Six participants were recruited for the intervention, constituting a participation rate of 13% (47 young people approached: 22 unavailable due to employment/education, 19 declined without providing a reason). Participants characteristics and corresponding attendance to the intervention sessions are presented in Table 2.
Table 2
Participant characteristics and attendance data
Participant | Age | Gender | First Attendance | Total Attendance |
1 2 3 4 5 6 | 16–18 16–18 16–18 16–18 16–18 19–21 | F F M M F M | W1 W1 W2 W7 W1 W2 | Sessions | PA | DBT-ST |
1 1 7 2 7 5 | 0 0 7 2 1 3 | 1 1 7 2 7 5 |
Notes
W = Week; F = Female; M = Male; PT = Part-time; PA = Physical activity component; DBT-ST = Dialectical Behavioural Therapy Skills Training component.
Qualitative analysis of data from participants (n = 4) and intervention implementers (n = 4) enabled identification of ten barriers and facilitators to implementation processes across intervention, organisation, and individual levels. Sub-themes relating to each implementation component are presented in Table 3.
Table 3
Barriers and facilitators to implementation process components
Component | Individual-level | Organisational-level | Intervention-level |
Recruitment and retention Fidelity Dose delivered Dose received | Beliefs and perceptions - Competing priorities - Past experiences +/- Incentives + Beliefs and perceptions + Beliefs and perceptions +/- Past experiences - Incentives + | Resources and time - Staff support + Staff support + Staff support + Staff support + Resources and time - | Materials +/- Setting - Materials + Implementer skills + Adaptations + Adaptations + Implementer skills + Setting - |
Note: +/- denotes whether each sub-theme presented a barrier (-) or facilitator (+) to implementation |
Qualitative findings were triangulated with the other data sources to comprehensively assess overall quality of the intervention, evaluate whether the components were implemented and delivered as intended. Pseudonyms are provided to preserve anonymity of participants.
Recruitment and retention
Although multiple strategies were adopted, recruitment of participants was challenging; six participants engaged with the intervention, three of whom achieved > 75% attendance across the eight-week period. Despite promotion and full explanation that the programme comprised two distinct sessions each week (DBT-ST and physical activity), participants demonstrated a clear preference for attending the DBT-ST component, compared to the group physical activity.
The collective evidence from key stakeholders indicated that a predominant barrier to recruitment of participants was the timing of the intervention, which coincided with competing priorities, such as education, training, or work:
“This started just in early September when a lot of young people were going back to college” (Support Worker)
Despite the intentions to target and recruit those young people considered the least engaged, there was further evidence of selection bias towards those who were most likely to attend, over those who were available to attend and would potentially benefit the most. It is also plausible that beliefs and perceptions such as the perceived benefits of participating in a multi-component intervention may have been outweighed by the perceived ‘burden’ of committing to a three-hour session each week, and dedicating additional time to practice DBT skills (40). These barriers may have been compounded by the intervention setting, which, for some participants, was deemed as potentially anxiety-provoking:
“It's not that inclusive. I mean I was intimidated walking in the first time and I like sports you know?” (Coach 3)
Correspondence with the organisation’s staff indicated that barriers to reaching and recruiting study participants emanated from a lack of resources and time. This impacted on staff’s capacity to disseminate information and further explain the purposes and benefits of the intervention to potential participants. This also limited 'reach' to the target population, and reinforces participant recommendations that effective recruitment may necessitate strategies external to the organisation:
" if you really wanna attract an audience you've gotta get on social media. Like for the younger audience and that, get the social media on the go" (Leo)
Staff shortages within the organisation were specifically cited as a barrier to participation in the intervention, with documented correspondence indicating this encompassed issues from the staffing perspective (i.e. no access to transport), and those more generally related to the anxiogenic effects of utilising public transport which these young people may experience.
