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ory__et_al._re_aim_for_older_adults.pdf
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ORIGINAL RESEARCH ARTICLE
PUBLIC HEALTH
published: 27 April 2015
doi: 10.3389/fpubh.2014.00143
Perceived utility of the RE-AIM framework for health
promotion/disease prevention initiatives for older adults: a
case study from the U.S. evidence-based disease
prevention initiative
Marcia G. Ory 1 *, Mary Altpeter 2 , Basia Belza 3 , Janet Helduser 4 , Chen Zhang 5 and Matthew Lee Smith 6
1
2
3
4
5
6
Department of Health Promotion and Community Health Sciences, School of Public Health, Texas A&M Health Science Center, College Station, TX, USA
Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
Health Promotion Research Center, School of Nursing and School of Public Health, University of Washington, Seattle, WA, USA
Department of Health Policy and Management, School of Public Health, Texas A&M Health Science Center, College Station, TX, USA
Emory Global Health Institute, Emory University, Atlanta, GA, USA
Department of Health Promotion and Behavior, College of Public Health, The University of Georgia, Athens, GA, USA
Edited by:
Sanjay P. Zodpey, Public Health
Foundation of India, India
Reviewed by:
Himanshu Negandhi, Public Health
Foundation of India, India
Katherine Henrietta Leith, University
of South Carolina, USA
*Correspondence:
Marcia G. Ory , Department of Health
Promotion and Community Health
Sciences, School of Public Health,
Texas A&M Health Science Center,
TAMU 1266, College Station, TX
77843, USA
e-mail: mory@sph.tamhsc.edu
Dissemination and implementation (D&I) frameworks are increasingly being promoted in
public health research. However, less is known about their uptake in the field, especially
for diverse sets of programs. Limited questionnaires exist to assess the ways that frameworks can be utilized in program planning and evaluation. We present a case study from
the United States that describes the implementation of the RE-AIM framework by state
aging services providers and public health partners and a questionnaire that can be used to
assess the utility of such frameworks in practice. An online questionnaire was developed
to capture community perspectives about the utility of the RE-AIM framework. Distributed
to project leads in 27 funded states in an evidence-based disease prevention initiative for
older adults, 40 key stakeholders responded representing a 100% state-participation rate
among the 27 funded states. Findings suggest that there is perceived utility in using the
RE-AIM framework when evaluating grand-scale initiatives for older adults. The RE-AIM
framework was seen as useful for planning, implementation, and evaluation with relevance for evaluators, providers, community leaders, and policy makers. Yet, the uptake
was not universal, and some respondents reported difficulties in use, especially adopting the framework as a whole. This questionnaire can serve as the basis to assess ways
the RE-AIM framework can be utilized by practitioners in state-wide D&I efforts. Maximal benefit can be derived from examining the assessment of RE-AIM-related knowledge
and confidence as part of a continual quality assurance process. We recommend such
an assessment be performed before the implementation of new funding initiatives and
throughout their course to assess RE-AIM uptake and to identify areas for technical
assistance.
Keywords: RE-AIM, program planning, program implementation, program evaluation, older adults, aging
INTRODUCTION
With concerns about the aging population and attendant growth
of multiple co-morbidities (1, 2) support has grown for national
initiatives to improve the health, function, and quality of life of
older adults (3, 4). Despite the growing evidence base about the
nature of public health problems among older adults and successful intervention approaches for improving their health and
well-being (5–7), there remains a notable gap in transferring
what we know works into practice (8, 9). Many reasons can be
cited for the existence of a research-to-practice gap including that
researchers are not aware of the realities of programmatic implementation in real world settings and community providers lack
the guidance for implementing proven programs tested in other
settings (10). There is also a lack of quality questionnaires for
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assessing programmatic implementation, especially in multi-site
intervention initiatives (11).
