Perceived versus actual factors associated with adoption and maintenance of an evidence-based physical activity program

Overcoming Barriers to Walk With Ease Implementation in Community Organizations

Introduction

The Arthritis Foundation’s Walk With Ease (WWE) program has been shown to reduce arthritis symptoms and increase physical performance for up to 1 year. However, research on community-based WWE implementation is limited. The purpose of this study was to examine early implementation at community organizations that received 1-year WWE implementation grants from the Osteoarthritis Action Alliance.

Method

Program managers at five Osteoarthritis Action Alliance grantee organizations participated in 45-minute telephone interviews. Interviewees represented organizations with the highest WWE enrollment at 6 months (n = 3, >30% of goal enrollment) and no enrollment at 6 months (n = 2). The Planning for Sustainability framework guided qualitative analysis of factors affecting early implementation.

Results

All grantees were confident in WWE’s evidence base, thought it a beneficial supplement to other programming, stressed the importance of senior leadership support for WWE, and engaged community partners for marketing support and as walking sites. Implementation experiences unique to low enrollment grantees were (1) recent major structural changes within their organization, (2) difficulties in communicating logistics internally, and (3) difficulties in balancing WWE with other responsibilities. All organizations experienced barriers that required altering their original implementation plans; however, practical solutions like adapting the program to improve flexibility, training organizational staff as leaders, and utilizing community partnerships served to address multiple barriers simultaneously.

Discussion

Building organizational capacity by overcoming early barriers is a key element of early implementation. Our findings offer concrete solutions to early WWE implementation barriers and suggest the need for further research on adaptations to improve WWE’s flexibility in community organizations.

Barriers and Enablers to Implementation of Dietary Guidelines in Early Childhood Education Centers in Australia: Application of the Theoretical Domains Framework

OBJECTIVE

To identify perceived barriers and enablers to implementation of dietary guidelines reported by early childhood education center cooks, and barriers and enablers associated with greater implementation based on assessment of center menu compliance.

DESIGN

Cross-sectional telephone interview.

SETTING

Early childhood education centers, New South Wales, Australia.

PARTICIPANTS

A total of 202 cooks responsible for menu planning; 70 centers provided a menu for review of compliance with dietary guidelines.

MAIN OUTCOME MEASURE

Barriers and enablers to dietary guideline implementation were determined using a tool assessing constructs of the Theoretical Domains Framework (TDF). Higher scores (≥6) for each construct indicated enablers to guideline implementation; lower scores (<6) suggested barriers.

ANALYSIS

Multivariable linear regression identified TDF constructs associated with greater guideline implementation.

RESULTS

Scores were lowest for reinforcement (mean, 5.85) and goals (mean, 5.89) domains, and highest for beliefs about consequences (mean, 6.51) and social/professional role and identity (mean, 6.50). The skills domain was positively associated with greater implementation of guidelines based on menu review (P = .01).

CONCLUSIONS AND IMPLICATIONS

Cooks perceived social/professional role and identity, and beliefs about consequences to be enablers to dietary guideline implementation; however, only the skills domain was associated with greater implementation. There are opportunities to target the incongruence in perceptions vs reality of the barriers and enablers to implementation. Future research could examine the utility of the TDF to identify barriers and enablers to implementation to inform intervention development and for evaluating interventions to examine intervention mechanisms.

GPs' attitudes, beliefs and behaviours regarding exercise for chronic knee pain: a questionnaire survey

OBJECTIVES

The aim of this study was to investigate general practitioners' (GPs) attitudes, beliefs and behaviours regarding the use of exercise for patients with chronic knee pain (CKP) attributable to osteoarthritis.

SETTING

Primary care GPs in the UK.

PARTICIPANTS

5000 GPs, randomly selected from Binley's database, were mailed a cross-sectional questionnaire survey.

OUTCOME MEASURES

GPs' attitudes and beliefs were investigated using attitude statements, and reported behaviours were identified using vignette-based questions. GPs were invited to report barriers experienced when initiating exercise with patients with CKP RESULTS: 835 (17%) GPs responded. Overall, GPs were positive about general exercise for CKP. 729 (87%) reported using exercise, of which, 538 (74%) reported that they would use both general and local (lower limb) exercises. However, only 92 (11% of all responding) GPs reported initiating exercise in ways aligning with best-evidence recommendations. 815 (98%) GPs reported barriers in using exercise for patients with CKP, most commonly, insufficient time in consultations (n=419; 51%) and insufficient expertise (n=337; 41%).

