Translating an early childhood obesity prevention program for local community implementation: a case study of the Melbourne InFANT Program
Laws et al. BMC Public Health
Translating an early childhood obesity prevention program for local community implementation: a case study of the Melbourne InFANT Program
R. Laws 0 1
K. D. Hesketh 1
K. Ball 0 1
C. Cooper 1
K. J. Campbell 0 1
0 Centre for Obesity Management and Prevention Research Excellence in Primary Health Care (COMPaRE-PHC) , Sydney , Australia
1 Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Science, Deakin University , Geelong, VIC , Australia
Background: While there is a growing interest in the field of research translation, there are few published examples of public health interventions that have been effectively scaled up and implemented in the community. This paper provides a case study of the community-wide implementation of the Melbourne Infant, Feeding, Activity and Nutrition Trial (InFANT), an obesity prevention program for parents with infants aged 3-18 months. The study explored key factors influencing the translation of the Program into routine practice and the respective role of policy makers, researchers and implementers. Methods: Case studies were conducted of five of the eight prevention areas in Victoria, Australia who implemented the Program. Cases were selected on the basis of having implemented the Program for 6 months or more. Data were collected from January to June 2015 and included 18 individual interviews, one focus group and observation of two meetings. A total of 28 individuals, including research staff (n = 4), policy makers (n = 2) and implementers (n = 22), contributed to the data collected. Thematic analysis was conducted using cross case comparisons and key themes were verified through member checking. Results: Key facilitators of implementation included availability of a pre-packaged evidence based program addressing a community need, along with support and training provided by research staff to local implementers. Partnerships between researchers and policy makers facilitated initial program adoption, while local partnerships supported community implementation. Community partnerships were facilitated by local coordinators through alignment of program goals with existing policies and services. Workforce capacity for program delivery and administration was a challenge, largely overcome by embedding the Program into existing roles. Adapting the Program to fit local circumstance was critical for feasible and sustainable delivery, however balancing this with program fidelity was a critical issue. The lack of ongoing funding to support translation activities was a barrier for researchers continued involvement in community implementation. Conclusion: Policy makers, researchers and practitioners have important and complementary roles to play in supporting the translation of effective research interventions into practice. New avenues need to be explored to strengthen partnerships between researchers and end users to support the integration of effective public health research interventions into practice.
Obesity prevention; Children; Infants; Implementation; Research translation; Dissemination
It is widely accepted that the transfer of new knowledge
from public health research into policy and practice is
far from optimal. Government agencies, including the
National Institute of Health in the USA emphasise the
need for widespread dissemination of evidence-based
interventions to help bridge the gap between research and
]. There is a growing body of literature
investigating the translation of public health research into
]. Five main stages of building evidence in
public health have been proposed: Stages one and two,
Problem definition and Solution generation relate to
program development; stage three, intervention testing,
represents process and impact evaluation to determine
program efficacy or effectiveness; and stage four,
intervention replication, refers to subsequent studies in which
effective programs are adapted for other settings to
determine if and how similar outcomes can be achieved in
different places and populations [
]. Finally stage five,
intervention dissemination, focuses on the scaling up of
an effective program to population level to maximise
public health impact [
Translational research in public health has been
defined as studies that focus on stages four and five, that is
replication and scaling up of effective interventions [
Scaling up is the process by which health promotion
interventions shown to be effective in controlled
conditions or on a small scale are expanded into real world
]. There is growing interest in the concept of
‘scaling up’; however existing literature to date has been
limited in focus, for example, investigations of
conceptual frameworks [
] or case studies of scaled up
programs in low income countries [
]. There are
relatively few examples of published studies reporting on
the scaling up of effective public health interventions
into practice [
In the emerging field of obesity prevention in young
children much of the research conducted to date is in
the early stages of intervention development and
efficacy testing (stages one to three), with a lack of
effective population wide programs, particularly in young
children 0–5 years [
]. Further, reporting of
external validity information such as selection and
representativeness of settings, intervention characteristics and
delivery costs and program sustainability is poor in
existing intervention studies [
] and in systematic
reviews on the topic [
]. Given the extent of child
obesity as a public health problem, there is currently
limited practice-relevant information for policy makers
and practitioners to inform decisions about how
effective programs can be disseminated ‘at scale’.
This paper provides a case study of the scaling up of
the Melbourne InFANT Program (herein referred to as
the InFANT Program), a group-based obesity prevention
program that was effective in improving child and
maternal diet, parental feeding behaviours and sedentary
behavior in children [
]. The aim of the study was to
explore the key factors influencing the scaling up and
translation of this program into routine practice from
the perspective of the main players involved, including
researchers, policy makers and implementers. This will
provide much needed insights into the ‘scaling up’
process and key lessons for public health researchers,
policy makers and practitioners to inform the
dissemination of other obesity prevention programs targeting
young children into practice.
Study context – The InFANT Program
The InFANT Program was a cluster randomised
controlled trial (RCT) targeting first time mothers through
existing universal care services which trialled the efficacy
of a low dose program (six sessions delivered by
dietitians quarterly over 15 months, commencing when
Infants were 3 months of age) to improve parent and child
diet and physical activity and to reduce sedentary
]. This study was informed by qualitative
research with the target group [
] and by two systematic
]. At follow up when children were 18
months old, the Program did not change children’s
growth, but did improve aspects of child’s diet and
sedentary behaviours ; improved child diet quality [
improved water and vegetable intakes in sub-groups
]; increased maternal knowledge and improved
preferred feeding behaviours [
]; and improved mother’s
dietary patterns [
The Program was delivered as part of The Victorian
Department of Health and Humans Services (referred to
throughout as ‘the Department’) prevention platform
taking a complex whole of systems approach to reducing
chronic disease risk. This approach involves delivering
multiple strategies, policies and initiatives at both the
state and local levels to target individuals in places
where they spend their time, including childcare centres,
schools, workplaces, food outlets, sporting clubs,
businesses, local governments, health professionals
and more to create healthier environments for all.
This has shifted action from projects, small in scale,
to prevention at scale delivered by multiple
stakeholders, organisations, and sectors together with a
community led placed based approach in 12
prevention areas across the state. Prevention areas were
generally defined by local government area boundaries,
however in some cases prevention area incorporated
more than one local government area.
High quality health promotion programs have long
played a significant role in health promotion, and with
an opportunity to implement a complex system approach
to prevention in Victoria, an opportunity emerged to
rethink how programs can be delivered to contribute to
prevention system change. The Department provided the
opportunity for the 12 prevention areas to select quality
health promotion programs using a selection criteria
developed by the Department (Additional file 1) to support
this decision making process. A list of recommended
programs was created, which included the InFANT Program
to fast track and support this process.
