Depression is one of the leading causes of illness and disability in young people, with approximately 20% having experienced a depressive episode by the age of 18 years. Behavioral activation (BA), a National Institute for Health and Care Excellence–recommended treatment for adults with depression, has shown preliminary support for its use with young people. BA may have the potential to be adapted and delivered in a computerized format to address the barriers often associated with young people accessing support. Despite the benefits of adopting computerized therapy delivery, the limited effectiveness of some programs has been attributed to a failure to tailor interventions to patients and practices. Therefore, while developing new treatments, it is important that target users be involved in the intervention design.This qualitative study aims to explore the views and preferences of young people and health care professionals regarding the development of a new computerized BA therapy for young people with low mood or depression, to ensure that the therapy was suitable for the target user.Semistructured focus groups and individual interviews were conducted with young people (those with experience in accessing support and those without) and health care professionals regarding the development of a new computerized BA therapy for young people with low mood or depression. The data were analyzed using thematic analysis.A total of 27 individuals, comprising both health care professionals and young people, participated in this study. Vital information pertaining to the important components of a new therapy, including its presentation, delivery, and content, was collected.Variations in perspectives highlighted the need to adopt a systemic approach in therapy development by considering the opinions of young people with and without experience in accessing mental health support and health care professionals. Approximately 20% of young people experience at least one depressive episode by the age of 18 years ,4, negatDespite the evident benefits of adopting a computerized approach to therapy delivery, including increasing therapy accessibility, availability , and anoWhen designing a computerized BA program, those deemed the best to inform the development include not only those who may use such a program but also those involved in treatment delivery. Research suggests that one important process that may enhance treatment effectiveness is the incorporation of young people’s views in treatment design to ensure that the developmental needs of the users are considered . HoweverIn research that has incorporated the views of young people, differences have been evident between their perceptions and those of health care providers. When reviewing research related to the experiences of care systems, health care professionals’ priorities contrasted with the key points highlighted by young people . FurtherThis qualitative study explores the views and preferences of young people and health care professionals regarding the development of a new computerized BA therapy for young people with low mood or depression. The information gathered about the treatment components that such a therapy should include and how it should be presented and delivered inform the development of the new treatment.This research adopted an exploratory, qualitative design using a critical realist approach  and was In total, 3 groups of individuals participated: young people from a community sample, young people from a service user sample, and health care professionals with experience of working with young people with low mood or depression. Participants were identified using a combination of purposive and snowball sampling approaches.As many young people experiencing a depressive disorder do not seek help , a commuAll prospective participants received information about the study, with those expressing interest providing written assent alongside consent from a parent or guardian.A sample of health care professionals with experience of working with young people with low mood or depression from 2 CAMHS was invited to a focus group or an individual interview if more convenient. Anyone expressing interest provided written consent for participation.All focus groups and interviews were conducted by the lead researcher within the schools and CAMHS sites where recruitment occurred. Before all interviews and focus groups, attendees completed a short questionnaire—young people were asked to supply basic demographic information and health care professionals provided information about their clinical practice.The interviews and focus groups closely followed 1 of 2 interview schedules . Definitions of terms were provided as part of this activity to aid in participants’ understanding. This list was generated from a review of the treatment components often included in BA  and the Data were analyzed using thematic analysis, which was selected to provide rich and detailed insights about a given topic . The anaIn total, 27 individuals comprising young people from a community sample, young people from a service user sample, and health care professionals attended interviews and focus groups with the lead researcher. Participant demographic information is presented in In total, 3 main themes were identified: supporting autonomy, addressing treatment concerns, and adolescent-appropriate treatment.Most young people in the community sample were unsure of how to access support if required, with only 2 having ever received any support—one for bullying support and another for dealing with their parents’ divorce. Most assumed that, if they needed any support, their parents would access it on their behalf. None of the users had ever accessed any web-based support, with the majority unaware of its existence, thus highlighting the need for increased awareness of its availability:I think that’s why a lot of kids nowadays are feeling more pressured into committing suicide and things like that because it’s like “oh I can’t get any help” because they don’t know what to do.Male, community, aged 13 yearsYoung people wanted the opportunity for autonomy if using the new program, highlighting the need for flexibility and wanting to make treatment decisions. Therefore, they wanted much of the program to be optional, with users choosing what to view and when. Examples included deciding whether to disclose information about experiences of low mood or depression, selecting which activities to participate in, and deciding whether to complete additional follow-up sessions if available. They also wanted to decide how long they spent on sessions and the frequency of logging on. However, if flexibility with session length was not possible, approximately 30 minutes per session was regarded as reasonable.Wanting to be independent and able to make treatment-related decisions, many young people did not want parents to be involved, reporting that such involvement could be detrimental to improving mood. Particular concerns included feeling that parents would not understand young person–specific issues:I’m not being disrespectful to them, but they’ll think they know everything about kids and stuff, but they really like, they don’t.Male, community, aged 13 yearsFriends were suggested as an alternative support to parents, but shortcomings of this approach were identified, including concerns that this could place great pressure on friends who might worry too much, who may not take things seriously, or who could be patronizing. Therefore, if any risk was presumed, young people felt that parents needed to be informed. Consequently, they contended that the new program should include some information for parents but that this should be both minimal and optional, so young people could retain autonomy.Concerns were raised about how young people would be treated if they accessed support. In particular, they worried that information disclosed would be reported back to parents who may then treat their child differently and place restrictions on them that could worsen their low mood:...your mum and dad would be like “right I’m not letting you out the house, I’m not letting you do this, I’m not letting you do that” because that kind of puts you down more.Male, community, aged 13 yearsSuch concerns were not limited to parents, with some worried about what would happen if they were to report low mood to health care professionals, particularly general practitioners. For most participants, the prospect of computerized therapy delivery allayed some of these concerns. However, for one individual, even accessing therapy in a computerized format could lead to others finding out about their low mood and treating them differently. Specifically, this individual was worried that if they felt particularly low and accessed computerized therapy, people might arrive at their house to tell them “don’t kill yourself.”Young people wanted assurance that, if accessing computerized therapy, confidentiality would be maintained. They suggested having good security with individual usernames and passwords required for access, incorporating automatic log-offs after short periods of inactivity, and ensuring no personal information requests were made. They also wanted the program’s name to be discrete and not indicative of its purpose.A consensus emerged that young people would only disclose information about how they were feeling to another person if trust was both established and retained. One young person had concerns about trust if therapy was delivered in a computerized format, stating that “anyone can set up a website.” This was different for others, with one individual highlighting that if therapy was set up by a reputable source, trust could be gained. Second, the anonymity of a computerized approach meant that establishing trust was not an issue.The community sample felt that the adolescent period was where computerized therapy could be of most importance, particularly for those already experiencing low mood or depression. They outlined specific stressors, including the transition to secondary school, changes to curriculum and workload, and working toward and completing the General Certificate of Secondary Education.Overall, they felt that 2 or 3 different presentations were needed to suit the target age range, with developmental level guiding the program presentation and chronological age guiding the