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Translational Formative Evaluation before Scale-up of a Physical Activity Intervention for Older Men

McKay, Heather A.1; Mackey, Dawn C.1,2; Gray, Samantha M.1; Hoy, Christa L.1; Ahn, Rei1; Perkins, Alexander D.1; Bauman, Adrian3; Sims-Gould, Joanie1

Translational Journal of the American College of Sports Medicine: July 15, 2019 - Volume 4 - Issue 14 - p 106–113
doi: 10.1249/TJX.0000000000000090
Original Investigation
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Introduction Despite irrefutable health benefits of physical activity, older adults remain among the least active Canadians. To achieve population health, physical activity interventions that proved effective in controlled research settings must be delivered at scale to reach broader populations of older adults across multiple settings. Formative evaluations are essential, as they identify barriers and enablers to implementation across levels of stakeholder groups and settings. Thus, we conducted a formative evaluation of a choice- and evidence-based physical activity intervention (Men on the Move) designed for scalability.

Methods We adopted key elements of two implementation frameworks that place characteristics of the innovation, prevention delivery system, prevention support system, and prevention synthesis and translation system at the core of implementation success. Guided by the Interactive Systems Framework for Dissemination and Implementation, data were collected from delivery partners, including 1 leader from a key provincial recreation organization, 6 recreation directors/coordinators and 3 activity coaches, and 14 participants (older men). This research team participated in prevention support and prevention synthesis and translation systems. Two trained interviewers conducted telephone interviews with delivery partners, and five trained interviewers and a notetaker conducted in-person interviews with participants.

Results Five themes emerged from analyses of delivery partner interviews: support, activity coaches, intervention delivery, Men on the Move continuation, and the absence of men. Two themes emerged from our analyses of participant data: monitoring and connectedness.

Conclusion Lessons learned from this formative evaluation will guide the adaptation of the intervention to context and population for scale-up across British Columbia, Canada. In so doing, we aim to bridge the know–do–scale-up gap, which is imperative as we seek to improve older adult health at the population level.

1Centre for Hip Health and Mobility, University of British Columbia and Vancouver Coastal Health Research Institute, Vancouver, British Columbia, CANADA;

2Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, British Columbia CANADA; and

3School of Public Health, Sydney University, Sydney, New South Wales, AUSTRALIA

Address for correspondence: Heather A. McKay, Ph.D., 7F-2635 Laurel Street, Centre for Hip Health and Mobility, Vancouver, BC, Canada V5Z 1M9 (E-mail: heather.mckay@ubc.ca).

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INTRODUCTION

In Canada for the first time, older adults outnumber children (1), and within the next 30–40 years, there will be two adults over 65 years of age for every child under the age of 15 years (2). Currently, only 13% of older adults attain recommended levels of physical activity (3). As the physical (4), social (4), and financial (5) repercussions of low levels of physical activity are well documented, countering this downward trajectory is a global health priority (6).

To achieve population-level health impact, physical activity interventions that proved effective in a controlled research environment must be delivered at scale to reach broader populations across multiple settings (7). Although a focus on populations rather than individuals represents a central tenet within public health (8), there remains a knowledge gap regarding how best to translate outcomes from research trials into real-world settings while retaining effectiveness and relevance (9). Although many evidence-based practices have been developed, few were successfully translated into usual care at a larger scale (10,11). Further, an estimated two-thirds of all evidence-based intervention translation attempts fail (10,11).

Many effective physical activity interventions for older adults have been conducted—but to our knowledge, only five have been scaled-up (12–16). Milat and colleagues (17) conducted an evaluation of the proportion and type of published physical activity studies across settings and populations that spanned descriptive to dissemination trials; among the thousands of studies they reviewed, dissemination studies did not surface in the literature until 2008–2009, and just 3% of physical activity interventions were implemented and evaluated at scale. The one with the largest evidence base, the Community Healthy Activities Model Program for Seniors (CHAMPS), was an effective choice-based physical activity program that considered each participant’s abilities and circumstances (18,19). The CHAMPS program was then replicated in several community settings as part of a small-scale approach (13,16,20). Few published physical activity interventions focused exclusively on the needs of older men (21), and none of these were delivered at scale. Inability to translate evidence-based interventions into larger-scale practice has been attributed to limited time and resources of practitioners, insufficient training (15), lack of feedback, and absence of infrastructure and organizational systems that support scale-up (22). This is worth noting because we must implement effective interventions for both men and women, at scale, to positively enhance the health of older adults at the population level. More specifically, despite a preponderance of evidence to support the need for broadly disseminated physical activity interventions for older adults, only five interventions (12–16) targeting older adults were scaled-up (defined as “deliberate efforts to increase the impact of successfully tested health interventions to benefit more people” (23)).

