Context before Implementation: Decision Makers' Views of a Peer-Led Healthy Lifestyle Intervention for People with Serious Mental Illness in Supportive Housing

Objectives: People with serious mental illness (SMI; e.g., schizophrenia) die at an earlier age than people in the general population largely due to cardiovascular disease. Healthy lifestyle interventions that improve dietary habits and increase physical activity can help reduce this health inequity.  However, these interventions have limited reach among people with SMI since they are mostly delivered by health professionals in clinical settings (e.g., mental health clinics).  In a federally-funded Hybrid Trial Type 1 study, we are testing the effectiveness and examining the implementation of a peer-led healthy lifestyle intervention for people with SMI in supportive housing agencies. In this study, we expanded the reach of this intervention by employing peer-specialists (people with lived experiences with SMI) and by delivering it in supportive housing agencies in order to bring this intervention to people’s doorsteps.  In this presentation, we report findings from a qualitative study in which we used concepts from the Diffusion of Innovations Theory and the Consolidated Framework for Implementation Research to examine decision makers’ perceptions of our peer-led healthy intervention and to identify contextual factors that could shape the implementation of our intervention at these agencies.

Methods: A purposive sample of 12 decision makers (3 agency directors and 9 program managers) from three supportive housing agencies was recruited. We presented participants a vignette describing our peer-led healthy lifestyle intervention and used semi-structured qualitative interviews to examine decision makers’ views of our intervention and potential for implementation.  Interviews were recorded, professionally transcribed, and analyzed using grounded theory.  The following strategies were used to ensure the trustworthiness and rigor of our analysis: developing of an audit trail documenting analytical decisions, peer-debriefing meetings, and member checking presentations.

Results: The majority of participants were female, non-Hispanic whites, social workers or nurses. On average, participants had worked at their agencies for 5 years and had more than 10 years of experience working with people with SMI. Participants reported positive views toward the intervention with the most valued intervention attributes being relative advantage over existing services, compatibility with clients’ needs and preferences, ability to pilot the intervention, and cost.  Participants’ concerns about the introduction of this new intervention into their organizations focused on addressing logistic matters (e.g., space to hold group sessions), staffing issues (e.g., training, time), sustaining fidelity overtime, and maintaining clients’ engagement and motivation.  A grounded model emerged from our data depicting multilevel contextual factors believed to shape the implementation of our intervention at these agencies, including system- (funding, marketability, and external regulations), organization- (leadership support, fit with organization, staff buy-in and burden), and client-level (adaptability to clients’ needs and clients’ buy-in) factors.

Conclusions: Study findings illustrate the importance of understanding the context of practice before implementation. This examination can help identify critical views from decision makers that could undermine or advance the integration of peer-led healthy lifestyle interventions in supportive housing agencies and help identify structures, policies and organizational practices that can inform the implementation process.