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PREVENTING CHRONIC DISEASEP U B L I C H E A L T H R E S E A R C H , P R A C T I C E , A N D P O L I C Y Volume 17, E156 DECEMBER 2020

IMPLEMENTATION EVALUATION

An Evidence-Based Walking Program inOregon Communities: Step It Up! Survivors

Cynthia K. Perry, PhD, FNP-BC1; Laura P. Campbell, MBA, MPH2; Jessica Currier, PhD2;

Paige E. Farris, MSW2; Elizabeth S. Wenzel, MPH2; Mary E. Medysky, PhD1; Adrienne Zell, PhD2;Miriam McDonell, MD3; Jackilen Shannon, PhD4; Kerri Winters-Stone, PhD1

Accessible Version: www.cdc.gov/pcd/issues/2020/20_0231.htm

Suggested citation for this article: Perry CK, Campbell LP,Currier J, Farris PE, Wenzel ES, Medysky ME, et al. AnEvidence-Based Walking Program in Oregon Communities: StepIt Up! Survivors. Prev Chronic Dis 2020;17:200231. DOI: https://doi.org/10.5888/pcd17.200231.

PEER REVIEWED

Summary

What is already known on this topic?

Providing technical assistance and small-grant funding to community or-ganizations is a promising approach to support implementation ofevidence-based programs.

What is added by this report?

Community organizations are challenged by some aspects of implement-ing an evidence-based program, particularly balancing fidelity and adapta-tion and conducting a rigorous evaluation.

What are the implications for public health practice?

Difficulties experienced by some organizations in balancing fidelity and ad-aptation of the Step It Up! Survivors program indicate that flexible, indi-vidualized guidance and enhanced technical assistance are needed whenthey are in the process of adapting, implementing, and sustaining anevidence-based program locally.

AbstractPhysical activity can help mitigate the long-term symptoms andside effects of cancer and its treatment, but most cancer survivorsare not active enough to achieve these benefits. An evidence-basedstrategy to promote physical activity among adults is a com-munity group–based walking program. However, many evidence-based programs do not achieve intended population health out-comes because of the challenges of real-world implementation.We used the Interactive Systems Framework for Disseminationand Implementation to conceptualize implementation of a

capacity-building intervention to support delivery of a communitygroup–based walking program. We adapted an evidence-basedguide for community group–based walking programs for cancersurvivors and their support network. We provided a capacity-building intervention (technical assistance and small-grant fund-ing) and evaluated this implementation intervention. We assessedeffectiveness of the intervention by measuring adoption, acceptab-ility, appropriateness, feasibility, fidelity, implementation costs,and penetration through monthly progress reports, site visit obser-vations, interviews, and a final report. Eight organizations re-ceived a small grant and technical assistance and implementedStep It Up! Survivors (SIUS). SIUS helped cancer survivors in-crease their physical activity, establish social connections, and bepart of a supportive environment. Despite receiving monthly tech-nical assistance, some grantees experienced challenges in recruit-ing participants, developing community partnerships, and adher-ing to the prescribed implementation plan. Implementation facilit-ators included community partners and specific components (eg,incentives for participants, webinars). Organizations needed differ-ent amounts and types of assistance with adaptation and imple-mentation. Overall fidelity to SIUS ranged from 64% to 88%.Some integrated SIUS within existing organizational program-ming for sustainability. The provision of funding and technical as-sistance was a successful implementation intervention. Our resultssuggest a need to better tailor technical assistance while organiza-tions are in the process of adapting, implementing, and sustainingan evidence-based program in their local communities.

IntroductionIn 2019, approximately 16.9 million cancer survivors were livingin the United States, and their number is estimated to increase to22.1 million by 2030 (1). Cancer survivors experience long-termsymptoms and side effects of cancer and its treatment, includingpain, fatigue, sleep disturbances, mood disturbances, reduction inquality of life (2), decreased physical functioning, and bone andmuscle loss (3). Physical activity can mitigate many of these long-

The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Healthand Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.

This publication is in the public domain and is therefore without copyright. All text from this work may be reprinted freely. Use of these materials should be properly cited.

www.cdc.gov/pcd/issues/2020/20_0231.htm • Centers for Disease Control and Prevention 1

term symptoms and side effects (1,3,4). Additionally, regular suf-ficient physical activity may reduce the risk of recurrence, cancermortality and all-cause mortality (1,3,4). The American CancerSociety recommends that cancer survivors engage in 150 minutesper week of moderate activity, such as brisk walking (4). TheAmerican College of Sports Medicine indicates 90 minutes ofmoderate level activity mitigates symptoms and side effects ofcancer and its treatment (5). Less than half of cancer survivors aresufficiently physically active (6).

Group exercise is a promising approach for cancer survivors.Group and/or supervised exercise has resulted in greater improve-ments in primary outcomes (eg, fitness, muscle strength) com-pared with unsupervised and/or home-based interventions amongcancer survivors (7). Group walking programs, an evidence-basedstrategy recommend by The Guide to Community Preventive Ser-vices (8), is a promising approach to enhance physical activityamong cancer survivors because it is simple, geographically con-venient, inexpensive, and suitable for most people. Community-based group walking programs enhance adherence because of thesocial support and cohesion developed among group members (9).

