Schools are key settings for health promotion (HP) but the development of suitable approaches for evaluating HP in schools is still a major topic of discussion. This article presents a research protocol of a program developed to evaluate HP. After reviewing HP evaluation issues, the various possible approaches are analyzed and the importance of a realistic evaluation framework and a mixed methods (MM) design are demonstrated.The design is based on a systemic approach to evaluation, taking into account the mechanisms, context and outcomes, as defined in realistic evaluation, adjusted to our own French context using an MM approach. The characteristics of the design are illustrated through the evaluation of a nationwide HP program in French primary schools designed to enhance children's social, emotional and physical health by improving teachers' HP practices and promoting a healthy school environment. An embedded MM design is used in which a qualitative data set plays a supportive, secondary role in a study based primarily on a different quantitative data set. The way the qualitative and quantitative approaches are combined through the entire evaluation framework is detailed.This study is a contribution towards the development of suitable approaches for evaluating HP programs in schools. The systemic approach of the evaluation carried out in this research is appropriate since it takes account of the limitations of traditional evaluation approaches and considers suggestions made by the HP research community. Schools are key settings for health promotion (HP). The contribution of HP to the health and well-being of pupils has been increasingly widely recognized -3. HowevAccording to the definition given by the World Health Organization (WHO), evaluation aims to produce information that can be used by those who have an interest in the improvement and effectiveness of interventions . HoweverPotvin et al (2008) identified three main challenges for those evaluating HP programs: (1) defining the activity to be evaluated in order to raise pertinent evaluation questions, (2) implementing an appropriate, rigorous research methodology, and (3) producing pertinent knowledge for actions . In thisThis article presents a research protocol developing particularly the theoretical and methodological approach for evaluating HP interventions. It reviews the various evaluation approaches available and then describes the design developed and applied to the evaluation of an HP program in the specific context of the French school system.Various evaluation approaches have been used in HP . They arAlternative approaches have been developed. Guba and Lincoln (1989) defined the fourth generation evaluation as "a form of evaluation in which the claims, concerns, and issues of stakeholders serve as organizational foci (the basis for determining what information is needed), that is implemented within the methodological precepts of the constructivist inquiry paradigm" . Over tOther authors ,15 suggeThe realistic evaluation framework aims: (1) to understand the mechanisms through which HP interventions produces change; (2) to understand the contextual conditions necessary to trigger these mechanisms; and (3) to develop outcome pattern predictions according to the context and mechanisms triggered. These are the three guiding themes of the research strategy defined by Pawson and Tilley . AccordiThe realistic evaluation framework does not require the use of a specific method. Indeed, Pawson and Tilley (1997) acknowledge that, when it comes to the choice of method, realistic evaluation can be based on methodological pluralism and thus on both qualitative and quantitative approaches.According to Chen (1997), there are three types of configuration depending on different program evaluation contexts. In the first configuration, evaluation contexts require intensive information and have low availability of credible information and an open program system. In this type of configuration, it is more appropriate to use qualitative methods. In the second configuration, evaluation contexts require extensive, precise information, have high availability for credible information and a closed program system. This would require a quantitative approach. The third configuration concerns programs requiring information that is both intensive and extensive, that provides high access to some information but low access to other information and has the characteristics of both open and closed systems. In this case, the use of mixed methods is the most appropriate. Due to their complexity, HP interventions can be considered as an example of this last case.Mixed methods (MM) and methodological pluralism are more and more often used within the HP field ,8. UsingThe MM approach can have different designs depending on how qualitative and quantitative approaches are combined. Creswell and Plano Clark (2007) classified the MM designs into four major types:(1) triangulation: its purpose is to obtain different but complementary data on the same topic to best understand the research problem;(2) embedded: one data set provides a supportive, secondary role in a study based primarily on the other data type;(3) explanatory: a two-phase MM design where qualitative data helps to explain or build upon initial quantitative results;(4) exploratory: the results of the first method  help to develop or form the basis of the second method (quantitative).Creswell and Plano Clark (2007) identified three factors to which the choice of a research design is related: the timing of the use of the collected data, the relative weight of the quantitative and qualitative approaches and the approach to mixing the datasets.This section covers research questions, the HP program, the sample, data collection and data analysis. It takes account of the guidelines for reporting observational epidemiological data given in the STROBE initiative . The stuIn the literature concerning research methodology, the purpose of a research study is defined as the reason or reasons for carrying out the study. These purposes are interrelated with the research questions and methods. Newman et al  stress tAccording to Newman's typology , this reBased on these hypotheses and research purposes, the research questions can be defined as follows:- What are the mechanisms and contextual factors that allow the school community to develop an HP approach?- How do the strategies developed through the program influence the development of teachers' HP practices and the schools' health promoting environment? How do these practices affect well-being in the schools? What is the influence of the program on the children's perceived life skills?The French system is national and centralized. Schools set a low priority on HP . ProfessThe evaluation framework for this HP project was based on the "theory-driven" approach to evaluation defined by Chen and Rossi (1983). This approach "is not the global conceptual scheme of the grand theorists, but more prosaic theories that are concerned with how human organizations work and how social problems are generated [...]. What we are strongly advocating is the necessity for theorizing, for constructing plausible and defensible models of how programs can be expected to work before evaluating them" . For thFigure Many factors govern the ways in which schools can develop and implement HP programs: sustainable commitment on the part of institutions and communities, a favorable environment, such as the support of the school head, and factors linked to the implementation of the program itself. A program cannot be implemented using a top down approach without consulting those involved locally and without taking into account of the local situation. The HP program was proposed in 2007 to all 31 French teacher training institutes. These institutions have the authority and legitimacy to sustain a school HP program. Ten institutes in 10 different French regions agreed to participate in the project. Six regions were able to gain institutional support and set up a support team to implement the program and collect data. Within those 6 regions, a total of 115 schools were given institutional support to participate to the program , on their motivation, interest in HP and feeling of competency in HP, as well as on their perception of the life in their school  This questionnaire was primarily developed in 1991 in a study on teachers' practices and attitudes to HP , it was This one page questionnaire was designed to collect data on how the families perceived life at the school, their relationships with the school and their involvement in the school's activities ,35.This questionnaire was designed to collect data on the local community's attitudes to HP, on HP activities implemented in schools and on how schools can be considered an HP environment. The last part of the questionnaire was based on the criteria defined by the IUHPE in 2005 and reviewed in 2008 . These dTwo forms were drawn up to collect contextual and process data, one on the school's structural and social background and one on the implementation of the program in each region.Two main interview guides were drawn up: one for the school community  and one for the support teams. Members of each support team are interviewed to find out their perception of the implementation of the program: facilitators, obstacles, results observed and added-value of the program. The second interview guide is adapted to each group, the main common themes being perception of the program, facilitators, obstacles and results observed.Data collection tools must be validated to ensure the rigor and quality of the research. All the tools were first tested for face and content validity by consulting the research team who undertook the pilot study, the scientific committee for the project and the support teams in the regions. The questionnaires were validated by structured interviews with 10 persons from each group . The reliability of the teachers' and children's questionnaires was then tested. The questionnaires were administered in real conditions to a sample of 30 individuals from each target group. The data was entered and tested for internal reliability using the Cronbach alpha coefficient method whenever appropriate . The questionnaires were administered a second time to the same sample 15 days later. The new data was entered and analyzed to check the reliability using the Kappa coefficient method whenever appropriate. At the end of each stage of the validation procedure, the tools were modified according to the conclusions drawn.0, T1, T2, T3). The questionnaires are self-administrated and distributed by the members of the support team.Data is collected from pupils, parents, teachers, school communities and support teams in a three year multiple time series design, at the beginning of the project and at the end of each school year . Teachers, school staff and some parents and children are interviewed. All the interviews are recorded with the approval of the participants and transcribed.http://cran.r-project.org/, Stata http://www.stata.com/ and SAS http://www.sas.com/ software. NVivo http://www.qsrinternational.com/ software is used to analyze the qualitative data and a content analysis is carried out [Quantitative analysis  is performed using R 2.2.1 ried out . Furtherried out  into quaried out  to mountried out . The anaThis article presents the theoretical and methodological approach of research designed to evaluate an HP program in French schools. It presents the HP evaluation issues and describes the main evaluation approaches used in the field and gives a detailed illustration of the evaluation framework applied to an HP program in French schools. It discusses how the realistic evaluation of such an HP program is a valuable approach to take account of the general and local context. The systemic approach of the evaluation carried out in this project is appropriate since it takes into account the limits of traditional evaluation approaches and considers the suggestions of the HP research community ,9,41,42.The authors declare that they have no competing interests.This article was drafted by JP and MRG and the manuscript was revised by DJ. The project design was developed by DJ and JP. All authors were involved in implementing the project and in developing the evaluation design. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/10/43/prepub


