A national clinical practice guideline for pediatric palliative care was published in 2013. So far there are only few reports available on whether an educational program fosters compliance with such a guideline implementation. We aimed to test the effect of the education program on actual compliance as well as documentation of compliance to the guideline.We performed a prospective study with pre- and post-intervention evaluation on compliance to the guideline of the nurse specialists of a pediatric palliative care team for case management at a children’s university hospital. Eleven quality indicators were selected from 192 recommendations from the pediatric palliative care guideline, based on frequency, measurability and relevance. The multifaceted education program included e-learning and an interactive educational meeting. Four e-learning modules addressed 19 patient cases on symptoms, diagnostics and treatment, and a chart-documentation exercise. During the interactive educational meeting patient cases were discussed on how to use the guideline. Documentation of compliance to the guideline in the web-based patient-charts as well as actual compliance to the guideline through weekly web-based parent reports was measured before and after completion of the e-learning.Eleven quality indicators were selected. The educational program did not result in significant improvement in compliance for any of these indicators. The indicators “treatment of nausea”, “pain medications two steps ahead” and “pain medication for 48 h present”, measured through parent reports, scored a compliance beyond 80 % before and after e-learning. The remaining indicators measuring compliance, as well as six indicators measuring documentation by chart review, showed a compliance below 80 % before and after e-learning.The multifaceted education program did not lead to improvement in documentation of compliance to the guideline. Parent reported outcome revealed better performance and might be the more adequate assessment tool for future studies. Although life-shortening disease is rare during childhood, yearly about 4200 children in the Netherlands are entitled to palliative care . PediatrOur university children’s hospital has initiated a specialized pediatric palliative care team (PPCT) in June 2012 which consists, among other specialists, of five specialized pediatric nurse specialists that fulfill the role of case manager for children with life-shortening disease and their families. The team’s goal is to provide support from the moment the child’s disease is considered incurable until death has occurred. The nurse specialists organize, coordinate and support the care from primary, secondary and tertiary healthcare professionals and also provide aftercare . The teaWe hypothesized that an education program could increase the compliance of the nurse specialists from the PPCT to the Dutch CPG. Our first research question was: what is the baseline compliance of the nurse specialists to the guideline, measured with selected quality indicators. Our second research question was: can introduction of a multifaceted education program, which we specifically designed for this purpose, improve the team’s compliance to the CGP.To allow measurement we aimed to use preset quality indicators, measuring compliance of the CPG. An extensive literature search did not reveal such indicators . TherefoE-learning modules and an interactive educational meeting were developed by two authors (CJ and AS) and were offered as a multifaceted education program for the nurse specialists of the PPCT. The goal of the e-learning modules is not to learn recommendations by head specifically, but primarily to stimulate regular review of the CPG and thus get familiar with using the CPG. The e-learning has four modules describing a total of 19 cases of patients with any life-shortening disease. Each module consists of 8–10 questions, addressing theoretical background as well as recommendations on symptom management given by the CPG. All chapters describing a specific symptom-group are addressed in at least one of the modules as is presented in Fig. During the e-learning session an open access available guideline was provided, stimulating the nurse specialists to find the answer in the CPG and thus get familiar with the use of it. Since the guideline stresses the importance of correct and complete documentation of symptoms and interventions, every module ends with a documentation assignment testing performance of complete documentation by the nurse specialist/participant. After completion of the module, direct electronic feedback is provided to the nurse specialist individually, with the correct answers as well as directions on which chapter and page the answer is displayed in the guideline and the exact text of the guideline is provided.The different modules were offered to the nurse specialists for four consecutive weeks. All five nurse specialists participated in the e-learning. One week after the last module was offered and completed, the education program was completed with an interactive educational meeting with examples of actual recent patient cases and discussions on how and when to use the guideline.Evaluation of effects of the education program as perceived by the nurse specialist was obtained 3 months after completion, through a short web-based questionnaire addressing experiences with the education program as well as self-evaluation of degree of current adherence to the guideline. Attendants approved that data could be used for research purposes.th 2014 and post-intervention from April 8th until October 8th 2014. The web-based patient charts, used for daily documentation by the PPCT, were reviewed to measure documentation of compliance. The charts were reviewed on occurrence of a clinical situation in which one of the recommendations used for the quality indicators would apply. All relevant reports were scored on whether compliance to the CPG was documented. Information on actual compliance to the CPG was retrieved from a web-based parent report on symptom occurrence and management. Parents were asked whether a symptom was present, and if so, the quality indicators concerning the symptom were literally asked to parents  and 40 patients had a non-malignant disease (NMD). During the second evaluation period, 56 children received support from the PPCT of whom 19 patients had a MD and 37 patients had a NMD. Forty-five patients, who were supported by the PPCT during the first study period, were still supported by the PPCT at the start of the second study period. Eleven patients were newly introduced to the PPCT in between the two periods or during the second study period and thus included in the second test-period only.Table We report a pilot study to investigate methods for improvement in compliance to the CPG for palliative care for children, by introducing a multifaceted education program. In contradiction to our hypothesis that the multifaceted education program would lead to a significant increase in compliance to the CPG, no significant difference is seen for any of the selected quality indicators before and after the education program.Although Grol and Grimshaw found that structured implementation can improve adherence to CPGs , many reA multifaceted intervention including a combination of small group interactive postgraduate training, with personalized feedback, and additional instruction material, such as a website, was found to be more successful for implementation of a guideline than a single-faceted intervention –9. One oWe showed correct use of the CPG, defined as compliance in at least 80 % of the measurements, in three out of eleven indicators (numbered 7–9) before and after the intervention. These indicators evaluate the right choice of medicament to treat nausea, the upfront defining of pain treatment, and the upfront prescription of pain medication.Two indicators (10–11), measuring the recommendations of the CPG to give certain advices to patients with fatigue showed low scores before and after the intervention. The low compliance scores on indicator 10 and 11 might be biased by the relatively short test periods of the study. Assessment of given advises to patients with fatigue, can be performed during the whole period of fatigue of the child. The PPCT might have provided specific advises according to the CPG at some point earlier outside our measurements periods. Since it is not prescribed and unwanted to repeat these advises on a weekly base no manifest application of the CGP could have been observed in our measurement episodes.The scores in the indicators measuring documentation in the medical charts of compliance to the CPG (1–6) were low before and after the intervention. Although the low compliance scores may be in line with other publications reporting limited compliance , 24, sevA strength of our study is that we were able to collect many measurements, by assessing web-based charts as well as parent reports of all patients receiving support of the PPCT. The easy and complete access will have limited the risk of information and selection bias. Moreover, we have developed a multifaceted education program addressing a national CPG, with high satisfaction and perceived effectiveness scores from participants that can easily be distributed to all professionals providing support in the palliative phase of children. Evaluating compliance to the CPG shortly after introduction, allows rapid implementation efforts to be developed, hopefully leading to effective implementation of the CPG and thus improving quality of care. A limitation of the study could be that not for all the indicators enough measurements were available. However, according to our power-calculation, for most of the indicators on documentation enough measurements were available for reliable analysis.Assessment of charts has the limitation that only documentation of compliance is measured. This, together with the short test periods of the study, might have led to lower scores. Another interpretation could be that our education program was nog good enough. Perhaps lessons from the literature should have been taken more into account . FinallyBased on our study results we would argue that further research is needed to identify whether the low compliance scores are underestimated due to short study periods or suboptimal assessment, or the intervention was not optimal. Future research should focus on parent- or observer- based reports for adequate assessment of compliance and effectiveness of the multifaceted education program.In conclusion, in this study we showed that a multifaceted education program, including e-learning did not increase (documentation of) compliance to the CPG. Documentation of compliance, as measured by 6 indicators through web-based chart review, remained low after the multifaceted education program. Sufficient compliance to the CPG was seen in three indicators measured through parent reported performance before and after the intervention. Additional research is required to define different methods for assessment of guideline compliance in clinical practice as well as to investigate optimal education for guideline performance.


