Table 1 Adaptation of intervention elements for each IM step resulting from phase one and phase two
Original intervention | Phase one – design prototype intervention | Phase two – pilot test prototype intervention | ||
|---|---|---|---|---|
Original intervention elements | Adapt? | Adaptation to original intervention Rationale | Adapt? | Adaptation to prototype intervention Rationale |
Intervention Mapping step 2: Adaptation of target population and objectives based on needs assessment (step 1) | ||||
Target group:  - age ≥ 65 years  - (pre)frail  - community-dwelling | Yes | Homecare-receiving clients of care organisation Clients of care organisation where implementing HCP work. No screening on (FRIED) frailty criteria Simplified inclusion criteria as frailty screening is not part of regular HCP work. Assumed that care-dependent elderly are also (pre)frail. | Yes | Broader population from the community, focus on experienced muscle weakness Pilot had difficulty recruiting homecare clients. PTs and OR indicate better to focus on elderly who are (pre)frail or heading towards frailty; staying close to target group of original intervention. |
Specified exclusion criteria, checked by research physician | Yes | Similar exclusion criteria, but checked by participants’ own GP Check by GP resembles real-life situation and allows large-scale implementation. | No |  |
No explicit behavioural outcomes for participants | Yes | Behavioural outcomes and objectives were defined Behavioural outcome: participants initiate and maintain participation in the exercise and nutrition intervention. As different behaviours were targeted, i.e. changing and maintaining nutrition and exercise behaviours, outcomes were specified in more detail. | No | Â |
Intervention Mapping step 3: Adaptation of methods and practical applications (Techniques, instruments, and methods) | ||||
Progressive training:  - work towards 75% of 1RM  - check 1RM every four weeks  → Method: Tailoring | Yes | Still progressive, but check 3RM and recalculate to 1RM Implementing PTs were not confident in using 1RM in this TG; using 3RM and recalculating to 1RM is acceptable measure of strength. | Yes | Only check 1RM at week 6 PTs perceived 4-weekly 1RM checks as too intensive for PPs. More focus on reaching 75% of 1RM Training intensity in pilot not always up to 75% of 1RM. |
Trainers  - encourage and motivate participants  - explain purpose of exercises/nutrition  → Method: Persuasive communication, arguments | No |  | No |  |
Tailored personal exercise schedule → Method: Tailoring | No |  | Yes | Still tailored exercise scheme, but ensure that physiotherapists train at the intensity desired in the protocol PTs did not always use 1RM to change intensity. PTs changed lay-out of individual schedules, so it is easier to track progress. |
Monitoring protein intake using calendars → Method: Self-monitoring | Yes | Still use calendar, but now with more options to indicate consuming cheese/yoghurt/drink DTs also perceived this as suitable and feasible way to monitor intake. | Yes | Add more detailed monitoring, make it easier to complete calendar Monitoring intake was not always easy for DTs due to mixed quality of completed calendars. E.g. make calendar more personally programmed, ask about compensation during meals. |
One flavour protein drink (250 mL) containing 15 g protein/drink | Yes | Range of protein-rich products (not only drinks) instead of just one drink → Method: facilitation DTs expect that choice from a range of ordinary products would fit better with regular dietary habits and thus increase compliance. However, DTs doubt whether it is feasible to provide personalised advice over a longer period of time (maybe in the future better work with ‘standardised’ advice). | Yes | Focus more on energy content of products PPs experienced weight increase, so energy content of products should be taken into account in advice. Try to incorporate more variety in products during trial Some PPs missed product variation during trial. |
Two protein drinks a day (just after breakfast and lunch), aiming for intake of 25 g of protein per meal | Yes | DTs check during which meals protein intake should be increased and provide tailored advice on which products and portion sizes to take (in agreement with participant preferences) → Method: Tailoring DTs and product developers emphasise the importance of tailoring protein products to individual needs and desires. | No |  |
Handing out proteins for whole week drink at training, by researcher → Method: Facilitation | Yes | Protein products for whole week organised per person by DT, distributed at training by PT Most convenient according to DT and PT, also for product storage; DT knows personal advice and PT can distribute after training session. | Maybe | PPs were satisfied with receiving products for the week during training. Logistics depend on whether products are provided or whether the participants should purchase them themselves. |
Arranged free transport to all trainings by volunteers → Method: Facilitation | Yes | Participants should come to training on their own In real-life setting, more emphasis on independence. Create the training location in the community, near the participants. | No |  |
Intervention Mapping step 4: Revision of programme materials (Intervention design: Delivery mode, intensity, materials) | ||||
General | Â | Â | Â | Â |
Programme of 24 weeks | Yes | Prototype intervention of 12 weeks Researchers saw great improvement in outcomes after 12 weeks in experimental trial. HCPs perceive this as a sufficient period to test implementation of the prototype intervention. | Yes | Intensive intervention of at least 12 weeks, with addition of a maintenance programme Maintenance programme was requested by HCPs and PPs, focusing on both exercise and nutrition. Some PPs indicated that 12 weeks of ‘obligations’ was long enough. PTs indicated that around 12 weeks participants reach an ‘optimum’. |
