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Sustainable community health improvement often requires the implementation of complex interventions in complex systems. Drawing from the Four Keys to Success frame (theory, implementation, support, and evaluation), this article describes how we used a formative evaluation approach to foster a learning system capable of monitoring and addressing emerging community needs within the Spreading Community Accelerators Through Learning and Evaluation (SCALE) initiative—a national capacity-building effort to support 24 community coalitions’ progress toward a Culture of Health. The formative evaluation approach resulted in critical advancements to the theory, implementation, and nature of supports provided in SCALE. These improvements enabled the SCALE evaluation team to shift from the initial focus on program implementation issues to a greater emphasis on downstream factors (community-level outcomes). The ability of formative evaluation to grapple with the emerging challenges of implementing complex interventions in complex systems makes it particularly valuable for community health improvement initiatives.

Many evaluations of programs tend to show few outcomes. One solution to this has been an increasing prominence of the movement that requires programs to implement evidence-based interventions (EBIs). But in a complex world with complex organizations and complex interventions, many challenges have arisen to the implementation of EBIs with fidelity to achieve outcomes at scale. This includes challenges to achieving outcomes in each setting. In this article, we propose the use of empowerment evaluation and one of its major approaches (Getting To Outcomes [GTO]) as a promising method to address the challenges, and GTO can help organizations achieve outcomes by leading them through a set of “accountability questions” for implementing EBIs in their particular setting. These questions can be asked at multiple levels (e.g., national, state, and local organizations) responsible for achieving outcomes. Although we illustrate the possibilities with examples from health care and public health, the potential strategie...

This study describes the process evaluation of Project SHINE, a randomized family-based health promotion intervention that integrated parenting and peer monitoring for improving sedentary behavior, physical activity, and diet in African American families. Adolescent–parent dyads (n = 89) were randomized to a 6-week behavioral, positive parenting, and peer monitoring skills intervention or a general health education comparison condition. Process evaluation included observational ratings of fidelity, attendance records, psychosocial measures, and qualitative interviews. Results indicated that the intervention was delivered with high fidelity based on facilitator adherence (>98% of content delivered) and competent use of theoretically based behavior change and positive parenting skills (100% of ratings >3 on a 1-4 scale). Although only 43% of peers attended the “bring a friend” session, overall attendance was high (4.39 ± 1.51 sessions) as was the retention rate (88%). Parents in the intervention condition reported significant improvements in communication related to adolescents’ engagement in health behaviors both on their own and with peers. These findings were supported by qualitative themes related to improvements in family communication and connectedness. This study provides an innovative example of how future family-based health promotion trials can expand their process evaluation approaches by assessing theoretically relevant positive parenting variables as part of ongoing monitoring.

While the body of evidence-based healthcare interventions grows, the ability of health systems to deliver these interventions effectively and efficiently lags behind. Quality improvement approaches, such as the model for improvement, have demonstrated some success in healthcare but their impact has been lessened by implementation challenges. To help address these challenges, we describe the empowerment evaluation approach that has been developed by programme evaluators and a method for its application (Getting To Outcomes (GTO)). We then describe how GTO can be used to implement healthcare interventions. An illustrative healthcare quality improvement example that compares the model for improvement and the GTO method for reducing hospital admissions through improved diabetes care is described. We conclude with suggestions for integrating GTO and the model for improvement.

The Families Improving Together (FIT) randomized controlled trial tests the efficacy of integrating cultural tailoring, positive parenting, and motivational strategies into a comprehensive curriculum for weight loss in African American adolescents. The overall goal of the FIT trial is to test the effects of an integrated intervention curriculum and the added effects of a tailored web-based intervention on reducing z-BMI in overweight African American adolescents.The FIT trial is a randomized group cohort design the will involve 520 African American families with an overweight adolescent between the ages of 11-16 years. The trial tests the efficacy of an 8-week face-to-face group randomized program comparing M + FWL (Motivational Plus Family Weight Loss) to a comprehensive health education program (CHE) and re-randomizes participants to either an 8-week on-line tailored intervention or control on-line program resulting in a 2 (M + FWL vs. CHE group) × 2 (on-line intervention vs. control on-line program) factorial design to test the effects of the intervention on reducing z-BMI at post-treatment and at 6-month follow-up.The interventions for this trial are based on a theoretical framework that is novel and integrates elements from cultural tailoring, Family Systems Theory, Self-Determination Theory and Social Cognitive Theory. The intervention targets positive parenting skills (parenting style, monitoring, communication); cultural values; teaching parents to increase youth motivation by encouraging youth to have input and choice (autonomy-support); and provides a framework for building skills and self-efficacy through developing weight loss action plans that target goal setting, monitoring, and positive feedback.