Identifying provider characteristics associated with greater capacity to implement new practices geared toward reducing the disparities gap in health-care services has become a chief priority. Yet, there is limited information on conceptual frameworks and methodologies to understand key organizational factors associated with positive client outcomes.To evaluate program capacity factors associated with client outcomes in publicly funded substance abuse treatment in one of the most populous and diverse regions of the United States.Using multilevel cross-sectional analyses of program data (n = 97) merged with client data from 2010 to 2011 for adults (n = 8599), we examined the relationships between program capacity  and client wait time and retention in treatment.Acceptance of Medi-Cal was associated with shorter wait times, whereas organizational readiness for change was positively related to treatment duration. Staff attributes were negatively related to treatment duration. Finally, compared to low program capacity, high program capacity was negatively associated with wait time and positively related to treatment duration.Program capacity, an organizational indicator of performance, plays a significant role in access to and duration of treatment. Implications for reducing disparities under the current health-care reform context are discussed.


Falls threaten the independence of adults aged 65 years and older. In the U.S., one in three older adults fall annually, causing significant disability and reduced quality of life . The higCDC Compendium of Effective Fall Interventions is intended to help public health practitioners use the best scientific evidence to effectively address falls among older adults in the community .YMCAs are independent but federated organizations working to spread health and wellness in their communities. YMCAs offer classes for all ages, all skill levels, and all interests. As a national resource center, YMCA of the USA (Y-USA) supports over 2,600 YMCAs located across 10,000 U.S. neighborhoods and with 20.6 million members  and contracted with the program’s creator to train YMCA Faculty Trainers as Y-MFBB instructors. As of September 2013, 287 Y-MFBB instructors have been trained. To encourage implementation of Y-MFBB locally, Y-USA awarded 131 YMCAs grants of $1000 each to hold instructor trainings and initiate Y-MFBB classes.Motivated by the success of the National Diabetes Prevention Program, CDC initiated a similar strategy to implement an evidence-based older adult fall prevention program using the YMCA infrastructure. With funding from the CDC, Y-USA licensed the rights to the  program  and adapIn fall 2013, the Y-USA interviewed staff directors from 8 of the 75 YMCAs offering Y-MFBB in the last year to gather lessons learned about local Y-MFBB implementation. After approximately 17 months, these 8 YMCAs had reached 706 participants. Most participants were women, aged 65 years and older, and YMCA members  the growing number of older adult members; and (2) the high incidence of falls among them. However, Y-MFBB instructors also need the opportunity to check program fidelity and offer progressively more challenging classes. With more Y-MFBB instructors and training, the directors are considering placing Y-MFBB into a larger portfolio of falls prevention programing at their sites. CDC is currently supporting the development of a national Y-MFBB rollout plan based on further research into program and implementation effectiveness.While CDC and state public health agencies have the tools to assess and address public health problems, community-based organizations are often tasked with delivering programs. The YMCA has been an important partner for scaling up the CDC fall prevention program to a wider and more diverse audience. This example of leveraging partnerships with organizations that already have a robust infrastructure in place for large-scale program delivery is critical for population-level gains. CDC will continue to work with organizations such as the YMCA to increase the availability of Y-MFBB and other evidence-based fall prevention programs to reduce fall risk among older adults.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.This paper is included in the Research Topic, “Evidence-Based Programming for Older Adults.” This Research Topic received partial funding from multiple government and private organizations/agencies; however, the views, findings, and conclusions in these articles are those of the authors and do not necessarily represent the official position of these organizations/agencies. All papers published in the Research Topic received peer review from members of the Frontiers in Public Health  panel of Review Editors. Because this Research Topic represents work closely associated with a nationwide evidence-based movement in the US, many of the authors and/or Review Editors may have worked together previously in some fashion. Review Editors were purposively selected based on their expertise with evaluation and/or evidence-based programming for older adults. Review Editors were independent of named authors on any given article published in this volume.


Currently, the increasing interest in telehealth and significant technological breakthroughs of the past decade create favorable conditions for the widespread adoption of telehealth services. Therefore, expectations are high that telehealth can help alleviate prevailing challenges in health care delivery. However, in order to translate current research to policy and facilitate adoption by patients and health care providers, there is need for compelling evidence of the effectiveness of telehealth interventions. Such evidence is gathered from rigorously designed research studies, which may not always be practical in many real-world settings.Our aim was to summarize current telehealth evaluation strategies and challenges and to outline practical approaches to conduct evaluation in real-world settings using one of our previously reported telehealth initiatives, the Diabetes Connect program, as a case study.We reviewed commonly used current evaluation frameworks and strategies, as well as best practices based on successful evaluative efforts to date to address commonly encountered challenges in telehealth evaluation. These challenges in telehealth evaluation and commonly used frameworks are described relevant to the evaluation of Diabetes Connect, a 12-month Web-based blood glucose monitoring program.Designers of telehealth evaluation frameworks must give careful consideration to the elements of planning, implementation, and impact assessment of interventions. Evaluating performance at each of these phases is critical to the overall success of an intervention. Although impact assessment occurs at the end of a program, our review shows that it should begin at the point of problem definition. Critical to the success of an evaluative strategy is early planning that involves all stakeholders to identify the overall goals of the program and key measures of success at each phase of the program life cycle. This strategy should enable selection of an appropriate evaluation strategy and measures to aid in the ongoing development and implementation of telehealth and provide better evidence of program impact.We recommend a pragmatic, multi-method, multi-phase approach to telehealth evaluation that is flexible and can be adapted to the characteristics and challenges unique to each telehealth program. Current global trends suggest that the popularity of telehealth is at an all-time high since the advent of modern telehealth over 40 years ago . This riOver the last decade, support has been growing for the use of telehealth. The ongoing health care reforms have significantly increased government funding as well as increased state legislation supporting expansion of telehealth services ,8. ConseDespite the great strides made in the field, critics argue that evidence of the impact of telehealth is not strong . The eviDiabetes Connect is a 12-month Web-based blood glucose monitoring program. The program is designed to help improve blood glucose control by promoting patient self-management in the area of regular self-monitoring (a recommended diabetes self-care behavior) and facilitating patient-care provider connection . The proA number of program evaluation frameworks are available, depending on the phase of program development and the feasibility of data collection. In this paper, we provide a brief summary of challenges in telehealth evaluation and commonly used frameworks relevant to the evaluation of DC to orient investigators new to telehealth project design and program evaluation. For a comprehensive review of existing telehealth evaluation frameworks, see Ekeland et al  and van To date, most telehealth research has been small-scale studies, and evaluation research has largely been formative and focused on process variables . AlthougThere have been calls for larger, long-term telehealth studies that would provide measures amenable to summative evaluation examining the intended effect of a program. Perhaps the most important outcomes are health care costs, and the potential benefits and gains in efficiency that telehealth might bring to health care delivery processes . SummatiThere are many issues that complicate the ability to conduct telehealth program evaluations, particularly robust summative evaluations. We summarize these issues into three interrelated challenges: (1) the diversity of telehealth programs, (2) traditional research designs like RCTs are often impractical for telehealth evaluation, and (3) telehealth programs are complex and dynamic, and evaluation frameworks do not capture all process and outcome metrics satisfactorily.The first challenge is that telehealth interventions are diverse and span a range of medical conditions, health care delivery problems, and types of intervention strategies, thereby making it difficult to specify the parameters of a standard telehealth program. This problem sometimes makes outcome metrics program specific and restricts the generalizability of findings. This is further complicated by the insufficient description of many telehealth interventions, which makes reproducibility and comparison of interventions very difficult . The CONA second challenge is that an RCT, the most widely accepted evaluation methodology, is often impractical for telehealth programs ,18. The The third challenge to telehealth evaluation is that health programs are more complex and dynamic than other types of interventions ,20. The In response to these challenges, many current frameworks conceptualize telehealth as a complex health intervention that undergoes several stages of development, testing, and deployment. In addition, these frameworks highlight the role of stakeholders  and contextual factors in determining success. Khoja et al propose a framework that spans a telehealth program “life cycle” consisting of four phases: (1) development, (2) implementation, (3) integration, and (4) sustained operation . Across The RE-AIM Evaluation Framework see  has beenRather than creating new methods for telehealth evaluation, many authors recommend greater standardization of existing methods and the use of multiple or mixed methods. Where possible, the standardization of study design, outcome measures, and analytic techniques would improve the ability to compare results between telehealth programs and conduct meta-analyses aimed