The WISEWOMAN program targets low-income under- and uninsured women aged 40–64 years for screening and interventions aimed at reducing the risk of heart disease, stroke, and other chronic diseases. The program enters its third phase on June 30, 2008. Design issues and results from Phase I and Phase II have been published in a series of papers. We summarize remaining challenges, which were identified through systematic research and evaluation. Phase III will address these challenges through a number of new initiatives such as allowing interventions of different intensities, taking advantage of resources for promoting community health, and providing evidence-based interventions through the program's Center of Excellence. Finally, we provide a framework and vision so that organizational, community, and other partners can make the case for the importance of the program to their communities and for what is needed to make it work. The Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) ,2 prograPhase I of WISEWOMAN (1995–1998), which focused on research only, tested whether enhanced lifestyle interventions were more effective than lifestyle interventions using minimal or usual care. Design issues and results from this phase have been covered in a series of articles -6. DurinWISEWOMAN has identified lessons learned through randomized controlled trials ,6, nonraIn Phase II, performance indicators for nonresearch projects included screening 2500 women annually and ensuring that 75% of screened participants began the lifestyle intervention, that 60% of women starting the intervention completed it, that 75% of women screened were rescreened within 10–14 months, and that 95% of women with systolic blood pressure >180 mm Hg or diastolic blood pressure >110 mm Hg were seen within 1 week of screening. Programs varied substantially in their ability to meet performance indicators. For example, the number of annual screenings performed by programs ranged from 449 to 5629, and initiation of lifestyle interventions ranged from 16% of participants in the lowest-performing program to 100% in the highest-performing program . Although the highest-performing programs demonstrated that most of the performance indicators are achievable, the WISEWOMAN program decided to revisit the feasibility of using these indicators and to identify obstacles to reaching them.www.cdc.gov/wisewoman).In an example of the mixed-methods approach, investigators conducted case studies of the sites that had the highest and the lowest public health impact within a select number of states and tribes ,12. FromP < .05), total cholesterol , smoking , and 10-year risk of coronary heart disease  . In the subgroup with abnormal screening values at baseline, these reductions were even more striking .Target geographic areas in each state and tribe with the highest death rates and hospital discharge rates for heart disease and stroke.Deliver effective behavioral counseling based on sound theoretical approaches.Tailor lifestyle interventions according to degrees of risk for heart disease and stroke and readiness-to-change behaviors.Maximize the number of women being reassessed to determine whether their risk for heart disease and stroke has decreased and their health behaviors have improved.Collaborate with state, local, and community partners who can make policy, environmental, and system changes that support the adoption and maintenance of heart-healthy behaviors by underserved populations where they work, live, and play.These challenges will be addressed through the requirements published in funding announcements, stronger program guidance, clarified program vision and goals, new performance indicators, and evidence-based technical assistance and training. As in the past, WISEWOMAN will use a variety of evaluation methods to determine the degree to which these key challenges have been met.Most of the remainder of this article addresses two specific priorities: increasing the reach of the WISEWOMAN program and ensuring the effectiveness of its projects. Reach and effectiveness are the two criteria most directly related to determining WISEWOMAN's impact and thus merit extensive discussion. First, however, we focus on the importance of having a clear programmatic vision.Recent evidence from implementation of the Chronic Care Model ,20 suggeThe WISEWOMAN program employs the models used by Abrams et al  and Glaswww.effectiveinterventions.org).Another issue to be clarified involves approaches to implementing an intervention. Projects were required to select an evidence-based intervention, but ongoing guidance was not provided on tailoring interventions to new target populations or unique settings. Consequently, many projects did not faithfully implement the elements of their intervention that were credited with its effectiveness. Faithfully implementing these core elements is important, as demonstrated by the translation work of CDC's Division of HIV/AIDS Prevention, the Center on AIDS and Community Health, and the Academy for Educational Development   screening of risk factors for cardiovascular disease and other chronic diseases, 2) lifestyle interventions, 3) assurance of access to needed treatment and medication, and 4) follow-up visits for monitoring and evaluation. These components are required by congressional legislation. The clinical guidelines that are the source of the evidence for each of these four components  include One approach to expanding the reach of WISEWOMAN is to better match participants' needs with the program resources. Various interventions tailored to participants' degrees of risk or readiness to change might be the best way to proceed, or interventions might be designed to reduce costs per woman served. During Phase II, CDC asked that all participants be required to attend the same lifestyle intervention regardless of how strong their risk factors were or how ready they were to change. For many reasons, however, designing only one intervention for all women can limit a program's reach. Furthermore, women with normal screening values will most likely not need an intensive intervention designed to control risk factors, nor is it reasonable or cost-effective to ask a woman who is not ready to change to participate in a costly intervention. Referring women with highly abnormal screening values to low-intensity interventions that may not help control their risk factors is also likely to be ineffective.Because women often describe time as the major barrier to participation in public health programs , asking www.wiseinterventions.org). Evaluation will focus on monitoring the implementation of core elements.Scientists have debated the degree to which every aspect of an intervention must be delivered exactly as it was in the randomized trial that demonstrated its effectiveness . An extrFor the practitioner, CDC's state and tribal partners, and CDC staff, knowing how to deliver a program is often the most difficult challenge. The various levels of the socioecologic model dictate different strategies for change. For example, the WISEWOMAN program endorses the 5A's strategy   for creaAt the organizational and community level, we will use the following steps advocated by Kotter  Figure  to encouCreating community and policy changes using Kotter's approach means first establishing a sense of urgency among community leaders about providing financially disadvantaged populations with access to resources and ensuring social and environmental support through such activities as creating walkable environments in the lowest-income neighborhoods. For policy changes, the initial task of creating a sense of urgency can involve issues such as universal access to preventive health services and the expansion of successful health promotion programs statewide.When it enters its implementation phase (Phase III), WISEWOMAN will be moving in some new directions. To extend reach and reduce costs, the program will help projects design interventions based on degrees of risk and levels of motivation and will ensure that projects have access to resources for promoting community health. These strategies are also likely to increase the effectiveness of the program. For example, one strategy has CDC providing evidence-based interventions and core elements through the Center of Excellence that conducts research on improving the public health impact of the WISEWOMAN program. Another strategy for increasing effectiveness is the provision of a clear framework and vision so that organizational, community, and other partners can make the case for why the program is important to their communities and what is needed to make it work.Moving in a new direction always presents challenges. For WISEWOMAN, some of these challenges are ensuring that underfunded sites are not overburdened by having to conduct multiple interventions, measuring readiness to change when addressing multiple behaviors, packaging new interventions and updating old versions, monitoring projects for faithful implementation of core elements, and ensuring that women with normal screening values receive appropriate counseling and resources. Acknowledging these challenges, CDC looks forward to Phase III and hopes to be able to demonstrate the impact of these new directions through increased services to a greater number of women and a reduction in heart disease and stroke.


