Abstract
HealtheSteps is a pragmatic, evidence-based lifestyle prescription program aimed at reducing the rates of chronic disease, in particular, type 2 diabetes. A process evaluation was completed to assess the feasibility of the implementation of HealtheSteps in primary care and community-based settings across Canada. Key informant interviews (program providers and participants) were conducted to identify facilitators and barriers to implementation and opportunities for future program adaptation and improvement. Forty-three interviews were conducted across five regions in Canada (15 sites ranging from remote, rural, suburban, and urban). Transcripts were analyzed using a qualitative naturalistic inquiry approach with several facilitating factors identified: pragmatic program design, in-line goals with sites’ mandates, and access to ongoing support. Barriers were related to administrative challenges such as booking space, personnel changeovers, and scheduling participants. Findings from this analysis revealed insights on program delivery, design, and importance of site champions. Key lessons learned focused on two areas: infrastructure support and program implementation. The application of these learnings from the HealtheSteps program may inform the development of strategies that can optimize program adaptation and support while reducing real and perceived barriers experienced, thus increasing the success of translation of the evidence-based diabetes program to different points of care.
Introduction
Obesity has reached epidemic proportions in Canada with over one in five adults reporting height and weight measurements categorizing them as obese (Statistics Canada, 2015). Obesity is a main contributor to the growing number of Canadians at risk for and living with chronic diseases including cancer, kidney disease, heart disease, and type 2 diabetes, which is of particular concern due to high medical costs, comorbidities, and premature mortality (The Global Burden of Metabolic Risk Factors for Chronic Diseases Collaboration, 2014). A significant concern is the increase in the number of Canadians with type 2 diabetes in rural and remote communities where access to prevention and management services and programs is limited (DesMeules & Pong, 2006; Smith, Humphreys, & Wilson, 2008). By 2020, it is estimated that 4.2 million Canadians will have diabetes (Canadian Diabetes Association, 2011). Projections are even more alarming on a global scale with an estimated 439 million people living with diabetes by 2030, an increase of 154 million people from 2010 (Shaw, Sicree, & Zimmet, 2010). Given the increasing prevalence of diabetes worldwide, appropriate and practical prevention and management solutions are critical.
Leading an unhealthy lifestyle (i.e., being sedentary, not eating enough fruits and vegetables, and physical inactivity) is a main contributor to the growing rates of type 2 diabetes (Janssen, 2012). Research has shown that comprehensive lifestyle interventions that focus on more than one risk factor have positive effects in reducing the incidence of type 2 diabetes in high-risk patients (Lindström et al., 2006; Schellenberg, Dryden, Vandermeer, Ha, & Korownyk, 2013) more so than pharmacological treatments (Mozaffarian et al., 2009). Moreover, interventions that include coaching or counseling patients on how to improve physical activity levels and diet have shown to be effective in reducing chronic disease risk (Clark, Hampson, Avery, & Simpson, 2004). Lifestyle coaching programs have also shown success in reducing risk factors for diabetes in rural communities, particularly when they are low-cost and incorporate community resources, events, and practical tools patients can access to improve their lifestyle (Vadheim et al., 2010). An important determinant of health outcomes for those living in rural and remote communities is their access to health services and their use of health-related Internet supports (Hale, Cotten, Drentea, & Goldner, 2010; Stuckey et al., 2011). Barriers often found in program implementation surround administrative processes where competing interests result in scheduling issues (Stoutenberg, Stanzilis, & Falcon, 2015), especially in community-based diabetes prevention programs that are often limited by process- and resource-related barriers (Green, Brancati, Albright, & The Primary Prevention of Diabetes Working Group, 2012; Oldenburg, Absetz, Dunbar, Reddy, & O’Neil, 2011).