Over the past decade, many theoretical frameworks and strategies have emerged to guide implementation (24)—somewhat fewer provide insights and mechanisms that support the successful implementation of effective models at scale (25,26). Common to these approaches is the need to examine barriers to implementation and the interdependency across multiple levels of influence, as described within some socioecological models of behavior change (27). That is, for interventions to be relevant and feasible and for change to be sustained, effective models must engage multilevels and multisectors through collaborative partnerships and ongoing stakeholder interaction (28,29). Within a community-based physical activity paradigm, this includes understanding barriers to implementation at the level of decision makers (heads of relevant organizations), delivery organizations (e.g., recreation centers), those who deliver the intervention (e.g., fitness leaders), and those in receipt of them (participants).

We rename the so-called “know–do gap” to “know–do–scale-up gap” as evidence from physical activity interventions to support effective implementation at scale is scarce. This may be a product of the complexity of scaling-up health interventions (7). Successful implementation involves substantial forward planning and evaluation and a well-defined progression through stages of implementation (27). Although summative end point health outcomes are the ultimate goal of physical activity interventions, formative evaluations provide crucial insight into effective implementation in a specific context and with a specific population (30).

It is imperative to distinguish between conducting a pilot study to assess potential effectiveness of an intervention (e.g., health impact of the intervention; often done) and the need to conduct a formative evaluation to assess specific context for implementation, sustainability of the intervention in that context, and dissemination of the intervention into other contexts (seldom done) (11). Formative evaluations are deemed “critical” (9) and essential (10) by some as they provide an opportunity to identify barriers and enablers to implementation across levels of stakeholder groups, and to pilot appropriate evaluation tools and approaches. Although a formative evaluation borrows many methods common to process evaluation, formative evaluation is designed specifically to feed data back to researchers and delivery partners so as to adapt and, where possible, to enhance the implementation of an intervention (at scale) in the future (30).

Thus, we conducted a formative evaluation of a choice-, evidence-, and community-based physical activity intervention (Men on the Move) designed for scalability. We were guided by Yamey’s (25) scale-up “Framework for Success” and elements of Durlak and DuPre’s (27) “Framework for Successful Implementation” that embed elements of the “Interactive Systems Framework” (ISF) by Wandersman et al. (31). Results from our formative evaluation were used to inform the adaptation and implementation of a physical activity intervention at larger scale (Choose to Move) (32), across the province of British Columbia, Canada.

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METHODS

Study Design and Context

This formative evaluation was a developmental work for a companion randomized controlled trial (clinical trials no. NCT02527655) that assessed the feasibility and effects of Men on the Move, a 12-wk choice-based physical activity intervention (compared with waitlist control) in older community-dwelling men (33).

Participants who were randomized to the Men on the Move intervention were paired with a trained activity coach who delivered 1) one-on-one participant consultations to develop personal action plans for physical activity and active transportation, 2) monthly group-based motivational meetings, 3) weekly telephone support, 4) complimentary recreation and transit passes, and 5) pedometers and diaries for self-monitoring.

Our formative evaluation was designed to provide critical information about the implementation of Men on the Move to inform delivery at scale of a choice-based physical activity intervention for older adults (Choose to Move), designed to positively affect health on a larger scale. We obtained approval for the randomized controlled trial and formative evaluation from the research ethics boards at the participating universities and research institutes, and all participants provided written informed consent.

