Rapid cycle adaptation of a classroom-based intervention to promote equity in access to youth physical activity

Abstract

Our objective was to systematically adapt Interrupting Prolonged sitting with ACTivity (InPACT), a classroom-based physical activity intervention, for home delivery to equitably increase access to structured youth physical activity opportunities during the COVID-19 pandemic. Key steps in the rapid-cycle research adaptation process included: (Step 1) identifying partner organizations; (Steps 2 and 3) engaging in problem and knowledge exploration to examine the problem from different perspectives; (Steps 4 and 5) initiating solution development and testing by selecting an intervention and adapting the format and content for home delivery. Using Rapid RE-AIM to guide online assessment and refinement of InPACT at Home; and (Step 6) utilizing dissemination strategies to extend the reach of the program. Core elements of the InPACT program that were retained included: the use of exercise videos, maintenance of the intervention dose, and teacher-led physical activities. Key adaptations included: utilization of physical education specialists to develop the exercise videos, incorporation of health messaging in videos, and utilization of dissemination strategies (intervention website) to reach K-12 students across the state. Intervention website reach included all 83 counties in Michigan, but goals were not met for website pageviews (5,147; 85% of goal) and video view duration (7 min 19 sec; 37% of goal). Accordingly, dissemination was expanded to include public television broadcasting (monthly viewers: 500,000) and videos were shortened to 8 minutes. Dissemination and implementation science frameworks guided the rapid adaptation of an existing intervention, InPACT, to equitably increase access to structured youth physical activity opportunities at home during the pandemic.

Dissemination and implementation science frameworks guided the rapid adaptation of an evidence-based intervention to promote statewide access to youth physical activity through public television.

Implications.

Practice: Dissemination and implementation science frameworks can be used to guide the rapid adaptation of existing evidence-based interventions to equitably increase access to structured youth physical activity opportunities.

Policy: Policymakers who want to rapidly roll out physical activity programs and practices to address urgent public health issues should explore implementation science frameworks to guide systematic adaptations of existing evidence-based interventions.

Research: Future research should be aimed at balancing a rapid response with sufficient tailoring to enhance equity in program uptake to reach pediatric populations with the lowest reported physical activity participation.

Introduction

In March 2020, the US government declared a national health emergency with most governors issuing shelter-in-place orders to restrict movements of individuals across the nation [1]. These restrictions included closing schools and other gathering places to mitigate virus spread. While these restrictions were successful in flattening the COVID-19 curve during Spring of 2020 many traditional opportunities to engage in physical activity became difficult to access, especially for children [2]. School closures eliminated opportunities to engage in classroom activity breaks as well as physical education, recess, active travel to school programs (e.g., Safe Routes to School), after school physical activity programs, and extracurricular athletic activities [2]. Outside of the school environment, exercise facilities and gyms were closed; parks, beaches and camps were closed; sport activities were suspended, and recommendations were given to children and families to avoid public recreational spaces [2].

These restrictions led to significant declines in youth physical activity during the pre-COVID-19 period (February 2020) and the early-COVID-19 period (April–May 2020) and had a disproportionate impact on ethnic minorities residing in low-resource communities [3, 4]. Youth experiencing disadvantage were more reliant on schools for structured physical activity due to a lack of safe spaces to be active in their own neighborhood [5]. By June 2020, there was an urgent need to provide physical activity opportunities that were responsive to the immediate needs of children and youth to be active in the safety of their own home during the COVID-19 pandemic.

Developing new physical activity interventions de novo, however, is time and resource intensive [6, 7]. Accordingly, adapting interventions with an existing evidence base could be more efficient than developing new interventions when attempting to address time-sensitive public health issues as with the COVID-19 pandemic [8]. Adaptation, from the perspective of dissemination and implementation research, is the degree to which an evidence-based intervention is modified to improve the fit between the intervention, the context, and the population served [9]. This has typically been accomplished primarily through considering race, ethnicity, service setting, location, and organizational characteristics ^{[9, 10]}. These types of adaptations focus on enhancing flexibility to meet population needs while also maintaining fidelity to the core functions of the intervention that make it effective (e.g., fidelity consistent adaptations) [10].

The field of implementation science has made notable progress in developing theories and frameworks to guide such adaptations ^[7,9,10], but there is an urgent need to make this process more rapid and iterative to achieve public health impact [11]. Most adaptation frameworks propose thorough but lengthy steps to adapt evidence-based programs and practices that are unlikely to meet the timeline and needs of decision-makers and stakeholders when faced with time-sensitive decisions [7, 8]. Stakeholders and practitioners must make rapid decisions about programs and practices to adopt as public health issues, such as physical inactivity during the pandemic, are emerging [12]. Thus, the application of adaptation frameworks to support rapid and systematic adaptations is urgently needed.

