Translation of a lifestyle physical activity intervention into a regional rehabilitation service

Individuals with neuromusculoskeletal (NMS) conditions are significantly less physically active compared to the general population and hence, are at increased risk of chronic disease. Additional barriers to physical activity (PA) for this population arise from the diverse range of physical, cognitive, linguistic and psychological impairments that they experience. The Adapted Physical Activity Program (APAP) is a lifestyle PA intervention that utilises evidence-based strategies to assist individuals with NMS conditions to increase their PA behaviour. APAP evolved at the School of Human Movement and Nutrition Sciences at the University of Queensland (UQ). APAP efficacy was demonstrated in a controlled clinical trial with individuals with brain impairment conducted by an Exercise Physiologist (EP) within the individual's home and community environment. The purpose of this research project was to translate APAP from the metropolitan educational setting of UQ into a regional community rehabilitation service, Community Rehab nQ (CRnQ) in Townsville. The project comprised three phases. The aim of phase 1 was to establish factors that influence PA participation by gaining the perspective of individuals with NMS conditions. The aim of phase 2 was to plan and develop a protocol implementation and evaluation of APAP within the CRnQ setting. The aim of the third and final phase was to implement and evaluate APAP at CRnQ. Phase 1 consisted of Study 1 (literature review) and Study 2 (focus groups and interviews). Study 1 revealed that factors that influence participation in PA for this population are complex, common to all, yet unique to the individual's context. Findings of Study 1 indicated that an individually tailored approach to PA interventions was required. Study 2 narrowed the focus to individuals with NMS conditions residing in regional North Queensland. Focus groups and interviews were conducted with participants who attended CRnQ. Factors reported to influence PA were consistent with the findings of Study 1, however social support arising from attendance at regional health services was reported to be a major contributing factor to PA. Phase 2 and 3 involved a mixed-method hybrid effectiveness-implementation Type 1 study design based on the (Reach, Effectiveness, Adoption, Implementation, Maintenance (REAIM) framework. In Phase 2, Study 3 (Part 1), a plan was developed throughout three overlapping and iterative stages: (i) Engagement and familiarisation with the APAP intervention and the implementation context of CRnQ (ii) Identification and familiarisation with the RE-AIM framework (iii) Tailoring the implementation of APAP to CRnQ's context guided by RE-AIM. This process identified that APAP was a complex intervention that was sufficiently flexible to be translated into a different setting. The process also identified that CRnQ was a suitable setting for translation of APAP on the basis that it provided services for the appropriate target audience and that it was sufficiently responsive to new ideas and opportunities to be able to adopt APAP. Key consistencies and differences between UQ and CRnQ were highlighted and corresponding strategies were developed to overcome associated challenges and enhance facilitators. Subsequently, an overall plan was devised for implementation and evaluation of APAP at CRnQ. In Phase 2 of Study 3 (Part 2) a protocol for implementation and evaluation of APAP at CRnQ was developed. This involved integration of APAP into CRnQ processes, as well as inclusion of additional processes along the rehabilitation pathway. To reach the target audience the intake assessment was expanded to include additional PA questions and the clinical meeting included reminders to clinical staff to refer suitable participants to the program. To determine effectiveness, a range of therapist- administered and self- report measures were included in the CRnQ package of outcome measures to determine changes in PA levels, mediators of PA (e.g. social support), levels of fitness and participant satisfaction. Adoption was fostered through discussion of participant progress during clinical meeting and inclusion of APAP in the emerging electronic health records. Implementation was driven through formal training of EPs prior to implementation, weekly feedback sessions between EPs during implementation and checklists to monitor APAP fidelity within the CRnQ context. Maintenance was promoted at the individual level through additional social support including a Facebook page and a buddy system and at the organisational level by embedding APAP in CRnQ electronic systems and processes. Phase 3 involved implementation and evaluation of APAP at CRnQ. Study 4 consisted of a hybrid effectiveness-implementation type1 trial based on the RE-AIM framework. APAP program reach over an eight-month period was 16% (n=23) with 88% completion with EPs working to full capacity. APAP was considered effective based on observed increased participant confidence, sense of well-being, independence in PA and successful integration into community. Based on quantitative outcome measures, significant increases were found in 'friend' and 'family' social support but not with perceived PA barriers and benefits. Increases were not significant for PA and fitness, possibly due to the use of outcome measures that were inappropriate for individuals who have complex conditions and a disproportionate amount of time spent on psychosocial issues versus PA. Time taken to conduct community sessions and between-session preparation were considered the greatest cost. An unanticipated outcome identified by EPs was a potential increase in workload for the family carer of an individual with a low level of function. APAP was considered to be adopted well as the clinical team perceived that it added value to CRnQ and that it positively influenced the way they practiced. During implementation the average number of sessions was the same as the UQ efficacy intervention but with an increased average intervention duration; mostly due to health setbacks. EPs reported a delayed uptake with training and understanding of the APAP due to its evolving nature and complexity. The program was delivered with fidelity; however, EP Motivational Interviewing required further practice. APAP functioned satisfactorily as an individual program and concurrently with other CRnQ programs. APAP was delivered via Skype and telephone to those in rural and remote areas and the intervention was adapted for those with aphasia. Maintenance at the individual level was variable with factors exerting the greatest influence perceived to be social support and social media. Maintenance of APAP at the organisational level reduced upon withdrawal of the intervention champion and upon turnover of the clinical team. Suggestions made by the clinical team to improve implementation of APAP at CRnQ included the use of appropriate outcome measures, further integration of APAP into CRnQ processes and systems, allocation of EP resources and education of new clinical team members. In conclusion, APAP was translated from the metropolitan university setting to a regional community rehabilitation setting. The individually-tailored, person-centred, flexible design of APAP enabled individuals with NMS conditions to participate in PA. Although APAP participant satisfaction was high and significant increases were demonstrated for 'friend' and 'family' social support, PA and fitness outcome measures chosen for this study did not demonstrate significant increases. APAP was considered a valuable addition to CRnQ by the clinical team and a positive influence on the way they practised, however they perceived the intervention to be too time consuming and complex. Feedback from the team suggests further integration of APAP into CRnQ with some intervention and delivery modification. More in-depth assessment of intervention fidelity and evaluation of contextual factors that influence adoption and implementation is required.