Record characteristics
Peer reviewed literature searches, grey literature searches, custom Google search engines and targeted-web search approaches identified 528 records. As Web of Science’s cited reference feature allowed us to search multiple databases simultaneously, duplicates from these databases were not recorded. With grey literature searches, duplicates were also not recorded. Thus, zero duplicates were recorded during title and abstract screening. Of the 528 records, 163 records were deemed potentially relevant and were retrieved for full-text screening. Of the 11 contacted content experts, 10 participated and contributed an additional 58 records, all of which were retrieved for full-text screening. The full texts of 221 records were screened and 81 were included in data synthesis (Fig. 1).
PRISMA diagram of study flowa
The content expert consultation search approach had the highest yield at 44 unique records, followed by targeted web-based searches (n = 27). All other records were identified through peer-reviewed and grey literature searches (n = 10). The custom Google searches identified zero records.
Of the 81 records, 79 pertained to single guidelines while two related to two guidelines (i.e., for cancer survivors and pregnancy) [77, 78]. Forty-two records reported only dissemination strategies, 28 reported only implementation strategies, and 11 reported both D&I strategies, for a total of 53 records discussing dissemination strategies and 39 discussed implementation strategies. There were 23 instances where multiple strategies were used in a single record (e.g., “counselling” and “planning tools”) [106], resulting in 109 instances of the use of a strategy. Members of specific populations were targeted in 51 records, stakeholders (e.g., healthcare professionals) were targeted in 23 records, and 7 records targeted both.
Dissemination
RQ1: What strategies have been used in Canada to disseminate PA guidelines for specific populations?
Of the 53 dissemination records, six records identified six dissemination process strategies. The remaining 47 records identified a total of 49 dissemination strategies, with two records having used more than one strategy. No records identified dissemination scale-up strategies. Thus, a total of 55 instances of dissemination strategies were identified. Of the 6 dissemination process strategies, all were categorized as “formative research”. For example, the Ontario Brain Institute conducted surveys regarding end-user perceptions of the benefits, appropriateness, and overall usefulness of the Alzheimer’s recommendations [40].
Of the 49 dissemination strategies identified, the most common strategy was “distribution of guideline materials” (n = 30). For example, CSEP released their scientific statement on the PA guidelines for MS on their website [48]. Next was “education” (n = 10), such as Diabetes Canada’s information pamphlets on the importance of engaging in resistance and aerobic exercise and how to progress through resistance training [49, 85,86,87,88]. The least common dissemination strategy was “mass media/communications campaigns” (n = 9). For instance, a New York Times article explained the benefits of exercise for cancer survivors, including advice from experts in the field.
Two records used two dissemination strategies [50, 51]. For example, a podcast functioned both to distribute guideline materials and as a mass media/communications campaign to disseminate the guidelines for cancer survivors [50].
RQ2: Of the dissemination strategies used, how have they been evaluated?
Of the 55 dissemination strategies, six (11%) included an evaluation (2 dissemination process strategies [40, 41]; 4 dissemination strategies) [52, 89,90,91]. Surveys were the most common evaluation method (n = 5), but two studies used semi-structured interviews [52, 91]. Dissemination process outcomes included the quality of completion of activities related to the process strategy [40, 41]. Dissemination outcomes included guideline awareness [52, 90], knowledge [90], and attitudes [89]. Outcomes beyond those specified in RQ3 are reported in Table 4.
RQ3: Of the dissemination strategies evaluated, which were reported to be effective in enhancing guideline awareness, attitudes, and knowledge?
Over the two evaluated dissemination process strategies, both cross-sectional studies involving “formative research” demonstrated that physicians and end users had positive perceptions of the appropriateness, utility, and clarity of guideline messages [40, 41]. Of the four evaluated dissemination strategies, one cross-sectional study [52] involving “distribution of guideline materials” found low levels of guideline awareness (23.7%) prior to distribution of materials, but omitted a follow-up assessment. One prospective study [90] found “education” to be associated with significant increases in guideline awareness and knowledge among healthcare professionals and trainees, with increases in awareness being sustained at one-month follow-up. However, this study found that low levels of guideline awareness (17.8%) and knowledge (4.3%) among practicing healthcare professionals persisted across time-points [90]. Finally, one RCT [89] found “education” to be associated with significant increases in attitudes toward the guidelines among adults with MS from pre- to post-intervention; increases were not maintained at three-week follow-up.
