Predictors of implementation in the Faith, Activity, and Nutrition dissemination and implementation study: application of the Consolidated Framework for Implementation Research (CFIR) in a statewide initiative.

Faith-based organizations, with broad reach and trust, are well-positioned to promote health. The purpose of the study was to examine 12-month implementation and its predictors in the statewide Faith, Activity, and Nutrition (FAN) dissemination and implementation (D&I) study. Churches (n = 93; 42% predominantly African American) in the [South Carolina] Conference of the United Methodist Church trained by Community Health Advisors participated in the study. Church FAN coordinators (n = 92) completed implementation surveys regarding opportunities, policies, messages, and pastor support for physical activity (PA) and healthy eating (HE) at baseline and 12 months. FAN coordinators and pastors (n = 93) completed CFIR-based measures at baseline, immediate post-training, and 12 months. Repeated measures ANOVAs tested change in PA and HE implementation composite scores; Cohen's d indicated magnitude of change. Mixed model linear regression tested whether CFIR items predicted 12-month implementation, controlling for baseline implementation. PA (d = 1.42) and HE (d = 2.05) implementation increased significantly over time. PA and HE implementation were significantly greater in predominantly African American (versus White) congregations, and HE implementation was greater in churches with <500 members. FAN coordinators' ratings of the inner setting (networks/communication, culture, tension for change, organizational rewards, readiness, and congregant needs) and implementation process (engaging opinion leaders and champions) domains were most predictive of implementation outcomes. Few pastor ratings related to implementation outcomes. This study identified constructs, guided by CFIR, that may be important for understanding PA and HE implementation in churches. Future studies will need to test them for replication. Greater changes in implementation outcomes among African American churches underscores the potential of promoting health equity through this setting.

The Faith, Activity, and Nutrition (FAN) Dissemination and Implementation Study: 24-Month Organizational Maintenance in a Countywide Initiative.

Introduction: Despite the important role that faith-based organizations can play in eliminating health disparities, few studies have focused on organizational change and maintenance of interventions in this setting, making their long-term impact unknown. This study reports 24-month maintenance of the Faith, Activity, and Nutrition (FAN) program in a southeastern county. Previously reported findings of reach, adoption, implementation, and effectiveness are also summarized. Methods: Church coordinators from 35 intervention churches (97% predominantly African American) located in a rural, medically underserved county in South Carolina were interviewed at baseline (2015), and 12- and 24-months post-training regarding implementation of physical activity (PA) and healthy eating (HE) components of the FAN program. Guided by the RE-AIM framework, organizational maintenance was defined as church coordinator-reported 24-month implementation of the four FAN components (providing opportunities, setting guidelines/policies, sharing messages, engaging pastor). Repeated measures analyses (mixed models) examined change in implementation over time. Churches were also classified as maintainers, non-sustained implementers, and low implementers for each FAN component. Statistical analyses were conducted in 2019. Results: Church coordinators reported significantly greater implementation of both PA and HE FAN components at 12 and 24 months compared to baseline (medium to large effects). The percentage of churches classified as maintainers ranged from 21 to 42 and 27 to 94% across PA and HE components, respectively. Most churches (58% for PA, 97% for HE) were maintaining at least one FAN component at 24 months. Conclusions: These promising findings position FAN well for the national implementation study now underway. Trial Registration: This study is registered at www.clinicaltrials.gov NCT02868866.

Evaluation of a comprehensive school physical activity program: Be a Champion!

