ArticleMethodologic Challenges in Disseminating Evidence-Based Interventions to Promote Physical Activity
Introduction
Physical inactivity has been estimated to account for 12% of total mortality and for 2.4% of annual healthcare expenditures in the United States.1, 2 Despite well-established evidence that indicates the importance of regular physical activity in reducing the burden of chronic diseases,2, 3, 4 55% of adults and 33% of adolescents in the U.S. do not achieve the national recommendations for physical activity.5, 6 Compared with other behavioral risks, the study of physical activity interventions is regarded as a relatively new area of research.7 However, during the past decade, numerous intervention studies have been published on the efficacy of programs to promote active living in both clinical and community settings.8, 9
When a body of efficacious interventions is available, the attention shifts to the dissemination of research-tested programs and policies for population-wide impact. This is illustrated in Phase 5 of the behavioral epidemiology framework developed by Sallis and colleagues (Figure 1).10 There has been extensive research on Phases 1 through 4; however, few studies have been done on the dissemination of effective physical activity interventions (Phase 5).11 While literature on Phase 5 is limited for nearly all health behaviors,10, 12, 13, 14 there are even fewer studies on physical activity dissemination.12, 13, 15
It is also important to note that, as suggested in Figure 1, dissemination of evidence-based interventions (Phase 5) is likely to occur in stages.13, 16, 17, 18, 19 Dissemination can also be regarded as a “push–pull capacity” process, in which the potential adopter of the intervention must be receptive (pull) and at the same time there must be a systematic effort provided to the adopter to enhance the implementation of the intervention (push), in addition to an adequate capacity of the infrastructure to deliver the intervention.20, 21, 22, 23
Although the literature is sparse, there are enough studies to begin to understand the successful attributes of physical activity dissemination. In this article, dissemination is defined as an “active process through which the target groups are made aware of, receive, accept, and use information and other interventions.”20 The object of dissemination can be an evidence-based program, practice, policy, or tool. The literature suggests that diffusion or passive forms of spread (e.g., clinical practice guidelines; mass mailing; presentations to large, heterogeneous groups) that are untargeted and undifferentiated are usually largely ineffective in achieving widespread program adoption.20, 24, 25, 26, 27, 28 Effective dissemination of evidence-based programs often requires a more active, systematic, and controlled approach and strong organizational commitment.26, 27, 29 Several factors influence the extent to which the dissemination of evidence-based interventions occurs in community and clinical locations.19 These factors can be classified as the characteristics and perceptions of the innovation, characteristics of the adopter, contextual factors within the community, or organizational setting, and are summarized in Figure 2. Understanding the delivery context for the intervention (e.g., channels, organizational characteristics, managerial factors) is essential for the success of the dissemination and often creates tension between fidelity and reinvention.30, 31 It is important to mention that the adoption rate of the innovation will be determined by the interaction among the attributes of the innovation, characteristics of the intended adopters, and the given context.32
Both community settings (i.e., schools, worksites, faith-based organizations, health departments, other healthcare organizations, community-based institutions and organizations) and healthcare settings (i.e., physician and dental offices, community health clinics, managed care practices) are important locations for dissemination.20 A major gap in the existing literature involves the appropriate methodologic approaches for planning, evaluating, and reporting dissemination of effective and promising interventions in these locations.
The aim of this article is to contribute to a better understanding of these challenges in ways that are practical and relevant for researchers, practitioners, and policymakers. Therefore, two hypothetical dissemination studies are presented, one focusing on local health agencies (Scenario 1) and one in primary care clinical practices (Scenario 2) to elucidate the barriers and opportunities for implementing evidence-based physical activity interventions into practice across different settings. Based on the scenarios, the existing literature, and the authors’ experience, the challenges and lessons learned for the field are then described.
Section snippets
Brief Description of the Program/Evidence
Practitioners and policymakers often seek out scientific evidence when searching for effective programs and policies. To support this need, systematic reviews sum up the results of primary scientific studies that meet explicit criteria.33 They provide an overview of current scientific literature through a definable and rigorous method in which available studies themselves are the units of analysis. As an example, an expert panel (i.e., the Task Force on Community Preventive Services) has
Evaluation and Measures of Effectiveness
Three inter-related evaluation approaches would be used. These include baseline and follow-up surveys with agency staff that focus on the use of the evidence-based recommendations in the Community Guide. Program records would also be reviewed to assess the extent of adoption and implementation to validate responses to the surveys. Finally, post-assessment qualitative case studies would be conducted with selected health departments to identify the factors that lead to high versus low levels of
Brief Description of Program/Evidence
In addition to public health practice, the public may also be encouraged to increase their levels of individual physical activity through their regular attendance in a primary care practice setting. Between 1999 and 2000, there were 169.9 primary care visits per 100 Americans.39 With some health behaviors (e.g., smoking cessation), there is good evidence that a brief counseling intervention can lead to behavior change.40 While the U.S. Preventive Services Task Force (USPSTF), through its
Objectives and Hypothetical Design
In Scenario 2, the PACE program would be adapted for delivery in community health centers serving a primarily Latino population. The primary aim might be to determine the effectiveness of a culturally adapted dissemination approach in increasing the rate of health-provider counseling to promote physical activity. The PACE program counseling protocol would be adapted to make it culturally appropriate for Latinos using focus groups of Latino patients, and would also be contextually adapted to
Challenges and Opportunities
The two previously presented hypothetical dissemination studies will serve as a point of departure for discussing the challenges that researchers and practitioners may experience when their applications are reviewed, researching the dissemination of, and disseminating evidence-based physical activity interventions, leading to suggestions and lessons learned.
