High school student researchers and teen leaders from the Health Science Technology Academy (HSTA), under the supervision of HSTA teachers, led a childhood obesity prevention (COP) program (iCook 4-H). The objective was to evaluate the feasibility and perceptions of having teen leaders implement a COP program for dyads of youth (9–10 years old) and their primary adult food preparer. Behavior change and perceptions were assessed through surveys and open-ended interviews. Across eight HSTA organizations, 43 teen leaders participated in teaching the iCook 4-H program to 24 dyads. Increased frequency of culinary skills, physical activity and mealtime behavior were reported by youth. Almost all adults (93%) reported that their youth had learned kitchen skills and that the program provided youth-adult quality time and developed culinary skills. Youth echoed adult perceptions with additional themes of food safety and physical activity. HSTA teen leaders perceived the program to be successful and reported the training they received to implement the program was adequate 98% of the time. HSTA teachers found the program to be beneficial for HSTA students in improving leadership, confidence and responsibility. iCook 4-H was feasible to be disseminated through teen leaders in the HSTA program. This teen-led approach could serve as a model for youth health-related programming. The obesity epidemic in the United States has been a paramount focus this past decade, especially regarding the younger generation. Regardless of numerous public health initiatives, obesity rates in youth continue to rise . ObesityAlthough childhood obesity is present nationally, researchers have reported that certain regions are more affected by the obesity epidemic than others ,12. One Many programs have been developed to address the childhood obesity crisis. These programs are usually developed as adult-led; however, peer-led interventions have also been found to be effective . Peer-leWhile utilizing teens to engage peers has been successful , these eTherefore, the objective of this study was to examine the effectiveness of a “Teens as Teachers”, cross-age approach using teens from the Health Science and Technology Academy (HSTA) in delivering a childhood obesity prevention research program, iCook 4-H ,35,36. HTherefore, as a program that promotes health awareness and community engagement, it is an ideal avenue for the dissemination of a childhood obesity prevention (COP) program, such as iCook 4-H. The researchers investigated the feasibility of using HSTA teens, under the supervision of HSTA teachers, to implement a 4-H modeled curriculum for COP programming and explored the perceptions of program (youth-adult dyad) participants, teen HSTA leaders, and adult HSTA teachers.n = 15) remained active throughout all eight iCook sessions and completed post assessments. A participant flowchart is represented in This study was a mixed-methods, exploratory evaluation to test the feasibility of using HSTA teens to disseminate the iCook 4-H program, a childhood obesity prevention program for youth (9–10 years old) and their primary adult food preparer. The program was focused on the promotion of cooking, eating and playing together for healthful lifestyles. Semi-structured interviews and surveys were collected from participants at baseline, during and post intervention. Additionally, HSTA teen leaders and HSTA teachers completed interviews after the intervention. The iCook 4-H program was delivered in eight West Virginia high schools. Between the eight schools, a total of 43 teens were involved in delivering the iCook 4-H curriculum to a total of 24 youth-adult dyads. Initially 26 dyads signed consent forms with 24 participating in baseline assessments. Of the baseline dyads, 62.5% . All researchers and HSTA teen leaders completed the appropriate Collaborative Institutional Training Initiative (CITI) trainings. HSTA teen leaders and teachers and iCook 4-H dyad participants all completed the appropriate informed consent and media releases before participating in the study. Adult supervision from HSTA teachers was present at all times to ensure the safety of dyad participants.Training for the iCook 4-H program began with HSTA teachers. All HSTA teachers from participating schools were introduced to the curriculum, training platforms and procedures for training HSTA students during an hour-long, in-person training by researchers. The in-person training was followed up by a conference call with iCook 4-H program researchers to provide more detailed step-by-step program procedures on training the HSTA teen leaders. Teachers were then sent training materials through the mail to use to train the HSTA teens to deliver the program. HSTA teachers divided HSTA teens into groups of three teens per group to review their roles as session leaders and become familiar with the training materials prior to the start of the program. The training materials included leader guides for all eight iCook 4-H sessions, quizzes to ensure the teens learned the curriculum before implementation, instruction sheets, online videos and resource posters as well as leader t-shirts and a video camera to record the sessions. All the training materials were also available in an online training platform, eXtension Campus, to provide ease of access for students and teachers. Training continued for each session biweekly that included specific descriptions of the responsibilities of each HSTA teen leader for that specific session.The intervention curriculum, iCook 4-H, consisted of three major concepts; cooking, eating and playing together. A description of the iCook 4-H sessions is provided in Data was collected at baseline and post intervention for youth participant behavior change. Youth completed a 46-item program outcome tool to assess changes in cooking, eating and playing together behaviors. Survey questions were developed from previous literature and a review of the curriculum content . ReponseDyad program perceptions were collected during and at the completion of the intervention. Youth and adult participants completed a 15-item evaluation that had a combination of 10 Likert scale questions, three open-ended questions, with remaining questions pertaining to the HSTA club and session description . Using Likert scale questions, participants responded about applying the lessons learned in the iCook 4-H sessions at home with responses ranging from “never” to “all the time”, “strongly disagree” to “strongly agree” or “very unlikely” to “very likely”. In open-ended questions, participants reported on the most important part of the iCook 4-H program.HSTA teen leader feedback was collected during and at the completion of the intervention with HSTA teen leaders completing a 12-item leader process evaluation at the completion of each session. Leaders’ reported on their perception of sessions and effectiveness of curriculum materials. Post program, HSTA teen leaders also completed open-ended questions regarding their perception of what were the most beneficial aspects of the program for the dyads.Program feedback was gained from HSTA supervising teachers through open-ended questions by email and semi-structured video interviews at the end of the intervention. The teachers were asked to provide what they thought was beneficial to the dyads and any thoughts on what worked or needed improved in the curriculum for teen leaders.t-test was conducted to detect statistical differences from baseline to post intervention for youth behavior change. Level of statistical significance was set at p < 0.05.All analysis took place after the completion of the intervention. Written response data were grouped by participant type  for analysis. Video interview data from HSTA teachers were transcribed verbatim by a researcher. Thematic analysis was used to analyze the data with a code book developed to represent codes, definitions and examples following the thematic analysis steps outlined by Braun and Clarke (2006) ,43. An ip = 0.0407) at post intervention. Other culinary skills increased but not to statistical significant improvements including ability to use a knife (p = 0.0849), ability to use an oven (p = 0.3334), plan a meal with all food groups (p = 0.4546) and cook to the right temperature (p = 0.3572). Being physically active for at least 60 min per day slightly increased from baseline to post (p = 0.8845), although families played together less (p = 0.5460). Family mealtime behavior improved with improvements in stressful mealtimes (p = 0.3673) and eating without distractions (p = 0.0777) after the intervention, although not statistically significant.As presented in About 70% of youth reported they completed a fun iCook 4-H activity at home, stated they had a family meal together during the week between sessions and reported they were physically active at home for at least 60 min each day. When asked an open-ended question “What was the most valuable thing you learned in iCook 4-H?”, youth comments were positive. The theme healthy eating emerged. Youth comments included “Eating cooked apples! They were awesome! The spinach was actually good too,” and “I learned I don’t like bananas, but you should try different foods to be healthy”, showing youth were actively trying, and liking, healthy foods during their iCook 4-H experience. The theme of food safety also emerged with one youth stating, “Always wash your hands before and after so you do not cross contaminate”. Lastly, physical activity was mentioned by youth, with an example: “The most important thing I learned today was exercising my body and how to take my pulse after”. These themes align with the goals of iCook 4-H and encompass the core concepts of cooking  and playing from the iCook 4-H curriculum.Almost all adults (93%) reported either strongly agreeing or agreeing that their youth had learned kitchen skills from sessions that would be used at home. Almost 75% stated they were likely or very likely to use the recipes they learned in the sessions. Themes that emerged from open-ended questions