Since the development of evidence-based medicine (EBM) over two decades ago (1), the Centers for Disease Control and Prevention (CDC) has promoted healthy aging with an emphasis on reliable, efficient, and cost-effective care models with measurable outcomes (2). The goal of evidence-based programs is to create healthier communities and prevent chronic diseases (3). Translating evidence-based programs from research studies to community practice and sustaining them is a top priority for public health researchers and practitioners.

Evidence-based health promotion programs for older adults have been adopted and implemented by organizations in communities throughout the United States (4, 5). Enhance^®Fitness (EF) is an evidence-based group exercise program for frail and active older adults (6–8). The one hour classes meet three-times a week and include exercises for cardiovascular endurance, balance, flexibility, and strength. Research has demonstrated that EF improves upper and lower body muscle strength and flexibility (9, 10). EF participants report improved over-all health (9). Participation in EF has been associated with healthcare costs saving. The average increase in annual total healthcare costs was less among EF participants compared to non-participating controls in a managed health care plan ($642 vs. 1175) (6). Among Medicare beneficiaries, enrollment in EF was associated with per person medical savings of $945/year after enrollment (8). Since 2001, there have been a total of 42,560 EF participants (unduplicated) served at a total of 689 sites in 33 states and Washington DC (Susan Snyder, personal communication, Senior Services, 2014 April 14).

Senior Services (Seattle, WA, USA) licenses and disseminates EF to multipurpose social service agencies, faith-based organizations, retirement communities, and recreational organizations. With more than 10,000 community locations, Young Men’s Christian Association (Y) is a leading non-profit committed to improving the nation’s health and well-being by offering programs that nurture the mind, body, and spirit. From 2005 to 2012, 116 Y-affiliated community sites adopted EF. These included both classes on-site at Y brick-and-mortar buildings, and classes licensed by Ys but offered in community settings such as churches or retirement communities. These sites represent a first stage in the adoption of EF by a nationally networked organization; as such, their experience is likely to inform efforts to scale-up adoption of EF and other evidence-based programs. In this paper, we refer to these sites as early adopters (11).

Various models have been used to evaluate evidence-based health promotion programs. One of these program planning and evaluation models is RE-AIM. RE-AIM, an acronym for Reach, Effectiveness, Adoption, Implementation, and Maintenance, is a systematic process that researchers, practitioners, and policy makers use to evaluate the dissemination of health promotion programs (12). Within the RE-AIM framework, adoption refers to the “proportion and representativeness of settings willing to initiate a given program” (13). Understanding how adoption of interventions plays out in different organizational settings is critical to the current and potential impact of an intervention (14).

Previous research has identified a number of motivating factors for program adoption: participant interest and/or demand, proven safety and effectiveness for older adults, cost, and a well-rounded program structure that attracts multiple groups (13). Additionally, the availability of resources is important for program adoption (15). Facilitating factors for program adoption identified in previous studies include having a curriculum, availability of training, space, and equipment (12), awareness of the importance of promoting physical activity in the community and internal support for physical activity interventions (15), sufficient funds, leadership support, capable staff, and successful partnerships and collaborations (16). Barriers include scheduling issues, lack of space, and insufficient participant recruitment efforts (13), program cost (16, 17), and lack of leadership, and time and training (16). These findings reinforce the idea that adoption can be improved by developing organizational support and capacity to deliver a program (18).

The research question for this study was: what are the facilitators and barriers among early adopters of EF in Y-affiliated sites from the perspective of program staff. Based on our findings, we provide practice, research, and policy recommendations that may help inform the adoption of other evidence-based programs in community settings. Increasing the number of community organizations that adopt evidence-based health promotion programs for older adults will contribute to the goal of creating healthier communities and preventing chronic disease.

Study participants were, on average, 48.7 years old (SD 13.5) and had been involved with EF for 5.2 years (SD 3.1). Three staff (20%) had some college education, seven (47%) had a college degree, and five (33%) had more than a college degree. Ten staff members (67%) were employed by a Y while the remaining five staff (33%) were employed by other organizations (faith-based organization, senior center, social service organization, and residential facility). Titles and levels of responsibility varied: five were Health and Wellness staff, four had roles specific to older adults, six were at the program coordinator/instructor level, and eight were at the program manager/director level or above.