Few researchers have applied dissemination and implementation frameworks to systematically adapt physical activity interventions to enhance equity and even fewer have used these frameworks to rapidly respond to changes in youth physical activity during public health crises such as the COVID-19 pandemic [13]. The overarching objective of the current project was to systematically adapt InPACT for the home environment to enable K-12 students to safely engage in physical activity during school closures. InPACT at Home development was guided by principles of rapid-cycle research and rapid RE-AIM [14, 15].

Rapid-cycle research is especially well-suited for quickly adapting interventions to achieve public health impact as it provides a systematic process by which research teams identify urgent problems and address them using practice-based evidence [11, 12, 16, 17]. This process occurs across multiple phases to help research teams accelerate the research cycle from concept development to implementation in practice. This process also enables researchers to proactively identify and address challenges that may impede health equity [18]. RE-AIM is a planning and evaluation framework that has been recently applied to guide adaptations in response to changing contexts and emerging information [14]. The iterative rapid RE-AIM process assesses the importance of, and progress on, each RE-AIM dimension (i.e., reach, effectiveness, adoption, implementation, and maintenance) to inform and guide midcourse adjustments to intervention and implementation strategies, specifically during the solution testing phase of rapid-cycle research. Both the rapid-cycle research and rapid RE-AIM implementation frameworks have helped to accelerate intervention adaptation; however, neither framework has been used to adapt school-based physical activity interventions for implementation in the home.

The current paper: (a) describes key steps in the rapid, systematic adaptation of InPACT to disseminate InPACT at Home and increase access to health-enhancing physical activity during the COVID-19 pandemic, (b) presents the initial dissemination evaluation results for InPACT at Home during three months of delivery, and (c) discusses how the initial dissemination evaluation was used to inform further refinement of dissemination strategies to increase the reach of the intervention to homes across the state of Michigan.

Method

The state of Michigan was selected for InPACT at Home dissemination because of the high rates of obesity, inactivity, and poverty reported in this state, prior to the pandemic. According to the National Survey of Children’s Health, 16.2% of Michigan youth ages 10–17 were classified as obese in 2020, giving Michigan a ranking of 23 among the 50 states and DC [19]. Data from the Youth Risk Behavior Surveillance System suggest 76% of Michigan high school students had low physical education participation and only 22% of students were physically active at least 60 min/day [19]. Approximately 46% of school age children were eligible for free/reduced-price lunch, with 14% of children classified as food insecure. The state of Michigan also has limited physical activity policies in place as the state does not require elementary or middle school students to participate in physical education, nor does it have statutes or regulations on Safe Routes to School. The state did however adopt a complete streets policy in 2010 [19].

Rapid adaptation of the InPACT at Home program

The Vice President of the Michigan State Board of Education contacted the principal investigator of the InPACT intervention during the early COVID-19 period (May 2020). This discussion was centered on equitably increasing physical activity opportunities for youth across the state while families were sheltering-in-place. The principal investigator agreed and subsequently assembled an interdisciplinary team of behavioral interventionists, school district consultants, state legislators, professional sports teams, regional school health coordinators, community outreach specialists, and implementation scientists at two universities. These individuals and organizations were selected based on their expertise in school- and community-based interventions, health disparities, clinical psychology, social-emotional health, physical activity promotion, and child development from disciplines including kinesiology, public health, and education. The principal investigator and/or Vice President contacted each member via email or telephone to confirm their involvement as part of the adaptation team.

Diversity in demographics and social experiences of both the coalition members and researchers was prioritized to ensure differing perspectives were considered throughout the planning and adaptation process. Approximately 29% of coalition members were African American (71% white) and 42% female (58% male); 50% of researchers were African American (50% white) and 100% were female (0% male). White and black races represent the two largest racial groups in Michigan. Throughout the adaptation and dissemination process, the partner coalition worked in close collaboration with Michigan’s State Superintendent of Public Instruction and Vice President of the Michigan School Board of Education. Administrative support was key for the successful adaptation and dissemination of InPACT at Home [20].

Each of the six steps of rapid-cycle research and their associated activities are described in Table 1. These steps were based on the Framework for Rapid-Cycle Research developed by the Agency for Healthcare Research and Quality [15]. The framework outlines six phases of the adaptation/research process, from conceptualization through implementation, and provides resources to accelerate both the research and intervention adoption timeframes.

