This study was done in response to 1) the recent call for evaluations of how research findings translate into large-scale projects and 2) the need for understanding the logistics of implementing such projects (12
). Our study results provide a comprehensive overview of the implementation and evaluation of the Health-e-AME Physical-e-Fit program. By using the RE-AIM framework, project staff collected valuable formative and summative information that helped with implementing the intervention and providing HDs and PACs with technical assistance. Overall, the intervention was only somewhat effective at increasing PA, and elements of the RE-AIM analysis show why it was not more successful.
We examined the public health effect of the Health-e-AME Physical-e-Fit program using the RE-AIM framework to assess the individual and organizational factors associated with a large public health project with community participation. Although we did formative research with both men and women, the intervention as designed did not reach male AME members, which means that the intervention needs to be adapted to make it more appealing to men. Other public health programs set up in churches found that recruiting the pastor as a role model and supporter of the program can increase participation (23
), and this approach may increase interest among the men in the AME churches. Additional approaches could include recruiting more men as HDs and PACs, enlisting the help of men who are leaders in the church, and offering more competitive activities such as basketball. A factor that may have limited our finding on male participation is that all of the interviewed HDs and PACs were women, and they may have been successful at mobilizing their own social network within the church (other women in their age groups), and they may have struggled with how to reach men and how to reach women in age groups other than their own. Reach among all AME churches in the state was good (303 churches, about half of all eligible churches). The effectiveness analysis also related to reach, in that we found that people who had heard of the intervention activities at their church were more likely than those who had not heard of them to engage in some type of physical activity either at the church or elsewhere.
Assessing barriers to adoption while the project was ongoing allowed program planners to modify the training and overcome the most common barriers. During the final year of the program, planners worked to overcome obstacles to getting the program started by adding training on issues such as how to deal with pastor-related problems and how to increase motivation and interest among congregants. In addition, more than one person from a church was trained so that program implementation was not dependent on one person. Our results emphasize that the program's success depended on volunteers, and future intervention planners should consider other approaches to implementing the program in churches (e.g., providing incentives for leading the program, changing the program to ease the burden on the HDs and PACs, or having a paid church member assist with the program). Theories on the capacity of a community to implement and maintain health promotion programs emphasize the need to train and motivate volunteers in order to be successful (24
To ensure the institutionalization and sustainability of the intervention, it is essential to ensure that volunteers receive adequate training, support, and recognition. Lack of training and recognition may explain some of the challenges churches experience with maintaining health promotion programs over time. Future large-scale interventions could include additional trainings for volunteers on how to overcome barriers, recognize successes, network with other volunteers, and re-energize programs to promote their continuation. Given the size and scope of this project (303 churches statewide), program organizers could not provide the additional training. Organizers of similar interventions with lay health volunteers found that incentives and a large team of church members running the program were useful ways to improve success rates (23
). The higher rates of adoption by churches enrolled during the first year than by those enrolled during the second year could simply be because the first-year churches had more time than the second-year churches to get their program started rather than because of a fundamental difference between the two sets of churches. The rates of adoption could also have affected the effectiveness analysis, since individuals who had heard of Health-e-AME at their church were more likely than those who had not heard of it to engage in some type of physical activity, at or outside church.
Given the less-than-ideal rates of organizational maintenance, we believe that additional strategies to encourage and support continuation of the intervention are needed. Some ideas for doing so are holding special training sessions for church HDs and PACs every year to deal with common barriers and developing new program activities to increase interest and excitement for the program. Other interventions in churches also struggled with maintenance and developed approaches for ensuring that the interventions continued (9
). Our intervention was large and relied on volunteers to lead the activities and to deal with barriers (e.g., pastor turnover, problems within the congregation), which caused difficulties for continued success. Since Health-e-AME is a community intervention, HDs and PACs must be able to adapt it to fit within a particular church community and prevent it from competing with other church events. Such competition could result in the less-than-ideal rates of maintenance.
Interventions that produce great environmental and social changes (e.g., create or enhance access to PA facilities) might have a better chance of succeeding than would interventions that promote only PA. This intervention included activities designed to create social and environmental changes, but they were not as successful as we had planned. Perhaps more training on ways to make environmental changes would improve maintenance of the intervention at churches. Individual participants who joined a church's PA program as soon as it was offered maintained their participation; similarly, people who join other church activities (e.g., choir, missionary groups) usually continue participating. Unfortunately, because of the large size and geographical dispersion of this intervention's participants, we were unable to assess maintenance directly through interviews with participants, a stronger method of doing so than the one we used. Future adjustments to the program should include providing activities and events of interest to more members of the church, particularly men and adults older than 65.
This study assessed factors that affect the many layers of this intervention in order to understand individual and organizational participation. The RE-AIM model allowed us to examine comprehensively the intricacies of program design, implementation, and evaluation. A recent review by Klesges et al (27
) indicated the need for designing health promotion programs with dissemination in mind. We suggest that considering RE-AIM during planning stages of a new program will result in a more complete program, one that addresses issues associated with improving the external and internal validity of translating programs from research projects into practical public health interventions. Recent research (12
) cites the need to focus on the public health effect of health promoting programs when considering issues of design and dissemination. This study contributes to the limited body of knowledge on interventions that are translatable and useful beyond a tightly controlled research setting.
This study has some limitations. Although interviewees were selected at random, the cohort may have been biased. HDs and PACs whose programs are successful may be more likely to agree to an interview than those who struggle with their programs. Some HDs and PACs may be reluctant to disclose that they were not successful with their programs for fear of repercussion from their pastor or other church leader. Related to this limitation, because this study relied on self-reported information, the possibility that interviewees gave socially desirable responses must be considered. Interviewees may have wanted to make themselves or their church look successful. Lastly, more than 250 churches had HDs or PACs trained in the Health-e-AME Physical-e-Fit program when the interviews occurred. Therefore, this group of 50 interviewees represented a relatively small sample of trained HDs and PACs. Despite these limitations, these results contribute to a growing body of knowledge about the design, implementation, and evaluation of large interventions implemented in churches to increase levels of PA.
Limited information is available about the RE-AIM framework for health promotion programs conducted in partnership with community organizations. This study provides the groundwork for future community health promotion programs as a model for intervention design, implementation, and dissemination. In addition, the results of this study contributed to the intervention being modified to address barriers to implementation and helped us to understand some reasons for the suboptimal effectiveness of the program.