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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.

The “Positive Action for Today’s Health” (PATH) trial tested an environmental intervention to increase walking in underserved communities. Three matched communities were randomized to a police-patrolled walking plus social marketing, a police-patrolled walking-only, or a no-walking intervention. The 24-month intervention addressed safety and access for physical activity (PA) and utilized social marketing to enhance environmental supports for PA. African-Americans (N = 434; 62 % females; aged 51 ± 16 years) provided accelerometry and psychosocial measures at baseline and 12, 18, and 24 months. Walking attendance and trail use were obtained over 24 months. There were no significant differences across communities over 24 months for moderate-to-vigorous PA. Walking attendance in the social marketing community showed an increase from 40 to 400 walkers per month at 9 months and sustained ~200 walkers per month through 24 months. No change in attendance was observed in the walking-only community. Findings support integrating social marketing strategies to increase walking in underserved African-Americans (ClinicalTrials.gov #NCT01025726).

The current study examined the effects of a Web-based tailored parenting intervention on increasing fruit and vegetable intake in African American families.Forty-seven African American parents (mean age, 41.32 ± 7.30; 93.6% female) with an adolescent (mean age, 13.32 ± 1.46; 59.6% female) participated in a Web-based autonomy-support parenting tailored intervention session to increase both parent and youth fruit and vegetable (FV) intake. The session lasted 45-60 minutes and included three phases: a feedback phase; a Web-based information phase, and a goal-setting and action plan phase. Self-reported measures of parenting skills [based on autonomy (choice), support, and communication] and FV intake (assessed as average daily intake) were assessed at baseline and at a 1-week follow-up session.There was a significant increase in parents' self-reports of daily fruit intake from pretest to the 1-week follow-up. Parent and adolescent combined FV intake also significantly increased from pretest to 1-week follow-up. Overall, parents reported that the program was easy to navigate and that they enjoyed participating in the Web-based online program.Current findings provide preliminary support for an autonomy-support parent tailored Web-based program for improving dietary intake in African American families.

This study examined imputational modeling effects of spatial proximity and social factors of walking in African American adults.Models were compared that examined relationships between household proximity to a walking trail and social factors in determining walking status.Participants (N=133; 66% female; mean age=55 years) were recruited to a police-supported walking and social marketing intervention. Bayesian modeling was used to identify predictors of walking at 12 months.Sensitivity analysis using different imputation approaches, and spatial contextual effects, were compared. All the imputation methods showed social life and income were significant predictors of walking, however, the complete data approach was the best model indicating Age (1.04, 95% OR: 1.00, 1.08), Social Life (0.83, 95% OR: 0.69, 0.98) and Income$10,000 (0.10, 95% OR: 0.01, 0.97) were all predictors of walking.The complete data approach was the best model of predictors of walking in African Americans.

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.

Objective This study examined the interaction between parental limit setting of sedentary behaviors and health factors (weight status, physical activity [PA], fruit and vegetable [FV] intake) on standardized body mass index (zBMI) in African American adolescents. Methods Data were from 67 parent–adolescent dyads. Parental limit setting, PA and FV intake were assessed via self-report, and objective height and weight measurements were collected. Results Regressions examined the interaction between parental limit setting and BMI, PA, FV intake on adolescent zBMI. The model for parent BMI and FV intake accounted for 31% of the variance in adolescent zBMI. A significant interaction for parent BMI by limit setting showed that as parental BMI increased, higher (vs. lower) limit setting was associated with lower adolescent zBMI. Higher parent FV consumption was associated with lower adolescent zBMI. Conclusion Future interventions should integrate parent limit setting and target parent fruit and vegetable intake for obesity prevention in underserved adolescents.

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.

Introduction We examined the influence of an intervention to increase fruit and vegetable purchases at farmers' markets for recipients of food assistance, Shop N Save (SNS), on revenue trends at a farmers' market located at a federally qualified health center (FQHC) in rural South Carolina. We compared revenue trends for 20 weeks before the intervention (2011) and 20 weeks after (2012). Methods SNS provided one $5 monetary incentive per week to customers spending $5 or more in food assistance at the farmers' market. SNS was available to any farmers' market customer using Supplemental Nutrition Assistance Program (SNAP), Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and/or Senior or WIC Farmers' Market Nutrition Program (FMNP) vouchers. Sales receipts were recorded for each transaction at the farmers' market to document payment type and the cost of the purchase. All SNS participants completed a one-time enrollment survey. Results A total of 336 customers self-enrolled in SNS from June through October 2012. Most SNS participants were female, African American, and patients at the FQHC. In total, the use of all forms of food assistance (SNAP, WIC, and FMNP) at the farmers' market increased significantly after the intervention (from 10% before, to 25% after, P = .003). Senior FMNP vouchers and SNAP usage increased the most. Conclusion Interventions that provide incentives to recipients of food assistance programs at farmers' markets are a viable strategy for increasing food assistance usage and revenue.