BACKGROUND: Comprehensive School Physical Activity Programs (CSPAPs) are widely supported to increase physical activity (PA) in schools, but little has been reported to inform a comprehensive evaluation effort. The purpose of this report is to describe a comprehensive evaluation and monitoring strategy for CSPAP implementation. METHODS: The System for Observing Staff Promotion of Activity and Nutrition (SOSPAN), System for Observing Student Movement in Academic Routines and Transitions (SOSMART), and System for Observing Play and Leisure Activity (SOPLAY) were employed to record student and staff behaviors (2642 total scans). To assess policies, practices, and environments, a CSPAP Policies and Practices questionnaire was used, which included components of the School Health Index, the School PA Policy Assessment, the School Environment and Policies Survey, and the School Health Policies and Practices Study. Youth PA (minutes/day) was assessed using accelerometers. RESULTS: Working with school sites to ascertain the number of opportunities that are provided for PA and the amount of PA students engage in is challenging but feasible. The use of systematic observation, accelerometers, and questionnaires can provide a comprehensive representation of policies, practices, and behaviors to aid in establishing targeted PA action items. CONCLUSIONS: Developing an evaluation framework that was rigorous enough to assess the physical, social, and policy environment of a school in order to answer the overarching research questions of the study but flexible enough to be feasibly streamlined for utilization by a school implementation team proved to be challenging but possible.

Change in Children's Physical Activity: Predictors in the Transition From Elementary to Middle School.

INTRODUCTION: Interventions to promote physical activity in children should be informed by knowledge of the factors that influence physical activity behavior during critical developmental transitions. The purpose of this study is to identify, from a comprehensive, multidomain set of factors, those that are associated with change in objectively measured physical activity in children as they transition from elementary to middle school. METHODS: The study used a prospective cohort design, with children observed in fifth, sixth, and seventh grades. Growth curve analyses were used to examine associations between exposure variables measured at baseline and children's physical activity across three observations. A total of 828 children, aged 10.6 (SD=0.5) years at baseline provided physical activity data in fifth grade and at one or both follow-ups. Exposure variables assessed child characteristics, parent characteristics, home characteristics, social factors, school environment, and community characteristics. Physical activity was measured via accelerometry. Data were collected in two school districts in South Carolina in 2010-2013 and analyzed in 2017. RESULTS: Variables measured within the child, parent/home, and community domains were positively associated with children's physical activity as they transitioned from fifth to seventh grade. These included parent encouragement of physical activity, parental support for physical activity, child sports participation, parent's report of the child's physical activity level, the child's time spent outdoors, social spaces for physical activity in the community, and the number of physical activity facilities that were proximal to the child's home. CONCLUSIONS: Interventions designed to increase children's physical activity should include strategies that target multiple domains of influence.

The Faith, Activity, and Nutrition (FAN) Dissemination and Implementation Study, Phase 1: Implementation Monitoring Methods and Results.

Faith-based settings offer opportunities for reaching populations at risk for chronic conditions and are optimal settings for dissemination and implementation (D&I) research. Faith, Activity, and Nutrition (FAN) is an evidence-based program designed to promote physical activity (PA) and healthy eating (HE) through church policy, systems, and environmental change. We report implementation fidelity for Phase 1 of the FAN D&I project, a countywide effort. The group randomized study included pre- and postintervention assessments of core PA and HE components. We compared implementation in early intervention ( n = 35) versus delayed intervention (control, n = 19) churches; assessed individual church implementation; and examined the effects of level of implementation on church member outcomes. Implementation assessments were conducted with the FAN coordinator via telephone survey. Study outcomes were assessed with church members 8 to 12 months following baseline assessment via self-administered surveys. We found significantly higher levels of implementation for PA opportunities, PA and HE guidelines, PA and HE messages, and PA and HE pastor support in intervention versus control churches and showed church-level variation in PA and HE implementation. PA self-efficacy varied by level of implementation; high and low implementers did not differ in proportion of church members physically inactive, although low implementers had fewer members inactive than controls. The high level of implementation in intervention churches shows promise for broader dissemination of FAN.

Physical and Social Contexts of Physical Activity Behaviors of Fifth and Seventh Grade Youth.

