Our aim was to evaluate the implementation of a widely available, before-school, physical activity program in a low-resource, racially/ethnically and socioeconomically diverse, urban school setting to identify adaptations needed for successful implementation.We used a collaborative effort with stakeholders to implement the Build Our Kids’ Success (BOKS) program in 3 schools in Revere, Massachusetts. Program structure followed a preexisting curriculum, including 60-minute sessions, 3 mornings per week, over 2 sessions . Programs had a capacity of 40 students per school per session and the ability to adapt as needed.We used a mixed-methods approach, guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. RE-AIM domains were assessed by use of baseline and follow-up student measures, parent interviews, and program administrative records.z score or self-reported quality of life from baseline to follow-up assessment. Parents reported positive program effects. Enrollment was sustained in elementary schools and decreased in the middle school during the study period, expanding to 3 additional schools for spring 2019.From a district of 11 schools, 3 schools  implemented the BOKS program. Program enrollment reached 82% capacity . Of the 188 enrolled students, 128 (68%) had parental consent for study participation. Among the 128 study participants, 61 (48%) were male, 52 (41%) identified as Hispanic/Latino, and mean age was 9.3 years . Program duration varied by school (25–60 minutes), with a mean of 33%  of the session spent in actigraphy-measured moderate-to-vigorous physical activity (MVPA), or mean 16.3  minutes of MVPA. Participants attended a median 90%  of sessions. We observed no change in body mass index (BMI) Implementation and evaluation of an evidence-based physical activity program, in a low-resource setting, are feasible and yield relevant information about program adaptations and future dissemination of similar programs. Despite strong evidence supporting school-based physical activity interventions, a knowledge gap exists that relates to intervention delivery in real-world settings.We evaluated the implementation of a before-school physical activity program in 3 schools by using a structured evaluation framework. Each school had different approaches to program delivery, with potential implications for program results and sustainability.Use of a structured implementation evaluation framework provides key insights into program implementation and delivery that can be used to guide future dissemination efforts across different settings.Physical activity is an important lifestyle behavior that is associated with a reduced risk of chronic diseases  and is kDespite strong evidence supporting a role for school-based physical activity interventions , a signiUse of the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework allows investigators to systematically address the gap between research and practice, recognizing that optimal research conditions often do not reflect the complexity of real-world settings . By undeOur study used a mixed-methods design, guided by the RE-AIM framework, to evaluate an evidence-based, before-school physical activity program, Build Our Kids’ Success, or the BOKS program, in 3 public schools in a low-income community in Revere, Massachusetts. Previous studies showed the effectiveness of BOKS in improving child weight status, social–emotional wellness, and overall physical activity levels ,14; howeThe primary goal of this study was to perform a structured implementation evaluation of a widely available and preexisting before-school physical activity program, Build Our Kids’ Success (BOKS), in a low-resource setting and to identify adaptation needs and targets for optimizing future interventions in similar settings. The BOKS program includes a freely available curriculum, designed for delivery by trained volunteers, with sessions occurring 2 to 3 times weekly during a 12-week period. For our study, the BOKS program was implemented and evaluated for 2 sessions of 12 weeks each  in collaboration with stakeholders, including community health infrastructure, and school district administration.The BOKS program aligns with a systems-level framework of obesity, which highlights the importance of considering both the interpersonal and community levels in effective obesity prevention initiatives . The RE-Implementation of BOKS was supported by a Massachusetts General Hospital community health improvement grant awarded to target health disparities in Revere, Massachusetts. In this community, 65% of students speak a first language other than English, 47% are from economically disadvantaged families, defined as participation in ≥1 state-administered program, including public health insurance, food assistance, or child protective services , and 66%Before the initiative was funded, our research team participated in collaborative community engagement meetings, forming a coalition with local community health leaders, school principals, and BOKS program staff to align program and evaluation priorities. This group met throughout the project to discuss program implementation and delivery .For our study, 3 schools committed to implementing the BOKS program for 1 year, beginning in the spring of 2018. School leadership identified candidate schools in the target community and selected 1 middle school (grades 6–8) and 2 elementary schools (grades K–5) from 11 schools in the district. Each participating school recruited 2 trainers to lead the program, enrolled students, and completed 2 sessions of the BOKS program for 12 weeks, 1 session in spring 2018 (February–June) and 1 session in fall 2018 (September–December).Because BOKS is widely available, the primary intention was to deliver the program within the standardized BOKS curriculum; however, we prioritized each school’s ability to adapt the program as needed to suit their delivery capabilities. A grant-funded, school-based coordinator assisted each school, working in consultation with a coordinator from the BOKS program. We chose this train-the-trainer approach to build capacity in the community.https://www.bokskids.org/, which provided resources and access to the standardized curriculum as well as participation in a sample lesson. Each school had the capacity for 40 students per 12-week session, based on the BOKS standard of 1 trainer for every 20 students. Total program capacity was originally 120 maximum students enrolled per session . Maximum capacity decreased to 230 students following one school’s decision to limit capacity to 30 students for their fall program.Before the start dates of the spring and fall programs, program leaders from each school attended a 2-hour BOKS training session held in the community. Training consisted of an introduction to the online TrainerHub at We performed an exploratory concurrent-nested mixed-methods evaluation, guided by the RE-AIM framework. We chose this approach to embed supportive qualitative data within the larger quantitative evaluation . We collThe study was conducted from February 2018 through December 2018 and included 2 BOKS program sessions with program maintenance observed through spring 2019. The study was recorded in clinicaltrials.gov (NCT#2017P002770) and approved by the Partners HealthCare Institutional Review Board of Boston, Massachusetts.All children enrolled in the 3 participating schools (K–8) were eligible to enroll in the BOKS program, although 1 school excluded kindergarten because of scheduling conflicts. Each school directed program enrollment at the start of the spring and fall sessions. To increase program access for the fall session, schools gave enrollment preference to children who had not previously participated.To facilitate enrollment, study staff provided schools with information and recruitment materials to send home with children at the start of each session. Materials were available in English, Spanish, Arabic, and Portuguese. Parents returned signed consent forms in a sealed envelope to the school, where study staff picked them up. A telephone number was included for parents to call and ask questions. For collection of child measures, children provided verbal assent to trained research staff at the start of study visits.Students were eligible to participate in the study with enrollment in the BOKS program, valid written parental consent, and verbal child assent. Of 188 total children enrolled in the BOKS program during the study period, 128 (68%) had both parental consent and child assent for study participation . AlthougParents from 1 participating elementary school formed a convenience sample for a 20-minute semistructured, qualitative telephone interview. Parents received a letter describing the interview and returned a form providing permission to be contacted. Eligibility criteria included being an English-speaking parent and having a child enrolled in the BOKS program. Parents provided verbal consent at the start of the interview. We randomly selected participants from interested parents until the target sample size was reached (n = 20). Ultimately, 25 of 40 parents (62.5%) expressed interest, 23 were contacted for participation, 20 completed the interview, and 2 were not contacted because the target sample size was already reached. Parents received a $10 gift certificate when they completed the interview. Interviews were conducted by trained research assistants and were recorded and transcribed for qualitative analysis.For evaluating program adoption, school records provided information on district and school demographics (17). We compared demographics of participating schools to overall district demographics. Program administrative records provided information on trainer recruitment. District records detailed the number of students eligible for participation in each school. We obtained program enrollment data from registration forms and attendance records to evaluate program reach. Baseline participant characteristics included race/ethnicity, sex, and age (obtained from registration forms) as well as anthropometrics (obtained through study visits). We compared participant demographics at baseline to overall school demographics. Parents also answered semistructured interview questions addressing reasons for enrolling their child in the BOKS program.Implementation evaluation occurred at both the program and individual levels. Program administrative records provided information on program costs. We assessed intervention fidelity through review of program structure, administrative records, and session visits. Trained research assistants visited each school at least once (range 1–3 times) per 12-week session to perform a structured physical activity observation and obtain objective measurement of participant physical activity.Research staff conducted structured observations by using the System for Observing Fitness Instruction Time (SOFIT) ,22. WithOn session observation days, 10 to 15 study participants wore an ActigraphGT3X+  accelerometer on the wrist or an ActigraphGTX on the hip. Upon arrival to the morning program, research staff fitted children with