Potential participants wouldn't come alone due to social anxiety, or lack of transport
(Documented feedback)
Despite efforts to ascertain specific reasons for the poor uptake and attendance, documented correspondence indicated a general ‘lack of interest' in what was involved; with potential participants expressing negative beliefs and perceptions towards physical activity and/or psychotherapy:
"Then call it something else then, it doesn’t have to be ‘therapy’. Like the title, the name, make it sound fun" (Sian)
“Sport…exercise. It's just effort” (Kwame)
This evidence suggests there were limitations to the appropriateness and clarity of the recruitment materials, thereby undermining the information conveyed to potential participants (directly and via staff), resulting in extrinsically motivated reasons to attend (i.e. incentives):
“I said to Kwame, he gets a free fiver, so he needs to come along” (James)
It is likely that participants' motivation to engage necessitated a personal, face-to-face approach to recruitment. Indeed, evidenced derived through the lead researcher’s field notes attributed improved reach and recruitment of participants at week two to an 'active outreach' campaign (i.e. visiting projects). This helped facilitate trust, answer further questions, and alleviate any initial concerns which may have been exacerbated through the recruitment materials. This strategy was complemented with a recruitment flyer (see Additional file 6) which framed the intervention as a 'wellbeing group' rather than focussing on terms such as ‘physical activity’ or ‘therapy’, which participants may have associated with negative past experiences:
"I think people might get put off thinking they're going to be psychoanalysed as well...when you hear 'Dialectical Behavioural Therapy Skills' it’s a bit scary" (Support Worker)
Fidelity
For clarity and transparency in reporting, fidelity to the physical activity and DBT-ST components will be discussed independently, with reporting of findings guided by appropriate evaluation frameworks (31, 35, 41).
While the DBT-ST manual was utilised to teach the selected skills as intended (see Dose delivered), there were occasions when the psychologist adapted pre-specified exercise to better suit the group size and dynamic (e.g. 'positive memories' in week seven was changed to ‘mindful music’ due to one participant having received bad news). Contrary to standard DBT protocol (33), practice tasks provided throughout the materials were conveyed by the psychologist as opportunities for participants to reinforce what they had learned each week, rather than framed as mandatory ‘homework’ which needed to be completed by the following session. Omission of homework assignment is common when delivering DBT skills to this population (35), however it was evident that staff presence and support could promote DBT skills practice outside of the intervention setting:
“We talked about it yesterday...I was telling a relief worker in the house about what we had been doing and James was there, and so we were having a little debate about the 'DEAR MAN' skills” (Support Worker)
In conjunction with the psychologist’s adherence to structure and content of DBT-ST (besides necessary adaptations for implementation), participants’ perceptions of their skill and expertise were also positive overall, thereby supporting the integrity of this component, and overall quality and fidelity of implementation (31, 35).
“My impression was when I sat down in the room, that it seemed professional…the psychologist seemed like a professional lady with what she was teaching” (Leo)
Due to the difficulties in initially recruiting and engaging participants, the physical activity component of the intervention involved just one participant (James) for 3/8 sessions delivered. Despite the variations in group size and engagement throughout the intervention, it was evident that the coaches had adapted their approach without compromising or deviating from the theoretical framework:
"I felt like the young people were more focused on the skills that they could get out of sport, as opposed to the enjoyment. I think they were enjoying that it was more individualistic" (Coach 3)
The psychological principles embedded within the physical activity framework were conducive to positive psychosocial, rather than fitness-oriented outcomes (i.e. well-being, self-esteem), however in session 3 of the intervention, participants requested to undertake the 'bleep' test of aerobic endurance (42). While this outwardly deviated from protocol, and arguably compromised fidelity of the intervention, it is highly plausible that—in conjunction with supporting psychological needs—this adaptation contributed to the continued engagement and progression of James, through incorporating a shared-decision making approach (autonomy), and instilling mutual trust and respect between coaches and participants (relatedness):
"With James you saw a real development because we were focused on them you know? Obviously there were other young people, but like James was there every session so it was really nice to see the progress" (Coach 3)
The extent to which interventions may be modified has been debated extensively throughout the extant literature (43, 44), however this study highlights the importance of not only allowing, but endorsing intervention facilitators' decisions to adapt interventions in accordance with contextual nuances- provided such adaptations are reported with reference to the theoretical framework and effect on outcomes (45).
The physical activity monitoring feedback provided by coaches, and follow-up interviews evidenced that fidelity to the content and delivery approach of the physical activity component was associated with co-facilitation of sessions, as it had enabled collaborative decision-making on the necessary adaptations to best 'fit' the context and participant preferences:
"We'd bounce ideas off of each other on the way there. And we'd be like, "right, if it's slow this week, let's introduce this rule"" (Coach 1)
Utilising multiple coaches also promoted adherence to the theoretic framework and psychological principles underpinning the intervention:
"I didn't have any in depth knowledge about the research. After I spoke to the others about it, I was kind of like, "OK so I missed that, that's what actually is going to happen"" (Coach 2)
Finally, facilitating physical activity sessions as a group had evidently promoted the coaches' self-efficacy and confidence to deliver the intervention as intended (i.e. adhering to fidelity and dose; 45):
"There's like a unified approach and I think that's what we're trying to say is like, we're working together- we're creating these games, these ideas for the group, together" (Coach 3)
Dose delivered
Monitoring and observational data confirmed that both the DBT-ST and physical activity components of the intervention were available each week at the specified times, and each session was delivered for the intended duration (90 minutes and 60 minutes, respectively).