Public health programs, such as group-based walking programs,should reflect the best available evidence. However, manyevidence-based programs (EBPs) do not achieve intended healthoutcomes because of challenges in implementation. Capacity-building interventions enhance community public health practi-tioners’ adoption and implementation of EBPs (10). The Interact-ive Systems Framework for Dissemination and Implementation(ISF) describes a process for translating research evidence andsupporting community organizations to implement programs toachieve the intended outcomes with capacity building as the cent-ral component (11,12). The ISF describes 3 interacting systems:the Prevention Synthesis and Translation system, which distills re-search, the Prevention Support System, which provides capacitybuilding, and the Prevention Delivery System, which delivers theprogram (12).

Standard approaches are needed to assess the implementation ofevidence-based cancer prevention, control, and treatment interven-tions. Proctor and colleagues developed a taxonomy of implement-ation outcomes that includes acceptability, adoption, appropriate-ness, feasibility, fidelity, cost, penetration and sustainability (13).Using a standard approach to assessing the effectiveness of imple-mentation of capacity-building interventions can allow compari-sons across interventions and provide information on the best ap-proaches to promote implementation of EBPs.

Purpose and ObjectivesThe goals of this study were to 1) adapt an evidence-based guidefor community walking programs for cancer survivors and theirfriends and family, 2) provide capacity-building support (technic-al assistance and small-grant funding) for community organiza-tions to implement this program, and 3) evaluate the success of theimplementation of the intervention.

We used the ISF to conceptualize implementation of a capacity-building intervention to support delivery of a communitygroup–based walking program. We adapted an evidence-basedguide for delivering group-based walking programs for cancer sur-vivors and their friends and family and called the program Step ItUp! Survivors (SIUS). We provided capacity-building support,technical assistance, and small-grant funding to community andpublic health organizations in Oregon.

We used a mixed-methods design to assess the implementationoutcomes. We collected qualitative and quantitative data from sev-eral sources during the study period. The study was approved bythe Oregon Health & Science University (OHSU) Institutional Re-view Board. The study, including planning, took place from July2017 through February 2019.

Intervention ApproachWe completed implementation strategies and activities in each ofthe 3 interacting systems delineated in the ISF: The PreventionSynthesis and Translation System and the Prevention Support Sys-tem were represented by OHSU and the Knight Cancer Institute.The Prevention Delivery System was represented by thecommunity-based organizations.

Prevention Synthesis and Translation System

We identified the core elements of a walking program and its keycharacteristics to meet the needs of cancer survivors through a lit-erature review. We searched PubMed by using the followingsearch terms without limiting study year or study type: “group-based,” “community,” and “walking program.” We adapted an ac-tion guide developed by the Partnership for Prevention with sup-port from the Centers for Disease Control and Prevention,Establishing a Group Based Walking Program to Increase PhysicalActivity Among Youth and Adults (14), to create a user-friendlytoolkit for use by community-based organizations with programsdesigned for cancer survivors. Our toolkit (Figure 1) outlined 7steps to implementing the program. It included a week-by-weektimeline and guidance for completing each step and additional re-sources and deliverables for grantees. The program included

PREVENTING CHRONIC DISEASE VOLUME 17, E156

PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY DECEMBER 2020

The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services,the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.

2 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2020/20_0231.htm

friends and family members of survivors because of the import-ance of social support for behavior change.

Figure 1. Cover of toolkit developed for Step It Up! Survivors walking program,Oregon, 2017–2019.

Prevention Support System

Innovation-specific capacity buildingSmall grant funding. We added a special request for applicationsto the OHSU Knight Cancer Institute Community Partnership Pro-gram (www.ohsu.edu/knight-cancer-institute/community-partnership-program-grants), which provides small grants($10,000–$50,000) to community organizations. We issued a re-quest for proposals for implementation of SIUS. Communitygroups, health and medical clinics, public health departments, andhealth systems in Oregon that did not have an active walking pro-gram were eligible to submit an application for a 1-year $15,000grant, plus technical assistance. Before the application submissiondate, we hosted a webinar about the competitive funding process,and funding decisions were based on proposal review by mem-bers of our Cancer Prevention and Control Research Network’sTribal and Rural Advisory Board, a previous Community Partner-ship Program grantee, and OHSU researchers. Final funding de-cisions were made by Community Partnership Program leadership.Funding was provided from January 2018 through December2018.

Technical assistance. The team of researchers worked withgrantees to implement the SIUS, including assistance with any rel-evant regulatory approvals. In March 2018, representatives fromeach organization attended a train-the-trainer webinar on how totrain local community members to be walking group leaders. Wefacilitated 8 monthly, 60-minute webinars on recruitment, reten-tion, and motivation of walking group leaders and participants, ad-aptation logs, and program sustainability. Each month, a differentgrantee made a 30-minute presentation on various topics (eg, datacollection techniques, recruiting and retaining walking parti-cipants, engaging community partners), leaving 30 minutes fordiscussion facilitated by the research team. The webinars provided

an opportunity for organizational leaders to learn from and sup-port each other. Additionally, we responded to questions andprovided individual guidance to grantees via telephone calls andemail.