Table 1.

Key rapid cycle steps to adapt the InPACT program for dissemination in the home

Rapid cycle steps	Description	InPACT at Home
Preparation	Identify partner organizations and individuals within those partners who will champion the program	MEMSPA, MiSCHA, SHAPE Michigan, Detroit Lions, Detroit Pistons, MPHI, MDE, Playworks Michigan, KWWF
Problem exploration	Understanding problems that are important to solve	Lack of PA opportunities with school closures: sports, PE, recess, safe routes to school, before/after school programming
	Dialogue = “understanding of the problem based on sharing different perspectives”	Engaged partners individually and in a group using a dialogic approach to communication to discuss PA/PE issues with program partners and PE teachers
Knowledge exploration	Explores the problem from different perspectives
	Step 1. Characterize the problem	Ineffective delivery of PA/PE programming
	Step 2. Identify other industries that face the same problem	Hosted a community forum to investigate how industries were handling this problem
	Step 3. Identify organizations in those industries that have best address the problem	Fitness industry/Playworks/PE teachers- developing videos
	Step 4. Identify the process or activities that differentiate the best organizations from others by how they addressed the problem- what makes them better	Social distance in person, cancelling of programs, live video conferencing activities vs developing videos that could be watched asynchronously
Solution development	Identifies the simplest possible solutions that can be applied. Simplest, least invasive, most scalable solution	Logic model and adaptation of InPACT
Solution testing	Process for determining if the identified solutions work/ project team members were asked to assess the importance of and progress on each RE-AIM dimension at the current phase of their project. Based on these ratings, each team identified one or two RE-AIM dimensions for focused attention. Teams developed proximal goals and implementation strategies to improve progress on their selected dimension(s). RE-AIM reiterative process.	RE-AIM (reach, efficacy, adoption, implementation, maintenance); data quality and website launch July 6-january 4; how important is each dimension to this project currently? and (b) how is the project doing on each dimension to date?
Dissemination	Final steps	Partnership with DPTV broadcast reach data

MEMSPA, Michigan Elementary and Middle School Principals Association; MiSCHA, Michigan School Health Coordinators Association; SHAPE Michigan, Society of Health and Physical Educators; MPHI, Michigan Public Health Institute, MDE, Michigan Department of Education, KWWF, Karen Weaver Water Foundation; PA, physical activity; PE, physical education; RE-AIM, Reach, Effectiveness, Adoption, Implementation, Maintenance; InPACT, Interrupting Prolonged sitting with ACTivity.

Step 1: Preparation—identifying partner organizations

During the preparation phase, a list of organizations across the state whose primary aim was to promote youth physical activity, fitness, physical education, or sport was created to ensure widespread support for the development and dissemination of the InPACT at Home program. From that list, nine organizations were approached and agreed to form a pediatric physical activity dissemination task force. Within each organization, a point of contact was identified to champion the program and attend task force meetings. In collaboration with the research team, the coalition worked to develop a clear timeframe and objectives to improve the probability of increased uptake of the InPACT at Home program across the state. Because of increased urgency related to the spread of the pandemic and evolving student health issues, a shortened time frame (i.e., 2 months) for program adaptation and launch was selected. Potential opponents of the program were also identified both within and outside of the school system and discussions were scheduled to gain an understanding of their perspectives and develop a plan to address their concerns.

Step 2: Problem exploration—understanding the problems that were important to solve.

During the problem exploration phase, the research team engaged key stakeholders (i.e., physical education teachers and coalition members) to identify problems related to promoting youth physical activity during the COVID-19 pandemic. Specifically, physical education teachers participated in group meetings to discuss issues related to promoting school-based physical activity programming in a virtual environment. Coalition members were engaged in one-on-one and group sessions to discuss issues related to statewide restrictions limiting access to community recreational facilities and programs during the early COVID-19 pandemic period. The research team used a dialogic approach to communication (e.g., suspension of judgment, respect for differences of opinion, intentional listening, and giving voice to different perspectives) to facilitate these discussions via video conferencing with the goal of achieving shared understanding and common purpose among stakeholders. This process was also used to engage key stakeholders and coalition members in the problem-solving process.

Like other health outcomes during the pandemic, experts early on indicated that there would be notable disparities in the availability of physical activity opportunities among children and youth [2, 21]. Thus, a member of the research team also worked with health disparities researchers from across the country through the American College of Sports Medicine to conduct a review of the available scientific literature on the impact of COVID-19 on physical activity behaviors, health disparities, and health equity [2]. This review of literature broadened the research teams’ perspective of the national problem of physical inactivity during the pandemic. These data were used in combination with responses collected from key stakeholders in Michigan to provide a comprehensive understanding of the problem of promoting physical activity during the COVID-19 pandemic.