Originally conceived in the late 1990s, the RE-AIM framework
(12) was designed to assess the public health impact of health promotion interventions through the identification of five core evaluation elements (i.e., reach, efficacy/effectiveness, adoption, implementation, and maintenance). In an attempt to understand better
the translation of interventions tested within controlled trials to
implementation within community settings (13), RE-AIM has
changed the research paradigm from one focused exclusively on
controlled clinical trials with a priority on internal validity to one
that acknowledges the importance of pragmatic interventions that
give salience to external validity – or the degree to which intervention results can be generalized across interventions, populations,
April 2015 | Volume 2 | Article 143 | 1
Ory et al.
and settings (14–18). The use of the RE-AIM framework has been
refined since its conception to include guidance for the planning,
implementation, maintenance, and evaluation of programs and
policies by clinicians, community providers, and policy makers
(19). Its utilization is appropriate for those in the fields of aging
services and public health, as well as allied disciplines.
Building on early community-wide efforts to identify best practice programs for older adults through the aging services network,
the United States Administration on Aging (AoA), a program division within the Administration for Community Living (ACL),
has dedicated resources to the implementation and dissemination of state-wide evidence-based practices (20). This emphasis
on evidence-based practices reflects the emergence of several welltested health promotion/disease prevention programs, which have
been shown to not only make a difference in older adults’ health
but also in reduced health care utilization (21).
In 2006, the Atlantic Philanthropies and the AoA funded the
evidence-based disease prevention (EBDP) initiative with the
intention of supporting stronger linkages between State Aging Services and State Health Departments to address the health needs of
the growing population of older adults. The overall goals of this
initiative were to (1) develop the systems necessary to support
the ongoing implementation and sustainability of evidence-based
programs for older adults; (2) develop multi-sector community
partnerships to enhance program accessibility and extend program capacity; (3) reach the maximum number of at-risk older
adults who could benefit from the programs; and (4) deliver
evidence-based programs with fidelity (22).
Seen as an opportunity for fostering learning collaborative,
the funders contracted for technical assistance to the 27 state
grantees funded under the EBDP initiative. Since this was the first
time RE-AIM was integral to health promotion program implementation activities for these partnerships, there was interest in
exploring how well and in what ways the framework was being
adopted and applied, especially since no systematic collection of
this information existed. As investigators from three CDC Prevention Research Center–Healthy Aging Research Network (HAN)
campuses charged with providing technical assistance to the funder and State grantees, we wanted to explore how translational
research frameworks were being implemented in the real world
settings by state-level aging services providers and their public
health partners. This paper expands upon previously reported
findings (23). Its purposes are to (1) introduce the reader to the
RE-AIM framework; (2) describe the development of a questionnaire to assess the implementation processes in the field based
on elements from the RE-AIM framework; (3) using this questionnaire, examine ways RE-AIM was viewed by grantees and
used in their program planning, implementation, and evaluation of evidence-based programs; and (4) summarize implications
for future use of RE-AIM and training needs in the evaluation
of community-based dissemination and implementation (D&I)
efforts of evidence-based programs.
MATERIALS AND METHODS
DEFINITIONS OF RE-AIM ELEMENTS
As illustrated in Figure 1, the acronym RE-AIM represents the
five essential components of the RE-AIM framework: reach,
Frontiers in Public Health | Public Health Education and Promotion
RE-AIM framework for health promotion/disease prevention
effectiveness, adoption, implementation, and maintenance (24).
Each component addresses a major research question that can
guide program planning and evaluation.
“Reach” is the extent to which a program attracts and retains
the target audience. Measures of Reach include the number, proportion, and representativeness of participants. It is important to
monitor Reach to determine if the desired audience is participating
in the program, in what numbers, and whether there is program
completion or attrition. This in turn, can help gage the success of
marketing, recruitment, and retention efforts.
“Effectiveness” refers to assessing the change in short- and/or
long-term program outcomes, such as health behaviors and
lifestyles, symptom management, health status, or health care utilization outcomes. Effectiveness indicators also monitor for other
outcomes, whether negative or unintended that result from the
program. It is important to monitor Effectiveness to provide the
evidence as to whether the program is producing positive changes,
which ultimately makes the case for the program’s value and return
on investment.
