TYPE Original Research PUBLISHED 07 March 2023 DOI 10.3389/fpubh.2023.1062843 Co-designing implementation OPEN ACCESS strategies to promote remote physical activity programs in frail EDITED BY Narelle Warren, Monash University, Australia REVIEWED BY Yun Zhang, older community-dwellers Columbia University Irving Medical Center, United States Xun Luo, Lorena Villa-García1,2,3*† , Vanessa Davey1,4† , Laura M. Peréz1 , Kerry Rehabilitation Medicine Research Institute, China Luis Soto-Bagaria1 , Ester Risco5,6 , Pako Díaz7 , Kerry Kuluski8,9 , *CORRESPONDENCE Maria Giné-Garriga10,11 , Carmina Castellano-Tejedor1 and Lorena Villa-García lorena.v22@gmail.com Marco Inzitari1,12 1 † Research Group on Aging, Frailty and Care Transitions in Barcelona, Parc Sanitari Pere Virgili and Vall These authors share first authorship d’Hebron Research Institute (VHIR), Barcelona, Spain, 2 Doctorate Program, Department of Medicine, SPECIALTY SECTION Universitat Autònoma de Barcelona, Barcelona, Spain, 3 QIDA, Sabadell, Spain, 4 Population Health This article was submitted to Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, Aging and Public Health, United Kingdom, 5 Nursing Research Group, Parc Taulí Hospital Universitari, Institut d’Investigació i a section of the journal Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain, 6 Nursing Frontiers in Public Health Department, Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain, 7 Centre d’Atenció Primària Bordeta-Magòria, Barcelona, Spain, 8 Bridgepoint Collaboratory for Research and RECEIVED 06 October 2022 Innovation, Bridgepoint Health, Toronto, ON, Canada, 9 Institute of Health Policy Management and ACCEPTED 08 February 2023 Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, PUBLISHED 07 March 2023 10 Department of Sport Sciences, Faculty of Psychology, Education and Sport Sciences, Blanquerna, CITATION Universitat Ramon Llull, Barcelona, Spain, 11 Department of Physical Therapy, Faculty of Health Sciences, Villa-García L, Davey V, Peréz LM, Blanquerna, Universitat Ramon Llull, Barcelona, Spain, 12 Faculty of Health Sciences, Universitat Oberta Soto-Bagaria L, Risco E, Díaz P, Kuluski K, de Catalunya (UOC), Barcelona, Spain Giné-Garriga M, Castellano-Tejedor C and Inzitari M (2023) Co-designing implementation strategies to promote remote physical activity programs in frail older community-dwellers. Background: The “AGIL Barcelona (AGILBcn)” community-based integrated care Front. Public Health 11:1062843. program is a multicomponent healthy aging intervention for frail older adults. doi: 10.3389/fpubh.2023.1062843 In this context, the present study aimed to identify implementation strategies COPYRIGHT to optimize the accessibility, acceptability, and adaptability of mobile health © 2023 Villa-García, Davey, Peréz, (mhealth) interventions to enhance physical activity in frail older adults, and to Soto-Bagaria, Risco, Díaz, Kuluski, Giné-Garriga, Castellano-Tejedor and Inzitari. prioritize action points according to their importance and feasibility, through a This is an open-access article distributed under co-design process. the terms of the Creative Commons Attribution License (CC BY). The use, distribution or Material and methods: A mixed methods approach was used. In the qualitative reproduction in other forums is permitted, phase, a method adapted from the World Café was applied in 6 virtual groups provided the original author(s) and the to identify strategies to facilitate the virtual physical activity program. In the copyright owner(s) are credited and that the original publication in this journal is cited, in quantitative phase, prioritization and feasibility of the strategies was analyzed accordance with accepted academic practice. through surveys. Strategies were ranked based on priority vs. feasibility, revealing No use, distribution or reproduction is if strategies should either be: implemented first; if possible; taken into account for permitted which does not comply with these terms. future consideration; or directly disregarded. The convenience sample included older adults (n = 7), community professionals (n = 9) and health professionals (n = 13). Qualitative data were analyzed by summative content analysis and quantitative data by nonparametric descriptive analyses. Results: A total of 27 strategies were identified and grouped into four categories: general strategies for reducing barriers; specific strategies for facilitating the use of a digital application; specific strategies for facilitating participation in virtual exercise groups; and specific strategies for facilitating external support. According to the ranking of strategies, the first ones to be implemented included: digital literacy, digital capability assessment, family technology support, weekly telephone follow-up by professionals, personalizing exercises, and virtual exercises in small groups. Frontiers in Public Health 01 frontiersin.org Villa-García et al. 10.3389/fpubh.2023.1062843 Conclusion: The active participation of all stakeholders enabled us to identify potential strategies for implementing person-oriented technology in physical activity programs and for engaging older adults. KEYWORDS older adults, frailty, aging, mhealth, World Café, integrated care, participatory methods, co-design 1. Introduction The present study is part of the +AGIL Barcelona (AGILBcn) program (15), a complex community intervention co-designed The aging of the population is accompanied by an acceleration by and for frail older adults, together with primary care teams in the incidence of disability (1). Frailty, defined as a pre-disability and community stakeholders. The program encompasses different state of initial impairment of intrinsic capacity, is a target for aspects of health including physical activity, nutrition, emotional interventions aimed at improving function and delaying disability wellbeing, sleep hygiene, cognitive screening and stimulation, (2). Multicomponent lifestyle interventions aimed at promoting loneliness, and medication review. The AGILBcn multicomponent healthy aging have proven to be effective in the short term (3, 4). exercise program consists of 10 face-to-face group sessions led During the COVID-19 pandemic, social distancing protocols by a physiotherapist in a primary care setting. The program is and the subsequent demand for community spaces led to an complemented by exercises performed at home and prescribed increase in sedentary behavior in older adults (5), contributing through the publicly available ViviFrail R App (16). Results showed to the progression of frailty and disability (6). An alternative a positive impact on physical function at 3 months (17). approach to traditional face-to-face physical activity interventions Due to the COVID-19 pandemic and the ensuing challenges that has gained special momentum is the use of mobile health facing health services, pressure to