We adopted the ISF (31) that depicts that the successful implementation of innovation (an intervention) is driven by factors within an inner circle of influence composed of prevention delivery, prevention support, and prevention synthesis and translation (research) systems. These systems were deemed core to effective implementation (31) and include factors such as organizational capacity, elements of technical training, ongoing support, evaluation, and knowledge synthesis. We also include elements of Durlak and DuPre’s (27) Framework for Successful Implementation that embeds the ISF within an ecologic model to create outer circles that consider the context for the delivery of an innovation (e.g., provider characteristics and community factors).

Within both the ISF (31) and Durlak and DuPre’s (27) frameworks, the Men on the Move intervention would be termed innovation (although we use the term intervention throughout).

Those from whom we collected data traversed community, provider, and participant levels, consistent with these two frameworks (27,31). Three groups represented the level of community and providers: the senior leader from British Columbia Recreation and Parks Association (BCRPA, bcrpa.ca) who made strategic and policy decisions for their organization, the six recreation directors/recreation coordinators who made decisions as to their capacity to deliver Men on the Move, and the three activity coaches who operationalized the delivery of Men on the Move to participants. These groups (termed “delivery partners”) served within the prevention delivery system (31). Finally, a convenience sample of 14 Men on the Move participants from the larger study volunteered to participate in this formative evaluation; all men enrolled in the Men on the Move intervention were eligible for the formative evaluation. We describe each of these groups in the next paragraph.

The delivery of Men on the Move was enabled in close partnership with BCRPA as they had reach to delivery partners (all recreation centers across British Columbia), who would host the implementation of Men on the Move. BCRPA is a not-for-profit organization dedicated to building and sustaining active healthy lifestyles and communities in British Columbia. A senior leader at the BCRPA introduced Men on the Move to recreation directors at four recreation centers (referred to as centers throughout) in the City of Vancouver. BCRPA facilitated the development of partnership agreements between our research team and centers where Men on the Move would be delivered by trained activity coaches (described below). Recreation managers gave permission to advertise the intervention at their centers and provided space to conduct measurement sessions, group-based intervention meetings, and one-on-one intervention meetings. Potential benefits to centers offering Men on the Move included an increase in men to their center, increase in the center’s capacity to serve the needs of older adults, and opportunities for center staff to share knowledge and experience with other participating recreation centers. Finally, centers would benefit as key partners in physical activity research whose participation would inform provincial strategies for keeping older adults active and healthy. With guidance from the recreation directors at each participating center, we hired and trained three activity coaches to deliver Men on the Move. Activity coaches were BCRPA registered fitness leaders certified to work with older adults. Each activity coach had previous experience leading fitness interventions at participating centers, and they completed approximately 12 h of Men on the Move–specific training over 4 d. Training involved an overview of the study rationale, evaluation, and timeline; review of the activity coach role and responsibilities; and discussion of the goals, content, delivery, and outputs of each of the intervention components. Emphasis was placed on the one-to-one participant consultations, monthly group-based motivational meetings, and weekly telephone support; activity coaches led mock consultations, meetings, and calls followed by feedback sessions for questions and reflections on strengths and areas of improvement.

Finally, our research team provided training and technical support throughout the study, and in this role, we served as the prevention support system as per the ISF (31). In our role as “evaluators,” we also served prevention synthesis and translation system roles (31).

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Data Collection

Before conducting interviews, we pilot tested the evaluation tools with two recreation directors, two recreation coordinators, and two fitness leaders and obtained feedback as to appropriateness. The interview consisted of questions that assessed the policy climate surrounding physical activity promotion (community level factors); the fit of Men on the Move with organizational priorities; impressions, needs, and interests of stakeholder groups regarding the Men on the Move intervention (characteristics of the innovation, provider characteristics); leadership, governance, and organizational facilitators and barriers to intervention delivery (organizational capacity); opportunities to improve or tailor the intervention design and/or implementation (adaptation); and participant engagement and satisfaction with the intervention (participant responsiveness) (27). The questions are outlined in our Supplemental Digital Content 1 (Table of interview guide questions, http://links.lww.com/TJACSM/A44).

