translating an early childhood obesity prevention program

RESEARCH ARTICLE Open Access

Translating an early childhood obesityprevention program for local communityimplementation: a case study of theMelbourne InFANT ProgramR. Laws1,2,3* , K. D. Hesketh1,3, K. Ball1,2, C. Cooper1, K. Vrljic4 and K. J. Campbell1,2,3

Abstract

Background: While there is a growing interest in the field of research translation, there are few publishedexamples of public health interventions that have been effectively scaled up and implemented in the community.This paper provides a case study of the community-wide implementation of the Melbourne Infant, Feeding, Activityand Nutrition Trial (InFANT), an obesity prevention program for parents with infants aged 3–18 months. The studyexplored key factors influencing the translation of the Program into routine practice and the respective role ofpolicy makers, researchers and implementers.

Methods: Case studies were conducted of five of the eight prevention areas in Victoria, Australia who implementedthe Program. Cases were selected on the basis of having implemented the Program for 6 months or more. Data werecollected from January to June 2015 and included 18 individual interviews, one focus group and observation of twomeetings. A total of 28 individuals, including research staff (n = 4), policy makers (n = 2) and implementers (n = 22),contributed to the data collected. Thematic analysis was conducted using cross case comparisons and key themeswere verified through member checking.

Results: Key facilitators of implementation included availability of a pre-packaged evidence based program addressinga community need, along with support and training provided by research staff to local implementers. Partnershipsbetween researchers and policy makers facilitated initial program adoption, while local partnerships supportedcommunity implementation. Community partnerships were facilitated by local coordinators through alignment ofprogram goals with existing policies and services. Workforce capacity for program delivery and administration was achallenge, largely overcome by embedding the Program into existing roles. Adapting the Program to fit localcircumstance was critical for feasible and sustainable delivery, however balancing this with program fidelity was acritical issue. The lack of ongoing funding to support translation activities was a barrier for researchers continuedinvolvement in community implementation.

Conclusion: Policy makers, researchers and practitioners have important and complementary roles to play insupporting the translation of effective research interventions into practice. New avenues need to be explored tostrengthen partnerships between researchers and end users to support the integration of effective public healthresearch interventions into practice.

Keywords: Obesity prevention, Children, Infants, Implementation, Research translation, Dissemination

* Correspondence: [email protected] for Physical Activity and Nutrition, School of Exercise and NutritionScience, Deakin University, Geelong, VIC, Australia2Centre for Obesity Management and Prevention Research Excellence inPrimary Health Care (COMPaRE-PHC), Sydney, AustraliaFull list of author information is available at the end of the article

© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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BackgroundIt is widely accepted that the transfer of new knowledgefrom public health research into policy and practice isfar from optimal. Government agencies, including theNational Institute of Health in the USA emphasise theneed for widespread dissemination of evidence-based in-terventions to help bridge the gap between research andpractice [1]. There is a growing body of literature inves-tigating the translation of public health research intopractice [2–4]. Five main stages of building evidence inpublic health have been proposed: Stages one and two,Problem definition and Solution generation relate to pro-gram development; stage three, intervention testing, rep-resents process and impact evaluation to determineprogram efficacy or effectiveness; and stage four, inter-vention replication, refers to subsequent studies in whicheffective programs are adapted for other settings to de-termine if and how similar outcomes can be achieved indifferent places and populations [5]. Finally stage five,intervention dissemination, focuses on the scaling up ofan effective program to population level to maximisepublic health impact [5].Translational research in public health has been de-

fined as studies that focus on stages four and five, that isreplication and scaling up of effective interventions [5].Scaling up is the process by which health promotion in-terventions shown to be effective in controlled condi-tions or on a small scale are expanded into real worldpractice [6]. There is growing interest in the concept of‘scaling up’; however existing literature to date has beenlimited in focus, for example, investigations of concep-tual frameworks [6–8] or case studies of scaled up pro-grams in low income countries [8–10]. There arerelatively few examples of published studies reporting onthe scaling up of effective public health interventionsinto practice [11–14].In the emerging field of obesity prevention in young

children much of the research conducted to date is inthe early stages of intervention development and effi-cacy testing (stages one to three), with a lack of effect-ive population wide programs, particularly in youngchildren 0–5 years [15–18]. Further, reporting of exter-nal validity information such as selection and represen-tativeness of settings, intervention characteristics anddelivery costs and program sustainability is poor inexisting intervention studies [17, 19] and in systematicreviews on the topic [20]. Given the extent of childobesity as a public health problem, there is currentlylimited practice-relevant information for policy makersand practitioners to inform decisions about how effect-ive programs can be disseminated ‘at scale’.This paper provides a case study of the scaling up of

the Melbourne InFANT Program (herein referred to asthe InFANT Program), a group-based obesity prevention

program that was effective in improving child and ma-ternal diet, parental feeding behaviours and sedentarybehavior in children [21]. The aim of the study was toexplore the key factors influencing the scaling up andtranslation of this program into routine practice fromthe perspective of the main players involved, includingresearchers, policy makers and implementers. This willprovide much needed insights into the ‘scaling up’process and key lessons for public health researchers,policy makers and practitioners to inform the dissemin-ation of other obesity prevention programs targetingyoung children into practice.

Study context – The InFANT ProgramThe InFANT Program was a cluster randomised con-trolled trial (RCT) targeting first time mothers throughexisting universal care services which trialled the efficacyof a low dose program (six sessions delivered by dieti-tians quarterly over 15 months, commencing when In-fants were 3 months of age) to improve parent and childdiet and physical activity and to reduce sedentary behav-iours [22]. This study was informed by qualitative re-search with the target group [23] and by two systematicreviews [15, 24]. At follow up when children were 18months old, the Program did not change children’sgrowth, but did improve aspects of child’s diet and sed-entary behaviours [21]; improved child diet quality [25];improved water and vegetable intakes in sub-groups[26]; increased maternal knowledge and improved pre-ferred feeding behaviours [27]; and improved mother’sdietary patterns [28].

