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"We can adapt it to our needs" : tailoring Choose to Move for Chinese older adults living in the Metro… Wong, Venessa 2021

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    “WE CAN ADAPT IT TO OUR NEEDS”: TAILORING CHOOSE TO MOVE FOR CHINESE OLDER ADULTS LIVING IN THE METRO VANCOUVER REGIONAL DISTRICT  by Venessa Wong B.A., Simon Fraser University, 2017  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  MASTER OF SCIENCE in The Faculty of Graduate and Postdoctoral Studies (Experimental Medicine)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)  March 2021  © Venessa Wong, 2021  ii The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, the thesis entitled: “We can adapt it to our needs”: tailoring Choose to Move for Chinese older adults living in the Metro Vancouver Regional District  submitted by Venessa Wong  in partial fulfillment of the requirements for the degree of Master of Science in Experimental Medicine  Examining Committee: Joanie Sims-Gould, Department of Family Practice, UBC Supervisor  Heather McKay, Department of Orthopaedics and Family Practice, UBC Supervisory Committee Member  Catherine Tong, Geriatric Health Systems Research Group, University of Waterloo Supervisory Committee Member Patti-Jean (PJ) Naylor, Exercise Science, Physical & Health Education, University of Victoria Additional Examiner      iii Abstract Introduction Chronic conditions are more common as people age. There are various causes to chronic conditions so strategies to prevent and treat multiple health conditions and promote health are needed. Physical activity (PA) is a viable evidence-based intervention to prevent and treat chronic conditions and prevent pre-mature mortality. Yet, only 13% of older adults meet the recommended PA guidelines. Community-based PA interventions improve older adult physical activity but little is known on how PA interventions can be adapted to meet the needs of a growing segment of the Canadian population: ethnic minority older adults. This thesis aimed to describe why and how coordinators and activity coaches adapted Choose to Move implementation strategies and content for use with Chinese older adults.  Methods The socio-ecological model and Framework for Reporting Adaptations and Modifications-Enhanced guided this focused ethnography. Framework analysis was used to analyze interviews (n=12), ethnographic observations (n=11) and meetings minutes (n=38).   Findings Connection with other organizations, service structure, time required to deliver the intervention, participant characteristics and drop out influenced both adapted implementation strategies and content. Factors that influenced adapted implementation strategies only included partnership with the project team, available resources, social networks and volunteer characteristics. Factors iv  that influenced adapted content only included activity coach competency, desire for variety, spoken language, literacy and engagement and motivation.  Adapted implementation strategies included adding a referral network, adding activity inventories, sharing recruitment resources, adding volunteers, recruitment through other departments, condensing recruitment material, switching to other screening tools, volunteer training, recruitment during the delivery phase and extending the implementation period. Adapted content included group-based goals, adding guest speakers to group meetings, visual goal-setting, peer-led movement breaks, adding group meeting activities, hosting group meetings during intake, reiterating goals and objectives, extending check-ins, providing additional resources and cancelling components or programs.  Conclusion The findings from this study contribute to the scarce literature on adapting evidence-based PA interventions for Chinese older adults and may inform future intervention adaptations and delivery. Those who deliver evidence-based interventions to ethnic minority older adults should consider socioecological factors when planning for adapted implementation and delivery.        v  Lay summary People are more likely to have diseases as they grow older. Physical activity can prevent and treat diseases and prevent early death but only 13% of older adults get enough physical activity. Programs in the community can increase physical activity in older adults.  Many older adults in Vancouver have a Chinese background. Yet, we know very little about how to make programs suitable for them. I used interviews, meeting minutes and observation notes from program staff to identify reasons for changes and the changes made to prepare for program delivery and program content.   Reasons for changes to program preparation and content include connection with others, partnerships, available resources, service structure, social network, staff skills, time required, drop out, variety, language, participant fit, volunteer fit and motivation. Changes to program preparation and content included recruitment, resource lists, preparation time, screening, training, one-on-one meetings, group meetings, check-ins and cancelled programs.   vi  Preface  This thesis is part of the Choose to Move Scale-Out sub-study. I worked with Drs. Joanie Sims-Gould, and received feedback from Drs. Heather McKay and Catherine Tong, to create my research question and design. The UBC Research Ethics Board [#H18-02202] approved the study.  I worked with Dr. Joanie Sims-Gould, Dr. Thea Franke and Ms. Sarah Lusina to develop the interview guides and ethnographic observation guide. I did not contribute to the Choose to Move program or study design. I recruited participants to the study, collected meeting minutes and ethnographic observations, and analyzed the data in NVivo 12. Caroline MacLennan interviewed the participants. I debriefed with Drs. Joanie Sims-Gould and Thea Franke during and after data analysis. Text in this thesis is not published.    vii Table of Contents Abstract ........................................................................................................................................ iii Lay summary ................................................................................................................................. v Preface ........................................................................................................................................... vi Table of Contents ........................................................................................................................ vii List of tables ................................................................................................................................ xii List of figures ............................................................................................................................. xiii List of abbreviations ................................................................................................................... xiv Glossary ........................................................................................................................................ xv Acknowledgements ..................................................................................................................... xix Chapter 1: Introduction ................................................................................................................ 1 1.1 Aging population ................................................................................................................... 1 1.2 Physical Activity ................................................................................................................... 1 1.3 Ethnic minorities ................................................................................................................... 4 1.3.1 Chinese population ......................................................................................................... 5 1.3.1.1 Chinese older adults and health ............................................................................... 6 1.3.1.2 Chinese older adults and physical activity .............................................................. 7 1.4 Implementation ...................................................................................................................... 9 1.4.1 Implementing evidence-based interventions .................................................................. 9 viii  1.4.2 Implementation frameworks ........................................................................................... 9 1.5 Adaptation ........................................................................................................................... 10 1.6 Choose to Move study ......................................................................................................... 13 1.7 Theoretical approach ........................................................................................................... 20 1.7.1 Socio-ecological model ................................................................................................ 21 1.7.2 Framework for reporting adaptations and modifications-enhanced (FRAME) ............ 23 1.8 Aims and objectives ............................................................................................................ 25 2. Methods .................................................................................................................................... 26 2.1 Study design ........................................................................................................................ 26 2.2 Inclusion/exclusion criteria ................................................................................................. 26 2.3 Recruitment ......................................................................................................................... 26 2.4 Data collection – semi-structured interview ........................................................................ 28 2.5 Data collection – ethnographic notes .................................................................................. 29 2.6 Data collection – meeting minutes ...................................................................................... 30 2.7 Confidentiality ..................................................................................................................... 31 2.8 Data analysis ........................................................................................................................ 31 2.9 Rigour .................................................................................................................................. 36 3. Results ....................................................................................................................................... 39 3.1 Implementation strategies and content adaptations ............................................................. 46 ix  3.2 Socio-political setting: public policy factors ....................................................................... 46 3.3 Organization/setting: community and institutional level factors ......................................... 46 3.3.1 Community: Connection with other organizations ....................................................... 47 3.3.2 Community: AART partnership ................................................................................... 51 3.3.3 Institutional: Available resources ................................................................................. 56 3.3.4 Institutional: Service structure ...................................................................................... 60 3.4 Provider: interpersonal level factors .................................................................................... 64 3.4.1 Social network .............................................................................................................. 64 3.4.2 Activity coach competency .......................................................................................... 66 3.4.3 Time required ............................................................................................................... 67 3.4.4 Drop-out ....................................................................................................................... 70 3.4.5 Variety .......................................................................................................................... 71 3.4.6 Spoken language ........................................................................................................... 73 3.5 Recipient: intrapersonal level factors .................................................................................. 75 3.5.1 Participant characteristics ............................................................................................. 76 3.5.2 Volunteer characteristics .............................................................................................. 87 3.5.3 Drop-out ....................................................................................................................... 90 3.5.4 Literacy ......................................................................................................................... 91 3.5.5 Engagement and motivation ......................................................................................... 92 4. Discussion ................................................................................................................................. 95 4.1 Community factors .............................................................................................................. 96 x  4.2 Institutional factors .............................................................................................................. 97 4.3 Interpersonal factors ............................................................................................................ 97 4.4 Intrapersonal factors ............................................................................................................ 98 4.5 Adaptations from community, institutional, interpersonal and intrapersonal factors ......... 99 4.5.1 Implementation strategies ........................................................................................... 100 4.5.2 CTM Content .............................................................................................................. 103 5. Conclusion .............................................................................................................................. 108 5.1 Capitalize on resources available ...................................................................................... 108 5.2 Provider competencies ....................................................................................................... 109 5.3 Adapt to suit the participant’s characteristics .................................................................... 109 5.4 Strengths and limitations ................................................................................................... 111 5.5 Future research .................................................................................................................. 113 Bibliography ............................................................................................................................... 115 Appendix A Instrument 3: 3-month Activity Coach Interview Guide v2 ............................ 136 Appendix B Instrument 3: 3-month Activity Coach Interview Guide v5 ............................ 139 Appendix C Instrument 14: Activity Coach 6-month Interview Guide (last program) v1 143 Appendix D Instrument 14: 6-month Activity Coach Interview Guide v2 .......................... 147 Appendix E Instrument 2: 3-month Coordinator Interview Guide v2 ................................ 152 Appendix F Instrument 2: 3-month Coordinator Interview Guide v4 ................................. 154 xi  Appendix G Instrument 2: 3-month Coordinator Interview Guide v5 ................................ 156 Appendix H Instrument 10: Ethnographic Notes v1 .............................................................. 159 Appendix I Instrument 10: Ethnographic Notes v2 ............................................................... 160    xii List of tables Table 1. Standard CTM Phase 3 Implementation Strategies at Recreation Delivery Partner Organizations ................................................................................................................................. 14 Table 2. Standard CTM Phase 3 Implementation Strategies at Scale-out Delivery Partner Organizations ................................................................................................................................. 18 Table 3. Initial Nodes, Working Definitions and Final Nodes in my Coding .............................. 33 Table 4. Example Journal Entries During Data Analysis ............................................................. 37 Table 5. Summary of Adaptations to CTM Implementation Strategies and Content Across Four SEM Levels ................................................................................................................................... 40 Table 6. Summary of Delivery Partner Organization Context ..................................................... 45    xiii  List of figures Figure 1. Support Provided by an Activity Coach in One CTM Program. .................................. 16 Figure 2. CTM Fundamentals That Delivery Partner Organization Adhered to. ......................... 18 Figure 3. Five Levels in the SEM. ................................................................................................ 22 Figure 4.  FRAME Components ................................................................................................... 24    xiv  List of abbreviations AART: Active Aging Research Team BCRPA: British Columbia Recreation and Parks Association CHHM: Centre for Hip Health and Mobility CTM: Choose to Move FRAME: Framework for Reporting Adaptations and Modifications-Enhanced ISF: Interactive systems framework MVRD: Metro Vancouver Regional District PA: Physical activity SEM: Socio-ecological model UBC: University of British Columbia   xv  Glossary Action plan: the short-, medium- and long-term goals set by older adult participants Active Aging Research Team: a group of community-based researchers at the University of British Columbia Activity coach: the staff who delivers Choose to Move Adaptation: “planned or purposeful changes to the design or delivery of an intervention” (Stirman et al., 2013, p. 2) Check-in: 15-minute telephone calls between the activity coach and older adult participant to discuss progress towards their action plan and troubleshoot challenges Coordinator: the staff who plans and coordinates Choose to Move  Content: “the intervention procedures, materials or delivery” (Stirman et al., 2013, p. 7) Context: the surrounding environment or circumstance Core components: necessary activities or components for an intervention to be effective Culture: shared symbols, meanings, values, beliefs and practices among a group of people (Carpenter-Song et al., 2007; Garneau & Pepin, 2015) Delivery partner organization: organizations funded and contracted to deliver Choose to Move Ethnic minority: persons who are non-Caucasian and non-Aboriginal, also referred to as racialized (Perez et al., 2013) Evaluation: the project team activities that examine and assess Choose to Move implementation Evidence-based intervention: interventions with demonstrated efficacy to improve outcomes in research settings  Factors: forces that have influence over others xvi  Fidelity: “the extent to which the implemented program reflects theoretical methods, strategies, and determinants” (Bopp et al., 2013) Group meeting: one-hour gatherings where older adult participants learn about information on health topics (e.g., physical activity, brain health, stress and anxiety, food and nutrition, overcoming obstacles), socialize and engage in activity coach-led movement breaks Implementation: “systematic uptake of research findings and other evidence-based findings into routine practice” (Eccles & Mittman, 2006, p. 1).  Implementation strategy: “methods or techniques used to enhance the adoption, implementation, and sustainability of a clinical program or practice” (Proctor et al., 2013)  Interpersonal factor: “formal and informal social network and social support systems, including the family, work group, and friendship networks” Intrapersonal factor: “characteristics of the individual such as knowledge, attitudes, behavior, self-concept, skills, etc.” (McLeroy et al., 1988, p. 355) Intersectionality: “a theory of knowledge that strives to elucidate and interpret multiple and intersecting systems of oppression and privilege” (Hankivsky & Christoffersen, 2008, p. 275) Institutional factor: “social institutions with organizational characteristics, and formal (and informal) rules and regulations for operation” (McLeroy et al., 1988, p. 355) Metro Vancouver Regional District: the 20 municipalities, one Electoral Area and one Treaty Nation that surrounds Vancouver, BC (Metro Vancouver, n.d.)  One-on-one consultation: one-hour meeting between where activity coaches create an action plan with the older adult participant Participant: older adults who participated in Choose to Move at delivery partner organizations xvii  Organizational factor: “relationships among organizations, institutions, and informal networks within defined boundaries” (McLeroy et al., 1988, p. 355) Physical activity: “any bodily movement produced by skeletal muscles that results in energy expenditure” (Caspersen et al., 1985, p. 126)  Prevention delivery system: individuals or groups involved who “[carry] out the activities necessary to implement innovations” (Wandersman et al., 2008, p. 177) Prevention synthesis & translation system: individuals or groups involved who “distill information generated through research and to prepare it for dissemination and implementation in the field” (Wandersman et al., 2008, p. 175) Prevention support system: individuals or groups involved who provide “innovation-specific support (innovation specific capacity-building) and general support (general capacity-building)” (Wandersman et al., 2008, p. 175) Program: one intervention delivered from start to finish Project team: AART members who work with delivery partner organizations to plan, implement and troubleshoot CTM Provider: persons who deliver an intervention (Stirman et al., 2013) Provider characteristics: the skills, competencies and features of the person who delivers an intervention Public policy: “local, state, and national laws and policies” (McLeroy et al., 1988, p. 355) Scale-out: “deliberate use of strategies to implement, test, improve, and sustain evidence-based interventions as they are delivered in novel circumstances distinct from, but closely related to, previous implementations” (Aarons et al., 2017, p. 2) xviii  Scale-up: “deliberate effort to broaden the delivery of an evidence-based intervention with the intention of reaching larger numbers of a target audience” (Aarons et al., 2017, p. 3) Socio-ecological model: conceptual framework that suggests “patterned behavior is the outcome of interest, and behavior is viewed as being determined by … [intrapersonal factors, interpersonal factors, institutional factors, organizational factors and public policy]” (McLeroy et al., 1988) Target population: the group of individuals the delivery partner organization intends to reach   xix  Acknowledgements Thank you Dr. Joanie Sims-Gould for your continuous support and guidance throughout my thesis. You were never more than a phone call or email away when I needed support.  Thank you Dr. Heather McKay for your meticulous feedback on my thesis. You always provided thoughtful suggestions on my thesis and helped me become a better academic writer.   Thank you Dr. Catherine Tong for your guidance, feedback and encouragement. I appreciate your guidance on performing cross-cultural research and I will continue to apply the learnings in my future endeavours.   Thank you Dr. Thea Franke for your mentorship in qualitative research. You were always so generous with your time in answering my endless questions.  Thank you Ms. Sarah Lusina for your constant encouragement and advice. You were invested in my success beyond the scope of this thesis and cheered me on at my most challenging moments.   Thank you to all the coordinators and activity coaches involved in this project for welcoming me with enthusiasm and open arms. You are the experts within your community and I am grateful you allowed me to glean insight on your experiences.    1 Chapter 1: Introduction 1.1 Aging population By 2050, nearly 25% of the Canadian population will be an older adult (age 65 and above) (Sanmartin, 2015). With this demographic shift, there will be a greater prevalence of health concerns, as many chronic conditions such as arthritis, osteoporosis, heart disease and diabetes are more prevalent in older adults (Sanmartin, 2015). For example, over 50% of older adults have high blood pressure, compared to approximately 25% of 45 to 64-year-olds (Sanmartin, 2015). Chronic conditions can create ongoing challenges that range from compromised quality of life to increased economic burden on the health care system (Megari, 2013; Public Health Agency of Canada, 2009; Resnick et al., 2014). With a range of etiology for chronic conditions, upstream, preventative approaches that promote health are needed.  1.2 Physical Activity Physical activity (PA) is “any bodily movement produced by skeletal muscles that results in energy expenditure” (Caspersen et al., 1985, p. 126). PA, unlike exercise, does not need to be planned, repetitive or structured (Caspersen et al., 1985). PA includes purposeful exercise, incidental (non-purposeful) activity and lifestyle-embedded activities (e.g., chores) (Tremblay et al., 2007).   PA is recognized as a viable, evidence-based intervention to prevent and treat chronic conditions (Warburton et al., 2006; Warburton & Bredin, 2017). The Canadian Physical Activity Guidelines suggest older adults should engage in 150 minutes or more of moderate-to-vigorous intensity 2  aerobic PA, in bouts of 10 minutes or more, per week to achieve health benefits (Canadian Society for Exercise Physiology [CSEP], n.d.). Engaging in PA influences biological mechanisms associated with better health outcomes. For example, cardiovascular disease is one of the leading causes of death in Canada (Statistics Canada, 2019). Regular PA can stop disease progression and reduces the risk of cardiovascular-related deaths (Warburton et al., 2006). Yet, 87% of older adults in Canada fail to meet PA guidelines (Colley et al., 2011). The largely sedentary older adult population speaks to the need to promote PA as one means to maintain and improve health.   There are benefits to increasing PA despite older adults not meeting PA guidelines. Increases in PA are associated with increased health benefits (Warburton et al., 2016). The dose-response relationship between PA and health suggests individuals can reap health benefits (e.g., reduced risk for all-cause mortality, cardiovascular disease, stroke, hypertension, colon cancer, breast cancer, type 2 diabetes and osteoporosis) without reaching PA guidelines (Warburton et al., 2010). Notably, those who were previously physically inactive saw the greatest improvements in their health for each incremental increase in PA, compared to those who were already active. Health benefits from PA had diminishing returns at higher levels (Warburton et al., 2016). Thus, efforts to promote small increases in PA among physically inactive older adults have the potential reduce the risk for all-cause mortality and prevalent chronic conditions (e.g., cardiovascular disease) (Warburton et al., 2010).  