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BMC Public Health. 2019 Dec 03;19(1):1619
Centre for Hip Health and Mobility
The Author(s).
Sims-Gould, Joanie
McKay, Heather Anne, 1954-
Hoy, Christa L.
Nettlefold, Lindsay
Gray, Samantha M.
Lau, Erica Y.
Bauman, Adrian
Background: Despite the many known benefits of physical activity (PA), relatively few older adults are active on a regular basis. Older adult PA interventions delivered in controlled settings showed promising results. However, to achieve population level health impact, programs must be effectively scaled-up, and few interventions have achieved this. To effectively scale-up it is essential to identify contextual factors that facilitate or impede implementation at scale. Our aim is to describe factors that influence implementation at scale of a health promotion intervention for older adults (Choose to Move). This implementation evaluation complements our previously published study that assessed the impact of Choose to Move on older adult health indicators. Methods: To describe factors that influenced implementation our evaluation targeted five distinct levels across a socioecological continuum. Four members of our project team conducted semi-structured interviews by telephone with 1) leaders of delivery partner organizations (n = 13) 2) recreation managers (n = 6), recreation coordinators (n = 27), activity coaches (n = 36) and participants (n = 42) [August 2015 – April 2017]. Interviews were audio-recorded and professionally transcribed and data were analyzed using framework analysis. Results: Partners agreed on the timeliness and need for scaled-up evidence-based health promotion programs for older adults. Choose to Move aligned with organizational priorities, visions and strategic directions and was deemed easy to deliver, flexible and adaptable. Partners also noted the critical role played by our project team as the support unit. However, partners noted availability of financial resources as a potential barrier to sustainability. Conclusions: Even relatively simple evidence-based interventions can be challenging to scale-up and sustain. To ensure successful implementation it is essential to align with multilevel socioecological perspectives and assess the vast array of contextual factors that are at the core of better understanding successful implementation.
RESEARCH ARTICLE Open AccessFactors that influence implementation atscale of a community-based healthpromotion intervention for older adultsJoanie Sims-Gould1*† , Heather A. McKay1†, Christa L. Hoy1, Lindsay Nettlefold1, Samantha M. Gray1,Erica Y. Lau1 and Adrian Bauman2AbstractBackground: Despite the many known benefits of physical activity (PA), relatively few older adults are active on aregular basis. Older adult PA interventions delivered in controlled settings showed promising results. However, toachieve population level health impact, programs must be effectively scaled-up, and few interventions haveachieved this. To effectively scale-up it is essential to identify contextual factors that facilitate or impedeimplementation at scale. Our aim is to describe factors that influence implementation at scale of a healthpromotion intervention for older adults (Choose to Move). This implementation evaluation complements ourpreviously published study that assessed the impact of Choose to Move on older adult health indicators.Methods: To describe factors that influenced implementation our evaluation targeted five distinct levels across asocioecological continuum. Four members of our project team conducted semi-structured interviews by telephonewith 1) leaders of delivery partner organizations (n = 13) 2) recreation managers (n = 6), recreation coordinators (n =27), activity coaches (n = 36) and participants (n = 42) [August 2015 – April 2017]. Interviews were audio-recordedand professionally transcribed and data were analyzed using framework analysis.Results: Partners agreed on the timeliness and need for scaled-up evidence-based health promotion programs forolder adults. Choose to Move aligned with organizational priorities, visions and strategic directions and wasdeemed easy to deliver, flexible and adaptable. Partners also noted the critical role played by our project team asthe support unit. However, partners noted availability of financial resources as a potential barrier to sustainability.Conclusions: Even relatively simple evidence-based interventions can be challenging to scale-up and sustain. Toensure successful implementation it is essential to align with multilevel socioecological perspectives and assess thevast array of contextual factors that are at the core of better understanding successful implementation.Keywords: Physical activity, Public health, Seniors, Implementation scienceBackground“Most good ideas, however, do not spread with suchease. They require the backing and energies ofcommitted individuals and organizations to designand carry out strategies for expansion that arecarefully tailored to the realities of their settings.” [1]In Canada and the United States, the population ofolder adults (> 65 years) is projected to double over thenext 25 years [2, 3]. The most rapidly growing segmentof North America’s population are those over age 85 [3,4]. Indeed, longevity is an unprecedented societalachievement. However, living longer will inevitably gen-erate substantial health care costs unless governmentsinvest in innovative health promotion strategies thatsupport and sustain health across what possibly com-prises three decades of older adult life.Despite the many known health benefits of physicalactivity (PA) [5], older adults are the least active citizens© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.