In this study we identified common multi-level determinants of adoption of a PWMI across sites in different stages of implementation. In addition to these common themes, we report aspects specific to pre-implementation sites that need to be addressed and incorporated as implementation is planned and executed. Similarly, findings from sites in maintenance stages suggest further modifications to consider during dissemination and implementation at new sites. Adaptations brought on by the COVID-19 pandemic can also serve to highlight the role of telehealth in PWMIs moving forward. Our findings of common multi-level determinants between both sites are encouraging given the success of the PWMI in improving BMI and health behaviors at the sites in maintenance stages.(30)
Existing literature supports the use of systematic approaches to implementation, such as using the Consolidated Framework for Implementation Research (CFIR), to describe the determinants of implementation of evidence-based practices and produce generalizable knowledge about implementation science methods. By using this framework, we were able to understand the needs of the new sites launching HWC and react accordingly. We anticipate that following this approach will help with launching HWC in new sites as we move into further dissemination stages. Furthermore, by categorizing modifications made to the PWMI at sites in maintenance stages using FRAME we can gain a better appreciation of the circumstances driving program modifications. This can help us understand the downstream effects of these modifications on implementation and clinical outcomes. Stakeholders in both sites concurred that there is a pressing need for PWMIs in their communities. They believed that HWC would help address this need, which is likely to grow with reported worsening rates of childhood obesity following the onset of the COVID-19 pandemic.(3) Reducing these needs has been shown to correlate with high levels of acceptance of new programs in the local healthcare community.(31) This tension for change serves as a facilitator to implementation.
The attention of the PWMI to patient needs and resources (CFIR Outer Setting) was one major aspect brought up by stakeholders in both groups. This reflects the heightened awareness of the medical community to the social drivers of health (SDH) and how they influence health disparities, particularly following the COVID-19 pandemic. The AAP has called for addressing SDH given its deleterious effects on childhood health;(32–34) however, gaps between recognition of SDH and intervention continue to exist. Clinical-community partnerships have been proposed as one strategy to address SDH needs.(35) In the realm of childhood obesity prevention and interventions such partnerships have been reported, particularly in the school setting.(36) One example is the modification of school meals resulting in improved dietary behaviors.(37) It is encouraging that pre-implementation sites’ stakeholders recognized potential local partnerships that, if leveraged, could lead to increased recruitment and engagement, while contributing to sustainability of the PWMI beyond the pilot phase.
To contextualize HWC to each community, placing a greater emphasis on the role of the CHW as part of the team would be important. This role could serve a dual purpose of helping address SDH while ensuring HWC delivers culturally relevant care, another aspect that stakeholders appreciate as crucial during implementation. Despite limited data, integration of CHWs into healthcare teams has been suggested to contribute to improving clinical outcomes.(38) By collaborating with stakeholders throughout the implementation process, we maximize our understanding of the nuances of the community and brainstorm necessary adaptations while ensuring fidelity to the evidence-based intervention. Adaptations of evidence-based interventions are commonly reported,(39) particularly those that aim to adapt the intervention to a new setting and make it more culturally-relevant to the target community.
Another key facilitator that was identified is that staff members in these health centers are motivated, creating a greater degree of self-efficacy in the capability of the center to initiate and continue the intervention. Self-efficacy and a positive perception of the intervention have been linked to positive implementation outcomes; notably, program supports can impact this self-efficacy.(40) Individuals with higher self-efficacy may also have less training needs over time.(41) Champions were quintessential to the success of the intervention, in keeping with the implementation science literature.(42)
There are barriers specific to the pre-implementation sites that need to be addressed. One cultural aspect that was mentioned by stakeholders is that many people in this geographical region do not worry about obesity until complications develop since obesity is very prevalent within the community. Studies have shown that many parents tend to underestimate their child’s weight status(43, 44) and this misperception is more common in populations with lower incomes and Hispanic and Black populations.(45) This could impact the acceptability of HWC in the community and requires that clinicians be trained to effectively educate families about childhood obesity.
