Health and Social Development, Faculty of (Okanagan)
Health and Exercise Sciences, School of (Okanagan)
DSpace
UBCO
Cranston, Kaela
Doctor of Philosophy - PhD
University of British Columbia
Type 2 diabetes (T2D) prevention programs have demonstrated efficacy at reducing risk of T2D through physical activity and dietary modifications. Implementing T2D prevention programs in community-based settings, led by lay educators, extends their reach to more individuals at risk for developing T2D. E-learning offers a practical and efficient approach for training lay educators to deliver T2D prevention programs. Thoroughly evaluating e-learning trainings provides details about the resources and activities necessary to develop and implement the trainings and examines the effectiveness of e-learning trainings. Evaluating e-learning trainings is critical for improving and determining the effects of trainings, enabling data-informed decision-making. This dissertation used the technology-enhanced learning evaluation framework and the knowledge-to-action framework to develop, implement, and evaluate an e-learning training for Small Steps for Big Changes (SSBC) T2D prevention program coaches. First, the SSBC coach e-learning training was developed by engaging with SSBC coaches and the SSBC research team. Next, one component of the newly developed e-learning training, a cultural safety and inclusivity module was tested for effectiveness and acceptability. Results demonstrated that the module was effective and acceptable. Thus, the e-learning training was implemented to train new SSBC coaches. Semi-structured interviews with SSBC coaches and SSBC coach training delivery staff were conducted to understand the users’ experiences with the e-learning training. Coaches and staff detailed what was working well and suggested modifications to improve the training. Fourth, the effectiveness of the e-learning training was examined to determine coaches’ satisfaction with the training, whether coaches learned from the training, if coaches delivered SSBC to clients as intended after completing the training, and the effects of coach training on client outcomes. The final study included in this dissertation outlined how the e-learning training enhanced equity and inclusion within SSBC. Additionally, it detailed furthers steps taken within SSBC to advance equity and inclusion, and offered recommendations to improve equity and inclusion within other health programs. The results of this pragmatic series of studies provided details on the processes involved in developing, implementing, and evaluating the SSBC coach e-learning training. This dissertation can be used as a blueprint for conducting thorough e-learning training evaluations.
EVALUATING THE DIGITALIZATION OF THE SMALL STEPS FOR BIG CHANGES COACH TRAINING: FROM CONCEPTUALIZATION TO EFFECTIVENESS by Kaela Cranston M.Sc. University of British Columbia, 2019 B.Sc., Brandon University, 2016 A DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE COLLEGE OF GRADUATE STUDIES (Kinesiology) THE UNIVERSITY OF BRITISH COLUMBIA (Okanagan) May 2024 © Kaela Cranston, 2024 ii The following individuals certify that they have read, and recommend to the College of Graduate Studies for acceptance, the dissertation entitled: EVALUATING THE DIGITALIZATION OF THE SMALL STEPS FOR BIG CHANGES COACH TRAINING: FROM CONCEPTUALIZATION TO EFFECTIVENESS submitted by Kaela Cranston in partial fulfilment of the requirements for the degree of Doctor of Philosophy Examining Committee: Dr. Mary E Jung, School of Health and Exercise Sciences Supervisor Dr. Tanya Forneris, School of Health and Exercise Sciences Supervisory Committee Member Dr. Kathleen Martin Ginis, School of Health and Exercise Sciences Supervisory Committee Member Dr. Toni Schmader, Department of Psychology University Examiner Dr. Peter Sinclair, University of Technology Sydney External Examiner iii Abstract Type 2 diabetes (T2D) prevention programs have demonstrated efficacy at reducing risk of T2D through physical activity and dietary modifications. Implementing T2D prevention programs in community-based settings, led by lay educators, extends their reach to more individuals at risk for developing T2D. E-learning offers a practical and efficient approach for training lay educators to deliver T2D prevention programs. Thoroughly evaluating e-learning trainings provides details about the resources and activities necessary to develop and implement the trainings and examines the effectiveness of e-learning trainings. Evaluating e-learning trainings is critical for improving and determining the effects of trainings, enabling data-informed decision-making. This dissertation used the technology-enhanced learning evaluation framework and the knowledge-to-action framework to develop, implement, and evaluate an e-learning training for Small Steps for Big Changes (SSBC) T2D prevention program coaches. First, the SSBC coach e-learning training was developed by engaging with SSBC coaches and the SSBC research team. Next, one component of the newly developed e-learning training, a cultural safety and inclusivity module was tested for effectiveness and acceptability. Results demonstrated that the module was effective and acceptable. Thus, the e-learning training was implemented to train new SSBC coaches. Semi-structured interviews with SSBC coaches and SSBC coach training delivery staff were conducted to understand the users’ experiences with the e-learning training. Coaches and staff detailed what was working well and suggested modifications to improve the training. Fourth, the effectiveness of the e-learning training was examined to determine coaches’ satisfaction with the training, whether coaches learned from the training, if coaches delivered SSBC to clients as intended after completing the training, and the effects of coach training on iv client outcomes. The final study included in this dissertation outlined how the e-learning training enhanced equity and inclusion within SSBC. Additionally, it detailed furthers steps taken within SSBC to advance equity and inclusion, and offered recommendations to improve equity and inclusion within other health programs. The results of this pragmatic series of studies provided details on the processes involved in developing, implementing, and evaluating the SSBC coach e-learning training. This dissertation can be used as a blueprint for conducting thorough e-learning training evaluations. v Lay Summary Type 2 diabetes prevention programs can help individuals reduce their risk of developing type 2 diabetes through diet and exercise changes. Brining these programs into community settings and training people in the community to lead them, will help more people reduce their risk of type 2 diabetes. Online learning makes it easier to train these community members efficiently. This dissertation looked at how well the online training worked for the Small Steps for Big Changes (SSBC) diabetes prevention program. First, I developed the online training with the people taking the training and those delivering it. Then, different aspects of the training were tested to see how effective the training was, and if people liked it. Last, I discussed how this training and other aspects of SSBC help make everyone feel included in SSBC. This research can help guide future efforts to create and test e-learning training. vi Preface I declare that the composition of this dissertation is the result of my own work. In the case of co-authored work, all sources have been acknowledged and contributions to each study are outlined below. All experimental chapters in this thesis were approved by the respective research ethics board at the University of British Columbia (Okanagan). Data collection, data analysis, and manuscript writing for all published works included in this dissertation were conducted at the University of British Columbia (Okanagan). Chapter 2 (Study 1) Cranston, K.D., Grieve, N.J., Dineen, T.E., and Jung, M.E. (2024). Designing and developing online training for diabetes prevention program coaches using an integrated knowledge translation approach: Development and usability study. JMIR Formative Research, 8, E50942. DOI: 10.2196/50942 Cranston’s role in Chapter 2: • Responsible for study design and methods • Developed interview guide • Led focus groups, research team meetings, and data analysis • Main contact for the 3C Institute and SSBC coaches • Primary author of manuscript, drafted manuscript, led revisions Co-authors’ role in Chapter 2: • Jung provided guidance for all stages of the project vii • Grieve assisted with data collection and project coordination • Dineen assisted with script development • All authors read and approved the final manuscript Ethics approval: This study protocol was approved by the University of British Columbia Okanagan Research Services Behavioural Research Ethics Board (H21-01800). Chapter 3 (Study 2) Cranston, K.D., Sim, J.A.P., and Jung, M.E. (submitted). Impact of a 20-minute cultural safety and inclusivity module on current and future fitness and healthcare professionals. International Journal of Medical Education. Cranston’s role in Chapter 3: • Conceived research question and methods • Led data analysis and interpretation • Primary author of manuscript, drafted manuscript Co-authors’ role in Chapter 3: • Jung provided guidance for all stages of the project • Sim assisted with study design and led data collection • All authors read and approved the final version of the manuscript before submission Ethics approval: This study protocol was approved by the University of British Columbia Okanagan Research Services Behavioural Research Ethics Board (H20-03840). viii Chapter 4 (Study 3) Cranston, K.D., Grieve, N.J., and Jung, M.E. (submitted). Exploring perspectives of type 2 diabetes prevention program coaches and training delivery staff on online coach training: A qualitative study. BMC Medical Education. Cranston’s role in Chapter 4: • Conceived research question and study design • Developed interview guides • Led training delivery staff interviews • Led data analysis and interpretation • Primary author of manuscript, drafted manuscript Co-authors’ role in Chapter 4: • Jung provided guidance for all stages of the project • Grieve led coach interviews and assisted in the analysis and interpretation of the data • All authors read and approved the final version of the manuscript before submission Ethics approval: This study protocol was approved by the University of British Columbia Okanagan Research Services Behavioural Research Ethics Board (H21-01800). Chapter 5 (Study 4) Cranston, K.D., Grieve, N.J., Reitsma, R., and Jung, M.E. (submitted). Effectiveness of brief e-learning training for diabetes prevention program coaches: Outcome evaluation. Journal of Medical Internet Research. ix Cranston’s role in Chapter 5: • Conceived research question and study design • Led data collection, analysis, and interpretation • Primary author of manuscript, drafted manuscript Co-authors’ role in Chapter 5: • Jung provided guidance for all stages of the project • Grieve assisted with measure development, data collection, and data analysis • Reitsma assisted with data analysis • All authors read and approved the final version of the manuscript before submission. Ethics approval: This study protocol was approved by the University of British Columbia Okanagan Research Services Behavioural Research Ethics Board (H21-01800). Chapter 6 (Study 5) Cranston, K.D., MacPherson, M.M., Sim, J.A.P., and Jung, M.E. (2023). Small steps towards an inclusive diabetes prevention program: How Small Steps for Big Changes is improving program equity and inclusion. Community Health Equity and Research, 0(0), 1-10. DOI: 10.1177/2752535X231189932. Cranston’s role in Chapter 6: • Conceived research question and study design • Led many of the changes outlined • Primary author of manuscript, drafted manuscript, led revisions x Co-authors’ role in Chapter 6: • Jung provided guidance for all stages of the project • MacPherson assisted research question, study design, and with many of the changes outlined • Sim assisted with some of the changes outlined • All authors read and approved the final version of the manuscript before submission. Additional manuscripts that were completed during the degree program, but are not included in the thesis are: Sim, J.A.P., Craven, S.A., Cranston, K.D., and Jung, M.E. (submitted). A qualitative needs assessment for type 2 diabetes prevention at a community food bank. Submitted to Diabetes Care. Der, S., Cranston, K.D., & Jung, M.E. (submitted). One step towards closing the gap: A case study with an adult to understand how to make type 2 diabetes prevention programs more inclusive. Submitted to Community Health Equity Research & Policy. Craven, S., Sim, J.A.P., Cranston, K.D., & Jung, M.E. (submitted). “People need to know; we’re part of the community. We’re here.”: A mixed-methods study examining experiences on sharing demographic information for a community-based diabetes prevention program. Submitted to International Journal for Equity in Health. MacPherson, M.M., Johnston, C., Cranston, K.D., Der, S., Sim, J.A.P, & Jung, M.E. (2024). Identification of Intervention Characteristics within Diabetes Prevention Programs using xi the TIDieR: A Scoping Review. Canadian Journal of Diabetes. DOI: 10.1016/j.jcjd.2024.02.004 Grieve, N., Cranston, K. D., Jung, M. E. (2023). Examining the effectiveness of an e-learning training course for coaches of a type 2 diabetes prevention program. Journal of Technology in Behavioral Science, 1-11, DOI: https://doi.org/10.1007/s41347-023-00316-3 Cranston, K. D., Ivanova, E., Davis, C. & Jung, M. E. (2022). Fidelity and maintenance of motivational interviewing skills in diabetes prevention program coaches: A pilot study. International Journal of Health Promotion and Education, DOI: 10.1080/14635240.2022.2136976. Dineen, T. E., Locke, S. R., Cranston, K. D., Beauchamp, M.R., & Jung, M. E. (2021). Self-regulatory efficacy and long-term physical activity engagement: Examining mediators from a randomized trial. Psychology of Sport and Exercise, 56, 102001, DOI: 10.1016/j.psychsport.2021.102001. MacPherson, M.M., Cranston, K. D., Locke, S.R., Bourne, J.E., & Jung, M.E. (2021). Using the behavior change wheel to develop text messages to promote diet and physical activity adherence following a diabetes prevention program. Translational Behavioral Medicine, 11(8), 1585-1595, DOI: 10.1093/tbm/ibab058. MacPherson, M.M., Cranston, K. D., Johnston, C., Locke, S., & Jung, M.E. (2021). Evaluation and refinement of a bank of SMS text messages to promote behavior change adherence xii following a diabetes prevention program: Survey study. JMIR Formative Research, 5(8), e28163, DOI: 10.2196/28163 Dineen, T. E., Bean, C., Cranston, K. D., MacPherson, M. M., & Jung, M. E. (2021). Fitness facility staff can be trained to deliver a motivational interviewing-informed diabetes prevention program. Frontiers in Public Health, 9, DOI: 10.3389/fpubh.2021.728612. MacPherson, M.M., Dineen, T.E., Cranston, K. D., & Jung, M.E (2020). Identifying behaviour change techniques and motivational interviewing techniques in Small Steps for Big Changes: A community-based program for adults at risk for type 2 diabetes. Canadian Journal of Diabetes, 44(8), 719-726, DOI: 10.1016/j.jcjd.2020.09.011. MacPherson, M., Cranston, K. D, Locke, S., Vis-Dunbar, M., & Jung, M. (2020). Diet and exercise interventions for individuals at risk for type 2 diabetes: A scoping review protocol. BMJ Open, 10, e039532, DOI: 10.1136/bmjopen-2020-039532. xiii Table of Contents Abstract ......................................................................................................................................... iii Lay Summary .................................................................................................................................v Preface ........................................................................................................................................... vi Table of Contents ....................................................................................................................... xiii List of Tables ............................................................................................................................ xxvi List of Figures .......................................................................................................................... xxvii List of Abbreviations ............................................................................................................. xxviii Acknowledgements ....................................................................................................................xxx Dedication ............................................................................................................................... xxxiii Chapter 1: Introduction ................................................................................................................1 1.1 Type 2 diabetes prevention ............................................................................................. 1 1.1.1 Small Steps for Big Changes .................................................................................... 3 1.2 Motivational interviewing ............................................................................................... 5 1.2.1 MI training ................................................................................................................ 6 1.2.2 SSBC coach training ................................................................................................. 7 1.3 E-learning ........................................................................................................................ 7 1.3.1 Development of e-learning platforms ....................................................................... 9 1.4 Evaluation ..................................................................................................................... 10 1.5 Theoretical approaches ................................................................................................. 11 1.5.1 Technology-enhanced learning evaluation framework ........................................... 11 1.5.2 Knowledge-to-action framework ............................................................................ 12 xiv 1.6 Dissertation aims ........................................................................................................... 13 1.7 Overview of the dissertation structure .......................................................................... 13 1.7.1 Chapter 2: Designing and developing online training for diabetes prevention program coaches using an integrated knowledge translation approach: Development and usability study ....................................................................................................................... 14 1.7.2 Chapter 3: Impact of a 20-minute cultural safety and inclusivity module on current and future fitness and healthcare professionals .................................................................... 14 1.7.3 Chapter 4: Exploring perspectives of type 2 diabetes prevention program coaches and training delivery staff on online coach training: A qualitative study ............................. 15 1.7.4 Chapter 5: Effectiveness of brief e-learning training for diabetes prevention program coaches: Outcome evaluation ................................................................................. 15 1.7.5 Chapter 6: Small steps to an inclusive diabetes prevention program: How Small Steps for Big Changes is improving program equity and inclusion ..................................... 16 1.8 Methodology ................................................................................................................. 16 1.8.1 Research positioning ............................................................................................... 16 1.8.2 Paradigm ................................................................................................................. 17 1.8.3 Methods ................................................................................................................... 17 1.9 Summary ....................................................................................................................... 18 Chapter 2: Designing and developing online training for diabetes prevention program coaches using an integrated knowledge translation approach: Development and usability study ..............................................................................................................................................19 2.1 Introduction ................................................................................................................... 19 2.2 Methods......................................................................................................................... 20 xv 2.2.1 Context .................................................................................................................... 20 2.2.2 Needs analysis ......................................................................................................... 21 2.2.2.1 Overview ........................................................................................................... 21 2.2.2.2 Previous research .............................................................................................. 21 2.2.2.3 SSBC research team meetings .......................................................................... 21 2.2.2.4 Focus groups with SSBC coaches..................................................................... 22 2.2.3 Design and development ......................................................................................... 22 2.2.4 Test usability ........................................................................................................... 23 2.2.5 Ethical considerations ............................................................................................. 24 2.3 Results ........................................................................................................................... 24 2.3.1 Needs analysis ......................................................................................................... 24 2.3.1.1 Previous research .............................................................................................. 24 2.3.1.2 SSBC research team meetings .......................................................................... 24 2.3.1.3 Focus groups with SSBC coaches..................................................................... 25 2.3.2 Design and development ......................................................................................... 26 2.3.3 Test usability ........................................................................................................... 28 2.4 Discussion ..................................................................................................................... 28 2.4.1 Principle results ....................................................................................................... 28 2.4.2 Limitations .............................................................................................................. 29 2.4.3 Conclusions ............................................................................................................. 30 Chapter 3: Impact of a 20-minute cultural safety and inclusivity module on current and future fitness and healthcare professionals ...............................................................................35 3.1 Introduction ................................................................................................................... 35 xvi 3.1.1 Context .................................................................................................................... 37 3.2 Methods......................................................................................................................... 39 3.2.1 Positionality ............................................................................................................ 39 3.2.2 Participants .............................................................................................................. 39 3.2.3 Procedures ............................................................................................................... 40 3.2.4 Measures ................................................................................................................. 41 3.2.4.1 Demographics ................................................................................................... 41 3.2.4.2 Beliefs about relevance of EDI training to education or job ............................ 42 3.2.4.3 Implicit association test..................................................................................... 42 3.2.4.4 Explicit bias ...................................................................................................... 43 3.2.4.5 Empathic awareness .......................................................................................... 43 3.2.4.6 Perceptions of patient ........................................................................................ 44 3.2.4.7 Perspectives of CS&I module ........................................................................... 44 3.2.5 Analyses .................................................................................................................. 45 3.2.5.1 Quantitative data ............................................................................................... 45 3.2.5.2 Qualitative data ................................................................................................. 45 3.3 Results ........................................................................................................................... 46 3.3.1 Participants .............................................................................................................. 46 3.3.2 Beliefs about relevance of EDI training to education or job................................... 46 3.3.3 IAT .......................................................................................................................... 46 3.3.4 Explicit bias, empathic awareness, and perceptions of patient ............................... 47 3.3.4.1 Explicit bias ...................................................................................................... 47 3.3.4.2 Empathic awareness .......................................................................................... 47 xvii 3.3.4.3 Perceptions of patient ........................................................................................ 48 3.3.5 Perspectives of CS&I module ................................................................................. 49 3.4 Discussion ..................................................................................................................... 50 3.4.1 Implications ............................................................................................................. 52 3.4.2 Limitations and future directions ............................................................................ 53 3.5 Conclusion .................................................................................................................... 54 Chapter 4: Exploring perspectives of type 2 diabetes prevention program coaches and training delivery staff on online coach training: A qualitative study .....................................63 4.1 Background ................................................................................................................... 63 4.1.1 Context .................................................................................................................... 64 4.1.2 The SSBC e-learning training ................................................................................. 65 4.2 Methods......................................................................................................................... 66 4.2.1 Paradigmatic position .............................................................................................. 66 4.2.2 Participants and recruitment.................................................................................... 66 4.2.3 Interviews ................................................................................................................ 67 4.2.3.1 Coach interviews ............................................................................................... 67 4.2.3.2 Staff interviews ................................................................................................. 68 4.2.4 Data analysis ........................................................................................................... 68 4.2.4.1 Coach interviews ............................................................................................... 68 4.2.4.2 Staff interviews ................................................................................................. 69 4.3 Results ........................................................................................................................... 69 4.3.1 Participants .............................................................................................................. 69 4.3.2 SSBC coach interview findings .............................................................................. 70 xviii 4.3.2.1 Training design ................................................................................................. 70 4.3.2.1.1 Course content ............................................................................................ 70 4.3.2.1.2 Learning modalities – the “how” ................................................................ 70 4.3.2.1.2.1 Current learning modalities .................................................................. 71 4.3.2.1.2.2 Ideas for additional learning modalities ............................................... 71 4.3.2.1.3 Online platform organization – the layout .................................................. 72 4.3.2.1.4 Training synchronicity and mode ............................................................... 72 4.3.2.1.5 Training process .......................................................................................... 72 4.3.2.1.5.1 Communication to coaches .................................................................. 72 4.3.2.1.5.2 Systematic steps to becoming a certified coach ................................... 73 4.3.2.1.6 Coach testing ............................................................................................... 73 4.3.2.1.7 Receiving feedback ..................................................................................... 74 4.3.2.2 “I didn’t know what to expect from the training” ............................................. 74 4.3.2.3 Technology usability ......................................................................................... 74 4.3.2.4 Learning ............................................................................................................ 75 4.3.2.4.1 Coaches learned .......................................................................................... 75 4.3.2.4.1.1 Learning new knowledge ..................................................................... 75 4.3.2.4.1.2 Demonstrating new knowledge ............................................................ 75 4.3.2.4.1.3 Readiness to deliver SSBC sessions .................................................... 76 4.3.2.4.1.4 Application of learning ........................................................................ 76 4.3.2.4.1.4.1 Anticipating application of learning within SSBC ....................... 77 4.3.2.4.1.4.2 Applying learning within SSBC ................................................... 77 4.3.2.4.1.4.3 Transcending SSBC: applying learning in other contexts ............ 77 xix 4.3.2.4.2 The learning journey ................................................................................... 78 4.3.2.4.2.1 Approach to completing the training ................................................... 78 4.3.2.4.2.2 Individual learning strategies ............................................................... 78 4.3.2.4.2.3 Gradual learning curve ......................................................................... 78 4.3.2.4.2.4 “Practice, practice, practice” before the mock session ........................ 78 4.3.2.4.2.5 The nerve-wracking experience of being evaluated ............................ 78 4.3.2.4.2.6 Learning through trial and error ........................................................... 79 4.3.2.4.2.7 Continued learning after certification .................................................. 79 4.3.2.4.2.7.1 Using resources to foster session success ..................................... 80 4.3.2.4.2.7.2 Real-world practice enhances mastery .......................................... 80 4.3.2.4.2.7.3 Supplemental learning ideas ......................................................... 80 4.3.2.5 Coaches’ backgrounds shaped their training experience .................................. 81 4.3.2.6 Support .............................................................................................................. 81 4.3.2.6.1 SSBC staff-to-coach support....................................................................... 81 4.3.2.6.2 Coach-to-coach support .............................................................................. 82 4.3.2.6.2.1 Words of wisdom for new coaches starting the training ...................... 82 4.3.2.7 Coaches valued the training .............................................................................. 82 4.3.2.7.1 Viewing the training as continuing education ............................................ 83 4.3.2.7.2 The trickle-down effect of coach training on clients .................................. 83 4.3.2.7.3 Extending the training to non-coaching staff .............................................. 83 4.3.3 SSBC training delivery staff interview findings ..................................................... 84 4.3.3.1 Streamlining the training delivery .................................................................... 84 4.3.3.1.1 What’s working ........................................................................................... 84 xx 4.3.3.1.1.1 The online platform usability ............................................................... 84 4.3.3.1.1.2 Staff communication isn’t all bad ........................................................ 85 4.3.3.1.1.3 On the way to a sustainable process..................................................... 85 4.3.3.1.2 Removing unnecessary training steps ......................................................... 85 4.3.3.1.3 Redistributing workload.............................................................................. 86 4.3.3.1.3.1 Amount of staff time required to train each coach............................... 86 4.3.3.1.3.2 Automating procedures ........................................................................ 86 4.3.3.1.3.3 Defined roles ........................................................................................ 87 4.3.3.1.3.3.1 Staff coordinator ........................................................................... 87 4.3.3.1.3.3.2 Site lead ......................................................................................... 87 4.3.3.1.3.3.3 Mock session coders ..................................................................... 88 4.3.3.1.4 Clearly communicating all expectations ..................................................... 88 4.3.3.1.5 Standardizing procedures ............................................................................ 89 4.3.3.2 Ensuring coaches meet the “SSBC standard” ................................................... 90 4.3.3.2.1 Extra support for the first coach at each site ............................................... 90 4.3.3.2.2 Setting coaches up for mock session success ............................................. 90 4.3.3.2.2.1 More realistic mock sessions ............................................................... 90 4.3.3.2.2.2 Resource modification ......................................................................... 91 4.3.3.2.2.3 Encouraging practice............................................................................ 91 4.3.3.2.3 Feedback is a necessary training component .............................................. 92 4.3.3.2.4 Importance of testing coaches ..................................................................... 92 4.3.3.2.5 Can’t stop training after certification .......................................................... 92 4.4 Discussion ..................................................................................................................... 93 xxi 4.4.1 Limitations .............................................................................................................. 95 4.4.2 Future directions ..................................................................................................... 96 4.5 Conclusion .................................................................................................................... 96 Chapter 5: Effectiveness of brief e-learning training for diabetes prevention program coaches: Outcome evaluation ....................................................................................................101 5.1 Introduction ................................................................................................................. 101 5.2 Methods....................................................................................................................... 103 5.2.1 Study design .......................................................................................................... 103 5.2.2 Participants (coaches and clients) ......................................................................... 104 5.2.3 Kirkpatrick level 1: reaction ................................................................................. 104 5.2.3.1 Procedures ....................................................................................................... 104 5.2.3.2 Measure ........................................................................................................... 104 5.2.3.3 Data analysis ................................................................................................... 104 5.2.4 Kirkpatrick level 2: learning ................................................................................. 104 5.2.4.1 Procedures ....................................................................................................... 105 5.2.4.2 Measures ......................................................................................................... 105 5.2.4.2.1 T2D prevention knowledge....................................................................... 105 5.2.4.2.2 MI knowledge ........................................................................................... 105 5.2.4.2.3 SSBC program knowledge ........................................................................ 105 5.2.4.3 Data analysis ................................................................................................... 106 5.2.5 Kirkpatrick level 3: behaviour .............................................................................. 106 5.2.5.1 Procedures ....................................................................................................... 106 5.2.5.2 Measures ......................................................................................................... 106 xxii 5.2.5.2.1 MI delivery................................................................................................ 106 5.2.5.2.2 SSBC session content delivery ................................................................. 107 5.2.5.3 Data analysis ................................................................................................... 107 5.2.6 Kirkpatrick level 4: results .................................................................................... 108 5.2.6.1 Procedures ....................................................................................................... 108 5.2.6.2 Measures ......................................................................................................... 109 5.2.6.2.1 Learning climate questionnaire ................................................................. 109 5.2.6.2.2 Weight ....................................................................................................... 109 5.2.6.2.3 Waist circumference ................................................................................. 109 5.2.6.3 Data analysis ................................................................................................... 109 5.3 Results ......................................................................................................................... 110 5.3.1 Kirkpatrick level 1: reaction ................................................................................. 110 5.3.2 Kirkpatrick level 2: learning ................................................................................. 110 5.3.3 Kirkpatrick level 3: behaviour .............................................................................. 110 5.3.4 Kirkpatrick level 4: results .................................................................................... 