Studies across various populations suggest non-exercise PA (e.g., housework and caregiving), or light-to-moderate intensity PA, also offer health benefits. In The English Longitudinal Study of 3  Ageing, adults ³ 50 years old who engaged in non-exercise PA had a lower risk of all-cause mortality (Hamer et al., 2014). In Stockholm, researchers found similar results--adults ³ 50 years had more preferable health indicators (e.g., waist circumference), cardiovascular health and longevity (Ekblom-Bak et al., 2014). Older men engaged in low-intensity PA were also associated with a lower risk of mortality (Jefferis et al., 2019). Findings do not undermine the importance of moderate-to-vigorous PA. Rather, they reiterate the value of PA across intensity levels.  Community-based PA interventions effectively increased older adult PA. For example, Community Health Activities Model Program (CHAMPS), based on social cognitive theory (SCT), was a six-month PA promotion program delivered in congregate housing settings for older adults in California (Stewart et al., 1997). The CHAMPS model was delivered through Medicare health maintenance organizations (CHAMPS II) and community organizations (CHAMPS III) (Stewart, Verboncoeur et al., 2001; Stewart et al., 2006). CHAMPS measured PA change through activity logs and self-administered questionnaires. Those enrolled in the intervention group engaged in more PA during the program versus the comparison group (Stewart et al., 1997). Participants in CHAMPS II increased caloric expenditure by 487 calories/week (p < .001) in moderate-intensity activities and 687 calories/week (p < .001) in all activities (Stewart, Verboncoeur et al., 2011). Participants in CHAMPS III increased caloric expenditure by 213 kcal/week (P = .10) (Stewart et al., 2006).  Active for Life was a four-year intervention that evaluated two PA programs – Active Choices and Active Living Every Day (Wilcox et al., 2008). Participants (³ 50 years ) were from diverse 4  backgrounds. Active Choices was a six-month program comprised of a face-to-face meeting and eight telephone calls. Active Living Every Day was a 20-week program conducted in a small group setting. PA, measured using the CHAMPS questionnaire (Stewart, Mills et al., 2001), was reported as the amount of moderate- to vigorous-intensity activities and total PA (minutes/week both). Across all years, participants in Active Choices and Active Living Every Day increased their moderate- to vigorous-intensity activities and total PA (Wilcox et al., 2008). Both CHAMPS and Active for Life demonstrate the potential for community-based programs to increase PA across settings and populations.  The current body of knowledge highlights the need to promote PA among older adults, the value of light-to-moderate intensity or non-exercise PA and the potential to improve health outcomes at a population level. Community-based PA interventions are a viable solution to increase PA.  1.3 Ethnic minorities The ethnic minority, or racialized (Perez et al., 2013), population in Canada is rapidly growing. Ethnic minorities accounted for 7.6 million people in 2016 (Statistics Canada, 2017a). This population is projected to grow by between 12.8 million and 16.3 million by 2036 (Statistics Canada, 2017b). In Toronto and Vancouver close to half the population belongs to an ethnic minority group; 60% of people are projected to belong to an ethnic minority group in both areas by 2031 (Statistics Canada, 2017b). The older adult population is projected to follow a similar trend and be more ethnically diverse; roughly 25% of older adults will identify as an ethnic minority by 2032 (Carrière et al., 2016; Kei et al., 2019)  5   Ethnocultural factors can negatively influence access to health services and health promotion opportunities. Barriers to Access to Care for Ethnic Minority Seniors (Koehn, 2009) reported that older adults in minority groups living in Vancouver faced challenges accessing health-care services. This was due to family dynamics, lack of independence, language barriers, cultural norms and service permeability (Koehn, 2009). These older adults faced similar challenges with access to health promotion initiatives (Khan & Kobayashi, 2015). Hence, efforts to promote health and wellbeing need to consider ethnocultural diversity.   1.3.1 Chinese population The Chinese population in Canada is one of the largest ethnic minority groups. Similar to other ethnic minority groups, many opt to live in large urban centres. Roughly 30% of the Chinese population in Canada live in the Metro Vancouver Regional District (MVRD) (Statistics Canada, 2017b). Within the MVRD, approximately 20% of the population is Chinese (Statistics Canada, 2017c). Over 20% of the Chinese population is expected to be 65 years or older by 2036 compared to 11% in 2011 (Statistics Canada, 2017b). The Chinese population will have the greatest proportion of individuals 65 years or older among all ethnic minority groups (Statistics Canada, 2017b).  The term “Chinese population” refers to those of Chinese descent. However, the Chinese population is not homogenous. Subethnicity further divides an ethnic population based on factors such as language, place of origin, biases and transnational politics (Yan et al., 2019). In Vancouver, the Chinese population speak different languages (e.g., Mandarin and Cantonese) 6  and come from different places of origin (e.g., Mainland China, Hong Kong and Taiwan) (Yan et al., 2019). Additionally, ethnic identity varies among Chinese older adults. Reducing ethnic identity to ethnic background fails to acknowledge differences in cultural activity participation, community ties, linkage with the country of origin and cultural identity (Lai & Lai, 2012). The Chinese populations’ subethnicity and heterogeneity are important considerations as it influences their preferences in interpersonal relationships (e.g., favouring interpersonal relationships with those in the same subethnic group) (Yan et al., 2019). The sections that follow draw from research on Chinese older adults in Canada, unless otherwise specified.   1.3.1.1 Chinese older adults and health Health and Well Being of Older Chinese in Canada (Lai et al., 2003) reported the general health of Chinese older adults. Chinese older adults reported better physical health but poorer mental health and general health perception compared to the overall Canadian older adult population (Lai, 2004). Chinese older adults had more chronic conditions, and more limitations in instrumental activities of daily living, but reported fewer limitations in activities of daily living (Lai et al., 2007). Among Chinese older adults, those who resided in communities with a smaller number of Chinese individuals reported better mental and physical health than those in communities with a greater number of Chinese individuals (Chau & Lai, 2011). The available data on this group of older persons in Canada suggests health challenges, both mental and physical.  Health beliefs among Chinese older adults in Canada are influenced by culture. Health and Well Being of Older Chinese in Canada also examined health and culture among Chinese older adults 7  in large Canadian cities (Lai & Surood, 2009). As a diverse group, health beliefs varied based on education, country of origin, religion and city of residence. Chinese older adults were more likely to have higher agreement with traditional Chinese health beliefs when they immigrated from China, had lower education, practiced a non-Western religion and lived in cities with a longer Chinese settlement history (Lai & Surood, 2009). Traditional Chinese health beliefs include traditional Chinese exercises, balanced diet and lifestyle according to yin-yang concepts and traditional Chinese medicine (Lai & Surood, 2009). Over 65% of participants used traditional Chinese medicine (e.g., acupuncture, herbal supplements and bone-setters) along with Western health services (Lai & Chappell, 2007).  1.3.1.2 Chinese older adults and physical activity There is very little evidence regarding the PA habits of Chinese older adults who live in Canada. Many studies investigated the effect of PA on a variety of health (e.g., musculoskeletal health, prostate cancer and cognitive function) (Manson et al., 2013; Whittemore et al., 1995; Bherer et al., 2013). Immigrants were less likely to engage in PA compared to Caucasians and non-immigrants (Tremblay et al., 2006). A study in California found similar results; Asian Americans were less likely to engage in leisure-time PA and had lower energy expenditure (Kandula & Lauderdale, 2005). Recent immigrants to Canada were less likely to engage in leisure-time PA compared to established immigrants and non-immigrants (Mahmood et al., 2019). Chinese immigrant older adults in Canada reported being less active than older adults in their country of origin (Garcia & Da, 2011). Yet, foreign-born older adults in Vancouver commonly engaged in non-exercise and low intensity physical activity, and their step count was similar to their Canadian-born peers (Tong et al., 2018).  8   Enablers to PA for Chinese older adults include health benefits, social opportunities, enjoyment, weight loss and reduced stress (Matthews et al., 2010; Garcia & Da, 2011). Barriers to PA include time constraints, no place to exercise, schedule conflicts, lack of programs in Chinese, lack of transportation, health conditions and weather (Garcia & Da, 2011). Specific to immigrants, PA provided social opportunities but was hindered by competing responsibilities (e.g., care-giving and household work) (Da & Garcia, 2015). Older Hong Kong Chinese Australians perceptions on aging were both enabler and barrier to PA (Koo, 2011). For example, those who viewed aging more positively believed PA could help maintain their health status. Conversely, those who viewed aging as inevitable and had fatalistic, traditional Chinese beliefs were less likely to view PA as a solution to health. The decision to engage in PA for Chinese older adults in Western countries was influenced by situational factors and cultural beliefs (Matthews et al., 2009; Garcia & Da, 2011; Koo, 2011).  Chinese older adults viewed PA as a way to improve their health (Matthews et al., 2010; Jette & Vertinsky, 2011). However, the PA habits among Chinese older adults were influenced by cultural beliefs. Chinese older adults engaged in individual activities such as walking, gardening and housework, ping pong (mostly men) and exercises on TV (mostly by women) (Garcia & Da, 2011). Chinese older adults also engaged in group-based activities such as Luk Tung Kuen and Tai Chi which they described as soft, balancing and not risky (Jette & Vertinsky, 2011). Tai Chi is a Chinese martial art that Asians considered beneficial for many centuries (Cheng, 2007; Lam et al., 2012). Among Chinese women, supervised aerobic exercise demonstrated greater 9  compliance and showed greater improvement in aerobic capacity compared with home aerobic exercise (Hsieh et al., 2009).  1.4 Implementation 1.4.1 Implementing evidence-based interventions Evidence-based interventions need to be implemented in real-world settings and scaled-up to impact population health. Implementation is the “systematic uptake of research findings and other evidence-based findings into routine practice” (Eccles & Mittman, 2006, p. 1). Implementation is an effort to bridge the gap between what is known and what is done in practice (Wandersman et al., 2008).   1.4.2 Implementation frameworks Implementation frameworks provide a structured approach to understand the process of moving evidence to practice. However, the field is murky as there are currently more than 60 implementation frameworks that guide health promotion programs, processes and evaluation (Tabak et al., 2012).  Wandersman et al.’s (2008) Interactive Systems Framework (ISF) described key elements and relationships among them that drive effective implementation. The ISF identified the prevention synthesis & translation system, prevention support system and prevention delivery system as key actors. The prevention synthesis & translation system represents information distilled and translated into usable and understandable concepts by the practitioner (i.e., those who deliver the 10  intervention or program). The prevention support system represents support and assistance to practitioners (e.g., a central unit that provides training and resources). The prevention delivery system represents efforts to implement the innovation in real world-settings (i.e., groups or individuals across levels who are responsible for implementing the intervention). These three systems are situated and function within a larger context (influenced by contextual factors such as funding, climate, existing research and theory, and macro policy). All elements of the ISF interact with one another to effectively move evidence into practice (Wandersman et al., 2008).  The ISF is embedded in the innermost circle of Dupre and Durlak’s (2008) Framework for Successful Implementation. This ecological model further emphasized the prevention delivery systems organizational capacity (e.g., effective leadership and program champions) and the prevention support systems training (e.g., modelling and performance feedback) and technical assistance (e.g., re-training and providing emotional support) as necessary components for effective implementation. These systems (as per the ISF) are influenced by community-level factors (i.e., the context in which the intervention is conducted), provider characteristics (i.e., beliefs and traits of those who deliver the intervention) and innovation characteristics (i.e., how adaptable and compatible the intervention is for the delivery organization). All elements in the framework interact to achieve successful implementation (Dupre & Durlak, 2008).  1.5 Adaptation Adaptation is a central tenet of implementation. Not adapting an intervention to fit the context may hinder uptake in real-world settings (Aarons et al., 2012). Adaptation, “planned or purposeful changes to the design or delivery of an intervention” (Stirman et al., 2013, p. 2), is 11  often required when transitioning from research settings to the real world (Aarons et al., 2012; Lundgren et al., 2011). Adaptations may result from changes to the context, target population and delivery system (Movsisyan et al., 2019; Cabassa et al., 2014; Aarons et al., 2017). A benefit to adapting existing evidence-based interventions to fit within existing systems, is cost savings that would be accrued by otherwise developing new interventions and establishing a supportive context for implementation (Movsisyan et al., 2019). Adaptation is an iterative process that considers the delivery context and various stakeholders who have a vested interest in some aspect of the intervention (Aarons, et al., 2012).  There is a “tug-of-war” between adaptation and fidelity—while researchers strive to ensure the intervention and its delivery resemble the original design—community partners must adapt to the current context for delivery (e.g., consider priorities and available resources) (Bopp et al., 2013). Both fidelity and adaptation are necessary for implementing evidence-based interventions. Focusing strictly on fidelity may compromise evidence-based intervention fit for the context or population and lead to low uptake or efficacy (Castro et al., 2004). Adapting evidence-based interventions and not adhering to fidelity can compromise efficacy. To address concerns with intervention effectiveness when adapting evidence-based interventions, core components (i.e., necessary activities or components) of the intervention need to remain intact (Aarons et al. 2017; Shelton et al., 2018; Mohr et al., 2015).   Two recent systematic reviews outlined reasons for adaptations and common types of adaptations (Escoffery et al., 2018; Movsisyan et al., 2019). Studies were published during 1995-2015 and examined public health evidence-based interventions adaptation processes and 12  outcomes (Escoffery et al., 2018). Movsisyan et al.’s (2019) systematic review of studies published during 2000-2018 examined how to adapt public health or health service evidence-based interventions or re-evaluate interventions in new contexts. Both reviews highlighted intervention fit as the most common reason for adapting evidence-based interventions (Movsisyan et al., 2019; Escoffery et al., 2018). Fit was related to context and population (Movsisyan et al., 2019) or to cultural appropriateness, population and setting (Escoffery et al., 2018). Evidence-based interventions were also adapted to enhance acceptability, increase reach, support implementation, enhance sustainability, maintain effectiveness, improve feasibility and accessibility and condense the evidence-based intervention (Movsisyan et al., 2019; Escoffery et al., 2018). Modified content was the most common adaptation in both systematic reviews (Movsisyan et al., 2019; Escoffery et al., 2018). Interventions were also modified to accommodate personnel, context and culture. A small number of studies reported adaptations to training, evaluation and core components (Escoffery et al., 2018).   Intersectionality (i.e., the interplay between social domains, such as sex and education, related to power and oppression) is complex and needs to be considered when one wishes to identify factors that contribute to adaptations (e.g., culture) (Bauer, 2014; Hankivsky & Christoffersen, 2008; Viruell-Fuentes et al., 2012). To illustrate, ethnicity was a factor for adapted interventions for minority groups but was commonly discussed with age and gender (Liu et al., 2016). Age and gender, among other social domains, interact with an individual or population’s ethnicity and contributed to adaptations. It is difficult to tease out the intricacies between the different factors as they interact with one another.  Thus, it is hard to attribute adaptations to a specific intersectionality between social domains. 13   Relatively few studies focus on adapting evidence-based health promotion interventions to meet the needs of diverse older adults (e.g., Chu et al., 2012; Griffin et al., 2010; Boekhout, et al., 2017; Reijneveld et al., 2003); no published implementation studies focused on the PA habits of Chinese older adults in Canada. Over half of evidence-based public health interventions adapted globally were implemented in the United States -- only one was conducted in Canada (Escoffery et al., 2018). Adaptation studies commonly focused on HIV/AIDS, mental health, substance abuse and chronic conditions. Thus, little is known about how best to adapt and implement preventative programs for the growing older Chinese population in Canada.  1.6 Choose to Move study The Active Aging Research Team (AART) -- a group of community-based researchers at the University of British Columbia (UBC) -- and community partners co-created a 6-month, flexible, choice-based intervention called Choose to Move (CTM) (McKay et al., 2018). CTM is derived from the evidence-based CHAMPS intervention; implementation was guided by the ISF (Stewart et al., 1997; Wandersman et al., 2008). The first three months are the active phase and comprised of a one-on-one consultation, five group meetings and three telephone check-ins; the last three months comprised of three telephone check-ins and are considered the taper phase – given the reduced contact time with older adult participants (participants). CTM effectively supported older adults  (>60 years old and had low activity) to improve their PA, mobility and social connectedness and also demonstrated implementation effectiveness (McKay et al., 2018; Sims-Gould, McKay, Gray et al., 2019). A project team from AART acts as the central support unit and facilitates all aspects of implementation using a variety of implementation strategies with 14  recreation delivery partner organizations (e.g., British Columbia Recreation and Parks Association (BCRPA) and YMCAs in British Columbia). Table 1 outlines all standard implementation strategies used to support CTM implementation in chronological order. Within each organization, a coordinator facilitates CTM planning and coordination (e.g., recruitment and scheduling) and an activity coach delivers CTM components. Coordinators are staff at the organization. Activity coaches are older adult fitness leaders at BCRPA locations and kinesiologists at YMCA locations. Activity coaches receive training from the project team to deliver CTM and provide support to participants through: 1) a 60-minute one-on-one consultation to create an Action Plan (i.e., short-, medium- and long-term goals); 2) five 60-minute group meetings to deliver information on health topics (e.g., physical activity, brain health, stress and anxiety, food and nutrition, overcoming obstacles), provide opportunities for social interactions and engage in activity coach-led movement breaks; and 3) six 15-minute telephone check-ins to provide ongoing support. Figure 1 describes the support provided by an activity coach in one program during the 6 months.   Table 1. Standard CTM Phase 3 Implementation Strategies at Recreation Delivery Partner Organizations Implementation Strategies The Active Aging Society received funding from the Ministry of Health to develop and deliver Choose to Move. AART partnered with the two community organizations to deliver CTM at their affiliated facilities. Both organizations have signed contract agreement committing on program delivery. CTM was first piloted in (8 communities) in Phase I before a larger scale roll out in Phase 2 (48 communities). This pilot provided an opportunity for delivery partners to provide feedback on the feasibility of CTM implementation and identify barriers and facilitators of implementation. This feedback was then used to refine the intervention, materials and implementation plan in Phase 3. 15  AART planned phased delivery and scale up with evaluation (of impact and implementation) occurring at each phase. Underwent a formal adaptation process prior to Phase 3 to enhance fit. Data collected across stakeholder levels: provincial partners/provincial coordinators, recreation managers/coordinators, activity coaches and older adult participants. Data collected includes: i) Older adults’ acceptability of CTM  ii) Delivery partners’ perceived adaptability of CTM to context and population iii) Activity coaches’ perceived feasibility of implementing CTM implementation of the intervention by activity coaches (to assess feasibility) iv) Fidelity and quality of delivery v) Evaluation tools and methods to assess the effectiveness of CTM at scale During CTM implementation, AART formed two advisory committees that provide ongoing feedback we use to adapt the program as needed throughout the intervention period. Both advisory committees meet annually. • The Community Advisory Committee comprises older adult participants, recreation coordinators, and activity coaches from partner organizations and members of AART. This committee shares lessons learned during the implementation of CTM.  • The Leadership Advisory Committee comprises leaders of delivery partner organizations and members of AART. This committee was the organizational lens we used to monitor the implementation of CTM in collaboration with partner organizations and to assess the need for further adaptation of CTM to meet the specific needs and capacity of delivery organizations before scale-up. Both advisory committees meet annually. The project team built a referral network with organizations working to support older adults across BC (e.g., Legion, Pain BC, MS society) The project team held ‘all partner’ meetings with BCRPA, YMCA, and United Way. AART created an organization, the Active Aging Society. The project team developed and provided the following materials for the delivery organization. i) Program managers • Recruitment materials (i.e., recruitment checklist and promotional material) • Descriptions of program coordinators and activity coaches hiring process and job descriptions ii) Program coordinators • Outline of implementation and evaluation tasks iii) Activity coaches • Training material • Presentation materials on health topics for motivational group meeting sessions • Tools to record participants attendance and responses during one-on-one consultations and telephone check-ins. 16  The project team held regular community of practice meetings for activity coaches at BCRPA (monthly) and YMCA (quarterly) The project team held community of practice meetings with recreation coordinators at BCRPA only (1-2/yr). The project team migrated training to an online format. Training content included an overview of CTM, motivational interviewing techniques, active listening skills. They were provided with skills demonstration, opportunities to practice the learned skills and ask questions. AART provided training updates to activity coaches. Training contributes to Continuing Education Credits for BCRPA activity coaches. The project team liaised with recreation managers onboard them for CTM and receive CTM updates (e.g., recruitment). Delivery partner organizations held information sessions for older adult participants at delivery partner sites (BCRPA, YMCA). The project team functioned as the central support unit to provide centralized technical assistance to the program coordinators, managers and activity coaches.  Figure 1. Support Provided by an Activity Coach in One CTM Program.   17  Scale-up is defined as “deliberate effort to broaden the delivery of an evidence-based intervention with the intention of reaching larger numbers of a target audience” (Aarons et al., 2017, p. 3). CTM was scaled-up across British Columbia in three phases. CTM Phases 1 and 2 (Jan 2016-May 2017) engaged >450 community-dwelling older adults; CTM implementation evaluation, conducted across 26 communities, demonstrated that community partners could deliver CTM in diverse recreation settings (McKay et al., 2018). CTM significantly enhanced older adults’ mobility and social connectedness and decreased loneliness (McKay et al., 2018). CTM Phase 3 (Jan 2018-Jun 2021), engages >2000 older adults in 73 BC communities.  Scale-out is the “deliberate use of strategies to implement, test, improve, and sustain evidence-based interventions as they are delivered in novel circumstances distinct from, but closely related to, previous implementations” (Aarons et al., 2017, p. 2). In Phase 3, CTM was adapted for scale-out to engage new delivery partner organizations and reach more diverse populations. The project team and delivery partner organization representatives (i.e., coordinators and activity coaches) collaborated to adapt CTM to align with the context for delivery (e.g., priorities and available resources) and ensured core components (Figure 2) remained. Implementation strategies specific to Phase 3 scale-out are described in Table 2. The project team engaged in regular meetings with representatives from delivery organizations who shared expertise on the local delivery context. 18  Figure 2. CTM Fundamentals That Delivery Partner Organization Adhered to.   Note. The first row describes the program length. The second row describes the activity coach characteristics. The third row describes the desired outcomes from CTM. The fourth row describes the support.  