regarding “What was the most important part of sessions?”, included quality time together and cooking skills of youth and adult. Quality time quotes were very similar for most adults regarding “Spending time with my child” or “Spending some one on one time with my daughter.” With regards to cooking skills, one said, “Helping my child with knife skills and building her confidence.” And another commented, “Learning to cook because I’m not even close to Martha Stewart level.”Adults also answered, “What did you think was the most important part of this class for your child?” with similar responses under quality time, cooking skills and healthy eating. Adult comments included: “Getting a mommy and me day and learning how to make a delicious snack”, “Learning about a new vegetable, trying a new recipe that is healthy”, “spending some time with her mom that we don’t often get” and “Quality time together, she wants to keep coming to class every session”. One parent had a child that was both a HSTA teen leader and iCook participant and expressed the value of time with both, “Spending time with my HSTA children and my iCook kid that doesn’t normally occur.” Additionally, the theme of physical activity emerged as well, with one parent stating “[iCook 4-H] helps my child make healthier decisions than I did growing up. The activities were great. Any kind of movement is up and off the couch. They loved the activity with the cups. Just because you are not running laps or walking miles does not mean you are inactive. You are up and moving. Great fun!”. The themes and comments expressed align with all core concepts of iCook 4-H through cooking, eating and playing with an emphasis on togetherness.n = 43) were predominately female (83.7%). Class standing ranged from freshman to senior with the mean age being 15.1 ± 1.2 years. A majority of the teen leaders were white (60.5%).Demographic characteristics of the HSTA teen leaders are reported in HSTA teen leaders found the curriculum to be successful and reported that the provided curriculum and training was adequate to teach the session 98% of the time. Open-ended feedback from HSTA teen leaders’ perceptions of the beneficial aspects of sessions for the dyads provided rich insight. When asked “What was the most beneficial aspect of the class for the dyads?”, the themes quality time, healthy eating, cooking skills, physical activity and food safety emerged again with the additional theme of family meals. HSTA teen leaders stated “I feel it gave the parents a fun way to play with their children without wearing themselves completely out. I also believe it provided a lot of the dyads with an easy, tasty recipe.”, “Both the child and the parent are learning new techniques in the kitchen to make their meals healthier and fun” and “The most beneficial aspect was when the child and parent were cooking together because they learned to bond over making healthy meals”. One HSTA teen leader expanded on this adding that iCook 4-H was a good fit as a HSTA project stating, “I thought the whole experience was great for participants. Getting dyads to sit down for a family meal and have dinner time family conversations seemed new for some kids. Kids were timid to start conversations, but it got better. This is a really fun project for HSTA”.When prompted “What impact did the iCook 4-H program have on the HSTA teen leaders?”, teachers provided positive comments and discussed the confidence teens gained through leading the program. Themes that emerged were leadership, confidence and responsibility. Concerning increased confidence, one teacher noted, “The students taught iCook which meant they had to teach adults and children thus giving them confidence not only in their presentation skills, but in their knowledge and their ability to manage groups of people.”, with another teacher adding “[the HSTA teen leaders] did the program themselves, they were responsible for its success. These skills are beneficial for them”. The HSTA teachers acknowledged the leadership and responsibility gained, with one of the teachers stating: “The HSTA students called the youth by their names, encouraged them to eat new foods and to try different things. They also shared personal stories with them. It was a great experience for all involved and really brought out the responsibility and leadership in our teenagers!” Further, HSTA teachers reflected the HSTA teen leaders were even making changes in their personal lives, for example, “I think that the teens learned how to prepare new foods and engaged in more family time with their own families. They tell me of the changes they are making in their own lives because of this program”.However, while most comments were positive, some constructive feedback was provided regarding the design of the program when HSTA teachers were asked “What could be improved in training or curriculum?” Teachers expressed trouble with some of the curriculum content regarding length and required content. One teacher expressed, “I think the transcripts [in the curriculum guides] are great to help the students lead, but they do contain a lot of extra info which I think makes them feel a bit overwhelmed”. Another reflected on the required training videos that used YouTube, stating, “Our problem has been that our students are blocked from YouTube and can’t watch [training] videos. They have had to watch on their phones and that has not been great.” Lastly, one teacher stated the curriculum could be more flexible for high school students in the future and commented, “The recipes are delicious, activities are great, but I think it is too restrictive for high school students to follow protocol exactly. If we do it again, we will modify slightly”.Based on these results, it was feasible to adapt an adult-led childhood obesity prevention program into a teen led model and participants had a positive perception of the program. Youth behavior frequencies showed slight increase in positive nutrition, physical activity and family meal behaviors suggesting a teen led model can influence youth participant behavior. In addition, qualitative results were positive for the teen led program. Adults reported that their children had learned new skills from the teen leaders during the iCook 4-H sessions. Feedback provided showed that participants found the program to be beneficial to their families through increased quality time with children, learning new recipes and skills and youth being active. Youth echoed the adults’ perceptions of the program through learning healthy eating habits, food safety and the importance of being active. Teen leaders were successful in getting behaviors to translate into the home as a majority of children reported cooking an iCook recipe at home, eating as a family and being active. HSTA teens found the curriculum to be adequate and perceived the sessions as important for families and creating closer family bonds. The HSTA supervising teachers observed the changes in the HSTA teen leaders, reporting their confidence and leadership skills excelled. Further, teachers suggest that leading a COP program impacted the knowledge and decisions the teens were making in their personal lives.Using teens as leaders has been promoted in recent years and offers a successful alternative to a traditional delivery system of many intervention programs. Using this model allows for peer relationships to be formed which allows for healthy behaviors to be modeled to others, often utilizing the social learning theory framework, in which youth mimic behaviors of others . ThroughIt is unclear why more COP programs are not capitalizing on lifestyle interventions utilizing teens as teachers/leaders. One possible explanation is the perception of the skill level of teenagers. Many adults view teens at a lower level of skill and expertise compared to adults and would be skeptical to promote this avenue of intervention , or withIn addition, there are “essential elements” for successful programming using teen leaders ,47. TeenWhile this study showed promising results, there were limitations. This study took place exclusively in one state, which leads to lack of generalizability to other locations. Further, HSTA teens were provided training as student researchers and were highly motivated to be involved in this study. Therefore, high school students not trained as HSTA teen leaders might not be as effective. This study was also limited by its small sample of dyad participants, with a large sample size potentially able to provide more insight on the program and teen leader model. Additionally, the self-reported nature of the surveys may have resulted in potential errors as participants could have unintentionally misreported some data. More specifically, self-reported physical activity measures are less dependable than objective measures of physical activity such as with accelerometers . Lastly,Future research is needed to expand the study to a larger population sample, in diverse geographical areas. The small sample size may not accurately represent the teenage population. A larger sample size would allow for a broader range of teenage participants representing all types of teen leaders. In the future, researchers might also want to consider collecting more data on the teen leaders, such as anthropometrics as well as biomarkers. This would allow researchers to explore the impact that implementation of a lifestyles approach to obesity prevention has on teen leaders. Further, curriculum materials should be adapted to address the issues expressed by HSTA teachers and teens with extra training and online methods of training as a solution.The iCook 4-H program had positive perceptions from the HSTA teachers, HSTA teen leaders and impact on dyads. Based on this study, it is feasible to disseminate iCook 4-H COP programming through well-trained and supervised teen leaders, although further testing is needed in other geographical areas. This approach could serve as a model to implement COP programming while also promoting teen skills and leadership development.


