Dimensions of sustainability for a health communication intervention in African American churches: a multi-methods study

Barriers and Facilitators to 24-Month Maintenance of the Faith, Activity, and Nutrition Program in the U.S

Little is known about the barriers and facilitators to organizational maintenance of faith-based health promotion programs. This study used qualitative data (collected from 2016-2019) from pastors (n = 81) and program coordinators (n = 103) to identify barriers and facilitators to 24-month maintenance of a faith-based physical activity (PA) and healthy eating (HE) intervention in South Carolina. Barriers differed for PA versus HE: resistance to change impeded HE while church characteristics tended to impede PA. Similar themes emerged for PA and HE facilitators: healthy opportunities, church communication, and consistency. Future research should build upon this study to tailor faith-based health promotion programs for long-term sustainability.

Community-Based Culturally Tailored Education Programs for Black Communities with Cardiovascular Disease, Diabetes, Hypertension, and Stroke: Systematic Review Findings

BACKGROUND

Community-based culturally tailored education (CBCTE) programs for chronic diseases may reduce health disparities; however, a synthesis across chronic diseases is lacking. We explored (1) the characteristics and outcomes of CBCTE programs and (2) which strategies for culturally appropriate interventions have been used in CBCTE programs, and how they have been implemented.

METHODS

A systematic review was conducted by searching three databases to identify empirical full-text literature on CBCTE programs for Black communities with cardiovascular disease, hypertension, diabetes, or stroke. Studies were screened in duplicate, then data regarding study characteristics, participants, intervention, and outcomes were extracted and analyzed. Cultural tailoring strategies within programs were categorized using Kreuter and colleagues' framework.

RESULTS

Of the 74 studies, most were conducted in the USA (97%) and delivered in one site (53%; e.g., church/home). CBCTE programs targeted diabetes (65%), hypertension (30%), diabetes and hypertension (1%), cardiovascular disease (3%), and stroke (1%). Reported program benefits included physiological, medication-related, physical activity, and literacy. Cultural tailoring strategies included peripheral (targeted Black communities), constituent-involving (e.g., community informed), evidential (e.g., integrated community resources), linguistic (e.g., delivered in community's dialect/accent), and sociocultural (e.g., integrated community members' religious practices).

CONCLUSIONS

CBCTE programs may have beneficial outcomes, but a small sample size limited several. The strategies identified can be adopted by programs seeking to culturally tailor. Future interventions should clearly describe community members' roles/involvement and deliver programs in multiple locations to broaden reach.

TRIAL REGISTRATION

PROSPERO CRD42021245772.

Evaluating Disparities in Pathways to Breast Reconstruction

BACKGROUND

 Rates of postmastectomy breast reconstruction have been shown to vary by racial, ethnic, and socioeconomic factors. In this study, we evaluated disparities across pathways toward breast reconstruction.

METHODS

 All women who underwent mastectomy for breast cancer at a single institution from 2017 to 2018 were reviewed. Rates of discussions about reconstruction with breast surgeons, plastic surgery referrals, plastic surgery consultations, and ultimate decisions to pursue reconstruction were compared by race/ethnicity.

RESULTS

 A total of 218 patients were included, with the racial/ethnic demographic of 56% white, 28% Black, 1% American Indian/Native Alaskan, 4% Asian, and 4% Hispanic/Latina. The overall incidence of postmastectomy breast reconstruction was 48%, which varied by race (white: 58% vs. Black: 34%; p < 0.001). Plastic surgery was discussed by the breast surgeon with 68% of patients, and referrals were made in 62% of patients. While older age (p < 0.001) and nonprivate insurance (p < 0.05) were associated with lower rates of plastic surgery discussion and referral, it did not vary by race/ethnicity. The need for an interpreter was associated with lower rates of discussion (p < 0.05). After multivariate adjustment, a lower reconstruction rate was associated with the Black race (odds ratio [OR] = 0.33; p = 0.014) and body mass index (BMI) ≥ 35 (OR = 0.14; p < 0.001). Elevated BMI did not disproportionately lower breast reconstruction rates in Black versus white women (p = 0.27).