* Correspondence: simsg@mail.ubc.ca†Joanie Sims-Gould and Heather A. McKay contributed equally to this work.1Centre for Hip Health and Mobility, University of British Columbia andVancouver Coastal Health Research Institute, 7F-2635 Laurel Street,Vancouver, British Columbia V5Z 1M9, CanadaFull list of author information is available at the end of the articleSims-Gould et al. BMC Public Health (2019) 19:1619 https://doi.org/10.1186/s12889-019-7984-6in Canada [6]. Regular PA effectively ameliorates the riskof chronic disease [7], decreases the odds of functionallimitation, including ‘mobility-disability’ [8] and socialdisengagement [9], substantially. These broad-sweepingphysical and social health benefits are crucial to main-tain older adult independence. Strategies that integratePA into opportunities for older adults to socially engage,may diminish risk of chronic disease, preserve olderadults’ mobility and independence [7], and mitigate theincreasing number of lonely and socially isolated olderadults [10, 11]. During the past five decades the focus ofPA research has broadened from an almost exclusivefocus on fitness to include different choice-based do-mains of PA for health that span walking for transporta-tion to household activities [12] and those that increaseopportunities to socially connect [13].Although there are promising results from older adultPA interventions delivered in controlled settings [14], toachieve population level health impact programs mustbe effectively scaled-up. To do so, interventions are de-signed with scalability in mind [15], and implementationis guided by implementation or scale-up frameworks[16]. Ultimately, multi-levels and multi-sectors [17, 18],collaborative partnerships, ongoing stakeholder interac-tions [19] and defined progression through stages of im-plementation [20] are key to scale-up and sustainedimplementation [21]. However, to our knowledge, onlyeight studies targeting older adults and PA were scaled-up (defined as “the process by which efficacious healthinterventions are expanded under real world conditionsinto broader policy or practice” [22, 23]), with mixedoutcomes [24–31]. Thus, there is an implementation –scale-up gap within health promotion that warrants ourattention. Specifically, we need to better understand 1)how an intervention that is effective at smaller scale canbe adapted to meet the needs of diverse settings and indifferent older adult populations and 2) how interven-tions can be adapted for delivery at large scale to en-hance health of older adults.We aim to fill this gap in the literature by sharing ourapproach to the implementation and phased scale up ofa health promotion intervention called Choose to Move(CTM) for older adults in British Columbia, Canada. Wepreviously published the conceptual frameworks forimplementation and scale up that underpin our re-search approach [32], the translational formativeevaluation that informed design and implementationof the intervention at scale up [33], and the positiveimpact of CTM on older adults’ health during thefirst two phases of scale up [13]. Thus, our objectiveis to describe factors that influence successful imple-mentation of CTM during Phase 1 and 2 (2016–2017)scale up. Results will be used to adapt CTM forbroader scale-up in Phase 3.MethodsIn this section, we provide a brief overview of; 1) theCTM intervention; 2) context for implementation andscale-up of CTM, 3) the implementation framework thatguides CTM implementation, and 4) the role of partnerorganizations. Using qualitative methods, we focus onfactors that influenced implementation of CTM acrossfour levels of delivery partners and from the perspectiveof older adult participants. All study procedures wereapproved by the Clinical Research Ethics Board at theUniversity of British Columbia [H15–02522] and the Re-search Ethics Board at Simon Fraser University [22,015s0614]. All participants provided informed written con-sent prior to each interview. There was no financial in-centive for participating in the interview.The intervention – choose to moveCTM is a 6-month, choice-based, flexible, scalable,health promotion intervention for low active (< 150 minof moderate to vigorous PA/wk) older adults (60+ years).To guide CTM content and delivery, we adopted core el-ements of the effective Community Healthy ActivitiesModel Program for Seniors (CHAMPS; choice-based,telephone assisted approach). CHAMPS was delivered atscale by 13 diverse community agencies [24, 34–36]. In-creased PA participation was of similar magnitude as re-ported for efficacy studies – despite greater diversity inparticipants’ ethnicity, socio-economic status, and healthconditions [27, 37]. We then conducted a translationalformative evaluation in order to assess context for im-plementation, adapt where needed, and pilot our ap-proach and measurement tools [33].CTM is currently being delivered in three phases at in-creasingly greater scale across the province of BritishColumbia (BC) (Fig. 1). Phase 1 [2016; n = 8 programs,n = 67 participants] and Phase 2 [2016–2017; n = 47 pro-grams, n = 391 participants] comprised implementationof CTM at smaller scale, in urban, suburban and smallurban communities. Phase 3 [2018–2020] targets broadscale-up [13]. In this study we focus on implementationof CTM during Phases 1 and 2 (n = 55 programs, n =458 participants). In total, CTM was delivered at 26unique sites with either 1 (n = 15 sites), 2 (n = 8 sites), 3(n = 3 sites) or 5 (n = 3) program cycles delivered duringphases 1 and 2.CTM is comprised of three core elements delivered bytrained activity coaches. First, a 60-min one-on-one con-sultation with activity coaches assists participants to setand maintain PA goals that cater to their physical cap-acity and preferences (create an Action Plan). Second,participants attend four 60-min Motivational GroupMeetings (once/month in months 1–2; twice in month 3to connect socially with other participants (max 12/group) and with their activity coach. Third, activitySims-Gould et al. BMC Public Health (2019) 19:1619 Page 2 of 12coaches call participants regularly by phone (15 min/callon average) to monitor progress, address challenges, andmodify the Action Plan as needed (three times in month1; twice/month in months 2 and 3; once/month inmonths 4–6). As CTM is supported through a govern-ment grant, there is no cost to participants. We use mul-tiple implementation strategies [38] with our partners todeliver CTM (Table 1).Context for implementation and scale-upIn response to the escalating rates of chronic disease[39], physical inactivity, and social isolation in Canada[6, 40, 41], BC Ministry of Health developed ActivePeople, Active Places, a PA Action Plan for BC [42].Older adults were identified as a priority area. A fundingpartnership was established between the Ministry ofHealth and the Active Aging Research Team (AART;www.activeagingrt.ca).Implementation frameworkWe provided details of the conceptual frameworks forimplementation and evaluation, guiding principles, theintervention, and evaluation methods that guide ourwork at length in a previous publication [32]. Briefly, theFramework for Effective Implementation [43] guided de-velopment, implementation and evaluation of CTM(Fig. 2). This