Interviews with state public health practitioners provided insights into the initial awareness, dissemination, uses, challenges, and future recommendations for the NPAP since its launch in 2010. Applying the RE-AIM framework , we found high awareness (reach) of the NPAP among the state-level practitioners we interviewed. The channels through which they learned of the plan varied. This implies that regular communication through several different communication channels (e.g., website, newsletters, webinars, listservs) would continue to inform and engage practitioners. This would strengthen the NPAP’s relevance, remind practitioners of its intent and usefulness, and may be particularly important considering staff turnover within public health agencies [22, 23].
Dissemination of the NPAP through state practitioners to local health departments and coalitions was inconsistent. Among those who disseminated the NPAP locally, most did so only one time. Yet, the interviewees had high awareness of the plan and served as state wide contacts for local practitioners, making state practitioners a possible conduit to communicate with local practitioners. Given that there are 59 state and territorial health departments and more than 3000 local health departments in the US , state-level practitioners could have substantial reach, beyond current levels. Such dissemination efforts could be augmented by providing state-level practitioners with example text and summary documents to send local partners. Among the public health workforce, only 44% are identified as health professionals, and even fewer are specifically trained in public health . Thus, assumptions that all practitioners understand how to use the NPAP should not be made. There was also inconsistency in bringing awareness of the NPAP to leadership within state health departments. Further promotion with targeted tools and materials related to the NPAP may enhance this targeted outreach.
Most respondents either were not aware of the companion implementation plan or had rarely or never used it. This lack of use was evident in suggestions to connect the NPAP’s strategies and tactics directly to implementation examples. This finding demonstrates a significant opportunity to enhance NPAP implementation. It may be useful to bundle the documents and resources together, to facilitate connecting a strategy or tactic to implementation guidance. More broadly, there was confusion by a few respondents about overlap in several major physical activity documents, including the NPAP and its implementation plan, the 2008 Physical Activity Guidelines for Americans , the Guide to Community Preventive Services (http://www.thecommunityguide.org) , and the Community Tool Box (http://www.ctb.ku.edu/en/default.aspx). Development of a national-level document that summarizes the critical reports, guidelines, and tools pertaining to physical activity, and electronically linking to each of them for easy access, may help facilitate a better understanding of the guidance and resources available and how best to use and distinguish among them from one another.
A 2010 survey of NSPAPPH members corroborated several findings from these interviews . The survey indicated high awareness of the NPAP among NSPAPPH members, more so among state than local practitioners, and low awareness of the implementation plan. Few survey respondents agreed that the NPAP was effectively disseminated to physical activity practitioners in their state. Only about half of those respondents reported awareness of the NPAP among leadership and intervention staff at their workplace. Limited resources were identified as a barrier to implementing the NPAP, similar to what emerged from our in-depth interviews.
The Diffusion of Innovations theory suggests that specific attributes may contribute to the speed or extent that an innovation is disseminated [20, 26, 27]. Applying this to the NPAP, and without prompting by the interviewers on positive aspects and challenges to using the NPAP, the plan was described by some respondents as useful, simple, flexible, and compatible with existing state plans. Each of these attributes helps facilitate the dissemination of the NPAP. However, we also identified ways to make the plan more useful, particularly for implementation, noting that several respondents described the plan as complex or incompatible with federal policies. Moving forward, a focus on addressing these characteristics as suggested in recommendations below may widen the use and adoption of the plan. Moreover, the forthcoming book on specific case examples of best practices can aid those intending to use the NPAP .
The most frequent positive use of the NPAP was as a reference to development of state-level goals. To enhance use of the NPAP instead as a direct guide for state-level planning, new materials could describe how to use the national plan, particularly for states updating their health-related plans or developing stand-alone physical activity plans . Other research indicates that challenges to implementing evidence-based public health strategies include organizational factors, such as staff turnover, limited resources, lack of policy maker’s support, lack of rewards for using evidence-based practices, and individual factors, such as lack of time, knowledge, and communication skills [24, 30, 31]. Addressing these factors can also enhance dissemination of the NPAP.
A typology for using research evidence in practice can be applied to also help illustrate how the NPAP is being used . Instrumental use occurs when research evidence is directly applied to decision-making, such as using the NPAP to assist with development of state plans. Conceptual use refers to situations in which research evidence influences how practitioners think about issues, problems, or potential solutions. For the NPAP, several respondents mentioned that learning from non-traditional sectors (transportation) influenced their thinking. Tactical, political, or symbolic use occurs when research evidence is used to justify particular positions, such as the NPAP validating their own plans or work. The final use, imposed use, is defined as situations in which there are mandates to use research evidence, such as when government funding requires practitioners to choose strategies from the NPAP. The authors note that the typology is not exhaustive, nor mutually exclusive, but demonstrates how research evidence (in our case the NPAP) serves multiple purposes and is used in multiple ways.
In the US, this is the first national-level plan to focus exclusively on physical activity, though national plans exist for a number of related health behaviors and diseases, such as tobacco control [33
], diabetes mellitus [34
], cancer [35
], and cardiovascular disease [36
]. Building upon the suggestions of practitioners, we offer several recommendations. These suggestions have implications for other national plans and include:
Providing short synopses of different sections to assist users in digesting information, particularly for those only interested in one sector in the case of the NPAP.
Using diverse communication channels to distribute the plan and to provide regular plan updates to maintain awareness and increase use of the plan.
Linking implementation strategies and examples to the plan.
Grouping strategies by cost and impact into high, medium, and low categories.
Offering two-way communication (rather than one-way, focusing on streaming the plan to practitioners) to enhance dissemination . For example, a social network could be created through sites such as Community Commons (http://www.communitycommons.org/) where information can be shared and professionals from different sectors with similar interests can connect.
Developing a national-level document that summarizes the critical reports, guidelines, and tools pertaining to physical activity together, and electronically linking to each of them for easy access, to facilitate an understanding of the guidance and resources available and how best to use and distinguish among them.
Strengths and limitations
We gathered perspectives from state public health practitioners about their awareness and use of the NPAP. The sample included broad geographic coverage, with half of all states represented. We met our goal number of interviews across census regions; however, it is unclear whether respondents were more likely to be familiar with and use the NPAP than those who did not participate. Despite the geographic representation, the absolute sample size limited our ability to explore regional variations. Moreover, awareness of the NPAP may have been over reported, since interview questions were sent to participants prior to the interview.