content :A low level sixteen-year-old might have the same ability as a high level twelve-year-old.Female, community, aged 14 yearschildish, and videos, if these were nonpatronizing, modern, showed depression in a “serious way,” and included actors that users could identify with. Several young people wanted homework to be included but only if it were called something else and minimal, thus considering other demands on users’ time. If information about depression was included, young people wanted this to incorporate depression statistics, information about coping strategies, and current treatments. Advice from health care professionals was requested as part of any problem solving. Although recording activities and moods was the least favored component for inclusion (with some participants concerned that this could lead to information disclosure), others wanted this to be included to allow connections to be made between periods and moods.The community sample identified communication, goal setting, activity scheduling, and identifying barriers as the most important components for inclusion. In particular, they felt that communication would help users to develop their social skills and described how the inclusion of links to clubs would aid activity scheduling. Additional content for consideration included games or puzzles, if these were not The colorfulness of the new program, including information about depression and having additional follow-up sessions, was regarded as the most important component in making the new program attractive to users, whereas having printable handouts and homework activities was considered less important. Participants also wanted the program to be sensitive, fun, and relaxed and to provide adequate information—not too much so that users would be overwhelmed or too little so that they would not take it seriously.Concerns were expressed that not all young people would be able to access a computerized program with proposals made to place it in accessible locations  to ensure equal access. Furthermore, young people wanted the program to be available at all times and therefore accessible not only when most convenient but also when most required. Consequently, young people wanted the program content to be downloadable to ensure it could be viewed even if an internet connection was unavailable. Program access also had to be simple, with no requirements for young people to trawl through terms or conditions or have to “sign up now,” which they described would dissuade them from using the program.A total of 4 main themes were identified: constructive safe space, developmentally appropriate formatting, accessibility, and regulation of parental involvement.In total, 4 service users had accessed web-based support, searching the internet and browsing websites, generally when they felt particularly low and when alternative support was unavailable. Although 2 users had found web-based help useful, shortcomings of the approach were described, including a lack of personal rapport, automated responses described as “robotic,” and a feeling that information was more directed at parents:I found the [name of website] one to be a lot of phone numbers and it was a lot more directed towards parents than the child.Female, service user, aged 16 yearsAll the service users had received face-to-face support for low mood or depression, with the majority describing how hard they had found this, particularly talking with another person about their feelings. Similar to the community sample, their main concern related to how they would be perceived, with several reporting feelings of embarrassment or worry that others would not understand. Consequently, they felt that a computerized treatment approach addressed some of these difficulties, providing young people with anonymity that allowed them to talk freely without judgment, in a format that they were both familiar with and comfortable using:...our safe space is talking through a phone, through a screen because that seems easier than talking to people.Female, service user, aged 15 yearsOther perceived benefits included enabling young people to access support without having to ask for it and the opportunity to receive it within their own surroundings where they felt most comfortable.None of the service users had ever had any web-based therapies recommended to them or been directed to it as part of therapy. They were therefore keen to ensure that young people were aware of its availability and suggested advertising the new program in health care settings and schools and via social media.The consensus was that 2 versions of the new program were needed. A simpler version was proposed for younger users aged 11-13 years, with more in-depth information presented for older individuals aged 14-16 years.The service users wanted the new program to be fun, relaxed, and nonpatronizing while being simple, so that young people would not disengage:If an eleven-year-old who is anxious, low mood, stressing out about themselves is answering questions or reading words that they don’t understand, it is only going to make it worse for them.Female, service user, aged 15 yearsFurthermore, it was highlighted that many young people, especially those with low mood or depression, tend to procrastinate; therefore, the simpler and more focused the new program, the more likely young people would be to use it.getting bored.The activities considered most important for inclusion included learning about coping, playing games or puzzles, practicing new skills, and having information about relapse prevention. Several service users had previously used mood monitoring, finding it useful in allowing them to monitor their feelings over time; therefore, this was suggested for inclusion by some users. Additional components identified included information about exercise and other conditions , a chat option so that users could communicate with similar others, useful telephone numbers, and satisfying videos (videos designed to reduce anxiety and aid relaxation). Homework was considered the least important for inclusion, with the requisite that, if included, it had to be minimal to increase adherence and avoid people Some users wanted notifications included to remind users to complete sessions and the option to print content. However, these were not favored by all. Some users felt that as long as program content was downloadable, printable content was not required, and it would be easier to keep all information in one place, that is, on the computer. Although some users could see the benefits of notifications, they felt that these needed to be optional, with users controlling how and when to receive them.To make the program more attractive to users, its interactivity and its availability for completion were considered the most important components, whereas homework and having printable handouts were considered less important.Although the majority of service users wanted information about depression presented in the new program, several concerns were raised. Some worried that information of this type could make some people feel worse, and therefore, this needed to be optional. Similar concerns were also discussed regarding the recording of activities and moods and watching videos:I know the videos are to show that people have overcome it, but the only other thing I would say is that I remember looking at people and stuff like that and then I’d feel bad because I’d feel like “well they’ve got it worse than me, so I’m just being dramatic for no reason.”Female, service user, aged 16 yearsThe service users felt that the program length—both its session number and the time needed to complete them—required flexibility. Although they had made suggestions about this, they felt that more or less time could be spent on the program relative to how users were feeling and how they were progressing through it. Therefore, anyone noticing positive changes and feeling better would cease program use, whereas those who did not would use it for longer. They also proposed that anyone experiencing a relapse should be offered a follow-up session or be able to repeat the new program in its entirety.The service users felt that through computerized therapy delivery, more young people would be aware of and more likely to access support. They reported that “nowadays everyone has access to the internet” and therefore wanted the new program to be widely available and not restricted to specific locations . This was deemed especially important for those who might struggle to access face-to-face support  and would help to address lengthy waiting lists in CAMHS:The process of getting into CAMHS is like a bit of a pain with waiting lists and then maybe not having enough sessions and getting discharged before you’re ready and stuff because the fact that there are so many people that need to use the service, but if it’s internet, like, as many people can use it as they need I’m guessing.Female, service user, aged 15 yearsAlthough the service users felt that internet access would not be a problem for most young people, they did however recommend that all program content should be downloadable so that individuals could ensure program access even without an internet connection.Although some users felt that it should be available to all, others felt that, to monitor risk, only those given access by a clinician should be able to use it. One individual suggested that clinicians could send program log-in details to anyone they deemed suitable or their parents.Although variation in the number of sessions was proposed, the consensus was that this should be dependent on the level of support required. Furthermore, some form of follow-up, to review progress and ensure therapy did not simply stop, was regarded as important. There was variation in how this could be incorporated, with some users suggesting a single session after therapy completion to be sufficient and others wanting monthly follow-ups for up to 6 months. One individual suggested making follow-ups optional and aimed at those who might not have processed all of the program content.lose focus if sessions were too long and proposed that larger topics could be covered in multiple sessions to keep session lengths shorter.The service users felt that the program length needed to consider the attention spans of young people, with most deeming between 30 and 