An Evaluation of Behavior Skills Training to Teach Staff to Implement the Step It UP! Game with Adults with Disabilities

Abstract

The Step it UP! Game, a modified version of the Good Behavior Game, has been used to increase physical activity among elementary school children and adults with disabilities. One important benefit of the Step it UP! Game is that it can be implemented by a single staff member for many clients simultaneously. To date, previous implementations of the Step it UP! Game have only been facilitated by researchers. The purpose of the present study is to determine whether staff members could be trained to proficiently implement the Step it UP! Game with adults with disabilities and determine if a staff-implemented Step it UP! Game could increase the mean steps per min of adults with disabilities. Three staff members (N = 3) were trained to implement the Step it UP! Game using video modeling and behavior skills training (BST). The percentage of correct implementation was evaluated using a concurrent multiple baseline design across participants. The baseline percentage of correct implementation was M = 38.75% (range, 30–52.38%). Following training, staff members rapidly mastered the skill, and the percentage of correct implementation increased to M = 99.29% (range, 96.67–100%) in post-training. BST with video modeling enhanced the competency of three staff members in executing the Step it UP! Game. Use of the Step it UP! Game by staff resulted in increases in the step counts of adults with disabilities.

The Step it UP! Game, a modified version of the Good Behavior Game (Barrish et al., 1969), is an interdependent group contingency in which participants are placed into teams, compete to take the most steps, and the winning team receives a prize. Galbraith and Normand (2017) evaluated the Step it UP! Game during recess with 20 third-grade students as participants. The winning team received raffle tickets for a school-wide raffle. Fourteen out of the 20 participants increased their step counts during the Step it UP! Game (Galbraith & Normand, 2017). Normand and Burji (2020) have also tested the effectiveness of the Step it UP! Game in an elementary school physical education classroom with longer duration games across more sessions than done in previous studies, providing evidence that the effectiveness of the Step it UP! Game does not decrease with repeated administration. Fourteen of 18 participants took more steps during physical education class with the Step it UP! Game compared to the typical physical education class (Normand & Burji, 2020). Further, Nieto and Wiskow (2020) improved the effectiveness of the intervention with the addition of an adult attention component. Seward and Redner (2023) evaluated the effectiveness of the Step it UP! Game among ten young adults with disabilities. All ten participants took more steps during the intervention condition, demonstrating that the Step it UP! Game is effective among adults with disabilities. The Step it UP! Game is a promising intervention that has demonstrated effectiveness among a range of participants and settings.

An important feature of the Step it UP! Game is that it can be implemented for a large group of participants by a single interventionist. This is partly because of the automated data collection by an accelerometer, the lack of necessity for individual data monitoring, and the use of an interdependent group contingency. The Step it UP! Game does not require time-intensive individualized intervention planning for each player because rewards are delivered contingent on the behavior of the group. Further, the interdependent group contingency encourages players to engage in prosocial interactions with their teammates and encourages appropriate behavior during the game (Seward & Redner, 2023). These features of the Step it UP! Game procedure makes the game relatively easy for the interventionist to facilitate with a group of players. Therefore, because the Step it UP! Game can be implemented easily and effectively by one individual it lends itself well to widespread implementation in relevant service settings.

The Step it UP! Game is relevant not only because of the ease of implementation but also because many people are not engaging in enough physical activity. Adults should complete at least 150 min of moderate-intensity aerobic activity per week or 30 min per day five times a week (US Department of Health and Human Services [USDHHS], 2018). Moderate-intensity aerobic physical activity can be a brisk walk at a step cadence of 100 steps per min (Tudor-Locke et al., 2018). Therefore, an individual can meet the USDHHS recommendation by taking a brisk 30-min walk per day five times per week. The CDC reports that only 53% of adults with developmental disabilities meet the physical activity recommendation (CDC, 2015). Research has found that individuals with disabilities engage in lower levels of physical activity and consequently suffer from a higher prevalence of noncommunicable diseases caused by long-term sedentary habits compared to their typical counterparts (Draheim et al., 2002; Kim et al., 2011; Pan, 2008; Rimmer & Rowland, 2008; Stubbs et al., 2016). As a result, individuals with disabilities are more likely to be obese (Ells et al., 2006) and to develop heart disease, stroke, diabetes, and cancers compared to individuals without a disability (Havercamp et al., 2004). Furthermore, Page et al. (2021) reported that people with mild to profound intellectual disabilities experience environmental barriers such as accessibility of gym facilities and cost-efficient transportation, natural physical barriers such as limb differences or limited bodily range of motion, and coaches or special educators who lack knowledge on the importance of physical activity for people with disabilities. These barriers may contribute to low physical activity trends among individuals with intellectual and developmental disabilities. The Step it UP! Game may be a good candidate intervention to address physical inactivity among individuals with disabilities.

To encourage the adoption of the Step it UP! Game in relevant settings that provide services to individuals with disabilities, such as schools, special education classrooms, and adult day programs, it may be beneficial to train staff members in these settings to implement the game. In previous research, the Step it UP! Game has been implemented by researchers rather than staff or direct service providers (Galbraith & Normand, 2017; Nieto & Wiskow, 2020; Normand & Burji, 2020; Seward & Redner, 2023, 2024). Therefore, the purposes of the present study were to (a) test whether staff members could be trained to proficiently implement the Step it UP! Game with adults with disabilities and (b) determine if a staff-implemented Step it UP! Game could increase the physical activity level of adults with disabilities. To do so, we used behavior skills training (BST), a performance- and competency-based training with video modeling (Catania et al., 2009; Smith et al., 2024). BST has been used to effectively train a wide range of skills practitioners, such as discrete trial training, differential reinforcement procedures, behavior intervention plan implementation, and incidental teaching procedures, to name a few (Smith et al., 2024). BST includes a verbal rationale and description of the skills to be taught, modeling, rehearsal, and feedback. The use of video modeling reduces variability in training procedures between participants. Reviews have been conducted on BST and have provided guidance on the best practices for its implementation and suggestions for increasing acceptability (e.g., Briggs et al., 2024; Smith et al., 2024). Recommendations on best practices of BST include implementing measures of generalization and long-term maintenance outcomes for participants to extend the external validity of BST, inclusion of technological descriptions of BST conditions to accommodate replication, reporting time in training to assess the efficiency of BST, and reporting client outcomes and characteristics to assess the indirect effects of BST on client behavior (Smith et al., 2024). We attempted to implement the recommended strategies to increase the adoption of these methods.

