Factors That Influence the Statewide Scaling-up of an Evidence-Based Arthritis Self-Management Program : Walk With Ease Public Deposited

http://ir.library.oregonstate.edu/concern/graduate_thesis_or_dissertations/tx31qn451

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  • Interest by public health organizations in scaling-up efficacious health interventions is increasing as the prevalence of arthritis increases and treatment becomes more costly. Although arthritis evidence-based interventions (EBIs) have been found efficacious in improving healthy behaviors and the ability to self-manage symptoms, little research has examined whether scaled-up delivery of arthritis EBIs is effective. The goal of this dissertation was to examine the experience of Oregon State University Extension in scaling-up Walk With Ease (WWE), an arthritis self-management EBI, for state-wide delivery. This dissertation had four aims: 1) examine factors that influenced the installation of WWE during Year 1 of scale-up; 2) describe program adoption and reach after two years of scaled-up delivery and examine facilitators of each; 3) explore participant retention and quality of program implementation; and 4) evaluate the effectiveness of WWE. A two-phase project was conducted. First, I explored factors that influenced the installation of WWE during Year 1 of scale-up. I interviewed the program implementers and administrators (n=11) to examine installation of WWE. Two categories of barriers and facilitators emerged that influenced installation. Organization-level themes included the timing of installation, sufficient resources and time, and the relationships of the staff of the delivery system with local community partners. Program-specific themes included recruiting and training volunteer leaders, identifying suitable walking locations, and flexibility in adapting WWE to local settings. These factors impeded installation, delayed delivery and highlighted the importance of devoting sufficient time to the installation phase. Second, guided by the RE-AIM model, I conducted a mixed-methods evaluation after two years of scale-up activities. I interviewed WWE leaders (n=39) and collected and analyzed program forms and pre/post-program participant surveys. Results indicated that WWE was implemented by diverse organizations that successfully expanded recruitment to reach the targeted number of participants (n=598). Most programs were delivered with high fidelity, however, adaptations and participant retention posed threats to successful implementation. Program completion was associated with a reported interest to increase physical activity (Odds Ratio [OR] = 2.6; 95% Confidence Interval [CI] = 1.0, 6.5), and incompletion was associated with older age (OR = 0.2; CI = .7, 0.8), physician referral to the program (OR =0.2; CI = .1, .7), and attending a WWE class in a church setting (OR = 0.1; CI = .0, .5). Despite these barriers, WWE delivery demonstrated effectiveness: participants reported significant reduction in pain and fatigue (β= -.47, p<.01, β= -.58, p<.05; respectively), and increased physical activity (β=.86, p<.001). Adjustments for missing data modestly affected these associations. The findings from this dissertation provide the following implications for future scale-up projects: 1) the installation phase is critical and cannot be overlooked; 2) EBIs chosen for scale-up must be reputable and flexible; 2) a support system is needed to guide scale-up and recruit and train delivery partners; and 3) fit between the program, leaders, and participants is critical to facilitating desired outcomes. Identifying strategies to scale-up EBI delivery warrants future exploration to better impact population-level health and wellbeing.
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