45 minutes per session as sufficient. They felt that young people might Some users felt that weekly sessions with time to practice skills would be appropriate, with concern that users may forget what they had done in a session if longer than a week was left until the next. Others wanted a higher frequency of sessions, with both completing 2 sessions per week and completing sessions on alternate days. It was also suggested that program content should remain accessible following completion so that it could be repeated if needed.Several service users felt that there should be no parental involvement in the new program with concerns that those not having a close relationship with their parents would not engage with a parent present. Some felt that parental involvement should be decided by the user, whereas one service user felt that parents should be informed if their child was using the program simply to show them that they were using the computer in an appropriate way.In contrast, parental involvement was regarded positively by some users who felt that the program could be completed more successfully if parents were involved. These individuals described how this could result in parents gaining a better understanding of how their child was feeling and how parents could learn techniques to be able to provide more suitable support:If parents have techniques for the child, they could then show them techniques, you know that could help them, or maybe learn not to maybe act a certain way with them and stuff.Male, service user, aged 16 yearsHandouts providing information about low mood or depression and coping techniques were suggested as a way of implementing parental involvement. There were also suggestions about including parents in some sessions with variations, including young people completing sessions together with parents, having parent-only and young person-only sessions completed separately, or combining these approaches with parents attending sessions at various points.In total, 6 main themes were identified: familiarity and experience of BA and computerized therapies, essential elements required for a successful BA program, developmental considerations and flexibility of the program, depression severity and care pathway positioning, risk monitoring and systemic approach, and collaborative working.Most health care professionals were familiar with the components of BA, having used some of them—mainly mood and activity monitoring—in therapy. However, most health care professionals, unaware of the term, did not refer to this as BA. Those who were familiar with BA described how their knowledge of the treatment was derived from an adult model. Therefore, if they had applied BA principles to young people, this was through them adapting their knowledge of BA with adults and creating a bespoke treatment approach.All health care professionals were familiar with, and valued, the increased use of computerized therapies, with some having referred young people to web-based resources while awaiting face-to-face therapy. Despite this, limitations of the approach were discussed, particularly the lack of therapist presence during therapy delivery:Instilling the hope, the computer cannot instill hope.Health care professional, maleFurthermore, they felt that computerized therapy delivery was not suitable for all, especially in high-risk situations, and expressed concern about what would happen to young people if they felt particularly low following completion of computerized treatment sessions.vital component in assisting therapists to gauge treatment direction, health care professionals also felt it was important for young people to monitor their mood regularly and identify factors affecting it. Most users also wanted to see information about depression, problem solving, and quizzes included. However, there was concern about how components such as goal setting and problem solving could be implemented in a computerized format, given that they are person-centered and individualized approaches. Some users wanted homework to be included, but they stipulated that this needed to be presented under a different name and monitored with reminders sent to support engagement.Goal setting, activity scheduling, coping skills, mood or activity recording, and monitoring feelings were deemed the most important criteria for inclusion in the new program. Although goal setting was regarded as a To increase inclusivity, health care professionals suggested presenting information in different modes and allowing users to adjust program settings to enhance ease of use. They also wanted users to be able to ask questions about anything they did not understand and have key points revisited in each session to assist understanding.It was felt that more than one presentation of the new program, based on developmental level, was needed. There was concern that some young people would not understand particular words and others, especially those with low mood or depression and lacking energy, would struggle if presented with a lot of text. Therefore, breaking words down to aid understanding, using combinations of words and pictures in the program, and embedding an audio option so that content could be read aloud were suggested.The health care professionals wanted both session frequency and length to be tailored to each user with consideration given to energy levels, depression severity, developmental level, and the number of questions a young person had. One individual, highlighting that those with low moods might have shorter attention spans, proposed basing sessions upon graded exposure. Overall, the consensus was that approximately 8-12 sessions, delivered weekly and lasting between 30 and 45 minutes, would be optimal.It was felt that those with severe low mood or depression might have difficulties using a computerized program; therefore, it would be most suited to those experiencing mild-to-moderate low mood or depression. Aligning to this, tiers 2 (early help and targeted services) and 3  of CAMHS and step 2 of the children and young people’s improving access to psychological therapy stepped care model (low-intensity services) were suggested as areas where the new program would be best placed.further treatment and used before discharge from CAMHS.Health care professionals felt that the new program could be positioned anywhere in the care pathway. First, it could be used by young people awaiting treatment, thus reducing the number of subsequent face-to-face appointments and allowing more time to be allocated to those with more severe depression. Another recommendation was for the program to be used alongside usual care, either between or during face-to-face sessions with the therapist present. Particular benefits of this included providing young people with a new medium within their care and providing therapists with an additional tool to monitor progress. Finally, it was proposed that the new program could be offered as a Several recommendations were made about how to identify anyone deemed at risk following computerized therapy and how to manage this situation. These included incorporating live chat or crisis numbers into the new program, allowing young people to request a call back from a health care professional if they were feeling at risk and encouraging users to take control and agree to seek additional support if required. To implement this, one health care professional suggested using contracts:You could have it in the contract...so just something that they signed to say that “if you do feel at risk or you feel that you need to talk to someone that you are willing to contact the crisis team and speak to someone,” even the Samaritans.Health care professional, femaleTherapeutic alliance was particularly important to health care professionals. They felt that during the treatment process, clinicians were required to instill hope and monitor both progress and deterioration with individual clients, providing support accordingly. They were therefore concerned about the lack of human contact inherent to computerized therapy delivery and, although supportive of the new program, wanted treatment delivery to incorporate a balance between the computer and therapist:I think for me though there is nothing more powerful that the connection between the therapist and the client, you know.Health care professional, femaleHealth care professionals felt that parental involvement was also essential, particularly regarding risk monitoring, and reported that therapies were often more successful if parents were included. However, they acknowledged that relationships with parents can be difficult, and therefore, parental support within the new program would need to be adapted based on user-parent relationships.Finally, it was highlighted that, for treatment success, a systemic approach to therapy delivery was required with the cooperation of multiple agencies. They contended that everyone had a role during therapy delivery, and therefore, it was important to be flexible and ensure roles were clearly defined:Everybody has a role to play from the preventative early intervention, the mild end, the moderate end, the severe end so it will be quite clear who does what, when, and how, and then that maxes our public money, so we’re not stop starting.Health care professional, maleThrough collaboration, it was felt that multilevel monitoring would be in place throughout treatment completion, with young people having a variety of support contacts when required, something especially important if the risk was presumed.This study allowed vital information to be collected from various perspectives to inform the development of a new computerized BA program for young people. Previous research suggests that differences exist between the views of young people and health care professionals ,28, withThe findings from this qualitative work demonstrated that both young people and health care professionals endorsed the use of computerized therapy delivery, and the advantages of the approach were identified. These included enhanced anonymity, treatment accessibility, and awareness; these findings were concordant with previous research in the area ,16,18. TApart from providing support for the development of a new computerized therapy program based on BA, this qualitative work also provided vital information regarding the presentation, delivery, and