Using an Implementation Research Framework to Identify Facilitators and Barriers to Physical Activity and Weight Loss in Appalachia

Abstract

Objectives:

West Virginia (WV) is the only state entirely located in Appalachia, a large, mostly rural area in the eastern United States. WV has the highest adult obesity rate in the United States, as well as one of the highest physical inactivity rates. Obesity has been found to be significantly higher in rural counties than in urban counties, and many rural communities do not have the resources to address this growing health concern. It is well documented that healthy eating and becoming more physically active can be successful in reducing weight and managing obesity-related illness. Despite this overwhelming evidence, obesity rates in WV continue to climb. The purpose of this study was to understand the factors associated with obesity in WV and identify what influences the behavior of people in regard to weight loss and exercise.

Methods:

Four focus groups were conducted across the state of WV, transcribed, and thematically analyzed to examine the facilitators and barriers associated with healthy behaviors. The Consolidated Framework for Implementation Research (CFIR) was used as an approach to classify characteristics and plan implementation strategies integrating five domains. The CFIR has been used to identify potential barriers and facilitators to interventions and can be used before or during an intervention. In addition, the CFIR has been used as a framework to guide analysis and provide a means to organize intervention stakeholders’ perceptions of barriers and facilitators to successful interventions.

Results:

Participants identified barriers and facilitators across all 5 major domains of the CFIR—intervention characteristics, outer setting (eg, cultural norms, infrastructure), inner setting (eg, access to knowledge), characteristics of individuals, and the implementation process—and 16 subdomains. Participants discussed how socioeconomic, cultural, and environmental factors influenced diet and exercise. Cost, family culture, and limited access to resources (eg, healthy foods, community-based fitness programs, health care) were common themes expressed by participants.

Conclusions:

The results of this study identify how individuals living in rural Appalachian view lifestyle changes and what influences their ability to pursue physical activity and healthy eating. Future programs to encourage healthy lifestyles in Appalachia need to consider the characteristics of the given community to achieve the goal of a tailored lifestyle intervention program that is feasible and effective. In addition, the findings suggest that the CFIR can be used to implement and refine intervention strategies that can be used in the real world.

The Centers for Disease Control and Prevention reports that ~39.8% of US adults are obese,¹ meaning they have a body mass index of >30. Obesity has been linked to many health conditions, including stroke, heart disease, and type 2 diabetes mellitus.² It is reported that nearly 117 million American adult individuals have at least 1 chronic disease related to obesity and physical inactivity.³ Along with the serious health consequences of obesity, there is a significant economic cost estimated at $190 billion annually related to obesity-related illness.⁴ As of 2020, the state with the second-highest rate of adults with obesity in the United States is West Virginia (WV), 39.1%.⁵ The rate of obesity is higher in rural areas than in urban areas.^6,7 This has been found to be associated with lower physical inactivity, increased intake of sugar-sweetened beverages,⁸ and barriers to medical care.⁹ In addition, WV has the highest rate of cardiovascular disease (14.6%) in the nation, and 1 in 10 WV adults has diabetes mellitus.¹⁰ It is well documented that healthy eating and becoming more physically active can be successful in reducing weight and managing obesity-related illness.^1,2

Implementation research explores the challenges faced when implementing research findings in the real world. Damschroder et al combined 19 published implementation theories into the Consolidated Framework for Implementation Research (CFIR).¹¹ The CFIR has been used to identify potential barriers and facilitators to interventions and can be used before or during an intervention. In addition, the CFIR has been used as a framework to guide analysis and provide a means to organize intervention stakeholders’ perceptions of barriers and facilitators to successful interventions.^12,13 In previous research, the CFIR has been used to assess characteristics as a guide to constructing more effective health initiatives.¹⁴ The CFIR is particularly useful when used in combination with participatory research methods in culturally unique communities. WV is the only state entirely in the area commonly referred to as Appalachia, which is characterized by disproportionate healthcare disparities as compared to the rest of the nation.¹⁵ The purpose of this study was to identify the barriers and facilitators that may influence healthy eating, physical activity, and weight loss in an Appalachian population.

Methods

Study Design

The study used open-ended, semistructured focus groups with a convenience sample of health practitioners, clinic staff, and community members in the West Virginia Practice-Based Research Network (WVPBRN). The open-ended question interview guide was developed by two members of the research team (C.L.S. and T.H.) to elicit a range of responses about physical activity and healthy eating in their community.