at evaluating the field as a whole . HoweverIn sum, these challenges highlight the need to carefully consider a practical set of goals and strategies for conducting telehealth evaluations in “real-world” settings, given the limitations of available resources and opportunities to collect data.We describe some best practices based on successful evaluative efforts to date to address commonly encountered challenges in telehealth evaluation: time, impracticality of RCTs, and the heterogeneity of implementation and diversity of outcomes across the program pathway. In its simplest form, the life cycle of any project involves three main phases with several activities: planning, implementation, and impact assessment . EvaluatThe first step in planning is to define the goals and set the direction for the project using guidelines for SMART  goals and objectives . Goals mBased on the outcomes expected, processes and activities required for project implementation should be defined. This includes identification of the target population, identification of stakeholders and role definition, design of project protocol, budgeting, staff allocations, setting timelines, etc. One must keep in mind that performance indicators should be generated for each step in the process.After relevant outcome measures are agreed upon, a suitable evaluation design should be identified. Some goals, like engagement or adoption metrics, can be interpreted without any comparison data. However, for most other goals, including access and clinical outcomes, a comparison arm is required. Randomized control groups are considered to be the gold standard, but a variety of other methodologies have been used in telehealth evaluation, albeit with certain limitations. Paired analyses before and after the intervention, matched control analysis, as well as using existing population-level metrics for comparison have all been used with varying success . These oThis is usually the longest phase in a project and consists of assigning inputs and generating outputs for project execution.Project objectives and design will inform the decisions that need to be made about technology and operational processes, which are the main inputs needed to perform project activities. Inputs, by definition, are the resources needed to support the primary activities of the project, and they include funding, staff and their expertise, technology, and other materials needed for project implementation. During this time, careful consideration must be given to select the “right” technology to develop an effective telehealth intervention  and alsoOnce the technology has been chosen, deployment strategies can be designed. Program adoption and engagement can vary widely based on who offers the technology to patients, how it is set up, and the availability of customer service after initial deployment. Measures for each of these assumptions and requirements should be made part of the evaluation plan.Strategies relating to major stakeholder (patient and provider) engagement and adoption are critical elements of a telehealth intervention. Rogers describes an “innovation-decision” process involved in adopting or rejecting a new intervention  and defiThis phase includes measurement of both intermediate outcomes and overall effects (impact assessment) of the intervention. Intermediate outcomes are direct effects attributable to project outputs, like increased knowledge, increased adherence to recommended treatments, behavior change, early detection, and treatment of symptoms. Often they may be used as proxies to measure endpoints. In cases where objective measurements of effects may be difficult to assess quantitatively, common qualitative approaches, like patient interviews or focus groups, can be used to more fully measure the effects attributable to the intervention and are particularly useful for assessing subjective patient preferences.Impact assessment, on the other hand, estimates the net impact and overall effect of the intervention. They may be clinical or financial and are usually more meaningful to stakeholders. As a rule of thumb, the more rigorous the research methodology, the more accurate the effect estimate. However, in practice, the most rigorous design is not usually feasible. The goal should be to achieve a balance between managing real-world constraints and the next best possible design. Therefore, based on the setting and other limiting factors where the telehealth intervention is deployed, alternative study designs, which maximize efficiency, validity, and reproducibility while minimizing risk of bias should be considered .considering multi-site trials to address the problem of small sample sizes using validated questionnaires/tools to assess impact using unobtrusive data collection techniques or routine clinical data using both quantitative and qualitative approaches to completely and accurately estimate effects of intervention considering formative approaches to improve next iteration of the project to increase scalability potential and maintain ongoing successusing alternative research designs including quasi-experimental designs, matched control trials, staged interventional trials, crossover trials, etc In our DC program, we were interested in whether augmenting regular care with home monitoring of BG (thereby enabling patient self-management and providing clinicians with home BG data in between office visits) improved clinical outcomes as measured by change in HbA1c. This goal definition further helped us to specify program objectives and outcome variables. Our objectives were to determine the effect of the program on clinical outcomes . Being one of our first experiences with remote monitoring for diabetes, we were also interested in general usability, satisfaction, and determinants of participant engagement in the program.In DC, the adopted technologies integrated well with existing systems and data transfer was confirmed within 24 hours of set-up. Technical personnel were available during business hours to answer questions or help troubleshoot for ongoing problems. Tracking the frequency of troubleshooting calls was particularly important for us to identify some differences early in the study in the pattern of participants’ interactions with the technologies. We also found it very important for staff to standardize all practices, time log all problems, and track them until resolution. These processes were important for continuous system improvement.A trial of the initial version of the DC in a pilot phase before mass enrollment of participants helped us identify early any problem areas in deployment, adoption, and engagement that required further work.In this phase, some of the key evaluation questions in DC included:Was the target audience appropriately reached?Has the program been adopted by key stakeholders?Are key stakeholders engaged?Are engagement patterns different based on time, demographic group, or location?Are some participants responding differently to engagement techniques than others?Are ongoing troubleshooting issues reported and addressed promptly?DC was adopted by clinicians in four different practices within the Partners HealthCare network of hospitals who enrolled suitable patients in the program for 12 months. Help desk support was available  to address in a timely fashion any technical issues that might arise. Patient engagement was assessed by number of uploads and BG readings recorded by the DC. We also assessed provider and practice engagement by assessing the number of times providers logged on to the Web portal to view patients’ BG readings and the average number of provider logins to the Web portal by practice.We used focused groups as a measure with DC because they allowed us to capture contextual content on participants’ experiences, understandings, perspectives, or stories we might have otherwise missed in personal interviews. They facilitated lively conversations around usage, interactions with clinicians, and difficulties they encountered as they interacted with the system. We found focus groups particularly helpful to evaluate program perception, engagement, and adoption. From these groups, we discovered that most participants’ favorite part of the program was the ability to easily send BG readings to their providers and when appropriate, they appreciated the timely feedback. Additionally, participants reported that their provider’s interest in the program was the strongest predictor of whether or not they would use the program. These findings would have been nearly impossible to discover without the focus group and were very helpful in future program development.A critical assumption in impact assessment is the availability of high-quality data. We ensured that our endpoint data were collected appropriately and in a timely manner. Data points from DC include HbA1c, BG readings, frequency of data uploads, and frequency of logins to the portal. These data were vital for continued program improvement and outcome evaluation. For example, we found that the mean changes in HbA1c showed promising results: those who uploaded more BG readings had a further decline in their HbA1c. Additionally, the nature of DC made measuring engagement quantitatively through more than one metric simple, and we successfully measured the frequency of uploads by participants as well as logins by both participants and providers. We also used qualitative methods to assess our outcomes in participants recruited from four different sites. Through the focus groups, users and potential users of the program were interviewed to obtain feedback including comfort level using the system and how the program could be better tailored to their needs. Knowing what information was most important to collect during the program-planning phase made the impact assessment process easier to conduct, and we were able to detect meaningful changes in our outcome measures.We have provided a brief review of evaluation strategies, drawing on our experiences in creating and evaluating telehealth programs to describe a practical approach to conducting evaluations in real-world settings. We recommend that each telehealth program have an evaluation procedure in place at every stage of the program life cycle, from ideation to large-scale deployment and impact assessment, while considering the different characteristics and challenges unique to each telehealth program. Key to implementing this strategy is early planning involving all stakeholders to define overall goals and goals for each project phase. Once consensus is reached, an evaluation design should be selected that best fits the identified goals and the constraints of project resources. Early planning is essential to ensure valid measurement of goals across program phases and to evaluate overall impact.The telehealth evaluation strategy we described has two distinct advantages over classic, large-scale RCT studies. First, telehealth interventions are complex health interventions that can be best understood as “works in progress” tailored to fit the unique needs of each site and set of users. Telehealth evaluation across the program life cycle can provide useful data to guide program design and improve the reach, effectiveness, and adoption of new interventions. This evaluation strategy may accelerate the translation of research into practice to create programs that are well integrated into existing clinical workflows to improve efficiency and ultimately control