In implementing comprehensive lifestyle interventions, there is a need to explore the facilitators to program implementation and barriers that challenge implementation in real-world, community-based settings (Oldenburg et al., 2011; Stoutenberg et al., 2015). In particular, there exists a need for research detailing best practices for implementing healthy lifestyle programs in rural and remote communities in Canada. Detailing the experience of those delivering these types of programs at different points of care (i.e., family practice, workplace, educational institutions, community centers, fitness centers) and settings (i.e., urban vs. rural and remote) can help us better understand the needs of patients, program administrators, and community health organizations running these programs. Previous research has focused on exploring the experiences of primary care practitioners delivering programs in controlled settings, which may not reflect the multiple avenues where health promotion programs can and are currently being delivered (Blonstein et al., 2013; Green et al., 2012; Josyula & Lyle, 2013; Lee, Hillier, & Weston, 2014). Often literature addressing diabetes prevention in real-world settings underscore their efficacy as a diabetes prevention program rather than establishing and understanding effective strategies for implementation (Dunkley et al., 2014). Through our previous research, we found that few physicians prescribed exercise to manage chronic diseases such as type 2 diabetes (Petrella, Lattanzio, & Overend, 2007) and often lacked specific health promotion tools, training, and the time to address at-risk patient needs (Petrella et al., 2011; Petrella, Koval, Cunningham, & Paterson, 2003; Petrella & Wright, 2000). In addressing the barriers to prescribing lifestyle changes in primary care, the HealtheSteps program was developed from an extensive research base (Foisey, Cook, Intzandt, Stuckey, & Petrella, 2012; Petrella et al., 2003; Petrella et al., 2007; Petrella et al., 2011; Petrella, Koval, Cunningham, & Paterson, 2001; Petrella, Lattanzio, Demeray, Varallo, & Blore, 2005; Petrella & Wright, 2000; Stuckey, Shapiro, Gill, & Petrella, 2013). HealtheSteps was designed to be adaptable to different settings as the program can be delivered by nonregistered health care professionals in order to support delivery in areas where access to health care professionals is limited.
A community trial of HealtheSteps was completed to test the acceptability and feasibility of delivering the program at a variety of community settings (i.e., urban, rural, and remote). The HealtheSteps community trial was an 8-month lifestyle prescription program focused on three modifiable risk factors for type 2 diabetes: sedentary behavior, physical inactivity, and unhealthy eating. Participants met bimonthly (Months 0, 2, 4, 6, and 8) with a HealtheSteps coach to set prescriptions to incrementally improve their physical activity levels (daily step counts), exercise (moderate to vigorous activity), and diet (based on Canada’s Food Guide recommendations for healthy eating). As a part of the exercise component of the program, participants completed a submaximal fitness test, the STEP™ test (Petrella & Wright, 2000). After each prescription was set, the coach and participant discussed strategies to achieve those prescriptions. The coaching was grounded in the Co-Active coaching model, a patient-centered approach that incorporates the participants’ personal values, goals, self-defined issues, and self-confidence into goal setting (Irwin & Morrow, 2005; Newnham-Kanas, Irwin, & Morrow, 2008). This model fits well within the intent of the program in working with a participant to identify goals, and desires from a health promotion program, and collaborating with the participant to create strategies to achieve those goals. The Co-Active coaching model is based on practical, pragmatic application rather than theoretical constructs and stages. To further support participants between coaching sessions, they were offered free eHealth technology support tools, which included access to an exclusive online social network, telephone-based coaching, and the HealtheSteps app. This community trial was followed by a randomized control trial completed in South West Ontario (Gill et al., 2017), which used similar goal setting, supports, and objectives.
A process evaluation was conducted after the community trial to better understand the feasibility and acceptability of delivering HealtheSteps in “real-world” settings. This article explores the facilitators and barriers of the delivery of the HealtheSteps program from the perspectives of those involved in all aspects of program delivery to better inform program development and literature surrounding implementation of healthy lifestyle programs in diverse communities.
