Scaling-up and sustaining physical activity interventions: A mountain too high?

Purpose: Ideally, physical activity interventions that work would be scaled-up and sustained to achieve a population health benefit. However, this is seldom achieved—only about 5% of effective physical activity interventions are scaled-up. Even fewer are sustained. The purpose of this symposium is to share and discuss the approaches we have relied upon to successfully scale-up and sustain physical activity interventions in community and school settings.

Description: In this symposium we blend the science of scale-up and sustainment with our more than 20-years’ experience implementing and scaling-up effective physical activity interventions. Animated with real-world examples, presenters will 1) introduce scale-up pathways and the crucial need to adapt an intervention and its implementation for scale-up; 2) discuss the need to co-identify, name, define and specify implementation strategies across the scale-up process and partner levels (e.g., community organizations; schools); 3) present approaches and discuss risks and opportunities when evaluating scaled-up interventions; and 4) differentiate between sustainment and sustainability, and discuss approaches and challenges sustaining effective interventions. We will close with a brief synopsis of key research gaps that might be addressed to advance scale-up and sustainment science in physical activity research.

Chair: Adrian Bauman, Emeritus Professor, University of Sydney
Presenter 1: Heather McKay, Professor, University of British Columbia
Presenter 2: Luke Wolfenden, Professor, University of Newcastle
Presenter 3: Lindsay Nettlefold, Senior Researcher, University of British Columbia
Presenter 4: Nicole Nathan, MRFF Investigator Fellow, University of Newcastle
Discussant: Adrian Bauman, Emeritus Professor, University of Sydney

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PRESENTER 1: Dr. Heather McKay, Professor, University of British Columbia

Title: Scaling-up physical activity interventions–Is there a secret sauce?

Purpose: Despite the known benefits of implementing effective health-promoting (physical activity) interventions, only about 5% are ever delivered at scale. During scale-up, it is often necessary to adapt implementation strategies and the intervention itself to achieve ‘best fit’ for specific settings and populations. Here we describe scale-up and discuss the need to co-adapt interventions for different contexts; we animate concepts using real world case studies.

Background: Implementation and scale-up coexist on a continuum or within a ‘program life cycle’ that spans development, implementation, maintenance, and dissemination/scale-up. To impact population health, interventions that ‘work’ must be implemented at large scale. Despite this critical need to scale-up, most interventions never make it out of controlled research environments, and few plan for implementation at broad scale in real world settings.

Methods: Scale-up is a process, not an endpoint. We highlight the need to ‘begin with the end in mind’—engage partners/end users early, at the outset of program during intervention planning. We define scale-up, describe different pathways for scaling-up and introduce levels of influence as outlined in scale-up frameworks. Although adapting for scale-up is not without controversy, we delve into the need to adapt (simply defined as ‘to make fit’)’ as scale-up proceeds.

Results: The scale-up process can be daunting, and there is no secret sauce. However, with key partnerships and a commitment to doing so — scale-up is possible.

Conclusion: It is important for researchers to design evidence-based scalable interventions, obtain ‘buy-in’ from relevant partners that support the scale-up process, and co-adapt interventions to achieve ‘best fit.

Practical implications: Attendees will gain a greater understanding of scale-up processes and challenges; knowledge can be used to plan for scale-up of their own evidence-based interventions, in future.

Funding: Canadian Institutes of Health Research

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PRESENTER 2: Dr. Luke Wolfenden, Professor, University of Newcastle

Title: Implementation strategies–the key to successful scale-up and sustainment?

Purpose: To explore the role of implementation strategies in supporting the scale-up and sustainment of physical activity interventions. Here we discuss the role of implementation strategies in achieving these two outcomes.

Background: Implementation is a key step in the scale-up process. Sustainment of scaled-up programs is warranted when interventions are implemented with enough fidelity and achieve beneficial effects for individuals and communities. We will explore how implementation strategies are used, and the role they play in successfully implementing and scaling-up an intervention.

Methods: We will present the findings of systematic reviews that characterise the use of implementation strategies in scale-up efforts; their effects on implementation outcomes, and the extent to which these effects are sustained over time. We will use case studies to illustrate strategies that may be particularly important to achieve desired outcomes, and how they may differ at small versus large scale.