content of the new program to ensure that it meets the needs of the target user.Although there were individual differences across the 3 participant groups, with novel themes emerging from each , agreemeHowever, opinions regarding some of the program content were more complex to reconcile, both in incorporating the views of the 3 participant groups where differences were apparent and also being mindful of the need to include evidence-based components of therapy.Across all groups, concern was expressed about the inclusion of homework, with this component regarded as less important than others. Despite these concerns, research has demonstrated correlations between homework compliance and clinical improvements when delivered within CBT . IncludiDiscussions also occurred regarding the involvement of others in the completion of a computerized therapy, particularly parents. As reported elsewhere in a systematic review of young people’s experiences of using technology-assisted CBT , both poThe needs of young people can be better met if there is knowledge about where they seek help when they are distressed . DespiteSimilar to previous research ,28 and aTherefore, a systemic approach to the development of new interventions needs to be adopted to ensure that they meet the needs of the target user. Such an approach should incorporate the views of those with treatment experience, who are experts on what works and what does not; those who have not accessed treatment, who are the experts on the barriers and how these may be overcome; and health care professionals, who are experts on the practical application of therapy and its integration into services.Owing to several limitations of this study, the results need to be interpreted with caution. To ensure that rich and trustworthy information was collected as part of this study, 3 different participant groups were recruited. Despite this, several factors may have affected the transferability of the findings. As an opt-in method was used, the young-person participants were more likely to be those motivated to engage and thus might not have expressed views demonstrative of the general age range population. Only one service user participant was male, which, although unsurprising with research suggesting that males are less likely to access mental health services , meant tVital information was collected to inform the development of a new computerized therapy. Although similarities in the opinions of the participant groups were evident, differences highlighted the need to adopt a systemic approach in therapy development. In the context of young-person therapy, the opinions of young people with and without experience in accessing mental health support and health care professionals need to be incorporated.


Recognizing that adolescents face barriers in accessing services, may feel embarrassed, face stigma on sexual matters, or have concerns about judgmental providers, youth-friendly service (YFS) has been introduced to deliver health services that meet the sexual and reproductive health (SRH) needs of young people. Evidences on the role of YFS in addressing the socio-cultural norms influence unmarried adolescent SRH behaviour are limited. Therefore, this study explore whether the socio-cultural norms influencing adolescent SRH behaviour vary between youth friendly service program and non Program areas in West Gojjam Zone, North West Ethiopia.Qualitative case study design was employed to explore the socio-cultural context of adolescent sexuality. Purposive sampling was used to identify study participants. Data were collected from 112 participants both from YFS program and non-program areas using semi-structured in-depth interviews, key informants, and focus group discussions guides. A total of 18 key informant interviews, twelve FGDs and four in-depth interviews were conducted. Participants were comprised from unmarried adolescents, parents, religious leaders, community elders, health professionals, teachers, and unmarried adolescents who experienced SRH problem. Thematic analysis was used to summarized the data.The socio-cultural norms related to adolescent sexuality in both YFS program and non-program areas indicated that the community is intolerant to premarital sex, SRH service utilization  by unmarried adolescent; and discourage SRH communication with unmarried adolescents. According to the participants, premarital sex and SRH service use were not accepted by the community. Moreover, participants believed that, having communication on SRH issues with unmarried adolescents are equivalent to encouraging them to initiate sex, therefore, should not be practiced.The socio-cultural norms influencing adolescent sexual behaviour were more or less the same between settings. In both areas, the socio-cultural context discourages YFS intervention like SRH communication and service use. Also, the YFS program does not modify the socio-cultural norm affecting adolescent sexuality. Therefore, the YFS interventions strategies should give due emphasis to the socially accepted sexual norms like sexual abstinence. Young people aged 10–24 years face various challenges during their transition to adulthood . RecogniThe YFS approach is believed to improve adolescents’ SRH by targeting the barriers to services at the individual, social, and structural levels. At the individual level, YFS approach emphasizes increasing young peoples’ SRH knowledge, skills, and health care seeking behavior. At the social level, YFS promotes supporting community environment for adolescents’ to seek services with targeted effort of awareness activities for parents, young people, and community at large. At the structural level, YFS works by promoting national, regional, and local YFS oriented policies into the existing public health systems –18.The Ethiopian government introduced YFS program in the country’s public health system in 2005. Following the inception of the program, the National Adolescent and Youth Reproductive Health Strategy (AYRHS 2006–2015) was developed. The strategy laid out the vision and objectives for increasing access and use of quality reproductive health information and services . The FedYFS programs promote access to SRH services, including information and counseling on the issue, promotion of healthy sexual behaviors, and contraceptive promotion /provision regardless of age and marital status in a right-based approach , 24. TheA comparative study between YFS program and non- program areas on SRH service utilization reported that SRH service utilization was 33.8 and 10% in the program and non- program areas . A quasiOther studies reported that social and cultural factors shape adolescents’ SRH experiences, decision making, and behaviors at different levels. Perceived norms about acceptability/unacceptability of adolescent sexual activity and its consequences , religion and abstinence teachings about premarital sex, and limited access to quality SRH care were identified as a major factor for adolescent poor health , 32 MoreBesides, making marriage and childbearing-related decisions, individual members of the society are expected to adhere not to their personal interests, but the prevailing norms of the society –42. WhenThus, this study explored whether differences are existed in the socio-cultural norms related to SRH behavior of adolescents’ between YFS program and non-program areas considering the prevailing socio-cultural norms towards premarital sexual practice, parent-adolescent communication on SRH issues, and use of SRH services by unmarried adolescents. The findings may help concerned bodies to design tailored intervention to improve the SRH of unmarred adolescents.A qualitative case study design was used to explore the difference on the socio-cultural norms affecting unmarred adolescent sexual behaviour. The study was carried out on September 2019 in west Gojjam Zone, Northwest Ethiopia. West Gojjam zone is divided in to 13 rural districts and 02 city administrations with 362 rural and 15 urban kebeles, respectively. The estimated population of the zone in 2016 was 2,611,925  . In the The study was conducted in areas with YFS program (program area or intervention area was used interchangeably) and non-YFS program areas (non-program area or non-intervention areas was used interchangeably) to explore whether differences in the socio-cultural norms influencing adolescent sexuality. Description of the areas is presented in Table The participants were purposively selected from YFS program and non-program areas. Typical purposive sampling was used to select the potential research participants to be included in the focus group discussions (FGD), key informant interviews (KII) and in-depth interview (IDI). This is a procedure of selecting research participants on the basis of their relevance to the research issues. Additionally, unmarried adolescents who became pregnant following previous risky sexual behavior were included using snowball sampling. The adequacy of the sample was determined based on data saturation. A total of 112 participants included in the study. The participants comprised of different groups who were relatively knowledgeable of the prevailing socio-cultural norms regarding sexuality and governed by such norms. Accordingly, 31 unmarried adolescents  age ranging from 15 to 19 years, 30 parents who had unmarried adolescents, 18key informants comprised of religious leaders, community elders, health professionals and teachers participated in the study. In addition, four unmarried adolescents who experienced reproductive health problems (pregnancy) were included in the study.To collect the qualitative data, FGD, KII and IDI guides were prepared. Data were collected by five qualitative data collectors  with social science background and familiar to the area and experience in conducting qualitative data collection. The qualitative data collection guides were pre-tested and issues that might be encountered in the main data collection process were discussed before the actual data collection. The main data collection process was started by explaining the purpose of the study, read the consent form to each respondent and asked them to participate in the study. Once their consents were obtained, an interview date and place of interview were arranged in advance with each respondent. Those respondents who were ready to be interviewed on