Method
The HealtheSteps community trial was conducted across five different regions within 15 sites across in Canada. Participants were recruited opportunistically through connections with the research team by September 2013: North East Ontario (4 sites; primary care and education institutions), South West Ontario (5 sites; primary care), North West Ontario (2 sites; workplace wellness initiatives and community center), Northwest Territories (2 sites; education institutions), and British Columbia (2 sites; health and fitness community center and primary care). We provided role-specific training prior to program onset, which included a 2-day in-person workshop. Our team sought to build multifunctional teams within sites with diverse functional backgrounds as they bring different and complementary knowledge (Bunderson, 2003) and used a centralized research team to the support program implementation across sites. This pragmatic approach was developed to limit costs and increase access to resources. Study recruitment began in September 2014 with a total of 169 recruited by April 2015 across all 15 sites. Many participants were recruited through another existing program, e-mail, advertisements, or referrals. Each region was supported by key stakeholders (KSs) such as academic leads and program partners (i.e., management/leadership from organizations hosting the HealtheSteps program), a regional knowledge broker (KB) including kinesiology undergraduate/graduate students or administrative site staff designated to support the program, and coaches such as health care providers (dieticians/health promoters/nurses) or undergraduate university students.
Individual telephone interviews were conducted from September 2015 to April 2016 with key informants after program completion from each region in this study. Interview participants were recruited by the central research team who contacted potential interview participants (via e-mail or telephone depending on available contact information) to invite them to participate. Key informants interviewed included 5 KBs, 9 coaches, 20 program participants, and 9 KSs (Table 1). Unique interview guides were developed for each of the respondent groups with the aim of eliciting their unique experiences consistent with their role in the program with questions designed to provide insight in their experience with program implementation. Interviews were conducted by one author who is a third-party researcher who was not involved in study implementations and delivery to ensure consistency and to reduce potential response bias. A total of 54 individuals were invited to participate in the interviews; 43 interviews were completed, representing an 80% response rate. Across the sites, response rates ranged from 67% to 86%, with the highest response rates for the Ontario sites (86%) and lowest for Northwest Territories. A majority of the 20 program participants interviewed were female (85%), ranging in age from 31 to 76 years in age, with a mean age of 52 years, and lived in medium (40%) or large (30%) urban settings with some (30%) living in rural and small population center (less than 29,999). Field notes were maintained for all interviews; additionally, all interviews were digitally recorded and transcribed.
Summary of Roles of Key Informants
To achieve the aggregate experience of all the individuals involved in the program, transcripts were analyzed using a qualitative naturalistic inquiry approach that allowed us to understand key informants’ experiences in the program while engaging in their everyday lives (Lincoln & Guba, 1985) as a whole rather than separately. Reoccurring themes were identified through inductive analysis of the data without prior assumptions to interpret meaning from their experiences (Patton, 2002). The analysis reflected the constructivist paradigm, acknowledging multiple perspectives to a specific phenomenon and allowing the generation of a thorough understanding of each individual’s perceptions of and experience with the program within the context of his or her role within the program (Denzin & Lincoln, 2008). Two authors reviewed the interview transcripts several times to achieve immersion and gain full understanding of the perspectives of interview participants. An initial review of the transcripts allowed for the generation of broad categories and the identification of emerging themes. Study rigor was ensured during this review of transcripts by another analyst, providing feedback on the coding. Furthermore, additional rigor was achieved by the entire research team providing overall feedback on the themes generated by the analysis. Interrater coding served to reduce bias in the identification of emerging themes. Discussions of identified themes among the research team resulted in several iterations of the broad themes and subthemes to achieve greater clarity of the data (Braun & Clarke, 2006). Ethical permission was provided by the Western University Health Sciences Research Ethics Board (No. 105331).
Findings
Key informants identified several facilitating factors toward program implementation: program design, program goals, and access to ongoing support (Table 2). The HealtheSteps program was found to support both success and sustainability through its pragmatic design and delivery. The design and participant focus within the program were perceived as simple and easy to grasp. Specifically, the program design and messaging were realistic and attainable. Participants met bimonthly with a HealtheSteps coach to create goals that used small and incremental lifestyle behavior changes that were integrated to the program participants’ everyday lives contributing to sustained behavior change. The participant-centered focus of the program, in terms of individualizing the program and supports to participant needs and preferences, encouraged behavior change. Participants established goals that were self-relevant and reflected how they lived their lives, a factor that was perceived as a strength of the program. The focus on self-management and the self-directed nature of the program were perceived as facilitating sustained change in their health behaviors. The low cost and resources needed facilitated implementation, which supported the strength in the program’s adaptability to different settings, organizations, geographic regions, and populations.