framework highlight six categories of con-textual factors that influence effective implementation;1) the innovation (CTM), 2) the prevention delivery sys-tem (e.g., activity coaches, recreation center coordina-tors/ managers and delivery partner organizationalleads), 3) the prevention support system (e.g., our ActiveAging Research Team), and 4) the prevention synthesisand translation (research) system (e.g., our Active AgingResearch Team) - all nested within the socioecologiccontext of 5) provider and 6) community characteristics[43, 44]. These different ‘levels of influence’ also guideour evaluation approach.Although we aligned our approach with one of morethan 60 published frameworks [45], there are many com-mon elements among them. These often include, attri-butes of the intervention, factors that supportimplementation, delivery strategy, characteristics of theadopting community, the broader socio-political context,Fig. 1 Phased delivery of Choose to Move and timing of interviews by participant group. Blue and yellow bars represent programs delivered bydifferent delivery organizations. Leaders of delivery organizations were interviewed before (or during) phase 1 and at the end of phase 2. Timingof interviews for other groups (Recreation Managers, Recreation Coordinators, Activity Coaches and Participants) are illustrated in the bottomportion of the figure. All Recreation Managers at sites delivering 3 or more programs were interviewed once at the mid point of the finalprogram. All Recreation coordinators were interviewed at program mid-point the first and last time their site delivered a program. All Activitycoaches were interviewed at program mid-point the first and last time they delivered a program; a subset were interviewed post-intervention aswell. Participants were interviewed at baseline, mid-point and post-intervention. *Although 23 programs were initiated during this cycle, 1program was cancelled after baseline measures were collected. Adapted with permission from “Implementation of a co-designed physical activityprogram for older adults: positive impact when delivered at scale,” by McKay H, Nettlefold L, Bauman A, Hoy C, Gray SM, Lau E, and Sims-Gould J,2018, BMC public health, 18 [1]:1289. CC BY 4.0Sims-Gould et al. BMC Public Health (2019) 19:1619 Page 3 of 12and the use of research and evaluation to inform thescale-up process [46]. However, others contend thatthere is no single or straightforward implementationframework that offers a formula for success [21]. As im-plementation research evolves it will, “help implementersto better understand the complex array of contextualfactors, such as politics, socio-cultural norms and beliefs,and the fiscal environment, that can influence scale-upsuccess” [29].Delivery partners and the support unitConsistent with the Framework for Effective Implemen-tation [43] community partners served along a con-tinuum from strategy (leaders of delivery partnerorganizations), to operations (recreation coordinatorsand managers), to on the ground delivery (activity coa-ches) – together they comprised the delivery system.Two major delivery partner organizations delivered 56CTM programs between January 2016 and May 2017 inTable 1 Choose to Move (CTM) Implementation StrategiesCTM Implementation Strategies [38] DescriptionsConduct needs assessment (at provincialpartner level)Prior to CTM implementation, the CTM project team (project team)* conducted formative evaluationusing semi-structured focus interviews to assessi) Older adults’ acceptability of CTMii) Delivery partners’ perceived adaptability of CTM to context and populationiii) Activity coaches’ perceived feasibility of implementing CTM implementation of the intervention byActivity Coaches (to assess feasibility) and to identify and pilot evaluation tools and methods to assesseffectiveness of CTM at scale. We collaborated with both delivery partners to adapt the program totheir organizational contextDevelop community partnership and obtainformal commitmentsThe project team partnered with the two community organizations to deliver CTM at their affiliatedfacilities. Both organizations have signed contract agreement committing on program delivery.Develop program materials and tools The project team developed and provided the following materials for the delivery organization. Theseinclude materials for:i) Program managers• Recruitment materials• Descriptions of program coordinators and activity coaches hiring process and job descriptionsii) Program coordinators• Outline of implementation and evaluation tasksiii) Activity coaches• Presentation materials on health topics for motivational group meeting sessions• Tools to record participants attendance and responses during one-on-one Action Planning and tele-phone check-ins.Centralized technical assistance The project team functioned as the prevention support system to provide centralized technicalassistance to the program coordinators, managers and activity coaches.Conduct dynamic training The project team provided a 1-day training for activity coaches. Training content included overview ofCTM, motivational interviewing techniques, active listening skills. They were provided with skills dem-onstration, opportunities to practice the learned skills and ask questions.Provide on-going consultation The project team provided on-going telephone consultations to each delivery sites throughout theintervention period. The purpose of these phone calls was to identify and troubleshoot implementa-tion issues. These included:• Regular phone call (weekly to start, then monthly as Phase II progressed) with provincial coordinators• On-going email communications to provide additional supportUse advisory boards and workgroups During CTM implementation, the project team formed two advisory committees that provide ongoingfeedback we use to adapt the program as needed throughout the intervention period. Both advisorycommittees meet annually.• The Community Advisory Committee comprises older adult participants, recreation coordinators, andactivity coaches from partner organizations and members of the Active Aging Research (AART) team.This committee shares lessons learned during the implementation of CTM.