General capacity buildingIn January 2018, we held a training session developed by the Can-cer Prevention and Control Research Network, Putting PublicHealth Evidence into Action (www.cpcrn.org/training). This 1-dayin-person training session provides instruction on implementationof EBPs in public health. This instruction was applied by granteesto the SIUS program, but the skills could also be applied bygrantees in future programs.

Prevention Delivery System

Each grantee was responsible for implementing the SIUS in theircommunity using the toolkit. Program Implementation was di-vided into 4 phases. The first 3 months involved start-up and pro-gram planning, which encompassed the first 6 of 7 steps: enga-ging the community; recruiting walking leaders; attending a train-the-trainer session; training the walking leaders; selecting andmapping walking routes, securing indoor location for use asneeded; publicizing SIUS; and organizing a kick-off event. Thesecond 3 months involved implementation of the program by hold-ing weekly community walking groups for cancer survivors, theirfamily and friends (step 7), continuing to publicize and recruit par-ticipants, maintaining interest and attendance in the program, andcontinuing to engage with the community. The third phase was a2-month maintenance phase, and the final phase was 2 months forfollow-up. In addition, each organization had 2 months to com-plete a final report.

Evaluation MethodsWe assessed effectiveness of the implementation intervention bymeasuring acceptability, adoption, appropriateness, feasibility, fi-delity, implementation costs, penetration, and sustainability as de-scribed by Proctor and colleagues (13), through monthly progressreports, site visit observations, interviews, and a final report (Ta-ble 1).

Community organization reports. Monthly grantee progress re-ports described strategies for publicizing SIUS, tactics and incent-ives used to motivate participants and leaders, walking route, num-ber of groups held, and attendance. A final report gathered data onSIUS objectives and outcomes (eg, create a safe and supportiveenvironment for cancer patients, survivors, and their friends andfamily to come together for socializing through movement),project reach (eg, number of unique individuals attending groups),community partnerships (eg, number and role of community part-





ners), strengths and benefits of the project, barriers, challenges andlessons learned, future plans, and evaluation of the technical as-sistance (eg, webinars, trainings, toolkit). The monthly and finalreports were completed in a secure online database. Additionally,the grant applications provided information on the grantee (eg,size, rural/urban).

Fidelity assessment: observation and stakeholder interviews. Foreach grantee, research staff members observed a walking groupand interviewed the program manager to assess fidelity. Duringthe observation, the researchers completed a fidelity checklist ofthe key components of conducting a walking group outlined in thetoolkit. Key components included characteristics of the walkingleaders, the routes, use of team building and social supportstrategies, and accessibility and aesthetics of walking routes.

One research staff member conducted 30- to 60-minute semistruc-tured interviews with key leadership at each organization and asecond staff member completed the fidelity checklist and tooknotes during the interview. Key components of implementationdescribed in the toolkit that were not possible to observe duringthe walking group were asked about during interviews, includingtypes of stakeholders engaged in planning and implementation,identification and training of walking group leaders, alternateroutes for inclement weather, minimizing loss of interest, and re-sources used to plan routes.

Adaptation logs. We provided organizations with an adaptationlog to record adaptations to the program, the date and descriptionof the adaptation, reason for the adaptation, and its level of import-ance. These logs allowed for comparison across organizations.

Walking group participant survey. Walking group leaders invitedcancer-survivor participants to complete an online survey atbaseline, 3 months, and 6 months. The survey included 11 state-ments about their experience and satisfaction with SIUS; respond-ents rated agreement on a scale from 1 to 6 (1 = strongly disagree,6 = strongly agree). At baseline, the survey also collected informa-tion on cancer-survivor participants’ demographic characteristics(age, race, ethnicity, highest academic degree attained, maritalstatus, employment status), height and weight, and cancer (type ofcancer and number of years since diagnosis).

Data analysis

Qualitative data analysis. We exported notes taken during the lead-ership interviews and coded them line by line. We exported textfrom the final project reports into Dedoose version 8.1 (Dedoose,LLC), a web-based program for analyzing qualitative and mixed-methods data. Two researchers coded the texts independently andmet to reach agreement. The coding focused on implementationoutcomes, barriers, and facilitators.

Quantitative data analysis. We exported quantitative data from themonthly progress reports and site visits into R statistical softwareversion 3.5.1 (R Foundation for Statistical Computing), data fromthe online participant surveys into Stata version X (StataCorpLLC), and data from the fidelity checklist and monthly and finalreports into Excel (Microsoft). We calculated descriptive statisticsfor each organization.

Walking group attendance was recorded each month by each or-ganization. The average weekly attendance is the mean number ofpeople attending a walking session across all groups hosted by anorganization. Some organizations had more than one walkinggroup that met weekly. The average monthly attendance is the av-erage total attendance for all organizations across weeks in a par-ticular month.

