There are >13 million new cases of stroke per year worldwide [1], and 1 in 4 adults aged >25 years will experience a stroke in their lifetime [2]. Advances in acute stroke treatment have significantly reduced mortality; however, this increased survival rate has led to more people living with chronic stroke-related disabilities. With stroke now being a leading cause of long-term disability [3,4], rehabilitation researchers have identified enhancing brain recovery and promoting long-term healthy behaviors as a priority; this research has generated a wealth of new evidence-based stroke recovery practices [5,6]. However, there is a need to move this evidence into practice and close the gap between best and current stroke rehabilitation practices [7].

Although many individuals see improvements during the acute rehabilitation phase after the stroke, many lose their initial gains when they return to the community, and their disability progresses over time [8]. Evidence suggests that exercise improves motor function [9,10], health-related quality of life [11,12], cognitive function [13,14], and cardiovascular risk factors [15,16] in those with stroke. The implementation of community-based exercise programs, which are defined as “structured, instructional programs of exercise for groups or individuals delivered outside the public health care setting and available in community settings,” are avenues for engaging in lifelong physical activity [17]. Community programs that are focused primarily on walking, such as outdoor walking or mall walking programs, are often difficult to follow for individuals with mobility impairment from stroke, and many traditional fitness facilities and health clubs have accessibility barriers [18] that present additional challenges for people with stroke. Thus, people living with stroke may require adaptations to meet their unique needs and abilities. Stroke exercise programs should incorporate functional tasks that mimic daily activities, be guided by trained personnel knowledgeable in stroke and stroke-related impairments, and be delivered with an appropriate instructor-to-participant ratio [17]. Moreover, pre-exercise medical clearance by a health care provider and further eligibility screening by exercise providers are recommended to ensure the safety and appropriateness of adapted programs [17]. Despite the established benefits of ongoing exercise and evidence-based recommendations in the design and delivery of community-based exercise programs for stroke [17], most people with stroke do not have access to such community-based exercise programs that provide the specialized support to meet their long-term needs.

In 2016, the Heart and Stroke Foundation’s Canadian Partnership for Stroke Recovery (CPSR) [19] convened its Knowledge Translation Advisory Committee to identify priority areas for knowledge translation. The committee, comprising people with stroke, caregivers, stroke recovery experts, health care providers, policy makers, and knowledge translation and mobilization experts, identified poststroke exercise as a high priority and specifically identified the need to develop sustainable evidence-based and community-based exercise programs for people with stroke. Within Canada and internationally, researchers and clinicians have developed various community-based exercise programs for people with stroke [20-22]; there is now a need to catalyze the implementation of these evidence-based approaches to optimize the health and social benefits for people with stroke.

Building on this momentum, our team aimed to develop an evidence-informed resource [23] to guide community program planners (eg, program managers and coordinators, rehabilitation health partners, fitness professionals, people with stroke, and caregivers) through the process of planning for the successful implementation of community-based exercise programs for people with stroke. We used a multistep process over 3 years to develop the Stroke Recovery in Motion Implementation Planner (hereafter referred to as the “Planner”; Figure 1).

The well-established Knowledge-to-Action (KTA) cycle, which helps bring the results of health care research into effective changes in practice, provided the overarching framework for the planning process [24-26]. It also builds on the CAN-IMPLEMENT guideline adaptation process, which divides the KTA cycle into 3 substantive planning phases [27,28]. Furthermore, the planning model incorporates elements of the Implementation Roadmap, which is based on the KTA cycle, and further breaks the 3 planning phases into practical steps and activities to facilitate implementation planning and execution [29]. The planning process is underpinned by 6 guiding principles (Textbox 1).

The “Planner development” phase (Figure 1) informed early decisions related to the content and organization of the Planner. For example, we identified the type of information and tools that would be most helpful to end users, decided on the use of a generic approach that could be applied to any stroke-specific community-based exercise program, worked to include real-world examples, and reduced technical language. As part of this development process, we conducted a national survey of potential end users across Canada (health partners, agency administrators, program managers, and fitness professionals). Of the 21 invited people, 13 (62%) reviewed the initial Planner prototype and completed a web-based questionnaire on what they liked and what could be improved.

As the prototype was developed, the research team engaged stroke advisors, including members from an existing group of Stroke Community Advisors through the CPSR. These stroke advisors (3 people with stroke and 2 caregivers of an individual with stroke) reviewed the Planner and provided feedback on the content and format to ensure that people with stroke, their families, and caregivers were reflected appropriately.

On completing this rigorous initial Planner development process, the resource was deemed ready for evaluation (user evaluation and field testing).