the accelerometer and recorded time for program arrival (monitor on) and program departure (monitor off). We recorded physical activity intensity levels using Evenson cut-point thresholds . ChildreIndividual-level data included child attendance and parent feedback through semistructured qualitative interviews on program feasibility and acceptability, including barriers to program participation and parental input on program content and structure. Stakeholder conversations throughout the intervention planning and implementation periods documented logistical support provided for programming.z score for each participant . Trained research assistants measured child weight and height using a Seca scale and stadiometer . We calculated child body mass index (BMI) and age- and sex-specific BMI ticipant . Additioticipant . The Pedt tests, ANOVA, and Wilcoxon tests as appropriate for continuous variables, and χ2 for categorical variables. We assessed all data for outlier values and errors in data entry.We tabulated descriptive statistics of participant characteristics by session and school. We assessed differences between sessions and schools by using For the analyses of anthropometrics and quality of life, we used linear regression to measure change across assessment points, using each assessment point as a categorical predictor and model coefficients to estimate change in outcome from baseline. We included all available cases for analyses, with only complete cases included in measurement of change from baseline to each assessment point. For objective measurement of physical activity, we calculated means for wear time as well as time spent in MVPA. We performed 1-way ANOVA to evaluate differences between schools and frequencies for participants achieving thresholds of MVPA. We also report a Pearson correlation coefficient to describe correlation between program duration and MVPA minutes. Due to nonnormality of attendance, we report median and interquartile ranges. We performed Wilcoxon tests to assess for difference in attendance by school, spring versus fall program participation, identification as Hispanic/Latino, and study participant versus nonparticipants.z score, with 80% power at significance level P = 0.05. However, with actual enrollment at 188, we were underpowered to detect statistically significant change in BMI z score so we report the observed difference from baseline to follow up only. We performed quantitative analyses using R 3.5.0 (R Core Team) (At maximum program capacity (n = 230), this study would be powered to detect a 0.38 unit change in BMI re Team) . We collre Team) .All interviews were recorded and transcribed for analyses. We conducted thematic analyses using the Framework Approach , establiGrant funding for implementation of the BOKS program was available for 3 schools in a district with 11 schools. Overall, participating schools were representative of the district in the percentage of economically disadvantaged students  and students whose first language was not English  .A total of 11 program trainers were trained across all sessions and schools. Elementary school 1 had 2 trainers, with the addition of an occasional parent volunteer. Elementary school 2 recruited 6 trainers in total, with 2 present each morning. The middle school recruited 3 trainers; 1 led both sessions and the other 2 led 1 session each. Roles of trainers in the school included gym teacher (n = 2), school nurse (n = 1), academic teacher (n = 7), and counselor (n = 1); 9 of 11 trainers were female. One trainer served as the grant-funded community coordinator and was responsible for coordination within schools and primary communication with the BOKS program.At maximum capacity, the program could accommodate 230 students over 2 sessions, or approximately 17% of the total student body across schools. A total of 188 students (82%) of potentially 230 students began the program. Total enrollment for the fall session was reduced to 110 students, as 1 school (elementary school 2) decreased target enrollment from 40 to 30 students for a lower student-to-trainer ratio . Of the 128 students in the study, a different number was present at baseline and follow-up measurements. Because this study evaluated participation in the program, we did not count the number of students who completed the program .At baseline, 60 (55%) participating students met criteria for overweight, with a BMI in the 85th to the 95th percentile for age and sex, or obesity, with a BMI in the 95th percentile or higher for age and sex . These pDemographics of consenting participants were representative of school and district demographics overall. Within the school district, 55.3% of students identify as Hispanic/Latino (participating schools range 43.5%–56.7%) and 34.3% of students identify as non-Hispanic white (participating schools range 33.3%–43.1%) . Most stLogistical support for programming was provided by the district superintendent, school principals, and the BOKS program. Each school managed program location, dates, and times, as well as student program enrollment and trainer recruitment.Total program cost for each 12-week session per school was $2,600 and included trainer stipends, gym equipment ($300 per school), and participant t-shirts (approximately $300 per school). The program curriculum was free of cost. Assuming full capacity, total cost per participant was $65/student; at actual capacity, cost was $83/student. Program costs for the study period were grant funded; therefore, participation was free for students and participating schools.Structure. All schools adhered to recommended program frequency (3 times/week) and scheduled program duration . Schools completed 32 to 36 sessions, or 89%–100% of scheduled sessions. Reasons for missed sessions included inclement weather (n = 2) or a school event (n = 2). Recommended program time was 60 minutes; as implemented, sessions were 25 minutes at the middle school, 45 minutes at elementary school 1, and 60 minutes at elementary school 2. Both schools that were unable to achieve the prescribed length were limited by early morning access to school facilities and school start time. Overall program capacity was 40 students (1 trainer per 20 students).Content. We performed 10 structured observations using the SOFIT observational measure. Interobserver reliability was 87% for activity observations and 84% for context observations. Across SOFIT-observed sessions, mean 19%  of sessions were spent in vigorous activity, 14%  standing, 37%  walking, 28%  sitting, and 3%  lying down. For lesson context, 54%  of the lesson was spent on fitness, skills, or games, 43%  was spent on management/knowledge, and 3%  was classified as other.Attendance. Overall participant attendance was 77.2%  of sessions, with significantly higher attendance among study participants  versus program enrollees who did not participate in the study . No significant difference in session attendance occurred from the first to the second program sessions among schools in 2018. Median attendance in spring 2018 was 91%  of sessions. Median attendance in fall was 84%  of sessions (P = .89) (P = .89) .Physical activity delivery. Overall, 32% to 35% of the session was spent in MVPA, with no significant differences in percentage of time in MVPA between schools .  schools . Total MParent feedback on program implementation relating to feasibility, acceptability, barriers, and suggestions for future programming supported positive program outcomes. 2, 95% CI, −1.2 to −1.0), BMI z score  and self-reported quality of life  from baseline to completion of program at the 12-week follow-up. Parent observations regarding impact of program participation are summarized in Table 2.Effectiveness evaluation revealed maintenance in BMI (mean change −0.1 kg/mEnrollment decreased between sessions from 103 students (120 capacity) in spring 2018 to 85 (110 capacity) that fall. The decrease was primarily a result of decreased middle school enrollment. Both elementary schools had sustained interest, reaching 100% enrollment capacity in the second session  with an additional 143 students on wait lists. In elementary school 1, 20 of 36 spring participants were on the fall wait list. Elementary school 2 solicited enrollment paperwork only from new participants. No middle school student participated in both sessions.P = .89)  of sessions. Median attendance in fall was 84%  of sessions (P = .89) .In spring 2019, the program continued in schools with district-supported funding and expanded to 3 additional schools  through additional grant funding for a total of 6 schools, representing 61% of the district’s K–8 enrollment. Total enrollment was 189 students of 230 for spring 2019 . Overall, 17 trainers led the spring 2019 session . Trainers who did not continue cited the time and administrative burden; elementary school 1 addressed this by splitting responsibilities among 3 trainers.Using the RE-AIM framework to guide our implementation evaluation, we observed that each of the 3 participating schools successfully implemented the BOKS program. Each school had different approaches to program delivery, with potential implications for program results and sustainability. Overall, schools that adopted the program were representative of the school community at large, successfully reaching a diverse target population at risk for obesity-related sequelae. Program implementation varied most between schools in session length and structure of trainer teams. Both elementary schools had sustained interest between the spring and fall sessions, although interest decreased in the middle school. These findings should be considered in dissemination and delivery of school-based physical activity programs, as well as broader population health efforts to increase access to physical activity opportunities in diverse and low-resource settings.In collaboration with stakeholders, our implementation strategy prioritized program adaptability within each school’s capabilities, maximizing fidelity through ongoing support and training from BOKS and school-based coordinators . LiteratLimited space and schedule constraints warranted decreased session time in 2 schools from the prescribed 60 minutes. With one-third of session time spent in MVPA, a further reduction influenced the total time promoting MVPA to participants. Fixed logistical constraints and competing priorities are common barriers to implementing wellness initiatives in schools and are not unique to this study . As a reSchools also adapted their approach to trainer recruitment, either concentrating responsibilities between 2 trainers or distributing responsibilities among a larger group. Program sustainability depends on maintaining trained personnel who are willing to deliver the intervention . With voAfter the first year, stakeholder discussions focused on program sustainability. Additional grant funding supported program expansion; however, our shared priority was to identify existing funding streams in the district budget to support trainers. School wellness personnel and current trainers also proposed strategies requiring minimal