Background African-American adults experience the highest rates of elevated blood pressure (BP), and this disparity may be linked to socioeconomic and neighborhood-related disadvantage. Based on a bioecological stress-buffering framework, relations of poverty and neighborhood environmental perceptions with BP were assessed using multilevel regression in at-risk African-American adults. Methods This cross-sectional study used baseline data that were collected in 2008 as part of the Positive Action for Today's Health (PATH) trial (N = 409), a community-based intervention to increase walking in low-income, high-crime neighborhoods. BP and perceived neighborhood crime and satisfaction were investigated as individual-level indicators of health and neighborhood environment. Census block groups (N = 22) served as geographic proxies for neighborhoods, and poverty was obtained using 2010 U.S. Census data, to characterize the neighborhood-level socioeconomic environment. Results There were no individual-level direct associations. Significant cross-product interactions demonstrated that with higher perceived crime, high satisfaction was associated with lower systolic (γ = 3.34) and diastolic (γ = -1.37) BP, but low satisfaction was associated with higher systolic (γ = 15.12) and diastolic (γ = 7.57) BP. Neighborhood-level poverty was associated with diastolic (γ = 11.48, SE = 4.08, P = 0.008) and systolic BP (γ = 12.79, SE = 6.33, P = 0.052). Variance in BP across block groups was low (intraclass correlation coefficients = 0.002-0.014) and there were no significant random effects. Conclusions Results supported hypotheses, with greater neighborhood satisfaction linked to lower systolic and diastolic BP when perceived crime was high. Neighborhood poverty was also linked to higher systolic and diastolic BP. Prevention efforts should further investigate whether attending to issues of poverty and related neighborhood perceptions reduces high BP in at-risk African-American communities.

Background Spreading Community Accelerators for Learning and Evaluation (SCALE) was an 18 month initiative designed to help 24 community coalitions accelerate their health improvement work by a) applying improvement science methods and b) developing a peer-to-peer learning system to spread good ideas between communities. Objectives We will demonstrate how formative evaluation supported and enhanced learning in SCALE. We will share how partnerships between all stakeholders and discussions on shared values facilitated co-design of methods and joint sense-making of results. Methods We used a multi-level, mixed method formative evaluation design grounded in the principles of empowerment evaluation and improvement science. The evaluation results were fed back to other stakeholders and processed in a timely manner to inform improvements in program design and implementation. Results The support system (trainings and coaching) changed over time in response to evaluation data. The community coalitions reported significant progress on building improvement capability, though there were challenges in implementing and documenting outcomes from PDSA use. The majority of coalitions (∼88%) made formal commitments to continue working together past the end of SCALE. As would be expected in a 24-community study, there was considerable variability in overall progress. Conclusions Large and complex initiatives like SCALE demand much from community coalitions. Consistent with past research on evaluation of health initiatives (Craig et al., 2008; Parry et al., 2013), we recommend the use of formative evaluation as means to support learning while implementation is taking place as a means to increase the likelihood of reaching outcome and making progress toward health, wellness, and equity.