Implementation
RQ4: What strategies have been used in Canada to implement PA guidelines for specific populations?
Thirty-nine records reported on one or more implementation strategies (i.e., 8 records used 2 strategies [97, 98, 100,101,102, 106,107,108]; 2 records used 4 strategies [42, 103] for a total of 53 instances of the use of an implementation strategy). All four implementation strategy categories were represented, with integration strategies as the most commonly used category (n = 31), followed by implementation process (n = 9), scale-up (n = 7), and capacity-building (n = 6) strategies.
Five of the nine implementation process strategies were categorized as “engaging stakeholders”. For example, Gainforth et al.[97] partnered with three organizations to co-develop a workshop to promote the 2011 SCI guidelines [53]. The other four implementation process strategies were categorized as “human resources”. For instance, Parkinson Canada [100] employed studio directors to deliver a dance program to help adults with Parkinson’s disease engage in guideline-level PA.
Regarding the 31 integration strategies identified, six types of strategies were used. “Feedback” was used in one instance, where Trinh et al. [103] provided participants with activity trackers to view real-time feedback of their daily PA levels. Interestingly, this study also utilized “alerts”, “financial incentives”, and “planning tools” [103]. Worn activity trackers also gave sensory alerts to break up sedentary time lasting 30 min or longer to help participants meet the 2015 guidelines for people with cancer [6]. Participants were awarded points for engaging with the intervention that could be redeemed for items valuing a maximum of $50 CAD. Next, there were five instances of “skills training”. For example, Santa Mina et al. [102] had qualified professionals deliver an in-person 30-week exercise program to help adults with cancer meet the PA guidelines. Seven instances of “counselling” were identified. For example, Tomasone et al. [108] used telephone-based counselling to promote PA in line with the guidelines among clients with SCI. Lastly, “planning tools” were utilized in 16 instances. For instance, McMaster University’s Physical Activity Centre of Excellence [111] offers the “MS Get Fit Toolkit Online”, an interactive e-learning module for adults with MS in achieving guideline-recommended PA.
All six capacity-building strategies involved “stakeholder training”. In one, Salci et al. [107] delivered an online mentorship program to train adults with SCI and able-bodied personal trainers to enhance their self-efficacy to promote PA to adults with SCI. All seven instances of scale-up strategies used “implementation toolkits”. For example, CSEP’s [122] PARmed-X tool is available on their website for any healthcare provider to use when assessing whether patients who are pregnant may safely engage in PA in accordance with the pregnancy guidelines [1].
RQ5: Of the implementation strategies used, how have they been evaluated?
Out of 53 instances of an implementation strategy, 23 (43%) were evaluated [i.e., 2 implementation process strategies, 16 integration strategies (1 “feedback”, 1 “alerts”, 1 “financial incentives”, 4 “skills training”, 6 “counselling”, 3 “planning tools”) and 5 capacity-building strategies]. No scale-up strategies were evaluated. Five records evaluated multiple implementation strategies, totaling 16 records evaluating 23 implementation strategies.
Evaluated outcomes included self-efficacy [42, 98, 109, 110] and intention to meet guideline recommendations [42, 106, 108, 109], and behaviour in line with guideline recommendations [42, 98, 101,102,103, 108,109,110]. Included studies reported self-efficacy through subjective measures (i.e., task self-efficacy questionnaire items [98]; social cognitive predictors of Leisure Time PA (LTPA) among adults with SCI [109]; perceived capability to increase aerobic exercise) [110]. Intention was measured subjectively (i.e., intention to be active [42]; Health Action Process Approach stages of change [106]; LTPA intentions [108]; social cognitive predictors of LTPA among adults with SCI) [109]. Lastly, behaviour was assessed subjectively (i.e., LTPAQ-SCI [42, 98, 106, 108, 109]; GLTEQ-leisure score [102, 110]; International PA Questionnaire) [101] and objectively (i.e., Jawbone activity trackers [103]; wrist accelerometers) [98].