Table 2. Standard CTM Phase 3 Implementation Strategies at Scale-out Delivery Partner Organizations Implementation Strategies CTM Phase 3 scale-out design was informed by Phase 1/2 evaluation. The evaluation included: • An older adult participant focus group prior to the launch of the Phase 3 model. The project team adapted CTM and promotion material based on the feedback received. • Feedback from Phase 1/2 older adult participants to inform the Phase 3 model. Activity coach Supportive, approachable, connectorGoal setting for healthy physical activity & social behavioursGroup or individualGroup meetingsShare experiencesLearn healthy lifestyle choicesAccess to resources & supportsMoveCheck insMotivate TroubleshootRegular goal reviewActivitiesFacilitate/ConnectInspireChoose to Move – Fundamentals6 months of supportThe first 3 months provide greater support and the latter 3 months see a tapering of  support 19  AART assessed the state of the community-based service sector for older adults and determined that there was a gap in evidence-based health promotion programs for older adults; there was a need for CTM. Delivery partner organizations were solicited through a grant call co-designed and delivered by the Active Aging Society and the United Way of the Lower Mainland. The Active Aging Society fully funded the selected organizations for the CTM provision. Funding originated from the BC Ministry of Health. The project team held meetings with potential applicants to discuss project deliverables and expectations before the funding call. The review committee assessed the organization’s readiness to deliver CTM through a grant call. Organizations answered application questions related to their implementation plan and previous experience with health promotion programs. Those deemed ready were funded. Delivery partner organization conducted a local needs assessment to identify the target population. The Active Aging Society partnered with eight community organizations to deliver CTM. All organizations signed a contract agreement committing on program delivery. AART builds a referral network with organizations working to support older adults across BC (e.g., Legion, Pain BC, MS society). The project team supported the delivery partner to establish local level connections with seniors service and/or health promotion organizations. Executive directors/organization leaders, coordinators, and activity coaches assessed barriers and facilitators that informed CTM delivery at their organization. Coordinators and activity coaches surveyed their communities for recruitment opportunities and programs to refer participants to. The project team held regular community of practice meetings every one to six months with all coordinators and activity coaches. At the site level, the project team supported the delivery partner organization to foster relationships and alliances with local-level organizations that offer health promotion programs to older adults. The project team shared CTM design knowledge and facilitated discussion between coordinators and activity coaches to share facilitators and barriers at the community of practice meetings.  The project team provides the training, training debrief and training updates. The project team delivered training online via a dedicated, user-friendly, well-organized website. The activity coach received accreditation in CTM. The project team developed and provided the following materials for the delivery organization.  i) Executive director/organization leaders • Descriptions of program coordinators and activity coaches hiring process and job descriptions for reference ii) Coordinators • Outline of implementation and evaluation tasks • Recruitment material including promotional material • Screening/intake tools • Website to download all CTM implementation material and serve as a reference for CTM information 20  iii) Activity coaches • CTM training, including group meeting PowerPoint presentations, skill development on coaching, skill development on group dynamics, meeting facilitation, goal setting and motivational interviewing Tools to record older adult participant attendance and responses during one-on-one consultations and telephone check-ins. The project team functioned as the central support unit. The project team to guide and document adaptations, evaluate CTM roll-out, troubleshoot during implementation and delivery, facilitate individual and community of practice meetings, oversee project deliverables and oversee funding reports.  The project team held individual meetings with stakeholders to discuss: i) Executive director/organization leader • CTM fit within the organization • Human resource requirements • Funding • Project deliverables and timelines ii) Coordinator • Project deliverables and timelines • Recruitment • CTM implementation and delivery • Adaptations iii) Activity coach • Recruitment • CTM implementation and delivery  • Adaptations The project team provided regular newsletter updates and social media engagement for delivery partner organizations and older adult participants. Activity coaches held information sessions for potential older adult participants Activity coaches screened potential older adult participants to assess needs/interest and determine fit with CTM. The project team used summary documents to monitor process, implementation and adaptation, community of practice meetings and participation in evaluation The project team created summary reports for each organization after their grant ended to illustrate the setting, local resources and CTM adaptations.  1.7 Theoretical approach Community-based organizations do not operate in silos to deliver evidence-based interventions. They are continuously changing operating ways in response to opportunities and stressors (e.g., population needs and organization priorities). The socio-ecological model (SEM) and 21  Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) offer a structured approach to categorize and describe adaptations. I describe each, below.  1.7.1 Socio-ecological model The SEM has been applied extensively in health promotion (e.g., tobacco control and sedentary behaviour) to understand factors that influence health behaviours and provide a structural guide to modify behaviour change (e.g., Figure 3) (Sallis & Owen, 2015). The ecological perspective suggests health behaviours are influenced by factors that are nested within factors most proximal (e.g., individual characteristics) to distal (e.g., policies) factors across five levels (McLeroy et al., 1988). The five levels include intrapersonal factors, interpersonal factors, institutional factors, community factors and public policy (McLeroy et al., 1988). Intrapersonal factors are the characteristics of the individual (e.g., skills, attitude and behaviours). Interpersonal factors are the social networks (e.g., family and friends). Institutional factors are the social institutions where humans interact and their rules and regulations (e.g., organization policies). Community factors encompass relationships among groups and organizations within a specific area. Finally, public policies are the regulatory policies, procedures and laws in place that might influence behaviours. According to this perspective, health behaviours are influenced and shaped by all levels interact with one another and the environment (McLeroy et al., 1988).  22  Figure 3. Five Levels in the SEM.   Note. Reprinted from Creating and supporting a healthy food environment for type 2 diabetes prevention by B. Liu, Y. Sun, & W. Bao, 2018, The Lancet Planetary Health, 2(10), p. e423. Copyright 2018 by The Lancet.   The SEM can readily be applied to factors across levels that influence CTM implementation, adaptations to CTM and ultimately, change in individual physical activity behaviours. I provide one example of how an organization might adapt CTM to fit, in this case, a specific sociocultural context. Consider that CTM is delivered by an organization that provides services to new Hispanic immigrants. At the intrapersonal level, the organization offers CTM in Spanish because many Spanish-speaking participants express interest in increasing their PA now that they are 23  settled in a new country. At the interpersonal level, the organization offers CTM in Spanish and adapts activities to reflect Hispanic culture as a way to engage this close-knit community. At the institutional level, an organization that serve the needs of Hispanic people is engaged to deliver CTM and to adapt it based on the needs of their client base. At the community level, this organization is well-connected to other Hispanic seniors-serving organizations which facilitates program uptake and dissemination. At the public policy level, the local government increases funding to provide support for new immigrants to engage in health-promoting opportunities (like CTM).   1.7.2 Framework for reporting adaptations and modifications-enhanced (FRAME) Adaptations are an important part of the evidence-based intervention implementation process (Chambers et al., 2013). FRAME (Figure 3) (Stirman et al., 2019) provides structure to describing how an intervention might be modified across levels of influence. Previous iterations of the framework captured who made the modification, what was modified, level of delivery where the modification was made, types of modifications to context, and nature of the content modified (Stirman et al., 2013). FRAME captures additional components including modification timing, planned/reactive modifications, fidelity, goal of the modification and reasons for the modification (Stirman et al., 2019). FRAME reasons for modifications is influenced by the SEM (e.g., reasons for adaptation at the recipient level is influenced by intrapersonal factors). Using FRAME provides structure and consistency to describe adaptations in a standardized way.  24 Figure 4.  FRAME Components  Note. Reprinted from “The FRAME: an expanded framework for reporting adaptations and modifications to evidence-based interventions,” by S.W. Stirman, A.A. Baumann & C.J. Miller, 2019, Implementation Science, 14(58), 1-10. Copyright (2019) by Stirman, Baumann & Miller.  25 1.8 Aims and objectives This thesis aimed to understand how CTM can be adapted by coordinators and activity coaches to serve Chinese older adults in MVRD. The objectives were: 1. To describe the factors that contributed to CTM implementation strategy and content adaptations. 2. To describe the adapted CTM implementation strategies and content.  This thesis was guided by FRAME (Stirman et al., 2019) to analyze interviews, meeting minutes and ethnographic observation notes. Factors that contributed to adapted implementation strategies and CTM content, and the adaptations were described across four levels of the SEM (McLeroy et al., 1988).   26  2. Methods 2.1 Study design Given the focused nature of my research questions, and bound by timelines (e.g., the CTM intervention takes six months), I employed a focused ethnographic approach to examine how three organizations serving Chinese older adult in MVRD adapt CTM implementation strategies and content. Focused ethnographies investigate pre-determined questions (Wall, 2014; Knoblauch, 2005; Roper & Shapira, 2000). Compared to conventional ethnographies, focused ethnographies investigate a specific context and subgroup and larger amounts of data are collected over a short period of time (Wall, 2014; Knoblauch, 2005). I used interview, meeting minute and ethnographic observation data collected from coordinators and activity coaches between April 2018 and April 2020.  2.2 Inclusion/exclusion criteria The inclusion criteria were coordinators and activity coaches who: 1) planned and delivered CTM in Chinese; and 2) spoke English. The exclusion criteria were: 1) non-activity coach and coordinator staff, 2) coordinators and activity coaches at the organizations who did not plan or deliver CTM in Chinese; and 3) coordinators and activity coaches who did not speak English.   2.3 Recruitment Coordinators and activity coaches were informed of the research study upon hire. Coordinators and activity coaches were hired by the delivery partner organization. The Director of Strategic Partnerships and Strategy communicated key activity coach characteristics (e.g., experience 27  working with older adults and physical activity knowledge) verbally and through written correspondences, and provided past activity coach job descriptions for the delivery organizations to consider. The delivery organizations hired activity coaches and coordinators based on skills required for their target population and resources available. I sent the coordinators and activity coaches research study invitation letters and consent forms via email. I obtained the coordinator and activity coaches email when the Executive Director or organization leader introduced them to AART at our meetings. They were asked to confirm whether they accept or decline the invitation; no coordinators or activity coaches refused to participate in the study. Those who accepted the invitation were asked to complete, scan and send the consent form back to me. I used purposive sampling to identify CTM coordinators (n=4) and activity coaches (n=4) at three delivery partner organizations (Robinson, 2014).  One coordinator and activity coach dropped out of the study due to a change in their staff role. No AART team member or I had a prior relationship with any study participants. Both men and women from AART were involved with the evaluation. The Director of Strategic Partnerships and Strategy met one coordinator when she inquired about the opportunity to deliver CTM in January 2018. The coordinators and activity coaches were informed their data will be used in my Master’s research project. The study was approved by the University of British Columbia, Research Ethics Board H18-02202.  Focused ethnographies use multiple data collection strategies (Roper & Shapira, 2000). I used semi-structured interviews, ethnographic observations and meeting minutes.  28  2.4 Data collection – semi-structured interview I contacted eligible participants who expressed interest to participate in a scheduled 30-60 minute telephone interview. activity coaches were interviewed at 3-month of the first program and 6-month of the last program, and coordinators were interviewed at 3-month during the first and last program. I sent the semi-structured interview guide via e-mail prior to the interview so they could review the questions and prepare responses. Activity coaches were asked about CTM training, development, planning, implementation strategies and delivery (Appendix A. Instrument 3: 3-month Activity Coach Interview Guide v2, Appendix B. Instrument 3: 3-month Activity Coach Interview Guide v5, Appendix F. Instrument 14: Activity Coach 6-month Interview Guide (last program) v1, and Appendix G. Instrument 14: 6-month Activity Coach Interview Guide v2). Coordinators were asked about CTM fit, implementation strategies and planning (Appendix C. Instrument 2: 3-month Coordinator Interview Guide v2, Appendix D. Instrument 2: 3-month Coordinator Interview Guide v4, and Appendix E. Instrument 2: 3-month Coordinator Interview Guide v5). I worked with AART principle scientists and experienced qualitative researchers to develop the interview guides informed by FRAME. An AART Research Coordinator, who holds a Master of Health Leadership and Policy degree and has experience with qualitative methods, conducted the interviews. The interviews were conducted from September 2018-April 2020 in a private room at the Centre for Hip Health and Mobility (CHHM) located on the Vancouver General Hospital Campus in Vancouver. One telephone interview was conducted at the Research Coordinator’s home because research activities on UBC campuses were curtailed due to COVID-19. Only the interviewer was present during the interviews. The interviewer placed the call on speakerphone to audio record on a password-protected iPhone and took field notes on a printed interview guide. Data files were immediately 29  transferred to a secure encrypted server and deleted from the iPhone. The Manager of Research Operations at CHHM will perform a factory reset on the iPhone at the end of the study. The field notes were scanned to a secure encrypted server and stored in a locked filing cabinet. The audio files were transcribed verbatim by a professional transcription agency, OnLine & OnTime. All files are stored on password-protected encrypted computers/servers at CHHM.  2.5 Data collection – ethnographic notes An AART Research Assistant and I collected ethnographic notes from September 2018-December 2019 at the first and fifth group meetings for programs that delivered CTM in Chinese. Only ethnographic notes collected from programs delivered in Chinese were included in this study. Prior to the group meeting, I contacted the coordinator and activity coach to confirm the date, time and location for data collection. The coordinator and activity coach were informed the purpose of the visit was to observe the group meetings and not to evaluate their performance. I worked with AART principle scientists and experienced qualitative researchers to develop the ethnographic observation guide (Appendix H. Instrument 10: Ethnographic Notes v1 and Appendix I. Instrument 10: Ethnographic Notes v2) informed by FRAME. I attended 10 group meetings to conduct ethnographic observations. The group meetings took place at the delivery partner organization or community spaces identified by the delivery partner organization and lasted 60-135 minutes. I did not conduct ethnographic observations at three group meetings due to cancelled group meetings and communication challenges with the coordinator and activity coach. I was unable to conduct one ethnographic observation due to two group meetings scheduled at the same time. An AART Research Assistant conducted the ethnographic observation at one group meeting. During that time, I held a Bachelor of Arts in 30  Health Sciences and was working towards my Master of Science in Experimental Medicine. I was trained in qualitative methods (i.e., interviewing and observations) through my Research Assistant role with AART and graduate qualitative coursework. The AART Research Assistant was an undergraduate student in Biomedical Physiology and Kinesiology and received qualitative observation training from AART. An AART Communications Manager, a Health Communications and Project Operations Lead and a Communications and Digital Engagement Assistant attended two group meetings with me. They attended the group meetings to gather communications material. The activity coach informed the participants of our researcher status. The notes were written on an observation sheet or in a notebook, typed in Microsoft Word within 24 hours and saved on password-protected encrypted computers/servers at CHHM.   2.6 Data collection – meeting minutes The AART Director of Strategic Partnerships and Strategy and/or I held operations meetings with the coordinator and/or activity coach from April 2018-April 2020. We, along with a Research Coordinator, formed the project team (as described in Section 1.6). I emailed the coordinator and/or activity coach to schedule the meetings approximately once a month when they planned and delivered CTM. The Director of Strategic Partnerships and Strategy and/or I wrote the meeting minutes in a notebook and transcribed them into Microsoft Excel. I used data pertaining to implementation and content adaptation for programs delivered in Chinese. Most meetings were conducted in a private, enclosed room at CHHM via telephone. Three meetings were conducted in-person at the delivery partner organizations. Two telephone meetings were conducted at my home because research activities on UBC campuses were curtailed due to COVID-19. Hardcopies of all data, including field notes, meeting minutes, audio files etc. are 31  stored in a locked cabinet and electronic files are stored in password-protected encrypted computers/servers at CHHM.  2.7 Confidentiality All interviews, ethnographic notes and meeting minutes were assigned a unique eight-digit ID. Data with IDs, names and identifiers are stored separately. I de-identified the interview transcripts, ethnographic notes and meeting minutes with pseudonyms prior to analysis. Master lists linking the original and de-identified data are password protected and encrypted. All data and master lists are stored in locked filing cabinets or password-protected computers/servers at CHHM. Only the principal investigator and research team members had access to the study data. All AART team members completed TCPS 2.0 training on confidentiality and ethics in research.  2.8 Data analysis All data were blinded before they were analyzed (Richards et al., 2019). Transcripts, ethnographic notes and meeting minutes for each site were analyzed with framework analysis (Ritchie & Lewis, 2003). The steps in framework analysis include: 1) familiarization, 2) identifying a thematic framework, 3) indexing, 4) charting and 5) mapping and interpretation (Ritchie & Lewis, 2003). I analyzed data from questions asking about implementation and content adaptations. In the familiarization step, I read through three transcripts, three ethnographic notes and three meeting minutes to understand key concepts in the data. I noted recurring themes and created a thematic framework in discussion with two AART members. The thematic framework was informed by FRAME. FRAME reasons for modifications are nested within the SEM’s proximal to distal factors. To index the data, I coded data deductively 32  (Saldaña, 2015) in NVivo 12. I used paragraph coding to provide context for indexed data, and to ensure the meaning was not lost. Table 3 outlines my initial nodes, working definitions and changes made for my final nodes. I charted the data by lifting quotes from the transcripts that illustrated a theme. In the mapping and interpretation step, I regularly debriefed with AART members and discuss themes and sub-themes (Long & Johnson, 2000). I led data analysis and consulted with AART members on the methods and interpretation.  33 Table 3. Initial Nodes, Working Definitions and Final Nodes in my Coding Initial nodes informed by FRAME and familiarization step Definition for initial nodes Final changes to the initial nodes What is the goal of the modification? - Increase reach/engagement - Improve retention - Improve feasibility - Improve fit with participants - Address cultural factors - Improve effectiveness - Reduce cost - Increase satisfaction The purpose an adaptation serves Removed “improve feasibility” due to no references in that node. Reasons for modification - Sociopolitical o Existing policies o Societal/cultural norms o Funding or community allocation/availability - Organization/setting o Cultural/religious norms o Location/accessibility o Organization description o Organizational fit o Service structure Reasons for adapting CTM pertaining to the organization and/or the setting where CTM is delivered Removed “existing policies” under “sociopolitical” due to no references in that node.   Collapsed references in “funding or community allocation/availability” and “organization description”  under 34  o Social context o Time required o Volunteers  - Provider o Race o Ethnicity o First/spoken languages o Activity coach characteristics o Cultural norms, competency - Recipient o Race; ethnicity o Access to resources o Literacy and education level o First/spoken languages o Cultural/religious norms o Gender identity o Age o Interaction among participants o Participant barriers to joining CTM o Participant attendance o Drop out o Other  “sociopolitical” due to a small number of references.  Collapsed references in societal/cultural norms” and “organization description” under “sociopolitical” due to a small number of references.  Collapsed the child nodes “cultural/religious norms” and “location/accessibility” under “organization/setting” due to the low number of references  Removed “race” under “provider” due to no references in that node. What is modified? - Implementation strategies o AART support (planning) o AART support (partnership)  Added the child node “language” to content modifications 35  o Screening for participants o Activity inventory o Recruitment § Participant recruitment and referral § Volunteer recruitment § Recruitment material provided by AART - Content modifications o Group meeting o Guest speaker o Group discussion o Check-ins o Additional opportunity o Additional resources provided by the Activity Coach o Goal setting o Language  - Training and evaluation o Volunteer training o Activity coach training o Participant evaluation   36  2.9 Rigour Rigour in research is often judged on validity, reliability and generalizability (Noble & Smith, 2015). Although these terms are mostly applied to quantitative research, the intent or purpose can be applied to qualitative research. I outline my strategies to enhance the rigour of my research below.  Validity is how accurately the findings reflect the data (Long & Johnson, 2000; Noble & Smith, 2015). Qualitative research is concerned with representing the participants’ perspective accurately (Noble & Smith, 2015). A focused ethnographic approach allowed me to triangulate my data by using multiple data collection methods (i.e., semi-structured interviews, ethnographic observations and meeting minutes) and data sources (i.e., collecting data from coordinators and activity coaches at different time points) to comprehensively understand the participants’ perspective (Patton, 1999). Additionally, the interviewers and I engaged the participants in member checking/reflections by summarizing and rephrasing what we heard (Smith & McGannon, 2017). We informed the participants before we summarized and rephrased what we heard so they are aware that we processed and interpreted the dialogue. I also sent summaries from the meeting minute data during each program to the participants. We asked participants to clarify if our summaries and interpretations were inaccurate during the interviews, during the meetings and via email.    Reliability is concerned with analytical consistency (Long & Johnson, 2000). I enhanced reliability through journaling to leave an audit trail detailing my data analysis processes and 37  decision points (Koch, 2006). Table 4 includes examples of my journal entries. I also peer de-briefed with AART team members and discussed themes to address biases and reach a consensus on findings (Long & Johnson, 2000).  Table 4. Example Journal Entries During Data Analysis Journal entries April 3, 2020. Coded info session references to “recruitment” under the implementation strategy parent node because the older adults are not registered and the info session is not formally part of CTM. April 6, 2020. Re-coded references in “other” to existing nodes (if applicable) to understand the bigger picture on the differences in adaptations versus the standard model. May 9, 2020. Omitted the meeting minute documents where the Executive Director was present and there was no novel data not captured elsewhere.  Generalizability refers to the ability to apply findings to other contexts (Noble & Smith, 2015). Qualitative research findings can be transferred or applied to other cases if there is a fit between the two contexts (Smith, 2017). I enhanced generalizability by describing my research participants and the contexts they work in (Mays & Pope, 1995). In doing so, readers can reflect on the research findings’ fit for their context (Smith, 2017).  Saturation, the state where new data does not generate new ideas, is often a marker of rigour (Green & Thorogood, 2004; O’Reilly & Parker, 2012; Saunders et al., 2018). Saturation is varied as there is not a “one-size-fits-all” approach (Fusch & Ness, 2015). The elements in my focused ethnography study design that support saturation included: lengthy timelines where I collect 38  thick (i.e., quantity) data; multiple data sources and time points where I collect rich (i.e., quality) data; and semi-structured interview guides that asked the same questions across interviewees which contributed to consistent response categories (Fusch & Ness, 2015).   