Dissemination contextThe Program was delivered as part of The Victorian De-partment of Health and Humans Services (referred tothroughout as ‘the Department’) prevention platformtaking a complex whole of systems approach to reducingchronic disease risk. This approach involves deliveringmultiple strategies, policies and initiatives at both thestate and local levels to target individuals in placeswhere they spend their time, including childcare centres,schools, workplaces, food outlets, sporting clubs,businesses, local governments, health professionalsand more to create healthier environments for all.This has shifted action from projects, small in scale,to prevention at scale delivered by multiple stake-holders, organisations, and sectors together with acommunity led placed based approach in 12 preven-tion areas across the state. Prevention areas were gen-erally defined by local government area boundaries,however in some cases prevention area incorporatedmore than one local government area.High quality health promotion programs have long

played a significant role in health promotion, and with

Laws et al. BMC Public Health (2016) 16:748 of 15

an opportunity to implement a complex system approachto prevention in Victoria, an opportunity emerged to re-think how programs can be delivered to contribute to pre-vention system change. The Department provided theopportunity for the 12 prevention areas to select qualityhealth promotion programs using a selection criteria de-veloped by the Department (Additional file 1) to supportthis decision making process. A list of recommended pro-grams was created, which included the InFANT Programto fast track and support this process.

Dissemination processThe InFANT Program researchers were funded by TheDepartment to prepare program materials for dissemin-ation. This included a facilitator manual, a parent hand-book, a program website (www.infantprogram.org) and aguide for program implementation. A one day trainingprogram was developed and delivered by InFANT Pro-gram research staff to facilitators. Facilitators includeddietitians, Maternal and Child Health (MCH) nurses andparent support workers. MCH nurses in Victoria providea universal free service to parents of children 0-6 yearsand parent support workers typically work alongsideMCH nurses to facilitate group programs such as firsttime parent groups. Prevention area staff were responsiblefor coordinating the implementation of the Program ineach locality in partnership with key stakeholders and de-livery agents.

MethodsA case study approach was used to explore factors influen-cing the translation of the InFANT Program into routinepractice. Case study methods are appropriate for answering‘how’ and ‘why’ questions and when the phenomenon ofinterest (research translation) is embedded within a real-world policy and practice context [29]. The study consistedof a case series of five areas implementing the InFANTProgram along with interviews with research staff and pol-icy makers involved in the translation efforts across sites.The study methods were informed by a constructionist

epistemology. This assumes that knowledge is constructedand shaped by people’s perception, that phenomenon canonly be understood in the context in which they are stud-ied, and that truth is a matter of consensus amongst in-formed constructions, not a correspondence with anobjective reality [30]. This was applied to the study by col-lecting detailed information on contextual factors influen-cing participants’ perceptions and recognising that thefindings are co-created by participants and researchersand not an objective truth to be discovered.

RecruitmentThe sampling frame for the study sites were preventionareas that had been implementing the Program for at

least 6 months at the commencement of data collection.The 6 month timeframe for implementation was se-lected to allow areas to have had some experience of keyimplementation issues. As of January 2015, eight out ofthe 12 prevention areas choose to deliver the Program,five were eligible to participate in this study having im-plemented the Program for at least 6 months.The sampling strategy was purposeful with the aim to

obtain insight from a range of stakeholders in each siteas well as researchers and policy makers (Table 1). Coor-dinators (n = 5) from these five areas were emailed bythe Department personnel to invite them to participatein an individual telephone interview, and all agreed. Fol-lowing each interview, coordinators were asked to passon the interview invitation to key local stakeholders andprogram facilitators who they considered might offeradditional insights into program implementation in theirarea. Local key stakeholders included MCH Nurse Man-agers, those working in roles within Child and FamilyServices, staff involved in hosting or organising programvenues, administrative or evaluation staff. A total of 11staff (seven key stakeholders and four facilitators) wereinvited and agreed to participate using this snowballingmethod (Table 1). In one area, this took the form of afocus group (as this was already planned as part of locallevel evaluation), in the remaining areas individual tele-phone interviews were conducted. An online survey ofprogram facilitators was also used as a concurrent re-cruitment strategy. A total of eight program facilitatorsfrom the participating areas completed the survey, andall agreed to be interviewed including three who had notalready been identified through the snowballing strategy.Research staff and policy personnel who were activelyinvolved in the translation effort were also invited toparticipate by email invitation from the study lead (RL),and all except one (a policy maker who had moved onto a different role) agreed. Research staff included thelead investigator involved in the design and testing ofthe Program in the RCT, those involved in training pro-gram facilitators and liasing with with policy personneland local implementers.

Data collectionData were collected from January to June 2015 and in-cluded 18 individual semi-structured interviews, a focusgroup in one area and observation of two meetings in-volving researchers, policy makers and implementers(Table 1). In total 28 individuals contributed to the datacollected consisting of research staff (n = 4), policymakers (n = 2) and implementers (n = 22) from acrossfive prevention areas. Implementers included programcoordinators (n = 5) responsible for overall implementa-tion of the Program in each area, program facilitators


http://www.infantprogram.org

Table 1 Participant position, area, recruitment and data collection methods

Interviewee code Position Area Recruitment method Data collection method

Research staff

1 Research Staff n/a Direct invitation Individual interview

2a Research Staff n/a Direct invitation Individual interview

2b Research Staff n/a n/a Meeting 1

2c Research Staff n/a n/a Meeting 2



Implementers

5a Coordinator 1 Direct invitation Individual interview

5b Coordinator 1 n/a Meeting 1

5c Coordinator 1 n/a Meeting 2

5d Coordinator 1 Direct invitation Focus group

6 Program Facilitator 1 Snowballing Focus group



9 Key Stakeholder 1 Snowballing Focus group




13 Key Stakeholder 1 n/a Meeting 2



15 Program Facilitator 2 Facilitator survey Individual interview




18 Key Stakeholder 3 Snowballing Individual interview


20 Program Facilitator 3 Snowballing Individual interview

21 Key Stakeholder 3 n/a Meeting 1





25 Program Facilitator 5 Direct invitation Individual interview

26 Coordinator 5 n/a Meeting 1

Policy makers

27a Senior Project Officer n/a Direct invitation Individual interview

27b Senior Project Officer n/a n/a Meeting 1

27c Senior Project Officer n/a n/a Meeting 2

28 Senior Project Officer n/a Direct invitation Individual interview

1–28: each number represent a different participant, a,b,c,d: Represents a different occasion of data collection from the same participant


(n = 8) who delivered the Program to parents, and localstakeholders (n = 9).The interviews and focus group guides were informed

by the consolidated framework for advancing implemen-tation science [31] which integrates existing implemen-tation theories into five key domains shown to be criticalto implementation success. Key topics covered included:

� Role in implementing the InFANT Program� Planning for program implementation - who, how

and why the InFANT Program was selected?� Models of implementation, including any adaptions to

the Program and degree of program fit with existingservices/programs and policies.