The InFANT Program researchers were funded by The
Department to prepare program materials for
dissemination. This included a facilitator manual, a parent
handbook, a program website (www.infantprogram.org) and a
guide for program implementation. A one day training
program was developed and delivered by InFANT
Program research staff to facilitators. Facilitators included
dietitians, Maternal and Child Health (MCH) nurses and
parent support workers. MCH nurses in Victoria provide
a universal free service to parents of children 0-6 years
and parent support workers typically work alongside
MCH nurses to facilitate group programs such as first
time parent groups. Prevention area staff were responsible
for coordinating the implementation of the Program in
each locality in partnership with key stakeholders and
A case study approach was used to explore factors
influencing the translation of the InFANT Program into routine
practice. Case study methods are appropriate for answering
‘how’ and ‘why’ questions and when the phenomenon of
interest (research translation) is embedded within a
realworld policy and practice context [
]. The study consisted
of a case series of five areas implementing the InFANT
Program along with interviews with research staff and
policy makers involved in the translation efforts across sites.
The study methods were informed by a constructionist
epistemology. This assumes that knowledge is constructed
and shaped by people’s perception, that phenomenon can
only be understood in the context in which they are
studied, and that truth is a matter of consensus amongst
informed constructions, not a correspondence with an
objective reality [
]. This was applied to the study by
collecting detailed information on contextual factors
influencing participants’ perceptions and recognising that the
findings are co-created by participants and researchers
and not an objective truth to be discovered.
The sampling frame for the study sites were prevention
areas that had been implementing the Program for at
least 6 months at the commencement of data collection.
The 6 month timeframe for implementation was
selected to allow areas to have had some experience of key
implementation issues. As of January 2015, eight out of
the 12 prevention areas choose to deliver the Program,
five were eligible to participate in this study having
implemented the Program for at least 6 months.
The sampling strategy was purposeful with the aim to
obtain insight from a range of stakeholders in each site
as well as researchers and policy makers (Table 1).
Coordinators (n = 5) from these five areas were emailed by
the Department personnel to invite them to participate
in an individual telephone interview, and all agreed.
Following each interview, coordinators were asked to pass
on the interview invitation to key local stakeholders and
program facilitators who they considered might offer
additional insights into program implementation in their
area. Local key stakeholders included MCH Nurse
Managers, those working in roles within Child and Family
Services, staff involved in hosting or organising program
venues, administrative or evaluation staff. A total of 11
staff (seven key stakeholders and four facilitators) were
invited and agreed to participate using this snowballing
method (Table 1). In one area, this took the form of a
focus group (as this was already planned as part of local
level evaluation), in the remaining areas individual
telephone interviews were conducted. An online survey of
program facilitators was also used as a concurrent
recruitment strategy. A total of eight program facilitators
from the participating areas completed the survey, and
all agreed to be interviewed including three who had not
already been identified through the snowballing strategy.
Research staff and policy personnel who were actively
involved in the translation effort were also invited to
participate by email invitation from the study lead (RL),
and all except one (a policy maker who had moved on
to a different role) agreed. Research staff included the
lead investigator involved in the design and testing of
the Program in the RCT, those involved in training
program facilitators and liasing with with policy personnel
and local implementers.
Data were collected from January to June 2015 and
included 18 individual semi-structured interviews, a focus
group in one area and observation of two meetings
involving researchers, policy makers and implementers
(Table 1). In total 28 individuals contributed to the data
collected consisting of research staff (n = 4), policy
makers (n = 2) and implementers (n = 22) from across
five prevention areas. Implementers included program
coordinators (n = 5) responsible for overall
implementation of the Program in each area, program facilitators
(n = 8) who delivered the Program to parents, and local
stakeholders (n = 9).
The interviews and focus group guides were informed
by the consolidated framework for advancing
implementation science [
] which integrates existing
implementation theories into five key domains shown to be critical
to implementation success. Key topics covered included:
Role in implementing the InFANT Program
Planning for program implementation - who, how
and why the InFANT Program was selected?
Models of implementation, including any adaptions to
the Program and degree of program fit with existing
services/programs and policies.
Support for implementation, including on the
ground logistical support, management support,
researcher and policy support
Perceived outcomes including program strengths
Perceived sustainability of program and factors
Key lessons for researchers, implementers and
Individual interviews were conducted over the phone
by RL and lasted 40 min on average (range:17 to 65
min). The focus group was conducted face to face,
facilitated by RL and lasted one hour and five minutes.
Opportunistic data collection also occurred at two
meetings of local implementers, research staff and policy
personnel. These meetings provided an opportunity to
gather data on key issues relating to the
implementation of the Program. The first meeting lasting 1 h and
5 min involved seven individuals including
representatives (n = 5) from all the prevention areas as well as
research staff (n = 1) and policy personnel (n = 1). This
meeting focused on models for implementation where
participants discussed implementation progress,
challenges and various program adaptions that had been
made. The second meeting, lasting 1 hour and 35 min
included representatives (n = 3) from two prevention
areas, research staff (n = 2) and policy personnel (n = 1).
The focus of this meeting was to share the preliminary
findings from the interviews and focus group to firstly
verify key themes arising and secondly, to use this to
generate further discussion and insights about key
The interviews, meetings and the focus group were
audio recorded with participants’ permission and
transcribed verbatim. Transcripts were imported into Nvivo
10 which was used for coding, sorting and retrieval of
data. The study used thematic analysis informed by the
methods of Braun and Clarke [
] and involved the
following steps undertaken by RL:
1. familiarisation with the data by checking the
accuracy of transcripts against audio recording.
2. line by line coding of the data using an inductive
approach guided by the research aims, resulting in
the development of an initial coding framework. The
coding framework was iteratively refined based on
new concepts identified in the data.
3. review of codes to identify broader conceptual
themes. At this stage the researchers’ knowledge of
empirical literature and existing frameworks for
implementation science helped in conceptualising
codes into broader categories.
4. Review of all data within a given theme to identify
common and divergent views using constant
comparison technique [
5. First draft of results section which involved
rereading data coded at each theme, along with
memo’s about sub-themes to succinctly summarise
the theme using illustrative quotes.
6. Member checking which involved 1) presentation of
key findings at a meeting of study participants (see
above), which contributed to further data collection
and elaboration and refinement of themes; 2)
emailing coordinators (n = 3), research staff (n = 2)
and policy personnel (n = 1) a copy of the initial
draft results section of the manuscript. Participants
were asked to comment on whether the themes
sufficiently captured their views on the key factors
influencing translation process and whether any key
issues were omitted in the representation of the
results. There was strong agreement with the themes
presented and only minor modifications were made to
the results based on feedback from participants.