39  3. Results In this chapter, I present my findings on CTM implementation strategy and content adaptations gathered from coordinators and activity coaches at three delivery partner organizations. In Table 5, I summarize factors that influenced CTM implementation strategies and content adaptations and elements of CTM that were adapted--nested within four levels of the SEM. I describe delivery partner organizations that collaborated in my study in Table 6. All quotes presented in this chapter are from the interview transcripts. Meeting minutes and ethnographic observation notes informed my analysis and confirmed themes.    40 Table 5. Summary of Adaptations to CTM Implementation Strategies and Content Across Four SEM Levels FRAME level Mapped on SEM Factor that influenced adaptations Implementation strategy adapted Content adapted Organization/ setting Community/ institutional Connection with other organizations Recruitment:  1. created a referral network Group meeting:  1. added guest speakers  2. cancelled group meetings Activity inventory:  1. created an activity inventory with resources for participants AART partnership Recruitment:  1. shared adapted recruitment resource with other organizations that delivered CTM in Chinese 2. used new recruitment methods (suggested by the project team) 3. reverted to a fixed recruitment period n/a Activity inventory:  41  1. created an activity inventory with resources for participants Available resources Recruitment:  1. used volunteers to translate recruitment material and identify and recruit eligible older adults Group meeting 1. added group meetings Activity inventory:  1. tailored activity inventory resources based on resources available from the organization Service structure Recruitment:  1. recruited participants through settlement worker referrals 2. obtained eligible older adult contact information from their database  3. displayed recruitment material in the office One-on-one consultation:  1. changed to group-based goals Group meeting:  1. invited participants to programs offered by the organization that were led by the activity coach  Provider Interpersonal Social network Recruitment:  1. used volunteers to recruit older adults in their social network n/a 42  Activity coach competency n/a Group meeting:  1. skimmed over group meeting topic 2. added guest speakers Time required Implementation period:  1. extended beyond the original timeline Check-in:  1. cancelled check-ins Group meeting:  1. used peer-led movement breaks 2. extended beyond 60-minutes Drop out n/a Cancelled program:  1. ended the program before all components were delivered Variety n/a Group meeting: 1. added guest speakers and a youth volunteer Spoken language n/a Group meeting:  1. added activities that don’t require verbal communication 2. communicated through volunteers Recipient Intrapersonal Participant characteristics Recruitment:  1. condensed the recruitment material allowed older adults to take the material home 2. conducted individual information sessions One-on-one consultation:  1. changed to group-based goals  43  Screening:  1. used the Get Active questionnaire Check-in:  1. added additional check-ins  2. extended check-ins beyond 15-minutes  3. held check-ins in-person after the group meetings  4. provided reminders for upcoming check-ins and group meetings  Group meeting:  1. changed the language to Mandarin and Cantonese 2. added activities 3. made the group meetings more interactive 4. reminded participants about the program concept and their goals  5. hosted group meetings during the intake process 6. invited participants to attend other programs at the organization 7. provided additional resources to programs  8. added additional group meetings  Volunteer characteristics Training:  1. created physical training material for volunteers; included relevant material in binders n/a 44  2. held a discussion-based training for a volunteer Drop out Recruitment:  1. recruited volunteers while delivering CTM (i.e., implementation and delivery phase overlapped) n/a Literacy n/a One-on-one consultation:  1. drew pictures to represent action plan goals Engagement and motivation n/a Group meeting:  1. incorporated hands-on activities to make the group meeting more interactive   45 Table 6. Summary of Delivery Partner Organization Context Context Description Name of Organization Choices Setting Choices is located in a MVRD suburb. The area is semi-industrial with warehouse buildings and big box stores. Organization type Not-for-profit charity Population served by the organization Immigrants and refugees across all ages Population served in CTM Chinese older adult immigrants (<age 65) Coordinator The first coordinator, Jordan, held the Volunteer Support Worker role at Choices. He is of Korean descent and speaks English and Korean. He has a background in facilitation and teaching ESL students. He supported CTM programs 1 and 2.   The second coordinator, Simran, held the Volunteer Support Worker role at Choices. She is of South Asian descent and speaks English and Punjabi. She has a background in seniors recreation and volunteer management. She supported CTM programs 2 and 3. Activity Coach As above. The same individual held the coordinator and activity coach roles.  Name of Organization Dynamic Collective Setting Dynamic Collective is located in a residential neighbourhood in Vancouver with many single-family homes. Organization type Neighbourhood house Population served by the organization Local residents age 18 months and above Population served in CTM Chinese older adults, including caregivers and immigrants Coordinator Julie held the Intergenerational Coordinator role at Dynamic Collective. She is of Chinese descent and speaks English and Cantonese. She has a background in counselling. Activity Coach Brenda held the Seniors Programmer role at Dynamic Collective. She is of Chinese descent and speaks Cantonese. The activity coach was well connected to the local residents and community programs. Name of Organization Spruce Setting Spruce is located in Chinatown, part of Mid-Railtown in Vancouver. The area has many commercial and social housing buildings. Organization type Not-for-profit organization Population served by the organization Immigrant older adults living in Chinatown or Mid-Railtown 46  Population served in CTM Low socio-economic status Chinese older adults living in Chinatown or Mid-Railtown Coordinator Nina held the Outreach Worker and Programs Coordinator role at Spruce. She is of Chinese descent and speaks English and Cantonese. She was one of the founding members of Spruce. Activity Coach Sylvia held the Coordinator role at Spruce. She is of She was one of the founding members of Spruce.  3.1 Implementation strategies and content adaptations Coordinators and activity coaches adapted CTM to fit their local context. Below, I use Stirman’s (2019) FRAME to categorize factors that influenced implementation strategies and CTM content adaptations. I also describe what was adapted. I situate factors within four levels of the SEM (i.e., community factors, institutional factors, interpersonal factors and intrapersonal factors). Implementation strategies and content I describe below was adapted from CTM Phase 3 scale-out implementation strategies and content (described in section 1.6).  3.2 Socio-political setting: public policy factors  While I acknowledge public policies impact adaptations to evidence-based interventions, participants did not discuss public policy factors that influenced CTM implementation strategy and content adaptations.  3.3 Organization/setting: community and institutional level factors At the community and institutional level, two organization/setting factors influenced implementation strategy and/or CTM content adaptations: Community: connection with other organizations and the partnership with AART. Institutional: available resources and service structure. 47   3.3.1 Community: Connection with other organizations Coordinators and activity coaches described the delivery partner organization’s past and existing connections with others in the community. The delivery partner organizations had various relationships with others which influenced the adapted implementation strategy (e.g., activity inventory and recruitment) and content (e.g., group meetings).  “The people that I talk to, every non-profit organization, they have 200 programs running” (Jordan - coordinator).  “They are also busy recruiting their own things, and often they’ll be organizations-- Georgetown is a big organization, all these big organizations, they don’t exactly know who’s the coordinator for Choose to Move … people also mind their business” (Jordan - coordinator).    “We are already quite connected to other Chinese senior workers in the Mid-Railtown”(Sylvia - activity coach).  “It’s always good to have these type of partnerships because with new programs … Some of the partnerships have been from before too, that we’ve 48  reached out and just continuing to build this relationship—partnership” (Julie - coordinator).  “We already had a relationship with the Brain Health Group” (Nina – coordinator)  Simran was unaware of other Chinese older adult programs held at the same time as her group meetings. She adapted the content (e.g., group meetings) due to the scheduling conflict.  “There was a Chinese Society [meeting] every time that started with AART” (Simran - coordinator)  Implementation strategy adapted  Recruitment: Coordinators and activity coaches connected with delivery partner organizations to create a referral network for recruitment. The referral network included building managers, frontline workers, caseworkers, programmers, health care providers and local businesses. The referral network partners displayed recruitment material (e.g., posters, rack cards and flyers) at their venues and identified and referred older adults to the delivery partner organization.  “I was reaching out to other organizations, especially other frontline workers, with the Chinese [inaudible 11:43] in the neighbourhood, as building that 49  referral network. And asking them, yeah, to provide referrals for participants.” (Nina - activity coach)   “As well as we distributed those materials and I sent, like, a personal email to each of the community organizations we partner with, our neighbourhood, asking them for referrals. Especially for frontline workers who have a better idea of, like, types of people’s needs so we can reach people who are more in need of a physical activity program or social connections.” (Julie - coordinator).  Activity inventory: Coordinators and activity coaches connected with local organizations (e.g., community and recreation centres, neighbourhood houses and not-for-profit organizations) and created an activity inventory prior to delivery of the CTM program. They leveraged connections between the delivery partner organization and others to collect resources (e.g., exercise classes and social gatherings) for their participants.  “We asked the workers to send us what’s going on in their spaces, which includes community centres” (Sylvia - activity coach)  50  “I also reached out to other, yeah, community senior programmers or community centres to see what kind of programs they were offering” (Nina - coordinator)  Content adapted  Group meeting: Connections with other organizations overlapped at the community/institutional and interpersonal level to influence the adapted group meetings. Coordinators and activity coaches invited other organizations/individuals to the group meetings as guest speakers based on partnerships between the two organizations (community/institutional level) and/or personal relationships from past jobs and projects (interpersonal level). The Brain Health Group presented at all three organizations. Simran invited a yoga instructor to lead chair yoga after a group meeting.  “‘Cause I had resources from before too, so that’s how I reached out to the yoga lady and the people that are brought in” (Simran - activity coach)  “The one that was, like, on top of things and she-- so she actually was a psychologist from back home and she was still practicing” (Simran - activity coach)  51   “This lady that came from before that did chair yoga for seniors, so I reached out to her and she sent me one of her students” (Simran - coordinator)   “We also worked with the Brain Health Group. They came and did a presentation on brain health for one of the group meetings”(Nina - coordinator).  Other Chinese older adult programs occurred at the same time as the CTM group meetings. Many participants attended other programs instead. Simran cancelled some group meetings and guest speakers where the date and time conflicted with other programs and participants could not attend.  “So when I would have, like, when I had the ones-- I had to cancel many of them, the speakers and the workshops” (Simran - coordinator)  3.3.2 Community: AART partnership A partnership developed between AART and the delivery partner organization as they collaborated on a grant call for funding to deliver CTM. Coordinators and activity coaches described the support (e.g., regular check-in meetings and teleconferences) project team members from AART provided. The partnership with AART influenced how implementation strategies were adapted (e.g., activity inventory and recruitment). 52   “AART was the only people who gave me guidance. [laughs] I really thought it was too much amount of researching in the beginning … too much work” (Jordan - activity coach)  “I remember doing, like, the homework assignments from Tanya (AART) and Ann (AART) looking through the materials and seeing, like, filling out the Excel sheet about what is appropriate, what kind of adaptations we made, what suggestions we had, just to help start thinking through how we might want to, like, adapt this to fit with our organization” (Nina - coordinator)  “I think they were just helpful in being a soundboard in listening to ideas and suggesting and helping us brainstorm different ways of doing things” (Sylvia – activity coach)  “It was useful to talk about-- connect with [Choices and Dynamic Collective’s] experience and will help influence the way we-- it will be something that helps influence the way we do recruitment and thinking about our activity inventory as well” (Nina - coordinator).  53  “[AART] connected us with Spruce who’s also doing a Chinese group and Choices which is doing a Mandarin group. And they even set up different teleconference lines for us so that we can actually discuss what-- some challenges and what-- some strategies they’ve used” (Julie - coordinator).  Implementation strategy adapted:  Activity inventory. Coordinators and activity coaches surveyed their community for programs and resources suitable for their target population. Project team suggested that coordinators and activity coaches should compile the resources before they delivered CTM. Many would not have taken this step if they did not connect with the project team.  “I had to find four different places where seniors can go to in the community. Like, research the senior activities, like, at rec centres on that particular day of my sessions ... And because I got the headache out of the way in the beginning, I had a lot more resources” (Jordan - activity coach)  “That was super helpful to be already thinking about those things early on. So then when we got to the place where I was making those decisions around, okay, this group meeting we’re going to do this and this group meeting we’re going to do that, I already had an idea of what materials we were given and what was-- the base format is” (Nina - coordinator) 54   “And they tried to kind of encourage us to use more community resources such as, you know, there was a supplement program in the community centres and all that. So I think that that was useful” (Julie - coordinator)  Nina adapted her activity inventory after connecting with Choices and Dynamic Collective. The delivery partner organizations shared implementation strategy ideas (e.g., activity inventory resources) during the teleconferences.  “But it was useful to talk about-- connect with their experience and will help influence the way we-- it will be something that helps influence the way we do recruitment and thinking about our activity inventory as well” (Nina - coordinator)  Recruitment. The project team supported delivery partner organizations that delivered CTM in similar contexts to develop new relations. The project team shared the coordinator and activity coaches contact information (with permission) and hosted and moderated community of practice meetings. The delivery partner organizations all agreed that the recruitment resources provided in English would not be compatible with the target population’s primary language. Dynamic Collective shared a poster they translated to Chinese with others.   55  “So we did adapt the poster using one of the posters and we were working alongside Dynamic Collective and Choices [inaudible] the very beginning in terms of translation ‘cause all the materials were in English. And our group isn’t Chinese so, yeah, we-- the three organizations, we worked together to-- in terms of, like, sharing our translations that we did to minimize our costs” (Nina - coordinator)  Coordinators and activity coaches adapted their recruitment strategy after they connected with the project team and other organizations who delivered to Chinese older adults. They included new recruitment avenues they had not considered before (e.g., health care providers and building managers).   “But it was useful to talk about-- connect with their experience and will help influence the way we-- it will be something that helps influence the way we do recruitment and thinking about our activity inventory as well” (Nina - coordinator)  “Art, helped with considering people out-- people we might not have thought of. So, like, family doctors and building managers, yeah” (Sylvia - activity coach)  56  For Jordan, the partnership with AART and subsequent conversations with the project team clarified the recruitment strategies used in the standard CTM model and influenced his decision to move from a continuous intake back to a fixed recruitment period.    “I’m finding out, like phone call I had with Tanya, the continuous intake was never possible” (Jordan - coordinator)  3.3.3 Institutional: Available resources Coordinators and activity coaches described the resources available at their organization. All of the delivery partner organizations had a volunteer base they drew from to support CTM implementation (e.g., recruitment). The volunteers typically support other programs or services (e.g., immigrant services) at the organization.   “We didn’t hire them as staff but volunteers. We recruited them, all of the activity coaches, they were already our volunteers for Immigrant Services” (Jordan - coordinator)  “The biggest thing is our wellness connectors which are volunteers”(Julie - coordinator)  57  “We also had one of the past participants come back as a volunteer and that was really helpful” (Nina - coordinator)  Furthermore, programs that already existed at the delivery partner organization, or lack thereof, influenced the adapted implementation strategies (e.g., activity inventory).   “‘Cause we don’t have a seniors program other than the Choose to Move at that point” (Simran - activity coach)  “We also looked online for the local community centre programs. So I developed a list that seniors could attend” (Sylvia - activity coach)  “Dynamic Collective we really in the center of Ackerman, right. We have lots of activity already … the programs already existing already in the market” (Brenda - activity coach)  Coordinators and activity coaches also described advisory committees that guided and supported their implementation strategies (e.g., recruitment) and content adaptations (e.g., group meetings).  Implementation strategy adapted:  58  Recruitment. Many delivery partner organizations had volunteers involved with other programs. Coordinators and activity coaches added volunteers to various recruitment activities. Volunteers translated CTM material for Jordan because he did not speak Chinese (described in section 3.4.7).  “Translation, took me forever, forever. The volunteers-- I have to get it checked by two, three other people” (Jordan - coordinator)  Brenda’s volunteers identified and recruited eligible older adults to CTM.  “I, like, basically it’s really hard to find out those, like, inactive seniors. ‘Cause I don’t really know them. So I really have to rely on some kind of the referral as well from the other active senior in this neighbourhood” (Brenda - activity coach)  In the operational meetings with the coordinators and activity coaches, they received support with recruitment from their advisory committee through word of mouth.  Activity inventory. Programs and resources offered within the delivery partner organization influenced the activity inventory composition. Coordinators and activity coaches included older adult programs offered at their organization if it existed. Choices did not offer older adult 59  programming other than CTM. Consequently, Simran’s activity inventory included many programs and resources from other organizations (e.g., local community centres).   “I told them about the recreation centre, Mansfield Community Centre, and the library as well as George Art Gallery. I even gave them references to other programs that were offering, like, diversity, THRIVE. They even have a Chinese help line so I also referred them to other organizations as well that, like, if they wanted to continue and-- going to different programs” (Simran - activity coach)  Brenda’s and Sylvia’s organization offered other older adult programming, in addition to CTM. Their activity inventory included programs (e.g., walking group) offered internally and those offered by other organizations (e.g., community centres).  “I did find some, like, resource or activity that’s in our neighbourhood before I have the group form”(Brenda - activity coach)  “We also looked online for the local community centre programs. So I developed a list that seniors could attend” (Sylvia - activity coach)   60  Content adapted: Group meetings. Jordan described adding additional group meetings to his CTM programs in our operational meetings. The decision to add additional group meetings came from feedback from the advisory committee at Choices and participants in the program.  3.3.4 Institutional: Service structure Each delivery partner organization was situated in a different neighbourhood. Consequently, the demographic who accessed the delivery partner organization and programs offered also differed. Coordinators and activity coaches adapted the implementation strategies (e.g., recruitment) and CTM content (e.g., one-on-one consultation and group meetings) based on older adults who accessed the delivery partner organization. Many noted the target population already accessed the delivery partner organization.   “I already knew a lot of people in the community … We have a Chinese settlement worker here who deals with maybe 200 clients a year” (Jordan - coordinator)  “Our organization we already work with such a big population of folks who would be eligible for the program and are folks who would be interested in the benefit of the program”(Julie - coordinator)  61  “Our organization has already built a lot of trust in the community and we’re really pretty well respected from the community” (Nina - coordinator)  The delivery partner organization’s service structure (e.g., programs offered at Dynamic Collective and Spruce) influenced their content adaptations (e.g., one-on-one consultation). Many discussed the typical programs offered by the delivery partner organization (e.g., walking group and casework) and how CTM’s structure differed from it.   “Dynamic Collective we really in the center of Ackerman, right. We have lots of activity already … the programs already existing already in the market” (Brenda - activity coach)  “And I think another thing that really contributed is because the nature of the neighbourhood house is a place where we provide programs. So for a lot of seniors to be, like, what do you mean you’re not providing a fitness class for us and I’m choosing my own exercise” (Julie - coordinator)  “I think for the first time for us we are introducing a very structured program that has different stages and different layers and phases” (Sylvia - activity coach) 62   Implementation strategy adapted:  Recruitment. Coordinators and activity coaches tailored their recruitment strategies to capitalize on to the target population that accessed the delivery partner organization. Choices worked with many new immigrants and had an established settlement department. The settlement workers at Choices referred eligible clients to CTM.   “We have a Chinese settlement worker here who deals with maybe 200 clients a year. So she’s got referrals left and right” (Jordan - coordinator).  “We talked to our settlement worker. I’ve talked to our Chinese students in the classes. I’ve been to different Chinese churches. I also emailed some of my old Chinese senior students” (Jordan - activity coach)  Simran used the Choices client database to identify and contact Chinese older adults for recruitment.  “And also I went on to our own OCMS documentation, the software, and then I pulled up seniors from the ages. And then I called them up to ask if you’re isolated, where it’s kind of [inaudible] if they’re interested in this program and then that’s how I recruited people” (Simran - coordinator) 63   Jordan displayed recruitment material (e.g., flyers) in his office because the target population frequent the area.  “My office is in the Immigrant Service building. So I can make flyers, have it on my wall and the traffic would be actually really good ‘cause we have English classes here” (Jordan - coordinator)  Content adapted:  One-on-one consultation. CTM differed from typical programs offered by Dynamic Collective and Spruce (e.g., choice-based goal setting). Hence, participants found the CTM concept, choice-based goal setting, unfamiliar in that setting. Dynamic Collective and Spruce changed the action plan goals to group-based goals to make goal-setting more acceptable.   “I mean, for us in-- for the-- being in the neighbourhood house we were grateful that this doesn’t have to be an individual goal and that it can be a group goal too. Just something to-- that I always say to Tanya (AART) is that being-- with the neighbourhood house where we offer programs sometimes having the participants to come up with what they actually want can be a little bit more challenging. And just fill in the gap in that aspect of it” (Julie - coordinator)  64   Group meeting. Many participants wanted to continue meeting as a group after CTM ended. Delivery partner organizations with existing programs offered participants the opportunity to continue to meet and stay connected. Brenda invited participants to other programs (e.g., knitting) she led at Dynamic Collective during the last group meeting.  “So I did invite them to join my other activities” (Brenda - activity coach).  3.4 Provider: interpersonal level factors At the interpersonal level, six factors influenced the decision to adapt implementation strategies and/or CTM content: social network, activity coach competency, time required, drop out, variety and spoken language.  3.4.1 Social network Many coordinators and activity coaches did not personally know the target population they intended to recruit. Coordinators and activity coaches used their volunteers’ social network (e.g., neighbours and friends) in CTM implementation strategies (e.g., recruitment) to expand their reach.   