111 5.4 Discussion ................................................................................................................... 112 5.4.1 Limitations ............................................................................................................ 114 5.4.2 Future directions ................................................................................................... 115 5.4.3 Conclusion ............................................................................................................ 115 Chapter 6: Small steps to an inclusive diabetes prevention program: How Small Steps for Big Changes is improving program equity and inclusion ......................................................119 6.1 Introduction ................................................................................................................. 119 6.2 Changes to SSBC ........................................................................................................ 122 xxiii 6.2.1 Stakeholder engagement ....................................................................................... 122 6.2.2 SSBC content ........................................................................................................ 122 6.2.3 SSBC program delivery ........................................................................................ 123 6.2.4 SSBC promotional material .................................................................................. 124 6.2.5 Train-the-trainer .................................................................................................... 124 6.2.6 Program clients ..................................................................................................... 125 6.2.7 Measurements ....................................................................................................... 125 6.2.7.1 Sociodemographics ......................................................................................... 126 6.2.7.2 Waist circumference ....................................................................................... 127 6.2.7.3 Measurement tools .......................................................................................... 127 6.3 Discussion ................................................................................................................... 128 6.4 Conclusion .................................................................................................................. 129 Chapter 7: General discussion ..................................................................................................132 7.1 Summary of findings................................................................................................... 132 7.2 Estimate of the cost, reusability, and sustainability .................................................... 136 7.3 Theoretical contributions ............................................................................................ 137 7.3.1 Incorporating user feedback with the TEL evaluation framework and KTA framework throughout the SSBC e-learning training evaluation process .......................... 137 7.3.2 Use of the complete TEL evaluation framework and KTA framework action cycle 138 7.3.2.1 Using the TEL evaluation framework............................................................. 138 7.3.2.2 Using the KTA framework action cycle ......................................................... 139 7.3.2.3 Using the TEL evaluation framework and the KTA framework together ...... 140 xxiv 7.4 Methodological contributions ..................................................................................... 141 7.4.1 Rigorous design and development of the SSBC e-learning training .................... 141 7.4.2 Engaging multiple user groups in process evaluation ........................................... 142 7.4.3 Using an SDT measure to assess client receipt of MI........................................... 142 7.5 Practical implications .................................................................................................. 144 7.5.1 SSBC implications ................................................................................................ 144 7.5.1.1 SSBC coach e-learning training modifications ............................................... 144 7.5.1.2 Importance of dissertation results for SSBC scale-up .................................... 144 7.5.1.3 SSBC is more inclusive .................................................................................. 145 7.5.2 Equity, diversity, and inclusion considerations .................................................... 146 7.5.2.1 Module 1 study leading to more generalized training for health and fitness staff in Canada ........................................................................................................................ 146 7.5.2.2 Other health programs can work to improve inclusion and equity based on Chapter 6 commentary .................................................................................................... 147 7.6 Strengths ..................................................................................................................... 148 7.7 Limitations .................................................................................................................. 149 7.8 Future directions ......................................................................................................... 150 7.9 Conclusion .................................................................................................................. 152 References ...................................................................................................................................154 Appendices ..................................................................................................................................183 Appendix A. Supplementary material for Chapter 2 ........................................................ 183 A.1. Screenshots from the SSBC coach e-learning platform ........................................ 183 Appendix B. Supplementary material for Chapter 3 ........................................................ 185 xxv B.1 Empathic awareness questions ..................................................................................... 185 B.2 Perceptions of client vignettes...................................................................................... 186 B.3 Beliefs about relevance of EDI training to education or job disaggregated results ..... 187 Appendix C. Supplementary material for Chapter 4 ........................................................ 189 C.1 Version 1 of the coach interview coding template ....................................................... 189 Appendix D. Supplementary material for Chapter 5 ........................................................ 190 D.1 Individual coach Kirkpatrick level 3 results ................................................................ 190 Appendix E. Supplementary material for Chapter 6 ........................................................ 192 E.1 Use of inclusive language ............................................................................................. 192 E.2 Sociodemographic questions – how should they be asked? ......................................... 193 Appendix F. Ethical Certificates of Approval ..................................................................... 196 F.1 Certificate of approval for Chapters 2, 4, 5 .................................................................. 196 F.2 Certificate of approval for Chapter 3 ............................................................................ 197 xxvi List of Tables Table 2.1 Focus group participants’ demographics and experience (N=9) .................................. 30 Table 2.2 Overview of SSBC e-learning platform........................................................................ 32 Table 3.1 Demographics of participants ....................................................................................... 56 Table 3.2 Means (M) and standard deviations (SD) for empathic awareness, explicit bias, and perceptions of client ...................................................................................................................... 57 Table 3.3 Conventional content analysis results for perspectives on the CS&I module .............. 58 ....................................................................................................................................................... 62 Table 4.1 Participant demographics .............................................................................................. 98 Table 5.1 Coach demographics ................................................................................................... 116 Table 5.2 Kirkpatrick level 3 MICA strategies and intentions scores ........................................ 117 Table 5.3 Client demographics ................................................................................................... 118 Table 6.1 Recommendations to developing an inclusive behaviour change intervention .......... 130 Table 6.2 Guiding questions to develop or critically appraise existing behaviour change programs ..................................................................................................................................... 131 xxvii List of Figures Figure 2.1 E-learning platform design and development process with each group’s contributions....................................................................................................................................................... 34 Figure 3.1 CONSORT flowchart of participants .......................................................................... 62 Figure 4.1 Final template for coach interview analysis ................................................................ 99 Figure 4.2 Final template for staff interview analysis ................................................................ 100 Figure 7.1 Combined TEL evaluation framework and KTA framework ................................... 153 xxviii List of Abbreviations ANOVA: analysis of variance BMI: body mass index CAD: Canadian dollars CEGEP: Collège d'enseignement general et professionnel cm: centimeter CS&I: cultural safety and inclusivity CSEP: Canadian Society for Exercise Physiology DPP: diabetes prevention program EDI: equity, diversity, and inclusion IAT: implicit association test IKT: integrated knowledge translation KC: Kaela Cranston kg: kilogram KTA: knowledge-to-action LCQ: learning climate questionnaire M: mean MI: motivational interviewing MICA: Motivational Interviewing Competency Assessment MJ: Mary Jung n/a: not applicable NDA: non-disclosure agreement NG: Natalie Grieve xxix PABAK: prevalence- and bias-adjusted kappa PAC: patient advisory committee RR: Rebecca Reitsma SAC: stakeholder advisory committee SD: standard deviation SDT: self-determination theory SSBC: Small Steps for Big Changes T2D: type 2 diabetes TEL: technology-enhanced learning UBC: University of British Columbia USD: United States dollars xxx Acknowledgements I would like to acknowledge that I completed all of the work included in this dissertation on the ancestral, traditional unceded territory of the syilx Nation. As an uninvited visitor, I have benefitted from the colonial system which has and continues to disadvantage the sʔuknaʔqín̓ peoples, the traditional and current caretakers of these lands. I am committed to reconciliation and justice through learning, unlearning, teaching, and advocating in every aspect of my life. To my supervisor, Dr. Mary Jung, thank you for your mentorship, encouragement, trust, and commitment over the past seven years. This dissertation was only possible because of the hard work and dedication you have given to SSBC and DPRG. I’m grateful for all the work that you do to support me, DPRG, and SSBC. Thank you for supporting me and pushing me to grow as a researcher, writer, mentor, and human. I have loved my time as a student in DPRG. A big thank you to my committee members, Dr. Kathleen Martin Ginis and Dr. Tanya Forneris for your guidance and support throughout my PhD. Kathleen and Tanya, I am grateful to have learned from both of you; thank you for your time. Additionally, thank you to Dr. Erica Bennett for being on my comprehensive examination committee. Erica, this dissertation is better because of the readings you provided me, which allowed me to think about my work in new and different ways. Thanks to my co-authors, collaborators, partners and participants for your time and efforts while conducting my studies. Thank you to all the SSBC coaches that made this work possible. Thank you to WorkSafe BC and the Social Sciences and Humanities Research Council (SSHRC) for the training awards and financial support. xxxi To all my DPRG lab mates and the members of the Centre for Health Behaviour Change over the course of my PhD for your support and assistance. To the DPRG postdocs (past and present): Sean, Corliss, Matt, and Jess. Thanks to all of you for leading by example, for your mentorship, and for your friendship. Thanks to the DPRG research coordinators (past and present): Amanda, Steph, Christine and Joe, thanks for keeping DPRG running smoothly, for the many conversations at your office door, and for the coordinating and behind-the-scenes work that you do to keep the lab running smoothly. A special thank you to my three original PhD friends, Tineke, Meghan, and Alex. I couldn’t have asked for a better group of peers to work with as I started my PhD. Megan, thank you for the many walks, and for letting me “bubble” with you and Kohle at the beginning of the pandemic. Tineke, my PhD experience and the last seven years are better because you were in them. Thanks for the bike rides, the mentorship, and your friendship. To my friends that joined DPRG in the second half of my PhD: Natalie, Kyra, and Jenna. Jenna, thank you for your help on my projects, for teaching me, and for your enthusiasm. Kyra, your infectious personality, upbeat energy, laidback attitude, humour and work ethic always made coming into the lab more exciting. Nat, this dissertation and my life would not be the same without you. Thank you for being an amazing friend, for your tireless assistance and guidance with my PhD, and for laughing with me through everything. I loved working on these studies with you. Finally, thank you to my family for your love and encouragement throughout this degree. Mom and Dad, I am eternally grateful for your support, for providing me with the skills and confidence needed to complete this degree, and for all the visits and phone calls. You are my biggest role models. Thanks to Ty and Cody for your love and friendship. I have and will always look up to both of you for your work ethic, humour, and chill attitudes. To Ed, I am so happy I xxxii met you. Thanks for being a constant source of support, comfort, and fun. I am incredibly appreciative to you for listening to my stories, for the Excel help, for the laughter and joy you bring to my life, and for all our outdoor adventures. This PhD was possible thanks to all of you. xxxiii Dedication To my five best friends – Mom, Dad, Ty, Cody, and Ed. I love you all. 1 Chapter 1: Introduction 1.1 Type 2 diabetes prevention Approximately 6.1% of Canadian adults have prediabetes (Public Health Agency of Canada, 2022). Prediabetes is characterized by elevated blood glucose levels that are below the diagnostic threshold for type 2 diabetes (T2D) but are associated with an increased risk of developing T2D. Up to 50% of individuals with prediabetes progress to T2D within five years (Richter et al., 2018). Preventing T2D is critical as a T2D diagnosis can be associated with many health risks including stroke, heart disease, kidney disease, lower limb amputation and retinopathy, and can reduce an individual’s lifespan by five to fifteen years (Banasiak, 2020; Diabetes Canada, 2023; Public Health Agency of Canada, 2022). Reducing one’s risk of T2D can be achieved through pharmacological methods, however medication and devices can cost those living with T2D up to 16% of their gross annual income (Diabetes Canada, 2023). Landmark diabetes prevention programs have demonstrated efficacy at reducing risk of T2D in individuals living with prediabetes through physical activity and dietary modifications (Knowler et al., 2002; Lindström et al., 2003; Pan et al., 1997). Results from the United States Diabetes Prevention Program revealed that dietary and physical activity modifications were more efficacious than the leading pharmacological intervention (Knowler et al., 2002). While effective at reducing the risk of T2D, these landmark diabetes prevention programs were time-consuming and costly (Hernan et al., 2003), leaving room for more sustainable diabetes prevention program models. To improve sustainability, translational diabetes prevention programs (i.e., efficacious interventions that have been adapted to be implemented in a variety of settings and to more diverse populations) have demonstrated effectiveness when implemented in real-world settings 2 (Galaviz et al., 2018). A systematic review revealed that most translational studies were 1) conducted in North America, 2) implemented in community-based settings, and 3) delivered by healthcare professionals (Galaviz et al., 2018). Another systematic review and meta-analysis examining translational diabetes prevention programs highlighted that client outcomes appeared to be similar regardless of whether programs were delivered by lay educators or medical and allied health professionals (Ali et al., 2012). Diabetes prevention programs delivered by lay educators have the potential to reduce costs and resources associated with programs because training costs and salaries are lower than those required for health professionals. Reducing the costs and resources required to deliver diabetes prevention programs can make them more accessible to a greater number of individuals. T2D prevalence and incidence levels are disproportionately higher for individuals with lower socioeconomic status, and those of African, South Asian, and Indigenous ethnic origins (Booth et al., 2012; Branfield Day et al., 2020; Hill-Briggs & Fitzpatrick, 2023; Lipscombe et al., 2010; Public Health Agency of Canada, 2018). The patterns of disproportionate T2D prevalence and incidence associated with race, ethnicity, and socioeconomic status demonstrate that T2D is highly influenced by social determinants of health (Hill-Briggs & Fitzpatrick, 2023; World Health Organization, n.d.). Social determinants of health, the non-medical factors that influence a person’s health (e.g., income, education) play a significant role in shaping health outcomes and contribute to the health inequities that exist worldwide (World Health Organization, n.d.). Despite the pressing need for diabetes prevention for individuals belonging to equity-owed groups, diabetes prevention programs have often fallen short in reaching and addressing these groups. Galaviz and colleagues (2018) found that the majority (60.8%) of participants in translational diabetes prevention programs were White or European. Diabetes prevention 3 programs should consider those who are both at greatest risk and who are not proportionately represented in program reach. Taking a broad view, health behaviour research and programs should take action to address health inequities. Some emergent approaches to address health inequities include targeted recruitment (Alcaraz et al., 2011; Yancey et al., 2006), culturally-competent communication (Teal & Street, 2009), community-based participatory research (Israel et al., 2001), and utilizing appropriate technology (Alcaraz et al., 2017). This dissertation addresses some approaches to improve equitable and inclusive care within the Small Steps for Big Changes (SSBC) diabetes prevention program. 1.1.1 Small Steps for Big Changes SSBC is an evidence-based T2D prevention program that aims to empower individuals with prediabetes to make long-lasting diet and physical activity changes. The program is delivered free-of-charge to individuals with prediabetes or at increased risk of T2D. Efficacy (Jung et al., 2020; Locke et al., 2018) and preliminary effectiveness (Bean et al., 2021) have been demonstrated as SSBC transitioned from a tightly controlled laboratory to community setting. When SSBC transitioned to the community-based effectiveness program, it was initially delivered in one YMCA site within Kelowna, British Columbia, and was delivered by research staff and graduate students. To improve sustainability and reach, SSBC then expanded to a second YMCA site within Kelowna and both sites transitioned to YMCA staff delivering the program. Dineen and colleagues (Dineen, Cranston, et al., 2021) demonstrated that YMCA staff delivered the SSBC program at a similar level of fidelity to research staff and graduate students (Cranston et al., 2022) and that SSBC clients felt supported and were satisfied with their YMCA 4 coach. SSBC has since expanded to a third YMCA in Kelowna, five rural and remote fitness facilities in British Columbia, and one site in Portugal. In the community-based SSBC, 87% of SSBC participants were White (Bean et al., 2021). While SSBC participant race data is representative of Kelowna demographics, this may not be reflective of the demographics of individuals with prediabetes within Kelowna. As SSBC continues to expand to additional sites provincially, nationally, and globally, it is critical to ensure that the program is both inclusive and effective for more diverse populations, especially those at disproportionately higher risk of developing T2D. SSBC consists of six one-on-one counselling and supervised exercise sessions over four- to six-weeks followed by a one-year follow-up maintenance phase. The six counselling and supervised exercise sessions include 40 minutes of counselling on diet and exercise behaviour followed by 10 to 30 minutes of either high-intensity interval training or moderate-intensity continuous training. The one-year follow-up phase consists of a check-in session at 1-month post-program, and measurement timepoints at 6- and 12-months post-program. Measurements at the 6- and 12-month follow-up time points are also taken at sessions one and six, and include anthropometric data, psychosocial measurements, behavioural outcomes, and satisfaction data. SSBC coaches deliver sessions using a motivational interviewing (MI)-informed approach. MI is a person-centred conversation style that aims to strengthen clients’ own motivation and commitment to change (W. R. Miller & Rollnick, 2023). Each SSBC counselling session focusses on checking in on clients’ previous goals, information exchange related to physical activity (e.g., exercising throughout the seasons) or nutrition (e.g., reducing consumption of added sugar), and then setting new goals. MI-informed delivery can increase 5 clients’ autonomy and self-efficacy to adhere to their own self-set health behaviour goals established during the program. 1.2 Motivational interviewing MI originated as a communication style to treat substance use disorder and has since expanded to be used within many other health behaviours by a variety of health professionals and lay people. MI is effective in helping individuals manage and prevent T2D (S. M. Chen et al., 2012; Chlebowy et al., 2015; Christie & Channon, 2013; M. Clark et al., 2004; Martins & McNeil, 2009; Thepwongsa et al., 2017; West et al., 2007). Specifically, MI has had positive effects on glucose control (S. M. Chen et al., 2012; Thepwongsa et al., 2017; West et al., 2007), physical activity (Soderlund, 2018; Thepwongsa et al., 2017), weight loss (Phillips & Guarnaccia, 2017; Thepwongsa et al., 2017; West et al., 2007), dietary changes (Phillips & Guarnaccia, 2017), and self-efficacy to engage in dietary and exercise changes (S. M. Chen et al., 2012; Phillips & Guarnaccia, 2017). MI is effective at helping people make behaviour changes because it helps people focus on their reasons for making changes and builds their commitment to those changes (W. R. Miller & Rollnick, 2023). MI consists of both a specific skill set as well as an underlying attitude towards helping people, which is known as the spirit of MI. The spirit of MI is made up of four elements: partnership, acceptance, compassion, and empowerment (previously called evocation in Miller and Rollnick’s (2013) 3rd edition of their MI book) (W. R. Miller & Rollnick, 2023). The spirit of MI is what makes MI a person-centred approach; practitioners come from a place of wanting to help someone make changes without directing or forcing them. Additionally, four tasks embody MI: engaging, focussing, evoking, and planning. These tasks build upon one another but are not always linear. The MI tasks help guide a conversation from rapport-building 6 to drawing out a client’s ideas or strengths, and then work towards developing an action plan. Ultimately, the goal of MI is to focus on what the client wants, and to guide them towards making those changes. Due to the client-centred focus of MI, it has the potential to be a communication style that promotes an inclusive environment for clients belonging to equity-owed groups, including non-White individuals and those of lower socioeconomic status. MI is currently delivered in many countries and languages across Africa, Asia, Europe, North America, and South America (W. R. Miller & Rollnick, 2023). Furthermore, there is some evidence to suggest that the effects of MI are greater in non-White than White populations (Hettema et al., 2005; Lundahl et al., 2010). Therefore, MI could be an effective communication style used within health programs that aim to reach all individuals, especially those belonging to equity-owed groups. 1.2.1 MI training Healthcare professionals and lay educators can be effectively trained to deliver MI (Baer et al., 2004; Cranston et al., 2022; Dineen, Cranston, et al., 2021; W. R. Miller & Mount, 2001). MI training varies in length and training modalities, but workshops combining didactic and interactive components are commonly used (Britt & Blampied, 2010; Madson et al., 2009; W. R. Miller et al., 2004). Brief workshops lasting two- to three-days are regularly and effectively used to train individuals naïve to MI (Baer et al., 2004; Cranston et al., 2022; W. R. Miller & Mount, 2001). MI training enhancements (i.e., additional training following a workshop) can further improve practitioners’ MI skills. Specifically, supervision and feedback are effective training enhancements to progress MI skills (Britt & Blampied, 2010). 7 1.2.2 SSBC coach training The SSBC program is delivered by site (i.e., fitness facility) staff and volunteers. To deliver SSBC, staff and volunteers are trained to become SSBC coaches. Prior to this dissertation, all coaches were certified by attending a three-day (17-hour) in-person training workshop covering MI, SSBC program content, and standard operating procedures. The workshop consisted of didactic and interactive teaching, role-play exercises with partners, and reviewing videos of SSBC session delivery using MI. Following the workshop, all coaches were shadowed by a research team member for their first six sessions with a client and were given feedback immediately after each session. Staff reported high levels of satisfaction with the training, showed high levels of MI and SSBC program content knowledge after the training, and delivered SSBC sessions at a client-centred level of MI (Dineen, Cranston, et al., 2021) and with high program delivery fidelity (Dineen, Banser, et al., 2021). While the in-person SSBC coach training was effective and acceptable, it is not a sustainable training format for SSBC provincial, national, and global expansion. E-learning serves as a viable option to replace in-person training as it is not limited by coaches’ location and schedule, has the potential for coaches to be able to revisit training components, and could be less resource-intensive over time. 1.3 E-learning E-learning is a broad term that refers to training or educational content delivered using electronic devices or technologies (R. C. Clark & Mayer, 2011). E-learning is often used synonymously with other terms including technology-enhanced learning, computer-based learning, online learning, virtual learning, digital learning, and web-based learning. E-learning can vary in synchronicity (asynchronous, synchronous), location (referring to learners and 8 students being in the same or different locations), independence (individual learning, collaborative learning), and mode (electronic only, combination of electronic and face-to-face) (Cook, 2007; Cook & McDonald, 2008; Ruggeri et al., 2013). E-learning offers numerous advantages over in-person training for learners, including flexibility to access training from a wide range of geographical locations and at a time that works for them, the capability to revisit training components, and self-paced learning (Cook, 2007; Kimura et al., 2023). Additionally, e-learning provides advantages for training deliverers, such as ease of updating online materials or resources, automated record-keeping and progress tracking, and time efficiency (Cook, 2007; Kimura et al., 2023). The adoption of e-learning, as opposed to in-person learning, can effectively address issues related to equity and inclusiveness. E-learning offers greater accessibility for individuals belonging to equity-owed groups who may have competing life demands. While e-learning has many advantages, there are also challenges, including a lack of communication between learners and training deliverers, technology issues, lack of real-time feedback, large up-front costs, and social isolation (Cook, 2007; Kimura et al., 2023). Training deliverers must examine their specific needs for training to determine which mode of delivery - in-person or e-learning – is best for their specific context. With increased access to the internet, the COVID-19 pandemic, and technological advancements, e-learning has become a popular training method for healthcare professionals (Roskvist et al., 2020; Seymour-Walsh et al., 2020). E-learning for healthcare professionals produces similar (Cook et al., 2008; Rohwer et al., 2017; Vaona et al., 2018) or better (Reeves et al., 2017) outcomes compared to traditional in-person training. Learners are satisfied with e-learning and experience increased knowledge, skills, self-efficacy, and confidence (Kulaksız et al., 2023; Rouleau et al., 2019). Within the field of T2D, e-learning has shown some success at 9 improving healthcare professionals’ knowledge (Moattari et al., 2014). Similarly, pilot studies have demonstrated that e-learning is a feasible and acceptable mode of training (G. Fontaine et al., 2016; Schechter et al., 2021). E-learning for MI has also improved learners’ MI knowledge (Schechter et al., 2021) and skills with high levels of satisfaction with e-learning courses (Oster et al., 2022). E-learning implementation success can be affected by key elements and characteristics, known as critical success factors (Alqahtani & Rajkhan, 2020; Naveed et al., 2020). Critical success factors can vary based on the learners’ demographics (e.g., age, region, social culture) (Naveed et al., 2020), however research suggests that learner support, clear instructions to learners, training delivers’ management of the e-learning platform, flexibility, and technology usability can be key to successful e-learning implementation (Alqahtani & Rajkhan, 2020; Naveed et al., 2020; Sun et al., 2008). 1.3.1 Development of e-learning platforms Published e-learning research has primarily focussed on effectiveness and acceptability data, with less of a focus on the design, development, and implementation of e-learning (Donkers et al., 2018; Lewis et al., 2014; Richmond et al., 2017). Reporting on the processes involved in developing and implementing e-learning trainings could lead to further advancement in e-learning research. Furthermore, documenting development and implementation enables the optimization of resources for enhancing e-learning trainings, presenting the opportunity to expand upon existing knowledge. In instances when the design and development of e-learning trainings is reported, the process often involves end-user feedback (Richmond et al., 2017). Effectively incorporating end-user feedback enhances the likelihood that users will rate the e- 10 learning trainings as engaging, usable, and acceptable (Gainforth et al., 2021; Jull et al., 2017; Yardley, Ainsworth, et al., 2015; Yardley, Morrison, et al., 2015). 1.4 Evaluation Program evaluation systematically examines the effectiveness of a project (M. J. Harris, 2017), and is inherently focussed on rendering judgments of a program’s merit, worth, and significance (Patton, 2018). Two common types of program evaluation are process evaluation and outcome evaluation. Outcome evaluations are most common and assess a program’s effects on those who were exposed to a program (i.e., did the program meet the intended goals?) (M. J. Harris, 2017). Process evaluations focus on whether a program was implemented appropriately, or the extent to which the program was implemented, as well as adaptations during implementation (M. J. Harris, 2017). Both types of evaluations are important and fulfill distinct purposes, however neither in isolation can comprehensively explain the success of a program. Within the context of e-learning, a process evaluation would describe the resources and activities involved in development and implementation of an e-learning training, the degree to which the e-learning training was implemented as planned, and the intensity, dose, and reach of the e-learning training. An outcome evaluation for e-learning training could include assessing learners’ satisfaction with the training and changes in knowledge, behaviours, and self-efficacy due to the training. Ultimately, the type of evaluation and methods chosen should address the primary intended users’ (e.g., program developers, program deliverers, end-users) needs (Patton, 2008). 11 1.5 Theoretical approaches 1.5.1 Technology-enhanced learning evaluation framework The technology-enhanced learning (TEL) evaluation framework (Cook & Ellaway, 2015) is a comprehensive process-oriented evaluation framework, meaning it considers the entire lifecycle of an online training program from the inception of the idea through implementation and delivery, to making summative judgments about the program. Developed specifically to evaluate online trainings, the TEL framework was based on existing training evaluation models including the Kirkpatrick model of learning (Kirkpatrick, 1998) and the Context, Input, Process, and Product evaluation model (Stufflebeam, 2003). The TEL framework emphasizes seven activities that should be considered when evaluating e-learning training: 1) conduct a needs analysis and environmental scan to determine the need for change to e-learning training; 2) document processes, decisions, and final product including specific processes or milestones associated with the e-learning training; 3) test usability of the e-learning training to determine the ease with which users can perform tasks and to identify any errors; 4) document key events during implementation and final product to report on the final e-learning training product and the associated process, as well as gather feedback on implementation; 5) assess participant experience and satisfaction to explore the subjective opinions of those involved in the e-learning training (e.g., learners, training deliverers, support staff); 6) assess learning outcomes to understand the extent to which the e-learning training changes learners’ knowledge, behaviours, and the associated outcomes; and 7) estimate cost, reusability, and sustainability to assess the resources required to develop, implement, and maintain the e-learning training. Using an e-learning-specific framework to evaluate e-learning training is critical to gain a full understanding of the processes and outcomes associated with e-learning. In this dissertation, the TEL 12 framework was used to guide the evaluation of the SSBC coach e-learning training from inception through to sustainability. 1.5.2 Knowledge-to-action framework Knowledge to action (i.e., the application of knowledge) gaps occur when knowledge and research findings are not implemented into real-world practice (Graham et al., 2006). The knowledge to action gap in the health context is problematic as it means that resources are not always used to create meaningful change, and out-of-date or less effective practices are still used when working with patients. Some factors that contribute to the knowledge to action gap include research being solely conducted by researchers, and when research findings are not relevant or applicable to knowledge brokers and knowledge users (Graham et al., 2006). Knowledge mobilization aims to close the gap between research knowledge and action, or the application of knowledge (Sharp et al., 2022) through a reciprocal approach between researchers, knowledge users, and knowledge brokers (Social Sciences and Humanities Research Council, 2021). Graham’s (2006) knowledge-to-action (KTA) framework offers key elements and steps to help close the knowledge to action gap. The KTA framework is comprised of two concepts: the knowledge creation funnel and the action cycle. The knowledge funnel demonstrates the process of synthesizing knowledge from primary knowledge sources (e.g., individual studies, personal experience) and then aims to generate knowledge tools and products from the synthesized knowledge. The goal of the knowledge creation phase is to present knowledge that is clear and concise and can be applied by knowledge users. Within the context of this dissertation, the knowledge product was the previous in-person SSBC coach training. Previous research demonstrated the first cycle through the action process (Cranston et al., 2022; Dineen, Cranston, et al., 2021), and this dissertation serves as the second round through the action cycle. The 13 action cycle consists of seven phases that can lead to knowledge application. In the context of this dissertation, they are: 1) identifying the problem that needs to be addressed (i.e., that the SSBC coach training needs to be moved to an e-learning format); 2) adapting the knowledge to the local context to ensure the new e-learning training is relevant and valuable; 3) assessing barriers to knowledge use that could impede knowledge uptake or application of the e-learning training; 4) selecting, tailoring, and implementing the intervention (i.e., the e-learning training); 5) monitoring the knowledge use from the e-learning training; 6) evaluating the outcomes to determine the impact of the e-learning training; and 7) sustaining knowledge use from the e-learning training. The KTA framework action cycle was used in this dissertation to ensure the coach e-learning training was relevant and useful to both the SSBC research team and the SSBC coaches. 1.6 Dissertation aims There is a lack of clear and transparent reporting of the systematic process to develop, implement, and evaluate e-learning training programs. Failure to report on the development process of e-learning training programs can lead to uncertainty about what and why components are included in training. When outcomes of e-learning training and subsequent delivery of the program are not assessed and reported, no conclusions can be made about the effectiveness of training. The overall aim of this dissertation was to describe and evaluate the SSBC coach e-learning training from inception to implementation. 1.7 Overview of the dissertation structure This dissertation includes this introductory literature review chapter (Chapter 1), and five manuscripts, each making up a chapter of the dissertation (Chapters 2-6), followed by a general 14 discussion tying everything together (Chapter 7). The purpose of each manuscript and their connections to the theoretical approaches (described in Section 1.5) are outlined below. 1.7.1 Chapter 2: Designing and developing online training for diabetes prevention program coaches using an integrated knowledge translation approach: Development and usability study The purpose of Study 1 was to describe the process of determining what the SSBC coach e-learning training should consist of through a needs analysis with coaches and members of the SSBC research team, followed by the design and development process, and usability testing of the coach e-learning training. This chapter outlined the first four TEL data collection activities: needs analysis and environmental scan, document processes, decisions, and final product, test usability, and document key events during implementation and final product. It also addressed the KTA framework phases of: adapting knowledge to local context, assessing barriers to knowledge use, and selecting, tailoring, and implementing the intervention (note this chapter does not include discussion around the implementation of the e-learning training, however the e-learning training is ready for implementation at the conclusion of this chapter). Study 1 has been published in JMIR Formative Research (Cranston et al., 2024). 