Article
Methodologic Challenges in Disseminating Evidence-Based Interventions to Promote Physical Activity

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Abstract

During the past decade, numerous intervention studies have been published on the effectiveness of programs to promote active living; however, few studies have addressed the dissemination of effective physical activity interventions. Both community settings and healthcare settings are important locations for dissemination of evidence-based programs and policies. A major gap in the existing literature involves the appropriate methodologic approaches for planning, evaluating, and reporting on dissemination efforts for effective and promising interventions in these locations. To address this gap, two hypothetical dissemination studies are presented: a quasi-experimental study of local health agencies (Scenario 1) and a group-randomized trial of clinical practices (Scenario 2). These studies help to elucidate the barriers and opportunities for implementing evidence-based physical activity interventions across different settings. Based on the scenarios, the existing literature, and the authors’ experience, dissemination challenges that researchers and practitioners may experience (i.e., issues of design, measures of outcomes and external validity, the balance between fidelity and adaptation to local settings, and the review and funding of dissemination science) are discussed. Researchers, practitioners, and policymakers are invited to address the issues outlined in this article in order to bridge the gap between the generation of new knowledge on efficacious physical activity interventions and widespread application of these approaches in community and clinical settings.

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

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