Conclusion
It is now widely recognized that the mere existence of scientific knowledge is not sufficient for its subsequent application.21, 69 Active dissemination methods are necessary to increase the effectiveness of dissemination efforts.24 For physical activity researchers and practitioners, there is now an array of effective intervention approaches and analytic tools available for use, such as the Community Guide and Cancer Control PLANET. A major challenge involves finding creative and
References (74)
- et al.
Translating evidenced-based physical activity interventions into practiceThe 2010 challenge
Am J Prev Med
(2002) - et al.
The effectiveness of interventions to increase physical activityA systematic review
Am J Prev Med
(2002) - et al.
Toward a better understanding of the influences on physical activity: the role of determinants, correlates, causal variables, mediators, moderators, and confounders
Am J Prev Med
(2002) Organizational interventions to encourage guideline implementation
Chest
(2000)- et al.
A controlled trial of physician counseling to promote the adoption of physical activity
Prev Med
(1996) - et al.
Translating what we have learned into practicePrinciples and hypotheses for interventions addressing multiple behaviors in primary care
Am J Prev Med Aug
(2004) - et al.
Using RE-AIM metrics to evaluate diabetes self-management support interventions
Am J Prev Med
(2006) - et al.
Behavior change intervention research in healthcare settings: a review of recent reports with emphasis on external validity
Am J Prev Med
(2002) - et al.
Researchers and policymakers: travelers in parallel universes
Am J Prev Med
(2006) - et al.
Multiplying health gains: the critical role of capacity-building within health promotion programs
Health Policy
(1997)
The public health burden of a sedentary lifestyle
Med Sci Sports Exerc
Economic costs of obesity and inactivity
Med Sci Sports Exerc
Physical activity promotion through primary care
Jama
Physical activity and healthA report of the Surgeon General
Prevalence of physical activity, including lifestyle activities among adults—United States, 2000–2001
MMWR Morb Mortal Wkly Rep
Youth risk behavior surveillance–surveillance summaries—United States, 2003
MMWR Morb Mortal Wkly Rep
The effectiveness of urban design and land use and transport policies and practices to increase physical activity: a systematic review
J Phys Activity Health
Behavioral epidemiology: a systematic framework to classify phases of research on health promotion and disease prevention
Ann Behav Med
Health promotion research and the diffusion and institutionalization of interventions
Health Educ Res
The case for dissemination research in health promotion and disease prevention
Can J Public Health
The future of physical activity behavior change research: what is needed to improve translation of research into health promotion practice?
Exerc Sport Sci Rev
The adoption process for health curriculum innovations in schools: a case study
J Health Educ
Diffusion of innovations in schools: a study of adoption and implementation of school-based tobacco prevention curricula
Am J Health Promot
Implications of diffusion research for planned change
Int J Health Educ
Diffusion of innovations
Introduction to the special section on dissemination: dissemination research and research dissemination: how can we close the gap?
Health Psychol
Translating research into improved outcomes in comprehensive cancer control
Cancer Causes Control
Helping pregnant smokers quit: meeting the challenge in the next decade
Tob Control
Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findingsThe Cochrane Effective Practice and Organization of Care Review Group
Bmj
Bridging the gap between the science and service of HIV prevention: transferring effective research-based HIV prevention interventions to community AIDS service providers
Am J Public Health
Diffusion, dissemination, and implementation: who should do what?
Ann N Y Acad Sci
Translating scientific discoveries into public health action: how can Schools of Public Health move us forward?
Public Health Rep
Disseminating effective cancer screening interventions
Cancer
Disseminating research results—the challenge of bridging the gap between health research and health action
Health Promot Int
Reinventing fidelity: the transfer of social technology among settings
Am J Community Psychol
Evaluating the relevance, generalization, and applicability of research: issues in translation methodology
Eval Health Prof
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