redesign the program in a (mhealth) (7). Technology-based interventions appear to positively virtual or semi-virtual format increased. However, despite the influence physical activity levels in older adults (8) and offer the great potential of digital technology to enhance the promotion of potential to reach individuals on a large scale while allowing healthy lifestyles in older adults, a lack of specific implementation for personalized programs. Despite the availability and potential strategies could even exacerbate health inequalities, increase costs, of technology for enhancing physical activity (9), barriers to its and jeopardize implementation in routine practice. adoption and use by older adults and in different care settings This work aims to identify implementation strategies for remain (10, 11). optimizing the accessibility, acceptability, and adaptability of It is widely recognized that there is a significant gap between mHealth interventions aimed at increasing physical activity, within the development of evidence-based interventions for public the framework of AGILBcn or similar programs, and to assess their health and health promotion and their successful and sustainable level of priority and feasibility through a co-design process aimed at implementation (12). Approaches for promoting physical ensuring equal and equitable participation of multiple stakeholders. activity in older adults using mhealth present unique challenges. Currently, most physical activity promotion interventions remain limited to the experimental or pilot phase, as their 2. Materials and methods continuous implementation or scale-up poses large difficulties. These include a limited understanding of implementation 2.1. Study design strategies and a failure to match these to the needs of end users. A mixed-methods study was designed, incorporating both Engaging end users in the development of health promotion qualitative and quantitative data and adopting a triangulation interventions and the design of digital solutions incorporating multilevel model, to elicit views from key stakeholders: older adults elements derived from participatory methodologies, conceived (OA) as end users; health professionals (HP); and professionals within the framework of patient and public involvement (PPI), from the community and voluntary sector (CVS). We selected these is key to achieving strategies that are contextually adapted and key participants in order to assess the accessibility, acceptability conducive to their sustained adoption and implementation (13). and adaptability of the AGILBcn virtual program, aimed at older Participatory design, now known as co-design, is hypothesized adults with frailty but absent or mild disability. Specific themes were to have a strong and lasting impact on health outcomes and addressed, including: barriers related to the “digital divide” that may represent a promising strategy for addressing complex health must be overcome, to ensure the viability of incorporating mHealth behaviors. Co-design in this context specifically refers to patients (app and virtual exercise sessions) into the program; logistics of and caregivers working collaboratively with health and allied health exercising and conducting virtual exercise sessions from the homes professionals to improve service delivery by sharing knowledge of older adults; and monitoring, support and other factors that and experience (14). Its goal is to optimize the implementation could affect uptake, motivation and adherence to the program. of evidence-based interventions according to the priorities and The co-design process was carried out in two phases described preferences of all stakeholders, enabling designed solutions to below: (1) six virtual “World Café” (18) sessions (renamed as achieve maximum feasibility and sustainability. “AGIL Café” sessions) to identify implementation strategies for Frontiers in Public Health 02 frontiersin.org Villa-García et al. 10.3389/fpubh.2023.1062843 facilitating the deployment of the AGILBcn virtual program; and 2.3. Data collection (2) evaluation of the level of priority and feasibility of the strategies identified during the AGIL Café sessions, using digital surveys. 2.3.1. Phase 1: Procedure of AGIL Café This study used the World Café participatory research approach (18) to facilitate structured and unstructured collaborative dialogue and knowledge generation for the resolution 2.2. Settings and participants of common problems from the perspective of multiple stakeholders (21, 22). This method allows for obtaining the lived experience Participation was sought to represent the main stakeholders of the participants and their needs and preferences for services, in the community-based multi-component AGILBcn program dividing large groups into smaller ones while remaining part of (15). Participants included older adults, health professionals and a single, connected conversation (22). It has been used in a wide professionals from the community. Purposive sampling was used variety of settings, including the development and evaluation of to identify and select key participants capable of offering a wealth health services (22) and for the improvement of care for older of information regarding the phenomenon of interest (19, 20). adults (23). Inclusion criteria for participants were: Six AGIL Café sessions (2 groups for each profile) were conducted. The decision to avoid mixed groups was made to give • Older adults with no or minimal disability in performing equal status to end users and thereby avoid the risk of reduced basic daily living activities, and with no acute diseases, aged participation due to differentials in status and experience (24). 70–90 years, and presenting at least one sign of frailty (i.e., The AGIL Café sessions took place between December 2020 slow gait speed, weakness, memory complaints, involuntary and March 2021, with a duration of 1.5 h per session, conducted weight loss, or poor social support), able to participate in in a virtual format (25). The Zoom R communication platform videoconferences, fluent in Catalan or Spanish and without was chosen for its video and audio quality, functionalities and speech disorders. simplicity. Meetings were password protected. At the time of the • Health professionals (physicians, nurses, physiotherapists, meeting, attendees were sent to a waiting room where identity was neuropsychologists, occupational therapists, or social confirmed. Sessions were video and audio recorded. The process workers) with more than 6 months of work experience was guided by a multidisciplinary research team with experience in primary care or geriatric services and in complex in primary, geriatric care, physical activity promotion programs chronic conditions. and qualitative research experience. In each workshop, a member • Professionals from the community and voluntary sector: of the team acted as