Step 3: Knowledge exploration—exploring the problem from different perspectives

During the knowledge exploration phase, the research team explored alternative solutions to solving the problem of promoting physical activity during the COVID-19 pandemic from different perspectives. Using the information gathered from Step 2 (problem exploration), the research team engaged other industries (e.g., fitness industry, nonprofit organizations, and youth sports programs) that were facing similar challenges to identify creative solutions to promoting youth physical activity during the pandemic. The research team hosted a community forum where industry representatives, parents, teachers, school administrators, and community members were invited to attend and participate in the conversation [22]. During the forum there were two panel discussions with a live audience question-and-answer period. The first panel discussion covered the topic of what had been done about the problem of children having fewer structured physical activity opportunities during the pandemic and included the following panelists: the Community Ambassador for the Detroit Pistons, the program director for Playworks Michigan, an elementary physical education teacher/varsity girls’ basketball coach, and a mother of four children (ages 6–14). The second panel discussion included school administrators and legislators to discuss the statewide plan to promote youth physical activity moving forward. Panelists included a Michigan Department of Education consultant, the Whole Child Program Director for Saginaw Intermediate School District, the former Mayor of Flint, Michigan, and the Vice President of the Michigan State Board of Education. There were 231 registrants for the community forum, which was hosted by the research team. Immediately following the forum, the research team along with the partner coalition identified the activities and processes that differentiated the best organizations from others in how they were continuing or discontinuing their youth physical activity programming.

Step 4: Solution development—identifying the simplest possible solution to be applied.

During the solution development phase, the research team selected InPACT, a classroom-based physical activity intervention to systematically adapt for implementation in the home [23, 24]. InPACT was selected because of its use of exercise videos to deliver activity breaks in the classroom and the existence of a program guide that identified adaptable elements (i.e., forms) and core functions (i.e., foundations) of the intervention. The core functions that needed to be retained to ensure effectiveness included: the use of exercise videos, maintenance of the intervention dose, and the requirement that activities were instructor-led. These core functions were the foundational elements for enhancing children’s classroom physical activity, on-task behavior, physical activity enjoyment, and goal achievement [23, 24]. Adaptable elements (i.e., forms) of the intervention included: the type of instructor leading the activity break, type of exercises and health messages included in video content, the type of dissemination strategies employed to disseminate the intervention, and the age of the target audience. After identifying InPACT as the intervention to adapt, research staff developed a description of the inputs, outputs and expected outcomes, which were summarized in a logic model (see Figure 2). After identification of those elements, an adaptation plan was developed to create the InPACT at Home program.

Figure 2.

Logic model for the InPACT at Home program. MEMSPA, Michigan Elementary and Middle School Principals Association; MiSCHA, Michigan School Health Coordinators Association; SHAPE Michigan, Society of Health and Physical Educators; MPHI, Michigan Public Health Institute, UM, University of Michigan; PA, physical activity; PE, physical education; LEP, Limited English Proficiency; SE, social-emotional.

Step 5: Solution testing—develop a process for determining if the identified solutions work.

Consistent with rapid-cycle research, the RE-AIM framework was applied during the solution testing phase. The research team and coalition partners assessed the importance of each RE-AIM dimension prior to the initial program launch. Dimensions included: (1) reach: the number, proportion, representativeness of children reached; (2) effectiveness: the ability of InPACT at Home to increase physical activity participation; (3) adoption: development of institutional support to disseminate InPACT at Home; (4) implementation: ensuring the InPACT at Home program was delivered properly; and (5) maintenance: sustainment of the program. The research team and coalition partners collectively identified one RE-AIM dimension, reach, for focused attention and developed proximal goals and dissemination strategies to improve progress on the selected dimension over the next 3 months. Key performance indicators for InPACT at Home included: (1) program reach would include all 83 counties in Michigan; (2) the program website would record 6,000 pageviews (2,000 visitors per month is considered strong website page views); (3) average time on InPACT at Home webpage would equal 2–3 min; and (4) duration of video views on the study Vimeo channel would be 20 min. These goals were developed from previous research on website traffic and average website session duration conducted by Databox, Inc [25].

Step 6: Dissemination and evaluation.

