Abstract
BACKGROUND: Investment in scale-up and sustainment of effective health-promoting programs is often hampered by competing demands on scarce health dollars. Thus, optimizing programs to reduce resource use (e.g., delivery costs) while maintaining effectiveness is necessary to promote health at scale. Using a phased approach (2015-2024), we adapted and scaled-up an evidence-based, health-promoting program for older adults (Choose to Move; CTM). For CTM Phase 4 we undertook a systematic, data-driven adaptation process to reduce resource use. In this paper we: 1) describe the CTM Phase 4 program ('CTM Phase 4') and assess its 2) implementation and 3) effectiveness. METHODS: For CTM Phase 4 (30-min one-on-one consultation and 8, 60-min group meetings with an activity coach), we reduced activity coach hours by 40% compared to Phase 3. To evaluate effectiveness of CTM Phase 4 we conducted a type 2 hybrid effectiveness-implementation study involving 137 programs (1126 older adults; 59-74 years, 75 + years) delivered by 29 activity coaches. We assessed implementation indicators (e.g., dose, fidelity, adaptation, participant responsiveness, self-efficacy) via survey in activity coaches and older adults. We assessed older adults' physical activity (PA), mobility, social isolation, and loneliness before and after (0, 3 months) the program. RESULTS: Implementation indicators demonstrated that CTM Phase 4 was delivered successfully. Post-intervention, PA (+ 1.4 days/week; 95% CI 1.3, 1.6), mobility limitations (-6.4%), and scores for mobility (+ 0.7; 95% CI: 0.4, 1.3), social isolation (+ 0.9; 95% CI: 0.67, 1.17), and loneliness (-0.23; 95% CI: -0.34, -0.13) were improved in those < 75 years. Among those ≥ 75 years, PA (+ 1.0 days/week; 95% CI, 0.7, 1.2), mobility score (+ 1.1; 95% CI: 0.4, 1.8), and social isolation score (+ 0.5; 95% CI: 0.08, 0.86) were improved post-intervention. Participant-level benefits were comparable to, or greater (PA and social isolation in those < 75) than, those observed in Phase 3. CONCLUSIONS: CTM was co-designed as a flexible program, adapted over time based on user group needs and preferences. This flexibility enabled us to reduce activity coach delivery hours without compromising implementation or benefits to older adults' health. Optimizing effective health-promoting programs to enhance their scalability and sustainability provides an important pathway to improved population health. TRIAL REGISTRATION: ClinicalTrials.gov, NCT05678985. Registered 10 January 2023 - Retrospectively registered, https://clinicaltrials.gov/study/NCT05678985 .