Translation encompasses the continuum from clinical efficacy to widespread adoption within the healthcare service and ultimately routine clinical practice. The Parenting, Eating and Activity for Child Health (PEACH™) program has previously demonstrated clinical effectiveness in the management of child obesity, and has been recently implemented as a large-scale community intervention in Queensland, Australia. This paper aims to describe the translation of the evaluation framework from a randomised controlled trial (RCT) to large-scale community intervention (PEACH™ QLD). Tensions between RCT paradigm and implementation research will be discussed along with lived evaluation challenges, responses to overcome these, and key learnings for future evaluation conducted at scale.The translation of evaluation from PEACH™ RCT to the large-scale community intervention PEACH™ QLD is described. While the CONSORT Statement was used to report findings from two previous RCTs, the REAIM framework was more suitable for the evaluation of upscaled delivery of the PEACH™ program. Evaluation of PEACH™ QLD was undertaken during the project delivery period from 2013 to 2016.Experiential learnings from conducting the evaluation of PEACH™ QLD to the described evaluation framework are presented for the purposes of informing the future evaluation of upscaled programs. Evaluation changes in response to real-time changes in the delivery of the PEACH™ QLD Project were necessary at stages during the project term. Key evaluation challenges encountered included the collection of complete evaluation data from a diverse and geographically dispersed workforce and the systematic collection of process evaluation data in real time to support program changes during the project.Evaluation of large-scale community interventions in the real world is challenging and divergent from RCTs which are rigourously evaluated within a more tightly-controlled clinical research setting. Constructs explored in an RCT are inadequate in describing the enablers and barriers of upscaled community program implementation. Methods for data collection, analysis and reporting also require consideration. We present a number of experiential reflections and suggestions for the successful evaluation of future upscaled community programs which are scarcely reported in the literature.PEACH™ QLD was retrospectively registered with the Australian New Zealand Clinical Trials Registry on 28 February 2017 (ACTRN12617000315314). Implementation science is an emerging area of research that studies the translation of evidenced-based interventions into routine practice and is particularly applicable to healthy lifestyle public health initiatives. The ideal translation continuum begins with an evidence-based randomised controlled trial (RCT) to establish efficacy, followed by community trials to determine clinical effectiveness  and finally, adoption and routine delivery by health care delivery systems . The traWhile there is a growing body of literature on changes to the implementation of healthy eating programs across the translation continuum, there is little dissemination of the corresponding changes in evaluation, or reflections on evaluation challenges once upscaled. The aim of this paper is to describe the translation of the evaluation framework from a randomised controlled trial (RCT) to a large-scale community intervention using the PEACH™ Program as a case study. This paper also aims to provide the authors’ experiential reflections on their lived tension between RCT and implementation research paradigms, and provide examples along with key learnings which are beneficial for future evaluation of upscaled programs to assist the implementation of programs along the translation pathway.Child obesity is a global public health crisis which requires the implementation of available and effective programs . The recThe translational pathway of the PEACH™ Program to-date is depicted in Fig. An overview of the evaluation in each of the three selected PEACH™ iterations to-date is shown Table . PEACH™ The evaluation framework and approach was carried forward from the RCT to the community setting with relatively few changes as the program progressed from demonstrating efficacy in an RCT to determining effectiveness in small- and large-scale community trials.In 2012, the Queensland Department of Health awarded a tender to Queensland University of Technology (QUT) to deliver the PEACH™ family-focussed, parent-led, child weight management program to 1400 Queensland children in order to: 1) increase the capacity of the families who participate to adopt healthy lifestyles related to healthy eating and physical activity; and 2) promote healthy weight and weight management through sustainable behaviour change. Rather than a research project, PEACH™ QLD was first and foremost a community service delivery project. The team at QUT were responsible for the implementation and delivery of the PEACH™ QLD Project (Project Implementation Team). Flinders University  was subcontracted by QUT as external evaluators of the program  with the funder prescribing the required effectiveness outcomes in the tender. The evaluation of PEACH™ QLD was funded by the service delivery tender awarded to QUT. The evaluation framework, including the research questions and tools proposed by the QUT and Flinders University teams, was subject to approval by the funder, the Queensland Department of Health. Amendments required by the funder were limited to the use of standardised demographic questions for comparability with population monitoring and surveillance conducted by the Department. No restrictions were placed on the reporting of data, however communication of results during the funding period was also subject to approval. As evaluators of PEACH™ QLD, Flinders University were responsible to the Project Implementation Team at QUT. Ultimately QUT were responsible for the delivery of the project to Queensland Health. Queensland Health received interim reports on program outcomes approximately 6-monthly. Along with project updates, consultation with facilitators and feedback from families, these regular evaluation reports both precipitated and informed changes to program implementation and evaluation during the project lifecycle which were approved by the funder.PEACH™ originated at Flinders University and so the evaluators had intimate knowledge of the program and had conducted the first RCT and small scale community trial. Comprehensive evaluation on program outcomes, impact and process indicators, as well as assessment of adherence to program protocol and implementation were tailored to fit the upscaled program from the RCT evaluation framework. In contrast to the RCT, parent-completed questionnaires were administered on-line using Survey Monkey. This modification was designed to enable immediate data access to the evaluators and to reduce administrative time and cost associated with printing, distributing, collecting and returning hard copies, as well as data entry. Tablet computers were provided to parent facilitators to allow parents to complete questionnaires at the first session if not done prior.The evaluation of the PEACH™ QLD Project was adapted to the REAIM framework components of Reach ; Effectiveness ; Adoption ; Implementation ; and Maintenance  . Table 2The evaluation framework of PEACH™ QLD was designed to meet the needs of the funder and as much as possible reflected its evolution from the RCT and community trial settings, comprising a range of outcome, impact and process evaluation indicators. It also included a range of broader environmental- and systems-based measures reflecting the Team’s experience in evaluating OPAL, South Australia’s settings-based community-wide childhood obesity prevention initiative . DespiteIn large scale community trials, a trade-off exists between the evaluation data required by the funder and the actual or perceived response burden on participants. From PEACH™ RCT to community iterations of PEACH™, we simplified data collection in order to better meet participant expectations, minimise participant burden and to reduce evaluation costs . PEACH™ QLD enrollees were participating in a healthy lifestyle program in the community setting and so were unlikely to consider themselves enrolled in a research project as participants in an RCT would. Furthermore, there was no requirement to provide data in order to participate and additionally no incentive to complete evaluation. Evaluation was hence simplified to collect only essential data in later iterations of the program, in order to minimise the influence of evaluation on program engagement and attendance. A specific example is the replacement of the lengthy CLASS questionnaire Table  with theSome data were collected as routine during the stages of program enquiry and enrolment for the purposes of determining eligibility and planning groups, including demographic information . These data were also collected as part of the formal evaluation. The collection of data at multiple time points may have placed an unnecessary burden on participants. Additionally burdensome was the use of a 9-digit ID number conceived at the beginning of the Project to contain program delivery information including wave, site, group, facilitator, family and child information. Correct transcribing of the 9-digit ID number in evaluation by participants and facilitators was difficult and there were a number of errors. To maximise usable data, child date of birth was added to questionnaires to facilitate data matching and even this was inaccurately recorded a number of times. Future programs should consider simple ID numbers, with at least 2 other variables suitable to use as a cross check of information, such as date of birth and sex. Alternatively, data pertaining to program uptake and success  may be better gathered by existing service provider information systems, where applicable, and linking evaluation data to a Medicare number or My Health Record as part of the National Digital Health Strategy. This would also enable ready access of the data to service providers and can be used internally to justify ongoing service delivery in their catchment, or for continuous quality improvement. Finally, we could have allocated participant ID numbers a posteriori, matching data to names rather than numbers, which may have placed greater focus on the Program delivery and less emphasis on the research component of the Project.Online data collection was a key strategy to maximise the amount of data collected, reduce facilitator burden, and enable ready access to evaluation data for monitoring and reporting. This was closely monitored and parent facilitators were