funding, including a peer mentorship model with older student volunteers. These strategies rely on fitting the current intervention within existing school programs and policies as well as continuing to build capacity .Ultimately, program results depend on overall reach and efficacy . At maxiAlthough this intervention successfully engaged a diverse group of youth at risk for obesity-related sequelae, students not enrolled in the study had lower levels of program attendance. Although those students might have been less interested in the program, other disparities might exist between the study and nonstudy groups. Although we translated our study consent forms to reduce language barriers, both overall literacy and health literacy might have influenced enrollment. As vulnerable populations have lower rates of intervention delivery , social Additionally, the middle school had high rates of attrition compared with both elementary schools. Although school leadership changed between sessions, an identified risk factor for poor sustainability , other fOur study’s primary strength is its use of a structured framework, RE-AIM, to evaluate a before-school physical activity program. This approach provides a comprehensive view across each measure with qualitative insights from parents and a focus on identifying program adaptations needed for successful implementation. We identified key objectives for program improvement, which can be explored through more work on processes to maximize physical activity delivery. Furthermore, using the before-school period to deliver a physical activity intervention is an innovative approach, as it takes advantage of a time when children and adolescents are not typically active.Although we have detailed information on implementation in each school, we were not able to test implementation strategies between schools. Without a greater number of participating schools, differences in each school’s capabilities would have confounded differences in implementation strategies. School district stakeholders identified participating schools, which might limit generalizability. Although schools were representative of the district, other unmeasured characteristics, such as openness to innovation or school leadership qualities, may have made these early adopters likely to succeed .Additional perspectives are missing from this study, including teacher input, detailed trainer feedback, and qualitative interviews with non–English-speaking and middle school parents. For parent interviews, adequate representation would have required translation to Arabic, Portuguese, and Spanish, which was not feasible. Although we focused on parents of elementary students, challenges in the middle school setting highlight the importance of engaging the middle school population and provide a target for future work. This study was performed within a single school district and results may not be generalizable beyond this community; however, the evaluation process used may be applied across different school settings.This study demonstrates that structured implementation and evaluation of an evidence-based physical activity program in a low-resource setting is feasible and yields relevant information on program delivery. Program adaptations may be crucial to successful implementation; however, they might also have implications for program outcomes. Through structured implementation evaluation following a similar procedure to this study, it may be possible to identify program components that are key to successful implementation, allowing for targeted dissemination and diffusion of the effective intervention components across various settings.


Contact tracing is one of the oldest social network health interventions used to reduce the diffusion of various infectious diseases. However, some infectious diseases like COVID-19 amass at such a great scope that traditional methods of conducting contact tracing  remain difficult to implement, pointing to the need to develop reliable and valid survey approaches. The purpose of this research is to test the effectiveness of three different egocentric survey methods for extracting contact tracing data: (1) a baseline approach, (2) a retrieval cue approach, and (3) a context-based approach. A sample of 397 college students were randomized into one condition each. They were prompted to anonymously provide contacts and populated places visited from the past four days depending on what condition they were given. After controlling for various demographic, social identity, psychological, and physiological variables, participants in the context-based condition were significantly more likely to recall more contacts (medium effect size) and places (large effect size) than the other two conditions. Theoretically, the research supports suggestions by field theory that assume network recall can be significantly improved by activating relevant activity foci. Practically, the research contributes to the development of innovative social network data collection methods for contract tracing survey instruments. Because infectious diseases like COVID-19 can be spread through respiratory droplets from being near and communicating with infected individuals, researchers have taken advantage of contact tracing to help mitigate the spread of the virus. Contact tracing is the process of retrospectively identifying persons who may have made interpersonal contact with a confirmed infectious individual [At its core, contact tracing is a form of egocentric network analysis (ENA) and, thus, one type of social network intervention to influence public health. ENA is the study of individuals  and people in their immediate social environment . Conducting a reliable and valid ENA study is challenging, and there is a rich academic literature dedicated to improving the rigor behind these efforts ,3. IndeeIn traditional egocentric network research, face-to-face interviews are often considered the gold-standard data collection mode . The reaHowever, there are growing challenges to implementing face-to-face interviews for contact tracing with respect to infectious diseases like COVID-19. First, face-to-face interviews are risky endeavors because the interviewer may put themselves at risk for contracting the infectious disease, especially when diagnoses specifically require a patient to quarantine. Second, interviewers need to be appropriately trained and inevitably vary in how skilled they are, resulting in interviewer effects . As suchThese challenges to collecting contact tracing data via face-to-face interviews points towards the need to developing a reliable survey approach that could be instantly administered and standardized across various contexts. Following past egocentric network research, we examine the impact of three different survey designs: (1) baseline, (2) retrieval cue, and (3) context-based approaches. Each is described below.Perhaps the most important obstacle for egocentric data collection is recall and forgetting . For theA baseline approach to surveying individuals about their contacts would be to simply ask them about who they made contact within a given period of time. This is commonly known as the interaction approach  because The retrieval cue approach for ENA was formalized by Hsieh . This apBeyond contacts, it is also important for egos to remember populated places because individuals could have made contact with strangers whom they may not remember . Likewise, overlapping data from multiple infected individuals who visited the same location could reveal “hotspots” that may be useful for public health purposes. As such, we hypothesize the following:Hypothesis 1.A retrieval cue approach will elicit more (a) contacts and (b) places visited than a baseline approach.The context-based name generator was formalized by Bidart and Charbonneau . The conHypothesis 2.A context-based approach will elicit more (a) contacts and (b) places visited than a baseline approach.Finally, it is important to ask about whether or not a retrieval cue or context-based approach will significantly yield more contacts and places. To our knowledge, no study has specifically compared these two approaches and there exists little theoretical basis for expecting more or fewer differences. Thus, we keep this comparison as a research question as follows:Research Question 1.How do retrieval cue or context-based approaches differ in their ability to elicit more (a) contacts and (b) places visited?The experiment was a one-way between-subjects design. The related manipulation was contact elicitation, with three levels . Other unrelated control variables were uniformly collected across all participants (see Measures). There were two primary dependent variables: (1) unique contacts and (2) unique places visited. An a priori power analysis with the program GPower  suggestsTo recruit participants for the experiment, we used convenience sampling from a college-wide research participation pool from a large southern university. A university sample was chosen for two reasons. First, COVID-19 restrictions  differ state-by-state. In order to control for policy differences, we opted for keep geographic location constant. Second, there is increasing attention paid to the role of college students’ role in spreading COVID-19 . Indeed,The inclusion criteria required that students must be enrolled in participating classes where they are required to participate in at least two studies during that semester, which counts for 5% of their total grade. Alternative assignments were available if the students declined to consent in any of the available studies in the research pool. The selected university still had the majority of its classes face-to-face, and the county had minimal restrictions regarding business openings .The study launched on 18 September 2020 and concluded on 16 November 2020. The reason for terminating the study on 16 November 2020 was that the state and county were soon to enact new COVID-19 restrictions, which may have affected the rates of interpersonal contact and places visited. After removing 18 cases of missing data , the final sample size was 397: 138 in the baseline condition, 127 in the retrieval cue condition, and 132 in the context-based condition. The participants’ ages ranged from 18 to 42, with an average age of 19.94 (SD = 2.35). Regarding gender, 262 (65.8%) identified as woman, 135 (33.9%) as men, and one (0.03%) preferred not to disclose. Finally, 305 (76.6%) identified as white, 50 (12.6%) as African American, 17 (4.30%) as Hispanic, 10 (2.50%) as Asian, 1 (0.03%) as Native Hawaiian or other Pacific Islander, and 15 (3.80%) as Other see .The experiment was conducted online using Qualtrics. Participants were required to complete the study over a computer and laptop in the setting of their choice . Students were not able to participate using a mobile device. Our decision to disallow mobile devices stemmed from the required textual input needed for providing contacts and places visited, which may be more difficult to supply over a mobile device.Participants took part in the experiment individually over a computer at the