"Now is the time for institutions to be investing in growing exercise programs as part of standard of care": a multiple case study examining the implementation of exercise oncology interventions.

BACKGROUND: Implementation science seeks to systematically identify determinants, strategies, and outcomes within a causal pathway to help explain successful implementation. This process is applied to evidence-based interventions (EBIs) to improve their adoption, implementation, and sustainment. However, this method has not been applied to exercise oncology services, meaning we lack knowledge about implementing exercise EBIs in routine practice. This study aimed to develop causal pathways from the determinants, strategies (including mechanism of change), and implementation outcomes to explain exercise EBIs implementation in routine cancer care. METHODS: A multiple-case study was conducted across three healthcare sites in Australia. Sites selected had implemented exercise within routine care for people diagnosed with cancer and sustained the delivery of services for at least 12 months. Four data sources informed the study: semi-structured interviews with staff, document reviews, observations, and the Program Sustainability Assessment Tool (survey). Framework analysis was applied to understand the findings. The Implementation Research Logic Model was used to identify commonalities in implementation across sites and develop causal pathways. RESULTS: Two hundred and eighteen data points informed our findings. Across sites, 18 determinants and 22 implementation strategies were consistent. Sixteen determinants and 24 implementation strategies differed across sites and results of implementation outcomes varied. We identified 11 common pathways that when combined, help explain implementation processes. The mechanisms of implementation strategies operating within the pathways included (1) knowledge, (2) skills, (3) secure resources, (4) optimism, and (5) simplified decision-making processes associated with exercise; (6) relationships (social and professional) and support for the workforce; (7) reinforcing positive outcomes; (8) capability to action plan through evaluations and (9) interactive learning; (10) aligned goals between the organisation and the EBI; and (11) consumer-responsiveness. CONCLUSION: This study developed causal pathways that explain the how and why of successful implementation of exercise EBIs in cancer care. These findings can support future planning and optimisation activities by creating more opportunities for people with cancer to access evidence-based exercise oncology services. IMPLICATIONS FOR CANCER SURVIVORS: Understanding how to implement exercise within routine cancer care successfully is important so cancer survivors can experience the benefits of exercise.

Implementation of physical activity interventions in a community-based youth mental healthcare service: A case study of context, strategies, and outcomes.

AIMS: Physical activity interventions are recommended for community-based youth mental health services to prevent physical health disparities. Implementation is challenging, and studies focusing on the methods to achieve change are needed. This study aims to identify the context, implementation strategies, and implementation outcomes that illustrate how physical activity interventions were implemented within an early intervention service in Australia. METHODS: A theoretically informed case study was undertaken. Data from a community-based youth mental health service that delivers an early psychosis programme were collected between July and November 2020. Three data sources were accessed (1) interviews with service managers, mental health clinicians and exercise physiologists; (2) document review of organizational policies and procedures; and (3) survey using the Program Sustainability Assessment Tool. The implementation outcomes investigated were acceptability, fidelity, penetration, and sustainability. Framework analysis was used, and a logic model developed guided by an established template, to interpret findings. RESULTS: Forty-three contextual factors and 43 implementation strategies were identified. The data suggests that creating a new clinical team and auditing and feedback are critical for implementation. High levels of acceptability and sustainability were described, while fidelity of implementation was difficult to establish, and penetration was low. CONCLUSIONS: The relationship between constructs suggests several mechanisms underpinned implementation. These include changing professional beliefs, establishing new organizational norms, augmenting existing work processes, and aligning physical activity with priorities of the mental healthcare system and existing work tasks. This case study provides direction for future health service planning of physical activity interventions in community-based youth mental health service.

Developing an implementation research logic model: using a multiple case study design to establish a worked exemplar.

BACKGROUND: Implementation science frameworks explore, interpret, and evaluate different components of the implementation process. By using a program logic approach, implementation frameworks with different purposes can be combined to detail complex interactions. The Implementation Research Logic Model (IRLM) facilitates the development of causal pathways and mechanisms that enable implementation. Critical elements of the IRLM vary across different study designs, and its applicability to synthesizing findings across settings is also under-explored. The dual purpose of this study is to develop an IRLM from an implementation research study that used case study methodology and to demonstrate the utility of the IRLM to synthesize findings across case sites. METHOD: The method used in the exemplar project and the alignment of the IRLM to case study methodology are described. Cases were purposely selected using replication logic and represent organizations that have embedded exercise in routine care for people with cancer or mental illness. Four data sources were selected: semi-structured interviews with purposely selected staff, organizational document review, observations, and a survey using the Program Sustainability Assessment Tool (PSAT). Framework analysis was used, and an IRLM was produced at each case site. Similar elements within the individual IRLM were identified, extracted, and re-produced to synthesize findings across sites and represent the generalized, cross-case findings. RESULTS: The IRLM was embedded within multiple stages of the study, including data collection, analysis, and reporting transparency. Between 33-44 determinants and 36-44 implementation strategies were identified at sites that informed individual IRLMs. An example of generalized findings describing "intervention adaptability" demonstrated similarities in determinant detail and mechanisms of implementation strategies across sites. However, different strategies were applied to address similar determinants. Dependent and bi-directional relationships operated along the causal pathway that influenced implementation outcomes. CONCLUSIONS: Case study methods help address implementation research priorities, including developing causal pathways and mechanisms. Embedding the IRLM within the case study approach provided structure and added to the transparency and replicability of the study. Identifying the similar elements across sites helped synthesize findings and give a general explanation of the implementation process. Detailing the methods provides an example for replication that can build generalizable knowledge in implementation research.