informed of completion in real-time. Supplying an online link to the baseline questionnaire allowed parents to provide baseline data before their first session. This led to the collection of some baseline data – including parent and family socio-demographics – from 24% of enrolled families who did not attend any session. While these data were limited, they proved valuable in understanding the profile of families who enrolled but do not attend. Pre-program completion of questionnaires may have served as an early indication of engagement and commitment to the program.Where baseline evaluation were not completed online before the sessions, trained facilitators played a supportive role in data collection at sessions as the geographical spread of groups precluded centralisation of data collection. This is in contrast to clinical research settings, where data collection during sessions/after program commencement is not appropriate as this can either distract from the delivery of the intervention or not serve as a true baseline measurement. Tablets provided for data collection at sessions were inefficient as devices had to be shared between group members and many participants were unfamiliar with their use. However, given the service delivery nature of the program, an additional session pre-program for data collection may not have been acceptable for families, and would have been a significant additional cost for the Project. Future programs need to develop their own strategies to optimise (and prioritise where necessary) the collection of data during program delivery.Evaluation data, particularly at the child level, were largely uncollectable for those families who did not attend any program session (24%). Despite this non-attendance rate, parental response rate to questionnaires was reasonable (75%) and there was a modest level of questionnaire completeness (74%) leading to varying levels of missing outcome data. Of those children enrolled, 41% did not have any paired outcome data, largely due to non-attendance, at the final session in particular. Data collection was the responsibility of session facilitators  and may not have been existing routine practice. To ensure more complete data collection in future, the importance of this task should be emphasised and supported so as to inform future practice and meet the ethical obligations of sharing and disseminating findings via peer-reviewed publications.In addition, not all anticipated evaluation Table  was ableWhile external evaluation has several strengths for research rigour and impartial expert assessment, it presented some challenges in the present study, particularly as the implementation and evaluation teams were two organisationally and geographically separate teams based in Brisbane, Queensland and Adelaide, South Australia, respectively. The main drivers for the Brisbane-based Project Implementation Team were ensuring a smooth running program and satisfying the tender milestone requirements, principally child enrolment numbers which were tied to financial payments. In contrast, the main driver for the Evaluation Team was the amount and quality of data collected with little direct connection to program facilitators.Overall, attendance was a concern and the catalyst for modifications to program delivery, in particular a change from fortnightly, to weekly delivery of sessions 1–9. It was a challenge for the Evaluation Team to provide process evaluation data, in particular participant concerns, program satisfaction and acceptability in real-time to support this change as these data are only captured at the end of the 6-month program in the follow-up questionnaire. In response to this, additional qualitative research efforts to explore factors associated with enrolment  and engaImplementation research is a relatively new and rapidly emerging field and theoretical approaches and frameworks underpinning implementation science have become more common over the past decade. There are now a number of conceptual frameworks for implementation including REAIM , ProctorIn order to present a case for a program to be implemented long-term or become adopted as part of routine practice, it is critical that there is solid evidence, which requires collection of comprehensive and valid data. Collection of these data requires adequate funding for health service surveillance or specific program-targeted funding, as appropriate. Evaluation of upscaled programs in the real world is challenging as unlike gold standard efficacy studies in clinical or research environments, behavioural interventions and evaluation can evolve over time to meet participant need and fit within changing public health systems and settings. There may be some loss of control when upscaling potentially affecting participant engagement, intervention fidelity and hence evaluation rigour. Ultimately, there can be many trade-offs in translation research and researchers who find themselves working in this space need to be prepared to settle at times for something less than ideal.Understanding practicalities in data collection and management may help others to design their data collection tools and processes to optimise data quality and ease and efficiency of data collection. Our learnings from the evaluation of PEACH™ as a service delivery program in Queensland provide new knowledge which can assist to inform the evaluation of future evidence-based, family-focussed interventions for children or other upscaled programs.


Care coordination has been identified as a person-centred response to the difficulty in meeting the needs of people with severe and persistent mental illness and complex needs. This study evaluated the processes and outcomes of the Partners in Recovery initiative in the Australian Capital Territory, a program established to improve coordination of health and social care for this population.n = 25) and service providers (n = 14). Qualitative data comprised open-ended written feedback from the surveys, together with semi-structured interviews with selected clients (n = 6), carers (n = 2), and service providers (n = 4). In both study elements, questions focused on dimensions of experience such as communication, continuity and coordination, teamwork and sustainability. Descriptive statistics were calculated for quantitative data; qualitative data were analysed using content analysis.Client, carer and service provider experiences were investigated using a combination of quantitative and qualitative methods. Quantitative data were collected through questionnaires completed by clients  were central to client and carer reports of the impacts of the program, and to coordination between services through connections built at the individual level. Challenges included difficulties with information continuity, a lack of role clarity for service providers, and uncertainty about the legacy of the program given the absence of formal agreements connecting different services.The Support Facilitator role was critical to the success of the program. Support Facilitators acted as a source of stability and relational continuity for clients, while also enabling connections with external services through the development of individual level partnerships and personal networks. Systems level coordination was limited by communication difficulties and a lack of formalised infrastructure to support cooperation between services, calling into question the lasting impact of the program for system change.The online version of this article (10.1186/s13033-018-0194-2) contains supplementary material, which is available to authorized users. Providing services to people with severe and persistent mental illness is complex as it requires both coordinated and collaborative efforts between multiple sectors. This includes primary mental health and physical health care, as well as income support services, employment, education, housing support and non-government sector organisations such as alcohol and drug treatment services . Due to Coordination in mental health care usually includes flexible care plans that facilitate team services across health and social care boundaries over time , 3, and However, the evidence for the effectiveness of care coordination is currently limited. Programs that have demonstrated success suggest that it is a caring and personal relationship with the care coordinator that is the defining element , 5. The The Partners in Recovery Program, funded by the Australian Government in the 2011/12 Budget , is a meAt the core of the program’s design was the Support Facilitator (care coordinator), whose primary responsibilities were to assess client needs, manage referrals and develop partnerships for participants’ recovery goals . A clienThe flexible development and implementation of the program according to local systems necessitated evaluation of the processes and outcomes of the PIR care coordination model in individual locations in addition to the National evaluation . This paAre clients and carers satisfied with the Program?Do clients experience better coordination of their care?Do service providers believe coordination has improved?Are service providers satisfied with the local Partners in Recovery model?What are the barriers and facilitators for effective partnerships and referrals?What are the main factors that may affect sustainability of the model, both within and beyond PIR Program funding?The key evaluation questions of interest were:The ethical aspects of the study were approved by The Australian National University Human Research Ethics Committee (2015/148). Written informed consent was obtained from all participants included in the study.Client, carer and service provider experiences of PIR were investigated using a combination of quantitative and qualitative methods. Quantitative measures comprised client and service provider questionnaires as described below; qualitative data collection consisted of open-ended survey responses, and individual semi-structured interviews with selected clients, carers and service providers.Participants in the evaluation comprised three key groups: PIR clients, carers of PIR clients and service providers in the region connected with the PIR Program. The Support Facilitators were located in six community mental health service providers, and referred clients to a wide range of health and social care services throughout the region.To be eligible for the PIR Program, potential clients had to satisfy five criteria: 1) a severe and persistent mental illness, (2) complex needs requiring substantial services from multiple agencies, (3) recent engagement with services, (4) experienced a failure of coordination between services previously that would be likely to be