Barriers and Facilitators to Initial and Ongoing Implementation of Community-Based Exercise Programs for Persons with Physical Disabilities: Qualitative Perspectives of Program Providers

Abstract

Community-based exercise programs (CBEPs) designed for persons with physical disabilities can promote participation in physical activity (PA). Despite their importance, few CBEPs for persons with physical disabilities exist in Canada. Understanding successful CBEP implementation may provide exercise providers with a framework to support the development, implementation, and long-term sustainability of CBEPs. The purpose of this study was to explore CBEP providers’ perceptions of the barriers and facilitators surrounding the initial and ongoing implementation of CBEPs using the Consolidated Framework for Implementation Research 2.0 (CFIR 2.0). Fifteen eligible CBEPs were identified, of which nine program providers expressed interest in participating in semi-structured interviews. Transcripts were subject to inductive thematic analysis, and codes were deductively mapped onto domains of the CFIR 2.0. Barriers and facilitators were organized into six overarching themes and eighteen subthemes. Across themes, barriers and facilitators were present through initial and ongoing implementation and spanned all five domains of the CFIR 2.0, suggesting factors at all levels influence CBEP implementation. Ultimately, the barriers and facilitators to CBEP implementation may act as a roadmap to support the creation and sustainability of new and existing CBEPs, thereby increasing the number of programs that offer PA opportunities for persons with physical disabilities.

1. Introduction

For persons with physical disabilities, engaging in physical activity (PA) is vital for physiological and psychological well-being [1]. Indeed, participation in PA has been linked to various health benefits among this population, including improved strength [2], balance [3], endurance [4], and quality of life [5,6]. Nonetheless, persons with physical disabilities demonstrate substantially lower levels of PA compared to persons without disabilities [1]. This discrepancy is concerning given that persons with physical disabilities do not have the same access to the benefits of PA as those without disabilities [7]. Further, persons with physical disabilities are at an increased risk of experiencing secondary complications and decreases in functioning with physical inactivity [8].

Community-based exercise programs (CBEPs) serving persons with physical disabilities have emerged as a promising avenue to promote PA participation among this group [2,4,8]. Specifically, CBEPs for persons with physical disabilities have been shown to mitigate common barriers to PA, such as lack of local opportunities, knowledgeable professionals, adaptive equipment, and accessible environments [7]. By increasing access to safe opportunities for persons with physical disabilities to engage in PA, CBEPs can also act as a bridge between rehabilitation programs and sustained PA [8]. While rehabilitation programs may empower persons with physical disabilities to improve their health and gain function, these benefits can plateau and even decrease if participation in a rehabilitation program is not proceeded with regular PA [8]. Therefore, CBEPs may offer the optimal conditions that enable persons with physical disabilities to maintain participation in regular PA after rehabilitation [9]. For example, staff who work at CBEPs [10] create individually tailored exercise plans that encourage self-efficacy, mastery, community participation, and independence for persons with physical disabilities which may contribute to continued PA participation [4].

Despite the important roles that CBEPs can play in fostering participation in PA among persons with physical disabilities [11], relatively few programs exist [12]. There is a scarcity of research that seeks to understand the complex and nuanced implementation processes of CBEPs for persons with physical disabilities [13]. Consulting program providers regarding their experiences administering CBEPs could begin to address this empirical gap and strengthen both the initial and ongoing implementation of new and existing programming for persons with physical disabilities.

The Consolidated Framework for Implementation Research 2.0 [14] can be used for systematic investigation of the multi-level factors that impact implementation of CBEPs. The CFIR 2.0 comprises 48 constructs and 19 subconstructs categorized into five domains: innovation, representing key features of interventions (8 constructs); outer setting, referring to aspects of the external context or environment (7 constructs); inner setting, denoting aspects of the implementing organization (11 constructs); individuals, related to actions and behaviors of individuals (9 constructs); and implementation process, which incorporates factors involved in maintenance (9 constructs) [14]. The original conceptualization of the CFIR [15] has been used to synthesize barriers and facilitators to implementing community-based PA interventions [16]; however, studies targeting persons with physical disabilities were excluded from the review given the unique considerations faced in delivering community PA interventions for this population. Given its comprehensive nature, exploring the initial and ongoing implementation of CBEPs for persons with physical disabilities using the CFIR 2.0 will unpack numerous factors for program providers to consider when designing or sustaining their programs, respectively.

The purpose of this study was to explore CBEP providers’ perceptions of the barriers and facilitators surrounding the initial and ongoing implementation of CBEPs for persons with physical disabilities using the CFIR 2.0. Accordingly, our study was guided by two key objectives: (1) to identify and understand CBEP providers’ perceptions of barriers and facilitators to initial and ongoing program implementation; (2) to highlight the theoretical linkages between the barriers and facilitators reported and the domains of the CFIR 2.0 framework.

2. Materials and Methods

2.1. Philosophical Assumptions

We approached our work from an interpretivist paradigm. As such, this study is grounded ontologically in relativism and epistemologically in subjectivism. Our assumptions reflect that reality is socially constructed, and as a result, multiple viewpoints and subjective realities exist [17]. Furthermore, we acknowledge that, as researchers, we are not separate from the objects and phenomena explored in our study. Rather, the findings we present are not only shaped by the complex and intimate interactions between the researchers and study participants but capture the positionality, subjectivities, and biases we hold as well. All authors are affiliated with a CBEP for persons with physical disabilities, bringing real-world experience of the challenges and successes of CBEP implementation to this work. All authors are or have been engaged in research that aims to enhance PA participation among persons with physical disabilities. Using this lens, we were and continue to be cognizant of how our biases might influence the data collection, analysis, and interpretation processes.

2.2. Sampling and Recruitment

2.2.1. Identifying CBEPs

Using a modified targeted web-based search methodology developed by D’Urzo et al. [12], we identified potentially eligible CBEPs (

Table 1. Inclusion and Exclusion Criteria for CBEPs and Participants.

Inclusion Criteria	Exclusion Criteria
A. CBEP criteria
Appropriate for adults (18+ years)	For children (<17 years)
Intended for persons with physical disabilities	Intended for persons with intellectual/cognitive disabilities
Intended for community-dwelling persons	Intended for persons in assisted living
Delivered in Ontario, Canada	Delivered outside of Ontario, Canada
Described as a group- or individual-based program to provide opportunities for program members to meet aerobic and/or resistance training recommendations in the physical activity guidelines for special populations	Described physical activity guidelines/recommendations only Described information resources only Described training resources only Intended as therapy of rehabilitation only
Offered weekly sessions a	Did not offer weekly sessions
B. Participant Criteria
Involved in the initiation of the program or was knowledgeable about the history of the program	Not involved in the implementation and development of the program, or without knowledge about the history of the program
Involved with organizing or leading the program on a daily basis	Not involved with organizing or leading the program on a daily basis

CBEP: community-based exercise program. ^a Inclusion criteria were selected to ensure that program members could meet the physical activity guidelines for persons with physical disabilities (e.g., spinal cord injury [19], multiple sclerosis [20]) on a weekly basis.