Method

Participants and Setting

Three staff participants were recruited from a vocational and residential program that provides rehabilitation services to adults with disabilities. Staff participants participated in the current study within their regularly scheduled working hours at the center. The inclusion criterion for staff participants consisted of being employed at the center in a position that required working directly with clients. Staff were excluded from participation if they were enrolled in a behavior analysis training program to protect the validity of the study, as these staff may have introduced bias due to their coursework and familiarity with behavior analytic research methods. Staff participants were identified through their supervisor as ideal candidates for the present study because they met the inclusion and exclusion criteria for participation in the study. All three staff participants signed a consent form before participating. All training and test sessions with staff participants took place on the campus of the developmental center. Sessions that included staff training components (instruction, modeling, and feedback) were conducted in an office on the campus of the developmental center. The office measured 3.05 m × 3.66 m and contained a desk with a Windows desktop computer setup, two rectangular tables measuring 91.44 cm W × 76.20 cm D × 182.88 cm L, three chairs measuring 48.26 cm W × 80.01 cm H, and a filing cabinet measuring 91.44 cm W × 60.96 cm D × 182.88 cm H. Sessions that included the rehearsal training component took place on the campus of the developmental center with access to the entire outdoor recreational area (100 m × 57 m, i.e., large open space with sidewalks, playing courts, and grassy areas) and the developmental center’s indoor space (i.e., three 123 m² hallways and one 355 m² foyer).

Staff 1 (S1) had been employed at the center for 1 year, reported no previous experience working with individuals with disabilities before her position at the center, and was earning her bachelor’s degree in psychology. S1 identified as a white female and was 21 years old. Staff 2 (S2) had been employed at the center for 7 months, reported 6 months of previous experience working with individuals with disabilities before his position at the center, and was earning his master’s degree in computer science. S2 identified as an Asian male and was 26 years old. Staff 3 (S3) had been employed at the center for 7 months, reported 2 years of previous experience working with individuals with disabilities before his position at the center, and was earning his master’s degree in economics. S3 identified as a black male and was 23 years old.

Fifteen client participants were recruited from the same vocational and residential program. All client participants were 18 years of age or older and diagnosed with a disability. Client participant inclusion criteria included being diagnosed with a disability and being 18 years of age or older. The exclusion criterion for client participants included any persons who were unable to walk independently without the assistance of a mobility device (e.g., wheelchair, canes, walkers, or leg splints). No client participants were excluded from participation in the current study. Client participant demographic data are displayed in Table 1.

Table 1.

Client demographics and percentage of participation across sessions

Participant	Gender	Race	Age	Diagnosis	Participation across sessions (participated/opportunity)
P1	Male	Hispanic	20	Autism; language disorder; processing disorder; ADHD	94.29% (33/35)
P2	Female	Hispanic	21	Anxiety; depression; dyslexia; dyscalculia; dyspraxia; receptive/expressive disorder; learning disability; asthma	81.25% (26/32)
P3	Male	White	21	Specific learning disorder; ADHD	98.31% (58/59)
P4	Male	White	20	Severe intellectual disability	87.27% (48/55)
P5	Male	White	19	Severe speech impairment; specific learning disability; verbal apraxia; Dupuytren contracture	97.14% (34/35)
P6	Male	White	19	Autism	84.48% (49/58)
P7	Female	White	23	Reactive attachment disorder; specific learning disability; anxiety disorder; bipolar disorder with schizotypal features; fetal alcohol spectrum disorder; developmental trauma	84.51% (60/71)
P8	Male	White	19	Intellectual disability; speech delay	100% (43/43)
P9	Female	White	19	Specific learning disability	72.88% (43/59)
P10	Male	White	23	Autism; psychosocial impairments (interpersonal and behavioral)	21.05% (4/19)
P11	Male	White	22	Autism	54.55% (12/22)
P12	Male	Asian	19	Autism; intellectual disability; bipolar; anxiety	86.36% (19/22)
P13	Male	White	23	Cognitive impairments (learning, thinking, processing, concentration); specific learning disability; psychosocial impairments (interpersonal and behavioral); anxiety disorder	62.96% (17/27)
P14	Male	White	20	Autism; ADHD combined type; bipolar 1 disorder; generalized anxiety disorder; history of PTSD	100% (4/4)
P15	Female	White	22	Severe intellectual disability	100% (6/6)

Sessions took place on the campus of the developmental center, which had access to the entire outdoor recreational area and the developmental center’s indoor space. Ten client participants signed a consent form prior to participating. The remaining five client participants (P1, P4, P8, P12, & P15) were not their own legal guardians. Consent to participate in the current study was obtained from P1, P4, P8, P12, and P15’s legal guardians, and the client participants signed assent forms prior to participating. At the beginning of the study, client participants were informed by the researcher that they may elect to participate or decline to participate in any given session throughout the study. Thereafter, client participants were asked if they wanted to participate at the beginning of each session by the staff participant. Participation data are reported as a dependent variable of interest. Absences were not included in the participation percentage. P14 had low engagement in the developmental center’s programs due to repeated absences. Consequently, P14 was absent for most sessions and was not in attendance for any sessions following session 8. P15 dropped out of programming at the developmental center and informed the researcher that she would no longer be able to participate in the study. As a result, P15 did not have the opportunity to participate in any sessions following session 4. The remaining thirteen client participants completed the entire study. The study was reviewed and approved by the university’s institutional review board.

The first author implemented the BST procedures in the current study with staff participants. The first author was enrolled in a doctoral program in behavior analysis, a Board Certified Behavior Analyst for 3.5 years, and had 5.5 years of experience working with adults with disabilities. The first author had previous experience implementing the Step it UP! Game among adults with disabilities prior to the current study and facilitated approximately 67 Step it UP! Game sessions across a timespan of about 2 years.

Materials and Measurement

Provided materials in baseline sessions included Fitbit activity trackers, lanyards with two different colored tags, a calculator, a labeled grid-lined sheet of paper (i.e., datasheet), a prize bowl with paper slips labeled “1”, “2”, and “3”, and prizes of three different types: gift cards, toys, and candies. Materials provided in training and post-training sessions included all of the same materials as the baseline session, with the addition of an iPad to interact with an Excel spreadsheet with pre-entered calculating functions and the Step it UP! Game task analysis. At the conclusion of all staff participant sessions, a compensation fishbowl containing 500 slips was available to staff participants; 274 had a message stating “Thank you for participating! 😊”, 200 were worth $1, 25 were worth $10, and 1 was worth $50. Slips of monetary worth were redeemed as Walmart gift cards. The first author received a student funding award from the University to fund the current study.

The fidelity of the treatment implemented by staff participants was the primary dependent measure. Procedural fidelity is the degree to which the treatment is delivered compared to how the treatment is intended to be delivered (Falakfarsa et al., 2022). The procedural fidelity measure of staff participant implementation of the Step it UP! Game will be referred to as “treatment adherence” throughout this writing. A treatment adherence checklist was used to track the completion of each step, and each step was scored according to how well the staff participant completed the step (e.g., 0 = step was not completed by the staff participant; 1 = step was partially completed by the staff participant; 2 = step was fully completed by the staff participant). The treatment adherence checklist is included in Table 2. Treatment adherence checklist items were organized into five important Step it UP! Game components: division of participants into competing teams (see treatment adherence checklist items 1a–c, 4a–d, 22a–b, 23, & 24), establishing rules for the game (see treatment adherence checklist items 3, 6a–d, 7b, 8, 9a–b, 11, & 12a–b), delivering feedback at the conclusion of the game (i.e., how many steps participants or teams took during the session; see treatment adherence checklist items 2, 7a, 14–18, & 19a–b), establishing criteria to win the game (i.e., the team that takes the most steps wins; see treatment adherence checklist items 5 & 10), and rewarding the winning team at the conclusion of the game (see treatment adherence checklist items 1d, 20, & 21a–d) (Galbraith & Normand, 2017; Nieto & Wiskow, 2020; Normand & Burji, 2020; Seward & Redner, 2023, 2024). A researcher directly observed the staff participant implement the intervention with client participants and scored the checklist accordingly. A treatment adherence percentage was calculated by adding up the total number of points earned by the staff participant, dividing it by the total number of points possible, and multiplying by 100. The duration of sessions was also recorded by writing down the start time and end time of each session with staff participants.