Reflexivity and the role of the researcher
As the study methods were informed by a constructivist
approach, it is important to make explicit the role and
background of the researcher which may influence how
one understands and interprets the data [
undertook all data collection and analysis with member
checking and input into final results. RL is a postdoctoral
researcher with experience in research translation having
worked on previous empirical studies exploring the
process of research translation [
] and conceptual
]. Over the past 18 months, RL had been
engaged with the researchers, implementers and policy
makers involved in the translation of the Program. This
has provided in-depth understanding of the translation
issues where RL has essentially been a participant
observer. We believe this adds strength, heightening RL’s
sensitivity to translation and implementation issues in
the data. RL was not involved in the original InFANT
Program trial and had no input into the development of
Description of study sites
All five of the eligible prevention areas took part in this
study and had been implementing the Program between
six and 15 months. All areas were in the lowest tertile
for socio-economic disadvantage as defined by an area
level indicator of disadvantage (Socioeconomic index for
]). Four of the areas were located in
metropolitan Melbourne, with populations ranging from 25,000
to 150,000. One area was in a regional location in
Victoria, approximately 550 km from Melbourne with
a population of around 50,000. This is in contrast to
the areas participating in the RCT of the Program
where only three of 14 areas were in the the lowest
tertile for socioeconomic disadvantaged (eight medium,
three high) and all areas were located within
metropolitan Melbourne [
Role of researchers, policy makers and implementers
Researchers, policy makers and implementers all had
specific roles to play in the scaling up and translation of
the InFANT Program into routine practice (Table 2).
For researchers, this centered on translation of
intervention materials from the research trial into a
‘pre-packaged program’ ready for community wide delivery,
developing and delivering a training program to
implementers as well as being an expert point of contact for
the Program. Policy makers provided support towards
the translation effort by funding prevention areas as well
as working closely with these areas to support multiple
system wide prevention strategies including the
implementation of specified programs. The Department also
funded the printing of InFANT Program materials and
funded researchers’ involvement in translation activities.
Policy makers also acted as an important link between
researchers and implementers on the ground. Local
implementers were responsible for all aspects of program
delivery at the community level including program
planning and adaption, engaging delivery agents/services and
Key factors affecting the translation process
A number of key barriers and facilitators to the
translation process were identified (summarised in Table 2) and
these are outlined in the following key themes.
Program specific factors
A number of program specific factors were considered
important in influencing program uptake both at the
policy and local community level. At the policy level, the
feasibility of program delivery was considered to be
critical in selection of the Program for dissemination.
Researchers reported that the Program was designed with
scalability and community implementation in mind. The
process evaluation spoke to the feasibility of the
Program in terms of delivery within the MCH setting as
well as high rates of recruitment and retention. The
positive outcomes of the research trial in terms of
maternal beliefs, attitudes and behaviours were also
considered important in policy makers endorsing the Program,
despite the trial not demonstrating changes in the
primary outcome of child weight:
“the primary outcome was weight and we didn’t
change weight. But…I’ve promoted fairly strongly to
the Department of Health (‘the Department’) that
we’ve seen changes in maternal attitudes and beliefs,
…a number of the mediators, if you like, have
improved…They were very impressed by the fact that
87 percent of people we approached wanted to
participate, which I guess evokes some maternal
interest in the space…That groups have worked quite
well, so seven out of ten people attended four of six
sessions. The mechanics appear to be a good model
that they were interested in” (Research staff 1).
of the groups as well as mode of delivery through
engaging families, all appealed to local implementers.
There was a general endorsement of the concept of
starting healthy lifestyle messages early to prevent future
problems and associated impact on service demands.
The fact that the Program was ‘pre-packaged’ including
program resources and training made it an attractive
option as discussed by this local implementer:
“because it was a pre-packaged program all the
resources were there, the training was offered …so we
identified a need, identified where we wanted to run
it, found brilliant staff to run it, got the okay from
sort of management level and then we were able to
just kind of…take it up as a whole and roll it out
Prevention areas had direct access to research staff
involved in the design of the InFANT Program through
face to face meetings, a dedicated training program and
an online forum. This was considered to be an
important facilitator for local implementation as described by
“one of the main factors for encouraging uptake was
the support that was delivered around it,…there were
only two programs where the department engaged the
researchers themselves to support the implementation.
So that was in my view a big bonus for the HTCs
(prevention areas) just because they got access to the
researchers, they felt quite supported” (Policy maker 28).
Strong partnerships were an important facilitator at every
stage in the translation process. Researchers actively
sought to engage policy makers early in the research phase
of the InFANT Program. This well-established trusted
relationship facilitated the early sharing of findings from the
trial and helped to establish the researchers’ expert role
and credibility. However, the high turnover of policy staff
was a barrier to continuity of partnerships.
“I think what the existing relationship did was gave us
the opportunity to get our foot in the door, so we were
a trusted source, we were considered to be experts in
the field” (research staff 1).
At the local level, the InFANT Program was perceived
to address an area of need and a gap in current service
provision as there were very few (if any) existing healthy
lifestyle programs targeting parents with young infants.
Much of the current focus was on preschools and
schools. The Program content including the clarity of
the Program key messages, the discussion based nature
At the local level, the viability and sustainability of
delivering the Program was dependent on engaging key
delivery partners including MCH services, local council
and community health services. The funded prevention
workforce played a critical coordination role in engaging
these partners during the initiation of the Program. A
key engagement strategy included aligning the goals of
the Program with the needs and priorities of key
stakeholders. This involved using a combination of ‘bottom
up approaches’ such as informal conversation with
individual staff and ‘top down approaches’ such as negotiation
between high level managers and formal agreements.
“it's having a workforce that is able to do a lot of that
legwork and, yeah, pitch it in such a way that a
director or a manager can say, “Okay, I see our stake
in this program” (Key stakeholder 13).
It was acknowledged that building such partnerships
takes time, requires a dedicated staff member(s) to drive
partnership development as well as clear goals, regular
communication and mutual benefits. A number of
contextual factors were noted to influence partnership
development across the areas involved, including the size
of the area (with partnerships easier to forge in smaller
areas with fewer stakeholders and existing relationships),
individual personalities (degree of openness to innovation
and willingness to champion the Program), whether
prevention staff were co-located with key partners and the
degree of program fit with the local policy context.
Coordinators, champions and leaders
Coordinators, champions and leaders were key drivers in
the translation of the InFANT Program into routine
practice and these individuals worked at the local level
as well as in policy and research. As mentioned above,
Prevention Coordinators were critical in bringing key
partners around the table to agree on how the InFANT
Program would be delivered at the local level. They did
much of the ‘leg work’ of setting up the administration
of the Program, reducing the risk for partners because
Prevention Coordinators took initial responsibility for
managing the Program.