). Given that such exercise programs are typically operative within the community—rather than a research setting—utilizing a targeted web-based search methodology was the most suitable approach to locate as many CBEPs as possible. Heeding the advice of a professional health sciences librarian, authors agreed to select Google as the search engine to identify CBEPs. As detailed by Godin et al. [18], custom Google searches may be an effective tool to achieve the most relevant and timely results on particular subjects. Next, as the authorship team is affiliated with a local CBEP (i.e., Program 1), we connected with the coordinator of the program to attain a list of the most common physical disabilities in the program: cerebral palsy, stroke, Parkinson’s disease, multiple sclerosis, and spinal cord injury. Using this information, we developed the following search term groupings as keywords for five individual searches: (a) “PA,” (b) “exercise,” (c) “program,” (d) “community,” and (e) the physical disability (i.e., “cerebral palsy,” “stroke,” “Parkinson’s disease,” “multiple sclerosis,” and “spinal cord injury”). Due to the vast amount of information generated by our search strategy, we elected to screen the first 50 records resulting from each of the five targeted web-based searches. The first author led the screening process, wherein potentially relevant records were identified by title screening and documented in an Excel spreadsheet with relevant information (i.e., full title of the record and a corresponding URL). Once all searches were complete, the website of each record was explored. This process, known as hand searching, yielded successful results if a CBEP’s name, description, and contact information were found within two “clicks” of the original record [12]. Finally, all successful results from the searches were comprehensively cross-referenced with the eligibility criteria (see Table 1).

Altogether, title screening identified 28 potentially relevant CBEPs, and hand searching limited the results to 15 potentially eligible CBEPs. Thereafter, using the contact information identified from our searches, we emailed CBEP representatives to describe the present study and invite them to participate. During this process, two follow-up emails were sent as reminders two weeks apart from the date of initial contact. In total, we received interest from representatives of nine programs.

2.2.2. Participants

Informed by Shirazipour et al’s work [21], we strived to highlight the collective voices of program providers at various levels within a CBEP (i.e., program directors, coordinators, managers, instructors, specialists, assistants, and kinesiologists) to deepen and diversify the accounts of implementation barriers and facilitators. We asked our contacts at each of the nine CBEPs to nominate a “primary participant” to complete a preliminary survey. The primary participant was required to be a staff member who was either involved in the initial development of the program or knowledgeable about the history of the program. As shown in

Table 2. Program and Participant Information.

Program Details				Program Number
	1	2	3	4	5	6	7	8	9
Launch Year	2008	2006	2013	2013	1984	2012	2012	2001	2001
Type of Disability	Physical disabilities; Intellectual disabilities	SCI MS Lower limb amputations	Physical disabilities	Physical disabilities	Physical disabilities	Neurological conditions (including physical disabilities) Aging	Physical disabilities	Physical disabilities	SCI
Members/ Session	3 to 15	Varied	8 to 12	15 to 18	Varied	12	4	Varied	20–30
Schedule/ Week	2, one-hour sessions	Drop in Mon–Fri	2, one-hour sessions	3, one-hour sessions	2, forty-five-minute sessions	1 h session	1, three-hour session	2, two-hour sessions	Drop in Mon–Fri
Duration	Ongoing	Ongoing	8 weeks	12 weeks	Ongoing	Ongoing	Ongoing	12 weeks	Ongoing
Structure	Cardio and strength training	Open gym	Circuit program for strength, balance, and mobility	Two days: cardio, strength and balance training One day: sports	Cardio and strength training	Circuit program for strength, balance, and mobility	Nervous system activation technique Strength and balance training	Cardio, strength, balance, and coordination training	Cardio and strength training
Type	Individual based	Individual based	Group based	Individual based	Individual based	Group based	Individual based	Individual based	Individual based
Volunteers	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes
Affiliation	University, research institution	University, research institution	University, community center	University, community center	Independent	University, health network, physical activity center	Physical activity center	Community center	University, research institution
Primary Participants (n = 8)
Title	Rylie, Program Coordinator	Paul, Program Director	Skylar, Program Coordinator	Skylar, Program Coordinator	Kiernan, Manager of Client Services	a Program Director	Hellen, Manager	a Program Manager	a Program Coordinator
Accreditation	B.Sc., B.Ed.	Ph.D.	None listed	None listed		Ph.D.	B.Sc., Paramedic	B.Sc., M.Sc.	Ph.D., ACSM, CAN
Role	Oversees program	Oversees program	Manages program	Manages program			Oversees program	Oversees program	Manages program
Secondary Participants (n = 7)
Name, Title		June, Program Coordinator	Cam, Wellness Director	Cam, Wellness Director	Cliff, Program Support Worker	Cory, Program Instructor	Remi, Program Assistant	Holly, Program Specialist	Alannah, Program Director Mark, Program Assistant
Accreditation		M.Sc., R.Kin	R.Kin	R.Kin	Diploma in Health Services	B.Sc., CSEP trainer	B.Sc., R.Kin	B.Sc.	Ph.D. B.Sc., CSEP trainer
Role		Day-to-day operation	Develops exercises	Develops exercises	Delivers exercises	Delivers exercises	Develops exercises	Day-to-day operation	Founder and Director Day-to-day operation

Note: All primary participants took part in the interviews, except those denoted by ^a. Names are pseudonyms. ACSM, American College of Sports Medicine; B.Ed., Bachelor of Education; B.Sc., Bachelor of Science; CSEP, Canadian Society for Exercise Physiology; MS, multiple sclerosis; M.Sc., Master of Science; Ph.D., Doctor of Philosophy; R.Kin, Registered Kinesiologist; SCI, spinal cord injury.

, primary participants held the positions of program coordinator, director, or manager. Following submission of the survey, primary participants were invited to complete a semi-structured interview and to nominate a “secondary participant” to partake in an interview as well. We sought to interview more than one provider from each CBEP to capture diverse perspectives from individuals in various roles. Three primary participants did not self-nominate to participate in the interview (Programs 6, 8, and 9, see note in Table 2), one primary participant did not nominate a secondary participant (Program 1), and one secondary participant was nominated to represent two separate CBEPs that were offered out of the same facility (Programs 3 and 4). Altogether, the final interview sample consisted of 12 participants (n = 5 primary participants, n = 7 secondary participants). Herein, both primary and secondary participants are collectively referred to as providers, with pseudonyms being utilized for confidentiality.

2.3. Measures

In this study, we collected data through two measures: a preliminary survey and semi-structured interviews. The preliminary survey sought to collect information pertaining to each CBEP’s key characteristics (i.e., name, location, launch date, mission, etc.) and develop a comprehensive description of the CBEP’s delivery structure (i.e., schedule, group vs. individual based, etc.). Subsequently, semi-structured interviews were conducted with one or more representatives from each CBEP (see Table 2). Prior to each interview, the interview guide was tailored towards each program with reference to their responses to the preliminary survey—this enabled us to have more rich, descriptive, and specific conversations about each program and its practices. Interviews lasted an average of 70 min (range of 32–85 min).

2.4. Data Analysis

Survey results are descriptively summarized in Table 2. As participants’ responses to the preliminary survey were a means to structure the discussion within the interview, they were not included in the qualitative analysis.

Based on Braun et al’s six-stage model for reflexive thematic analysis [22], the lead author (K.E.M.) engaged in familiarization and deep immersion with the data (i.e., reading and rereading transcripts, listening to audio files). Then, after developing initial notes regarding patterns in the data, preliminary codes were generated to highlight interesting features of each transcript. The third phase of analysis involved organizing codes into candidate themes. Throughout the analytic process, co-authors (L.K., J.R.T.) were engaged as critical friends, encouraging reflexivity and explorations of alternative interpretations of the data [17]. During this process, we engaged in key dialogue to identify that barriers and facilitators could be discreet and non-discreet (i.e., shared) in terms of when they emerged during the implementation process. Hence, barriers and facilitators to CBEP implementation were divided into two stages—initial and ongoing implementation—to clarify when program providers should expect to encounter such barriers or focus on using certain facilitators. We operationalized “initial implementation” as the period leading up to program launch, whereas we operationalized “ongoing implementation” as the period after launch, when a program would be fully operational. Finally, we reviewed, revised, and cross-referenced all themes and subthemes to develop a robust and nuanced understanding of the barriers and facilitators to initial and ongoing program implementation faced by CBEP providers. Once themes and subthemes were finalized, the second author (O.V.) deductively mapped the findings onto the domains of the CFIR 2.0 [14] and discussed mapping with a critical friend (J.R.T). All authors reviewed and agreed on the presentation of the findings.