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Data Analysis

Interview recordings were transcribed verbatim by a professional transcriptionist. Data were deidentified and imported into NVivo 10 (QSR International, 2015) for data analysis. Because of small sample sizes, we grouped interview data from our delivery partners together. Interview data from Men on the Move participants were analyzed separately. For delivery partners and participants, data were analyzed using framework analysis (34), an appropriate analytic approach for qualitative studies with specific questions, a predesigned sample, and issues identified a priori (34). Three coders sorted data and initially created a broad coding framework aligned with the aim of each interview question. During the second cycle of coding, we applied a focused coding procedure to the broad coding framework. We emphasized codes that aligned with the implementation frameworks we adopted to guide our work (27,31). In the third and final cycle, we simplified the coding framework into thematic categories, and we reached consensus on this final codebook. The study team met three times to discuss coding, to determine the most dominant themes and the preliminary findings, and to reach consensus. These steps were taken to ensure rigor and reproducibility in interpretation (35).

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RESULTS

We present our findings from the perspectives of Men on the Move delivery partners and our participants.

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Delivery Partners

Five key themes emerged from analyses of delivery partner interviews: support, activity coaches, intervention delivery, Men on the Move continuation, and absence of men. Comments related to both the implementation of Men on the Move and the aspects of research and evaluation. Thus, we differentiate between these as we discuss each theme in turn.

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Support

The presence of a delivery support system was perceived as the predominant factor that facilitated the implementation of Men on the Move across all levels of delivery partners. Support was offered at the facility level (e.g., recreation centers) to implement Men on the Move and by our research team in our role within a delivery support system. At the facility level, support was provided in different forms. These included existing administrative processes to assist with intervention registration, provision of space, support for activity coaches by recreation coordinators, and buy-in from community center associations. Recreation coordinators, those involved in the marketing and recruitment of Men on the Move, spoke at length about the importance of having ongoing communication from the study team. One coordinator commented, “… having the support, the resources—you guys, sort of, very self-sufficient, made it really easy for me to support [the running of Men on the Move].”

Activity coaches noted that training and informational materials supplied by our research team (in our role as delivery support) helped them deliver Men on the Move. As intervention delivery progressed over time, activity coaches also found support among themselves. The network and sharing between activity coaches helped them to troubleshoot and learn from each other. An activity coach stated:

“Outside of the program, the three of us did meet up a few times to discuss what our likes and dislikes are about how currently things are going with your program. So that was really nice just to build that rapport and that support group.”

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Activity Coaches—the Core of Men on the Move

Among all delivery partners, across levels of organizational leadership, strategy to operations, activity coaches were perceived as most essential to success of Men on the Move. Specifically, stakeholders viewed activity coaches’ knowledge of the community and existing interventions, fitness leader training, and certification as beneficial to effectively lead Men on the Move. Delivery partners viewed activity coaches’ enthusiastic and positive personalities as important to sustained participation in the intervention. A coordinator noted, “So, having the right people running the program and dealing with the individuals really helps the coordinators quite a bit.”

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Intervention Delivery

As delivery partners at the “ground level” of intervention delivery, activity coaches stated that Men on the Move was a “good” model. They attributed this to its concrete, yet flexible design and its choice-based nature. Activity coaches also appreciated being informed of the bigger picture behind the study (e.g., evidence to support its choice-based design and plans for the research team to scale-up the model (Choose to Move) in the future. An activity coach remarked, “Overall the concept of the study is, I think, incredibly valuable and hopefully the men would find that to be the case as well.”

Activity coaches had some challenges understanding the scope of their role. In particular, activity coaches were unsure of when to prioritize the way the intervention was designed (fidelity) versus adapting to participant needs (adaptability). Other challenges they confronted related to intervention administration (e.g., adequate time to administer the medical clearance form and adequate time to deliver all informational content during one-on-one consultation). Activity coaches recommended increasing the length of one-on-one consultation to address these challenges in the future.

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Men on the Move Continuation

All delivery partners provided strong support for the intervention itself and its continued delivery, as it aligns very closely with organization and center mandates. However, they acknowledged there were also challenges adopting Men on the Move as part of usual practice. In particular, they wondered about ongoing financial costs, for example, the need to pay for activity coaches and facility space. (Note: Men on the Move formative evaluation was fully subsidized by competitive research grant funding.) A coordinator stated, “I think it really blends well with what we do … the way the program utilized what we’re already offering was the best part about it.”