health care costs. The results from formative/process evaluations are often key to developing telehealth programs with high levels of sustained user adoption and engagement. Patient engagement is an important objective in creating telehealth programs that focus on lifestyle change, improved patient self-management, and the prevention and control of chronic disease.Second, greater participation by stakeholders early in the program planning process may foster sustained involvement and commitment to telehealth programs during implementation and large-scale deployment. This could increase the number of telehealth programs that are successfully transitioned to larger programs integrated into standards of care practices.Some of the lessons we learned from DC and our other telehealth programs that have proven to be useful over the years are found in Start thinking about evaluation early and involve as many stakeholders as possible, including participants, funders, etc.Design your project based on proposed outcomes. Keep in mind the requirements to collect adequate data at the appropriate times and the need for objective metrics to evaluate each process in the program.Consider the limitations of the evaluation design. An RCT may not always be feasible, so explore other program design options, keeping in mind resource considerations and internal validity.Technology is essential, but not the focus of the program. Evaluate whether you are using the right technology based on ease and appropriateness of use, integration capabilities, and scalability. Remember that the final goal is to use something that your target population will adopt easily and engage with in the long term.Engagement in the program is key. Remember to include proven elements in your program design  as well as metrics to evaluate their effectiveness in your evaluation plan.To maximize the potential of a valid, reliable evaluation, choose program design elements that reduce the potential for bias, like using validated survey instruments, using both qualitative and quantitative assessment methodologies, etc.Efforts to evaluate telehealth programs create what Bashshur et al describe as a “quandary” . On one


Allied health professionals play a critical role in enhancing health outcomes in primary and tertiary settings. Issues affecting the recruitment and retention of allied health workers in rural and remote areas are multifactorial. Access to relevant and effective continuing professional development is argued to be a recruitment and retention strategy for health professionals in non-metropolitan areas, however trial of the effectiveness of professional development programs and identification of enablers and barriers to participation is needed. The Allied Health Rural and Remote Training and Support (AHRRTS) program aimed to provide an integrated program of education and professional support activities for allied health professionals working within Queensland Health in rural and remote locations. The aim of this study was to explore enablers and barriers to access to, and effective participation in, the AHRRTS program from various allied heath stakeholders’ perspectives.A qualitative descriptive study utilising semi-structured interviews with various allied heath stakeholders was undertaken. The interview questions focussed on a number of issues pertinent to AHRRTS program, with specific probing questions regarding barriers and enablers to participation in the AHRRTS program. The interviews were then transcribed verbatim and analysed using thematic analysis.Using purposive sampling, a total of 55 stakeholders were interviewed for this study. Time, organisational factors and travel were identified as common barriers and organisational factors, travel and presentation modes were identified as common enablers. Interestingly, some of these factors act as barriers and/or enablers highlighting that these are essentially two sides of the same coin. The findings suggest that while it is important to have policies and procedures for ongoing support of allied health professionals, it should be complemented by enabling strategies to address persistent barriers.The study suggests that while a program such as AHRRTS is accessible and facilitates participation in a number of ways, significant barriers to participation continue to persist at the coal face. Addressing these barriers will require a targeted, multifaceted approach. Lessons from this study provide unique insights into factors which influence the successful implementation and sustainability of recruitment and retention initiatives for rural and remote allied health workers. Health care in Australia faces a number of unique challenges. Armstrong et al.  summarisAllied health professionals play a critical role in enhancing health outcomes in primary and tertiary health settings, providing independent and multi-professional services in chronic disease management, rehabilitation, palliative care, mental health, health promotion and care planning . DespiteDespite concerted efforts, there are ongoing issues in the recruitment and retention of this diverse workforce. Some of the barriers to recruitment include social, professional and geographical isolation, lack of resources, high workload, and complexity of caseload and workplace stress for rural and remote clinicians –8 as welWhile issues with recruitment and retention in rural and remote areas are multifactorial, some factors are more amendable to change than others, for example, access to education, training and professional support within the organisation . Allied The Allied Health Rural and Remote Training and Support (AHRRTS) program coordinated by the Cunningham Centre, Division of Allied Health, Darling Downs Hospital and Health Service was designed to provide coordinated, capability based education, training and professional support to the rural and remote allied health workforce in Queensland Health. Eligibility for the AHRRTS program was dependent on the allied health professional’s primary work location. The program was available to allied health professionals in all categories of employment .One of the drivers for the development and implementation of the AHRRTS program was the poor uptake and variability in the access to existing programs for rural and remote allied health practitioners and the lack of a coordinated program of capability development and skill maintenance for the rural and remote allied health workforce. The intention of the AHRRTS initiative was to provide a holistic program of clinical education, training and professional support strategies specifically focused on the development and maintenance of capabilities required for rural and remote allied health practice.The AHRRTS program design incorporated existing as well as new initiatives to form an integrated framework for education and support for rural and remote allied health. Components of the AHRRTS program include distance-based  and face-to-face delivery of training based on individual practitioner and/or team requirements. AHRRTS offerings cover eight domains of capability training, namely service delivery, equity and diversity, professional skills, ethical practice, development and support, quality and safety, clinical management and clinical skills in line with the Allied Health Rural and Remote Allied Health Capability Framework . ProgramThe AHRRTS program was formally launched in Queensland Health in February 2010 and over the course of the initial two-year trial, over 170 out of 380 eligible allied health professionals participated in the AHRRTS program. A formal evaluation of the AHRRTS program was conducted by an independent organisation which investigated the impact and uptake of the AHRRTS program. An important component of the evaluation was the exploration of enablers and barriers to access to, and effective participation in, the AHRRTS program from various allied health stakeholders’ perspectives and this manuscript provides an overview of these findings.A qualitative descriptive research design  was usedEthical approval for the statewide evaluation was obtained from the Human Research and Ethics Committee of the Prince Charles Hospital, Queensland Health, and the Human Research Ethics Committee of the University of South Australia.Potential participants were key stakeholders within Queensland Health and included allied health professionals, their managers, supervisors and mentors. Participants were purposively identified through the AHRRTS program and were invited to participate in this research project. Purposive sampling was chosen in order to ensure diversity of participants, and that participants represented a range of allied health disciplines. Using this framework, a sample of 55 stakeholders including nine line managers/directors, four professional supervisors/mentors and 42 rural and remote allied health professionals who had been involved in the program for at least six-months participated in this research. The disciplines represented by the 42 AHRRTS program participants are displayed in Table Following informed consent, semi-structured interviews were conducted with participants at their nominated time and place. The semi-structured interviews were conducted over the phone by a member of the research team trained in a standardised semi-structured interview protocol. The interview questions focussed on a number of issues pertinent to AHRRTS program, with specific probing questions regarding barriers and enablers to participation in the AHRRTS program. Each interview took between 20–40 minutes and was recorded. The interviews were then transcribed verbatim by an independent transcribing service. The transcripts were de-identified in order to ensure participant confidentiality.Thematic analysis  was undeIn qualitative research, as part of ensuring rigour in its research methods, trustworthiness is an important concept to consider. Trustworthiness relates to a number of different constructs including credibility (the level of confidence in the truth of the research findings), transferability (the applicability of the findings to other contexts), dependability (the consistency and repeatability of results from the research) and the influence of the researcher on the result of the research .