65  So that the wellness connectors or other seniors can relay the messages and promote to their, maybe, for neighbours and so forth like that. (Julie - coordinator)  “I really need to kind of outreach to the isolated senior or non-active seniors. So it means that they are not actually in the neighbourhood. I don’t able to see them, right. So I really have to outreach them. So that’s a tough time that, like, how can I know them or how I can connect them if they don’t show up the space, right.” (Brenda - activity coach)  Implementation strategy adapted:  Recruitment. Coordinators and activity coaches involved their volunteers in recruitment activities if they did not have a personal connection to the target population. The delivery partner organizations increased their reach by tapping into their volunteers’ social network. Volunteers supported with recruitment through conversations with their friends and neighbours about the program and potential benefits.   “[Volunteers] were given the role to outreach for us and to refer either their neighbours or their friends who they feel would get benefit from Choose to Move to us” (Julie - coordinator).  66  3.4.2 Activity coach competency Coordinators and activity coaches had varied backgrounds (described in Table 6). Sylvia discussed a generational and cultural gap with her participants’ and lack of knowledge in certain group meeting topics that led to adapted content (e.g., group meetings).  “It’s not something that I’m well versed in, in Chinese culture or Chinese language. So there was a barrier for myself to talk about it with the seniors” (Sylvia - activity coach)  Content adapted: Group meeting. Sylvia described ‘stress and anxiety’ as a culturally sensitive topic for her participants. She had challenges with delivering the material in a culturally appropriate way. Consequently, Sylvia and her participants did not discuss the group meeting topic in depth. Sylvia also invited an expert in the field (e.g., Brain Health Group) to present on the group meeting topics.  “They were engaged and they were able to share a little bit. But I don’t think we were able to talk too much in depth about it” (Sylvia - activity coach)  67  3.4.3 Time required Coordinators and activity coaches delivered CTM for the first time to Chinese older adults and found the population hard to reach. Many adapted their implementation strategies (e.g., implementation period) and CTM content (e.g., group meetings and check-ins) because activities required more time than originally planned. For example, many of Nina and Sylvia participants could not remember when program components (e.g., group meetings and check-ins) take place so they added reminders to their programs.  “We realized is that the implementation took a long time from our activity coach than we originally thought it would. And it had to do with the community we were working with” (Nina - coordinator)  “Very time consuming. Especially in the beginning, the amount of work that Brenda (AC) had to go through, it was very time consuming” (Julie - coordinator)  “Just a lot of work in the recruiting stage as a part-timer, like, seven hours a week definitely not enough. And also during implementation stage, just underestimating the community realities” (Jordan - coordinator)  68  “‘Cause the volunteers-- seniors took so long with their activity that we couldn’t get to it” (Simran - activity coach)  Sylvia adapted CTM content (e.g., group meetings) so it required less time and planning for her activity coach role.  “So I felt like that was a really good way to do a movement break that didn’t require too much planning on my part and it engaged people kind of-- leadership in a small way” (Sylvia - activity coach)  Implementation strategy adapted:  Implementation period. Implementation strategies required more time than originally thought. Some extended the implementation phase to account for the extra work needed.   “We realized is that the implementation took a long time from our activity coach than we originally thought it would.”(Nina - coordinator)  Others worked more hours than they planned for in order to complete implementation tasks (e.g., recruitment and training).  69  “I think she stayed till like eight p.m. a few nights just to go over everything” (Julie - coordinator)  So it took both of us to-- kind of like me supporting her, like, that just took a lot more time than anticipated” (Julie - coordinator)  Content adapted:  Check-in. Simran adapted the check-ins to take place after the group meetings (described in section 3.5.1). The group meetings ran over the scheduled time, leading Simran to cancel three check-ins.  “Yeah, the first one was the [inaudible] one and the second one we had to move it to the third, like, it had to be removed” (Simran - activity coach)  Group meeting. Sylvia adapted the group meeting movement breaks to be peer-led so it would require less time and planning in her activity coach role. Participants, the activity coach and a volunteer led movement segments.  We did movement breaks every time and each–every movement break became the same thing and I felt that that was–so what it was was everyone would stand in a circle and each person would take turns leading a movement. And 70  we’d all copy them. And that became fun and interesting and something that they could expect, you know, and could understand” (Sylvia – activity coach) I observed at my ethnographic observations and noted at the operations meetings that group meetings often extended beyond the standard 60-minutes. No coordinator or activity coach discussed this adaptation in their interviews.  3.4.4 Drop-out Participants dropped out of Jordan’s first CTM program due to health and family problems. Jordan described family being a priority for Chinese older adults and many dropped out of CTM because they prioritized family (e.g., leaving the country for a newborn grandchild and to be with family during holidays). CTM drop-out led to adapted content (e.g., cancelling the program).  “Health problems and family problems. Understand, our Choose to Move is, like, Mandarin speaking clients and this is, like, the first. And we’re also learning a lot as we’re doing this. But a lot of them have family members back home or somewhere else, scatter through the area” (Jordan – coordinator)  Content adapted:  Cancelled program. Many participants dropped out of Jordan’s first CTM program. Jordan could not continue CTM while participants were out of the country (e.g., check-ins via telephone) because the participants did not prioritize CTM over their family. Jordan cancelled his program before he completed all the components because no participants remained.  71   “Whatever happens, these grandmas and grandpas leave. And to be perfectly clear, working with the Mandarin seniors for a few years now, I totally understand. They will go back to Singapore to see their sick granddaughter. I can’t say no” (Jordan - coordinator)  “They were really sad to leave, but their granddaughter-- they have a brand new granddaughter in Singapore. And Tanya told me, “May I should call them.” That’s not going to work. I know my Mandarin clients. Nobody is going to answer a phone call from George, W.A. as they’re celebrating their granddaughter’s first birthday” (Jordan - coordinator)  3.4.5 Variety Sylvia wanted to expose her participants to more people and perspectives. She invited both experts (e.g., Brain Health Group) and other individuals at the delivery partner organization (e.g., volunteers) which led to adapted content (e.g., group meetings).  “Definitely having another voice speak to the seniors was helpful, especially someone who is an expert in the field” (Sylvia - activity coach)  72  “So that was really great too because she added so much lightness and humour to the meeting” (Sylvia - activity coach)  Content adapted:  Group meeting. Sylvia invited guest speakers (e.g., Brain Health Group) and a youth volunteer to the group meetings to increase the variety of speakers/presenters and share different approaches to well-being beyond Chinese cultural practices. Participants were also curious to learn about different cultural approaches to care for their health. The volunteer shared cultural cuisine from her Lebanese background and led movement breaks (e.g., dance routine) to offer a new perspective to the group meeting content. The youth volunteer also brainstormed group meeting ideas (e.g., smoothie-making) with the activity coach.   “She as a volunteer really helped shaped our Choose to Move from the first session and came up with the activities we did for the one about nutrition and led a dance routine as part of our movement break” (Sylvia - activity coach)  “Having our youth volunteer present, `cause she got to lead some games and talk about her own experience. And relationships that are already built between me and the seniors and within-- among the group as well” (Sylvia - activity coach)  73  Guest speakers (e.g., psychologist, Brain Health Group and THRIVE) provided expert information on group meeting topics. Added guest speakers were an adaptation influenced by both variety and the activity coaches lack of knowledge on group meeting topics (discussed in section 3.7.5).   “We were able to deepen that relationship and also rely on that relationship to help provide more workshops and outside information to support our participants.”(Nina - coordinator).  3.4.6 Spoken language Activity coaches and participants needed a common language to communicate. The coordinators and activity coaches had varied language skills. The coordinators and activity coaches at Spruce and Dynamic Collective spoke the same language (i.e., Cantonese) as their participants. The coordinator and activity coach at Choices did not speak the same language (i.e., Mandarin) as their participants. The coordinator and activity coaches spoken language and the ability to communicate with participants influenced content adaptations (e.g., group meetings).    “‘Cause I don’t speak Mandarin” (Jordan - coordinator)  74  “My problem is that I don’t speak Mandarin and I was serving to Mandarin seniors so there was that language communication breakdown”(Simran - coordinator)  Content adapted:  Group meeting. Participants wanted more activities in the group meetings (described in section 3.5.1). Simran adapted the group meetings to include activities that did not require verbal communication. She incorporated activities that participants and children could do together.  “So I took them to the daycare, the local daycare across the street, because they did speak the same language. I didn’t see a problem because before in care homes I used to bring in daycare children and it wasn’t such a big issue about the age-- or not the age, the language. Because you can do things like balloon volleyball or other things and communicate to each other” (Simran – activity coach)  Simran and Jordan communicated through their volunteers because they did not speak any Chinese dialect. Volunteers held a key role to bridge the language gap between Simran and Jordan and their participants. Volunteers translated Simran and Jordan line by line and/or communicated the general message they learned from training to the participants in Mandarin.  75  “I am the activity coach, but we have three Mandarin speaking volunteer activity coaches” (Jordan - coordinator)  “It did, however because of communication, I believe it broke down because I always got the answers from volunteers is that they’re not interested in this. They already do this. They do this at home. They don’t-- but I wouldn’t know what the seniors were saying ‘cause of that conflict of language-- the language barrier. So I had to rely solely on the volunteers to tell me what the seniors were saying” (Simran - activity coach)  “Later on when they came to yoga they said we don’t want this. We never picked this. ‘Cause it was a new volunteer coach. And then I’m, like, oh. So then I went back to my boss to ask, like, this is the situation at hand. So I quickly cancelled her and then I had bocce ball and I had [inaudible] activities in my car [inaudible, laughing] so I brought them out and I did it with the, like, she led it, the volunteer activity coach” (Simran - coordinator)  3.5 Recipient: intrapersonal level factors At the intrapersonal level, five factors influenced the decision to adapt implementation strategies and/or content: participant characteristics, volunteer characteristics, drop out, literacy and engagement and motivation. 76   3.5.1 Participant characteristics Coordinators and activity coaches adapted implementation strategies (e.g., recruitment and screening) and content (e.g., one-on-one consultations, group meetings and check-ins) to better suit Chinese older adults. Many coordinators and activity coaches already worked with Chinese older adults in their other roles. They described their knowledge of Chinese older adults beliefs.  “I think a lot of it is just already having some relationship with these seniors and understanding their specific situations. And then a broader knowledge of the broader senior’s community’s experiences in the Mid-Railtown” (Sylvia - activity coach)   “At the information session there’s a resource that’s a couple pages … so people were able to take that home and have a greater description of the program as well” (Sylvia - activity coach)  “We realized that the PAR-Q was deterring a lot of our participants to not engage into the Choose to Move because of-- it was a bit invasive for some of our seniors. And they just didn’t feel like they were comfortable doing that.” (Julie - coordinator)  77  Jordan described distrust in free programs among Chinese older adults and the belief that “it’s too good to be true”.   “[Chinese older adults are] going to be super cautious about which program they join, no matter how good it sounds. I know my seniors. I’ve taught them-- I taught them art classes … These are free programs, and people think it’s too good to be true. It’s too good to be true. And free programs sometimes get less respect than paid programs ‘cause when people pay they go.” (Jordan - coordinator)  Many adapted CTM to be more compatible with their participants. Coordinators and activity coaches factored the participants’ past experiences (e.g., jobs), interests (e.g., being in nature) and preferences (e.g., participants wanting to gather in groups) into their effort to make CTM more compatible.  “We realized that wasn’t working and the people were having trouble in remembering their goals. Or feeling committed to their goals” (Nina - coordinator)  78  “That was decided at the previous group meeting where we were talking about going out to nature as a way to address stress and anxiety” (Sylvia - activity coach)  “So telephone check ins were good. They didn’t really help. They want to be here anyway” (Jordan - activity coach)   “And I had asked volunteers could we not start with it and then-- they said, no, no, no, they want to have it at the end. And I’m, like, okay. So we waited till the end” (Simran - activity coach)  “Yeah, totally, ‘cause they-- actually they really upset that when I told them this is the last group meeting. ‘Cause they really upset. They say, oh, why not-- why continue, this and that” (Brenda - activity coach)  “I asked the input from the seniors on the first day was what they wanted, what were the goals they wanted. So based on that and based on your topics and the layout of it is how I reached out to different places” (Simran - coordinator)  79  Many factored in the participants’ cultural norms when they decided to adapt the content (e.g., group meetings).  “We couldn’t have delivered it the way it was in English and-- without those cultural adaptations” (Sylvia - activity coach)  “I adapted the PowerPoints that were given to us for each group meeting and restructured which topic would happen on which week and yeah, restructured-- came up with more culturally appropriate content for some of the weeks” (Nina - coordinator)  “They don’t trust anything. To be honest, only thing that worked was word of mouth from people who have been there and tried it. ‘Cause once they started coming-- and that’s how it always works in the settlements business, we believe in continuous intake. These are free programs, and people think it’s too good to be true. It’s too good to be true. And free programs sometimes get less respect than paid programs ‘cause when people pay they go. So these free programs we know when people come and see if they’re good, they keep on coming. That’s the only thing that works because as soon as we have four or five seniors in there and the teamwork was there, they started giving me 80  eighteen, nineteen different people’s names in the community, per person” (Jordan - coordinator)  “They don’t really-- the culture’s different, so they don’t really do things initiatively … but really kind of need people to tell them what to do. Instead that they will telling you what they want” (Brenda - activity coach)  Implementation strategy adapted:  Recruitment. The standard recruitment material provided by the project team did not suit Sylvia’s target population. Sylvia condensed the recruitment material so they were shorter and older adults could take them home to read.  “So I turned [a resource that’s a couple pages] into two pages only” (Sylvia - activity coach)  “Yeah, I guess it was, like, kind of an adaptation of our existing strategy, how we [inaudible] for other programs and then seeing the resources-- definitely the resources that were provided with the logo and the posters and just adapting them” (Sylvia - activity coach)  81  In the meeting minutes, Julie and Brenda conducted individual information sessions with each potential participant after the standard information session. It was hard for the older adults to grasp CTM concepts (e.g., choice-based goal setting).  Screening. The PAR-Q+ health screening tool (Warburton et al., 2011) deterred older adults from joining CTM. Chinese older adults did not want to disclose their health information to non-healthcare institutions (e.g., neighbourhood houses) and found the questions in the PAR-Q+ tool (Warburton et al., 2011) invasive. Dynamic Collective changed the health screening tool to the ‘Get Active’ questionnaire (Canadian Society for Exercise Physiology, 2017), which was perceived as less invasive by the participants.  “And changing into the Get Active was a lot more receptive in that sense” (Julie - coordinator)  Content adapted:  One-on-one consultation. Participants were unfamiliar with goal setting. Spruce adapted the language used in the one-on-one consultation from an individual endeavour to a common goal among the group. They also identified similar interests among participants during the one-on-one consultation so they could form smaller groups with the larger cohort.  82  “We did change some things in terms of the Active Age plan and making it more group-focused and finding opportunities for people to work on their goals together as a group and set group goals”(Nina - coordinator).  “So in order to adapt to that. We still had that initial conversation with them about their physical activity levels and where they want to be. But in the first group meeting for the last session we focused on grouping people together who had similar goals and, like, also meshed well together personality-wise. And wanted to work together towards their goals and go do activities together or support each other. Yeah, in a small group, like, as a smaller group within the larger mix of cohorts” (Nina - coordinator)  Check-in. Some activity coaches needed more touchpoints with their participants to build trust and a better connection than in the standard CTM model. Activity coaches assessed the participant’s needs and added more check-ins partway through the program.   “I, like, called them more than what you guys suggest. Like [inaudible] once a month [inaudible] ever, and I called them more frequent than usual. And that has really allowed me to have the better connection to them and they will kind of trust me and also enough encouragement for them to continue their goal” (Sylvia - activity coach) 83   “I, like, basically we kind of need to do only once a month phone check-in, right. But it’s not enough. So I did do more than that. I think I did, like, at least once a week to do the connection” (Brenda - activity coach)  Sylvia’s participants had many challenges (e.g., health and language). Some needed support in aspects outside of physical activity (e.g., housing). Some check-ins took longer than outlined in the standard CTM model.  “A lot of them became lengthier conversations “ (Sylvia - activity coach)  Simran planned the program with her participants and many requested to have the check-ins in-person after the group meetings. The participants wanted to be in a group setting.  “So the group meetings is when we had actual-- the speakers or the tai-chi, chi-gong people come in. And then-- talk to them and then they did whatever the person was either talking about or activity they were doing. And then for the-- supposed to be phone check-ins, which were drop-in, so that was whatever activity they had chosen. Plus doing their check-ins” (Simran - coordinator)  84  Participants at Spruce could not remember when group meetings were scheduled and did not show up on time. Nina and Sylvia added additional calls to remind participants when the next check-ins and group meetings were.   “In addition to doing those check-ins we also had to make calls to each participant to remind them to come to group meetings. And remind them when those check-ins were” (Nina - coordinator)   Group meeting. The group meetings I attended, as part of my ethnographic observations, were conducted in Cantonese at Dynamic Collective and Spruce and Mandarin at Choices. Jordan encouraged participants to speak in Mandarin.  “We encourage them to speak Mandarin. They love it” (Jordan - coordinator)  Participants wanted to do more activities in the group meetings. Choices added tai chi, Zumba, yoga and balloon volleyball to their group meetings. Spruce added a field trip to a local park.  “From the feedback I’ve gotten from my Mandarin clients, they want to do tai-chi, which is not in any of this stuff. What else? They want to do their little Zumba dance routine”(Jordan - activity coach) 85    “Yeah, so for-- we decided at the last group meeting we would go on an out trip to Prince Johnathan Park” (Sylvia - activity coach)  The group meeting content did not fit the participants’ cultural norms. Spruce made the group meetings more interactive, included culturally specific content in the group meetings and tailored ice breaker questions to the community (e.g., what is your favourite place in Chinatown?). Participants learned about the group meeting topics through games.  “Food and nutrition we altered a lot because it’s just such a culturally specific topic. So we made it really interactive. We played games. And I think the challenging part was reading nutrition labels, which was part of the content I think in the meetings, because of the language barrier. So I think it was actually a really good lesson for the seniors because they can now-- even if they don’t remember what-- how to read the English, they can recognize it and know at least maybe what to look for and that” (Sylvia - activity coach)  “I think there’s always a curiosity and interest to learn about Western ways of taking care of our bodies because they already know the Chinese way. And they really-- they’re really interested in, like, merging those cultures together” (Sylvia - activity coach) 86   Sylvia reminded participants of the program concept and their goals in the group meetings because those were new concepts (e.g., choice-based goal setting) to the participants.  “It was more time consuming than I thought, doing all the little things. Like, sometimes I had to remind seniors that I was going to call them. There’s a lot of reminding involved, a lot of helping them understand material and goal setting and planning, things like that” (Sylvia - activity coach)  Chinese older adults were weary of free programs. Jordan held group meetings while he recruited participants, before CTM officially started, so potential participants could better understand what the program entailed.  “So me and Tanya worked out the deal where we could have continuous intake for maybe January and then start a one point five cohort as soon as we have fifteen people” (Jordan - coordinator)  Brenda’s participants wanted CTM to continue beyond six months. The delivery partner organization Brenda works at offered other older adult programs (described in section 3.3.3) so she invited her participants to join other programs (e.g., tai chi) at Dynamic Collective.   87  For example, when I’m planning to do some kind of the-- I’m doing some new program like tai-chi and then I invite them come to do tai-chi. And then-- this is something that I would like. And maybe in the future hopefully for the summertime I can do some kind of like out trip for them. (Brenda - activity coach).  Activity coaches offered additional program resources to their participants. For example, Brenda provided community centre brochures to her participants.   So actually I do have some kind of-- the community resource like, other community centre brochure or-- one time we do some-- provide some information about the healthy net [?] and they ask us where to buy those healthy net and then they-- whatever material we give them, they would love to have one (Brenda - activity coach)  In the meeting minutes, Jordan added additional group meetings to his program based on feedback from Choices’ advisory committee, volunteers and participants.  3.5.2 Volunteer characteristics Volunteers played critical roles (e.g., translation) in CTM. Volunteers had varied schedules, language skills and cultural competencies. The volunteer’s age influenced their preferred method 88  to learn (i.e., virtual or printed material). Coordinators and activity coaches adapted their implementation strategies (e.g., training) to better fit their volunteer’s preferences.  “English is their second language. They’re all in their 40s, 50s. They’re not as fluent as we’d like them to be” (Jordan - activity coach)  “So that became easier when I was training the volunteers. So they can look at the Mandarin and understand it much better” (Simran - activity coach)  “And she also doesn’t speak Chinese. So it was also, like, meeting that cultural language difference as well” (Nina - coordinator).   “They like physical copies. And not only that, we don’t have four or five computers where volunteer activity coaches can sit and learn for hours. They will have to do it at home, and these are very busy community members” (Jordan - coordinator).   “We were hoping to recruit more young people to be a part of this and join in as activity buddies. But that didn’t pan out ‘cause of scheduling” (Sylvia - activity coach) 89   Implementation strategy adapted:  Training. Simran and Jordan modified the activity coach training module, provided by the project team, to train their volunteers. The volunteers’ age (40 years and above) and imperfect English skills factored into the decision to adapt how they trained volunteers. They made the training paper-based and only included relevant material for the volunteers in a binder.  “They need to have physical binders, and that’s what I did when I went through the Moodle. Like, I made it as simple as possible, colour coded, with all the paperwork they need. It’s pretty much like the Moodle but just in paper form. So when they come, they don’t have to panic. And everything you need is there, step by step in simple English” (Jordan - activity coach)  “I made a separate binder for each volunteer that showed interest. And so when I called them in for training I went through each, like, paper and explained it to them how it works and the whole purpose of the program” (Simran - activity coach)  Nina’s volunteer was not Chinese and did not speak Cantonese. Nina trained her volunteer using a discussion-based approach before the program began and checked-in with her volunteer throughout the program. 