1.7.2 Chapter 3: Impact of a 20-minute cultural safety and inclusivity module on current and future fitness and healthcare professionals The purpose of Study 2 was to examine the effectiveness and users’ perspectives of a component of the e-learning training, the cultural safety and inclusivity module, prior to delivering the entire e-learning training to SSBC coaches. This study explored current and future fitness and health practitioners’ (a population representative of SSBC coaches) changes in biases and empathic awareness towards individuals at higher risk of developing T2D (i.e., non-White, 15 overweight), as well as quantitatively and qualitatively explored participants’ perspectives of the module. This chapter does not delve into any of the TEL activities or KTA framework phases, however, it represents an important component of the dissertation, gaining an understanding of the effectiveness of this one module from the training. Study 2 has been submitted to International Journal of Medical Education (Cranston, Sim, et al., Submitted). 1.7.3 Chapter 4: Exploring perspectives of type 2 diabetes prevention program coaches and training delivery staff on online coach training: A qualitative study The purpose of Study 3 was to qualitatively explore both coaches’ and training delivery staffs’ experiences with the implementation of the e-learning training to understand what worked well and what changes should be made to the training. Interviewing SSBC coaches and training delivery staff provided the opportunity to conduct TEL data collection activity 4: document key events during implementation and final product, TEL activity 5: assess participant experience and satisfaction, and collect necessary information for TEL activity 7: estimate cost, reusability, and sustainability. Additionally, this study addressed the KTA framework phase of sustain knowledge use. Study 3 has been submitted to BMC Medical Education (Cranston, Grieve, & Jung, Submitted). 1.7.4 Chapter 5: Effectiveness of brief e-learning training for diabetes prevention program coaches: Outcome evaluation Study 4 utilized a quasi-experimental design to determine SSBC coaches’ ratings of acceptability of the e-learning training, their learning (i.e., knowledge) and behaviour (i.e., delivery of SSBC to clients) from the e-learning training, and the outcomes of coaches’ behaviour on clients (i.e., clients’ ratings of perceived support of their basic psychological needs, weight, waist circumference). This study further addressed TEL data collection activity 5: 16 assess participant experience and satisfaction and TEL data collection activity 6: assess learning outcomes, as well as KTA framework phases monitor knowledge use and evaluate outcomes. Study 4 has been submitted to Journal of Medical Internet Research (Cranston, Grieve, Reitsma, et al., Submitted). 1.7.5 Chapter 6: Small steps to an inclusive diabetes prevention program: How Small Steps for Big Changes is improving program equity and inclusion The purpose of Study 5 was to provide a broader commentary of the ongoing changes that have been made to SSBC, including the addition of the e-learning coach training, to work towards improving the accessibility and inclusivity of SSBC. This paper showcases the approach to improving health equity that I took throughout my dissertation and highlights how Studies 1-4 are integral pieces to a broader puzzle of rendering SSBC more inclusive and accessible. Study 5 has been published in Community Health Equity Research and Policy (Cranston et al., 2023). 1.8 Methodology 1.8.1 Research positioning I conducted this research as a Brown multi-racial cis-gender woman. I hold unearned privilege in that I am able-bodied, exist in a thin body, was raised in an upper-middle class family by married parents who both attended and graduated from post-secondary education. I was born in what is now known as Canada and have resided in four Canadian provinces over my lifetime. I have no personal experience with prediabetes or T2D, and neither do any of my immediate family members. My father is a race-conscious scholar-educator, which among my personal experiences of belonging to equity-owed groups, likely shaped my desire to improve health equity, and inclusive and safe healthcare. 17 1.8.2 Paradigm I conducted this dissertation from a pragmatic paradigm. A pragmatic approach emphasizes solving practical real-world problems (Poucher et al., 2020) through finding shared meaning and joint actions (Morgan, 2007). The focus of pragmatic research is often on answering research questions with the most appropriate methods rather than prioritizing specific methods (Morgan, 2007). As such, pragmatism often employs a combination of qualitative and quantitative methods (Feilzer, 2010). Additionally, pragmatism is intersubjective (i.e., neither subjective nor objective) because it is possible to assert that a single ‘real world’ exists and that individuals have their own unique interpretations of said world (Morgan, 2007). 1.8.3 Methods This dissertation includes components of both process and outcome evaluations. A Utilization Focused Evaluation approach was adopted for this dissertation, meaning the evaluative components were done for and with specific intended primary users for specific intended uses (Patton, 2008). Utilization focused evaluation is methodologically coherent with the pragmatic paradigm because both prioritize methods based on use rather than a methodological hierarchy (Patton, 2008). For this dissertation, a mixed methods approach was used to address the research aims, including both quantitative and qualitative methods. The methods within each chapter were strategically chosen to answer the specific research questions. Qualitative and quantitative results were viewed as equally valuable. Across the studies, a range of methods were used. The descriptions of these methods are further offered within each of the subsequent chapters. Methods of data collection included: (a) semi-structured interviews and focus groups, (b) research team meeting notes, (c) questionnaires, (d) audio recordings, and (e) intervention 18 delivery checklists. A variety of analyses were used, including quantitative analyses: (a) descriptive statistics, (b) repeated-measures ANOVA, and (c) MI coding; and qualitative analyses: (a) conventional content analysis and (b) template analysis. 1.9 Summary Systematic and thorough evaluation of e-learning platforms is necessary to further e-learning research and implementation. This dissertation evaluates the e-learning training for SSBC coaches from the planning stage through to effectiveness and sustainability, and then provides context for how the e-learning training fits within the broader context of changes to improve inclusivity of SSBC. Chapters 2-5 encompass both process and outcome evaluation work, and all fit within the TEL evaluation framework and the KTA framework. 19 Chapter 2: Designing and developing online training for diabetes prevention program coaches using an integrated knowledge translation approach: Development and usability study 2.1 Introduction E-learning has emerged as a popular alternative to traditional in-person education in recent years, particularly with the advancement of technology and widespread availability of internet connectivity. E-learning has revolutionized the way people learn by providing flexible, wide-reaching, and convenient access to educational resources, as well as personalized learning experiences that cater to individual needs and preferences. E-learning has been adopted across various fields, including health care, and is effective in enhancing learning outcomes and improving overall learner engagement (Rouleau et al., 2019; P. M. Sinclair et al., 2016; Vaona et al., 2018). There is a paucity of research on how e-learning platforms are designed and developed. Partnering with end users can help guide e-learning platform development. An integrated knowledge translation (IKT) approach meaningfully engages the right research users at the right time throughout the research process and can increase the chances that the e-learning platform is usable, engaging, and acceptable (Gainforth et al., 2021; Jull et al., 2017; Yardley, Ainsworth, et al., 2015; Yardley, Morrison, et al., 2015). Such approaches require in-depth qualitative methods to understand the perspectives of end users throughout the entire research process. Frameworks can help guide the process of platform conception, design, development, implementation, and evaluation. This study was guided by the technology-enhanced learning (TEL) evaluation framework (Cook & Ellaway, 2015). The TEL evaluation framework was informed by commonly used learning models, including the Kirkpatrick Model (Kirkpatrick, 20 1998). The seven TEL evaluation framework stages are (1) conduct needs analysis and environmental scan; (2) document processes, decisions, and final product; (3) test usability; (4) document key events during implementation and final product; (5) assess participant experience and satisfaction; (6) assess learning outcomes; and (7) estimate cost, reusability, and sustainability. The TEL lacks specific guidelines, which can be seen as both a strength and a limitation, as it permits flexibility for different users and contexts, but it can also be used haphazardly and may result in a product that has not considered end user needs. This paper offers a guide for including an IKT approach to the needs analysis, design, development, and usability testing of an e-learning platform using the first 3 stages of the TEL evaluation framework. The proposed partnered stages of the TEL evaluation framework are described using the example of developing an e-learning platform for type 2 diabetes (T2D) prevention program coaches. 2.2 Methods 2.2.1 Context Small Steps for Big Changes (SSBC) is a community-based T2D prevention program that aims to empower individuals with prediabetes to increase physical activity and improve their diet to reduce their risk of developing T2D. SSBC is delivered in and by staff and volunteers of the YMCA of Southern Interior British Columbia. Trained SSBC coaches (YMCA staff and volunteers) deliver 6 one-on-one sessions to clients over 4 weeks using a motivational interviewing (MI)-informed approach. In-person 3-day workshops were previously used to train coaches to deliver SSBC. After completing the in-person training, coaches delivered the SSBC program with good levels of fidelity (Cranston et al., 2022; Dineen, Cranston, et al., 2021). However, in-person coach training is not a viable format for future coach training due to 21 difficulty in scheduling training time and the inability to revisit training components. Additionally, the in-person training was not developed using an IKT approach. To ensure usability and acceptability, the development of the SSBC coach e-learning platform used an IKT approach (i.e., partnering with current SSBC coaches). 2.2.2 Needs analysis 2.2.2.1 Overview The information was gathered on the program needs and capacities (e.g., the specific knowledge and skills required to become an SSBC coach) and individual needs of SSBC coaches (e.g., preference for specific content and instructional approach). The various components of the needs analysis stage were assessed through meetings with the SSBC research team, focus groups with previously trained SSBC coaches, and analysis of previous research. 2.2.2.2 Previous research Dineen et al (Dineen, Cranston, et al., 2021) evaluated the effectiveness of the SSBC in-person training. Data from this study helped determine coaches’ baseline levels of knowledge and skills prior to any training. 2.2.2.3 SSBC research team meetings The SSBC research team included the founder and director of SSBC (the last author) and the 2 in-person training facilitators (first and third author). The first meeting was held to determine whether the in-person training was a feasible and viable mode to continue to train SSBC coaches. The main reasons discussed for transitioning to e-learning were difficulties scheduling a 3-day in-person SSBC coach training for YMCA staff and volunteers, and concerns for practicality in the future expansion of SSBC to other Canadian and global facilities. Additional meetings with the research team were used to determine what knowledge and skills 22 would be required of new SSBC coaches, what content from the in-person training would be included and excluded, and what new concepts could be added. Finally, SSBC research team meetings included discussions on measures to determine the effectiveness of the e-learning platform. In-depth meeting notes and minutes were recorded during meetings for later analysis. 2.2.2.4 Focus groups with SSBC coaches Incorporating end users into the development of the e-learning platform (a main tenant of IKT) was done throughout the needs analysis, design, and development of the SSBC coach e-learning platform. Within the need analysis, focus groups with previously trained SSBC coaches were conducted. SSBC coaches who were trained through the in-person workshop were recruited via email to participate in a 2-hour focus group. Focus group questions centered on what content should or should not be included in the e-learning platform. Coaches also answered questions about motivation to learn, learning preferences (i.e., synchronicity, length of time, interactivity, and choice), and potential barriers for new coaches. Focus group data were analyzed using conventional content analysis (Hsieh & Shannon, 2005). 2.2.3 Design and development To facilitate the design and development phase of this project, the research team hired a third-party digital health solutions company (3C Institute) that specializes in developing e-learning platforms. The first and last author had meetings with 3C Institute every 2 weeks to discuss project progress and make decisions. Throughout this time, the research team created a blueprint and storyboard of the detailed topics to be taught, discussed options for teaching formats (i.e., a variety of didactic and user-engaging methods), and defined the learning objectives. The research team wrote the content for the module scripts, which were edited by 3C 23 Institute to ensure they were clear and succinct. Modules were filmed by the research team, and 3C Institute developed graphics and compiled the modules. SSBC coaches from the needs analysis phase were invited to participate in the design and development phase, specifically to review the overview of modules and methods of instruction and provide feedback. All processes and decisions were documented in detailed meeting notes (e.g., attendees, discussion points, and decisions). Calendar events and contracts captured the resources (e.g., financial and time) required to develop the e-learning platform. 2.2.4 Test usability Usability evaluation helps to ensure that a product is usable, efficient, effective, and satisfying to its end users. Nielsen (2012) identified five key components of usability (1) learnability—how easily end users can accomplish basic tasks the first time they enter the e-learning platform; (2) efficiency—how well end users can perform tasks on the e-learning platform; (3) memorability—how easily end users can reestablish proficiency when they return to the e-learning platform after a period of not using it; (4) errors—how many errors the end users make, the severity of the errors, and their ease of recovery from the errors; and (5) satisfaction—how pleasant it is to use the e-learning platform. Initial usability testing was conducted by the SSBC research team and the SSBC coaches involved in the e-learning platform design and development. Users were asked to navigate through the modules and learning activities and complete various tasks (e.g., log in to the training platform, move through modules, and access the resource center). Written and verbal feedback on issues and errors were collected. A summary of concerns and usability issues was documented and sent to 3C Institute to be addressed. The level of usability was deemed 24 acceptable by the first and last authors once all errors were resolved. In the true spirit of IKT, further usability testing will be examined through qualitative and quantitative methods upon release and implementation of the e-learning platform to ensure that the platform is usable by the end users. 2.2.5 Ethical considerations This study was approved by the university’s behavioural research ethics board. The participants provided informed consent for the focus groups and were involved in the further design and development of the e-learning platform. All data were deidentified upon data collection. Individuals were renumerated for their participation via e-transfer. Participants each received $50 CAD ($36.83 USD) for their participation in a focus group, and participants were given $25 CAD ($18.42 USD) for each module storyboard that they reviewed. 2.3 Results 2.3.1 Needs analysis 2.3.1.1 Previous research Dineen et al (Dineen, Cranston, et al., 2021) demonstrated that coaches had little knowledge about MI and SSBC program content prior to taking the in-person training. Coaches also reported high levels of satisfaction with the in-person training topics. 2.3.1.2 SSBC research team meetings The SSBC research team made the following decisions based on 3 meetings. SSBC coaches needed to have basic knowledge about T2D prevention, specific SSBC session content (i.e., Canada’s physical activity guidelines, daily added sugar limits, carbohydrates, and the talk test), what MI is, the spirit of MI, MI skills (i.e., open-ended questions, affirmations, reflections, summaries, and ask-tell-ask), the 4 processes of MI, how to deliver SSBC content using MI, and 25 how to deliver culturally safe and inclusive care. Coaches would need to demonstrate skills associated with delivering the SSBC program to clients, which includes appropriately delivering the correct information using an MI-informed approach. Once a coach completed the e-learning modules, the coach would demonstrate their skills through a mock session, providing an opportunity for assessment and provision of feedback. Sufficient knowledge would be determined by scoring a minimum of 70% on a knowledge test on T2D prevention, SSBC-specific content, and MI at the end of the training. The research team would develop the knowledge tests, drawing from content directly covered in the SSBC coach e-learning training. Finally, the coaches’ skills would be monitored and assessed by coding a random selection of audio recordings from sessions with clients using session-content checklists and the Motivational Interviewing Competency Assessment tool (Jackson et al., 2015). 2.3.1.3 Focus groups with SSBC coaches Invitation emails were sent to 15 SSBC coaches to participate in a focus group, including information about the purpose of the focus group and remuneration of time. A total of 9 SSBC coaches volunteered to take part in a focus group, and they were split into 3 equal-numbered focus groups based on their availability. See Table 2.1 for focus group participants’ demographics and experience as a coach. On average, each focus group was 62 minutes. The results from the conventional content analysis showed that coaches wanted more information on the evoking process of MI, on transitioning from sustain talk to change talk, and an understanding of the effectiveness of MI. The coaches spoke about the importance of knowledge checks throughout the e-learning training, a collection of resources and commonly used documents (i.e., a resource center), role-play videos demonstrating the skills being taught, and live sessions with a workshop facilitator to practice skills and receive feedback. The coaches 26 suggested that modules be short in duration and for training to span over 2 weeks. The coaches’ recommendations also included the integration of a variety of learning methods through the use of didactic and user-engaging components. Additional resources suggested by coaches included video examples of delivering SSBC content using MI and various SSBC program delivery styles and scenarios. The participants desired a blended approach of asynchronous and synchronous learning, with an opportunity for practice and feedback. 2.3.2 Design and development The research team worked with 3C Institute and SSBC coaches over a series of 13 months (21 meetings) to design and develop the e-learning platform. Correspondence with the involved SSBC coaches to collect feedback was done over email. The flow of the entire design and development phases can be seen in Figure 2.1, showing each group’s contributions to development. Information collected in the needs analysis stage was used to develop a blueprint for the e-learning platform, which was then reviewed by the 3C Institute. After consultations with 3C Institute and SSBC coaches, it was determined that the e-learning training would include seven modules—1 introducing SSBC and inclusivity, 1 covering SSBC-specific content, 4 covering MI, and 1 putting everything together. Additionally, 3C Institute provided suggestions for learning activities (e.g., narrated videos, demonstration videos, and user-engaging activities) based on their expertise in developing e-learning platforms. All modules were designed to be asynchronous so coaches could move through them at their own pace, with user-engaging components and knowledge checks throughout the modules, and at the end of each module. The e-learning platform includes a resource center for coaches to access resources (e.g., PDFs, video examples, and SSBC session paperwork). 27 The research team drafted 1 module script at a time. Scripts included what the narrator would say, and the content for the user-engaging activities and knowledge. The script for each module underwent numerous editing cycles between the 3C Institute and the research team before being sent to the 3C Institute multimedia artist. The multimedia artist developed storyboard proofs for each module. Storyboard proofs included still images representing what would be on the screen with the associated script. Feedback was collected from both the research team and SSBC coaches from the focus groups. For each module storyboard proof, 2 to 4 coaches provided feedback (dependent on their schedules and availability) and were remunerated for their time. After the storyboard proofs were approved by the SSBC research team and coaches, the narrators for the videos (first and last author) worked with a University of British Columbia Studios Okanagan producer and the 3C Institute editor to film the 7 modules. Talent was hired to act as coaches and clients in the role-play videos for the modules and the resource center. After each module was filmed, the 3C Institute multimedia artist and video director worked to edit and finalize the modules. An overview of the SSBC e-learning training platform is provided in Table 2.2 and a selection of screenshots from the online training platform are provided in Appendix A.1. Based on decisions made following the needs analysis, the entire training process for new SSBC coaches includes 3 stages. First, the coaches must complete the 7 modules. Next, the coaches are required to schedule a 1-hour mock session with an SSBC research team member and are then provided with written feedback within 2 weeks of completing the mock session. Following the mock session, coaches would be given access to the final knowledge test. After passing the final knowledge check, coaches would be certified to take on SSBC clients independently. 28 Overall, the authors spent a total of 192 hours on this project (e.g., preparing for and leading SSBC research team meetings and focus groups, analyzing data from needs analysis, designing blueprints, writing and editing scripts, developing knowledge check questions, emails, correspondence with SSBC coaches and talent, meetings with 3C Institute, filming, and usability testing). The final cost of developing the SSBC coach e-learning platform was ~$80,000 USD (cost to hire 3C Institute and professional talent for filming). 2.3.3 Test usability Results from the initial usability tests conducted by the research team and the SSBC coach partners showed high levels of learnability, efficiency, memorability, and satisfaction within the provided feedback. Some errors were recorded including technical bugs, which were corrected by 3C Institute. 2.4 Discussion 2.4.1 Principle results This paper provides a clear and transparent outline for the needs analysis, design, development, and initial usability testing of the SSBC coach training e-learning platform. Importantly, this process demonstrates how an IKT approach can be used with the TEL evaluation framework. To our knowledge, this is one of the first e-learning platforms that has been developed using an IKT approach. Engaging end users through this process increases the chances that they will find the e-learning platform useful, acceptable, and appropriate (Graham et al., 2014; Kothari et al., 2017). The development and use of e-learning platforms for SSBC coaches will improve the viability of the program as new coaches will be able to take the training from any location and at a time that is convenient for them. This process can be used to inform other T2D prevention and 29 health programs currently training coaches in person. E-learning has become a popular education tool; however, there is still a lack of meaningful engagement with end users and research outlining the development process. A preliminary study demonstrated high levels of satisfaction and gain in coach knowledge after completing this SSBC e-learning platform (Grieve et al., 2023). The next steps include implementing and evaluating the SSBC coach e-learning platform to examine the real-world applicability and effects of the platform using the TEL evaluation framework phases 4-7. This will include documenting key events during implementation, assessing new coaches’ experience and satisfaction with the e-learning platform (i.e., user-friendliness and appropriateness of the platform), assessing learning outcomes (Kirkpatrick levels 2-4) through changes in knowledge, behaviour, SSBC client outcomes, and finally, estimating the total costs to develop and implement the e-learning platform, as well as determining viability. Beyond the use of SSBC, other programs should consider an IKT approach in developing e-learning platforms and transparently report the process. Once training programs have been developed and implemented, it is crucial that research teams monitor coaches’ knowledge, skills, and behaviours and report on the fidelity of their coaches (Frost et al., 2018). 2.4.2 Limitations Only a small number of previous SSBC coaches were involved in the design and development of this e-learning platform, and their preferences for content and delivery style might not be reflective of that of all coaches who will take this e-learning training. However, working with 3C Institute allowed us to incorporate their expertise in e-learning platforms, content, and learning styles. This study does not examine the effectiveness of this training, and at 30 this point, we cannot be certain that this training will improve coaches’ knowledge, skills, and behaviours. Future research will look at these learning outcomes. 2.4.3 Conclusions This is the first paper to outline the needs assessment, design, and development of an e-learning platform for a T2D prevention program. One of the main limitations of the current T2D prevention programs is the limited reporting of coach training modes and training fidelity. This paper demonstrates how an e-learning platform can be designed and developed for T2D prevention program coaches using an IKT approach combined with the TEL evaluation framework. It is expected that this training will be acceptable and effective because of the methods and approaches used in this study. Table 2.1 Focus group participants’ demographics and experience (N=9) 31 Individual-level factor N Percent (%) Age (years) 18-24 3 33.3 25-34 3 33.3 35-44 1 11.1 45-54 2 22.2 Gender identity Woman 8 88.9 Man 1 11.1 Race White 8 88.9 White and Indigenous 1 11.1 Education University certificate, diploma, or degree 4 44.4 Apprenticeships, trades services, or diploma 1 11.1 College, CEGEP, or other non-university certificate or diploma 1 11.1 High school 3 33.3 Years of experience working in customer service 1-2 1 11.1 Greater than 5 8 88.9 32 Table 2.2 Overview of SSBC e-learning platform E-learning component Topics covered Learning objectives Module features Module 1 Introduction to SSBC, prediabetes and T2D, cultural safety and inclusivity - Broadly describe type 2 diabetes and prediabetes - Explain how diet and exercise changes can help prevent type 2 diabetes - Describe what the SSBC program includes - Understand why having an inclusive mindset is integral to being a SSBC coach - Understand the need to learn and act with empathy when working with clients, regardless of their background and life experiences Narrated video, roleplay videos, knowledge check questions Module 2 SSBC session content, taking client measurements, tools associated with the program (e.g., health tracking mobile application), exercise protocols - Describe the content that comprises each of the six SSBC counselling sessions - Understand the program tools and session documentation requirements - Know the difference between SSBC’s moderate-intensity continuous training and high-intensity interval training exercise sessions and the weekly progressions for each - Know which measurements to perform on your clients and when to take them Narrated videos, demonstration videos, knowledge check questions Module 3 Introduction to MI, definition of MI, spirit of MI - Define MI and identify where it falls on the spectrum of counselling styles - Describe each of the four elements of the spirit of MI - Understand how to implement the spirit of MI in SSBC sessions Narrated videos, roleplay videos, knowledge check questions 33 E-learning component Topics covered Learning objectives Module features Module 4 MI skills: open-ended questions, affirmations, reflections, summaries, ask-tell-ask - Define and use the open-ended questions, affirmations, reflections, and summaries skills - Describe and use the method “ask-tell-ask” to provide information or advice to your clients Narrated videos, roleplay videos, knowledge check questions Module 5 Listening and responding to change talk, sustain talk, and ambivalence. - Define change talk and sustain talk - Define ambivalence - Describe preparatory change talk and mobilizing change talk - Understand which skill (i.e., open-ended questions, affirmations, reflections, summaries) will work best when a client engages in change talk, sustain talk, or ambivalence Narrated videos, roleplay videos, knowledge check questions Module 6 4 processes of MI: engaging, focussing, evoking, and planning - Describe the four processes of MI - Understand how to use them in sessions with your clients Narrated videos, roleplay videos, knowledge check questions Module 7 Putting it all together: how to deliver the SSBC content using MI - Describe the elements of an SSBC session - Understand how to provide SSBC content in a way that embodies the spirit and skills of MI Narrated videos, roleplay videos, knowledge check questions Resource Centre Additional information on topics covered in modules, sessions scripts, session checklists, video roleplays N/A PDFs and roleplay videos 34 Figure 2.1 E-learning platform design and development process with each group’s contributions 35 Chapter 3: Impact of a 20-minute cultural safety and inclusivity module on current and future fitness and healthcare professionals 3.1 Introduction Weight and racial biases are two types of biases that are prevalent within healthcare and fitness environments. Weight bias is negative beliefs and attitudes about obesity and people with obesity (Obesity Canada, n.d.). Rubin believes that weight bias is considered to be the last acceptable bias due to the erroneous perception that weight is completely under an individual’s control (Rubin, 2019). Racial bias includes negative feelings, stereotypes, and perceptions, and inequitable treatment towards people based upon their race (American Psychological Association, n.d.). Understanding current and future fitness and healthcare practitioners’ weight and racial biases is important because of the impact biases can have on how practitioners interact with patients as well as patient outcomes (Hall et al., 2015; Peek et al., 2011). People with overweight or obesity commonly report that healthcare practitioners are disrespectful (Alberga et al., 2019; Bombak et al., 2016), attribute all of their health issues to their excess weight (Alberga et al., 2019; Ferrante et al., 2016), and only want to discuss weight- or diet-related topics at appointments (Ferrante et al., 2016). Patients’ reports of experiences of weight bias from practitioners are also reflected in studies examining future and practicing fitness and healthcare practitioners’ levels of weight bias. Most medical students hold moderate-to-strong anti-fat biases (D. P. Miller et al., 2013; Phelan et al., 2014), and future healthcare practitioners have described people with overweight or obesity as lazy, unattractive, participating in unhealthy behaviours, and unmotivated (Chambliss et al., 2004). Additionally, approximately 30% of a sample of Canadian family physicians reported feelings of frustration and non-compliance when treating patients with overweight or obesity, and nearly 50% believed that 36 people with overweight or obesity were a strain to the public health system (Alberga et al., 2019). Similarly, individuals from equity-owed ethnic and racialized groups often face discrimination, racism, and stereotyping when interacting with fitness and healthcare practitioners (Fante-Coleman et al., 2022; Higginbottom et al., 2016; Turpel-Lafond, 2020). For example, common misconceptions that Indigenous people face when interacting with healthcare workers are that they are drunk or seeking drugs, do not care about their health, and are less intelligent than White patients (Ly & Crowshoe, 2015; Turpel-Lafond, 2020). Negative stereotypes and unsafe healthcare interactions, coupled with structural barriers has resulted in Indigenous people and other equity-owed ethnic and racialized groups being less likely to use healthcare services (Turpel-Lafond, 2020). Research corroborates these findings, showing that healthcare and fitness practitioners hold negative perceptions of patients from equity-owed racialized and ethnic groups (e.g., Black, Latin(x), Indigenous, etc.) (Hall et al., 2015; R. Harris et al., 2018), and hold pro-White/anti-Black implicit racial biases (Maina et al., 2018). Reducing these negative weight and racial biases is an important step in improving healthcare for those belonging to equity-owed groups. One way to improve the care that patients from equity-owed groups receive is to provide practitioners with cultural safety and inclusivity training. We define inclusivity as making sure everyone feels welcome, valued, and respected, no matter who they are, where they come from, or how they identify. Cultural safety is when the service people receive within the healthcare and fitness systems are free from racism, and discrimination (BC Centre for Disease Control, 2021). Inadequate provision of culturally safe and inclusive care may act as a barrier to individuals accessing healthcare and fitness settings, potentially compromising their overall experience upon engagement. 37 Currently, there are no agree upon components for interventions or trainings aimed at reducing weight or racial bias. Bias-reduction interventions thus far have included watching videos, classroom instruction, role-plays, group discussions, and interactions with equity-owed groups. There are mixed results on what types of interventions are effective in changing individuals’ weight and racial biases (Chapman et al., 2018; Rukavina et al., 2010; Wijayatunga et al., 2019). In addition to the varying successes of bias-reduction interventions, it is challenging to compare bias-reduction interventions to each other due to the variability in outcome measures assessed. While there is evidence that bias-reduction interventions can be effective, the lack of both consistent evidence and standardized bias-reduction intervention components leaves room for new interventions to be developed and tested in the health and fitness context. When testing bias-reduction interventions, gathering end-user feedback in addition to commonly-used outcome measures of interest can provide insight into components that are acceptable, useful, and appropriate. Such information can help refine interventions and provide context for research findings. 3.1.1 Context We developed a 20-minute cultural safety and inclusivity (CS&I) module for coaches of a type 2 diabetes prevention program, Small Steps for Big Changes, to teach about biases in general, with a more specific focus on weight bias, and the harmful effects that practitioners’ biases can have on patients. The module also provides a brief overview of what cultural safety is, that patients are the only person within a practitioner-patient relationship that can determine whether an interaction is safe and inclusive, the positive effects that self-reflecting can have on practitioners’ biases, and ways to reduce inherent client-practitioner power imbalances. Finally, 38 the module shows a demonstration of a culturally unsafe interaction, followed by the practitioner self-reflecting, and finished with a culturally safe interaction. In this study, we were interested in focussing on the effects of the CS&I module on weight and racial biases because they are very prevalent within diabetes and diabetes prevention (Batterham, 2022; Beltrán et al., 2019; Egede et al., 2023; Potter et al., 2015; Teixeira & Budd, 2010). Excess weight or obesity is recognized as a risk factor for the onset of type 2 diabetes (Potter et al., 2015; Teixeira & Budd, 2010). Non-White populations also exhibit a heightened susceptibility compared to their White counterparts (Booth et al., 2012; Branfield Day et al., 2020; Lipscombe et al., 2010; Public Health Agency of Canada, 2018). The complex interplay of systemic and confounding factors contributes to these associations, highlighting the potential adverse impact of weight and racial biases on individuals. The primary objective of this study was to investigate the impact of watching the CS&I module on university students enrolled in health and exercise sciences and fitness facility staffs’ 1) empathic awareness towards individuals who experience weight or racial biases, 2) perceptions of a mock patient described as overweight or Black, and 3) explicit biases towards people of different weights or races from pre- to post-module. The secondary objective of this study was to explore participants’ perspectives on the CS&I module. We hypothesized that there would be a significant interaction effect between viewing the module and time on participants’ empathic awareness, perceptions of patients, and explicit bias, indicating that the change in empathic awareness, perceptions of patients, and explicit bias over the two timepoints would differ between those who viewed the CS&I module and those who did not. 39 3.2 Methods 3.2.1 Positionality It is critical that we acknowledge that we all exist in thin bodies and benefit from thin privilege, and as such, have no lived experience of weight bias. Two of us (KC and MJ) belong to equity-owed racialized groups, but our experiences with racism are certainly not reflective of all non-White individuals’ experiences with racial bias. JS is White and has never experienced racial discrimination. Additionally, none of us have prediabetes or type 2 diabetes, and therefore, cannot understand the complexities of weight and racial biases on prediabetes or type 2 diabetes healthcare. All three of us are part of the Small Steps for Big Changes diabetes prevention program research team, and have worked one-on-one with individuals with prediabetes. While addressing the secondary study objective, we recognize our collective constructivist epistemology (Drisko & Maschi, 2015). Following constructivism, we acknowledged participants did not enter our study as blank slates, and therefore, their responses are based on their lived experiences and previous knowledge. Similarly, our lived experiences and identities likely influenced the analysis of participants’ responses. 3.2.2 Participants Based on the results observed in a previous study examining the effects of bias-reduction training on healthcare practitioners’ ethnocultural empathy (Chapman et al., 2018), we anticipated medium-to-large sized effects (i.e., 2 = ~0.80). Thirty participants per group were required to have 80% power to detect significant between-group differences of this magnitude, with  = .05. 