Methodological Rigor

To date, there is no consensus on the necessary criteria for establishing quality in qualitative research. Ensuring that specific criteria are followed implies that there is a fixed way to conduct research, while qualitative—particularly relativist researchers—do not believe that research should be rigid [23]. Instead, researchers should have the discretion to choose to follow only those criteria that are relevant to their study [24]. Thus, in line with Tracy’s suggestions [25], this study focused on making a significant contribution (e.g., filling in a research gap to improve CBEP development), rich rigor (e.g., conducted interviews with as many programs as possible), sincerity (e.g., clear documentation of research methods and limitations of the study), and credibility (e.g., provided detail in descriptions, used a critical friend).

3. Results

Through rich conversation with program providers, multiple barriers and facilitators were identified and organized into six overarching themes and eighteen subthemes. Across each theme and subtheme, barriers and facilitators existed during initial (

Table 3. Theme and subthemes relevant to initial implementation.

Initial Implementation
Theme	Subtheme	Barriers	Facilitators
Leveraging CBEP champions	Passionate program champions		Creating the program due to inspiration from a family member with a physical disability
			Championing the cause/mission of the CBEP
			Ensuring founders/early staff members are invested in the cause
			Promoting an openness to change for program improvement
			Engaging in a deeper understanding of program’s mission with a personal connection to disability PA
	Research-based champions		Initiating program development based on a faculty member’s existing research (e.g., an idea for an randomized control trial was turned into a CBEP)
	Community-based champions		Identifying a need for the program in the community through speaking to community partners
			Initiating the program based on a community need to better inform the development/implementation of the program
Prioritizing connection and learning	Modeling	Lack of knowledge of how to start a CBEP	Informing launch with an existing CBEP and how it operates
			Gathering input from knowledgeable informants (i.e., director of another program)
			Designing program as a continuation of another CBEP
Investing in partnerships	Academic and institutional partnerships	Finding the right people/groups to partner with is challenging	Recruiting a faculty member on the board with relevant research experience
		Having providers that do not prioritize the program	Collaborating with other program providers/faculty for planning
		Lacking support from partners when searching for a space	Seeking out the support of multiple informants
			Having the support from an influential member of affiliated institution
			Acquiring a gym space provided by academic partner
			Partnering with health care professionals from adjacent hospitals to increase member enrolment
	Community partnerships		Developing a key advisory group of relevant informants
			Acquiring a gym space provided by a community partner
			Partnering with industry to provide accessible/adaptive equipment
			Sourcing members from partner organizations
			Asking community partners to provide training for student volunteers
			Partnering with organizations who can provide evidence to inform the CBEP’s practice
Conditions of supportive exercise	Accessible space and equipment	Finding an accessible and inclusive space	Unifying multiple CBEPs into a centralized location
		Having to continually move between spaces before the official launch	Offering the CBEP in a facility with other recreational opportunities
		Fatiguing to continually search for a proper space	Offering the CBEP in a facility that is accessible and inclusive
		Lacking equipment prior to and immediately after launch
		Experiencing limitations with where to acquire adaptive equipment
	Shared spaces	Finding a space that is large enough for the CBEP
		Occupying a shared program location leads to spatial limitations
Flexible program administration	Program policies		Organizing consistent meeting times between directors and staff
			Developing a strategic plan for continued growth
			Organizing consistent meetings with partners
	Scheduling and time constraints	Lacking time and resources because of not-for-profit budget
		Lacking time and resources for community outreach
		Lacking resources to support full-time staff positions
	Managing finances	Acquiring equipment/cost of operations	Receiving funding from the local integrated health network
		Coping with budgetary constraint	Partnering with an academic institution that provides financial support
		Managing the cost of operations exceeding revenue
		Lacking funding to support full-time staff
		Meeting grant requirements is difficult
		Writing grant applications is challenging
		Relying on grants is unsustainable
		Raising enough funds to keep costs low for members
	Feedback and quality improvement	Having to run a pilot program until a formal grand opening	Creating a pilot program to address key issues of CBEP before implementation
	Volunteer management	Recruiting volunteers is challenging	Organizing volunteer training to ensure they are knowledgeable and fit to support members Offering volunteer training sessions online
		Training volunteers is challenging with time/resource constraint	Hiring paid staff positions for students to supervise sessions
	Staff management	Hiring appropriately trained staff members is often challenging	Hiring staff members with knowledge of the field
		Lacking resources to support full-time staff positions	Creating a hierarchy such that there is a flow of knowledge between positions
	Member registration and attendance	Recruiting new members is challenging	Utilizing online resources to facilitate referrals to the program
		Turning away potential members due to limited physical space	Using word of mouth and community awareness increases member enrolment
			Performing outreach at community events
			Finding alternative ways to raise community awareness of the program (e.g., pamphlets, website, talks)
			Using advertising to increase community awareness of the program
			Sourcing members from partner

Note: Some cells are left blank due to the fact that there were not equal numbers of barriers and facilitators per subtheme. Additionally, barriers and facilitators that are in the same row in the table have no correlation.

) and ongoing (

Table 4. Theme and subthemes relevant to ongoing implementation.

