Background
The global obesity epidemic represents a great public health challenge. The Australian Preventative Taskforce has advocated the need for obesity prevention programs amongst all population groups [
1]. Reproductive aged women are an important target group with longitudinal population data revealing high rates of unhealthy weight gain [
2] and many barriers to participation in obesity protective behaviours [
3]. Furthermore, the prevalence of obesity is elevated in women living in rural settings in comparison to their urban counterparts [
4,
5]. Rural communities are often socio-economically disadvantaged, and have relatively poor access to primary health care services, resources and trained health professionals [
6]. The need for novel low cost lifestyle programs that can be implemented easily in such groups is critical, where greater program implementation challenges exist. Yet despite this urgency, few healthy lifestyle programs have been implemented in vulnerable target groups such as rural settings [
7,
8]. Furthermore, a systematic review highlighted that the efficacy of weight gain prevention programs in rural communities has yet to be established [
9].
The International Obesity Task Force highlights the need for monitoring and evaluating all obesity prevention and management programs [
10]. In this context, evaluation should focus on the processes required to effectively establish and maintain evidence-based programs in real world conditions [
11,
12] to inform policy and practice [
13]. Process evaluations through the rigorous documentation and assessment of implementation strategies, improves our understanding of the impact of a program and informs how each program component contributes to outcomes [
14]. Process evaluations also assess program internal and external validity, generalisability to diverse populations and identifies factors (program specific and contextual) influencing consistency of program delivery with the protocol [
13,
15]. Common components of process evaluation include an assessment of program fidelity (the extent to which the program was implemented as per the protocol), dose delivered (the amount of intended components delivered), context (socio-cultural and physical environment), dose received (the extents to which participants actively engage with, interact with and/or used the program materials) and acceptability (primary and secondary audiences satisfaction with the program) [
13,
16,
14].
The value of conducting obesity prevention program evaluations has been established [
17]. There has been multiple process evaluations of school based childhood obesity prevention programs conducted [
18,
19], demonstrating their value and enabling replication of successful programs to maximise research investments and population benefit [
20]. However, there is a current dearth of process evaluations of adult obesity prevention programs, limiting understanding of the interplay between the underlying program theory, processes and outcomes. This information gap also curtails potential for translation of evidence into improved public health outcomes [
18,
9]. Further research and evaluation is clearly needed in this area.
Another key research gap is the value and “audience appeal” of obesity prevention programs in women overall and the acceptability of various modes of delivering lifestyle advice (face–to-face and remotely including resources, correspondence and mobile phones) [
21]. To our knowledge, there has only been one study which has assessed the acceptability of various delivery modes within an obesity prevention program. In this study the acceptability of delivery modes (group or correspondence delivery) were compared to controls, with significantly less women choosing to participate in face to face groups. However, the group delivery mode produced the largest short-term changes in weight [
21]. Thus, further exploration of the acceptability of remote delivery methods alone is warranted.
Understanding participant’s value and preferences for various modes of delivering lifestyle advice, can inform translation and impact on participation rates and program reach, effectiveness and sustainability [
21]. In addressing these clear and important research gaps, we aimed to conduct a process evaluation within the context of a large scale rural obesity prevention program, measuring implementation fidelity, dose delivered, context, reach and acceptability of diverse delivery modes. This evaluation focused on informing the acceptability of obesity prevention program implementation strategies in general within complex systems.
Discussion
The evaluation results from the HeLP-her Rural program highlight the acceptability of delivering healthy lifestyle programs via mixed face-to-face and remote delivery modes. We reached women experiencing relative socioeconomic disadvantage and report a high level of program fidelity, dose delivered and program acceptability. The most commonly preferred method of receiving lifestyle advice was via the face-to-face group session. Whilst text messages and phone coaching also had high reported value, they appeared to be most helpful when used in combination with face-to-face contact. Overall, participants emphasised that the combination of various delivery modes maximised program acceptability and value. Based on our evaluation findings, key learnings to optimise the future implementation of the HeLP-her Rural program are described in Table
3.
Table 3
The key evaluation learnings to improve the implementation of the HeLP-her Rural program
• Simple low cost participant recruitment strategies were effective in recruiting rural women into a healthy lifestyle program (i.e. the distribution of flyers to women provided through primary schools, pre-schools and health services, media releases and researcher presence in each community). Multiple pathways and repeating recruitment methods may capture those women who are contemplating joining programs. |
• High program satisfaction was achieved through combining face-to-face and remote delivery modes. |
• Good uptake of phone coaching was achieved within the HeLP-her Rural program through providing flexible session times, scheduling phone coaching time in advance. |
• Phone coaching uptake could be improved by research staff clearly explaining to participants the aim and personal benefit of phone coaching at program commencement. Additionally, there is a need to address participants concerns and a need to set realistic outcome expectations prior to phone coaching. |
• Program manual use varied greatly with many reasons reported including: lack of time and motivation, forgetfulness, poor literacy levels and personal preferences for more interactive modes of receiving health information. Alternatives to the paper based program manual such as electronic versions or social media forums should be considered where participants might choose the resource that is most relevant to them. |
In this healthy lifestyle program, we have engaged women from broad socioeconomic backgrounds including the most socially disadvantaged communities in the State of Victoria, Australia. This is in contrast to previous literature highlighting the challenges of engaging low income population groups into research trials [
39], with most weight trials in women attracting highly educated participants of high socio-economic status, who are not representative of the total population [
40,
9]. Here we also report no clear relationship between program reach and socioeconomic status of the townships as it appears this locally delivered, community based low intensity program appealed to women of relatively low income backgrounds. This is important, as people experiencing social disadvantage are more likely to be obese, as a result of reduced physical activity participation and poorer diet quality [
41,
42]. Potentially, the variation in participant numbers recruited across the 41 townships was influenced by multiple socio-cultural influences such as the presence and engagement of local community champions, social norms, partnerships, program awareness and accessibility [
39,
43]. The current results are encouraging and in future greater investigation is needed to identify sociocultural influences and optimise program engagement strategies in low income communities.