40 We recruited university students in programs related to health and exercise sciences and fitness facility staff to participate in this study. These groups of participants were chosen as they reflect individuals who are Small Steps for Big Changes diabetes prevention program coaches. Participants were recruited through social media, email listservs, classroom and fitness facility visits, and word of mouth. Anyone interested in participating in the study contacted the research team via email to schedule a time to complete the study. Following completion of the study, participants were remunerated with a $20 electronic gift card. 3.2.3 Procedures The study was approved by the University of British Columbia Behavioural Research Ethics Board. This study used deception, as participants were told that the purpose of the study was to test the effectiveness of an online training module for diabetes prevention program coaches. Deception was necessary because if participants were aware that this study was focussed on biases, it may have altered results or recruitment. Participants each scheduled one-on-one Zoom meetings with a research assistant to complete the study. All participants completed the study on Zoom in an attempt for us to prevent scammers or bots from interfering with data collection. The research assistant stayed on Zoom with the participants for the entire study duration, with both parties instructed to stay muted with videos turned off unless the participant had questions. Participants joined the Zoom meeting, provided consent to participate, and then completed the demographics section of the online survey. Two parallel studies (a Weight study and a Race study) each utilized a pre-post experimental design. Participants were randomly allocated to either the Weight study or the Race study. Further, participants were then randomized into a condition to watch the CS&I module or to watch a filler video. “Our Planet: From Deserts to Grasslands” (2019) was chosen as the filler video because it did not include any 41 images of humans, reducing the chances that this video might have any unintended effects on participants’ biases, perceptions, and empathic awareness. To examine levels of implicit bias, all participants completed an Implicit Association Test (IAT), with individuals in the Weight study completing a Weight IAT, and those in the Race study completing a Race IAT. All participants then completed pre-module/video questionnaires, which consisted of measures of empathic awareness, explicit bias, perceptions of a patient based on a vignette, past experiences with equity, diversity, and inclusion (EDI) training, and perceptions of how important EDI training is in their field. We asked participants about previous EDI training rather than cultural safety and inclusivity because we wanted to capture whether participants had received any previous training on the broader topics of equity, diversity, and inclusivity. Participants then either viewed the 20-minute CS&I module or 20 minutes of the Our Planet video, depending on their randomization. Finally, all participants completed a post-module/video questionnaire, including measures of empathic awareness, explicit bias, perceptions of a patient based on a vignette, and those who viewed the CS&I module were asked to answer questions regarding their perspectives on the module. 3.2.4 Measures 3.2.4.1 Demographics Participants were asked to self-report their gender identity; whether they identify as a visible minority/racialized individual; whether they identify as Indigenous; age; postal code; whether they were a student, fitness professional, or both; employment status if they answered that they were a fitness professional; year of study if they were a student; their BMI category; whether they have previously received EDI training as part of their job and/or education, and if so, whether they felt that the training they received was sufficient. 42 3.2.4.2 Beliefs about relevance of EDI training to education or job Participants were asked to answer two 5-point Likert scale questions, with a one being very irrelevant and a five being very relevant. The questions asked participants if they believed that EDI training is relevant to their job/education, and if they believed that EDI training is relevant to other positions in their facility (for fitness facility staff) or if EDI training is relevant to their future job (for students). 3.2.4.3 Implicit association test The IAT is a measure of the strength of associations between concepts (e.g., African American people and European people; fat people and thin people) and evaluations (e.g., good and bad). We worked with the non-profit organization Project Implicit, to collect information from the IATs. The Race and Weight IATs used in this study were previously developed and tested by Project Implicit and were not study specific. Participants in the Race study completed the race IAT, and participants in the Weight study completed the weight IAT. For more information on the IAT, please visit https://implicit.harvard.edu/implicit/iatdetails.html. The IAT score is based on how long it takes a participant, on average, to sort the words when concepts are paired with evaluations compared to how long it takes them to sort the words when the concepts are paired with the opposite evaluation (e.g., when African American is paired with good and European is paired with bad, compared to when African American is paired with bad and European is paired with good). Scores are reported as either a strong, moderate, slight, or no implicit preference for African American people to European American people (or European American people to African American people; fat people to thin people; or thin people to fat people). 43 3.2.4.4 Explicit bias The explicit bias measures were adapted from Project Implicit’s IATs (Project Implicit, n.d.). Participants were asked to what extent they prefer White people in comparison to Black, Indigenous, or other people of colour (if in Race study) or thin people in comparison to people with overweight or obesity (if in Weight study). Participants responded on a 7-point Likert scale, with a 1, 2, and 3 indicating a strong, moderate, or slight preference, respectively, for White people over Black, Indigenous, and other people of colour (Race study) or thin people over people with overweight and obesity (Weight study); a 4 indicating no preference between groups; and a 5, 6, and 7 indicating a slight, moderate, or strong preference, respectively, for Black, Indigenous, and other people of colour over White people (Race study) or people with overweight and obesity over thin people (Weight study). 3.2.4.5 Empathic awareness Empathic awareness is a subscale within the Scale of Ethnocultural Empathy. Empathic awareness targets an individual’s knowledge and awareness about the life experiences of people from ethnic or racialized groups other than one’s own (Wang et al., 2003). The empathic awareness scale was adapted for the Weight study, with the words “racial or ethnic” being replaced by “weight or size” (See Appendix B.1). Participants were asked to rate the following on a 6-point Likert scale (with a 1 being strongly disagree it describes me, and a 6 being strongly agree it describes me): 1) whether they were aware of how society treats people of different racialized or ethnic groups (or weight and sizes); 2) how the media portrays people of different racialized or ethnic groups (or weight and sizes); 3) the oppression that people of different racialized or ethnic groups (or weight and sizes); and 4) the barriers that discriminate against 44 racialized or ethnic groups (or weight and sizes). An overall empathic awareness score was calculated by taking the mean of the four items. 3.2.4.6 Perceptions of patient Vignettes were adapted from Green and colleagues (A. R. Green et al., 2007) and Kosteniuk and colleagues (Kosteniuk et al., 2012) to fit our study context. Participants read a vignette about a 42-year-old male patient who was Black (for Race study) or overweight (for Weight study). The identification of the individual being Black or overweight was the only difference between the two vignettes (see Appendix B.2). After reading the vignette, participants were asked to rate the patient on a 7-point Likert scale (adapted from Harris and colleagues (R. Harris et al., 2016)) for each of the following items: competence, compliance, reliability, and motivation, with a 1 indicating not at all, a 4 indicating neutral, and a 7 indicating extremely. The mean of the four items was used as an overall perception score of the patient. 3.2.4.7 Perspectives of CS&I module Following completion of the intervention and completing the pre- and post-module/video questions, participants were asked one multiple choice question about whether the content from the module would change the way they interact with patients in the future, with response options being yes, no, or other, and were then provided an open textbox to explain their response. Participants were then asked two 5-point Likert scale questions about whether they 1) think this module should be mandated for people in their field, and 2) would recommend this training to their peers and/or colleagues, with a 1 being strongly disagree and a 5 being strongly agree. After each Likert-scale question, participants were once again provided with an open textbox if they wished to explain their response. Finally, participants were asked an open-ended question about what their biggest take-aways from the module were. 45 3.2.5 Analyses 3.2.5.1 Quantitative data Quantitative data were analyzed in SPSS (version 29). Participants were removed for analysis if they indicated that they did not watch the CS&I module or the Our Planet video, or if we deemed them likely be a bot or scammer based on the provided email address or postal code. Demographics, belief about relevance of EDI training, IAT, and perceptions of CS&I module data were analyzed using descriptive statistics (frequencies, means, standard deviations). Separate 2 (condition) X 2 (time) repeated measures analyses of variance (ANOVA) were conducted on each of the pre-post variables (empathic awareness, explicit bias, and perceptions of patient). Data for the Weight and Race studies were analyzed separately. 3.2.5.2 Qualitative data Using NVivo to manage the data, open-ended question responses were analyzed by a single-coder (KC) using conventional content analysis (Hsieh & Shannon, 2005). After becoming familiar with the text responses, the responses were coded to capture key concepts. Coded excerpts were reviewed, and KC developed labels for codes that were related. Codes and labels were sorted into themes and subthemes that reflected meaningful clusters of codes. Based on the codes within each theme and subtheme, KC developed descriptions of each theme and subtheme. Finally, we created a concept map to identify the relationship between the themes and subthemes. To ensure credibility, JS acted as a critical friend to review KC’s analysis and then debriefed with KC. 46 3.3 Results 3.3.1 Participants A total of 74 participants consented to participate in the study. Figure 3.1 shows participant flow through the study. 58 participants were included in the final analysis, with 28 participants in the Weight study and 30 participants in the Race study. Table 3.1 shows participant demographics for each study. 3.3.2 Beliefs about relevance of EDI training to education or job Overall, most participants responded that EDI training is relevant to their job and/or education. Responses between the Weight and Race studies were very similar, and as such, the results for this section are collapsed across the two studies. Appendix B.3 shows results with the two studies disaggregated. When asked whether they believed that EDI training was relevant to them, 94% of fitness facility staff and 94% of students said it was either very or somewhat relevant to their job and/or education. When fitness facility staff were asked whether they believed that EDI training is relevant to other jobs within their organization, 83% said it was very or somewhat relevant. Students were asked whether they believed EDI training was relevant to their future jobs, and 94% of them said it was very or somewhat relevant. Results showed that 39% of fitness facility staff had previously received EDI training as part of their job and 68% of students had previously received EDI training as part of their education. Of those who responded that they had previously received EDI training, 60% said they believed that the training they had received was sufficient. 3.3.3 IAT Results of the IAT for the Race study showed that 23.3%, 36.7%, and 20% of participants had a strong, moderate, or slight automatic preference for European over African American 47 people, respectively; 10% of participants had no preference between the two groups; and 3.3% and 6.7% of participants had a slight or moderate automatic preference, respectively, for African American over European people. For the Weight study, 28.6%, 53.6% and 3.6% had a strong, moderate, or slight automatic preference, respectively, for thin over fat people; and 14.3% had no preference between the two groups. 3.3.4 Explicit bias, empathic awareness, and perceptions of patient Means and standard deviations for explicit bias, empathic awareness, and perceptions of patients, and the results of the ANOVA tests are presented in Table 3.2. 3.3.4.1 Explicit bias The main effect of time did not show a statistically significant difference in explicit bias at the two timepoints for the Weight study, F(1, 26) = 2.22, p > .05, partial 2 = .079 or the Race study, F(1, 27) = .161, p > .05, partial 2 = .006. The main effect of condition also did not show a statistically significant difference in explicit bias between conditions for the Weight study, F(1, 26) = .78, p > .05, partial 2 = .029 or the Race study, F(1, 27) = 1.48, p > .05, partial 2 = .052. Although reaching small- to medium effect sizes, there was no statistically significant interaction between the condition and time on explicit bias for the Weight study, F(1, 26) = 1.02, p > .05, partial 2 = .038 or the Race study, F(1, 27) = 1.76, p > .05, partial 2 = .061. 3.3.4.2 Empathic awareness For the Race study, the main effect of time showed a statistically significant difference in empathic awareness at the two time points, F(1, 26) = 4.61, p = .041, with a large effect size of partial 2 = .150. The main effect of condition did not show a statistically significant difference in empathic awareness between conditions, F(1, 26) = .34, p > .05, partial 2 = .013. There was no statistically significant interaction between the condition and time on empathic awareness, 48 F(1, 26) = 3.02, p > .05, partial 2 = .104, although the large effect size is noted. For the Weight study, there was a statistically significant interaction between conditions and time on empathic awareness, F(1, 26) = 5.69, p = .025, partial 2 = .180. There was no statistically significant difference in empathic awareness between conditions at the pre-intervention timepoint, F(1, 26) = .002, p > .05, 2 = .000 or at the post-intervention timepoint, F(1, 26) = 3.41, p > .05, 2 = .116. There was also no statistically significant effect of time on empathic awareness for either the module condition, F(1, 14) = 2.94, p > .05, 2 = .173 or the Our Planet condition, F(1, 12) = 2.74, p > .05, 2 = .186. 3.3.4.3 Perceptions of patient For the Race study, the main effect of time did not show a statistically significant difference in perceptions of patients at the two timepoints, F(1, 28) = .78, p > .05, partial 2 = .027. The main effect of condition also did not show a statistically significant difference in perceptions of patients between conditions, F(1, 28) = .21, > .05, partial 2 = .008. There was no statistically significant interaction between the condition and time on perceptions of patients, F(1, 28) = 1.69, > .05, partial 2 = .057. For the Weight study, there was a statistically significant interaction between the intervention and time on perceptions of patients, F(1, 26) = 4.78, p = .038, partial 2 = .155. There was not a statistically significant difference in perceptions of patients between conditions at the pre-intervention timepoint, F(1, 26) = .08, p > .05, 2 = .003. There was, however, a statistically significant difference in perceptions of patients between conditions at the post-intervention timepoint, F(1, 26) = 5.75, p = .024, 2 =1.81. There was a statistically significant effect of time on perceptions of patients for the module condition, F(1, 14) = 5.82, p = .030, 2 = .294, but not for the Our Planet condition, F(1, 12) = .000, > .05, 2 = 0.000. 49 3.3.5 Perspectives of CS&I module Of the 30 participants who were randomized to view the CS&I module, 27 answered that the content from the module would change the way they interact with patients in the future. Three participants said that the content would not change their future interactions with patients for reasons such as they “already treat everyone equally” (P48) and already deliver inclusive care. When asked if participants thought the CS&I training should be mandated for people in their field, 23 participants strongly agreed, five agreed, and two were neutral. Notably, there were no participants who responded that they either disagreed or strongly disagreed. Only one of the participants who responded neutrally gave an explanation, and they said that “[the module] should be mandated, but it probably won’t do much” (P38). Participants also responded favourably when asked if they would recommend this CS&I module to peers and/or colleagues, with 24 participants strongly agreeing, four agreeing, and two responding that they were neutral. Similar to the previous question, there were no participants that disagreed or strongly disagreed with the question. The participants who responded with a neutral answer explained that one of them was working in a bank and they did not see the relevance of this training for their colleagues, and the other said “I feel as if [the content from the module] is common sense, however some people do not realize that it is and how important [cultural safety] truly is” (048). The results from the open-ended questions were organized into six themes: people are diverse beings, importance of the topics, importance of this CS&I module, satisfaction, the how-to’s, and this isn’t new information. The results from the conventional content analysis are shown in Table 3.3. 50 3.4 Discussion This study aimed to examine the impact of watching the CS&I module on participants’ empathic awareness, perceptions of a mock patient, and explicit bias, as well as to explore participants’ perspectives on the module. Among participants in the Weight study, empathic awareness and perceptions of patients both had differential changes over time in the CS&I module condition compared to the Our Planet condition. The Weight study participants who viewed the CS&I module had significantly more favourable perceptions of the mock patient from pre- to post-intervention. Despite most participants having received previous EDI training and believing that EDI training is important, we found that 80% participants in the Race study had some level of implicit bias in favour of European over African American people, and that 85.8% of participants in the Weight study had implicit biases in favour of thin over fat people. These results are similar to those seen in other research on future and current healthcare and fitness professionals (Maina et al., 2018; D. P. Miller et al., 2013; Phelan et al., 2014). Implicit biases are difficult to change as they have been ingrained through familial, peer, cultural, and social norms, and beliefs. Continued education on cultural safety and EDI topics is likely needed to make a lasting impact on healthcare and fitness practitioners’ biases. Our hypotheses that explicit bias, empathic awareness, and perceptions of patients would significantly change in both Race and Weight studies was not supported. Societal condemnation of racism in recent decades, and social desirability bias, may have contributed to our null findings on explicit racial bias. Overall, participants in the Weight study reported having a preference for people in thin bodies versus those who are overweight and obese. This finding may reflect Western perceptions that, although discrimination is publicly condoned, fat bias 51 remains an exception to this rule, with thinness being associated with health. While we had hoped that viewing the CS&I module would change explicit biases, participants started with little to no explicit racial bias and only slight weight bias, leaving little room for improvement. It also might take more than a 20-minute module that only briefly touches on weight bias to move viewers to a level of zero explicit weight bias. We saw no significant interactions in the Race study for empathic awareness or perceptions of patients, whereas we had significant interactions for the Weight study. The medium- to large effect sizes for empathic awareness and perceptions of patients in both studies suggests that the CS&I module had a large impact on levels of empathic awareness and perceptions of patients. The large effect size for the effect of time on perception of patients for the Weight study module condition suggests that the module positively influences viewers’ perceptions of patients with overweight and obesity compared to before watching the module. Our CS&I module addresses biases broadly but uses weight bias as an example due to its ubiquity and deleterious impact within the realm of type 2 diabetes prevention. It is possible that the module’s focus on weight bias specifically, contributed to the significant interactions for the Weight study and not for the Race study. It might take a more explicit focus on racial bias to see an impact of watching the module on changes in empathic awareness and perceptions of patients over time. Other bias-reduction interventions have shown mixed findings regarding effectiveness at changing empathic awareness (Fleming et al., 2015; Lu et al., 2020) and implicit and explicit biases (Chapman et al., 2018; Rukavina et al., 2010; Steed, 2014; Wijayatunga et al., 2019). The length, structure, and synchronicity of an intervention may play a role in the effectiveness of such interventions. It is conceivable that the emphasis of an intervention on individuals or groups 52 may influence which measures we see changes in. For instance, our CS&I module focussed on delivering culturally safe and inclusive care at the individual level, offering examples of instances where individuals had encountered discrimination due to biased thinking. Given the emphasis on individuals rather than broader equity-owed groups, measures framed around group-related empathic awareness may exhibit smaller changes compared to those focussed on individuals (e.g., perceptions of patients). Most study participants had previously received some type of EDI training as part of their job or education and believed that the training they had previously received was sufficient. A large majority of participants also said that they believed EDI training was relevant to their job or education. Participants expressed high levels of satisfaction regarding our CS&I module, with the majority advocating for its mandatory integration into the education for individuals within the healthcare and fitness sectors. Participants highlighted the commendable instructional design of the module, and the module’s dual focus on underscoring the importance of cultural safety and inclusivity and providing actionable guidance for practitioners in delivering culturally safe and inclusive care. 3.4.1 Implications This study demonstrated that our brief online CS&I module can elicit a positive impact on current and future health and fitness practitioners’ perceptions of patients and empathic awareness for individuals with overweight or obesity. The observed positive outcomes, medium- to large effect sizes, and participants’ favourable responses instill confidence in the module’s merit for integration into the coach training for the Small Steps for Big Changes diabetes prevention program. Given the prevalent weight bias among healthcare and fitness practitioners, this module stands as a valuable initiative in mitigating such biases. Further augmentations to the 53 training program could encompass modules targeting other biases, including those associated with race, sex, gender, and culture. 3.4.2 Limitations and future directions The target sample size was not reached, and we believe there were a few factors that influenced this. First, the study duration time was approximately 50 minutes, which could be burdensome for students and fitness and healthcare professionals. Despite our best recruitment efforts, we exhausted recruitment avenues and resources. Secondly, this study was conducted during the COVID-19 lockdowns, and many people were experiencing Zoom fatigue. Conducting this study on Zoom likely deterred some potential participants from participating. Additionally, five participants were excluded from analyses because after completing the entire study, they self-reported that they did not watch the module or filler video in full. We do, however, acknowledge that this manipulation check was a strength to our study because including participants in the analyses could have skewed our results. We were also inundated with bot and scammers, some of whom completed our study. We believe that we were able to catch and remove most bots and scammers, but this took extensive resources. Recommendations such as those from Loebenberg and colleagues (Loebenberg et al., 2023) could be useful to detect automated bots and participant deception in online studies, such as ours. A second limitation to our study was that our sample was fairly homogenous, with the majority of our participants self-identifying as White and women. Although this limits the generalizability of these findings, this study sample is likely somewhat representative of current fitness and healthcare professionals in the country in which this study took place. Third, some of our racial bias measures grouped Black, Indigenous, and people of colour together. This is a limitation because people may have different perceptions and levels of 54 empathic awareness and biases for these three groups. A strength of this study, however, was that we examined both racial and weight biases, whereas most studies examine one or the other. Understanding the effects of this CS&I module on multiple biases can lead to a better understanding of the treatment that equity-owed individuals could receive from a professional that has taken this training. Finally, this CS&I module was only 20 minutes in duration, which is considerably shorter than the bias-reduction interventions used in other studies (Chapman et al., 2018; Rukavina et al., 2010; Steed, 2014; Wijayatunga et al., 2019). Even though time-intensive bias-reduction interventions could lead to greater changes in biases and perceptions of patients, our brief intervention still had small- to large effects and participants had positive perceptions of the duration of this module. Bias-reduction and cultural safety training developers need to find a balance between providing adequate amounts of information and keeping viewers engaged with the content. Future research could examine whether this CS&I module is effective at improving cultural safety and inclusivity within the healthcare field. While an acute bias-reduction study provides useful information, the end goal is to train future and current fitness and healthcare professionals to deliver culturally safe and inclusive care, and ultimately make patients feel respected, safe, and included in their health and fitness journey. 3.5 Conclusion The CS&I module was effective at improving empathic awareness and perceptions of patients in our Weight study. This study demonstrated that a 20-minute module on cultural safety and inclusivity could be effective at reducing some biased thinking students and practitioners hold. The findings from this study can inform the content, duration, and measures of future bias- 55 reduction interventions. Reducing current and future fitness and healthcare professionals’ biases will lead to move inclusive and equitable care for individuals belonging to equity-owed groups, ultimately improving the fitness and healthcare systems. 56 Table 3.1 Demographics of participants Variable Race group Weight group n (%) n (%) Gender identity Woman 23 (76.7) 21 (75) Man 6 (20) 7 (25) Non-binary 1 (3.3) 0 (0) Self-identify as visible minority Yes 5 (16.7) 12 (42.9) No 25 (83.3) 16 (57.1) Indigenous Yes 3 (10) 4 (14.3) No 27 (90) 24 (85.7) Age (years) 18-24 21 (70) 23 (82.1) 25-29 7 (23.2) 2 (7.1) 30-34 1 (3.3) 1 (3.6) 35-39 0 (0) 1 (3.6) 45-49 1 (3.3) 0 (0) 50-54 0 (0) 1 (3.6) Student or fitness facility staff Undergraduate student in the field of health and exercise sciences 18 (60) 22 (78.6) An employee or volunteer at a fitness facility 5 (16.7) 3 (10.7) Both a student and work in a fitness facility 7 (23.3) 3 (10.7) Employment status for staff Full-time (> 30 hours/week) 3 (27.3) 3 (50) Part-time 6 (54.5) 2 (33.3) Volunteer 2 (18.2) 1 (16.7) Year of study for students 1st 7 (28) 7 (28) 2nd 5 (20) 4 (16) 3rd 10 (40) 9 (36) 4th 2 (8) 4 (16) 5th + 1 (4) 1 (4) BMI status Normal weight 24 (80) 25 (89.3) Overweight 6 (20) 3 (10.7) 57 Table 3.2 Means (M) and standard deviations (SD) for empathic awareness, explicit bias, and perceptions of client Race Weight Dependent variables Pre M(SD) Post M(SD) Pre M(SD) Post M(SD) Empathic awareness † CS&I Module 5.1(.85) 5.1(.73) 5.2(.62) 5.4(.62) Our Planet 4.7(1.26) 5.1(.94) 5.2(.55) 4.9(.90) Explicit bias CS&I Module 4.1(.52) 4.0(.00) 3.1(1.03) 3.5(.99) Our Planet 4.4(.93) 4.4(1.09) 3.0(.41) 3.1(.49) Perceptions of client † CS&I Module 5.3(.60) 5.7(.74) 4.8(1.31) 5.6(.71) Our Planet 5.4(.97) 5.3(1.06) 4.9(.92) 4.9(.83) *p < .05 significant Condition X Time interaction for Race group †p < .05 significant Condition X Time interaction for Weight group 58 Table 3.3 Conventional content analysis results for perspectives on the CS&I module Themes and subthemes Definition Selected quote People are diverse beings The CS&I module made participants recognize that their clients will have a wide range of identities and backgrounds, and that this is important to acknowledge. “My biggest takeaway is that everyone, regardless of demographic distinctions, is different” (P43) Importance of the topics Client is the only one to determine if the interaction is safe Clients, not practitioners, are the only people in interactions who can determine how culturally safe an interaction is. “Each component [of this training] is very important, especially letting the client decide their own cultural safety.” (P40) Delivering culturally safe care is important The CS&I module taught and reinforced that cultural safety is important in all interactions with clients. “Safety is the most important thing to offer your client” (P28) Power dynamics need to be reduced Practitioners need to work to reduce the inherent power imbalances that exist between themselves and clients. “You want the patient to feel culturally safe and be able to feel as if they hold equal power to the coach” (P30) Self-reflection is necessary A necessary aspect to delivering culturally safe and inclusive care is for practitioners to self-reflect on their biases, beliefs, and behaviours. “It is important to reflect on our behaviours and language as well as identify any underlying assumptions or biases we have to create culturally safe [environments] for clients” (P60) Importance of the module Clients benefit from receiving culturally safe care By training practitioners in cultural safety using this CS&I module, it could lead to clients feeling safer, more included, and more comfortable in health and fitness settings. “I believe [this module] is very important because everyone deserves a place to feel safe in order to improve their health and reach their health goals” (P10) Practitioners should watch this module All health and fitness practitioners should view this CS&I module because 1) not everyone receives this training as part of “I believe anyone can learn from this, especially since many people may not recognize what they’re 59 Themes and subthemes Definition Selected quote their job and education, 2) it is important for continuing education, and 3) it is relevant for anyone working with people. saying/doing could be harmful to people of oppressed groups” (P30) “I think that everyone should be educated on how to be inclusive with their interactions towards everyone” (P51) “Cultural safety and inclusivity training can be beneficial in pretty much every field as well in our everyday lives, therefore everyone should have this training” (P59) Reluctance to believe that this training will make an impact The CS&I module is important, but likely won’t change practitioners’ behaviours. “It should be [mandated], but it probably won’t do much” (P38) Satisfaction Instructional design The CS&I module was informative, clear, engaging, a good length, and provided useful examples. “It was time efficient and effective, clear and relevant to the field of health and exercise” (P07) Module provided actionable suggestions The CS&I module provided viewers with tools and strategies to improve cultural safety that they can use in practice. “Offered insight in ways that I can apply [the lessons] to my own practices” (P23) The How-To’s How to be compassionate The CS&I module covered information on how to approach clients with compassion. “I will approach clients with a more compassionate and understanding tone” (P41) How to be culturally safe The CS&I module broke cultural safety into three components, which helped show practitioners how to work towards cultural safety. “I already was aware that cultural safety is very important but I didn’t really know how to go about those interactions” (P40) How to be inclusive of diverse clients The CS&I module helped viewers understand how to better engage with clients from various backgrounds and “I found it gave me more ideas in how to best accommodate all clients” (P23) 60 Themes and subthemes Definition Selected quote identities – it is not a one-size-fits-all approach. How to engage in self-reflection Viewers learned what types of questions they can ask themselves to reflect on their own biases, assumptions, and beliefs. “The self-reflection piece really stood out to me and is something I want to get better at doing as I interact with clients and other people in the future because it is easy to get stuck in your own way of thinking and following the ways you have always done things. By asking self-reflection questions I am challenging my normalized beliefs to open my mind up to new ways of thinking and doing things” (P13) How to give client more control The CS&I module, especially the role-play video, demonstrated the importance of listening and asking questions to give clients more autonomy. “I should always make sure that myself and the client know that their sessions are about them and their ideas, and how they would like to improve their health. They should feel comfortable enough to be able to bring there own ideas, as well as share personal ideas/thoughts” (P24) How to reduce biases The CS&I module helped viewers to understand how to recognize their own biases and work to reduce them. “Although my conscious thoughts about people who are overweight or have diabetes have not necessarily changed, I have a much better awareness of the unconscious biases that I and others have, and I'm in a better place to minimize the effects of those biases“ (P43) How to reduce power dynamics The CS&I module provided viewers with strategies to reduce the inherent power dynamics between practitioners and clients. “I will ask more self-reflective questions and be more aware of the discourse and the power dynamics that can be inherently present” (P35) This isn’t new information Some viewers have already learned the information in the CS&I module. “I already treat everyone equally and make sure that everyone feels welcomed especially in fitness domains and health issues as I have had personal bad experiences with my family and myself in these medical settings” (P48) 61 62 Figure 3.1 CONSORT flowchart of participants 63 Chapter 4: Exploring perspectives of type 2 diabetes prevention program coaches and training delivery staff on online coach training: A qualitative study 4.1 Background With the widespread accessibility of the internet and the ramifications of the COVID-19 pandemic, e-learning has emerged as a prominent option for training healthcare practitioners (Roskvist et al., 2020; Seymour-Walsh et al., 2020). E-learning provides a flexible and time-efficient method for individuals to receive training (Kimura et al., 2023). Systematic reviews demonstrate that learners are satisfied with e-learning and experience increases in knowledge, skills, confidence, and self-efficacy (Kulaksız et al., 2023; Rouleau et al., 2019). The benefits of e-learning include, but are not limited to, individualized learning, flexibility for learners in terms of geographical location and time, accessing updated resources, and the ability to revisit the training (Cook, 2007; Kimura et al., 2023). To optimize the effectiveness of e-learning, it is imperative that e-learning training evaluation follows a systematic approach characterized by a well-defined framework and incorporates input from end-users (Cook & Ellaway, 2015). One such framework is Cook and Ellaway’s (Cook & Ellaway, 2015) technology-enhanced learning (TEL) evaluation framework, which begins with a needs analysis and environmental scan to understand the need for e-learning and the components to be included before developing the e-learning training. Incorporating end-user (i.e., the learners) input into the development process can increase the likelihood that the training components will be appropriate, and the training will be acceptable and effective (Yardley, Ainsworth, et al., 2015; Yardley, Morrison, et al., 2015). While using a framework and incorporating end-user feedback can improve the chances of e-learning training being 64 satisfactory and effective, e-learning improvements can also be made throughout the implementation phase. Evaluating e-learning training is important to judge effectiveness and also provides insightful information on improvements that can be made (Cook & Ellaway, 2015). 4.1.1 Context Small Steps for Big Changes (SSBC) is a community-based type 2 diabetes prevention program delivered in fitness and recreation facilities, hereafter referred to as sites. Individuals at risk of developing type 2 diabetes meet with a trained SSBC coach (i.e., fitness facility staff member) for six one-on-one sessions over the course of four to six weeks. Coaches use a motivational-interviewing (MI)-informed approach (W. R. Miller & Rollnick, 2023) to deliver exercise (e.g., gauging exercise intensity) and nutritional information (e.g., reducing added sugar and improving carbohydrate choices) to clients. SSBC is delivered by fitness facility staff who have received SSBC coach training/certification. The online coach training was developed using the TEL evaluation framework (Cook & Ellaway, 2015) and an integrated knowledge translation (IKT) approach (Cranston et al., 2024; Gainforth et al., 2021; Jull et al., 2017). The IKT approach to develop the SSBC coach e-learning training included focus groups with SSBC coaches who had been trained using the previous in-person version of the SSBC coach training, SSBC research team meetings regarding the goals and needs of the training, and continued input from coaches throughout the development stages. For more details about the TEL evaluation framework activities 1-3 (needs analysis, design and development, and usability testing), please see Cranston et al (Cranston et al., 2024). By incorporating knowledge and input from both coaches and the research team and using the TEL evaluation framework, the goal was to have an acceptable and effective e-learning training. 65 4.1.2 The SSBC e-learning training The e-learning training consists of five components: 1) signing a non-disclosure agreement (NDA) to protect the SSBC research team’s intellectual property; 2) a pre-training knowledge test; 3) seven asynchronous modules covering information on cultural safety and inclusivity, type 2 diabetes information, SSBC session content, and MI; 4) a mock session with an SSBC staff member; 5) and a post-training knowledge test. An online platform houses the modules and a resource centre. The online modules incorporate didactic educational videos, interactive activities (e.g., matching activities), and knowledge checks. The resource centre includes additional information, session guides (i.e., scripts), and video roleplay examples featuring actors portraying scenarios of coaches interacting with clients. Coaches are required to pass both the mock session and post-training knowledge test. Mock sessions were initially conducted on a video conference software customized for SSBC, but then got switched to Zoom for better user experience (see theme 4.3.2.3 for more detail). To pass the mock session, coaches are required to demonstrate a client-centred level of MI (assessed by the abbreviated Motivational Interviewing Competency Assessment tool; (Jackson et al., 2015)) while delivering SSBC session 1 content. Coaches are required to receive a minimum score of 70% on the post-training knowledge test. Grieve and colleagues (Grieve et al., 2023) demonstrated that SSBC coaches quantitatively rated the training as highly acceptable, and significantly increased program knowledge from pre- to post-training. Further exploration into coaches’ and staffs’ perspectives on the training can offer insight into what is working well and where improvements can be made in the SSBC coach e-learning platform and can potentially lead to improved coach and client 66 outcomes. Thus, the purpose of this manuscript was to explore SSBC coaches’ and training delivery staffs’ perspectives of the online SSBC coach training. 4.2 Methods 4.2.1 Paradigmatic position This study was guided by a pragmatic paradigm, which prioritizes solving practical problems in the real-world (James, 1907; Kaushik & Walsh, 2019). Pragmatism accepts that reality is not static, is socially constructed, and that there can be both single and multiple realities (Kaushik & Walsh, 2019). In line with the pragmatic paradigm, this study employed a qualitative descriptive methodology (Sandelowski, 2000). It is important for transparency to report that all three authors are affiliated with the SSBC research team. All authors’ involvement in SSBC aligns with the pragmatic paradigm, and we assert its necessity for both rich data collection and analytic methods. MJ is the founder of SSBC, and KC and NG are graduate students working on SSBC under MJ’s supervision. NG was also involved in portions of the training delivery as an SSBC staff. KC and MJ developed the SSBC online coach training (Cranston et al., 2024) and are the video narrators within the online training module videos. All three authors are committed to improving the online coach training for coaches and staff. Tracy’s (Tracy, 2010) eight big-tent criteria were considered to enhance the research quality. Additionally, KC engaged in reflexive journaling throughout the data analysis process to reflect on biases and assumptions. 