Ongoing Implementation
Theme	Subtheme	Barriers	Facilitators
Develop and maintain partnerships	Academic and institutional partnerships	Finding the right people/groups to partner with is challenging	Recruiting a faculty member on the board with relevant research experience
		Having providers that do not prioritize the program	Having a guarantor for rent and program costs
	Community partnerships		Planning and executing community events used to increase awareness of the program
			Offering ongoing resources for members
Conditions of supportive exercise	Accessible space and equipment	Finding an adequate and accessible space	Unifying multiple CBEPs into a centralized location
	Shared spaces	Finding a space that is large enough for the CBEP	Laying out the gym such that program members can socialize
		Occupying a shared program location leads to spatial limitations	Spacing out the gym to avoid overcrowding
			Accessing larger facility with program fee
Flexible program administration	Program policies		Organizing consistent meeting times between directors and staff
			Recording program members’ attendance to keep them accountable
			Developing a contract for the program member after the initial assessment
			Checking in on members when they are not present
			Screening potential program members to ensure they are eligible for the program
			Instituting appointments and canceling policies to promote attendance
	Scheduling and time constraints	Scheduling is a challenge because of rolling admission (different start dates and times for everyone)	Recruiting volunteers that can commit for longer periods of time
		Attending members all wanting to come at the same time	Planning and executing ongoing training for volunteers
		Scheduling cannot accommodate all members
		Operating on part-time schedule impedes staff quality
		Working on quality improvement initiatives takes time
		Monitoring progress and updating members’ programs takes time
		Offering ongoing resources for members takes time
		Aligning transportation times with programs does not work
		Managing volunteers is time consuming and resource intensive
		Getting volunteers during the school day (student volunteers)
		Aligning volunteer availability with program schedule
		Having partners that do not prioritize the program
	Managing finances	Locating and acquiring grants is challenging	Receiving grants to support ongoing development
		Relying on grants is unsustainable	Receiving funding from the local integrated health network
		Determining a payment scheme is challenging	Acquiring provincial/external scholarships to support upper students to be employed at the program
		Losing funds due to member non-payment	Organizing community-based fundraising to support the program
		Having a limited amount of funds means that they cannot invest in creating an accessible space	Organizing internal fundraising to support the program
		Expanding program is costly	Collecting membership payment to support the program upfront
		Employing trainers on not-for-profit budget	Creating a payment benefit schedule for program members
		Managing the high cost for members
	Quality improvement	Working on quality improvement initiatives takes time	Gathering feedback from members to inform change
			Gathering feedback from staff members to improve program delivery
			Asking program members for their opinion when acquiring new equipment
			Conducting annual reviews of the program
			Conducting program evaluations frequently to improve the program
			Developing an internship program for continued education/support of volunteers
			Developing a goal-setting program for program members
			Circulating a newsletter to communicate current events to program members
			Developing new ways to deliver exercise instruction
	Staff management	Achieving ideal staff:participant ratio challenging with program cost	Building communication between staff to ensure consistency and quality program delivery
		Being understaffed leads to stress and overworking	Recruiting qualified trainers to staff the program
		Coordinating meetings with many staff members is difficult	Developing new ways to deliver exercise instruction
		Working with inexperienced staff who do not have sufficient expertise to accommodate the needs of the program
		Hiring appropriately trained staff is often challenging
		Challenges due to insurance and training	Training volunteers to take precautionary measures for member safety
	Volunteer management	Recruiting volunteers is challenging	Planning and executing ongoing training for volunteers
		Having volunteers who do not have proper qualifications limits their capacity	Ensuring a low ratio of volunteers to program members
		Interacting with individuals with disabilities may be out of volunteer’s comfort zone	Recruiting volunteers with a health and kinesiology background to educate members
		Recruiting volunteers for off-season	Providing exercise support for members
		Managing volunteers and planning according to their availability is time consuming and resource intensive	Contributing to positive social atmosphere
		Managing the high volunteer turnover rate	Recruiting volunteers to provide help for day-to-day tasks
		Canceling sessions when volunteer turnout is low	Asking mature volunteers to mentor new volunteers
			Enabling volunteers to make changes to program members’ routines
			Recruiting volunteers who can commit for longer periods of time
			Structuring volunteer roles to align with volunteers’ levels of commitment
	Member registration and attendance	Exceeding program member capacity	Utilizing online resources to facilitate referrals to the program
		Fluctuating membership is difficult to plan for	Allowing members to re-enroll in the program to keep numbers up
		Recruiting new members is challenging	Allowing members to graduate out of the program to make room
		Denying program access to some
Focusing on member retention	Social engagement	Managing relationships between participants	Organizing social activities that foster a sense of community/belonging
		Including participants with varying abilities complicates group exercises	Asking volunteers to foster positive social experiences
	Addressing members’ concerns	Developing a payment scheme that accommodates all	Creating a positive gym culture
		Ensuring low costs for program members leads to financial instability	Allowing caregivers to accompany members and provide support
		Dissuading potential members with a fee for service	Accommodating program members by offering a flexible payment schedule
		Paying for the program may be difficult for members	Providing flexible schedules for program members (e.g., multiple options to accommodate members)
		Aligning transportation times with the program does not work	Creating subsidies for program members
	Tailoring experiences	Tailoring to a variety of participant needs is a challenge	Providing the program free of charge
		Finding best method for tracking progress	Identifying and communicating accessible transportation options to program members
		Updating members’ exercise programs continually	Tailoring exercise to an individual’s needs
	Behavior maintenance	Educating members is difficult when they are unreceptive to learning	Challenging program members when exercising so they see progression
		Dealing with a lack of member commitment	Offering group-based or individual-based exercise programs
			Educating program members on the benefits of exercise
			Creating a graduate program to support exercise maintenance

Note: Some cells are left blank due to the fact that there were not equal numbers of barriers and facilitators per subtheme. Additionally, barriers and facilitators that are in the same row in the table have no correlation.

) implementation and spanned all five domains of the CFIR 2.0, suggesting factors at all levels influence CBEP implementation (

Table 5. Themes mapped onto CFIR 2.0 constructs.

Theme	Implementation Stage		CFIR 2.0 Constructs
	Initial	Ongoing	Innovation	Outer Setting	Inner Setting	Characteristics of Individuals	Implementation Process
Having a CBEP champion	✓					✓
Connect with and learn from an existing CBEP	✓		✓
Develop and maintain partnerships	✓	✓		✓
Acquire an accessible gym space and equipment	✓	✓			✓
Tailor program administration to the context	✓	✓	✓				✓
Focus on member retention		✓	✓

Note: CBEP: community-based exercise program; CFIR 2.0: Consolidated Framework for Implementation Research 2.0; ✓: Theme was mapped to the CFIR 2.0 domain.

).

3.1. CBEP Initial Implementation

When asked to reflect upon the preparation for and launch of a new CBEP, providers commonly discussed the important themes of “leveraging CBEP champions,” and “prioritizing connection and learning.” These themes, as well as their subthemes, appeared to be most relevant in initial program implementation.

3.1.1. Leveraging CBEP Champions

Across providers, the notion of “leveraging CBEP champions” captured the importance of access to and collaboration with a person who had a strong connection to the cause of the CBEP. Often, CBEP champions were described as highly passionate individuals who wanted to drive forward the initial implementation of CBEPs. While some of these champions were from the community, acting as an advocate and important voice representing the people being served, others were researchers, who wanted to see the CBEP take off and succeed.

Passionate program champions. Many providers shared that launching a CBEP was easier if a core staff member was invested in the cause—whether that stemmed from past training in the field of adaptive exercise or from a personal connection to an individual with a disability. For example, as Hellen from Program 7 indicated, “For twelve years I was an advanced care paramedic, [because] I have a medical background, […] I was able to help develop the program from my aspect as well as being the caregiver for my husband.” Motivated to create a space where her husband could safely participate in exercise, Hellen was instrumental in her CBEP’s successful implementation. At the same time, some program providers intentionally sought out staff members who had a deep understanding of the CBEP’s mission, citing the concept of “shared passion” within a team as an important facilitator for implementation.

Research-based champions. One provider’s accounts of initial implementation highlighted a unique circumstance of CBEP conception. Namely, their CBEP was derived from the research program of a partnering faculty member who studied adaptive PA. Prompted by their research participants’ desires to continue the exercise protocol designed for a study, Alannah from Program 9 took the initiative to develop a CBEP with a more formal connection to research. As Program 9 was born in partnership with an academic institution, Alannah acted as an important bridge to the research community and facilitated a complementary relationship where the researchers could recruit from CBEPs, while ensuring that program members could benefit on-the-ground from the evidence-based programming offered.

Community-based champions. Throughout our conversations with providers, it was clear that all CBEP champions had strong ties to the community that the CBEP served. This facilitated the creation of local partnerships, which further strengthened the ability to reach more participants and tailor the programs to the needs of the community members. Providers sought the input of multiple informants to inform program implementation. While some adopted a community participatory-action approach (i.e., engaging persons with physical disabilities from the community in decision making), others reached out to specific groups to collaborate. A comment from Skylar from Program 3 exemplifies this: “Physiotherapists from the neuro rehab program [at the local hospital] approached us and just shared that there wasn’t anything in the community where they felt comfortable referring their patients once they completed rehab. What was happening was that they were keeping individuals longer in their programs because of that.” Here, providers from Program 3 invested the time to not only unpack current gaps in care for individuals post-rehab but worked in partnership with a local hospital to tailor a new CBEP to the needs of their patients.