Staff interviewed represented 10 different YMCA associations in six states. Fourteen out of 15 staff worked in locations where classes were conducted; one staff worked in an administrative office. Ten sites currently offered EF classes; the remaining five had previously offered EF but did not have active classes at the time of the interview.

In the remainder of this paper, we summarize our findings regarding facilitators for adoption of EF and barriers that interfered with adoption of EF, with representative quotes presented in Tables 2 and 3, respectively.

In this study, we examined the facilitators and barriers to the adoption on EF in early adopter Y-affiliated sites. The Health Promotion Research Center (HPRC) dissemination framework provides a context for interpreting the findings from this study and informs the translation of our findings to other community-delivered, evidence-based programs (26). The HPRC dissemination framework incorporates the terminology of the RE-AIM framework such that the definition of adoption is consistent between the two frameworks.

The HPRC dissemination framework (Figure 1) identifies three main actors involved in the dissemination of an evidence-based program: researchers, disseminating organizations, and user organizations. Researchers and disseminating organizations partner to develop a dissemination approach that is suitable for the targeted user organizations. The approach is built on learnings about the user organization’s characteristics and readiness for adoption and implementation, and is continually refined through the collaboration of the three main actors. At the same time, all actors operate within a broader context that includes both modifiable and unmodifiable components, such as funding and partnerships, and economic conditions, respectively.

Study participants identified several facilitators and barriers related to the characteristics of Y-affiliated sites, the user organizations in this study. Ys have made major strides in recent years to become leaders in community-based health promotion programs. It was readily apparent that there was a strong fit between EF and the Y mission to offer older adults an environment that promotes physical and emotional health, and the availability of resources to ensure adequate programing. This rich environment also included champions for both EF and older adult programs. Programs with this type of fit have an enhanced ability to sustain themselves. On the other hand, our findings suggest a need for improved evaluation of organizational readiness prior to the adoption of any evidence-based program. Structured and rigorous determination of organizational readiness would help organizations avoid known barriers to successful implementation, such as competing programs, and limited space and resources. Organizational readiness for change is an important precursor to the successful implementation of health promotion programs (27).

Our study also identified facilitators related to the modifiable context in which user organizations operate. Staff noted the significant role grant funding played in the initial adoption of the program, as well as the importance of building partnerships at the local and state level.

Finally, we would like to highlight the role of the disseminating organization, Y-USA, the national office of the Y. Between 2007 and 2011, Y-USA significantly increased its national effort, Activate America^®, to engage Ys in organizational and community change focused on supporting health seekers, those who struggle to adopt and maintain a healthy lifestyle. Nearly two-thirds of Y Associations committed to Activate America and built their capacity to better align their programs, practices, and policies with the needs of health seekers. This was the Y climate when EF was being brought into the organization by early adopters. The organization was primed for embracing evidence-based health promotion programs and working with a community of adults with chronic conditions. At this time, chronic disease prevention programs were introduced as well, including LIVESTRONG at the YMCA, a cancer survivorship program, and the YMCA’s Diabetes Prevention Program (DPP).

Ackermann and colleagues tested offering DPP at Y sites (11, 28–30). Ys were able to increase the number of participants and offer DPP at a lower cost compared to other community settings, making Ys an ideal community partner. They noted a variety of factors contributing to the success of DPP offered at Ys: the Y is a nationwide, community-based organization reaching diverse U.S. communities; it has a successful history of adopting and implementing health promotion program for all age groups; it takes a group-delivery approach, which uses minimal over-all personnel cost; and it has a national policy to accept all participants regardless of their ability to pay the membership fee. Y-USA and its associations and branches nationwide are well-positioned to successfully adopt new evidence-based programs, and more broadly disseminate existing programs based on the program experience noted above, and the organizational infrastructure already in place.