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Absence of Men

All delivery partners commented on the very small number of men who generally participate in publicly offered recreational activities, and on the paucity of interventions that cater specifically to men. Delivery partners viewed Men on the Move as an effective means to bring men into recreation facilities and introduce or reintroduce them to recreation and fitness. They noted that an intervention specific to men was novel and filled a need, “But it’s nice that they’re targeting older men ‘cause that is one thing that we don’t see a lot of” (coordinator).

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Participants

Two themes emerged from our analyses of participant-level data: monitoring and connectedness.

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Monitoring

Monitoring was described by participants in two ways: 1) the essential role of activity coaches to oversee participants’ physical activity journey and 2) the importance of ongoing feedback to highlight participants’ progress (i.e., pedometer). In the first month of the intervention, participants began to see the activity coach as someone who monitors their physical activity and their goals. Participants understood and trusted their activity coach’s expertise and viewed easy access to this expertise as crucial support toward increased physical activity. During in-person sessions, activity coaches helped participants solve physical activity–related problems. Participants expressed feeling “looked after” throughout the intervention. Activity coaches served to motivate all participants to become more physically active, as participants felt accountable to someone other than themselves. Participants stated:

“[My activity coach] used to ask … how are you doing, how was your objective, your travel objective, has your health changed, has your—any problems with this, and have you, you know, seen—did—are you going to see a doctor or whatever … It was like you knew someone … you knew you were being looked after” (participant).

“If you monitor, I get to know the results and we can tweak it and it helps me to be healthier” (participant).

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Connectedness

The theme of connectedness manifested in participants’ relationships with their activity coach and through interactions with other participants and the research team. Participants developed a trusted relationship with their activity coach through interactions across the 3 months they actively delivered Men on the Move. Men valued activity coach recommendations and encouragement, and many enjoyed the check-ins. Participants described their activity coach as approachable and accessible. Many men expressed liking their activity coach as an individual. Some men subsequently attended other fitness classes the activity coach instructed, so they had additional opportunities to personally interact with their activity coach. One participant noted, “I like my [activity coach] a lot … I think that because of her approach and her personality and that, that she has a good chance of motivating all of us.”

Men on the Move participants enjoyed interacting with other men in their group. Participants were generally friendly toward each other, although no one stated they were there specifically to make friends. Some men sought more interaction with fellow participants. They indicated how they would have appreciated more opportunities for participants to connect by sharing their progress or doing an organized activity together.

“When we meet occasionally … I think three or five of them, we will recognize each other and talk to each other … right now is more than just a casual friend. That now … if I see them, we would talk more openly” (participant).

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DISCUSSION

As a means to successfully disseminate physical activity interventions in the future, there is a need to conduct formative evaluations to better understand the often complex and layered (36) context for the delivery of the intervention in preparation for scale-up (11). Currently, the traditional research focus on internal validity may overlook the importance of engaging stakeholders across levels of implementation delivery and support, early on in the planning phase (37). Developing effective implementation strategies that support flexible, adaptable interventions at the formative stage has tremendous implications on the outcome of intervention (38,39). Indeed, given that successful implementation is strongly influenced by implementation approaches, and the substantial time and resources required for scale-up (36), it seems imperative to invest in planning through formative evaluation to guide decision making and to identify effective strategies.

Thus, we extend the literature by conducting a formative evaluation that focuses on the implementation of a physical activity intervention for older men designed to be adapted for scale-up. By doing so, we sought to fill a knowledge gap and overcome some of the barriers to scale-up (22). We adopted key elements of two implementation frameworks that place characteristics of the innovation (the intervention), the prevention delivery system (defined as “implementation of innovations in the field”), the prevention support system (defined as “supporting the work of those who will put the intervention into practice”), and the prevention synthesis and translation system (defined as “distilling information about the intervention and supporting implementation by end users”) at the core of implementation success (27,31). These systems interact to support successful implementation (31).

