Introduction

Many chronic health conditions, such as stroke and multiple sclerosis, result in persistent balance and mobility limitations [1,2,3]. Balance and mobility limitations contribute to functional dependence [1] and physical inactivity [4] which can further diminish health [1, 5,6,7]. Community-based exercise programs (CBEPs) that involve a healthcare professional have emerged in the United Kingdom [8,9,10,11,12,13], Australia [14], Italy [15], Canada [16], and the United States [17]. These programs can facilitate safe exercise participation for people with disabilities to help mitigate the negative consequences of balance and mobility limitations [12,13,14,15,16, 18].

In Canada, a group, task-oriented, CBEP incorporating a healthcare-recreation partnership (CBEP-HRP) called “Together in Movement and Exercise” (TIME™) has been developed [16, 19]. This program has been proven safe and appropriate for people with balance and mobility limitations who can walk at least 10 m independently and have sufficient cognitive and communication ability to function in a group setting [16]. In the TIME™ partnership, healthcare professionals, typically physical therapists, train and support fitness instructors to deliver the exercise program in community centers run by recreation organizations. The partnership was designed to maintain program quality and safety and support participant referral.

TIME™ involves a 1-h exercise class provided twice a week for 12 weeks. Classes involve seated warm-up and cool-down exercises, and practice of functional exercises (e.g., sit-to-stand, modified lunges, step-ups, walking), with standardized progressions, designed to improve balance and mobility. A minimum instructor-plus-volunteer-to-participant ratio of 1:4 is required to maintain adequate supervision and exercise progression [16]. Family members are invited to assist during the class if needed.

After a pilot study demonstrated the safety, feasibility, and potential benefit of the TIME™ model [16], a toolkit [20] that includes exercise guidelines and space/equipment requirements to run the program was developed. Using this toolkit, coordinators within stroke networks and regional health authorities facilitated spread of the TIME™ program to 28 community centers in Ontario and British Columbia, Canada by 2014. Although the ultimate goal of the TIME™ model was to enable long-term access to safe and beneficial exercise for people with balance and mobility limitations, the extent to which the TIME™ program was being delivered as designed, and the feasibility of sustaining the program were unclear. Thus, the aim of this study was to identify challenges with initial and sustained implementation of the TIME™ program model and solutions as perceived by program stakeholders. Results are expected to inform action plans to improve access to group, task-oriented, CBEP-HRPs for people with balance and mobility limitations.

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Methods

A 1-day stakeholder meeting and two follow-up surveys were undertaken. Seventy-seven individuals from academic, healthcare, and recreation sectors from across Canada who had experience with the TIME™ program or a similar program were invited to participate in the stakeholder meeting in May 2014. Recreation coordinators obtained permission from TIME™ exercise participants and caregivers to contact them with an invitation to participate.

Prior to the meeting, individuals were asked to document challenges, facilitators and strategies to implementing or participating in CBEPs using a standardized form (Additional file 1). Forms were submitted at meeting registration. Data were synthesized and presented during the meeting (agenda in Additional file 2). Morning meeting activities involved sharing of experiences with delivering or participating in the TIME™ program, research evidence supporting group, task-oriented training, and funding and policy issues affecting program expansion. In the afternoon, participants, seated by stakeholder group, were asked to identify and report on the two most important challenges with implementing the TIME™ model. Meeting facilitators (authors NMS & DB) documented the challenges. Each participant was then asked to vote for his/her top two challenges using a ballot that was color-coded by stakeholder group. After collecting the ballots, each stakeholder group was assigned one challenge and asked to identify and report on strategies to address the challenge. The strategies were documented. Immediately following the meeting, participants were invited to complete an online questionnaire to rate the level of priority of strategies as: not a priority, low priority, medium priority, and high priority. In September 2014, supervisors of TIME™ programs at 28 community centers were invited to complete an online questionnaire (Additional file 3) designed to characterize TIME™ program delivery.

