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

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.

Key considerations for designing capacity-building interventions to support evidence-based programming in underserved communities: a qualitative exploration

Increasing the use of evidence-based programs (EBPs) in community settings is critical for improving health and reducing disparities. Community-based organizations (CBOs) and faith-based organizations (FBOs) have tremendous reach and trust within underserved communities, but their impact is constrained by limited staff capacity to use EBPs. This exploratory study sought to identify design and delivery considerations that could increase the impact of capacity-building interventions for CBOs and FBOs working with underserved communities. Data come from a community-based participatory research project addressing cancer disparities in Black, Latino, and Brazilian communities from Greater Boston and Greater Lawrence, Massachusetts. We conducted four focus group discussions with program coordinators in CBOs and FBOs (n = 27) and key informant interviews with CBO and FBO leaders (n = 15). Three researchers analyzed the data using a multi-stage coding process that included both prefigured and emergent codes. Key design considerations included embedding customized capacity-building interventions into community networks with local experts, supporting ongoing engagement with the intervention via a range of resources and communication channels, and addressing resource constraints. Regarding the contextual factors that should influence capacity-building intervention content, participants highlighted resource constraints, environments in which EBP use is not the norm, and challenges linking available programs with the multi-level barriers to good health faced by community members. Overall, the study highlights the need for integrated, long-term capacity-building efforts developed in partnership with, and ultimately sustained by, local organizations.

A longitudinal implementation evaluation of a physical activity program for cancer survivors: LIVESTRONG® at the YMCA

Purpose

Increased physical activity (PA) levels in cancer survivors are associated with decreased risk of recurrence and mortality as well as additional positive health outcomes. PA interventions have shown to be efficacious, though many lack translation to and sustainability in community settings. We used dimensions of the RE-AIM framework to evaluate LIVESTRONG® at the YMCA, a nation-wide community-based PA program for cancer survivors delivered at Ys.

Methods

This was a longitudinal study design using national LIVESTRONG at the YMCA data compiled between 2010 and 2018. Data is from all YMCAs who deliver LIVESTRONG at the YMCA, submitted by Program Directors to the YMCA-USA. We assessed reach (number of participants), adoption (associations offering the program), implementation (conducting 3 fidelity checks), and organizational level maintenance (associations recently offering program). We also examined relationships between organizational characteristics (years of program existence and association area household income) and program implementation factors with member conversion rates.

Results

As of 2018, LIVESTRONG at the YMCA has reached 62,044 survivors and 245 of the 840 (29.2%) of Y associations have adopted the program. Among the adopters, 91% were aware of fidelity checks; implementation of observational (62.3%), goal setting (49.9%), and functional (64.6%) checklists varied. Most (95.1%) adopters reported offering ≥ 1 LIVESTRONG session per year (organizational-level maintenance) and a facility-level mean membership conversion percentage of 46.9 ± 31.2%. Fewer years implementing the program and higher association area household income were significantly associated with a greater membership conversion rate vs their comparison. In a multiple regression model controlling for organizational characteristics, conducting the fidelity checks independently (observational, β = 8.41; goal-setting, β = 9.70; and functional, β = 9.61) and collectively (β = 10.82; 95% CI 5.90–16.80) was positively associated with higher membership conversion rates.

Conclusions

LIVESTRONG at the YMCA, in its early years, has shown promise for high reach, while adoption at more associations could be facilitated. Implementing fidelity checks along with organizational characteristics were associated with membership conversion rate. Identification of association-level strategies to increase reach, adoption, implementation, and maintenance may increase the impact of this community-based PA program.

Is There a Difference in Serum Vitamin D Levels and Bone Mineral Density According to Body Mass Index in Young Adult Women?

Background

In the life cycle, bone mineral density (BMD) is the most optimal condition in the 20s. In Korea, vitamin D deficiency status is very serious in Korean women due to recent lack of activity, weight polarization, and inadequate nutritional intake. The purpose of this study was to compare serum vitamin D and BMD according to obesity status in Korean young adult women.