Medical school administrators, educators, and other key personnel must often make difficult choices regarding the creation, retention, modification, or termination of the various programs that take place at their institutions. Program evaluation is a data-driven strategy to aide decision-makers in determining the most appropriate outcome for programs within their purview. The purpose of this brief article is to describe one program evaluation model, the utilization-focused approach. In particular, we address the focus of this model, the personal factor, the role of the evaluator, and the evaluation process. Based on the flexibility of this model as well as its focus on stakeholder involvement, we encourage readers to consider the utilization-focused approach when evaluating programs. Medical education is a dynamic, rapidly-evolving enterprise. Technological advances such as simulation, virtual reality, and personal digital assistants, to name a few, have considerably altered the way in which medical students are educated and trained. By incorporating such technologies into the learning experience, administrators at various levels of medical training are faced with an important series of questions: Do these technologies sufficiently enhance student learning, and are the costs associated with implementing these technologies justifiable?Questions such as these extend well beyond technologically-driven learning experiences. Consider medical school administrators attempting to determine whether an alternative admissions program is effective or if a new standardized patient approach might increase pass rates on high stakes exams. In the post-graduate years, residency directors need to know if trainees meet educational goals as well as ensure that their training programs are of sufficient quality. In each of these scenarios, the effectiveness of the program is questioned. The means for answering such questions are accomplished through a systematic and comprehensive program evaluation. Unfortunately, the majority of evaluations performed often lack the proper structure or theoretical framework to effectively guide the process.According to Fitzpatrick, Sanders, and Worthen, program evaluation is defined as "the identification, clarification, and application of defensible criteria to determine an evaluation object's value (worth or merit) in relation to those criteria" . In broaThere are many program evaluation models. A few examples include: objectives-oriented approaches, management-oriented approaches, participant-oriented approaches, expertise-oriented approaches, and logic models. These models have been adopted in various educational fields and have enjoyed widespread usage. Program evaluation models for medical education also exist but are much more limited. Durning, Hemmer, and Pangaro rightly note that research related to program evaluation in medical education is less developed than other educational fields . ReadersGiven the limited exposure of program evaluation models in medical education, the purpose of the current article is to briefly describe one model of program evaluation, the utilization-focused method. The authors feel that this model is well-suited for medical education, given its flexibility in approach as well as its focus on the active involvement of stakeholders. This active position promotes the stakeholders' investment in the process and increases the likelihood that they will see value in the results needed to affect change. In the next sections we will address the focus of this model, the personal factor, the role of the evaluator, and the evaluation process. For additional information regarding this evaluation model, readers are referred to Patton, the source from which the following information is based , 6.Utilization-focused evaluation begins with the assumption that evaluations should be judged by their actual use and utility . It is tUtilization-focused evaluation is context specific. It is not limited to a particular approach or methodology. Rather, it is a means of aiding users in determining the approach and methodology that works best within the context of their particular program. Situational responsiveness facilitates this interactive process between the evaluator and the users. With the expansive options available, users are able to choose the purpose of the evaluation (formative or summative), the data type , the type of research design , and the evaluation focus . In addition, specific situational variables are always present and must be incorporated into the evaluation. Examples might include the diversity of the stakeholders, available resources, political factors, and interests. To briefly demonstrate a utilization-approach in contrast with other evaluation models, consider the example of stakeholders interested in evaluating a standardized patient program. An objectives-oriented method would establish clearly defined objectives that the program must meet in order to be effective, such as a pass rate percentage on a high stakes exam. In contrast, a participant-oriented evaluator might conduct qualitative interviews or focus groups of medical students or standardized patients to understand their perspectives in greater depth. Since utilization-focused evaluations are flexible and vary by context, they are able to incorporate elements from any program evaluation model to best meet the stakeholders' needs.Utilization-focused evaluation is also very personal. In fact, the personal factor is highly emphasized. Given that there may be an unlimited number of stakeholders, each with competing interests, it is the responsibility of the evaluator to scale down potential stakeholders to a group of interested individuals who actively participate and care about the evaluation and the findings it generates. The evaluation seeks to serve their interests primarily. The evaluator often develops a strong working relationship with users and actively engages them throughout the evaluative process.Within the context of evaluation, the role of the evaluator is often a key element. For example, if the goal of the evaluation is to provide generalizable knowledge of cause-effect relationships between the program and a particular outcome variable, the evaluator serves as a methodologist with expertise in research design. Consider a second example in which the purpose of an evaluation is to examine a program's overall merit. In this case, the evaluator must become a judge. The primary role of the utilization-focused evaluator is that of negotiator. In this function, the evaluator negotiates with users the roles in which he or she will take part. Patton also expresses the role of the evaluator as active-reactive-adaptive. Utilization-focused evaluators are, first of all, active in deliberately and calculatedly identifying intended users and focusing useful questions. They are reactive in listening to intended users and responding to what they learn about the particular situation in which the evaluation unfolds. They are adaptive in altering evaluation questions and designs in light of their increased understanding of the situation and changing conditions .As with any program evaluation, utilization-focused evaluations are systematic and follow a logical sequence. First, the primary users/stakeholders of the evaluation are identified. Next, the evaluator and users commit to the purpose of the evaluation and derive a focus to address particular goals or to take into account the program's theory of action. The third step of the process involves the selection of the research design and measurement considerations. Sampling issues, the nature of the data, and the quality of assessment devices are but a few of the decisions that must be made during this phase. Following data collection, users are brought together to assist in interpreting findings and making judgments based on the data to derive recommendations. In the final step, decisions are made about the dissemination of the evaluation report.Medical schools are required to continuously assess program effectiveness, especially in light of recent budget cuts and diminishing resources. Given that programs are under increased scrutiny, effective program evaluation has never been more vital. For these reasons, the previous description provides a glance into a program evaluation model that is useful in a wide array of contexts within medical education. One of its key benefits is that it is a flexible approach that can be useful in answering a wide variety of programmatic questions. It also actively includes principal stakeholders in the decision making process, increasing the likelihood that results will be used to guide program development and decision making. For these reasons, we encourage those interested in evaluating a particular program to consider the utilization-focused approach.