� Support for implementation, including on theground logistical support, management support,researcher and policy support

� Implementation challenges� Perceived outcomes including program strengths

and weaknesses� Perceived sustainability of program and factors

influencing sustainability� Key lessons for researchers, implementers and

policy makers

Individual interviews were conducted over the phoneby RL and lasted 40 min on average (range:17 to 65min). The focus group was conducted face to face, facili-tated by RL and lasted one hour and five minutes.Opportunistic data collection also occurred at two

meetings of local implementers, research staff and policypersonnel. These meetings provided an opportunity togather data on key issues relating to the implementa-tion of the Program. The first meeting lasting 1 h and5 min involved seven individuals including representa-tives (n = 5) from all the prevention areas as well as re-search staff (n = 1) and policy personnel (n = 1). Thismeeting focused on models for implementation whereparticipants discussed implementation progress, chal-lenges and various program adaptions that had beenmade. The second meeting, lasting 1 hour and 35 minincluded representatives (n = 3) from two preventionareas, research staff (n = 2) and policy personnel (n = 1).The focus of this meeting was to share the preliminaryfindings from the interviews and focus group to firstlyverify key themes arising and secondly, to use this togenerate further discussion and insights about key im-plementation issues.

Data analysisThe interviews, meetings and the focus group wereaudio recorded with participants’ permission and tran-scribed verbatim. Transcripts were imported into Nvivo10 which was used for coding, sorting and retrieval of

data. The study used thematic analysis informed by themethods of Braun and Clarke [32] and involved the fol-lowing steps undertaken by RL:

1. familiarisation with the data by checking theaccuracy of transcripts against audio recording.

2. line by line coding of the data using an inductiveapproach guided by the research aims, resulting inthe development of an initial coding framework. Thecoding framework was iteratively refined based onnew concepts identified in the data.

3. review of codes to identify broader conceptualthemes. At this stage the researchers’ knowledge ofempirical literature and existing frameworks forimplementation science helped in conceptualisingcodes into broader categories.

4. Review of all data within a given theme to identifycommon and divergent views using constantcomparison technique [30].

5. First draft of results section which involved re-reading data coded at each theme, along withmemo’s about sub-themes to succinctly summarisethe theme using illustrative quotes.

6. Member checking which involved 1) presentation ofkey findings at a meeting of study participants (seeabove), which contributed to further data collectionand elaboration and refinement of themes; 2)emailing coordinators (n = 3), research staff (n = 2)and policy personnel (n = 1) a copy of the initialdraft results section of the manuscript. Participantswere asked to comment on whether the themessufficiently captured their views on the key factorsinfluencing translation process and whether any keyissues were omitted in the representation of theresults. There was strong agreement with the themespresented and only minor modifications were made tothe results based on feedback from participants.

Reflexivity and the role of the researcherAs the study methods were informed by a constructivistapproach, it is important to make explicit the role andbackground of the researcher which may influence howone understands and interprets the data [30]. RL under-took all data collection and analysis with member check-ing and input into final results. RL is a postdoctoralresearcher with experience in research translation havingworked on previous empirical studies exploring theprocess of research translation [33–37] and conceptualstudies [5, 38]. Over the past 18 months, RL had beenengaged with the researchers, implementers and policymakers involved in the translation of the Program. Thishas provided in-depth understanding of the translationissues where RL has essentially been a participant obser-ver. We believe this adds strength, heightening RL’s


sensitivity to translation and implementation issues inthe data. RL was not involved in the original InFANTProgram trial and had no input into the development ofthe Program.

ResultsDescription of study sitesAll five of the eligible prevention areas took part in thisstudy and had been implementing the Program betweensix and 15 months. All areas were in the lowest tertilefor socio-economic disadvantage as defined by an arealevel indicator of disadvantage (Socioeconomic index forareas, [39]). Four of the areas were located in metropol-itan Melbourne, with populations ranging from 25,000to 150,000. One area was in a regional location inVictoria, approximately 550 km from Melbourne witha population of around 50,000. This is in contrast to

the areas participating in the RCT of the Programwhere only three of 14 areas were in the the lowest ter-tile for socioeconomic disadvantaged (eight medium,three high) and all areas were located within metropol-itan Melbourne [21].

Role of researchers, policy makers and implementersResearchers, policy makers and implementers all hadspecific roles to play in the scaling up and translation ofthe InFANT Program into routine practice (Table 2).For researchers, this centered on translation of interven-tion materials from the research trial into a ‘pre-pack-aged program’ ready for community wide delivery,developing and delivering a training program to imple-menters as well as being an expert point of contact forthe Program. Policy makers provided support towardsthe translation effort by funding prevention areas as well

Table 2 The role of researchers, policy makers and local implementers in the translation process and key barriers and facilitators

Role/Translation tasks Facilitators of translation Barriers to translation

Researchers

• Negotiate funding for translation activities• Translate research intervention intopre-packaged program materials

• Develop and deliver training programfor community facilitators

• Develop and maintain program websiteand update program materials as required

• Meetings with actual and potential programdelivery agents

• Point of contact for expertise on theProgram for policymakers and practitioners

• Custodian of program intellectual property• Advice on program sustainability andevaluation

• Well established relationships betweenresearchers and policy makers

• Funding of researcher involvement intranslation activities

• Researcher/institutional commitment toresearch translation

• Coordinating role for research translationactivities

• Intervention program initially designed tobe scalable and feasible to implement withinexisting service delivery structures.