There were several limitations in this study. First, we used a convenience sample. Convenience samples can introduce response bias, with those having positive experiences being more likely to participate than those with less favorable experience. However, staff who volunteered to participate in this study shared a range of experiences, both positive and negative, related to the adoption of EF. Second, our sample size of 15 may have limited our ability to reach conceptual saturation with regard to the research questions. After completing 15 interviews, the research team determined that additional interviews were unlikely to return substantively new information, and that we had reached conceptual saturation. Third, inherent in qualitative methodologies is the potential issue of transferability. To minimize issues with transferability and assure our findings would have applicability in other contexts, a partner from the Y (AHH) was actively involved in all phases of our study and another Y staff member served on our Project Advisory Group. Fourth, some of the staff had started overseeing EF up to 8 years prior to the phone interviews, resulting in potential recall bias with respect to the initial decisions and process of adopting EF. Last, Y staff who were the target of our interviews were in positions in which they had responsibilities for program management and also could adopt new initiatives like EF. When further exploring the concept of adoption, it would be valuable to also include senior leadership who are likely to be key decision makers and have an influence in whether a new program would be considered, paid for and/or adopted.

Based on the findings in this study, we propose practice, research, and policy recommendations for the adoption of evidence-based health promotion programs by community organizations. They are summarized in Table 4, which also includes the facilitator/barrier themes they address.

Our practice recommendations focus on organizational readiness for adopting new programs. Assessing organizational readiness, formally or informally, identifying gaps in readiness, and addressing any gaps may improve adoption (11). Organizational readiness can be evaluated through the following activities: assessing fit of the program with organizational mission; assessing overlap with other programing, and physical space and time constraints; identifying potential partners and funding/revenue models; identifying capable instructors and securing training and technical assistance for staff and potential instructors; and assessing cultural and demographic needs of the target population. Addressing these aspects of readiness may provide opportunities to open dialog with partners and stakeholders, or develop supporting resources like a business plan to support successful adoption.

The practice recommendations outlined above are based on the experience of early adopters. However, the adoption experience of majority adopters and late adopters/laggards may face different facilitators and barriers (11). Future research is needed to better understand the spectrum of adoption in all phases, and how early adopters’ experience may influence later adopters. In addition, successful adoption should lead to program implementation and, ultimately, maintenance. Additional research on how adoption strategies influence subsequent implementation and maintenance of evidenced-based health promotion programs could contribute to development of best practices for the translation of research into practice.

Finally, broad policy support for evidence-based programs may create an environment more primed for successful adoption. Policy support may include establishing a revenue stream to offset program costs, an approach that has been seen in other programs (30, 31). Policy approaches to developing revenue streams may be fruitful among evidence-based programs demonstrating health improvements and reductions in health care costs (6, 8).

While these recommendations are based on our study of the experience of early adopters of EF at Y-affiliated sites, they are likely applicable to other evidence-based programs conducted in community settings. Facilitators and barriers to adoption apply across programs and settings (8). Furthermore, facilitators, barriers, and recommendations address modifiable aspects of adoption that may improve success, including support of the organizational mission, available resources, and options for offsetting costs. Y-USA has successfully adopted a variety of evidence-based programs, and can serve as a model for other regionally and nationally networked community organizations. Organizations looking to adopt new programs may increase their likelihood of success by applying the recommendations appropriate to their organization and program.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

This paper is included in the Research Topic, “Evidence-Based Programming for Older Adults.” This Research Topic received partial funding from multiple government and private organizations/agencies; however, the views, findings, and conclusions in these articles are those of the authors and do not necessarily represent the official position of these organizations/agencies. All papers published in the Research Topic received peer review from members of the Frontiers in Public Health (Public Health Education and Promotion section) panel of Review Editors. Because this Research Topic represents work closely associated with a nationwide evidence-based movement in the US, many of the authors and/or Review Editors may have worked together previously in some fashion. Review Editors were purposively selected based on their expertise with evaluation and/or evidence-based programming for older adults. Review Editors were independent of named authors on any given article published in this volume.