• The Leadership Advisory Committee comprises leaders of delivery partner organizations andmembers of AART. This committee was the organizational lens we used to monitor theimplementation of CTM in collaboration with partner organizations and to assess the need forfurther adaptation of CTM to meet the specific needs and capacity of delivery organizations beforescale-up. Both advisory committees meet annually.Stage implementation scale up CTM was first piloted in DP2 (8 communities) in Phase I before a larger scale roll out in DP1 and DP2in Phase II (48 communities). This pilot provided opportunity for delivery partners to provide feedbackon the feasibility of CTM implementation and identify barriers and facilitators of implementation. Thisfeedback was then used to refine the intervention and implementation plan in Phase II.* The Choose to Move project team (project team) was convened by the Active Aging Research Team to support delivery of CTM. Specifically, the project teamcomprised of two principal investigators (HM, JSG), international research collaborators, a program manager and several research assistants to support day-to-dayoperation and program evaluationReproduced with permission from “Implementation of a co-designed physical activity program for older adults: positive impact when delivered at scale,” byMcKay H, Nettlefold L, Bauman A, Hoy C, Gray SM, Lau E, and Sims-Gould J, 2018, BMC public health, 18 (1):1289. CC BY 4.0Sims-Gould et al. BMC Public Health (2019) 19:1619 Page 4 of 1226 community centres or other facilities. They were se-lected based on their established relationships with re-creation centres, their capacity to coordinate delivery ofprograms at scale, and their desire to sustain implemen-tation of a health promotion intervention for olderadults across BC, in future. We defined this operation-ally as CTM being aligned with the vision and missionof the delivery partner organization.We convened a project team (from AART) that servedas CTM implementation support and research systems[43, 44]. The support unit provided leadership, training,and created a communications plan and governancestructure. The support unit engaged delivery partners todesign, implement, and evaluate CTM to meet the needsof older adults. The support unit ensured that imple-mentation strategies varied as little as possible acrosssites.CTM implementation evaluationWe consider implementation evaluation an essentialcomponent of intervention studies as 1) it provides con-text to interpret participant level health outcomes [13],2) it can be adopted by researchers who wish to evaluatescale-up of most health focused interventions, and 3)implementation outcomes can be used to guide adapta-tion of an intervention to setting and population, as ameans to enhance likelihood of successful scale-up andsustainability, in the future. We aligned our implementa-tion evaluation with the Framework for Effective Imple-mentation [43]. We present our results across levels ofinfluence (from leaders of delivery partner organizationsto CTM participants) as per the socioecologic model[43]. We identified these stakeholders using the influ-ence approach reported by Colvin [47].Four members of the support and research system con-ducted semi-structured interviews by telephone with allparticipant groups. The interview questions were tai-lored to participant group and focused on perceivedlevels of support, challenges and opportunities, adapta-tions, and perceived fit of CTM to the local context. In-terviews used an interview guide, specific to eachparticipant group and time point. Guided by our imple-mentation framework, the project team developed ques-tions for the interview guide. Questions for the activitycoach and participant interview guides were used previ-ously in our translational formative evaluation [33].Questions for the recreation manager and coordinatorinterview guides were tested in those groups beforePhase 1. For all groups, we interviewed the same individ-ual across time points. Table 2 provides examples ofquestions we asked to identify factors influencing imple-mentation. Interviews were audio-recorded and profes-sionally transcribed. Interviewers were trained by thelead author to take high level notes to serve as back upshould the audio recording be faulty or unclear.Leaders of delivery partner organizationsWe interviewed leaders of delivery partner organizationsbefore or during Phase 1 (August 2015–September 2016;n = 13) and again at the end of Phase 2 (March–April2017; n = 6). Interviews were designed to ascertain thepolitical and organizational climate surrounding PA pro-motion (context for delivery), the fit of CTM withorganizational priorities, perceived (baseline) and actual(follow-up) facilitators and barriers to delivering CTMFig. 2 The framework for effective implementation. Implementation of the Choose to Move is guided by the prevention delivery system and itsorganizational capacity, the prevention support system and the prevention synthesis & translation system. These critical components areembedded within a larger context of provider characteristics and community factors (outer rings). Interactions between all components in theouter and central rings are illustrated by bidirectional arrows. Reprinted with permission from McKay HA, Sims-Gould J, Nettlefold L, Hoy CL,Bauman AE. Implementing and Evaluating an Older Adult Physical Activity Model at Scale: Framework for Action. Translational Journal of theACSM. 2017;2 [2]:10–9. https://journals.lww.com/acsm-tj/pages/default.aspx. Figure originally adapted from American Journal of CommunityPsychology, Volume 41 [3, 4], Dupre, J.A. and Durlak E.P., Implementation Matters: A Review of Research on the Influence of Implementation onProgram Outcomes and the Factors Affecting Implementation, 327–350, Copyright (2008), with permission from John Wiley and SonsSims-Gould et al. BMC Public Health (2019) 19:1619 Page 5 of 12across BC, and willingness to continue to deliver CTM(follow-up only; sustainability). Interviews were con-ducted by one trained interviewer for Phase 1 and an-other at follow-up and lasted approximately 12 min(range = 5 to 22 min).Recreation managers and recreation coordinatorsWe interviewed recreation managers (n = 6) once (atprogram mid-point) at six sites where programs weredelivered in 3 or more cycles. We interviewed recreationcoordinators at program mid-point the first and lasttime their site delivered a program during Phases 1 or 2(April 2016 – February 2017; n = 27 completed oneinterview; n = 14 completed two interviews). We askedrecreation managers and coordinators about facilitatorsand barriers to program delivery, suggestions for im-provement, any adaptations to the implementationprocess, and willingness to continue