Methods

A total of 143 female college students participated in the research. Body fat and lean body status were analyzed using a body composition analyzer. Nutrient intakes of the subjects were assessed by 3-days food record method. The BMDs was measured by dual energy X-ray absorptiometry. The subjects were divided into normal weight group and obesity group on their body mass index.

Results

Obesity group showed significantly higher weight, body fat (%), and body fat (kg) than normal weight group and T-scores of lumbar-2 spines were significantly lower. Obesity group showed high triglyceride and low-density lipoprotein cholesterol levels and vitamin D levels were significantly lower. Physical fitness and activity status showed that sit and reach and sit up were significantly lower in obesity group. The intake of carbohydrates was higher in the obesity group than in the normal weight group, and the intake of vitamin C and vitamin D was significantly lower. Factors affecting serum vitamin D were analyzed as body fat (%), lumbar-2 T-score, triglyceride, and carbohydrate intake.

Conclusions

Obese women need more effort to manage their serum vitamin D status and balanced nutrition to prevent bone loss.

Barriers and facilitators to implementing evidence-based interventions among third sector organisations: a systematic review

BACKGROUND

The third sector is becoming a growing provider of public, social, and health services. However, there is little evidence on the effectiveness of third sector organisations (TSOs), and their capacity to implement evidence-based interventions (EBIs). Understanding implementation aspects of service delivery remains an important issue in clinical practice, but is poorly understood in the context of TSOs. This is problematic, since implementation issues are known to be critical for effective intervention outcomes.

OBJECTIVES

To identify and synthesise existing research on what barriers and facilitators influence the implementation process of TSOs delivering EBIs.

METHODS

This review is reported according to PRISMA guidelines and was pre-registered in PROSPERO. Key databases were searched using relevant terms, experts in the field were contacted, and websites were reviewed. All identified studies were double-screened, and data were extracted independently by two authors. Included studies were synthesised using thematic analysis and were quality appraised.

RESULTS

Thirty-one studies were included, most of which were conducted in North America. The thematic synthesis identified resource limitations, in particular staff and finance, to be the most reported barrier to TSOs implementing EBIs. Organisational culture, including factors such as alignment between the mission of the TSO and EBI, and support/prioritisation of the implementation process were the most reported facilitators. These findings generalise across the included studies and are robust to study quality assessment.

CONCLUSIONS

While it is often assumed that good outcomes follow when implementing interventions that have been developed and tested according to best practice, little attention has been paid to how EBIs are best transported, contextualised, and implemented by third sector providers. This systematic review found that TSOs faced considerable challenges in implementing EBIs, which were primarily a lack of support and expertise, and unclear/insufficient guidelines on how to adapt EBIs to different populations. To address these challenges, it is important to engage with central stakeholders, such as funders, researchers, policymakers, and practitioners, to discuss how these needs can be met.

TRIAL REGISTRATION

PROSPERO: CRD42017073090 .

A Pragmatic Approach to Guide Implementation Evaluation Research: Strategy Mapping for Complex Interventions

INTRODUCTION

Greater specification of implementation strategies is a challenge for implementation science, but there is little guidance for delineating the use of multiple strategies involved in complex interventions. The Cardiovascular (CV) Toolkit project entails implementation of a toolkit designed to reduce CV risk by increasing women's engagement in appropriate services. The CV Toolkit project follows an enhanced version of Replicating Effective Programs (REP), an evidence-based implementation strategy, to implement the CV Toolkit across four phases: pre-conditions, pre-implementation, implementation, and maintenance and evolution. Our current objective is to describe a method for mapping implementation strategies used in real time as part of the CV Toolkit project. This method supports description of the timing and content of bundled strategies and provides a structured process for developing a plan for implementation evaluation.

METHODS

We conducted a process of strategy mapping to apply Proctor and colleagues' rubric for specification of implementation strategies, constructing a matrix in which we identified each implementation strategy, its conceptual group, and the corresponding REP phase(s) in which it occurs. For each strategy, we also specified the actors involved, actions undertaken, action targets, dose of the implementation strategy, and anticipated outcome addressed. We iteratively refined the matrix with the implementation team, including use of simulation to provide initial validation.