90   “We had a volunteer come in for the first session and her training was more of a sit-down conversation with me. And just like check-ins throughout the process to make sure, yeah, she was fitting in well with the group” (Nina - coordinator)  3.5.3 Drop-out  Similar to above, volunteers dropped out partway through Simran’s program. Since Simran did not speak Mandarin (described in section 3.4.7), volunteers were crucial in her programs (e.g., Simran communicated through her volunteers). Simran adapted her implementation strategies (e.g., recruitment) to ensure she had volunteers to support CTM.  “And then it came to the volunteer coaches that-- their schedules. So two of them found jobs and then they had kids or they had health issues that came up” (Simran - coordinator).  “So she did that for awhile, but then she got a job. So she did for two sessions, and then she got a job so she left” (Simran - activity coach)   Implementation strategy adapted: 91  Recruitment. Simran could not continue to deliver CTM without volunteers. Simran’s implementation period overlapped with CTM delivery because she recruited volunteers partway through the program.  “I realized that I just kept-- had to recruit more volunteers” (Simran - coordinator)  3.5.4 Literacy Sylvia targeted Chinese older adults living in Chinatown and Mid- Railtown. Many residents have low socioeconomic status. Many of Sylvia’s participants did not read or write and found the written CTM material a challenge. Sylvia adapted CTM content (e.g., one-on-one consultations) to accommodate her participants’ literacy skills.  “So many haven’t really set goals in their lives before, not, like, being from here and having pretty, what do you call that, like, their jobs never required them to set goals, or they forgot their goals, or some don’t know how to read” (Sylvia - activity coach)  Content adapted:  One-on-one consultation. Many of Sylvia’s participants did not read or write. Participants found it hard to create an action plan with resources from the project team because it used 92  written language. Sylvia drew pictures for the action plans at the one-on-one consultation so the participants who didn’t read could refer back to the conversation and their goals.  “And so I had to be creative on giving their action plan to them. I’d just draw pictures and things like that” (Sylvia - activity coach)   3.5.5 Engagement and motivation Many participants were not familiar with CTM concepts (e.g., goal setting). Participants at Spruce needed additional support to stay engaged and motivated in CTM. Nina and Sylvia adapted the content (e.g., group meetings) to keep their participants engaged.  “We did change some things … [to keep] participants engaged and feeling motivated”(Nina - coordinator).  “People were having trouble in remembering their goals. Or feeling committed to their goals” (Nina - coordinator)  “I wanted to shake it up and be creative and make the session more interactive and interesting” (Sylvia – activity coach)  93   Content adapted:  Group meeting. Nina and Sylvia’s participants were not engaged when they delivered CTM with the standard group meeting content. They adapted their group meetings to be more interactive with hands-on activities (e.g., smoothies-making) and grouped participants with similar interests for discussions.   “I went through-- oh, I took the B.C. Nutrition Guide for Seniors. They have a presentation online already prepared for educators. It was very helpful. I went through a lot of the vitamins and minerals that are important for seniors. And the seniors were able-- were very interactive about that and they already knew a lot and learned from. And then we put that knowledge into practice by making smoothies. So I laid out a bunch of-- our seniors aren’t very familiar with smoothies. They don’t really drink cold drinks. So this was new and exciting. They could pick how-- what can go into the smoothie” (Sylvia - activity coach)  “Yeah, so, for example, the food and nutrition one, we played, like, a food guest tasting game where we got them to blindfold-- we blindfolded the seniors and then we got them to taste some snacks and just identify-- tell us what it is they’re eating. So we had, like, sardines and nuts and things like that. We made sure that they were nutritional and snacky because the seniors don’t 94  really snack. So we were trying to introduce them to, like, snacky foods. And then-- yeah, and then we talked about it, the nutritional values of them” (Sylvia - activity coach)  “But in the first group meeting for the last session we focused on grouping people together who had similar goals and, like, also meshed well together personality-wise. And wanted to work together towards their goals and go do activities together or support each other. Yeah, in a small group, like, as a smaller group within the larger mix of cohorts” (Nina - Coordinator)     95  4. Discussion There is scarce literature on adapted physical activity evidence-based interventions to meet the needs of Chinese older adults. To my knowledge, only one study investigated implementation strategies for evidence-based interventions which included ethnic minority older adults (Wilcox et al., 2006; Wilcox et al., 2008) and none investigated adapted evidence-based intervention implementation strategies for ethnic minority older adults. No implementation studies focused on adapted PA evidence-based interventions for Chinese older adults in Canada. Two studies used qualitative methods to investigate adapted evidence-based interventions (e.g., problem-solving therapy and cognitive stimulation therapy) for Chinese older adults in the United States and Hong Kong (Chu et al., 2012; Wong et al., 2018). Two studies focused on adapted evidence-based interventions for ethnic minorities included Chinese older adults (Wilcox et al., 2006; Wilcox et al., 2008; Falgas-Bague et al., 2020). In fact, few studies investigated adapted implementation strategies for evidence-based interventions overall (e.g., Yoong, 2019; Cook et al., 2019; Moore et al., 2013). Thus, my study makes an important contribution to the current literature, because it demonstrates how a current evidence-based intervention can be adapted to meet the needs of the growing Chinese older adult population.    Several factors influenced how CTM implementation strategies and content were adapted across levels of influence as described in the SEM. Factors ranged from connections to other organizations to participant preferences. Adapted implementation strategies ranged from shared recruitment material to modified training material for volunteers. Adapted content included adding guest speakers and the transition to group-based goals. Factors that influenced adapted implementation strategies and content were consistent with the implementation science literature. 96   4.1 Community factors Community factors that influenced adaptations were connecting with other organizations and partnership with the project team. These factors were consistent with studies that suggested how to adapt an intervention for minority ethnic communities (Netto et al., 2010). This may be due to the interplay between factors at different levels of influence in the SEM (e.g., public policies). Delivery partner organizations received grant funds to collaborate with the project team to implement and deliver CTM. The project team was involved with the CTM implementation and delivery process from start to finish as per the funding scheme (i.e., public policy factor). The importance of connecting with others reflects the established, community-based nature of the delivery partner organizations involved with CTM. Compared to interventions delivered in controlled, clinical settings (e.g., Falgas-Bague et al., 2020), CTM delivery partner organizations had experience and relationships through past program/service delivery.  The partnership with the project team also represents the fidelity and adaptation “tug-of-war” (Bopp et al., 2013). The coordinators and activity coaches adapted CTM based on their context, as described across SEM factors. The project team functioned as the central support unit (i.e., the prevention support system, researcher and program developer) and sought to maintain fidelity and preserve the standard CTM model’s impact. The coordinators and activity coaches negotiated CTM adaptations with the project team at the operations meetings as illustrated by project team’s influence on adapted implementation strategies (e.g., recruitment).   97  4.2 Institutional factors The delivery partner organization’s available resources influenced CTM adaptations, similar to previous interventions designed for ethnic minority and non-minority populations (Falgas-Bague et al., 2020; Carvalho et al., 2013; Bunce et al., 2020). Specific to my study, service structure influenced adaptation. This may have emerged as delivery partner organizations did not typically offer programs like Choose to Move. More factors may have been considered for organizations to ‘fit’ CTM within their program or delivery context. Although service structure was a factor that surfaced, other studies also considered the organization’s service structure for implementation (Mendel et al., 2008; Cabassa & Baumann, 2013).   4.3 Interpersonal factors Time required to implement and deliver the intervention was a consistent factor that influenced adaptations for CTM at not-for-profit delivery partner organizations, CTM at recreation delivery partner organizations (Sims-Gould, McKay, Hoy et al., 2019) and other studies conducted with Chinese older adults (Chu et al., 2012). Time constraints were consistent across CTM delivery partner organizations (Sims-Gould, McKay, Hoy et al., 2019) as CTM operated within delivery partner organizations with other programs. Coordinators and activity coaches needed to be mindful of the resources available (e.g., monetary funds for their salary and room availability) and adapted CTM to fit within their context. Participant drop-out was consistent with the literature, which described the need to be flexible and accommodate Chinese cultural values (Chu et al., 2012). Transnational lives among the Chinese population further complicated program delivery. Relocation is often a family affair that impacts multiple generations (Kobayashi & Preston, 2007). For example, adult children may emigrate to Canada to seek a 98  better education for their offspring, bring their older adult parents with them then return to their country of origin. As family members migrate, this may influence the frequency and length of time spent abroad for older adults. In CTM, the participant’s travel plans and subsequent drop-out challenged coordinators and activity coaches to consistently deliver the program.   Social networks, provider competency, variety and spoken language also influenced CTM adaptations. These factors may be influenced by broader public policies (e.g., funding and industry practices). All three delivery partner organizations were not-for-profits and had not previously delivered an evidence-based intervention designed to elicit PA behaviour change. The staff appointed to deliver the evidence-based intervention may have lacked the specialized skills as they originally held other roles within the not-for-profit organization. This contrasts with staff hired to specifically to deliver the evidence-based intervention where the individual would have a specified skillset. Not-for-profits, typically with limited funding, rely on volunteers to deliver services/programs/interventions (Nesbit et al., 2018). With a volunteer base, the delivery partner organizations adapted their intervention to tap into the volunteers’ social network and spoken language.   4.4 Intrapersonal factors Participant characteristics (i.e., norms, experiences and interests), literacy, engagement and motivation contributed to adaptations similar to the literature on Chinese and ethnic minority older adults and CTM participants at recreation delivery partner organizations. These factors speak to efforts that providers (i.e., coordinators and activity coaches) make to meet the needs of this population (Chu et al., 2012; Falgas-Bague et al., 2020; Wong et al., 2018; Griffin et al., 99  2010; Sims-Gould, McKay, Hoy et al., 2019) as well as their interests (Griffin et al., 2010; Sims-Gould, McKay, Hoy et al., 2019), experiences (Griffin et al., 2010; Wong et al., 2018), language skills (Chu et al., 2012; Griffin et al., 2010) and to engage them in an intervention (Wong et al., 2017; Griffin et al., 2010). Intervention providers need to consider the participant’s literacy in their mother tongue as well as the language the evidence-based intervention was designed to be delivered in. Participants at one organization did not read or write in their mother tongue which required language-based content adaptations (e.g., using visuals instead of words to complete the action plan).  Volunteer characteristics (e.g., schedules and skills) and drop out influenced CTM adaptations. These factors may be influenced by broader public policies (e.g., funding) and that not-for-profit organizations’ commonly recruit volunteers to support program delivery. Delivery partner organizations needed to accommodate volunteers and, ultimately, volunteer drop-out as these are a common challenge for not-for-profit organizations (Nesbit et al., 2018).   4.5 Adaptations from community, institutional, interpersonal and intrapersonal factors  Delivery partner organizations adapted CTM in response to both proximal (e.g., service structure) and distal (e.g., participant characteristics) SEM factors. As described in SEMs of behaviour change (McLeroy et al., 1988), factors at different levels of influence interacted with one another. I observed that adaptations were influenced by multiple factors and a given factor influenced multiple adaptations. For example, both the organization’s service structure and participant characteristics influenced the decision to move from individual goals to group-based goals. Conversely, the organization’s service structure influenced recruitment through internal 100  staff, group-based goals at one-on-one consultations and inviting participants to other programs offered by the organization.  4.5.1 Implementation strategies Adapted recruitment strategies were consistent with how recruitment strategies were adapted in other studies with ethnic minority older adults. These recruitment strategies were supports from the project team (Wilcox et al., 2008; Griffin et al., 2010), condensed take-home recruitment material, a referral network of external partners and use of multiple recruitment methods (e.g., posters and word of mouth) (McKay et al., 2019). Importantly, CTM and other evidence-based interventions with ethnic minority older adults used targeted approaches to recruit those who were already connected to the delivery partner organization (i.e., clients in the database and other departments) (Wilcox et al., 2006). This contrasts with CTM recreation delivery partner organizations that used recruitment methods that likely recruited older adults who did not use the facility (e.g., posters, newspaper ads and word of mouth). The different recruitment approaches may stem from the typical programs offered at the organization and those who access them. Recreation facilities offer many PA programs and those who access the facility are likely to engage in the programs offered. On the contrary, not-for-profit organizations involved with CTM had little to no PA programs so older adults who accessed the facility were not there to engage in PA. As CTM targeted older adults who did not meet physical activity guideline recommendations, it was plausible for not-for-profit organizations to recruit internally for older adults who did not access PA programs.  101  Unique adapted recruitment strategies included shared resources, volunteer support (i.e., translate material and recruitment), individual information sessions and continuous intake. These recruitment strategies are linked across levels to community, institutional and intrapersonal factors. To illustrate, all delivery partner organizations were delivering CTM to Chinese older adults for the first time (institutional factor). Some recruitment strategies and materials provided that were part of the standard implementation, were not suitable and needed to be adapted for the target population (intrapersonal factor). Finally, the project team brought all delivery partner organizations together to share their implementation and delivery experiences (community factor). Project team facilitation contributed to connections with others and helped identify areas of overlap (i.e., sharing adapted recruitment resources).  Expanded reach through volunteer recruitment demonstrates flexibility in the implementation strategies. Reach may be limited if coordinators and activity coaches relied on their own networks. With volunteer support, coordinators and activity coaches have the potential to recruit individuals they would not have reached otherwise.   Added activity inventories was an implementation strategy also used in one other intervention with ethnic minority older adults (Griffin et al., 2010). Activity inventories were tailored based on the resources (i.e., programs and services) available at delivery partner organizations. Institutional factors help explain this adaptation. Although all delivery partner organizations were not-for-profit, they offered different programs and services. Delivery partner organizations that offered PA programs included them in their activity inventory, whereas delivery partner organizations without PA programs relied upon external programs.  102   Coordinators and activity coaches switched from the PAR-Q+ (Warburton et al., 2011) to the Get Active Questionnaire (Canadian Society for Exercise Physiology, 2017), despite the former being more frequently used (Duncan et al., 2016; Wilcox et al., 2006). Other PA evidence-based interventions with ethnic minority older adults were mostly delivered by health-related institutions (Wilcox et al., 2006). Delivery partner organizations involved with CTM were not health-related. Chinese older adults are cautious with sharing personal and health information (Wong et al., 2018), particularly with non-health institutions. These factors help explain the adaptation to the Get Active Questionnaire (Canadian Society for Exercise Physiology, 2017). CTM participants perceived the Get Active Questionnaire (Canadian Society for Exercise Physiology, 2017) to be less invasive and more acceptable in the information it gathers.  It is not uncommon for training to be adapted for interventions specific to ethnic minority older adults (Wilcox et al., 2008). Delivery partner organizations adapted the standard CTM training material and added training for volunteers. Those who delivered evidence-based interventions were often trained by a central team such as the prevention support system (Dupre & Durlak, 2008), researcher (Wong et al., 2018) or program developer (Wilcox et al., 2006). CTM coordinators and activity coaches were trained by the CTM project team (i.e., prevention support system, researcher and program developer). Other evidence-based interventions used a “train-the-trainer” approach whereby trained staff train and approve others in their organization (Wilcox et al., 2008). For the adapted training, the project team trained the activity coaches and the activity coach trained the volunteer; this mimics the “train-the-trainer” approach.  103  Implementation activities extended beyond the planned period for CTM and other interventions (Griffin et al., 2010). Training and recruitment for CTM took more time than anticipated. Delivery partner organizations often responded to the call to participate and do not have prior experience with the evidence-based intervention (Wilcox et al., 2006). Implementation activities and the evidence-based intervention would have been unfamiliar to delivery partner organizations. Thus, they required more time to be trained and to implement the evidence-based intervention.  4.5.2 CTM Content Delivery partner organizations adapted individual goals to group-based goals. These changes stemmed from Chinese culture which includes collective and conservative values (Wong et al., 2018). Chinese individuals in other studies had similar challenges with sharing their opinions and ideas (Wong et al., 2018). Chinese culture also values hierarchy, power dynamics and respect (Chu et al., 2012). Those who delivered CTM may be seen as someone with more knowledge and authority (Chu et al., 2012).   Delivery partner organizations also adapted the Action Plan and used visual aid (e.g., drawings) instead of writing for the participant’s goals. The participants’ literacy contributed to the adaptation (Chu et al., 2012; Griffin et al., 2010). Participants in CTM and previous studies with Chinese and ethnic minority older adults (Chu et al., 2012; Falgas-Bague et al., 2020) had literacy (i.e., reading and writing) barriers. Activity coaches accounted for written literacy with visual depictions of the participant’s goals.  104  Adaptations to the group meeting were influenced by various factors across levels of the SEM (e.g., community factors, institutional factors, interpersonal factors and intrapersonal factors) and included tweaks (i.e., changes that leave the intervention core components intact) (Stirman et al., 2013), added components, condensed components, re-ordered components and removed components. Added components (e.g., guest speakers, invitation to other programs, activities, reiterate concepts and goals, extra group meetings and resources), tweaked components (e.g., language change and activity coach to peer-led movement breaks) extended components (e.g., group meetings lasted 60+ minutes) and condensed components (e.g., reduced group discussion) were adaptations made in studies with Chinese and ethnic minority older adults (Griffin et al., 2017; Falgas-Bague et al., 2020; Chu et al., 2012). Cultural competency is “culturally safe, congruent, and effective care in partnership with individuals, families, and communities living health experiences, and which takes into account the social and political dimensions of care” (Garneau & Pepin, 2015; p. 12). Activity coaches cultural competency contributed to how many group meetings were adapted. For example, activity coaches who lacked cultural competency invited guest speakers to present on a given health topic. Conversely, an activity coaches’ cultural competency led them to adapt the program delivery language (i.e., Cantonese). Cultural competency elements that influenced group meeting adaptations were language, social relationships, beliefs, expectations, experiences (Garrett et al., 2008; Flores, 2000).  CTM for Chinese older adults at non-profit delivery partner organizations and CTM at recreation delivery partner organizations also shared similar adaptations to the group meetings. Coordinators and activity coaches across delivery partner organizations tweaked the group meeting content to fit the community context and provided additional resources upon request 105  (Sims-Gould et al., 2019). Although recreation delivery partner organizations were all similar in their service structure, the community context (e.g., older adult population and participant preferences) varied much like CTM delivered through not-for-profits. Changes to the group meeting content and additional resources provided across all delivery partner organizations highlights the need to be flexible in the content based on the community context.   Coordinators and activity coaches who delivered CTM to Chinese older adults added additional group meetings. Group meetings were also added between Phase 1/2 and Phase 3 for CTM at recreation delivery partner organizations. Activity coaches discussed the need to maintain contact with participants across deliver partner organizations (Gray et al., 2020). This adaptation highlights the importance of activity coach support for physical activity behaviour change across older adults populations.  Removed components (i.e., cancelled group meetings, check-ins and programs) was unique to CTM for Chinese older adults. Other interventions often combined components if they could not be delivered (Griffin et al., 2010) or tweaked program components (e.g., group meeting content) if there were time constraints (Sims-Gould, McKay, Hoy et al., 2019). Cancelled intervention components may have emerged because of interpersonal factors. For example, some coordinators and activity coaches did not speak the same language as the participants. They relied on volunteers to translate the conversation. This communication barrier may have hindered feedback and suggestions that participants offered the activity coach. No intervention components were removed in delivery partner organizations where the coordinators and activity 106  coaches spoke the same language as the participants. Intervention components were also removed due to time constraints at one delivery partner organization.  Check-ins were adapted in ways similar to other studies of older adults representing ethnic minorities (Griffin et al., 2017; Falgas-Bague et al., 2020; Chu et al., 2012). CTM and Active Choices (Griffin et al., 2017) check-ins extended beyond the standard check-in length, which suggests a need for increased support among ethnic minorities in PA interventions. Other CTM adaptations were added components (e.g., extra check-ins and reminder calls) and re-ordered components (e.g., moved check-ins to the end of in-person group meetings). These adaptations also relate to the need for increased support through increased frequency and in-person contact. As each evidence-based intervention and context is unique, added components (e.g., added sessions, added visual cues) and tweaked components (e.g., modified group meeting examples to align with older adult experiences) are not uncommon and often specific to the evidence-based intervention, participants and the delivery system (Falgas-Bague et al., 2020; Chu et al., 2012).  CTM for Chinese older adults had both similar and divergent adaptations compared to CTM at recreation delivery partner organizations. Activity coaches adapted the check-ins to take place in-person (i.e., the mode for check-ins changed from telephone to in-person or check-ins were combined in-person group meetings) in response to participant characteristics (e.g., preferences) across delivery partner organizations (Sims-Gould, McKay, Hoy et al., 2019). Additional check-ins were added when delivered to Chinese older adults while the number of check-ins reduced at recreation delivery partner organizations. The divergent adaptations stem from the different decision-making stakeholders involved and their priorities. Coordinators and activity coaches 107  adapted CTM program components based on Chinese older adult characteristics. On the contrary, the project team consulted key CTM stakeholders between Phase 1/2 and Phase 3 to adapt CTM and reduce delivery costs (Gray et al., 2020). The difference in decision-making stakeholders (i.e., coordinators, activity coaches and project team) involved and their priorities contributed to added or reduced check-ins.   108  5. Conclusion This study demonstrated how coordinators and activity coaches adapted Choose to Move to accommodate the needs of Chinese older adults in MVRD. Findings advance the scarce implementation literature on Chinese older adults in three ways. First, it highlights that a PA intervention (Choose to Move), designed and scaled up in a primarily Caucasian older adult populations needs to be adapted to meet the needs of Chinese older adults. Second, it highlights the key role of urban and sub-urban not-for-profits as delivery systems that provide and adapt programs like CTM for older adults considered ethnic minorities. Third, it highlighted that adaptations were often organic and chaotic. That is, where a single adaptation reflected multiple factors that may not have been common among usual delivery partner organizations (e.g., connection with other organizations and activity coach competency prompted the decision to include guest speakers to the group meetings). Further, a given factor influenced more than one adaptation (e.g., available resources influenced adapted recruitment and activity inventory). Below I describe the implications for practice, strengths and limitations and future research opportunities.  