delivering CTM.One trained interviewer conducted all interviews thatlasted approximately 18 min (range = 7 to 46min). Dueto small sample sizes, we aggregate recreation managerand recreation coordinator data together to preserveanonymity.Activity coachesWe interviewed all activity coaches at program mid-point, the first (n = 23) and last (n = 13) time they deliv-ered CTM during Phase 1 and 2 [March 2016 – January2017]. We interviewed a subset (randomly selected) ofactivity coaches (n = 19) at 6-months. We asked similarquestions at both 3-month and 6-month interviews, in-cluding facilitators and barriers to CTM delivery, adapta-tion made to the intervention or its implementation,suggestions for improvement, lessons learned, and suc-cess stories. If they delivered programs during five cycles(n = 1), we interviewed activity coaches at 3-months ofCycle 1, 3 and 5. One trained interviewer conducted allinterviews. Interviews lasted approximately 27 min(range = 10 to 54 min).ParticipantsWe randomly selected one participant per site fromthose who consented to the interview portion of thestudy so as to ensure geographic diversity. Our CTMparticipants are mostly white (85%) women (77%); this isalso reflected in the subset of participants completingthe interview (91% white, 63% women). We interviewedthese participants at baseline (n = 42), 3-months (n = 38)and 6-months (n = 34) of their program [January 2016 –April 2017]. Two trained interviewers conducted all in-terviews. Interviews lasted approximately 11 min(range = 3 to 25 min).AnalysisInterview recordings were transcribed verbatim by a pro-fessional transcriptionist. Data were de-identified andimported to NVivo 11 (QSR International, 2015) for dataanalysis. For all participant groups, interview data wereanalyzed using framework analysis [48–50], an appropri-ate analytic approach for qualitative studies with specificquestions, a pre-designed sample, and a-priori issues[50]. In framework analysis, data are sifted, charted andsorted in accordance with key issues and themes usingfive steps: 1) familiarize; 2) identify a thematic frame-work; 3) index; 4) chart; and 5) map and interpret [50,51]. First, two team members read through a subset oftranscripts to establish a sense of the interviews(familiarize). Through team meetings we developed apreliminary thematic framework, consisting of themesand sub-themes, based on key issues and commonalitiesemerging from the transcripts (identify). Using Nvivo 11software, one team member coded interviews based onthe thematic framework, with discussion among otherteam members, as new codes and sub-themes were iden-tified (index). Full paragraphs were coded so that con-textual meaning was not lost. Data were thensummarized by charting illustrative quotes that best ex-emplified the themes (chart). As part of the interpretiveprocess a series of team meetings (n = 6) were held todiscuss the data for common themes and sub-themes(map and interpret). We used a number of strategies toreinforce the rigor of our analysis: crosschecking fulltranscripts against original audio files for quality andTable 2 Five participant groups across levels of influence withsample questions for each groupParticipant Group Sample QuestionsLeaders of deliverypartner organizationsHow does offering this type of program fitwith the strategic direction of yourorganization moving forward?What needs to be in place for this type ofprogramming to be successful in yourorganization on a longer term? Across theprovince?Recreation managers What needs to be in place for a program likeCTM to be successful in your centre on alonger term?What is the likelihood that your organizationwill continue to deliver this type ofprogramming as part of usual practice?Recreation coordinators What factors have helped your organizationimplement CTM?What has made it challenging for yourorganization to implement CTM?Activity coaches Generally, how well did the implementationof CTM proceed for you?Did you modify any of the programcomponents? If so, why?Participants What are your favourite parts of theprogram?Sims-Gould et al. BMC Public Health (2019) 19:1619 Page 6 of 12completeness and reflexive memoing throughout thedata generation and data analysis process [52].ResultsThe support and research system (comprised of an AARTproject team) worked in close proximity with CTM deliv-ery partners across levels. The central role of the supportand research system was to provide ongoing oversightacross levels of delivery partners with a focus on imple-mentation. Importantly, the support and research systemmonitored intentional or unintentional adaptations to theintervention and its implementation. We describe key ele-ments that delivery partners felt either supported or hin-dered implementation and scale-up of CTM, below. Themain themes are illustrated in Fig. 3.Leaders of delivery partner organizationsLeaders of delivery partner organizations discussed theorganizational context [43] for program delivery. Theyfelt that while there is some political support for PA inthe province, there are very few (if any) systemically or-ganized programs for older adults. Against this backdropthey highlighted the challenge for older adults to becomeactive or to access programs:“So there’s definitely a need for that population to bephysically active. There’s definitely a need and thedemand and market for older adult fitness is for surethere. I think with the growing aging population thisdemand is needed--not going anywhere. It’s just amatter of, you know, accessibility … ”Further, this group noted that programmatic offeringsvary by region, and it is often challenging for older adults tonavigate the community-based system in order to find suit-able programs. Overall, CTM was considered timely, neces-sary, relevant, and scalable. This speaks to the importanceof the organizational context for delivery. Leaders notedcomplete alignment with their organizational priorities, vi-sion, and strategic directions. As noted by one leader:“this gives us the resources to actually fulfill our ownmandate, and our own mandate as an organization is toenable communities in their attempts to build theircommunities and build strong, healthy resilientindividuals.”Leaders indicated that their organizations have the in-frastructure and capacity but not the financial resourcesto offer CTM. By virtue of its choice-based nature, CTMwas deemed flexible and scalable. In this way, leadershighlighted their organization’s capacity to sustain CTM:“And we do have the infrastructure, so we have the staffwho can take it on and provide training and the pas-sion”. On the other hand, leaders expressed concernabout how CTM might be sustained in the absence ofongoing provincial funding. They saw currently intactlinkages with Ministry of Health as essential for scale-upof CTM and a possible mechanism to ensure sustainabil-ity. CTM was considered a good place to refer olderadults who are currently engaged with BC’s health caresystem (i.e. awaiting treatment or involved with homeand community care) and where PA was not contraindi-cated. There was also discussion about the need to reacholder adults who are more isolated and/or marginalized.