Using process evaluation to identify implementation barriers and solutions for a physical activity program for Latinas

Successful health promotion interventions must engage in continuous quality improvement to address factors at multiple levels of influence that impact program implementation and effectiveness.  Enlace is a study designed to assess the efficacy of a promotora-led physical activity (PA) intervention for Latinas.  Eight community resource centers (CRCs) in 3 predominantly Latino counties in South Texas were randomly assigned to either the Enlace PA Intervention (4 CRCs) or a control condition (4 CRCs). To date we have enrolled 208 women; 111 PA (28/CRC) and 97control (24/CRC). The 40-week Enlace intervention includes 16 promotora-led weekly sessions plus a 24-week maintenance program. Using the RE-AIM framework we used a structured, ongoing process evaluation to identify issues relevant to implementation of the PA intervention. Sources of process data included site observations, attendance logs, program implementation checklists, and promotora weekly reports and debriefings. These data were triangulated to identify issues relevant to program content, delivery, infrastructure, and environmental context. We identified implementation barriers at multiple levels: individual (i.e., health literacy, depression, varying levels of fitness and exercise skills), interpersonal (i.e., childcare, spousal support and other family responsibilities), organizational (i.e., inadequate meeting space and equipment; community relations; promotora’s schedules), and environmental (i.e., presence of border patrol, poverty, violence). Strategies to address these implementation barriers include curriculum modifications to simplify content, additional training and support for promotoras, strategic communication with CRC directors, enhanced rewards/recognitions structure to increase program identity and participation, and increased opportunities for participant social interaction.