BACKGROUND: The purpose of this study was to characterize the temporal, social, and physical contexts for physical activities commonly reported in a diverse cohort of 753 boys and girls from fifth to seventh grade. METHODS: Data were obtained from a multilevel longitudinal study, the Transitions and Activity Changes in Kids. The Physical Activity Choices instrument assessed previous 5-day participation in specific physical activities and their temporal, social, and physical contexts. Mixed model repeated measure analyses of variance and multinomial analyses examined sex differences and change over time. RESULTS: Fifth grade boys and girls reported participation in similar activities at similar frequencies, which declined significantly by seventh grade. One temporal pattern, playing with younger children, changed over time from "both inside/outside" to "outside" school. Boys and females reported more activities performed in class/team groups over time. Most activities took place primarily at home for all participants in both grades. CONCLUSIONS: Boys and girls reported declines in the variety and frequency of activities from fifth to seventh grade. There were sex-specific patterns in physical activities and groups; however, all participants reported home as the primary location and a shift to class/team groups over time. Schools are well-positioned to provide additional physical activity opportunities.

Evaluating and Refining the Conceptual Model Used in the Study of Health and Activity in Preschool Environments (SHAPES) Intervention.

This study investigated the utility of the Study of Health and Activity in Preschool Environments (SHAPES) conceptual model, which targeted physical activity (PA) behavior in preschool children, by examining the relationship between implementation monitoring data and child PA during the school day. We monitored implementation completeness and fidelity based on multiple elements identified in the conceptual model. Comparing high-implementing, low-implementing, and control groups revealed no association between implementation and outcomes. We performed post hoc analyses, using process data, to refine our conceptual model's depiction of an effective preschool PA-promoting environment. Results suggest that a single component of the original four-component conceptual model, providing opportunities for moderate-to-vigorous physical activity through recess for 4-year-old children in preschool settings, may be a good starting place for increasing moderate-to-vigorous physical activity. Interventions that are implemented with optimal levels of completeness and fidelity are more likely to achieve behavior change if they are based on accurate conceptual models. Examining the mechanisms through which an intervention produces its effects, as articulated in the conceptual model that guides it, is particularly important for environmentally focused interventions because they are guided by emerging frameworks. The results of this study underscore the utility of using implementation monitoring data to examine the conceptual model on which the intervention is based.

Process evaluation of a preschool physical activity intervention using web-based delivery.

BACKGROUND AND PURPOSE: Preschool/childcare settings offer a practical target for physical activity interventions. Online learning programs have the potential for greater public health reach and impact. The SHAPES-Dissemination (SHAPES-D) project adapted the original SHAPES in-person intervention for online delivery to teachers. The purpose of this paper is to describe the implementation monitoring and process evaluation for the SHAPES-D project. METHODS: Nine preschools with 26 classrooms participated. A total of 41 teachers were trained via online learning to implement the SHAPES-D program in their classrooms. The dose received, completeness, and fidelity of implementation were assessed through website metrics, teacher surveys and interviews, and classroom observations. RESULTS: Dose received was adequate (73%). Observed completeness and physical activity enjoyment fidelity were high (100%), although moderate-to-vigorous physical activity fidelity and social environment fidelity were low (25% each). Overall implementation was high (91%). DISCUSSION: Results indicate that the online method of delivery is viable for dissemination. The online delivery system provides an easy method of monitoring dose received. This may be the first structural intervention to monitor dose received through web metrics. CONCLUSION: The adaptation of an in-person intervention to an online delivery system increases the potential for dissemination of a successful program to increase physical activity in preschool settings.

Process for massage therapy practice and essential assessment.

BACKGROUND: Little evidence exists about processes in massage therapy practice. Investigating current frameworks is warranted. This qualitative study is a secondary data analysis using grounded theory to understand how massage therapy experts describe massage therapy practice. METHODS: 31 massage therapy experts were invited to a 2-day symposium to discuss best practices for the profession. Through qualitative analysis, memoing, and discussion, the data were summarized into themes. RESULTS: Three themes were identified around massage therapy practice: 1) client centered, 2) structure for practice, and 3) influencing factors. Each theme is clarified and expanded. DISCUSSION: Conceptual models were developed for research and clinical practice and a definition for massage therapy practice was identified. Challenges and limitations are discussed. CONCLUSION: The goal of providing these models is to give massage therapists tools to deliver the best possible care. The models need testing to see if they help advance the profession.