4.2.2 Participants and recruitment Using information power (Malterud et al., 2016), we aimed to recruit eight SSBC coaches. Prior to beginning the online training, all SSBC coaches were asked whether they would be interested in being contacted for an interview after completing the training. Purposive 67 sampling was used to recruit a diverse sample of coaches based on site, rural or urban setting, and self-reported sex. Recruiting a diverse sample of coaches aligned with our pragmatic approach, aiming to capture a spectrum of perspectives. We aimed to recruit three SSBC training delivery staff based on information power (Malterud et al., 2016). SSBC training delivery staff were recruited approximately two years after the launch of the SSBC online coach training. Staff were purposively recruited to ensure we gained staff insight from those involved in various aspects of training delivery (e.g., oversight, communication, mock session delivery, mock session coding) and those involved in the delivery of the training at the start of implementation and at present time to capture the iterative changes that have been made over time. 4.2.3 Interviews One-on-one semi-structured interviews were conducted over Zoom and lasted approximately one hour each. Interviews were recorded using Zoom and transcribed using Otter.ai. All participants selected their own pseudonyms to ensure anonymity. The interview guides for SSBC coaches and SSBC training delivery staff were different. The SSBC coach interview guide asked questions centred on coaches’ experiences going through the entire training process, individual components of the training, delivering SSBC to clients, and the value of the training to their professional or personal growth. The interview guide for SSBC training delivery staff covered topics including the training delivery process, sustainability of the training process, and communication with coaches. 4.2.3.1 Coach interviews At the outset of the study, SSBC coaches were interviewed three months after receiving SSBC coach certification so that they had experience using their training with SSBC clients. 68 After conducting six coach interviews, we added a new interview timepoint immediately post-certification so that we could gain insights from coaches on the training immediately after certification to prevent hindsight bias. Additionally, one coach was interviewed at both the new timepoint and the original three-month timepoint to capture new perspectives based on experience delivering SSBC to clients. NG conducted the SSBC coach interviews to reduce power imbalances so coaches would feel comfortable sharing both positive and negative feedback on the SSBC coach training. 4.2.3.2 Staff interviews SSBC training delivery staff were interviewed by KC two years after implementation of the online coach training. Delivery staff were informed that their supervisor (MJ) would not be involved in the interview and would not have access to individual transcripts due to perceived or real conflicts of interest. All three staff members held different roles in the training delivery. Interviewing each staff member was critical to gain diverse insights. 4.2.4 Data analysis Template analysis (Brooks et al., 2015; King, 2004) was used to analyze all transcript data. Separate templates were used for the coach and staff interview analyses. 4.2.4.1 Coach interviews The initial template for coach interviews was informed by the Technology Enhanced Learning Framework Quality Domains (Cook & Ellaway, 2015). KC and NG reviewed the nine quality domains, discussed their applicability to the study objective and interview guide questions, discussed ideas that the quality domains missed that were included in the interview guide, and created the first version of the coach interview template. This first version consisted of five main codes, each with two to six subcodes. Appendix C.1 shows the initial version of the 69 coach interview coding template. KC and NG each used the first version of the coach template to independently code one transcript from different coaches. KC and NG then met to discuss inadequacies in the template and modifications required (e.g., insertion or deletion of codes, changing scope, changing classification). KC then coded all coach transcripts using the updated version of the coach template, continuing to make changes as needed. In total, KC went through each coach transcript three times, re-coding as necessary with the continually updated coach template. KC consulted NG about template changes when uncertainties arose. After three rounds of coding, KC deemed the coach template as final. NG acted as a critical friend, reviewing the final codes, and discussing with KC to encourage reflexivity (Smith & McGannon, 2018) and achieve descriptive and interpretive validity (Sandelowski, 2000). 4.2.4.2 Staff interviews The first version of the staff coding template was developed by inductively coding the three staff interviews. Codes were added to the template if they addressed the study objective. After coding each staff interview once, KC examined the codes, grouped similar codes together, and created a template. The template was used to recode the staff interview transcripts, with modifications occurring as needed. After three total rounds of coding, the template was finalized. MJ acted as a critical friend for staff interviews. 4.3 Results 4.3.1 Participants Eight coaches and three SSBC training delivery staff participated in this study. Half of the SSBC coaches self-identified as female, with the other half self-identifying as male. Most coaches were delivering SSBC in an urban fitness facility. On average, SSBC training delivery 70 staff have been involved in training delivery for 20 months. Additional participant demographics for coaches and staff can be found in Table 4.1. 4.3.2 SSBC coach interview findings There were seven themes and 35 subthemes constructed from the SSBC coach interviews, see Figure 4.1 for the final SSBC coach thematic template. Themes and subthemes are described below with example quotes. 4.3.2.1 Training design Coaches shared their perspectives on the overall design of the training and were satisfied with the training. Coach data was broken down into a number of subthemes related to specific aspects of the training design. 4.3.2.1.1 Course content All eight coaches talked about the content covered within the training, which captured content in the online modules, the resource centre, and the mock session. Deborah highlighted a common perspective that “[the training] was really comprehensive”, with Tina adding that “there’s quite a bit of training and it’s very in-depth training.” One coach, Lebron, felt that the training was potentially too comprehensive, saying, “it could have been like, a lot more concise.” Paul specifically talked about the content from the mock session, specifically that the mock client and the role-play videos in the resource centre displayed clients that were “super ideal…I don’t think they really adequately prepare [coaches] for the actual conversations that you kind of have [with clients] because most of the time the clients are less receptive or unaware [compared to the examples in the training].” Finally, coaches found the content contained in the resource centre to be very thorough. 4.3.2.1.2 Learning modalities – the “how” 71 Learning modalities refer to the various teaching methods used within the training, such as the videos, interactive activities, and resources within the online platform, as well as the mock session and knowledge tests if coaches viewed those as learning tools. Coaches talked about: (a) current learning modalities, and (b) ideas for additional learning modalities. 4.3.2.1.2.1 Current learning modalities Coaches had varied opinions about which learning modalities were most useful. Several coaches discussed the mock session being an invaluable component of the training. The usefulness of the mock session was highlighted by Deborah, “I would say [the mock session] was really helpful because, yeah, it kind of gets the kinks out before you actually do it [with real clients].” Paul found the “scripts and the extra materials [in the resource centre] really helpful.” Sally thought that the videos were “awesome because they are short and they help [coaches] to understand [the content].” Some coaches believed they benefitted from the knowledge checks and interactive activities within the online modules “to make sure [coaches were] paying attention” (Tina). 4.3.2.1.2.2 Ideas for additional learning modalities Suggestions for additional learning modalities emerged throughout the coach interviews. Several coaches described the desire to shadow a coach delivering SSBC sessions to a client. They expressed that an additional modality of learning between completing the modules and the mock session would be beneficial. Lebron summarized this with a metaphor, saying, “I kind of think of it like, this is how you swim, now go show us how to swim…I’ve never been to water before. I’d rather [have someone go], this is how you do it.” Paul offered an alternative idea to shadowing, saying, “I don’t know if you can take actual sessions and ask permission to use those because I think that’d probably be helpful to kind of get an idea because there are a lot of lulls 72 when you have conversations between clients and coaches.” Another suggested learning modality was shorter resources similar to the current session guides (e.g., scripts), but condensed, for example, “one page per session with like, the most important information…for example, [listing] 1) checking in, 2) goes to information exchange, and then bullet points about like physical sensation during exercise, red face, sweating, dry mouth…” (Sally). 4.3.2.1.3 Online platform organization – the layout Many coaches highlighted the layout of the online course, focussing on the layout of the resource centre and how well the resource centre aligned with the content in the modules. Some coaches, such as Tina, found the resource centre to be laid out “and labelled well enough so you know what you’re looking for or looking at”, while Deborah suggested “laying it out by week” or making it easier to find resources at a glance. Coaches also described the resources supplementing and overviewing the module content very well. 4.3.2.1.4 Training synchronicity and mode Half of the coaches in this study had a strong desire for there to be in-person training components. Specifically, coaches suggested that the mock session would be an ideal component to be conducted in-person. Some coaches stated they “learn better when a human talks to [them] instead of [watching a] video” (Lebron). Coaches also acknowledged that incorporating in-person and additional synchronous components could be inconvenient or impractical. 4.3.2.1.5 Training process Two subthemes were constructed surrounding the design of the training process from start to completion: 1) communication to coaches and 2) systematic steps to becoming a certified coach. 4.3.2.1.5.1 Communication to coaches 73 Generally, coaches requested better communication around the details of the training process and specific steps. Coaches talked about the confusion surrounding what to expect for the mock session and the pre- and post-training knowledge tests. Coaches requested additional information in emails from SSBC staff with details on the steps within the training process, with Marisol suggesting, “a simple graph that says, you know, first step is a pre-test, and then the seven modules with quizzes”, etc. Suggestions for improvements also included more details in emails about how to prepare for the mock session including greater emphasis on the relevant resources. 4.3.2.1.5.2 Systematic steps to becoming a certified coach Coaches perceived the steps within the training to be logical and important, as they started with learning information and then worked on applying the information in the mock session. Marisol summarized the training process as following “a competency-based approach, which…was enlightening…and a complete process because there was a pretest for the knowledge, then it went into the modules, and then it went to the mock…So theoretically, do you know the information, now you can apply it and implement…and then a final test for knowledge.” 4.3.2.1.6 Coach testing All but one of the coaches talked about the evaluative components of the training (i.e., the mock session and the post-training test). Coaches discussed the desire they had to pass the evaluative components. For example, when talking about the mock session, Marisol mentioned that they “obviously took it pretty seriously and wanted to pass it.” Coaches understood that the testing components were necessary so that the SSBC staff could ensure coaches knew the material well enough to become certified coaches. 74 4.3.2.1.7 Receiving feedback Seven of the eight coaches highlighted the importance and utility of the feedback from the SSBC staff following the mock session. The eighth coach, Lebron, did not remember receiving feedback after his mock session. Of those coaches who found the feedback an important part of the training, they all mentioned that they learned from the feedback. Sally failed her first mock session and reported that she “learned and understood my mistakes…After the [feedback], I could understand what I should do on the next [mock session].” Coaches also found the feedback useful when they passed the mock session, as highlighted by Mike, “it was good because there were some things that I missed [in the mock session] and that was pointed out to me. So, it was good, once again, going into my first session to remind myself not to forget certain items.” 4.3.2.2 “I didn’t know what to expect from the training” Most coaches did not know what to expect from the training before they began. Coaches had a very general idea that they would learn about “prediabetes and helping clients to know how to exercise and to eat healthier” (Sally). Some coaches learned about what to expect from other coaches at their site, which was deemed helpful. 4.3.2.3 Technology usability Two main technology platforms were used for the SSBC online coach training: the online platform that housed the online modules, resources, and pre- and post-training knowledge tests; and a program-specific video conferencing platform to host the mock session video calls. Coaches shared their perspectives on the ease of use and technical difficulties associated with these platforms. Overall, coaches were extremely satisfied with the simplicity and professionalism of the online platform with the modules. Tina described that, “everything 75 worked as it should, which is good because I’m pretty technologically challenged. So didn’t have any issues.” Additionally, Marisol characterized the online platform as “seamless.” While coaches had no issues with the online platform, Ryan suggested that adding the option to display subtitles could be useful for some coaches. When it came to the video conferencing software, some coaches experienced technical difficulties related to joining the call, not being able to access all features of the software (e.g., accessing the space for writing client notes during the session and accessing the session checklist within the platform). After the switch to using Zoom instead of the original video conferencing software, coaches did not experience any technical issues. 4.3.2.4 Learning Throughout the interviews, all coaches discussed learning, regarding their learning from the training and their learning journey through the training. 4.3.2.4.1 Coaches learned The SSBC online coach training enabled coaches to learn new information. Coaches gained knowledge, were able to demonstrate their knowledge through behaviours, and applied the knowledge in real-world situations. 4.3.2.4.1.1 Learning new knowledge Coaches gained knowledge in a variety of topics, including prediabetes, the SSBC program content, MI, and inclusivity. When asked what coaches learned from the training, most emphasized the MI knowledge. For example, Paul talked about learning how “it comes down to more obviously client-centred…more or less kind of motivate them.” 4.3.2.4.1.2 Demonstrating new knowledge 76 After coaches learned new knowledge, they talked about being able to take what they learned and put it into action before certification. Coaches talked about the skills they learned from going through the training, with a heavy focus on their MI skills and learning how to talk about specific SSBC topics. Deborah reflected on their learning of “the skills on like coaching things, like how to concisely teach the talk test, and how to concisely talk about carbohydrates and sugar. And only like giving the actual information that is wanted from the client, so not word vomiting a bunch of information to people, and so just being like, oh, what do they want…kind of listening.” One of the training components that particularly enhanced skill development was the mock session, however, coaches talked about how they still need to practice using these skills to become more proficient at using them. 4.3.2.4.1.3 Readiness to deliver SSBC sessions Despite all coaches having demonstrated their new knowledge in the mock session, coaches varied in their readiness to deliver SSBC sessions to clients. Sally described, “I wasn’t completely ready to start. I would say that my second client was way better than the first one.” On the other hand, Marisol described feeling ready to deliver SSBC because of the entire training process: “The actual modules and the training process, whether it was like the pretest and the modules right through the mock session, I felt competent at the end – that I can start to go and deliver to the clients.” 4.3.2.4.1.4 Application of learning Coaches also shared their perspectives on applying everything they learned from the training into practice. For those coaches who had not yet started to deliver SSBC to clients (interview timepoint 1), they talked about their anticipated application of learning within SSBC. Coaches who had already begun delivering SSBC to clients (interview timepoint 2) discussed 77 both the ways they were applying their learning within SSBC sessions and in other contexts as well. 4.3.2.4.1.4.1 Anticipating application of learning within SSBC The two coaches who were interviewed immediately post-certification discussed their anticipated application of learning within SSBC sessions. The primary learning that coaches anticipated applying within SSBC related to MI skills, including building rapport, using their MI micro-skills, and goal setting. Marisol also anticipated applying learnings around inclusivity, “I have to be careful of the biases, right. So like, I can walk into a gym and I’m not intimidated, right. But I think for some people that will be their first experience, right? Or it could be very intimidating. So I think there’s some things that we have in our, you know, in our own toolbox that will apply and make us more aware.” 4.3.2.4.1.4.2 Applying learning within SSBC Coaches felt that they were well-equipped to deliver information related to SSBC session content, to use their MI skills, and to develop positive coach-client relationships. Sally described that, “I think the most important…the things that I can see that I changed about the way I talk to clients, that I do differently in the Small Steps is listen more. So ask them to tell more about things instead of just providing them [with information].” 4.3.2.4.1.4.3 Transcending SSBC: applying learning in other contexts Every coach described that they were applying skills from the training in contexts other than SSBC. Ryan described how, “the part of managing slips – [that’s] something that I might like even apply for myself”. When asked to elaborate on what contexts she was using her skills from the training, Tina said, “I do find the motivational interviewing can actually be very helpful in the personal training.” 78 4.3.2.4.2 The learning journey 4.3.2.4.2.1 Approach to completing the training Each coach had a different approach to completing the training. Some coaches intermittently completed portions of the training during work hours, while others completed the training from home. Coaches also reported spending varied amounts of time on the training, with it taking between four and twenty hours to complete. 4.3.2.4.2.2 Individual learning strategies Learning strategies used throughout the training varied among coaches. Within this theme, coaches talked about the learning strategies that they used throughout the training. Some coaches, such as Marisol and Tina, took notes on cue cards to learn information, while other coaches created their own resources informed by documents housed in the resource centre. Multiple coaches described using resources to help them prepare for the mock session. 4.3.2.4.2.3 Gradual learning curve The training provided lots of information, and coaches were expected to demonstrate their learning by passing both the mock session and the post-training knowledge test. One coach, Mike, mentioned in their interview that he, “assumed [the training] was going to be easier than it was. So it was a learning curve.” 4.3.2.4.2.4 “Practice, practice, practice” before the mock session Coaches highlighted the importance of practicing prior to the mock session to increase the likelihood of passing the mock on their first attempt. Some coaches shared that they practiced their skills with other SSBC coaches before their mock session, and Marisol said she “started to practice [MI] around the house with my husband and friends and family.” 4.3.2.4.2.5 The nerve-wracking experience of being evaluated 79 Related to the Coach Testing subtheme 4.3.2.1.6 under the Training Design theme, coaches talked about the emotions associated with being evaluated. While coaches did not view the mock session as a negative training component, many discussed the nerves associated with going into a situation where they would be evaluated. Deborah explained, “When you do something for the first time, it’s nerve-wracking, but the mock session kind of helps get out the kinks.” Other coaches described feeling nervous going into the mock session, but relaxing as they began talking to the SSBC staff running the mock session: “[the SSBC staff] guided me through in the beginning of the session so that I knew what to, like, expect, which helped me a lot to relax a little bit and focus more on what I had to ask and accomplish” (Ryan). 4.3.2.4.2.6 Learning through trial and error Four coaches talked about learning both training information and more about the training process from failing the mock session or from a colleague failing the mock session. Lebron shared that his colleague failed the mock session, “So I asked, what happened? What didn’t you do?...[They] showed me the printouts and how to go over it…It definitely helped that my co-worker did [the training] before me.” Tina described learning from failing her mock session, “And I found the feedback from my first failed interview very, very good. And it actually helped me become successful for my second interview, which I did fine with.” While the hope was that the training set coaches up for success, additional communication could better prepare coaches for the mock session. Regardless, coaches may still fail the mock session on their first attempt, and this sub-theme highlights that coaches can learn from their failings. 4.3.2.4.2.7 Continued learning after certification An unanticipated theme that we constructed was around the idea that coaches continued to learn after receiving their SSBC coach certification. They reported to continue their learning 80 with the resource documents and through delivering real-world SSBC sessions. Additionally, coaches provided suggestions for continued learning beyond certification. 4.3.2.4.2.7.1 Using resources to foster session success The session guides housed in the resource centre were the most used resource for coaches as they continued to learn SSBC content and MI after receiving their coach certification. Ryan described, “with my first two clients, I mentioned to them that they were my first two clients. So I had the [guide] in front of me. So I was making sure that I [had] all the information down. And I even told them like, I don’t want to be like robotic, but I’m just like learning.” As mentioned in the Ideas for Additional Learning Modalities subtheme (4.3.2.1.2.2.), Sally created her own one-page session summary and used that to continue learning about session content beyond certification. 4.3.2.4.2.7.2 Real-world practice enhances mastery Coaches discussed that the best way to get better at delivering SSBC sessions to clients was to practice and have more clients. Tina captured this idea when she said, “I think [with] every client, I’m a little bit better at [using MI].” 4.3.2.4.2.7.3 Supplemental learning ideas Some of the coaches had ideas about continued learning after certification. These ideas included refresher courses or workshops, feedback on sessions between coaches and clients, and meetings with other coaches and an SSBC staff meeting facilitator. Coaches thought that supplemental learning after certification was important because, as Marisol put it, “it’s easy to swing back to our old, I guess, ways of doing things as a coach.” 81 4.3.2.5 Coaches’ backgrounds shaped their training experience While every coach learned from the training, some coaches had backgrounds that affected the ease of their learning journey. English was both Ryan's and Sally’s second language, which made the training challenging for Sally. Some coaches had previously learned MI or had backgrounds in health and exercise, so those components of the training served as more of a refresher. Sally reflected, “the motivational interview, that is something completely new for me. I’m way better than before the training, but I still think I have a lot to improve on…And for the specifically about diabetes. I already knew those information. So that thing wasn’t new for me. And it’s a good part because then I can focus my efforts in being better about how to coach the session and not necessarily about to know the technical information.” 4.3.2.6 Support Coaches received support throughout the training from the SSBC staff as well as from other coaches. On the flip side, coaches also shared ideas for how they could receive more support throughout the training process. Additionally, they shared advice for new coaches embarking on the SSBC online coach training. 4.3.2.6.1 SSBC staff-to-coach support One of the biggest times that coaches reported feeling supported by the SSBC staff was during the mock session and in the feedback that the SSBC staff wrote for coaches following the mock session. As mentioned in the subtheme of The Nerve-Wracking Experience of Being Evaluated (4.3.2.4.2.5) coaches felt like they could relax in the mock session once they met the SSBC staff they would be working with. Deborah spoke about how “the feedback was really nice and encouraging and gave helpful tips and stuff”, and Marisol added, “I didn’t mind that [the feedback] took a little bit of time [to receive] because the feedback I got from the analysis of the 82 mock was really very helpful for me.” Some coaches suggested that the training design could be enhanced by adding in more touchpoints between SSBC staff and coaches. 4.3.2.6.2 Coach-to-coach support In the instances where coaches going through the training had co-workers who had already completed the training, they all spoke about how the certified coach supported them throughout their training process. This support helped coaches prepare for mock sessions, and understand which resources were useful. Coaches also talked to each other after certification when they had questions that arose from their SSBC sessions. Marisol highlighted the importance of support from another coach, “She has kind of been my mentor throughout [the training] and continues to do that…I think that helped me through the training…I’ll highlight it a few times, having that mentor was important.” Tina was the first coach at her site to go through the training, and spoke about the support she’ll provide future coaches, “I printed [the resources] off for all my coaches that are coming…so they have a successful first, first interview.” 4.3.2.6.2.1 Words of wisdom for new coaches starting the training When we asked coaches what advice they would give new coaches beginning the training, they were very willing to share suggestions. Coaches emphasized the importance of practicing MI skills, knowing that the training is a worthwhile process, taking the training seriously, and reading and using the resources provided. 4.3.2.7 Coaches valued the training The final theme that we constructed from the coach interview data centred around the notion that coaches saw value in the SSBC coach training. One idea that coaches spoke about was that they saw value in the coach training as well as the SSBC program in general. Coaches also described that this training was valuable for their careers, that their training would positively 83 affect the clients that they work with, and that other employees within their sites could benefit from pieces of the SSBC online coach training. 4.3.2.7.1 Viewing the training as continuing education Coaches viewed this training as being valuable for their professional development. Sally highlighted that, “especially for personal trainers, I think we do learn a lot about exercising, but we don’t learn about how to talk to people. So it’s not just telling them that they should exercise and that they will get the importance of it. So it is very important for us to know more [about] how to talk to people, and the Small Steps training helps us to do this.” Some coaches also suggested that they would like their employers to view this training as eligible for Continuing Education Credits because the training was comprehensive and could be applied to many contexts. 4.3.2.7.2 The trickle-down effect of coach training on clients Beyond seeing the value of the SSBC online coach training for themselves, coaches also talked about the value of this training for their clients. Coaches specifically focused on the benefits clients would receive from the MI and inclusivity portions of the training. Tina described this idea when she said, “As I get better at [MI], I think it is helping [my clients] take a bigger role in how they’re coming up with the ideas themselves. And I think that in the long run, they will be more successful than me telling them what to do.” 4.3.2.7.3 Extending the training to non-coaching staff Lastly, coaches suggested that other staff within their facilities (e.g., managers, front-desk staff) could benefit from taking portions of the SSBC coach training. Deborah discussed, “I think it would be really good for like all the managers to do motivational interviewing, even customer service and aquatics. As well as the inclusivity, I think it’s important. I don’t think every 84 department has to learn about diabetes prevention, but I think just some of the like, skills are transferrable.” 4.3.3 SSBC training delivery staff interview findings We constructed two themes and 22 subthemes from the SSBC training delivery staff interviews (see Figure 4.2). Descriptions of each theme and subtheme with quotes are below. 4.3.3.1 Streamlining the training delivery SSBC staff discussed several ways to streamline the training delivery process. While the training delivery process was less resource-intensive than in-person delivery, there were still back-end tasks that staff had to complete. Staff highlighted what is currently working, ways to improve the efficiency of tasks, identifying and eliminating unnecessary steps, and utilizing automation and technology to achieve make the SSBC coach training process more straightforward, cost-effective, and acceptable. 4.3.3.1.1 What’s working There were three primary topics that SSBC staff highlighted when talking about what was currently working: (a) the online platform usability, (b) staff communication isn’t all bad, and (c) being on the way to a sustainable process. 4.3.3.1.1.1 The online platform usability All three SSBC staff spoke highly of the quality of the online modules and the seamless nature of the online platform. The high-quality online platform is beneficial for both the coaches and staff. Jennifer emphasized the usefulness of the online module for coaches, “I think that the modules are really high quality, and I think that that, once coaches have access to the modules, I think that that process goes relatively smoothly.” John spoke about how the online platform made his job easier, “I really like the way that the platform kind of takes control of the training 85 for most of it. And then there’s only really three instances where I need to be in contact with them. And the like, there seems to be a kind of flexibility around what notifications I can send from the platform, which is quite useful.” 4.3.3.1.1.2 Staff communication isn’t all bad Despite there being room for improvement in the communication between staff and coaches (see 4.3.2.1.5.1 Communication to coaches and staff subtheme 4.3.3.1.4 Cleary communicating all expectations), the staff also discussed that some of the communication with coaches was going well. Jennifer specifically highlighted that the staff were “supporting [coaches] throughout the process…even though we’re getting a lot of emails, John’s always responding. So they should feel hopefully supported.” 4.3.3.1.1.3 On the way to a sustainable process It is critical to consider sustainability throughout the process of developing and modifying the online training as one of the major benefits of e-learning is that it can be a more sustainable model than in-person training. Sophie mentioned that the fact that the training is both online and free promotes sustainability, and Jennifer discussed that, “[the online training] process has allowed us to train a lot of coaches really quickly with less resources [than in-person training], and I think that’s a huge win.” 4.3.3.1.2 Removing unnecessary training steps To further streamline the training process, staff were asked to consider whether all components of the training were necessary to include for continued implementation. Staff agreed that the pre-training questionnaire was no longer necessary “because it doesn’t matter to me what their knowledge is before [the training]. I think we just obviously had that in for like to test the effectiveness” (Jennifer). Staff had mixed feelings about removing the post-training 86 questionnaire. Similar to the pre-training questionnaire, there were items within the post-training questionnaire (e.g., user satisfaction, self-efficacy) that had been analyzed and published, and were likely fine to remove. Staff felt conflicted about removing the post-training questions related to knowledge that coaches had to pass to be certified. Jennifer mentioned, “scoring is a pain and I know it takes time”, but that it was an important way to assess coaches’ knowledge. Staff leaned towards moving the post-training questionnaire to after the modules and before the mock session, and modifying it to be more of a knowledge check than a test, whereby coaches would be required to answer each question correctly before they could move on, therefore removing the need for a staff member to score the test. 4.3.3.1.3 Redistributing workload Staff discussed redistributing the online delivery training workload, including reallocating who should be involved in the various tasks required to deliver the online training and automating certain steps. 4.3.3.1.3.1 Amount of staff time required to train each coach Staff estimated that they spent approximately three hours and 30 minutes on the various training delivery tasks to get each coach from the start of training to certification. John reported that he spent an average of 45 minutes for each coach, which included sending them the NDA, giving them access to the online modules, coordinating with another staff member to deliver the mock session, and scoring the post-training questionnaire. Jennifer noted that scheduling and delivering a mock session took about one hour and 15 minutes per coach. Finally, Sophie reported that coding each mock session and writing feedback took approximately one and a half hours. 4.3.3.1.3.2 Automating procedures 87 SSBC staff discussed that one obvious way to reduce staff burden and time was to automate as many training steps as possible, which made sense due to the high-quality online platform. John provided suggestions including embedding the NDA into the online platform because “it’s a bit like administratively laborious to have the NDA separate when it could be included in the [online platform] login page.” As mentioned in the subtheme 4.3.3.1.2 Removing unnecessary training steps, staff also mentioned that changing the post-training questionnaire into more of a knowledge check format would reduce staff time because the online platform could force coaches to answer each question correctly before moving on, removing the need for a staff member to score the post-training questionnaire. 4.3.3.1.3.3 Defined roles Defining roles for everyone involved in the training procedure was another subtheme related to streamlining the training delivery. The main roles highlighted by staff were staff coordinator, site leads, and mock session coders. 4.3.3.1.3.3.1 Staff coordinator All three SSBC staff noted that they would like to see John, the coordinator, take on more responsibility so that there was only one main staff member involved in training delivery. Sophie discussed that there was a “back and forth between a coach and the like three different people on our team….it feels like there’s so many spots where something can get messed up.” Staff suggested that John and site leads should act as liaisons between the coaches and the training delivery staff. 4.3.3.1.3.3.2 Site lead At the time of this study, the role of the site leads was largely undefined and differed greatly between sites. To further streamline the communication process, staff suggested that site 88 leads take on the role of liaising between coaches and John. Jennifer noted that SSBC should be “putting the responsibility [of communication] on the people who we want to be responsible. So John, the site lead…those people are in those positions because we want them to be responsible. So actually, like following through with that and then having less people involved. I think it’s a big thing for sustainability as we expand.” John highlighted the importance of this because he “doesn’t really understand the inner context of the coaches [at each site]…without like the understanding of the different contexts, it’s hard.” Further suggestions included having coaches communicate with their site leads, and site leads communicating with John. Additionally, Sophie suggested that “site leads running the mock sessions [would be] great.” Defining the site lead role more clearly would reduce questions, allow the site leads to take more responsibility for the coaches at their sites because of their intimate knowledge of the inner contexts within their sites, and improve the communication process. 4.3.3.1.3.3.3 Mock session coders With the prospect of SSBC continuing to scale-up and a large influx of coaches going through the online training, John and Sophie both emphasized that the number of mock session coders would need to increase. Sophie reflected on her experience as the sole mock session coder, “coding mock sessions and writing feedback is very mentally taxing…for this program to expand, it needs to be more than one person coding mock sessions and writing feedback. It’s just like not, it’s just like a non-starter. Like there needs to be more than one person. It’s completely unfeasible and unsustainable.” Sophie suggested that SSBC staff and graduate students working within the SSBC program would make strong coders with the appropriate training. 4.3.3.1.4 Clearly communicating all expectations 89 Another aspect that staff brought up as an area for improvement was communicating expectations to coaches. Staff discussed that they could more clearly communicate expectations to coaches, specifically regarding the mock session and post-training questionnaire. John suggested, “maybe just a bit more information about what the mock session is…and possibly like, the fact that it takes 45 minutes.” As reflected in the coach subtheme of 4.3.2.1.5.1 Communication to coaches, both coaches and staff agreed that coaches did not always know what to expect from the mock session. Clarifying this in emails to coaches, as well as having site leads take on a larger role in the training could address this. 4.3.3.1.5 Standardizing procedures Two topics came up when staff discussed standardizing procedures. First, John talked about the email notifications from the online platform sometimes getting blocked by the site’s firewalls. He talked about what he was doing to help alleviate that, “And something I’ve been doing is to just whenever I release a notification [from the platform], I also email [site leads], particularly at the start because if it gets redirected to their spam folder then they can move it and [their inbox] should accept the rest of the emails that come. But I have wondered if it’s maybe worth like, at the start of new sites, asking site leads or senior management to whitelist the emails from [the online platform] so they’re never blocked.” Sophie emphasized another procedure that should be standardized to benefit mock session coders, “I feel like pass-failing on the [MI] is very clear, but then this other SSBC content, it seems a little ambiguous…I think coaches need to pass two parts [of the mock session]. I think they need to pass SSBC and they need to pass MI…no more leaving it up to the coder’s discretion [if a coach passes or fails].” 