Results: We will present evidence describing how implementation strategies are used during scale-up of physical activity programs (e.g., strategies delivered via modes or using infrastructure at relatively low cost). We address the impact of strategies and their potential effectiveness when ‘scaling-up’ programs (‘scale-up penalty’). ‘Best-bet’ implementation strategies for fostering sustainment will also be discussed.

Conclusion: It is important for researchers to deploy implementation strategies during the scale-up process. Strategies should still be relevant when implementing an intervention ‘at scale’ and maintain (or strengthen) beneficial effects long-term.

Practical implications: Attendees will understand the critical role of implementation strategies for the scale-up and sustainment of physical activity interventions. New knowledge will help researchers select appropriate implementation strategies to guide their own scale-up initiatives.

Funding: National Health and Medical Research Council

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PRESENTER 3: Dr. Lindsay Nettlefold, Senior Researcher, University of British Columbia

Title: Evaluating physical activity interventions – adapting approaches as scale-up proceeds

Purpose: In this presentation we will discuss evaluation methods and consider real-world challenges when assessing implementation and impact of physical activity interventions during scale-up.

Background: Evaluation is key to implement, adapt and scale-up physical activity interventions. As scale up proceeds, research priorities change—this has implications for study design and measurement approaches. Across the program lifecycle, the main focus of the evaluation shifts from the impact of the intervention on participant-level outcomes (efficacy; quantitative methods) towards a greater focus on effectiveness (mixed methods) and factors that influence implementation of the intervention (qualitative methods). Similarly, as scale-up proceeds, the proportion of the evaluation focused on implementation of the intervention compared to implementation strategies may also change.

Methods: We have been implementing, scaling-up and evaluating a health promotion intervention called Choose to Move since 2015. We will use Choose to Move as a case study to illustrate how the evaluation focus and methods have changed over time.

Results: Our evaluation data has been used in a number of ways: 1) to assess the impact of Choose to Move; 2) understand what facilitators and barriers our delivery partners experience; 3) guide adaptations to the program and the implementation strategies; and 4) encourage prospective partners (e.g., funders, delivery partners) and participants to engage.

Conclusion: A purposeful and strategic evaluation plan is essential to guide implementation and scale-up of physical activity interventions. Ultimately, data support a constant knowledge to action approach, sustained delivery of effective interventions and long-term health benefits.

Practical implications: Attendees will gain a greater understanding of the role, focus, and challenges of evaluation during implementation and scale-up. This knowledge can be used to guide evaluation of their own evidence-based interventions, in future.

Funding: Canadian Institutes of Health Research

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PRESENTER 4: Dr. Nicole Nathan, MRFF Investigator Fellow, University of Newcastle

Title: Sustainment: What happens to physical activity programs when implementation support ends?

Purpose: Here we address the challenge of sustaining efficacious physical activity interventions. We explore strategies to maintain delivery and impact of evidence based interventions (EBIs) over time. To do so we utilize case studies from schools, early care and education (ECEC) settings.

Background: In health promotion, researchers have made significant progress adopting and implementing physical activity interventions in schools and ECEC settings. However, sustaining effective programs remains a substantial challenge. Only 23% of public health and clinical interventions endure beyond two years. This squanders investments and diminishes potential long term health benefits.

Methods: We will present qualitative findings from case-study analysis of physical activity initiatives implemented in Australian schools and ECEC over a 20yr period. We used Inductive thematic analysis to analyse and derive emergent patterns, themes, and insights from the data.

Results: We identified the following themes:
• Design for sustainment from the outset: Early involvement and integration of knowledge users and policy makers is critical.
• Leadership support is essential: Committed and engaged leaders, co-designed strategies, the provision of relevant resources and active endorsement are all crucial for success.
• Provide ongoing education and training: Staff turnover challenges EBI sustainability; this emphasizes the importance of continuous education and training.
• Routine monitoring facilitates sustainability: Establish valid measures, as inconsistencies in defining and measuring sustainability pose challenges.

Conclusion: Failure to sustain EBIs undermines health system investments. Policymakers, practitioners, and researchers must carefully select sustainable innovations, and plan for sustainment at the outset of the project.

Practical Implications: We provide insights into sustainment for researchers, practitioners and policymakers. Sustained impact is possible with early planning, engaged leaders, continuous education, and continually monitoring strategies for EBIs.

Funding: National Health and Medical Research Council