New Perspective on Factors Related to Coalition Success: Novel Findings From an Investigation of Physical Activity Coalitions Across the United States.

CONTEXT: Physical activity (PA) coalitions are a fundamental component of efforts to increase population levels of PA in the United States. Coalitions are often composed of organizational members including government agencies, for-profit corporations, and nonprofit organizations. Very little is known about PA coalitions, their organizational members, and the factors related to their success. OBJECTIVE: First, this study aimed to describe the characteristics of PA coalitions across the United States. Second, the study aimed to describe the characteristics of organizational members of PA coalitions. Third, the study aimed to investigate the association between organizational membership and coalition success. DESIGN: A cross-sectional design was employed to study individuals from a diverse sample of PA coalitions across the United States. A total of 120 individuals (86% response rate) completed the Member Involvement in Physical Activity Coalitions (MIPAC) survey. The MIPAC included 3 sections: (1) demographic items assessing descriptive characteristics of PA coalitions and their organizational members; (2) 3 subscales for assessing key organizational membership factors (Strategic Alignment, Organizational Alignment, and Providing Input); and (3) 2 subscales for assessing perceived coalition success. MAIN OUTCOME MEASURES: Descriptive statistics characterize PA coalitions and their organizational members. Univariate analyses were employed to investigate associations between key organizational membership factors and perceived coalition success. RESULTS: Statistically significant associations were observed between the key organizational membership factors (Strategic Alignment, Organizational Alignment, and Providing Input) and measures of perceived coalition success. Many PA coalitions lacked organizational members from the settings in which the coalitions strive to make change. CONCLUSIONS: Physical activity coalitions and health-based coalitions overall may be more likely to succeed when they can identify ways in which their coalition provides opportunities for strategic alignment, organizational alignment, and providing input to existing and perspective organizational members. In addition, PA coalitions may benefit from engaging more organizational members from the built environment and education sectors.

The role of pastor support in a faith-based health promotion intervention.

Pastor support has been viewed as an integral part of successful faith-based health promotion programs; however, few studies have systematically studied these relationships. This study examined associations between pastor support and program-related variables among African American churches taking part in a physical activity and dietary intervention. Results showed that some pastor support-related variables were associated with participant recruitment, retention, and implementation of study requirements but not to changes in health behavior outcomes. Much work remains in how to conceptualize and measure pastor support. A better understanding of the pastor's role may assist in developing more effective faith-based programs.

The tug-of-war: fidelity versus adaptation throughout the health promotion program life cycle.

Researchers across multiple fields have described the iterative and nonlinear phases of the translational research process from program development to dissemination. This process can be conceptualized within a "program life cycle" framework that includes overlapping and nonlinear phases: development, adoption, implementation, maintenance, sustainability or termination, and dissemination or diffusion, characterized by tensions between fidelity to the original plan and adaptation for the setting and population. In this article, we describe the life cycle (phases) for research-based health promotion programs, the key influences at each phase, and the issues related to the tug-of-war between fidelity and adaptation throughout the process using a fictionalized case study based on our previous research. This article suggests the importance of reconceptualizing intervention design, involving stakeholders, and monitoring fidelity and adaptation throughout all phases to maintain implementation fidelity and completeness. Intervention fidelity should be based on causal mechanisms to ensure effectiveness, while allowing for appropriate adaption to ensure maximum implementation and sustainability. Recommendations for future interventions include considering the determinants of implementation including contextual factors at each phase, the roles of stakeholders, and the importance of developing a rigorous, adaptive, and flexible definition of implementation fidelity and completeness.

Perceived environmental church support and physical activity among Black church members.