CONCLUSION

 Despite statistically equivalent rates of plastic surgery discussions and referrals, black women had lower breast reconstruction rates versus white women. Lower rates of breast reconstruction in Black women likely represent an amalgamation of barriers to care; further exploration within our community is warranted to better understand the racial disparity observed.

Can improvement in delivery of smoking cessation care be sustained in psychiatry inpatient settings through a system change intervention? An analysis of statewide administrative health data

OBJECTIVE

This study evaluated maintenance of improved delivery of smoking cessation assistance in adult acute psychiatry inpatient units 3 years post statewide implementation of a system change intervention through analysis of a statewide administrative health dataset.

METHOD

Rates of documenting smoking status and providing a brief smoking cessation intervention (the Smoking Cessation Clinical Pathway) in all eligible Queensland public adult acute psychiatry inpatient units (N = 57) during the implementation phase (October 2015-September 2017) of a system change intervention were compared to the maintenance phase (October 2017-October 2020) using interrupted time series analysis.

RESULTS

Across implementation and maintenance phases, the percentage of discharges from psychiatry inpatient units that had a smoking status recorded remained high with the statewide average exceeding 90% (implementation phase 93.2%, 95% confidence interval = [92.4, 93.9]; and maintenance phase 94.6%, 95% confidence interval = [94.0, 95.2]). The percentage of discharges statewide with a completed Pathway stabilised during the maintenance phase (change in slope -3.7%, 95% confidence interval = [-5.2, -2.3]; change in level 0.4%, 95% confidence interval = [-7.0, 7.9]).

CONCLUSION

An evidence-based smoking cessation intervention implemented with a system change intervention resulted in sustained improvement in addressing smoking in adult inpatient psychiatry units up to 3 years post implementation.

The role of organizational capacity in intervention efficacy in a church-based cancer education program: A configurational analysis

It is well-established in the field of implementation science that the context in which an intervention is delivered can play a crucial role in how well it is implemented. However, less is known about how organizational context or capacity relates to efficacy outcomes, particularly with health promotion interventions delivered outside of healthcare settings. The present study examined whether organizational capacity indicators were linked to key efficacy outcomes in an evidence-based cancer control intervention delivered in 13 African American churches in Maryland. Outcomes included increases in colorectal cancer knowledge and self-report colonoscopy screening behavior from baseline to follow-up. We used Coincidence Analysis to identify features of organizational capacity that uniquely distinguished churches with varying levels of cancer knowledge and screening. Indicators of organizational capacity (e.g., congregation size, prior health promotion experience) were from an existing measure of church organizational capacity for health promotion. A single solution pathway accounted for greater increases in colorectal cancer knowledge over 12 months, a combination of two conditions: conducting 3 or more health promotion activities in the prior 2 years together with not receiving any technical assistance from outside partners in the prior 2 years. A single condition accounted for greater increases in colonoscopy screening over 24 months: churches that had conducted health promotion activities in 1-4 different topical areas in the prior 2 years. Findings highlight aspects of organizational capacity (e.g., prior experience in health promotion) that may facilitate intervention efficacy and can help practitioners identify organizational settings most promising for intervention impact.

Examining Community Engagement Research Strategies Used in Flint, Michigan: The Church Challenge

BACKGROUND

The ways in which researchers may need to adapt traditional community-based participatory research engagement strategies during ongoing community trauma are understudied. We describe our efforts to engage the Flint, Michigan community in community-based participatory research in the aftermath of the Flint Water Crisis.

OBJECTIVES

This manuscript describes 1) recruitment strategies selected before the Flint Water Crisis, 2) engagement lessons learned in the context of the Flint Water Crisis, and 3) barriers and facilitators encountered while engaging African American churches.

