Applying the RE-AIM conceptual framework for the promotion of physical activity in low- and middle-income countries

ABSTRACT Objective: the RE-AIM framework has been widely used to evaluate internal and external validity of interventions aimed to promote physical activity, helping to provide comprehensive evaluation of the reach, efficacy, adoption, implementation and maintenance of research and programming. Despite this progress, the RE-AIM framework has not been used widely in Latin America. The purpose of this manuscript is to describe the RE-AIM framework, the process and materials developed for a one-day workshop in Guadalajara, and the acceptability and satisfaction of participants that attended the workshop. Methods: lecture, interactive examples and an agenda were developed for a one-day RE-AIM workshop over a three month period. Results: thirty two health care practitioners (M age = 30.6, SD=9.9 years) attended the workshop. Most (100%) rated the workshop as credible, useful (100%) and intended to apply it in current or future research (95%). Conclusion: results suggest intuitive appeal of the RE-AIM framework, and provide a strategy for introducing the utility and practical application of the framework in practice settings in Mexico and Latin America.


Introduction
Regularly performed physical activity (PA) is an international health priority (1,2) . Physical inactivity is endemic in Mexico, and a majority of Mexican children (58.6 %) and many adults (19.4%) fail to meet physical activity recommendations (3)(4)(5)(6) . Like other low and middle income countries (LMIC), the Mexican population is at high risk for developing health compromising conditions related to physical inactivity (7)(8)(9) . Implementing research and practice in LMICs provides an opportunity to understand and investigate the application of research techniques such as the RE-AIM framework, that have, to date, almost entirely focused on high income countries.
The RE-AIM framework has been broadly applied in the US as well as other high -income countries across a wide array of PA-related research and programming; however, use of the framework has not been established in LMICs. The RE-AIM framework provides a model to inform the design, implementation and evaluation of physical activity, so its introduction in a LMIC country, like Mexico, is timely and promising. RE-AIM components of reach, efficacy/effectiveness, adoption, implementation and maintenance (individual and organizational) have been used to review internal and external validity of PA interventions using behavior change theories, school-based strategies, telephone-delivered strategies, workplace interventions, and interventions targeting cancer survivors (10)(11)(12)(13)(14) .
Similar to other LMIC, infrastructure and public health needs in Mexico have historically focused on the prevention and treatment of infectious diseases. More recently, behavioral research has started to focus on preventing chronic conditions. In the case of Mexico, national statistics describing high rates of obesity and type 2 diabetes have led to recent sweeping policy changes. These commenced in 2012 with a change in political leadership, along with international supports, leading to activities throughout Mexico to improve cardiometabolic health, with a focus on increasing PA among all Mexicans (2) . The Mexican health statistics and policy changes have provided a favorable macrolevel context to plan and evaluate current research and evidence-based interventions to increase PA in Mexico. The use of frameworks like RE-AIM allow for the possibility of achieving a public health impact by focusing on a range of outcomes such as the reach, efficacy, adoption, implementation and maintenance of these strategies. Like many LMIC, health promotion efforts in Mexico tend to rely on both clinic-based and community public health programming (15)(16)(17)(18)(19) . Programs that have a broad reach into the population while demonstrating robust effectiveness across subgroups within the population can have a strong public health impact and may be considered for broad dissemination to other communities, systems and regions (20)(21) . Despite their promise, a review of PA public health programs in Mexico showed that programs might report reach and adoption, but there was poor monitoring and evaluation of factors related to effectiveness, implementation and maintenance (22) . The evidence supporting these programs is insufficient for determining public health impact, limiting the ability to implement these programs on a broader state or national scale (9,15,19,23) . Current methods of evaluation and reporting exclude key areas that would facilitate dissemination about the expertise of those delivering the program, the program components, implementation activities and costs, the long-term sustainability of the programs and health and behavior outcomes for participants (16) .
Despite the ability of the RE-AIM framework to help researchers and practitioners evaluate and assess the public health impact, there has been little use of the framework in Latin American countries such as Mexico, in part driven by a lack of knowledge and expertise.
There is a strong need to develop capacity among public health practitioners and health promoters so that efforts can be systematically evaluated in order to disseminate successful programs across Mexico and to other LMICs with sizeable Hispanic populations. In this manuscript, we present the development and outcomes of a RE-  to report factors related to scalability, such as cost.
Another example was how retention and sustainability might make a difference in which program was more likely to be adopted across organizations. Polls were based on items from the RE-AIM measure presented in Figure 1, previously developed by Glasgow et al. and later expanded by Allen et al. (28)(29) .

Interactive examples
Materials were developed over a two month period involving three teleconference calls among the authors.

Workshop Agenda and Materials
The resulting workshop agenda featured classroom style learning for the entire group in the first half of  100 children from each center were eligible. All children were exposed to the curriculum and policy changes at the preschools. 65% of children received dietary habits report cards. Lower income families were more likely to participate in report cards. Report cards revealed that 25% of the children met fruit and vegetable recommendations before the staff training and curriculum and 70% met recommendations after the implementation. French fry and juice consumption remained high.
200 centers were invited to participate and 20 joined. 85% of teachers completed all 12 hours of training. 45% of parents at each center completed a dietary habits report card. All of the nutrition workshops were delivered as intended. Only 50% of the curriculum was delivered as intended. All report cards were completed as intended.
No cost data is available.
70% of children continued to meet fruit and vegetable guidelines at 6 months follow up. The policy was institutionalized and all centers integrated the nutrition curriculum into their regular curriculum.  This study relied on a relatively small sample size, insufficient for more elaborate statistical modeling. as examples (22) . It was a great strength to have an experienced team of presenters that included native speakers to help explain constructs to the diverse audience and overcome barriers to understanding.
Last, the RE-AIM framework may help enhance teamwork by providing clear definitions and real-world understanding of health outcomes. Workshops such as this one can promote understanding, communication, and planning across multiple disciplines, enhancing interprofessionalism and successful teamwork (30) .

Conclusion
Although the RE-AIM framework was initially conceptualized as a model to evaluate research, in reality, most interventions are tempered by the community in which they are administered. Programs can operationalize processes that involve local organizations and the intervention community itself.
For example, in health care settings, interventions and programming must be designed to integrate within the existing organizational processes as well as the abilities of the practitioners and the reach of the clinic.
There is an important role for partnerships between practitioners and researchers so that practice realities can inform research ideals. There is also room for to evaluate programming that builds on existing resources, requires little advance planning, and that is reasonably easy to accomplish given existing resources.