With more people surviving stroke [1], community-based exercise programs [2-4] have emerged to provide safe and effective exercise opportunities for people living with the effects of stroke. Although participating in exercise after stroke conveys broad benefits [5], most people with stroke lack access to these specialized exercise programs in their own communities. As a result of this gap, the Canadian Partnership for Stroke Recovery identified increasing implementation and sustainability of these community-based exercise programs as a knowledge translation priority [6,7].

Planning and implementing new evidence-based practices and programs is a complex process requiring specific knowledge and skills. There is a growing body of literature and resources aimed at building the capacity for implementation science, but there is less support for building the capacity of those actually practicing implementation [8-10]. Practitioners may not have the knowledge or skills to apply implementation science theories or frameworks in their work [11,12], nor do they report feeling confident in their ability to complete key steps in implementation planning, such as conducting a barriers and facilitators assessment [12]. Community organizations in particular may face barriers to implementing evidence-based practices, including a lack of implementation expertise [13].

As a means to build implementation-planning capacity for community-based exercise programs for people with stroke, our team developed an implementation-planning guide, the Stroke Recovery in Motion Implementation Planner (hereafter referred to as the Planner) [14]. The Planner was based on established knowledge translation and implementation frameworks, including the Knowledge-to-Action framework [15], CAN-IMPLEMENT [16,17], and the Implementation Planning Roadmap [18]. The focus of the Planner is on implementation planning, which is a process that turns strategy into action through three phases: phase 1: establishing a diverse, interdisciplinary planning team and working together to understand the community population, their needs, potential program options, and the available resources; phase 2: conducting a barriers and drivers assessment and developing tailored solutions (implementation strategies), as well as building an evaluation plan; and phase 3: launching, monitoring, and maintaining the exercise program.

Many strategies promoting uptake of evidence-based practices focus on modifying the individual or their environment. Throughout the Planner development and evaluation process [7], we prioritized the design of the product itself by applying a user-centered design approach [19]. User-centered design is an iterative process whereby the needs and context of the intended users are central to informing the content and design of the product [19,20]. An example of a user-centered design strategy is to field test the product. Through prolonged engagement with end users who provide feedback on their experience with the product, field testing facilitates an understanding of how the product is being applied in real-world settings [21]. Such an exploratory approach can help to challenge the prototype and subsequently lead to meaningful changes [22], thereby creating a product that is more functional, acceptable, and effective. Upon completing a prototype of the Planner [7], we conducted a field test study with end users to explore how the Planner was used and adapted in diverse settings.

This study was part of a larger research program that developed and evaluated the Planner, which included a cross-sectional user evaluation of the Planner by diverse stakeholders (reported elsewhere [7]) and the field test reported here. The objectives of the field test were to (1) describe how teams used the Planner in real-world conditions; (2) describe the effects of using the Planner on participants’ implementation-planning knowledge, attitudes, and activities; and (3) identify factors influencing use of the Planner.

This field test study used a longitudinal qualitative design [23,24], which facilitated in-depth discussions about use and impressions of the Planner over time. We used the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist [25] to inform the reporting of this study (Multimedia Appendix 1).

Using the professional networks of the study team, we identified primary contacts (ie, team leads tasked with program planning) at Canadian community organizations that were intending to implement a community-based exercise program for people with stroke in the next 6 to 12 months (current planners) and willing to use the Planner to guide their ongoing planning. We welcomed representatives from several occupations, including program managers and coordinators, health partners (eg, physiotherapists and occupational therapists), and fitness professionals. As the purpose of this study was to observe how teams used the Planner to guide planning processes, teams were required to be at an early stage in their planning. A research team member (J Reszel) contacted potential participants by email with study information, with up to two reminders. If the contact was interested in participating, a memorandum of understanding was signed between the participating organization and our research institution. We asked the contact person to nominate other planning team members (ie, snowball sampling) whom we could invite to take part in the study. All participants signed an individual consent form. Participants did not receive any incentives to test the Planner or fund their program initiatives; however, participants were provided an honorarium to compensate them for time spent on study activities.

Initially, we aimed to enroll 9 to 12 teams to field test the Planner; however, the onset of the COVID-19 pandemic resulted in significant disruptions to community-based program planning and the closure of many facilities. This recruitment challenge caused us to lower our enrollment to 5 teams prepared to use the Planner to guide program planning during this period.