addressed by PIR, and (5) expressed a willingness to be referred for ongoing treatment and consented to participation  and I have worked really well together… it’s definitely evolved and I feel like I’ve always been able to negotiate with her what I’ve wanted, what I haven’t wanted. Client 5 (endpoint)This was supported by comments from interview participants both during and after the program. Clients were positive about their rapport with their Support Facilitators, who they described as “…always looking for ways to improve,” challenging them about things that were not healthy but also listening to their stories and ideas.I don’t think he really understood … with people like my son, they take a long time to trust people and a long time to work with because of the nature of the illness. And it takes a long time to get the trust and to actually do something. But they need that contact. And I don’t know if he really understood the whole situation. Carer 1However, there was some evidence that rapport was dependent on the success of individual connections. One carer, who described experiences with a range of programs and multiple Support Facilitators, felt that one Support Facilitator did not have a good understanding of how to relate to people with psychotic illness.With a new service or worker it’s like starting again. No history was shared-or if it was they haven’t read it. Client survey participantI think there needs to be a little bit more communication between the actual services and PIR about how things are working… Client 6 (midpoint)Client experience of continuity and coordination of care was assessed by seven items that explored information continuity and perceptions of coherent care. Although the majority of ratings were still positive, percentage of positive responses were comparatively lower than for other dimensions: all items scored 80% or fewer positive ratings for at least one time point. In particular, more than a quarter of clients indicated that their history was not available at all providers and they had to repeat information.Most programs or services that I’ve accessed have been very specific it’s either been counselling and this is what we do, whereas this, it’s not really counselling. I guess its facilitation and empowerment and reconnection. It’s so holistic that I’ve never experienced anything like it… Client 5 (midpoint)By the end of the evaluation, participants reported improvements in the coherence of the care services provided. For client interview participants, this coherence gave a sense of holistic care, focused on them as a person rather than a mental health problem.… when we first heard that they were doing the coordinating, because it’s the carer that usually ends up doing all the coordinating…And that’s with everything, it’s not just the health part, it’s the housing, the [social security], whatever…specialists. You’re the one that has to run around and try and coordinate everything and link it all up, and that’s kind of what I thought PIR would maybe have taken that role. But it hasn’t worked out like that. Carer 1 (endpoint)Consistent with her description of a poor fit between her son and his Support Facilitator, one carer did not believe that PIR had delivered on its role in care coordination.Two items explored clients’ satisfaction with the support and services provided. The overwhelming majority (over 90%) reported that PIR had provided everything they expected and a slightly smaller majority (84–87%) also indicated that the program provided sufficient support.Partners in Recovery is like an advocate. They are, they can speak for you, you tell them what you want and they know exactly where to go, what to do to get it done. Client 2 (midpoint)I’ve always felt like Partners in Recovery really understood mental illness. Really had a very modern understanding of it, that it’s not about somebody coming in telling you what to do, “Take your pills and do this and do that”. It’s like “OK, you’re struggling with that, what can we do to, you know, change your life, tweak it in ways that you can do that better.” Client 5 (endpoint)Most interview participants reported that their Support Facilitators were proactive in their support, making time to find the right services, and demonstrating a “modern” understanding of mental illness that was not just about medication or telling clients what to do without consideration for other influencing factors or for shared decision-making.…it went OK. I meet with my support worker usually every 2 weeks. They’ve arranged some things for me like collecting food packages and some other things…[but] I feel like I’ve been meeting with my support worker less as time goes on and sometimes it’s not often enough because like if I run out of food I don’t really feel like I can contact them like “Hey can you take me out to that place to get a food package” or whatever. Client 4 (endpoint)However, one client was equivocal about the benefits of the program, particularly over time, commenting at the endpoint that the program had been better than others, but had not really been very good at referrals or contacts.…one of the good things that came out strongly for me was that it was trying to promote me doing something for myself if that makes sense… So rather than something being handed to me on a platter… I had to contribute to it. Client 1 (midpoint)On every level. … he’s caring about his appearance. He’s cooking for himself. The gardening thing. Yeah on every level. I can’t think of one level where it’s not this 125% improvement. Yeah, it’s been amazing. Carer 2 (endpoint)The final three quantitative client experience items assessed how well PIR enabled clients to feel in control of their own health. At least 80% of clients reported positive impacts of the program at both time points. A major theme in interviews was the destigmatising nature of the program, which helped people with their sense of self-efficacy, and one carer also credited the program with a complete turnaround in their son’s life.… you know everything’s till the end of June because we don’t know what’s happening… And that… and we know as a consumer, oh those of us that are able to understand, that all this stuff’s uncertain. But that’s how we… we live and feel the way our… the way the organisations that help us feel, because they live with uncertainty all the time about their funding… Client 3 (midpoint)Notably, although there was a greater percentage of positive responses for sense of control at endpoint compared with midpoint, feeling that the recovery plan would make a difference and confidence in self-care both decreased from midpoint to endpoint. Comments from interview participants suggest that some clients felt a lack of self-confidence from past experience of the course of mental illness. This may have been exacerbated by funding uncertainty for the program, giving clients concern that there would no longer be support available if they needed it, undermining the self-efficacy built by the program.Fourteen service providers completed the survey; all were at least “somewhat familiar” with the program and five indicated that it was central to their role, with a strong working knowledge. In addition, four service providers completed in-depth interviews at the conclusion of the evaluation.Table I actually enjoy the model, and one of the successes I think is, one of the good things that’s challenging and it’s great as well, is having a whole lot of different organisations involved, because we all come together and then we all… so I have access into all these other organisations through these other workers that I know very well, get to know very well. Service provider 3Service provider satisfaction with team functioning was measured by seven items that explored communication, role perceptions and collaborative decision-making. The majority of participants were satisfied with team functioning in the PIR Program and some interview participants felt that the consortium model was successful.And as each change of worker in the agency, they’ve required us to do things, and then when they’ve left the requirement to do that thing has not existed anymore. Service provider 3I would like to say it’s been successful from my personal point of view, because I’ve worked quite hard to make it successful. I think the reason I say that is more to do with my hard work than amazing leadership, which I think has been really lacking. So I think that’s compromised the model. I think the model in theory is a positive model, but in practice there have been many limitations that haven’t been resolved… In the absence of leadership and you know capacity to resolve things. Service provider 2However, two areas scored substantially lower positive responses: collaboration on goals and involvement in administrative decision-making. This was reflected in comments made by interview participants, who were concerned that significant turnover of staff at the Lead Agency created inefficiencies in program administration and a lack of clear leadership.… I have found that communication is usually one-sided. I am not kept informed as to information which may affect my ability to make progress with a client. We also receive very little to no feedback through the program as to the impact on the client and whether we can improve the way we work with them. Service provider survey respondentThe data program that we work to was designed not specifically for PIR, but it was designed more broadly for a range of programs within [the Lead Agency]. So there’s been lots of tweaking and so on… We need to be able to put the information in the right places on the database, and sometimes it doesn’t happen, so that creates more work and more downtime for …staff to go through and find the information. Service provider 1Coordination from the service delivery perspective was measured by seven items investigating information continuity and collaboration on care. As for client experience, service provider responses suggest some issues with information continuity: for example, only 40% of providers said they were aware of 60% or more of their clients’ health and social care consultations and only 58% reported that the same information was available to all providers. Comments from interview participants suggested that this may have stemmed, at least in part, from challenges in the program management software.We’ve learnt a lot of about the services that are out there, and I think also we’ve built up a good level of relationship with the various services. You know we get to know a lot of the service workers around the ACT. And I think you know that’s where part of the success is, too, is connecting with other services and taking a more personal