Factors that influence implementation at scale of a community-based health promotion intervention for older adults

CTM is a 6-month, choice-based, flexible, scalable, health promotion intervention for low active (< 150 min of moderate to vigorous PA/wk) older adults (60+ years). To guide CTM content and delivery, we adopted core elements of the effective Community Healthy Activities Model Program for Seniors (CHAMPS; choice-based, telephone assisted approach). CHAMPS was delivered at scale by 13 diverse community agencies [24, 34‐36]. Increased PA participation was of similar magnitude as reported for efficacy studies – despite greater diversity in participants’ ethnicity, socio-economic status, and health conditions [27, 37]. We then conducted a translational formative evaluation in order to assess context for implementation, adapt where needed, and pilot our approach and measurement tools [33].

CTM is currently being delivered in three phases at increasingly greater scale across the province of British Columbia (BC) (Fig. 1). Phase 1 [2016; n = 8 programs, n = 67 participants] and Phase 2 [2016–2017; n = 47 programs, n = 391 participants] comprised implementation of CTM at smaller scale, in urban, suburban and small urban communities. Phase 3 [2018–2020] targets broad scale-up [13]. In this study we focus on implementation of CTM during Phases 1 and 2 (n = 55 programs, n = 458 participants). In total, CTM was delivered at 26 unique sites with either 1 (n = 15 sites), 2 (n = 8 sites), 3 (n = 3 sites) or 5 (n = 3) program cycles delivered during phases 1 and 2.

CTM is comprised of three core elements delivered by trained activity coaches. First, a 60-min one-on-one consultation with activity coaches assists participants to set and maintain PA goals that cater to their physical capacity and preferences (create an Action Plan). Second, participants attend four 60-min Motivational Group Meetings (once/month in months 1–2; twice in month 3 to connect socially with other participants (max 12/group) and with their activity coach. Third, activity coaches call participants regularly by phone (15 min/call on average) to monitor progress, address challenges, and modify the Action Plan as needed (three times in month 1; twice/month in months 2 and 3; once/month in months 4–6). As CTM is supported through a government grant, there is no cost to participants. We use multiple implementation strategies [38] with our partners to deliver CTM (Table 1).

In response to the escalating rates of chronic disease [39], physical inactivity, and social isolation in Canada [6, 40, 41], BC Ministry of Health developed Active People, Active Places, a PA Action Plan for BC [42] .Older adults were identified as a priority area. A funding partnership was established between the Ministry of Health and the Active Aging Research Team (AART; www.​activeagingrt.​ca).

We provided details of the conceptual frameworks for implementation and evaluation, guiding principles, the intervention, and evaluation methods that guide our work at length in a previous publication [32]. Briefly, the Framework for Effective Implementation [43] guided development, implementation and evaluation of CTM (Fig. 2). This framework highlight six categories of contextual factors that influence effective implementation; 1) the innovation (CTM), 2) the prevention delivery system (e.g., activity coaches, recreation center coordinators/ managers and delivery partner organizational leads), 3) the prevention support system (e.g., our Active Aging Research Team), and 4) the prevention synthesis and translation (research) system (e.g., our Active Aging Research Team) - all nested within the socioecologic context of 5) provider and 6) community characteristics [43, 44]. These different ‘levels of influence’ also guide our evaluation approach.

Although we aligned our approach with one of more than 60 published frameworks [45], there are many common elements among them. These often include, attributes of the intervention, factors that support implementation, delivery strategy, characteristics of the adopting community, the broader socio-political context, and the use of research and evaluation to inform the scale-up process [46]. However, others contend that there is no single or straightforward implementation framework that offers a formula for success [21]. As implementation research evolves it will, “help implementers to better understand the complex array of contextual factors, such as politics, socio-cultural norms and beliefs, and the fiscal environment, that can influence scale-up success” [29].

Consistent with the Framework for Effective Implementation [43] community partners served along a continuum from strategy (leaders of delivery partner organizations), to operations (recreation coordinators and managers), to on the ground delivery (activity coaches) – together they comprised the delivery system. Two major delivery partner organizations delivered 56 CTM programs between January 2016 and May 2017 in 26 community centres or other facilities. They were selected based on their established relationships with recreation centres, their capacity to coordinate delivery of programs at scale, and their desire to sustain implementation of a health promotion intervention for older adults across BC, in future. We defined this operationally as CTM being aligned with the vision and mission of the delivery partner organization.

We convened a project team (from AART) that served as CTM implementation support and research systems [43, 44]. The support unit provided leadership, training, and created a communications plan and governance structure. The support unit engaged delivery partners to design, implement, and evaluate CTM to meet the needs of older adults. The support unit ensured that implementation strategies varied as little as possible across sites.