Table 2.

Step it UP! Game treatment adherence checklist

Checklist Item
1. Prepare all provided materials for the session a. Put the team assignment sheet on the table b. Put Fitbits on the table c. Put lanyards on the table d. Put prize drawing materials under the table
2. Write in starting step counts from the Fitbits on the datasheet
3. Tell all participants that you will begin the Step it UP! Game soon and they should gather in the break room if they want to participate
4. The Game requires a minimum of 4 participants to play (2 players per Team) a. If 4 participants are not available, do not play the Game. Indicate this on the datasheet b. If Teams are misbalanced by 3 or more players, temporarily re-assign players (by writing on the team assignment sheet) by moving participants from the larger team to the smaller team until teams are equal or a difference of 1 is met c. If a Team has only 1 player, temporarily re-assign players (by writing on the team assignment sheet) by moving participants from the larger team to the smaller team until teams are equal or a difference of 1 is met d. If Teams meet the above requirements with no team re-assignments necessary, continue to step 5
5. Read the Step it UP! Game rules (provided script) to participants: “Today we are going to play the Step it UP! Game. The goal of the game is to take as many steps as you can. You will wear a Fitbit to count your steps and a colored lanyard that represents your team. As a reminder, please do not shake your Fitbit, swap your Fitbit with others, or remove the tape covering the Fitbit screen. At the end of the game, the team with the most steps will win and participate in a prize drawing. The team with the least steps will not participate in a prize drawing. If both teams take close to the same number of steps during the game, both teams will get to participate in the prize drawing. Does anyone have any questions?”
6. Read the following script: “Please come to the table and put on your Fitbit and lanyard. Once you have your Fitbit and lanyard on, please wait until I announce the Game is starting.” a. Hand out Fitbits to each participant and write their name next to the Fitbit number they receive on the datasheet b. If a participant asks about their team assignment, point to the team assignment sheet on the table and state their team assignment c. If a participant asks for help with putting on a Fitbit, place the Fitbit on their arm and attach it to their wrist with the band d. If a participant asks for help with putting on a lanyard, take the correct colored lanyard and place it over their head and on their neck so that the colored card hangs against their chest
7. Once the last Fitbit/lanyard is put on: a. write down the start time on the datasheet and b. tell participants the Game has started
8. Immediately following the start time, set a timer for 5 min
9 a. Observe participants playing the Game for 5 min b. If a participant engages in a rule violation, restate the rule reminder: “Please do not shake your Fitbit, swap your Fitbit with others, or remove the tape covering the Fitbit screen.”
10. When the timer goes off, state this instructional reminder: “The goal today is to take as many steps as you can and at the end, I will tell you how many steps your team took. The team with the most steps will get to participate in the prize draw. Participants on the team that takes the least steps will not participate in the prize draw. If both teams take close to the same number of steps during the game, both teams will get to participate in the prize drawing.”
11. Immediately following stating the instructional reminder, start another 5-min timer
12 a. Observe participants playing the Game for 5 min b. If a participant engages in a rule violation, restate the rule reminder: “Please do not shake your Fitbit, swap your Fitbit with others, or remove the tape covering the Fitbit screen.”
13. When the timer goes off, state to all participants at the same time: “The game is over. Please remove your Fitbits and lanyards and place them on the table. Please stay in the break room until I announce the winner.”
14. Write in the ending time on the datasheet once the last Fitbit is placed on the table
15. Write in ending step counts from the Fitbits on the datasheet
16. Type in session duration (how many minutes the session lasted from start time to end time) in the designated Excel spreadsheet cell
17. Type in starting step count and ending step count for each participant that played the Game in the designated Excel spreadsheet cells
18. Type in the number of participants on each Team in the designated Excel spreadsheet cells
19. Using the output cells in the Excel Spreadsheet that show the average number of steps each team took during the Game, state: a. If one team is the winner: “Team Red took about ‘insert Excel output number here’ steps per min and Team Blue took about ‘insert Excel output number here’ steps per min. Team ‘insert team color with highest steps here’ is the winner of the Step it UP! Game. Please come up to the table for a prize draw if your Team won.” b. If both teams tie: “Team Red took about ‘insert Excel output number here’ steps per min and Team Blue took about ‘insert Excel output number here’ steps per min. Both Team Red and Team Blue are the winners of the Step it UP! Game. Please come up to the table for a prize draw.”
20. Take the prize materials from under the designated table and place the candy box, toy box, and gift cards on the table
21. Have each winning participant draw a paper from the bowl a. If a participant draws a 1, point to the box of candy on the table and tell them to pick one b. If a participant draws a 2, point to the box of toys and tell them to pick one (or they may pick 2 pieces of candy instead of a toy) c. If a participant draws a 3, give them a gift card (or they may pick 3 pieces of candy instead of a gift card or they may pick 2 toys instead of a gift card) d. If a participant on the losing team tries to draw a prize, tell them prizes are only for the winning team and they will have another chance to win next time
ONLY CONTINUE FOR STAFF THAT HAVE IMPLEMENTED A MINIMUM OF 3 STEP IT UP! GAME SESSIONS FOLLOWING TRAINING START 22. Using the tabs in the spreadsheet, check to see if the same Team has won 3 consecutive times in a row (excluding Games in which both Teams tied) a. If both Teams have won across the last 3 consecutive sessions, no further steps are required b. If only one Team has won across the last 3 consecutive sessions, permanent team reassignment is required
23. Identify the participant with the highest step count on the Team that won 3 consecutive times —Permanently reassign this participant to the opposite team (write their name under the new Team on the Team assignment sheet)
24. Identify the participant with the lowest step count on the Team that lost 3 consecutive times —Permanently reassign this participant to the opposite team (write their name under the new Team on the Team assignment sheet)

In addition to calculating the treatment adherence percentage from the results of the treatment adherence checklists, we reviewed the errors staff participants made in each Step it UP! Game component area represented on the checklist across baseline, training, and post-training sessions. An analysis of errors was conducted by having a researcher review each of the scored treatment adherence checklists, count how many item errors were committed in each component area, and how many item opportunities were available in each component area. A percentage of errors was then calculated for each staff participant in each condition by dividing the number of errors committed by the total number of item opportunities and multiplying by 100.