We measured fidelity to the SIUS implementation toolkit by us-ing a checklist, which we completed during site visits (observa-tions of the group walks), and an interview guide, which we usedduring interviews of organizations’ leadership. We calculated a fi-delity score for each of the 7 steps of program implementation as apercentage. The checklist included 9 yes/no questions and 12questions answered on a scale of 1 to 5; the checklist was alsoused to record the location and date of the site visit. To assignquestions equal weight among the fidelity scores, we coded therating-scale questions from 1 to 5, and we coded dichotomousquestions yes = 5 and no = 1. We did not count responses markedas not applicable or missing in the calculation of the fidelity per-centage. This method is commonly used in analysis of survey data(15).

Mixed-methods analysis. We placed the coded text and the quant-itative results into an implementation outcomes matrix for furtheranalysis. The mixed-methods analysis for organizational-level dataspanned 3 areas: measuring program success using attendance datafor each organization, assessing fidelity to the SIUS toolkit, andanalyzing strategies and tactics to recruit and incentivize walkingleaders and participants. Walking group attendance was a quantit-ative measure of program success, with larger attendance numbersindicating better program engagement. A higher fidelity percent-age indicated greater fidelity to the SIUS toolkit. Strategies to re-cruit and incentivize walking leaders and walking group parti-cipants were deduced from the monthly reports, and qualitativethemes were deduced from site visit data and monthly reports. Wecreated a case-based matrix with the organizations in rows and thestrategies in columns.





ResultsCancer survivor survey results

Sixty cancer-survivor participants completed eligibility screening,35 met eligibility requirements, 30 consented to participate andcompleted the baseline survey, and 17 completed the survey at 3and 6 months. Eligibility requirements included a cancer diagnos-is, participation in an SIUS walking group, being aged 18 or older,and ability to speak English. Grantees did not prioritize comple-tion of the online surveys.

Of the 30 cancer-survivor participants who completed the baselinesurvey, the average age was 60.4 (range, 44–79). Most were non-Hispanic (n = 28) and White (n = 28), had a bachelor’s degree orhigher (n = 20), and were married (n = 26). About half were re-tired (n = 13), and half were employed full-time or part-time (n =12). The most common form of cancer was breast cancer (n = 21)with time from diagnosis ranging from 4 months to 30 years.

Implementation outcomes

Adoption. Ten organizations responded to the request for propos-als for implementing SIUS; 8 organizations received awards. Or-ganizations that received awards were local health departments (n= 3), community cancer centers (n = 3), a nonprofit organizationthat supports cancer survivors (n = 1), and a physical therapy prac-tice (n = 1); 6 were in rural communities.

Acceptability. The average weekly attendance varied within andacross organizations (Figure 2). One organization followed a dif-ferent protocol to record walking group attendance than the other7 organizations; we did not include these data in our analysis. Thenumber of unique participants across all organizations was 258and included cancer survivors, their family and friends, and com-munity members. The median number of participants across all or-ganizations was 34. The median number of monthly walkinggroup attendees per organization ranged from 6 (Organization H)to 114 (Organization B). The median weekly attendees per groupwas 12 and the average weekly attendance per organization was13.7.

Figure 2. Average weekly attendance in walking group by organization and bymonth.

Overall participant feedback was positive. Six organizations repor-ted that their participants enjoyed the program and kept comingback. Additionally, organizations reported that walking group par-ticipants developed connections with each other. Anecdotally, can-cer survivors reported having stronger social connections and amore positive outlook on life than before participating in SIUSand the value of receiving and giving peer support to their fellowcancer survivors. One community organization reported the fol-lowing: “There was an overwhelming support from individualsvolunteering to become walking leaders, as well as walking parti-cipants. The success led to friendships and socializing. There is acore group of walkers that faithfully attend and help welcome innew walkers.” Another stated, “The greatest success was the so-cial connections created. Everyone agreed that being with andmeeting others was a huge highlight of the program.”

Of the 17 participants who completed the online survey at 3months, 16 agreed or strongly agreed that they were satisfied withthe walking leader, the walking routes, and the program. At 6months, all 17 survey respondents slightly agreed, agreed, orstrongly agreed that they were satisfied with the walking leader,the walking routes, and the program.

Appropriateness. Walking was generally considered by organiza-tions’ leadership and walking leaders an appropriate form of exer-cise for cancer survivors because they could move at “their ownpace and ability.” Five of 8 sites reported that their participants ex-perienced increased physical activity, health benefits, and socialconnectedness and engagement. As one organization stated, “Hav-ing this weekly walking group has created a safe space for our pa-tients who are currently undergoing treatment to come and move





at their own pace and ability, while meeting and talking with sur-vivors who have been in their shoes.” Another stated, “Parti-cipants reported significant improvements to health and cited in-creased social engagement as their primary participation benefit.”

At 6 months, 15 of 17 survey respondents agreed that the programhelped them increase their physical activity, 17 agreed the pro-gram was a good way to be physically active, and 16 reported feel-ing connected to other members of the walking group who weresupportive of each other.

Five organizations stated that participants wanted the groups tocontinue after the end of the project. Reasons provided by the or-ganizations for discontinuing the walking groups included climate,(ie, high temperatures and unsafe air quality from wildfires), lackof commitment from organizational leadership, challenging reten-tion during the summer because of summer travel and vacations,and weak community partnerships.