The field test teams participated in 3 core data collection points. After reading the Planner and completing a questionnaire [7], all participants completed a baseline interview or focus group to discuss their initial impressions of the planning process. Next, research staff conducted monitoring interviews (ideally every 1-2 months) with a primary contact for each team to discuss planning work completed, Planner sections and tools used, and feedback on what was helpful and what was not. Each monitoring call started with the researcher summarizing the last call, allowing the participants to make corrections. Finally, primary contacts completed an end-of-study interview. At this time (February-March 2021), each team was at a different point in their planning process, but this end-of-study interview provided an opportunity for participants to reflect on their overall experience of using the Planner to date and share final feedback. The primary contact was the team member who was taking the lead in the planning process and had the most direct experience working through all Planner steps and activities. We anticipated that this person could therefore provide the richest updates on the team’s work throughout the process.

In keeping with a user-centered design approach, the baseline, monitoring, and end-of-study interview guides (Multimedia Appendix 2) focused on the users’ needs and their experiences and contexts as they engaged with the Planner [19,20]. The discussions were all conducted by video call or phone. The interviews were audio recorded, and the baseline and end-of-study interviews were transcribed verbatim. Field notes were written after the discussions to document observations about the setting and participants’ (including interactions between participants in focus groups) and interviewer’s reflections. All data collection was conducted by 1 cisgender female research coordinator (J Reszel), a master’s-prepared registered nurse experienced in qualitative research. At the start of the study, the researcher had no relationship with participants. Extensive notes were taken during each monitoring call and later verified and enhanced using the audio recording to complete the call log (Multimedia Appendix 3). In addition, we asked each team to share completed planning tools to understand how teams used and adapted the Planner material.

Applying a cross-sectional approach [23], we used conventional content analysis [26] to inductively code all transcripts and monitoring-interview notes as they became available. This allowed us to identify what the teams were currently working on and their perceptions of the Planner at that time. This approach facilitated probing and follow-up in the subsequent interviews with the participant. All interviews were coded in Microsoft Word by 1 research staff member (J Reszel), with 20% coded independently by a second research team member (TN) as a form of analyst triangulation to enhance credibility [27,28]. Any differences in coding were discussed and resolved by the 2 coders. As analysis progressed, coding and findings were discussed at regularly scheduled meetings with the core research team. We also discussed the field notes for additional context on the setting and team dynamics, such as the extent to which different participants contributed to the discussion and which questions they answered versus those they did not answer. As codes emerged from the transcripts and notes, and the coding scheme was developed, we grouped similar codes into broader categories, including contextual information, Planner feedback, the planning process, and how the Planner is used. We also analyzed the data temporally [23] to identify changes in perceptions over time and to create timelines to map if and when teams completed the various Planner activities. The completed Planner tools were reviewed by the research team and documented as completed or not. When reviewing the tools, the researchers assessed whether the teams made any adaptations to the tools and whether they were used as intended. Exemplary completed tools were identified to be included in the Planner, with permission.

We received ethics approval for this study from the Ottawa Health Science Research Ethics Board (20190594-01H). Before starting any study procedure, each participant signed a consent form.

We enrolled 5 planning teams in Canada. The teams were diverse in their geography and composition. There were teams representing the west coast to east coast of Canada in urban and rural settings. The teams ranged from a single person leading all aspects of planning to interdisciplinary teams sharing the planning work (Table 1).

To provide context for interpreting the findings, we provide a brief description of each planning team before describing the study participants.

Team 1 included a physiotherapist in private practice and a program coordinator from the municipality who had previously collaborated to plan and implement other adapted fitness programs in the community. On the basis of their previously successful partnership and the perceived need for stroke-specific community programs, they decided to plan a new program together.

Team 2 comprised a single program coordinator from the municipality who was working within its usual organizational model whereby an individual coordinator is largely responsible for all planning activities. The municipality had an existing suite of adapted fitness programs and wished to explore adding a stroke-specific exercise class to its model.

Team 3 was led by a physiotherapist who had previously piloted a stroke-specific exercise program in a long-term care setting. The municipality had expressed interest in collaborating with the health authority on an adapted exercise program. The physiotherapist subsequently formed a new partnership with the municipality to begin planning a stroke-specific exercise program in the community.

Team 4 comprised rehabilitation health professionals and a manager from a primary care clinic affiliated with the local hospital. The team members had experience planning and implementing other group programs tailored to various health conditions within their primary care setting and were considering offering a stroke-specific program in their clinic.

Team 5 included 2 program coordinators from a nonprofit organization planning a web-based adapted exercise program. Before the COVID-19 pandemic, the program was offered in person. The onset of the pandemic provided an opportunity to explore whether the program could transition to a new web-based format reaching a broader geographical area.