Health-e-AME was a 3-year intervention designed to promote physical activity at African Methodist Episcopal churches across South Carolina. It is based on a community-participation model designed to disseminate interventions through trained volunteer health directors.We used the RE-AIM  framework to evaluate this intervention through interviews with 50 health directors.Eighty percent of the churches that had a health director trained during the first year of the intervention and 52% of churches that had a health director trained during the second year adopted at least one component of the intervention. Lack of motivation or commitment from the congregation was the most common barrier to adoption. Intervention activities reached middle-aged women mainly. The intervention was moderately well implemented, and adherence to its principles was adequate. Maintenance analyses showed that individual participants in the intervention's physical activity components continued their participation as long as the church offered them, but churches had difficulties continuing to offer physical activity sessions. The effectiveness analysis showed that the intervention produced promising, but not significant, trends in levels of physical activity.Our use of the RE-AIM framework to evaluate this intervention serves as a model for a comprehensive evaluation of the health effects of community programs to promote health. Participating in regular physical activity (PA) results in many physical and mental health benefits , includiAlthough interventions to increase PA are effective, relatively few include African Americans as participants, and fewer still are designed specifically for African Americans. A recent review by Yancey and colleagues  of commuHealth promotion programs in churches have enjoyed moderate success among African Americans -10. The Reach is the proportion of eligible people in the target population who participate in an intervention and the extent to which those participants represent the target population. Effectiveness is the extent to which the intervention has a positive effect on relevant outcomes. Adoption is an organizational measure of the number of program providers who implement a program and the extent to which they represent all possible program providers. Implementation is an organizational measure of the quality of the intervention's delivery and its adherence to the essential elements of the research program. Implementation is sometimes called treatment fidelity. Maintenance is a measure of the intervention's effectiveness at achieving the desired outcome for an extended time. It is also a measure of the sustainability of a program and indicates whether a program is likely to become institutionalized , chair exercises, walking programs, and a behavior and skill-based class that focused on helping participants become active and eat healthfully. The Physical-e-Fit program also had educational messages about PA posted within the church and built PA into other church activities. All activities and messages had spiritual or religious components involving scripture and culturally specific materials.The Health-e-AME project staff trained health directors (HDs) or physical activity coordinators (PACs) to organize and deliver the intervention within their churches' health ministry. HDs are generally responsible for all health-related activities in their churches, and PACs are responsible only for the Physical-e-Fit program. Usually PACs are in churches that do not have an established health ministry or in churches that have a health ministry large enough to delegate responsibilities to different people. Churches select which intervention activities to adopt on the basis of the resources available and the interests of their congregation.The training sessions that the HDs and PACs attended were held at churches and lasted 2 to 4 hours. Attendees were given didactic and hands-on learning experiences with PA demonstrations and participation. The sessions covered the basics of PA and healthy eating, details of the physical activity components of the intervention, ideas for educational activities, and tips for getting their pastors and congregations interested and motivated. The HDs and PACs were given simple manuals on how to implement the intervention at their churches and incentives to share with the congregation. Technical assistance was also provided after the trainings.We selected for interview a random sample of 50 trained HDs or PACs (25 trained during the first year of the intervention and 25 trained during the second year) from all trained HDs and PACs. The interviewees consented verbally to participate. Trained project staff conducted the interviews and took detailed interview notes. Also collected was information about the church, including size  and congregation composition .An interview guide was developed so that we could collect data and assess each component of RE-AIM. The guide consisted of open-ended questions asking HDs and PACs to describe details about their program activities (if any), barriers they encountered, and their successes and struggles with offering the Physical-e-Fit program. Additional details about the interview guide are given in the next section with the description of how we assessed each component of the RE-AIM framework.reach , we asked interviewees to estimate the number of participants in their Health-e-AME Physical-e-Fit programs and to describe the demographic characteristics  of the participants. We analyzed separately the data on women, people aged 41 to 64, and people aged 65 or older. The number of churches with trained HDs or PACs was also recorded.To assess Given the large size of the Health-e-AME Physical-e-Fit program, detailed information on the effectiveness analyses of this intervention is beyond the scope of this article. However, measuring its effects on levels of PA is described in detail elsewhere . In brieWe estimated the adoption rate  through interviews with the HDs and PACs. Interviewers assessed whether the interviewees implemented the program correctly. If the interviewers determined that the program was not implemented correctly, they asked what barriers the HDs and PACs met and how they planned to overcome those barriers. We also estimated the adoption rate by church size, geographic location, and characteristics of the church neighborhood as determined by census data .We measured the level of implementation  at churches that had at least one PA program. The interviewers went through a checklist of principles for the Physical-e-Fit programs with the interviewees and determined how well each church adhered to the program's principles when implementing the intervention.We assessed both organizational and individual maintenance. That is, we determined the extent to which the Health-e-AME Physical-e-Fit program became integrated into the activities of the churches that had a trained HD or PAC, and we determined the extent to which individuals who enrolled in intervention activities continued with those activities. To do so, we interviewed only the 25 trained HDs and PACs from year 1 of the intervention. The interviewers assessed whether the interviewees had taken one of three actions: 1) implemented intervention activities that were still ongoing, 2) implemented intervention activities that were no longer being offered at the church, or 3) had never implemented any intervention activities. Interviewees who were still offering intervention activities described 1) their challenges to continuing to offer the activities and 2) their plans for continuing to offer them in the future. Those who had once offered intervention activities but stopped described what prevented them from continuing to offer the program. On the basis of data collected through these interviews, we assessed the percentage of churches who continued to participate in the program.We assessed individual maintenance in the program by asking the HDs and PACs to estimate the length of participation in PA by individuals involved in any PA activity. On the basis of these estimates, we assessed the percentage of continued individual participation in the programs.We contacted 76 HDs or PACs with a request for an interview and actually interviewed 50. All interviewees were women, which was representative of all of trainees, whom we estimated to be 95% female. We were unable to interview 26 HDs or PACs for the following reasons: unable to reach after repeated attempts (n = 14), telephone number incorrect or disconnected (n = 6), no longer attending the church (n = 2), unwilling to participate (n = 2), and reason unknown (n = 2). A total of 889 congregants from 303 churches, about 50% of all AME churches in South Carolina, were trained in the activities and principles of the intervention. Because reach data were skewed, we report only ranges and medians. Overall reach (the proportion of church members who participated in PA sessions) among