3.1.2. Prioritizing Connection and Learning

The second overarching theme, which was resounding in both initial and ongoing implementation, was “prioritizing connection and learning.” Unsurprisingly, providers shone light on the importance of sharing best practices between existing and new CBEPs.

Modeling. In some instances, providers felt that they lacked the knowledge and/or necessary experience to successfully get a CBEP off the ground. To mitigate this barrier, providers located existing CBEPs and used them as a model to inform their own launch: “I have very good friends at [other CBEPs] and if I needed to ask, you know, what did you do to solve x, y, yes or z problems, it was usually just a phone call” (Paul, Program 2). As in the case of Alannah from Program 9, some providers modeled their program after an exercise protocol tied to research occurring at a partnering institution. Rather than starting from scratch, prior key learnings and expertise were applied to help facilitate the initial implementation of a new CBEP. In another example, Skylar explained that program members in a supervised and assisted program (Program 3) were making substantial progress in their physical fitness. Conversely, when the service cycle concluded and members “graduated out of the program,” their fitness gains were lost. To remedy this, Program 4 was developed to offer independent exercise opportunities for members in the adaptive gym.

3.2. Initial and Ongoing Implementation

The themes and subthemes below were noted to be relevant to both initial and ongoing implementation.

3.2.1. Investing in Partnerships

The theme “investing in partnerships” underscored the impact of collaborating with other organizations, groups, or individuals to collectively support CBEP implementation. Across providers, partnerships were seen to have a variety of benefits; whereas academic partners could provide funding opportunities and recommendations for evidence-based practice, community partners expanded program promotion efforts and aided with recruitment.

Academic and institutional partnerships. Having academic partners provided many benefits to all program providers interviewed. Collaborating with faculty members from local institutions with relevant research interests opened access to a wealth of knowledge and expertise to inform an evidence-based program. In-kind support from an affiliated institution was immensely helpful for many CBEPs; they helped advocate for improvements to the program facility or assisted with program finances: “But now what the university does is they don’t charge us for heat and hydro… so you know that’s a I’d say a good contribution that the university gives us for free” (Mark, Program 9). Many providers found that establishing partnerships with health care professionals from nearby hospitals augmented member recruitment. An important aspect of these partnerships was the notion of trust—the more a health care professional knew about the quality of the CBEP or the people who ran it, the more likely they were to develop a referral relationship. However, finding supportive academic partners was also reported to be particularly challenging for providers who did not have prior connections with institutions. Developing partnerships did not always yield concrete benefits as some groups or people could not prioritize the CBEP due to competing interests, time constraints, or administrative hurdles.

Community partnerships. All providers interviewed shared that it was essential to develop partnerships with community organizations. These partnerships were deepened when community organization representatives were invited to join the CBEP’s advisory boards to ensure that program-related decisions were made in the best interest of those being served. In addition to supporting decision making, community partners also assisted by providing spaces to run CBEPs and aided with the sourcing of accessible/adaptive equipment. Paul from Program 2 offered, “[Our community partners] have been helpful by donating two pieces of functional electrical stimulation equipment to our program … in return for getting those two pieces of equipment we have done research for them that has used that equipment.” Finally, community partnerships acted as a conduit to funnel potential members to CBEPs: “Our partners also support referrals, so they promote our program within their organizations wherever it is appropriate. And they have also supported training in the past” (Cam, Program 3).

Maintaining academic, institutional, and community partnerships appeared to also facilitate program development after program launch. Some CBEPs that were tied to academic institutions benefited from having a guarantor for rental and programmatic costs, as well as a steady inflow of volunteers: “We are very, very fortunate that we have so many volunteers from [university students] if we didn’t have them, it certainly wouldn’t have evolved” (Alannah, Program 9). In a similar vein, sustaining community partnerships often meant that providers could offer members ongoing resources external to the CBEP: “We can always refer members to him [the community partner] and he has lots of contacts for different supports for people with disabilities” (Rylie, Program 1).

3.2.2. Conditions Supportive of Exercise

When asked about the qualities that support the ongoing success of a CBEP, several program providers spoke to the importance of building a physical space that is conducive to quality exercise experiences. Not only did this refer to an accessible gym space and adaptive equipment, but geographical access and location of the CBEP as well.

Accessible spaces and equipment. All providers were steadfast in the fact that CBEPs should be offered in an accessible and inclusive facility. Acquiring an adequate and accessible space was a challenge for some, as told by Paul (Program 2):

When I was up on [the university’s] campus, I had those grants, but I just didn’t have enough room. It was difficult to be granted permission to retrofit or make adaptations to pre-existing campus spaces.

Coupled with this, Kiernan reported that acquiring adaptive equipment “was difficult due to the limited vendors in the market” (Program 5). This experience was vastly different from that of Cory, who facilitated Program 6 out of a recently built, accessible community center with the mission to make communities more accessible and inclusive:

It’s the only facility like it in the world where people of all abilities can come together and exercise, so I think that the main goal of the facility, was that no matter what your ability you will have an option available to you to exercise.

A few providers mentioned benefits due to their spatial arrangements: “The layout of our gym kind of boosts that morale, you can’t go to one piece of equipment without passing somebody… the environment is definitely situated for social interaction” (Mark, Program 9).

Shared spaces. Paul explained that Program 2 operates in a facility that houses multiple community-based programs and supports for people with chronic conditions. He suggests that “having services in a centralized location facilitated program development,” especially if resources—human, financial, consultative, or others—are shared between programs. Similarly, providers indicated that housing a CBEP in a facility that offered other recreational opportunities encouraged members to commit to maintaining a physically active lifestyle. For example, Cam describes that, in Program 3: “[Participants] can come to the program three times a week, but their membership also allows them to access the facility outside of the program.” While utilizing shared spaces enhanced member experience in some instances, in others, it led to spatial limitations for each program. Providers noted that having minimal space for pieces of equipment led to decreased member capacity and limited their ability to expand and make their own decisions as an “independent exercise facility” (Paul, Program 2).

3.2.3. Flexible Program Administration

Across providers, many conversations surrounded the concept of program administration and its ability to vastly improve, or hinder, ongoing implementation of a CBEP. The overarching theme of “flexible program administration” highlights the importance of tailoring CBEP management and administration to the specific program context—including the needs of its members, relationships with academic/institutional and community partners, elements of the physical environment, and more. For example, having individualized program policies, appropriate scheduling, organized finances, strong quality improvement initiatives, thoughtful management of staff and volunteers, and initiatives to optimize member inflow and outflow all should be thoughtfully mapped onto the context of the CBEP.

Program policies. To facilitate the development of a successful CBEP, it was important for all providers to organize consistent meetings with multiple stakeholders: “We have an annual meeting with our partners. Our directors sort of sought feedback from them as well. So that’s kind of how the goal setting works each year” (Rylie, Program 1). Additionally, including individuals from all levels of partner organizations was crucial to obtaining relevant input from various persons with expertise. Meetings were an important avenue to receive feedback about strategic planning and allowed the opportunity to turn feedback into achievable goals. While some providers like Rylie held strategic planning meetings annually, Mark employed an approach that enabled more frequent communication:

Every month with all the staff members, not just [our program] but all of the programs [in the center], meet to provide updates and talk about like new incentives that we are doing, other features that we might offer.

(Program 9)

Other administrative policies that facilitated program development included strategies to enhance member retention. For instance, providers described developing participation agreements to enhance accountability (e.g., “they sign a letter of acceptance, which has the program dates and times, and what to bring to class” Program 3) and following up with members regarding low attendance:

If someone misses more than two classes, I generally follow up with a phone call. If I haven’t heard there is a particular reason why—if it’s just a one off ‘I was feeling sick,’ they usually come back, but if its more serious issue I delay [participation] until the next offering, because we do want them to get like the most out of program.