● adherence to a standardised data collection protocol including the semi-structured interview protocol used during the interview process● all interviews were audio taped and transcribed verbatim by an independent typist with subsequent validation by the interviewer● all interviews were monitored for consistency of data collection methods including either an independent observer regularly monitoring the process by sitting in on interviews or a second review of the audio recording to ensure adherence to the interview protocol during interviews● coding of the qualitative data was undertaken by more than one coder and consistency between coders was ensured (cross checking). If there were differences between the codes, these were discussed until consensus was reached● thick descriptions in the form of meaningful quotations to represent important themes and categories were included when reporting data analysisRecognising the importance of trustworthiness in qualitative research data collection and analysis, a number of key processes were put in place for this evaluation research. These processes have been widely recommended within the qualitative research literature as means of ensuring rigour –20. The Identified barriers related to factors which negatively influenced access to and effective participation in the AHRRTS program for allied health professionals. Identified enablers related to factors which positively influenced access to and effective participation in the AHRRTS program for allied health professionals. Within barriers, three key themes were identified. They were time, organisational factors and travel. Within the enablers, three key themes were identified. They were organisational factors, travel and presentation mode.Thematic analysis of the qualitative data indicated key themes pertinent to enablers and barriers to access to, and effective participation in, the AHRRTS program. “Time is a really big one for me especially too, before the Senior Physio was here and because we don’t have an admin staff or anything, being the sole Physio, you’ve got your clinical load as well as the administration load and I also outreach”Time was an important barrier commonly reported by allied health professionals, line managers and supervisors. Informants’ views were that limited time was a significant barrier in accessing and participating in the AHRRTS program. Many informants commented that there were competing priorities for their time  and often this resulted in them not being able to participate, or discerningly choosing what to participate in, within the AHRRTS program. An allied health professional commented that,“Again it’s just that clinical time. And for me, clinical work will always, depending on what it is, and the urgency, will always take precedence over going and attending something.”Another allied health professional commented on prioritising his/her time to match clinical load.“I’ve got a lot of competing interests and I have to really pick and choose what I do so when it comes to the AHRRTS program.”Line managers also seemed to echo this view that in many instances clinical issues and time spent with patients tend to override time for personal development.“Well, we don’t really go anywhere long enough - we avoid going anywhere long enough that would require backfill. So we don’t go to that much that it affects us. It does have an effect on our workplace afterwards, catching up.”Many informants also commented that existing staffing levels meant that many were not in a position to participate in the AHRRTS program due to their status as sole practitioners and lack of availability for backfill.“The problem with me is that working as a sole physio up here, being responsible for over 3500 people but only having 24 hours; it’s hard for me to take the time away from all my other responsibilities and sit in front of a video conference.”Allied health professionals also commented about being sole practitioners and its effect on their participation in the AHRRTS program. The issue of competing priorities for a sole practitioner was highlighted by a line manager,“I suppose time also affects my ability to participate in those support programs because being only .5 you need to get out to those towns and so sometimes you cannot participate in education sessions or professional support because you need to get to those town and see clients.”Difficulties associated with staffing levels were also highlighted as a barrier to accessing AHRRTS program in rural and remote areas. Having a small number of staff, who had to manage their time between treating patients and participating in professional development activities were seen as a constant challenge. An allied health professional commented that,“When you’re only working .6 it’s very hard to find time within your schedule. Like it takes an hour every week to do your supervision and then if you have a video conference it’s another 30 minutes or another 60 minutes. Plus there are a lot of other demands. I’ve got video conferences coming from all directions.”A line manager commented that,organisational barriers to access to and effective participation in the AHRRTS program. Organisational barriers reflected factors within the organisation which hindered effective participation in AHRRTS programs. A common finding was the difficulty associated with accessing appropriate videoconferencing facilities. One line manager commented that,“With the video conferences they, they’re generally really good, biggest issue is accessing a video conference machine.”The second theme identified from the interviews was “That’s the main thing that I struggle with across the board is just that being able to just go and do it and not be drilled about why you’re doing that because it’s our district team, but why are you doing it.”More commonly, though, many informants highlighted poor managerial support for participation in the AHRRTS program. Informants commented that they had to convince their managers that professional development was a worthwhile exercise and get them to “sign off” on these activities. One allied health professional commented that,“For line managers just so the willingness to let people go, particularly new graduates to give them time to because there’s a lot of training options available and when they start seeing the days add up they start questioning and it just needs the support from top down and that was probably one of my hurdles trying to get the staff off to some of the things.”A line manager also echoed similar views with particular reference to new graduates. They commented on the need to support these new allied health professionals and at times this was not forthcoming from his/her organisation.“Basically just budgets. All my managers are really supportive of any sort of PD, professional support that we can do but it basically comes down to the budget.”Administrative and budget difficulties were also highlighted as an important barrier within the organisational theme. One allied health professional commented that despite support from line managers, ultimately availability of funds dictated this.The third barrier identified to access to and effective participation in the AHRRTS program was travel. This theme related to issues associated with travelling for professional development which hindered participation for many allied health professionals.“I only just last week went to my first professional development workshop which was a two day workshop in Brisbane on Thursday/Friday…….would’ve like to have gone to more just day workshops and that, but really it is the travel and the distance that I haven't.”One allied health professional recounted his/her first experience of attending an AHRRTS program. They said that,“If there’s a workshop say in [metropolitan city], well in the current climate no one will be able to attend, they’ll have to do it on their own time. If it’s in “regional city”, I’ll probably be able to send one person. If it’s held locally I can send a whole team because it’s only the day’s work that’s affected, whereas to go to [regional city] you lose two days and you’ve got accommodation and travel and transport and those sorts of things.”This view was also supported by a line manager who commented on the increasing costs that were associated with travelling for professional development activities and how they had to prioritise participation in these activities.organisational enablers, or factors within an organisation which may assist in the participation and uptake of activities supported by AHRRTS program. Theme two related to travel, or the enabling factors associated with travelling. Theme three related to mode of presentation which enabled access to and participation in the AHRRTS program activities.Informants discussed a number of enabling factors which could assist in promoting access to and effective participation in the AHRRTS program. Within enablers, three key themes were identified. Theme one related to “I think if your line manager and our Director of Allied Health in our district really value or can see the benefit of AHRRTS so it’s well supported in our district for people to have that protected time to link into the videoconferences too. …….if you didn’t have supportive line management then it might be a challenge for some people because they’re not given that time off line but our team certainly is.”Within organisational enablers, a theme that was most commonly reported by many informants was the importance of support from their line managers. Many commented that if the line manager was supportive of participation in the AHRRTS program, this was likely to occur. Alternatively, if this was not the case, participation was likely to be hindered. One line manager commented that,“So I have an amazing line manager and our director is awesome as well. So between the two of them, if I feel the training is valuable, I get to go.”This was also reflected by allied health professionals who valued the support provided by their line managers and team leaders who supported them to participate in conferences and training workshops.“The fact that it (AHRRTS program) is internal, I suppose makes it a little bit more, you know you’ve got that support to go yes, you should do this because it is endorsed by Queensland Health. I think if you were an external program, it might influence things a bit differently, might change things.”Support from the state department of health was also identified as an important organisational enabler in participating in AHRRTS programs. Participants commented that given that the AHRRTS program was endorsed by the state health department and was intrinsic to this state, this facilitated their participation in training activities.“I think financially, because the district didn’t have a problem with me going either because it was covered financially, so it wasn’t coming out of the district budget. So, I was allowed to go.”Many participants commented that funding support provided by the AHRRTS program meant there was little financial burden for local health services as part of allied health professionals participating in the AHRRTS program. An allied health professional commented that,“Having another organisation or fund an organisation to provide these services, whether it be whole of government or somewhere, it takes off that day to day worry about coming in under budget and how do you get everything done, so that was a big, that was great, somebody’s taking on the or being the champion for the allied health team.”Similar views were also echoed by line managers who highlighted that having another organisation contribute to the professional development of their staff facilitated its uptake.“I recently applied for some funding to be able to go out and spend a couple of days with ***** in [rural location] and knowing that someone was willing to pay for those costs was really great, unfortunately I had to cancel that visit due to some things at ***** end. But it was good to know that the programme would support that.”Supervisors were also positive for the funding support provided by the AHRRTS program to promote participation in supervision and mentoring activities. A supervisor, whose supervisee was geographically distant from her, commented about these funding opportunities.