the churches that participated in the program ranged from 2% to 100% with a median of 18.5%.Reach was also calculated to assess representativeness. On the basis of 50 interviews, reach among adult women ranged from 2% to 100% ; reach among adults aged 65 or older ranged from 0% to 100% ; and reach among adults aged 41 through 64 ranged from 0% to 100% . Data on men were not analyzed because interviewees reported minimal participation by men in any activity. Interviewees reported that their congregations were on average 58% female; 31% were 41 to 64, and 39% were 65 or older.P = .08). Interviewees who had heard of Health-e-AME were significantly more likely to report engaging in some type of PA at the 1- and 2-year follow-ups, and were significantly more likely to be following PA recommendations at the 2-year follow-up interview than at the 1-year interview.As previously reported, 418 (73%) people from the baseline cohort of randomly selected church members completed the 1-year and 316 (55%) completed the 2-year follow-up telephone surveys , congregants' ethnicity or race, or the socioeconomic status of the census tract in which the church was located. Reported barriers to adoption at churches with more than one person trained in the Health-e-AME intervention were not different from the barriers faced by churches with only one person trained.The most commonly reported challenges at churches that adopted the program were lack of motivation or commitment from the congregation (45%), problems related to the pastor  (24%), and problems related to the health director  (18%). Among churches that did not adopt the program, issues related to the HDs or PACs  were the most common barriers (80%). Also stated as barriers were church-related factors  (60%) and lack of motivation and commitment from the congregation (60%).8 Steps to Fitness) was the least commonly offered. Adherence to program principles ranged from 50% to 100%. Screening potential participants to ensure they could safely engage in praise aerobics was the principle least adhered to.Implementation results are shown in HDs and PACs trained during year 1 estimated the length that individuals participated in the PA components of the intervention. HDs and PACs from the 13 churches (52%) that maintained their programs throughout year 1 indicated that most participants who enrolled when the program began stayed with the program.Of the 25 churches with HDs or PACs who were trained during the first year, 13 were still offering at least one PA component when we interviewed the HDs and PACs, 7 had begun the intervention but were no longer offering any components, and 5 had never offered any components. The 13 churches that were still offering intervention components most often cited lack of motivation or commitment from the congregation (38%) as their greatest challenge to maintaining it. The primary reasons (71%) that seven churches stopped offering PA components were problems related to the HDs or PACs .This study was done in response to 1) the recent call for evaluations of how research findings translate into large-scale projects and 2) the need for understanding the logistics of implementing such projects ,20-22. OWe examined the public health effect of the Health-e-AME Physical-e-Fit program using the RE-AIM framework to assess the individual and organizational factors associated with a large public health project with community participation. Although we did formative research with both men and women, the intervention as designed did not reach male AME members, which means that the intervention needs to be adapted to make it more appealing to men. Other public health programs set up in churches found that recruiting the pastor as a role model and supporter of the program can increase participation , and thiAssessing barriers to adoption while the project was ongoing allowed program planners to modify the training and overcome the most common barriers. During the final year of the program, planners worked to overcome obstacles to getting the program started by adding training on issues such as how to deal with pastor-related problems and how to increase motivation and interest among congregants. In addition, more than one person from a church was trained so that program implementation was not dependent on one person. Our results emphasize that the program's success depended on volunteers, and future intervention planners should consider other approaches to implementing the program in churches . Theories on the capacity of a community to implement and maintain health promotion programs emphasize the need to train and motivate volunteers in order to be successful .To ensure the institutionalization and sustainability of the intervention, it is essential to ensure that volunteers receive adequate training, support, and recognition. Lack of training and recognition may explain some of the challenges churches experience with maintaining health promotion programs over time. Future large-scale interventions could include additional trainings for volunteers on how to overcome barriers, recognize successes, network with other volunteers, and re-energize programs to promote their continuation. Given the size and scope of this project (303 churches statewide), program organizers could not provide the additional training. Organizers of similar interventions with lay health volunteers found that incentives and a large team of church members running the program were useful ways to improve success rates ,25. The Given the less-than-ideal rates of organizational maintenance, we believe that additional strategies to encourage and support continuation of the intervention are needed. Some ideas for doing so are holding special training sessions for church HDs and PACs every year to deal with common barriers and developing new program activities to increase interest and excitement for the program. Other interventions in churches also struggled with maintenance and developed approaches for ensuring that the interventions continued ,25,26. OInterventions that produce great environmental and social changes  might have a better chance of succeeding than would interventions that promote only PA. This intervention included activities designed to create social and environmental changes, but they were not as successful as we had planned. Perhaps more training on ways to make environmental changes would improve maintenance of the intervention at churches. Individual participants who joined a church's PA program as soon as it was offered maintained their participation; similarly, people who join other church activities  usually continue participating. Unfortunately, because of the large size and geographical dispersion of this intervention's participants, we were unable to assess maintenance directly through interviews with participants, a stronger method of doing so than the one we used. Future adjustments to the program should include providing activities and events of interest to more members of the church, particularly men and adults older than 65.This study assessed factors that affect the many layers of this intervention in order to understand individual and organizational participation. The RE-AIM model allowed us to examine comprehensively the intricacies of program design, implementation, and evaluation. A recent review by Klesges et al  indicateThis study has some limitations. Although interviewees were selected at random, the cohort may have been biased. HDs and PACs whose programs are successful may be more likely to agree to an interview than those who struggle with their programs. Some HDs and PACs may be reluctant to disclose that they were not successful with their programs for fear of repercussion from their pastor or other church leader. Related to this limitation, because this study relied on self-reported information, the possibility that interviewees gave socially desirable responses must be considered. Interviewees may have wanted to make themselves or their church look successful. Lastly, more than 250 churches had HDs or PACs trained in the Health-e-AME Physical-e-Fit program when the interviews occurred. Therefore, this group of 50 interviewees represented a relatively small sample of trained HDs and PACs. Despite these limitations, these results contribute to a growing body of knowledge about the design, implementation, and evaluation of large interventions implemented in churches to increase levels of PA.Limited information is available about the RE-AIM framework for health promotion programs conducted in partnership with community organizations. This study provides the groundwork for future community health promotion programs as a model for intervention design, implementation, and dissemination. In addition, the results of this study contributed to the intervention being modified to address barriers to implementation and helped us to understand some reasons for the suboptimal effectiveness of the program.