facilitator; an additional member admitted workers from third sector services targeted at older adults participants to the call and helped to solve technical problems (municipal or non-profit programs). during the session (LS); two recorded ideas (VD and MI); and two others acted as observers and evaluators of the process (LMP and Three researchers (LMP, LS, MI) were responsible for LV). To stimulate the conversation, the team developed a script, recruitment. Potential participants were contacted either by adapted for each group, containing main questions and subsidiary telephone (OA, previous or potential participants in AGILBcn) or prompts (Supplementary Table 1). These were guided by study e-mail (HP and CVS), to request participation and to explain the objectives, existing literature, and independent and representative objectives, structure and format of the sessions. HP were recruited feedback on understandability and comprehensiveness. Sessions from an intermediate care hospital and a primary care center in were conducted in rounds (introduction followed by a round Barcelona and were selected for diversity in profession, work area for each question). To facilitate the participation of all attendees and professional experience. CVS were recruited based on the type and to prevent any single participant from monopolizing the of community organization they worked for (e.g., civic centers, conversation, each participant was invited to respond by the pharmacies), and professional experience related to community moderator, who carefully monitored responses. After each round, programs targeting older adults (e.g., programs to increase physical time was allocated to unstructured discussion. The real-time activity, improve digital skills, reduce loneliness). LucidChart R app was used by the researchers to record and We aimed for between 6 and 12 participants per stakeholder visualize ideas presented by participants using virtual “sticky group and invited 13 participants to each group to ensure notes” and graphics functions. This enabled the correction and participation. Sample size was determined based on the capacity clarification of suggestions made and permitted the continuous of the selected sample to provide information and on a criterion overview of ideas generated, facilitating reflection. of information redundancy in the identification of new codes or themes (20). Of the 13 candidates from each group who were contacted for recruitment, 6 OA decided not to participate due to health- 2.3.2. Phase 2: Prioritization and viability of related problems or overlapping duties (which the research team changes identified in the co-design groups: had tried to accommodate), 4 CVS declined the invitation due to Surveys work commitments, and all HP agreed to participate. Finally, 7 OA, Based on the qualitative analysis of the AGIL Café sessions 9 CVS and 13 HP agreed to participate. No participants withdrew (phase 1), an ad hoc questionnaire was developed in Catalan, from the study. consisting of 27 potentially actionable strategies for facilitating the Frontiers in Public Health 03 frontiersin.org Villa-García et al. 10.3389/fpubh.2023.1062843 AGILBcn virtual program, which were subdivided into 4 categories for priority (P) and feasibility (F) (separately) and converted all or blocks. responses into numerical scores. Values were as follows: P1/F1 The questionnaire required that each item be ranked according −100 (highest), P2/F2 −75 (high), P3/F3 −50 (medium), P4/F4 to its perceived priority and feasibility using a 5-point Likert scale −25 (low), P5/F5 −0 (lowest). Using these values, we calculated: from P1/F1, representing the highest priority/highest feasibility, to • The “priority vs. feasibility score” (PvF score), which P5/F5, representing the lowest priority/lowest feasibility (the range corresponds to the average of the priority and feasibility scores, of options is described in Supplementary Table 2). A participant providing an estimate of the global relevance of each item. from each stakeholder group was asked to review the questionnaire • The difference between the mean priority and feasibility prior to its dissemination, to identify any problems and rate its score, which gives an idea of the agreement between P comprehensibility. The survey was conducted using the online and F. We included this parameter because, although a platform LimeSurvey R between May and June 2021 with a 100% strategy might rank high overall in PvF, it might show response rate. The survey was distributed to HP and CVS via email, a gap between its P and F (e.g., high P and average or with information on its purpose and objectives. The survey entry low F) reflecting a lack of agreement between priority and screen specified how data would be used and requested informed feasibility scores. consent. Participants could withdraw at any time before submitting All scores were calculated for each of the participant profiles. their final responses. Data were analyzed and processed using STATA R and Excel R . For OA, the survey was disseminated and completed via computer-assisted telephone interviewing to avoid any potential difficulties from the use of online platforms. Questions were read 2.5. Ethical and research approvals aloud directly from the online survey, and responses were recorded in real-time in the online system. A single trained interviewer (LS) Ethical approval was obtained from the Clinical Research Ethics conducted all surveys from the call center of the referral hospital. Committee (CREC) of the Foundation University Institute for Primary Health Care Research Jordi Gol i Gurina (IDIAPJGol) (20/048-P) and by the Ethics Committee on Animal and Human Experimentation (Authorization Number CEEAH 5066) of the 2.4. Data analysis Universitat Autònoma de Barcelona (UAB). All participants received verbal and written information about the study and 2.4.1. Qualitative data provided written consent for recording the sessions, using Content analysis (26, 27) was performed to identify all anonymized verbatim quotations in the reporting of data, and potentially actionable strategies raised by participants in the AGIL using audio, photograph and/or video recordings of the sessions Café sessions using AtlasTiTM , based on transcripts, field notes and in dissemination. visual record captured in LucidchartTM for additional clarification. Some interpretation was required, to distinguish relevant material: two researchers worked together (LV, VD), thoroughly reviewing the material generated from each session, and carrying out analysis 3. Results independently. Once finished, the codes, categories and themes 3.1. Characteristics of study participants were unified and agreed upon. Once coded, frequencies and quotations were derived for The ages of participating OA (n = 7) ranged from 70 to 90 years all potentially actionable items and analyzed. Initially, 48 (Table 1), in line with participants in the AGILBcn program. CVS codes were identified, discussed and reviewed by the research was the most diverse in background, encompassing professionals team. Codes representing the same underlying concept were working as part of neighborhood health plans (n = 2), a community collapsed into one category, and codes were grouped into project aimed at tackling loneliness (n = 1), a city community sections covering specific themes, resulting in the categorization project for improving the situation of people in need of care and of four umbrella categories and 27 codes. Questions for the their caregivers (n = 1), a neighborhood civic center (n = 1), a survey were then developed to elicit views on the priority community pharmacy (n = 1) and a foundation that assists older and feasibility of the proposed strategies, for practical purpose adults living alone (n = 2). and to validating and triangulating the groups’ data (28). We From the participating HP (n = 13), the most represented also analyzed the quantitative data to show the participation of professions were medical doctors (5) and nurses (3). Other allied stakeholders in the categories, and as such, their initial “ownership” HP included a psychologist (n = 1), a physiotherapist (n = 1), an of ideas; this provided a background to the interpretation occupational therapist (n = 1), and a social worker (n = 1). We of survey results and assisted in our appraisal of the co- also included in this group an expert in healthcare information and design methodology. communication technology (n = 1). 2.4.2. Quantitative data 3.2. AGIL Café results The Likert scale results for each of the 27 items of the phase 2 questionnaire were analyzed using non-parametric descriptive The results have been structured into 2 themes: (1) Suggested statistics. We assigned numerical values to the categorical ratings strategies that were, on the surface level: (i) actionable (to some Frontiers in Public Health 04 frontiersin.org Villa-García et al. 10.3389/fpubh.2023.1062843 TABLE 1 Characteristics of the sample. organized into four categories: (1) general strategies for reducing barriers to older adults participating in a virtual program (2) Participant Sex Age specific strategies for facilitating the use of a digital application OA1 Woman 82 to prescribe and teach individualized exercises and to monitor OA2 Man 81 progress; (3) specific strategies for facilitating the participation of OA3 Woman 84 older adults in virtual exercise groups, performed at home via group video calls; and (4) specific strategies for facilitating external OA4 Woman 86 support, if needed. OA5 Woman 88 Below, we provide an overview of how each stakeholder profile OA6 Woman 79 contributed to the set of actionable implementation strategies generated, with examples; observations are presented in accordance OA7 Woman 83 with the Consolidated group exercise for Reporting Qualitative Participant Sex Professionals from the Research guidelines (COREQ) (29). community and voluntary sector CV1 Woman Community Pharmacy CV2 Man Technician developing neighborhood health 3.2.1. Category 1: General strategies for reducing plans barriers to older adults in a virtual program CV3 Woman Foundation that helps elderly people living alone Strikingly, 85% (n = 17) of the strategies generated in this category came from HP, with lengthy discussions on concerns CV4 Man Foundation that helps elderly people living alone of lack of digital literacy among OA, much of which was from CV5 Man Community project to tackle solitude direct experience (Table 2). Early assessment of digital capacity was CV6 Woman Technician developing neighborhood health considered something that should become standard practice. plans CV7 Woman Departament Promoció persones grans “In geriatrics we are very used to using scales for everything, if there is a scale for a pre-measurement of their CV8 Woman A city community project to improve the digital skills, it should be part of the holistic assessment of the situation of people in need of care and their caregivers person” (HP 3: Woman, health professional, Doctor). CV9 Woman Neighborhood Civic Center Moving beyond this, pre-intervention face-to-face contact with Participant Sex Profession end users and caregivers was perceived as key to guaranteeing an HP1 Woman Computer systems expert understanding of the program and of potential barriers for each person (and his/her caregiver), and to devising person-centered HP2 Man Physiotherapist strategies to trying to reduce them. HP3 Woman Doctor HP4 Woman Doctor “There is a need for an initial visit, where they are accompanied. This is how to introduce physical activity, HP5 Woman Neuropsychologist technology and stimulate involvement and motivation” (HP 4: HP6 Woman Doctor Woman, health professional, Doctor). HP7 Woman Nurse All participating groups described the need for digital training HP8 Woman Nurse programs, although suggestions varied. HP underlined the benefits HP9 Woman Nurse of paper manuals, in combination with further scheduled contact HP10 Man Doctor during the intervention period: HP11 Woman Doctor “At the time of seeing them, if you can, reinforce and HP12 Woman Occupational Therapist review their ability to interact and use ‘the app’... To do HP13 Woman Social Worker this, I have created written support, a mini-manual, with steps adapted to the person’s ability” (HP 5: Woman, health professional, neuropsychologist). degree) on the short term; (ii) within the boundaries of the project and, (iii) within the scope of influence of the actors involved, either 3.2.2. Category 2: Specific strategies for at an individual or institutional level; and (2) Priorities for change facilitating the use of a digital application to that were wider in scope than the project and could not be actioned prescribe and teach individualized exercises and upon on the short term. to monitor progress This paper focuses on the first theme. Our data coding Relatively few suggestions (n = 12) were made on how to and categorization process revealed four main categories and 27 improve the accessibility and viability of using a digital application codes of potentially actionable strategies (Table 2). The results are for personalized exercise plans for all groups (Table 2). End users’ Frontiers in Public Health 05 frontiersin.org Villa-García et al. 10.3389/fpubh.2023.1062843 TABLE 2 Description and frequency of the main strategies (codes) suggested by the participants for implementing a virtual exercise program, grouped into four main categories. Codes All (n = 29) CvS (n = 9) HP (n = 13) OA (n = 7) General strategies for reducing barriers to older adults in a virtual program Assess digital capacity 8 0 8 0 Conduct educational meetings in advance to train and educate in the use of technology 3 0 3 0 Provide simple, paper-based educational materials on how to use technology 