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Table 1 Adaptation of intervention elements for each IM step resulting from phase one and phase two

From: Translation of a tailored nutrition and resistance exercise intervention for elderly people to a real-life setting: adaptation process and pilot study

Original intervention Phase one – design prototype intervention Phase two – pilot test prototype intervention
Original intervention elements Adapt? Adaptation to original intervention
Rationale
Adapt? Adaptation to prototype intervention
Rationale
Intervention Mapping step 2: Adaptation of target population and objectives based on needs assessment (step 1)
Target group:
 - age ≥ 65 years
 - (pre)frail
 - community-dwelling
Yes Homecare-receiving clients of care organisation
Clients of care organisation where implementing HCP work.
No screening on (FRIED) frailty criteria
Simplified inclusion criteria as frailty screening is not part of regular HCP work. Assumed that care-dependent elderly are also (pre)frail.
Yes Broader population from the community, focus on experienced muscle weakness
Pilot had difficulty recruiting homecare clients. PTs and OR indicate better to focus on elderly who are (pre)frail or heading towards frailty; staying close to target group of original intervention.
Specified exclusion criteria, checked by research physician Yes Similar exclusion criteria, but checked by participants’ own GP
Check by GP resembles real-life situation and allows large-scale implementation.
No  
No explicit behavioural outcomes for participants Yes Behavioural outcomes and objectives were defined
Behavioural outcome: participants initiate and maintain participation in the exercise and nutrition intervention. As different behaviours were targeted, i.e. changing and maintaining nutrition and exercise behaviours, outcomes were specified in more detail.
No  
Intervention Mapping step 3: Adaptation of methods and practical applications (Techniques, instruments, and methods)
Progressive training:
 - work towards 75% of 1RM
 - check 1RM every four weeks
 → Method: Tailoring
Yes Still progressive, but check 3RM and recalculate to 1RM
Implementing PTs were not confident in using 1RM in this TG; using 3RM and recalculating to 1RM is acceptable measure of strength.
Yes Only check 1RM at week 6
PTs perceived 4-weekly 1RM checks as too intensive for PPs.
More focus on reaching 75% of 1RM
Training intensity in pilot not always up to 75% of 1RM.
Trainers
 - encourage and motivate participants
 - explain purpose of exercises/nutrition
 → Method: Persuasive communication, arguments
No   No  
Tailored personal exercise schedule
→ Method: Tailoring
No   Yes Still tailored exercise scheme, but ensure that physiotherapists train at the intensity desired in the protocol
PTs did not always use 1RM to change intensity. PTs changed lay-out of individual schedules, so it is easier to track progress.
Monitoring protein intake using calendars
→ Method: Self-monitoring
Yes Still use calendar, but now with more options to indicate consuming cheese/yoghurt/drink
DTs also perceived this as suitable and feasible way to monitor intake.
Yes Add more detailed monitoring, make it easier to complete calendar
Monitoring intake was not always easy for DTs due to mixed quality of completed calendars. E.g. make calendar more personally programmed, ask about compensation during meals.
One flavour protein drink (250 mL) containing 15 g protein/drink Yes Range of protein-rich products (not only drinks) instead of just one drink → Method: facilitation
DTs expect that choice from a range of ordinary products would fit better with regular dietary habits and thus increase compliance. However, DTs doubt whether it is feasible to provide personalised advice over a longer period of time (maybe in the future better work with ‘standardised’ advice).
Yes Focus more on energy content of products
PPs experienced weight increase, so energy content of products should be taken into account in advice.
Try to incorporate more variety in products during trial
Some PPs missed product variation during trial.
Two protein drinks a day (just after breakfast and lunch), aiming for intake of 25 g of protein per meal Yes DTs check during which meals protein intake should be increased and provide tailored advice on which products and portion sizes to take (in agreement with participant preferences) → Method: Tailoring
DTs and product developers emphasise the importance of tailoring protein products to individual needs and desires.
No  
Handing out proteins for whole week drink at training, by researcher
→ Method: Facilitation
Yes Protein products for whole week organised per person by DT, distributed at training by PT
Most convenient according to DT and PT, also for product storage; DT knows personal advice and PT can distribute after training session.
Maybe PPs were satisfied with receiving products for the week during training. Logistics depend on whether products are provided or whether the participants should purchase them themselves.
Arranged free transport to all trainings by volunteers → Method: Facilitation Yes Participants should come to training on their own
In real-life setting, more emphasis on independence. Create the training location in the community, near the participants.
No  
Intervention Mapping step 4: Revision of programme materials (Intervention design: Delivery mode, intensity, materials)
General     
Programme of 24 weeks Yes Prototype intervention of 12 weeks
Researchers saw great improvement in outcomes after 12 weeks in experimental trial. HCPs perceive this as a sufficient period to test implementation of the prototype intervention.