• Staff turnover amongst policy makers• Researcher capacity – translation not corebusiness

• Translation activities not traditionallyrewarded for researchers

• Funding for researcher involvement intranslation time limited

Policy makers

• Funding prevention areas• Funding researchers involvement intranslation activities

• Selection of evidence based programsfor implementation

• Facilitate meetings and connectionsbetween implementers and researchers

• Printing and distribution of programmaterials

• Prevention funding available for 12prevention areas

• Personnel available to support programimplementation

• Well established relationships withresearchers and program implementers

• Awareness and knowledge of the InFANTProgram throughout the research phase

• The InFANT Program addressed a gapand aligned with policy context of usingprograms within a complex systems approach

• Changes in government and fundingarrangements

• Resistance to programs as part ofa systems based approach to prevention

Local implementers

• Plan program delivery• Engage delivery partners,• Program administration, deliveryand evaluation

• Prevention area funding• The InFANT Program addressed a gap inservices

• Access to a pre-packaged evidence basedprogram

• Program training and local mentoring• Access and support from researchers whodesigned the Program

• Strong partnerships with delivery agents• Coordinators / champions/leadership• Congruence with existing programs, servicesand policy

• Program adaption to suit local context

• Heavy administrative burden of the Program• Availability of workforce to deliverthe Program

• Competition with existing programs(one area)

• Lack of centralised program evaluation


as working closely with these areas to support multiplesystem wide prevention strategies including the imple-mentation of specified programs. The Department alsofunded the printing of InFANT Program materials andfunded researchers’ involvement in translation activities.Policy makers also acted as an important link betweenresearchers and implementers on the ground. Local im-plementers were responsible for all aspects of programdelivery at the community level including program plan-ning and adaption, engaging delivery agents/services andprogram evaluation.

Key factors affecting the translation processA number of key barriers and facilitators to the transla-tion process were identified (summarised in Table 2) andthese are outlined in the following key themes.

Program specific factorsA number of program specific factors were consideredimportant in influencing program uptake both at thepolicy and local community level. At the policy level, thefeasibility of program delivery was considered to be crit-ical in selection of the Program for dissemination. Re-searchers reported that the Program was designed withscalability and community implementation in mind. Theprocess evaluation spoke to the feasibility of the Pro-gram in terms of delivery within the MCH setting aswell as high rates of recruitment and retention. Thepositive outcomes of the research trial in terms of ma-ternal beliefs, attitudes and behaviours were also consid-ered important in policy makers endorsing the Program,despite the trial not demonstrating changes in the pri-mary outcome of child weight:

“the primary outcome was weight and we didn’tchange weight. But…I’ve promoted fairly strongly tothe Department of Health (‘the Department’) thatwe’ve seen changes in maternal attitudes and beliefs,…a number of the mediators, if you like, haveimproved…They were very impressed by the fact that87 percent of people we approached wanted toparticipate, which I guess evokes some maternalinterest in the space…That groups have worked quitewell, so seven out of ten people attended four of sixsessions. The mechanics appear to be a good modelthat they were interested in” (Research staff 1).

At the local level, the InFANT Program was perceivedto address an area of need and a gap in current serviceprovision as there were very few (if any) existing healthylifestyle programs targeting parents with young infants.Much of the current focus was on preschools andschools. The Program content including the clarity ofthe Program key messages, the discussion based nature

of the groups as well as mode of delivery through en-gaging families, all appealed to local implementers.There was a general endorsement of the concept ofstarting healthy lifestyle messages early to prevent futureproblems and associated impact on service demands.The fact that the Program was ‘pre-packaged’ includingprogram resources and training made it an attractive op-tion as discussed by this local implementer:

“because it was a pre-packaged program all theresources were there, the training was offered …so weidentified a need, identified where we wanted to runit, found brilliant staff to run it, got the okay fromsort of management level and then we were able tojust kind of…take it up as a whole and roll it out(Coordinator 5d).

Prevention areas had direct access to research staff in-volved in the design of the InFANT Program throughface to face meetings, a dedicated training program andan online forum. This was considered to be an import-ant facilitator for local implementation as described bythis participant:

“one of the main factors for encouraging uptake wasthe support that was delivered around it,…there wereonly two programs where the department engaged theresearchers themselves to support the implementation.So that was in my view a big bonus for the HTCs(prevention areas) just because they got access to theresearchers, they felt quite supported” (Policy maker 28).

PartnershipsStrong partnerships were an important facilitator at everystage in the translation process. Researchers activelysought to engage policy makers early in the research phaseof the InFANT Program. This well-established trusted re-lationship facilitated the early sharing of findings from thetrial and helped to establish the researchers’ expert roleand credibility. However, the high turnover of policy staffwas a barrier to continuity of partnerships.

“I think what the existing relationship did was gave usthe opportunity to get our foot in the door, so we werea trusted source, we were considered to be experts inthe field” (research staff 1).

At the local level, the viability and sustainability of de-livering the Program was dependent on engaging key de-livery partners including MCH services, local counciland community health services. The funded preventionworkforce played a critical coordination role in engagingthese partners during the initiation of the Program. Akey engagement strategy included aligning the goals of


the Program with the needs and priorities of key stake-holders. This involved using a combination of ‘bottomup approaches’ such as informal conversation with indi-vidual staff and ‘top down approaches’ such as negotiationbetween high level managers and formal agreements.

“it's having a workforce that is able to do a lot of thatlegwork and, yeah, pitch it in such a way that adirector or a manager can say, “Okay, I see our stakein this program” (Key stakeholder 13).