Frequencies and percentages were used to summarize meeting and survey data. A descriptive content analysis [21] of the qualitative data from pre-meeting and meeting activities describing challenges to program implementation was performed. Similar challenges were clustered to identify themes.

Results

Of the 77 individuals invited, 53 (69%) attended the meeting. Of the 53 attendees (positions and organizations are listed in Additional file 4), 21 (40%) completed the pre-meeting activity, 40 (75%) participated in discussions at stakeholder-specific tables of 6 stakeholder groups to identify challenges and solutions related to TIME™ program delivery, and 42 (79%) rated the priority level of solutions post-meeting. Stakeholders who discussed program delivery challenges and solutions included 7 healthcare professionals, 9 healthcare system representatives, 11 fitness instructors, 9 recreation coordinators/managers, 3 researchers and 1 exercise participant.

Challenges identified during meeting discussions and voting results are described in Additional file 5. Challenges were captured by seven themes. (1) Resources to deliver the exercise class: Recreation centers faced issues related to inadequate space to run the class and store equipment and inappropriate exercise equipment. Recreation staff described difficulty finding instructors with the skills to work with people with multiple health conditions, language barriers, and low mobility levels, and to adapt the exercises to account for changes in participant ability or injury. Some centers were faced with high staff turnover; thus, maintaining a roster of trained staff over time was difficult. Recruiting, training and scheduling volunteers who were sometimes needed to maintain the 1:4 instructor-plus-volunteer-to-participant ratio was also noted as challenging. (2) Program marketing: Healthcare and recreation personnel recognised the challenge of promoting and raising awareness of the program among healthcare and rehabilitation professionals who could endorse the program and support referral to ensure adequate registration. (3) Transportation: Exercise participants and healthcare/recreation personnel agreed that transportation to the program could be costly and inconvenient. Adapted transport services did not consistently arrive on schedule, were cancelled during inclement weather, or were unavailable in rural areas. (4) Program access: Registration was not always possible. The program was either full or the exercises were inappropriate for some clients with multi-morbidities and low mobility levels and some clients with high functional levels who had already taken the program. These challenges were perceived as preventing long-term exercise participation. (5) Maintaining program integrity: This challenge related to ensuring consistent delivery of the program as intended over time across centers. (6) Sustaining partnerships: Maintaining roles, communication and collaboration between healthcare and recreation partners was considered challenging. (7) Funding: All stakeholders identified the need for additional funding to sustain the TIME™ program model. Recreation partners needed funding for staff wages, equipment, and program expansion; healthcare providers required funding to offer training and support; and clients needed funding to pay for program registration and transportation. Table 1 lists 29 strategies proposed to address the program challenges and associated priority ratings.

Table 1 Prioritization of strategies targeting challenges to implementing the TIME™ model for people with balance and mobility limitations (n = 42)a
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Seventeen supervisors of TIME™ programs run by 25 organizations in 28 community centers completed the online questionnaire (100% response rate). Across 28 centers, TIME™ programs had been running for ≤ 1 year (14%), 1–2 years (46%), 2–4 years (32%), and 6–8 years (7%). Exercises were performed in a circuit (original version) or three superstations (three exercises/superstation; updated version), in 57 and 29% of centers, respectively. Most frequently, classes were 60 min in length (89%), provided twice a week (57%) for 12 weeks (36%), and 3 times per year (39%). Volunteers and caregivers were permitted to assist in 75 and 89% of centers, respectively. Table 2 describes characteristics of program referral, advertisement, intake, format, and registration.

Table 2 Characteristics of TIME™ programs at 28 community centers
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Discussion

This mixed methods study revealed a range of program challenges related to recreation center resources, program marketing, transportation, access, integrity, funding, and sustaining partnerships, relevant to six stakeholder groups. Stakeholders identified high priority strategies targeting each of these challenges, with the exception of transportation. These strategies can be used to inform the development of action plans to help implement and sustain the TIME™ program. Following spread of the TIME™ program to 28 community centers, certain recommended program elements, including class format and duration, participation of caregivers, involvement of and referral of participants by healthcare professionals, were maintained, while others, such as admission criteria, weekly class frequency, program duration, maximum class size, instructor-to-participant ratio, and use of volunteers, were adapted.

