Predictors of Sustained Implementation of Low-Literacy Health Education Programs Bergen B Nelson 1,2,* , Carol Teutsch 3 , Paul J Chung 1,2,4, and Ariella Herman 3 1 Department of Pediatrics, Mattel Children’s Hospital and David Geffen School of Medicine at UCLA, USA 2 UCLA Children’s Discovery and Innovation Institute, USA 3 Health Care Institute, Anderson School of Management, UCLA, USA 4 Department of Health Management and Policy, Fielding School of Public Health, UCLA 5RAND Corporation, Santa Monica, CA, USA * Corresponding author: Bergen B Nelson, Division of General Pediatrics, UCLA, 10833 Le Conte Ave, Los Angeles, CA, USA, Tel: (310) 794-8833; Fax: (310) 206-4855; E-mail: bnelson@mednet.ucla.edu Rec date: Aug 12, 2014; Acc date: Nov 19, 2014; Pub date: Nov 21, 2014 Copyright: © 2014 Nelson BB, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Abstract Sustained implementation of health education interventions is important to optimize the impact of initial investments in program development and training. From 2002-2012, the Health Care Institute (HCI) at UCLA trained 192 Head Start grantees, serving low-income preschool children and families in the U.S., on how to implement low- literacy health education programs, using a train-the-trainer (TTT) model. The purpose of this study was to investigate what key factors of implementation are associated with sustainability of HCI programs, based on an online survey of Head Start grantees who have participated in the HCI TTT. A 51% response rate was achieved, with 96 surveys returned from the 188 sent to agencies that are still open. Of the grantees responding to the survey, 84% reported that they continue to implement HCI programs and 71% continue to implement them annually. Key predictors of annual implementation included: engagement of stakeholders at all levels; continuing to provide incentives for families; putting HCI into the annual training and technical assistance budget; sending additional staff to the TTT; seeing an improvement in overall program performance; and adapting HCI topics to meet local Head Start grantee needs. Qualitative responses described these same factors in additional detail. These results are consistent with previous research on program sustainability and suggest which elements of implementation may be most important as initial and ongoing investments, if sustainability is a program goal. Keywords: Head start program; Health education; Program implementation; Sustainability Introduction Achieving sustained implementation of health-related projects beyond initial funding periods is an important feature of nearly all successful public health and policy investments. Despite increasing interest in implementation science and a growing literature on program sustainability [1-5], few previous studies have empirically measured the specific factors associated with sustainability. The purpose of this study was to examine key predictors of sustained implementation of low-literacy health education programs in Head Start, a federally-funded preschool program in the United States that serves approximately one million low-income families each year. Because of the disproportionate health risks faced by families living in poverty [6-8], especially when also challenged by poor health literacy, finding effective and sustainable approaches to health promotion is especially important. This study analyzes survey data from Head Start grantees trained from 2002-2012 to deliver health education interventions, using an approach developed by the Health Care Institute (HCI) at the Anderson School of Management at the University of California, Los Angeles (UCLA). The HCI training approach has been described previously [9] and is based upon a 2-day multi-agency train-the-trainer (TTT) event, which provides teams from each Head Start grantee agency with the skills for project planning; targeted marketing approaches for staff, parents, and community; and tools for staff and family engagement. The health topic showcased during the TTT demonstrates how to engage and teach parents of young children to manage common childhood illnesses, emphasizing key basic skills such as how to take a child’s temperature and when to contact a health care provider. Prior research has shown a reduction in reported emergency room visits among families after participating in this health education module [10]. Additional HCI modules available to the Head Start grantees participating in this study included oral health, healthy nutrition and physical activity, prenatal care, vaccination, over-the-counter medications and sun safety. The healthy nutrition and physical activity module (“Eat Healthy, Stay Active!”) has previously been associated with statistically significant reductions in body mass index (BMI) among Head Start students, parents and staff [11]. Once grantees have participated in the full 2-day HCI TTT program, they may choose to continue to implement additional HCI health promotion modules for families using the same approach, with local adaptations as needed, without needing to attend another live training event. The purpose of this study was to document to what extent Head Start grantees trained in the HCI approach continued to implement HCI health education modules, and to explore the factors associated with sustained implementation. A long-standing conceptual model for sustainability comes from Robert Yin’s (1979, 1981) ‘routinization’ framework, developed using case studies of how innovations introduced into local governments become standard practice [12,13]. Yin argued that new practices Journal of Community Medicine & Health Education Nelson, et al., J Community Med Health Educ 2014, 4:5 http://dx.doi.org/10.4172/2161-0711.1000314 Research Article Open Access J Community Med Health Educ ISSN:2161-0711 JCMHE, an open access journal Volume 4 • Issue 5 • 1000314