setting of their choice. When a student logged into the research participation pool website, there were a variety of studies they could choose to complete. The research pool website included the name of the study, which read “Mock Contact Tracing Study”. A brief description of the study below the title included the text, “This study will ask if you can remember, using anonymous pseudonyms, the people and places you have visited from the last four days”.If a student clicked to participate in the study, they first encountered a consent form, which described the purpose, description, and potential benefits of the survey. A key element stressed was that participation was anonymous and when entering contacts and places visited, that the participants should use pseudonyms or nicknames because we were not interested in the actual contacts or places visited, just that if they could remember them. Examples of pseudonyms were given as helpful suggestions .The experiment began with definition of “contacts” and “places”. Contacts were defined as “being in the same proximity within six feet with anybody for at least a duration of 10 min”, a definition borrowed from John Hopkins University . An illuContact elicitation was the key manipulation. There were three independent conditions. In the baseline approach, participants were asked to report their close social contacts motivated by wording from the General Social Survey . The quelast four days. Can you recall all of the places you have visited during those 4 days? Please use pseudonyms as we are not interested in the actual place.Please take several minutes to think back from the The “contact” question similarly read as follows:last four days. Can you recall all of the contacts you have made during those 4 days? If so, enter each name below. Please use pseudonyms as we are not interested in their real names.Please take a few minutes to think back from the For the retrieval cue approach, we followed procedures laid out by Hiesh . Before Homelife: Many people have permanent residencies where they live with family members, partners, and/or friends.homes you have visited within the past 4 days?Can you identify all of the homelife within the past 4 days? These include people who you live with and people who have visited your home. These also include people whose home you have visited.Can you identify all of the people that you have had any contact regarding Worklife and resources: Many people must travel to places to gather resources for daily life. These include things like their workplace and shopping for food, clothes, gas, medical prescriptions, home supplies, or various technologies .worklife/resources within the past 4 days?Can you identify all of the places that you have visited regarding worklife/resources within the past 4 days? These include people who you work closely with and people you interact with to get the resources you need.Can you identify all of the people that you have had any contact regarding Leisure: Many people engage in leisure activities with other people outside of work. These include things like going to churches, social clubs, restaurants, bars, gyms, going to the beach, and public events.leisure within the past 4 days?Can you identify all of the places that you have visited regarding leisure within the past 4 days? These include people who you engage with in leisure activities outside of work.Can you identify all of the people that you have had any contact regarding Other: Are there any other places you have visited that you have not entered yet?past 4 days?Can you identify all of the other places that you have visited within the past 4 days?Can you identify more contacts within the Finally, for the context-based approach, four activity foci were activated to elicit contacts and places: (1) homelife, (2) worklife and resources, (3) leisure, and (4) other. More specifically, the questions read as follows:In all three conditions, participants provided contacts and places in a text box for convenience. Each participants’ text was counted individually by the authors to check for duplicates  and general adherent to the survey procedures . The final two dependent variables were the amount of unique contacts and places elicited by each participant.Past research on individual level factors and network alter recall can help give guidance for additional control variables to include. Our review identified such factors as gender , age 1010, race Finally, we sought to include three single item questions regarding attitudes to COVID-19 and masks. It may be the case that individuals who have more relaxed views on the risk of COVID-19 and the efficacy of masks may be more likely to engage in interpersonal contacts and visit more places. The questions included were “On a scale of 1-10, how serious of a public health threat is COVID-19?”, “How worried are you about getting COVID-19?” and “Do you think wearing a mask helps to reduce the spread of COVID-19?” All items are listed in the Because both dependent variables represent “count” data  with skewed distributions, we opted for a negative binomial regression model. A negative binomial regression was chosen over a Poisson model particularly because the variance was greater than the mean for both contacts and places . TypicalEffect size measures were calculated following Coxe’s  method fOn average, the baseline approach elicited 9.28 contacts (SD = 8.69), the retrieval cue elicited 10.61 (SD = 7.68), and the context-approach elicited 13.13 (SD = 7.60). The number of places visited was lower. On average, the baseline approach elicited 5.72 places (SD = 2.30), the retrieval cue elicited 5.67 (SD = 3.08), and the context-approach elicited 8.27 (SD = 4.01).Est. = 0.13, SE = 0.10, p = 0.13, SMD = 0.22) or places . As such, the null hypothesis assuming no differences between the baseline approach and retrieval cue was not rejected.H1 predicted that the retrieval cue approach, which instructs contacts to view their previous text messages, emails, and social media posts, would stimulate higher recall of contacts and places compared to a baseline approach see . H1 was Est. = 0.34, SE = 0.09, p < 0.01, SMD= 0.62) and large effect sizes when predicting places .H2 predicted that the context-based approach, which primes participants to think about contacts and places with respect to homelife, worklife/resources, leisure, and other, would elicit more contacts and places than a baseline approach. H2 was supported. Compared to the baseline approach, the context-based approach garnered medium effect sizes when predicting contacts . With respect to places, the coefficient contrast was significant as well and larger .RQ1 asked about differences between the retrieval cue approach and the context-based approach. To keep the effects of the control variables, coefficient contrasts were estimated using Bonferroni corrected z-scores with post-estimation see . In termEst. = 0.16, SE = 0.07, p = 0.03), as well as those who identified as White when compared to those is identified as Asian, African American, and Hawaiian/Pacific Islander. Psychologically, those in better moods reported more contacts , and those who were less worried about COVID-19 reported fewer contacts  and places .Finally, although the addition of the control variables did not impact any of the effects of the experimental manipulations, some of the results were worth noting. Demographically, participants who identified as women were likely to report more contacts  baseline, (2) retrieval cue, and (3) context-based approach. Overall, significantly more contacts and places were elicited when participants were randomized into the context-based condition, which primed users on activity foci of homelife, worklife/resources, leisure, and other. Theoretically, the results provide support field theory’s suggestion that better recall can be stimulated when relevant activity foci are triggered. Practically, the study begins to shed light on more effective ways to design egocentric contact tracing surveys. Each of these realms are discussed further below.p = 0.13). However, a few caveats much be mentioned before any premature conclusions. First, Hsieh [There are a few examples of research that test somewhat competing methods of eliciting interaction-based contacts. The current study nearly replicated Hsieh’s  study, wt, Hsieh  elicitedt, Hsieh ), it mayNevertheless, the results found that the context-based approach elicited more contacts and places visited than the baseline and retrieval cue approaches. Following field theory, Corman and Scott  theorizeThe main innovation the current research makes is with respect to developing changes in social network data collection methods for one of the oldest types of relational health-based interventions: contact tracing. This is the first study, to the best of our knowledge, that tests different methods for eliciting interaction-based contacts and places. Overall, the current results provide support for the context-based approach, which first attempts to trigger relevant activity foci and then elicits contacts corresponding to such foci. Participants in the context-based were significantly more likely to elicit more contacts and places visited compared to traditional baseline approaches and the retrieval cue approach. The identification of more true positive contacts and places may allow public health officials to better implement quarantine and testing interventions because fewer contacts and places are slipping through the cracks.To put it simply, some communicative interactions may appear on the surface as random , which may make it difficult for individuals to remember them. However, this only appears to be the case if they are not viewed as situated action and stripped away from relevant activity foci . If it is true that contact tracing is only as good as the data that can be extracted, then making strides at developing a reliable and valid survey for easier and faster deployment can significantly impact public health with respect to infectious diseases that diffuse through interactive-based contact.