“I would say one of the issues is just how do you reachthe people that need the program, you know, becauseFig. 3 Themes emerging from our analysis. We illustrate key themes that emerged from our analysis. Some themes emerged across multiplelevels; others were only identified by one participant groupSims-Gould et al. BMC Public Health (2019) 19:1619 Page 7 of 12just given the fact that the people who need theprogram often may be isolated, well, how do you reachthem?”When speaking specifically about design of CTM,leaders noted that the social aspects of the program wereparamount to older adults. They identified the need toprovide opportunities for older adults to socialize andthat CTM created those opportunities. Leaders alsohighlighted that an evidence-based program developedby researchers made CTM more ‘credible’ for those de-livering CTM and for older adults enrolled in CTM.Recreation managers/coordinatorsRecreation managers/coordinators were very positiveabout CTM. One manager stated “it is a beautifulmodel” and “a good fit with the mandate of ourorganization”. The social components were deemed anexcellent component of CTM. Recreation managers/co-ordinators also noted the essential need for externalfunding to run the program and to find the right staff todeliver CTM; highlighting questions around sustainabil-ity. Sustainability was deemed uncertain without longterm financial commitments to CTM. Specifically, theyhighlighted the need to recover costs to support activitycoaches.“And for us we don’t have a budget to subsidizeprograms. So all our programs have to be cost-recovery, so in order for us to keep this on-- as part ofour regular practice we would need to cover the costfor our instructors and/or space.”They highlighted that charging a fee for CTM mightbe one way to do this, although that could pose a poten-tial barrier to participation among older adults.Through implementation of CTM, managers/coordi-nators gained valuable insight into time management,communications, and recruitment needs of CTM.Central to delivery of CTM, the pivotal role of theactivity coach surfaced time and again. Recreationmanagers/coordinators expressed concern about thelack of older adult certified instructors in certaincommunities, issues with staff turnover, and chal-lenges related to bringing instructors in from outsidea recreation centre as this may lead to unfamiliaritywith processes specific to that city/centre. They notedthat it is much easier when an activity coach is hiredwho is already part of a specific centre’s program-ming. Finally, they emphasized that it was very help-ful when activity coaches took ownership of CTMand in so doing, assisted with recruitment, registra-tion, and screening. This sentiment also speaks tolimited organizational capacity.“I think one of the big ones is that the Choose to Move(activity coach) is somebody we have a relationshipwith already. It’s a staff member at the facility so it’sjust-- I find that that’s-- that’s helped with theimplementation of the program”They noted that materials provided for CTM partici-pants were appropriate and contributed to CTM being“easy to implement”. The role of the support and re-search system was viewed as instrumental to successfulimplementation of CTM.“the support we receive from (the support and researchsystem) is really important. Certainly, the trainingmaterials, the weekly, bi-weekly check-ins that we havewith (support and research system lead) are also veryimportant to us. It gives us an opportunity to touchbase, kind of just provide updates but also kind ofproblem solve any challenges that we may be experien-cing as well.”They also stated how crucial it was to ensure ad-equate lead time to allow recreation centres to pro-mote CTM, to generate other communicationmaterials (e.g. recreation calendars), and to provideinformation sessions for all those involved in recruit-ment and delivery of CTM (e.g. front desk staff). Thiswould ensure that those delivering CTM at everylevel had a clear understanding of CTM and couldadequately answer any questions they were asked.This, in turn, was thought to increase recruitment ef-forts of more vulnerable or marginalized older adults(i.e. those who may not normally participate in recre-ation centre activities). Finally, they deemed central-ized training and opportunities for activity coaches toengage with one another as highly beneficial.“Yeah, so when we first started there was-- the timingof it didn’t allow us to get it into our normal kind ofFit Living guide cycle. So we felt like we had to do a,you know, ton of extra work to spread the word,otherwise it wouldn’t be out there.”Activity coachesActivity coaches highlighted that CTM was an ‘excel-lent’ program, well laid out, and easy to deliver. Theyalso noted that the support and research system wascentral to CTM’s success. Activity coaches felt theirrole was very rewarding; there was a strong desire forCTM to continue. When speaking about other re-warding aspects of CTM, the significant changes inSims-Gould et al. BMC Public Health (2019) 19:1619 Page 8 of 12participants’ level of activity and connectedness werenoted.