“Adoption” activities assess organizational capacity and partnership support. Measures include the number, proportion, and
representativeness of staff and settings who adopt a program as
well as tracking of the various ways partners contribute to program delivery. It is important to know if the supply of delivery
staff and sites matches program demand and is located in areas
where the target audience resides and whether there is capacity to
bring the program to scale.
“Implementation” is the extent to which the program is delivered consistently, as intended by the program developers, across all
implementation sites by all instructors. Implementation measures
also tracks program costs. It is important to monitor Implementation in order to identify areas of need for improvement in program
delivery, assure participant results can be attributed to the program
and identify return on investment for stakeholders.
At the setting level, “Maintenance” refers to the extent to which
the program can be embedded within the routine organizational
practice. Some factors, such as “ongoing staff support,” “partnership with community,” “sufficient funding,” and “health marketing,” are all essential elements for organizational maintenance. At
the individual level, “Maintenance” refers to the extent to which
individual participants experience long-term benefits (longer than
6-months following program completion) and better quality of life
from the health promotion interventions or policies. Attention to
these elements helps inform strategies to ensure individual benefits are sustained over time and that the necessary infrastructure is
in place to ensure a program will receive ongoing institutional or
community support.
PROCEDURES
Data were collected using internet-delivered methodology. The
questionnaire utilized to collect data from respondents was developed by the HAN project team using online survey software. Electronic mail-based invitations to participate in the questionnaire
were sent in January 2009 to designated project leads representing
27 states receiving funding from and participating in the EBDP
initiative. The instructions requested that the questionnaire be
completed separately by one state lead (either public health or
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Ory et al.
RE-AIM framework for health promotion/disease prevention
REACH
How do I reach
those who need
this intervention?
MAINTENANCE
EFFECTIVNESS
How do I
incorporate the
intervention so it is
delivered over the
long-term?
How do I know my
intervention is
working?
RE-AIM
IMPLEMENTATION
How do I ensure
the intervention is
delivered properly?
ADOPTION
How do I develop
organizational
support to deliver
my intervention?
FIGURE 1 | RE-AIM elements: planning and evaluating questions (see www.re-aim.org for more information).
aging) and one state-level program evaluator. Other team members who played key roles in program implementation and/or
evaluation (e.g., a local project coordinator and/or regional coordinator or university partner) were also welcome to complete the
questionnaire. Some of the items (e.g., knowledge and confidence
in applying the RE-AIM framework) were asked retrospectively.
After completing the questionnaire, the respondents were invited
to share their responses with their state team as a way of enhancing
their planning and evaluation efforts. The initial survey requested
that responses be returned within 2 weeks. Two follow-up emails
were sent to state respondents to increase the survey response rate.
This study received Institutional Review Board (IRB) approval at
Texas A&M Health Science Center where data were collected and
analyzed.
QUESTIONNAIRE AND MEASURES
Reflecting expertise in several health professions (public health,
nursing, and social work) and prior experience with the RE-AIM
model and implementation research (25–29), the authors designed
the questionnaire to address how state grantees integrated RE-AIM
elements into different planning, implementation, evaluation, and
monitoring processes (a copy of the full questionnaire is appended
to the end of this article).
As there were no comparable questionnaires in the literature, the authors built the questionnaire around concepts deemed
important to reflect implementation processes. The questionnaire
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was designed to collect information about the respondent’s knowledge, attitudes, and current practices related to different aspects
of the RE-AIM framework as a whole as well as attention to its
individual components. The questionnaire was pilot tested for
ease of understanding and face validity with local community
practitioners.
The final questionnaire contained 47 multi-part items including close-ended and open-ended items, as well as checklists. Recognizing the importance of “survey fatigue” or attrition, the HAN
project team was careful not to make the questionnaire too long.
Therefore, close-ended items with Likert-type scaling were used
to make it easy for respondents to respond to questionnaire items.