The secondary dependent measure was the client participants’ mean steps per min. The Fitbit Inspire 2 (San Francisco, California) accelerometer recorded the number of steps taken by each client during each session. Chevance et al. (2022) determined that the Fitbit Inspire 2 was accurate. Each Fitbit display was covered with opaque tape to conceal the display from client participants. This prevented client participants from interacting with the Fitbit and viewing step count data during the session (i.e., reactivity). The number of steps taken per min was calculated by dividing the total number of steps taken during the session (subtracting the starting step count from the ending step count) on the Fitbit by the total session duration.

Experimental Design and General Procedure

A concurrent multiple baseline across participants design was used to evaluate the effectiveness of a BST procedure to train implementation of the Step it UP! Game. Phases included baseline, training, and post-training. All staff participants began study participation at the same time (i.e., concurrently). Each staff participant participated in one session per day.

The general procedure followed across baseline, training, post-training, and follow-up conditions. All three staff participants implemented the Step it UP! Game procedures with the same fifteen client participants, although client participant composition varied slightly between staff participant implementers from session to session. Prior to the start of sessions, an experimenter provided all the necessary materials to implement the Step it UP! Game and instructed the staff participant to implement the game with client participants to the best of their ability. At the conclusion of all sessions with staff participants, a compensation fishbowl procedure was implemented. Similar to the method utilized by Kelly et al. (2014), a fishbowl contingency management procedure in which an escalating schedule of positive reinforcement was used to promote the staff participant’s continued attendance throughout the study. Following attendance of each session, staff participants drew slips of paper from a fishbowl containing slips with a thank you message or slips worth Walmart gift cards. The number of slips a staff participant could select during a drawing started at one and increased by one with each consecutive session they attended. For example, staff participants could select up to five slips per drawing each session as long as they had perfect attendance for the last five consecutive sessions. The maximum number of slips that could be selected at each drawing was capped at five, and if a staff participant was absent for a session, the number of slips they could draw was reset to one. S1 was compensated $70, S2 was compensated $135, and S3 was compensated $105 throughout the current study. Step it UP! Game sessions across all phases were M = 12.55 (range, 9–20) min in duration. At the outset of the study, the researcher asked staff participants not to discuss their experiences during participation in the study with other staff participants throughout the entire duration of the study.

Baseline

Similar to the baseline procedure outlined in Sarokoff and Sturmey (2004), a brief written description containing general information about the Step it UP! Game was provided to staff participants at the beginning of every baseline session:

The Step it UP! Game is a tool for increasing step count. The Step it UP! Game is conducted by dividing players into teams, telling players the rules of the Game and how to win, announcing a winner, and giving the winning players a prize. Players are not required to play if they do not want to.

Before the first baseline session, the researcher briefly described each of the materials provided and showed the staff participant how to access the step count data on the Fitbits (peel back tape on display and scroll to the step count display on the device). During the baseline phase, no specific Step it UP! Game treatment implementation protocol (i.e., task analysis) was provided to the staff participants. A researcher observed the staff participants during baseline sessions and collected data using the treatment adherence checklist. Staff participants remained in the baseline phase for at least three sessions, as well as until stable responding occurred. Stable responding was analyzed through visual analysis of adherence scores.

During baseline, client participant assent was assessed by the researcher through observation of client-staff participant interactions. At the outset of the study, the researcher informed staff participants that client participants were not required to participate if they did not want to. Therefore, staff participants asked client participants if they would like to participate at the beginning of each session. If a client participant refused to engage with the staff participant or follow the staff participant’s guidance to start the game, the researcher marked it as a refusal, and if the client participant engaged with the staff participant and began to follow the guidance of the staff participant, the researcher marked it as assent was obtained. Absences were not included in participation percentages.

Prior to the start of each baseline session, the experimenter read the following script to the staff participant: “Do your best to implement the Step it UP! Game with clients for 10 min. You may use any of the materials provided to you.” If a staff participant asked questions about how to implement the Step it UP! Game during this phase, the researcher reminded the staff participant to do the best they could to implement the game with the information and materials provided to them. Staff participants were not given feedback during the baseline phase. Step it UP! Game sessions across baseline were M = 13.81 (range, 9–20) min in duration.

Staff Training

During the training phase, staff participants received one-on-one training to implement the Step it UP! Game. Instruction, modeling, rehearsal, and feedback were used to train staff participants to implement the Step it UP! Game with client participants at the developmental center. Training was terminated once the staff participant reached a mastery criterion of 100% treatment adherence for two consecutive training sessions. Step it UP! Game sessions across training were M = 12.31 (range, 11–13) min in duration.

Instruction. At the beginning of the training phase, the researcher introduced the instruction component of the BST procedure. Instructions were reviewed with staff participants a single time and included a detailed verbal description of the Step it UP! Game and handout that was a list of steps (i.e., task analysis) that described the Step it UP! Game procedure in simple steps (the list of steps were the same steps in the treatment adherence checklist). A researcher reviewed the provided task analysis with the staff participant in detail (i.e., by reading each step, describing why each step was important, and presenting any corresponding materials relevant to each step as it was reviewed) and answered any questions the staff participant asked. Staff participants were provided a copy of the printed task analysis at the outset of each training and post-training session that they could refer to during the session.

Modeling. The researcher presented the staff participant with all relevant materials necessary to implement the Step it UP! Game. Following the sequence of steps outlined in the task analysis as a guide, the researcher then presented video models to the staff participant on the iPad. Video models consisted of the researcher and research assistants modeling how to use each of the presented materials and complete each of the task analysis steps to implement the Step it UP! Game. Each video model of the task analysis was played in the sequence listed in the task analysis until the entire list had been completed. In the video models, the primary researcher modeled steps with two assistant researchers who role-played as client participants. The staff participant was free to re-watch or re-wind video models as needed.

Rehearsal. Following instruction and modeling, the staff participant was instructed to conduct the Step it UP! Game to the best of their ability with client participants. A researcher observed the staff participant during rehearsals and collected data using the treatment adherence checklist. If the staff participant did not implement the Step it UP! Game in a rehearsal session to 100% adherence, the researcher re-played video models of the incorrectly performed steps immediately following the conclusion of the rehearsal session and again immediately before the next rehearsal session. Prior to the start of each rehearsal session, the experimenter read the following script to the staff participant: “Do your best to implement the Step it UP! Game with clients for 10 min. You may use any of the materials provided to you.” Only one Step it UP! Game rehearsal was conducted per staff participant per day. Sessions were conducted 4 days per week, Monday through Thursday.

Feedback. After the staff participant completed a rehearsal session, the researcher showed the staff participant the treatment adherence checklist results, explained what step(s) the participant performed correctly and incorrectly, and replayed the video model of any steps that were performed incorrectly. Feedback and video modeling of previously incorrectly performed steps were repeated immediately following the rehearsal session and again immediately before the next rehearsal session.

Post-Training

At the beginning of each post-training session, a researcher provided all necessary materials to conduct the game and instructed the staff participant to implement the game with client participants to the best of their ability. Step it UP! Game sessions across post-training were M = 11.97 (range, 11–13) min in duration. The researcher observed staff participants during post-training sessions and collected data using the treatment adherence checklist. Feedback was not delivered during this condition. Prior to the start of each post-training session, the experimenter read the following script to the staff participant: “Do your best to implement the Step it UP! Game with clients for 10 min. You may use any of the materials provided to you.”