Yes Intensive intervention of at least 12 weeks, with addition of a maintenance programme
Maintenance programme was requested by HCPs and PPs, focusing on both exercise and nutrition. Some PPs indicated that 12 weeks of ‘obligations’ was long enough. PTs indicated that around 12 weeks participants reach an ‘optimum’.
Information materials: leaflet (easy language, large font, clear information) Yes Adapt materials to practice setting. DTs also provide printed overview of individual advice
DTs are used to doing this with their clients, to help them remember advice.
No  
Contact person for questions was researcher Yes Contact person for training was PT, for dietary intervention was DT
It is likely that these are the first persons participants will ask questions about the nutrition/exercise programme.
Maybe Depends on organisational structure in implementing organisation.
Training sessions     
Training twice a week, one hour per session No   No  
Training supervised by researcher, assisted by trained students Yes Training supervised by PT, assisted by assistant PTs
(Geriatric) PTs are skilled professionals who can implement this programme in real-life. Researchers think that presence of a skilled supervisor during training sessions is important. OPs indicated that enthusiasm, social skills, and the ability to stimulate participants were important trainer qualities.
No  
No intake consultation by trainer Yes Intake by PTs before start intervention
PTs perceive this as necessary to gain knowledge on possible health problems/injuries.
No  
Training:
 - one trainer per two participants (individual exercise performance guidance)
 - same trainers all sessions
No   Yes No 1-on-1 guidance, more flexible
According to PTs two trainers for six participants was (more than) sufficient, especially after the first few weeks. Flexible guidance was successful during pilot. PPs were satisfied with guidance. PTs’ work schedule did not allow same trainer every training session, but two different trainers was feasible.
Training in mixed groups of maximally six elderly No   No  
Training in gym location equipped for the trial at university Yes Gym location in local community, near the elderly
TG wanted training location close by. Depends on the possibilities of the care organisation; a meeting room was transformed to a gym for the intervention period as other locations were occupied.
No  
Training session structure:
 - warming-up, resistance exercises, cooling-down
 - six training machines
 - no specific exercise order
No   Yes Group-based cooling-down (stretching)
PTs added group-based stretching to enable group cohesion. According to PPs, it was a nice way to close the session.
Researcher organised individual training schedules and trainings Yes Individual training schedules organised by PTs
The PTs organise the training and complete the individual training schedules during/after the training sessions. Fits their regular work.
No  
Nutrition intervention     
Only short explanation of protein drinks at start intervention by research dietician (no real consultation) Yes Face-to-face consultations with DT before intervention and midway through, added (phone) consultation when needed → Method: persuasive communication, arguments
As the nutrition programme in the prototype is more extensive, DT guidance is needed to explain the need of the nutrition programme and provide advice on the protein-rich products. Individual consultations ensured two-way communication. A midway evaluation opportunity is added to evaluate and adjust the advice if necessary.
Yes Add contact opportunity at start intervention and include monitoring of weight and dietary compliance
DTs had to inform PPs about the protein advice again when they were handing out products. Weight gain, indicated as problem by PPs, should be monitored. PPs indicated that they sometimes compensated for the protein-rich products. Therefore, DTs should closely monitor weight and dietary compliance.
Intervention Mapping step 5: Planning implementation
No involvement of other organisations Yes Involvement of care organisation to implement intervention
Building support by discussions with organisation and involving them in adaptation process.
No  
Recruitment by researchers, using letters to all community-dwelling elderly ≥65 years of selected cities Yes Recruitment by homecare nurses and care organisation’s communication department
The care organisation is also partly responsible for recruiting enough participants as it is implementing the programme.
Yes Provide more management support for recruiting HCPs
Pilot showed that recruitment through homecare nurses needs more attention.
No protocol for dieticians or physiotherapists Yes Implementation protocol and registration forms developed for dieticians and physiotherapists
Including detailed information describing implementation of the dietary and exercise intervention. Includes detailed training protocol for PTs, although they were already familiar with exercises.
No  
Implementing students trained by principal researcher Yes HCPs who recruit and implement intervention are trained by principal researcher
HCPs receive training before the intervention starts, to inform them about the implementation manual content and to train them to implement the intervention as planned. Also, the DTs and PTs meet one another during this training session, thus easing collaboration during the intervention.
Organise interdisciplinary discussion halfway through the implementation period with all implementing HCPs
HCPs indicated need to exchange experiences, so implementation could be altered if needed.
No  
Sustainability not taken into consideration No   Yes Include care organisation and municipalities in project
To ensure prolonged use of intervention, after (cost)- effectiveness is shown.
  1. HCPs healthcare professionals, PTs physiotherapists, OR original intervention researchers, GP general practitioner, 1RM 1 repetition maximum strength, TG target population of the intervention in real-life setting, 3RM 3 repetition maximum strength, PPs Pilot study participants, DTs dieticians, OPs original intervention participants