METHODS

Researchers collaborated with community partners to engage and recruit a traumatized Flint community into the Church Challenge, a multilevel intervention to reduce chronic disease burden.

LESSONS LEARNED

Recruitment and engagement strategies must be flexible, innovative, and may require nontraditional methods.

CONCLUSIONS

Flexibility and adaptability are crucial for engaging with a traumatized community. Community-based participatory research work in traumatized communities must acknowledge and respond to community trauma to be successful.

Racial/Ethnic Differences in Provider-Engaged Religious Belief Discussions with Older Adults at the End of Life

The purpose of this study was to determine racial/ethnic differences in provider-engaged religious belief discussion with older adults in the final month of life. Data were derived from the combined 2012 to 2020 National Health and Aging Trends Study. Chi-square tests were used for bivariate analysis, and a binary logistic regression model was used to test the association between race/ethnicity and provider-engaged religious belief discussions at the end of life. After controlling for other explanatory factors during the analysis, results showed that providers were less likely to have religious belief discussions with Black and Hispanic older adults compared to Whites. The results of this study point to a significant gap in knowledge among healthcare providers whose diversity training may not be inclusive of religious/spiritual cultural humility. Implications for research, policy, and practice are provided.

M.I.C.A.H. Project HEAL: Sustainability of a Faith-Based Community Health Advisor Training Program in Urban Underserved Communities in the USA

Faith-based organizations (FBOs) can play an important role in improving health outcomes. Lay community health advisors (CHAs) are integral to these efforts. This paper assesses the sustainability of a CHA training program for congregants in African-American and Latino FBOs and subsequent implementation of educational workshops. The program is unique in that a health care chaplain in an academic medical center was central to the program's development and implementation. Forty-eight CHAs in 11 FBOs were trained to teach workshops on cardiovascular health, mental health, diabetes, and smoking cessation. Two thousand four hundred and forty-four participants attended 70 workshops. This program has the potential to be a model to educate individuals and to address health inequities in underserved communities. Health care chaplains in other medical centers may use this as a model for enhancing community engagement and education.

Sustainability of Donor-Funded Health-Related Programs Beyond the Funding Lifecycle in Africa: A Systematic Review

This study aimed to determine if implemented donor-funded health related-programs in Africa were sustained beyond the funding lifecycle and determine their facilitators and impeders. A systematic review was conducted after the documentation of a study protocol. A database search was done across three databases namely Google Scholar, PubMed, and Medline between January 27 and February 15, 2022. All peer-reviewed articles on sustainability of health interventions in Africa published between 2015 and 2021 that provided one or more context-relevant definitions of sustainability were included. Publications with no use of quantitative or qualitative methods and studies with no information on project evaluation after initial implementation were excluded. Screening of titles and abstracts was done, and the full texts of all relevant articles were retrieved. The risk of bias in systematic reviews (ROBIS) tool was used to assess the risk of bias in the systematic review. Overall, 4,876 articles were retrieved, and only nine articles were eligible for inclusion in the review following the removal of duplicates. Overall, sustainability was described in only three of the five regions in Africa. Donor-funded projects were sustained beyond the funding lifecycle in seven (77.8%) studies. Facilitators of sustainability in Africa included community ownership of the project through the engagement of community stakeholders in the design and implementation of such projects, use of locally available resources, sound infrastructure, and the constitution of interdisciplinary team to facilitate capacity building. Impeders to the sustainability of donor-funded projects included weak health systems exemplified in poor documentation and integration of records, lack of financial leadership, shortage of resources, political interference, poor feedback mechanism, and weak donor-community interactions. From the ROBIS tool, a low risk of bias existed in the studies included in the review. Although the included studies appropriately considered the review’s research question, seven studies had a low risk of bias in the domains one to three, and two studies had high risk of bias in domain four. To derive maximum benefits from donor-funded health interventions, sustainability of such projects is key. During program planning phase, context-based facilitators of sustainability should be promoted, while impeders are immediately addressed.