90 4.3.3.2 Ensuring coaches meet the “SSBC standard” Staff highlighted the importance of ensuring that certified SSBC coaches were reaching and maintaining a level of proficiency that met the standards of the SSBC research team. The SSBC research team asserts that SSBC coaches deliver the program with knowledge of the SSBC program content and at a client-centred level of MI. Staff shared the perspective that changes made to the training should ensure coaches continue to reach or exceed those standards. Five subthemes were constructed within this theme. 4.3.3.2.1 Extra support for the first coach at each site Without knowing that coaches also brought this topic up (see 4.3.2.6.2 Coach-to-coach support), staff suggested that additional support be provided for the first coach trained at each site. Often, the first coach trained at a site was the site lead, but this was not always the case. John discussed that, “the mock session can feel a bit intimidating, particularly for people who are either the first in their site or just haven’t had contact with anyone else in the site. And it’s come up [in conversations with coaches] that support around the mock would be valuable.” 4.3.3.2.2 Setting coaches up for mock session success The coach subtheme 4.3.2.4.2.5 The nerve-wracking experience of being evaluated, emphasized that coaches often feel nervous about the mock session and this was often the most difficult part of the training. Staff discussed mock session improvements to hopefully reduce the difficulty and nerves surrounding the mock session, and how to make the mock session more realistic to better prepare coaches for delivering SSBC sessions to real-world clients. 4.3.3.2.2.1 More realistic mock sessions Sophie’s experience with coding mock sessions allowed her to understand in general, how coaches were approaching the mock session. Sophie discussed that, “95% of the mock 91 sessions I code is the coach with the script open on their desk, reading it line for line for line for line. And if we want our coaches to be delivering SSBC at a client-centred way, having conversations their client, reading a script isn’t doing that.” To combat coaches approaching the mock session with the intent to pass without having to necessarily demonstrate their use of MI, Sophie suggested, “I think if we don’t want coaches to read from the script, I know we’ve changed to calling it a session guide, we need to change the formatting so [the script is] not a conversation that you can follow through.” A more thorough explanation of Sophie’s idea is echoed and further explained in the next subtheme. To better prepare coaches to deliver real- world sessions using a client-centred level of MI, the mock session should be more realistic. 4.3.3.2.2.2 Resource modification Building on Sophie’s idea to modify the mock session guide from the previous subtheme, Jennifer discussed, “I just sometimes think that the script, like the script for like, the sessions are actually like, confusing a little. I feel like there’s a lot of information in them so then [coaches]…we’re trying to make it as like simple as possible by giving them all this info, but it’s actually really overwhelming.” Sophie and Jennifer both independently proposed that rather than giving coaches a five-page session guide, coaches should be given a one-page resource highlighting the main session topics with suggested open-ended questions, affirmations, and reflections “because then we’re putting the responsibility on coaches to make [the session] a conversation. And we can more accurately assess their quality of becoming a coach” (Sophie). In addition, both Sophie and Jennifer suggested additional videos in the resource centre could be beneficial, especially ones that depict real coaches and clients “so that coaches can see what a session where maybe there, it doesn’t go perfectly” (Sophie). 4.3.3.2.2.3 Encouraging practice 92 Another idea that staff brought forward to improve the mock session was suggesting that coaches practice mock sessions before completing the formal mock session with an SSBC staff member. Staff were aware that coaches wanted more opportunities to practice the mock session, but Jennifer stated that, “adding another mock session is not sustainable. I think encouraging potential practice though, with especially at the site…Maybe we upload like a mock client script of some sort [to the resource centre], and they can like practice with someone at their [site] who’s also training and they can switch roles.” Staff also suggested that site leads could help coaches practice mock session scenarios before completing the formal mock session. 4.3.3.2.3 Feedback is a necessary training component Sophie viewed the mock session feedback as a critical step in the coach training process, saying, “I think the feedback is almost equally [important as doing the mock session]…I write them feedback so that if they were to implement all of those pieces [from the feedback], they would be delivering SSBC [to our standards].” Based on coach interviews, coaches agreed that the feedback was a necessary training component. 4.3.3.2.4 Importance of testing coaches Staff noted that evaluating the coaches’ skills and knowledge was important for the coaches to learn and to ensure that all coaches met the SSBC standard before delivering SSBC to real-world clients. Jennifer summed up sentiments from all three staff when she noted, “[Coaches] learn a lot from the modules. I think a mock session gives them a chance to practice their skills and get feedback.” Sophie highlighted that, “Having the mock session as like a failsafe check almost, to make sure that coaches are up to our standards. So I do think that is really important.” 4.3.3.2.5 Can’t stop training after certification 93 All three SSBC staff believed that the training should not stop after coaches are certified. The staff did not think that additional components should be added to the training process for coaches to become certified, but did discuss ways to help the coaches learn after certification and ensure coaches were maintaining their skills and knowledge. Suggestions included incorporating a community of practice or forum for coaches to connect with and learn from other coaches; refresher courses to maintain certification; and regular meetings with coaches at each site led by site leads. 4.4 Discussion E-learning is an efficient and effective way to deliver training to large numbers of people spread across large geographical areas (Cook, 2007; Kimura et al., 2023). Understanding the perspectives of e-learning training users is important to further refine e-learning training to enhance effectiveness, acceptability, and sustainability. The purpose of this study was to understand SSBC coaches’ and staffs’ perspectives on the SSBC coach e-learning training. Several themes were constructed in this study to capture coaches’ and staffs’ various perspectives. There were seven main themes constructed from the coach interviews: (a) training design, (b) “I didn’t know what to expect from the training”, (c), technology usability, (d) learning, (e) coaches’ background shaped their training experience, (f) support, and (g) coaches valued the training; and two themes constructed from the staff interviews: (a) streamlining the training delivery and (b) ensuring coaches meet the “SSBC standard”. The online modules and resource centre were favourably viewed by all coaches and staff. Technology issues are often cited as one of the downsides to e-learning training (Kimura et al., 2023), however, it is possible that the high up-front cost associated with the online platform for this training helped to avoid technology issues. Staff suggested additional applications for the 94 online platform to further alleviate their workload required per coach. Automating staff tasks could enhance the cost-effectiveness of the training because once they are implemented, these components would require minimal staff attention and oversight. Coaches and staff all saw high value in the mock session training component as a means for learning and ensuring coaches were at the SSBC standard of delivery before delivering the program to clients at sites. The nervousness that coaches felt before engaging in the mock session could potentially be minimized by staff suggestions of clearer communication of expectations and better preparing coaches for the mock session. Some coaches will likely feel nervous before the mock session regardless of changes because the purpose of the mock session is to evaluate the coach's MI skills to ensure they meet the SSBC standard to pass the training. Coaches’ desire for more synchronous and in-person training components, specifically surrounding the mock session needs to be balanced with sustainability as the training scales up and reaches more coaches. The staff recommendation of promoting coaches practice for the mock session with peers and the site lead, has the possibility of striking the balance between giving coaches further practice and maintaining a sustainable training process. It is possible that as e-learning continues to become more widespread, coaches will have less desire for in-person and synchronous components due to their familiarity and confidence in e-learning training designs and their ability to learn through e-learning. The majority of the SSBC coach e-learning training design and development efforts were focussed on the process coaches would go through to become certified (Cranston et al., 2024). Less attention was paid to the staff delivery of the online training, which was reflected in several themes. Standardization of staff procedures, including clearer communication, needs to be highly prioritized to enhance both the coaches’ and staffs’ training experiences. It is possible that less 95 attention was given to the staff experience due to a scarcity of research on e-learning design and development (Cook & Ellaway, 2015). Evaluating user experience for both those taking and delivering e-learning training is important to capture nuances associated with training design. Despite the training design still needing further improvements, it is promising that coaches highlighted that they learned from the SSBC online coach training. Coaches shared what they learned and discussed their ability to practice and apply their gained knowledge and skills both within their SSBC sessions and other contexts. The training design allowed coaches to follow a systematic training process, while also utilizing their own learning strategies and approaches. Incorporating input from SSBC coaches during the design and development phases of the SSBC online coach training and working with experts in e-learning likely played a role in attenuating different learning styles. Our findings support Cook and Ellaway’s (Cook & Ellaway, 2015) sentiment of the importance of assessing participant experience and satisfaction. Despite thoroughly incorporating SSBC coach input and feedback during the design and development processes of the SSBC online coach training, there are still many areas for improvement within the training. The two main user groups for this online training were SSBC coaches and the SSBC staff facilitating the delivery of the training. Findings suggest that investing both time and resources into usable and high-quality technology may be worthwhile to enhance user experience. The use of technology that goes beyond PowerPoint slides and voice-over may lead to improved learner engagement as well as reducing staff burden. 4.4.1 Limitations The sample of coaches and staff was fairly homogenous with regard to the ethnicity of all participants, and the age of staff. As SSBC continues to scale-up nationally and globally, there 96 will be greater diversity in coach and staff demographics, and future research may be needed to further explore the experiences of those belonging to demographic groups not represented in this study. Secondly, this study was specific to the SSBC online coach training, which limits generalizability of study results. However, we attempted to structure the coding templates and results in a manner that other e-learning training developers or evaluators could learn from these results. Finally, coach interviews were predominantly conducted approximately three months after certification, which could limit their memory of how long they took to complete training and could have affected their perspective on the training. 4.4.2 Future directions Coaches and staff discussed that coaches learned from the SSBC online training and that there was a positive trickle-down effect for clients. In line with Cook and Ellaway’s TEL evaluation framework (Cook & Ellaway, 2015), future research must assess the learning outcomes (e.g., Kirkpatrick levels 2, 3, and 4) from this training, and a cost estimate of this training should be conducted to fully understand the sustainability. 4.5 Conclusion This study highlights the perspectives and experiences of coaches and staff as they interacted with the SSBC coach e-learning training. Understanding coach and staff perspectives is important given that they are the individuals delivering and receiving the training. Results demonstrated that coaches and staff valued a high-quality online platform, the importance of developing training with both coaches and staff in mind, and that incorporating several learning modalities and modes could cater to different learning styles and backgrounds. This study demonstrates that continued evaluation beyond the design and development of e-learning 97 training can provide insightful information which could lead to more effective, efficient, and acceptable e-learning training iterations. 98 Table 4.1 Participant demographics Variable Coaches Staff N Percent (%) N Percent (%) Age (years) 18-24 1 12.5 1 33.3 25-34 4 50 2 66.6 35-44 1 12.5 0 0 45+ 2 25 0 0 Sex Female 4 50 2 66.6 Male 4 50 1 33.3 Gender Man or primarily masculine 4 50 1 33.3 Woman or primarily feminine 4 50 2 66.6 Work status Working full-time (30 hours/week or more) 2 25 1 33.3 Working part-time (below 30 hours/week) and student 4 50 2 66.6 Student 1 12.5 0 0 Retired 1 12.5 0 0 99 1 Training design 1.1 Course content 1.2 Learning modalities – the “how” 1.2.1 Current learning modalities 1.2.2 Ideas for additional learning modalities 1.3 Online platform organization – the “layout” 1.4 Training synchronicity and mode 1.5 Training process 1.5.1 Communication to coaches 1.5.2 Systematic steps to becoming a certified coach 1.6 Coach testing 1.7 Receiving feedback 2 “I didn’t know what to expect from the training” 3 Technology usability 4 Learning 4.1 Coaches learned 4.1.1 Learning new knowledge 4.1.2 Demonstrating new knowledge 4.1.3 Readiness to deliver SSBC sessions 4.1.4 Application of learning 4.1.4.1 Anticipating application of learning within SSBC 4.1.4.2 Applying learning within SSBC 4.1.4.3 Transcending SSBC – applying learning in other contexts 4.2 The learning journey 4.2.1 Approach to completing the training 4.2.2 Individual learning strategies 4.2.3 Gradual learning curve 4.2.4 “Practice, practice, practice” before the mock session 4.2.5 The nerve-wracking experience of being evaluated 4.2.6 Learning through trial and error 4.2.7 Continued learning after certification 4.2.7.1 Using resources to foster session success 4.2.7.2 Real-world practice enhances mastery 4.2.7.3 Supplemental learning ideas 5 Coaches’ background shaped their training experience 6 Support 6.1 SSBC staff-to-coach support 6.2 Coach-to-coach support 6.2.1 Words of wisdom for new coaches starting the training 7 Coaches valued the training 7.1 Viewing the training as continuing education 7.2 The trickle-down effect of coach training on clients 7.3 Extending the training to non-coaching staff Figure 4.1 Final template for coach interview analysis 100 1 Streamlining the training delivery 1.1 What’s working 1.1.1 The online platform usability 1.1.2 Staff communication isn’t all bad 1.1.3 Being on the way to a sustainable process 1.2 Removing unnecessary training steps 1.3 Redistributing workload 1.3.1 Amount of staff time required to train each coach 1.3.2 Automating procedures 1.3.3 Defined roles 1.3.3.1 Staff coordinator 1.3.3.2 Site lead 1.3.3.3 Mock session coders 1.4 Clearly communicating all expectations 1.5 Standardizing procedures 2 Ensuring coaches meet the “SSBC standard” 2.1 Extra support for the first coach at each site 2.2 Setting coaches up for mock session success 2.2.1 More realistic mock sessions 2.2.2 Resource modification 2.2.3 Encouraging practice 2.3 Feedback is a necessary training component 2.4 Importance of testing coaches 2.5 Can’t stop training after certification Figure 4.2 Final template for staff interview analysis 101 Chapter 5: Effectiveness of brief e-learning training for diabetes prevention program coaches: Outcome evaluation 5.1 Introduction Approximately 4.5 million Canadians are currently living with type 2 diabetes (T2D) (Diabetes Canada, 2023). T2D prevention programs have demonstrated efficacy in reducing individuals’ risk of developing T2D through diet and exercise modifications (Knowler et al., 2002; Lindström et al., 2003; Pan et al., 1997). These landmark diabetes prevention programs were resource-intensive and therefore not sustainable for scale-up. Modifications to improve the scale-up of landmark diabetes prevention programs have included implementing them in community-based settings, and training lay educators rather than highly trained healthcare professionals to deliver the programs (Galaviz et al., 2018). Small Steps for Big Changes (SSBC) is a Canadian community-based diabetes prevention program currently offered in British Columbia. SSBC is delivered in fitness facilities (e.g., YMCAs) by fitness facility staff and volunteers (e.g., SSBC coaches). SSBC clients (i.e., adults at an elevated risk of T2D) meet one-on-one with an SSBC coach for six sessions over 4-6 weeks. In each of the six sessions, SSBC coaches deliver evidence-based diet and physical activity information using a motivational interviewing (MI)-informed style. MI is a client-centred communication style that aims to bolster clients’ motivation and commitment to making change (W. R. Miller & Rollnick, 2023). Self-determination theory (SDT) has been proposed as a possible theoretical framework to explain how MI works (Vansteenkiste & Sheldon, 2006) because of the close alignment between the relational aspect of MI (i.e., the spirit of MI) and the components of SDT. SDT posits that humans have three basic psychological needs – autonomy, 102 competence, and relatedness – and when these needs are met, people tend to be more motivated to act or change. SSBC coaches are provided with brief training covering topics related to MI, SSBC content, and T2D prevention. To further sustainability of SSBC, coach training transitioned from a three-day in-person workshop to an online format. Online training provides a more flexible training option, which is critical as SSBC scales up nationally and globally (Kimura et al., 2023). The online SSBC coach training consists of: 1) seven asynchronous modules; 2) a mock session with an SSBC training delivery staff, where coaches are required to demonstrate a level of client-centred MI and delivery of SSBC session content; and 3) passing a post-training knowledge survey with a minimum score of 70%. The online coach training was developed with a systematic and user-centred approach (Cranston et al., 2024) and has since been implemented within the SSBC program across all sites. Evaluation of training programs is a critical step following implementation to understand if and how the training program is working, and where improvements could be made. The technology-enhanced learning (TEL) evaluation framework (Cook & Ellaway, 2015) is a seven-step comprehensive framework used to evaluate online training. Briefly, the seven steps are: 1) a needs analysis and environmental scan, 2) document processes, decisions, and final product, 3) test usability, 4) document key events during implementation and final product, 5) assess participant experience and satisfaction, 6) assess learning outcomes, and 7) estimate cost, reusability, and sustainability. Steps one to four of the TEL evaluation framework have previously been published (Cranston et al., 2024). A qualitative examination of coaches’ and SSBC training delivery staffs’ experiences (TEL evaluation framework step five) with the online training has also been published, with favourable results and suggestions for improvements to the 103 training (Cranston, Grieve, & Jung, Submitted). The Kirkpatrick model (Kirkpatrick, 1998), which is embedded within the TEL evaluation framework, provides a sequence of four steps to further evaluate coaches’ satisfaction (TEL evaluation framework step 5) with the training using quantitative methods (Kirkpatrick level 1), as well as evaluating the effects of the training (TEL evaluation framework step 6) on coaches’ learning (Kirkpatrick level 2), their behaviours delivering SSBC to clients (Kirkpatrick level 3), and the effect of their knowledge and skills on client outcomes (Kirkpatrick level 4) The objective of this study was to evaluate the outcomes of the online SSBC training coach training using the Kirkpatrick model. Thus, this study had four aims: 1) to assess coaches’ satisfaction with the online coach training; 2) to examine the extent to which the training changed coaches’ knowledge regarding T2D prevention, MI, and SSBC content; 3) to assess coaches’ enactment of MI and delivery SSBC session content to SSBC clients after completing the training; and 4) to assess client results (i.e., satisfaction with coaches’ support of basic psychological needs, and changes in weight and waist circumference) after going through the SSBC program. 5.2 Methods 5.2.1 Study design This study was conducted as part of a larger SSBC effectiveness study. All coach participants were provided with the same online SSBC coach training. Data was collected while SSBC was being delivered at six fitness facilities in British Columbia, Canada. Ethical approval was obtained by the University of British Columbia’s Behavioural Research Ethics Board. 104 5.2.2 Participants (coaches and clients) All coaches and clients provided informed consent prior to participating in this study. Coaches were included in this study if they completed the training and had delivered SSBC sessions to a minimum of two clients and had: a) audio-recorded their sessions with the clients, and b) completed session delivery checklists for the clients. 5.2.3 Kirkpatrick level 1: reaction 5.2.3.1 Procedures To assess coaches’ reactions to the training, they were provided with a satisfaction survey via the online training platform upon completion of the coach training. 5.2.3.2 Measure The 27-item study-specific reaction survey was informed by Cook and Ellaway’s TEL evaluation framework (2015), Ruggeri (2013), Sun (2008), and Wang (2003). The satisfaction survey contained three subscales: 1) satisfaction with training content, 2) user engagement, and 3) technical experience. Coaches were asked to respond to each item on a 5-point Likert-scale, with 1 representing totally disagree and 5 representing totally agree. 5.2.3.3 Data analysis A mean score and standard deviation were calculated for the entire satisfaction survey as well as for each of the three subscales. 5.2.4 Kirkpatrick level 2: learning Based on the results observed in a previous study examining the preliminary effects of the SSBC e-learning training on a broader population (e.g., graduate students, YMCA staff) (Grieve et al., 2023), we anticipated a large effect size (i.e., Cohen’s d = .83). 14 participants 105 were required to have 80% power to detect significant within-groups differences of this magnitude with  = .05. 5.2.4.1 Procedures Once coaches were provided with access to the online training platform, they completed the pre-training questionnaire, which consisted of demographics questions, and knowledge questions categorized into three groups: T2D prevention, MI, and SSBC program content. Upon completion of the pre-training questionnaire, coaches completed the seven asynchronous training modules at a self-directed pace, completed a synchronous mock session with an SSBC training delivery staff, and then completed a post-training questionnaire. The post-training questionnaire included the T2D prevention, MI, and SSBC program content knowledge questions, and the reaction survey (see Level 1: Reaction). The pre-and post-knowledge questionnaires asked questions related to information contained in the seven asynchronous modules. 5.2.4.2 Measures 5.2.4.2.1 T2D prevention knowledge The nine-item measure consisted of true-or-false questions related to general knowledge about T2D and T2D prevention. 5.2.4.2.2 MI knowledge MI knowledge included seven multiple-choice questions related to the spirit of MI and foundational MI skills. 5.2.4.2.3 SSBC program knowledge Ten multiple-choice questions covered information related to SSBC program content and logistics. 106 5.2.4.3 Data analysis Two-tailed paired samples t-tests were used to compare changes in knowledge from pre- to post-training with a significance value of 0.05. Cohen’s d was calculated to determine the size of any potential effects. 5.2.5 Kirkpatrick level 3: behaviour 5.2.5.1 Procedures After certification, coaches independently led clients through the SSBC program. For each SSBC session, coaches were instructed to audio-record the counselling session and complete session-specific checklists that covered core session components. Using the counselling session audio recordings and session-specific checklists, two coach behaviours were examined: MI delivery and SSBC session content delivery. One randomly selected session (either session 2, 3, 4, or 5) per coach-client pair was included in the behaviours analysis. SSBC sessions 1 and 6 were excluded from the random selection as they had slightly different session structures. 5.2.5.2 Measures 5.2.5.2.1 MI delivery Quality of MI delivery was assessed using the MI Competency Assessment (MICA) (Jackson et al., 2015) to code selected session audio-recordings. For each selected session, a maximum of 20-minutes was coded (per MICA recommendations). Up to 15 minutes of coaches delivering new information and up to 5 minutes of goal setting were coded. Using the MICA, we were able to assess coaches’ use of five MI intentions (partnering, evoking, guiding, expressing empathy, and supporting autonomy and activation) and two MI strategies (strategically responding to sustain talk and strategically responding to change talk). The MI intentions 107 represent aspects of the spirit of MI as well as behaviour change theories including SDT (Ryan & Deci, 2000). Coaches’ responses to client change talk, sustain talk, and ambivalence have the potential to help clients move towards making change, and this is assessed by the two MI strategies. Each MI intention and strategy was scored on a 5-point scale (with half points permitted) where 1 represented fundamentally inconsistent with MI and 5 represented proficient MI. 5.2.5.2.2 SSBC session content delivery To measure coaches’ behaviour of delivering SSBC session content, 1) coach checklists were reviewed (hereafter referred to as coach-reported SSBC session content delivery) for selected sessions, and 2) audio-recordings of selected sessions were reviewed and session checklists were re-completed by the first author based on audio-recordings (hereafter referred to as audited SSBC session content delivery). Session checklists were divided into four sections: checking in on client’s previous goals, delivering new information, goal setting, and wrapping up the session. For audited SSBC session content delivery, coaches responded to whether they addressed each session component within their session by checking boxes labelled yes or no. Coders listened to audio recordings of the session and completed blank session checklists by checking boxes labelled yes or no for the same session components that coaches filled out. 5.2.5.3 Data analysis As per MICA recommendations for analysis, the average of the five MICA intentions was summed with the average of the two MICA strategies to create a total MICA score (/10). Additionally, we reported an average MICA intention score (/5) because in cases where sustain talk or change talk were not present in a session, a score of 3/5 would be given for those strategies, which could bias the total MICA score. The average MICA intention score (/5) was 108 calculated by averaging the five MI intentions. MICA total scores and average MICA intention scores were broken down per coach and reported as descriptive statistics including mean, standard deviation, and range. SSBC session content delivery (both audited and coach-reported) was calculated on a session-by-session basis by counting the number of instances content was delivered as intended and dividing by the total number of items. Scores were then converted to percentages, representing the percentage of session content delivered. For each session, a coach-reported score and an audited score were calculated. Additionally, we calculated the agreement between coach-reported and audited SSBC session content delivery, as well as coder agreement for audited SSBC content delivery, using Cohen’s kappa, prevalence and bias adjusted kappa (PABAK) (Byrt et al., 1993; G. Chen et al., 2009), and percent agreement. Measures using the audio recordings (MI delivery and audited SSBC session content delivery) were double-coded to enhance coding reliability. For the MICA, KC coded all selected sessions. NG and RR acted as double-coders for KC. 10% of sessions were coded by KC, NG, and RR to ensure all coders were consistent with one another. An additional 15% and 10% were double-coded by NG and RR, respectively. For audited SSBC session content delivery, KC coded all selected sessions, with a research assistant acting as a double-coder for 46% of coded sessions. Coding agreement statistics for MICA coding were analyzed using intra-class correlation coefficients (Koch, 2005). 5.2.6 Kirkpatrick level 4: results 5.2.6.1 Procedures Client demographics and anthropometrics were collected at their first and final (i.e., sixth) SSBC session with their coach. At the end of a client’s sixth SSBC session, coaches were 109 also instructed to ask clients to complete a 15-item measure; the learning climate questionnaire (LCQ) (Standage et al., 2005; Williams & Deci, 1996), to examine the extent to which clients felt coaches supported their basic psychological needs. 5.2.6.2 Measures 5.2.6.2.1 Learning climate questionnaire In a systematic review, Phillips and Guarnaccia (Phillips & Guarnaccia, 2017) recommended that measuring SDT variables could be useful to assess MI interventions. At the end of their sixth session, clients responded to each question using a 7-point Likert-scale where 1 was strongly disagree and 7 was strongly agree. Of the 15 questions six address autonomy-support, four address competence, and five address relatedness. 5.2.6.2.2 Weight At their first and sixth SSBC session, coaches measured clients’ weight by having them stand on a stadiometer wearing light clothes and no shoes. Weight was measured in pounds and rounded to the nearest pound. 5.2.6.2.3 Waist circumference Waist circumference was also measured at the clients’ first and sixth sessions. Coaches were instructed to measure clients’ waist circumference at the top of clients’ iliac crest (hip bone). Measurements were taken at the end of a client’s normal exhale. Waist circumference measurements were recorded in centimeters and rounded to the nearest tenth of a centimeter. 5.2.6.3 Data analysis The LCQ total score and the three sub-scale scores (i.e., autonomy-support, competence, and relatedness) were calculated by averaging the included items. LCQ results were reported using descriptive statistics including mean, standard deviation, and range. Changes in weight and 110 waist circumference were calculated using two-tailed paired samples t-tests with a significance value of 0.05. Effect size was reported as Cohen’s d. 5.3 Results A total of 14 coaches were included in this study. Of the coaches, 64% self-reported as female, 57% were not born in Canada, and 33% reported receiving previous training in counselling. See Table 5.1 for more demographic details. For levels 3 and 4, coaches had a range of two to five clients, with a total of 41 clients included in this study. 5.3.1 Kirkpatrick level 1: reaction Overall, coaches were satisfied with the training (M = 4.58/5  .32). Coaches had very favourable levels of satisfaction with all three subscales: satisfaction with the training (M = 4.65/5  .29), user engagement (M = 4.5/5  .41), and technical experience (M = 4.46/5  .49). 5.3.2 Kirkpatrick level 2: learning Paired samples t-tests demonstrated statistically significant increases in coaches’ knowledge from pre- to post-training for T2D prevention (Mpre = 6.29  1.73, Mpost = 7.86  1.1; t(13) = 2.75, p < .05, d = .74), and SSBC (Mpre = 3.14  1.7, Mpost = 8.00  1.3; t(13) = 8.48, p < .001, d = 2.27), but not in MI (Mpre = 5.21  1.97, Mpost = 5.14  .95; t(13) = .11, p = .91, d = .03). 5.3.3 Kirkpatrick level 3: behaviour On average, counselling sessions lasted 37 minutes (SD = 15.6). Coaches were delivering an average MICA total score of 4.7/10 (SD = .8), meaning they were delivering sessions at a level generally inconsistent with MI. Similarly, the average MICA intentions score (M = 2.5  .4) demonstrated that coaches were at an overall level of generally inconsistent with MI. Coaches reported delivering 97% of SSBC session content (SD = 7.8), with audited SSBC session content 111 delivery revealing that coaches delivered 78.3% of session content (SD = 19.8). See Table 5.2 for behaviour MICA scores broken down into each MI intention and strategy. Coder agreement scores for the MICA was moderate to excellent (ICC = .65-.97). Agreement between coach-reported and audited session content delivery demonstrated a 79% percent agreement (Cohen’s kappa = .09; PABAK = .59). The two coders for audited SSBC content delivery agreed on 83% of items (kappa = .53; PABAK = .66). 5.3.4 Kirkpatrick level 4: results Of the 41 total clients included in this study, 30 had weight measurements taken at both timepoints, 29 had waist circumference measurements taken at both timepoints, and 23 completed the LCQ. Of the clients (n=32) with any valid level 4 data, the average age was 65 years (SD = 13), 75% self-reported as female, and 34% were retired. Additional client demographic data can be found in Table 5.3. Clients perceived that their coaches were highly supportive of their basic psychological needs, with an average total LCQ score of 6.67/7 (SD = .61). Average LCQ scores for autonomy-support, competence, and relatedness were 6.59/7 (SD = .64), 6.7/7 (SD = .62), and 6.76/7 (SD = .61), respectively. A paired samples t-test for weight demonstrated no significant changes in weight from session 1 (Mpre = 177.53  45.71) to session 6 (Mpost = 171.57  38.62; t(29) = 1.5, p = .14, d = .28).. Conversely, a paired samples t-test for waist circumference demonstrated a statistically significant decrease from session 1 (Mpre = 103.41  15.03) to session 6 (Mpost = 101  13.02; t(28) = 2.2, p < .05, d = .41). 112 5.4 Discussion This study aimed to evaluate the outcomes (TEL evaluation framework steps 4 and 5) of the online SSBC coach training using the Kirkpatrick model (Kirkpatrick, 1998). As e-learning continues to become more widespread, it is imperative to evaluate the effectiveness of online training programs to discern success strategies and areas for improvement. Understanding the effects of training on multiple levels including coaches’ satisfaction, learning, behaviours, and training outcomes is necessary to have confidence in the training. In general, SSBC coaches were highly satisfied with the online training and the training increased coaches’ knowledge about T2D prevention and SSBC. Coaches delivered the majority of SSBC session content to clients using a communication style that was generally inconsistent with MI. There were significant reductions in clients’ waist circumference, and they reported that coaches met their basic psychological needs. Coaches were highly satisfied with all aspects of the SSBC coach online training, which is consistent with previous qualitative results looking at their experiences and satisfaction with the SSBC training (Cranston, Grieve, & Jung, Submitted). The high levels of satisfaction could be in part related to the systematic and user-centred approach to developing this training (Cranston et al., 2024). Additionally, the satisfaction results from this study are consistent with other e-learning research (Kulaksız et al., 2023; Rouleau et al., 2019), supporting the idea that e-learning should continue to be considered when training healthcare professionals and lay educators to deliver health programs. Results demonstrated that coaches gained knowledge about T2D prevention and SSBC (i.e., learned) from the training. These results are promising in that a brief online training, a sustainable format for training coaches across diverse geographical locations, can effectively 113 teach SSBC coaches the knowledge they need to deliver SSBC to clients. While knowledge in MI did not significantly change from pre- to post-training, on average coaches started the training with strong levels of MI knowledge (based on pre-training MI knowledge scores). Unsurprisingly, coaches had low baseline levels of SSBC content, likely due to their naivety to the SSBC program before signing up to become coaches. The majority of e-learning evaluation research has focussed on Kirkpatrick’s levels one and two (Kulaksız et al., 2023; Rouleau et al., 2019; S. Sinclair et al., 2016). However, evaluating coach behaviour (level 3), or delivery fidelity, is critical as it allows for replicability and accurate interpretation of health programming results (Bellg et al., 2004). Overall, coaches delivered the session content with high fidelity. While coaches reported higher levels of SSBC session content delivery than the audited data suggested, agreement was still high. The discrepancy between coach-reported and audited session content delivery may be attributed to social desirability bias, wherein coaches felt compelled to overstate the amount of content delivered to please the research team. As SSBC continues to scale-up, the research team can have fairly high confidence in coaches’ reported session content delivery, potentially reducing the need to audit audio recordings for content delivery. MI fidelity data revealed that coaches were delivering SSBC at a level generally inconsistent with MI (<6/10). Despite no coaches averaging a level of client-centred MI (6-7.9/10), there were instances of coaches delivering client-centred MI to individual clients (see coach 9 and 14 in Appendix D.1). MI is a collaborative communication style that might differ from the prescriptive and directive communication style traditionally seen in healthcare and fitness. As all coaches were staff and volunteers within fitness facilities, it is likely that the communication styles they use in their professional roles (e.g., group fitness class, personal training) might differ from the principles of 114 MI. Previous research demonstrates that MI training enhancements, such as booster sessions following initial training, are effective at improving practitioners’ MI skills (Britt & Blampied, 2010). Future research should explore whether additional training following SSBC coach certification can help coaches reach a level of client-centred MI. Despite coaches delivering SSBC sessions in a generally MI-inconsistent manner, clients still decreased their waist circumference and reported that coaches supported their basic psychological needs. There is ample evidence suggesting that MI is effective at helping individuals make health behaviour changes (Frost et al., 2018; Martins & McNeil, 2009), and yet SSBC clients still saw positive outcomes. Potential explanations for favourable client outcomes despite coaches’ delivery of client-centred MI are that SSBC clients are highly motivated to make behaviour changes, that the 43 behaviour change techniques embedded in the SSBC program (MacPherson et al., 2020) promote clients to successfully engage in behaviour changes, and that coaches’ attempts at delivering MI are good enough to help people move towards change. 5.4.1 Limitations This study was conducted in real-world settings, and therefore had some missing data. Some certified SSBC coaches could not be included in this study as they did not have audio recordings or completed SSBC content session delivery checklists. As such, results from this study might not be generalizable to those coaches not included. Additionally, we encountered missing data for client outcomes, limiting the power for the level four paired samples t-tests. Additionally, level three data was reported for only one of six sessions with each client. Selecting only one session per client does not account for coaches having “off” days in terms of MI and session content delivery. 