Implementation process outcomes included the quality of completion of activities related to implementation process strategies [97, 130]. Implementation capacity-building outcomes included self-efficacy to engage in implementation process strategies [97, 107, 117,118,119]. Outcomes beyond those specified in RQ6 are reported in Table 5.
RQ6: Of the implementation strategies evaluated, which were reported to be effective for enhancing self-efficacy, intention, and behaviour in line with the guideline, and self-efficacy and intent to use the guideline?
In the two evaluated implementation process strategies, “engaging stakeholders” was associated with increased social cognitions to perform an integration strategy among trainers in one experimental study [97] and among healthcare professionals in one cross-sectional study [130].
Of the 16 integration strategies evaluated, “feedback” was associated with significant increases in PA in line with the guideline in one experimental study [103]. “Skills training” was evaluated in four experimental studies, reporting increases in self-efficacy [98], intentions [42], and PA behaviour [42, 98, 102]. One of these studies found no significant changes, but identified a high adherence to guideline-level PA behaviour across all time-points [101]. “Counselling” was evaluated in six experimental studies, showing positive associations with self-efficacy [98, 109, 110], intentions [42, 106, 108, 109], and PA behaviour in line with the guidelines [42, 98, 108, 110]. Three studies found “planning tools” to be associated with significant increases in intentions [42, 106] and guideline-level PA [42, 103]. Interestingly, Trinh et al., [103] who incorporated “feedback”, “alerts”, “financial incentives” and “planning tools”, found significant increases in PA in line with the guidelines.
Latimer-Cheung et al. [42] also amalgamated four strategies; however, this involved three integration strategies (i.e., “skills training”, “counselling”, and “planning tools”) and one implementation process strategy (i.e., “human resources”). Two studies combined two integration strategies (i.e., “counselling” and “planning tools” [106]; “skills training” and “counselling”) [98], and four studies combined one integration strategy with either one implementation process strategy or one capacity-building strategy (i.e., “counselling” with “human resources” [100,101,102] or with “stakeholder training”) [107]. Given their study designs, we cannot determine whether positive outcomes resulted from a single implementation strategy, or from multiple, concurrent implementation strategies.
Of the five evaluated capacity-building strategies, “stakeholder training” was associated with high levels of self-efficacy to engage in the implementation process strategy across five experimental studies [97, 107, 117,118,119]. Logically, one of these studies paired “engaging stakeholders”, an implementation process strategy, with “stakeholder training” to promote PA in adults with SCI [97].
Risk of Bias
Of the six records evaluating six dissemination strategies, all but one used a non-randomized study design and were rated as “serious” ROB (see last column in Table 4) because of missing data (n = 3) [40, 41, 90], subjective outcome measurement (n = 1) [90], and confounding bias (n = 1) [90]. The one RCT was rated as “high” ROB (see last column in Table 4) due to blinding participants and assessments, attrition bias, and large initial between-group differences [89].
Of the 16 records that evaluated 23 evaluated implementation strategies, 13 were non-randomized study designs and were all deemed as “serious” ROB (see last column in Table 5) due to confounding bias (n = 11) [42, 97, 101,102,103, 106,107,108, 117,118,119], sampling (n = 4) [97, 102, 103, 107], intervention measurement (n = 4) [42, 102, 106, 108], outcome measurement (n = 6) [42, 97, 101, 102, 106, 117], and missing data (n = 1) [130].
The remaining three records evaluating implementation strategies were all RCTs deemed as “high” ROB (see last column in Table 5) due to lack of blinding participants and assessments (n = 3) [98, 109, 110] and attrition bias (n = 2) [98, 109]. Full ROB ratings can be seen in Supplement 2 (RCTs) and Supplement 3 (non-randomized, quasi-experimental, and observational study designs).
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