5.1 Capitalize on resources available Providers involved in planning and delivery should assess resources, both internal and external, that are available. Available resources may influence implementation (e.g., volunteer support with recruitment) to delivery (e.g., guest speakers who deliver program component(s)) adaptations to reduce cost. Recruiting volunteers, a typical not-for-profit sector practice (Nesbit et al., 2018), may offset costs needed to deliver a standard program or additional components of 109  future programs. It seems advantageous to identify and use available resources to improve both the feasibility and sustainability of an evidence-based intervention, particularly in not-for-profit organizations where funds are typically limited (Nesbit et al., 2018) (Bodkin & Hakimi, 2020).   It is particularly important to maximize asset use and minimize costs.   5.2 Provider competencies Organizations need to consider the provider’s language skills and whether they can communicate with their participants. The providers play a critical role in intervention delivery; interventions like CTM cannot be delivered without an activity coach. Providers who do not speak the same language as their participants may have their message conveyed incorrectly through translators. Organizations should carefully consider the target population’s spoken/preferred language and aim to hire or appoint staff who can speak the same language to minimize communication barriers (Lor & Martinez, 2020).   5.3 Adapt to suit the participant’s characteristics The target population’s characteristics (e.g., beliefs, norms, language skills and schedules) should be considered from implementation to delivery as it determines participant uptake and attrition to the evidence-based intervention. Recruitment will not be successful if the strategies used don’t align with the target populations beliefs (e.g., Chinese older adults may be wary of free programs). Recruitment strategies need to be adapted to better reach the target population (e.g., partner with organizations that have access to the target population for referrals). Other departments in the organization that work with the target population may offer useful strategies and/or support with recruitment. 110   Providers may need to adapt evidence-based intervention components to fit the target population’s norms. The target population’s norms may be shaped by past experience and cultural ideas. Program components and concepts that are foreign may make delivery a challenge for providers. New concepts may require providers to increase the support provided to their participants. Providers may seek to adapt a given component so it better aligns with their participant’s norms (e.g., change from telephone to in-person check-ins and individual goals to group-based goals) while adhering to evidence-based intervention fundamentals.  Program components that do not take into account the target population’s language skills may compromise attrition. Adapting the language for an evidence-based intervention should not end with translations alone. Providers need to consider the participant’s language skills, both written and oral, when adapting evidence-based interventions.   Intervention components should be scheduled around known and pre-scheduled activities common among the target population. Ethnic minority older adults may celebrate cultural holidays, attend cultural gatherings and activities and lead transnational lives. Providers need to be aware of the target population’s schedule and plan intervention components so they do not clash with pre-scheduled activities. Ethnic minority older adults may regard their pre-scheduled activities as more important than the intervention, drop out or miss intervention components, and compromise the intended benefits of the evidence-based intervention. Chinese older adults, for example, place a high value on family (Chu et al., 2012). When asked to choose between family 111  affairs and an evidence-based intervention they recently joined, Chinese older adults in this study were reportedly more likely to prioritize the former.  Interventions need to be adapted to fit the context, given that each delivery organization is unique. Future evidence-based intervention providers may opt to use checklists, such as the Context and Implementation of Complex Interventions framework checklist (Pfadenhauer et al., 2017), to help systematically identify where intervention characteristics and context intersect to understand how interventions work in their situation. Using a checklist may help: 1) evidence-based providers to work through compatible and incompatible components and necessary adaptations; 2) researchers to have a standard adaptations strategy that organizations use; 3) and evidence-based intervention knowledge translation from research to communities.  5.4 Strengths and limitations My study had several strengths. First, it described that adaptations to a PA evidence-based intervention scaled-up in a primarily Caucasian population of older adults, could be adapted for Chinese older adults. There is a dearth of information on evidence-based interventions tailored to meet Chinese older adult needs. Second, it highlighted the role of diverse not-for-profit organizations in urban and suburban neighbourhoods as novel evidence-based intervention delivery partners. Current studies in the literature suggest that not-for-profit organizations could be involved in various roles (e.g., coordinate, disseminate, train, deliver) to move evidence-based intervention into practice (Garney et al., 2018; McHugh & Barlow, 2010; Petch et al., 2014; Stewart et al., 2006; Quinn et al., 2005) but do not examine adaptations when delivered in that setting. My study fills a gap as it presents adaptations to CTM when moved from recreation 112  organizations to not-for-profit non-recreation based organizations. Third, I triangulated my data collection method and data source to make my data more comprehensive. Data collected with various methods and at multiple timepoints helps address researcher bias. Fourth, I used FRAME, an established and comprehensive framework, to code adaptations (Stewart et al., 2019; Coronado et al., 2020). Like other research projects (e.g., cancer screening, psychotherapies, autism spectrum disorders and mental health) (Chlebowski et al., 2019; Corondo et al., 2020; Mackie et a., 2020; Lyon et al., 2019), I used FRAME to categorize factors that contributed to adaptations and the adaptations themselves. FRAME is useful for studies that involve ethnic minorities, compared to other frameworks (e.g., Stirman et al., 2013), because it conceptualizes cultural factors (e.g., language and ethnicity) (Chlebowski et al., 2019) in adaptations. Finally, I used SEM to situate proximal and distal factors that influenced adaptations to CTM across different levels of influence. The SEM is underrepresented in implementation and adaptation research compared to health behaviour research where it is extensively used (Sallis & Owen, 2015; Langille & Rodgers, 2010; Nelson et al., 2010). Few studies used an ecological approach to understanding implementation (e.g., facilitators and barriers) (Ockene et al., 2007; Kellou et al., 2014) and adaption (Castro et al., 2004; Podorefsky et al., 2001) to evidence-based interventions. My study demonstrates the SEM’s utility to understand the factors that contributed to CTM adaptations and complex relationships between CTM adaptations and the factors that influenced them.  There were four limitations to my study. First, my study only investigated CTM adaptations in three not-for-profit organizations. The findings may only apply to similar organizations and similar contexts (described in Table 6). I addressed this limitation with a detailed description of 113  the delivery partner organizations involved so readers can determine where the findings align with their context. Second, there may have been recall bias in the responses provided by the coordinators and activity coaches because the interviews and meeting minutes were not collected immediately after each program component was delivered. I scheduled data collection activities as close to program components as possible (e.g., select operations meeting dates after group meetings and the last check-in) and probed the coordinators and activity coaches for adaptations to minimize recall bias. Third, my study cannot quantify the adaptations (e.g., number of cancelled group meetings). We asked coordinators and activity coaches about the adaptations they made but not the quantity. This limits how thoroughly adaptations were described and to what extent core components were adapted or removed. Finally, the findings only represent the coordinator and activity coach perspective. CTM was embedded within organization structures beyond the providers who delivered CTM (i.e., coordinators and activity coaches). Thus, my study did not capture all the SEM factors that influenced adaptations (e.g., public policy).  5.5 Future research Little is known about evidence-based interventions adapted for Chinese older adults and no studies investigated PA evidence-based interventions for this population. Implementation strategies are particularly important to understand as they are the activities that move evidence-based interventions from research to routine practice (Proctor et al., 2013). To better understand implementation strategies, future research should investigate other stakeholders (e.g., organization leaders) that influence evidence-based intervention implementation strategies for Chinese older adults. More research is needed to understand evidence-based intervention implementation strategies delivered at scale for minorities populations. Future research should 114  also investigate different organization types (e.g., non-urban cores, long term care, for-profit) to understand implementation strategies suitable in other settings. A quantitative study that investigates diverse setting variables, and how evidence-based intervention implementation strategies and content are adapted may provide a better understanding of how evidence-based interventions, like CTM, are implemented at scale for various target populations. Understanding the relationship between how evidence-based intervention implementation strategies and content adaptations and stakeholder and setting variables may contribute to best practice policies, efficient evidence-based intervention uptake and better population health outcomes.     115  Bibliography Aarons, G. A., Green, A. E., Palinkas, L. A., Self-Brown, S., Whitaker, D. J., Lutzker, J. R., . . . Chaffin, M. J. (2012). 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Prostate cancer in relation to diet, physical activity, and body size in blacks, whites, and asians in the united states and canada. Journal of the National Cancer Institute, 87(9), 652-661. doi:10.1093/jnci/87.9.652 Wong, G. H. Y., Yek, O. P. L., Zhang, A. Y., Lum, T. Y. S., & Spector, A. (2018). Cultural adaptation of cognitive stimulation therapy (CST) for chinese people with dementia: multicentre pilot study. International Journal of Geriatric Psychiatry, 33(6), 841-848. doi:10.1002/gps.4663 Yan, M. C., Wong, K. L. Y., & Lai, D. (2019). Subethnic interpersonal dynamic in diasporic community: A study on chinese immigrants in vancouver. Asian Ethnicity, 20(4), 451-468. doi:10.1080/14631369.2019.1613885 Yoong, S. L., Nathan, N., Reilly, K., Sutherland, R., Straus, S., Barnes, C., . . . Wolfenden, L. (2019). Adapting implementation strategies: A case study of how to support implementation of healthy canteen policies. Public Health, 177(1), 19-25. doi:10.1016/j.puhe.2019.07.003    136  Appendix A Instrument 3: 3-month Activity Coach Interview Guide v2 Activity Coach ID: ______________ Today’s date (DD/MM/YYYY): ______________  Development & Delivery:  Question 1. Can you tell me about the work you did to develop a CTM referral network in your community? • How useful was this effort in supporting recruitment? • How useful was AART’s guidance? • How might you continue to use this network and/or the connections with people and organizations in your community in the work that you do in your role at your organization?  2. Can you tell me about the pre CTM delivery work you did to develop your community resources inventory? • How useful was this effort in supporting action plan development for your CTM participants? • How useful was AART’s guidance?  3. Were the resources provided to deliver Choose to Move useful (e.g., activity coach toolkit, group meeting slides)? • Probe: How so, which ones were mort useful?  4. Did you use and follow the resources provided to deliver Choose to Move (e.g., activity coach toolkit, group meeting slides)? • Probe: If not, why not? What did you add or change? How did those additions or changes influence the experience/value/impact of your CTM?  5. Did the CTM training provide you with the resources & support you needed to deliver Choose to Move? • Probe: what was the quality of this information & support?  6. Is this your first time delivering Choose to Move?  7. How confident were you in delivering CTM? 8. What are your skills and strengthens that help you deliver CTM?  9. To enhance your ability to deliver CTM, what skills or strengthens do you wish you had?  10. What worked really well for you in delivering Choose to Move to this group?  11. What challenges did you experience in delivering Choose to Move to this group? • If not first time, did anything work particularly well this time that you haven't experienced before? If yes, please describe.    Individual Meetings: 12. How did you find the one-on-one action plan meetings?  • Probes: Probe for Quality. Did you find you were able to deliver them with high quality?  137  13. How were the check-ins?  • Probes: Did you find that you could deliver them with high quality? Were they were valuable to the participant?  14. How did you think the telephone check-ins were for your participants? • Probe: were you able to trouble shoot challenges with the action plan, keeping them motivated/goal oriented?   Group Meetings: 15. How were the MGMs?  • Probes: Probe for Quality. Did you find the information of high quality? Did you find how they were delivered of high quality?  16. By the last CTM group meeting, did you feel a sense of community was developing with the participants? 17. How useful do you think the MGMs were for the participants?  18. How interactive was the group in the MGMs?  • Probe: extremely, very, somewhat, slightly, not at all  19. How enthusiastic, interested, and engaged were the participants with the Choose to Move content and with each other during MGMs?  • Probe: no, few, most, all meetings   Training: 20. Did training provide you with the skills you needed to deliver Choose to Move?  21. Did training provide you with the content knowledge you needed to deliver Choose to Move?  22. What did you like about training?   23.  How would you improve training?    Overall Program Reflection: 24. How useful did you find the program materials?  25. How useful did you think the participants found the program materials?  26. How is the program working for you?  27. What are your favourite parts of the program?  28. What are your least favourite parts of the program?  29. What has your involvement in Choose to Move meant to you?  30. Overall, how satisfied were you with CTM?  31. Overall, how satisfied do you think participants were with CTM? 138   32. What additional activities or opportunities did you plan to offer in your CTM? How valuable do you think these were to participants?  33. What additional activities or opportunities did you add or change as you delivered CTM? How valuable do you think these were to participants?     139  Appendix B Instrument 3: 3-month Activity Coach Interview Guide v5 Choose to Move – Scale out pilot sites [INSERT NAME OF ORGNAIZATION]  Interviewer: [INSERT NAME]  [INSERT TIME of call]  Below are the list of questions that the Interviewer will pose. Based on the information the Active Aging Research Team has acquired during operational meetings. Some of the questions have been answered for you and are seen in GREEN. Please review the questions and answeres and determine how you would like to add to or change the answer the questions. Please also review the Overview and determine if edits or additions are needed.  Note that some questions might spur a lengthy response and other questions might spur a very brief response.   The goal is to keep this interview to ~30 minutes, so please prepare in advance.   Overview of CTM at [INSERT NAME OF ORGNAIZATION]. (Please also refer to the summary document prepared collaboration with the site and AART)  • [INSERT notes from operations meetings/general overview]  140  To begin, I was hoping you could share with me your experiences of developing and delivering the Choose to Move program.  Development 1. Perhaps we could start with how you developed a CTM referral network in your community? Can you think back and tell me how you developed the referral network? o Probe: Where did you start? Did you make any new connections? How useful was this effort for recruitment? What was AART’s guidance like? Looking back, do you see any room for improvement/ anything you would have done differently? 2. Can you tell me about the pre CTM delivery work you did to develop your community resources inventory? o Probe: How useful was this effort in supporting your CTM participants and developing their action plans? • Probe: Was AART useful in guiding you to develop your community resource inventory? Is there anything that could have been more useful? Training  I was hoping you could share with me a bit about your experience delivering the CTM program. 3. How did you find the CTM training? What did you like about the training? Overall did you find it helpful? • Probe: Training was divided into self-directed and interactive. What did you think about these different formats? 4. Did training provide you with the content knowledge you needed to deliver Choose to Move? • Probe: If yes, how did it do that? If no, what was missing and how do you think training can better prepare you to deliver Choose to Move?  5. Did training provide you with the skills you needed to deliver Choose to Move? Were there aspects of CTM you were unsure of/not confident about delivering? • Probe: What are your thoughts on promoting physical activity? Do you think you have enough fitness knowledge, or do you think you would have benefited from more training?  6. How useful did you find the resources & support material? Did you use the resources provided (e.g., activity coach toolkit, group meeting slides)?  o Probe: How so, which ones were most useful? o Probe: If not, why not? What did you add or change? How did those additions or changes influence the experience/value/impact of your CTM? Delivery 7. Was this your first time delivering CTM? 8. Can you share your thoughts on the types of skills and strengths that an Actvity Coach should have in order to deliver the CTM program? o Probe: Did you feel that you have these skills and strengths? Do you feel there are other skills you wished you had to deliver the program? If so, which ones and why? 9. What have you noticed in terms of who shows up to the social and physical activity opportunities you provide? Is it mostly men or women or mixed? 141  • Probe: What about with CTM? (If this is not the baseline interview) • Probe: Why do you think this is? • Probe: Do you see this as a ‘problem’ or an issue? Why? • Probe: Have you or anyone in your organization thought about or addressed anything in relation to gender differences before? • Probe: Are your staff primarily men or women? 10. In general, do you feel that delivering the CTM program is feasible (e.g. is it easily achieved, difficult)? o Probe: Is the program appropriate for this organization? For the participants? o Probe: What about the program is not feasible, appropriate or acceptable? 11. Where there any activities or opportunities you added or changed as you delivered CTM? o Probe: What were they and why? Action Plan Meetings and Check-ins 12. Can you tell me about your experiences with the one-on-one meetings? o Probe: Did you find you were able to deliver the matierals and information? Did you enjoy them? Did you find they worked well? Please explain? 13. What are your thoughts on the check-in meetings? o Probe: What kinds of information were provided to the participants? What worked? What didn’t? What kinds of information did you find most impactful? o Probe: How do you think the check-in meetings are of value to participants? Or if you don’t think they are of value, why not? Were you able to trouble shoot challenges with the action plan, keeping them motivated/goal oriented? Group Meetings 14. Can you share with me your experience of the group meetings? What was the overall “feeling” of the group meetings (if necessary probe: relaxed, focused, friendly, serious), and how, if at all,  did this “feeling” change from the begining to the end of the program? o Probe: What do you think were the most useful parts of the group meeting? Any suggestions on how to improve them? o Probe: What were your interactions like with the group? what were the interactions like between the group members ? In your view, were there enough opportunities for participants to create or deepen relationships? Can you provide an example? o Probe: What came about because of these relationships? o Probe: Were participants engaged with the CTM content and with each other? o Probe: Overall, do you believe participants were satisfied with CTM? o Probe: Did anyone keep to themselves, and not interact with other members? Why do you think that was/was not? 15. What sort of activities took place during the group meetings? o Probe: Please describe. What activities worked well, why? What didn’t work well, why? Planning & Implementation 16. Once the program is up and running, how does AART provide support to you/your organization? o Probe: Is the AART helpful or not helpful in supporting you to deliver CTM? What works/ doesn’t work? 142  17. On a scale of 1-10, how would you rate the effectiveness of this partnership (10 being most effective)? o Probe: Why? 18. How, if at all, has hosting CTM in your organization influenced how your organization prioritizes older adults programming?  o Probe: Has it influenced your considerations of physical activity programming? Social programming? Please explain? 19. How, if at all, has hosting CTM in your organization enhanced your organization’s capacity to serve older adults? o Probe: Offer health promotion/physical activity opportunities? Final Questions 20. As we come to a close, can you share with us what your involvement in CTM has meant to you and what your thoughts are on what it has meant to your participants? 21. Is there anything else you would like to add or you think is important for us to know?    THANK PARTICIPANT FOR THEIR TIME!!!!    143  Appendix C Instrument 14: Activity Coach 6-month Interview Guide (last program) v1 Activity Coach ID: ______________ Today’s date (DD/MM/YYYY): ______________  General Skills: 1.  Is this your first time delivering Choose to Move?  2.  How confident were you in delivering CTM?  3.  What are your skills and strengths that help you deliver CTM?  4.  To enhance your ability to deliver CTM, what skills or strengths do you wish you had?  5.  From your experience with CTM and from your perspective, what skills are essential for an activity coach to be effective?   Training: 6.  Did the CTM training provide you with the resources and support you needed to deliver Choose to Move? • Probe: what was the quality of this information & support?  7.  Training was divided into self-directed and interactive. What did you think about this process overall?    8.  Did training provide you with the content knowledge you needed to deliver Choose to Move? • If yes, how did it do that? If no, what was missing and how do you think training can better prepare you to deliver Choose to Move?  • What are your thoughts on promoting physical activity? Do you think you have enough fitness knowledge or do you think you would have benefited from more training?   9.  Did training provide you with the skills you needed to deliver Choose to Move?  10.  Were there any aspects of Choose to Move delivery you were unsure of/not confident about? • What could be added to increase your confidence in these areas?   11.  What did you like about training?   12.  How would you improve training?    Planning & Central Support  13.  What has been the Active Aging Research Team’s role in your set up and delivery of Choose to Move? • How is the support provided by the Active Aging Research Team helpful or not helpful in assisting Choose to Move implementation at the operational level? 14.  What is working well in the partnership with the Active Aging Research Team?  • What aspects of this partnership could be improved? 144  • On a scale of 1-10, how would you rate the effectiveness of this partnership (10 being most effective)?   Development & Delivery: 15.  Were the resources provided to deliver Choose to Move useful (e.g., activity coach toolkit, group meeting slides)? • Probe: How so, which ones were mort useful?  16.  Did you use the resources provided to deliver Choose to Move (e.g., activity coach toolkit, group meeting slides)? • Probe: If not, why not? What did you add or change? How did those additions or changes influence the experience/value/impact of your CTM?  17.  Can you tell me about the work you did to develop a CTM referral network in your community? • How useful was this effort in supporting recruitment? • How useful was AART’s guidance? • How might you continue to use this network and/or the connections with people and organizations in your community in the work that you do in your role at your organization?  18.  What was the value of developing a local referral plan for your CTM program?  19.  Can you tell me about the work you did to develop your community resources inventory? • How useful was this effort in supporting action plan development for your CTM participants? • How useful was AART’s guidance?  20.  Did you incorporate any additional activities or opportunities in your CTM?  • If so, what were these activities or opportunities? • If so, how valuable do you think these were to participants? • How often each of these activities were made available (i.e. once; weekly over the 6 month period; weekly over the first three months)? • How long were these activities (i.e. one hour)?  21.  You worked with AART to identify an adapted version of CTM for your organization based on the needs of the older adults you intended to reach.   Were you able to deliver your version of CTM according to your plan?  a) If Yes, completely: a. If you were able to deliver according to your plan, what facilitated your ability to adhere to your delivery plan? b) If Yes, partly: a. Please explain what facilitated or impeded your ability to adhere to your delivery plan? c) If No, not at all:  If you were not able to deliver according to your plan, what prevented you from adhering to your delivery plan?  22.  