the first contact were interviewed on the same day of first contact. All interviews were conducted separately at respondent’s convenient hour and place. All FGDs were held in schools compounds during weekends, when the classrooms were free. The data collection from males were facilitated by trained same gender moderator and note-taker, while the focus group discussions and IDI for females were facilitated by the principal investigator and trained female note-taker. The discussions were held in Amharic  which is spoken by all participants, and they were also audio-recorded. On average, the informant interviews lasted for about 40 min while the FGD lasts about 2 h. The data were conducted to the point of saturation.A total of 18 key informant interviews, twelve FGDs and four in-depth interviews were conducted. Of the twelve FGDs, six were conducted in the YFS program areas with unmarried female adolescents (two FGDs), unmarried male adolescent (one FGD), male parents (one FGD) and female parents (two FGDs). In a same way, the other six FGDs were conducted in the non-program areas. Additionally, in both settings eighteen KII with religious leaders, health professionals and teachers were conducted. Moreover, four IDI (two from the program and two from the non-program areas) were conducted with unmarried adolescents who had previous experience of SRH problems.In this study, the constructs of credibility, transferability, dependability, and confirmability were enhanced , 48. To As to transferability, a thick description was used to show that the research findings can be applied to other contexts, circumstances, and situations. This included the number of participants, where the participants are from, the number of participants involved in the fieldwork, the data collection methods that were employed, the number of activities, and the length of the data collection sessions. Lincoln and Guba stress the close ties between credibility and dependability, arguing that, in practice, a demonstration of the former goes some distance in ensuring the latter . DependaAll interviews were transcribed verbatim into Amharic  and translated into English and were analyzed by using thematic analysis approach. The transcriptions were read several times to understand contents and contexts. This was followed by extraction of meaning units from the transcripts. The meaning units were condensed by shortening the original text while maintaining the central meaning. The condensed versions were later assigned codes, which were grouped into similar categories Table . The PriA total of 112 informants participated in the qualitative study. Of this, 46 and 44 were unmarried adolescents and parents respectively. Ten religious leaders and community elders (five from each) were also participated as key informants. Additionally four (two in each setting) unmarried adolescents who experienced SRH problem were included in the study. Majority of the participants were orthodox Christian and literate Table .Table 3SAdolescence is conceptualized in a similar way among informants. Discussants explained that the onset of adolescence is marked by physical and behavioral changes around the age of 15/16 years and ends when he/she started showing adult behavior at marriage. Girls often marry between the ages of 16–17 years while boys marry about 18 years and above. Once married, adolescents are considered adult members of the community and participate in different social events, such as monthly and annual festivities.Adolescent discussants argued that marriage by itself does not necessarily indicate a passage to adulthood. In some localities, there are contexts where children marry below age 10 when only the marital ceremony might be celebrated. The couples may live with their biological parents till they reach the expected age to start married life. For these discussants, the onset of adolescence is around 15/16 years and ended when youth are married and start married life.Both discussants  mentioned that physical and behavioral changes are observed in both males and females during the adolescence period.Parents and community elder discussants stated that males become masculine, grow hair in the face, and their voice becomes deepen during adolescence. Girls show breast development, growth spurt, and fat accumulation. Regarding behavioral characteristics, discussants shared that both males and females show moody, turmoil, aggressive, disobedient behavior, and desire for opposite sex during adolescence stages of development. Discussants also maintained that desire to be independent and risk-taking behaviors are often observed among males during adolescence.In this study, social norm related to premarital sex was more or less the same in both settings. Premarital sex is not accepted in the study settings and considered as a sin by religion. As it is clear in the following excerpts from religious leaders from the program area, premarital sex is a sin that led to punishments from the lord.“… sex following marriage is a sacred activity. … premarital sex negates this wish. It is a sin human beings exercised violating the lord’s wishes that led to punishment from the lord such as incurable diseases.” .The narration illustrates that sexual practice is allowed following marriage. Premarital sex dusts the individuals physically and morally, and has lasting consequences. Parents who participated in the discussion in both settings also stated that premarital sex is a taboo in their communities. Parents explained that the practice of premarital sex by adolescents is a sign of poor parenting and disobedience of religious teachings as follows:“We learned that being a virgin is a sacred status for individuals. Religious leaders always reiterate this idea for the followers. They often remind us to nurture our children to grow within this belief. … premarital sex is considered as a poor follow-up from parents as well as disobedience of adolescents to their religion”. .“… especially for girls, having premarital sex is very disgraceful for herself and her family. Our culture is intolerant of such practices. We learned such practice from our parents, and we are teaching our children to avoid such practice”. .Parents also shared that though premarital sex is taboo in their community, a few adolescents might practice it secretly. When the event is disclosed, it might be a discussion agenda in the community. Parents maintained that:The excerpt revealed that though premarital sex is forbidden for both sexes, it is very strict when it comes to girls. Premarital sex is shameful not only for the individuals who practiced it but also for the family. This thinking is intergenerational and maintained by culture.In consonant with parents’ view, adolescent discussants in the two settings explained that premarital sex is considered as a sinful activity the society condemned most.“Our community discourages premarital sex for both of us [boys and girls]. It violates our Lord’s wish and it exposes adolescents to various health risks that might have lasting consequences (teenage pregnancy or unsafe abortion) … these events may interfere with girls’ education or future aspirations”. .Both male and female adolescents shared that they are often advised to abstain from such actions that violate the Lord’s good wish for human beings. A discussant from the program area illustrated that:The excerpt revealed that adolescents have a similar opinion to their parents that premarital sex is not accepted by their religion. The community had a greater stake in avoiding premarital sex for girls. For girls, premarital sex has consequences that interfere in their life and development.Informants from both settings revealed that they rarely discuss sexual and reproductive health issues with their unmarried adolescents. Cultural taboos, fear that adolescents may initiate sex, and too young to be told were appealing as a common reason for not discussing SRH issues with their adolescents. The data indicated that communication topics on SRH issues seem similar between the program and non-program areas.“… there are some sexual issues that I am not able to provide appropriate information for my children … . even I am worried about the terminology that should be used during communication … ., in our culture, it is taboo to call reproductive organs with its appropriate term, … . that is why we usually used synonym that may decrease the degree of embracement (laugh)”. .SRH issue is considered a very embarrassing topic to discuss. There are also taboos attached to sexuality. For instance, reproductive anatomy could not be mentioned freely by the majority of the community. And hence, the community in both settings has conservative attitudes to make meaningful communication with their children. An elder informant pointed out that“… I repeatedly advise my son to study his lesson strongly. I did not discuss reproductive health issues. If I do so, my boy may feel as I am reminding him to accomplish such unwanted activities. I also believe that it would initiate adolescent’s sexual practice”. .Moreover, discussants perceived that informing their children about sexual matters would lead them (unmarried adolescents) to engage in sex. Instead, parents usually discussed issues other than SRH. A 46-year-old man from the program area said:Supporting the above concern, a discussant from the non-program area stated that “… discussing about sex may lead them (children) to try it out and engage in risky sex. … this (discussion) will be like to allow them to engage in sexual activities.” 