BCR/ABL1 fusion gene, which is a constitutively activated tyrosine kinase. Around 1% of CML patients appear to have a Ph negative karyotype but carry a cryptic BCR/ABL1 fusion that can be located by fluorescence in situ hybridisation (FISH) at chromosome 22q11, 9q34 or a third chromosome. Here we present FISH mapping data of BCR and ABL1 flanking regions and associated chromosomal rearrangements in 9 Ph negative BCR/ABL1 positive CML patients plus the cell line CML-T1.Chronic myeloid leukaemia (CML) is a haematopoietic stem cell disorder, almost always characterized by the presence of the Philadelphia chromosome (Ph), usually due to t or its variants. The Ph results in the formation of the BCR/ABL1 was located at 9q34 in 3 patients, 22q11 in 5 patients and CML-T1 and 22p11 in 1 patient. In 3 of 6 cases with the fusion at 22q11 a distal breakpoint cluster was found within a 280 Kb region containing the RAPGEF1 gene, while in another patient and the CML-T1 the distal breakpoint fell within a single BAC clone containing the 3' RXRA gene. Two cases had a duplication of the masked Ph while genomic deletions of the flanking regions were identified in 3 cases. Even more complex rearrangements were found in 3 further cases.BCR/ABL1 formation resulted from a direct insertion (one step mechanism) in 6 patients and CML-T1, while in 3 patients the fusion gene originated from a sequence of rearrangements (multiple steps). The presence of different rearrangements of both 9q34 and 22q11 regions highlights the genetic heterogeneity of this subgroup of CML. Future studies should be performed to confirm the presence of true breakpoint hot spots and assess their implications in Ph negative BCR/ABL1 positive CML. BCR/ABL1 fusion gene, a constitutively activated tyrosine kinase, harbored by the Philadelphia chromosome (Ph), which is a result of a t or a related variant translocation [BCR/ABL1 fusion gene can be identified by molecular means and located by fluorescence in situ hybridisation (FISH) on chromosome 22q11, 9q34 or even a third chromosome. The biology and clinical significance of the genetic rearrangements in Ph negative BCR/ABL1 positive disease have been widely discussed following the first descriptions [ABL1 into the BCR region (or vice versa) or by a multiple step model where a classical t is followed by a translocation of both products and/or another autosome, thereby restoring the normal chromosome morphology. In both instances, more than the 2 breaks associated with classical t are implicated. Although as early as 1990 Morris et al. [3' ABL1 site, the extent of the genomic rearrangements in this form of CML are unknown.Chronic myeloid leukaemia (CML) is a pluripotent haematopoietic stem cell disorder defined by expression of the  of a t9;2, 22q11 (5 patients and CML-T1) and 22p11 (3 patients), resulting in relocation of sequences well in excess of either 3' ABL or 5' BCR by means of a direct insertion (6 patients and CML-T1) or a sequence of events (3 patients). Recurrent distal breakpoints were found at the regions of RAPGEF1 and RXRA genes.In view of the few studies published with a precise map of the insertions -10, we aBCR/ABL1 positive disease collected from Hammersmith and Royal Free Hospitals , together with the cell line CML-T1, were investigated  with Ph negative tine use . A minimtine use .BCR/ABL1 Dual Color, Dual Fusion Translocation Probe  was initially performed using manufacturer's protocol to identify the chromosome location of the BCR/ABL1 fusion gene. FISH mapping was carried out with Bacterial Artificial Chromosomes (BAC) clones obtained from the BACPAC Resources Center , the Sanger Centre  and Invitrogen   Table . Clones BCR gene. Since this BAC covers both major and minor BCR breakpoints, it is found split when BCR gene is rearranged. RP11-61N10 covers BCR non-coding sequences centromeric to the breakpoint and it was used to identify 5' BCR region. RP11-83J21, which covers the 3' end of ABL1 incorporating the whole of the coding region, was used to identify the sequences telomeric of the ABL1 breakpoint, whereas RP11-57C19 was used to identify the ABL1 sequences centromeric of the breakpoint.BAC RP11-164N13 was used to target The BAC clones and genes were located according to the UCSC database, hg17  . MappingArray CGH analysis (aCGH) was carried out on the cell line CML-T1. The aCGH was performed using two platforms – 1 Mb BAC clone chip (SGI2600)  and oligBCR/ABL1 positive samples from 9 CML patients with normal bone marrow (BM) karyotype as well as the cell line CML-T1 with masked Ph chromosome is presented Figure A summary of the molecular cytogenetic investigations carried out on BCR/ABL1 D-FISH probe (Vysis) contains sequences covering both genes labelled in different colours, so that rearrangements affecting them can be visualised at chromosome level. The ABL1 probe (red) targets a 650 Kb region of 9q34.1 including the whole of the ABL1 gene (173.8 Kb), thus spanning the common breakpoint, and extends 5' of ABL1 to incorporate the ASS gene. The BCR probe (green) is represented by two 600 Kb regions of 22q11.2 separated by a 300 Kb gap, one of the regions covering the entire BCR gene and extending 5' of it in order to include the IGLV gene, and the other starting 300 Kb telomeric of BCR and ending at 900 Kb 3' of the gene. The application of this probe revealed the BCR/ABL1 fusion at three different chromosome sites: at 22q11.2 (samples no 1–6), at 22p11 (sample no 7) and at 9q34 (samples no 8–10). There was evidence for the formation of the reciprocal ABL1/BCR fusion in just one patient (no 4), which showed 2 fusion signals at der(22) and der(9). In the remaining cases only 1 fusion signal was observed, irrespective of the fusion gene location.The ABL1 . Patient no 3 had also developed a sub-clone with a duplication of the masked Ph and loss of the normal 22 homologue (2 red 2 fusion D-FISH pattern), as seen in 4 out of 20 metaphases (20%). On the other hand, D-FISH in patient no 1 showed a 1 red 1 green 1 fusion signal pattern, uncovering a deletion of sequences centromeric to ABL1 at the der(9)ins in all cells screened .In addition, D-FISH also revealed the presence of different clones with further rearrangements in CML-T1 and patients no 1 and 3. CML-T1 was found to harbour 3 clones: i) 7 out of 20 metaphases (35%) showed a 2 red 2 fusion signal pattern typical of diploid cells with duplication of the masked Ph and no normal 22 homologue ; ii) 7 out of 20 metaphases (35%) showed a 4 red 4 fusion pattern for tetraploid cells with duplication of the masked Ph and no normal 22; iii) 6 out of 20 metaphases (30%) showed a 2 red 4 fusion pattern for tetraploid cells with duplication of the masked Ph, no normal 22 and deletion of 5' ABL1 moved to 22q11 in 6 cases (no 1–6), whereas RP11-57C19 remained at der(9) in all but one , 1 Mb in 2 cases (no 2–3), between 1.6 Mb and 2.2 Mb in 1 case (no 6) and 3.9 Mb in 2 cases (no 4–5). The estimated sizes of the insertions were calculated based on the information of the BAC clones chromosome location available at the UCSC database (genome build 35). In cases no 1–5 the insertions were found to stretch distally falling into two sub-groups: a "small" insertion (720 Kb–1 Mb) and a "large" insertion (3.9 Mb)  the inserted material was found to be larger (estimated size of 3.9 Mb) and the distal breakpoint fell within a single BAC clone (RP11-92B21) containing the 3' end of the RXRA gene  and affect not the der(9)ins but the "normal" 9. This was demonstrated by FISH when co-hybridizing a BAC clone found within the insert (in green) and a BAC from chromosome 9 centromeric or telomeric to the inserted sequences (in red). Tetraploid cells with a deletion displayed 2 red signals from two chromosome 9 and 4 green signals from the 4 masked Ph chromosomes. Therefore not only two red signals were deleted, but also the 2 green signals from the "normal" 9 were missing, demonstrating that the loss had occurred at the "normal" homologues.High-resolution aCGH analysis of the cell line CML-T1 identified a gain at 9q34.1 starting at BCR flanking regions, all probes tested from chromosome 22 remained at their original locations