Health practitioners were recruited through the WVPBRN. The WVPBRN is a group of practice sites linked together to answer clinical questions in primary care clinics.¹⁶ Each practice site taking part in the study was asked to recruit two clinic staff and five community members. Practice sites were provided a flyer for participant recruitment. Patient participants were compensated with $25 gift cards. Participating practice sites were compensated $1500 for the use of their space and time for recruitment. Focus groups were held at four WVPBRN practices across WV. All participants were older than 18 years. Community members had an elevated body mass index, and were either patients at the clinic or worked as healthcare providers in the clinic.

Data Collection and Processing

The focus groups were conducted in four 2-hour sessions at the local clinical practice site. The focus groups were audio-recorded and later transcribed verbatim. Transcribed data were uploaded into the NVivo qualitative data analysis software (QSR International, Doncaster, Australia).

Primary Data Analysis

All of the transcripts were printed and read repeatedly to encourage familiarity with the content. We used an a priori set of codes in the thematic analysis. To strengthen the reliability of the results, three researchers coded the transcripts independently before comparing codes and assigning labels. Segments of the text were labeled with codes related in the margins using an open coding process, and codes were clustered into categories based on themes in the data. Categories were subsequently mapped to common codes using the comprehensive taxonomy of constructs in the CFIR in the NVivo program. This study was approved by the West Virginia University institutional review board protocol.

Results

Intervention Characteristics

Evidence Strength and Quality

Evidence strength and quality is defined as the “stakeholders’ perceptions of the quality and validity of evidence supporting the belief that the intervention will have desired outcomes.”¹⁷ In this study, participants acknowledged that weight was associated with other medical problems, and that improving weight could improve those problems. For example, “I’ve tried to do more exercise and improve that blood pressure and I’ve seen improvements when I do it consistently.”

Complexity

Complexity is defined as the “perceived difficulty of the intervention, reflected by duration, scope, radicalness, disruptiveness, centrality, and intricacy and number of steps required to implement.”¹⁷ Interventions targeted at obesity were acknowledged to be complex because of a wide variety of personal, societal, and environmental impediments to lifestyle changes. Statements categorized in this subdomain included, “And they [host of lunch outside of the home] were feeding us for lunch, and what they would feed us for lunch it was, like, it was like pizza every day… It was not at all good.”

Cost

Cost is defined as the “costs of the intervention and costs associated with implementing the intervention including investment, supply, and opportunity costs.”¹⁷ Many participants described their experiences associated with cost, particularly of healthy food, for example, “I see a lot of people that just cannot even… afford groceries, so they go to Roger & Crits store and you can get little baby cakes for a dollar a box.”

Outer Setting

Patient Needs and Resources

Patient needs and resources are defined as the “extent to which patient needs, as well as barriers and facilitators to meet those needs, are accurately known and prioritized by the organization.”¹⁷ Participants addressed the needs and resources in their local community by describing local resources for activity and healthy eating: “We’re seeing a big change in healthier lives being available to us as far as like the healthy store up this street in Fairmont Avenue and… a few other places are offering… greener foods.”

Peer Pressure

Peer pressure is defined as “mimetic or competitive pressure to implement an intervention; typically because most or other key peer or competing organizations have already implemented or are in a bid for a competitive edge.”¹⁷ The focus group participants described their experiences with peer pressure, noting that it was perceived generally to be motivated by caring and applied by family members. “I think it’s a, um, a gesture of caring… you can start to motivate somebody appropriately… I know we’re talking about your back pain, or your diabetes today or your cholesterol, but, you know… your weight plays into that. Have you thought about losing weight?”

Inner Setting

Networks and Communications

Networks and communications are defined as the “nature and quality of webs of social networks and the nature and quality of formal and informal communications within an organization.”¹⁷ Existing social networks were reinforced, including the importance of family and patient–physician relationships. The utilization of readily available technology for social support was also noted. One participant explained, “and my first question was, ‘Can I eat meat?’ And she said, ‘Yes, but it has to fit right here [palm of the hand].’”

Culture

Culture is defined as “norms, values, and basic assumptions of a given organization.”¹⁷ Participants from each group explained the cultural factors affecting weight loss, which were primarily an impediment to weight loss, given long-standing cultural norms of food and relationships that may be counterproductive to healthy choices. A participant explained, “No, because there’s too much heritage. I mean, this is what we eat when we’re sad. It’s this day of the week, this is what we eat.”

Implementation Climate

Implementation climate is defined as the “absorptive capacity for change, shared receptivity of involved individuals to an intervention, and the extent to which use of that intervention will be rewarded, supported, and expected within their organization.”¹⁰ Participants expressed support from members of their family and coworkers. Some participants noted reciprocity of their fitness goals in the workplace: “Well, on their 15-minute break they are taking a walk or they’re doing some squats or whatever. You know. They’re working together to do it.”