Additionally, open-ended items were integrated into the questionnaire to allow for additional responses to give richer detail and
context to close-ended items.
It was estimated that the online survey would take approximately 10–20 minutes to complete. Individualized links were sent
through the online survey website to state leads that were identified through the AoA’s Technical Assistance Center. Respondents
had unlimited access to the online questionnaire to enable them to
complete the task at their convenience and as a means of increasing
completion rates. The questionnaire opened with a brief definition of the RE-AIM elements, with directions to the respondents
to go to the RE-AIM website (www.re-aim.org) if they desired
more information about the rationale for and measurement of
each element.
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Ory et al.
RE-AIM utilization
Respondents were asked to rate the degree to which the RE-AIM
framework was used for planning, implementation/evaluation,
and maintenance. A series of 15 items were used to assess aspects of
utilization. For example, for planning, respondents were asked to
respond to how they used RE-AIM to“select community partners,”
“select host and/or implementation sites,” and “select assessment/evaluation tools.” For implementation/evaluation, respondents were asked to rate the framework use for “plan or alter
participant recruitment,” “conduct mid-course evaluations,” and
“present/publicize program findings.” For maintenance, respondents rated the framework use for “secure funding for maintaining program delivery,” “build infrastructure to maintain program
staffing,” and “build capacity for ongoing quality assurance (QA).”
Self-rated knowledge
Respondents were asked to rate their knowledge about “EBDP
programs” and “the RE-AIM framework” at the start of the grant
initiative (retrospectively) versus the current time. If respondents
were not present at the initial stages of program implementation,
they were instructed to mark the “not relevant” category.
RE-AIM-related confidence
Self-efficacy refers to individuals’ beliefs in their ability to succeed
in a given situation (30). These beliefs act as determinants of how
individuals think, behave, and feel (31). Individuals’ sense of selfefficacy determines how goals, tasks, and challenges are addressed.
Individuals with a strong sense of self-efficacy view challenging
problems as tasks to be mastered; develop stronger interest in the
activities in which they participate; and are more committed to
their interests. (30) We were interested in learning about grantees
confidence in the use and application of RE-AIM and whether
their confidence levels changed over the course of the grant. “Confidence” is the term Bandura uses as synonymous to self-efficacy
when measuring the construct. Respondents were asked questions
to measure their confidence about applying each of the five REAIM at the start of the grant initiative (retrospectively) versus the
current time. Again, if respondents were not present at the initial
stages of program implementation, they were instructed to mark
the “not relevant” category.
Perceptions of RE-AIM usefulness
Respondents were asked to share their attitudes about the application of RE-AIM for various tasks related to their grant efforts.
Respondents were asked to rate the usefulness of RE-AIM applied
to the following activities: “planning of this initiative,”“implementation of this effort,” “evaluation of this effort,” “planning efforts
with our other aging programs,” and “implementation efforts with
our other aging programs.” Respondents were also asked to report
how valuable they believed RE-AIM was for different audiences.
Participants were asked to respond to the following audiences:
“providers,” “community leaders,” “policy makers,” and “evaluators.” Finally, respondents were asked to indicate if they would
apply RE-AIM in their future projects.
Ease of RE-AIM use and application
Respondents were asked to report how easy they believed RE-AIM
was to use/apply and their preferences about monitoring RE-AIM
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RE-AIM framework for health promotion/disease prevention
elements. Respondents were asked to respond to seven statements
about the RE-AIM framework as a whole as well as its component
elements.
Respondent characteristics
Items were included to collect information about the respondents’ role on the AoA/Atlantic EBDP grant (i.e., state lead, state
evaluator, regional project coordinator, local project coordinator,
and other); the year that the respondent started working with
evidence-based programs (i.e., from 2000 to 2008); and the type
of evidence-based programs being delivered (from a list of 16
approved evidence-based programs).
RESULTS
UTILITY OF AN ONLINE SURVEY FOR COLLECTING INFORMATION …
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