Process evaluation of the Activity for Well-Being program found that the reach of the program was moderate but adoption was low. The use of self-management tools and self-determined methods of regulating physical activity intensity appeared to be feasible. The website had mixed responses and low engagement. The element of having a support person elicited a strong positive response in the program participant interviews. Involving local implementing staff more directly into the delivery of the intervention could have potentially improved reach, adoption, and feasibility of the program.The need to undertake pilot testing and evaluation of novel health promotion programs has become increasingly apparent for the purpose of understanding the true effects of complex interventions and for testing and refining behavioral theories that these interventions are informed by. A mixed-methods process evaluation and feasibility study was undertaken for a need-supportive physical activity program that was piloted in a single-group pre–post study. The piloted program was designed to support participant needs of autonomy, competence, and relatedness through evidence-based and theory-informed behavior change strategies including a motivational interviewing style appointment, education on self-management tools , and self-determined methods of regulating physical activity intensity . The program aimed to positively impact physical activity behavior, psychological well-being, and associated motivational processes. Reach, adoption, fidelity, context, change and performance objectives, and feasibility of the program were evaluated using information from survey respondents from the target population ( London, United Kingdom), as an organization that provides funding for preventative health research, has developed and refined guidance to account for these elements through process evaluation To evaluate the reach, adoption, fidelity, and context related to the implementation of the Activity for Well-Being program in the form of a pilot intervention trial.(2)To investigate the feasibility and limitations of the program for the target population of frontline aged care workers and to provide recommendations and guidance regarding the future directions for the program.The Activity for Well-Being program was run as a single-group pre–post pilot trial with follow-up measures at 9 months. Methods of evaluation drew from multiple well-established guidelines and frameworks . Data coprogram participants, non-program participants, and implementing staff.All participants in the pilot program, process evaluation, and feasibly study were employees of a large not-for-profit, aged care organization in the metropolitan and surrounding regional areas of Adelaide, South Australia. The process evaluation and feasibility study outlined here included survey and interview data from Program participants included community- and residential-based aged care workers who chose to participate in the pilot study of the Activity for Well-Being program during the period of November 2017–April 2019. Frontline aged care workers were identified as the target population during the initial needs assessment and consultation with the funding organization. Program participants were recruited from all community-based areas and three residential sites using a combination of emails, posters, flyers, staff newsletter entries, and face-to-face introductions at staff meetings . Community-based employees were primarily recruited through emails and team meetings, since they had limited time in an office or physical space and received most communications on work phones or devices. Residential employees were primarily recruited through the use of posters/flyers or newsletter entries, as well as staff meetings, since these employees worked in a regular location but had limited access to work emails. All program participants provided informed, written consent for the program and the interviews at baseline, at which point they indicated whether they would like to be contacted regarding an interview. Program participants were invited to participate in an interview during the period between the 3- and 9-months measures but were under no obligation to accept the invitation.Non-program participants consisted of members of the target population (frontline aged care workers) who did not participate in the pilot study of the program. Non-program participants were recruited via an online survey (the Reach Survey) that was sent out after the conclusion of the pilot study. Consent for this survey was implied by the respondent completion of the survey, while all participants gave recorded verbal informed consent at the start of the interview. All survey respondents had access to an online version of the participant information for interviews and were given the chance to opt-in to an interview during the Reach Survey process. Interviews were offered to survey respondents who had “opted-in” until data saturation was reached. Purposive sampling was used to include participants with a range of responses to survey questions in interviews.Implementing staff consisted of any employee involved with the implementation or promotion of the program within the local site or location. These staff may have included managers or assistant managers, team leaders, staff involved with healthy aging and health promotion , administration staff, or others. All implementing staff members were emailed directly with a copy of the participant information and an invitation to participate in the interviews.For all invitations to participate in interviews , the researchers made it clear that invited staff were under no obligation to accept the invitation. For all interviews, points of consent were read, and clarified where necessary, and written (for face-to-face interviews) or verbal (for telephone interviews) consent was obtained prior to initiating any interviews. All Reach Survey respondents went into a draw to win a $50 AUD gift card (with one in 10 chance of winning), and all interview participants received a gift card honorarium of $30 AUD in appreciation of their participation.n = 10, all community based)  . In briey based)  and Borgy based)  to keep,Participants were also provided with ongoing physical activity support by the AEP, including need-supportive follow-ups, exercise prescription for home- or gym-based programs, face-to-face assistance with initiating exercise programs, and sign posting to community activities depending on the goals and preferences of the participant. Support was actively offered for the 3 months of the active program period, initiated via two need-supportive follow-up communications . For the follow-up period of 6 months, support was no longer actively offered by the AEP, but participants were able to contact the AEP for support until the end of the follow-up period (the 9-month time point). This approach was taken in order to promote autonomy in activity management within the program participants without withdrawing all need support. Participants also received access to a website, previously piloted  and modiThe process evaluation of the program included assessments of reach, adoption, fidelity, and context. Outcome, performance, and change objectives that were created through the intervention mapping process were evaluated for program participants through a questionnaire at 3 months. The feasibility of the program was evaluated through qualitative and quantitative research methods and included elements of attrition, adherence, subjective outcomes, program components, and sustainability. The theoretical mechanisms of behavior change were evaluated as process measures, along with the outcomes, and are not within the scope of this paper.would the Activity for Wellbeing program have been something you would have been interested in participating in, had you known about it; what do you feel would have been the best way to promote the program; and why did you choose to/not to participate in the program? Adoption was calculated as the percentage of the population who chose to participate in the program. Demographic data for the program participant sample were compared with the whole population data and data for individual sites and areas, where available. An Implementer Survey that was sent to all implementing staff at the same time as the Reach Survey was distributed. This survey assessed the level of knowledge about the nature of the program by allowing the respondent to select different components of the program according to their understanding. Other questions included in this survey were as follows: do you feel that the program had value for improving the health and wellbeing of your employees; during the course of the program, did you feel that the program was something that you promoted to your employees or encouraged participation in; did you notice any impact of the program; what do you feel may have been the greatest barrier(s) to participation; what do you feel were the main incentives to participate; do you feel that it would be valuable to maintain the use of a program such as this in the future; and do you feel that it would be valuable to use a different type of program in the future? Information gathered from this survey was used to compare differences between community and residential locations.After the completion of the program, the online Reach Survey was sent to all frontline workers from all sites and areas that were originally invited to participate. Reach was calculated as the percentage of the population aware of the program. Additional information gathered from the survey included the following: Fidelity of the implementation of the initial appointments was evaluated through consented recordings of four randomly selected initial appointments . These recordings were evaluated by a member of the research team who was highly proficient in motivational interviewing but not directly involved in the implementation of the program or delivery of the interviews. The interviews were assessed using a pre-prepared fidelity checklist that scored 15 components as achieved, not achieved, or not applicable. These components included education around six program components ; four elements relating to the collaborative development of the program ; and five fundamentals of the initial appointments , emphasizing autonomy support and principles of motivational interviewing . The supEvaluation of the intervention mapping components included outcome objectives , performance objectives, and change objectives. The results of the behavioral, well-being, and interpersonal environmental outcomes, along with additional process and performance measures, will be reported elsewhere.Specific performance objectives and change objectives were developed during the program development using guidance from the intervention mapping framework. Performance objectives were three “sub-behaviors” of the target behavior  that were identified as important for this population during the pre-program needs assessment. These performance objectives were as follows: find time to undertake physical activity, find motivation to undertake physical activity, and identify opportunities to undertake physical activity. Twelve change objectives were developed as composites of these sub-behaviors and four targeted determinants of behavior . The matrices of performance and change objectives can be seen in Supplementary Material 1.Each of the performance and change objectives was assessed through a questionnaire that was completed at the 3-month data collection point. The achievement of performance objectives was assessed using questions that specifically related to the objectives, e.g., for the performance objective “find time to undertake physical activity,” the evaluating question was “do you generally feel you are better able to find time to be active?” Change objectives were assessed using a small cluster of questions developed within the domains of the targeted personal determinants . Participants rated each objective-related question on a five-point Likert scale, where 1 = not at all and 5 = very much so. Since “3” could be considered a “neutral” score between “1” and “5,” scores of “1” or “2” could be considered negative changes, and scores of “4” or “5” could be considered positive changes. Mean scores for the whole participant sample were calculated for each of the single-item performance objectives and composite change objectives. Groupings of questions for the change objectives were assessed for internal consistency using Cronbach’s alpha (α) in SPSS . In the cases where the questions were deemed to contain elements of more than one domain, groupings were refined based on best fit. Questions that demonstrated a poor fit within all groups were excluded from the final groupings.What aspects of the program were helpful for increasing/maintaining physical activity levels? What aspects of the program were not helpful? Do you think you have you maintained physical activity levels since the end of the three-month program? What has helped you/stopped you from doing this?Qualitative research methods were used to gather information to support the quantitative data outlined for each of the different components of the process evaluation. In addition to this, qualitative methods were used to assess the overall feasibility of the program for the target population as well as the context in which the program was implemented. Individual telephone or face-to-face interviews were undertaken with program participants, non-program participants, and implementing staff. Interviews used a semi-structured, emergent-systematic approach. Interviews with program participants investigated elements of the program that the participant felt did or did not work, as well as the perceived impact of the program from the perspective of the individual program participant. The following open-ended facilitating questions were used (and adapted where necessary) to initiate discussion and address the objectives of the study: What aspects of the recruitment for the program were effective? What aspects of the recruitment were not effective? How could the recruitment for the program be improved? What aspects of the implementation of the program were effective? What aspects of the implementation were not effective? How could the implementation of the program be improved? Do you have any other feedback about the program?Interviews with implementing staff explored feasibility and perceived impact of the program from their perspective. The primary facilitating questions for the implementing staff were as follows: what are your reasons for choosing not to participate in the program? Information on the level of awareness of the program, the recruitment methods, and the work context within which the program was being implemented was drawn from emergent conversation that developed across all  interviews. All interviews were undertaken during the period of April 2018–May 2019.Interviews with non-participants focused on the reasons for choosing not to participate in the program or other well-being programs offered by the organization. The primary facilitating question for non-participant interviews was as follows: QSR International). All interviews were analyzed using a structured thematic approach , six non-program participants , and three implementing staff .n = 1) and time constraints (n = 2). The results of the mixed-methods process evaluation and feasibility study are outlined here. Themes, sub-themes, and selected quotes from the interviews can be found in Supplementary Material 2.The pilot trial of the Activity for Well-being Program was finalized with 25 participants. One participant withdrew from the program at 3 months, and two participants withdrew at 9 months. No participants who withdrew from the program gave consent to an interview; however, the reasons that were given for the withdrawal from the program included pregnancy . Recruitment of community-based workers may have benefited from SMS notifications. Some responses to the Reach Survey and non-participant interviews indicated a level of confusion around the program, with responses referring to other well-being initiatives that were implemented by the organization. Four residential survey respondents made reference to a different  well-being initiative that had been implemented in residential sites when describing their reasons for choosing not to participate. This was supported by some level of confusion and uncertainty around the program that was seemingly present within the non-program participant interviews, where some interview participants were not sure if they were thinking of the correct program.Sometimes I get a bit mixed up with other programs. We get a lot of information through work, and I just read things through in the moment.Non-participant 02, community support workerThrough thematic analysis of qualitative interviews, all barriers to reach seemed to be related to issues of communicating the program information to potential participants. Barriers included workers missing or not reading information due to having a relatively large number of email communications and the automatic deletion of emails. Promotion of the program using a face-to-face approach  and promotion via team leaders or line managers were identified as factors that did facilitate, or could have improved, the reach of the program.I don’t know whether it’s practical for someone like yourself, or your team, or – I’m not quite sure how the project is run – to be at every one of those team meetings. But one of our team leaders is definitely at one of those meetings. So that’s definitely a much better way to get the message across. We’re in a small group. We take it in better, and they’re really mandatory. We have to be there.Non-participant 01, community-based workerRecruitment for the pilot program took place over a 6-month period (October 2017–May 2018). The final number of participants adopted into the pilot program included 5.07% of the invited population. The median age of the program sample was 57 years, which was slightly older but relatively comparable with the median age of the whole community-based employee population (52 years). The sample was 88% female compared with 85% of the total community-based population. Demographic information for the total residential worker population was not available for comparison.The interviews explored factors impacting adoption into the program. Barriers to adoption included competing priorities, cognitive factors, and current physical activity levels. Consistent with the pre-intervention interviews and Reach Survey responses, competing priorities that acted as barriers to adoption to the program consisted of home and family commitments, and associated work–life balance and lack of time.And again, I don’t have time - I just wish I had time for me. The only time I have off, when the kids go to bed and I watch my shows, and then I have to go to sleep. So I just - I do try and focus on the weekends catching up with friends at night-time with them coming over, in between the sports during the day, et cetera. And that’s my “me time” to say, “okay, I’m seeing the girls,” or, “the family’s coming over,” or we’re visiting somebody else or going to a birthday party. So yeah, that’s it.Non-participant 03, community-based workerOther participants reported to be maintaining regular physical activity, either through work or in leisure time, as a reason for not participating in the program. Cognitive factors included wanting to keep their work and private lives separate and a reluctance to enter into the program if they felt that they would not be able to commit to it entirely.If I can’t make a commitment to something, I can’t - I’m not going to do it because I won’t be able to put in 100%, but I didn’t want to waste your time doing that when I’m not going to do it, you know?Non-participant 03, community-based workerPotential facilitators of adoption from the interviews included factors relating to the nature of the program; nature of the promotion; and having site level input, involvement, and support. Factors relating to the nature of the program included having the choice to engage without pressure, keeping the program/information relevant to the workers, and offering initiatives at set or suitable times. Having the choice to engage without pressure mainly encompassed positive feedback around having other well-being services, or potential services such as the Activity for Well-Being program, as something that staff have the option to access if they want to but were not obligated to do so.I’ve never actually – I’ve worked in lots of different industries in my life and I’d probably say this is the first industry that I’ve worked in that offers like all sorts of different supports, networks, to their employees. So even if you –whether you choose to use them or to access them or not, that’s to your discretion. But at least we’re always made aware that they are there if we need them.Non-participant 04, community support workerThe qualitative information from the interview data was consistent with the findings of the Reach and Implementer Surveys. Interviews indicated that using a face-to-face approach and having clearer communication about the nature of the program were potential facilitators relating to adoption of the program. Other potential facilitators were selling the program better and including multiple prompts (nature of the promotion). Having site level input, involvement, and support was also identified as a strong theme throughout the interviews. In accord with factors influencing the reach of the study, strategies such as making team leaders a part of the process, having better input at the local/site level, and having support from those around the workers (such as line managers and work peers) were thought to be factors that could improve participation in the program at the individual level.We would’ve been a good resource for you because in a lot of cases, we’ve known these people for a long time and there’s that trust element. So, often, if I have to read through a lot of information myself or do something, but if someone who I really trust says to me, “this is a great thing, you should just try it,” you just go, okay, I’ll give that a try.Implementer staff 01, communityBut we just think yeah…not realizing how much it could actually benefit us as individuals. Because, even I’m sort of thinking now, well I’m learning more talking to you now than I knew before, so yeah, I don’t know how else you’d sort of bring things to people’s fore. Unless you try and got somebody like [us] that could bring things, a little bit more information to staff and then be a bit more of an encourager.Implementer staff 02, residentialFindings of the Implementer Survey highlighted a notably better understanding of the program by the community-based implementers compared with those in residential sites. The most frequently stated perceived barriers to adoption from the perspective of the implementing staff were reported as time constraints, a lack of confidence in individuals’ ability to be active, and a perceived lack of support from those around them . A potential lack of interest in the program itself was also highlighted