“I think it was a great initiative. I’m a nurse ………so when it came to the professional development side in my allied health team I didn’t have a lot of knowledge in that area and along came the AHRRTS program and with the leader of the allied health team for the district, solved a lot of my worries and was able to help facilitate that.”Many participants also commented positively about the AHRRTS program driving professional development for rural and remote allied health practitioners and its benefits in promoting participation and uptake. One of the line managers commented that, given his/her non-allied health professional background, having AHRRTS take the ownership for professional development of his/her allied health staff was a significant enabler. He comments,“At other rural and remote places I’ve worked we have initiated our own education because our needs are so specific but that took a lot of time and then we had to write up the proceedings and it was often done in our own time. So this just makes things a lot more efficient which means that we can do client services.”Another line manager also commented on the efficiencies involved in having AHRRTS programs being centrally coordinated and delivered. The time saved can then be put to use in other areas more efficiently (such as client services). They commented that,“The best training that I find is to really get away from the workplace to actually do it. That’s probably the biggest factor. Because if you’re not there at the work, if there’s a crisis that happens someone else from the team has to deal with it and you don’t have the interfering phone calls like a client might be phoning up saying ‘can you do this for me’ or helping them in some area.”Theme two within the enablers was travel. allied health professionals commented that being able to travel away from their workplace meant there was dedicated, undisturbed time for professional development and opportunities for networking. This was an important enabler as allied health professionals saw this as an opportunity to learn, reflect and bond with fellow team members.“so it was really nice to be able to travel as a team and we got to know each other quite well and we all bonded as a team quite well from that Rural Skills Conference because we had to travel together, yes.”Another allied health professional commented on the bonding opportunities travel away from work provided. They commented that“I think that the delivery by video conference was exceptionally handy. I’ve spent so much time away from my base at face-to-face training and professional development, it’s good to be able to just duck down to the VC machine for a couple of hours and still be able to do close to a full day in the office and not have to take that travel time.”Theme three within the enablers was the mode of presentation. Having access to videoconferencing was an important enabler, which overcame numerous barriers . Many participants reflected on the opportunities presented by videoconferencing and the flexibility it afforded them.“The use of videoconferencing and teleconferencing is just, it’s vital and it really underpins a lot of what AHRRTS does so I think that’s been great and a lot of the programs under AHRRTS are very flexible so whether it be mentoring or videoconference series and those sorts of things have been very flexible that where people can link into them in a variety of ways so that’s been brilliant.”Line managers too agreed with such statements as having access to videoconferencing provided opportunities which otherwise may not be accessible and also meeting the requirements of their allied health staff.An accessible, confident and capable rural and remote allied health workforce is necessary to meet the current key challenges of health care provision in Australia. Previous research has highlighted the need for organisational initiatives to ameliorate professional isolation for rural and remote health providers and increase coordination of training and development to support best practice –8. TheseThis study reveals important barriers and enablers to successful engagement in a rural and remote specific professional development program tailored to support the rural and remote allied health workforce in Queensland, Australia. One factor for successfully engaging in AHRRTS was organisational support including the general perception of support from the broader public service organisation, as well as work-unit specific support from local line managers, and AHRRTS program specific support including coordination, funding, and accessible training offerings. These findings are in agreement with previous evidence that broad organisational initiatives such as professional development allowance and leave; policies and guidelines including performance appraisal and development processes are important aspects of employment contracts .The AHRRTS program’s focus on continuing professional development tailored to the learning requirements of individual health practitioners across the span of their careers provided a structured pathway to engaging in professional development for informants. Informants indicated that AHRRTS program coordination or “ownership” for supporting their professional development was a key enabler to their participation. This highlights the importance of a centralised agency coordinating and delivering such programs. These in addition to key funding provisions within the AHRRTS program, including for face-to-face supervision meetings and some travel bursaries for rural skills training, were seen as enablers.It is interesting to note the emphasis placed by informants on the support from local line managers as a key enabler and this is consistent with previous research . Good reThe final enabler that emerged was presentation mode and it was clear from the evaluation that videoconferencing and distance based forms of delivery are critical for the rural and remote workforce to allow effective access to professional development. With the increasing role of technology and distance based training, it is not surprising that such modes of presentations were valued by the informants.However, it does raise an interesting paradox. While travelling away  was considered by some of the informants as an enabler, use of videoconferencing and distance based forms of delivery  were considered by others as an enabler. This dichotomy highlights the need for a flexible approach of such programs, which caters for a wide range of learning styles – as well as other factors that prohibit travel, for example, family commitments - and the perils of a “one-size fits all” approach.Time was the most often cited barrier to participation, though the underlying analysis of this construct showed that participants had diverse meanings attributed to “not having enough time” or “needing more time”. Both internal and external pressures impacted on participants’ “lack of time”. Internal sources included pressure on self to justify time spent on professional development  and lack of knowledge regarding the “right” balance of direct client care and professional development. A theme expressed by many informants was problems managing competing clinical versus non clinical priorities.Prioritisation of time was clearly an issue with multiple tasks such as direct client contact, outreach travel and administration duties conflicting with allowing time for professional development and supervision. These findings are supported by previous research by Dawson et al.  and HyrkOrganisational issues continue to pose significant challenges for informants and there is research evidence which indicates the impact of organisational culture on support activities such as clinical supervision . It is nThis research reported on the perspectives of various stakeholders, who represented a range of allied health and other health disciplines, as a whole. While this could be considered a strength (rich diversity among informants), it may also be viewed as a weakness, as it did not provide specific information about individual allied heath disciplines. Some of the interviews were conducted by project officers of the AHRRTS program and therefore this may have inhibited informants from fully disclosing their perspectives of the AHRRTS program. This is not a significant limitation though as the data collected by the project officers of the AHRRTS program did not differ from those collected by independent researchers.There is increasing international recognition that participation in continuing development initiatives such as the AHRRTS program are important to enhance safe and evidence based practice , particuThe findings from this research adds to the current body of evidence on factors involved in the successful implementation of recruitment and retention initiatives for rural and remote allied health. Organisational support and “not having enough time” with all its associated meanings were commonly reported by AHRRTS program stakeholders as key enablers and barriers respectively.Recognition that time will be a critical barrier requiring targeted enabling strategies. Facilitation of time management and prioritisation through effective engagement with allied health practitioners, line managers, professional supervisors, mentors and peer groups is imperative. Time management and prioritisation training is important as is education around the importance of continuing professional development, particularly with senior clinicians who may not have had prior access to support.In order to remedy organisation support being both an enabler and barrier; our recommendation is twofold: First, engaging with line managers and directors is critical. In particular it is important to ensure that line managers are aware of the program, “on board”, and that initiatives are tailored to line manager priorities in order to facilitate their support of staff participation. Secondly, organisational support can be clearly communicated through existing policies that support participation in continuing professional development including allowances, paid professional development leave . In addiFinally, to continue to address the persistent barrier associated with travel, and in accordance with the enabler of presentation mode, it is recommended to deliver training via videoconferencing and continue to focus on enhancing the impact of distance based training, including, incorporating strategies to enhance confidence and competence with technology use  as this Based on these findings, our recommendations for continued development of rural and remote health workforce training and support programs are:


EF is an evidence-based group exercise program for seniors.To identify facilitators and barriers among early adopters of EnhanceThis qualitative study used semi-structured phone interviews with 15 staff members representing 14 Y-affiliated sites. Interviews were digitally recorded, transcribed, and analyzed using qualitative content analysis informed by the RE-AIM framework.Staff were, on average, 48.7 years old (SD 13.5) and had been involved with EF for 5.2 years (SD 3.1). Key themes related to facilitating adoption of EF were: match with the Y mission, support from different organizational levels, match between the target population need and EF, initial and on-going financial support, presence of champions, novelty of EF, an invitation to partner with a community-based organization to offer EF, and program-specific characteristics of EF. Key themes related to barriers interfering with EF adoption included competing organizational programs and space limitations, limited resources and expertise, and costs of offering the program.Our findings identify the types of organizational support needed for adoption of evidence-based health promotion programs like EF. Recommendations for practice, research, and policy based on the findings, including assessing organizational readiness, researching late adopters, and developing revenue streams, may help facilitate program adoption. Packaging and sharing these practical recommendations could help community-based agencies and nationally networked organizations facilitate adoption of EF and other evidence-based programs. Since the development of evidence-based medicine (EBM) over two decades ago , the Cen®Fitness (EF) is an evidence-based group exercise program for frail and active older adults  licenses and disseminates EF to multipurpose social service agencies, faith-based organizations, retirement communities, and recreational organizations. With more than 10,000 community locations, Young Men’s Christian Association (Y) is a leading non-profit committed to improving the nation’s health and well-being by offering programs that nurture the mind, body, and spirit. From 2005 to 2012, 116 Y-affiliated community sites adopted EF. These included both classes on-site at Y brick-and-mortar buildings, and classes licensed by Ys but offered in community settings such as churches or retirement communities. These sites represent a first stage in the adoption of EF by a nationally networked organization; as such, their experience is likely to inform efforts to scale-up adoption of EF and other evidence-based programs. In this paper, we refer to these sites as early adopters  staff on this list without complete contact information, and (2) staff during the pre-enrollment screening call were determined that they did not have experience with EF. The list included 94 names of EF program management staff; of which 75 has complete contact information. Recruiting letters were sent to those 75 staff. Additionally, a Y-USA staff member (AHH) sent emails to the staff employed by Ys inviting them to participate in our study. Two reminder recruiting postcards were sent to staff who had not responded to the initial recruiting letter; reminders were sent at 2 and 4 weeks after the initial mailing. Interested staff called a study phone line or sent an email to the study email account. Twenty-five out of 75 (33%) responded to the recruiting letter, and 8 were determined ineligible for the study. Two staff were placed on a wait list. The study recruiting coordinator (LF) tracked and responded to all phone and email messages, determined eligibility, and scheduled interviews. At the beginning of each phone interview, verbal informed consent was obtained. Interviews were conducted by two members of the research team (BB and MPP). Each study participant received a gift card for $20. Interviews ranged from 30 to 71 min (average duration was 47 min) and were digitally recorded. In 2008, Gill et al.  double-coded a subset of five transcripts until agreement reached 85%. Remaining transcripts were divided between both team members (BB and GK) and coded independently. After the initial coding, we used a deductive approach  and had been involved with EF for 5.2 years (SD 3.1). Three staff (20%) had some college education, seven (47%) had a college degree, and five (33%) had more than a college degree. Ten staff members (67%) were employed by a Y while the remaining five staff (33%) were employed by other organizations . Titles and levels of responsibility varied: five were Health and Wellness staff, four had roles specific to older adults, six were at the program coordinator/instructor level, and eight were at the program manager/director level or above.Staff interviewed represented 10 different YMCA associations in six states. Fourteen out of 15 staff worked in locations where classes were conducted; one staff worked in an administrative office. Ten sites currently offered EF classes; the remaining five had previously offered EF but did not have active classes at the time of the interview.In the remainder of this paper, we summarize our findings regarding facilitators for adoption of EF and barriers that interfered with adoption of EF, with representative quotes presented in Tables Key facilitators identified by staff, which contributed to EF adoption, were match with the Y mission, support from different organizational levels, match between the target population need and EF, initial and on-going financial support, presence of champions, novelty of EF, an invitation to partner with a community-based organization to offer EF, and program-specific characteristics of EF, such as being evidence-based and having a recognizable name.The Y mission is to put Christian principles into practice through programs that build a healthy spirit, mind, and body for all . Staff eSupport from different organizational levels of the Y also served to facilitate adoption. For example, staff were consulted when EF marketing materials were developed. This helped the staff feel like they had a say in how and to whom the program was being promoted. Staff also felt that adoption of EF was facilitated with support from junior management, Wellness Directors, Executive Directors, and CEOs.®Fitness was more easily adopted when the staff perceived there was a good fit between the needs of the target population (older adults) and the program itself (EF). Older adults were considered to be in an age bracket that had previously been underserved by the Y. A perceived gap in programing led staff to look for exercise programs like EF because it was a valuable addition for the senior community. Because EF exercises can be adapted to suit participant abilities, the staff felt it was a very inclusive program in which older adults at varying levels of function could participate. In addition, some of the EF classes were offered off-site in settings that catered to older adults and with which the Y branch had been partnering. One such setting was a retirement community. One staff commented: “the residents [in assisted living] were good candidates because they were at a point where they had not been exercising. We could start at the beginning and see where their progress was which would not have been if we brought it into our Y and tried to offer it to our regular seniors”.EnhanceInitial financial support was an important factor in the adoption of EF. Several staff members reported receiving funding through grants at the time of EF adoption to cover EF training for their instructors, weights and other equipment, licensing fees, and/or instructor salaries. These funds also allowed Ys to offer the program at no charge to participants in some sites.Champions for both EF and older adult programing facilitated adoption of EF. When asked to identify champions for EF, staff identified both paid staff and volunteers who fully embraced EF, and passionately and frequently promoted the program both within and outside the Y. Staff champions advocated for and secured resources to launch the EF program. Champions described themselves as “go-getters,” extolled the virtues of EF, and communicated often with managers, staff, and site members about the benefits of EF. One staff champion expressed adopting the “we will make it work” attitude when it came to rolling out EF for the first time. Volunteer champions welcomed new comers, brought guests to class, and took on other tasks such as setting up fitness check areas. “[Champions] just do it on their own. Nobody asked them to do that (in reference to setting up fitness check areas). They just love the community that EF provides and obviously the physical benefits. They want to capture anybody that comes into class and really helps them feel that same way.”Staff were looking for new and exciting programs to offer older adults. They viewed adopting EF as an opportunity to keep their programing fresh, and valued being an early adopter when the program was just getting started: “Back then [when EF was adopted] EF was kind of an experiment. There were only a few sites in the country offering it, I believe, and so I thought that it would be nice to be part of that group.”The initial adoption of EF by Y-affiliated sites was often triggered by an invitation from an established community partner, providing motivation to adopt EF. The Y has close links with community partners and values their suggestions. Being part of an active community-based network that also provides services to older adults positions the Y to be on the cutting-edge of learning when new programs are launched. Established relationships with state departments of health and affiliations with academic and philanthropic organizations were often key to adoption. These relationships afforded access to financial resources that provided initial start-up and on-going funding for EF. One staff member noted: “the opportunity to work with and partner with an outside agency to help address another portion of our population definitely interested me.” There were also examples of invitations to partner with new organizations, such as assisted living communities that had never had a program like EF. An invitation from a new partner “opened doors.”There were program-specific facilitators that helped with adoption. Staff described EF as being unlike other programs they had offered. Most frequently mentioned was EF being evidence-based, branded, and having name recognition. Staff reported that EF was, “… an easy sale as it was proven to improve things,” and “it has solid backing.”A number of factors that interfered with the adoption of EF were noted such as competing senior programs and space limitations, limited staff resources, and costs of the program.per se but we’re not going to take away our already very strong programs and try something new.” Off-site locations like retirement communities also had issues with finding adequate space.Staff noted one of the barriers to offering EF was that the Y Association was already offering a number of other programs for active older adults, and the health and wellness staff did not see the need or benefit to offering another one. Additionally, in some Y sites staff reported there was a “space crunch” with rooms that would be appropriate for offering EF being allocated to other programs such as camps for children. One staff member said: “we no longer had the luxury of having two senior programs running because of space limitations.” One staff that was trained to offer EF but never did said: “we were having a time and space crunch. It wasn’t anything wrong with the program Another factor that interfered with the adoption of EF was the lack of staff resources, both in terms of time availability and the need to find instructors with appropriate skills for working with older adults. Staff noted that costs of the program were a potential barrier to adoption: rent, materials, and instructor costs, on the one hand, and affordability for participants, on the other, were taken into account before deciding to adopt EF.In this study, we examined the facilitators and barriers to the adoption on EF in early adopter Y-affiliated sites. The Health Promotion Research Center (HPRC) dissemination framework provides a context for interpreting the findings from this study and informs the translation of our findings to other community-delivered, evidence-based programs . The HPRThe HPRC dissemination framework Figure  identifiStudy participants identified several facilitators and barriers related to the characteristics of Y-affiliated sites, the user organizations in this study. Ys have made major strides in recent years to become leaders in community-based health promotion programs. It was readily apparent that there was a strong fit between EF and the Y mission to offer older adults an environment that promotes physical and emotional health, and the availability of resources to ensure adequate programing. This rich environment also included champions for both EF and older adult programs. Programs with this type of fit have an enhanced ability to sustain themselves. On the other hand, our findings suggest a need for improved evaluation of organizational readiness prior to the adoption of any evidence-based program. Structured and rigorous determination of organizational readiness would help organizations avoid known barriers to successful implementation, such as competing programs, and limited space and resources. Organizational readiness for change is an important precursor to the successful implementation of health promotion programs .Our study also identified facilitators related to the modifiable context in which user organizations operate. Staff noted the significant role grant funding played in the initial adoption of the program, as well as the importance of building partnerships at the local and state level.