In total, 12 different activities and games were delivered throughout the physical activity component. Further analysis of physical activity monitoring forms completed by the coaches indicated that sessions incorporated varied activities ranging from structured ‘drills’ (e.g. basketball skills) to more informal games (e.g. catch the flag), depending on the size and ability of the group. While the quantity of delivery remained consistent, there was evidence to suggest that adaptations may have impacted on the quality of dose delivered by the coaches:
“It gave the young people a chance to kind of have more one on one time, attention, and one on one connection” (Coach 2)
Observations of sessions and scrutiny of workbooks also confirmed that the psychologist had adhered to the intended structure of sessions, and order of DBT skills delivery as per the manual. On occasion, more time was used on certain content due to open discussions between group member, however this was mitigated by the psychologist’s ability to steer the session back ‘on track’:
"They were professional, they knew what they were doing, and they knew how to handle the time they had with us" (Sian)
There was evidence to suggest that delivery of the intervention per protocol was also facilitated by staff support when required, as this enabled facilitators to adhere to the session structure and timing:
“Having support workers present is also really useful tool when it's like an anxiety-based or nervous-based issue why they’re not participating or engaging” (Coach 2)
Dose received
Although quantifiable measures of 'dose' represent what was available and delivered to participants, assessment of dose received requires more subjective interpretation of how participants interacted and engaged with each intervention component. Despite the consistency of dose delivered (see above), the dose received by participants was variable throughout the duration of the intervention (Table 4), and furthermore, attendance was not always a direct indication of this.
Staff availability to accompany participants was integral to initial attendance to the intervention, while continued engagement was attributed to weekly financial incentives to attend:
“My support worker introduced me to you all the first time, then the second time I found it alright- it was OK... but knowing I get a fiver at the end of it, it gave me motivation” (Leo)
Despite these facilitators to attendance, it was evident that quantity of sessions received was not indicative of enjoyment or perceived utility of skills learned:
"The DBT itself was quite boring to be fair…I wouldn't use the 'DEAR MAN' [key DBT skill] (James)
In contrast, other participants described a more positive experience of the DBT-ST group, and described how they had actively engaged with the materials and information delivered in the sessions:
" If I didn’t come here, if I'd had a problem with someone I would fight it out. But now I feel I have a better set of ways to go about it. So I feel like that’s what I've come away learning" (Leo)
There was further evidence that some participants had volitionally attempted to practice skills outside of the sessions, such as changing thoughts and behaviours by 'checking the facts' of a situation (34):
"You've gotta evaluate every situation, like before jumping from A to Z… unless you actually know all the facts you can’t just say, ‘oh well, I'm not gonna do it’" (Sian)
These excerpt demonstrate the complexity associated with evaluating the dose of intervention received, and highlight the importance of considering individual levels of engagement rather than assuming treatment is ‘passively’ received (31).
Attendance and engagement of other participants varied according to their perceptions of each intervention component, suggesting that high dosage of one (physical activity or DBT-ST) is not indicative that high dosage of the intervention was received:
" The sports part of it, I really didn’t wanna do it. I felt I got more out of the DBT and, like now, I think I'm a better person for it in a sense" (Sian – high 'dose' of DBT-ST)
Triangulated data also highlighted that quantitative indicators alone may be misrepresentative of ‘dose received’ depending on participants’ satisfaction with each component:
"I was more like into the sports which is why I came. Most of the DBT shit I actually didn’t agree with anyway. I don’t like classroom work, I'm more into physical activity" (James – high ‘dose’ of both DBT-ST and PA)
For other participants, exposure to the intervention may have been undermined by a lack of engagement, due to associations between the intervention setting and negative past experiences:
“It felt like school, and I didn't like school” (Kwame)
While these extracts cannot unequivocally determine 'dose received', and further affirm the difficulties associated with evaluating the extent to which participants engaged (31), they highlight the necessity for considering the quality of participant's experiences and contextualising the (often misleading) quantifiable indicators of intervention dose received.
Table 4
Participant attendance to intervention components
Participant | Attendance |
James Kwame Sian Leo Total | DBT-ST | PA |
7 2 7 5 21 | 7 2 1 3 13 |
Notes
DBT-ST = Dialectical Behavioural Therapy Skills Training;
PA = Physical Activity.