Step Count Baseline Probes

Researcher-implemented baseline probes of step count data were conducted to determine the approximate level of physical activity without intervention from staff participants. During baseline probes, a researcher instructed client participants that they may engage in any activity they would normally engage in at that time. There were no programmed consequences for engaging in physical activity. All client participants wore activity trackers with concealed screens. The duration of baseline probes was M = 11.67 (range, 10–13) min. Prior to the start of each baseline probe session, the researcher read the following script to the client participants as a group:

Today, we are going to wear Fitbits. As a reminder, please do not shake your Fitbit, swap your Fitbit with others, or remove the tape covering the Fitbit screen. You are free to do whatever activity you would normally do at this time. Do you have any questions?

Follow-Up (Maintenance)

Following the final post-training session, staff participants discontinued the implementation of the Step it UP! Game until follow-up. Two follow-up sessions were conducted at 7 days and 32 days following the final post-training session. The follow-up session procedures were identical to post-training session procedures. Step it UP! Game sessions across follow-up were M = 11.17 (range, 10–12) min in duration. Prior to the start of each follow-up session, the experimenter read the following script to the staff participant: “Do your best to implement the Step it UP! Game with clients for 10 min. You may use any of the materials provided to you.”

Interobserver Agreement (IOA)

Staff Participant Treatment Adherence IOA. An independent observer used the Step it UP! Game treatment adherence checklist to collect data for 33.77% of sessions (7.69% [2/26] of baseline sessions, 43.75% [7/16] of training sessions, and 48.57% [17/35] post-training sessions) for IOA purposes. IOA was calculated for 42.31% (11/26) of sessions with S1, 38.46% (10/26) of sessions with S2, and 20% (5/25) of sessions with S3. IOA was calculated by dividing the number of checklist steps marked in agreement between the primary researcher and the independent observer by the total number of items marked on the checklist and multiplying by 100 to obtain a percentage. The arithmetic mean IOA for individual staff participants was 97.12% (range, 92.68–100%) for S1, 96.81% (range, 92.31–100%) for S2, and 92.96% (range, 87.18–100%) for S3. The arithmetic mean IOA across all staff participants was 96.19% (range, 87.18–100%).

Client Participant Step Count IOA. Two independent observers reviewed photographs of the Fitbit displays for each client participant for 41.56% of sessions (26.92% [7/26] of baseline sessions, 50% [8/16] of training sessions, and 48.57% [17/35] post-training sessions). Data was collected for 42.31% (11/26) of sessions with S1, 30.77% (8/26) of sessions with S2, and 32% (8/25) of sessions with S3. A single disagreement occurred during session 6, a baseline session, with S2 resulting in an IOA of 91.67% for that session. Photographs were used to correct the error. IOA was 100% for all other sessions. IOA was calculated by dividing the number of agreements on step counts by the total number of agreements and disagreements and multiplying by 100 to obtain a percentage. The arithmetic mean IOA across client participants was 99.71% (range, 91.67–100%).

Researcher Procedural Fidelity

Data on the researcher’s implementation of the study procedures were collected for 36.36% of sessions, 11.54% (3/26) of baseline sessions, 50% (8/16) of training sessions, and 48.57% (17/35) of post-training sessions. These data were collected for 46.15% (12/26) of sessions with S1, 42.31% (11/26) of sessions with S2, and 20% (5/25) of sessions with S3. Prior to the sessions in which data were collected, a researcher provided a checklist to an independent observer, briefly explained how to complete the checklist, and answered any questions the observer asked. Three different checklists were used to collect data. Each checklist consisted of a list of steps the researcher was expected to implement during the specified experimental condition. Procedural fidelity was calculated by dividing the number of steps marked as completed by the total number of incomplete and completed steps. This proportion was multiplied by 100 to get a percentage. The arithmetic mean procedural fidelity for individual staff participants was 100% for S1 and S2 and 99.39% (range, 93.33–100%) for S3. The arithmetic mean procedural fidelity across all staff participants was 99.76% (range, 93.33–100%).

Reliability of Step Count Data

Throughout the study, a researcher evaluated the Fitbit Inspire 2’s step count feature. Data were collected for 36.36% (28/77) of sessions, 15.38% (4/26) of baseline sessions, 25% (4/16) of training sessions, and 57.14% (20/35) of post-training sessions. Data were collected for 46.15% (12/26) of sessions with S1, 30.77% (8/26) of sessions with S2, and 32% (8/25) of sessions with S3. The data collection procedures for assessing the reliability of the Fitbit Inspire 2’s step count feature were similar to those used by Hayes and Vancamp (2015). Data were collected by having client participants wear a secondary Fitbit on the opposite wrist of their primary assigned Fitbit throughout the duration of a session. One client participant wore a secondary Fitbit each session in which data were collected. At the end of the session, the researcher recorded step counts from both the primary and secondary Fitbit at the same time and calculated agreement by dividing the smallest step count by the largest step count and multiplying by 100 to obtain a percentage. The arithmetic mean reliability agreement for individual staff participants was 94.31% (range, 85.10–99.52%) for S1, 94.24% (range, 89.55–98.05%) for S2, and 96.69% (range, 92.87–99.92%) for S3. The arithmetic mean reliability agreement across all staff participants was 95% (range, 85.10–99.92%).

Social Validity Assessment

At the conclusion of the study, staff and client participants were asked to complete a social validity questionnaire (i.e., researcher-constructed questionnaires designed for use in the current study). A researcher was present when staff and clients completed social validity questionnaires, and responses on the questionnaires were identifiable to the respondent (i.e., not anonymous). A printed copy of the questionnaire was provided to staff participants following session 27. The researcher briefly described how to fill out the questionnaire and answered any questions the staff participant asked. The staff questionnaire included six statements (see Table 5). On the staff participant questionnaire, the lowest possible social validity score was 6 (i.e., 1 for each of the six statements), and the highest possible score was 30 (i.e., 5 for each of the six statements). Staff participants rated all statements on a five-point Likert scale with responses ranging from 1 (strongly disagree) to 5 (strongly agree).

Table 5.