It was acknowledged that building such partnershipstakes time, requires a dedicated staff member(s) to drivepartnership development as well as clear goals, regularcommunication and mutual benefits. A number of con-textual factors were noted to influence partnership de-velopment across the areas involved, including the sizeof the area (with partnerships easier to forge in smallerareas with fewer stakeholders and existing relationships),individual personalities (degree of openness to innovationand willingness to champion the Program), whether pre-vention staff were co-located with key partners and thedegree of program fit with the local policy context.

Coordinators, champions and leadersCoordinators, champions and leaders were key drivers inthe translation of the InFANT Program into routinepractice and these individuals worked at the local levelas well as in policy and research. As mentioned above,Prevention Coordinators were critical in bringing keypartners around the table to agree on how the InFANTProgram would be delivered at the local level. They didmuch of the ‘leg work’ of setting up the administrationof the Program, reducing the risk for partners becausePrevention Coordinators took initial responsibility formanaging the Program.

“Often you can have different people across differentorganisations, teams, departments, that are interestedbut you need someone to kind of bring it together, set itup” (Coordinator 5d).

Prevention Coordinators who had already begun imple-mentation of the Program often became champions andadvisers to other areas considering taking the Program on.Individual MCH nurses and managers engaged in deliver-ing the Program also became champions in promoting theProgram within and outside their own service.Further, individual policy personnel played an import-

ant coordinating role in bringing together researchersand local implementers to learn from each other as dis-cussed above. Having a policy position responsible forthe implementation of the Program was considered im-portant in ensuring this level of coordination occurred

between researchers and local implementers. At the re-searcher level, having university staff responsible for co-ordinating contracts with the Department and otheradministrative tasks was important in allowing the leadresearcher to focus on key translation tasks such as en-gaging with local implementers.

Workforce capacityWorkforce capacity to support the implementation ofthe Program at the community level and to support thetranslation effort more broadly was a major theme aris-ing. At the local level, program adaption and strongpartnerships were considered essential in ensuring a sus-tainable workforce to deliver the Program. In contrast tothe research trial, in which dietitians were used to de-liver the Program all areas (except one) adapted the Pro-gram to use MCH nurses and parent support workers todeliver the Program. In these areas, mentoring supportwas provided by local dietitians following the formaltraining program. This program adaption was predomin-antly influenced by workforce capacity and cost, as wellas fit with the existing health professional role.

“You have to adapt it to what you’ve got capacity torun. We’ve run it with Maternal and Child Healthnurses and parent support workers which makes itmuch more cost effective” (Coordinator14a).

MCH nurses and parent support workers were consid-ered a natural fit for the role because of their well estab-lished and credible relationship with parents and becausethey already addressed issues related to infant feeding andactive play in their routine consultations. The InFANTProgram was considered an innovative way of more com-prehensively addressing topics already covered in individ-ual consultations, potentially saving consultation time andcosts. As such, two areas reported embedding programdelivery into existing MCH nurse and parent supportworker roles, as a way of making program delivery moresustainable. Two areas had specifically funded the time ofMCH nurses and parent support workers to deliver theProgram as part of a pilot. The area that chose to use die-titians to deliver the Program perceived their expert skillsand knowledge to be a selling point for getting parents tothe Program. However the dietitians admitted themselves,that due to their limited capacity, additional support islikely to be needed in the future. More recently other al-lied health staff and health promotion officers in the areahave been trained to provide ‘back up’ support to dietitiansdelivering the Program if required.At the local level, the administration of the Program

including organising groups, booking venues and facili-tators, was a major burden largely taken on by Preven-tion Coordinators. To ensure sustainability of program


administration in the absence of ongoing preventionfunding, Coordinators discussed a number of options.These included making further adaptions to the Programto reduce the administrative burden, seeking funding foradministrative support or trying to embed these tasks inan existing administrative role which would depend onstrong partnerships with other services.

“So it just seems like the weaknesses might be linked tothe admin/workforce intensity of the Program.. if youdon’t have other partners engaged, then that might bea little bit more difficult” (Policy maker 27a).

Workforce capacity to support program translationwas also an issue from the researcher and policy makerperspective. Research staff commitment to ‘make a dif-ference’ was an important driver of their involvementdespite having limited capacity to undertake researchtranslation activities which are not considered core busi-ness or traditionally rewarded in academic roles.

“It's so tough because it's so much an add-on to mycore business, which is ironic isn’t it when you think thatthe academic role of developing knowledge and capacity,and then when it comes to actually doing what we saidwe wanted to do, which is implement it, we really hadvery little capacity to do that” (Research staff 1).

Furthermore university systems may not be set up toeasily support program delivery such as accepting pay-ment for program training or the storage of program re-sources. Research staff suggested that alternative modelsfor research translation are needed within the universitysector such as dedicated funds and staff for researchtranslation and researchers undertaking secondments toservice delivery settings to support program roll out. Atthe policy level, staff capacity was also an issue with staffcut backs making it difficult to have a dedicated positionto support program implementation.

Context – Fit with existing policy, program and servicesThe extent within which the InFANT Program fittedwith the broader policy environment, as well as localprograms and services was a central theme influencingtranslation opportunities. At the conceptual level, therewas a strong tension between the Department’s focus onsystem level approaches to prevention with an emphasison creating supportive policies and environments for be-haviour change on the one hand, and programs, such asthe InFANT Program, focusing on individuals/familieson the other. This tension was resolved at the locallevel by demonstrating how individual programs, likethe InFANT Program, fitted within and complementeda system based approach:

“If you’re going to get the biggest bang for your buck Ithink you’d want to make sure that it’s [the Program]linking into things …we thought, well, if parents aregetting this information early they’re going to be morereceptive to that information when settings and servicesare taking that up in kinder and long day care…thinking about it broadly and where it fits into thebroader system is important too” (Coordinator 22a).