We consider implementation evaluation an essential component of intervention studies as 1) it provides context to interpret participant level health outcomes [13], 2) it can be adopted by researchers who wish to evaluate scale-up of most health focused interventions, and 3) implementation outcomes can be used to guide adaptation of an intervention to setting and population, as a means to enhance likelihood of successful scale-up and sustainability, in the future. We aligned our implementation evaluation with the Framework for Effective Implementation [43]. We present our results across levels of influence (from leaders of delivery partner organizations to CTM participants) as per the socioecologic model [43]. We identified these stakeholders using the influence approach reported by Colvin [47].

Four members of the support and research system conducted semi-structured interviews by telephone with all participant groups. The interview questions were tailored to participant group and focused on perceived levels of support, challenges and opportunities, adaptations, and perceived fit of CTM to the local context. Interviews used an interview guide, specific to each participant group and time point. Guided by our implementation framework, the project team developed questions for the interview guide. Questions for the activity coach and participant interview guides were used previously in our translational formative evaluation [33]. Questions for the recreation manager and coordinator interview guides were tested in those groups before Phase 1. For all groups, we interviewed the same individual across time points. Table 2 provides examples of questions we asked to identify factors influencing implementation. Interviews were audio-recorded and professionally transcribed. Interviewers were trained by the lead author to take high level notes to serve as back up should the audio recording be faulty or unclear.

Interview recordings were transcribed verbatim by a professional transcriptionist. Data were de-identified and imported to NVivo 11 (QSR International, 2015) for data analysis. For all participant groups, interview data were analyzed using framework analysis [48‐50], an appropriate analytic approach for qualitative studies with specific questions, a pre-designed sample, and a-priori issues [50]. In framework analysis, data are sifted, charted and sorted in accordance with key issues and themes using five steps: 1) familiarize; 2) identify a thematic framework; 3) index; 4) chart; and 5) map and interpret [50, 51]. First, two team members read through a subset of transcripts to establish a sense of the interviews (familiarize). Through team meetings we developed a preliminary thematic framework, consisting of themes and sub-themes, based on key issues and commonalities emerging from the transcripts (identify). Using Nvivo 11 software, one team member coded interviews based on the thematic framework, with discussion among other team members, as new codes and sub-themes were identified (index). Full paragraphs were coded so that contextual meaning was not lost. Data were then summarized by charting illustrative quotes that best exemplified the themes (chart). As part of the interpretive process a series of team meetings (n = 6) were held to discuss the data for common themes and sub-themes (map and interpret). We used a number of strategies to reinforce the rigor of our analysis: crosschecking full transcripts against original audio files for quality and completeness and reflexive memoing throughout the data generation and data analysis process [52].

Leaders of delivery partner organizations discussed the organizational context [43] for program delivery. They felt that while there is some political support for PA in the province, there are very few (if any) systemically organized programs for older adults. Against this backdrop they highlighted the challenge for older adults to become active or to access programs:

“So there’s definitely a need for that population to be physically active. There’s definitely a need and the demand and market for older adult fitness is for sure there. I think with the growing aging population this demand is needed--not going anywhere. It’s just a matter of, you know, accessibility … ”

Further, this group noted that programmatic offerings vary by region, and it is often challenging for older adults to navigate the community-based system in order to find suitable programs. Overall, CTM was considered timely, necessary, relevant, and scalable. This speaks to the importance of the organizational context for delivery. Leaders noted complete alignment with their organizational priorities, vision, and strategic directions. As noted by one leader:

“this gives us the resources to actually fulfill our own mandate, and our own mandate as an organization is to enable communities in their attempts to build their communities and build strong, healthy resilient individuals.”

“I would say one of the issues is just how do you reach the people that need the program, you know, because just given the fact that the people who need the program often may be isolated, well, how do you reach them?”

When speaking specifically about design of CTM, leaders noted that the social aspects of the program were paramount to older adults. They identified the need to provide opportunities for older adults to socialize and that CTM created those opportunities. Leaders also highlighted that an evidence-based program developed by researchers made CTM more ‘credible’ for those delivering CTM and for older adults enrolled in CTM.

Recreation managers/coordinators were very positive about CTM. One manager stated “it is a beautiful model” and “a good fit with the mandate of our organization”. The social components were deemed an excellent component of CTM. Recreation managers/coordinators also noted the essential need for external funding to run the program and to find the right staff to deliver CTM; highlighting questions around sustainability. Sustainability was deemed uncertain without long term financial commitments to CTM. Specifically, they highlighted the need to recover costs to support activity coaches.

“And for us we don’t have a budget to subsidize programs. So all our programs have to be cost-recovery, so in order for us to keep this on-- as part of our regular practice we would need to cover the cost for our instructors and/or space.”