“Often you can have different people across different
organisations, teams, departments, that are interested
but you need someone to kind of bring it together, set it
up” (Coordinator 5d).
Prevention Coordinators who had already begun
implementation of the Program often became champions and
advisers to other areas considering taking the Program on.
Individual MCH nurses and managers engaged in
delivering the Program also became champions in promoting the
Program within and outside their own service.
Further, individual policy personnel played an
important coordinating role in bringing together researchers
and local implementers to learn from each other as
discussed above. Having a policy position responsible for
the implementation of the Program was considered
important in ensuring this level of coordination occurred
between researchers and local implementers. At the
researcher level, having university staff responsible for
coordinating contracts with the Department and other
administrative tasks was important in allowing the lead
researcher to focus on key translation tasks such as
engaging with local implementers.
Workforce capacity to support the implementation of
the Program at the community level and to support the
translation effort more broadly was a major theme
arising. At the local level, program adaption and strong
partnerships were considered essential in ensuring a
sustainable workforce to deliver the Program. In contrast to
the research trial, in which dietitians were used to
deliver the Program all areas (except one) adapted the
Program to use MCH nurses and parent support workers to
deliver the Program. In these areas, mentoring support
was provided by local dietitians following the formal
training program. This program adaption was
predominantly influenced by workforce capacity and cost, as well
as fit with the existing health professional role.
“You have to adapt it to what you’ve got capacity to
run. We’ve run it with Maternal and Child Health
nurses and parent support workers which makes it
much more cost effective” (Coordinator14a).
MCH nurses and parent support workers were
considered a natural fit for the role because of their well
established and credible relationship with parents and because
they already addressed issues related to infant feeding and
active play in their routine consultations. The InFANT
Program was considered an innovative way of more
comprehensively addressing topics already covered in
individual consultations, potentially saving consultation time and
costs. As such, two areas reported embedding program
delivery into existing MCH nurse and parent support
worker roles, as a way of making program delivery more
sustainable. Two areas had specifically funded the time of
MCH nurses and parent support workers to deliver the
Program as part of a pilot. The area that chose to use
dietitians to deliver the Program perceived their expert skills
and knowledge to be a selling point for getting parents to
the Program. However the dietitians admitted themselves,
that due to their limited capacity, additional support is
likely to be needed in the future. More recently other
allied health staff and health promotion officers in the area
have been trained to provide ‘back up’ support to dietitians
delivering the Program if required.
At the local level, the administration of the Program
including organising groups, booking venues and
facilitators, was a major burden largely taken on by
Prevention Coordinators. To ensure sustainability of program
administration in the absence of ongoing prevention
funding, Coordinators discussed a number of options.
These included making further adaptions to the Program
to reduce the administrative burden, seeking funding for
administrative support or trying to embed these tasks in
an existing administrative role which would depend on
strong partnerships with other services.
“So it just seems like the weaknesses might be linked to
the admin/workforce intensity of the Program.. if you
don’t have other partners engaged, then that might be
a little bit more difficult” (Policy maker 27a).
Workforce capacity to support program translation
was also an issue from the researcher and policy maker
perspective. Research staff commitment to ‘make a
difference’ was an important driver of their involvement
despite having limited capacity to undertake research
translation activities which are not considered core
business or traditionally rewarded in academic roles.
“It's so tough because it's so much an add-on to my
core business, which is ironic isn’t it when you think that
the academic role of developing knowledge and capacity,
and then when it comes to actually doing what we said
we wanted to do, which is implement it, we really had
very little capacity to do that” (Research staff 1).
Furthermore university systems may not be set up to
easily support program delivery such as accepting
payment for program training or the storage of program
resources. Research staff suggested that alternative models
for research translation are needed within the university
sector such as dedicated funds and staff for research
translation and researchers undertaking secondments to
service delivery settings to support program roll out. At
the policy level, staff capacity was also an issue with staff
cut backs making it difficult to have a dedicated position
to support program implementation.
Context – Fit with existing policy, program and services
The extent within which the InFANT Program fitted
with the broader policy environment, as well as local
programs and services was a central theme influencing
translation opportunities. At the conceptual level, there
was a strong tension between the Department’s focus on
system level approaches to prevention with an emphasis
on creating supportive policies and environments for
behaviour change on the one hand, and programs, such as
the InFANT Program, focusing on individuals/families
on the other. This tension was resolved at the local
level by demonstrating how individual programs, like
the InFANT Program, fitted within and complemented
a system based approach:
“If you’re going to get the biggest bang for your buck I
think you’d want to make sure that it’s [the Program]
linking into things …we thought, well, if parents are
getting this information early they’re going to be more
receptive to that information when settings and services
are taking that up in kinder and long day care…
thinking about it broadly and where it fits into the
broader system is important too” (Coordinator 22a).
As discussed previously, the InFANT Program fitted
well with the priorities and focus of local MCH services
in most areas and this was essential for partnering with
this service to deliver the Program. The Program was a
‘natural’ fit with first time parent groups running in all
areas. These groups formed the basis of recruitment to
the Program and provided a mechanism of linking
parents to other services and programs locally, an
important priority of both MCH services and local council.
However, in one area, MCH services were running
other concurrent parenting programs which were
perceived to be competing with the InFANT Program for
nurse and parent attention. The same area reported
that initially it was difficult for MCH Service to be
engaged as priorities and resources for the service had
already been allocated on the basis of previous annual
council business plans:
“we’re operating in the local government context, it is a
challenge to implement things in a timely manner
when there are plans and strategies …they go over a
four year period and there is already resources
allocated and prioritisation that’s occurred…So for
example, you know, an Infant type program wasn’t
necessarily a priority with Maternal and Child
Health.” (Coordinator 17a).
Balancing adaption versus program fidelity
As expected, all areas had adapted or proposed to adapt
the Program to some extent from the original trial
(Table 3). Most common changes included choice of
program facilitator, recruitment methods and use of
local supplementary materials. Adaptions were largely
driven by the need to make the Program viable to deliver
in terms of staffing costs as well as to improve the fit
with existing programs and services, to increase program
reach and tailor to specific population needs. There was a
clear tension between the need to adapt the Program to fit
the local context and the need to maintain program
fidelity and integrity as articulated by this participant:
“…we’ve got a program that is being developed on good
evidence, it’s been demonstrated to be effective in this
way…And then there’s reality and our ability to kind
of change and adapt the Program for what is realistic
for us into the future, that will be challenging for us
and getting support from [the university] around that”
Implementers and policy makers called for clear
guidelines from researchers about what were the core
components of the Program required to maintain fidelity and
effectiveness and what aspects could be adapted.