From these 5 teams, we enrolled 12 participants. Between February 2020 and March 2021, we conducted 25 interviews and focus groups with the 12 participants: the 7 baseline sessions lasted an average of 57 (range 40-75) minutes, the 13 monitoring calls lasted an average of 27 (range 18-35) minutes, and the 5 end-of-study sessions lasted an average of 44 (range 31-53) minutes. On average, the planning teams were followed by the research team for 9.6 (range 4-14) months (Table 2).

By following the 5 teams and comparing their engagement with the process defined in the Planner, we identified conditions that made the recommended planning elements easier or more difficult to apply in practice. These factors typically related to organizational context and support, team leadership style, the value placed on community-partner engagement, and the COVID-19 pandemic.

We followed 5 diverse teams as they used a newly created implementation-planning guide, the Stroke Recovery in Motion Implementation Planner, to plan for the implementation of community-based exercise programs for people with stroke. Because of the COVID-19 pandemic, none of the teams were able to work through the full planning process, with most activities focused on the first of the 3 phases. The findings of this field test study showed that teams took different approaches to applying and adapting the Planner in their settings. All teams indicated that the Planner influenced their approach to program planning and that they intended to continue using the resource in the future. We identified various team, organizational, and broader contextual factors that hindered or facilitated uptake of the Planner by teams. Study participants shared valuable tips from the field to help future teams optimize their use of the Planner. Given the paucity of literature reporting implementation toolkit evaluations [30,31], the findings of this study contribute data from our evaluative work on a novel implementation toolkit.

A key finding was that the teams did not complete the planning process in a linear manner. All teams conducted multiple steps simultaneously, with some steps being revisited multiple times during the planning process, a pattern reported elsewhere [16]. We also observed that many planning activities (including those across multiple phases) were worked on early in the planning journey. Although we attributed this finding partly to pandemic-related challenges, previous research found a similar pattern, with teams reporting using an implementation guide most frequently in the early stages [32]. Furthermore, despite all having access to the Planner, no 2 teams followed an identical planning path. Although we are unable to speak to the impact of these diverse planning journeys in terms of implementation outcomes, a previous study using an implementation guide found that it facilitated standardization, while allowing flexibility according to the individual context and resources, with all sites successfully implementing the planned program [33]. Among the barriers to implementation, one of the most common relates to challenges adapting evidence-based interventions [13]. The Planner was therefore designed to be a practical approach to planning based on evidence, which means that it is to be used in alignment with the local context [18]. It was not designed as a recipe that must be followed in a lock-step manner. The finding that diverse teams could, in fact, adapt and navigate the planning process in various ways suggests that the resource was applied as intended in real-world settings.

Even experienced planners described new things they learned from the Planner and how this improved their processes, suggesting that the Planner positively influenced end users’ planning capabilities, similar to other work reporting improvements in practitioner implementation skills [34]. In our study, 60% (3/5) of the planning teams were led by, or included, rehabilitation professionals. A recent study [12] of 384 allied health professionals (nearly half of whom were rehabilitation professionals) indicated that these practitioners reported lower levels of confidence in planning, implementation, and evaluation. Nearly all expressed an interest in learning about knowledge translation, with web-based training and resources (such as the Planner) being the preferred format [12].

Fitness professionals are another group essential to planning and implementing fitness programming; yet, it is largely unknown how fitness instructors engage in knowledge translation and implementation and what barriers and facilitators they encounter [35]. Although it is well acknowledged that fitness professionals have a critical role in delivering physical activity interventions and programs, there is limited information on this diverse group’s capacity and training needs [36]. In alignment with the Planner guiding principle of inclusiveness [7], we assert that fitness professionals are essential in cocreating the implementation plan. This field test included 12 participants, but only 2 (17%) were fitness professionals, which we attribute to the pandemic-related closure of fitness facilities and layoffs of fitness professionals. The inclusion of only 2 fitness professionals in our study was insufficient to reflect the overall heterogeneity of this group related to education, qualifications, and practice settings. Understanding this diversity and its effect on Planner use by this group may be important because there is evidence that fitness trainers with higher levels of education are more likely to access scientific journals than those with lower education, who prefer mass media and the internet [35]. Future work is needed to understand the implementation capacity and training needs of fitness professionals to enhance full participation in implementation planning.

