Our results suggest that while LIVESTRONG at the Y has linearly increased its participant reach and organizational adoption rates, it has room to continue to grow. Implementing community-based programs with high fidelity is challenging, and our findings suggest implementation measures of fidelity checks can be improved, While the data only shows whether checks were implemented and not actual fidelity to the program, we did find implementing checks were associated with participant-level maintenance. Further, we found that area household income was associated with participant-level maintenance. This supports the notion that inequities exist in survivor PA, and potentially access to community-based programs, in low socioeconomic status areas .
The estimated 60,000 survivors that the program has reached is only a small fraction of the roughly 16.9 million survivors in 2018 . Increasing the number of participants is an important research priority. A prior examination of a subset of program participants (7%) showed the highest reported method of referral to LIVESTRONG at the Y was from a doctor or other healthcare professional . Providers may serve on the front line to screen and refer patients to appropriate programs that fit their medical, geographic, social and economic preferences . Recent health reforms have placed an emphasis on using electronic medical health records for surveillance . Thus, integrating PA surveillance into standard of care may provide better insight into patient characteristics, medical clearances and referral to appropriate PA programs, such as LIVESTRONG at the Y.
Reach may also be increased if additional Ys adopt the program, though strategies are still needed. A previous study examining a health program in Y-affiliated sites found that adoption facilitators included organizational support, on-going financial support, matching the Ys mission and target population, novelty of the program, invitations from established partners and program champions . Barriers included limited resources and expertise, competing programs and space and costs of offering the program. A prior examination of the Diabetes Prevention Program delivered in YMCAs found that outreach and recruitment required 2 to 20 hours of staff time per week . As LIVESTRONG at the Y is free of cost, YMCA staff must use some of their time to employ fundraising efforts to fund the program. Alleviating staff time and the financial burden of program costs may increase adoption of the program and staff time to devote to outreach. The American Society of Clinical Oncology has encouraged a third-party payer system to provide coverage of services for cancer prevention and control, including those for PA . Payer financial assistance may alleviate fundraising burden from Ys and provide opportunities for more Ys to adopt the program, run additional sessions, perform outreach efforts and reach more individuals.
Program fidelity may potentially moderate the relationship between an intervention and its outcomes . Less than 40% of Associations were implementing all three checks which was associated with greater membership conversion rates. Fidelity is associated with an intervention’s outcomes  and incorporating checklists are one way to measure adherence to delivering the intervention as intended. However, fidelity monitoring delivered in non-research-based settings presents several logistical concerns of self-report measures, time and resources to complete checks while concurrently implementing the program, as well adaption to the local setting and drift from the intervention . Implementation strategies may be needed to promote fidelity. We also found that fewer years implementing the program was associated with a higher membership conversion rate. Examining setting-specific variables affecting programs implemented over a longer time, such as funding, community saturation, change in organizational structure, adaptability of the intervention and support from leadership , are warranted.
Consistent with prior data that the purchase of a fitness membership is limited to those of higher socioeconomic status [28, 29], we found that household area income was associated with membership conversion rate despite that the Y offers financial assistance to those in need. Strategies to motivate and support participants facing financial stress are needed to reduce the disparities in participation. Survivors have reported financial constraints as a barrier to exercise . They also report spending 1/3 of their household income on cancer care . Third-party payer systems covering survivor PA services may provide a re-allocation of funds to overcome financial barriers to program attendance, including childcare, transportation and athletic gear. Additionally, there are considerable disparities in the population being served in PA programs for survivors , thus there is a need to determine how to make even free-of-cost programs more accessible to minority survivors and those with low socioeconomic status. Providers may be able to assist in these efforts, as ACS guidelines and the Institute of Medicine recommend PA prescriptions and/or referrals be provided to survivors. However, specific recommendations on how to prescribe or where to refer patients are not included . Provider education coupled with assessing barriers to PA may aid in the PA referral process.
Several limitations should be noted. First, data is optionally self-reported from Program Directors; thus, it is unclear if an Association with no report conducted sessions and our results may under-estimate the outcomes of interest. Second, data is reported from Y Associations rather than individual branches; therefore, it is unclear as to how individual branches perform within each Association as well as a lack of branch-specific contextual factors (such as staffing, financial resources, facilities, equipment and leadership) which may influence the capacity and performance of programs. Third, the RE-AIM metrics identified in this study are limited to the data provided. This is a strength, as measures are collected by all Associations similarly, though a weakness as these measures do not fully capture all indicators of each RE-AIM aspect (such as the unknown characteristics of those not participating in the program). In lieu of PA maintenance measures, participant-level maintenance was limited to membership conversion rates upon program cessation. This does not account for those who purchase a membership later nor assess membership use or PA behaviors in alternative settings. Fourth, our metric of household income based on census data is limited to the corporate branch within the Association. Not having data at the level of the implementing branches limited our ability to understand the implementation context. Lastly, the metric of Associations offering at least one session per full reporting year provides only preliminary insight into an Association’s organizational maintenance.