The InPACT at Home program website was launched on July 6, 2020. The launch coincided with press releases from the host university and was advertised through social media channels, radio, television, and print media. The reach of the program website and video views from the program Vimeo channel was documented for 3 months using Google Analytics. Measuring website traffic and analyzing user navigation are common procedures for any website provider [26]. The monitored items can vary from simple statistics (“How many individuals visited the InPACT at Home website per day?”) to complex and comprehensive analyses of the navigation behavior of website visitors (“Which regions of the state are watching the exercise videos and for how long?”). That information was collected using page tagging, a commonly used method of placing an identification tag in one or more web pages of the website. When a web page was used the page identifying tag and information about the visitor was sent to Google Analytics that collected the information for later analysis. Google Analytics is used by approximately 80% of the commonly used websites that use traffic analysis tools [27], and researchers have previously published articles on the utility of Google Analytics as a web analytics tool [28]. That initial dissemination evaluation was used to further refine dissemination strategies to increase the reach of the program to homes across the state of Michigan where low program reach was reported.

Results

Preparation

The organizations that agreed to participate in the partner coalition included: Michigan Department of Education, Michigan Elementary and Middle School Principals Association, Michigan School Health Coordinators Association, Michigan Society for Health and Physical Educators, Michigan Public Health Institute, Playworks Michigan, Detroit Lions Football Education Program, Detroit Pistons, and the Karen Weaver Water Foundation. Coalition members attended regular meetings in the three months prior to program launch and agreed to disseminate the program and pursue funding opportunities to support dissemination.

Problem and knowledge exploration

Insights from the community forum along with communications with the partner coalition, PE teachers, and the community informed the problem and knowledge exploration phases of InPACT at Home adaptation. The problem was characterized as: disrupted delivery of physical activity and physical education programming during the COVID-19 pandemic. Feedback from fitness industries, nonprofit organizations (e.g., Playworks Michigan), and PE teachers noted that they were developing exercise videos at home and in their gyms that could be viewed asynchronously to promote physical activity during the pandemic. Youth sports organizations were either hosting socially distanced in-person programming, canceling programs, or implementing live video conferencing activities, with inconsistent deployment and levels of success in reaching youth. Collectively, the research staff and coalition partners determined that developing videos that could be watched asynchronously had the largest potential for success with the broadest reach.

Solution development

The research team developed a strategy to make systematic adaptations to InPACT to enhance its responsiveness during teaching/learning in the pandemic. This included developing new exercise videos, reviewing evidence-based approaches to addressing new topic areas (i.e., mental health), incorporating content and related activities informed by the Collaborative to Advance Social and Emotional Learning (CASEL) framework [29], developing new program components, and adapting activities as needed to enhance adherence in the home environment.

PE teachers, fitness professionals, pediatric exercise physiologists, athletes, and high school students from across the state were targeted and hired to develop exercise videos that were developmentally appropriate and could be completed at home with no or minimal equipment. The exercise protocol that was used to develop the 20-minute videos included: 1–2-minute warm-up, 18 min of circuit activities, and 1–2-minute cool-down. The types of exercises included were aerobic, isometric strength training, motor skills, sports skills, yoga poses, and mindfulness training (see Fig. 1). Prior to video development, all video developers received InPACT at Home training from the research team, which consisted of a one-hour workshop to familiarize the video developers with the program goals, content, video scripts, online video guidelines, and best practices. Guidelines and practices were adapted from the Centers for Disease Control and Prevention Online Video Guidelines and Best Practices [30]. Video developers were provided with written instructions of information presented at the workshop.

Figure 1.

Exercise videos developed and broadcast on public television.

Solution testing

Program reach included all 83 cities across the state of Michigan, 35 states across the United States, and 25 countries across the globe. InPACT at Home website page views totaled 5,147 (goal was 6,000) with average time on the program webpage being 2 min and 45 s (goal between 2 and 3 min). The average duration of video views on the Vimeo study site was 7 min and 19 s (goal was 20 min). In examining which regions of the state were visiting the study website and accessing the exercise videos, it was determined that the eastern, western, and southern regions of the state recorded higher usage compared to the northern (rural) regions of the state.

