"During early implementation you just muddle through": factors that impacted a statewide arthritis program's implementation

Overcoming Barriers to Walk With Ease Implementation in Community Organizations

Introduction

The Arthritis Foundation’s Walk With Ease (WWE) program has been shown to reduce arthritis symptoms and increase physical performance for up to 1 year. However, research on community-based WWE implementation is limited. The purpose of this study was to examine early implementation at community organizations that received 1-year WWE implementation grants from the Osteoarthritis Action Alliance.

Method

Program managers at five Osteoarthritis Action Alliance grantee organizations participated in 45-minute telephone interviews. Interviewees represented organizations with the highest WWE enrollment at 6 months (n = 3, >30% of goal enrollment) and no enrollment at 6 months (n = 2). The Planning for Sustainability framework guided qualitative analysis of factors affecting early implementation.

Results

All grantees were confident in WWE’s evidence base, thought it a beneficial supplement to other programming, stressed the importance of senior leadership support for WWE, and engaged community partners for marketing support and as walking sites. Implementation experiences unique to low enrollment grantees were (1) recent major structural changes within their organization, (2) difficulties in communicating logistics internally, and (3) difficulties in balancing WWE with other responsibilities. All organizations experienced barriers that required altering their original implementation plans; however, practical solutions like adapting the program to improve flexibility, training organizational staff as leaders, and utilizing community partnerships served to address multiple barriers simultaneously.

Discussion

Building organizational capacity by overcoming early barriers is a key element of early implementation. Our findings offer concrete solutions to early WWE implementation barriers and suggest the need for further research on adaptations to improve WWE’s flexibility in community organizations.

Perspectives on program mis-implementation among U.S. local public health departments

BACKGROUND

Public health resources are limited and best used for effective programs. This study explores associations of mis-implementation in public health (ending effective programs or continuing ineffective programs) with organizational supports for evidence-based decision making among U.S. local health departments.

METHODS

The national U.S. sample for this cross-sectional study was stratified by local health department jurisdiction population size. One person was invited from each randomly selected local health department: the leader in chronic disease, or the director. Of 600 selected, 579 had valid email addresses; 376 completed the survey (64.9% response). Survey items assessed frequency of and reasons for mis-implementation. Participants indicated agreement with statements on organizational supports for evidence-based decision making (7-point Likert).

RESULTS

Thirty percent (30.0%) reported programs often or always ended that should have continued (inappropriate termination); organizational supports for evidence-based decision making were not associated with the frequency of programs ending. The main reason given for inappropriate termination was grant funding ended (86.0%). Fewer (16.4%) reported programs often or always continued that should have ended (inappropriate continuation). Higher perceived organizational supports for evidence-based decision making were associated with less frequent inappropriate continuation (odds ratio = 0.86, 95% confidence interval 0.79, 0.94). All organizational support factors were negatively associated with inappropriate continuation. Top reasons were sustained funding (55.6%) and support from policymakers (34.0%).

CONCLUSIONS

Organizational supports for evidence-based decision making may help local health departments avoid continuing programs that should end. Creative mechanisms of support are needed to avoid inappropriate termination. Understanding what influences mis-implementation can help identify supports for de-implementation of ineffective programs so resources can go towards evidence-based programs.

The Feasibility of Recruiting and Training Lay Leaders During Real-World Program Delivery and Scale-up: The Case of Walk With Ease

Introduction. To maximize limited resources, many health promotion programs are designed to be delivered by volunteer lay leaders. But this model poses challenges to implementation in real-world settings and barriers to successfully scaling-up programs. This study examines the current lay leader training model for Walk With Ease, a Centers for Disease Control and Prevention-funded evidence-based arthritis program delivered at-scale. Method. Recruited volunteers (n = 106) opted into free online or in-person training and agreed to deliver one Walk With Ease program within the following year-only 49%, however, did. Using logistic regression models and qualitative interviews, we explored predictors of volunteer delivery. Results. Volunteers had higher odds of delivering programs if they trained online (odds ratio [OR] = 9.04, 95% confidence interval [CI: 2.30, 48.36]), previously taught health programs (OR = 15.52, 95% CI [3.51, 103.55]) or trained in the second year of implementation (OR = 27.08, 95% CI [2.63, 415.78]). Qualitative findings underscored that successful volunteers were readied by their previous health education experience. Conclusions. While online training modes appear effective to prepare experienced volunteers, lay leaders required additional support. This calls into question whether lay-led delivery models are suitable for scaling-up programs with limited resources. Given the many lay-led health interventions for chronic disease self-management, investing in common training and infrastructures for lay leader development could advance the quality and sustainability of real-world program delivery.