The Faith, Activity, and Nutrition (FAN) dissemination and implementation study: changes in and maintenance of organizational practices over 24 months in a statewide initiative

BACKGROUND

Few studies have examined the impact of ecological health promotion interventions on organizational practices over time, especially in faith-based settings. This statewide dissemination and implementation study examined change in organizational practices and their predictors across a 24-month period, as well as maintenance of change.

METHODS

Using a pre-post quasi-experimental design, church coordinators from 92 United Methodist Churches in South Carolina (42% predominantly African American congregations) completed surveys at baseline, and immediate, 12-, and 24-months post-training regarding physical activity (PA) and healthy eating (HE) organizational practices consistent with the Faith, Activity, and Nutrition (FAN) program (opportunities, policies, pastor support, messages) and possible predictors. The study was guided by the RE-AIM framework and the Consolidated Framework for Implementation Research (CFIR). Mixed model repeated measures analyses examined change in organizational practices over time. Regression models examined CFIR predictors of 24-month PA and HE organizational practices, controlling for baseline practices. Churches were also classified as maintainers (implemented at 12 and 24 months), non-sustained implementers (implemented at 12 but not 24 months), delayed implementers (implemented at 24 but not 12 months), and low implementers (implemented at neither 12 nor 24 months) for each FAN component.

RESULTS

PA and HE organizational practices increased over time (p < .0001). CFIR domains (and constructs within) of intervention characteristics (adaptability, relative advantage, cost/time), inner setting (relative priority, organizational rewards, readiness, congregant needs), characteristics of the implementer (self-efficacy, perceived benefits), and implementation process (engaging opinion leaders, engaging champions) were important predictors of 24-month PA and HE organizational practices. Over half of churches implementing PA policies, PA messages, HE policies, and HE opportunities at 12 months were maintainers at 24 months, and one-third were maintainers for PA opportunities, HE messages, and PA and HE pastor support. Furthermore, 16% of 12-month non-implementers were delayed implementers at 24 months for PA policies and 31% were delayed implementers for HE policies.

CONCLUSIONS

This study makes important contributions to the faith-based health promotion literature by including a large sample of churches, testing an ecological intervention approach, and assessing organizational practices over a 24-month period. Study findings can guide technical assistance and program adaptations over time.

TRIAL REGISTRATION

This study was registered in clinicaltrials.gov NCT02868866 on August 16, 2016.

Evaluation of organizational capacity in the implementation of a church-based cancer education program

Implementation evaluations have increasingly taken into account how features of local context help determine implementation outcomes. The purpose of this study was to determine which contextual features of organizational capacity led directly to the RE-AIM Framework implementation outcomes of intervention reach and number of days taken to implement, in an implementation trial of a series of cancer education workshops conducted across 13 African American churches in Maryland. We used a configurational approach with Coincidence Analysis to identify specific features of organizational capacity that uniquely distinguished churches with implementation success from those that were less successful. Aspects of organizational capacity (e.g., congregation size, staffing/volunteers, health ministry experience) were drawn from an existing measure of church organizational capacity for health promotion. Solution pathways leading to higher intervention reach included: having a health ministry in place for 1-4 years; or having fewer than 100 members; or mid-size churches that had conducted health promotion activities in 1-4 different topics in the past 2 years. Solution pathways to implementing the intervention in fewer number of days included: having conducted 1-2 health promotion activities in the past 2 years; or having 1-5 part-time staff and a pastor without additional outside employment; or churches with a doctorally prepared pastor and a weekly attendance of 101-249 members. Study findings can inform future theory, research, and practice in implementation of evidence-based health promotion interventions delivered in faith-based and other limited-resource community settings. Findings support the important role of organizational capacity in implementation outcomes in these settings.

Exploring the Readiness of African-American Churches to Engage in a Community-Engaged Blood Pressure Reduction Research Study: Lessons Learned from the Church Challenge

Introduction

The Transtheoretical Model (TTM) has been used to assess individual readiness for health behavior change. We describe our use of the TTM to assess organizational readiness of African-American churches to participate in the Church Challenge (CC) in Flint, Michigan; the processes of change that moved churches toward readiness for change; and lessons learned.