The purpose of the study was to conduct a dual-component evaluation of the Planner comprising a user evaluation and field test. The objective of the user evaluation was to elicit user perceptions of the usefulness and acceptability of the Planner and revise the Planner based on the data. The objective of the field test was to describe how teams used the Planner in real-world conditions; describe the effects of using the Planner on participants’ implementation planning knowledge, attitudes, and activities; and identify factors influencing Planner use [31].

The goal of this paper (part 1) is to describe the results of the user evaluation and the revisions we subsequently made to the Planner. The results of the field test are reported separately in part 2 [31].

To guide the reporting of this study, we used guidelines for mixed methods studies (GRAMMS [Good Reporting of a Mixed Methods Study]) [32], qualitative studies (COREQ [Consolidated Criteria for Reporting Qualitative Studies]) [33], and survey studies (CROSS [Checklist for Reporting of Survey Studies]) [34]. These checklists are provided in Multimedia Appendix 1 [32-34].

The user evaluation was a mixed methods study that used a concurrent triangulation design [35]. We used a convergent model where cross-sectional questionnaire data (closed and open-ended questions) and interview and focus group data were collected and analyzed separately, with the quantitative and qualitative findings merged during the interpretive phase [35]. The quantitative and qualitative data were assigned equal weight. The quantitative data facilitated identifying the “what”; specifically, it helped us identify what aspects of the Planner were most frequently identified as needing modification or removal, which enabled prioritization of essential changes. The qualitative data helped us understand the “why” of the participant feedback and provided insight into how we could best address participant concerns as we revised the Planner. The qualitative data also provided additional ideas to strengthen the Planner, which may not have been captured in the structured questionnaire. The settings for this study were Canada and Australia.

We used purposeful sampling. All staff involved or interested in the planning and delivery of community-based exercise programs for people with stroke were eligible to participate in the user evaluation, including community and municipal program directors, managers and coordinators, regional health authority staff, fitness or exercise professionals, physiotherapists, and other consulting health partners. We identified potential participants through the professional networks of (1) study coinvestigators, many of whom have developed exercise programs; (2) individuals who previously participated in the Planner development process; and (3) participants enrolled in the study (ie, snowball sampling).

In Canada, we aimed to identify participants from different geographical regions with various population densities. Using definitions from Statistics Canada [36], we created a matrix based on geographical region and population size category. As recruitment progressed, we aimed to identify individuals from the remaining undersampled cells (region × urban or rural) in our recruitment matrix. As the Canadian study progressed, we identified an emergent opportunity to include participants from Australia. One of the coinvestigators returned to Tasmania, Australia, where there was a state goal to increase community-based exercise opportunities for people with stroke. Unlike Canada, Tasmania had low rates of COVID-19 and fewer pandemic restrictions during the study period, and community-based program planning and implementation proceeded as usual. This gave us a unique opportunity to use the professional network of the coinvestigator, who was situated in an urban area of Tasmania, to identify participants who were currently actively engaged in the planning and delivery of community-based exercise programs for people with stroke. We consulted and received approval from our funding partner (CPSR) for the addition of participants from Australia, as there was perceived value in having an international perspective on the Planner.

We started recruiting individuals to prospectively field test the Planner in December 2019. In March 2020, the COVID-19 pandemic caused significant challenges for recruitment as the pandemic resulted in many teams stopping community-based program planning. In May 2020, we amended our protocol to add 2 additional groups (Table 1) to our study with different levels of experience in planning community-based exercise programs for people with stroke, allowing data collection on the Planner within pandemic restrictions. Study enrollment was completed in February 2021. The eligibility criteria for each participant group are presented in Table 1.

All 3 groups participated in the user evaluation component. The current program planners engaged in additional study activities as part of the field test component of the evaluation [31].

The study staff contacted potential participants via email with study information. If there was no response, we sent 2 follow-up reminders. Interested participants connected with the study staff to review the requirements, confirm eligibility, obtain informed written consent, and schedule a time for the study activities.

The study participants completed a web-based questionnaire and a minimum of 1 interview. The order of the activities and the content of the questionnaire and interviews were tailored to each group (Table 1). Participants received an honorarium at a rate of CAD $25 (US $19.5) per hour to compensate for their time.

We obtained ethics approval from the Ottawa Health Science Network Research Ethics Board (protocol 20190594-01H) and the Tasmania Health and Medical Human Research Ethics Committee (project ID 23559) for the initial and amended protocols. All participants signed an informed consent form before starting any study activities, and all study procedures were conducted in accordance with privacy and confidentiality requirements.

We enrolled 39 participants between December 2019 and February 2021. We contacted 27 current program planners, of whom 16 (59%) enrolled; 14 future program planners, of whom 9 (64%) enrolled; and 43 past program planners, of whom 14 (33%) enrolled. The participant demographic data are presented in Table 2, participant roles based on employment setting are presented in Table 3, and the types of data collected during the study are presented in Table 4.