“I guess the randomised control trials just cannot be
repeated and used in a practical sense. So …making
recommendations …what are the critical things that
can't be changed, and what are some of the things
that possibly could be changed or could be adapted
to maintain integrity for those programs, and
possibly testing them in that way as well.” (Policy
While researchers were considered to have ownership
over the Programs’ intellectual property, there was some
discussion about the value of having a centralised
evaluation framework to monitor both program fidelity and
outcomes, recognising that programs do not operate in
isolation but are part of the broader system wide
“What would be really nice is to test some of this stuff
and actually be able to …gather some information
about what’s actually happening to the participants,
and what benefits are the participants getting”
(Research staff 2b).
Tailor to needs of local population (culturally and
linguistically diverse groups)
Provide information on local services/facilities
More cost effective
Limited capacity of dietitians
Good fit with existing role of MCH nurses and
To increase recruitment to the Program and reach
To reduce burden on facilitators and make the Program
more viable to run
To fit with existing first time parent groups and
individual Maternal and Child Health nurse consultations
Reduce administrative burden of recruiting and
following up multiple groups over time
Open up the Program to more parents potentially
To address lower retention rates amongst parents
with older babies
To make groups viable, limited capacity of facilitators
Successful existing program already underway
Sustainability and scaling up
All the areas with the exception of area four (smaller
rural area), chose to pilot the implementation of the
Program in one or two neighbourhoods, or in one cohort of
parents. The rationale for this was to test
implementation processes and models and assess the feasibility and
value of the Program before considering area wide
dissemination. Three of the five areas largely embedded the
delivery of the Program into existing roles within MCH
or allied health services, with the view of setting up
sustainability systems for program delivery beyond funding
of prevention areas:
“…we’re really trying to embed it in the work of
Community Health. So if Healthy Together
[prevention areas] is not refunded or it gets less
funding that it continues, so it’s embedded within the
Allied Health teams,…Child and Maternal Health
structure as well, so if we are to pull away that it
continues “ (Coordinator 22a).
In contrast, two areas directly funded program delivery
with the view of using the pilot phase to make a business
case for continued funding through local council or
other external sources.
“So what we are hopeful [of] is that if we can have
enough evidence and information that can create a
very strong case for council and for budgets and for
Maternal and Child Health nurses, the value of this.
Then it may be sustained” (Coordinator 17a).
Local implementers recognised the challenge of
obtaining ongoing funding for the Program and hence
were exploring options to further integrate the
Program into existing service delivery structures, roles
and existing programs.
“I think as a program by itself, I don’t know how
financially and time-wise it can expand without
combining it with other programs that are already
there” (Program Facilitator 25).
There was general agreement that further program
adaptions were likely to be required to better integrate
the Program into what was feasible locally. Adaptions
being considered included running age specific group
sessions open to anyone (rather than existing parent
groups), reducing the number of sessions or delivering
the Program via existing groups such as playgroups.
From a policy perspective, there were varying views
about program sustainability. One view was that state or
federal funding of programs was unlikely, hence
programs need to be embedded within a complex system
based approach to prevention that provided an
infrastructure to promote sustainability and scaling up.
“I mean there's not going to be funding available to
support and fund multiple programs, I doubt in the
future to come…So it will just be about how that
program can be integrated within the system” (Policy
Another view was that the InFANT Program should
be a universal program with re-current government
funding as part of an ongoing commitment to
prevention in the early years:
“… [the Program] needs to be funded by government
and delivered by local council. The Government
should make a commitment to early childhood and
the InFANT program is one of those things…It’s not
fair that some local councils implement and others
don’t, …it should be universal” (Policy Maker 28).
From the research staff perspective, maintaining and
updating the Program website and materials and
providing training to local implementers were ongoing
activities that would require research staff time and hence
funding. The short term nature of funding for researchers
to be involved in these translation activities was a barrier
to sustained program implementation.
This study provides new insights into the respective role
that policy makers, researchers and implementers play
in the translation of a health promotion program into
practice and factors influencing this process. As
discussed below, a number of key themes were identified
by these stakeholders as being important in the
translation of the InFANT Program from research to
community level implementation.
In line with the findings from this study, the evidence
of program efficacy or effectiveness has been found to
be only one of many intervention characteristics
influencing research uptake [
6, 13, 31, 33, 40
]. Other important
factors identified in previous implementation research
include, the credibility of the Program source, its
feasibility, the quality of program materials, program
adaptability, trialability, relative complexity and cost [
findings concur with recent research highlighting the
importance of end users having information on program
reach and costs, key service delivery issues such as
acceptability and fit of the interventions with existing
delivery models, to help inform decisions about the scaling
up of public health interventions [
]. It also suggests
the importance of researchers designing scalable and
feasible interventions from the outset that align with the
policy context. This is likely to require co-development
of programs with practitioners on the ground or
extensive formative work, as was the case with the InFANT
15, 23, 24
]. This underscores the importance
of researchers conducting rigorous process evaluations
as part of efficacy /effectiveness trials to inform external
validity of public health interventions, an area generally
poorly reported by researchers [
17, 19, 35
The tension of balancing program adaption against
maintaining program fidelity identified in this study, has
been a commonly reported theme in the dissemination
of research interventions into practice [
While greater program fidelity has been shown to be
associated with better outcomes [
intervention programs to better suit the needs and circumstances
of local communities has also been shown to be essential
for successful sustained implementation [
8, 41, 42
help find this balance between fidelity and adaption,
implementation researchers have proposed various
]. At the heart of these recommendations are
the need for researchers to clearly articulate the Program’s
core components based on a logic model of how the
intervention is proposed to work, ideally supported with
mediation analysis to identify the ‘active ingredients’ of the
intervention. This is then married with consultation
with community implementers to refine and modify
non-core components to ensure program fit with local
circumstances in an iterative fashion . It is also
recommended that adapted programs are evaluated to
assess effectiveness and that these steps ideally involve
consultation between program developers and
]. Systems such as licensing agreements or
program guidelines may be helpful in monitoring
program fidelity and adaptions and encouraging
consultation between researchers and implementers. Service
delivery organisations (not for profit or commercial)
may have a role to play in ‘rolling out’ evidence based
public health programs and monitoring program
quality and fidelity. An example of this is the DECIPHer
Impact, a not for profit organisation set up to license
the 'ASSIST' peer-smoking intervention to schools to
ensure fidelity [
For researchers, avenues need to be explored to fund
research translation activities, including initial
consultation with communities around program adaptions and
ongoing program support, such as the provision training
and updating of program materials. This remains a
challenge, with translation activities not traditionally part of
research grant proposals when the study outcomes are
not yet known. More recently, specific research
translation grants have become more common and this may
provide an avenue for researchers to work with
community partners to fund such activities. In the absence of
external funding, researchers are likely to need to
consider program licensing fees to cover costs associated
with supporting program delivery, as has been done with
other widely implemented programs such as the
Standford Chronic Disease Self Management Programs [
At a system level, there is likely to be more incentive
for researchers to focus on translation in the future
with a growing focus on measuring research ‘impact’ as
part of the assessment of universities research outputs.