Summary of Factors Identified as Facilitators
NOTE: KB = knowledge broker; KS = key stakeholder; P = participant; C = coach.
A key determinant of program delivery was accountability, which included the relationship developed between the coach and participant. As evidence of this, when the program was first launched, participants were not assigned to a specific coach; rather, a coach was seen depending on coach availability, and high attrition rates were attributed to the lack of a relationship between participants and coaches. However, on recognition of the importance of matching coaches to participants, each participant was assigned a specific coach halfway through program delivery. This allowed for the development of a foundation on which to base future goals and health behavior changes. Also, participants with an established relationship with their coach were found more amenable to the research data collection, and without this, participants felt they were there primarily as research participants. As well as participants, dedicated personnel in the roles of the KB and coaches were key to successful delivery. Teams with committed personnel instilled confidence among participants. Another form of accountability that facilitated the program was the collaborative relationships between KSs and the central research team. For community partners, the program was described as well aligned and consistent with their organization’s mission and vision related to wellness and health promotion. Additionally, the use of evidence-based measurements provided objective, concrete evidence of improvement, which motivated participants to continue with their goals developed through the program.
Knowledge translation was a key factor that facilitated program implementation. Many participants expressed how the program increased their awareness about their health, suggesting that the length of the program promoted long-term health behavior changes. Moreover, KSs appreciated that the program provided training for students and staff, affording them the opportunity to apply what they had learned in their formal education to practice (real-life application). Additionally, the program provided KSs’ staff further expertise and confidence when working with patients within and outside the program. Transparency in communication further facilitated collaborative teamwork among sites and the central research team. KBs and KSs felt comfortable accessing the central research team. Program sites felt that the central research team respected their input and valued their feedback, as evidenced by requests for feedback and enthusiasm to take on suggestions.
Barriers
All but 3 of 15 program sites established and sustained the program over the 8-month period. Several barriers to implementation were identified (Table 3). The sites unable to sustain the program faced many challenges including loss of communication with KBs and limited support, as KSs were geographically distant as well as the central research team. Most barriers identified by key informants were primarily related to administrative processes. As this was the first time the program was run within each site, many informants perceived these challenges as resolvable.
Summary of Factors Identified as Barriers
NOTE: KS = key stakeholder; P = participant; C = coach; KB = knowledge broker.
While the central research team provided each site with program-specific training and worked together with them and the community partners to implement the program, often, coordinating competing priorities and schedules, managing cancelled sessions, and room availability placed constraints on the coaching sessions. Similarly, technological supports were underused and attributed to several factors: (a) competing interests, (b) introduction of supports too late in the program, and (c) technological problems. Sites without access to these supports from program launch found limited interest among participants to engage in this later in the program. Participants were noted to prefer working one-on-one with coaches, with whom they had established a working relationship and wanted to maintain this connection rather than establish a new one.
The implementation of the program was negatively affected by the additional paperwork and time commitments that research requires. Specifically, recruitment and support for the program was challenged by the need for detailed and multiple documentation that was often repetitious. This challenged the retention of participants and coaches in the program due competing priorities. Moreover, implementation of the program posed difficulty with frequent staff and student turnover. Turnover was frequent, and often when new personnel came in to take over a role, no formal training was provided, which resulted in miscommunication among sites and lack of coach continuity for coach and participant relationships. Limited funding and human resources were barriers found in remote settings and challenged sites in their ability to recruit coaches for the program. While undergraduate students were deemed appropriate for the coaching role, they also posed challenges with scheduling and required continual support to ensure that training was adhered to and that the objectives and goals of the program were clear and understood.