6 0 3 3 Inform family on the selected solutions to reinforce the use of technology 0 0 3 0 Assess the need for external support with technology and facilitate it, if necessary 5 1 4 0 Provide continuous technological support 6 4 2 0 Specific strategies to facilitating the use of a digital application to prescribe and teach individualized exercises and to monitor progress Provide feedback from a healthcare professional by phone, on individual progress 5 0 2 3 Use gamification techniques 3 0 2 1 Implement a formal digital “expert user” program (support by “peer champions”) 3 2 1 0 Create a simple educational video on how to use technology and share it via chat 1 0 0 1 Specific strategies for facilitating the participation of older adults in virtual exercise groups, performed at home via group video calls Establish preferred platform for video calls 1 0 1 0 Implement systems for sending reminders with dates, via chat apps or phone calls 1 0 1 0 Inform caregiver or support volunteers about the class schedule 1 0 1 0 Provide a variety of physical exercises 3 0 0 3 Limit the size of the virtual group 3 0 0 3 Incorporate music in the sessions 9 0 0 9 Involve older adults in the co-design of the sessions 2 1 1 0 Provide feedback from a healthcare professional by phone, on group progress 5 0 2 3 Create peer-to-peer/group messaging in the chat application 3 1 2 0 Specific strategies for facilitating external support if needed Recruit local volunteers offering digital support 6 6 0 0 Organize peer support for technology 4 3 1 0 Develop an intergenerational technology literacy program with students 0 2 0 0 Custom referrals to local support services 9 5 4 0 Use local groups or volunteer networks to provide technological support 11 6 5 0 Prioritize any agency/group known to the individual as external support 9 8 0 1 Develop a formal support plan agreement/ social prescription of the program 13 7 6 0 Train primary care staff in support options and referral processes 2 1 1 0 CvS, professionals from the community and voluntary sector; HP, Health professionals; OA, older adults. The numbers in the table represent the number of participants that suggested that particular strategy. reactions to indirect support mechanisms such as training videos or not they were “getting it right”. This was tied to a belief that and paper guides were mixed. Some participants found using a performing the exercises incorrectly would result in not obtaining video guide rather than written instructions more appealing, and the desired improvement. They felt more confident if a professional vice versa. One person described following exercises at home alone followed up on the activity at regular intervals to “control results; with a paper or video guide as “sad”. Support via trained expert if you have done it, or if you have not” (OA 2: Man, older adult). users in digital literacy was mentioned by professionals, in line Weekly follow-up by a health professional was suggested only by a with expert patient programs to promote autonomy and self-care in minority from this group; others spoke about capacity issues. Game people with chronic pathologies, but end users were unsure about elements, such as rewards and leveling up, were mentioned by a this when it was suggested by the researchers. Most of the end minority of HP and older adults, but signs of improvement were users said, however, that they would be concerned about whether viewed by end users as the primary motivation: Frontiers in Public Health 06 frontiersin.org Villa-García et al. 10.3389/fpubh.2023.1062843 “As long as you see that [doing exercise like this] program, for ensuring accessibility and promoting adherence helps...that you notice that you’re getting better...” (OA 2: Man, should be subsumed under other endeavors: older adult). “I think it would also be important to have the option of having two older people together who can receive the training, so we encourage something that is also very important... peer socialization” (CVS 5: Man, professional from the community). 3.2.3. Category 3: Specific strategies for facilitating the participation of older adults in virtual exercise groups, performed at home via group video calls 3.3. Prioritization process Older adults were most vocal in suggesting ways of making virtual exercise groups more accessible and appealing to them The AGIL Café sessions generated a large number of potentially (68%) (Table 2). The option of participating in virtual exercise actionable strategies (Table 2). There was also an obvious clustering groups was seen by end users as preferable to being prescribed of suggested by the professional group (HP vs. CVS). This physical exercise alone through videos or a worksheet. Many said created challenges for appraising the value and adaptability of that, ultimately, face-to-face groups were more desirable to them possible strategies to optimize the accessibility, acceptability and for social interaction. Still, some mentioned that virtual groups adaptability of the virtual program. Consequently, the survey, might be easier because of mobility concerns, fear of falling, pain eliciting views on prioritization, offered the participants the restricting mobility and fear of (COVID-19) infection: opportunity to evaluate all proposed strategies. “For me, the greatest difficulty would be not being able to do it in the neighborhood without having to take public 3.4. Priority vs. feasibility score transport” (OA 4: Woman, older adult). According to overall PvF score (Table 3), the top ten most Limited group size was raised by many as necessary to valued strategies were related to: (a) improving group exercise ensure personalized attention. Some had had negative experiences through videoconference (limited group sizes, personalized attending large and overcrowded group exercise classes, targeted exercises, choice of a preferred platform, reminders for the generally at their age range. Music featured heavily in the classes, and music); (b) general ways to overcome technological discussion. They felt that they would find it much more enjoyable barriers (meetings to prepare and train users of technology, and easier to perform if the accompanying music was adapted to identification of a support person, shared information with family the exercises to be performed. about the technology employed before the start of the program, and assessment of the need for external support with technology and facilitate it, if necessary and (c) the use of Apps (periodic 3.2.4. Category 4: Specific strategies for follow-up calls to check on the use of the App and the progression facilitating external support if needed of the program). In contrast to the first category, which was formed largely from Average PvF score for all stakeholder groups tended to HP input, “external support” mechanisms were predominantly smoothen the contribution of each group, compounded by