Implementation scale-up

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).

Background: To improve health at the population level, evidence-based interventions (EBIs) must be scaled-up and sustained. Implementation strategies (‘strategies’) facilitate this process. However, the role of strategies in implementing EBIs in community settings (often with insufficient resources and expertise) remains a ‘black box’. Organizational readiness [“tangible and immediate indicators of organizational commitment to its decision to implement an intervention”] may be key to effectively implementing and scaling an EBI. However, there is little evidence that describes how strategies are used to build readiness in community settings and whether they are effective. Purpose: We describe the roadmap we created to i) select, tailor, and implement strategies to improve readiness in community settings, and ii) evaluate the impact of strategies on the adoption and implementation of an EBI, called Choose to Move (CTM). CTM is an effective community-based health promotion program for older adults that we scaled-up across 9 years (> 5500 older adults). Methods: We used implementation mapping to i) identify, name and define CTM strategies; ii) operationalize strategies; and iii) outline proposed mechanisms of action. Results: Our roadmap identified 43 strategies that supported implementation and scale-up of CTM since 2015. We specified actors, action targets, outcomes, determinants and mechanisms of action of each strategy to develop a readiness building intervention (RBI). The RBI distributes 16 strategies across five stages of implementation: Engage, Assess, Feedback and Prioritize, Prepare for Delivery, and Support Delivery. Finally, we developed an evaluation plan to track and evaluate the use of strategies and their effectiveness. Conclusions: Our roadmap provides a practical approach to select and tailor readiness-building strategies and evaluate the impact of these strategies on implementation outcomes in community settings. Practical implications: Our roadmap opens the ‘black-box’ and supports community-based researchers to assess readiness to implement/scale-up EBIs. Funding: Canadian Institutes of Health Research

Background: Choose to Move (CTM) is an evidence-informed, 3-month program scaled-up across 9 years (2016-2024); CTM improved physical activity (PA), mobility, and loneliness in low active older adults. We designed a follow-up intervention (CTM-Next Steps; CTM-NS) comprised of ‘booster sessions’ to help participants maintain positive changes. We sought to identify whether a ‘minimum dose’ could sustain participant behaviours over 2 years. Purpose: To use an integrated knowledge translation (iKT) approach to evaluate CTM-NS implementation. Methods: From Fall 2020-2021 CTM programs, 576 participants were eligible for CTM-NS. We randomized interested participants into high (monthly; n=214) or low (quarterly; n=210) dose programs (n=19 each) delivered virtually by 5 activity coaches (ACs). We assessed implementation determinants (feasibility, acceptability) and outcomes (attendance, participant responsiveness) via survey and interviews with ACs and older adults 3, 12, and 24 months after CTM-NS program start. Using an iKT approach, we reviewed implementation data in January 2022, 12 months after the first program started. Results: CTM-NS was feasible, but ACs noted challenges with attendance (52% vs. 68%), commitment (“come in with a different attitude”) and connection (“like I’m meeting a new group every three months”) for quarterly groups versus monthly. At 3 months fewer older adults were satisfied with the frequency of quarterly (54%) vs monthly (80%) group sessions. Therefore, we adapted the quarterly program to become a monthly program during year 2. This adaptation was well received (“a game-changer”) and fostered social connection among participants. Conclusions: While both were feasible, ACs and older adults found monthly group meetings more acceptable. By evaluating implementation of CTM-NS early, we were able to address implementation challenges by adapting CTM-NS for the final year of the program. Practical implications: Evaluating implementation during program delivery ensures the needs of participants and program providers are met. Funding: Canadian Institutes of Health Research

Background: Investment in scale-up and sustainment of effective health-promoting interventions is often hampered by competing demands on scarce health dollars. Reducing resource use (e.g., delivery costs) while maintaining program effectiveness is the ‘holy grail’. We adapted and scaled-up an evidence-informed, health-promoting program for older adults (Choose to Move; CTM) across four phases (2016-2024). For CTM Phase 4 (P4) we reduced resource use by decreasing program delivery hours by activity coaches. Purpose: To assess implementation and effectiveness of the CTM P4 program. Methods: We conducted a type 2 hybrid effectiveness-implementation study involving 137 CTM programs (1126 older adults; 59-74 years, 75+ years) delivered by 29 activity coaches. Pre- and post- (3 months) intervention, we assessed implementation (e.g., dose, fidelity) and older adults’ physical activity (PA), mobility, social isolation, and loneliness. Results: CTM P4 required 40% fewer activity coach delivery hours than CTM P3. Implementation indicators demonstrated that P4 was delivered as intended. Post-intervention, PA (+1.5 days/week; 95% CI 1.3, 1.6), and mobility (+0.8; 95% CI: 0.4, 1.3), social isolation (+0.92; 95% CI: 0.67, 1.17), and loneliness scores (-0.24; 95% CI: -0.34, -0.13) improved in those <75 years. Among those ≥75 years, PA (+1.0 days/week; 95% CI, 0.7, 1.2), and mobility (+1.1; 95% CI: 0.4, 1.8), and social isolation scores (+0.47; 95% CI: 0.08, 0.86) improved post-intervention. Participant-level benefits were comparable to, and for some outcomes (PA and social isolation in those <75) greater than, those observed in P3. Conclusions: CTM was co-designed as a flexible program, adapted over nine years based on user group needs and preferences. This flexibility allowed us to reduce activity coach delivery hours without compromising implementation or benefits of CTM on older adults’ health. Practical applications: Supporting scalability and sustainability of evidence-informed health-promoting interventions is key to improving population health. Funding: Canadian Institutes of Health Research