As discussed previously, the InFANT Program fittedwell with the priorities and focus of local MCH servicesin most areas and this was essential for partnering withthis service to deliver the Program. The Program was a‘natural’ fit with first time parent groups running in allareas. These groups formed the basis of recruitment tothe Program and provided a mechanism of linking par-ents to other services and programs locally, an import-ant priority of both MCH services and local council.However, in one area, MCH services were runningother concurrent parenting programs which were per-ceived to be competing with the InFANT Program fornurse and parent attention. The same area reportedthat initially it was difficult for MCH Service to be en-gaged as priorities and resources for the service hadalready been allocated on the basis of previous annualcouncil business plans:

“we’re operating in the local government context, it is achallenge to implement things in a timely mannerwhen there are plans and strategies …they go over afour year period and there is already resourcesallocated and prioritisation that’s occurred…So forexample, you know, an Infant type program wasn’tnecessarily a priority with Maternal and ChildHealth.” (Coordinator 17a).

Balancing adaption versus program fidelityAs expected, all areas had adapted or proposed to adaptthe Program to some extent from the original trial(Table 3). Most common changes included choice ofprogram facilitator, recruitment methods and use oflocal supplementary materials. Adaptions were largelydriven by the need to make the Program viable to deliverin terms of staffing costs as well as to improve the fitwith existing programs and services, to increase programreach and tailor to specific population needs. There was aclear tension between the need to adapt the Program to fitthe local context and the need to maintain program fidel-ity and integrity as articulated by this participant:

“…we’ve got a program that is being developed on goodevidence, it’s been demonstrated to be effective in thisway…And then there’s reality and our ability to kindof change and adapt the Program for what is realistic


for us into the future, that will be challenging for usand getting support from [the university] around that”(Coordinator 17a).

Implementers and policy makers called for clear guide-lines from researchers about what were the core compo-nents of the Program required to maintain fidelity andeffectiveness and what aspects could be adapted.

“I guess the randomised control trials just cannot berepeated and used in a practical sense. So …makingrecommendations …what are the critical things thatcan't be changed, and what are some of the thingsthat possibly could be changed or could be adaptedto maintain integrity for those programs, andpossibly testing them in that way as well.” (Policymakers 27a).

While researchers were considered to have ownershipover the Programs’ intellectual property, there was somediscussion about the value of having a centralised evalu-ation framework to monitor both program fidelity andoutcomes, recognising that programs do not operate inisolation but are part of the broader system wide preven-tion effort.

“What would be really nice is to test some of this stuffand actually be able to …gather some informationabout what’s actually happening to the participants,and what benefits are the participants getting”(Research staff 2b).

Sustainability and scaling upAll the areas with the exception of area four (smallerrural area), chose to pilot the implementation of the Pro-gram in one or two neighbourhoods, or in one cohort ofparents. The rationale for this was to test implementa-tion processes and models and assess the feasibility andvalue of the Program before considering area wide dis-semination. Three of the five areas largely embedded thedelivery of the Program into existing roles within MCHor allied health services, with the view of setting up sus-tainability systems for program delivery beyond fundingof prevention areas:

“…we’re really trying to embed it in the work ofCommunity Health. So if Healthy Together[prevention areas] is not refunded or it gets lessfunding that it continues, so it’s embedded within theAllied Health teams,…Child and Maternal Healthstructure as well, so if we are to pull away that itcontinues “ (Coordinator 22a).

In contrast, two areas directly funded program deliverywith the view of using the pilot phase to make a businesscase for continued funding through local council orother external sources.

“So what we are hopeful [of] is that if we can haveenough evidence and information that can create avery strong case for council and for budgets and forMaternal and Child Health nurses, the value of this.Then it may be sustained” (Coordinator 17a).

Table 3 Summary of actual or proposed adaptions and rationale

Adaption Rationale Area

Program material supplemented with local information/resources • Tailor to needs of local population (culturally andlinguistically diverse groups)• Provide information on local services/facilities

All areas

Use Maternal and Child Health nurses or parenting workersto deliver the Program (instead of dietitians as per the trial)

• More cost effective• Limited capacity of dietitians• Good fit with existing role of MCH nurses andparenting workers

1,2,3,5

Recruit parents outside of first time parent groups • To increase recruitment to the Program and reach 1,3,4,5

Reducing the number of sessions from 6 to 3 or 4. • To reduce burden on facilitators and make the Programmore viable to run• To fit with existing first time parent groups andindividual Maternal and Child Health nurse consultations

2, 5

Plan to offer age specific group sessions open to anyone • Reduce administrative burden of recruiting andfollowing up multiple groups over time• Open up the Program to more parents potentiallyimproving reach

1, 2

Amalgamate some groups for sessions beyond 12 monthsof age

• To address lower retention rates amongst parentswith older babies• To make groups viable, limited capacity of facilitators

4

Key program messages were integrated into an existingprogram format

• Successful existing program already underway 5

Area 1,2,3,5: metropolitan Melbourne, Area 4 regional Victoria


Local implementers recognised the challenge ofobtaining ongoing funding for the Program and hencewere exploring options to further integrate the Pro-gram into existing service delivery structures, rolesand existing programs.

“I think as a program by itself, I don’t know howfinancially and time-wise it can expand withoutcombining it with other programs that are alreadythere” (Program Facilitator 25).

There was general agreement that further programadaptions were likely to be required to better integratethe Program into what was feasible locally. Adaptionsbeing considered included running age specific groupsessions open to anyone (rather than existing parentgroups), reducing the number of sessions or deliveringthe Program via existing groups such as playgroups.From a policy perspective, there were varying views

about program sustainability. One view was that state orfederal funding of programs was unlikely, hence pro-grams need to be embedded within a complex systembased approach to prevention that provided an infra-structure to promote sustainability and scaling up.

“I mean there's not going to be funding available tosupport and fund multiple programs, I doubt in thefuture to come…So it will just be about how thatprogram can be integrated within the system” (PolicyMaker 27a).

Another view was that the InFANT Program shouldbe a universal program with re-current governmentfunding as part of an ongoing commitment to preven-tion in the early years:

“… [the Program] needs to be funded by governmentand delivered by local council. The Governmentshould make a commitment to early childhood andthe InFANT program is one of those things…It’s notfair that some local councils implement and othersdon’t, …it should be universal” (Policy Maker 28).

From the research staff perspective, maintaining andupdating the Program website and materials and provid-ing training to local implementers were ongoing activ-ities that would require research staff time and hencefunding. The short term nature of funding for researchersto be involved in these translation activities was a barrierto sustained program implementation.

