Making Science Work in the Community

May 10, 2021 Joe Brady

When research shows that a health intervention works, you might think that health care providers and patients would start using it right away. But that may not happen. It can take years before research evidence is incorporated into clinical practice.

Over the last 20 years, a growing body of evidence suggests that some complementary approaches, such as acupuncture, hypnosis, massage, mindfulness meditation, spinal manipulation, tai chi, and yoga, may help to manage many types of health conditions including in the treatment of pain. Integrative health care often brings conventional and complementary approaches together in a coordinated way. It emphasizes a holistic, patient-focused approach to health care and wellness—often including mental, emotional, functional, spiritual, social, and community aspects—and treating the whole person rather than, for example, one organ system.

The use of integrative approaches to health and wellness has grown within care settings across the United States. Researchers are currently exploring the potential benefits of integrative health in a variety of situations, including pain management for military personnel and veterans, relief of symptoms in cancer patients and survivors, and programs to promote healthy behaviors.

Researchers have assumed that complementary and integrative therapies proven effective would be readily adopted and implemented in the community. This is turning out to be more difficult and compelling evidence is showing that there is a long way between science demonstrating the effectiveness of therapy and its implementation in the community. Even when interventions have been tested in the community, the development of the public education needed to support their broader use is lacking. In the context of complementary health approaches, for example, there is much evidence to support the efficacy and effectiveness of acupuncture for chronic low-back pain, and guidelines from the American College of Physicians recommend acupuncture as a first-line treatment for pain; however, there is very limited utilization or referrals in conventional health care settings for using acupuncture to treat pain. Providing the funding and training and resources need to implement any programs like exercise, meditation, yoga, tai chi, qigong, and a hundred other healthy lifestyle activities are very difficult to come by. Competing with large-scale pharmaceutical companies who can afford multi-million dollar ad campaigns for opioids, for example, is just not possible for your lowly little tai chi or yoga instructor no matter if a hundred studies show they are more effective for treating pain. 

To answer this problem many researchers have taken to a new area of scientific inquiry called implementation science. Implementation science is the study of strategies to make effective use of evidence-based health programs in community settings to improve the health of the population. The field of implementation science focuses on closing the gap between evidence and practice. Researchers in this field seek to understand the strategies and processes used to implement interventions, the barriers and facilitators to change, and how they vary in different contexts.

Community Med School Research at the University of Denver

In the research we are conducting for the University of Denver we are using an implementation science method called the RE-AIM model. To help program planners, evaluators, funders, and policymakers plan evaluate, and implement health programs in real-world settings, psychologist Russell E. Glasgow, Ph.D., and his colleagues developed a conceptual framework called RE-AIM. Initially created to evaluate interventions in health behavior, RE-AIM also serves as a helpful planning tool for a whole range of programs and policies in health promotion. 

The RE-AIM model (Reach, Effectiveness, Adoption, Implementation, and Maintenance) is a comprehensive framework for program planning and implementation in the community.

  • Reach refers to the program’s ability to reach those who can benefit from the program
  • Effectiveness is the benefits the program provides participants,
  • Adoption is the use of community partnerships to amplify the reach of the program
  • Implementation is how well the program is implemented
  • Maintenance is can the program be self-sustaining.

To participate in the study

If you have already filled out a survey for the study the next round will be sent out by the end of this month. If you are currently not a participant in the study and wish to participate contact Joseph Brady the principal investigator for the study at Joseph.brady@du.edu

Read more including a new paper in the Journal of Alternative and Complementary Medicine, written by four scientists from the National Center for Complementary and Integrative Health, takes a close look at implementation science methodologies and how they apply to complementary and integrative health research. The full text of the paper is available for free.

Implementation Science Methodologies for Complementary and Integrative Health Research

David Clark, Emmeline Edwards, Peter Murray, and Helene Langevin

https://www.liebertpub.com/doi/full/10.1089/acm.2020.0446

University of Denver Research and “The Re-AIM Model”

REACH describes the absolute number, proportion, and representativeness of the persons who participate in a given program. Representativeness refers to the extent to which participants’ characteristics are the same as or different from those who are eligible but do not participate. For example, if you intended to increase physical activity among sedentary but relatively healthy people between the ages of 65 and 85, you would compare information on demographics, health, and physical activity of those who participated with those who met your recruitment criteria but declined to join. If there are no significant differences between the two groups, your participants are likely representative of the entire population you hoped to reach. If that is the case, you can then more confidently advocate expanding the program further. 

EFFECTIVENESS describes the impact of a program on important outcomes. These outcomes may include quality of life, health status, functioning in daily life, healthcare costs, and potential negative consequences. (See box “A Presumption of Effectiveness” below.) 

ADOPTION is defined as the absolute number, proportion, and representativeness of settings that are willing to offer a program. If you intended to initiate a physical activity program in hospitals, clinics, and senior centers, for example but could locate funding only for larger hospitals, you would find it more difficult to generalize or apply your outcomes to smaller settings because those settings would represent a different set of characteristics (e.g., in terms of staff, space, and resources). 

IMPLEMENTATION is the degree to which staff members follow the program as it was originally designed. The implementation also addresses consistency of delivery and cost, using the original model as the standard. Rigorous documentation, often by a third party, is essential to measuring the success of implementation. We know, for example, that relying on lay leaders to assess the progress of an exercise class might render a far more optimistic picture than relying on reports from master trainers who periodically observe the class. 

MAINTENANCE describes the extent to which a program becomes part of the routine in both the setting of interest and at the level of the individual man or woman. In settings, “maintenance” refers to organizational practices and policies. At the personal level, it refers to monitoring the long-term effects (six or more months) of a program on the man or woman’s health and functioning. For example, one intervention in physical activity/cardiorespiratory capacity, Project ACTIVE1, showed that although activity increased from the program’s beginning to six months it decreased from six to twenty-four months, supporting the need for multiple assessments of behavior over time.
For a program to be truly successful, it must perform well in all five areas described above. If your REACH is strong and you are using an EFFECTIVE program, you are well on your way. But if staff deliver the program inconsistently (IMPLEMENTATION) or the program isn’t continued after its first year (MAINTENANCE), the absolute impact of your work will be limited.