by two of the residential-based implementers. Despite this, five out of the six implementing staff felt that it would be valuable to maintain the use of a program such as this in the future, with the remaining staff member suggesting the use of a well-being initiative, which becomes part of the training agenda and is partially funded.Program Components and table of selected quotes in Assessment of the fidelity recordings demonstrated high fidelity for all aspects of education around the program components and for the collaborative development of the program for all recorded interviews. The fundamental principles of motivational interviewing were assessed as having high fidelity for the use of an empathetic approach, rolling with resistance, supporting self-efficacy, and supporting autonomy; the support and development of discrepancy by the AEP could have been improved in the recorded interviews. In addition to the assessment of the fidelity recordings, the results of the HCCQ demonstrated high levels of autonomy support. From 25 program participants, the HCCQ had 16 respondents and achieved a mean score of 6.61 out of 7 (±0.54). Good fidelity of the implementation of the autonomy-supportive approach through the initial appointments and across the course of the intervention and follow-up was also supported by the qualitative data from the interviews , and work structure (nature of the work). Some differences in work culture appeared to be present in the community settings compared with residential contexts. Positive relationships and trust between community-based workers and their team leaders were outlined by community-based implementers, program participants, and non-program participants. Particularly important for this seemed to be a team leader understanding and experience of the role of the frontline workers as well as close communications between the two.What also is really good about our team leaders is our team leaders used to do our job, and previously the rostering staff used to do our job, and the advisors used to do our job. And anyone that used to do the job of the people that they’re now in charge of is so much better at their job.Non-participant 01, community support workerShort and long-term changes within the structure of the work also impacted work stress and culture. Substantial changes to work structure in the short-term that were occurring around the time of the 9-month measures appeared to have a large impact on work stress within the community-based population. Longer-term changes included community-based employees moving from a physical space and face-to-face interaction with work peers and line managers to an almost exclusive interaction via mobile devices due to changes in technology. This latter change seemed to have some impact on social support within a workplace context.We all used to work out of this office…and it was a lovely time because you’d always be popping in there to get out your rosters and things and you’d run into people. You’d run into the office staff and it was a really lovely atmosphere and that’s all gone now.Program participant 10, community support workerWithin residential settings, work stresses were focused more around staffing and residents . As outlined in the barriers to adoption, there also appeared to be a preference to keeping work and personal lives separate, or a general hesitancy toward engaging with activities that were not directly a part of their work. In addition to these issues, physical workload as an element of work structure was identified as a source of fatigue and a barrier to participation for residential staff. This was consistent with the findings of the pre-program needs assessment undertaken with community-based workers.We work all day, and it’s a physically demanding day. We just don’t want to do any more physically demanding things…but there’s some days that we just come home exhausted from work, and to actually think about doing more physical work – it would be a drain to even think about it.Non-participant 05, residential care workeridentify opportunities to undertake physical activity (4.05 ± 1.13). The remaining two performance objectives  received change scores of 3.73 (±1.24) and 3.93 (±1.13), respectively.Twenty-two program participants completed the 3-month questionnaire for the assessment of performance and change objectives. The mean participant-rated scores for each of the performance and change objectives are outlined in do you feel that you are now more confident in your ability to control activity intensity?) was initially considered to include elements of both autonomy and competence; however, the question had a poor fit with both clusters and was subsequently excluded from both of these clusters and presented as a stand-alone item. The composite scores for the autonomy, competence, and relatedness clusters were 4.16 , 3.75 , and 3.64 , respectively. The change score for the stand-alone item of do you feel that you are now more confident in your ability to control activity intensity was 3.90 (±1.26).The final groupings of questions relating to the change objectives included three questions each in the autonomy and competence clusters and two questions in the relatedness cluster. One question ; environmental and accessibility issues ; and individual factors . One notable individual factor that was identified as a barrier to adherence, but was not noted within the pre-program interviews, was “not wanting to inconvenience people.” This barrier related to participants within the program not wanting to ask too much of the supporting AEP. One specific example of this was a change of gyms for one participant (due to convenience of location). The program AEP supported the participant with adapting her initial program and using the equipment in the new gym; however, the participant was initially reluctant ask for this support since the AEP had also assisted the participant with the previous gym.Because I’d gotten used to the [first gym], and then I thought “oh, this [second gym],” there’s no-one there; can’t get anyone to help you. And I think I’d joined up on the “I’m going to do it” because I didn’t want to lose that continuity of I’m going to stop again. And the whole thought, went in there and gone “oh, how am I going to do all this again, is it going to be the same equipment?” or whatever, and I’d sort of temporarily lost the mojo for a while of going “yeah, I don’t know.” And so then you sort of offered to do that and I’m like “oh”…“am I asking too much for that to happen?”Program participant 25, community support workerFacilitators of adherence included having accessible and comfortable environments, overcoming barriers to physical activity, personal motivators, social factors and support, and taking charge (independence) with behavior. The closely related sub-themes of taking charge (independence) with behavior and overcoming barriers to activity indicated a level of resilience in some of the program participants who appeared to facilitate adherence to regular physical activity participation.I might have adapted something differently at different times. When I’ve stopped going to [the gym], so I’ve tried to sort of compensate and do things.Program participant 20, community support workerSubjective outcomes of the program described within the interviews with program participants were varied but generally positive. These included subjective improvements in mental and physical health, improved motivation and mindset, positive emotion , and positive changes in perceptions around physical activity and health behavior. Many of these subjective outcomes appeared to be somewhat interrelated with participants expressing concurrent improvements in different subjective outcomes .But what happened was doing this program, is this program actually…helped me reach my – it was my mental senses, you know my state of mental health and my sense of – it motivated me. So it motivated me to be more active about everything and one of the problems that I’ve had with this depression and anxiety thing, is pursuing the things that I love.Program participant 01, community support workerI can see the benefits of what it’s done for me improving my mental health and physical health. I sleep better and I’m enjoying life a lot better. It’s definitely a plus. I can see the relationship between the exercise and mental health; helping to improve it.Program participant 09, voluntary community workerPositive changes in perceptions around physical activity and health behavior included changes such as increased awareness of habits and decreased negative emotions around relapse.I think I generally do quite well but every now and then I fall off the wagon, as I have with my eating. That’s the thing that starts it and I’ve just come to terms with it, “Well, we all do that. It’s not the end of the world.” I’ve learnt not to be so hard on myself. I think that’s it. I get very hard on myself.Program participant 10, community support workerSimilarly, positive emotions included the expression of positive emotions such as pride, a sense of achievement, and a feeling of value.But I guess it’s just mainly the satisfaction of knowing that I have done this myself – I mean with your help – and I am going to stick to it. Yeah. I am going to stick to it, and there will be times that I will probably lapse, and there’s probably times that I will do more but I know that it’s all there and it’s available to me.Program participant 15, community support workerThe use of self-monitoring of step counts or other health behaviors  was strongly endorsed by participants throughout the interviews as a way of managing their own behavior. Setting or using goals, exercise programming, and technical support from the AEP were also strongly identified as components of the program that assisted participants to manage their activity levels and develop independence with behavior management.Well I’m setting myself goals. I’m doing that and it’s just got me thinking. It’s always in the back of my head now. Always in there and yeah, it’s hard to get out what I’m trying to say. Definitely it has; it’s given me the motivation, and I have started thinking outside the square too and it’s got me thinking about more ways that I can try and do things and make it fun.Program participant 04, community support workerYeah, a lot of structure to my exercise routine, like the gym and that sort of thing. Going in there and being shown machines to use for what I was trying to achieve and that sort of thing. So yeah, it’s given a lot of structure to that, and encouragement to continue and go for it.Program participant 09, voluntary community workerIn addition to the self-management tools, the need support from the AEP was strongly referenced as a program component that was positively viewed by program participants. Of the sub-theme need support and affect, having someone that was non-judgmental and the participants felt comfortable contacting was viewed particularly positively.Well, the program has helped me tremendously and having you helped because I know I can ring you up at any time. That’s been