DiscussionThis study provides new insights into the respective rolethat policy makers, researchers and implementers play

in the translation of a health promotion program intopractice and factors influencing this process. As dis-cussed below, a number of key themes were identifiedby these stakeholders as being important in the transla-tion of the InFANT Program from research to commu-nity level implementation.In line with the findings from this study, the evidence

of program efficacy or effectiveness has been found tobe only one of many intervention characteristics influen-cing research uptake [6, 13, 31, 33, 40]. Other importantfactors identified in previous implementation researchinclude, the credibility of the Program source, its feasi-bility, the quality of program materials, program adapt-ability, trialability, relative complexity and cost [31]. Ourfindings concur with recent research highlighting theimportance of end users having information on programreach and costs, key service delivery issues such as ac-ceptability and fit of the interventions with existing de-livery models, to help inform decisions about the scalingup of public health interventions [40]. It also suggeststhe importance of researchers designing scalable andfeasible interventions from the outset that align with thepolicy context. This is likely to require co-developmentof programs with practitioners on the ground or exten-sive formative work, as was the case with the InFANTProgram [15, 23, 24]. This underscores the importanceof researchers conducting rigorous process evaluationsas part of efficacy /effectiveness trials to inform externalvalidity of public health interventions, an area generallypoorly reported by researchers [17, 19, 35].The tension of balancing program adaption against

maintaining program fidelity identified in this study, hasbeen a commonly reported theme in the disseminationof research interventions into practice [13, 41–44].While greater program fidelity has been shown to be as-sociated with better outcomes [45], adapting interven-tion programs to better suit the needs and circumstancesof local communities has also been shown to be essentialfor successful sustained implementation [8, 41, 42]. Tohelp find this balance between fidelity and adaption, im-plementation researchers have proposed various guide-lines [41, 46]. At the heart of these recommendations arethe need for researchers to clearly articulate the Program’score components based on a logic model of how the inter-vention is proposed to work, ideally supported with medi-ation analysis to identify the ‘active ingredients’ of theintervention. This is then married with consultationwith community implementers to refine and modifynon-core components to ensure program fit with localcircumstances in an iterative fashion [46]. It is also rec-ommended that adapted programs are evaluated to as-sess effectiveness and that these steps ideally involveconsultation between program developers and imple-menters [46]. Systems such as licensing agreements or


program guidelines may be helpful in monitoring pro-gram fidelity and adaptions and encouraging consult-ation between researchers and implementers. Servicedelivery organisations (not for profit or commercial)may have a role to play in ‘rolling out’ evidence basedpublic health programs and monitoring program qual-ity and fidelity. An example of this is the DECIPHerImpact, a not for profit organisation set up to licensethe 'ASSIST' peer-smoking intervention to schools toensure fidelity [47].For researchers, avenues need to be explored to fund

research translation activities, including initial consult-ation with communities around program adaptions andongoing program support, such as the provision trainingand updating of program materials. This remains a chal-lenge, with translation activities not traditionally part ofresearch grant proposals when the study outcomes arenot yet known. More recently, specific research transla-tion grants have become more common and this mayprovide an avenue for researchers to work with commu-nity partners to fund such activities. In the absence ofexternal funding, researchers are likely to need to con-sider program licensing fees to cover costs associatedwith supporting program delivery, as has been done withother widely implemented programs such as the Stand-ford Chronic Disease Self Management Programs [48].At a system level, there is likely to be more incentivefor researchers to focus on translation in the futurewith a growing focus on measuring research ‘impact’ aspart of the assessment of universities research outputs.In some countries, research ‘impact’ is being link touniversity funding, for example, in the UK ResearchExcellence Framework.Strong partnerships between researchers, policy makers

and implementers, as well as local partnerships were iden-tified as critical to the translation of the InFANT Programinto practice. Partnerships between researchers and endusers of research, such as policy makers and practitioners,has been consistently shown to be a facilitator of re-search use and scaling up in previous empirical studies[8, 11, 12, 33, 37]. As with this study, engaging endusers from the inception of a project and forging on-going relationships with policy makers and practi-tioners has been shown to be important in promotingthe uptake of health promotion programs [33, 37, 49].In this study, engaging practitioners in program modifi-cation ensured that the Program was designed to fitexisting service delivery structures (MCH services), wasrelevant to the policy focus on obesity prevention inthe early years, all of which were important facilitatorsof program uptake. The implementation of the Programwas facilitated by local implementers having direct accessto researcher staff who designed or delivered the Programto provide training and guidance for implementation.

Mentoring programs where researchers and practitionerscan learn from each other during the translation processhave been shown to be useful for both parties [50]. How-ever, challenges remain in funding researcher time, withresearch translation activities often considered outside ofthe traditional academic role. Dedicated funding for re-search translation and the establishment of mentoring orsecondment opportunities for researchers, policy makersand practitioners to work together may be a useful stepforward in supporting partnerships between researchersand end users of research.The findings highlight the importance of having key

individuals responsible for driving and coordinating re-search translation across the domains of research, policy,and practice. This case study is unique in that fundingwas provided to support the translation efforts. At thelocal level, the prevention workforce as part of the localprevention infrastructure was critical in engaging andworking with key partners to deliver the Program. Thesecoordinators undertook critical research ‘translation ac-tivities’ including exploring how the Program fitted withand enhanced existing services and how it could be bestadapted to ensure sustained program delivery. In thescaling up of public health programs, considerationneeds to be given to who will undertake these researchtranslation activities at the local level. From a researcherperspective, research staff need funding to support thetranslation of research interventions into pre-packagedprograms ready for community wide implementation.This study also demonstrates the important role thatpolicy personnel can play in supporting research transla-tion, highlighting the value of incorporating this compo-nent into existing policy positions. Previous case studiesof research interventions with positive practice and pol-icy impacts [33] as well as a recent literature review offacilitators of scaling up [8], have demonstrated the im-portance of leaders, champions and coordinators in ad-vocating for and supporting adoption of public healthinterventions into practice.The study findings point to important lessons regard-