From your perspective, were the adaptations you made to the CTM model positive or negative?  23.  Overall, what worked really well for you in delivering Choose to Move to this group? 145    Individual Meetings: 24.  How did you find the one-on-one action plan meetings?  • Probes: Probe for Quality. Did you find you were able to deliver them with high quality?  25.  How were the check-ins from your perspective?  • Probes: Did you find that you could deliver them with high quality? Were they were valuable to the participant?  26.  How did you think the telephone check-ins were for your participants? • Probe: were you able to trouble shoot challenges with the action plan, keeping them motivated/goal oriented?   Group Meetings: 27.  How were the MGMs?  • Probes: Probe for Quality. Did you find the information of high quality? Did you find how they were delivered of high quality?  28.  Comparing the last and first group meetings, what sorts of things did you notice about the participants in terms of their interaction with one another?  29.  How useful do you think the MGMs were for the participants?  30.  How interactive was the group in the MGMs?  • Probe: extremely, very, somewhat, slightly, not at all  31.  How enthusiastic, interested, and engaged were the participants with the Choose to Move content and with each other during MGMs?  • Probe: no, few, most, all meetings  32.  If you made modifications to the group meeting content provided by AART, what were they?  33.  If you made modifications to the group meeting content provided by AART, why did you make these modifications?  34.  If you made modifications to the group meeting content provided by AART, how did they benefit participants, from your perspective?    Overall Program Reflection: 35.  How useful did you find the program materials?  36.  How useful did you think the participants found the program materials?  37.  How did the program work for you?  38.  What are your favourite parts of the program?  146  39.  What are your least favourite parts of the program?  40.  What has your involvement in Choose to Move meant to you?  41.  Overall, how satisfied were you with CTM?  42.  Overall, how satisfied do you think participants were with CTM?  43.  From your perspective as the activity coach, is CTM a good fit for your organization?  44.  From your perspective, has CTM influenced your organization’s awareness of older adults’ needs in your community?  45.  From your perspective, has CTM influenced your organization’s awareness on physical activity programming for older adults? • If so, how? (from your perspective); provide examples   46.  Has hosting CTM in your organization influenced how your organization prioritizes older adults’ physical activity programming and/or social programming? • If so, how? (from your perspective); provide examples   47.  Has hosting CTM in your organization enhanced your organization’s capacity to serve older adults?  • If so, how? (from your perspective); provide examples  48.  Has hosting CTM in your organization enhanced your organization’s capacity to offer health promotion/physical activity opportunities? • If so, how? (from your perspective); provide examples  49.  If resources (i.e. funding) do not exist, would offering CTM at your organization remain a priority? • Please feel free to expand on your response.  50.  Is there anything else you would like to add?      147  Appendix D Instrument 14: 6-month Activity Coach Interview Guide v2 Activity Coach ID: ______________ Today’s date (DD/MM/YYYY): ______________ 03-10-2018 9:30 am  Choose to Move – Scale out pilot sites [INSERT NAME OF ORGNAIZATION]  Interviewer: [INSERT NAME]  [INSERT TIME of call]  Below are the questions that the Interviewer will pose. Based on the information the Active Aging Research Team has acquired during operational meetings. Some of the questions have been answered for you and are seen in GREEN. Please review the questions and answers and determine how you would like to add to or change the answer the questions. Please also review the Overview and determine if edits or additions are needed.  Note that some questions might spur a lengthy response and other questions might spur a very brief response.   The goal is to keep this interview to ~30 minutes, so please prepare in advance.   Overview of CTM at [INSERT NAME OF ORGNAIZATION]. (Please also refer to the summary document prepared collaboration with the site and AART)  • [INSERT notes from operations meetings/general overview]  148  To begin, I was hoping you could share with me your experiences of developing and delivering the Choose to Move program.  Development 22. Perhaps we could start with how you developed a CTM referral network in your community? Can you think back and tell me how you developed the referral network? o Probe: Where did you start? Did you make any new connections? How useful was this effort for recruitment? What was AART’s guidance like? Looking back, do you see any room for improvement/ anything you would have done differently?  23. Can you tell me about the pre CTM delivery work you did to develop your community resources inventory? o Probe: How useful was this effort in supporting your CTM participants and developing their action plans? • Probe: Was AART useful in guiding you to develop your community resource inventory? Is there anything that could have been more useful?  Training  I was hoping you could share with me a bit about your experience delivering the CTM program.  24. How did you find the CTM training? What did you like about the training? Overall did you find it helpful? • Probe: Training was divided into self-directed and interactive. What did you think about these different formats?  25. Did training provide you with the content knowledge you needed to deliver Choose to Move? • Probe: If yes, how did it do that? If no, what was missing and how do you think training can better prepare you to deliver Choose to Move?   26. Did training provide you with the skills you needed to deliver Choose to Move? Were there aspects of CTM you were unsure of/not confident about delivering? • Probe: What are your thoughts on promoting physical activity? Do you think you have enough fitness knowledge, or do you think you would have benefited from more training?   27. How useful did you find the resources & support material? Did you use the resources provided (e.g., activity coach toolkit, group meeting slides)?  o Probe: How so, which ones were most useful? o Probe: If not, why not? What did you add or change? How did those additions or changes influence the experience/value/impact of your CTM?  Delivery 149  28. Was this your first time delivering CTM?  29. Can you share your thoughts on the types of skills and strengths that an Actvity Coach should have in order to deliver the CTM program? o Probe: Did you feel that you have these skills and strengths? Do you feel there are other skills you wished you had to deliver the program? If so, which ones and why?  30. You worked with AART to identify an adapted version of CTM for your organization based on the needs of the older adults you intended to reach. Were you able to deliver your version of CTM according to your plan?  o Probe: If Yes, completely: § If you were able to deliver according to your plan, what facilitated your ability to adhere to your delivery plan? o Probe: If Yes, partly: § Please explain what facilitated or impeded your ability to adhere to your delivery plan? o Probe: If No, not at all: § If you were not able to deliver according to your plan, what prevented you from adhering to your delivery plan?  31. From your perspective, were the adaptations you made to the CTM model positive or negative? Please explain.  32. What have you noticed in terms of who shows up to the social and physical activity opportunities you provide? Is it mostly men or women or mixed? • Probe: What about with CTM? (If this is not the baseline interview) • Probe: Why do you think this is? • Probe: Do you see this as a ‘problem’ or an issue? Why? • Probe: Have you or anyone in your organization thought about or addressed anything in relation to gender differences before? • Probe: Are your staff primarily men or women?  33. In general, do you feel that delivering the CTM program is feasible (e.g. is it easily achieved, difficult)? o Probe: Is the program appropriate for this organization? For the participants? o Probe: What about the program is not feasible, appropriate or acceptable?  34. Were there any activities or opportunities you added or changed as you delivered CTM? o Probe: What were they and why?  35. Did you incorporate any additional activities or opportunities in your CTM o Probe: If so, what were these activities or opportunities? o Probe: If so, how valuable do you think these were to participants? 150  o Probe: How often each of these activities were made available (i.e. once; weekly over the 6 month period; weekly over the first three months)? o Probe: How long were these activities (i.e. one hour)?  Action Plan Meetings and Check-ins 36. Can you tell me about your experiences with the one-on-one meetings? o Probe: Did you find you were able to deliver the matierals and information? Did you enjoy them? Did you find they worked well? Please explain?  37. What are your thoughts on the check-in meetings? o Probe: What kinds of information were provided to the participants? What worked? What didn’t? What kinds of information did you find most impactful? o Probe: How do you think the check-in meetings are of value to participants? Or if you don’t think they are of value, why not? Were you able to trouble shoot challenges with the action plan, keeping them motivated/goal oriented?  Group Meetings 38. Can you share with me your experience of the group meetings? What was the overall “feeling” of the group meetings (if necessary probe: relaxed, focused, friendly, serious), and how, if at all,  did this “feeling” change from the begining to the end of the program? o Probe: What do you think were the most useful parts of the group meeting? Any suggestions on how to improve them? o Probe: What were your interactions like with the group? what were the interactions like between the group members ? In your view, were there enough opportunities for participants to create or deepen relationships? Can you provide an example? o Probe: What came about because of these relationships? o Probe: Were participants engaged with the CTM content and with each other? o Probe: Overall, do you believe participants were satisfied with CTM? o Probe: Did anyone keep to themselves, and not interact with other members? Why do you think that was/was not?  39. What sort of activities took place during the group meetings? o Probe: Please describe. What activities worked well, why? What didn’t work well, why?  40. If you made modifications to the group meeting content provided by AART, what were they? Why did you make these modifications? And how did they benefit participants, from your perspective?  Planning & Implementation 41. Once the program is up and running, how does AART provide support to you/your organization? o Probe: Is the AART helpful or not helpful in supporting you to deliver CTM? What works/ doesn’t work?  151  42. On a scale of 1-10, how would you rate the effectiveness of this partnership (10 being most effective)? o Probe: Why?  43. How, if at all,  has hosting CTM in your organization influenced how your organization prioritizes older adults programming?  o Probe: Has it influenced your considerations of physical activity programming? Social programming? Please explain?  44. How, if at all, has hosting CTM in your organization enhanced your organization’s capacity to serve older adults? o Probe: Offer health promotion/physical activity opportunities?  45. If resources (i.e. funding) do not exist, would offering CTM at your organization remain a priority? o Probe: Please feel free to expand on your response.  Final Questions 46. As we come to a close, can you share with us what your involvement in CTM has meant to you and what your thoughts are on what it has meant to your participants?  47. Is there anything else you would like to add or you think is important for us to know?    THANK PARTICIPANT FOR THEIR TIME!!!!    152  Appendix E Instrument 2: 3-month Coordinator Interview Guide v2 Coordinator ID: ______________ Today’s date (DD/MM/YYYY): ______________  Choose to Move Program:  Question 1. How acceptable is CTM for your organization?  • Probes: it meets my approval; it is appealing to me; I like it; I welcome it to my organization  2. How appropriate is CTM for your organization?  • Probes: It seems fitting, suitable, applicable, like a good match  3. How feasible is CTM for your organization?  • Probes: It seems implementable, possible, doable, easy to use   Goals: 4. Is there clear communication of the goals of Choose to Move to your organization – including coordinator and activity coach? • Probe: describe    Recruitment: 5. What recruitment strategies did you use? • Probe: poster/rack card distribution, newspaper ad or article, recreation center program guide, word of mouth, social media, presence at other community events, connect with other organization to refer clients to/promote Choose to Move, referral from family/friends, referral from health care providers  6. Did you use the recruitment toolkit to help plan your recruitment strategy?  7. Can you please describe the other recruitment strategies you used?  8. What skills influenced the hiring of your activity coach?  Referral and Partnerships: 9. Can you tell me about the work you did to develop a CTM referral network in your community? • How useful was this effort in supporting recruitment? • How useful was AART’s guidance? • How might you continue to use this network and/or the connections with people and organizations in your community in the work that you do in your role at your organization?  10. Did you work with any partners or other community agencies to deliver Choose to Move? Please describe the partners.   Planning & Implementation: 11. Tell me about the process for planning and implementing Choose to Move activities? 153  • Probe: was the process clear? Useful? What worked, what did not? Did you have the support you needed?  12. Did you receive the information you needed to contribute meaningfully to Choose to Move? • Probe: what was the quality of this information?  13. Did you receive the information you needed to adapt CTM to your organization/community?  • Probe: what was the quality of this information? Usefulness?  14. What factors are helping with the implementation of Choose to Move?  • Probe: activity coach, partnership, resources, existing capacity at local level, support from local leadership, other  15. What challenges have you faced during Choose to Move implementation?  • Probe: recruitment of participants, program start-up or administration, existing capacity at local level, others 16. What are some of the barriers and challenges to the successful implementation of Choose to Move? What aspects of Choose to Move need improvement?   General: 17. Is this the first Cycle your organization has delivered Choose to Move? (yes/no)  18. What aspects of Choose to Move are working well?  19. Are there any major challenges, lessons learned or success stories that you would like to share?  20. How was the training modified to meet the needs of your adapted CTM program model?  21. If the resources exist, is it a priority for you to continue offering Choose to Move?      154  Appendix F Instrument 2: 3-month Coordinator Interview Guide v4 Coordinator ID: ______________ Today’s date (DD/MM/YYYY): ______________  Choose to Move Program:  Question 1. How acceptable is CTM for your organization?  • Probes: it meets my approval; it is appealing to me; I like it; I welcome it to my organization 2. How appropriate is CTM for your organization?  • Probes: It seems fitting, suitable, applicable, like a good match 3. How feasible is CTM for your organization?  • Probes: It seems implementable, possible, doable, easy to use  Goals: 4. Is there clear communication of the goals of Choose to Move to your organization – including coordinator and activity coach? • Probe: describe   Recruitment: 5. What recruitment strategies did you use? • Probe: poster/rack card distribution, newspaper ad or article, recreation center program guide, word of mouth, social media, presence at other community events, connect with other organization to refer clients to/promote Choose to Move, referral from family/friends, referral from health care providers 6. Did you use the recruitment toolkit to help plan your recruitment strategy? 7. Can you please describe the other recruitment strategies you used? 8. What skills influenced the hiring of your activity coach?  Referral and Partnerships: 9. Can you tell me about the work you did to develop a CTM referral network in your community? • How useful was this effort in supporting recruitment? • How useful was AART’s guidance? • How might you continue to use this network and/or the connections with people and organizations in your community in the work that you do in your role at your organization? 10. Did you work with any partners or other community agencies to deliver Choose to Move? Please describe the partners.  Planning & Implementation: 11. Tell me about the process for planning and implementing Choose to Move activities? • Probe: was the process clear? Useful? What worked, what did not? Did you have the support you needed? 12. Did you receive the information you needed to contribute meaningfully to Choose to Move? • Probe: what was the quality of this information? 13. Did you receive the information you needed to adapt CTM to your organization/community?  • Probe: what was the quality of this information? Usefulness? 14. What factors are helping with the implementation of Choose to Move?  • Probe: activity coach, partnership, resources, existing capacity at local level, support from local leadership, other 15. What challenges have you faced during Choose to Move implementation?  155  • Probe: recruitment of participants, program start-up or administration, existing capacity at local level, others 16. What are some of the barriers and challenges to the successful implementation of Choose to Move? What aspects of Choose to Move need improvement? 17. How does the Active Aging Research team provide support to you/your organization at the operational level?  How is the support provided by the Active Aging Research Team helpful or not helpful in assisting Choose to Move implementation at the operational level? 18. What is working well in the partnership with the Active Aging Research Team?  What aspects of this partnership could be improved? On a scale of 1-10, how would you rate the effectiveness of this partnership (10 being most effective)? 19. Has hosting CTM in your organization influenced how your organization prioritizes older adults programming? And/or physical activity programming? And/or social programming? • If so, how? (from your perspective); provide examples  20. Has hosting CTM in your organization enhanced your organization’s capacity to serve older adults? Offer health promotion/physical activity opportunities? • If so, how? (from your perspective); provide examples  General: 19. Is this the first Cycle your organization has delivered Choose to Move? (yes/no) 20. What aspects of Choose to Move are working well? 21. Are there any major challenges, lessons learned or success stories that you would like to share? 22. How was the training modified to meet the needs of your adapted CTM program model? 23. If the resources exist, is it a priority for you to continue offering Choose to Move? 24. Is there anything else you would like to add?    156  Appendix G Instrument 2: 3-month Coordinator Interview Guide v5  Coordinator ID: ______________ Today’s date (DD/MM/YYYY): ______________ 03-10-2018 9:30 am  Choose to Move – Scale out pilot sites [INSERT NAME OF ORGNAIZATION]  Interviewer: [INSERT NAME]  [INSERT TIME of call]  Below are the questions that the Interviewer will pose. Based on the information the Active Aging Research Team has acquired during operational meetings. Some of the questions have been answered for you and are seen in GREEN. Please review the questions and answers and determine how you would like to add to or change the answer the questions. Please also review the Overview and determine if edits or additions are needed.  Note that some questions might spur a lengthy response and other questions might spur a very brief response.   The goal is to keep this interview to ~30 minutes, so please prepare in advance.   Overview of CTM at [INSERT NAME OF ORGNAIZATION]. (Please also refer to the summary document prepared collaboration with the site and AART)  [INSERT notes from operations meetings/general overview]  157  Choose to Move Program 1. How acceptable is CTM for your organization?  o Probe: it meets my approval; it is appealing to me; I like it; I welcome it to my organization 2. How appropriate is CTM for your organization?  o Probe: It seems fitting, suitable, applicable, like a good match 3. How feasible is CTM for your organization?  o Probe: It seems implementable, possible, doable, easy to use Goals 4. Is there clear communication of the goals of Choose to Move to your organization – including coordinator and activity coach? o Probe: describe Recruitment 5. What recruitment strategies did you use? o Probe: poster/rack card distribution, newspaper ad or article, recreation center program guide, word of mouth, social media, presence at other community events, connect with other organization to refer clients to/promote Choose to Move, referral from family/friends, referral from health care providers 6. Did you use the recruitment toolkit to help plan your recruitment strategy? 7. Can you please describe the other recruitment strategies you used? 8. What skills influenced the hiring of your activity coach? Referrals and Partnerships 9. Can you tell me about the work you did to develop a CTM referral network in your community? o Probe: How useful was this effort in supporting recruitment? o Probe: How useful was AART’s guidance? o Probe: How might you continue to use this network and/or the connections with people and organizations in your community in the work that you do in your role at your organization? 10. Did you work with any partners or other community agencies to deliver Choose to Move? Please describe the partners. Planning and Implementation 11. Tell me about the process for planning and implementing Choose to Move activities? o Probe: was the process clear? Useful? What worked, what did not? Did you have the support you needed? 12. Did you receive the information you needed to contribute meaningfully to Choose to Move? o Probe: what was the quality of this information? 13. Did you receive the information you needed to adapt CTM to your organization/community?  158  o Probe: what was the quality of this information? Usefulness? 14. What factors are helping with the implementation of Choose to Move?  o Probe: activity coach, partnership, resources, existing capacity at local level, support from local leadership, other 15. What challenges have you faced during Choose to Move implementation?  o Probe: recruitment of participants, program start-up or administration, existing capacity at local level, others 16. What are some of the barriers and challenges to the successful implementation of Choose to Move? What aspects of Choose to Move need improvement? 17. How does the Active Aging Research team provide support to you/your organization at the operational level?  o Probe: How is the support provided by the Active Aging Research Team helpful or not helpful in assisting Choose to Move implementation at the operational level? 18. What is working well in the partnership with the Active Aging Research Team?  o Probe: What aspects of this partnership could be improved? o Probe: On a scale of 1-10, how would you rate the effectiveness of this partnership (10 being most effective)? 19. Has hosting CTM in your organization influenced how your organization prioritizes older adults programming? And/or physical activity programming? And/or social programming? o Probe: If so, how? (from your perspective); provide examples 20. Has hosting CTM in your organization enhanced your organization’s capacity to serve older adults? Offer health promotion/physical activity opportunities? o Probe: If so, how? (from your perspective); provide examples General 21. Is this the first Cycle your organization has delivered Choose to Move? (yes/no) 22. What aspects of Choose to Move are working well? 23. Are there any major challenges, lessons learned or success stories that you would like to share? 24. How was the training modified to meet the needs of your adapted CTM program model? 25. If the resources exist, is it a priority for you to continue offering Choose to Move? 26. Is there anything else you would like to add?     159  Appendix H Instrument 10: Ethnographic Notes v1 Site ID __________________ Date ___________________ Note taker ____________________     Questions 1. Description of attendees (e.g., gender, race, age, overall behaviour, on time/late) 2. Feeling of the space (e.g., atmosphere, tone) 3. Description of the space (e.g., light, colors, size, furniture, equipment, seating arrangement) 4. Non-verbal cues 5. Activities 6.  Key topics discussed 7. Note-takers impression 8.  Other relevant observations 160  Appendix I Instrument 10: Ethnographic Notes v2 Site ID __________________ Date/total time ___________________ weather: ___________________ Note taker ____________________ Instructional Overview Observational field notes are a written synopsis of what happened at a given time and place. All field notes generally consist of two parts: 1. Descriptive information, in which you attempt to accurately document factual data [e.g., date and time] and the settings, actions, behaviors, and interactions/ interruptions that you observe.  2. Reflective information, in which you record your thoughts, ideas, questions, and concerns as you are conducting the observation.  The goal of these notes is to compliment and create a more fulsome picture of what occurred during the session or interview. You should elaborate on your field notes as soon as possible after the session.   DESCRIPTIVE 1. Context of observations (reason for meeting/interview/informal public space). 2. Description of exterior street/neighbourhood/ community centre etc. 3. Description of the interior space (e.g., light, colors, size, furniture, equipment, art, seating arrangement). 4. Physical description of attendees(s) (e.g., gender, race, age, mobility aids, #). 5. Non-verbal behaviours during interview/meeting (head nodding, looking out window, # participation in activity). IF one-on-one setting, skip to question 8 6. Observed interactions of and between the attendees (on time/late, talking, laughing, sitting in silence, smiling or serious, interruptions). 7. Activities observed (e.g guided stretch breaks). 8. Main content discussed. 9. Additional descriptive information. REFLECTIVE 10. Perceived feeling of the space (e.g., atmosphere, tone, light/dark). 11. Perceived disposition of attendee(s) (did they appear confident, happy, bored, tired, comfortable, uncomfortable, serious etc)? Did this change at all for any reason during the course of your observations? Any particular emotional responses? 12. Did anything you observe surprise and or challenge your own assumptions? 13. What were the prominent themes that stood out from the interview/meeting? 14. How were you feeling today, and how might this impact your reflections? 15. Overall reflections/ note taker impressions, did anything stand out positively or negatively?  (Free-flow write what comes up for you). 

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