In some countries, research ‘impact’ is being link to
university funding, for example, in the UK Research
Strong partnerships between researchers, policy makers
and implementers, as well as local partnerships were
identified as critical to the translation of the InFANT Program
into practice. Partnerships between researchers and end
users of research, such as policy makers and practitioners,
has been consistently shown to be a facilitator of
research use and scaling up in previous empirical studies
8, 11, 12, 33, 37
]. As with this study, engaging end
users from the inception of a project and forging
ongoing relationships with policy makers and
practitioners has been shown to be important in promoting
the uptake of health promotion programs [
33, 37, 49
In this study, engaging practitioners in program
modification ensured that the Program was designed to fit
existing service delivery structures (MCH services), was
relevant to the policy focus on obesity prevention in
the early years, all of which were important facilitators
of program uptake. The implementation of the Program
was facilitated by local implementers having direct access
to researcher staff who designed or delivered the Program
to provide training and guidance for implementation.
Mentoring programs where researchers and practitioners
can learn from each other during the translation process
have been shown to be useful for both parties [
However, challenges remain in funding researcher time, with
research translation activities often considered outside of
the traditional academic role. Dedicated funding for
research translation and the establishment of mentoring or
secondment opportunities for researchers, policy makers
and practitioners to work together may be a useful step
forward in supporting partnerships between researchers
and end users of research.
The findings highlight the importance of having key
individuals responsible for driving and coordinating
research translation across the domains of research, policy,
and practice. This case study is unique in that funding
was provided to support the translation efforts. At the
local level, the prevention workforce as part of the local
prevention infrastructure was critical in engaging and
working with key partners to deliver the Program. These
coordinators undertook critical research ‘translation
activities’ including exploring how the Program fitted with
and enhanced existing services and how it could be best
adapted to ensure sustained program delivery. In the
scaling up of public health programs, consideration
needs to be given to who will undertake these research
translation activities at the local level. From a researcher
perspective, research staff need funding to support the
translation of research interventions into pre-packaged
programs ready for community wide implementation.
This study also demonstrates the important role that
policy personnel can play in supporting research
translation, highlighting the value of incorporating this
component into existing policy positions. Previous case studies
of research interventions with positive practice and
policy impacts [
] as well as a recent literature review of
facilitators of scaling up [
], have demonstrated the
importance of leaders, champions and coordinators in
advocating for and supporting adoption of public health
interventions into practice.
The study findings point to important lessons
regarding the scaling up and sustainability of program
implementation. It is yet to be seen whether the InFANT
Program can be scaled up and delivered on an ongoing
basis in the absence of funding from the Department for
the Program. Given that ongoing funding for any
program at a state or local level was unlikely at the time of
this study, it appears that embedding program delivery
into existing service infrastructure will be critical for
both scaling up and sustainability of the Program. With
the strong competing demands on practitioner time and
resources, it will be important that ongoing program
evaluation be conducted to support a business case for
continuation of the Program locally within existing
services. This points to the importance of cost effectiveness
analysis to be conducted as part of intervention trials to
help make the case for investing in particular intervention
programs. This is in line with a recent narrative review,
which identified establishing monitoring and evaluation
systems and costing and economic modeling of
intervention approaches as important success factors for scaling
up public health interventions [
]. Alignment of the
Program to both state and local policy context will also be
important in harnessing ongoing support for the Program.
This study has a number of strengths and limitations.
The strengths include the use of multiple varied case
studies and cross case comparisons to explore the
important influence of local context on implementation.
We did however, only have one rural site participate in
the study and the inclusion of additional rural sites may
have resulted in different implementation issues
emerging. We also did not include sites that chose not to
implement the Program, which may have provided
interesting additional insights into factors influencing
initial uptake. Within cases, we interviewed a range of
stakeholders including coordinators, program
facilitators and those involved in supporting program delivery.
There was variation however in the number of people
interviewed across sites ranging from nine participants
(site one) to two participants (site five) and this may
have limited insights gained from some sites. The
inclusion of researchers and policy makers involved in
supporting program delivery as participants in the study
was also a strength as it enabled a comparison of views
across roles, providing important new insights from
these various perspectives. While the study used a
range of data collection methods including individual
interviews, focus groups and recording of meetings
involving key players, additional methods such as
observation of program sessions, analysis of key documents
and interviews with parents may have yielded additional
insights. While all data was collected and analysed by a
single researcher (RL), the trustworthiness of the
findings was verified by participants on two separate
occasions and the role and background of the research was
This study highlights the important and complementary
role that policy makers, researchers and practitioners
can play in the translation of health promotion programs
into routine practice. New avenues need to be explored
to comprehensively bring together researchers and end
users at all phases of the research to practice continuum.
This is likely to lead to the development of more feasible
and scalable programs, assist in adapting programs to fit
local circumstances, while maximising program fidelity
and supporting implementation at the local level. Key
recommendations for researchers arising from this study
include the need to develop feasible and scalable
interventions from the outset; to incorporate comprehensive
process evaluation measures, including cost effectiveness
to inform future program roll out; and to identify core
program components that are important for program
fidelity. Consideration should also be given to additional
mediation and dose response analysis to be conducted
to inform program fidelity recommendations.
Recommendations for practitioners include the importance of
having a key individual responsible for coordinating
translation activities in the initial startup phase, engaging
key delivery partners to enable the Program to be
adapted to fit and become part of existing local service
delivery infrastructure. Consideration needs to be given
to ongoing program evaluation at the local level to help
create a business case for sustained program delivery. At
the policy level, funding for research translation
activities and partnerships between researchers and end users
needs to be built into existing research funding schemes.
Additional file 1: Healthy Living Program and Strategy selection criteria.
(DOCX 199 kb)
The authors would like to acknowledge Rowland Watson and Maya Rivas (The
Victorian Department of Health and Human Service) for their contribution and
support in the delivery of the InFANT Program. Finally, the authors would like to
acknowledge all participants for their time and valuable insights.
The research reported in this paper is funded by Australian Primary Health
Care Research Institute, which was supported by a grant from the Australian
Government Department of Health and Ageing. The information and
opinions contained in it do not necessarily reflect the views or policy of the
Australian Primary Health Care Research Institute or the Australian
Government Department of Health and Ageing. Funding was provided by
the Victorian Department of Health and Human Services to support research
translation activities for the InFANT Program. The original InFANT Program
development and testing was Supported by the National Health and
Medical Research Council (grant 425801) with additional funds supplied by
the Heart Foundation Victoria and Deakin University. RL is supported by a
National Health & Medical Research Council Early Career Fellowship, ID
1089415. KB is supported by a National Health & Medical Research Council
Principal Research Fellowship, ID 1042442. KDH is supported by an Australian
Research Council Future Fellowship IDFT130100637 and an Honorary
National Heart Foundation of Australia Future Leader Fellowship ID100370.