®, to engage Ys in organizational and community change focused on supporting health seekers, those who struggle to adopt and maintain a healthy lifestyle. Nearly two-thirds of Y Associations committed to Activate America and built their capacity to better align their programs, practices, and policies with the needs of health seekers. This was the Y climate when EF was being brought into the organization by early adopters. The organization was primed for embracing evidence-based health promotion programs and working with a community of adults with chronic conditions. At this time, chronic disease prevention programs were introduced as well, including LIVESTRONG at the YMCA, a cancer survivorship program, and the YMCA’s Diabetes Prevention Program (DPP).Finally, we would like to highlight the role of the disseminating organization, Y-USA, the national office of the Y. Between 2007 and 2011, Y-USA significantly increased its national effort, Activate AmericaAckermann and colleagues tested offering DPP at Y sites , 28–30. There were several limitations in this study. First, we used a convenience sample. Convenience samples can introduce response bias, with those having positive experiences being more likely to participate than those with less favorable experience. However, staff who volunteered to participate in this study shared a range of experiences, both positive and negative, related to the adoption of EF. Second, our sample size of 15 may have limited our ability to reach conceptual saturation with regard to the research questions. After completing 15 interviews, the research team determined that additional interviews were unlikely to return substantively new information, and that we had reached conceptual saturation. Third, inherent in qualitative methodologies is the potential issue of transferability. To minimize issues with transferability and assure our findings would have applicability in other contexts, a partner from the Y (AHH) was actively involved in all phases of our study and another Y staff member served on our Project Advisory Group. Fourth, some of the staff had started overseeing EF up to 8 years prior to the phone interviews, resulting in potential recall bias with respect to the initial decisions and process of adopting EF. Last, Y staff who were the target of our interviews were in positions in which they had responsibilities for program management and also could adopt new initiatives like EF. When further exploring the concept of adoption, it would be valuable to also include senior leadership who are likely to be key decision makers and have an influence in whether a new program would be considered, paid for and/or adopted.Based on the findings in this study, we propose practice, research, and policy recommendations for the adoption of evidence-based health promotion programs by community organizations. They are summarized in Table Our practice recommendations focus on organizational readiness for adopting new programs. Assessing organizational readiness, formally or informally, identifying gaps in readiness, and addressing any gaps may improve adoption . OrganizThe practice recommendations outlined above are based on the experience of early adopters. However, the adoption experience of majority adopters and late adopters/laggards may face different facilitators and barriers . Future Finally, broad policy support for evidence-based programs may create an environment more primed for successful adoption. Policy support may include establishing a revenue stream to offset program costs, an approach that has been seen in other programs , 31. PolWhile these recommendations are based on our study of the experience of early adopters of EF at Y-affiliated sites, they are likely applicable to other evidence-based programs conducted in community settings. Facilitators and barriers to adoption apply across programs and settings . FurtherThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.This paper is included in the Research Topic, “Evidence-Based Programming for Older Adults.” This Research Topic received partial funding from multiple government and private organizations/agencies; however, the views, findings, and conclusions in these articles are those of the authors and do not necessarily represent the official position of these organizations/agencies. All papers published in the Research Topic received peer review from members of the Frontiers in Public Health  panel of Review Editors. Because this Research Topic represents work closely associated with a nationwide evidence-based movement in the US, many of the authors and/or Review Editors may have worked together previously in some fashion. Review Editors were purposively selected based on their expertise with evaluation and/or evidence-based programming for older adults. Review Editors were independent of named authors on any given article published in this volume.


Algae have been used for food and nutraceuticals for thousands of years, and the large-scale cultivation of algae, or algaculture, has existed for over half a century. More recently algae have been identified and developed as renewable fuel sources, and the cultivation of algal biomass for various products is transitioning to commercial-scale systems. It is crucial during this period that institutional frameworks  support and promote development and commercialization and anticipate and stimulate the evolution of the algal biomass industry as a source of renewable fuels, high value protein and carbohydrates and low-cost drugs. Large-scale cultivation of algae merges the fundamental aspects of traditional agricultural farming and aquaculture. Despite this overlap, algaculture has not yet been afforded a position within agriculture or the benefits associated with it. Various federal and state agricultural support and assistance programs are currently appropriated for crops, but their extension to algal biomass is uncertain. These programs are essential for nascent industries to encourage investment, build infrastructure, disseminate technical experience and information, and create markets. This review describes the potential agricultural policies and programs that could support algal biomass cultivation, and the barriers to the expansion of these programs to algae. Plants evolved from ancient algae ancestors, and the photosynthetic machinery in both plants and algae originally came from the same source: cyanobacteria , which can be converted to fatty acid methyl esters (FAMEs), the main components of biodiesel   was established in the 2008 farm bill  can participate, is the crop insurance program. The original crop insurance program began in 1938 and only covered major crops  program, in which farmers pay a subsidized premium for insurance delivered by private companies. While program crops are eligible for revenue-based loss insurance, specialty crops typically only participate in physical crop-loss insurance. If a crop is ineligible for the program, then it can still be insured through the Non-insured Crop Disasters Assistance program, established in the 1996 farm bill and run by the Farm Service Agency (FSA), which functions similarly to FCI , introduced in the 1996 farm bill, provides technical and financial assistance to farmers to increase the environmental quality of their farmland. EQIP funds are distributed by states in competitive programs that focus either on innovation of novel conservation practices or water enhancement, including enhancing water quality and conservation. EQIP also works in partnership with farms to aid in farm design that promotes environmental quality and resource conservation.The Conservation Stewardship Program (CSP) awards funds to farmers that have adopted uncompensated practices across their entire operation for overall conservation. To be eligible for CSP funds, farmers must be sustaining conservation of a certain resource and must demonstrate improvement and maintenance of conservation practices. Farmers can receive both EQIP support and CSP rewards. The final environmental program, the Agricultural Management Assistance (AMA) Program was established in the Agricultural Risk Protection Act of 2000 to address the fact that crop insurance is heavily concentrated among program crops in only a few states. The AMA provides assistance for conservation practices in a select 16 states.2 from corn ethanol fermentation to cultivate algal biomass for various end products. Coupling algae cultivation with waste outputs from other industrial processes provides cost-effective and sustainable solutions to cultivation barriers.The algae industry, which has most recently been associated with renewable energy production with the added constraints of reducing greenhouse gas emissions and being cost-competitive with fossil fuels, has already made substantial technological advances in freshwater conservation and nutrient recycling for commercial-scale production. In order to be categorized as advanced biofuel, the overall process of algal fuel production must represent a 50 % decrease in GHG emission compared to fossil fuels  identified ~90,000 sites in the U.S. that would be suitable for algaculture, comprising ~5.5 % of the contiguous U.S. land mass and consisting predominantly of shrub/scrub landscape. These sites exclude any cropland, urban land, protected lands, wetlands, wilderness, or significantly sloping landscapes  support and promote development, and commercialization. While the U.S. government has supported the R&D stage of algaculture for biofuels over the last few decades, it is imperative that policies anticipate and stimulate the evolution of the industry to the next level.Large-scale cultivation of algae merges the fundamental aspects of traditional agriculture and aquaculture. Despite this overlap, algaculture has not yet been afforded an official position within agriculture or the benefits associated with it. Recognition of algaculture as part of agriculture under the USDA at national, regional, and local levels will expand agricultural support and assistance programs to algae cultivation, thus encouraging progression of the industry. The U.S. is currently the world leader in algal biomass technology and hosts a disproportionate number of companies devoted to the industry Fig. . Continu