Exercise interventions for people diagnosed with cancer: a systematic review of implementation outcomes.

PURPOSE: Exercise is efficacious for people living after a cancer diagnosis. However, implementation of exercise interventions in real-world settings is challenging. Implementation outcomes are defined as 'the effects of deliberate and purposive actions to implement new treatments, practices, and services'. Measuring implementation outcomes is a practical way of evaluating implementation success. This systematic review explores the implementation outcomes of exercise interventions evaluated under real-world conditions for cancer care. METHODS: Using PRISMA guidelines, an electronic database search of Medline, PsycInfo, CINAHL, Web of Science, SportsDiscus, Scopus and Cochrane Central Registry of Controlled Trials was conducted for studies published between January 2000 and February 2020. The Moving through Cancer registry was hand searched. The Implementation Outcomes Framework guided data extraction. Inclusion criteria were adult populations with a cancer diagnosis. Efficacy studies were excluded. RESULTS: Thirty-seven articles that described 31 unique programs met the inclusion criteria. Implementation outcomes commonly evaluated were feasibility (unique programs n = 17, 54.8%) and adoption (unique programs n = 14, 45.2%). Interventions were typically delivered in the community (unique programs n = 17, 58.6%), in groups (unique programs n = 14, 48.3%) and supervised by a qualified health professional (unique programs n = 14, 48.3%). Implementation outcomes infrequently evaluated were penetration (unique programs n = 1, 3.2%) and sustainability (unique programs n = 1, 3.2%). CONCLUSIONS: Exercise studies need to measure and evaluate implementation outcomes under real-world conditions. Robust measurement and reporting of implementation outcomes can help to identify what strategies are essential for successful implementation of exercise interventions. IMPLICATIONS FOR CANCER SURVIVORS: Understanding how exercise interventions can be successful implemented is important so that people living after a cancer diagnosis can derive the benefits of exercise.

From impact factors to real impact: translating evidence on lifestyle interventions into routine mental health care.

The scandal of premature mortality in people with serious mental illness is well established. Despite an increase in studies evaluating the efficacy of lifestyle interventions, translating this evidence into routine clinical care and policies is challenging, in part due to limited effectiveness or implementation research. We highlight the challenge of implementation that is increasingly recognized in clinical practice, advocate for adopting implementation science to study the implementation and systematic update of effective interventions in practice and policy, and provide directions for future research.

Self-reported physical activity levels of the 2017 Royal Australian and New Zealand College of Psychiatrists (RANZCP) conference delegates and their exercise referral practices.

Background: Physical activity (PA) significantly improves physical health and clinical symptoms across mental disorders. Accredited Exercise Physiologists (AEPs) are trained to lead PA interventions for people with mental illness, but referrals to AEPs are low.Aims: To determine the knowledge and attitudes of delegates attending the 2017 Royal Australian and New Zealand College of Psychiatrists (RANZCP) conference toward physical health monitoring and exercise interventions for people with mental illness.Methods: A cross-sectional survey of RANZCP delegates investigated knowledge and attitudes toward PA for people with mental illness, self-reported PA, and their understanding of AEP's role within mental health settings. A subgroup of delegates underwent fitness assessments.Results: Seventy-three delegates completed surveys and 24 underwent fitness assessments. Delegates demonstrated good knowledge regarding associations between PA and cardiovascular disease risk. Delegates were less knowledgeable of AEP's role within mental health settings. Forty-six participants (63%) did not meet the Australian recommended guidelines for PA. No association between referrals to AEPs and self-reported PA or fitness measures were evident.Conclusions: Promoting PA participation for mental health professionals, coupled with education on the important role AEPs play in the multidisciplinary treatment of mental health consumers is vital to improve health outcomes for this vulnerable group.

Implementing Exercise in Healthcare Settings: The Potential of Implementation Science.

Exercise is an efficacious therapy for many chronic diseases. Integrating efficacious evidence-based interventions (EBIs), such as exercise, into daily healthcare practice is a slow and complex pursuit. Implementation science seeks to understand and address this phenomenon by conducting studies about the methods used to promote the routine uptake of EBIs. The purpose of this article is to explore implementation science and a common conceptual framework in the discipline, the Consolidated Framework for Implementation Research (CFIR), as it applies to exercise EBI. We conclude by offering recommendations for future research that leverage implementation science priorities to highlight the potential of this research field for advancing the implementation of exercise EBI.