CONCLUSIONS

While GPs' attitudes and beliefs regarding exercise for CKP were generally positive, initiation of exercise was often poorly aligned with current recommendations, and barriers and uncertainties were reported. GPs' use of exercise may be improved by addressing the key barriers of time and expertise, by developing a pragmatic approach that supports GPs to initiate individualised exercise, and/or by other professionals taking on this role.

Expanding the Reach of Evidence-Based Self-Management Education and Physical Activity Interventions: Results of a Cross-Site Evaluation of State Health Departments

Participation in community-based self-management education and physical activity interventions has been demonstrated to improve quality of life for those who have arthritis and other chronic diseases. The Centers for Disease Control and Prevention Arthritis Program funded 21 state health departments to expand the reach (defined as the number of people who participate in interventions) of 10 evidence-based interventions in community settings. The Arthritis Centralized Evaluation assessed the strategies and tactics used by state health departments to expand the reach of these evidence-based interventions. The evaluation compared and contrasted processes used by the states to expand reach. Engaging multisite delivery system partners, prioritizing reach, embedding interventions within partners' routine operations, and collaborating across chronic disease program areas were all dissemination strategies that were correlated with expanded intervention reach. However, states also encountered challenges that limited their ability to successfully engage delivery systems as partners. These barriers included difficulty identifying delivery system partners and the lengthy time periods partners needed to adopt and embed the interventions.

Evaluation of physical activity interventions in children via the reach, efficacy/effectiveness, adoption, implementation, and maintenance (RE-AIM) framework: A systematic review of randomized and non-randomized trials

CONTEXT

Existing reviews of physical activity (PA) interventions designed to increase PA behavior exclusively in children (ages 5 to 11years) focus primarily on the efficacy (e.g., internal validity) of the interventions without addressing the applicability of the results in terms of generalizability and translatability (e.g., external validity).

OBJECTIVE

This review used the RE-AIM (Reach, Efficacy/Effectiveness, Adoption, Implementation, Maintenance) framework to measure the degree to which randomized and non-randomized PA interventions in children report on internal and external validity factors.

METHODS AND RESULTS

A systematic search for controlled interventions conducted within the past 12years identified 78 studies that met the inclusion criteria. Based on the RE-AIM criteria, most of the studies focused on elements of internal validity (e.g., sample size, intervention location and efficacy/effectiveness) with minimal reporting of external validity indicators (e.g., representativeness of participants, start-up costs, protocol fidelity and sustainability).

CONCLUSIONS

Results of this RE-AIM review emphasize the need for future PA interventions in children to report on real-world challenges and limitations, and to highlight considerations for translating evidence-based results into health promotion practice.

A community-based partnership to promote exercise among cancer survivors: lessons learned

PURPOSE

We conducted a randomized controlled trial in partnership with a community-based organization (CBO) to examine the effects of peer mentoring to promote exercise among cancer survivors. At the end of the trial, to prepare for future program implementation on a larger scale, we obtained input from the CBO on the key elements that influenced the decision to collaborate, facilitators and challenges during the trial, and recommendations for program marketing.

METHODS

Structured telephone interviews were conducted with ten stakeholders at various job levels within the CBO. Notes of the interviews were coded, and themes were extracted independently by two study members.

RESULTS

Five themes were identified: costs of the partnership, its benefits, importance of communication, match of the trial goals with the CBO's mission, and achieving a balance between research and job tasks. Techniques to address these themes and improve implementation of the program are described.

CONCLUSIONS

The themes identified can guide evidence-based programs in planning implementation that involves partnerships with CBOs.

Exploring How Knowledge Translation Can Improve Sustainability of Community-based Health Initiatives for People with Intellectual/Developmental Disabilities

Community-based health initiatives (CBHI) play an important role in maintaining the health, function and participation of people with intellectual/developmental disabilities (I/DD) living in the community. However, implementation and long-term sustainability of CBHI is challenging. The Promoting Action on Research Implementation in Health Services (PARiHS) is a knowledge translation (KT) framework that is particularly relevant to intellectual/developmental disabilities research as it identifies the barriers and facilitators of implementation and action plans. This framework provides a foundation for understanding how KT can be used to aid the implementation and sustainability of CBHI for people with intellectual/developmental disabilities. The following study explores how KT - specifically the PARiHS framework - can be used to help sustain CBHI for people with intellectual/developmental disabilities.