This study demonstrates how a multi-theoretical, multilevel process evaluation was used to assess implementation of the Families Improving Together (FIT) for weight loss intervention. FIT is a randomized controlled trial evaluating a culturally tailored, motivational plus family-based program on weight loss in African American adolescents and their parents. Social Cognitive, Self Determination, Family Systems theories and cultural tailoring principles guided the conceptualization of essential elements across individual/family, facilitator, and group levels. Data collection included an observational rating tool, attendance records, and a validated psychosocial measure. Results Attendance records (0 = absent, 1 = present, criteria = ≥70%) indicated that 71.5% of families attended each session. The survey (1 = false, 6 = true, criteria = ≥4.5) indicated that participants perceived a positive group climate (M = 5.16, SD = 0.69). A trained evaluator reported that facilitator dose delivered (0 = no, 1 = yes, criteria = ≥75%) was high (99.6%), and fidelity (1 = none to 4 = all, criteria = ≥3) was adequate at facilitator (M = 3.63, SD = 0.41) and group levels (M = 3.35, SD = 0.49). Five cultural topics were raised by participants related to eating (n = 3) and physical activity (n = 2) behaviors and were integrated as part of the final curriculum. Discussion Results identify areas for program improvement related to delivery of multi-theoretical and cultural tailoring elements. Findings may inform future strategies for implementing effective weight loss programs for ethnic minority families.

The analysis of walking behavior in a physical activity intervention is considered. A Bayesian latent structure modeling approach is proposed whereby the ability and willingness of participants is modeled via latent effects. The dropout process is jointly modeled via a linked survival model. Computational issues are addressed via posterior sampling and a simulated evaluation of the longitudinal model’s ability to recover latent structure and predictor effects is considered. We evaluate the effect of a variety of socio-psychological and spatial neighborhood predictors on the propensity to walk and the estimation of latent ability and willingness in the full study.

Identifying potential mechanisms connecting farmers’ market interventions with health, economic, and community outcomes could inform strategies for addressing health disparities. The present study used social network theory to guide the in-depth examination of naturally occurring social interactions at a farmers’ market located at a federally qualified health center located in a rural, low-income community. Trained observers recorded 61 observation logs at the market over 18 weeks. Thematic analysis revealed a range of actors and nonhuman facilitators instrumental to the farmers’ market context. These actors connected with one another for communication and relationship development, economic and financial exchange, education, resource sharing, community ownership of the farmers’ market, and conflict resolution. These interactions provided opportunities for social networks to develop among attendees, which may have facilitated the acquisition of social supports related to improved health, economic and community outcomes. Results provide insight into the role social networks may play in mediating the relationship between a farmers’ market intervention and individual benefits. Findings also contribute to defining the typology of social networks, which may further disentangle the complex relationships between social networks and health outcomes. Future research should identify strategies for purposefully targeting social networks as a way to reduce diet-related health disparities.

Currently 41% of African American adolescents in the United States between the ages of 12 and 19 years are overweight or obese (Ogden, Carroll, Kit, & Flegal, 2012). Research has shown that adolescent obesity tracks into adulthood (Kvaavik, Tell, & Klepp, 2003; Power, Lake, & Cole, 1997), making adolescence an important developmental period for effective health promotion interventions. Previous positive associations between youth sedentary behavior (SB; e.g., screen time, sitting) and weight status (Epstein et al., 2008; Gortmaker et al., 1996; Laurson et al., 2008; Robinson, 1999, 2001) have made decreasing SB a recommended strategy for reducing pediatric obesity (Davis et al., 2007). Still, recent national estimates show a high proportion of ethnic minorities are not meeting recommendations to limit screen time to

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

Background. The current study examined parental factors related to risk of adolescent obesity within the context of a family systems framework.Methods. Seventy predominantly African American, low-income caregiver-adolescent dyads participated in the study. Validated measures of parental perceived child risk for development of type 2 diabetes mellitus, parental limit setting for sedentary behavior, and parental nurturance were evaluated as predictors of adolescent body mass index.Results. In this cross-sectional study, multiple linear regression demonstrated that parents of adolescents with higher zBMI reported worrying more about their child's risk of developing type 2 diabetes mellitus. Parent limit setting was also a significant predictor of adolescent zBMI. Contrary to expectations, higher levels of nurturance were associated with higher adolescent zBMI. Post hoc analyses revealed a trend towards a significant interaction between nurturance and limit setting, such that high levels of both parental nurturance and limit setting were associated with lower adolescent zBMI.Conclusions. Current findings suggest the importance of authoritative parenting and monitoring of adolescent health behaviors in the treatment of obesity.

Objectives. Evaluating programs targeting physical activity may help to reduce disparate rates of obesity among African Americans. We report formative process evaluation methods and implementation dose, fidelity, and reach in the Positive Action for Today’s Health trial. Methods: We applied evaluation methods based on an ecological framework in 2 community-based police-patrolled walking programs targeting access and safety in underserved African American communities. One program also targeted social connectedness and motivation to walk using a social marketing approach. Process data were systematically collected from baseline to 12 months. Results: Adequate implementation dose was achieved, with fidelity achieved but less stable in both programs. Monthly walkers increased to 424 in the walking-plus-social marketing program, indicating expanding program reach, in contrast to no increase in the walking-only program. Increased reach was correlated with peer-led Pride Strides (r = .92; P Conclusions: Formative process evaluation demonstrated that the walking programs were effectively implemented and that social marketing increased walking and perceived social connectedness in African American communities.