“I mean, success stories to me is just everybody that’sstill moving. I mean, people that I called on their sixmonth and they’re-- they still, you know, want to bragto me about, you know, what they’re doing and howthey’re feeling. Or if they’ve fallen off the wagon and,you know, push the restart button and got going again,how they felt when they were off the wagon. And howthey couldn’t believe it, right. I just felt so sorry and Ididn’t feel good and this and that. It’s like yeah. Great.So what did you do about it? I started exercisingagain. Awesome! Good for you. Good choice and youmade it without me.”In addition to changes in activity and connectedness,improvements in participants’ health status washighlighted as important. Activity coaches noted thatthey made a number of ‘small tweaks’ to the interventionto facilitate implementation. For example, some activitycoaches modified group meeting content due to timeconstraints and/or relevance to the community context.Other activity coaches modified the active travel compo-nent due to community built environment characteris-tics that limited opportunities for active travel. Inaddition, activity coaches used face-to-face meetings oremail as an alternative mode for check-ins (originalmode was telephone) due to participant preference or toaccommodate participant schedules. Finally, activity coa-ches distributed supplemental resources based on par-ticipant requests for further information on a topic ofinterest.ParticipantsParticipants were pleased with and very much enjoyedparticipating in CTM. They agreed overwhelmingly thatactivity coaches were central to their continued partici-pation and key to the success of CTM. Specifically, par-ticipants noted how positive attitudes andencouragement offered by activity coaches made a tre-mendous difference.“He’s extremely patient with everyone. He’s verysupportive. I think when he was on the phone therewas never-- I never felt like I was being rushed off thephone. It was always, you know, what can I do tohelp? Is there anything more I can help you with?”Most participants felt that the number of check-incalls from their activity coach was adequate. After thefirst three months of CTM, they felt that PA started tobecome a part of their everyday routine. Their activitycoaches’ words of support and guidance resonated intheir minds. Testament to them enjoying CTM, partici-pants wished it ran for a longer duration. They also of-fered suggestions as to how best to foster more socialopportunities amongst participants. Related to this, par-ticipants noted that group meetings provided importantopportunities for participants to share their experiences,discuss PA related issues, and generally interact withothers.“It’s just nice to hear what other people are doing,though. It’s nice to hear how, you know, they have beenmotivated. And I think it encourages everybody whenyou, you know, hear somebody else say, well, this iswhat happened with me. And so, yeah, that part-- Ilike the sharing part.”Participants cited an array of health benefits from theirparticipation in CTM. The three most often noted bene-fits were improvements in physical health, an increase inknowledge and awareness about the importance of PA,and an increase in motivation to engage in PA. Forhealth benefits, joint health most commonly improved.The most common barriers to participating in CTMwere unrelated to implementation factors. They mostoften related to individual health conditions such as in-jury, recent surgery, illness, or weather.DiscussionThe World Health Organization [53] and many coun-tries and their regions world-wide voiced the need to de-velop and communicate the need for effective strategiesto implement health promoting PA interventions atscale. However, few jurisdictions succeed in doing so[22, 54]. Of evidence-based health related programs andpractices, about 65% of attempts to scale-up fail [55, 56].This is due in large part to the prescriptive and some-times complex nature of these interventions and the var-ied and dynamic contexts in which they are delivered.There has been a global call for researchers to design,implement, and conduct implementation evaluations tounravel factors that influence implementation of PA in-terventions at scale [57, 58].We responded to this call and extend the existing lit-erature by identifying factors across five levels of influ-ence, that facilitate or impede implementation and scale-up of a health promotion intervention for older adults.We also capture the perspective of those whom theintervention is designed to positively benefit – olderadults. Our approach aligns with multilevel socioeco-logical perspectives and implementation frameworks thatacknowledge the vast array of contextual factors at thecore of successful implementation [43, 44, 59]. Withinscale up, Yamey [21] suggests that four elements arecrucial for successful implementation; an innovationSims-Gould et al. BMC Public Health (2019) 19:1619 Page 9 of 12(intervention) that is simple and technically sound,strong leadership and active engagement by a range ofstakeholders (delivery partners), the use of a wide varietyof strategies to implement the innovation, and a robustevaluation (research). We heard from stakeholders thatthey considered these elements a core part of CTM.First, all delivery partners expressed that CTM fit wellwith provincial organization and local facility mandatesand that it was simple and evidence-based. There wasalso strong consensus that CTM was appropriate and ef-fective for older adults. This was directly attributed toCTM’s concrete, yet flexible design and choice-based na-ture. This reflects the extensive (2-year) process weadopted to co-design CTM with community partners. Italso reflects our commitment to a continuous cycle offeedback (from partners across levels) and adaptation asper the Knowledge-to-Action Cycle [60]. Responding tothe needs of delivery partners and adapting to commu-nity context was supported by our phased approach toimplementation [13, 32] from formative evaluation tosmall scale-up [Phase 1; 2016] to implementation atmedium-scale [Phase 2; 2016–2017] in preparation forimplementation at large scale [Phase 3; 2018–2020]. Thenotion of scaling-up in a phased manner to capitalize onlessons learned along the way has been cited as import-ant in the expansion of other health-based initiatives[61, 62]. Older adults also identified many elements thatenticed them to engage in CTM. Of note, they found the‘choice-based’ concept that is core to CTM relativelyeasy to understand and most appreciated having choicerather than a prescribed program of exercise.Second, the capacity for CTM to be adapted speaks toengaging a range partners at the outset to co-design theintervention and its implementation [63], and to pro-gram flexibility and scalability. Strong leadership acrosslevels of partners facilitated implementation. The sup-port and research system also provided strong leadershipand was seen as the backbone for implementation andfor guiding ongoing adaptation of CTM. Leadership hasbeen noted elsewhere as a key element that promotesimplementation success [21].Third, we used