Availability of data and materials
The qualitative interview transcripts analysed during the current study are
not publicly available due to the possibility of identifying individuals.
RL led the design of the study with input from other authors. RL was responsible
for recruitment data collection and analysis and wrote the first draft of the
manuscript. All authors contributed to and commented on drafts of the
manuscript, approving the final manuscript submitted.
The authors declare that they have no competing interests. While KC, KB and
KH conducted the InFANT Program they have no financial interest arising
from the Program implementation or outcomes.
Ethics approval and consent to participate
The study was approved by Faculty of Health, Deakin University low risk ethics
committee (approval number: HEAG 183_2014) and participants gave informed
written consent to participate.
1Institute for Physical Activity and Nutrition, School of Exercise and Nutrition
Science, Deakin University, Geelong, VIC, Australia. 2Centre for Obesity
Management and Prevention Research Excellence in Primary Health Care
(COMPaRE-PHC), Sydney, Australia. 3Centre of Research Excellence in Early
Prevention of Obesity in Childhood, Sydney, Australia. 4Prevention and
Population Health, Department of Health and Human Services, Melbourne,
1. Woolf SH . The meaning of translational research and why it matters . JAMA . 2008 ; 299 ( 2 ): 211 - 3 .
2. Glasgow RE , Emmons KM . How can we increase translation of research into practice? Types of evidence needed . Annu Rev Public Health . 2007 ; 28 : 413 - 33 .
3. Marchand E , Stice E , Rohde P , Becker CB . Moving from efficacy to effectiveness trials in prevention research . Behav Res Ther . 2011 ; 49 ( 1 ): 32 - 41 .
4. Milat AJ , King L , Bauman A , Redman S . Scaling up health promotion interventions: An emerging concept in implementation science . Health Promot J Austr . 2011 ; 22 ( 3 ): 238 .
5. Rychetnik L , Bauman A , Laws R , King L , Rissel C , Nutbeam D , Colagiuri S , Caterson I . Translating research for evidence-based public health: Key concepts and future directions . J Epidemiol Community Health . 2012 ; 66 ( 12 ): 1187 - 92 .
6. Milat AJ , King L , Bauman AE , Redman S. The concept of scalability: Increasing the scale and potential adoption of health promotion interventions into policy and practice . Health Promot Int . 2013 ; 28 ( 3 ): 285 - 98 .
7. Kohl R , Cooley L. Scaling up - A conceptual and operational framework . Washington DC: International MS ; 2003 .
8. Milat AJ , Bauman A , Redman S. Narrative review of models and success factors for scaling up public health interventions . Implement Sci . 2015 ; 10 : 113 .
9. Larson CP , Koehlmoos TP , Sack DA . Scaling up zinc treatment of childhood diarrhoea in Bangladesh: Theoretical and practical considerations guiding the SUZY Project . Health Policy Plan . 2012 ; 27 ( 2 ): 102 - 14 .
10. Victora CG , Barros FC , Assunção MC , Restrepo-Méndez MC , Matijasevich A , Martorell R . Scaling up maternal nutrition programs to improve birth outcomes: a review of implementation issues . Food Nutr Bull . 2012 ; 33 ( 2 Suppl) : S6 - 26 .
11. Lorig KR , Hurwicz ML , Sobel D , Hobbs M , Ritter PL . A national dissemination of an evidence-based self-management program: A process evaluation study . Patient Educ Couns . 2005 ; 59 ( 1 ): 69 - 79 .
12. Teri L , McKenzie G , Logsdon RG , McCurry SM , Bollin S , Mead J , Menne H . Translation of two evidence-based programs for training families to improve care of persons with dementia . Gerontologist . 2012 ; 52 ( 4 ): 452 - 9 .
13. Lucas PJ , Curtis-Tyler K , Arai L , Stapley S , Fagg J , Roberts H . What works in practice: User and provider perspectives on the acceptability, affordability, implementation, and impact of a family-based intervention for child overweight and obesity delivered at scale . BMC Public Health . 2014 ; 14 : 614 .
14. Fagg J , Chadwick P , Cole TJ , Cummins S , Goldstein H , Lewis H , Morris S , Radley D , Sacher P , Law C . From trial to population: a study of a familybased community intervention for childhood overweight implemented at scale . Int J Obes (Lond) . 2014 ; 38 : 1343 - 9 .
15. Campbell KJ , Hesketh KD . Strategies which aim to positively impact on weight, physical activity, diet and sedentary behaviours in children from zero to five years. A systematic review of the literature . Obes Rev . 2007 ; 8 ( 4 ): 327 - 38 .
16. Doak CM , Visscher TLS , Renders CM , Seidell JC . The prevention of overweight and obesity in children and adolescents: A review of interventions and programmes . Obes Rev . 2006 ; 7 ( 1 ): 111 - 36 .
17. Laws R , Campbell KJ , Van Der Pligt P , Russell G , Ball K , Lynch J , Crawford D , Taylor R , Askew D , Denney-Wilson E. The impact of interventions to prevent obesity or improve obesity related behaviours in children (0-5 years) from socioeconomically disadvantaged and/or indigenous families: a systematic review . BMC Public Health . 2014 ; 14 : 779 .
18. Stice E , Shaw H , Marti CN . A meta-analytic review of obesity prevention programs for children and adolescents: The skinny on interventions that work . Psychol Bull . 2006 ; 132 ( 5 ): 667 - 91 .
19. Klesges LM , Dzewaltowski DA , Glasgow RE . Review of External Validity Reporting in Childhood Obesity Prevention Research . Am J Prev Med . 2008 ; 34 ( 3 ): 216 - 23 .
20. Wolfenden L , Wiggers J , Tursan D'Espaignet E , Bell AC . How useful are systematic reviews of child obesity interventions? Obes Rev . 2010 ; 11 ( 2 ): 159 - 65 .
21. Campbell KJ , Lioret S , McNaughton SA , Crawford DA , Salmon J , Ball K , McCallum Z , Gerner BE , Spence AC , Cameron AJ , et al. A parent-focused intervention to reduce infant obesity risk behaviors: A randomized trial . Pediatrics . 2013 ; 131 ( 4 ): 652 - 60 .
22. Campbell K , Hesketh K , Crawford D , Salmon J , Ball K , McCallum Z . The Infant Feeding Activity and Nutrition Trial (INFANT) an early intervention to prevent childhood obesity: Cluster-randomised controlled trial . BMC Public Health . 2008 ; 8 : 103 .