Background Efficacious school-based physical activity (PA) initiatives are rarely adapted for implementation at scale. Purpose The aim of this study was to determine the implementation and effectiveness of the TransformUs program on children’s PA, sedentary time, adiposity and quality of life (QoL) at scale. Methods TransformUs was offered to all 1740 primary schools in Victoria Australia (mid-2018 to 2022). Urban and regional schools in Victoria and NSW (controls) were recruited. Children in grades 3/4 wore an accelerometer for 1 week at baseline, 12- and 24-mths, and completed implementation surveys at 12- and 24-mths. Primary outcomes were children’s daily average minutes in moderate-vigorous PA (MVPA) and sedentary time. Body mass index (BMI) z-scores (height and weight), waist circumference (WC) and QoL were secondary outcomes. Linear mixed effects models accounting for clustering within schools, confounding and random effects examined intervention outcomes. Results Twenty-one primary schools were recruited in Victoria (72% government, 65% urban) and 19 in NSW (42% government, 92% urban). A total of n=725 (50% girls) intervention and n=493 (49% girls) control children provided valid accelerometer data at baseline. There were no significant effects on children’s daily mins sedentary time, or on BMI z-scores or WC. At 12-mths, there was an unfavourable intervention effect on children’s daily mins MVPA (-4.86, 95%CI: -8.77, -0.95, p=0.015), with no effect at 24-mths. At 24-mths there was an unfavourable overall QoL score. Similar percentages of children reported that they received the program in intervention and control schools. Conclusions There were no significant effects of the TransformUs intervention delivered under ‘real world’ conditions. Victorian school children experienced 267 days of home schooling in 2020-2021 (COVID-19). Practical Implications More research is needed to understand the process of scale-up and implementation to ensure programs are delivering outcomes as intended at scale. Funding NHMRC Partnership Grant (APP1115708)

Background: Children and youth with disabilities are less engaged in physical activity (PA) compared to their peers, necessitating effective municipal policies and initiatives to counter this gap. Purpose: This study evaluates municipal practices in the implementation of PA programs for children and youth with disabilities. Methods: In this qualitative multiple-case study, we explored five larger Danish municipalities, each with populations ranging from 80,000 to 200,000 residents, to understand the breadth of practices. We conducted 28 individual and 7 group interviews across various departments and included a review of local policy documents. Our thematic analysis was informed by Søren Winter’s integrated implementation model and Jody Gittell’s theory of relational coordination. Results: We found that implementing PA for children and youth with disabilities involves multiple sectors and actors, presenting complex challenges. Policies that focus on adapted sports and recreation — activities tailored to individuals with disabilities – can significantly influence both organizational and interorganizational behavior. Moreover, the role of coordinating consultants, as central figures in PA implementation, is crucial, although municipal support systems require further development. Conclusions: The key role of municipalities in promoting PA opportunities for children and youth with disabilities is clear. However, the need for enhanced, inclusive PA options persists. Practical Implications: We introduce a phase-oriented guide to assist municipalities in implementing sustainable PA initiatives, integrating various administrative sectors and community actors within educational and recreational settings. Funding: The study is supported by the Foundation Bevica Fonden.

Background: Icehearts Europe is a pan-European initiative promoting EU-wide adaptation and dissemination of the Finnish sport-based best practice ‘Icehearts’, focused on preventing social exclusion and promoting the psychophysical well-being of disadvantaged youth through a 12-year mentoring and comprehensive support. The project aims to develop tools to implement Icehearts Europe programme and involve more EU countries and grassroots sports organisations (GSOs). Purpose: This work elucidates the methodology employed to develop a comprehensive guide serving as a ‘lowest common denominator’ for adapting the programme to diverse contexts. Methods: The guide development was conceived as a sequence of stages: description, analysis, deconstruction of the model concept, identification of the essential ‘ingredients’ and procedural aspects to prepare the implementation, reorganisation, and ‘inspiration’ for the programme. A collaborative approach involving GSOs, Public Health Organisations, Universities, NGOs was adopted, based on opinion and information sharing, effort in writing collaboratively, meetings, and collection of first-hand data through a study visit to Icehearts Finland. The English version was translated into the languages of the pilot countries (Denmark, Estonia, Italy, Slovenia, Spain) using an online AI-based translation tool; each translation was completed by native translators from the pilot organisations. Results: The six-language ‘Icehearts Europe Implementation Guide’ consists of four main operative phases plus insights from Icehearts Finland and is freely available on the Icehearts Europe website. Conclusions: Developing an operational tool that facilitates the transfer of a best practice requires a collaborative process, sharing of experience and expertise between stakeholders through a teamwork characterized by the comprehension of the underlying characteristics of the practice and their possible adaptation to new contexts. Practical implications: The guide will provide operational information and basic guidelines for EU grassroots sport organisations seeking to implement the programme within their respective contexts to promote the health and well-being of disadvantaged youth. Funding: EU4Health Programme 2022.