During our formative evaluation, we encountered what researchers in health promotion referred to as a “tug-of-war” (37) between researchers’ desire to retain fidelity to an evidence-based intervention and the flexibility and responsiveness required to meet the needs of delivery partners and participants. Others term this collision between interests of researchers and values of stakeholders who ultimately implement the intervention as the “fidelity–adaptation dilemma” (37,40,41). In a companion paper (33), we assessed the dropout rates and the effect of this program and demonstrated that only 5% of Men on the Move participants were lost to follow-up and that participation across 12 wk enhanced self-reported physical activity when the intervention was delivered as planned. However, to scale-up the intervention into more diverse geographic settings (rural and remote communities) and populations (men and women; other ethnicities), elements of Men on the Move need to be culturally and contextually adapted. Thus, our findings further highlight the need to develop strategies for adaptation at scale-up, when “dynamic tensions” between adaptation and fidelity (37) are likely to be exacerbated.

Importantly, Men on the Move was designed with adaptation at scale-up in mind (7). In his six-item framework for successful scale-up, Yamey (25) contends that “if the intervention is simple, agreed, and there are no dissenting views, scale-up is much more likely to happen.” All delivery partners agreed that Men on the Move was simple to deliver based on its concrete yet flexible design and choice-based nature (participants choose activities based on preferences and abilities in consultation with an activity coach).

Other themes emerged from our evaluation that align with Yamey’s (25) framework and support continuation and scale-up and of Men on the Move in the future. They include collaborating with nongovernmental organizations as implementers, strong leadership, tailoring scale-up to the local situation, and integrating activities into existing program offerings. We discuss each in the succeeding paragraphs.

As per Yamey’s (25) framework, “attributes of the implementers,” in this case strong leadership and governance, surfaced as important. BCRPA, a nongovernmental organization backed by a committed board of directors, provided strong leadership for Men on the Move in their role as a community liaison between our research team and the recreation centers. Men on the Move received buy-in from all levels of delivery partners who were fully engaged and strongly supported intervention success. Activity coaches also served as strong leaders at the intersection between prevention delivery and support systems (between recreation coordinators and participants). They served to effectively tailor the intervention to the local context.

Yamey (25) also identified engaging local implementers and stakeholders and adapting the intervention to local contexts as key to successful scale-up. Both Men on the Move and CHAMPS referred participants to existing community resources to enhance the likelihood of continued participation in a familiar social context that offered both a variety of choices and a planned schedule. After a 6-month participation in CHAMPS, older adults effectively enhanced physical activity and reduced anxiety and depression with overall improvements in well-being (18). Similarly, after a 12-wk participation in Men on the Move, older men increased physical activity and sustained increased levels for the following 12 wk. They were also more likely to engage in active modes of transportation (33). CHAMPS was later delivered at larger scale through community centers (16,19) and subsequently evolved into Active Choices, a 6-month telephone-based physical activity program, and Active Living Every Day, a 20-wk group-based physical activity program. Together, Active Choices and Active Living Every Day comprised the Active for Life program and were delivered by community-based organizations to ethnically and economically diverse older adults. Active for Life achieved similar effects on physical activity, anxiety, depression, and well-being as the earlier efficacy studies of CHAMPS (13,20). This suggests that the future adaptation of the Men on the Move intervention to meet local needs and resources has strong potential of maintaining effectiveness.

Central support surfaced as key. This is not surprising given it is a key tenet of successful implementation models (31). As the prevention support system as described in the ISF (31), our research team served to support both direct delivery of the intervention and general capacity building. More accessible information, where delivery partners understand and are active participants in what the intervention is trying to achieve, has been linked to successful implementation (42).

Importantly, our role was to address the “fidelity versus adaptation tug-of-war” (37). To do so, we brought evidence to bear on the intervention and its implementation while incorporating the experience and learning of delivery partners to strengthen the implementation strategy, specific to one real-world context (43). This took the form of technical support and specific Men on the Move training, which the research team provided to activity coaches before intervention delivery. Specialized training may be one important determinant of adoption (44). Characteristics of an organization are thought to interact with core components of implementation (such as training, resources, and decision making) in complex ways (44). Capacity building took the form of providing delivery partners with ongoing information and feedback about the intervention and the evaluation as per knowledge to action cycles (45).