Methods

The CC was a faith-based, multilevel intervention to reduce chronic disease risk. A community-based participatory approach was used to engage and recruit churches. We used the TTM to capture church readiness for change and track church progress through the five stages.

Results

We engaged with 70 churches: 35 remained in Stage 1 (precontemplation), 10 remained in Stage 2 (contemplation), 3 remained in Stage 3 (preparation), 5 made it to Stage 4 (action), and 17 finished within Stage 5 (maintenance). Churches engaged in several processes of change as they moved through the various stages of change.

Lessons Learned

Utilizing processes of change, establishing rapport, and having previous participants share success stories helped move churches from stage-to-stage. However, certain barriers prevented progression, such as burnout/trauma from the Flint Water Crisis and scheduling conflicts.

Discussion

Faith-based organizational readiness greatly impacted participation in the CC. Researchers should utilize established social capital, build rapport, and remain flexible when working with African-American churches.

Conclusion

Although traditionally used at the individual level, the TTM works well at the organizational level to assess and monitor church readiness to participate in community-engaged research and health programming to improve health in an African-American faith community.

Cluster-randomized trial comparing organizationally tailored versus standard approach for integrating an evidence-based cancer control intervention into African American churches

The field of implementation science has devoted increasing attention to optimizing the fit of evidence-based interventions to the organizational settings in which they are delivered. Institutionalization of health promotion into routine organizational operations is one way to achieve this. However, less is known about how to maximize fit and achieve institutionalization, particularly in settings outside of the healthcare system. This paper reports on findings from a parallel cluster-randomized trial that compared an organizationally tailored with a standard (core components only) approach for institutionalizing ("integrating") an evidence-based cancer control intervention into African American churches. Churches randomized to the organizationally tailored condition identified three or more implementation strategies from a menu of 20, with an implementation time frame for each. The primary study outcome was assessed through the Faith-Based Organization Health Integration Inventory, a measure of institutionalization of health promotion activities in church settings, completed by pastors at baseline and 12-month follow-up. Seventeen churches were randomized and 14 were analyzed as 3 did not implement the study protocol. Though the percent increase in total integration score was greater in the tailored condition (N = 9; 18%) than in the standard condition (N = 5; 12%), linear mixed-effect models did not detect a statistically significant group × time interaction. Despite the challenges of integrating health promotion activities outside of healthcare organizations, the current approach shows promise for fostering sustainable health promotion in community settings and merits further study.

Web-based versus in-person methods for training lay community health advisors to implement health promotion workshops: participant outcomes from a cluster-randomized trial

Project HEAL (Health through Early Awareness and Learning) is an implementation trial that compared two methods of training lay peer community health advisors (CHAs)-in-person ("Traditional") versus web-based ("Technology")-to conduct a series of three evidence-based cancer educational workshops in African American churches. This analysis reports on participant outcomes from Project HEAL. Fifteen churches were randomized to the two CHA training methods and the intervention impact was examined over 24 months. This study was conducted in Prince George's County, MD, and enrolled 375 church members age 40-75. Participants reported on knowledge and screening behaviors for breast, prostate, and colorectal cancer. Overall, cancer knowledge in all areas increased during the study period (p < .001). There were significant increases in digital rectal exam (p < .05), fecal occult blood test (p < .001), and colonoscopy (p < .01) at 24 months; however, this did not differ by study group. Mammography maintenance (56% overall) was evidenced by women reporting multiple mammograms within the study period. Participants attending all three workshops were more likely to report a fecal occult blood test or colonoscopy at 24 months (p < .05) than those who attended only one. These findings suggest that lay individuals can receive web-based training to successfully implement an evidence-based health promotion intervention that results in participant-level outcomes comparable with (a) people trained using the traditional classroom method and (b) previous efficacy trials. Findings have implications for resources and use of technology to increase widespread dissemination of evidence-based health promotion interventions through training lay persons in community settings.