48-year father from non-program area, Pp5). In a similar vein, elder participants from the program area strongly oppose the communication, “...as a parent, one should feel ashamed to talk with their children about condom use and pregnancy prevention methods …” .Research participants were asked about their opinion on the SRH service use of unmarried adolescents such as family planning/ condom to avoid pregnancy and STIs, STIs treatment, HIV/AIDs testing, and healthy sexuality. Also, health professionals were asked whether adolescents are using SRH services and the contexts of service provision.Religious informants shared that the use of family planning methods is against the religious doctrine. The use of FP method is forbidden, not only for unmarried adolescents but also for married couples. Religious informants discussed that individuals who are obedient to their religion should not use family planning methods. A religious leader from the program area underlined that “we are teaching abstinence for unmarried adolescents and faithfulness for married couples. No flexibility when it comes to religion.” Informants further discussed that the use of FP methods violates the very doctrine of religiosity (procreation) and resulted in punishment from the Lord.In the same vein, parents and community elders discussed that use of FP services should not be allowed for unmarried adolescents. They argued that this service is against the religious teachings of abstinence and the social value attached to virginity. Besides, there is a possibility that girls will be pregnant before marriage, which is very shameful in our culture, or she might be infected by STIs. A parent explained that:“… we (parents) are advising them what is better for them …. abstinence is the only option to remain healthy for both males and females. The use of FP is against our religion and culture that values abstinence and virginity. In our community, no one advises his/her children two options- abstinence or use SRH services. We have been advising this (abstinence) and will continue in the future”. (70-year father from program area).The excerpt revealed that parents believed that they are the observer of their children’s sexual behavior. They are working to maintain culturally accepted sexual behavior. Parents argued that the promoted SRH services violate the accepted cultural values and are not full-fledged to ensure healthy sexual behavior of adolescents.Adolescents in both settings discussed that use of SRH service is taboo in their localities. The socio-cultural norms and attitudes regarding adolescent sexual behavior are not supportive for adolescents to access SRH services. Whenever they had a health problem, parents often decide whether the problem necessitates visiting a health facility. If there is a need to go to the health facility, parents/elder family members often accompany adolescents. They stated that those who accompanied may want to know the cause of the problem, which is embracing. Such a social environment is a barrier to adolescents’ SRH service utilization.Some discussants hold the position that SRH services should not be used by unmarried adolescents because of two reasons. They argued that the methods included in the service violate their religious teachings (abstinence). They also stated that they doubted the efficacy of the methods used  in preventing the occurrences of unwanted consequences (pregnancy or STIs). During the discussion, they presented pieces of evidence of pregnancy while taking contraceptive methods among some girls in their locality.“As premarital sex is taboo in the locality, pregnancy/STIs keep secret. Because the prevailing norm does not accept this behavior. … there are instances that some girls had unwanted delivery while SRH services are available in the locality” 18-year girl from program area, Pp1).Furthermore, adolescents shared that when there is SRH concerns such as STIs or teen pregnancy; they often hide it and experience the worst consequences. A discussant stated that:The narration revealed that some adolescent girls could not use SRH services to prevent the occurrences of the problem  due to the normative environment that serves as a barrier to services utilization. The context led to having premarital delivery. An adolescent girl who experienced such a problem illustrated it as follows:“I had sexual intercourse while I was in grade eight. I did not expect that I would be pregnant. … I went to a nearby town for pregnancy confirmation in a private clinic. I was told that it was pregnancy and it is late for termination so that I should give birth. When my belly grows, people began to whisper at me, thus, I dropped out of school. … when my mom noticed my status, she shouted at me. All family members felt sad and ignored me. … that was unforgettable bad event in my life”. .Regarding the SRH service use of unmarried adolescents, health professionals in the two settings were asked whether adolescents were using SRH services and the context of service provision in their health facilities. Both professionals shared a similar opinion that adolescents did not visit health facilities for prevention purposes. As to other community members, adolescents often visit the facilities when they had health problems. In the program setting, the informants explained that adolescent couples who proposed marriage often come to the health facility for HIV testing. They also reported that adolescents rarely came for termination of pregnancy.This study explore whether the YFS program bring a change on the socio-cultural norms related to adolescent sexuality. We found that adolescence is highly associated with the social context of a society. The social construction of sexual maturity is more or less the same in program and non-program areas. For instance, the onset of adolescence is marked by physical changes at around 15/16 years and ends at marriage in both study areas. Girls often marry between 16–17 years and are considered an adult member of the community, once married, clearing the cultural barrier to SRH services. Similar studies in Ethiopia and other developing countries reported that, in practice, adolescence, although its onset is marked by the individual’s biological maturation, its end is determined by the social context , 44. StuBesides, the social construction of sexual maturity, however, contradicts biological sexual maturity as marriage and childbirth are recommended after the age of 18 years. An obvious implication of this divergence in the socio-cultural and biomedical conceptualizations of adolescence is that it could make the acceptance and implementation of modern SRH intervention more challenging , 13, 30.This study also revealed that the community in the study area has culturally defined sexual behavior and norms for adolescents, and these behaviors and norms act as a social control to people’s behaviors. Also are considered as safeguards against risky sexual practices. For example, particularly for girls, being a virgin till marriage is highly encouraged, and viewed that the girl has good manners. Similarly, studies from various parts of Ethiopia revealed that abstinence is most socially acceptable norm. The social attitude attached to virginity is believed to encourage girls to stay virgins until they get married , 42, 44.This study also noted that, in both settings, premarital sex is not considered as problematic for males as it is for females. On the other side, communities in both study areas did not encourage male adolescent to use condom to prevent STIs. These cultural ambiguities may affect the SRH of unmarried boys by exposing them to unprotected sex (STIs). It also negates the idea of the modern approach (YFS) that encouraged protective sexual practice .Furthermore, religion is an important governing factor in the delineation and implementation of sexual norms and values . ReligioSRH services utilization promoted by the YFS program contradicts the coherence of the community’s normative climate. For example, safe sex practice suggested to unmarried adolescents, may be a challenge for a community to maintain or enforce norms prescribing the sequencing of sex or childbearing before marriage . In thisMoreover, the social norms observed in this study seem to discourage discussion on sexual issues with unmarried adolescents. Similarly, studies in Ethiopia reported that social norms are the major barrier to discuss sexual issues with unmarried adolescents , 33–38.In sum, our findings indicated that the SRH of adolescents is mainly governed by the cultural context that they live in which, in turn, has important implications on their sexual health. Such SRH related social norms challenge the implementation of YFS interventions in this community where more cultural/religious norms have considerable influence on people’s sexual behavior.Since respondents are not controlled in their movement between the program or non-program areas, they might have an opportunity to come into contact with YFS activities regardless of their study areas. Though the study addressed this limitation by using criteria for area selection and leaving buffer zone between settings, the results should be interpreted with these limitations in mind.Socio-cultural norms related to unmarried adolescent sexuality were more or less the same between YFS program and non-program areas. The community is intolerant to premarital sex, SRH service utilization  by unmarred adolescent; and discourage SRH communication with unmarred adolescents. Such SRH related social norms may challenge the YFS interventions to bring a change on SRH in societies where more cultural/religious norms have a particularly influence on people’s health behavior. Therefore, this study would suggest to re-evaluate the YFS interventions strategies so as to give due emphasis to the socio-cultural norms surrounding adolescent’s sexual and reproductive health.