the raised by CVS, reflecting their work (Table 2). As with the first uneven number of participants in each; thus, we also present category, almost none of the strategies from this domain user were the results stratified by groups (Table 3). Maintaining a person- shared by our older adults’ representatives. This was unsurprising, centered approach was a priority, so it is important to note that as all had some level of family support available for digital literacy: 9/10 items prioritized by the users were concordant with the top ten from the overall ranking. Finally, CVS scores were systematically “..... I see my daughter every morning, I will tell her to teach lower on all items, although the rank of priority was similar that of me” (OP 1: Woman, older adult). the other groups. While there was much agreement on drawing on community support networks to assist people without family support, the 3.5. Differences between priority and potentially actionable strategies offered were diverse. Local groups feasibility scores or established support networks featured more frequently than the more loosely defined “local volunteers”, with emphasis placed on When looking at the difference between priority and feasibility making the most of existing resources (whatever they may be) (Table 3), the top three actions in terms of feasibility (group sessions at the neighborhood level. To this extent, CVS representatives through videoconference with a low number of participants and a encouraged mapping local resources including spaces, such as high personalization of exercises, as well as setting-up a meeting libraries and civic centers, which offered meeting points and specifically for preparing for the use of technology), seemed internet connection. Many of the participants from the third sector coherent in terms of both priority and feasibility. In contrast, the spoke of the longer-term purpose of empowering older adults assessment of the need for external support, the identification of a and fostering social relations. The needs of the virtual AGILBcn support person and the provision of weekly follow-ups with users Frontiers in Public Health 07 frontiersin.org Villa-García et al. 10.3389/fpubh.2023.1062843 TABLE 3 Comparison of priority (P) vs. feasibility (F) score (PvF) for each suggested strategy, and differences between average P and F for each item of the questionnaire. Blocks (4) PvF Score Difference (P, F) All CVS HP OA All CVS HP OA n 29 9 13 7 29 9 13 7 Limit the size of the virtual group to facilitate personalized attention Virtual groups 81 64 87 93 −3 0 −6 0 Provide a variety of physical exercises to be tailored to the individual Virtual groups 75 54 83 89 −1 8 −7 0 Conduct educational meetings in advance to train and educate in the use of General 74 65 80 73 −4 8 −17 4 technology Establish a preferred platform for video calls Virtual groups 73 69 77 70 −6 −11 −6 0 Implement systems for sending reminders with dates via chat apps or phone Virtual groups 73 58 85 70 1 6 −3 3 calls Provide continuous technological support General 71 55 74 84 −12 0 −29 4 Incorporate music in the sessions Virtual groups 71 51 77 84 1 −8 8 4 Inform family on the selected solutions to reinforce the use of technology General 69 56 76 71 −8 6 −17 −7 Assess the need for external support with technology and facilitate it, if General 69 53 69 89 −14 0 −31 0 necessary Provide feedback from a healthcare professional by phone, on the individual App 69 65 65 82 −11 −8 −19 0 progress Assess digital capacity General 68 65 77 55 −4 −3 −19 4 Provide simple, paper–based educational materials on how to use the General 67 57 74 68 8 14 10 0 technology Provide feedback from a healthcare professional by phone, on the group Virtual groups 67 51 72 78 −7 −3 −14 0 progress Create a simple educational video on how to use technology and share it via App 66 64 68 64 6 17 2 0 chat Use gamification techniques App 66 55 76 61 0 12 −10 0 Involve older adults in the co–design of the sessions Virtual groups 64 36 83 66 −10 −12 −15 4 Inform caregiver or support volunteers about the class schedule Virtual groups 63 51 68 68 −2 −3 −2 0 Use local groups or volunteer networks to provide technological support External support 63 50 73 61 −7 8 −19 0 Recruit local volunteers offering digital support External support 62 59 63 61 −9 −3 −19 0 Create peer-to-peer/group messaging in the chat application Virtual groups 61 62 65 50 6 3 11 0 Custom referrals to local support services External support 61 54 70 54 −11 0 −23 0 Prioritize any agency/group known to the individual as external support External support 60 55 73 43 −9 −4 −16 0 Organize peer support for technology External support 57 53 59 59 −16 −17 −21 −4 Implement a formal digital “expert user” program (support by “peer App 55 66 47 60 −15 0 −22 −19 champions”) Develop an intergenerational technology literacy program with students External support 55 38 65 61 −8 −9 −12 0 Train primary care staff in support options and referral processes External support 54 50 68 36 −14 −7 −22 0 Develop a formal support plan agreement/ social prescription of the program External support 53 55 62 33 −5 18 −21 3 All 65 56 72 66 −6 <1 −12 <1 Items are ordered from highest to lowest PvS. Blocks (4) refer to the 4 categories into which the 27 strategies are grouped in Table 2. PvF score, priority and feasibility score; CVS, professionals from the community and voluntary sector; HP, Health professionals; OA, older adults. PvF score is calculated as the averaging the mean priority and feasibility scores; the difference is between the mean priority and feasibility score. For the PvF score, the higher score, the best “compromise” between P and F, whereas for the Difference, a value close to 0 indicates the highest coherence between the 2 construct. of digital apps correspond to actions with apparent lower feasibility 3.6. Prioritization of solutions by means of a than priority. End users tended to express the highest coherence in prioritization matrix the feasibility of the actions with higher priority. On the other hand, HP had the lowest confidence in the feasibility of actions with the The answers to the questionnaire were then plotted in a 4 highest priority. × 4 matrix categorizing the combined priority and feasibility Frontiers in Public Health 08 frontiersin.org Villa-García et al. 10.3389/fpubh.2023.1062843 FIGURE 1 Mapping of responses to general strategies to reduce digital barriers to older adults. response for each item ranging from top priority-top feasibility (Supplementary Table 2). The responses for each sub-section of the to no priority-no feasibility, according to the priority and questionnaire were plotted to create visual maps (Figures 1–3). feasibility scores for each item (score 75–100 = top, 50–74 = This procedure allowed us to map the proposed solutions in medium, 25–49 = low and 0–14 = no priority or feasibility terms of their