RESULTS

Mapping revealed patterns in the timing of implementation strategies within REP phases. Most implementation strategies involving the development of stakeholder interrelationships and training and educating stakeholders were introduced during the pre-conditions or pre-implementation phases. Strategies introduced in the maintenance and evolution phase emphasized communication, re-examination, and audit and feedback. In addition to its value for producing valid and reliable process evaluation data, mapping implementation strategies has informed development of a pragmatic blueprint for implementation and longitudinal analyses and evaluation activities.

DISCUSSION

We update recent recommendations on specification of implementation strategies by considering the implications for multi-strategy frameworks and propose an approach for mapping the use of implementation strategies within complex, multi-level interventions, in support of rigorous evaluation. Developing pragmatic tools to aid in operationalizing the conduct of implementation and evaluation activities is essential to enacting sound implementation research.

Impact of a Translated Disease Self-Management Program on Employee Health and Productivity: Six-Month Findings from a Randomized Controlled Trial

Disease management is gaining importance in workplace health promotion given the aging workforce and rising chronic disease prevalence. The Chronic Disease Self-Management Program (CDSMP) is an effective intervention widely offered in diverse community settings; however, adoption remains low in workplace settings. As part of a larger NIH-funded randomized controlled trial, this study examines the effectiveness of a worksite-tailored version of CDSMP (wCDSMP [n = 72]) relative to CDSMP (‘Usual Care’ [n = 109]) to improve health and work performance among employees with one or more chronic conditions. Multiple-group latent-difference score models with sandwich estimators were fitted to identify changes from baseline to 6-month follow-up. Overall, participants were primarily female (87%), non-Hispanic white (62%), and obese (73%). On average, participants were age 48 (range: 23–72) and self-reported 3.25 chronic conditions (range: 1–16). The most commonly reported conditions were high cholesterol (45%), high blood pressure (45%), anxiety/emotional/mental health condition (26%), and diabetes (25%). Among wCDSMP participants, significant improvements were observed for physically unhealthy days (uΔ = −2.07, p = 0.018), fatigue (uΔ = −2.88, p = 0.002), sedentary behavior (uΔ = −4.49, p = 0.018), soda/sugar beverage consumption (uΔ = −0.78, p = 0.028), and fast food intake (uΔ = −0.76, p = 0.009) from baseline to follow-up. Significant improvements in patient–provider communication (uΔ = 0.46, p = 0.031) and mental work limitations (uΔ = −8.89, p = 0.010) were also observed from baseline to follow-up. Relative to Usual Care, wCDSMP participants reported significantly larger improvements in fatigue, physical activity, soda/sugar beverage consumption, and mental work limitations (p < 0.05). The translation of Usual Care (content and format) has potential to improve health among employees with chronic conditions and increase uptake in workplace settings.

Motor Control-based Group Exercise: Can It be Delivered as Effectively by Lay Leaders?

PURPOSE

On the Move (OTM), a motor control-based group exercise program for community-dwelling older adults, has produced greater gains in mobility than a standard group exercise program when delivered by research leaders. The purposes of this study were:1) to examine the effectiveness of OTM versus a standard program when delivered by lay leaders and 2) to compare the outcomes of OTM when delivered by research versus lay leaders.

METHODS

Community-dwelling, medically stable older adults who could walk household distances participated. OTM consisted of warm-up, timing and coordination, strengthening, and stretching exercises. The seated standard program consisted of warm-up, aerobic, strengthening and stretching exercises. The primary outcome(s) of function and disability was the Late Life Function and Disability Instrument (LLFDI), and for walking ability were the Six Minute Walk Test and gait speed.