Feasibility. All organizations reported that they implemented atleast 1 walking group during the study period. Some organiza-tions experienced low attendance and challenges with keepingwalking leaders engaged over the 3 months (Table 2). Challengesin retaining walking leaders included life changes (eg, changingjob, moving away), summer travel, and physical limitations (somewalking leaders were receiving cancer treatment that affected theirability to fulfill their role). All organizations found the data report-ing requirements of the grant burdensome.

All organizations used the strategies suggested in the toolkit topublicize walking groups. The most common strategies were wordof mouth, social media, and posters around the community. Otherstrategies for recruitment and retention included advertising withlocal media and engaging other community organizations or stake-holders. The grant required use of participant incentives to encour-age retention; grantees used raffles, gift cards, and promotionalproducts. One organization commented, “Program participationincentives were cited [by participants] as being an important ele-ment of the program’s success, making it fun to participate.”

Despite these strategies, organizations that were not connectedwith a cancer center reported difficulties reaching cancer surviv-ors. Three organizations described challenges with recruitment.Five organizations expanded walking groups to include com-munity members interested in prevention and making healthychoices. One organization reported challenges with recruitingwalking leaders, and 1 organization reported challenges establish-ing community partners. All organizations used outdoor walkingroutes, and 4 organizations secured indoor locations for inclementweather (eg, poor air quality from forest fires, high ambient tem-peratures), allowing weekly groups to continue.

Fidelity. Fidelity was the degree to which the SIUS program wasimplemented as delineated in the toolkit. The number of adapta-tions across the 7 steps ranged from 0 to 4 (Table 3). Fidelityranged from 62% (step 1; 225 of 360 possible points) to 86% (step6; 212 of 245 possible points). Not counting missing responsesand those marked not applicable toward scores, average fidelityacross the steps for each organization ranged from 64% (163 of255 possible points) to 90% (230 of 255 possible points). Weasked grantees to propose and discuss adaptations with the re-search team to determine whether the proposed adaptation wouldaffect the evidence-based components of the program; we plannedto approve adaptations determined not to have an effect. This dis-cussion often occurred, but the research team was not alwaysaware of adaptations until after they had been made; some imple-mented adaptations were not approved by the research team.

Five organizations implemented program adaptations. The mostcommon adaptations were aimed at increasing reach, receptivity,and participation, including design changes to SIUS outreach ma-terials, such as expanding audiences to include all communitymembers interested in becoming more physically active and so-cial and increasing the frequency of walking group meetings totwice per week per the interest of walking group participants. Oneadaptation fundamentally changed SIUS from a group-based to anindividual-based walking program: the definition of attending awalking group was changed to include participants who sent anemail to the walking group leader indicating that they had walkedthat week. Although this adaptation was viewed as more inclusive,the expanded definition conflicted with a key premise of SIUSabout the importance of the group in providing social support,connectedness, and accountability. This adaptation was not pre-approved.

Cost. Each organization received approximately $15,000 to imple-ment SIUS; this amount varied slightly depending on the budgetrequested by the organization. The grant required that at least$1,000 be allocated for participant incentives. Organizations alsoreceived in-kind donations from community partners (eg, space,personnel paid by a partner, volunteer hours). All organizations re-ported implementation of SIUS within the budget as planned, in-cluding in-kind donations.

Penetration. The number of walking groups held in each organiza-tion ranged from 1 to 9, with a mean of 5.2 walking groups per or-ganization. One organization stated, “We set a goal of establish-ing 1 walking group and significantly exceeded our expectationswith 5 active walking groups in our community.”

Two organizations reported incorporating the walking program in-to existing organizational structures. One organization reportedthat SIUS was co-promoted with another well-known wellness





program in the organization, which contributed to successful re-cruitment. As one organization stated, “This walking group hasbecome a part of the survivorship and cancer support/educationgroup program that is led by the Oncology Social Worker, whichpromotes the likelihood of it continuing on into the next year.”

Sustainability. Four organizations reported that their program washighly likely or somewhat likely to be active 1 year after the fund-ing period. These organizations reported that the largest contribut-ing factors to expected sustainability were integration of the walk-ing groups into existing programs (within their own organizationor a community partner) and participant enjoyment. Another con-tributing factor was the use of volunteers to lead the walkinggroups. One organization noted, “[The city’s] recreation programhas taken on the long-term coordination of Step It Up! Survivorsin our town. The group is peer led and does not rely on paid staff[to lead the walking groups].”

Implications for Public HealthThis capacity-building intervention of providing technical assist-ance and small-grant funding was a successful approach to pro-moting implementation of an evidence-based community walkingprogram for cancer survivors, their friends, and families. The 8grantees varied in their capability to achieve success, suggestingthe need for tailored technical assistance. Fidelity to the toolkitvaried across the 7 steps in the program implementation andacross the 8 organizations, suggesting the need for more clarity,more education about the importance of fidelity, and more indi-vidualized guidance on balancing fidelity and adaptation. Integra-tion of SIUS into existing programs in the organization and parti-cipant enjoyment contributed to the likelihood of sustaining SIUSfor at least 1 year beyond the funding period.