The transitions in care along the stroke recovery path are challenging, particularly in finding mechanisms to continue one’s recovery once at home. We aim to evaluate the impact of training physiotherapists and fitness instructors from one regional community together to deliver an evidence-based group exercise program starting in the hospital and transitioning to the community using an implementation approach.The evidenced based exercise program Fitness and Mobility Exercise (FAME) for stroke was chosen as the intervention. Data from interviews with stakeholders  was transcribed and themes evaluated using the RE-AIM  framework. These data were supplemented by information collected as a quality assurance project within the health authority.Two programs were established; one in the community centre (run over 15 months by fitness instructors) and one in the regional hospital (run over 12 months by a rehabilitation assistant under the direction from a physiotherapist). Transitions in care were facilitated by implementing the same evidence-based group exercise class in both the hospital and community setting, so people living with stroke could seamlessly move from one to another. An existing physiotherapist navigator service also was valued as a support for the transitions between the two centres for people with stroke. The hospital group accessed group-based physiotherapy service on average 31 days earlier than they were able to in a one-to-one format.This case study described the implementation of the Fitness and Mobility Exercise (FAME) program in one community and the use of a physiotherapist navigator to assist transition between them. After a community training workshop, FAME programs were established within the health authority and the community centre. FAME program participants within the health authority benefited from reduced wait times to access hospital outpatient physiotherapy service. Improvements in function were measured in and reported by the people after stroke attending either the health authority or community centre FAME groups.The online version contains supplementary material available at 10.1186/s12913-021-07436-7. Stroke rehabilitation health professionals and people living with stroke have identified that transitions in care along the stroke recovery path are a major gap that needs to be rectified . The traThere are multiple barriers to participation for people after stroke that relate to individual and systems level issues. From an individual perspective, motivation and confidence, physical disability, support, and transport are important. Lack of availability and access to programs and models to support transitions in care on a systems level pose barriers to participation –12. In aThe purpose of this study is to evaluate the impact of training physiotherapists and fitness instructors from one community to deliver an exercise program for people after stroke starting in the hospital and transitioning to the community based on the Fitness and Mobility Exercise (FAME) program using the RE-AIM  framework . These ePotential delivery of a FAME program training workshop was discussed by telephone with a regional hospital manager, community centre programmer, and physiotherapist navigator, who were all supportive. A full-day workshop was delivered in September 2017 to teach the FAME Program to physiotherapists  and fitness instructors (who could implement the program in the community centre facility). Three participants with stroke acted as demonstrators for hands-on practice during the workshop. The workshop was delivered in the September 2017.Study participants were invited either from a list who had previously attended training  to deliver community-based exercise for people after stroke (FAME), or identified from participants as being key stakeholders . No study participants who were invited, declined to be involved. Ethical approval for the study was granted by the University of British Columbia and the Interior Health Quality Improvement and Patient Safety Office and FAME program participants provided written consent.A series of three stakeholder interviews were held approximately 21 months after the original workshop (July 2019). The first was held with the physiotherapist navigator, the second with staff employed at the community center (program manager and instructor delivering FAME), and the third with health authority staff .Semi-structured qualitative interviews were held with staff at the health authority and community centre in a face-to-face format using a pre-determined interview schedule focused on implementation factors . The researcher conducting the interviews was a rehabilitation clinician-scientist with a background in physiotherapy. All interviews were digitally recorded with the participant’s consent, with field notes taken during the interviews to add richness to the data and provide context.Data were supplemented by evaluation and participant feedback gathered from the hospital as part of a quality improvement evaluation during the third phase of the implementation (December 2019 to March 2020) and by a site visit by one of the authors (MLB) to a class at the community centre in July 2019. Outcome data included from the health authority includes pre- and post-FAME measures for ambulation status, 10 m Walk Test, Timed Up and Go (TUG) , and BerThe Short Physical Performance Battery was used to collect changes in function at the community centre . These dAll interviews were recorded, transcribed, and analyzed using standardized qualitative methods. Two analysts (ML and MLB) coded all of the data independently. Data were read and re-read and codes developed and agreed on by the research team. The RE-AIM framework  was usedThis framework includes elements of Reach, Efficacy, Adoption, Implementation and Maintenance. Interpretation on these elements and the use of the different data collection tools is outlined in Table The first analyst is a female occupational therapist with experience working with a neurological population in the acute and post-acute phase. The second is a female clinician scientist with a background in physiotherapy and more than 10 years of experience in qualitative research. The team met to discuss and reach consensus on the meanings or themes that relate the implementation of the exercise program. Quotes from stroke participants are labeled with a P ; health authority physiotherapists with the abbreviation PT, and community centre staff labeled with CC. Changes in physical functioning  were analyzed using Student T-test in excel.www.fameexercise.com.FAME is a cost-effective, evidence-based group exercise program that can be implemented into community or hospital settings for people post-stroke. The hour-long classes include exercises that aim to improve walking and mobility through a focus on functional strength, balance and fitness. Clinical trials have found high levels of effectiveness with FAME to improve motor function , cardiovascular fitness, and bone density in the stroke population –22. The The workshop was attended by three health authority physiotherapists and twelve community centre fitness instructors. Of these, one physiotherapist and one fitness instructor went on to teach the FAME program to people with stroke, with another physiotherapist assisting with screening and evaluation. Fitness instructors were eager to take the course despite knowing that the community centre would have limited instructors for the course. The skills gained in the workshop were applicable to other courses they taught, as well as for personal training with clients.Following the workshop training, FAME classes were delivered twice a week for one-hour each in both the hospital and the community centre. Group classes at the hospital were provided at no cost to people while they were on the waitlist to receive one-to-one outpatient physiotherapy. As spots became available in the FAME class in the health authority, new participants were added. Hospital classes were delivered in a maximum of one instructor to two participants ratio.Classes at the community centre were run in line with the schedule at the centre (around school terms) at a cost-recovery basis of $10 Canadian. The community centre has options for funding relief for those clients who are not able to afford the classes. Community centre classes were delivered in a maximum of one instructor to four participants ratio.Training of the centre fitness instructors and the health authority physiotherapists together.Implementation of FAME classes within the health authority as well as the community centre.Assistance of a physiotherapist who works as a community navigator out of the community centre for 90 minutes, three times a week, to help transition clients from hospital services to community-based exercise.Assistance of local university students who supported the running of the program at both the hospital and community centre site by providing exercise encouragement, supervision, and stand-by assistance, and recording attendance. In the hospital, students helped to teach the exercises to the participants and helped set up the physical space for the class.We have applied the RE-AIM framework to describe the implementation of an exercise program for people after stroke in the community that is supported by:This health facility admits over 400 people with stroke annually . During Half of the eligible participants attended an assessment session (14/28). Eleven participants participated in FAME classes, with a mean age of 69.5 years and a median age of 72 years (ranging between 31 to 87 years old). There were five males (45%), six females (55%). Ninety-one percent had a diagnosis of stroke, 9 % were neurosurgical, none had other types of ABI. Participants were an average of 44.5 days post-event (ranging between 23 to 77 days) before they started participating in the FAME program.The community centre used various media to reach participants. Printed and web-based program guides advertised relevant community centre programs. Targeted guides for seniors were distributed at the local seniors centre.“So we will put in the request again ...as this is the program that could use constant volunteers. And then we will be able to maybe allow a few more [program participants] in, only if those volunteers are in place’ [CC1].As this physiotherapy navigator also worked at the hospital outpatient program, the element of familiarity  was described to be beneficial in establishing a plan for continuity of therapy post-discharge. Sixteen participants attended the program. No participants were excluded. One other potential participant visited but did not enroll. Having a physiotherapy navigator was noted to be an effective service;‘…we have really good buy in by the navigators, the physiotherapists who come here 3 or 4 times a week and they use this as their office, and they meet with people and refer them’ [CC2].Facilities tried to mitigate cost-based barriers to access the programs.