RESULTS

126 participants (mean age = 80.7±7.8 years, gait speed = 0.91 m/s) were randomized to OTM (n=49) or standard (n=77) programs. When taught by lay leaders, there were no significant between-intervention group differences in any of the outcomes (p>0.10). Comparing OTM outcomes between leaders, there was a statistical but not clinically meaningful difference in LLFDI disability (1.87±0.89, p=0.04) when taught by research versus lay leader, and moderate differences (p=0.06) in LLFDI overall function (1.89±1.02) and gait speed (0.05±0.03). Qualitative interview responses suggest that instructor-related concerns may have impacted program outcomes.

CONCLUSION

When delivered by lay leaders OTM was not more effective than a standard program for improving function, disability, and mobility in older adults. Health promotion programs designed to improve mobility in community-dwelling older adults and based on a motor control theoretical background, may be best taught by rehabilitation professionals.

Champions of an Older Adult Exercise Program: Believers, Promoters, and Recruiters

Champions, who support, market, and promote programs, are a vital part of successful program adoption, implementation, and maintenance. Enhance®Fitness (EF) is an evidence-based, community-delivered group exercise program for older adults. Using semistructured phone interviews with 20 participants, 17 instructors, and 15 staff, we explored the roles of champions in adopting, implementing, and maintaining EF at YMCA-affiliated sites. Interviews revealed EF champions play critical roles in program dissemination. Champions are outgoing, passionate, and enthusiastic about EF. They believe in the program and its benefits (believers), are "walking advertisements" (promoters), and have magnetic personalities, persuading newcomers to join (recruiters). EF champions were not purposefully selected but naturally arose during the course of program delivery. Community sites adopting evidence-based programs can foster and support champions by engaging with them, and capitalizing on their energy as an emerging resource throughout the adoption, implementation, and maintenance of programs.

Beyond Strength

This study examines the expected and experienced benefits among participants in Enhance®Fitness (EF), an evidence-based group physical activity program for older adults. We also describe the implications for program dissemination (reach, implementation, and maintenance) within the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework. Twenty semistructured interviews were conducted with EF participants enrolled from 2005 to 2012. Interviews were digitally recorded, professionally transcribed, and analyzed using a deductive approach. Participants were motivated to join EF for expected physical benefits and the social environment of a group-based class. Actualized benefits of participation included physical, social, functional, and improved self-image/sense of well-being. Participants valued the practical application of class exercises to daily activities that support independent living, such as lifting objects and completing household chores. Organizations looking to implement EF or improve existing EF classes can improve program reach, implementation, and maintenance by incorporating participants’ expressed motivations and valued benefits in program marketing and by improving organizational support to meet participant needs. EF class instructors can tailor their classes to engage participants based on their motivations. Understanding participants’ motivations and valued benefits can improve EF dissemination by meeting participant needs with tailored class offerings and organizational needs informed by participant insights that aid program sustainability.

Implementation and Maintenance of a Community-Based Older Adult Physical Activity Program

PURPOSE OF THE STUDY

We examine facilitators and barriers to the implementation and maintenance of Enhance®Fitness (EF), a group exercise program for older adults, at early-adopter YMCA-affiliated sites, and summarize strategies employed by EF instructors and staff to overcome challenges.

DESIGN AND METHODS

This qualitative study used semi-structured phone interviews with 32 instructors, staff members, and master trainers from 24 different YMCA-affiliated sites. Interviews were digitally recorded, transcribed, and analyzed with a focus on the implementation and maintenance components of the RE-AIM framework.

RESULTS

We identified a series of factors affecting the implementation and maintenance of EF at YMCA-affiliated sites, which can be categorized into program-specific (such as instructor training, the structure of the program, reporting requirements, and insurance coverage), and organizational (such as organizational support and infrastructure for program delivery, champions, and funding to cover the costs of program delivery). Strategies used to overcome challenges associated with these factors include identifying parts of the program that can be adapted, hiring staff and instructors that understand and support the program, and educating staff and instructors about the importance of evidence-based programs and of data collection for program evaluation.

IMPLICATIONS

Assessing the readiness of organizations for program delivery and the match between program goals and the needs of organizations and participants would help facilitate the successful implementation and maintenance of physical activity programs in community settings.