A practice-led definition of ‘successful scale-up’: Evidence from globally scaled physical activity and nutrition interventions

Background: It is not known whether the WHO ExpandNet framework for scaling up is used in physical activity or nutrition interventions, adopted in practice, or which criteria stakeholders use to determine ‘successful scale-up’.

Purpose: To assess adoption of ExpandNet framework recommendations using an international sample of scaled up physical activity and nutrition interventions, and explore definitions of successful scale-up.

Methods: Online survey with stakeholders involved in scaled up physical activity and nutrition interventions globally. Survey questions (n=27) corresponded to 32 framework components: (1) intervention; (2) user organisation; (3) resource team; and (4) scale-up strategy. Data were analysed descriptively, qualitative survey responses coded thematically.

Results: Sixty-two survey responses (academia n=32, community n=20, government n=10) corresponding to 35 scaled interventions. Only 8% of participants reported all 32 ExpandNet components during scale-up. Participants reported 2-4 scale-up strategies and channels, and 36% used coalitions / networks for advocacy. Eight themes underpinned ‘successful scale-up’: Scaling Inputs: (1) Sustained partner buy-in, funding, resources, evaluation; Scaling Outputs: (2) Sustained implementation, with quality / integrity; (3) Sustained impact, beyond funding; Scaling Outcomes: (4) Increased and equitable reach to other populations / sectors; (5) Improved organisation and system capacity; (6) System embeddedness and part of routine practice; Scaling Context: (7) Stakeholder mental models, beliefs; and (8) Dynamic, complex and context-specific construct.

Conclusions: There is no universal definition of successful scale-up. We propose a comprehensive, practice-led definition that includes perceptions and beliefs of stakeholders, role of complexity and context, and intervention and implementation outcomes for equitable impact and sustainability.

Practical implications:
• There is a need for early awareness and agreement of what ‘success’ means to different groups, and this interpretation may evolve over time.
• Key elements underpinning ‘successful scale-up’ can be used for scale-up planning, evaluation, and engaging stakeholders.

Funding: Deakin University Faculty of Health project grant (2018).