BACKGROUND: Churches are an appealing setting for implementing health-related behavior change programs. PURPOSE: The objective of the study was to examine the relationship between perceived environmental church support for physical activity (PA) and PA behaviors. METHOD: Black church members from South Carolina (n = 309) wore an Actigraph accelerometer prior to the initiation of an intervention. Relationships between moderate to vigorous PA (MVPA; counts ≥1,952), light PA (LPA; counts 100-1951), sedentary behavior (counts <100), and perceived environmental church support for PA (total, spoken informational, written informational, instrumental) were examined. Support × Gender interactions examined whether relationships differed by gender. RESULTS: The mean age was 54.0 ± 12.3 years and mean body mass index was 32.9 ± 7.2 kg/m(2). On average, participants engaged in 14.4 ± 13.7 minutes/day of MVPA, 289.8 ± 82.4 minutes/day of LPA, and were sedentary 548.9 ± 102.2 minutes/day. Total, spoken informational, and written informational church support were significantly related to higher levels of LPA and lower levels of sedentary behavior in men but not women. The relationship between written informational support and MVPA approached significance for men but not women. Instrumental church support was not associated with PA behaviors. CONCLUSION: The church environment may have an important influence on Black church members' PA behavior, particularly men's, and thus should be targeted in interventions.

Conceptualizing, implementing, and monitoring a structural health promotion intervention in an organizational setting.

This article presents a framework for developing and carrying out an implementation monitoring plan of a complex structural intervention in an organizational setting and describes seven steps for analyzing and reporting results for fidelity and completeness of implementation. This process is illustrated using the Environmental Interventions in Children's Homes (ENRICH) Wellness Project. ENRICH aimed to promote physical activity and healthful nutrition behaviors among children residing in children's group homes by working collaboratively with organizational staff. A comprehensive implementation monitoring plan was developed based on the particulars of the setting, context, and the program framework and used multiple data sources, criteria for evidence of implementation, and data triangulation to examine evidence for organizational implementation. Eleven of 17 organizations (65%) met the criteria for nutrition implementation whereas 9 of 17 (53%) met the criteria for physical activity implementation. Implementation data can be used descriptively, as described here, and may also be used in future outcome analyses to better understand project outcomes. The framework and evaluation approach are applicable to complex interventions in other organizational settings.

The relationship of physical activity and the built environment within the context of self-determination theory.

BACKGROUND: Evidence is emerging of the combined effects of psychosocial and environmental determinants on exercise. PURPOSE: This study aims to examine the moderating effects of convenience, facilities at places of worship, access, crime/safety, and neighborhood characteristics on the relationship between exercise and psychosocial needs satisfaction (autonomy, competence, and relatedness). METHODS: Adults from four cities enrolling in a weight loss program (N = 477; 72.1% White, BMI = 32.21 ± 7.67) completed questionnaires on current exercise levels, perceptions of the environment for exercise, and autonomy, competence, and relatedness. RESULTS: There were significant interaction effects for neighborhood characteristics with all three psychological needs satisfaction, and for convenience with competence and relatedness, such that the relationship between psychosocial needs satisfaction and exercise is stronger for participants with better perceptions of convenience and neighborhood characteristics. CONCLUSIONS: Results indicate that the relationship between exercise and autonomy, competence, and relatedness is different for low and high perceptions of convenience to places for exercise and neighborhood characteristics.

Correlates of availability and accessibility of fruits and vegetables in homes of low-income Hispanic families.

Availability and accessibility (AA) has been consistently shown across studies as the most important correlate of fruits and vegetables (FV) intake. However, there is little data on factors that influence AA of FV, especially in Hispanic families. The objective of this cross-sectional study was to examine the association between parental factors, child's preferences for FV and AA of FV in homes of low-income Hispanic families with children 5-12 years old. A convenience sample of 184 parents of low socioeconomic status recruited through public elementary schools completed a self-administered questionnaire about demographics, language spoken at home and food insecurity (FI). Parental factors and child's preferences were measured using a 16-item questionnaire, which was developed specifically for the study. AA of FV was measured using a validated nine-item index. Hierarchical multiple regression analysis indicated that language spoken at home, parental practices that promote consumption of FV, parental role modeling and perceived benefits of fast food had significant and independent associations with AA of FV at home. Intervention programs should take into consideration the language spoken at home and target at improving parental factors in order to improve AA of FV.