Implementation and dissemination

To increase equity in the program’s reach, the research team acquired funding from the Michigan Department of Health and Human Services and the Michigan Public Health Institute through the Coronavirus Task Force Rapid Relief Initiative. The ability to quickly obtain funding demonstrated the strength of the partner coalition. This funding resulted in a new partnership with public television to develop additional exercise videos to be broadcast across the state. Because the homemade videos were not produced in the studio and were not developed with television quality technology, new videos were created in the studio. Creating new videos also provided a new opportunity to reduce the video length to 8 min, which aligned with the duration of video views on the program Vimeo channel. These new exercise videos were broadcast on the newly launched Michigan Learning Channel, which broadcasts free programming via special on-air channels established by each of the participating public television stations in Michigan. Programming was also available as a livestream and stored for on-demand viewing on a variety of digital platforms, ensuring accessibility to all students, teachers, and families across the state. One hundred and thirty videos were developed in the studio and began airing on January 6, 2021. As of June 1, 2021, data from the Nielsen television ratings noted the Michigan Learning Channel reached an estimated 15,000–20,000 daily broadcast viewers statewide (approximately 500,000 monthly viewers). The Michigan Learning Channel also featured InPACT at Home on social media (reach: 23,261 individuals, with 476 engagements) and featured the program in four issues of their education newsletter (reach: 4,720 readers).

To supplement the exercise videos, physical activity playing cards and family engagement toolkits were also developed to provide another opportunity for children and families to move and play together. A childhood obesity prevention coordinator from an out-of-state public health department was hired to develop movement-based social-emotional play cards that included cardio, strength, mindfulness, flexibility, and “with a buddy” activities that served as a supplement to the exercise videos. Activity playing cards were uploaded to the program website and made available for download. School psychologists, regional health coordinators, and classroom teachers from within the state were hired to develop seven family engagement toolkits that focused on the following topics: resilience, feeling good, focus, nutrition, sleep, family team building, and family discussion. One module was posted on the program website each month for seven months, starting with the resilience module. Each module also included a 20-day challenge that incorporated movement activities.

Discussion

With school closures and shelter-in-place orders restricting movements of individuals across the nation during the COVID-19 pandemic, the home became the epicenter of school and family life. And with the absence of physical activity opportunities outside the home, the broad array of screen-time activities available in the home made sedentary behaviors even more prevalent during the pandemic [3]. Dunton and colleagues noted that children engaged in about 90 min of school-related sitting and over 8 h of leisure-related sitting a day [3]. Adapting a classroom-based physical activity program guided by implementation science frameworks was a promising approach to improving equitable access to health-enhancing physical activities and achieving public health impact. The current project was an important step in accelerating research to practice, promoting physical activity among youth and providing an example of how dissemination and implementation frameworks can be applied to systematically guide rapid adaptation of a physical activity intervention to address urgent and emerging health issues.

It is important to note that during the first 6 months of intervention development and adaptation, this was an unfunded project. As such, resources were not available to complete all necessary components of the program (e.g., efficacy and effectiveness testing, cultural tailoring) prior to initial dissemination. Nevertheless, we strove to use inclusive principles of universal design in the development of exercise videos and include as much diversity and representation in the educators showcased in the videos that were posted on our website and broadcast on public television.

Working collaboratively with state legislators, school administrators, fitness and sport organizations, and K-12 teachers across the state of Michigan, the InPACT at Home program was developed using key steps in the rapid-cycle research and RE-AIM implementation science frameworks. Steps included: identifying partner organizations (Step 1) dedicated to improving the health and well-being of Michigan children and families through physical activity; engaging in problem and knowledge exploration (Steps 2 and 3) to examine the problem of youth physical inactivity during the pandemic from different perspectives; initiating solution development and testing (Steps 4 and 5) by selecting an intervention and adapting the format and content for home delivery; and utilizing dissemination strategies (Step 6) to extend the reach of the program. It is important to note that some of the steps in the adaptation process were integrated and overlapping. Each step in the adaptation process was critical, however, to systematically guide the rapid adaptation of InPACT to create the InPACT at Home program.

A key component of adapting the InPACT intervention included partnering with physical education specialists, fitness professionals, athletes, and pediatric exercise physiologists to develop exercise videos for the program. Those individuals were considered “physically educated” persons as they (1) had learned skills necessary to perform a variety of physical activities, (2) were physically fit, (3) participated regularly in physical activity, (4) were knowledgeable in the implications of and the benefits from involvement in physical activities, and (5) valued physical activity and its contribution to a healthful lifestyle [31]. PE teachers also had the competencies and training to teach basic movement skills, plan activities that help make exercise-based learning more engaging for students, create a noncompetitive environment, and provide a variety of activities to promote lifelong physical activity participation. Because athletes (both professional and amateur) are viewed as role models for health [32], and high school students can motivate their peers and younger children to be more active through peer support, both groups were also featured in exercise videos. By utilizing the expertise and role models in the field of youth physical activity the risk of injury associated with engaging in unsupervised physical activity at home was reduced and child motivation to participate in the program may have increased.