great. And yeah, just the whole aspect of it. I feel as if someone is prepared to listen to me and cares.Program participant 15, community support workerYou haven’t judged us, whether we’ve done it or not, you haven’t said “oh, you’re a rotten person, you should be up to doing five days a week by now, at least 5 km every time you go out.” You haven’t done that to us, and I think that’s important as well.Program participant 13, community support workerOther program components had mixed responses. Newsletters were generally well accepted, and positive feedback centered around the newsletters offering small amounts of information without extensive reading. The website had only a small number of regular users (12% of program participants regularly using the website for tracking step counts and 12% using the website for a short time before ceasing to log in), with a large number of participants who never used the website (76% of program participants). The two primary reasons for this were forgetting about the website and not being “tech savvy.”Although sustainability was not formally addressed within the pilot trial or evaluation of the Activity for Well-Being project, naturally emerging discussion within the interviews addressed some aspects of sustainability. Across the post-program interviews, several of the interview participants spoke positively about a number of ongoing well-being services that the organization had in place . Conversely, some other short-term initiatives seemed to be met with criticism and a lack of engagement. Responses from program participants, non-participants, and implementing staff indicated a good level of support for incorporating a similar program into the organization on a long-term basis.The primary reasons for program participants in the current study not utilizing organizational gym facilities (despite 20% of program participants choosing to utilize the university gyms during the course of the program) were all related to the accessibility of the facilities. Most organizational gyms were only available for a very limited number of hours per day (those where the site was accessible but the gym was not being used for customer services), which generally overlapped with participant working hours.Yeah and I did ask about that [the gym] but unless it’s during working hours, and now they’ve been promoting more they’re getting, the gym it’s quite full…And I mean they opened up the great big new gym complex down, that’s [in one area], which isn’t feasible for me distance wise because I live [in another]. But once again for us to use the equipment after hours - that’s not, it’s a no go.Program participant 20, community support workerIn some areas, organizational gyms not being available in the local area or difficulties finding time to be inducted into the gym were also barriers to utilizing these facilities.One of the nurses has been trying to do an induction for I don’t know how long, they keep saying, “I will… do it”, but she wants to do it in five minutes… so, that’s sort of put her off.Implementing staff 02, residentialProcess evaluation of the pilot trial of the Activity for Well-Being program indicated moderate reach, with just over half of the community-based workers and a slightly higher proportion of the residential workers who completed the Reach Survey reporting that they were aware of the program. Despite this, there was poor adoption into the pilot trial, with only 5% of the whole population choosing to participate. This is compared with the 27–84% reported by a previous review of participation in workplace exercise/fitness programs  and prevQualitative and survey data from the current project indicated that the actual modes of recruitment used  were appropriate; however, there was a need for more promotion through multiple sources, including promotion over a longer period of time and better education around the nature of the program, particularly in residential settings. Qualitative findings of the Activity for Well-Being project also indicated that incorporating local implementing staff  more actively into the project, as well as improving education about the program, may have improved employee engagement with the pilot program. More specifically, findings indicated the greater use of a face-to-face approach, directly or through line management, may have improved reach and adoption for the program across both community and residential settings and could have improved local knowledge around the program. An Austrian study by Despite the low levels of adoption, positive feedback was received from those who participated in the program. Interview data from program participants indicated that the fundamental approach of the Activity for Well-Being program may be feasible for community-based frontline aged care workers. The fidelity of the autonomy-supportive approach of the program was confirmed by multiple datasets, including the fidelity recordings, the HCCQ scores, and the change scores for the autonomy cluster of the change objective questions.Relatively high retention of participants within the Activity for Well-Being program and the positive subjective outcomes  that were outlined in the interviews indicate good feasibility of the program for those who did choose to participate. Various components of the program were commented on during the interviews. Monitoring of step counts using a pedometer or other wearable device along with setting or using goals, exercise programming and technical support from the AEP, and having a support person who could be contacted (even if they did not need to be) were all program components that seemed to elicit the strong positive feedback from program participants. A large proportion of program participants self-reported frequent use of the Feeling Scale, RPE, or self-pacing for regulating activity intensity at 3 and 9 months. Coupling this with positive qualitative feedback around these self-determined methods of regulating physical activity intensity indicated that these could be a feasible and need-supportive strategy for exercise prescription within this population. Conversely, the website had mixed responses, and only a small number of program participants opted to use the website for the whole 9-month period. Improving the accessibility of organizational fitness facilities for the workers would also improve the feasibility of that aspect of the Activity for Well-Being program. Previous investigations into the preferences of different populations around the use of web-based health promotion have indicated some characteristic differences regarding preferences for mode of delivery. A study by Barriers to adherence for program participants were found to be similar to those identified in the pre-program interviews , with thThe process evaluation highlighted that certain factors associated with the current delivery of the program would need to be addressed prior to implementing the intervention on a broader scale. These include implementation and contextual factors contributing to low adoption of the program, and thereby the cost-effectiveness of any adaptions of the program that may be developed in the future. Despite the inclusion of participatory, pre-program interviews, the findings of the process evaluation indicated a greater need for input and support at the local and site levels across all stages of the project. Input and support from line managers and team leaders in the early stages of the implementation were lacking in the current pilot of the program and may have improved both reach and adoption. This may be particularly important since the program was implemented in a large and geographically disperse organization and having more direct involvement of local staff and line management could potentially have facilitated a better understanding of the program and greater advocacy within trusted networks. Despite this, feedback from both community- and residential-based implementing staff indicated a good level of perceived value in continuing a program such as this on a broader scale within the organization.It should also be noted that despite the positive feedback from those program participants who consented to an interview, there are several limitations of the current study. Firstly, the low levels of adoption into the pilot program may limit the ability to generalize the results to the whole target population and may have increased the risk of selection bias in the sample. Additionally, feedback could not be obtained from the few program participants who withdrew from the program. There was an under-representation of residential staff within the pilot program, which makes it all the more difficult to draw any conclusions regarding the feasibility of this type of program for residential workers.Process evaluation of the Activity for Well-Being program found that the reach of the program was moderate but adoption was low. The process evaluation of the Activity for Well-Being project also demonstrated clear differences between community and residential employee populations in regard to reach, adoption, and context. Recruitment for the pilot trial of the program initially encountered challenges resulting in a low adoption level into the program. This number was sufficient for the pilot trial; however, barriers to adoption would need to be addressed prior to implementing a full trial. General feedback from those that did participate in the program was positive, and retention of participants was high. The use of self-management tools and self-determined methods of regulating physical activity intensity appeared to be feasible, while other components of the program, such as the website, had mixed responses and low engagement. The simple element of having someone that participants could contact if they needed (even if they did not) elicited a strong positive response in the program participant interviews. Qualitative information also indicated that involving local implementing staff, such as team leaders or line managers, more directly into the intervention could have potentially improved reach, adoption, and feasibility of the program.The data that support the conclusions of this article will be made available on request by the corresponding author. The data are not publicly available due to content that could compromise the privacy of research participants.All parts of this study involving human participants were reviewed and approved by the Human Research Ethics Committee, University of South Australia. All participants provided their written and/or verbal informed consent to participate in the pilot study and process evaluation.ML undertook initial development of this manuscript with all authors having contributed the final drafts of the manuscript. ML and DP collaborated on the development of the evaluation plan, the change and performance objectives matrices, and qualitative analyses. JD and GP have overseen the entire project from initiation to present and have contributed to the research design and implementation of all aspects of the plan outlined within this manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.