for Health: Adapting a mentored vegetable gardening intervention for cancer survivors in the southwest

Few diet and physical activity evidence-based interventions have been routinely used in community settings to achieve population health outcomes. Adapting interventions to fit the implementation context is important to achieve the desired results. Harvest for Health is a home-based vegetable gardening intervention that pairs cancer survivors with certified Master Gardeners from the Cooperative Extension Service with the ultimate goal of increasing vegetable consumption and physical activity, and improving physical functioning and health-related quality-of-life. Harvest for Health has potential for widespread dissemination since Master Gardener Programs exist throughout the United States. However, state- and population-specific adaptations may be needed to improve intervention adoption by other Master Gardener Programs. Our primary objective was to adapt this evidence-informed intervention that was initially incepted in Alabama, for the drastically different climate and growing conditions of New Mexico using a recommended adaptation framework. Our secondary objective was to develop a study protocol to support a pilot test of the adapted intervention, Southwest Harvest for Health. The adaptation phase is a critical first step towards widespread dissemination, implementation, and scale-out of an evidence-based intervention. This paper describes the adaptation process and outcomes, and the resulting protocol for the ongoing pilot study that is currently following 30 cancer survivors and their paired Extension Master Gardener mentors.

Evaluating "Take the Stairs, Wyoming!" Through the RE-AIM Framework: Challenges and Opportunities

Introduction: Health promotion delivery systems are increasingly being asked to implement policy, systems, and environmental interventions (PSEs). However, evaluating PSEs is challenging, especially in low-resource community settings. This paper describes the use of RE-AIM to evaluate a physical activity PSE delivered through University of Wyoming Extension and highlights challenges and opportunities in pragmatic, real-world program evaluation.

Methods: Extension health educators adapted a point-of-decision prompt intervention encouraging stairway use through posters, called Take the Stairs, Wyoming! Reach was assessed through estimates of daily traffic, effectiveness was assessed through opportunistic interviews, adoption was calculated as the number and proportion of sites that agreed to hang posters, implementation was calculated as the proportion of sites with a poster in place at a 2-weeks follow-up visit, and maintenance was assessed through 6-months opportunistic interviews (individual level) and proportion of sites with a poster in place (organizational level).

Results: Overall, the posters were widely adopted and most posters were implemented as intended. However, capturing reach, effectiveness, and maintenance was challenging, as health educators found the evaluation burdensome. Therefore, it was difficult to determine if the posters were effective at increasing physical activity levels.

Discussion: Suggestions are provided for capturing reach, effectiveness, and maintenance data in community settings. Future efforts are needed to create evaluation tools to pragmatically measure effectiveness of PSEs on changing behaviors, as well as to prioritize program evaluation in Extension.

Cooperative Extension Gets Moving, but How? Exploration of Extension Health Educators' Sources and Channels for Information-Seeking Practices

PURPOSE

The Cooperative Extension System (Extension) has implemented concerted efforts toward health promotion in communities across the nation by acting as an intermediary between communities and universities. Little is known about how these intermediaries communicate and learn about existing evidence-based programming. This study serves to explore this gap by learning about information sources and channels used within Extension.

DESIGN

Sequential explanatory mixed methods approach.

SETTING

National Cooperative Extension System.

PARTICIPANTS

Extension community-based health educators.

METHODS

A nationally distributed survey with follow-up semistructured interviews. Survey results were analyzed using a Kruskal-Wallis 1-way analysis of variance test paired with Bonferroni post hoc. Transcripts were analyzed by conventional content analysis.

RESULTS

One hundred twenty-one Extension educators from 33 states responded to the survey, and 18 of 20 invited participants completed the interviews. Educators' information seeking existed in 2 forms: (1) information sources for learning about programming and (2) channels by which this information is communicated. Extension educators reported contacting health specialists and other educators. Extension educators also reported using technological means of communication such as e-mail and Internet to reach information sources such as peers, specialists, academic journals, and so on.

CONCLUSION

Extension state specialists were preferred as primary sources for intervention information, and technology was acknowledged as an easy contact channel. This study identifies county-based health educators' information structures and justifies the need for future research on the role of specialists in communication efforts for educators.

Scaling Out a 4-H Healthy Meeting Initiative: Challenges in Implementation and Comprehensive Evaluation

The national Cooperative Extension System delivers a number of nutrition and physical activity interventions, but it is unknown how an intervention may translate from 1 state within the system to another. Using the reach, effectiveness, adoption, implementation, maintenance framework for program evaluation can improve intervention scale-out. Adoption is a key dimension of reach, effectiveness, adoption, implementation, maintenance: if delivery personnel do not deliver an intervention, it can have no impacts on health. Here, differences are discussed regarding adoption rates between state Extension systems when scaling out a 4-H healthy meeting intervention. This experience provides suggestions for improved scale-out of Extension programs, including state-specific adaptation and pragmatic data collection.

RE-AIM Planning and Evaluation Framework: Adapting to New Science and Practice With a 20-Year Review

The RE-AIM planning and evaluation framework was conceptualized two decades ago. As one of the most frequently applied implementation frameworks, RE-AIM has now been cited in over 2,800 publications. This paper describes the application and evolution of RE-AIM as well as lessons learned from its use. RE-AIM has been applied most often in public health and health behavior change research, but increasingly in more diverse content areas and within clinical, community, and corporate settings. We discuss challenges of using RE-AIM while encouraging a more pragmatic use of key dimensions rather than comprehensive applications of all elements. Current foci of RE-AIM include increasing the emphasis on cost and adaptations to programs and expanding the use of qualitative methods to understand "how" and "why" results came about. The framework will continue to evolve to focus on contextual and explanatory factors related to RE-AIM outcomes, package RE-AIM for use by non-researchers, and integrate RE-AIM with other pragmatic and reporting frameworks.