Introduction to the 3rd Biennial Conference of the Society for Implementation Research Collaboration: advancing efficient methodologies through team science and community partnerships

Determine whether macro- and micro-nutrient intake, energy intake, diet quality, adherence to recommended dietary intake, and psychosocial and behavioral factors are associated with household food security.Baseline data from in-person interviews and telephone-based, 24-hour dietary recall from women recruited to a diet and physical activity controlled trial.Neighborhoods encompassing 18 urban census tracts in South Carolina.Participants (n=202) were predominantly African American (87%), overweight or obese women aged 25 to 51 years with mean body mass index of 40.6±8.7.Macro- and micro-nutrient intake, energy intake, diet quality, adherence to recommended dietary intake (via multi-pass, 24-h recall); diet-related self-efficacy and social support, healthy/lowfat and emotional eating behaviors, and depressive symptoms.Women in food-secure (FS) and food insecure (FI) households were not different on health and sociodemographic characteristics. Women in FI households had lower self-efficacy and healthy/low-fat eating behaviors, and higher emotional eating and depressive symptoms compared with women in FS households. The groups did not differ on social support. Significant dietary differences were few (FSFI on protein and lean meat; FSFI on carbohydrate intake). For 29 of 35 (74%) dietary intake recommendations, less than 75% of women in both groups met each recommendation.While food security status was associated with diet-related psychosocial and behavioral factors, it was associated with few aspects of dietary intake. Dietary intake overall was poor. Participants were not meeting guidelines for a diet supportive of general health or weight loss and management, regardless of food security status.

Background: Well-designed evaluation is necessary to document the impact of farmers’ markets (FMs) on health, economic, and community outcomes. However, the complex nature of FMs poses challenges for evaluation. Objective: Our goal is to describe a participatory, multilevel framework used to evaluate a FM implemented at a federally qualified health center (FQHC) in a rural community in the Southeastern United States. Methods: An iterative, collaborative process involving three feedback loops was used to engage community stakeholders in the development, implementation, and utilization of the multilevel evaluation plan. Lessons Learned: A participatory approach helped to navigate the complexities of evaluating FMs and promoted stakeholder engagement. The evaluation became a core element of the intervention that informed continuous quality improvement (CQI). The development of strong university– community partnerships facilitated the ongoing use of results. Conclusions: The evaluation framework presented may be used to promote community engagement and rigor for evaluation of future FMs.

Community–university partnerships can lend themselves to the development of tools that encourage and promote future community health development. The electronic manual, “Building Farmacies,” describes an approach for developing capacity and sustaining a community health center–based farmers’ market that emerged through a community–university partnership. Manual development was guided by the Knowledge to Action Framework and experiences developing a multivendor, produce‐only farmers’ market at a community health center in rural South Carolina. The manual was created to illustrate an innovative solution for community health development. The manual was disseminated electronically through 25 listservs and interested individuals voluntarily completed a Web‐based survey to access the free manual. During the 6‐month dissemination period, 271 individuals downloaded the manual. Findings highlighted the value of translating community‐based participatory research into user‐friendly manuals to guide future intervention development and dissemination approaches, and demonstrate the need to include capacity building opportunities to support translation and adoption of interventions.

Objective: Determine whether macro- and micro-nutrient intake, energy intake, diet quality, adherence to recommended dietary intake, and psychosocial and behavioral factors are associated with household food security.Design: Baseline data from in-person interviews and telephone-based, 24-hour dietary recall from women recruited to a diet and physical activity controlled trial. Setting: Neighborhoods encompassing 18 urban census tracts in South Carolina.Participants: Participants (n=202) were predominantly African American (87%), overweight or obese women aged 25 to 51 years with mean body mass index of 40.6±8.7.Main Outcomes Measures: Macro- and micro-nutrient intake, energy intake, diet quality, adherence to recommended dietary intake (via multi-pass, 24-h recall); diet-related self-efficacy and social support,healthy/lowfat and emotional eating behaviors, and depressive symptoms.Results: Women in food-secure (FS) and food insecure (FI) households were not different on health and sociodemographic characteristics. Women in FI households had lower self-efficacy and healthy/low-fat eatingbehaviors, and higher emotional eating and depressive symptoms compared with women in FS households. The groups did not differ on social support. Significant dietary differences were few (FS>FI on proteinand lean meat; FSConclusions: While food security status was associated with diet-related psychosocial and behavioral factors, it was associated with few aspects of dietary intake. Dietary intake overall was poor. Participants were not meeting guidelines for a diet supportive of general health or weight loss and management, regardless of food security status Ethn Dis. 2016;26(2):139-146; doi:10.18865/ed.26.2.139