in cases no 1, 2, 3 and 5. However, in case no 4, sequences distal to the BCR breakpoint and housed by the BAC clones RP11-164N13, RP11-529P21, RP11-223O10 and RP11-698L6 were found embedded within the der(9) chromosome at the 9q34 region  Figure . FISH paBCR/ABL1 fusion was unexpectedly found at 22p11 in 1 patient (no 7)  Figure . FISH wiBCR/ABL1 fusion was located by FISH at band 9q34.1 in 3 patients (no 8–10) and thought to result from a direct insertion of 22q11.2 sequences. As expected, the telomeric breakpoint was found in all cases within the BAC clone RP11-164N13, which was always seen at both der(9) and der(22)  Figure . RP11-61BCR breakpoint, covered from the 3' end of RP11-164N13 to at least RP11-765G14 , UCK1 (uridine-cytidine kinase 1) and RAPGEF1 . In another patient and CML-T1 the breakpoint fell within a single BAC clone encompassing the 3' end of RXRA gene . Although further investigations were not carried out in this study, both RAPGEF1 and RXRA belong to pathways the disruption of which may be relevant to the evolution of the patients. RAPGEF1 has been shown to have transformation suppressor activity towards several oncogenes [BCR/ABL1 [RXRA belongs to a family of nuclear receptors that target multiple signalling pathways [RXRA to contribute in acute promyelocytic leukaemia transformation [RAPGEF1 or RXRA genes, their potential role merits further investigation.The fusion gene was located at 9q34.1 in 3 patients, at 22q11.2 in 5 patients and CML-T1, and at 22p11 in another patient. 5 out of the 6 cases with a 9q34 insertion at 22q11 displayed recurrent distal breakpoints that fell within two gene bearer regions. Thus, in 3 patients a common breakpoint cluster of 280 Kb was found. According to UCSC database, this region houses 3 genes: ncogenes ,21 and apathways  and its pathways . Other sormation ,26. AlthABL1 was identified in 1 patient, while the other had a 9q34 insertion at the BCR region with a distal breakpoint falling within the clone RP11-353C22 . This result matches with our findings since the latter BAC is located within the same 280 Kb common breakpoint region identified in 3 patients of our study. On the other hand, Valle et al. [BCR. This insertion is larger than the ones identified in our study and was not accompanied by any deletions or other rearrangements.Two other mapping studies that found similar insertions have been published ,8. In thABL1 and/or 3' BCR sequences at the der(9) chromosome in patients with classical and variant Ph translocations [BCR and ABL1 genes are very useful for revealing these events but they have a limited value in interphase nuclei in patients with masked Ph, since often the merging of the 5' BCR and 3' ABL1 signals by simple insertion leads to an apparent loss of one fusion signal that can be falsely assessed as deletion [ABL1 at der(9). If the patient has a direct ins the D-FISH signal pattern is 1 red, 2 green, 1 fusion, which could be mistaken for a typical t with deletion of 3' BCR at der(9). Furthermore, Ph negative BCR/ABL1 positive patients with either a cryptic deletion of 5' ABL1 or 3' BCR show a 1 red, 1 green, 1 fusion D-FISH pattern, also typical for a t with deletion of the reciprocal ABL1/BCR fusion. Therefore, when a deletion signal pattern is detected by interphase FISH with a dual colour, dual fusion probe, it is essential to look also at the metaphases in order to be able to differentiate a classical t with deletion from a simple insertion.Deletions of 5' ocations  have beeocations , althougocations -31. Dualdeletion . Thus, DBCR/ABL1 positive patient with an insertion of ABL1 into BCR associated with a deletion of the ASS – 5' ABL1 region. Zagaria et al [ABL1 and 3' BCR regions; the other patient with a multi-step variant translocation and a deletion of around 400 Kb telomeric of the ABL1 gene. In addition to them, De Melo et al [ABL1 deletions in 2 patients and 3' BCR deletion in 1 patient out of 14 CML patients with masked Ph. Our study confirmed and sized such deletions in 2 patients which where also part of De Melo's cohort. CML-T1 also had a 8.7 Mb deletion of 9q34 material in one of the sub-clones, but in this case the loss was found to affect the homologue not involved in the BCR/ABL1 formation.Batista et al  reportedia et al  also replo et al  identifiBCR/ABL1 fusion accompanied by loss of the normal homologue in 1 out of 9 patients in this study plus the cell line CML-T1. Such duplications of the BCR/ABL1 bearing chromosome (either chromosome 22 or 9) seem to be a relatively common event in Ph negative BCR/ABL1 positive CML patients, being accompanied by loss of the normal homologue in most of the cases and seen both in chronic phase and blast crisis [We identified a duplication of the chromosome 22 harboring the t crisis -35.BCR/ABL1 positive CML patients, Morris et al [BCR/ABL1 results from a simple insertion of either 3' ABL1 into BCR or 5' BCR into ABL after three genomic breaks; and a multiple step model, with an initial classical t followed by a second translocation of both products and/or a third chromosome, requiring a minimum of 4 genomic breaks.Regarding the formation of the fusion gene in Ph negative is et al  suggesteBCR and ABL1 breakpoints apart from the accompanying deletions seen in 2 patients and CML-T1. On the other hand, traces of sequential rearrangements indicating a multiple step mechanism were found in 3 patients. Patient no 4 had a 9q34 insertion at chromosome 22 with bits from 22q11 distal to the breakpoint embedded within the der(9), suggesting an initial t followed by further translocation of both products. Patient no 7 carried the BCR/ABL1 fusion at 22p11. Sequences downstream of the breakpoint remained at their original location, while 5' BCR and all 9q34 sequences distal to ABL1 breakpoint (including the telomere) were relocated at 22p11, which could be explained by an initial t followed by a three-way translocation between 9q34, 22q11 and 22p11. This sequence of events would have required 5 breaks (2 for the translocation and 3 for the second one). However, an initial ins followed by a reciprocal translocation between 9q34 and 22p11 would also require 5 breaks and therefore cannot be ruled out. Finally, patient no 6 had a three way cryptic t with 9q34 sequences embedded within the der(22), suggesting an initial ins followed by a translocation between chromosomes 16 and der(22)ins. These data show not only that the two mechanisms do happen, but also that they are not excluding options. An example of the latter is patient no 6, where an initial direct ins would be part of the spectrum of rearrangements that had restored the normal morphology of the der(22).Our study provided evidence for the existence of both mechanisms implicated in the formation of the fusion gene in Ph negative patients. We found a simple insertion (one step event) in 6 out of 9 patients  and CML-T1 (no 5), with no evidence of secondary rearrangements within the regions flanking BCR/ABL1 fusion resulted from relocation of not only the 3' ABL1 sequences within BCR at 22q11.2 or 5' BCR sequences within ABL but also a considerable amount of flanking material, with distal recurrent breakpoints of the excised 3' ABL1 sequences at RAPGEF1 and RXRA regions. BCR/ABL1 resulted from a direct insertion (one step mechanism) in 6 patients and CML-T1, while in 3 patients the fusion gene was a result of a sequence of events (multiple steps). Finally, the presence of different rearrangements of both 9q34 and 22q11 regions demonstrates the genetic heterogeneity of this subgroup of CML. Future studies should be performed to confirm the presence of true breakpoint hot spots and assess their implications in Ph negative BCR/ABL1 positive CML.In summary, we found that the The authors declare that they have no competing interests.AV carried out the FISH mapping and wrote the manuscript. DB, AC and CG performed the array CGH and qPCR analysis. AR, JH, MV and VDM performed G-banding and initial FISH analysis. DM and JFA provided clinical samples. EN designed the study, supervised its execution and co-participated in the writing of the manuscript. All authors read and approved the final manuscript.