(Program 3)

A specific example illustrating the importance of tailoring program policies to members’ needs was observed in Program 2. Here, Paul indicated that it was a challenge to determine a payment scheme for members prior to launch. With collaboration from partners, Paul decided that it would be best to offer multiple payment options for members to choose from:

We offer four different membership structures for our members. They can pay month by month; they can buy a three-month membership or six months membership or twelve months membership.

(Program 2)

An additional adjustment that Paul made to the payment scheme was that family members were able to purchase memberships to the facility as well, which helped support continued member retention.

Scheduling and time constraints. Most providers reported that it was challenging to accommodate participants’ scheduling preferences and it was common to see increased interest in specific class time offerings:

Everybody tends to want to come between 11 and 2. So, I mean we will be here as early in the morning as they want to be here and then as late into the evening that they’d want to be here. But logistically, it’s impossible to fit […] six people into the session when we only have three trainers.

(Hellen, Program 7)

Some providers preferred developing fixed schedules for staff, volunteers, and members, as opposed to a “drop-in” program offering. Related to scheduling, several providers also indicated lack of time and time management with competing priorities as major barriers in a CBEP setting. In particular, operational tasks took up a considerable portion of their working hours, leaving little time to address member-specific concerns. For example, if they tracked member attendance, monitored and updated members’ exercise routines, worked on quality improvement, and oversaw volunteers daily, carving out extra time to address members’ additional barriers to participation was difficult.

Managing finances. All providers stressed that having sufficient and consistent financial resources was integral for initial and ongoing implementation of a CBEP. Successful acquisition of funding supported the hard costs of launching a program for Alannah: “Our building and equipment was purchased and built on donation money and a federal grant” (Alannah, Program 9). Unfortunately, unlike Alannah, most providers faced a myriad of barriers when preparing applications for funding. Providers who were inexperienced grant writers suggested that they did not have the funds to hire a professional grant writer to fill their skill gap:

We’ve applied, I’ve applied, and before I started, I applied to a lot of grants. And I was refused on all of them. Partially because I wasn’t a grant writer and it was my first experience with it. Secondly, it was very difficult and competitive to get start-up funds.

(Hellen, Program 7)

All CBEPs included in the study were identified as not-for-profit organizations—as such, many providers underscored the unsustainability and consistent struggle of maintaining a funding model that was heavily reliant on the receipt of grants. Providers did highlight that other sources of funding came from the local integrated health network or from partnering with an academic institution. Having the support from the local university in the early stages of program implementation was essential for Program 9, as they “bailed us out a couple of times when we been so much in debt that we were not sure if we could continue for another year” (Alannah, Program 9).

Most providers stated that budgetary constraints persisted during program implementation. On top of overhead operational costs, including the location of the program offering and staff wages, providers were constantly given the tall task of program improvement whilst attempting to keep membership costs low for program participants. This was not always possible, as identified by June:

We are always meeting, trying to find new ways to bring in revenue other than memberships. We don’t want to raise our membership prices for our participants here in our center, but we do need to find ways to bring in more revenue.

(June, Program 2)

A common source of funds for CBEPs was through community-based or internal fundraising. Providers reported hosting their own events, collecting pledges to support their members’ participation (i.e., “we create forms that members can take home with them that they can use to get their own sponsors…” Mark, Program 9), or partnering with a philanthropic organization.

Feedback and quality improvement. Soliciting feedback from key informants prior to and following launch was a well-cited success factor for providers. Before launch, the decision to deploy a pilot program for a CBEP empowered providers to not only pinpoint but unpack and address important barriers to initial implementation. Cam from Program 4 described this process: “we did an 8-week pilot, did tests pre and post with the participants, collected information, did some focus groups as well and took that in and made some re-adjustments.”

Leveraging feedback for program improvement frequently occurred in a reactive manner; providers found it challenging to allocate the time and attention necessary for continuous quality improvement initiatives. Other providers offered contrary reflections, with CBEPs finding success with quality improvement initiatives with the assistance of student volunteers. Alternatively, Skylar explained that the CBEP leadership team at Programs 3 and 4 took advantage of the “program break” in the summertime to focus on quality improvement.

Volunteer management. With limited time and resources available, adequately training volunteers was a concern for most providers. Further exacerbating this problem, CBEPs were subject to high rates of turnover amongst student volunteers; thus, there was a constant need for training. Coupled with this, volunteers frequently needed to be trained in many areas, such as how to use the adaptive equipment, techniques for motivating program members and correcting exercise form, and general knowledge of disability and the populations that the CBEP served. To combat this, Program 1 developed an asynchronous training model where volunteers could go through modules at their own pace, without requiring staff members to deliver an in-person session:

There’s going to be a Google PowerPoint … where they go through the schedule, the procedure around attendance, and what you should wear, and confidentiality, and there’s a more extensive list and information on the ways that we modify and accommodate exercise in the gym.

(Rylie, Program 1)

Regardless of the challenges associated with training, having skilled volunteers made the initial implementation of the program more effective and was seen as instrumental for the success of ongoing program implementation as they fulfilled many duties (e.g., delivery of the program: “they help with set up and tear down” Cory, Program 6; monitoring: “just another set of hands another set of eyes to be there” Cory, Program 6; creating positive gym culture: “they’re keen and bright eyed and bushy tailed and that’s encouraging” Rylie, Program 1; updating exercise programs: “they have the knowledge and then the power to be able to make some changes to the programs” Rylie, Program 1). Paul’s sentiments underline the crucial role of volunteers in a CBEP:

Overall, […] I can’t say enough good about [our students]. They are outstanding, we couldn’t do this without them… [The program] is mostly run by volunteers.

(Paul, Program 2)

An unfortunate accompaniment of relying on a volunteer program was the challenge of staffing program sessions that ran during the school day and in the summer when university students returned to their hometowns: “in the summer it’s not uncommon, unfortunately, where there’s 12 participants and 3 volunteers” (Rylie, Program 1). Moreover, as most CBEPs primarily tapped into university students, this resulted in eventual volunteer turnover: “students are here for 4–5 years… people are kind of in and out, they stick around for 2–3 years and then they’re gone” (Rylie, Program 1). Cam had a unique approach to mitigating these risks:

When we are structuring our volunteers, we try and look ahead and see if we know they are not going to be necessarily a long-term volunteer, they may not be involved in the delivery of the core exercise stations. And if we know they are going to be a bit more permanent or may have the flexibility, we try and structure their task in a way where there’s minimal disruption to the program.

(Cam, Program 3)

Similarly, other providers have created program internships to facilitate a sense of commitment among students who support the program.

Staff management. Building thoughtful staff structures tended to be important for the development and implementation of a CBEP. Providers emphasized the importance of achieving clear delineation between staff roles and ensuring that each person’s job responsibilities were logically mapped onto their skills. For instance, Paul from Program 9 described how he delegated day-to-day operations of the program to one core staff member to create the space for him to focus solely on managerial duties. While this was an effective solution for some CBEPs, staffing at large remained challenging for others: “the biggest barrier from day one has been being able to staff the program sufficiently” (Alannah, Program 9). Likewise, as the singular full-time provider at Program 1, Rylie explained that he often had to rely on the support of the program’s co-directors, whose positions were voluntary:

The co-directors of the program develop our strategy, and basically, if there’s a question that I don’t know the answer to or if there’s something I want for the program, or if there’s an issue, I might go to them for guidance on what to do or how to approach it or refer anything up the chain.