Evaluation of physical activity interventions in youth via the Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework: A systematic review of randomised and non-randomised trials

CONTEXT

An identified limitation of existing reviews of physical activity interventions in school-aged youth is the lack of reporting on issues related to the translatability of the research into health promotion practice.

OBJECTIVE

This review used the Reach, Efficacy/Effectiveness, Adoption, Implementation and Maintenance framework to determine the extent to which intervention studies promoting physical activity in youth report on factors that inform generalizability across settings and populations.

METHODS AND RESULTS

A systematic search for controlled interventions conducted within the last ten years identified 50 studies that met the selection criteria. Based on Reach, Efficacy/Effectiveness, Adoption, Implementation and Maintenance criteria, most of these studies focused on statistically significant findings and internal validity rather than on issues of external validity. Due to this lack of information, it is difficult to determine whether or not reportedly successful interventions are feasible and sustainable in an uncontrolled, real-world setting.

CONCLUSIONS

Areas requiring further research include costs associated with recruitment and implementation, adoption rate, and representativeness of participants and settings. This review adds data to support recommendations that interventions promoting physical activity in youth should include assessment of adoption and implementation issues.

Translation of fit & strong! For middle-aged and older adults: examining implementation and effectiveness of a lay-led model in central Texas

The Fit & Strong! program is an evidence-based, multi-component program promoting physical activity among older adults, particularly those suffering from lower-extremity osteoarthritis. The primary purpose of the study is to examine if the Fit & Strong! program translated into a lay-leader model can produce comparable outcomes to the original program taught by physical therapists and/or certified exercise instructors. A single-group, pre–post study design was employed, and data were collected at the baseline (n = 136 participants) and the intervention conclusion (n = 71) with both baseline and post-intervention data. The measurements included socio-demographic information, health- and behavior-related information, and health-related quality of life. Various statistical tests were used for the program impact analysis and examination of the association between participant characteristics and program completion. As in the original study, there were statistically significant (p < 0.05) improvements in self-efficacy for exercise, aerobic capacity, joint stiffness, level of energy, and amount and intensity of physical activities. The odds of completing the program were significantly lower for the participants from rural areas and those having multiple chronic conditions. Successful adaptation of the Fit & Strong! program to a lay-leader model can increase the likelihood of program dissemination by broadening the selection pool of instructors and, hence, reducing the potential issue of resource limitation. However, high program attrition rates (54.1%) emphasize the importance of adopting evidence-based strategies for improving the retention of the participants from rural areas and those with multiple chronic conditions.

Adoption of Evidence-Based Health Promotion Programs: Perspectives of Early Adopters of Enhance(®)Fitness in YMCA-Affiliated Sites

Purpose

To identify facilitators and barriers among early adopters of Enhance^®Fitness (EF), in Young Men’s Christian Association-affiliated (Y-affiliated) sites from the perspective of program staff. EF is an evidence-based group exercise program for seniors.

Methods

This qualitative study used semi-structured phone interviews with 15 staff members representing 14 Y-affiliated sites. Interviews were digitally recorded, transcribed, and analyzed using qualitative content analysis informed by the RE-AIM framework.

Findings

Staff were, on average, 48.7 years old (SD 13.5) and had been involved with EF for 5.2 years (SD 3.1). Key themes related to facilitating adoption of EF were: match with the Y mission, support from different organizational levels, match between the target population need and EF, initial and on-going financial support, presence of champions, novelty of EF, an invitation to partner with a community-based organization to offer EF, and program-specific characteristics of EF. Key themes related to barriers interfering with EF adoption included competing organizational programs and space limitations, limited resources and expertise, and costs of offering the program.

Implications

Our findings identify the types of organizational support needed for adoption of evidence-based health promotion programs like EF. Recommendations for practice, research, and policy based on the findings, including assessing organizational readiness, researching late adopters, and developing revenue streams, may help facilitate program adoption. Packaging and sharing these practical recommendations could help community-based agencies and nationally networked organizations facilitate adoption of EF and other evidence-based programs.