approach, and just wading through all the mystical stuff, or the stuff that people just can’t deal with. Service provider 1Despite this, three quarters or more of respondents were positive about collaborative care, and there were no reported problems due to poor coordination. As one interviewee put it, the program was very successful at building relationships due to the “personal approach” of the Support Facilitators.I think first you have to be sure that there are all those services to coordinate in the first place…Do all the services exist? … If you want to coordinate something there has to be something there to coordinate, I guess… For the model to work it has to be available. Service provider 4As described above, the PIR consortium model was thought to facilitate partnerships, creating connections between organisations. However, some service providers thought the model was not without its challenges, including a lack of clarity of the precise role of the Support Facilitator and a lack of services available for coordination.I think in large part that’s been underpinned by the use of brokerage, because for the first time … Partners in Recovery was the first time that I’ve ever heard of a program where we had an appreciable amount of money allocated for each person that we work with to assist. So what that helped with in terms of local networks and partnerships with other orgs and other services is we were able to assist. Service provider 2One aspect of the program that was mentioned as a particular facilitator was the “flexible funds” (brokerage) available to help clients with immediate needs. Service providers noted that this was unusual and facilitated the referral process.…the challenge of earning our stripes and getting involved with the mental health team… So it was the mismatch thing, the classic NGOs versus clinical teams. I think we just, we had all this responsibility but no real authority like who were we, who was Partners in Recovery?… The challenge was trying to describe the program, I guess, like what is a Support Facilitator. Service provider 4… really haven’t been able to work close enough with [the Lead Agency] to look at developing some solid agreements with people like the hospitals and the health service, and some of the other people, Indigenous organisations and other services around the ACT… sometimes it’s good to have something like a service level agreement or an MOU in place, and particularly with places like the hospital, where they have you know protocols and procedures in place… Service provider 1Most service providers reported positive experiences connecting with the various government and community services associated with the PIR Program, but some did feel that their lack of role clarity and a lack of formalised agreements hindered their relationships with clinical teams.We still have a role as a co-ordinator of supports under the NDIS, but even that, we don’t know what’s going to happen at the end of next year, the 30th of June, when we definitely won’t be having jobs in PIR anymore …So what happens to the people who we were co-ordinating supports for and have had… you know generally we’re doing that for people who we’ve had a long relationship with in PIR, and then we just move into co-ordination of supports. Service provider 3Part of the program is systems change and I’m not sure what’s come of that. We had a really good chance to change the system, we had a lot of funding so my concern is—and it’s been for a while—what is the legacy of Partners in Recovery, what’s going to be left after we’re gone, did we change anything significantly that the whole system could have held onto and gone “Wow, that was really great and Partners in Recovery helped change that.” Service provider 4The primary threat to the coordination model created by the PIR Program was seen to be funding. The program was identified as “in scope” for the National Disability Insurance Scheme (NDIS), a National program to provide flexible packages of care to Australians with disability, including psychosocial disability. An extension of funding for PIR beyond the initial 5 year period was granted only to facilitate transitioning of eligible clients to the NDIS and to other services for those not eligible. Service providers struggled to reconcile themselves to this uncertainty after the program’s perceived success. The program’s lasting effects on the system also seemed unclear, and this was a source of disappointment to the people involved in the program, who felt that it had potential to have a strong legacy.Reflection on the PIR Program offers an opportunity to examine the successes and shortcomings of a local coordination of care model for severe and persistent mental illness, and its broader relevance to coordination of care programs internationally. Evaluation findings reflect a mostly positive overall experience with the PIR Program for clients, carers and service providers. Participants were satisfied with the program across the majority of experience dimensions, and there was evidence of improved access to coordinated care. Support Facilitators were central to client and carer reports of the impacts of the program and a recovery-oriented approach to care. However, service providers (including Support Facilitators) were not confident that the positive changes they had experienced would be sustained beyond the program’s end. This lack of confidence may reinforce arguments elsewhere that “relationship-centred care” is crucial to the success of care coordination initiatives for mental health , and thaGiven that successful implementation of care coordination is experienced by clients as continuity of care , experieConsistent with findings from other studies on care coordination, which report that availability and consistency of information between providers is a key challenge that can undermine the administration of care coordination initiatives , 17, somBuilding self-management skills and overcoming stigmatising beliefs about their own mental health were key topics raised by clients in open-ended feedback. Clients described the sense of “empowerment and reconnection” gained through working with PIR, focused particularly on Support Facilitators’ assistance in navigating and building bridges across the fragmented mental health care system. This is consistent with the program’s person-centred approach. However, this contrasts with the findings from interviews with Support Facilitators in Western Sydney: in this study, the authors noted a lack of explicit reference to recovery orientation by Support Facilitators and expressed concern that recovery may not be receiving adequate promotion within the program . EvidencA key aim for the PIR Program was to develop partnerships and linkages between services to effect system change . This syThese strengths and challenges have important implications for the sustainability and lasting impact of PIR on care coordination programs broadly. Kania and Kramer argue that for any large coordination of care initiative, “the expectation that collaboration can occur without a supporting infrastructure is one of the most frequent reasons why it fails” . As obseThe strength of these findings is limited by the small number of participants recruited, although the participation rate was similar to contemporary studies conducted with people with serious mental illness  and healA potential bias may also have been introduced by the Support Facilitators’ selection of client participants. Clients entering the program were often experiencing acute episodes of mental illness and were judged to be “too unwell” to be referred to the evaluation by the Support Facilitators. Whilst triaging helped ensure the safety of participants and reduce the burden of questionnaires they had to complete, this limited the amount of data collected across the entire evaluation and substantially reduced opportunities to assess changes in outcomes. Future work with care coordinators should consider embedding evaluation processes within service contacts to reduce the sampling effect and allow people who wish to participate the opportunity to do so with appropriate support.The involvement of the Lead Agency in advertising the service provider participation opportunities may also have influenced who responded to the invitation, and the nature of their feedback. However, there were both positive and negative findings, and participants were willing to comment on aspects of the program which they felt did not work as well, providing balance.Evidence from clients, carers and service providers suggests that the PIR care coordination model is successful in meeting its aim to provide tailored, wrap-around care to people experiencing severe and persistent mental illness, but the success is driven by the Support Facilitators. Support Facilitators developed strong, respectful relationships with most clients and carers, and partnerships with a broad range of health and social care services. Coordination was thus underpinned by strong relational continuity and management continuity, but this was weakened by poor communication (information continuity), and there was doubt that the system changes would endure beyond the program funding.This has important implications for care coordination programs with system-level outcomes amongst their core aims: although many such initiatives focus on the role of information and its ease of transfer in the digital age, success is still dependent on the relationships between clients, families and providers, and assigning responsibility for managing both the information and the relationships. In fragmented health and social care systems where poor communication is a defining feature, in at least the medium term, there will continue to be a need for the care coordinator role to span the boundaries of services and ensure people with complex needs are supported to receive the care they need.Additional file 1. Interview protocols.