Tension for Change

Tension for change is defined as “the degree to which stakeholders perceive the current situation as intolerable or needing change.”¹⁷ In regard to weight loss, participants expressed both external and internal motives for making diet and lifestyle changes. Many participants were made aware of their needs to change by family members and close friends. Two participants expressed their tension for change as “it’s my wife for health reasons more than anything else.”

Access to Knowledge and Information

Access to knowledge and information is defined as the “ease of access to digestible information and knowledge about the intervention and how to incorporate it into work tasks.”¹⁷ Participants received education about diet and exercise in their local community. Their knowledge about fitness classes, access to healthy food options, and healthcare opportunities came from friends, family, coworkers, and local physicians. Members expressed their access to knowledge and information by the following quotes: “We have… a little walking path for the hospital so…it’s a quarter of a mile—something to initiate our patients,” and “Then they also have, like, a little…a little gym in the parks and rec center.”

Characteristics of Individuals

Knowledge and Beliefs about the Intervention

Knowledge and beliefs about the intervention are defined as “individuals’ attitudes toward and value placed on the intervention as well as familiarity with facts, truths, and principles related to the intervention.”¹⁷ For this subdomain, participants believed that lower socioeconomic status was associated with fewer opportunities to improve health. Statements include “the economic situation in this state has a lot to do with it.”

Self-Efficacy

Self-efficacy is defined as “individual belief in their own capabilities to execute courses of action to achieve implementation goals.”¹⁷ One participant described their capacity to execute behavioral changes, such as going to the gym, “But that was… the only way that I could myself put the gym into my schedule was before… work. After work I had to pick the kids up and go home and cook dinner, you know, and it was an hour drive home.”

Individual Stage of Change

Individual stage of change is defined as the “characterization of the phase an individual is in, as he or she progresses toward skilled, enthusiastic, and sustained use of the intervention.”¹⁷ Most of the participants were in the process of making healthy choices, but also revealed difficulties in the past maintaining their health. Sustained use of the healthy behaviors also was the result of various health issues. Statements regarding the reasons for change included, “But, yeah, over time…my doctor, um, my blood pressure’s now controlled and I’ve been off of my blood pressure medicine since January.”

Other Personal Attributes

Other personal attributes are defined as “a broad construct to include other personal traits such as tolerance of ambiguity, intellectual ability, motivation, values, competence, capacity, and learning style.”¹⁷ Participants from each focus group attributed their current dietary habits to personal preference, openness to change, and access to health resources. Physical activity was linked to genetic factors or the capacity to incorporate exercise into a daily routine. Statements from this subdomain were expressed as, for example, “If you give me a suggestion, I’ll listen, but the badgering. I don’t do well with that.”

Implementation Process

External Change Agents

External change agents are defined as “individuals who are affiliated with an outside entity who formally influence or facilitate intervention decisions in a desirable direction.”¹⁷ Medical and fitness facilities were considered to be outside entities influencing behavioral changes: “I’ve been to a diet clinic where had a… had a fix. I’ve done workout videos, I’ve spent like $200 on something I’ve seen on some TV show that was supposed to work and give you some stretchy cord that you were supposed to exercise with.”

Executing

Executing is defined as “carrying out or accomplishing the implementation according to plan.”.¹⁷ Many individuals reported implementing behavioral changes regarding weight loss and fitness either by maintaining a fitness regimen, limiting unhealthy foods, or losing weight. One participant reported, “So, he started to make changes, started going to the gym, little by little and, uh, he started watching what he was eating and… and now he works out.”

Discussion

This exploratory study was aimed to partner with stakeholders to identify barriers and facilitators to healthy lifestyle choices in WV. The findings can be used to inform future interventions, guide policy, and future research. Participants in all of the focus groups were open to discussing weight loss strategies and personal struggles relating to healthy lifestyles. Cost was frequently discussed as a barrier to access, as was the price of fresh, healthful food. In addition, cost was a prohibitive factor associated with travel and membership to physical activity resources such as a pool or gym. Some participants discussed how gyms would open or classes such as yoga or Zumba would be organized, but they were not sustainable and eventually closed. Walking was frequently referenced as a preferred choice for exercise, but a lack of sidewalks, proper lighting, or steep hills were seen as environmental barriers to regular physical activity. Also prevalent was the discussion of food as a staple in family customs and cultural events. The participants discussed how “comfort foods” that traditionally contain high fat and carbohydrates are embedded in the customs and culture of WV: “It’s just what we do.”