23. Hesketh KD , Hinkley T , Campbell KJ . Children's physical activity and screen time: qualitative comparison of views of parents of infants and preschool children . Int J Behav Nutr Phys Act . 2012 ; 9 : 152 .
24. Waters E , de Silva-Sanigorski A , Burford B , Brown T , Campbell KJ , Gao Y , Armstrong R , Prosser L , Summerbell C . Interventions for preventing obesity in children . Cochrane Database Syst Rev . 2011 ; (Issue 12):Art . No.: CD001871 . doi: 10 .1002/14651858.CD001871. pub3 .).
25. Spence AC , McNaughton SA , Lioret S , Hesketh KD , Crawford DA , Campbell KJ . A health promotion intervention can affect diet quality in early childhood . J Nutr . 2013 ; 143 ( 10 ): 1672 - 8 .
26. Cameron AJ , Ball K , Hesketh KD , McNaughton SA , Salmon J , Crawford DA , Lioret S , Campbell KJ . Variation in outcomes of the Melbourne Infant, Feeding, Activity and Nutrition Trial (InFANT) Program according to maternal education and age . Prev Med . 2014 ; 58 ( 1 ): 58 - 63 .
27. Spence AC , Campbell KJ , Crawford DA , McNaughton SA , Hesketh KD . Mediators of improved child diet quality following a health promotion intervention: The Melbourne InFANT Program . Int J Behav Nutr Phys Act . 2014 ; 11 : 137 .
28. Lioret S , Campbell KJ , Crawford D , Spence AC , Hesketh K , McNaughton SA . A parent focused child obesity prevention intervention improves some mother obesity risk behaviors: The Melbourne infant program . Int J Behav Nutr Phys Act . 2012 ; 9 : 100 .
29. Yin R . Case Study Research: Design and Methods . London: Sage; 2003 .
30. Patton M. Qualitative Research & Evaluation Methods . 3rd ed. California: Sage; 2002 .
31. Damschroder L , Aron D , Keith R , SR K , Alexander J , Lowery J . Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science . Implement Sci . 2009 ; 4 : 50 .
32. Braun V , Clarke V . Using thematic analysis in psychology . Qual Res Psychol . 2006 ; 3 ( 2 ): 77 - 101 .
33. Milat AJ , Laws R , King L , Newson R , Rychetnik L , Rissel C , Bauman AE , Redman S , Bennie J . Policy and practice impacts of applied research: A case study analysis of the New South Wales Health Promotion Demonstration Research Grants Scheme 2000-2006. Health Res Policy Syst . 2013 ; 11 : 5 .
34. Laws RA , Fanaian M , Jayasinghe UW , McKenzie S , Passey M , Davies GP , Lyle D , Harris MF . Factors influencing participation in a vascular disease prevention lifestyle program among participants in a cluster randomized trial . BMC Health Serv Res . 2013 ; 13 : 201 .
35. Laws RA , St George AB , Rychetnik L , Bauman AE . Diabetes prevention research: A systematic review of external validity in lifestyle interventions . Am J Prev Med . 2012 ; 43 ( 2 ): 205 - 14 .
36. Laws RA , Vita P , Venugopal K , Rissel C , Davies D , Colagiuri S. Factors influencing participant enrolment in a diabetes prevention program in general practice: Lessons from the Sydney diabetes prevention program . BMC Public Health . 2012 ; 12 : 822 .
37. Laws R , King L , Hardy LL , Milat A , Rissel C , Newson R , Rychetnik L , Bauman AE . Utilization of a population health survey in policy and practice: a case study . Health Res Policy Syst . 2013 ; 11 : 4 .
38. Rissel C , Laws RA , St George A , Hector DJ , Milat AJ , Baur L. Research to practice: Application of an evidence building framework to a childhood obesity prevention initiative in New South Wales, Australia . Health Promot J Austr . 2012 . In Press.
39. Australian Bureau of Statistics. Census of Population and Housing: SocioEconomic Indexes for Areas (SEIFA), Australia' , vol. 2033 , updated 28 March 2013 , viewed 8th September 2014 , www .abs.gov.au/ausstats/abs@.nsf/mf/ 2033 .0.55.001.
40. Milat AJ , King L , Newson R , Wolfenden L , Rissel C , Bauman A , Redman S. Increasing the scale and adoption of population health interventions: Experiences and perspectives of policy makers, practitioners, and researchers . Health Res Policy Syst . 2014 ; 12 : 18 .
41. Bopp M , Saunders RP , Lattimore D. The tug-of-war: Fidelity versus adaptation throughout the health promotion program life cycle . J Prim Prev . 2013 ; 34 ( 3 ): 193 - 207 .
42. Castro FG , Barrera Jr M , Martinez Jr CR . The cultural adaptation of prevention interventions: Resolving tensions between fidelity and fit . Prev Sci . 2004 ; 5 ( 1 ): 41 - 5 .
43. Griffin SF , Wilcox S , Ory MG , Lattimore D , Leviton L , Castro C , Carpenter RA , Rheaume C . Results from the Active for Life process evaluation: Program delivery fidelity and adaptations . Health Educ Res . 2010 ; 25 ( 2 ): 325 - 42 .
44. Van Daele T , Van Audenhove C , Hermans D , Van Den Bergh O, Van Den Broucke S. Empowerment implementation: Enhancing fidelity and adaptation in a psycho-educational intervention . Health Promot Int . 2014 ; 29 ( 2 ): 212 - 22 .
45. Durlak JA , DuPre EP . Implementation matters: A review of research on the influence of implementation on program outcomes and the factors affecting implementation . Am J Community Psychol . 2008 ; 41 ( 3-4 ): 327 - 50 .
46. Backer TE . Finding the balance- Program Fidelity and Adaptations in Substance Abuse Prevention: A State-of-the-Art Review . Rockville: Centre for Substance Abuse Prevention; 2001 .
47. DECIPHer Impact. [http://www.decipher-impact. com]. Accessed 5 Apr 2016 .
48. Chronic Disease Self Management Program . [http://patienteducation. stanford.edu/programs/cdsmp.html]. Accessed 5 Apr 2016 .
49. Innvaer S , Vist G , Trommald M , Oxman A . Health policy-makers' perceptions of their use of evidence: A systematic review . J Health Serv Res Policy . 2002 ; 7 ( 4 ): 239 - 44 .
50. Purcell EP , Mitchell C , Celestin MD , Evans KR , Haynes V , McFall A , Troyer L , Sanchez MA . Research to Reality (R2R) Mentorship Program: Building Partnership, Capacity, and Evidence . Health Promot Pract . 2013 ; 14 ( 3 ): 321 - 7 .