Many informants expressed that they lacked support at beginning of the program, suggesting objectives were unclear, which led to difficulty with initial program implementation and participant success. The length of time between sessions was found to challenge participants to remain motivated and engaged, contributing to attrition. After the first session, many participants withdrew due to lack of interest and momentum in the program. Recognizing that 2 months between sessions was too long, given that participants were dropping out, one of the regions chose to have coaches connect with participants every few weeks by telephone. It was noted that additional contact with participants helped maintain momentum in the program.
Key Lessons Learned
Key informants identified several key lessons learned through the implementation of the program (Table 4) in two areas: infrastructure support and program implementation. Sites that experienced success with program implementation often had the infrastructure support in place (i.e., primary care). Other important facilitating factors included training (in-person and ongoing), additional support at program onset for both participant and implementation team, access to consultation and mentorship through creation of a community of practice (team members who would engage in a process of collective learning), and secure invested interest from the site and its team members to implement the program. While program implementation faced its challenges, key informants suggested that with more experience, the logistics of program implementation became more efficient and saw less attrition of participants.
Key Lessons Learned in the Implementation of a Healthy Lifestyle Program
Participants who expressed satisfaction with the program often viewed their relationship with the coach as key to program accountability and to their ability to change their health behaviors. In fact, many participants expressed that this accountability had a ripple effect to other family members. Barriers included ensuring adequate time was allotted for sessions to allow participants and coaches the opportunity to develop rapport; without this established relationship, participants felt their participation was primarily as a research participant. Identified constraints imposed by research protocols that affected the program implementation centered around the need for attention to detail and data collection requirements, which resulted in additional paperwork that was often perceived as redundant. Prior to program implementation, data collection methods should be reviewed with staff and participants to ensure they were in line with the objectives of the program. To facilitate technological uptake, it was suggested that the implementation team provide participants with all available resources and support for the program early in the program and promote this regularly during session visits to encourage uptake and understanding of its use and importance to support behavior change.
Discussion
We developed HealtheSteps as an evidence-based, pragmatic lifestyle program to address prevention and management of type 2 diabetes. The participant focused approach of the program and use of Co-Active coaching allowed for empowerment of participants to make changes through the development of rapport with their coaches, which is an integral component of program implementation (Lewis et al., 2014). Another integral component of the program was that all members of the health care team understood the program objectives and had access to ongoing support and training throughout program delivery; these types of factors have been identified as important for program efficacy and sustainability in primary care settings (Lee et al., 2014).
The HealtheSteps program supported the development of interprofessional collaborations by requiring teams to work together toward a common goal in order to improve the communities’ lifestyles and reduce type 2 diabetes; nevertheless, a key barrier continually found revolved around administrative processes due to competing interests that often resulted in scheduling issues (Stoutenberg et al., 2015). This reflects similar lessons learned from other programs’ experiences (Blonstein et al., 2013; Green et al., 2012; Josyula & Lyle, 2013; Lewis et al., 2014)—specifically, ensuring adequate facilities and space for programming (Blonstein et al., 2013) as well as dedicated health promotion resources that include personnel and materials for implementation (Green et al., 2012; Josyula & Lyle, 2013; Lewis et al., 2014). Moreover, strong multifunctional teams with diverse functional backgrounds were observed as being pivotal toward program implementation, including the role of centralized support to help move the program forward (Bunderson, 2003). The importance of the role of centralized support was often overlooked as local-level support was often preferred. This might explain why many informants expressed a lack of initial support at the beginning of program.
Perceived constraints with implementation of the research components included burdensome paperwork and underused resources. In many cases, this resulted in a heavier workload for the delivery sites, which restricted the adaptability of the program. Implementation as a community program without research requirements will allow increased flexibility and support the program goals, placing less burden on both the implementation team and participants. Consistent with the factors identified, and regardless of site readiness, it was identified that increased support at the beginning of program implementation was critical. To increase participant adherence and promote long-term success, additional motivational strategies to engage participants may be needed (Blonstein et al., 2013). Adequate and periodic meetings between sites and the central research team may further facilitate successful program implementation to address sites concerns, collaboration, and learning from different sites’ experiences (i.e., communities of practice). This might include a training portal where team members can openly discuss their successes and challenges experienced. While people living in rural areas may be less likely to access Internet resources (Hale et al., 2010) to support participants and how technological resources are used, further discussion and its use during one-on-one sessions might further facilitate uptake and decrease participant attrition as the use of education and technology tool supports health changes (Stuckey et al., 2011).