Another adaptation related to the dissemination strategies employed. The first information channel used to disseminate the InPACT at Home program was via a program website, which recorded participant engagement from all 83 counties across the state of Michigan. Nonetheless, viewership and engagement did not meet expectation with pageviews only reaching 85% of goal. When examining which regions of the state were visiting the study website and accessing the exercise videos, it was determined that the eastern, western, and southern regions of the state recorded higher usage of the program compared to the northern (rural) regions of the state. This pattern mirrored internet access across the state. Approximately 12% of Michigan youth do not have internet at home with internet access by county ranging between 65% and 95%; internet access is lowest in rural (predominantly white) areas. This lack of internet access likely played a role in the lower-than expected usage.

Lower than expected website engagement was also reported with video view duration only reaching 37% of goal. This underperformance could be the result of the lack of parent educational materials available at the onset of the program, prior to funding. Of the few previously implemented home-based physical activity interventions a key intervention strategy was to target parental education. Other studies have suggested that educational strategies should be combined with other intervention approaches such as goal setting to be successful at improving physical activity in the home [33]. Because of the inequities in internet access across the state and previous research supporting the use of educational materials and goal setting, we pivoted our dissemination strategies to include public television broadcasting and the development of family engagement toolkits. As such, the dissemination strategy was refined to include broadcast on public television.

While television is the most expensive dissemination strategy compared to other forms of media, public television broadcasting reaches 98% of households with televisions [34]. It is also considered the dominant leisure activity, with the average household viewing television almost four hours a day [35]. Previous research suggests African Americans and individuals experiencing socioeconomic disadvantage report viewing more television and engaging in less exercise compared to their non-Hispanic white and more affluent counterparts [36, 37]. By broadcasting the InPACT at Home program on public television, we were able to provide access to youth physical activity opportunities to all demographic groups across the state, including those with the lowest reported physical activity participation prior to the COVID-19 pandemic [38].

The third adaptation was developing family engagement toolkits and movement-based social-emotional play cards to help children and their parents enjoy being active together and develop effective coping strategies to deal with stressors related to the pandemic. The common theme of each toolkit highlighted the benefits of regular engagement in physical activity and complimented the exercise videos. Both the toolkits and play cards included physical activities designed to improve psychological mood and well-being [39–41]. Because pandemic-related stressors were exacerbated in socioeconomically disadvantaged communities of color [2], providing these resources at no cost was a key adaptation of the program designed to meet the diverse needs of children and families during the pandemic. Additional testing is needed, however, to confirm the effectiveness of the program to improve child and adolescent health.

Lessons learned

It is important to note that there were several challenges identified during the first iteration of program adaptation. The research team and partner coalition demonstrated success in disseminating the InPACT at Home program by providing access to exercise videos to children across the state of Michigan during the COVID-19 pandemic. While videos included modifications to accommodate different fitness levels, there was insufficient tailoring of videos to meet the needs of all students, particularly those with physical and cognitive disabilities. Specifically, videos did not include or emphasize functional movements (e.g., sit-to-stand and ambulation) to improve mastery of activities of daily living, which are important for the physical well-being of these students. The National Center on Health, Physical Activity and Disability (NCHPAD- https://www.nchpad.org/) has, however, created a playlist of the top exercise-from-home videos on its YouTube channel. The playlist for children and adults includes several options for all abilities to help students and families choose an exercise mode that is enjoyable to them. NCHPAD also offers a 14 Weeks to a Healthier You, web-based physical activity, and nutrition program for individuals with disabilities and chronic health conditions. Special Olympics’ Fit 5 Resources also includes fitness cards and videos that offer simple exercises to target endurance, strength, and flexibility, all of which were designed to be completed at home. All three of these programs have been linked to the InPACT at Home website to enhance the inclusivity of the program for children with physical and cognitive disabilities.

Due to time and resource constraints, cultural tailoring was not incorporated into the video content. Conducting exploratory focus groups that identify diverse thoughts, experiences, and assumptions associated with physical activity as well as unique environmental barriers and facilitators, are a critical step in developing equitable and inclusive physical activity programming [42]. Exploring beliefs related to differences in physical activity preferences, how the media portrays ethnic minorities, and the possible role of religion as motivation for exercising are additional factors that have been shown to influence physical activity behaviors [42]. While the barriers and facilitators for home-based physical activity may not always differ by race and ethnicity, this process is still necessary for achieving cultural sensitivity in physical activity programming.