Participants specifically noted that few, if any, interventions exist exclusively for older men, and delivery partners commented on the general absence of men in recreation programs; thus, Men on the Move filled an important niche. This is noteworthy given that in most developed countries, the proportion of older men is increasing—an outcome of the shrinking gender gap in life expectancy. Notably, older men have higher rates of 12 of the 15 leading causes of death in the United States (46). Men have been underrepresented in physical activity intervention studies (47); thus, we know very little about the interests, preferences, and motivations of older men surrounding physical activity (48). Emerging evidence suggests that some men are motivated by opportunities for social connection and seek activities that afford weak or strong connections, whereas other men value solitude and seek independent and individual activities (49). This heterogeneity underscores the need for future physical activity programs and policies to be appropriately customized for older men and developed with input from older men. Courtenay (50) contends that men and boys are more apt to adopt unhealthy beliefs, and behaviors generally, as a means to construct gender and signify manhood. He places the root cause of this firmly at the foot of “social and institutional structures that sustain and reproduce men’s gendered health risks.” The lack of health promotion strategies for older men and their unwillingness to adopt them shine a light on the need to apply a gendered lens to scale-up of interventions. This shift in focus from “the individual” to “the structural” (8) is a key tenet within public health research.

Not surprisingly, the opportunity to stay socially connected surfaced as important to Men on the Move participants. Among the various health challenges older adults face as they age, the ability to form and retain social relationships is considered one essential component (4). Although reports are mixed (51), older people who are socially connected have a greater likelihood of survival compared with older people who are not (52). In a recent systematic review, Poscia et al. (51) distinguished between social isolation (“characterized as an objective lack of meaningful and sustained communication”) and loneliness (“the way people perceive and experience lack of interaction”), each with distinctly negative effects on health status and quality of life. Although both individual and group interventions reported some positive benefits, the quality of the studies were ranked moderate at best, and most studies were considered of weak quality (87%). Promising interventions to counter loneliness and social isolation ranged from using academic and community resources and relationship-building techniques to foster connections among older adults (53) to the use of technology (computer training, companion robots, and Care TV) (54). However, of the 15 studies reviewed, all had a greater proportion of women as compared with men, the review did not disaggregate results by sex or gender, and no studies were delivered at scale. Thus, there is a great need to persist in developing and adequately evaluating scalable approaches that counter social isolation if we are to curb this trend at the population level.

Our study was among the first implementation and scale-up studies to focus exclusively on the physical activity needs of older men. In this way, it is novel and adds significantly to the literature on older men’s health promotion. Importantly, Men on the Move was designed with adaptation at scale-up in mind (7). To do so, we adopted key elements of three implementation and scale-up frameworks (25,27,31). In a recently conducted Delphi study (unpublished data), these frameworks ranked as three of five most often used by an international group of physical activity and healthy eating implementation scientists. These frameworks can be applied to guide health promotion interventions across populations and settings in the future.

We acknowledge that our study also has limitations. As a formative evaluation, our outcomes are not definitive but were generated to guide the development of larger physical activity scale-up studies in the future. Other larger intervention trials more purposely focus on the effect of physical activity interventions for older adults (12,55). Our results are specific to the delivery partners and local context with which we worked. Scale-up of Men on the Move will require that the nature of the intervention be adapted to match the needs and resources of the local contexts in which it is delivered.

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CONCLUSION

Many interventions that demonstrate efficacy in controlled settings fail to translate into real-world settings (10,11). Thus, there is a need for prevention researchers to generate formative outcomes to guide the implementation of an intervention in specific settings and to plan for sustainability and scale-up in the future (11). Themes that emerge can be adapted to inform scale-up and adapted to population and setting. However, outcomes are more suitably applied in a local context, and the tension that arises when effective interventions are adapted for scale-up need be considered. Finding ways to effectively bridge the know–do–scale-up gap is imperative as we seek to improve the health of older adults at the population level.

This work was supported by a grant-in-aid from the Ministry of Health, British Columbia, and a project grant from the Canadian Institutes of Health Research (PJT-153248). Drs. Mackey and Sims-Gould are supported by Scholar Awards from the Michael Smith Foundation for Health Research. Dr. Sims-Gould is also supported by a New Investigator Award from the Canadian Institutes of Health Research. Professor McKay is a 2018 Peter Wall Institute for Advanced Studies Scholar in Residence.

The authors declare no conflicts of interest. The results of the present study do not constitute endorsement by the American College of Sports Medicine.

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