multiple implementation strategies withour partners to implement CTM; our interview questionswere designed to provide participants an opportunity tocomment on them. For example, at the operational levelrecreation managers/coordinators identified three majorchallenges to implementation. In smaller communities, itwas difficult to find and retain trained fitness leaders andto recruit participants. Recreation coordinators alsounderestimated the time and effort required to fill and ad-minister programs in many communities. We addressthese issues as we implement CTM during Phase 3.Activity coaches were the front facing deliverers ofCTM and in this role were the major point of contactfor older adult participants. Activity coaches employed anumber of strategies to recruit and retain participants.Many activity coaches had long standing connections totheir communities and used these linkages to draw olderadults into CTM. Participants spoke at length about theimportance of a knowledgeable activity coach whoresponded to their individual needs and concerns.Finally, we developed and implemented CTM with astrong focus on evaluation. The important role of theproject team from AART as support and research systememerged as key to successful implementation and evalu-ation of CTM across delivery partners. This reflects thesupport and research system’s ability to integrate evalu-ation activities and engender commitment across levelsof influence to achieve positive benefits for older adults[43, 44, 64]. Many implementation frameworks note thecrucial nature of central support and knowledge synthe-sis and translation for effective implementation [1, 44,56]. The support and research system built capacitywithin community organizations by providing specializedtraining, through a formal communications plan enactedwithin and across levels, and through continual feedbackabout the intervention and the evaluation. Two-waycommunications also provided delivery partners the op-portunity to provide the support and research systemwith key evaluation data and to communicate about pro-gram adaptations to CTM that they felt would bettersupport its implementation. We agree that a comprehen-sive implementation evaluation can be used “to organizeand promote synthesis of research findings … which willfurther stimulate theory development” [56]. We envisionthat our implementation evaluation will serve as onetemplate to evaluate health promotion interventions,and in so doing contribute to filling the implementation-scale-up gap. We also note, an important next step is todesign a study with a more specific focus on fidelity toimplementation strategies.We would be remiss to ignore the impact of financialresources on successful implementation of CTM. Fund-ing for CTM reflects a commitment to enhance thehealth of older adults as one current priority within BCMinistry of Health. We secured competitive grant fund-ing to conduct a comprehensive evaluation. Althoughthere is no permanent, long term commitment fromgovernment to fund CTM, as we continue to rigorouslyevaluate scale up (including impact, implementation andcost-utility) we become better positioned to advocate forCTM’s sustained scale up and delivery over the longerterm.ConclusionEven relatively simple evidence-based interventions canbe a challenge to scale-up and sustain [57, 58], as theyare often implemented within complex geographical,Sims-Gould et al. BMC Public Health (2019) 19:1619 Page 10 of 12sociocultural and ethnically diverse environments. Olderadults, whose longevity now spans three decades ormore, represent a wide range of physical and cognitivecapacity. Further, the environments where they live mayor may not include access to support networks, commu-nity resources and/or health promotion programs thatcan be adapted to their needs and capacity. If we are toshift the trajectory away from increased chronic disease,mobility-disability, and problems such as loneliness – newstrategies that engage stakeholders across multiple levelswith a view to implementation at scale are needed. Healthpromotion models like CTM may be one solution. CTMunderscores the importance of a simple, technically soundintervention, committed and integrated partners, a widearray of implementation strategies, and a comprehensiveimplementation evaluation that provides ongoing feed-back so that implementation strategies can be customizedto context. CTM illustrates one approach to implementa-tion and scale-up of an effective health promotion inter-vention that can be adapted by policy makers, academics,and service deliverers.AbbreviationsAART: Active Aging Research Team; BC: British Columbia; CTM: Choose toMove; PA: Physical activityAcknowledgementsWe extend our thanks to our delivery partners (BCRPA, YMCA), recreationstaff, activity coaches and participants who made this research possible. Wealso thank Heather MacLeod Williams, Rei Ahn, Venessa Wong, and KaitlinHong Tai who all contributed to the acquisition and analysis of interviewdata for this manuscript.Authors’ contributionsJSG: study concept and design, data interpretation, manuscript writing andrevision. HM study concept and design, data interpretation, manuscriptwriting and revision. CLH: study design, data collection, data analysis, datainterpretation, manuscript revision. LN: study design, data interpretation,manuscript revision. SG: data analysis, data interpretation, manuscriptrevision. EL: data interpretation, manuscript revision. AB: study concept, studydesign, data interpretation, manuscript revision. All authors have read andapproved the manuscript and agree to be accountable for the workcontained within.FundingThis work was supported by the British Columbia Ministry of Health and theCanadian Institutes of Health Research [PJT-153248 to JSG]. The funders hadno role in study design, data collection, data analysis, interpretation orwriting of the manuscript.Availability of data and materialsThe datasets generated for this study are not publicly available due to therestrictions of the ethics approval.Ethics approval and consent to participateAll study procedures were approved by the Clinical Research Ethics Board atthe University of British Columbia [H15–02522] and the Research EthicsBoard at Simon Fraser University [22015 s0614]. 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Factors that influence implementation at scale of a community-based health promotion intervention for older adults
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