The Dissemination and Evaluation of a Telephone-Delivered Intervention for Physical Activity, Healthy Eating and Weight Loss

Background: Given increasing population prevalence of physical inactivity and poor diet, and associated overweight/obesity and lifestyle-related diseases (i.e.type 2 diabetes, cardiovascular disease and some cancers), development of population-based approaches to address these key health behaviours is imperative. Telephone-delivered interventions for physical activity and/or dietary change, and weight loss are promising in this regard. However, there are few reports of these interventions being taken up for delivery in ‘real-world’ contexts. Therefore, little is known about factors that influence translation into public health practice or whether such interventions can produce similar outcomes when delivered in non-research settings. The recent uptake of the Logan Healthy Living Program, a cluster-randomised controlled trial of a 12-month telephone-delivered intervention targeting physical activity and healthy eating, by a community health organisation provided the opportunity to address these issues. Aims and objectives: The primary aim of the Thesis was to evaluate the translation and dissemination of the Logan Healthy Living Program, now known as the Optimal Health Program (OHP). Four studies comprised the Thesis research. The first two studies, a systematic review and secondary analysis of Logan Healthy Living Program data, informed studies three and four, which addressed the process of translating the Logan Healthy Living Program, and OHP outcomes. Methods and results: 1. A systematic review of telephone-delivered interventions for physical activity and/or diet was conducted to update the evidence for their potential to inform translation. A structured search of PubMed, Medline, and PsycINFO was conducted. Findings from 25 included studies, showed strong evidence supporting the efficacy of telephone-delivered interventions for initiation of physical activity and/or dietary behaviour change, with growing evidence for maintenance. Although reporting of implementation was less than optimal, there was an association of longer duration interventions (i.e.at least 12 months) with improvements in behaviour change. 2. Secondary analysis of data from the Logan Healthy Living Program was conducted to examine associations of intervention dose with behaviour change. In the Logan Healthy Living Program, patients (n=228) completed an intensive 4-month initiation phase consisting of up to 10 weekly/fortnightly calls; followed by an 8-month maintenance- enhancement phase of up to eight monthly calls. Intervention dose was defined as the number of calls completed in total and during each phase, and categorised into tertiles. Multivariate analyses of call completion and change in health behaviours were conducted. Relative to low call completion, high completion during the maintenance-enhancement phase was associated with significantly greater behavioural improvement, supporting the importance of longer-term interventions. Findings from study one and two were used to inform implementation of the OHP. 3. A descriptive case study, using the Diffusion of Innovations model as a guiding framework was conducted to describe the process of translating the Logan Healthy Living Program to practice. Systematic documentation of process outcomes showed that research-community partnerships were critical in facilitating translation, including: 1) an initial competitive advantage; 2) advocacy to ensure adoption of the intervention; 3) subsequent support for the adaptation of program elements to ensure ‘fit’ with the community organisation’s objectives, while maintaining feasible elements of fidelity; 4) integration of program management and evaluation systems within the community organisation; and 5) ongoing support for staff members responsible for program delivery and evaluation. 4. Guided by the RE-AIM framework, participant (clinical and behavioural) and program implementation outcomes from the OHP were evaluated. As the OHP is an ongoing community-based dissemination, a ‘snap shot’ evaluation was undertaken using a single-group pre-post design. As of April 2011, the OHP had received 280 referrals from 22 primary care practices with 237 people taking up the program. The age range of participants was 18 to 77 years [mean (SD) = 46.4 (11.7) yrs] and BMI ranged from 26-77 kg/m2 [mean (SD) = 36.7 (7.5) kg/m2]. Preliminary outcomes assessed at 6-months (mid-program; n=109) and 12-months (end-of-program; n=46), indicated successful intervention delivery and promising effectiveness for those remaining in the OHP, although there was a high level of attrition (36%) prior to the mid-program assessment. At mid-program, statistically significant improvements were observed for weight [mean change (SD): -2.9 (5.6) kg] and waist circumference [- 3.6 (7.1) cm], underpinned by significant physical activity and dietary behaviour change. Improvements were sustained at 12-months. Conclusion: This Thesis makes an important contribution to the limited evidence base on the process of translation and dissemination outcomes of health behaviour change interventions. Key directions for future research involve: systematic tracking and reporting of uptake and adaptations; and reporting on indicators of external validity to inform program sustainability on an individual and organisational level