Some challenges to delivering the TIME™ program, such as program cost and transportation, have been noted previously by people with stroke [22,23,24], HIV [25], and COPD [26, 27], as primary barriers to participation in structured exercise programs. Individuals in these studies recommended making CBEP-HRPs widely available [24, 26]. The ability to attend programs in close proximity to one’s home was perceived to minimize travel time and cost of transportation, and offset the negative impact of unreliable public transit, and inclement weather on program attendance [24, 26]. Subsidization of program cost was desired [26] as people with physical disability may be receiving a fixed income [25, 26]. Results from the current study further highlight the need for financial support of healthcare and recreation partners to sustain the CBEP-HRP model. The issue of program funding was recently investigated in a survey of providers of 14 exercise program programs for people with stroke in Scotland [28]. In this survey [28], three programs run by physiotherapists, nurses and assistants in healthcare settings to help transition people from hospital to independent exercise, were government-funded. Although participation was free, only one 10-week session was provided which may be insufficient to facilitate lifelong participation in physical activity. The strategy proposed in the current study to obtain regional healthcare funding for programs like TIME™ would provide people with physical disability with ongoing opportunities to exercise.

The importance of maintaining partnerships to sustain program referral, delivery, and integrity was underscored in our study. People with physical disability prefer a trusted healthcare practitioner to refer them to CBEPs, as this reassures them that the program is safe and appropriate [27]. Knowledge that a healthcare professional has continued involvement in a CBEP, as in the TIME™ program, provides further reassurance [29]. As proposed in the current study, standardized marketing materials used by a local facilitator may help foster partnerships with physicians, charities, peer support groups, and homecare service providers to help support program registration. Finally, opportunities for instructor training and continuing education, and the continued involvement of a healthcare provider in program delivery through periodic visits, may help to minimize local program adaptations that could decrease program quality and safety. For example, a third of centers in the current study did not apply the admission criteria of ability to walk 10 meters independently with or without an assistive device, considered a core program element [16]. This criterion helps to ensure participants have a minimum level of mobility to safely perform and benefit from the program exercises. Similarly, approximately 20% of centers reported a maximum class size of 14–16, and an instructor-to-participant ratio exceeding 1:4. These practices may reflect the inclusion of individuals with a higher level of balance and mobility ability that do not require close supervision. However, a ratio of 1:4 is important to ensure adequate supervision and participant safety. Future research should aim to better understand the role of healthcare providers in maintaining the safety and quality of CBEP-HRPs. Finally, CBEP-HRPs for individuals with more severe balance and mobility limitations as well as a process for graduating TIME™ program participants to more advanced exercise programs, were suggested to address wait lists observed in 39% of community centres offering the TIME™ program and enable exercise participation for a larger group of individuals.

Conclusions

Stakeholders involved in the unplanned spread of the CBEP-HRP TIME™ model in a publicly-funded healthcare system encounter challenges related to inadequate funding and infrastructure that may threaten the sustainability of these programs. Local application of the solutions proposed in this research is likely to result in slow and haphazard improvements as it will depend on the resources of individual organizations. Public health agencies, supported by a mandate and dedicated funding, will find our study findings relevant to planning for systematic development and scale-up of CBEP-HRPs to enable widespread and equitable access to exercise participation for people with a wide range of balance and mobility limitations.

Limitations

Challenges and strategies identified in this study may primarily reflect the priorities of healthcare and recreation professionals as they had a high degree of representation. Their opinions, however, were informed by presentations made by exercise participants and caregivers early in the meeting. Seating participants by stakeholder group and inclusion of anonymous voting were strengths of the meeting process that helped to ensure representation of multiple stakeholder perspectives.