Plan for Scale Out: Adapting a Diabetes Prevention Program for Implementation in Rural and Remote British Columbia

Rural and remote communities in Canada face a higher incidence and risk of developing type 2 diabetes (T2D) compared to urban populations (Government of Canada SC, 2022). Small Steps for Big Changes is an evidence-based diabetes prevention program designed to support individuals at risk of T2D in adopting and maintaining sustainable changes to their diet and exercise through the application of behavior change techniques. To expand the reach of Small Steps for Big Changes and address the significant gap in T2D prevention resources in rural and remote communities, the program was scaled out to rural and remote community organizations across British Columbia. The aim of this study was to describe the process used to scale out Small Steps for Big Changes and to identify the program and implementation strategy (IS) adaptations made during the pre-implementation phase to support delivery.

Adoption rates were analyzed and reported according to the adoption dimension of the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework (Glasgow et al., Am J Public Health 89(9):1322-1327, 1999 Sep) to describe the proportion of settings willing to deliver Small Steps for Big Changes. Data on adaptations were extracted from meeting notes and email correspondence. Adaptations to IS were identified by comparing these data to IS used in a previous Small Steps for Big Changes implementation project. All adaptations were deductively coded by two independent coders using the Framework for Reporting Adaptations and Modifications to Evidence-Based Interventions (S, Wiltsey Stirman et al., Implement Sci 14(1):58, 2019 Jun 6) and the Framework for Reporting Adaptations and Modifications to Implementation Strategies (CJ Miller et al., Implement Sci 16(1):36, 2021 Apr 7).

Three organizations in the Interior and two in the Northern region of British Columbia adopted Small Steps for Big Changes, representing adoption rates of 23% and 22%, respectively. Twenty-seven program adaptations were made with a primary goal of improving program oversight and quality improvement. 15 implementation strategy adaptations were identified and an additional 15 implementation strategies were added to support scale-out in attempts to improve reach, adoption, acceptability, or fidelity of the program.

These findings can inform targeted implementation efforts and guide decisions about scaling diabetes prevention programs, such as Small Steps for Big Changes, into diverse community settings.