Associations among food insecurity, acculturation, demographic factors, and fruit and vegetable intake at home in Hispanic children.

The purpose of this cross-sectional pilot study was to examine associations between food insecurity, acculturation, demographic factors, and children's fruit and vegetable intake among a sample of Hispanic children ages 5 to 12 years. A convenience sample of 184 parents of low socioeconomic status completed one-time, self-administered questionnaires assessing demographic information, acculturation, and food insecurity in the spring of 2006. In addition, children's fruit and vegetable intake at home was measured using a validated seven-item index. Parents were recruited through local elementary schools in San Antonio, TX. Pearson and Spearman correlations were used to examine the associations between the variables. t tests were used to explore the differences in means of children's fruit and vegetable intake at home for acculturation and food insecurity levels. Statistical significance was set at P<0.05. Significant correlations were found between demographic variables, acculturation, food insecurity, and children's fruit and vegetable intake at home. The overall mean fruit and vegetable intake at home was 1.04+/-0.63 (mean+/-standard deviation) servings per day. Higher rates of acculturation and higher rates of food insecurity were associated with lower fruit and vegetable intake at home. The findings reported in this study suggest a need for culturally tailored interventions targeting Hispanic children because fruit and vegetable intake at home among Hispanic children was low, regardless of the level of acculturation or food insecurity.

Medical homes for children with special health care needs: a program evaluation.

PURPOSE: The purpose of the current study is to evaluate the effectiveness of a pilot project providing a medical home to children with special health care needs (CSHCN). This study differs from previous work in that it monitors a cohort of CSHCN one year prior to and two years after participation in a medical home intervention utilizing a quasi-experimental design. RESULTS: The groups being compared demonstrated descriptive differences in emergency room (ER) and preventive visits. Statistically significant differences in ER visits were achieved by the second intervention year. CONCLUSIONS: The current research demonstrates that a medical home can have demonstrable effect on utilization of preventive and emergency care by CSHCN. Limitations of the current research include small sample size and lack of information on acuity and quality of life.

The impact of states' small group health insurance reforms on uninsurance rates.

The impact of states' small group market reforms on uninsurance rates was examined. Reform status was quantified on five reform dimensions: Access Improvement, Premium Reduction, Premium Differential Reduction, Continuity of Coverage, and Enhancing Valued Plan Features. These reform indices were calculated based on actuarial judgment of the market impact potential of each regulation. Regression analysis showed no association between uninsurance rates and the depth of reforms on any dimension, while controlling for income, foreign-born population, black population, and employment in the smallest businesses. Possible reasons for the lack of impact are discussed.

Promotion of physical activity among high-school girls: a randomized controlled trial.

OBJECTIVES: Many adolescent girls fail to meet national guidelines for physical activity, and the prevalence of obesity is increasing among this group. Our study examined the effects of a comprehensive school-based intervention on physical activity among high-school girls. METHODS: A group-randomized controlled field trial was conducted at 24 high schools. A school-based sample of 2744 girls (48.7% African American, 46.7% White) participated in a measurement protocol when they were in eighth and then ninth grade. A comprehensive physical activity intervention was designed to change the instructional program and the school environment to increase support for physical activity among girls. RESULTS: At follow-up, 45% of girls in the intervention schools and 36% of girls in the control schools reported vigorous physical activity during an average of 1 or more 30-minute time blocks per day over a 3-day period. CONCLUSIONS: A comprehensive school-based intervention can increase regular participation in vigorous physical activity among high-school girls.