ing the scaling up and sustainability of program imple-mentation. It is yet to be seen whether the InFANTProgram can be scaled up and delivered on an ongoingbasis in the absence of funding from the Department forthe Program. Given that ongoing funding for any pro-gram at a state or local level was unlikely at the time ofthis study, it appears that embedding program deliveryinto existing service infrastructure will be critical forboth scaling up and sustainability of the Program. Withthe strong competing demands on practitioner time andresources, it will be important that ongoing programevaluation be conducted to support a business case forcontinuation of the Program locally within existing ser-vices. This points to the importance of cost effectiveness


analysis to be conducted as part of intervention trials tohelp make the case for investing in particular interventionprograms. This is in line with a recent narrative review,which identified establishing monitoring and evaluationsystems and costing and economic modeling of interven-tion approaches as important success factors for scalingup public health interventions [8]. Alignment of the Pro-gram to both state and local policy context will also be im-portant in harnessing ongoing support for the Program.This study has a number of strengths and limitations.

The strengths include the use of multiple varied casestudies and cross case comparisons to explore the im-portant influence of local context on implementation.We did however, only have one rural site participate inthe study and the inclusion of additional rural sites mayhave resulted in different implementation issues emer-ging. We also did not include sites that chose not toimplement the Program, which may have provided in-teresting additional insights into factors influencing ini-tial uptake. Within cases, we interviewed a range ofstakeholders including coordinators, program facilita-tors and those involved in supporting program delivery.There was variation however in the number of peopleinterviewed across sites ranging from nine participants(site one) to two participants (site five) and this mayhave limited insights gained from some sites. The inclu-sion of researchers and policy makers involved in sup-porting program delivery as participants in the studywas also a strength as it enabled a comparison of viewsacross roles, providing important new insights fromthese various perspectives. While the study used arange of data collection methods including individualinterviews, focus groups and recording of meetings in-volving key players, additional methods such as obser-vation of program sessions, analysis of key documentsand interviews with parents may have yielded additionalinsights. While all data was collected and analysed by asingle researcher (RL), the trustworthiness of the find-ings was verified by participants on two separate occa-sions and the role and background of the research wasmade explicit.

ConclusionThis study highlights the important and complementaryrole that policy makers, researchers and practitionerscan play in the translation of health promotion programsinto routine practice. New avenues need to be exploredto comprehensively bring together researchers and endusers at all phases of the research to practice continuum.This is likely to lead to the development of more feasibleand scalable programs, assist in adapting programs to fitlocal circumstances, while maximising program fidelityand supporting implementation at the local level. Keyrecommendations for researchers arising from this study

include the need to develop feasible and scalable inter-ventions from the outset; to incorporate comprehensiveprocess evaluation measures, including cost effectivenessto inform future program roll out; and to identify coreprogram components that are important for program fi-delity. Consideration should also be given to additionalmediation and dose response analysis to be conductedto inform program fidelity recommendations. Recom-mendations for practitioners include the importance ofhaving a key individual responsible for coordinatingtranslation activities in the initial startup phase, engagingkey delivery partners to enable the Program to beadapted to fit and become part of existing local servicedelivery infrastructure. Consideration needs to be givento ongoing program evaluation at the local level to helpcreate a business case for sustained program delivery. Atthe policy level, funding for research translation activ-ities and partnerships between researchers and end usersneeds to be built into existing research funding schemes.

Additional file

Additional file 1: Healthy Living Program and Strategy selection criteria.(DOCX 199 kb)

AcknowledgementsThe authors would like to acknowledge Rowland Watson and Maya Rivas (TheVictorian Department of Health and Human Service) for their contribution andsupport in the delivery of the InFANT Program. Finally, the authors would like toacknowledge all participants for their time and valuable insights.

FundingThe research reported in this paper is funded by Australian Primary HealthCare Research Institute, which was supported by a grant from the AustralianGovernment Department of Health and Ageing. The information andopinions contained in it do not necessarily reflect the views or policy of theAustralian Primary Health Care Research Institute or the AustralianGovernment Department of Health and Ageing. Funding was provided bythe Victorian Department of Health and Human Services to support researchtranslation activities for the InFANT Program. The original InFANT Programdevelopment and testing was Supported by the National Health andMedical Research Council (grant 425801) with additional funds supplied bythe Heart Foundation Victoria and Deakin University. RL is supported by aNational Health & Medical Research Council Early Career Fellowship, ID1089415. KB is supported by a National Health & Medical Research CouncilPrincipal Research Fellowship, ID 1042442. KDH is supported by an AustralianResearch Council Future Fellowship IDFT130100637 and an HonoraryNational Heart Foundation of Australia Future Leader Fellowship ID100370.

Availability of data and materialsThe qualitative interview transcripts analysed during the current study arenot publicly available due to the possibility of identifying individuals.

Authors’ contributionsRL led the design of the study with input from other authors. RL was responsiblefor recruitment data collection and analysis and wrote the first draft of themanuscript. All authors contributed to and commented on drafts of themanuscript, approving the final manuscript submitted.

Competing interestsThe authors declare that they have no competing interests. While KC, KB andKH conducted the InFANT Program they have no financial interest arisingfrom the Program implementation or outcomes.


dx.doi.org/10.1186/s12889-016-3361-x

Ethics approval and consent to participateThe study was approved by Faculty of Health, Deakin University low risk ethicscommittee (approval number: HEAG 183_2014) and participants gave informedwritten consent to participate.

Author details1Institute for Physical Activity and Nutrition, School of Exercise and NutritionScience, Deakin University, Geelong, VIC, Australia. 2Centre for ObesityManagement and Prevention Research Excellence in Primary Health Care(COMPaRE-PHC), Sydney, Australia. 3Centre of Research Excellence in EarlyPrevention of Obesity in Childhood, Sydney, Australia. 4Prevention andPopulation Health, Department of Health and Human Services, Melbourne,Australia.

Received: 15 December 2015 Accepted: 23 July 2016

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