Staff participant and client participant social validity prompts and responses

Staff Prompts:
	The Step it UP! Game increased client’s physical activity level	The Step it UP! Game is easy to implement	I would like to try to implement the Step it UP! Game again in the future	I think that increasing client’s physical activity level is important	The training I received helped me implement the Step it UP! Game with clients		The training I received was easy to understand	Score
S1	Agree (4)	Agree (4)	Strongly Agree (5)	Strongly Agree (5)	Neutral (3)		Agree (4)	25
S2	Strongly Agree (5)	Strongly Agree (5)	Strongly Agree (5)	Strongly Agree (5)	Strongly Agree (5)		Strongly Agree (5)	30
S3	Disagree (2)	Strongly Agree (5)	Neutral (3)	Strongly Agree (5)	Neutral (3)		Strongly Agree (5)	23
Client Prompts:
	The Step it UP! Game increased my physical activity level	The Step it UP! Game rules were easy to follow	I would like to play the Step it UP! Game again in the future	I think that increasing my physical activity level is important	Score	Additional Comments
P1	Neutral (3)	Agree (4)	Disagree (2)	Neutral (3)	12
P2	Neutral (3)	Strongly Agree (5)	Neutral (3)	Agree (4)	15	“More candy [options]”
P3	Strongly Agree (5)	Strongly Agree (5)	Strongly Agree (5)	Strongly Agree (5)	20	“The Step it UP! Game is amazing”
P4	Strongly Agree (5)	Agree (4)	Disagree (2)	Agree (4)	15
P5	Strongly Agree (5)	Strongly Agree (5)	Strongly Agree (5)	Strongly Agree (5)	20
Client Prompts:
P6	Neutral (3)	Strongly Agree (5)	Neutral (3)	Neutral (3)	14
P7	Strongly Agree (5)	Strongly Agree (5)	Strongly Agree (5)	Strongly Agree (5)	20	“I think that the Game was great!!! I think it doesn’t need anything or only it may need is more prizes for older people like rings!”
P8	Agree (4)	Neutral (3)	Agree (4)	Strongly Agree (5)	16
P9	Neutral (3)	Strongly Agree (5)	Neutral (3)	Neutral (3)	14
P10	Strongly Agree (5)	Strongly Agree (5)	Strongly Agree (5)	Strongly Agree (5)	20
P11	Agree (4)	Agree (4)	Agree (4)	Agree (4)	16
P12	Agree (4)	Neutral (3)	Strongly Agree (5)	Agree (4)	16
P13	Strongly Agree (5)	Strongly Agree (5)	Strongly Agree (5)	Strongly Agree (5)	20

The client participant questionnaire included four statements (see Table 5). A printed copy of the client participant questionnaire was provided to client participants following session 27 or at a later time if they were not present that day. Thirteen client participants completed social validity assessments. P1, P4, and P8 requested help to complete the questionnaire. The researcher read the questionnaire to the client participants who requested help individually. The remaining client participants completed the questionnaire independently. The lowest possible social validity score on the client participant questionnaire was 4 (i.e., 1 for each of the four statements), and the highest possible score was 20 (i.e., 5 for each of the four statements). All statements were rated by client participants on a five-point Likert scale with responses ranging from 1 (strongly disagree) to 5 (strongly agree).

Results

Client participants opted into 83.36% (456/547) of sessions (88.89% [160/180] with S1, 81.16% [168/207] with S2, and 80% [128/160] with S3). See Table 1 for the participation percentage of each client participant.

Staff Treatment Adherence

Figure 1 displays the percentage of correct implementation of the Step it UP! Game among staff participants. S1, S2, and S3 remained in baseline for three sessions, eight sessions, and fifteen sessions, respectively, during which all staff implemented the Step it UP! Game with consistently low treatment adherence (30.95% correct to 52.38% correct) across those phases. The mean scores of staff participants correctly implementing the Step it UP! Game during baseline sessions was 40.39% (range, 40–41.18%), 34.61% (range, 30.95–39.47%), and 40.63% (range, 35–52.38%) for S1, S2, and S3, respectively.

Fig. 1.

Percentage of correct implementation of the Step it UP! Game by staff. Note. This figure depicts the percentage of correct implementation of the Step it UP! Game for S1, S2, and S3 across baseline, staff training, and post-training conditions. Follow-up sessions were conducted at 1 week (7 days) and 1 month (32 days for S2 & S3 and 33 days for S1*) following the last post-training session

Following the introduction of the staff training intervention, treatment adherence of the Step it UP! Game among all three staff immediately increased to a high level (87.93% correct or greater) and remained high throughout the training condition. S1 spent 3 h and 50 min in training across a total of five sessions, S2 spent 4 h and 45 min in training across a total of six sessions, and S3 spent 4 h and 16 min in training across a total of five sessions to master the implementation of the Step it UP! Game. The mean scores of staff participants correctly implementing the Step it UP! Game during training sessions was 98% (range, 95–100%), 97.02% (range, 89.29–100%), and 96.55% (range, 87.93–100%) for S1, S2, and S3, respectively.

After training was removed and staff moved into the post-training condition, treatment adherence of the Step it UP! Game remained high (96.67% correct or greater) for all three staff participants across the entire post-training condition. Mean scores of staff participants correctly implementing the Step it UP! Game during post-training sessions was 99.47% (range, 96.67–100%), 99.03% (range, 96.67–100%), and 99.33% (range, 96.67–100%) for S1, S2, and S3, respectively. During the 1-week and 1-month follow-up sessions staff participant’s treatment adherence of the Step it UP! Game was high. S1, S2, and S3 implemented the Step it UP! Game during the 1-week follow-up session at 100%, 98.33%, and 100% correct treatment adherence, respectively. At the 1-month follow-up, S1, S2, and S3 implemented the Step it UP! Game at 100%, 100%, and 98.28% correct treatment adherence, respectively.

Table 3 displays the percentage of errors committed by staff participants across the five component areas of the Step it UP! Game in each condition. Versions of the Step it UP! Game in baseline and errors observed in treatment adherence varied considerably across each condition for S1, S2, and S3. Consequently, scores of treatment adherence may not represent the same errors among staff participants. Across baseline sessions staff participants made the most frequent errors in checklist item opportunities related to establishing rules (e.g., did not give any rules), establishing criteria to win the game, and delivering feedback and rewarding the winning team (e.g., did not announce a winning team and did not utilize prize drawing materials). Following the BST training, staff participant errors during the game in training and post-training were reduced to low levels or no longer occurred across the game’s component areas.

Table 3.

Step it UP! Game treatment errors committed by staff

		Step it UP! Game Component Areas:
		Division of participants into competing teams	Establishing rules for the Game	Delivering feedback at the conclusion of the Game	Establishing criteria to win the Game	Rewarding the winning team at the conclusion of the Game
		Checklist Items:
		1a-c, 4 a-d, 22 a-b, 23, & 24	3, 6 a-d, 7b, 8, 9 a-b, 11, & 12 a-b	2, 7a, 14 –18, & 19 a-b	5 & 10	1d, 20, & 21a-d
Baseline	S1	22.22% (2/9)	81.48% (22/27)	50% (6/12)	100% (6/6)	81.82% (9/11)
	S2	8.33% (2/24)	90.14% (64/71)	84.38% (27/32)	100% (16/16)	68.75% (22/32)
	S3	11.11% (5/45)	81.60% (102/125)	90% (54/60)	93.10% (27/29)	55.56% (50/90)
Staff Training	S1	8.70% (2/23)	3.92% (2/51)	No Errors	No Errors	No Errors
	S2	No Errors	8.93% (5/56)	6.25% (3/48)	No Errors	No Errors
	S3	No Errors	5.88% (3/51)	5% (2/40)	No Errors	16.67% (4/24)
Post-Training	S1	3.33% (3/90)	No Errors	No Errors	No Errors	No Errors
	S2	6.45% (4/62)	No Errors	No Errors	No Errors	No Errors
	S3	4% (1/25)	No Errors	No Errors	No Errors	No Errors