Falls are a public health problem for the growing population of older adults. We describe a statewide effort to implement and disseminate A Matter of Balance/Volunteer Lay Leader model, an evidence-based fall-prevention program.We analyzed 2 secondary databases: 1) a centralized administrative data set to document implementation processes and structures for delivering the program and 2) a common set of outcome measures for assessing the effect of the program on older Texans. We used multivariate analyses to examine changes on key outcome variables, controlling for major covariates.From 2007 through 2009, we reached 3,092 older Texas residents. Program capacity was built by certifying 98 master trainers and 402 lay leaders and delivering the program in 227 classes through the Area Agency on Aging network. Immediate outcome results were positive, which indicates a pathway to promote more successful aging: 1) increases in falls efficacy, 2) improvements in overall physical activity levels, and 3) reductions in interference with everyday normal routines.Widespread dissemination of a program to prevent falls can promote active aging among people who would otherwise be at risk for a downward cycle of health and functionality. Creating partnerships among different delivery sectors is needed for building community infrastructure to enhance the health of older adults. Falls among seniors are one of the most preventable causes of injuries, disabilities, and loss of independence ,2. In 20A Matter of Balance/Volunteer Lay Leader model (AMOB/VLL) is an evidence-based activity program for community-dwelling older adults; it is intended to reduce fear of falling and increase physical activity levels among seniors. AMOB/VLL can be implemented in 2 versions: a 4-week version with classes that meet twice a week or an 8-week version with weekly classes (www.texasfpc.org/index.php) disseminated AMOB/VLL across partnering Area Agencies on Aging (AAA) service areas. The Texas A&M Health Science Center provided standardized protocols for programs documenting implementation processes (program reach and adoption) and assessing program outcomes.Working with the leadership of the Texas Association of Area Agencies on Aging, the Texas Falls Prevention Coalition .The evaluation team created a detailed evaluation manual to standardize implementation processes and obtain common data across all participating sites  from AAA sites. Program coordinators at each participating AAA site kept administrative records that were requested by the evaluation center monthly. This information was checked for completeness and accuracy by the Texas Falls Prevention Coalition coordinator. We obtained information on program capacity, which we defined as the number of master trainers and lay leaders at each participating AAA site. We tracked trainer attrition (the number of active and inactive master trainers and lay leaders) through reports from program coordinators, who kept up-to-date rosters of people available to teach the classes. Consistent with the national implementation of evidence-based programs supported by the Administration on Aging, we used a standardized form to capture the types of delivery organization for each class. We defined program adoption in terms of the number and types of organizations that delivered classes under the auspices of the Texas Falls Prevention Coalition.Program coordinators who collected administrative data at each participating AAA site coded the class delivery sites as senior centers, residential facilities, community centers, faith-based organizations, health care organizations, workplaces, or others. We used administrative data to illustrate the spread of AAA site participation over time. This information was mapped for each AAA region across the 254 Texas counties. Using participant residential zip codes, we assessed how many participants were served by each AAA site.We collected baseline assessment data from participants at the beginning of the first class and postintervention data at the end of the last class (session 8). The self-reported assessment questionnaire was 9 pages and consisted of 28 items. Survey instrument items included Likert-type, yes/no, closed-ended, and open-ended questions. The questionnaire took approximately 15 minutes to complete, or longer for respondents who needed assistance.Participants voluntarily enrolled in Texas Falls Prevention Coalition-sponsored AMOB/VLL classes in 19 AAA participating regions throughout Texas. We included age, sex, race/ethnicity, education level, income, and number of chronic conditions as participant demographic characteristics. We used participant responses — health status indicator variables collected at baseline and postintervention — as outcome variables for this study. The falls efficacy scale  assessed participants' perceived ability to prevent falls and injuries from falls ,6. The h2 and F tests were used to test for substantial differences in the percentages or means of selected demographic characteristics for participants who completed baseline and postintervention assessments and those with no postintervention assessments.We examined participant data, collected at the beginning and end of the intervention, by using descriptive and multivariate analyses. Not all participants enrolled in the intervention completed instruments at baseline because not all sites collected data for every class they delivered. For participants with available data, we calculated frequencies of demographic characteristics to describe the reach and participant representativeness. We then performed analyses to identify any systematic biases resulting from missing data. The Pearson χFor multivariate analyses, we used only participant records with complete baseline and postintervention data on all variables. To analyze the AMOB/VLL data for differences from baseline to postintervention, we used a mixed model that accounted for cluster effects with repeated measures. We controlled for age, sex, race/ethnicity, and general health status in each multivariate model. We performed all analyses in SAS version 9.2 .As of October 1, 2009, a total of 3,092 unique participants were recruited throughout Texas. These participants averaged 77 years of age (15% were aged ≥85); most were women (83%) and were high school graduates (82%). A high proportion of disadvantaged seniors enrolled in the programs . Of the 3,092 participants, 87% had baseline data, 56% had postintervention data, and 51% had both.Before assessing program effects, we conducted a bivariate analysis to examine the potential existence of significant differences between those participants who had baseline data only versus those with both baseline and postintervention data. A few differences emerged. More participants who had complete data at both time periods, and thus were included in the multivariate analysis, were non-Hispanic white (73% vs 64%), had attended college (58% vs 50%), and reported fewer unhealthy days (4.8 vs 5.9).The Texas Association of Area Agencies on Aging sponsored 4 centralized master trainings. All participating sites were encouraged to send people in their AAA region to become certified, making them eligible to train lay leaders at their local site. As a large state with a commitment to preventing falls for seniors, Texas now has more trainers than any other state delivering AMOB/VLL. Of the 98 people trained as master trainers, 83 were still actively training. Of the 402 people trained to be lay leaders, 278 were still active. Given these data, the Texas Falls Prevention Coalition leaders recognized lay leader attrition as a problem. Local AAA sites now give more attention to recruitment and retention planning; their goal is to achieve higher retention of volunteer lay leaders and provide support services more efficiently.As of October 1, 2009, 227 AMOB/VLL classes had been delivered at 146 unique sites. The most frequent implementation sites were senior centers (77 classes) and residential facilities (63 classes). Other sites included faith-based organizations (23 classes), health care organizations (12 classes), and workplaces (7 classes). Programs retained most participants: 76% of class participants completed at least 5 of 8 sessions. The average class size was 15 participants, which was larger than the ideal class size of 8 to 12 participants.Twenty-six of the 28 AAAs contracted with the Texas Association of Area Agencies on Aging to deliver the AMOB/VLL program, for a potential reach of 236 of 254 Texas counties . Each paResults were uniformly positive for AMOB/VLL participants . Adjustemanualized so others may easily adopt them . Discussion is taking place at the national level of the need to document programmatic costs and compare these costs with reported outcomes. This is not possible in the current study, where analyses were conducted only at the immediate postintervention period. This study is also subject to a common research limitation — the lack of long-term follow-up data . Some siThe recent movement toward building healthy communities  may guidMost local AAAs have reached out to nontraditional aging partners for program delivery , and these types of partnerships are needed to broadly disseminate the intervention. We recommend that these types of evidence-based programs be implemented where seniors live, play, or pray, to achieve healthy aging and healthier communities . A broad