‘Financially we try to do away with the barrier for people with the access pass or we have recreational opportunity coupons that we can give people if they are financially disadvantaged. We just want to take away all the barriers that would keep them from coming’ [CC2].Prior to this study, the health authority had been collaborating with the local community centre via a physiotherapist navigator who provided service 3 days a week for 90 minutes at a time to screen and advise clients on appropriate programs. With the new addition of a stroke specific class at the community centre, the physiotherapist navigator could now provide an option for people after stroke to transition to those classes at the centre. Access to the program was improved by the use of student volunteers to provided additional supervision for those who needed it;Although they waited an average of 57 days for individual PT intervention, eligible clients were able to enter the FAME program an average of 26 days after hospital discharge. This meant that they could participate in the FAME-based group PT intervention rather than no intervention at all during the wait time for individual physiotherapy.n = 11; see Table The exercise class met my expectations.I felt safe in the class.I was able to access the facility easily.I progressed in the number of repetitions of the exercises over the course of the program.I progressed in the difficulty level of the exercises over the course of the program.The exercises were intense enough to improve my function.The instructors were encouraging in the class.The group met my needs while I was waiting for a spot in the full outpatient neuro rehab program.There were improvements in balance and walking, with significance reached for balance function  responded neutrally to the question that ‘The group helped me cope with my stroke or brain injury.’Comments on the questionnaire mostly related to the atmosphere of the class and the physical space. Participants enjoyed the instructors and felt well supervised. For example, ‘Very positive instructors’ [P1], and ‘I felt safe at all times’ [P2]. The camaraderie of the class was very positive as well, as evidenced by the following quotes, ‘Friendship and great work out’ [P3] and ‘Being with others in the same situation’ [P2]. Safety considerations were recognized by participants with the comment, ‘Usually always a spotter on the tougher stations’ [P3]. There were no adverse events reported.‘Freya used to be in my Get Up & Move, but it really wasn’t giving her what she needed so actually my other people that are in the FAME program talked to her into coming.’ They said ‘You need to come to this cause you're going to get more benefit in the FAME program than what we are getting in the Get Up & Go program. So she did and it's made a huge difference. Huge difference in her progress’ [CC1].Improvements in physical function were recorded by the Short Physical Performance Battery . Each class had three to six participants, with a mean of 4.7 participants (with multiple instructors as required to maintain a 1 instructor to 2 participant ratio). Attendance was excellent, with only four absences in sixteen classes.‘I think one of those transition things that as they are leaving, and having to become independent in the community, you need them to be able to self-monitor [PT1].The rehabilitation assistant developed a set of group planning sheets so that the instructor could rotate through these pre-determined programs with a different set of exercises each time. Using dry-erase markers, the participants initialed the laminated exercise sheets at each station to ensure that they completed all stations. Partway through the program, inpatient rehabilitation physiotherapists participated in some in-house training and subsequently took over the role of pre-screening for FAME, which saved time for the outpatient therapist to facilitate earlier entry into the program.Initially, screening for the FAME program was undertaken by the outpatient physiotherapist, and the program was run by a rehabilitation assistant with assistance from student volunteers. The hospital developed an abbreviated FAME education program to upskill university students to the FAME program in order to assist with running the program. Classes were capped at six participants to ensure appropriate supervision and adequate physical space. Furniture was moved to facilitate an open area with free wall space while a railing was installed along one wall for support during exercises. Clinical observation and vital signs monitoring were added as many of these sub-acute FAME program participants have cardiac or respiratory concerns. One study participant identified added benefits of providing the FAME program participants with education on how to self monitor,in terms of transition to the community:‘Well I just had to add extra stuff in for people over and above the level of the exercises so had to add in harder stuff for some of the participants” [CC1].Although several clients had significant aphasia, the instructor was able to include these individuals with support from a university kinesiology student.The program was implemented in line with the training provided. However, given several participants had reduced mobility, adaptations were made to meet their needs. Initially, the programs were delivered with all participants doing the same exercises until the instructor felt that they were competent and could perform the exercises safely and in good form. The instructor then set up a circuit style class that the participants rotated through, using printed handouts from the manual supplied in training to identify which exercises were to be performed at each station. That instructor was able to individualize the exercise then;FAME classes ran from April 2019 to March 2020 in three phases. After March 2020, in light of the COVID-19 pandemic, FAME was modified to be delivered by a rehabilitation assistant in a physically distanced format with two participants. Classes did not run regularly.FAME classes ran from February 2018 to March 2020 (with a break for the summer). Three participants transitioned to non-stroke classes. Since then, FAME classes have been on hold in response to the COVID-19 pandemic public health orders including restrictions on indoor gatherings and group exercise classes.This paper reported on the implementation of FAME, an evidence-based group exercise program for people after stroke within a hospital and a community centre environment. Through the provision of a training workshop to health professionals and fitness instructors, we have described how one community has overcome a range of system-wide and individual barriers in supporting physical activity for people after stroke during the challenging transition from being a hospital patient to a community member.Stroke rehabilitation is becoming more complex, with a greater number of transitions throughout the care continuum . It is kTo overcome barriers to ongoing care, community navigation models have been used in the context of multiple health conditions , 27, incImplementation of FAME in this community has resulted in positive upstream and downstream effect; namely reducing outpatient load and enhancing efficiency and access to outpatient rehabilitation post-discharge, thus noted a trend to reduce the need for individual physiotherapy after participation in FAME. From a process perspective, the outpatient therapy program delivering FAME found it beneficial for the inpatient unit to screen the participants for FAME since they would be most familiar with these individuals. The subsequent enhanced coordination in the hospital demonstrated the benefits of organization and communication between units. Through FAME training, knowledge and understanding of stroke was enhanced particularly for community centre staff, allowing the community centre to run a program for clients with specialized needs, in line with findings in the literature that stroke survivors prefer facility-based group exercise .Beyond smoothing the transition between hospital and home and addressing their needs while awaiting outpatient rehabilitation, FAME participants expressed increased confidence in exercising through practice, supervision, and coaching. Beliefs about physical activity and self-efficacy are known to be important factors in facilitating physical activity after stroke  and predThough FAME implementation was successful, there were some inefficiencies. Of note, only one of twelve fitness instructors went on to formally teach the program. It would have been ideal to rotate instructors to enable a small number to gain the skills in teaching the class to facilitate sustainability of the program. Rotation of physiotherapy and rehabilitation assistant staff through outpatient services also required ongoing training and the workload associated with this needs to be considered as part of implementation in other communities looking to use this as a model of service redesign. The advent of COVID-19 has changed the nature and feasibility of group exercise; hence, we were unable to measure ongoing effectiveness and sustainability of this intervention. Apart from training more instructors, utilizing university student volunteers has the potential to further increase efficiency and may even encourage some of these students to work in this area in the future – a strategy to recruit prospective clinicians across the province.This is a small uncontrolled study, with variation in the timeframe for collecting physical outcome data  impacting how the improvements in physical outcome measures should be interpreted. As well, the described changes over time may include natural improvements. While our timeframe allowed us to collect program data at a considerable time period after the initial training (21 months) we did not collect long term data on FAME program participants, which impedes our ability to describe maintenance at an individual level. The risk of sampling bias from the small number of people with stroke who completed the exit survey is high.This community case-study showcased the important role of a physiotherapist navigator in effecting positive outcomes on the implementation of the FAME program. Training health and community centre staff together promoted safe implementation of FAME in both contexts simultaneously and addressed some systemic issues that were barriers to community participation. We established a link between clinical and community centre staff along with establishing continuity and familiarity for patients transitioning from the hospital to community programs. Participants benefited from reduced wait times to access hospital outpatient physiotherapy service. Further, this paper highlighted the impact that implementing evidenced based programs can have on extending traditional rehabilitation services, while having a physiotherapist navigator can foster an environment supportive of active engagement across transitions and continued recovery post-stroke.Additional file 1.