115 5.4.2 Future directions Future research could explore whether client outcomes are predicted by coaches’ levels of MI delivery or SSBC session content delivery. Furthermore, future research should assess the effects of post-certification training enhancements on coaches’ MI skills. Future research could also examine long-term client outcomes (e.g., one-year post-program) to determine if coach training is helping clients maintain the health behaviour changes they made during the SSBC program. 5.4.3 Conclusion Evaluating e-learning programs at all four levels of the Kirkpatrick model is critical to fully understand the effects of training. This study demonstrated that SSBC coaches were satisfied with the online training, sufficiently gained knowledge from the training, applied their learning through behaviours with some success, and resulted in favourable outcomes for clients. Overall, results showed that the online SSBC coach training is effective. 116 Table 5.1 Coach demographics Individual-level factor M  SD (range) Age (years) 35.5  13.6 (23-64) N Percent (%) Sex Female 9 64.3 Male 5 35.7 Born in Canada Yes 6 42.9 No 8 57.1 Highest level of education High school 2 14.3 Apprenticeships, trades services, or diploma 1 7.1 College, CEGEP, or other non-university certificate or diploma 3 21.4 University certificate or diploma below the bachelor level 1 7.1 University certificate, diploma, or degree 6 42.9 Currently in some university or college 1 7.1 Occupation status Working full-time 6 42.9 Working part-time 6 42.9 Student 2 14.3 Previous counselling training Yes 5 35.7 No 9 64.3 117 Table 5.2 Kirkpatrick level 3 MICA strategies and intentions scores MICA category (/total) Mean  SD (range) MICA total score (/10) 4.7  .8 (2.2-6.1) MICA intentions score (/5) 2.5  .4 (1.2-3.1) MICA strategically responding to ST (/5) 2.5  .5 (1-3) MICA strategically responding to CT (/5) 1.8  .7 (1-3) MICA partnering (/5) 2.4  .5 (1-3.5) MICA evoking (/5) 2.3  .5 (1-3) MICA guiding (/5) 2.6  .5 (1-3) MICA empathy (/5) 2.6  .5 (1-3.5) MICA autonomy (/5) 2.5  .4 (1-3) 118 Table 5.3 Client demographics Individual-level factor M  SD (range) Age (years) 63.7  13.9 (20-80) N Percent (%) Sex Female 27 65.9 Male 5 9.8 Missing 10 24.4 Highest level of education Did not complete high school 2 4.9 High school 5 12.2 College, CEGEP, or other non-university certificate or diploma 15 36.6 Currently in some university or college 1 2.4 University certificate, diploma, or degree 6 14.6 Post-graduate degree 2 4.9 Missing 10 24.4 Occupation status Working full-time 2 4.9 Working part-time 2 4.9 Student 1 2.4 Retired 12 29.3 Retired and working part-time 2 4.9 Missing 22 53.7 Relationship status Single 2 4.9 Married 12 29.3 Widowed 5 12.2 Missing 22 53.7 119 Chapter 6: Small steps to an inclusive diabetes prevention program: How Small Steps for Big Changes is improving program equity and inclusion 6.1 Introduction Increased risk of developing type 2 diabetes (T2D) is associated with lower income and education levels, unemployment, immigrant status, and being of African, South Asian, or Indigenous origins (Booth et al., 2012; Branfield Day et al., 2020; Lipscombe et al., 2010; Public Health Agency of Canada, 2018). Not only are these groups at higher risk of developing T2D, but they also face many challenges when it comes to navigating healthcare systems. The stigma associated with T2D (Banasiak, 2020), the mistrust of those working in healthcare (Turpel-Lafond, 2020), and the costs associated with treatments (Diabetes Canada, 2021) are only a few barriers that these individuals may face. While landmark diabetes prevention programs (DPPs) (Knowler et al., 2002; Lindström et al., 2003; Pan et al., 1997) have shown that adhering to a healthy diet and engaging in regular physical activity can decrease T2D risk, many were not designed with sustainability or implementation in mind, nor with consideration of equitable and inclusive delivery. DPPs need to be flexible, low-cost, community-based, and inclusive to those at higher risk of developing T2D to overcome the systemic inequities and barriers they face. A review of lifestyle modification DPPs highlighted that most DPPs are implemented in high-income countries, few focus on ethnic groups that are at greatest risk for T2D, and on average, DPPs included in the review lasted 23 weeks (Galaviz et al., 2018). To address the incongruency between those at highest risk for T2D and those who participate in DPPs, we used the ConNECT Framework, designed to advance health equity within the field of behavioural medicine (Alcaraz 120 et al., 2017) and input from a stakeholder1 advisory group to make recommendations for changes to a community-based DPP, Small Steps for Big Changes (SSBC). SSBC is an evidence-based, diet and exercise behaviour change counselling program for individuals at risk of developing T2D. SSBC consists of a training and follow-up phase. The training phase includes six brief one-on-one sessions which take place over three to four weeks. The follow-up phase includes check-ins and measurements at one-, six-, and 12-months post-training. Efficacy and preliminary program effectiveness have been demonstrated (Bean et al., 2021; Jung et al., 2020; Locke et al., 2018). Individuals who completed the community-based program were highly educated (74.9% have college certificate or higher), female (70.9%), and White (85.2%; please note we reported “Caucasian” in Bean’s paper (Bean et al., 2021), but have since made changes to exclude the term “Caucasian” – see Table 6.1). Further, more than half of those who were eligible to participate in the community-based program and provided a reason as to why they chose not to, stated that it was due to geographical location because at the time SSBC was only offered in-person in Kelowna, British Columbia, Canada (Bean et al., 2021). Despite the promising results of SSBC, there is a need to ensure that program delivery is flexible and inclusive to improve program reach and sustainability as SSBC scales up to rural and more diverse communities. Core intervention components and further details of the SSBC program can be found in Bean and colleagues’ manuscript (Bean et al., 2021).This paper aims to describe the ongoing and iterative changes to SSBC to improve inclusivity and equity based on the stakeholder advisory committee and the ConNECT Framework, and provide recommendations (see Table 6.1) for others to incorporate into their own community health programs. The 1 The term stakeholder has colonial origins. Stakeholder was the term used in the published manuscript associated with this chapter, and thus has been left in. If I was to write this Chapter now, I would not use the term stakeholder and would have instead used the term invested party. 121 stakeholder advisory committee included members of the SSBC research team and SSBC coaches, who met and discussed inequities and missed opportunities for inclusion within SSBC. The ConNECT Framework’s principles (1. Integrating Context; 2. Fostering a Norm of Inclusion; 3. Ensuring Equitable Diffusion of Innovations; 4. Harnessing Communication Technology; and 5. Prioritizing Specialized Training) were then reviewed and used to provide additional actions to improve SSBC equity and inclusion. To improve program accessibility, delivery of the core components was adapted to better implement SSBC across different communities and increase program reach. Specifically, SSBC made changes to eligibility, and program delivery and evaluation. All changes were made in consultation with potential end-users. We hope that this paper can serve as a tool to improve the reach and inclusivity of DPPs. While we do not believe that there are any specific skillsets, training, or education required to implement the recommendations in Table 6.1 and throughout this paper, we do believe that it is important to state our positionality. All four authors have post-secondary education and have received training related to implicit biases, equity, diversity, and inclusion. We acknowledge that our positionality and privilege influenced this paper and the recommendations in Table 6.1. We hope that our collaborative team approach, the use of the ConNECT framework, and input from the stakeholder advisory committee increases the chances that our recommendations can be implemented by individuals of diverse backgrounds and experiences. The remainder of this paper provides detailed explanation regarding how and why changes were made within SSBC and provides recommendations for other dietary- and physical activity-based behaviour change programs to improve inclusivity and equity. 122 6.2 Changes to SSBC 6.2.1 Stakeholder engagement Development of a stakeholder advisory committee (SAC), patient advisory committee (PAC), and a formal partnership with the YMCA of Southern Interior BC (Bean et al., 2020) has ensured that SSBC has, and will continue to meaningfully engage with end-users. These committees meet twice yearly to discuss program processes and outcomes and provide feedback on the program. Including the SAC, PAC, and YMCA in the decision-making processes ensures that SSBC better meets the needs of all end-users, from those referring to and recommending the program (SAC), to those who deliver the program (YMCA), and those receiving the program (PAC). 6.2.2 SSBC content Diet and physical activity are key behavioural targets within SSBC. As such, we provide recommendations on why these behaviours influence T2D risk, and how clients can integrate these changes into their daily lives. However, these are complex behaviours that extend beyond the individual to their environmental context (i.e., does this client live in a food desert? Live near a gym?). Thus, we changed our recommendations. Rather than suggesting more expensive foods when discussing dietary changes such as avocados and nuts, clients learn about more affordable foods such as canned beans, legumes, and frozen vegetables that still fit within the complex carbohydrate, low-sugar guidelines. In addition to dietary behaviour changes, increasing exercise in the form of either moderate- or high-intensity exercise is another main component of SSBC. Clients are provided with recommendations on how to exercise in a variety of settings without the need to purchase a gym membership (e.g., walking outdoors). Examples also include activities beyond Western 123 ideas (e.g., dancing, food harvesting). These changes ensure that SSBC recommendations are attainable for clients of any income or cultural background. Language is powerful and can shape thoughts, feelings, behaviours, and experiences. It is important to ensure that program materials and delivery uses inclusive and person-first language. Further, all language we use in SSBC strives to be more inclusive (see Appendix E.1). 6.2.3 SSBC program delivery Many DPPs require clients to take time out of their workday to attend several in-person sessions at local fitness, community, or health centers. This can be a barrier for people with limited flexibility (Lieberman et al., 2019; Rho et al., 2020; Turcotte & Savage, 2020). DPPs that demand an intensive and rigid time commitment limit participation and exclude those who work long shifts, lack flexible transportation, or require childcare. To improve equity and reduce barriers to access, SSBC is offered to clients during all operating hours of the YMCA to accommodate a wider range of client availability. Additionally, SSBC changed the structure of the training phase from six sessions over three weeks, to four weeks. The YMCA (SSBC delivery site) offers assisted membership to reduce the financial barriers for those choosing the attend the program in-person. Reach and accessibility of SSBC has been greatly improved by offering a virtual program option. Virtual sessions increase reach to individuals who 1) cannot travel during the workday but may be able to call in during a break; 2) live in rural areas without a YMCA facility nearby, and 3) are immunocompromised and wary of entering heavily populated fitness facilities. Additionally, allowing clients to call in for sessions by phone or video ensures that those without access to stable high-speed internet are not excluded from participating. 124 6.2.4 SSBC promotional material The promotional materials for programs send a message about what type of person is being targeted. SSBC promotional material includes a website, posters, pamphlets, a coach training website, and social media. Previously, photo and video content included current and past SSBC clients; however, SSBC clients to date represent a homogenous group, mainly consisting of White women. This homogenous group does not represent those at highest T2D risk. As such, we have increased diversity across promotional materials through targeted hiring of models. It is critical that SSBC is promoted as a program for people of all backgrounds and identities. 6.2.5 Train-the-trainer Cultural safety training is becoming more common in healthcare (Kurtz et al., 2018), however, many health professionals still do not receive such training (Turpel-Lafond, 2020). Culturally safe care means that clients feel safe, respected, and like they have power in decisions (First Nations Health Authority, 2021). There is extant evidence of stereotypes and biases that health professionals hold against Indigenous peoples in Canada and other equity-deserving and historically oppressed groups (Browne, 2005; Cuevas et al., 2016; Higginbottom et al., 2016; Ly & Crowshoe, 2015; Salm Ward et al., 2013). Negative healthcare experiences can result in equity-deserving groups avoiding Western medical treatment altogether. SSBC mandates all coaches complete a program-specific cultural safety and inclusivity training module. The module was informed by existing healthcare provider resources (Indigenous Health, 2017; Interior Health, 2019; Saskatoon Health Region, 2016) and literature on culturally safe and unsafe interactions (Brascoupé, 2009; Hole et al., 2015; Jacklin et al., 2017), and was developed by a multidisciplinary team. Further details about this module can be found elsewhere (Cranston, Sim, et al., Submitted). 125 6.2.6 Program clients DPPs often have strict eligibility criteria (e.g., (Abujudeh et al., 2012; Aekplakorn et al., 2019; Aguiar et al., 2016)). These criteria are important in testing clinical efficacy but can lead to inequitable access to when applied in translational DPPs purposed for improvement of public health. Limiting participation within DPPs also limits the generalizability of results. Older adults and those with high BMI are often excluded from participating in DPPs (e.g., (Aekplakorn et al., 2019; Aguiar et al., 2016; Alfawawz et al., 2018)). Given that T2D risk increases with age, imposing such limits on participation can unnecessarily reduce the reach and representativeness of DPPs to those at highest risk. By increasing the age range of those eligible to participate in DPPs, this will improve program reach to those at higher risk. BMI is a commonly used measure of weight status; however, utility of BMI as a measure of obesity at an individual level is questionable (M. A. Green, 2016). Limitations of BMI are further supported by Obesity Canada’s updated 2020 guidelines (Rueda-Clausen et al., 2020). Using BMI as inclusion criteria provides little information about the contextual complexity of a patient and is problematic as BMI categories were originally developed based on predominantly White individuals, specifically males of European origins (K. R. Fontaine et al., 2003). SSBC has greatly expanded age and BMI eligibility, within safety limits, to 18 years of age and older and no BMI limits. 6.2.7 Measurements Measurements are necessary to ensure that a DPP is reaching the intended audience and is being implemented as intended, whilst making lasting health behaviour changes. Sociodemographic information can be useful in determining healthcare access and experiences, 126 health inequities, biological differences, and the reach of studies. Often, sociodemographic variables are asked inappropriately or missed. For all measurements in research, including sociodemographic measures, it is important to justify why and how questions are being asked, and decide a priori how data will be analyzed. To make programs more inclusive, it is critical to think about how the measures may be interpreted by clients and to make the measurements feel safe and inclusive. 6.2.7.1 Sociodemographics Our research team takes the stance that it is important to be purposeful with the measurements that you choose to collect, but that it is necessary to collect sufficient sociodemographic information to be able to accurately report who participated in a study. Commonly, research participants are predominantly from historically privileged groups (e.g., middle-class, heterosexual, able-bodied, White in Canada and the United States), and attention is rarely drawn to participant demographics in manuscript titles and abstracts. Conversely, when a manuscript focuses on a historically oppressed group (e.g., African Americans), this is often explicitly stated in the title and/or abstract. Such reporting perpetuates the idea that privileged groups remain the norm and what works in these groups is the standard, and translations of the research can be implemented with “minority” groups. It is rare that a group of research participants, no matter how large the sample, is representative of society (race, ethnicity, sex, gender, sexuality, ability, etc.). Therefore, asking and reporting on sociodemographics can ensure transparency in who participated in a study, who was missing, and who this research can or cannot be generalized to. SSBC measures will not be suitable for every research study, but we believe that the steps we have taken can be used to inform future research programs because of the steps we have 127 taken to ensuring our sociodemographic questions are inclusive, safe, and purposeful. For example, it is important to differentiate terms that are sometimes used interchangeably but have different meanings (e.g., race and ethnicity; sex and gender). Being strategic in the order that options to sociodemographic questions are listed can reduce the historically inherent hierarchy within sociodemographic categories. Other recommendations can be found in Table 6.1, and examples of sociodemographic questions that we use are in Appendix E.2. 6.2.7.2 Waist circumference Waist circumference is an easily conducted measure which, in addition to weight and BMI, can provide a low-cost estimate of adiposity (Rueda-Clausen et al., 2020). Previously, SSBC coaches were taught to instruct clients to expose the skin surrounding their waist for this measurement to be taken to comply with standardized guidelines. To be respectful of personal preferences and cultural practices, guidelines were modified to allow clients to choose whether the measurement is done directly on the skin or over light clothing. For clients who prefer video conferencing or phone sessions, coaches provide verbal and written instructions to clients on how to self-measure their waist circumference. 6.2.7.3 Measurement tools In addition to ensuring that measures are inclusive and safe, it is of utmost importance that the tools used for physical measures are also inclusive. For this reason, we use bariatric scales and measuring tapes. The weigh scales used in our program go up to 250kg. Similarly, measuring tapes for waist circumference measurements go up to 305cm. Simply joining a DPP and agreeing to research measures can be intimidating, so ensuring that the tools used in our program will accommodate everyone is imperative. 128 6.3 Discussion With the recent passing of Bill C-237, reducing T2D risk is on the forefront of the Canadian healthcare system (National Framework for Diabetes Act, n.d.). When developing this national framework for diabetes, designing preventative medicine to support improved access to health services for all Canadians was highlighted as a priority; however, existing DPPs have been designed, tested, and implemented in ways which exclude certain groups based on socioeconomic status. Given that all stages of behavioural research have the potential to exacerbate existing health inequalities (White et al., 2009), care must be taken at the onset of intervention development to ensure that a DPP or other behavioral health intervention does not inadvertently exclude those most in need. This paper outlined steps taken to improve the equity and inclusion of the SSBC DPP through use of a stakeholder advisory committee and the ConNECT Framework (Alcaraz et al., 2017) and provided recommendations on how these changes can be integrated into other health promotion programs. The changes did not alter the “core” evidence-based components of the intervention but will likely result in improved program equity and can act as an exemplar for other programs. The recommendations provided within this document are not exhaustive and will be continually modified and refined based on new learnings and emerging research. We urge other behaviour change and DPP researchers to critically appraise their own programs to ensure that the decisions made do not arbitrarily exclude individuals in need of a program. When designing and implementing a community health program, reaching those who could benefit from the program the most, and promoting inclusion and equity should be priorities. Table 6.2 provides some questions that can guide the design and implementation when keeping these priorities in mind are. 129 6.4 Conclusion Considering equity and inclusion in research programs might seem daunting, and take additional resources; however, this is an imperative step in advancing the fields of health promotion and behaviour change. Too often, those belonging to equity-deserving groups are an afterthought in designing and implementing health programs despite them being at higher risk for certain preventable conditions. There is a need for health programs and research to be more inclusive and equitable. This paper provides concrete steps, recommendations, and guiding questions to help researchers in navigating this tricky process. 130 Table 6.1 Recommendations to developing an inclusive behaviour change intervention Recommendation ConNECT Principle Action steps Include end-users throughout. 3 1) Develop advisory committees to aid in decision making; 2) form community partnerships and 3) actively engage groups representative of all potential end-users when making program decisions. Use inclusive language. 2 See Appendix E.1 for commonly used language and our suggested rephrasing. Ensure recommendations are economically accessible. 1 Consider costs associated with recommendations to ensure all behavioural targets can be achieved regardless of client socioeconomic status. Identify “core” intervention components, which can be modified for different groups. 3 Identify which aspects of the intervention are necessary and which are flexible. If possible, allow for flexibility with scheduling so that programs are more accessible. Include diverse promotional materials. 2 Ensure there is diversity among individuals in promotional materials. Inclusion of diverse models within photos and videos will not only improve representation, but also stop perpetuating White as “the norm”. Provide cultural safety training for all program deliverers. 5 1) Include cultural safety training for practitioners; and 2) weight bias training. Do not provide arbitrary limits on eligibility criteria. 2 Arbitrary limits on eligibility criteria (e.g., age, BMI) should not be used unless there is evidence that protocols are unsafe for specific groups. Sociodemographic questions should be asked with purpose and thought. 2 1) Provide a brief explanation about the purpose of the sociodemographic questionnaires; 2) ask sociodemographic questions in an inclusive and safe way, with a variety of response-options; 3) list sociodemographic question options in alphabetical to reduce hierarchy in responses that might place historically privileged groups as the first response options; 4) avoid the option of “other” as it may make individuals who are not represented within response options to feel othered, and instead use wording such as “another option (please specify: ___)”; 5) offer response options such as “prefer not to answer” and “do not know”; 6) provide clients with choices in how certain measurements are taken to ensure that they feel safe and respected; and 7) use measurement tools that accommodate all individuals’ shapes, sizes, and differences. See Appendix E.2 for suggestions on when and how to ask different sociodemographic questions. 131 Table 6.2 Guiding questions to develop or critically appraise existing behaviour change programs Guiding Question Things to consider Who is my target audience (i.e., who is identified as highest risk for developing T2D)? Once a target audience has been identified, engage them in intervention design to ensure that you are creating an acceptable, inclusive, and equitable program. For example, do not design a program to be tested on undergraduate students who are not the target audience, call your program effective, then transplant it into other settings What (if any) limits do I need to make on inclusion? Will adding limits to BMI, age, co-morbidities, etc. reduce my ability to reach those at highest risk? If so, is there any justifiable reason to impose these limits? If there are not any justifiable reasons to include these limits, modify or remove them What are my “core” evidence-based components of my intervention? How can these components be delivered or modified in ways that are more accessible to all individuals? How can I work with end-users to tailor different components to meet their needs? What are my indicators of success? Key success indicators should not only include behavioural and clinical outcomes, but also whether you are reaching those most in need? What demographic and anthropometric outcomes do I want/need to assess? Do I need sex, gender, race, or ethnicity data? What research questions do I want to answer with that data? Is it necessary for me to collect the data or can I have clients self-report if they are not comfortable with me taking the measurements? How can I promote and present my program to the public (i.e., via social media or in peer-reviewed publications)? What language and graphics can I use to make my knowledge dissemination/promotional materials more inclusive? 132 Chapter 7: General discussion There was a need for the in-person SSBC coach training to be transitioned to an online format, which initiated a systematic and rigorous evaluation process. The objective of this dissertation was to outline and evaluate the SSBC coach e-learning training program from inception, through implementation, to sustainability. This dissertation was guided by the TEL evaluation framework (Cook & Ellaway, 2015) and the KTA framework (Graham et al., 2006). An IKT approach (Gainforth et al., 2021; Jull et al., 2017; Yardley, Ainsworth, et al., 2015; Yardley, Morrison, et al., 2015) was used to design, develop, and test the usability of the SSBC coach e-learning training. Included in the coach e-learning training was a cultural safety and inclusivity module, which was tested for effectiveness before the e-learning training was delivered to SSBC coaches. After implementation of the e-learning training, SSBC coaches’ and training delivery staffs’ experiences with the e-learning training were examined. Next, an evaluation of training outcomes ranging from satisfaction metrics to SSBC client outcomes was conducted. The coach e-learning training was among a series of changes to enhance the accessibility and inclusivity of SSBC. In this section of the dissertation, a summary of the findings from Studies 1-5 is presented, followed by an overview of the theoretical, methodological, and practical contributions of this dissertation. The strengths and limitations of this research are then outlined, followed by future directions. Finally, a conclusion of the dissertation is presented. 7.1 Summary of findings Chapter 2 presented the first study, which outlined the IKT approach to the development and usability testing of the new SSBC coach e-learning training. The study aimed to transparently report on 1) determining the need for an e-learning mode of training, 2) the process 133 of designing and developing the e-learning training, and 3) testing the usability of the e-learning training. The methodology employed in this chapter was guided by the TEL evaluation framework activities 1-4 and KTA framework action cycle phases 1 and 2. This study resulted in an SSBC coach e-learning training consisting of seven asynchronous modules, a mock session with feedback from SSBC training delivery staff, and a final knowledge test. Results from the usability testing were favourable and led to minor modifications prior to implementation. At the conclusion of this study, the SSBC coach e-learning training was ready for implementation. Chapter 3 consisted of an examination of the effectiveness of the first module within the SSBC coach e-learning training. The first module covered how to deliver culturally safe and inclusive care to clients, a topic that was not covered in the previous in-person SSBC coach training. The objective of Chapter 3 was two-fold: 1) to assess the impact of the cultural safety and inclusivity module on participants’ empathic awareness, perceptions of a client, and explicit bias, and 2) to explore participants’ perspectives on the module. This chapter included two parallel studies: a Weight study and a Race study. Individuals who were representative of SSBC coaches (i.e., fitness facility staff and university students in programs related to health and exercise sciences) were recruited to participate. Participants (n=58) were randomly placed into one of the two studies, and then within each study were randomized to either view the SSBC module or an “Our Planet” video. This chapter used pre- and post-module/video questionnaires to assess changes in participants’ empathic awareness, explicit bias, and perceptions of a mock SSBC client. Results demonstrated that the module effectively improved empathic awareness and perceptions of clients in the Weight study. Additionally, participants reported favourable perspectives on the module. This study demonstrated that the SSBC research team could have confidence in the cultural safety and inclusivity training, as it offers SSBC coaches both 134 acceptable and effective education. Although Chapter 3 did not address any of the TEL evaluation framework activities nor the KTA framework action cycle phases, it served as a critical study in evaluating the new training topic. The study’s primary aim was to determine whether the module would be well-received and achieve the desired effects of reducing biases. Chapter 4 continued to build on the TEL evaluation framework and KTA framework referenced in Chapter 2, by focussing on coaches’ and SSBC training delivery staffs’ experiences with the training. This study addressed TEL evaluation framework activities 4 – document key events during implementation and final product and 5 – assess participant experience and satisfaction through qualitative methods, and the KTA framework phase of sustain knowledge use. Chapter 4 utilized semi-structured interviews with a purposive sample of SSBC coaches (n=8) and training delivery staff (n=3). Using a pragmatic approach and template analysis, seven themes were constructed from coach interviews: training design, “I didn’t know what to expect from the training”, technology usability, learning, coaches’ backgrounds shaped their training experience, support, and coaches valued the training. Additionally, two themes were constructed from the staff interviews: streamlining the training delivery, and ensuring coaches meet the diabetes prevention program standard. All themes described important perspectives, including the beneficial aspects of the training and where improvements could be made. Importantly, this study focussed on both coaches’ and training delivery staffs’ perspectives, offering a comprehensive understanding of the training experiences from all groups of individuals involved. Chapter 5 further expanded upon the TEL evaluation framework and the KTA framework, continuing to address TEL data collection activity 5 – assess participant experience and satisfaction, adding data collection activity 6 – assess learning outcomes, as well as KTA 135 framework phases monitor knowledge use and evaluate outcomes. To address these steps, the study used the Kirkpatrick model for training evaluation. Thus, the study had 4 aims: 1) to determine coaches’ reaction to the SSBC coach e-learning training, 2) to assess the extent to which coaches learned information related to T2D prevention, MI, and SSBC content from the SSBC coach e-learning training, 3) to examine coaches’ MI delivery and SSBC session content delivery behaviours with clients as a result of the SSBC coach e-learning training, and 4) to assess client satisfaction with coaches’ (who had passed the coach e-learning training) support of their basic psychological needs after their sixth SSBC session, and changes in clients’ weight and waist circumference from their first to sixth session. Overall, coaches were satisfied with the e-learning training and the online platform, gained knowledge regarding T2D prevention and SSBC content, delivered SSBC session content using MI to some extent, and clients had positive outcomes. The favourable training outcomes from this study were likely due to the systematic and rigorous nature of the previous three studies. Finally, Chapter 6 provided a broader perspective of how the SSBC coach e-learning training was one small step to making the SSBC program more accessible and inclusive. The commentary provided in Chapter 6 used the ConNECT Framework to describe changes made within SSBC to improve accessibility and inclusivity. Additionally, this chapter provided recommendations to improve the reach and inclusivity of other community health programs. Before proceeding to the theoretical, methodological, and practical contributions of this chapter, the next section will address the final TEL data collection activity – estimate cost, reusability, and sustainability. 136 7.2 Estimate of the cost, reusability, and sustainability Costs of both in-person and e-learning trainings include financial, personnel, facilities, and other resources (Cook & Ellaway, 2015). One method to determine cost-effectiveness of the SSBC coach e-learning training is to compare the costs to deliver the e-learning training with those associated with the previous in-person SSBC coach training. Due to lack of reporting, it was not possible to determine the resources that were used to develop the in-person coach training. Costs associated with delivering the in-person training primarily included printing training manuals and remuneration for training delivery staff leading the workshop, as well as coaches undergoing the training. The in-person SSBC coach training format incurred an approximate cost of $450 per coach. An estimate of the true cost of the SSBC coach e-learning training was informed by Levin’s “ingredients” model (Levin, 2001) and Ellaway’s “total cost of ownership” model (Ellaway, 2010a). Data collected in Chapters 2 and 4, along with contractual data not included in this dissertation, informed the cost breakdown of the SSBC coach e-learning training. One-time costs included initial development (~$100,650 CAD) and updating the e-learning training (~$3400 CAD). Ongoing costs include annual operational costs (~$6800 CAD) and remunerating training delivery staffs’ time (~$91.35 CAD/coach trained). Excluding the costs associated with developing the in-person training, a cost analysis suggests that more than 200 coaches would need to complete the SSBC coach e-learning training to justify the resources invested in its development and maintenance. However, this cost-effectiveness determination overlooks critical logistical considerations. The $450 CAD cost per SSBC coach for in-person training delivery does not include costs such as travel, accommodations, and per diem for staff delivering training outside of Kelowna. Moreover, scheduling constraints of part-time staff necessitate multiple in-person workshops to train coaches at each SSBC scale-up site. 137 Cook suggests that determining the cost-effectiveness of e-learning training entails a more complex analysis than merely comparing the costs of in-person and e-learning trainings (Cook, 2014). Some benefits of e-learning, such as addressing logistic constraints (i.e., flexibility for learners and instructors), greater instructor control over course processes, and automated data collection for usage and learning outcomes, can justify higher costs to develop, implement, and maintain e-learning training (Cook, 2014; Ellaway, 2014). The amount of resources (e.g., time, financial) invested in e-learning training should match the needs of the course and should account for the resources available (Cook, 2014). Logistical issues and travel costs associated with delivering in-person training would have prohibited SSBC scale up provincially, nationally, and worldwide. While the development of the SSBC coach e-learning training was resource-intensive, the transition from in-person to e-learning training will enable SSBC to sustainably scale-up with consistent, flexible, and practical coach training. Therefore, the higher price of e-learning training was justified because it solved logistical and practical issues. 7.3 Theoretical contributions 7.3.1 Incorporating user feedback with the TEL evaluation framework and KTA framework throughout the SSBC e-learning training evaluation process Although there is limited published research specifically focussed on the design, development, and modifications of e-learning trainings (i.e., process evaluation) (Theelen & Van Breukelen, 2022), there is evidence indicating that some researchers incorporate user feedback (Hasani et al., 2020). However, reports of engaging users within the design, development, and modifications of e-learning trainings often prioritize learners as the primary users and overlook input from the e-learning deliverers (Gavarkovs et al., 2019; Hasani et al., 2020; Hsu et al., 2014; Srikesavan et al., 2017). Within this dissertation, integrating extensive user (e.g., learners and 138 delivery staff) feedback throughout the TEL evaluation framework activities and the KTA framework phases likely contributed to the favourable outcomes in Chapter 5. Chapter 2 used data collected from SSBC research team meetings as well as focus groups with coaches to determine the content and format of the SSBC e-learning training. Additionally, coaches and the SSBC research team reviewed and provided feedback on the module storyboards prior to filming. Furthermore, SSBC coaches’ and training delivery staffs’ perspectives were considered in Chapter 4 to assess both the strengths of the training and areas for potential improvement. In order for the e-learning training to be effective and sustainable, it needed to satisfy all involved with the process, and not just those completing the training. Engaging all SSBC e-learning training users (i.e., coaches and training delivery staff) throughout the evaluation process likely contributed to the high levels of satisfaction and effectiveness of the training (Graham et al., 2014; Kothari et al., 2017). 7.3.2 Use of the complete TEL evaluation framework and KTA framework action cycle 7.3.2.1 Using the TEL evaluation framework Limited research has presented comprehensive evaluations of e-learning (Nicoll et al., 2018), which extend beyond merely assessing learner satisfaction and changes in knowledge from pre- to post-training. The use of all seven TEL evaluation framework activities in this dissertation provided a complete understanding of the processes and outcomes associated with the SSBC e-learning training. One limitation of Cook and Ellaway’s TEL evaluation framework is the lack of specific tools for conducting the evaluation activities. This dissertation addresses past calls to thoroughly evaluate e-learning trainings (Cook & Ellaway, 2015; Ellaway, 2006, 2010b; Pickering & Joynes, 2016), and provides a specific guide as to how each of the data collection activities can be rigorously conducted and reported. Future researchers may benefit 139 from using this dissertation work as a guide on how to plan and conduct all of the TEL evaluation framework data collection activities. As highlighted in the previous section, this dissertation highlights some benefits of incorporating user feedback throughout the TEL evaluation framework process. In systematic reviews of e-learning training, Kulaksız (2023), Rouleau (2019), and Sinclair (2016) highlighted that e-learning evaluations often do not examine Kirkpatrick levels 3 and 4. Chapter 5 addresses this gap by evaluating Kirkpatrick levels 3 and 4 within the TEL evaluation framework activity 6. In general, the goal of training individuals is to achieve favourable outcomes at Kirkpatrick level 4. In the context of the SSBC e-learning training, it is administered with the belief that coaches, equipped with an MI-informed approach, will effectively assist their clients in reducing their risk of developing T2D. Without evaluating level 4, the true effects of the training cannot be determined. Developing e-learning training can be resource-intensive (Cook, 2014). Determining the cost and reusability of e-learning training is critical to determine the sustainability of the training. To calculate cost, TEL evaluation activities 2 and 4 are essential, as they involve documenting the processes, decisions, and resources utilized throughout the development and implementation of the training. E-learning training should only be used and sustained if the benefits outweigh the costs (Cook, 2014). 