In this study we used a passive form of implementation; that is, the teams had access to the Planner guide and tools, but no active implementation facilitation or support or any financial incentives were provided. However, there is evidence to suggest that active facilitation can enhance implementation efforts [37,38]. Given the potential value of implementation facilitation, our research team formed a new partnership with March of Dimes Canada, with the goal of having the Planner endorsed and supported by a well-connected and reputable organization in community-based stroke care. March of Dimes Canada has a national After Stroke program [39] that includes regional coordinators, providing the infrastructure to develop its organizational role in implementation facilitation by supporting sites using the Planner. There is an opportunity for future exploratory work that can contribute to the implementation literature on the role of a national organization and its regional coordinators in disseminating and supporting the use of the Planner. Furthermore, although the purpose of this study was not to assess the impact of the Planner on program outcomes, previous literature has reported that implementation toolkits may contribute to improved clinical outcomes [30]; future work is needed to evaluate the influence of the Planner on program outcomes and sustainability.

We identified several cross-cutting barriers and facilitators to following the implementation-planning process proposed in the guide, including organizational context and support, team leadership style, and the value placed on community-partner engagement. These factors were also identified in a review as core capacity–building domains (leadership, organizational climate and culture, partnerships, workforce development, and financial processes) that can be modified to build capacity for the implementation of evidence-based practices [40]. Knowing that simply creating an implementation guide does not guarantee use, we have carefully considered the barriers and facilitators identified in the evaluation of the Planner and have used this information to make changes to the Planner itself. For instance, related to community-partnership engagement, we added new content to the Planner on partnership agreements and a sample invitation letter for stroke and caregiver partners [7]. Furthermore, to address the potential barrier of perceiving that some Planner activities were not applicable, we added “Why is this important” statements throughout to clearly show the potential benefits of completing the various steps, activities, and tools [7].

Finally, it is noteworthy that 80% (4/5) of the teams had already selected the specific exercise program they wanted to implement before enrolling in the study. The finding that most teams had already selected a program speaks to the reality that for many teams, identifying a program is, in fact, the starting point that launches their implementation-planning journey. Observing that not every team starts with a blank slate at step 1, we revised the Planner to illustrate various starting points, with directions on how to use the Planner accordingly [7].

The greatest limitation of this study was conducting a prospective field test during a pandemic. The pandemic created significant recruitment challenges, and we were unable to recruit our originally planned sample size. Furthermore, for the teams we did enroll in the field test study, the closure of community facilities and the public health restrictions led to significant planning delays. The enrolled teams were therefore unable to progress through the entire planning process, with only 20% (1/5) of the teams able to launch a program during the study period. The purpose of this study was not to ascertain the effectiveness of the Planner related to program implementation and outcomes; rather, we sought to understand if, how, and why the Planner was used in practice. Despite the pandemic-related planning challenges, many teams were still able to work through many steps and provided valuable insight on how they used the Planner, allowing us to meet the field test study objectives. However, it is important to acknowledge that because the teams engaged much more heavily in the early phases and activities of the Planner, we do not have the same depth of understanding of how teams would use the Planner in the later stages (ie, program launch, evaluation, and sustainability).

Furthermore, most (4/5, 80%) of the teams indicated that it was the study itself that prompted them to officially launch their planning activities. The study data collection procedures may have caused participants to engage more with the Planner (eg, completing Planner activities in anticipation of an upcoming monitoring interview with the study team). However, to model more typical program-planning scenarios, the research team did not provide any program funding and provided only minimal assistance with connecting study participants with resources (eg, people and websites). The interviewer (J Reszel) did not contribute to making decisions in the program-planning process. Finally, it is important to note that the monitoring calls and end-of-study interview were completed with 1 primary contact at each site, and their perceptions and experience of working through the Planner may not represent the experiences of their team members.

A strength of the study was the diversity of the sample, which included planning teams with differing compositions based in both urban and rural settings across the country. This allowed us to observe the use of the Planner in a variety of settings, which enhances the transferability of the findings. In addition, despite the challenging pandemic conditions, we were able to maintain contact with 80% (4/5) of the teams throughout the study period, allowing us to collect comprehensive data on Planner use and experiences over time.

Catalyzing the expansion of safe, effective, and sustainable community-based exercise programs is important to the long-term health of people with stroke. The Stroke Recovery in Motion Implementation Planner [14] is an adaptable resource that may be used in diverse settings to plan and implement community-based exercise programs for people with stroke. The results of this study contribute to the implementation science literature by describing how end users made use of an implementation guide and the influence of the guide on implementation-planning knowledge, attitudes, and activities. These findings may be informative to others who are developing resources to build the capacity of those working in community-based settings to implement new programs and practices. Future work is needed to understand how teams use the Planner to launch, evaluate, and sustain programs; to monitor ongoing use; and to understand the effect and outcomes of using the Planner. The Planner is now hosted by March of Dimes Canada and can be accessed on the organization’s website [14].