Hypothesis / aims of study
Mind over Matter: Healthy Bowels, Healthy Bladder (MOM) is an innovative three-session, small group workshop led by a trained facilitator from the community that improves urinary and bowel incontinence in older women. However, small group, in-person programs like MOM are difficult for communities to implement and sustain. The aim of this study, nested within a larger hybrid effectiveness-implementation trial, was to identify barriers to and facilitators of adoption, maintenance, and implementation with fidelity of the MOM intervention among community partners who participated in its randomized, controlled trial (RCT).
Study design, materials and methods
This study was nested within a larger type 1 hybrid effectiveness-implementation study that confirmed the impact of MOM on urinary and bowel incontinence. Eight community representatives from six community organizations across the state completed the MOM facilitator training prior to the 2017 RCT, during which each community offered two MOM workshops. Communities were permitted and encouraged to continue to offer MOM in the year following the completion of the RCT, but no financial support was provided for additional MOM workshops. Glasgow’s RE-AIM framework for evaluating the public health impact of an intervention (1) guided assessment of MOM’s adoption, maintenance, and implementation with fidelity.
For this study, adoption was defined as a community organization choosing to offer a MOM workshop on its own in the year following the RCT. Maintenance was defined as a community organization offering more than one MOM workshop in the 18 months following the RCT. Community organizations were queried individually via email and telephone contact regarding planned and offered MOM workshops in the 18 months following the RCT; absolute numbers and proportions of communities planning to offer and offering MOM workshops were calculated.
Qualitative data regarding barriers to and facilitators of adoption and maintenance were elicited from community organizations via individual and group emails, telephone conversations, and focus groups, and were analyzed using thematic content analysis. Focus groups were conducted with community partners shortly after the RCT and 6 months later to gain additional insight into potential barriers and facilitators to adoption, implementation, and maintenance.
Implementation fidelity, which refers to the MOM intervention being executed according to its protocol and in alignment with its key elements, was assessed using fidelity checklists at all MOM workshop sessions held during the RCT. In the 12 months following the RCT, random workshop sessions were observed by study staff to evaluate fidelity.
All six community organizations responded to email and telephone contacts from the study team and participated in the focus groups during the 18 months following the RCT. Regarding adoption, 83% (5/6) of communities planned to offer a MOM workshop in the 12 months following the RCT, and 67% (4/6) offered at least one MOM workshop that year. A total of 11 workshops were held in the 18 months following the RCT; 5 in community A, 3 in community B, 2 in community C, and 1 in community D. Using our predetermined definition of maintenance, 50% (3/6) of communities maintained implementation of MOM during that 18- month period.
Data from focus groups informed development and revision of an implementation package for future dissemination of MOM in coordination with our state dissemination agency. Implementation package materials were revised based on barriers to and facilitators of adoption and maintenance as well as observed fidelity lapses during ‘real world implementation’ in the 18 months following the RCT.
The strongest barrier to adoption and maintenance noted by all communities was limited resources (including funding and staffing limitations). Other barriers included competing organizational priorities and difficulty with participant recruitment, especially in small communities that had offered the program recently, or that started recruitment within one month of workshop start date.
Some facilitators of adoption and maintenance related to the intervention itself. Specifically, these included MOM’s well-organized facilitator manual and limited requirements for additional props and set-up, as well as its relatively low number of sessions (3 as opposed to 6-12 in other evidence-based health promotion programs). External facilitators of adoption and maintenance included high involvement of community partners in marketing and outreach, having a staff member in the agency dedicated to health promotion, and high community interest in MOM. These findings were incorporated into implementation package materials.
Regarding implementation with fidelity, there were no major fidelity lapses during the workshop sessions as part of the RCT, nor were there deviations from the facilitator script or key program elements during the sessions randomly audited in the 18 months following the RCT. However, there were 2 workshops (18%) held with either fewer or more participants than the recommended number of 8-12. One community scheduled MOM sessions one week apart rather than 2 weeks apart, as is required for participants to see improvements in symptoms between workshop sessions.
Interpretation of results
In addition to its effectiveness, demonstrated in the partner RCT to this implementation study, MOM demonstrated high adoption, maintenance, and implementation with fidelity by community agencies without healthcare training. Many barriers to and facilitators of adoption and maintenance of MOM are similar to those found with other evidence-based health promotion programs for older adults, and can be partially addressed through a robust implementation package.
Based on these findings, a calculated cost document was included in MOM’s implementation package so that communities can evaluate whether they have adequate funding and staff to invest in the program, and the recruitment guide was revised to suggest recruiting at least two months prior to the first MOM session start date, as well as keeping a list of interested members between sessions from which to augment recruitment. Having MOM administered by a dissemination agency that requires agencies to file a workshop registration form will ensure that timing of sessions and number of participants aligns with program requirements.
Mind Over Matter: Healthy Bowels, Healthy Bladder (MOM) has the potential for high public health impact, as evidenced by its effectiveness, implementation with fidelity, and high adoption and maintenance by community agencies. Future studies should evaluate its reach, the only component of Glasgow’s RE-AIM framework not addressed in this study.