Almost all (98%) HCAs were satisfied with the program. These quantitative results were corroborated by qualitative data from open-ended survey questions and focus groups. HCAs described how they exercised with clients and how the psychosocial work environment changed with the program. Building physical activity into HCAs’ job is feasible and can effectively promote HCAs’ health, especially among older HCAs.Home care aides (HCAs), predominantly women, constitute one of the fastest growing occupations in the United States. HCAs work in clients’ homes that lack typical workplace resources and benefits. This mixed-methods study examined how HCAs’ work environment was transformed by a pilot workplace health promotion program that targeted clients as well as workers. The intervention started with training HCAs to deliver a gentle physical activity program to their older clients in a Medicaid-funded home care program. Older HCAs aged 50+ reported increased time doing the types of physical activity that they delivered to their clients (stretching or strengthening exercise) ( Home care aides (HCAs) are non-medical paid caregivers who provide long-term services and support, such as routine housekeeping  and personal care services . Typically middle-aged or older, low-income, ethnic minority women, HCAs constitute one of the fastest growing occupational groups in the United States, projected to add 458,100 jobs between 2014 and 2024 [HCAs are similar to many other front-line service sector workers: HCAs receive limited workplace benefits such as work-site wellness programs and lack their own resources  to make the best use of evidence-based health care and prevention strategies ,3. Like Yet, HCAs’ work environment is unique. HCAs’ workplace is their clients’ private homes and thus it is difficult for managers or health promotion program staff to reach and intervene there. HCAs often work in isolation without direct supervision or peers in their workplace. Despite their regular contact with clients and intimate knowledge of their life styles and health conditions, HCAs lack opportunities to be part of their clients’ care team in current health care systems . HCAs arWorkplaces are increasingly recognized as important venues for promoting population health . HoweverTo address this gap, we pilot-tested a health promotion intervention program that trained HCAs to deliver a safe, gentle physical activity program to their older clients as part of HCAs’ work in a Medicaid-funded home care program. The program aimed not only to enhance the function of home care clients, but also to empower HCAs with health literacy and concrete tools to promote health behavior changes in their clients and others. The program’s implementation process has been described elsewhere . This cuA mixed methods approach was employed to evaluate the pilot program using a single group pre- and post-test design. The study participants consisted of 46 HCAs and their clients . All 46 HCAs attended the training and completed self-administered questionnaires in group settings before the intervention. Thirty-one attended a follow-up training after 4 months and participated in a post-intervention survey and a focus group discussion, while 10 HCAs who could not participate in the follow-up training session were interviewed individually by the trained research interviewers. Five HCAs did not participate in the post-intervention survey, because the research staff could not reach them. HCAs who dropped out were older and had fewer years of home care experience than those who stayed in the program  HCAs’ responses to open-ended questions in the surveys and (2) focus groups. The study was approved by the Institutional Review Board at the University of Illinois at Chicago (Protocol #: 2012-1115). All participants signed written informed consent forms.Study participants were recruited from a large home care agency that provides in-home services to older adults eligible for the Illinois Department on Aging Community Care Program. This program provides home and community-based services to residents of Illinois aged 60+ with assets ≤$17,500  who have an assessed need for long term care. This state program is partly financed by the Medicaid waiver program, a rapidly growing program that is the main mechanism through which states finance home and community-based services for older adults with limited resources. Qualifications for HCAs included a high school diploma or general education diploma, one year of HCA work experience, or demonstration of continued progress toward a general education diploma. The state requires HCAs to attend 24 h of initial pre-service training before employment, and thereafter, a minimum of 12 h per calendar year of interactive in-service training approved by the provider agency. The participating home care agency is unionized, and thus their HCAs were represented by the labor union, SEIU Healthcare Illinois & Indiana.Healthy Moves for Aging Well is a low-cost physical activity program, developed by Partners in Care Foundation to safely enhance the activity level of home-bound older persons who are nursing home-eligible in a Medicaid program . Based oHCAs attended a 4-h training session led by the research staff. HCAs learned how to deliver the brief motivational enhancement and 3 chair-bound movements to the clients, and how to remind their clients to do Healthy Moves every day as part of regular home care visits. The training hours were counted towards state-mandated in-service training hours to facilitate HCA participation. HCAs attended one of the eight training sessions that were offered between August 2014 and January 2015 to accommodate waves of participant recruitment.The intervention started immediately after the training. On the first home visit, HCAs assessed clients’ readiness for physical activity, had their clients set personally meaningful goals, and taught the 3 moves. On average the process took 27 min, ranging from 10 to 45 min. For the next 4 months, HCAs were asked to remind their clients of their personal goal and daily exercise routines as part of their regular home care, and to fill out a simple activity log. HCAs were asked to encourage clients to do the following moves every day: 15 arm curls two times (holding a 1 pound weight); ankle point & flex up to 30 s on each foot three times; and seated step-in-place up to 1 min.HCAs’ physical activity levels and related concepts were assessed by baseline and post-intervention surveys . ParticiIn the post-intervention survey, HCAs were asked to rate the extent to which the program motivated them to be physically active and made them more physically active. HCAs evaluated two additional aspects of Healthy Moves: the training , and the extent to which HCAs used what they learned . Five-point Likert scales were used (from “strongly agree” to “strongly disagree”). Finally, HCAs’ overall satisfaction with the program was assessed by a single question with four response categories (very satisfied to very dissatisfied).t-tests for continuous variables. HCAs’ evaluation of the program in the post-intervention survey was examined using descriptive statistics. Analyses were conducted by using Stata SE 13.1 .Changes in HCAs’ physical activity and related items between pre- and post-intervention assessments were examined by Wilcoxon signed-rank tests for ordinal variables and two-tailed paired The post-intervention survey included a question on how satisfied HCAs were with the Healthy Moves program, followed by an open-ended question probing reasons behind HCAs’ level of satisfaction. HCAs wrote one to two sentence responses in the relevant space in the self-administered survey, which were subsequently transferred into an electronic file using REDCap. Almost all 31 HCAs were very satisfied (80.6%) or somewhat satisfied (16.1%) with the program. The one HCA who was not satisfied did not provide any qualitative information.N = 9, N = 5, N = 5, N = 12). Each one-hour focus group session started with an ice breaker . The facilitator (N.M.) asked HCAs to share their experience with Healthy Moves during the 4-month intervention period. This study focused specifically on HCAs’ discussion of the program’s effects on HCAs themselves. The focus group sessions were audio-recorded and professionally transcribed.HCAs provided an in-depth description of their experiences with Healthy Moves in four focus group sessions attended by a total of 31 HCAs . However, no such increase was observed among younger HCAs. There was no statistically significant change in time spent on other types of physical activity nor in readiness to exercise regularly and exercise self-efficacy in HCAs.N = 12) increased time spent on stretching or strengthening exercise. In particular, older HCAs who reported “none” at pre-intervention assessment reported spending up to 30 min (N = 1), 30–60 min (N = 4), 1–3 h (N = 3), and more than 3 h (N = 1) weekly on stretching or strengthening exercise.To follow up on the significant finding that older HCAs increased time spent on stretching or strengthening, we graphically depicted changes in time spent on stretching or strengthening exercises between the baseline and Month 4 among older and younger HCAs. The post-intervention survey data corroborated the above findings among older HCAs. As shown in “…if it helped me it had to have helped her... I did it with my client… We’ll sit there and do them together… And I was like whoa. I can feel that.”Focus group data revealed that some HCAs did Healthy Moves with their clients. Twelve of the 13 HCAs who mentioned doing Healthy Moves were aged 50 or older (range: 51–73). Qualitative data analysis provided several themes about HCAs’ doing Healthy Moves with their clients. The most frequently mentioned theme was that HCAs felt they benefited from Healthy Moves themselves, as expressed by one HCA:“She (the client) is a diabetic, and she’s on the dialysis machine….. Sometimes she tells me, ‘I’m tired.’ So I say, ‘OK. We gonna get some rest.’ And then she’ll say, ‘we gonna do one more with the feet.’ I say, ‘OK’. So I let her, you know, go at her pace.”Another frequently mentioned theme was to help clients. For example, one HCA said:“….when I come in, he (the client) tells me ‘now we don’t need to do it ’, I say, ‘yeah, we gonna do it together.’”Some HCAs mentioned that they do Healthy Moves with clients to motivate them, as shown in the following quote:“My client is a 90-year old gentleman and he loves Healthy Moves. He reminds me most of the time. ….In fact, it helps him and it helps me as well because I always do it with him.”The benefit of Healthy Moves for the client sometimes leads HCAs to do Healthy Moves together:“….when we did the arm curls….she (the client) got me beat. Because you know after so long, my arms gonna get tired, but she just keep goin’.”Interestingly, some HCAs were motivated by their clients who were enthusiastic about Healthy Moves.“You got time to do Healthy Moves now? I say ‘OK, let me get to the computer. We do it FaceTime.’ She get on her laptop FaceTime, because we both have iPads, so we FaceTime each other.” One of the older HCAs reported doing Healthy Moves with her clients via FaceTime using her i-Pad:Overall, Healthy Moves was well-received by HCAs. As shown in “Every time I ask my aunt if she did her exercise, her face lights up and even when she talks about it to the doctor.”Ninety-eight percent of HCAs were satisfied with the program. Five major reasons for their satisfaction emerged: (1) client likes the program, (2) program benefits clients, HCAs, or both, (3) program makes the HCA helpful for their client(s), (4) program helps improve the HCA’s relationship with the client and (5) HCA was happy to see the client move around and do the program the HCA delivered. One of the HCAs responded:“Healthy Moves reminded me that I did not have to leave (the home) to engage in physical activity, that I needed to make time every day for my health. And I appreciate the past 4 months on a personal level.”The most frequently mentioned reason why HCAs were satisfied with conducting Healthy Moves with their clients was that it was beneficial for both the clients and the HCAs themselves. One of the HCAs responded:“It made my clients more motivated and wanting to do the exercises without any help. It also increased their strength as far as walking and balancing better.”“…I used to have (a) hard time exercising because of arthritis, but now I'm better and do more.”The following comments highlight Healthy Moves’ benefits:“It is very satisfying because the client (was) trying Healthy Moves and me, too. It gives us both energy to start the day.”The program’s dual benefits for clients and HCAs were expressed by one HCA:“It helps the client’s health, mood, and allows for a better bond with client...”The program also provided the chance for their clients to do something and helped HCAs’ relationship with their clients:Some HCAs commented that Healthy Moves helped their health problems, such as having poor circulation in their arms. Some of the HCAs stated that Healthy Moves inspired them to increase their level of exercise or to walk. One of them said, “I started the Healthy Moves, …if I need to lose weight, I’m gonna lose weight… so I’m walking a lot more than I was. My thing was walking…”“(My client) has arthritis really bad. And it’s really helped her. She used to get the shots. But since she’s been, we’ve been doing this; she hasn’t had to have it… And she was glad too. Actually she was the one that signed up for it and told me about it…. So that got me to even, you know, exercise more.” “I give my whole family Healthy Moves, because it helps us and we benefit from it.”Finally, one HCA said,This study demonstrated that building health promotion into the work of HCAs was feasible and effective in promoting physical activity in HCAs, especially among older HCAs. Results from quantitative analysis of pre- and post-intervention HCA surveys indicated that older HCAs spent more time on physical activity (stretching or strengthening) after the intervention. The program was well received by HCAs. The safe, gentle physical activity program delivered by HCAs helped create a positive working environment for most HCAs. Many HCAs perceived the program as fun and beneficial. One of the HCAs stated that her client enjoyed the Healthy Moves program so much that the HCA was motivated to do Healthy Moves with the client. Healthy Moves was instrumental in building HCAs’ relationships with their clients and in motivating HCAs on their jobs. Our mixed methods approach allowed triangulation of results from quantitative survey data and qualitative data (open-ended survey questions and focus groups) and revealed improvements in HCAs’ psychosocial work environment during the pilot intervention.Our study had limitations. The single group pre-post study design limited our ability to infer causality, and the small sample size did not allow multivariate analysis. Self-reported measures of HCAs’ physical activity are likely to have introduced recall and social desirability biases. Our mixed methods approach partly addressed those limitations. For example, the qualitative data helped us understand the context that produced the quantitative results, indicating how our intervention program led to increased physical activity among older HCAs. Our positive results warrant a larger randomized controlled trial for testing the effectiveness of our program for HCAs as well as for their clients. Future research should include objectively measured physical health as well as measures of mental health among HCAs to investigate the program’s additional effects on psychosocial work environment. This current study contributes to the small but growing literature on intervention programs that aim to improve the health and safety of home care workers, incorporating life style factors such as physical activity ,25. Our Our research challenges the current home care work paradigm of a “passive care model” where HCAs carry out care plans to help older adults. Our program aims to develop a new work environment for home care workers, which would facilitate a cultural shift towards a model where HCAs and their clients work together on a safe physical activity program that benefits both HCAs and their clients. We envision a home care model that empowers HCAs  to contribute to the service recipient’s care team through health promotion, not just housekeeping and personal care services.Workplace wellness programs that are popular in large companies and certain sectors are not available for the predominantly female direct care workforce . Buildin


Meanwhile, an analogous result is computed for the p-adic Lebesgue product spaces with power weights. In addition, we characterize a sufficient and necessary condition which ensures that the weighted p-adic Hardy type operator is bounded on the p-adic Lebesgue product spaces. Furthermore, the p-adic weighted Hardy-Cesàro operator is also obtained.In this paper, we introduce the  Howeveeader to –5. In rep, let p-adic numbers. It is defined as the completion of the field of rational numbers p-adic norm x is represented as γ is an integer and the integers m, n are indivisible by p, then (i)(ii)(iii)For a prime number p-adic analysis, we know that any non-zero element x of p-adic norm because p-adic integrals in It is well known that p-adic norm on The space Denote by dx on dx such thatSince f is a nonnegative integrable function on The most fundamental averaging operator is Hardy operator defined byto Hardy , states f is a nonnegative measurable function on For the multidimensional case ussed in –14. \docn-dimensional spherical averaging operator, which was introduced by Christ and Grafakos in [The other definition is the fakos in  as folloet al. [n-dimensional p-adic Hardy operator:f is a nonnegative measurable function on p-adic Hardy operator on Lebesgue spaces with power weights.In 2012, Fu et al.  defined et al. [f is a nonnegative measurable function on In 2013, Lu et al.  gave thep-adic product spaces as follows and discuss the boundedness and best bound on the product of p-adic Lebesgue spaces.Next, we will introduce the definition of Hardy type operator on the higher-dimensional f be a nonnegative measurable function on p-adic Hardy type operator is defined byLet ψ. For Example, when In 1984, Carton-Lebrun and Fosset  defined p-adic Hardy operator ψ is a nonnegative function defined on ψ for which p-adic Hardy operator In 2006, Rim and Lee  defined et al. [ψ defined on In 2013, Fu et al.  introducp-adic product spaces.Next, we will extend the operator f be a nonnegative measurable function on p-adic weighted Hardy type operator is defined byφ is a nonnegative measurable function on Let It follows from the Fubini theorem that we can easily formulate the dual operator of f be a nonnegative measurable function on p-adic weighted Hardy type operator is defined byφ is a nonnegative measurable function on Let In 2014, Chuong and Hung[f on Let p-adic analysisp-adic analog of the weighted Hardy-Cesàro operator on weighted Lebesgue spaces and weighted BMO spaces. In each case, the corresponding operator norms are obtained. In 2016, Chuong et al. [p-adic weighted Hardy-Cesàro operators and their commutators on weighted functional spaces of Morrey type, and the corresponding operator norms are also computed.In 2014, Hung  considerg et al.  considerp-adic weighted Hardy-Cesàro operator.Motivated by these famous results, first we will give a higher-dimensional version of the f be a nonnegative measurable function on p-adic weighted Hardy-Cesàro type operator is defined byLet p-adic Lebesgue product spaces with power weights. In Section p-adic weighted Hardy-Cesàro type operator also has the corresponding conclusion. In Section The paper is organized as follows. Section LetIfthen thep-adic Hardy type operatoris bounded onmoreover, the norm ofcan be obtained as follows:We provide the following weighted extension of this result.LetIfwhereandthen thep-adic Hardy type operatoris bounded onmoreover, the norm ofcan be obtained as follows:p-adic Hardy type operator will be easy to get on the p-adic Lebesgue product spaces, so we only provide the proof of Theorem When Without loss of generality, we consider only the situation when p-adic Lebesgue product spaces with power weights. We haveIt is clear that f is a radial function, then we have f is a radial function.This implies the claim that if Substituting the variable f is a radial function, we have Using the generalized Minkowski’s inequality and noting that Now let us prove that our estimate is sharp. For Letφis a nonnegative measurable function onIfthen thep-adic weighted Hardy type operatoris bounded onif and only ifSince the case We first prove the sufficiency of Theorem This completes the proof of the sufficiency of Theorem Next we prove the necessary of Theorem Now, for any Obviously, k approach ∞, then ε approaches 0 and Since the inequalitySince the operator Letandφbe a nonnegative measurable function onIfthen thep-adic weighted Hardy type operatoris bounded onif and only ifUsing methods similar to Theorem We note that in , the autp-adic Lebesgue product spaces.Inspired by the paper, we will consider sufficient and necessary conditions of the weighted Hardy-Cesàro type operator SupposeLetbe a measurable function such thatfor some realβand almost everywhereIfthen thep-adic weighted Hardy-Cesàro type operatoris bounded onif and only ifp-adic change of variables. It is worth pointing out that we need to make some appropriate modifications for the necessity. Applying this condition t, so it is easy to get the desired results by adopting the same method as Theorem Noting that Theorem p-adic Hardy type operator and considered the problem of finding a bound for the norm of it from p-adic Lebesgue product spaces with power weights to itself. Moreover, we characterized a sufficient and necessary condition which ensures that the weighted p-adic Hardy type operator is bounded on the p-adic Lebesgue product spaces. In addition, we also extended the results to the p-adic weighted Hardy-Cesàro operator.In the present study, we introduced a class of