Multiple strategies were employed to ensure high program fidelity and dose delivered. We report high program fidelity as result of all program facilitators attending program specific training and standardisation of resources used during program delivery. Dose delivered has been shown to be a limiting factor in intervention success with results from an intensive obesity prevention trial, reporting that only 50 % of participants received the intended program dose [
44]. The literature consistently demonstrates low adherence and reduced dose delivered in high intensity face-to-face programs limiting feasibility and effectiveness of intensive programs [
28]. We deliberately designed a low intensity intervention program with mixed delivery modes including both face-to-face and remote delivery modes to reduce participant burden and were able to optimise adherence and dose delivered. We also addressed common barriers to attendance and participation which limits dose delivered, such as inconvenient times, childcare and transport by offering multiple delivery times and using local familiar settings such a schools, and allowed toddlers to attend with mothers. We achieved high levels of phone coaching compliance through offering flexible phone coaching times (evening phone coaching conducted), making multiple calls to participants and scheduling phone coaching time in advance strategies which have been used in weight management programs in young women [
45]. Our results suggest that program design with some face–to-face content but low participant burden and mixed delivery mode optimises program acceptability of lifestyle obesity prevention programs.
Supporting the value of utilising various delivery modes, two systematic reviews have reported increased program efficacy with combined program delivery modes [
46,
8]. Prior to the current study, there was limited evaluation of the acceptability of isolated individual program components such as texts and phone coaching. Most programs include multiple components and do not include process evaluations, making the value of individual components difficult to ascertain [
46,
47]. Here we advance the literature by demonstrating that face-to-face delivery, combined with other modes including phone coaching and text messaging are valued by participants. This is consistent with the very few interventions that investigated efficacy of phone coaching and text messaging, which found that these approaches were most efficacious when supported by face-to-face group sessions [
48,
46]. This current research affirms the combined delivery modes in the HeLP-her Rural lifestyle program and informs delivery modes for use in future lifestyle interventions. However, greater research exploring the acceptability of various modes of delivering lifestyle advice during formative evaluations and pilot studies is warranted.
Regarding face-to-face delivery, group-based healthy lifestyle programs appear advantageous at the individual and systems level. A systematic review revealed that group-based education sessions produced significantly greater weight management effects over 12 month, compared to individual based treatments [
48]. These programs are a resource and cost effective delivery mode for health information and enhance the opportunity for social support [
49,
50], as social networks can encourage positive health behaviours, improve self-worth and individual perceptions of control [
51]. Furthermore, group education creates a sense of belonging, illustrating to program participants that it is “normal” to struggle to achieve healthy lifestyles. The enhanced sense of belonging promoted by group education is important in rural settings, with increased risks of social isolation [
52]. However, as rural women are high users of mobile phones and “remote counselling” has been shown to be efficacious in a recent systematic review [
53], combination of group and mobile phone delivery appears ideal [
54,
55]. Remote delivery modes also minimise participant burden associated with travel to group sessions [
21]. Interestingly, our quantitative findings indicated that phone coaching satisfaction scores were lower than face-to-face group sessions and text messages, highlighting the benefits of utilising diverse delivery methods. Whilst we have demonstrated the benefit of group face-to-face program delivery, exploration of the optimal balances and frequency of supplementary text messages and phone calls is still needed. Additionally, further exploration of program acceptability and methods of delivering lifestyle advice during formative evaluations and pilot studies is also warranted.
Challenges and lessons learned
The HeLP-her Rural program is one of the largest prevention trials in Australia presenting logistical challenges but providing an opportunity to learn valuable translation and scale-up lessons. To ensure our evaluation would yield useful and reliable results, extensive pre-planning was essential. Vital components included defined evaluation questions, aligning the evaluation with program objectives and prioritising and building an evaluation plan within our program resources (staffing, time, funding and logistics). Table
3 summarises the key evaluation learnings to improve the future implementation of the HeLP-her Rural program.
Strength and limitations
Strengths of the current study included the application of a mixed-method evaluation approach to a rigorously designed large-scale obesity prevention RCT, targeting a healthy population at risk of weight gain. The use of robust qualitative data analysis methods (theoretical framework and two independent staff conducted analysis) and a range of quantitative data collection tools (administrative data, checklists and questionnaires) strengthened results. Moreover, the purposeful sample utilised in the qualitative data collection increases the generalisability of the results to the wider RCT cohort. We chose to focus on the acceptability of numerous delivery modes for lifestyle advice, as this was a key gap in the literature [
20,
21] and can inform the design of future healthy lifestyle programs. We note that the acceptability of the HeLP-her Rural program was not explored in control participants, as they did not receive the active intervention components. However, data pertaining to dose delivered, context and fidelity was recorded for control participants and included within this manuscript. In order to improve program recruitment we believe that more intensive recruitment methods could have increased program uptake, however ethically we were unable to recruit more women than required. Limitations of this study include that our program checklists exploring program fidelity and contextual influences were completed by research staff involved in the trial rather than independent evaluators. In addition fidelity to motivational interviewing theory was not assessed. Exploration of the different delivery modes for healthy lifestyle advice using quantitative and qualitative data were not collected at the same time point.
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Competing interests
All authors declare no conflicts of interests.
Authors’ contributions
CL and HT conceptualised the RCT. All authors provided intellectual input into the evaluation design and methodology. S.K conducted the interviews and analysed the interviews. S.K drafted the manuscript and all authors contributed to, reviewed and approved the manuscript. All authors read and approved the final manuscript.