importance and feasibility or practical need for Frontiers in Public Health 09 frontiersin.org Villa-García et al. 10.3389/fpubh.2023.1062843 FIGURE 2 Mapping of responses to specific strategies to facilitate the use of physical activity App and specific strategies to facilitate the participation of the older adults in virtual exercise groups performed at home during group video calls. action: must do, do first; important, do second; do if possible; end of a virtual exercise program, with each task coded according bear in mind/ consider; and do not consider. Figure 4 represents to this 4-category priority matrix. This map might add value the different proposed solutions as a “visual journey” of tasks that in terms of a meaningful and workable way of looking at the should be considered on a timeline, from the beginning to the results in order to guide the adaptation process, in accordance Frontiers in Public Health 10 frontiersin.org Villa-García et al. 10.3389/fpubh.2023.1062843 FIGURE 3 Mapping of responses to specific strategies to facilitate external support. with the data generated from the co-design process. In particular, calls to those using digital apps, substituting virtual exercise class it ensures that the data on both priority and feasibility have an reminders). The other “must do” items are coherent with the PvF even influence on the results and that the results of each group score ranking (set up a preparation meeting, identify a support have an even influence, despite the differences among groups in person for technology, assess the need for external support, limit the respective number of participants. Consequently, one of the the group size and personalize the exercises during videoconference six items that appear as “must-do” does not match with the top groups). No solution was classified as “do if possible” or “do six items according to the PvF score (weekly follow-up telephone not consider”. Frontiers in Public Health 11 frontiersin.org Villa-García et al. 10.3389/fpubh.2023.1062843 FIGURE 4 Graphic representation of the main suggestions from all groups, plotted along an ideal timeline, from the preparation to the execution of the mHealth solution to foster physical activity. 4. Discussion educational sessions, collaborative learning and paper or video guides represented priorities to improve self-efficacy and digital Through the +AGIL Café sessions, 27 possible strategies were literacy at the individual, interpersonal and social/community suggested to adapt a multicomponent program aimed at enhancing levels. Second, for the participating health professionals, the physical activity in older adults, based on accessibility, acceptability assessment of access to digital infrastructure, social support and and adaptability. These were grouped into 4 categories: general digital skills should be systematically and universally added to the strategies for reducing digital barriers; specific strategies for comprehensive assessment of older people; this is a core element facilitating the use of a digital application; specific strategies of AGILBcn (15) and is consistent with previous studies (34). Our for facilitating the participation in virtual exercise groups; and findings are also consistent with the need for social and community strategies for facilitating external support, if needed. The priorities support for the adoption and use of technology by OAs, for the included improvement of digital literacy, assessment of training resolution of technical problems, and for a decrease in the potential and technology support needs, technological support from family digital divide, as highlighted by other authors (8). This support members, telephone feedback, personalized exercises, and exercise might be provided by family members or by local networks (e.g., conducted in small groups. volunteers or peers). Although mhealth interventions appear to be beneficial for Social interaction in face-to-face groups has been shown to increasing physical activity levels in OA (8, 30), there are benefit the adoption, increase and maintenance of physical activity still barriers to large-scale implementation, on personal, social, (35, 36). In our study, older adults recognized virtual group delivery technological, and organizational levels (10). We present solutions as an opportunity to remove some of the existing barriers to for program adaptation that vary in complexity from single- participating in face-to-face group programs and as a means to component strategies to multifaceted and multilevel strategies (31). interact with peers, avoiding exposure to COVID-19. In contrast, The variety of strategies proposed by our participants appears CVS highlighted that the potential benefits of virtual delivery are in line with the characteristics that m-health interventions for undeniable, but that the pandemic has amplified the barriers to physical activity promotion should have (8, 30) and with the technology in OA, increasing their social isolation and loneliness theoretical constructs for promoting and sustaining behavior (11). Controversy exists regarding the positive or negative impact change (BCT) (32). First, according to the existing literature, an of technology on loneliness, connectedness, and social support essential strategy for increasing physical activity levels is to develop (33). Future interventions should seek to mitigate the social digital health-literacy training resources (8, 33). In our study, connectedness paradox of COVID-19 (37). Our groups emphasized Frontiers in Public Health 12 frontiersin.org Villa-García et al. 10.3389/fpubh.2023.1062843 the importance of combining non-digital alternatives to decrease Although the platform allows the respondent to be seen, it is the digital divide. Providing feedback is another important strategy possible that we missed some non-verbal and body language cues, to promote and maintain adherence to physical activity, and to as participants often sit close to their cameras. Participants who trigger and sustain motivation for goal attainment (32). Among were not technologically skilled required additional attention from different options available [e.g., telephonic, via apps, wearable the research team members, which led to a delay in the start of the devices (38)], our participants still preferred to receive feedback sessions. The results should be interpreted with caution: the study by phone. was conducted in a particular area and with a particular group of Attitudes of OA toward mhealth exercise vary (39). In our case, participants, thus the results may not be completely generalizable; OA were willing to use technology-based exercise programs if they the integration of the different contributions made by the three perceived them as useful or beneficial for achieving their goals. different groups was limited to the final prioritization approach; Interestingly, all participating