Six of the 8 organizations that implemented SIUS were in rural(Rural–Urban Continuum Codes 4–9) communities (16). Ruralresidents of the United States experience health disparities be-cause of geographic isolation. Compared with their urban counter-parts, they have lower socioeconomic status, fewer job opportunit-ies, higher rates of health risk behaviors, limited access to healthcare specialists and subspecialists, and less likelihood to haveemployer-provided health insurance coverage; if they are experi-encing poverty, they are often are not covered by Medicaid(17–19). Cancer survivors living in rural areas are diagnosed atlater stages of disease and have more barriers to cancer prevention,control, and treatment than their urban counterparts (17,19). SIUSprovided a supportive health promotion activity to cancer surviv-ors, their family, and friends in an environment where health dis-parities persist.

Organizations commented that walking groups were an importantsource of social support for cancer survivors. Extension of thewalking groups to cancer survivors’ friends and family and, insome locations, the broader community expanded the network ofsocial support.

Capacity-building interventions providing technical assistanceand/or small-grant funding have been found to enhance the adop-tion and implementation of EBPs (10,20–24). Similar to thisstudy, other mini-grant programs have resulted in the recipient or-ganizations building and strengthening partnerships with othercommunity organizations (20,24). However, community organiza-tions are typically set up for program delivery and not for evalu-ation; thus, it was challenging for community organizations re-ceiving capacity-building interventions to complete the evaluationsteps (eg, data collection, data analysis). All grantees reported thatthey did not prioritize participants completing the online surveys,as reflected in the low number who completed eligibility screen-ing, and they found the grant reporting requirements burdensome.Similarly, in a mini-grant program, community organizationsfound it challenging to prioritize data collection for evaluation(23), and in a countywide mini-grant initiative, organizations didnot have the capacity for evaluation (eg, lack of time, skill, and re-sources) (25). It is critical to determine the effectiveness ofcapacity-building interventions to enhance organizational capacityto adopt, implement, and sustain delivery of EBPs as well as as-certain the effectiveness of the EBP to achieve desired outcomesin the local setting. Thus, the Prevention Support System deliver-ing the capacity-building intervention may need to provide addi-tional support for data collection and evaluation to ensure evalu-ation of effectiveness.

Although key leadership from each grantee received training on fi-delity and adaptation, we found a range of fidelity to and adapta-tions of the SIUS toolkit. A potentially inappropriate adaptationcould compromise an underlying evidence-based component of agroup-based walking program, as we found in the broadening ofthe definition of a walking group attendee. In a mini-grant pro-gram in which recipients received training on adaptation and fidel-ity of evidence-based interventions, the organizations made sub-stantial alterations that might have changed the evidence-basedcomponents of the programs (22). In another, the grantees werechallenged by balancing fidelity with adaptation, and somegrantees dropped core program elements (26). Although retainingthe core elements that produce the desired outcomes from theEBPs is critical, some adaptation is necessary to enhance a pro-gram’s relevance, community reach, alignment with local re-sources, and program sustainability (26). This balancing of fidel-ity and adaptation is difficult and requires careful consideration ofthe underlying theory and evidence base of the program as well as





the community needs, desires, barriers, and facilitators to programimplementation. The challenges of balancing fidelity and adapta-tion of EBPs, despite generalized training on these concepts, sug-gests that in addition to generalized training, individualized localguidance on fidelity and adaptation is needed. Our rural SIUSgrantees faced several challenges, including a small number ofcommunity partners with whom to collaborate in program promo-tion and recruitment of walking leaders and participants. Addition-ally, Oregon had an active wildfire season in 2018. Poor air qual-ity was more prevalent in rural locations than urban locations andaffected scheduled walking sessions.

We found that community organizations with previous programimplementation experience were able to build on that experienceand move through the steps in the SIUS toolkit better than organ-izations with less experience. Although we delivered technical as-sistance through multiple modalities, including telephone calls,emails, training sessions, and monthly webinars, we did not tailorour approach to the experience of each organization. Providingtechnical assistance in a flexible manner that aligns with and ad-dresses organizational realities (eg, leadership, resources) and isboth relationship building and content driven has been effective inpromoting implementation of EBPs (21,27). Assessing com-munity and organizational readiness for implementing an EBP andtailoring technical assistance approach, type, and intensity to thatlevel of readiness could enhance the effectiveness of the capacity-building intervention and harmonize the overall allocation of re-sources for the intervention.

Our study has several limitations. It was conducted in Oregononly, so results may not be generalizable to other areas of theUnited States. We did not audio record interviews with key stake-holders and despite careful notes taken during the interviews,some responses from interviewees may not have been fully reflec-ted. Because of a short funding cycle, we could not follow up 1year after the start of the walking groups to assess sustainability.The community organizations had challenges recruiting and re-taining cancer survivors, and most opened the groups to any com-munity member. Strengths of this study include use of theoreticalframework, ISF (12), to conceptualize the capacity-building inter-vention; the implementation and evaluation of a community walk-ing program for cancer survivors, a group for whom few com-munity programs exist, particularly in rural areas; and the use ofimplementation outcomes suggested by Proctor and colleagues(13). Overall, we believe this study provides support for the use ofcapacity-building interventions to promote the implementation ofEBPs by community organizations.