Pretesting is another important component of culturally tailoring physical activity interventions [42]. Pretesting involves exposing materials and messages to members of the target audience to obtain feedback regarding format and content [42]. Resnicow has demonstrated that, in some instances, communities of color may prefer audiovisual materials that represent their racial and ethnic groups whereas others may perceive targeted interventions as singling out or casting an unfavorable light on their community [42]. Because our truncated timeline prohibited extensive pre-testing, future work will need to balance a rapid response with sufficient cultural tailoring.

Limitations

Several limitations of the study should be noted. First, the feasibility of the InPACT intervention has been replicated in several elementary school classrooms across the state of Michigan and has demonstrated preliminary success in promoting physical activity in this environment [24, 43], but the effectiveness of the intervention to improve student-level health outcomes has not yet been rigorously tested. Nevertheless, the current study was an important first step in a theoretically guided, rapid adaptation of a classroom-based physical activity intervention to promote youth physical activity in the home. Second, the research team and organizations involved in the partner coalition were diverse in terms of race, ethnicity, gender, and area of expertise, but the video developers for the InPACT at Home program were primarily white and male. These demographics are consistent with the demographics of the physical education and fitness professionals across the state and nation but are not representative of Michigan students. Third, our feedback from teachers, fitness professionals, parents, and community members were informal and quantitative data were not collected during the coalition decision-making process. Future feedback would benefit from more structured focus groups or semi-structured interviews. Finally, pilot testing the InPACT at Home program prior to rollout did not take place due to resource and time constraints. While this is consistent with challenges associated with delivering interventions in community settings, future dissemination efforts would benefit from pilot testing the fully adapted intervention.

Efficacy and effectiveness testing of the InPACT at Home intervention is currently in progress in three separate studies. First, we are conducting a content analysis of the quality of the InPACT exercise videos, using an evidence-based evaluation rubric. The cognitive load of each video is the primary outcome being assessed as previous research has identified cognitive load as a predictor of video engagement [44–46]. Second, we are conducting a laboratory-based study to test the efficacy of the 8-minute studio-developed exercise videos to enhance mood, enjoyment, and determine exercise energy expenditure. Psychological outcomes are being assessed via visual analog scales, child questionnaires, and physical activity energy expenditure is being measured using indirect calorimetry. Finally, a mixed-methods feasibility study is underway to examine facilitators and barriers to child engagement in the program. Child physical activity participation is being assessed via accelerometry. These studies are designed to provide the evidence base for the continued use of InPACT at Home beyond the COVID-19 pandemic.

Conclusions

The focus of the current paper was on describing a novel application of adaptation frameworks from implementation science to extend the use of a classroom-based physical activity intervention to the home environment. The initial year of program dissemination results indicate a statewide reach of the program was achieved at a time when children had reduced access to structured physical activity at school and in their communities. High acceptability of the program among state legislators was also observed as evidenced by the inclusion of the program in the Governor’s Blueprint for Comprehensive Student Recovery [47]. That plan was designed to support local education leaders in developing and implementing a comprehensive COVID-19 recovery plan. Barriers to dissemination were identified which included lower internet access in the rural regions of the state. Those data were useful in informing refinement of the InPACT at Home dissemination to improve reach, which led to shifts from web-based dissemination strategies to distribution on public television. The initial adaptation and testing were critical initial steps in accelerating research-to-practice translation through developing a home-based physical activity intervention that can be highly implementable and sustainable, with the potential to increase youth physical activity during the COVID-19 pandemic and beyond.

Funding

This work was supported by the Michigan Department of Health and Human Services and Michigan Public Health Institute through the Coronavirus Task Force Rapid Relief Initiative (Q-80041). A.B. Eisman was supported during this project by a National Institute of Health training award (1K01DA044279-01A1).

Compliance with Ethical Standards

Conflict of Interest: No competing financial interests exist. All financial support for this project was provided by grants from the Michigan Public Health Institute and the Michigan Department of Health and Human Services. No project support was received from any other government or private sources. None of the state employees or legislators received compensation to participate in this project. Some members of the partner coalition team were also members of the Coronavirus Task Force Rapid Relief Initiative.

Primary Data: Findings reported have not been previously published and this manuscript is not being simultaneously submitted elsewhere. Data have not been previously reported elsewhere. The authors have full control of all primary data and agree to allow the Journal to review data if requested.

Ethical Approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.

Transparency: This study was not formally registered. The analysis plan was not formally pre-registered. De-identified data from this study are not available in a public archive.

Data Availability: De-identified data from this study will be made available (as allowable according to institutional IRB standards by emailing the corresponding author. There is not analytic code associated with this study. Some of the materials used to conduct the study are presented in a public archive: www.inpact.kines.umich.edu and https://inpactathome.umich.edu.