They highlighted that charging a fee for CTM might be one way to do this, although that could pose a potential barrier to participation among older adults.

Through implementation of CTM, managers/coordinators gained valuable insight into time management, communications, and recruitment needs of CTM. Central to delivery of CTM, the pivotal role of the activity coach surfaced time and again. Recreation managers/coordinators expressed concern about the lack of older adult certified instructors in certain communities, issues with staff turnover, and challenges related to bringing instructors in from outside a recreation centre as this may lead to unfamiliarity with processes specific to that city/centre. They noted that it is much easier when an activity coach is hired who is already part of a specific centre’s programming. Finally, they emphasized that it was very helpful when activity coaches took ownership of CTM and in so doing, assisted with recruitment, registration, and screening. This sentiment also speaks to limited organizational capacity.

“I think one of the big ones is that the Choose to Move (activity coach) is somebody we have a relationship with already. It’s a staff member at the facility so it’s just-- I find that that’s-- that’s helped with the implementation of the program”

“the support we receive from (the support and research system) is really important. Certainly, the training materials, the weekly, bi-weekly check-ins that we have with (support and research system lead) are also very important to us. It gives us an opportunity to touch base, kind of just provide updates but also kind of problem solve any challenges that we may be experiencing as well.”

They also stated how crucial it was to ensure adequate lead time to allow recreation centres to promote CTM, to generate other communication materials (e.g. recreation calendars), and to provide information sessions for all those involved in recruitment and delivery of CTM (e.g. front desk staff). This would ensure that those delivering CTM at every level had a clear understanding of CTM and could adequately answer any questions they were asked. This, in turn, was thought to increase recruitment efforts of more vulnerable or marginalized older adults (i.e. those who may not normally participate in recreation centre activities). Finally, they deemed centralized training and opportunities for activity coaches to engage with one another as highly beneficial.

“Yeah, so when we first started there was-- the timing of it didn’t allow us to get it into our normal kind of Fit Living guide cycle. So we felt like we had to do a, you know, ton of extra work to spread the word, otherwise it wouldn’t be out there.”

“I mean, success stories to me is just everybody that’s still moving. I mean, people that I called on their six month and they’re-- they still, you know, want to brag to me about, you know, what they’re doing and how they’re feeling. Or if they’ve fallen off the wagon and, you know, push the restart button and got going again, how they felt when they were off the wagon. And how they couldn’t believe it, right. I just felt so sorry and I didn’t feel good and this and that. It’s like yeah. Great. So what did you do about it? I started exercising again. Awesome! Good for you. Good choice and you made it without me.”

In addition to changes in activity and connectedness, improvements in participants’ health status was highlighted as important. Activity coaches noted that they made a number of ‘small tweaks’ to the intervention to facilitate implementation. For example, some activity coaches modified group meeting content due to time constraints and/or relevance to the community context. Other activity coaches modified the active travel component due to community built environment characteristics that limited opportunities for active travel. In addition, activity coaches used face-to-face meetings or email as an alternative mode for check-ins (original mode was telephone) due to participant preference or to accommodate participant schedules. Finally, activity coaches distributed supplemental resources based on participant requests for further information on a topic of interest.

Participants were pleased with and very much enjoyed participating in CTM. They agreed overwhelmingly that activity coaches were central to their continued participation and key to the success of CTM. Specifically, participants noted how positive attitudes and encouragement offered by activity coaches made a tremendous difference.

“He’s extremely patient with everyone. He’s very supportive. I think when he was on the phone there was never-- I never felt like I was being rushed off the phone. It was always, you know, what can I do to help? Is there anything more I can help you with?”

Most participants felt that the number of check-in calls from their activity coach was adequate. After the first three months of CTM, they felt that PA started to become a part of their everyday routine. Their activity coaches’ words of support and guidance resonated in their minds. Testament to them enjoying CTM, participants wished it ran for a longer duration. They also offered suggestions as to how best to foster more social opportunities amongst participants. Related to this, participants noted that group meetings provided important opportunities for participants to share their experiences, discuss PA related issues, and generally interact with others.

“It’s just nice to hear what other people are doing, though. It’s nice to hear how, you know, they have been motivated. And I think it encourages everybody when you, you know, hear somebody else say, well, this is what happened with me. And so, yeah, that part-- I like the sharing part.”

Participants cited an array of health benefits from their participation in CTM. The three most often noted benefits were improvements in physical health, an increase in knowledge and awareness about the importance of PA, and an increase in motivation to engage in PA. For health benefits, joint health most commonly improved. The most common barriers to participating in CTM were unrelated to implementation factors. They most often related to individual health conditions such as injury, recent surgery, illness, or weather.