Use of the ISF helped us to conceptualize the elements and rela-tionships of key stakeholders (eg, universities, community organ-izations) involved in providing a capacity-building intervention

aimed at disseminating and implementing an evidence-based com-munity health walking program for cancer survivors. Thecapacity-building intervention (technical assistance and small-grant funding) was a successful approach for dissemination andimplementation of SIUS. Difficulties experienced by some organ-izations in balancing fidelity and adaptation of the SIUS programindicates that flexible, individualized guidance and enhanced tech-nical assistance are needed while organizations are in the processof adapting, implementing, and sustaining an EBP locally. Use ofcapacity-building interventions to promote and guide the imple-mentation of EBPs by community organizations is an effectivemethod to achieve a program’s intended population health out-comes. Members of this research team have applied for funding toexpand the scope of group walking programs for cancer survivors,their family and friends, as well as community members in rurallocations throughout Oregon.

AcknowledgmentsFunding for the project is provided in part by the OHSU KnightCancer Institute Community Partnership Program. This publica-tion is a product of a Health Promotion and Disease PreventionResearch Center supported by Cooperative Agreement Number (5U48DP005006-05) from the Centers for Disease Control and Pre-vention. The findings and conclusions in this journal article arethose of the authors and do not necessarily represent the officialposition of the Centers for Disease Control and Prevention. Nocopyrighted materials were used in this research.

Author InformationCorresponding Author: Cynthia K Perry, PhD, FNP-BC, School ofNursing, Oregon Health & Science University, 3455 SW USVeterans Hospital Rd, Portland, OR 97239. Telephone: 503-494-3826. Email: [email protected].

Author Affiliations: 1School of Nursing, Oregon Health & ScienceUniversity, Portland, Oregon. 2Oregon Clinical and TranslationalResearch Institute, Oregon Health & Science University, Bend,Oregon. 3North Central Public Health District–Public Health, TheDalles, Oregon. 4Oregon Health & Science University–PortlandState University School of Public Health, Portland, Oregon.

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Tables

Table 1. Implementation Outcome Definitions and Data Sources for Implementation of an Evidence-Based Walking Program in Oregon Communities: Step It Up!Survivors, 2018

Outcome Definition Data Sources

Acceptability Perception among stakeholders that the program was agreeable andsatisfactory

Final project report; satisfaction survey; attendancerecords

Adoption Uptake of the program by the organization and community Grant application; monthly progress report

Appropriateness Perceived fit, relevance, and compatibility of the program for a given setting Final project report; monthly progress report;satisfaction survey

Feasibility The extent to which the program can be carried out Monthly progress report; final project report

Fidelity The degree to which the program was implemented as prescribed Site visits; interviews; adaptation logs

Implementation costs The costs of implementing the program Monthly progress report; final project reports

Penetration The degree to which the program is integrated within the setting Final project report; monthly progress report

Sustainability The extent to which the newly implemented program will be maintained orinstitutionalized

Final project report





Table 2. Challenges and Facilitators, by Implementation Step and by Organization, During Implementation of an Evidence-Based Walking Program in Oregon Com-munities: Step It Up! Survivors (SIUS), 2018

Organization:Rural/Urban andType

Step 1: CommunityEngagement

Step 2: RecruitWalking Leaders

Step 3: TrainWalking Leaders

Step 4: Selectand Map

Walking RoutesStep 5: Publicize

SIUSStep 6: Kick-

off Event

Step 7: MaintainWalking Groupand Participant

Interest

Organization A: Rural, nonprofit organization

Facilitator Program promotion;garnered support ofcommunity leaders;established communitypartners

Committed walkinggroup leaders

Walking groupleader toolkit

Publicpartnership withcommunitypartnersprovided walkingroutes and maps

Promoted walkinggroup amongcancer survivorsupport groups

None reported Solicited andintegrated inputfrom walkinggroup leaders forqualityimprovement;integratedprogram intoorganization’sbudget; supportfromorganization’sleadership

Challenge Community engagementrequired significantinvestment of staff time

None reported None reported None reported None reported None reported None reported

Organization B: Rural, nonprofit

Facilitators Community partnershipsresulted in exceedingexpectations for walkinggroup participation;Program built on andenhanced existingcommunity partner walkingand physical activityprograms to createawareness andparticipation countywide

Community partnerprovided avolunteer staffmember whohelped recruitwalking leadersand supportedprogramcoordination;Celebration ofwalking groupleaders at acommunity cancertribute event co-hosted by and theAmerican CancerSociety revitalizedpartnershipbetween the twoorganizations andrenewed interest incommunity forprograms forcancer survivors

Communitypartner helpedrecruit walkinggroup leaders

Communitypartner providedwalking groupvenue, mappedwalking routes,registeredparticipants, andreportedattendance datafrom their groupto projectcoordinator;Walking groupleader toolkit

None reported None reported Participants likedwalking venues/routes;Participantsestablishedimportant socialbonds and werethe impetus tosustain theprogram

Challenges None reported None reported None reported None reported None reported None reported None reported