(Rylie, Program 1)

Akin to this issue, an important yet often challenging feat for CBEPs was hiring or retaining staff with appropriate expertise or relevant training in the fields of disability and exercise:

When I got here, the occupational therapist was here full time and hired through the funding body. As time went on, we couldn’t afford it. It became very difficult to contract out these services…

(Kiernan, Program 5)

Though costly, Hellen prioritized finding knowledgeable health care professionals to ensure quality participatory experiences for program members:

That is why I’ve chosen to employ people with the qualifications that they have—our physiotherapists and registered kinesiologists… So, I know that my staff have the education behind what they are explaining.

(Hellen, Program 7)

Where CBEPs did have full-time staff, providers were keenly aware of the risk of burnout: “June’s (the program coordinator’s) job is extremely challenging because they wear a hundred different hats in here. They’re always a little overworked” (Paul, Program 2). Of the CBEP providers interviewed, all described being too dependent on volunteers or in-kind time and unanimously agreed that being able to support paid staff positions would be of great benefit to their programs.

Member registration and attendance. A requisite condition for successful program implementation was properly managing the inflow and outflow of program members. Recruiting new members was difficult for some CBEPs, but one of the most effective methods of recruitment was through word of mouth. Hellen described the community of people with lived experience as “a close and small community” (Hellen, Program 7). Program providers also used online resources to garner referrals to the program:

It’s basically an online directory referral system to community-based rehab services … it’s not an exhaustive list, but certainly there is a lot of information that other programs are available, and all of our programs are listed on there. And we receive referrals through this tool.

(Cam, Program 3)

Some providers preferred to recruit new members in the community through health fairs or social and philanthropic events. Using these platforms, providers disseminated information through educational presentations, informative pamphlets or brochures, or sharing social media accounts. Partnerships with institutions also set up a pipeline of new program members: “we’ve got a very good relationship with the hospital across the street. Now they refer people to us with spinal cord injury, multiple sclerosis, and amputations”. (Paul, Program 2).

To manage varying rates of inflow, providers employed strategies such as rolling enrolment (Program 1), allowing program re-enrolment, and developing graduate programs for members (Programs 3, 4) to keep numbers as consistent as possible. Despite these efforts, virtually all providers faced challenges with consistent member attendance:

People in our program have many health conditions. It’s not uncommon for somebody to miss a week, or two weeks or three weeks, or a month. If they have a depressed immune system and get a cold, they might not come out for three weeks.

(Rylie, Program 1)

In other instances, inconsistent member attendance was attributed to the season: “During the summer months a lot of our members are travelling or doing other PA. During the months from November through March, we are pretty much at capacity” (June, Program 2). June continued, stating that membership seemed to “fluctuate all the time,” providers could “never predict whether it is going to be busy or slow” (June, Program 2)—posing a challenge for planning and sustainability.

3.3. CBEP Ongoing Implementation

Focusing on member retention was relevant to ongoing program implementation. This theme is described in detail below.

Focusing on Member Retention

The theme “focusing on member retention” emphasizes the importance of employing specific strategies to encourage ongoing participation and engagement from CBEP members year over year. The subthemes include (1) the importance of social engagement, (2) promptly addressing members’ concerns, and (3) tailoring participants’ experiences and behavioral maintenance; all of which fostered positive and quality participation experiences for program members.

Social engagement. A frequently reported facilitator of member retention was developing a culture of community and inclusion in the gym. Paul articulates that this was often achieved through the support of student volunteers: “Just through their social interactions, it’s the members’ psycho-social improvements that are really are noticeable, and its mostly because of our volunteers” (Paul, Program 2). Many providers indicated that they also organized social activities outside of program hours:

The social aspect and the relationship building that happens in a group-based program is huge, you know we hold things like a charity gala every year for our members and the community… so it’s a totally different venue where they can interact with both their peers as well as all the staff. We get huge turnouts at those events.

(Mark, Program 9)

Addressing members’ concerns. Although providers strived to act on members’ concerns as soon as possible, some found it difficult to remove barriers. In particular, membership payment (e.g., “program sustainability without increasing membership fees, that’s the challenge” Paul, Program 2) and transportation (e.g., “sometimes just that scheduling of rides and the amount of time it does take to get here to attend a program can be a barrier to members that is out of our control” Holly, Program 8) were the largest issues. Providers challenged themselves to come up with innovative solutions, such as offering “no fee to the clients” (Cory, Program 6) or “month-by-month fees” (June, Program 2) instead of contractual agreements, or “trying and hooking them up with express wheelchair transit and brainstorming ways that they may be able to get here to the gym” (Mark, Program 9).

Tailoring experiences. Designing individualized exercise routines was unanimously reported as a strong facilitator of member retention. However, providing timely updates to a member’s exercise routine was hard for many providers to coordinate and execute:

Where the difficulty came in—the need to change the training—was that people would be working on the same weight program with the same weights and the same exercises for like a year or more.

(Rylie, Program 1)

Cam, who delivered a group-based CBEP, grappled with the difficulty of offering exercises that matched members’ varying preferences and abilities (e.g., flexibility, balance, cardio, strength) without someone being “left to the wayside” (i.e., without tailored exercise options; Cam, Program 3).

Behavior Maintenance. One of the goals of CBEPs is to support and inspire individuals to remain physically active throughout their lifetime. Empowering members to commit to being physically active long-term can facilitate member retention, as participants recognize that their PA journey extends beyond a single session at a CBEP. Promoting PA behavior maintenance was a commonly noted facilitator for ongoing CBEP implementation. For example, providers described their success with strategies such as educating program members on the benefits of exercise and creating a graduate program to support exercise maintenance.

4. Discussion

The purpose of this study was to explore providers’ perceptions of the barriers and facilitators surrounding the initial and ongoing implementation of CBEPs and to link identified barriers and facilitators to the CFIR 2.0. Several barriers and facilitators were specific to either initial or ongoing implementation, while other barriers and facilitators were applicable to both phases of implementation. Despite potential differences in programs (i.e., size, number of members, etc.; see Table 2), many similar barriers and facilitators were identified across interviews. Barriers and facilitators were divided into six themes (leveraging CBEP champions, prioritizing connection and learning, investing in partnerships, conditions of supportive exercise, flexible program administration, and focusing on member retention). To position our findings within implementation research, each theme is framed within a CFIR 2.0 domain, allowing us to paint a comprehensive picture of program providers’ perceptions of the implementation process of a CBEP. By focusing on the connection of our themes to program implementation, our intent is to offer guidance for how our findings may apply within and beyond CBEPs to the implementation of other community (e.g., employment training) or rehabilitation programs (e.g., stroke rehabilitation) for persons experiencing disability.

Theme 1, “leveraging CBEP champions,” pertains specifically to initial implementation; to form the groundwork for the creation of a CBEP, it is important to have founders and staff that are invested in the cause. The notion of having a “passionate program champion” is one that is pervasive within implementation literature [26]. We define program champions as influential individuals within an organization who act as strong advocates due to their passion or close connection to the mission of the organization [26]. Program champions may also be passionate health care providers who see a need for a CBEP in their community and take the initiative to work with exercise providers to ensure persons with physical disabilities are referred from the rehabilitation setting to a community exercise setting [27]. The impact of program champions was noted in a study by Kauffeldt et al. [28], where they were integral to the successful promotion and implementation of CBEPs for breast cancer survivors. Program champions possess the capability, opportunity, and motivation to work towards the betterment of their innovation [29], fitting into the “individual domain” of the CFIR framework [14]. Thus, identifying and leveraging a program champion to support a CBEP’s initial implementation sets a strong foundation for success.