Overall, feedback on the Planner was positive. All questionnaire participants felt that the Planner addressed the key factors to consider when planning a community-based exercise program for people with stroke; almost all (34/36, 94%) felt it would help them make decisions informed by evidence, and most (29/36, 81%) indicated that it would improve their usual approach to planning:

Most participants (26/28, 93%) reported that reading the Planner increased their knowledge of how to use evidence to inform decision-making in program planning. Nearly as many participants (24/28, 86%) also reported that reading the Planner increased their confidence in their ability to plan an adapted or specialized fitness program.

Several past program planners who had successfully launched and sustained programs commented on the alignment between the Planner and their own experiences and the added benefit of the Planner:

Nearly all future and past program planners (19/21, 91%) indicated that they would likely use the Planner for future program planning. Similarly, most questionnaire participants (33/36, 92%) said they would likely recommend it to colleagues to support program planning, described by one participant as follows:

Most questionnaire participants (34/36, 94%) agreed that the Planner could be applied to planning programs that were not stroke specific, including exercise programs for people with other health conditions and nonexercise programs:

Although the most commonly reported first impression of the Planner was that it was long and possibly overwhelming, over three-quarters (28/36, 78%) of the questionnaire participants agreed that the Planner presented the right amount of information. Most participants indicated that after reading and digesting the information, they saw great value in all the presented materials and could not identify materials that could be removed. Participants recognized the need to strike a balance between making the Planner a comprehensive information source for people with various roles and experience levels while also ensuring that the material was not overly long or onerous to read:

All questionnaire participants (36/36, 100%) agreed that the Planner was well organized, and nearly all agreed that it was easy to read and understand (35/36, 97%) and clearly presented the planning process (33/36, 92%). Participants were split on the format of the Planner: 56% (20/36) of participants would have preferred a web-based version over a paper-based version, and 28% (10/36) did not have a preference. Participants frequently desired access to both a web-based version for easy navigation and tool completion and a paper-based version for hard copy use.

The study participants made some suggestions for Planner modifications that after careful consideration, we decided not to make. Here, we provide 2 key examples with the rationale.

First, some participants requested that to facilitate use, the Planner should be separated into different sections to assign specific content to different roles on the planning team. However, the desire to distinguish between those “planning” and those “delivering” was not aligned with our guiding principle of using a participatory and inclusive approach. Planning teams are most effective when those delivering the program (eg, fitness or exercise professionals) and using the program (eg, people with stroke) are engaged early in the planning process. In addition, team members’ roles may be fluid over time and in different contexts. Therefore, we left the Planner as one document designed for all team members, with the goal of encouraging awareness of and participation in the full planning process. The importance of an integrated planning team was supported by a study participant who regularly delivered community programming:

Second, several participants commented on the level of repetition throughout the Planner and recommended making the document shorter and more concise. Although we carefully reviewed the Planner and eliminated unnecessary redundancies, some repetition was left in for pedagogical reasons [43]. Repetition helps readers remember and understand the information. We also recognized that some readers would not read the Planner from start to finish and skip from section to section; therefore, we chose to judiciously repeat essential contextual information throughout the Planner.

All the participants provided positive feedback on the Planner and identified features that they found useful. We used this positive feedback to identify content and features to keep in the final version. We also identified ways of expanding upon and further enhancing these features where possible (Table 7).

Using the data reported in this study, we revised both the content and format of the Planner. Integrating this feedback involved extensive rewriting and editing by the core study team; contracting the graphic designer; and a final review by 16 coinvestigators, consultants, end users, and stroke advisors. The largest revision of the Planner involved improving the overall structure and navigation (Figure 2).

The Stroke Recovery in Motion Implementation Planner is now hosted through March of Dimes Canada, a Canadian nonprofit organization offering services for people with disabilities, including the After Stroke program focused on stroke recovery in the community [44]. The Planner is free and publicly available here [23].

This paper provides a comprehensive description of how the Planner was developed, informing consumers of the rigorous process used. Our mixed methods user evaluation demonstrated that, overall, end users viewed the Planner positively and indicated that it was a useful and valuable resource. They reported that it would improve the planning process and help them make planning decisions informed by evidence. The participants’ constructive feedback on the content and organization was used to revise and strengthen the Planner.

Our development process aligns with that used by others to develop implementation guides and toolkits in different settings, including selecting an underpinning theory or framework [45-48], searching the academic and gray literature [46-50], consulting experts and consumers [45-48,50], and refining the guide based on end user feedback [45,46,48-50].

Some participants provided feedback consistent with findings reported in the literature; for example, perceptions that the implementation process could be overwhelming or the guide too long [50,51], the need to reduce the number of steps and technical language [51], and the desire for new content and tools to address team needs [48,49,51]. Engaging a wide variety of stakeholders in the development process and using several user-centered design strategies ensured that the final product was grounded in the needs and experiences of those who will use it in real-world settings [52].