Organization C: Urban, for-profit

Facilitators Recruiting through existingcancer survivor supportgroups

Community ofactive cancersurvivors ready andwilling to leadwalking groups


Parks andRecreationDepartmentactive andsupportive indevelopingwalking grouproutes

Targetedrecruitment tocancer survivorsand their networks

None reported Program organizerparticipated asactive member inwalking group;Participantincentives

Challenges None reported None reported None reported None reported Flyers were not aneffectiverecruitment tool

None reported Low walking groupparticipation;walking leader

(continued on next page)





(continued)








SIUSStep 6: Kick-

off Event


Interest

was in activecancer treatmentlimiting ability;Inability tocontinue providingparticipantincentives

Organization D: Rural, public health/government

Facilitator None reported Recruited atcommunity eventsand cancer center;Cancer centerprovided walkinggroup leaders


County Sherriffprovidedguidance indeterminingwalking routes

Cancer center andcommunitypartnerspublicized SIUS

Offeredflexibility byhosting 2 kick-off events

Communitypartner providedincentives toparticipants

Challenge Finding community groups/organizations interested inpartnering on this project

None reported None reported None reported None reported None reported Difficulty findingtime and locationamenable to allparticipants

Organization E: Rural, nonprofit

Facilitator Interest in the communityto participate; Participantincentives

Support fromindividualsvolunteering tobecome walkingleaders andparticipants


Communitypartners locatedindoor walkingroute asalternative forinclementweather

Cancer centerpublicized SIUS

Kick-off eventused toincreaseawareness andnumber ofparticipants

Friendships,opportunity tosocialize, andpeer support fromcancer survivorsled to sustainingwalking groups;Cancer Centerabsorbedadvertising andparticipantincentive costs tosustain program

Facilitator None reported None reported None reported None reported None reported None reported Hazardous airquality fromwildfire smoke ledto postponementof walking groupsfor a period oftime

Organization F: Rural, public health/government

Facilitator Community nonprofit andfor-profit partnerspromoted SIUS andsupported in recruitingwalking group participantsand leaders

Adopted a flexiblerecruitmentstrategy throughsocial media, in-person directcontact, andcommunitypartners


None reported Promoted SIUSthrough Facebook,local recreationactivities guide,and presentationsto service groups

Communitypartnerdonated food

Yoga studio and alocal gym offereddiscounts forwalking groupparticipants;community parksand recreationdepartmentassumed programoperations andmanagement

Challenge Lack of follow-throughpromoting SIUS amongsome community partners;Problematic to recruitcancer survivors because

None reported None reported None reported None reported None reported None reported

(continued on next page)





(continued)








SIUSStep 6: Kick-

off Event


Interest

no cancer center oroncology practices are inthe community

Organization G: Rural, public health/government

Facilitator Higher educationinstitution was animportant communitypartner

Communityorganizationshelped recruitwalking leaders


Communitypartnersprovided walkingroutes on theirproperty;Walking routesincluded indoorand outdooroptions

Communitypartners promotedprogram internallyand encouragedparticipation

Communitypartnersdonated giftcards forwalking groupparticipants

None reported

Challenge None reported Retaining walkinggroup leaders wasdifficult

None reported None reported None reported None reported Walking groupleader inability tocontinue in roleled to groupdisbanding;Walking groupattendancedeclined duringsummer months;Programsuspendedbecause of staffturnover andinability of otherstaff inorganization toassume programmanagement

Organization H: Urban, nonprofit

Facilitator Developed SIUS marketingmaterials and distributedto oncology centers in ametro area

Paid walking groupleaders a stipend

Walking groupleader toolkit;weeklyinformationalsessions onfitness (eg,hydration, safety,shoes, nutrition)

Used “Map MyWalk” app forwalking routeflexibility andvariation

Created anddistributedrecruitmentmaterials throughvarious mediasources (flyers,posters, socialmedia,neighborhoodgroup meetings);Welcome kitsdistributed toparticipants

None reported Walking groupsscheduled at 2locations, with aselection ofmultiple days andtimes (weekday,weekend,morning, andevening)

Challenge Some community groupsunwilling to shareinformation and allowaccess to survivor groups

None reported None reported None reported None reported None reported Program endedprematurelybecause it lackedsustainableprogrammanagementleadership





Table 3. Step It Up! Survivor Adaptations, by Program Implementation Step, During Implementation of an Evidence-Based Walking Program in Oregon Communities:Step It Up! Survivors, 2018

Implementation Step No. of Adaptations Adaptation Description Reported by Organization

Publicize Step It Up! Survivors (Step 5) 4 Changes to layout, design, and content of promotional flyer

Maintain walking group and participantinterest (Step 7)

3 Increased frequency of walking group meeting sessions, changed time of walking groupmeeting, implemented protocol for walker to maintain participation while on vacation

Train walking leaders (Step 3) 1 Trained new walking group leaders after program implementation began

Select and map routes (Step 4) 1 Added new walking routes after program implementation began

Organize the kick-off event (Step 6) 1 Liability language added to walker registration form

Community engagement (Step 1) 0 None

Recruit walking leaders (Step 2) 0 None





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