At the policy level, another concern brought up by stakeholders from the Mississippi pre-implementation sites was that at the time of the interviews, the state’s WIC policy did not allow for benefits to be claimed at regular grocery stores. The prevalence of household food insecurity in Mississippi is 15.3% from 2018–2020, or around 1.2 million households, which is the highest in the country.(46) Given the known links between food insecurity and obesity,(47) recent modification of the state’s WIC program which now allows cash benefits to be redeemed in retail stores may help alleviate food insecurity. The expansion of other federal programs would also be of benefit to decrease food insecurity.
An additional barrier identified by stakeholders pertains to the sustainability of this intervention. High rates of staff turnover could impair the ability of HWC to be sustained. Sites in maintenance stages were able to address this by promoting flexibility in staff roles to help bridge the gaps created by turnover. In pre-implementation sites, stakeholders recognized continuous training opportunities as a target for ensuring the sustainability of the program. In the nursing literature, achieving a higher sense of accomplishment, having interest in the job and accessing opportunities for development were identified as essential for occupational satisfaction.(48) While staff at the pre-implementation sites are motivated, leaders should leverage tools to maintain or enhance this motivation as the program launches and continues, particularly as the healthcare system experiences high turnover in the wake of the pandemic.
A potentially positive effect of the COVID-19 pandemic is that it propelled adaptations to the curriculum and the incorporation of telehealth options as part of PWMIs. Previous studies have reported the feasibility of conducting weight management interventions via telehealth and decreasing no-show rates.(11, 49) A recent systematic review suggests that a hybrid model may be ideal, providing flexibility by offering virtual follow-up visits after an initial in-person evaluation.(50) Including telehealth offerings in the package would help balance the transportation barrier that was reported by the pre-implementation sites stakeholders. However, it is important that the sites understand the technological literacy of the participants as well as the access to the internet and necessary equipment to be able to successfully use virtual platforms.
One of the major strengths of our study is that we engaged stakeholders at the FQHCs before implementation commenced to better understand local needs and resources. These stakeholders have a variety of roles in the health centers, which helps identify different perspectives. Multiple studies have previously supported the use of implementation science methods prior to implementation to maximize success of the interventions. By utilizing the CFIR domains and constructs, we were able to categorize these determinants systematically and compare them to the experiences at the sites in maintenance stages. We additionally incorporated implementation strategies and targeted outcomes into the Implementation Research Logic Model(51) to further plan for and guide our efforts to implement the HWC in the Mississippi FQHCs. This created a complete conceptual model of which strategies would be used to overcome barriers identified by stakeholders.(19) Moreover, including adaptations suggested by pre-implementation sites stakeholders could help create a sense of ownership of the intervention amongst staff in the Mississippi FQHC’s and keep them engaged to continue to offer HWC to their communities past the study period. As HWC moves into dissemination stages, understanding these determinants as categorized using CFIR, and with associated evidence-based strategies to overcome barriers and leverage facilitators, can help facilitate adoption in new sites.
One potential limitation of our study is that although we reached thematic saturation with the number of interviews conducted, the smaller sample size may not fully reflect the experiences of the entire team or of those that may join later. Our use of different interview guides based on whether the sites had implemented a PWMI or not may provide more heterogeneous data, however, our use of CFIR to code interviews uniformly reduces the risk of bias. Lastly, although the communities served by the FQHCs in Massachusetts and Mississippi are considered low-income, the racial and ethnic differences between these communities may suggest that different approaches to mitigating barriers to adoption, participant engagement and retention may be necessary. In particular, programs need to consider the deleterious effect that racism and negative experiences with healthcare has had on promoting medical mistrust within the Black community, which has been linked to adverse effects on physical and mental health indicators,(52) and delays in seeking medical care.(53)
By using systematic implementation science methods, we anticipate maximizing the uptake of this intervention and identifying areas that will help disseminate HWC nationwide. This way, we can help children with obesity and their families access the services and tools they need, and in turn decrease the prevalence of obesity and its complications in the populations that are at most risk.