The use of an implementation framework can contribute to more systematic planning, delivery, and evaluation of programs, thereby contributing to improved success and sustainability [53]. However, many implementers lack knowledge and experience in using these frameworks [53], and many third-sector organizations (eg, voluntary and community organizations and social enterprises [54]) face capacity and capability issues when implementing evidence-based interventions [55]. Leeman et al [56] identified “tools” as a strategy for building implementation capacity in community-based practitioners. The Planner is an evidence-informed tool for building the capacity of practitioners (in this context, community program planners, health professionals, fitness professionals, people with stroke, and caregivers) to plan for implementation in an applied and approachable way. Most study participants reported an increase in knowledge and confidence after reading the Planner, including many who reported being experienced program planners.

The Planner is based on the KTA, CAN-IMPLEMENT, and Implementation Roadmap frameworks [24,25,27-29] and is grounded in implementation science and practice. Studies on third-sector organizations in general [55] and on poststroke exercise specifically [57-60] have revealed factors that can influence program implementation, such as equipment, space, time, staffing, training, funding, marketing and recruitment, class capacity, sustainability, program adaptation challenges, organizational culture and priorities, and collaboration between organizations and professionals [55,57-60]. The Planner is specifically designed to help planning teams identify these and other factors unique to their settings, which may impede or support the implementation of community-based exercise programs for people with stroke. The Planner offers strategies, including some recommended by others [55,57], to overcome these barriers. Most importantly, the Planner provides a step-by-step action-oriented road map to plan for successful implementation and sustainability.

This study has some limitations that should be acknowledged. A key challenge was conducting the study during the COVID-19 pandemic. Although we successfully recruited 39 participants to review the Planner, the data collection period coincided with the pandemic, a time of high personal and professional stress. It is unknown how the stress of the pandemic may have influenced decisions to participate in the evaluation or how it influenced participants’ perspectives of the Planner. However, nearly half of the individuals approached to participate did so despite the burden of having to read the comprehensive Planner, complete a lengthy questionnaire, and participate in an interview. This suggests that those who participated were strongly committed to providing input on the Planner and provided thoughtful and detailed feedback.

Although our sample was diverse, we would have liked to have enrolled more fitness professionals, given their role in delivering exercise programs. There may be several reasons for their limited enrollment. For the current program planning group, our primary contact was often the manager or coordinator or health partner. These planning leads had sometimes not yet identified the fitness professional team members and were unable to connect the research team with fitness professional study candidates. Furthermore, the pandemic led to the closure of community centers and fitness facilities, and therefore, many fitness professionals were not actively employed during this time. Despite these challenges, approximately 20% (8/39) of the study participants were fitness or exercise professionals who offered rich and thoughtful guidance on how to improve the Planner to meet their needs.

Finally, the user evaluation involved the hard copy version of the Planner, and therefore, the findings may not reflect perceptions of a web-based format. Plans are underway to develop a web-based toolkit based on the hard copy version.

A strength of the study was the mixed methods design, which facilitated assessing perceptions of the Planner through a comprehensive questionnaire with standard questions for all participants, followed by an interview for in-depth discussions on dimensions that were particularly important to each participant. We used multiple types of triangulation, including methods (questionnaires and interviews), sources (participants from diverse settings), and analysts (coding and interpretation by multiple researchers), all of which enhanced the quality and credibility of our findings [61]. The targeted enrollment of stakeholders from 3 groups (current, future, and past) allowed us to collect data (and reach saturation) from a broad range of stakeholders in various geographical areas with differing experiences in community-based exercise programs for people with stroke. Our rigorous analysis process resulted in every comment being reviewed and carefully considered to inform the Planner revisions and facilitated improved relevance and feasibility of the Planner.

With the Planner finalized and freely and publicly available for use by community teams, we now have the opportunity to further evaluate its ongoing use and impact. Access and use will be monitored through website statistics and consumer inquiries. Working with key stakeholders, we also plan to augment the Planner to better address culturally tailored physical activity programs for racialized populations with stroke, as well as issues related to planning web-based programs for people with stroke. Finally, future work will involve developing products that distill the Planner information into alternate formats to meet diverse learning needs, including video vignettes, infographics, a condensed pocket guide, and a presentation slide deck.

Community-based exercise programs are urgently required to address community reintegration and transitions for people living with the effects of stroke. The Stroke Recovery in Motion Implementation Planner [23] was designed to address the limited use of evidence-informed planning practices for community-based exercise programs for people with stroke. Guided by knowledge from the field of implementation science on how to facilitate implementation, we used a rigorous process to develop and evaluate the Planner. The evaluation revealed that the Planner was perceived to be a valuable resource that may be used to guide interdisciplinary teams in the planning and delivery of evidence-informed, sustainable, community-based exercise programs for people with stroke.