7.3.2.2 Using the KTA framework action cycle The KTA framework is a conceptual framework that was developed to help move knowledge into action via sustainable and evidence-informed interventions (Graham et al., 2006). Similar to the TEL evaluation framework, the KTA framework does not outline specific tools or activities for each of the action phases (Graham et al., 2006). The lack of specificity in 140 the KTA framework allows for flexibility and adaptability (Field et al., 2014; Graham et al., 2006). A systematic review of empirical real-life applications of the KTA framework demonstrated that only two of the ten included studies reported applying all seven action cycle phases (Field et al., 2014). This dissertation demonstrates how each of the seven action cycle phases were applied, which could guide other researchers in developing and implementing e-learning trainings using the KTA framework. This dissertation document (e.g., Chapters 4 and 5) is not reflective of the sequential order of the action cycle phases as they unfolded throughout the SSBC e-learning training knowledge application process. While the action cycle phases did occur sequentially, they were not reported in that manner. Knowledge use and application (i.e., learning, coach behaviour) were monitored after the e-learning training was implemented (Chapter 5), then outcomes of the training were evaluated (Chapter 5), and finally the sustainability of the e-learning training (i.e., barriers to knowledge sustainability and tailoring based on these barriers) was assessed in Chapter 4. The choice to report the studies in the present order was based on the order of the TEL evaluation framework activities. 7.3.2.3 Using the TEL evaluation framework and the KTA framework together This dissertation demonstrated how the TEL evaluation framework and the KTA framework can be used together in a complementary manner. The KTA framework (Graham et al., 2006) is one of the most frequently cited frameworks for knowledge translation and has been implemented in a wide variety of settings (Field et al., 2014). Conversely, the TEL evaluation framework (Cook & Ellaway, 2015) was developed specifically for e-learning within health education. Developed for different purposes, these frameworks worked in a complementary manner with the various data collection activities and phases closely aligning. Figure 7.1 shows 141 how I mapped the TEL evaluation framework onto the KTA framework. The combined TEL evaluation and KTA framework provides guidance for researchers on both the important processes of developing and evaluating e-learning trainings, as well as considerations for the documentation and reporting of such processes. This combination of the TEL evaluation framework and the KTA framework can assist researchers who want to use a rigorous process to develop, implement, and evaluate e-learning trainings within a health context. 7.4 Methodological contributions 7.4.1 Rigorous design and development of the SSBC e-learning training Conducting program evaluation on interventions provides the opportunity to judge the effectiveness and worth of the intervention and helps to explain intervention outcomes (M. J. Harris, 2017; Stufflebeam, 2001). Well-designed and effective e-learning trainings can serve as templates for new e-learning trainings (Cook, 2014), however this requires thorough reporting of design, development, and implementation of e-learning trainings. Chapter 2 described the process of determining the need for the SSBC coach e-learning training, and subsequently outlined the design, development, and usability testing processes utilized. Specific results and subsequent decisions from Chapter 2 are likely not generalizable to other e-learning trainings, but the processes outlined can help inform others considering developing e-learning trainings. Section 7.5.2.1 will outline how the SSBC e-learning training informed a new e-learning training and reduced the cost of developing that training. This dissertation highlighted the importance of involving users throughout the SSBC coach e-learning training evaluation. Results from Chapters 4 and 5 demonstrated that users were satisfied with the training and had favourable perspectives. It is likely that these results would not have been as favourable without the rigorous design and development process. Additionally, 142 results from Chapter 4 provided insight into what modifications could be made to the training to further improve training efficiency and user experience. Researchers can use the processes and results from Chapters 2 and 4 as guidance when developing their own e-learning trainings. 7.4.2 Engaging multiple user groups in process evaluation One critique of the Kirkpatrick model is that it does not explain how and why outcomes occur (Allen et al., 2022). This critique is a result of the Kirkpatrick model being used as an outcome evaluation model and not emphasizing process evaluation. By utilizing a mixed methods approach to evaluate reactions to training (i.e., Chapters 4 and 5), this dissertation sought to answer the question of how the training was delivered. Using semi-structured interviews to understand coaches’ and training delivery staffs’ experiences with the training provided insight into how the training was experienced by the two user groups. The qualitative themes for the SSBC e-learning training provided a rich overview of satisfaction (TEL evaluation activity 5) with the training and Chapter 5 built on this by quantifying coaches’ level of satisfaction with the training. The quantitative satisfaction data is beneficial as it allows the SSBC e-learning training to be compared to other e-learning trainings. Future research should use a mixed methods approach to assess user satisfaction with e-learning training to be able to both quantify reactions to training and gain a deeper understanding of the results, possibly explaining the quantitative results. 7.4.3 Using an SDT measure to assess client receipt of MI SSBC coaches are trained to deliver sessions using an MI-informed counselling style to empower clients to reduce their risk of developing T2D. Extensive research demonstrates the effectiveness of MI on helping individuals make health behaviour changes (S. M. Chen et al., 2012; Chlebowy et al., 2015; Christie & Channon, 2013; M. Clark et al., 2004; Martins & 143 McNeil, 2009; Thepwongsa et al., 2017; West et al., 2007), however MI lacks a theoretical framework to explain why it works. SDT has been posited as one theory that could explain how MI works (Vansteenkiste & Sheldon, 2006). The three basic psychological needs from SDT (autonomy, competence, and relatedness) closely align with the spirit of MI (compassion, autonomy, partnership, and evocation) (Jackson et al., 2015; Vansteenkiste & Sheldon, 2006). SDT suggests that autonomy, competence, and relatedness are universally essential for autonomous motivation and psychological well-being (Ryan & Deci, 2000). SSBC coaches are trained to support clients’ basic psychological needs using MI. Specifically, coaches are trained to bolster clients’ autonomy by, evoking their clients’ motivations, acknowledging their clients’ goals and interests are necessary for long-term behaviour change, asking permission before providing information and suggestions and focussing on their clients’ strengths. Coaches can enhance clients’ sense of competence by utilizing affirmations, goal setting through brief action planning, and emphasizing clients’ successes. Finally, coaches’ MI-informed training supports them to strengthen clients’ relatedness by expressing empathy (i.e., using both verbal and non-verbal techniques), offering genuine reflections, and providing suggestions that have worked for other SSBC clients when clients encounter a hurdle or seek guidance. Chapter 5 assessed Kirkpatrick level 3 using the MICA, which is partitioned into two MI strategies and five MI intentions. The MICA intentions were developed to capture the spirit of MI as well as SDT and additional theories that support a client-centred approach (Jackson et al., 2015). To align the various measures within Chapter 5, the MICA and the LCQ were selected to assess Kirkpatrick levels 3 and 4. Future research should continue to use the MICA and LCQ as tools to evaluate MI delivery and receipt given the congruence of the measures. While SSBC coaches did not deliver a client-centred level of MI to SSBC clients, clients reported that coaches 144 met their basic psychological needs. Future research should also explore the relationship between the quality of MI delivered and LCQ results to determine any potential relationship between the two. 7.5 Practical implications 7.5.1 SSBC implications 7.5.1.1 SSBC coach e-learning training modifications Results from Chapter 4 highlighted modifications that can be made to the SSBC coach e-learning training. After consulting with key members of the SSBC research team on Chapter 4 results (Jung and an SSBC research coordinator), we determined that some changes to the e-learning training should occur. Modifications included reducing staff burden by automating more training steps, providing clearer communication to coaches regarding expectations of the training, modifying and adding coach resources in the online platform. Results from this dissertation (Chapter 5) demonstrated that coaches gained knowledge from the e-learning training, and thus an additional modification was removing the pre-training questionnaire. SSBC coach e-learning training modifications that have now been made will improve the training experience for coaches and training delivery staff and the training process efficiency by reducing staff time required to deliver the training. 7.5.1.2 Importance of dissertation results for SSBC scale-up In November 2022, the Canadian Institutes of Health Research, the Public Health Agency of Canada, and the National Health and Medical Research Council of Australia awarded Jung funding to scale up SSBC to 44 sites across Canada and 5 sites across Australia. The SSBC coach e-learning training developed and tested in this dissertation is a critical component in the scale-up of SSBC. The SSBC research team can have confidence in the e-learning training as 145 Chapter 5 demonstrated that coaches were satisfied with the training, learned from the training, and delivered most of the SSBC session content resulting in favourable client outcomes. Chapter 5 demonstrated moderate levels of agreement between coach-reported and audited session content delivery. Improving the accuracy of the coach-reported session content delivery could be achieved by emphasizing to coaches that session checklists are used for research purposes rather than to monitor coaches. Informing coaches that they will not be penalized for not delivering a session component to clients could reduce the desirability bias that was likely present in Chapter 5. Improving coach-reported session content delivery accuracy could remove the need to listen to session audio recordings, greatly reducing the financial and human resources required to assess delivery fidelity in the scale-up project. 7.5.1.3 SSBC is more inclusive The implementation of an effective cultural safety and inclusivity module in the SSBC coach training, coupled with the additional changes outlined in Chapter 6 is expected to foster enhanced feelings of inclusion within the SSBC program and promote improved health equity. By mandating successful completion of cultural safety and inclusivity training for all individuals wishing to become SSBC coaches, SSBC exemplifies its commitment to fostering equity and inclusion. This module helps SSBC coaches to serve all clients in an inclusive manner, and teaches coaches to recognize their biases, respect and celebrate clients’ backgrounds and identities, and take actions to reduce the inherent coach-client power imbalances. Additionally, changes to SSBC promotional material (e.g., increased diversity and representation), expanding client inclusion criteria, and adjusting dietary and physical activity recommendations to accommodate diverse financial capabilities improve the inclusivity and accessibility of SSBC. Diabetes prevention programs, and health programs more broadly, have a responsibility to reach 146 and serve everyone, especially those from equity-owed groups. As SSBC scales up to communities with more diverse populations than Kelowna, it is especially important that individuals from all backgrounds and identities feel included in the program. The steps highlighted in Chapter 6 will enhance equity, diversity, and inclusion within SSBC. This is essential for reducing Canadians’ risk of developing T2D, irrespective of their background or identity. 7.5.2 Equity, diversity, and inclusion considerations 7.5.2.1 Module 1 study leading to more generalized training for health and fitness staff in Canada Chapter 3 demonstrated that the SSBC cultural safety and inclusivity module was effective and favourably viewed by participants. The effectiveness of the cultural safety and inclusivity module within the SSBC coach e-learning training has created opportunities to provide similar training in broader health and fitness settings. A national fitness organization, Canadian Society of Exercise Physiologists (CSEP), and the UBC Okanagan School of Health and Exercise Sciences expressed interest in implementing a modified version of the SSBC cultural safety and inclusivity training within their organizations. Jung and I, both committed to enhancing equity, inclusion, and safety within health contexts, collaborated to develop a new cultural safety and inclusivity e-learning training module tailored for individuals currently working in a health-related field, as well as those enrolled in post-secondary health programs. The new cultural safety and inclusivity module was based directly on the SSBC cultural safety and inclusivity module, with SSBC-specific examples removed and aspects from the spirit of MI added. This new module has the potential to offer cultural safety and inclusivity training to current and prospective health professionals across Canada, an opportunity may not have been 147 available to many before. Improving the provision of culturally safe and inclusive care has the potential to enhance quality of care and patient satisfaction (Smylie et al., 2024). 7.5.2.2 Other health programs can work to improve inclusion and equity based on Chapter 6 commentary Chapter 6 highlighted improvements made to advance equity and inclusion within SSBC. Additionally, this chapter offers eight recommendations for other community health programs to consider enhancing inclusion and equity: 1) include end-users throughout, 2) use inclusive language, 3) ensure recommendations are economically accessible, 4) identify “core” intervention components and flexible components, the latter of which can be modified for different groups, 5) include diverse promotional material, 6) provide cultural safety training for all program deliverers, 7) do not provide arbitrary limits of eligibility criteria, and 8) sociodemographic questions should be asked with purpose and thought. Individuals involved in the development and implementation of health programs have a responsibility to consider equity and inclusion within the contexts of their programs. This may be reflected in who their programs are aiming to reach, how their program is staffed or governed, or through the information disseminated to program participants. Although the recommendations outlined in Chapter 6 may not be universally applicable and relevant to every health program, they can serve as a guide and brainstorming point for other community-based programs. The commentary and recommendations provided in Chapter 6 are not meant to be rigid or exhaustive, but rather aim to stimulate and motivate other existing health programs to (re)consider all areas in which there may be room for improvement to make their program more equitable, diverse, inclusive, or safe. 148 7.6 Strengths A main strength of this dissertation was the rigorous process used within each study. Chapters 2, 4 and 5 followed a logical order guided by the TEL evaluation framework and the KTA framework action cycle. Each chapter included within this dissertation is built upon the previous chapters. Additionally, the mixed methods approach utilized within this dissertation added to the research rigour. Rigour was also addressed in Chapter 4 by interviewing SSBC training delivery staff in addition to coaches. Understanding the training delivery staffs’ experiences with the SSBC coach e-learning training was critical to understand how the process could be made more efficient. Without this important perspective, the SSBC coach e-learning training would likely not be ready to be implemented within the SSBC scale-up sites. Another strength of this dissertation was the pragmatic paradigm. Adopting a pragmatic paradigm ensured that study objectives, methods, and analyses would all lead to results that were meaningful and could solve practical real-world and SSBC-specific problems. The methods used within this dissertation were selected based on addressing the research questions rather than being informed by methodological hierarchies. Fourth, this dissertation examined Kirkpatrick levels 3 (coaches’ behaviours regarding use of MI behaviour and delivering SSBC session content to clients) and 4 (clients’ satisfaction of coach-support of basic psychological needs, changes in waist circumference and weight), which are often missed in e-learning training evaluations (Kulaksız et al., 2023; Rouleau et al., 2019; P. M. Sinclair et al., 2016) and broader evaluations using the Kirkpatrick model (Allen et al., 2022). Determining coaches’ behaviours while delivering SSBC to clients and client 149 outcomes allows for greater confidence in the training and permits understanding the true effects of the training. Finally, this dissertation provided transparent reporting of the design, development, implementation, effectiveness, and sustainability of the SSBC coach e-learning training. Chapter 2 demonstrated the process of developing the e-learning training, including the resources required. Chapter 4 highlighted both favourable perspectives and shortcomings of the e-learning training, which other researchers can use to improve their own e-learning trainings. Finally, Chapter 5 demonstrated favourable results. Accurately reporting that coaches delivered generally inconsistent levels of MI highlighted that brief e-learning training for individuals naïve to MI might not be sufficient on its own to get coaches to deliver MI at a client-centred level. 7.7 Limitations In addition to the strengths of this dissertation, there were also some limitations. Despite advocating for the importance of collecting and reporting on participant sociodemographic details, I did not collect ethnic origin data in any study or sex data in Chapters 2 and 3. Sociodemographics questionnaire development and data collection for Chapters 2-5 began prior to developing the recommendations outlined in Chapter 6. While some sociodemographic data is reported for each study, there is not enough information to determine whether participants in this dissertation belonged to equity-owed ethnic groups. A limitation of Chapter 3 was that the intended target sample size was not achieved. As a result, the statistical power to detect small or moderate effects may have been limited, possibly affecting the generalizability and reliability of findings. Future research should consider the use of CAPTCHA and reduced advertisement of financial remuneration on social media recruitment materials to mitigate the bots and scammers recruited. By diminishing the recruitment of bots 150 and scammers, the need for conducting this (or similar) studies via Zoom could be eliminated, facilitating participants to complete the study at their preferred time and pace. Notably, effect sizes of the analyses that did not yield significant results imply the presence of effects. Third, in Chapter 5, coaches did not demonstrate delivering SSBC sessions to clients using MI. Results from the in-person SSBC coach training demonstrated that fitness facility staff were delivering sessions using a client-centred level of MI (Dineen, Cranston, et al., 2021). The in-person training however, consisted of 17 hours of group workshops, and coaches were shadowed and provided feedback by a research team member for their first six sessions with a client. It is possible that the longer training duration and the MI training enhancements (i.e., supervision and feedback) were necessary for coaches to reach a level of client-centred MI (Britt & Blampied, 2010). While the goal in Chapter 5 was for coaches to deliver sessions at a client-centred level, clients still exhibited favourable outcomes. Lastly, when examining client outcomes in Chapter 5, only pre- and post-SSBC data for waist circumference and weight were assessed. This is a limitation because previous research has demonstrated that SSBC and other diabetes prevention programs are effective at making health behaviour changes during a diabetes prevention program, but changes are often not sustained long-term (e.g., 12-months post-program) (Glechner et al., 2018; Haw et al., 2017; Jung et al., 2020). Future research should include timepoints that examine the maintenance of outcomes. 7.8 Future directions This dissertation points to areas for future research. Within the context of the SSBC coach e-learning training, future work could undertake another round of outcome evaluation with newly trained SSBC coaches following the implementation of modifications to the e-learning training (see 7.5.1.1). The modifications could affect results at all four levels of the Kirkpatrick 151 model. If resources are limited, incorporating open-ended response questions in the satisfaction survey could allow users to provide additional context or details about their quantitative satisfaction responses, eliminating the need to conduct interviews. Client results should include pre- and post-program measures, with additional long-term (e.g., 12 months) timepoints. If sample size permits, examining whether client outcomes are associated with the quality of session delivery (e.g., MICA scores, percent of session content delivered) would be beneficial. Researchers developing and implementing e-learning trainings can utilize the combined TEL evaluation framework and KTA framework (see Figure 7.1) to guide their work. By combining the two frameworks, researchers can address the gaps present in each individual framework. Furthermore, as researchers apply the combined frameworks, they can incorporate additional steps or guidance to address emerging gaps. Additionally, researchers developing and implementing e-learning trainings should be transparent with their processes and report all steps involved. Transparent reporting will advance the field of e-learning trainings as it enables researchers to gain insights from one another’s experiences and leverage successes while addressing areas for improvement. Additionally, e-learning training outcome evaluations should include assessments of Kirkpatrick levels 3 and 4 so that data pertaining to the effects of e-learning training can be comprehensively synthesized (Kulaksız et al., 2023; Rouleau et al., 2019; P. M. Sinclair et al., 2016). Process evaluations should also be conducted and documented to offer insights into the instructional design principles and theoretical frameworks used in the development e-learning trainings. Furthermore, process evaluations provide a deeper understanding of the resources required to develop and implement e-learning trainings, as well as the fidelity of such trainings. Additionally, process evaluations help explain the factors contributing to the success or failure of e-learning trainings. 152 7.9 Conclusion This dissertation aimed to evaluate the SSBC coach e-learning training from determining the need for the e-learning training to evaluating outcomes of the training. This research has implications for e-learning research, cultural safety and inclusivity research, and evaluation. Important theoretical and methodological contributions included using the TEL evaluation framework in conjunction with the KTA framework and incorporating user perspectives and mixed methods in the SSBC e-learning training evaluation. This dissertation also included practical implications for the scale-up of SSBC and for advancing equity, inclusion, and diversity within health settings. E-learning trainings should be systematically developed and evaluated, with transparent reporting of the entire process to further the field of e-learning research. 153 Figure 7.1 Combined TEL evaluation framework and KTA framework The KTA framework (Graham et al., 2006) phases are represented in blue trapezoids (knowledge creation funnel) and rectangles (action cycle). 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British Journal of Clinical Pyschology, 45, 63–82. Vaona, A., Banzi, R., Kwag, K. H., Rigon, G., Cereda, D., Pecoraro, V., Tramacere, I., & Moja, L. (2018). E-learning for health professionals. Cochrane Database of Systematic Reviews, 2018(8). https://doi.org/10.1002/14651858.CD011736.pub2 Wang, Y. (2003). Assessment of learner satisfaction with asychronous electronic learning systems. Information & Management, 41(1), 75–86. Wang, Y., Davidson, M. M., Yakushko, O. F., Savoy, H. B., Tan, J. A., & Bleier, J. K. (2003). The Scale of Ethnocultural Empathy: Development, validation, and reliability. Journal of Counseling Psychology, 50(2), 221–234. https://doi.org/10.1037/0022-0167.50.2.221 West, D. S., DiLillo, V., Bursac, Z., Gore, S. A., & Greene, P. G. (2007). Motivational interviewing improves weight loss in women with type 2 diabetes. Diabetes Care, 30(5), 1081–1087. https://doi.org/10.2337/dc06-1966 White, M., Adams, J., & Heywood, P. (2009). How and why do interventions that increase health overall widen inequalities within populations? . . Health, 12. Wijayatunga, N. N., Kim, Y., Butsch, W. S., & Dhurandhar, E. J. (2019). The effects of a teaching intervention on weight bias among kinesiology undergraduate students. International Journal of Obesity, 43(11), 2273–2281. https://doi.org/10.1038/s41366-019-0325-0 Williams, G. C., & Deci, E. L. (1996). Internalization of biopsychosocial values by medical students: A test of self-determination theory. Journal of Personality and Social Pyschology, 70(4), 767–779. 182 World Health Organization,. (n.d.). Social determinants of health. Retrieved January 19, 2024, from https://www.who.int/health-topics/social-determinants-of-health Wray, R. (2013). We ask because we care. The Tri-Hospital + TPH Health Equity Data Collection Research Project Report. http://torontohealthequity.ca/wp-content/uploads/2017/05/We-Ask-Because-We-Care-Report.pdf Yancey, A. K., Ortega, A. N., & Kumanyika, S. K. (2006). EFFECTIVE RECRUITMENT AND RETENTION OF MINORITY RESEARCH PARTICIPANTS. Annual Review of Public Health, 27(1), 1–28. https://doi.org/10.1146/annurev.publhealth.27.021405.102113 Yardley, L., Ainsworth, B., Arden-Close, E., & Muller, I. (2015). The person-based approach to enhancing the acceptability and feasibility of interventions. Pilot and Feasibility Studies, 1(1), 37. https://doi.org/10.1186/s40814-015-0033-z Yardley, L., Morrison, L., Bradbury, K., & Muller, I. (2015). The Person-Based Approach to Intervention Development: Application to Digital Health-Related Behavior Change Interventions. Journal of Medical Internet Research, 17(1), e30. https://doi.org/10.2196/jmir.4055 183 Appendices Appendix A. Supplementary material for Chapter 2 A.1. Screenshots from the SSBC coach e-learning platform 184 185 Appendix B. Supplementary material for Chapter 3 B.1 Empathic awareness questions Race Please respond to the following four statements with a rating of how closely you relate to the statement: 1. I am aware of how society differentially treats racial or ethnic groups other than my own. 2. I recognize that the media often portrays people based on racial or ethnic stereotypes. 3. I can see how other racial or ethnic groups are systematically oppressed in our society. 4. I am aware of institutional barriers (e.g., restricted opportunities for promotion) that discriminate against racial or ethnic groups other than my own. Weight Please respond to the following four statements with a rating of how closely you relate to the statement: 1. I am aware of how society differentially treats people of size or weight other than my own. 2. I recognize that the media often portrays people based on size or weight stereotypes. 3. I can see how people of other weights or sizes are systematically oppressed in our society. 4. I am aware of institutional barriers (e.g., restricted opportunities for promotion) that discriminate against size or weight groups other than my own. 186 B.2 Perceptions of client vignettes Race Your client is a 42-year-old Black man who has been recently told that his risk for developing type 2 diabetes is high if he doesn’t make changes to his diet and exercise. He is just starting the SSBC program, where he will meet his coach for six sessions over four weeks. He has been married for 15 years and has two teenage children. He works a full-time job and spends some of his evenings taking his children to their different extracurricular activities. He hasn’t been consistently active since he was in his early 20’s, when he played on some intramural sport teams. Between him and his wife, they cook dinner six nights a week, and order food in or go out for dinner once a week. His diet could be better, and he could reduce his beer consumption as he has a couple on Friday and Saturday evenings. Weight Your client is a 42-year-old man who has been recently told that his risk for developing type 2 diabetes is high if he doesn’t make changes to his diet and exercise. Your client is overweight, and knows that he should lose some weight, which will also help reduce his chance of developing type 2 diabetes. He is just starting the SSBC program, where he will meet his coach for six sessions over four weeks. He has been married for 15 years and has two teenage children. He works a full-time job and spends some of his evenings taking his children to their different extracurricular activities. He hasn’t been consistently active since he was in his early 20’s, when he played on some intramural sport teams. Between him and his wife, they cook dinner six nights a week, and order food in or go out for dinner once a week. His diet could be better, and he could reduce his beer consumption as he has a couple on Friday and Saturday evenings. 187 B.3 Beliefs about relevance of EDI training to education or job disaggregated results Questions Race group Weight group n (%) n (%) Do you believe that EDI training is relevant to your job? Very irrelevant 1 (8.3) 0 (0) Somewhat irrelevant 0 (0) 0 (0) Neutral 0 (0) 0 (0) Somewhat relevant 2 (16.7) 1 (16.7) Very relevant 9 (75) 5 (83.3) Do you believe that EDI training is relevant to your education? Very irrelevant 1 (4) 1 (4) Somewhat irrelevant 1 (4) 0 (0) Neutral 0 (0) 9 (0) Somewhat relevant 3 (12) 4 (16) Very relevant 20 (80) 20 (80) Do you believe that EDI training is relevant to other jobs within your facility or organization? Very irrelevant 1 (8.3) 0 (0) Somewhat irrelevant 0 (0) 0 (0) Neutral 0 (0) 1 (16.7) Somewhat relevant 2 (16.7) 0 (0) Very relevant 9 (75) 4 (66.7) Missing 0 (0) 1 (16.7) Do you believe that EDI training is relevant to your future job? Very irrelevant 1 (4) 2 (8) Somewhat irrelevant 0 (0) 0 (0) Neutral 0 (0) 0 (0) Somewhat relevant 4 (16) 3 (12) Very relevant 20 (80) 20 (80) Have you previously received EDI training as part of your job? Yes 5 (41.7) 2 (33.3) No 6 (50) 3 (50) I’m not sure 1 (8.3) 1 (16.7) 188 Questions Race group Weight group n (%) n (%) Have you previously received EDI training as part of your education? Yes 17 (68) 17 (68) No 4 (16) 5 (20) I’m not sure 4 (16) 3 (12) (For students and fitness facility staff who previously received EDI training) Do you feel that the training you received was sufficient? Yes 12 (57.1) 12 (63.2) No 9 (42.9) 7 (36.8) 189 Appendix C. Supplementary material for Chapter 4 C.1 Version 1 of the coach interview coding template 1. Process 1.1. Communication 1.2. Individual approach to training 1.2.1. Duration 1.2.2. Learning strategies (e.g., taking notes) 1.2.3. Practice (e.g., before mock or first client) 1.3. Order of training components/steps (e.g., module > mock > post-training survey) 2. Training/course design 2.1. Content 2.2. Organization of course (e.g., order of modules) 2.3. Feedback (mock, post-training survey, knowledge checks) 2.4. Synchronicity/mode 2.5. Modalities of learning (e.g., videos, interactives) 3. Support 3.1. From DPRG 3.2. From other coaches 3.3. Recommendations for other coaches 4. Learning 4.1. SSBC competencies/skills 4.2. SSBC-related knowledge 4.3. Application of knowledge 4.3.1. Within SSBC 4.3.2. Beyond SSBC 5. Value place on training 5.1. Recommend for other staff 5.2. Extended/continuing education 190 Appendix D. Supplementary material for Chapter 5 D.1 Individual coach Kirkpatrick level 3 results Coach ID # of clients Session time (minutes) M  SD (range) % client talk time M  SD (range) % coach talk time M  SD (range) MICA total M  SD (range) MICA intention score M  SD (range) % Session content delivered (reported) M  SD (range) Session content delivered (audited) M  SD (range) Session content delivered agreement between reported and audited % M  SD (range) 1 3 24.7  .6 (24-25) 49.7  11.9 (40-63) 50.3  11.9 (37-60) 4.6  .6 (4-5.2) 2.6  .2 (2.5-2.9) 95.2  8.3 (85.7-100) 84.9  14.4 (71.4-100) 89.7  9 (83.3-100) 2 2 34  2.8 (32-36) 49  9.9 (42-56) 51  9.9 (44-58) 4.5  .7 (4-5) 2.4  .2 (2.2-2.5) 100  0 (100) 60.7  15.2 (50-71.4) 60.7  15.2 (50-71.4) 3 3 39.3  18.6 (18-52) 63.3  29.3 (31-88 36.7  29.3 (12-69) 4.2  .4 (3.8-4.6) 2.4  .3 (2.1-2.6) 100  0 (100) 81  16.5 (71.4-100) 81  16.5 (71.4-100) 4 2 20  5.7 (16-24) 33  19.8 (19-47) 67  19.8 (53-81) 4.9  1.4 (3.9-5.9) 2.7  .4 (2.4-2.9) 83.3  23.6 (66.7-100) 91.7  11.8 (83.3-100) 91.7  11.8 (83.3-100) 5 4 31  10.6 (18-43) 77  11.3 (64-87) 23  11.3 (13-36) 4.6  .4 (4.3-5) 2.6  .3 (2.3-2.9) 92.9  14.3 (71.4-100) 76.8  18.9 (57.1-100) 83.9  13.7 (66.7-100) 6 2 27  2.8 (25-29) 38  5.7 (34-42) 62  5.7 (58-66) 3.5  .4 (3.2-3.7) 2.1  .5 (1.7-2.4) 100  0 (100) 71.4  40.4 (42.9-100) 71.4  40.4 (42.9-100) 7 2 20.5  4.9 (17-24) 41.5  9.2 (35-48) 59  8.5 (53-65) 4.7  .1 (4.6-4.8) 2.6  .1 (2.5-2.6) 100  0 (100) 66.7  47.1 (33.3-100) 66.7  47.1 (33.3-100) 191 Coach ID # of clients Session time (minutes) M  SD (range) % client talk time M  SD (range) % coach talk time M  SD (range) MICA total M  SD (range) MICA intention score M  SD (range) % Session content delivered (reported) M  SD (range) Session content delivered (audited) M  SD (range) Session content delivered agreement between reported and audited % M  SD (range) 8 2 34  8.5 (28-40) 53.5  19.1 (40-67) 46.5  19.1 (33-60) 3.2  1.4 (2.2-4.2) 1.7  .7 (1.2-2.2) 100  0 (100) 46.4  5 (42.9-50) 46.4  5 (42.9-50) 9 4 61.3  17.6 (47-87) 29.3  16.9 (14-50) 70.8 (16.9 (50-86) 5.9  .1 (5.8-6.1) 3  .2 (2.8-3.1) 100  0 (100) 96.4  7.1 (85.7-100) 96.4  7.1 (85.7-100) 10 4 34.8  6.5 (25-38) 32  8.2 (21-41) 68  8.2 (59-79) 5  .6 (4.1-5.6) 2.6  .2 (2.2-2.8) 95.8  8.3 (83.3-100) 100  0 (100) 95.8  8.3 (83.3-100) 11 2 43  8.5 (37-49) 54.5  34.6 (30-79) 45.5  34.6 (21-70) 5.1  .3 (4.9-5.3) 2.5  .2 (2.3-2.6) 92.9  10.1 (85.7-100) 69.1  3.4 (66.7-71.4) 76.2  13.5 (66.7-85.7) 12 2 34.5  4.9 (31-38) 41  14.1 (31-51) 59  14.1 (49-69) 4.1  .1 (4-4.1) 2.3  .3 (2.1-2.5) 92.9  10.1 (85.7-100) 61.9  6.7  (57.1-66.7) 69.1  3.4 (66.7-71.4) 13 5 49.8  22.3 (31-88) 46.8  14.5 (35-71) 53.2  14.5 (29-65) 4.2  .5 (3.6-4.7) 2.2  .3 (1.9-2.7) 100  0 (100) 71.9  14.9 (50-85.7) 71.9  14.9 (50-85.7) 14 4 35.3  7 (27-44) 39.8  18 (22-59) 60.3  18 (41-78) 5.5  .3 (5.2-6) 2.9  .1 (2.8-3) 100  0 (100) 81  15.1 (66.7-100) 81  15.1 (66.7-100) 192 Appendix E. Supplementary material for Chapter 6 E.1 Use of inclusive language Commonly Used Language in the Field Suggested Wording Justification Preventing T2D Reducing risk for developing T2D T2D is a multifaceted chronic disease which is influenced by genetic, behavioural, and environmental factors. By changing the emphasis from prevention to reducing risk, this takes the onus off the individual diagnosed with prediabetes and lessens the potential blame/fault on the individual Husband/wife Partner Husband and wife are gendered, heteronormative labels. Many people may choose to not get married or feel that these labels do not align with their personal identity. By using the word partner, it is inclusive of all relationships and identities. Risk of T2D is higher in Indigenous peoples. Groups who have inequitable access to culturally safe health promotion programming have higher risk of developing T2D The previous statement assumes that there is something inherent to being Indigenous that causes T2D, when the more likely cause is systemic racism leading to inequitable access to effective and safe healthcare. Diabetic, obese or overweight person Individual with type 2 diabetes; person with obesity or overweight The previous term defines a person by a condition that they live with. Person-first language puts the person first and says that they have or live with the condition. 193 E.2 Sociodemographic questions – how should they be asked? Sociodemographic question category Suggested wordinga References Sex What sex were you assigned at birth, meaning on your original birth certificate? o Female o Male o Undetermined o Another option (please specify: ____) o Prefer not to answer What is your current sex identity? o Asex o Female o Intersex o Male What is the sex category you currently use on administrative records/documents such as a driver’s license? o Female o Male o Another option (please specify: ___) Adapted from Bauer and colleagues (2017), and Reczek and Stacey (2022). Gender Which best describes your current gender identity? o Female or primarily feminine o Indigenous or other cultural gender minority identity (e.g. Two-Spirit) o Male or primarily masculine o Neither male nor female (e.g., gender non-confirming, gender fluid, non-binary, etc.) o Another gender (please specify: ____) o Prefer not to answer What was your gender assigned at birth? o Agender o Boy o Gender non-binary o Girl How would you define your gender expression? o Feminine (0-5 scale, with 0 being not at all and 5 being very) Adapted from Reczek and Stacey (2022). 194 o Masculine (0-5 scale, with 0 being not at all and 5 being very) How do other people see you? o Feminine (0-5 scale, with 0 being not at all and 5 being very) o Masculine (0-5 scale, with 0 being not at all and 5 being very) Race Do you identify as someone who is racialized, a visible minority, person of colour, or similar term? o No o Yes o Prefer not to answer Adapted from materials developed by Wray and colleagues for the “We ask because we care. The Tri-Hospital + TPH Health Equity Data Collection Research Project Report”. (http://torontohealthequity.ca/wp-content/uploads/2017/05/We-Ask-Because-We-Care-Report.pdf) (2013) Ethnicity Which of the following best describes your ethnic origins? Select all that apply. o African o African American o Caribbean o Central American o East Asian o Eastern European o Western European o Indigenous (e.g., First Nation, Métis, and/or Inuit)b o Latin(x) o Middle Eastern o Oceania o South American o South Asian o Southeast Asian o Another option (please specify: ___) o Prefer not to answer o Do not know Adapted from materials developed by Health Equity Office, Sinai Health System for the “Toronto Central LHIN Measuring Health Equity” project (torontohealthequity.ca) (2017). 195 Disability Disability is defined by The Accessible Canada Act as “any impairment, including a physical, mental, intellectual, cognitive, learning, communications or sensory impairment – or a functional limitation – whether permanent, temporary or episodic in nature, or evident or not, that, in interaction with a barrier, hinders a person’s full and equal participation in society.” Do you identify as a person with a disability as described above? o No o Yes o Prefer not to answer If “yes”, select the type(s) of disability that applies to you. o Communications o Developmental o Dexterity o Flexibility o Hearing o Learning o Memory o Mental health related o Mobility o Pain-related o Seeing o Disability not listed above (please specify: ___) o Prefer not to answer Adapted from the Accessible Canada Act a While this is the wording we currently recommend; research and terminology may change over time making these recommendations outdated. b This option is specific to the Canadian context and should be changed to include the Indigenous groups that are present in the area that the research is being conducted. 196 Appendix F. Ethical Certificates of Approval F.1 Certificate of approval for Chapters 2, 4, 5 197 F.2 Certificate of approval for Chapter 3
Thesis/Dissertation
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Jung, Mary E.
Evaluating the digitalization of the Small Steps for Big Changes coach training : from conceptualization to effectiveness
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