As noted, long-term sustainability of the program requires dedicated and sufficient resources including: financial, personnel, and facility space. Thus, partner organization’s invested interest becomes of great importance for the adoption and sustainability of the program with infrastructure support at the site. Encouraged consultation and engagement within the organization can also reinforce salience of participant health behavior changes (Green et al., 2012; Josyula & Lyle, 2013). The dedication of these resources within the program setting would also decrease participant attrition rates as well as improve access to the program. Clear objectives for program delivery need to be cocreated prior to implementation to ensure all key informants work as a team toward a common goal and have adequate access to resources.
A program “champion” is noted to improve program adoption (Lee et al., 2014; Shaw et al., 2012). Within the HealtheSteps program, two key champions facilitated program implementation at each site: a site (KS) and a program champion (KB see Table 1 for detailed roles). Sites that had community health programs in place, when HealtheSteps was added to the existing program, showed that the process was more easily implemented since resources were already established. In sites where the program was the first community health–related initiative, additional infrastructure support is needed to establish and identify resources, which required more time by the site and program champions prior to implementation. Future research by our team will include program optimization to understand the factors that contribute to long-term sustainability for both those who implement the program and its participants through knowledge translation efforts to support communities and build capacity.
Study Limitations
Selection bias may exist as participants interviewed had all completed the program. While attempts were made to have adequate representation of key informants, not all sites had the same degree of representation from all key informants who started with the program. Additionally, interviews were completed within 2 months after program completion, and thus we do not have information regarding long-term insights of the program. An aggregate experience of all the individuals involved in the program was analyzed; however, separate analysis of roles could have given more insight into each role of the program, rather than shared experiences.
Conclusion
Our findings of the HealtheSteps program implementation feasibility in a diverse range of points of care across Canada highlight the importance of infrastructure support for administrative processes and champions to engage the target populations and their providers. Within each site, it was observed that establishment of a detailed plan of implementation including necessary logistics and resources needed were critical for successful implementation and completion of the program. The key lessons learned we have observed will inform the optimization, adoption, and sustainability of future HealtheSteps program delivery among at risk Canadians.
Footnotes
Acknowledgements
We would like to thank those involved in program implementation: Ian Newhouse, Erin Pearson, Brenda Bruner, Barbi Law, Tina Karvinen, Shauna Burke, Pertice Moffitt, Gareth Jones, Kelly-Jo Gillis, Natalie Clark, Kim Froom, Jacqueline Harvey, Justine Templeman, Devyn Richards, Michael Lankin, Dennis Angevine, Sadaf Faisal, Alyssa Straatman, Andrea Fennell, Katie Mairs, Adam Gavarkovs, Roseanne Pulford, Wendy Blunt, Jessica Dutton, Betty-Ann Marriott, Jesse Evans, Eric Beech, Mathew Hoogveld, Makayla Rittinger, Nathaniel Calder, and Nick Bray. We would like to thank our research partners including Sykes Assistance Corporation, St. Elizabeth Health Care, Dietitians of Canada, and funders: Dairy Farmers of Canada, Sanofi-Aventis, and the Public Health Agency of Canada’s support of the program as a part of their Canadian Diabetes Strategy Community-based Program. PKS contributed to acquisition of data and was a major contributor in writing the article. LMH contributed to acquisition of data and critical revision of the article. RJP contributed to study conception and study design and was a major contributor in writing the article. All authors read and approved the final manuscript.
Funding was provided by the Public Health Agency of Canada (Canadian Diabetes Strategy). The Public Health Agency was involved in the study design but not the collection of data.
