Process evaluation of a community-based health promotion intervention: RE- AIM framework analysis of Happy Village Plus in Sri Lanka

Imagine a world where the biggest health threats aren't tiny bugs you catch from a sneeze, but rather habits we build over years: eating too much junk, moving too little, and smoking. These are called Non-Communicable Diseases (NCDs), and they are like a slow-moving fog that is getting thicker in many countries, especially those with fewer resources. To fight this fog, scientists and doctors often try "health promotion" programs. Think of these programs as a map and a compass designed to guide communities toward healthier lives. But here's the tricky part: a map is useless if the people walking the path don't trust the mapmaker, or if the path is blocked by rocks the map didn't show. This is where a special tool called the RE-AIM framework comes in. It's like a five-point checklist for health programs: Reach (who showed up?), Effectiveness (did it actually help?), Adoption (did the right people join in?), Implementation (did they do it the right way?), and Maintenance (will they keep doing it when the project ends?). Researchers use this checklist to see if a health program is just a good idea on paper, or if it can actually survive and thrive in the messy, real world.

This paper takes a deep dive into a specific health program in Sri Lanka called "Happy Village Plus" (HVP). The researchers wanted to see if this program, which relied heavily on local volunteers instead of just doctors, could successfully navigate the five points of the RE-AIM checklist. They didn't just count heads; they listened to stories, read daily logs, and interviewed people to understand the why and how behind the numbers.

The Story of Happy Village Plus

Imagine a team of scientists trying to plant a garden in six different neighborhoods in Sri Lanka. These neighborhoods are in the Colombo and Gampaha districts, areas that are quite crowded and where people are facing rising rates of diabetes and heart disease. The garden they wanted to grow was a community health program called Happy Village Plus. Instead of hiring a army of expensive doctors to march into these neighborhoods, the program recruited local volunteers—people who lived right there, knew the neighbors, and spoke the local language. Their job was to teach people about healthy eating, getting moving, and avoiding bad habits like smoking.

The researchers used a "mixed-methods" approach, which is like using both a camera and a microphone. They took photos of the numbers (how many events happened, how many people attended) and recorded the voices (what people felt, what barriers they faced). They analyzed 2,192 different activities that happened between 2021 and 2022.

Who Showed Up? (Reach)
The first thing they checked was "Reach." Did people actually come? The numbers showed that the program was busy, with 1,005 community-level events happening. However, the researchers found a big hurdle: many people were suspicious. They had seen health projects come and go before, leaving them with no results, so they didn't trust the new ones. They also didn't trust the government officials who usually ran these things.

But here's the magic trick: the local volunteers were the key. Because they were neighbors, not strangers in uniforms, people trusted them. One volunteer noted that people were happy to work with them because they were "from the community." The volunteers acted like a bridge, turning that initial suspicion into participation. They also had to get creative. In one village, people used to smoke and drink during funerals, which made talking about health difficult. The volunteers didn't fight this; they introduced yoga instead, which was a fresh, culturally acceptable way to get moving. It worked!

Did It Work? (Effectiveness)
The researchers couldn't measure if people's blood pressure dropped in this specific study (that's for a future report), but they looked at what made the program feel effective. They found three main helpers. First, people who already understood a bit about health were easier to teach. Second, when local doctors and clinics got involved, it added weight to the message. But the most surprising helper was the 2022 economic crisis in Sri Lanka. Because food prices skyrocketed, people couldn't afford expensive, unhealthy processed foods anymore. They were forced to cook at home and eat less sugar. This economic squeeze accidentally aligned perfectly with the program's health messages, making it easier for people to adopt healthy habits.

Who Joined In? (Adoption)
The study looked at who was actually doing the work. The community members were there in huge numbers (95% of events), but they were mostly the audience. The local volunteers were very active, showing up to 74% of events, but they only delivered the actual health lessons in 32% of cases. Why? Because they were great at gathering people and building trust, but they weren't trained to give medical advice. The heavy lifting of teaching and screening was still done by Health Promotion Officers (HPOs) and doctors.

Interestingly, the formal public health officers (the official government health staff) were surprisingly quiet. Even though they were involved in planning, they didn't show up to deliver the programs as much as the researchers hoped. It was like having a team where the coaches were talking a lot, but the players weren't on the field.

How Was It Done? (Implementation)
The program faced some real-world bumps. In one village, people wanted to exercise outside, but they couldn't afford proper shoes. The program didn't just say "too bad"; they worked with local leaders to find a way to help people get what they needed. This shows that the program was flexible. It didn't stick rigidly to a rulebook; it adapted to the reality of the village. The volunteers were trained to be flexible, learning how to teach health basics and how to use simple tools to measure health.

Will It Last? (Maintenance)
The final question is: will this garden keep growing after the researchers leave? The signs are promising. In one village, the volunteers themselves suggested starting a monthly "BMI check day" to keep the community engaged. In another, a local doctor promised to keep inviting people to health screenings as part of their regular job. The volunteers were eager to keep going, and community leaders said they would keep spreading the message. This "community ownership" is a huge sign that the program might stick around.

What This All Means

The paper concludes that Happy Village Plus was a success in showing that a volunteer-led program can work in a place with limited money. The biggest lesson is that trust is the most important tool. The local volunteers were the secret sauce that made people listen. However, the study also points out a flaw: the program relied too much on volunteers to do the heavy lifting of teaching, while the official health staff didn't step up enough to deliver the actual medical advice.

The researchers suggest that for this to work on a bigger scale, the government needs to give volunteers more formal training and clear roles, almost like making them official health workers. They also say that future health programs need to be ready for surprises, like economic crises, which can actually help or hurt the program in unexpected ways.

In short, this paper tells us that you can't just drop a health program into a community and expect it to work. You need local friends (volunteers) to build trust, you need to be ready to change your plan when things get tough, and you need to make sure the official health system is actually part of the team, not just watching from the sidelines. It's a reminder that in the world of health, the human connection is just as important as the medical facts.