Theme 2, “prioritizing connection and learning,” is categorized as an aspect of initial implementation, as the theme encompasses implementation barriers (i.e., lacking knowledge of how to start a CBEP) and facilitators (i.e., leveraging a connection to an existing CBEP) related to program launch. Sharing best practices amongst CBEP providers can optimize allocation of limited resources, ensuring program implementation is efficient [30]. Prioritizing inter-program connectiveness is similar to the notion of co-production within implementation literature, whereby partners are involved with the identification of the problem in addition to the solution [31]. Co-production, specifically with other established CBEPs, can help program providers learn about context-specific dynamics, allowing them to plan for possible barriers and launch their program on a ground of pre-established best practices. Through effective co-production, providers actively seek out and act on the recommendations of a “reputable innovation source”—an essential aspect of the innovation domain of the CFIR 2.0 [14]. Connecting with well-established CBEPs, such as through a community of practice [30], may be an effective strategy to combat the lack of knowledge and experience that new program providers may face when implementing a new CBEP.

While learning from existing CBEPs can aid initial implementation, theme 3, “investing in partnerships” is relevant to both initial and ongoing implementation, as it encompasses affiliations with groups that can support CBEP launch and sustain CBEP growth. Providers noted that academic or institutional partners can be guarantors for rent, provide gym space, and help recruit members through their own community outreach. However, finding the right organizations to invest in is challenging, as many potential partners have competing priorities which prevent their full support of a CBEP. Creating relationships with a wide range of partners (e.g., organizations, foundations, and academic institutions) rather than just one organization may ensure sufficient support [32]. Within implementation literature more broadly, relationships with existing groups has been identified as an effective mechanism to ensure collaboration and support for new interventions [33]. Fostering partnerships is an important aspect of linking the CBEP itself with the external environment (i.e., “outer setting” in the CFIR 2.0; [14]) in which the program exists, highlighting the importance of external perspectives in innovation sustainability. Accordingly, program providers should work to develop connections with diverse groups within the community as the support of partnerships can be vital to the success of a CBEP.

“Conditions of supportive exercise” is a theme that encompasses the barriers and facilitators that relate to the physical space, equipment, and geographic location that are required to initiate and run a CBEP. Specifically, one provider noted how the space that the university partner provided for the CBEP was not big enough and modifications had to be made to ensure that it was accessible for the participants. One of the primary factors that has been found to prevent persons with physical disabilities from participating in PA is a lack of accessible environments and adaptive equipment [34]. However, the aforementioned circumstance highlights how even university spaces which are meant to be accessible to all students regardless of their ability often need to be retrofitted to ensure sufficient support for those with disabilities. While a lack of an accessible space can physically deter persons with disabilities from participation, there is also an emotional deterrence that should be considered. Considering physical accessibility not only promotes participation but also drives forward a new narrative that those with disabilities are being thought about when spaces are being created [35]. Indeed, persons with physical disabilities highly value physical accessibility when considering their participation in community gym settings [36]. The importance of the physical layout of a CBEP is supported by the CFIR 2.0 “inner setting” domain, which highlights the weight that the physical infrastructure of an innovation carries in ensuring implementation success [14].

Across providers, many conversations surrounded the concept of program administration and its ability to vastly improve, or hinder, ongoing implementation of a CBEP. The theme of “flexible program administration” highlights the importance of tailoring CBEP management and administration to the specific program context—including the needs of its members, relationships with academic/institutional and community partners, elements of the physical environment, and more. As shown in our data, having individualized program policies, appropriate scheduling, organized finances, strong quality improvement initiatives, effective management of staff and volunteers, and initiatives to optimize member inflow and outflow all should be thoughtfully mapped onto the context of the CBEP.

Tailoring aspects of an intervention to the specific context, whether that be specific member needs or elements of the physical environment, speaks to the importance of strategies which are both effective for the innovation (the “core” in the CFIR 2.0) but can be altered to fit the specific implementation context (the “adaptable periphery” in CFIR 2.0; [14]). Indeed, the CFIR domains “innovation” and “implementation process” speak to the importance of tailoring both the innovation itself and the implementation processes to the context [14]. Tailoring aspects of an intervention to a specific context has been cited as a facilitator for the implementation of PA interventions [16]. Given the differing perspectives brought forth by CBEP facilitators, this study provides additional guidance to specific strategies that can be used to adjust one’s CBEP administration to better fit within a specific context.

The final theme, “focusing on member retention,” is relevant solely to ongoing implementation, as it pertains to the ability for CBEP providers to foster sustainable program engagement from members. Barriers to focusing on member retention include managing member commitment, while facilitators include organizing social activities to help members form a sense of community. While members of CBEPs can improve their PA levels through program participation [11], CBEP providers should strive for long-term member commitment to allow for a sustained healthy lifestyle beyond the walls of the program. Killingback et al. [37] identified several factors that can promote long-term adherence to CBEPs, including social support and tailoring the program design to best support members, two strategies that are in accordance with our own study findings. Indeed, persons with physical disabilities want their individual preferences considered when providers offer social support in community gyms [36]. In addition, focusing on member retention through hiring long-term staff who can form relationships with participants has also been found to be an effective strategy in ensuring CBEP sustainability [36,38]. There are a wide range of strategies that can promote CBEP member retention, with many strategies relating to the design of the program, an aspect of the “innovation” domain of CFIR [14].

To enhance the interpretation and application of our findings, it is important that we describe the limitations of the study. Primarily, only the perspectives of program providers were considered in this study, most (if not all) of whom did not identify as a person with lived experience of disability. The perspectives of persons with physical disabilities—the ultimate recipients of the service provided by CBEPs—were not collected and considered as part of our dataset. Indeed, weight needs to be given to the perspectives of persons with physical disabilities in both research studies and CBEP provision. Future research must explore the contributions of persons with physical disabilities in the initial and ongoing implementation of CBEPs. To minimize the traditional power imbalances inherent in engaging in research and knowledge mobilization efforts with and for the disability community, we recommend the use of the Integrated Knowledge Translation Guiding Principles [39], which offer a set of values to guide meaningful, non-tokenistic, and impactful partnerships with persons with physical disabilities. A second limitation of this work is that the nine program providers who were interviewed all represented CBEPs for individuals with physical disabilities from one geographical region (Ontario, Canada). Thus, findings may not be applicable beyond this context (e.g., programs serving persons with developmental or sensory disabilities, outpatient physical rehabilitation programs that take place in a hospital setting). Further work to explore the implementation process of other CBEPs which serve different populations within other and larger geographical regions is required. In addition, the interviews were conducted in 2017, prior to the COVID-19 pandemic. Since that time, new programs have certainly emerged and CBEPs may be faced with novel barriers and facilitators given changes in program operation during and following the COVID-19 pandemic (e.g., greater online offerings, fewer participants, fewer staff). Finally, the risk of social desirability bias is high, wherein respondents may have offered responses to create positive perceptions of their program. Social desirability bias may be why more facilitators than barriers were reported by program providers. We must also be aware of potential recall bias since interviewees were asked to reflect on the past when asked about the implementation and launch of their program. It is possible that they have forgotten or inaccurately remembered barriers and facilitators that they experience in the past.

5. Conclusions

The current study offers a novel exploration of barriers and facilitators to CBEP implementation. While the makeup and structure of programs differed, barriers and facilitators mentioned across interviews were similar and spanned all five domains of CFIR 2.0. The identification of barriers and facilitators can assist program providers in the initial and ongoing implementation phases of their programs, ultimately enhancing program success and thus PA participation among persons with physical disabilities.