Information materials: leaflet (easy language, large font, clear information) | Yes | Adapt materials to practice setting. DTs also provide printed overview of individual advice DTs are used to doing this with their clients, to help them remember advice. | No | Â |
Contact person for questions was researcher | Yes | Contact person for training was PT, for dietary intervention was DT It is likely that these are the first persons participants will ask questions about the nutrition/exercise programme. | Maybe | Depends on organisational structure in implementing organisation. |
Training sessions | Â | Â | Â | Â |
Training twice a week, one hour per session | No | Â | No | Â |
Training supervised by researcher, assisted by trained students | Yes | Training supervised by PT, assisted by assistant PTs (Geriatric) PTs are skilled professionals who can implement this programme in real-life. Researchers think that presence of a skilled supervisor during training sessions is important. OPs indicated that enthusiasm, social skills, and the ability to stimulate participants were important trainer qualities. | No | Â |
No intake consultation by trainer | Yes | Intake by PTs before start intervention PTs perceive this as necessary to gain knowledge on possible health problems/injuries. | No | Â |
Training:  - one trainer per two participants (individual exercise performance guidance)  - same trainers all sessions | No |  | Yes | No 1-on-1 guidance, more flexible According to PTs two trainers for six participants was (more than) sufficient, especially after the first few weeks. Flexible guidance was successful during pilot. PPs were satisfied with guidance. PTs’ work schedule did not allow same trainer every training session, but two different trainers was feasible. |
Training in mixed groups of maximally six elderly | No | Â | No | Â |
Training in gym location equipped for the trial at university | Yes | Gym location in local community, near the elderly TG wanted training location close by. Depends on the possibilities of the care organisation; a meeting room was transformed to a gym for the intervention period as other locations were occupied. | No | Â |
Training session structure:  - warming-up, resistance exercises, cooling-down  - six training machines  - no specific exercise order | No |  | Yes | Group-based cooling-down (stretching) PTs added group-based stretching to enable group cohesion. According to PPs, it was a nice way to close the session. |
Researcher organised individual training schedules and trainings | Yes | Individual training schedules organised by PTs The PTs organise the training and complete the individual training schedules during/after the training sessions. Fits their regular work. | No | Â |
Nutrition intervention | Â | Â | Â | Â |
Only short explanation of protein drinks at start intervention by research dietician (no real consultation) | Yes | Face-to-face consultations with DT before intervention and midway through, added (phone) consultation when needed → Method: persuasive communication, arguments As the nutrition programme in the prototype is more extensive, DT guidance is needed to explain the need of the nutrition programme and provide advice on the protein-rich products. Individual consultations ensured two-way communication. A midway evaluation opportunity is added to evaluate and adjust the advice if necessary. | Yes | Add contact opportunity at start intervention and include monitoring of weight and dietary compliance DTs had to inform PPs about the protein advice again when they were handing out products. Weight gain, indicated as problem by PPs, should be monitored. PPs indicated that they sometimes compensated for the protein-rich products. Therefore, DTs should closely monitor weight and dietary compliance. |
Intervention Mapping step 5: Planning implementation | ||||
No involvement of other organisations | Yes | Involvement of care organisation to implement intervention Building support by discussions with organisation and involving them in adaptation process. | No | Â |
Recruitment by researchers, using letters to all community-dwelling elderly ≥65 years of selected cities | Yes | Recruitment by homecare nurses and care organisation’s communication department The care organisation is also partly responsible for recruiting enough participants as it is implementing the programme. | Yes | Provide more management support for recruiting HCPs Pilot showed that recruitment through homecare nurses needs more attention. |
No protocol for dieticians or physiotherapists | Yes | Implementation protocol and registration forms developed for dieticians and physiotherapists Including detailed information describing implementation of the dietary and exercise intervention. Includes detailed training protocol for PTs, although they were already familiar with exercises. | No | Â |
Implementing students trained by principal researcher | Yes | HCPs who recruit and implement intervention are trained by principal researcher HCPs receive training before the intervention starts, to inform them about the implementation manual content and to train them to implement the intervention as planned. Also, the DTs and PTs meet one another during this training session, thus easing collaboration during the intervention. Organise interdisciplinary discussion halfway through the implementation period with all implementing HCPs HCPs indicated need to exchange experiences, so implementation could be altered if needed. | No | Â |
Sustainability not taken into consideration | No | Â | Yes | Include care organisation and municipalities in project To ensure prolonged use of intervention, after (cost)- effectiveness is shown. |