This table depicts the percentage of errors committed by S1, S2, and S3 across the five component areas of the Step it UP! Game in each condition and corresponding treatment adherence checklist items

Client Step Count

Figure 2 displays the mean number of steps per min of client participants across all sessions and conditions with S1, S2, and S3. When S1 implemented the Step it UP! Game during baseline, client participants engaged in a consistently high rate of step taking (mean of 81.99 steps per min; range, 79.09–83.53) across three baseline sessions. When S1 moved into training, client participants step counts slightly increased and a consistently high rate of step taking (mean of 95.36 steps per min; range, 94.46–96.26) continued across the five training sessions. After the training was removed and S1 moved into the post-training condition, client participants engaged in a moderate to high rate of step taking with some moderate session to session step count variability (mean of 85.05 steps per min; range, 68.92–102.70) across the nineteen post-training sessions. Baseline probes were collected for S1 and the percentage of client participants that had participation overlap in the treatment session and the baseline probe session (i.e., the percentage of client participants that participated in both sessions on that day) was 75%, 83.33%, 80%, 85.71%, 62.50%, and 50% for sessions 12, 16, 18, 23, 27, and 29, respectively. Client participant step counts collected during baseline probes for S1 showed consistently low step count rates among participants (mean of 8.84 steps per min; range, 3.61–14.05).

Fig. 2.

Mean steps per min of client participants with staff. Note. This figure depicts the mean number of steps per min of client participants across sessions with S1, S2, and S3 in baseline, staff training, and post-training conditions. Follow-up sessions were conducted at 1 week (7 days) and 1 month (32 days for S2 and S3 and 33 days for S1*) following the last post-training session

When S2 implemented the Step it UP! Game during baseline, client participants engaged in a high rate of step taking (mean of 85.83 steps per min; range, 72.26–95.38), with low session to session step count variability across the eight baseline sessions. When S2 moved into training, client participants step counts remained at a similar high level (mean of 88.78 steps per min; range, 80.51–97.51) with low variability across the seven training sessions. Following removal of the training and S2’s transition into the post-training condition, client participants step counts remained at a high level (mean of 86.19 steps per min; range, 73.73–96.33) with low variability across the twelve post-training sessions. Baseline probes were collected for S2 and the percentage of client participants that had participation overlap in the treatment session and the baseline probe session (i.e., the percentage of client participants that participated in both sessions on that day) was 62.50%, 100%, 77.78%, 57.14%, 75%, 50%, and 57% for sessions 11, 15, 18, 21, 24, 28, and 29, respectively. Client participant step counts collected during baseline probes for S2 showed consistently low step count rates among participants (mean of 7.29 steps per min; range, 4.08–19.55).

When S3 implemented the Step it UP! Game during baseline, client participants engaged in a high but variable rate of step taking (mean of 76.83 steps per min; range, 52.45–97.48) across the fifteen baseline sessions. When S3 moved into training, client participants step counts remained at a similarly high level (mean of 88.56 steps per min; range, 77.05–105.57) with slightly less variability as compared to the previous condition across the five training sessions. Following removal of the training and S3’s transition into the post-training condition, client participants step counts remained at a high level (mean of 94.80 steps per min; range, 91.49–101.13) with a slight increase, compared to the previous condition, across the five post-training sessions. Baseline probes were collected for S3 and the percentage of client participants that had participation overlap in the treatment session and the baseline probe session (i.e., the percentage of client participants that participated in both sessions on that day) was 83.33%, 25%, 85.71%, 100%, 66.67%, 100%, 40%, and 57% for sessions 8, 11, 12, 15, 19, 24, 28, and 29, respectively. Client participant step counts collected during baseline probes for S3 showed consistently low step count rates among participants (mean of 10.83 steps per min; range, 2.79–20.68).

Table 4 displays the mean number of steps per min of client participants across researcher-implemented baseline probe sessions and staff-implemented baseline, training, and post-training Step it UP! Game sessions with S1, S2, and S3. Across all staff participants, client participants took a mean of 8.56 (range, 2.39–18.05) steps per min during baseline probes and a mean of 80.55 (range, 67.10–93.82) steps per min during baseline, a mean of 92.85 (range, 73.93–108.98) steps per min during training, and a mean of 88.23 (range, 71.08–102.66) steps per min during post-training sessions. Finally, across all staff participants, client participants took a mean of 80.07 (range, 68.70–106.91) steps per min at the 1-week follow-up and a mean of 94.50 (range, 79–109.94) steps per min at the 1-month follow-up.

Table 4.

Mean steps per min of client participants

Participant	Baseline Probe Sessions (mean steps per min)	Baseline Step it UP! Game Sessions (mean steps per min)	Staff Training Step it UP! Game Sessions (mean steps per min)	Post-Training Step it UP! Game Sessions (mean steps per min)	1 Week Follow-Up Step it UP! Game (mean steps per min)	1 Month Follow-Up Step it UP! Game (mean steps per min)
P1	7.37	93.82	104.01	102.66	106.91	109.94
P2	3.73	84.02	100.69	94.01	—	104.54
P3	16.69	68.33	81.30	76.17	72.22	94.36
P4	5.27	67.10	73.93	72.48	80.66	—
P5	18.05	87.60	108.98	101.66	—	—
P6	7.16	83.00	97.04	91.85	—	93.33
P7	12.19	77.86	87.87	81.34	72.10	93.04
P8	12.37	72.19	80.59	78.19	72.53	79.00
P9	8.22	85.12	102.45	96.38	—	—
P10	5.50	81.65	89.85	71.08	—	—
P11	2.39	88.34	103.69	98.04	—	—
P12	11.63	85.24	92.70	91.77	87.36	87.29
P13	5.95	78.27	88.93	91.42	68.70	—
P14	3.38	77.05	—	—	—	—
P15	—	78.61	87.83	—	—	—
Mean	8.56	80.55	92.85	88.23	80.07	94.50

This table depicts the mean steps per min of client participants in researcher-implemented baseline probes and staff-implemented baseline, training, and post-training Step it UP! Game sessions

Staff and Client Social Validity Assessment

Table 5 displays the assessment prompts and results of the social validity assessment for staff participants and client participants. Staff participants yielded an average score of 26 (range, 23–30), indicating that they mostly agreed that the Step it UP! Game was socially valid. However, S3 indicated that he disagreed with the prompt, “the training I received helped me to implement the Step it UP! Game with clients,” and S1 and S3 indicated neutral to the prompt, “the Step it UP! Game increased client’s physical activity level.” Client participants rated the Step it UP! Game highly on the social validity assessment (16.77, range: 12–20), indicating that the Step it UP! Game was generally considered relevant, socially significant, and practical by most client participants. Some client participants rated the prompts “the Step it UP! Game increased my physical activity level” (P1, P2, P6, & P9) and “increasing my physical activity level is important” (P1, P6, & P9) as neutral.