groups paid little attention to safety and, finally, the phrasing of specific questions introduced the risk and privacy in technology use, as compared to available evidence of being leading or suggestive (this, however, was necessary at the (10). OA focused on the adherence to and safety of home exercise beginning of the sessions with OA, who had trouble understand performance, suggesting that technology is not an end in itself, but more open questions). a mean. As for strengths, the main advantage of the study was the While all the groups identified similar strategies, the results combination of qualitative and quantitative research methods to concerning priority and feasibility showed notable differences provide complementary information. Another strength was the among groups. The OAs appreciated the limited size of participants co-design approach involving all stakeholders, incorporating the in the virtual groups, the need for external support for participating diversity of perspectives of the AGILBcn program. Purposive in the intervention, personalization of the exercises, guarantee of sampling enabled us to recruit a wide range of participant access to technological support, incorporation of music in the types, although obviously selection bias cannot be completely virtual exercise sessions, and weekly telephone follow-up by HP. excluded, as participation could have been skewed toward In contrast, significantly lower scores for these solutions were motivated individuals. observed in CVS, and, in a smaller proportion, in HP. CVSs scored lower on all items compared to the other two groups. In HPs, we observed a tendency to score higher for 5. Conclusion priority than for feasibility. This may be due to health professionals’ experience regarding macro-, meso- and micro-level barriers to The present study provides practical solutions for the implementation, scalability, integration and sustainability of implementing a technology-based, multicomponent program for mhealth interventions. Among the items for which HPs perceived older adults from a variety of perspectives, namely, those of older feasibility to be higher than priority were: the use of messaging adults acting as end users, but also those of health professionals Apps (such as WhatsApp) to connect users, or as a vector for and professionals from the community. If confirmed by future education; the creation of instruction booklets on the use of studies in experimental and implementation research, these applications; and the incorporation of music in virtual exercise results might provide important considerations for policymakers, sessions. OAs perceived as a priority the design of an expert patient care providers, and practitioners, for designing, adapting, and program and the sharing of information with family about the implementing multicomponent, technology-based programs intervention, although ease of implementation was considered low, aimed to promoting physical activity in the older adult population. coinciding with HPs views. Conversely, the recruitment of local This can help to overcome barriers imposed by extreme conditions, volunteers to provide support was deemed both a higher priority such as the COVID-19 pandemic, and to improve adherence and and a feasible step for all three groups. enhance scalability to exercise programs. We aimed to engage a wide range of stakeholders from an early stage to address the problem, identify strategies and prioritize them. This is in line with current policies, care practices and growing Data availability statement evidence on the importance of engagement and co-design for the development, implementation and adaptation of health promotion The raw data supporting the conclusions of this article will be interventions and for the design of digital solutions (40, 41). made available by the authors, without undue reservation. However, there was some disparity in results regarding the potential benefits of this involvement concerning uptake and adoption (42). As in previous studies, the implementation of the co-design Ethics statement process was time- consuming, and it proved challenging to merge different stakeholder perspectives (43). In addition, involving OA The studies involving human participants were reviewed and in co-design was demanding, due to the extreme heterogeneity in approved by Clinical Research Ethics Committee (CREC) of physical and digital needs and capabilities (42). the Foundation University Institute for Primary Health Care As potential limitations of our study, the digital format of Research Jordi Gol i Gurina (IDIAPJGol) (20/048-P) and by the AGIL Café sessions provided opportunities to participate the Ethical Commission of Animal and Human Experimentation in conversations during the COVID-19 pandemic, but was (Authorization Number CEEAH 5066) of the Autonomous challenging due to technical limitations, such as signal loss, which University of Barcelona. The patients/participants provided their resulted in certain segments in which the audio was missing (44). written informed consent to participate in this study. Frontiers in Public Health 13 frontiersin.org Villa-García et al. 10.3389/fpubh.2023.1062843 Author contributions Conflict of interest LV-G, VD, LP, and MI contributed to the conceptualization of LV-G was employed by QIDA. the study. LV-G, VD, LP, and LS-B performed the data collection. The remaining authors declare that the research was LV-G and VD were responsible for data curation and formal conducted in the absence of any commercial or financial analysis. LV-G, VD, and MI were responsible for writing the initial relationships that could be construed as a potential conflict draft. ER, PD, KK, MG-G, and CC-T reviewed and edited the draft. of interest. MI supervised the process of manuscript preparation. All authors agreed to be accountable for the content of the work. All authors contributed to the article and approved the submitted version. Publisher’s note All claims expressed in this article are solely those of the Funding authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the LV-G was funded by the Industrial Doctorates Program reviewers. Any product that may be evaluated in this article, or [reference 2020 DI 76], promoted by the Government of Catalonia, claim that may be made by its manufacturer, is not guaranteed or Spain. This study received funding by the Barcelona Science Plan of endorsed by the publisher. the Cultural Institute of Barcelona-Barcelona City Council and by la Caixa Foundation [19S01576-006]. Supplementary material Acknowledgments The Supplementary Material for this article can be found We extend our sincere gratitude to the participants who shared online at: https://www.frontiersin.org/articles/10.3389/fpubh.2023. their time and effort in this study. 1062843/full#supplementary-material References 1. 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