National Working Group on the RE-AIM Planning and Evaluation Framework: Goals, Resources, and Future Directions

The National Working Group on RE-AIM Planning and Evaluation Framework (herein Workgroup) was established in 2004 to support the application of the framework and advance dissemination and implementation science (D&I). Workgroup members developed and disseminated products and resources (and continue to do so) to advocate for consistent application of RE-AIM and allow for cross study comparisons. The purpose of this paper is to summarize key Workgroup activities, products, and services (e.g., webinars, consultations, planning tools) and enhance bidirectional communication between the Workgroup and RE-AIM users. The ultimate goal of this work is to serve as a forum for dissemination to improve the balance between RE-AIM user demand (needs) and the currently limited RE-AIM Workgroup supply (consultation and resources) to demonstrate and expand the utility of RE-AIM as a D&I planning and evaluation framework. A summary of resources is provided as well as specific examples of how the Workgroup has been responsive to user needs.

Planning for Community Scale-Up of Project HEAL: Insights From the SPRINT Initiative

Project HEAL (Health through Early Awareness and Learning) is an evidence-based intervention rooted in health behavior change theory and aims to increase cancer awareness and early detection through African American faith-based organizations. This study explored the potential for broader scale-up and dissemination of Project HEAL with the team's participation in a training program called Speeding Research-Tested INTerventions (SPRINT). The SPRINT training was framed using tools from the Business Model Canvas and the Value Proposition Canvas to guide trainees in designing (1) compelling value propositions, (2) a minimal viable product, and (3) questions to gain critical insight from various stakeholders during a process called Customer Discovery. We report on our experiences and insights on intervention scale-up that we gained from the training, including key findings from 41 discovery interviews conducted with various stakeholders of the church. We learned several valuable lessons from the discovery interviews such as scale-up will likely be more incremental than immediate. Additional refinement is needed to scale up the intervention for "real-world" application, such as making our technology more user-friendly and including additional health topics beyond cancer. We discuss how insights from the training refined our plans for future scale-up and dissemination in a constituent-informed way.

Development of tailored feedback reports on organizational capacity for health promotion in African American churches

Standard community-engaged research methods involve reporting research findings back to study participants. Project HEAL is an implementation trial conducted in 14 African American churches. This paper reports on a strengths-based approach to reporting Project HEAL organizational capacity data back to church leadership, through use of individualized church reports. Pastors in each church completed a church organizational capacity assessment. The study team, including community partners representing church leadership, co-created a channel and content to disseminate the capacity data back to Project HEAL church leaders. This consisted of a 4-page lay report that included the church's capacity scores, and recommendations for future evidence-based health promotion programming matched to their capacity. The study team was able to meet with nine of the 14 churches to review the report, which took an average of six and a half weeks to schedule. The individualized church reports were well-received by pastors, who expressed an intention to share the information with others in the church and to sustain health promotion activities in their organizations. Though the individualized reports were embraced by the pastors, it is unknown whether this process will result in sustainable health promotion in these organizations without further follow-up.

The Sustainability of Evidence-Based Interventions and Practices in Public Health and Health Care

There is strong interest in implementation science to address the gap between research and practice in public health. Research on the sustainability of evidence-based interventions has been growing rapidly. Sustainability has been defined as the continued use of program components at sufficient intensity for the sustained achievement of desirable program goals and population outcomes. This understudied area has been identified as one of the most significant translational research problems. Adding to this challenge is uncertainty regarding the extent to which intervention adaptation and evolution are necessary to address the needs of populations that differ from those in which interventions were originally tested or implemented. This review critically examines and discusses conceptual and methodological issues in studying sustainability, summarizes the multilevel factors that have been found to influence the sustainability of interventions in a range of public health and health care settings, and highlights key areas for future research.