Discussion

The purpose of the current study was to evaluate whether staff members could be effectively trained to proficiently implement the Step it UP! Game with adults with disabilities, and to ascertain if a staff-implemented Step it UP! Game could enhance the mean steps per min of adults with disabilities.

Staff Treatment Adherence and Client Physical Activity During the Step it UP! Game

BST, with video modeling, rapidly increased the proficiency of three staff members to implement the Step it UP! Game. After the first training session, staff participants increased correct implementation by 55%, 54%, and 52%, respectively. Staff members S1, S2, and S3 reached the mastery criterion in 5 to 6 sessions, and training took no more than 5 h to complete. Treatment adherence data did not overlap across the study's conditions (i.e., baseline versus training and post-training). The results of the present study provide evidence that staff can be trained to implement the Step it UP! Game following just a few sessions of BST with video modeling. Previous reviews on BST have demonstrated that it can be effectively used with teachers and other professionals to train a wide range of skills and performances (e.g., Kirkpatrick et al., 2019; Slane & Lieberman-Betz, 2021). The findings of the current study serve as an additional demonstration that BST can also be effective in teaching staff to implement the Step it UP! Game. Furthermore, all staff participants maintained fairly high levels of treatment adherence without large decreases in the post-training and follow-up phases. While we did not target generality, the staff participants in our study implemented the Step it UP! Game at different times of the day and with slight variations in groups of participating clients. High treatment adherence across the differing conditions could be an indicator of generality. Future studies should attend to game implementation in novel facilities with varied types of participants and empirically test measures of generality.

The implementation of the Step it UP! Game by staff participants during baseline, training, and post-training conditions resulted in an increase in step counts among client participants. This increase is particularly notable when compared to the conditions without the game (i.e., baseline probes) implemented by the researcher, which reflect the typical levels of physical activity observed in client participants. A step cadence of 100 steps per min is indicative of moderate to vigorous physical activity (Tudor-Locke et al., 2018). Client participants were closer to or met the recommendation of 100 steps per min when staff participants implemented the Step it UP! Game. Further, while the Step it UP! Game sessions only lasted 10 min in duration in the current study, client participants were able to participate in all three Step it UP! Game sessions (one game per staff participant) throughout the day, totaling 30 min per day, four days a week. Future research may consider training staff participants to implement the Step it UP! Game for extended session durations of 30 consecutive min for more efficient utilization of the game and better adherence to the USDHHS recommendation for physical activity.

Two key factors should be considered when planning to implement the Step it UP! Game: the time needed for staff training and the potential impact of reinforcement on the game’s efficacy. First, staff participants in the present study required at least five sessions and an average duration of 4 h 17 min to complete training. This may seem fairly time-consuming in one sense, but not in the sense that one staff member can increase the step counts of all clients concurrently. It is noteworthy that a large portion of their training was delivered via video modeling, which may reduce barriers to BST implementation of the Step it UP! Game as recommended by DiGennaro Reed and Henley (2015). Further, the rehearsal phase in BST was conducted with actual clients, which improves the efficiency of BST because it reduces the amount of time staff spend in training (Smith et al., 2024).

Second, the immediacy of reinforcement delivery following winning the game and the variety of reinforcement options is important. Research has clearly demonstrated that the immediacy of reinforcement is relevant to its potency (e.g., Gentry & Marr, 1980; Lussier et al., 2006), and providing a variety of available reinforcers for winning the game may help account for individual differences in stimuli that may function as reinforcers. In the current study, prizes (which likely functioned as reinforcers) were delivered immediately following winning the game, and a variety of prize options were available for client participants to select from. Possibly, if prizes were not provided, noncontingently provided, or a limited selection of prizes was offered for winning the game, its effectiveness could have decreased.

Limitations of the Study

Five important limitations merit mention. First, the baseline probe step counts remained low throughout the study, indicating that the Step it UP! Game did not appear to have an impact on client participant engagement in physical activity outside the game. However, this finding is not surprising as it is consistent with previous research, which has exemplified that when behavioral interventions targeting increasing physical activity are removed, the effects are lost almost immediately (Barte et al., 2010). Future research could evaluate if long-lasting benefits can be achieved by offering regular access to the Step it UP! Game in schools, special education classrooms, and other relevant service settings.

A second limitation is the feedback system, which may have contributed to low social validity ratings from staff and clients. Baseline probe data were not shared with staff or client participants during the study, leaving them unaware of clients’ sedentary behavior outside of the Step it UP! Game sessions. It is vital to communicate feedback on client step counts during sessions without programmed physical activity contingencies (i.e., baseline probes) to both staff and clients, allowing them to see step count changes between baseline probes and game sessions. Additionally, baseline treatment adherence scores were not shared with staff participants, and they received no feedback on checklist items, which we suspect may have contributed to low social validity ratings regarding the training’s helpfulness in increasing the implementation of the Step it UP! Game. Baseline treatment adherence scores should be provided to staff participants before training to help them recognize their improvements in implementing the game before and after receiving training.

Third, the findings of the current study are limited because the participating staff may not be representative of the paraprofessionals, teachers, and direct care workers who are part of the target audience for implementing the Step it UP! Game in various service settings. Our staff participants were three university students who differed from the target audience in terms of education level, practical experience, workload, and clinical responsibilities. Future studies should aim to determine if the Step it UP! Game can be taught to teachers, paraprofessionals, and direct care workers who work in various settings with a broad range of clients.

Fourth, the use of consumable reinforcers (i.e., gift cards, toys, and candies), Fitbits, and edible reinforcers may be viewed as a limitation of the current study because not all schools and service agencies will have the resources to offer consumable prizes and purchase necessary devices. Further, sweet edibles may be considered counterintuitive to the health and wellness goals of the current study. Future studies should aim to evaluate a variety of other reinforcement stimuli that may maintain desired physical activity levels during the Step it UP! Game.

Fifth, the researcher-constructed social validity questionnaires may be considered a limitation of the current study because the questionnaire was custom-made for use in the current study and is not a standardized tool for evaluating the acceptability of the Step it UP! Game intervention among staff or adults with disabilities. Further, because a researcher was present while staff and client participants completed social validity questionnaires and responses were identifiable to the respondent (i.e., staff and clients wrote their name on their questionnaires) it is possible that some reactivity and biased responding may have resulted. Future research should aim to identify methods to mitigate reactivity and biased responding by collecting social validity responses anonymously and having someone who is not the researcher collect social validity responses.

Author Contribution

Both authors contributed to the study’s conception and design. The first draft of the manuscript was written by Rebecca Seward and both authors commented on previous versions of the manuscript. Both authors read and approved the final manuscript.

Data Availability

Data will be made available by the first author upon reasonable request.

Declarations

Ethics Approval

The current study was approved by the Southern Illinois University Carbondale Institutional Review Board.

Conflict of Interest

Rebecca Seward held an administrative graduate assistantship at the Evaluation and Developmental Center during the study; however, this research was conducted separately from that role. Ryan Redner has no conflicts of interest to declare.