Translating evidence to practice in the real world requires careful attention to the environment and social constructs that may affect the success of the intervention. Proven strategies for weight loss and healthy eating may be difficult to implement, depending on the unique characteristics of the community. WV is a large, mostly rural state, where lifestyle change and medical resources can vary greatly from county to county. In addition, obesity has been found to be significantly higher in rural counties than in urban counties, and many rural communities do not have the resources to address this growing health concern.¹⁸ Access to healthy and affordable food, distance to health care, and access to exercise facilities is an ongoing challenge to a healthier lifestyle for many rural residents.¹⁹

The results of this study reveal the similarities and differences that exist within WV in regard to cultural influence and local resources. Using the CFIR as a coding framework for the qualitative analysis of the focus group interviews illuminated challenges and successful strategies for healthy living across all five major domains among this population. The use of a priori constructs led to an in-depth, efficient, and methodical analysis of the data to consider personal and societal influences further supporting the use of the CFIR in health research.

The Centers for Disease Control and Prevention recommends a balance of healthy eating and exercise to lose and maintain a healthy weight. Even a modest loss of 5% to 10% of body weight is related to improved health outcomes.²⁰ The suggested healthful foods, such as fresh fruits and vegetables, low-sugar and low-sodium foods, and lean meats, were noted to be frequently unavailable (either by season or distance) or too expensive for the participants, however. People in the focus groups acknowledged that cheaper available foods were prepackaged processed foods and often a less healthy choice. The participants described how difficult it is to eat healthfully with a low income and described limitations of choice, and the lack of available fresh produce.

Based upon the results of this study, further efforts regarding lifestyle intervention and change for weight loss must consider the unique characteristics of the community. This includes the existing social infrastructure. Interventions may require accounting for the wide geographical and social limitations of different counties. The CFIR can be a valuable tool when exploring broad interventions in communities with varying characteristics. For example, Wilcox et al examined the implementation of a statewide faith, activity, and nutrition program.²¹ Their study found differences in the implementation of the program based on the characteristics of the congregations, highlighting the need to consider the inner setting of the church in the implementation process. This finding supports the need to consider the daily behaviors, values, and traditions of the participants when planning or developing an appropriate intervention for people across WV.

A study by Teeters et al used the CFIR in a mixed-method analysis to address organizational readiness for childhood obesity interventions in several states across the United States.²² Social infrastructure was emphasized in the preimplementation process for evaluating community programs. These findings, like our own, suggest that qualitative research may be useful for analyzing the compatibility of priorities between members of the community and community-based programs. In addition, this provides additional evidence that the CFIR can be used to identify facilitators and barriers across multiple levels, which can improve the effectiveness of interventions.

The limitations of this study include the relatively small sample size (20 participants in 4 focus groups) and being conducted in a single rural Appalachian state, which limits generalizability. The practitioner–patient interaction in the stakeholder focus group discussions may have influenced what the community members disclosed about their health choices as the practitioners were their healthcare providers. The focus groups also were facilitated by two different moderators, which could have affected the responses from participants. In addition, there is a possibility that researcher bias could have influenced the interview process as well as the coding process; however, researchers carefully framed questions and considered multiple revisions when interpreting the data to minimize bias. Although this analysis provided rich qualitative data, a future study using a mixed-methods approach on a larger scale may provide a better understanding of existing barriers and challenges for physical activity and dietary choices and hence readiness to adopt a healthy lifestyle among people living in rural WV.

Conclusions

Stakeholder focus groups revealed positive and negative determinants related to diet and exercise in rural Appalachian communities. This study suggests that future interventions aimed at lifestyle changes for rural Appalachians be culturally appropriate and incorporate local resources. The participants were knowledgeable and communicated a willingness to adopt physical activity and healthy eating into their lifestyles. There were, however, barriers in regard to resources, cost, and access to healthful food. Future programs to encourage healthy lifestyles in Appalachia need to consider the characteristics of the given community to achieve the goal of a tailored lifestyle intervention program that is feasible and effective.

Key Points.

• Participants identified barriers and facilitators across all 5 major domains of the Consolidated Framework for Implementation Research—intervention characteristics, outer setting (eg, cultural norms, infrastructure), inner setting (eg, access to knowledge), characteristics of individuals, and the implementation process—and 16 subdomains.

• Future programs to encourage healthy lifestyles in Appalachia need to consider the characteristics of the given community to achieve the goal of a tailored lifestyle intervention program that is feasible and effective.

• The results of this study reveal the similarities and differences that exist within West Virginia in regard to cultural influence and local resources.