The results are described in the order of the implementation process (see Table 1). The preparation phase will be reported first, and then the implementation phase will be discussed and, lastly, the outcomes with corresponding variables will be examined.
Evaluation of recruitment and reach
Four residential facilities and/or day activity centres supporting adults with moderate to profound ID were included. All of the approached teams were enthusiastic about the program and its relevance. The time to recruit the appropriate number of participants was 9 months (April 2018 until January 2019). DSPs also spent time to inform and obtain informed consent of the people with ID. The inclusion criteria could be met for this study, although difficulties were faced, for example, if people with mild ID lived or worked together with people with moderate to profound ID, and thus the target group did not completely match. In addition, the required time investment of the DSPs for the program and for the data collection was a challenge for the (residential) facilities.
Participants in this study were DSPs (n = 32), people with moderate to profound ID (n = 24), managers/coordinator of the participating (residential) facilities (n = 4), and the trainers of the program (n = 6). In total, 32 DSPs out of 41 DSPs from the four (residential) facilities participated in the study. The distribution of DSPs over the four (residential) facilities was as follows: 4, 16, 7, and 5 DSPs. Reasons for not doing so were: lack of presence at the (residential) facility at the time of the implementation due to attendance in another department of the ID care provider, not willing to commit to the time investment, or too recently hired. The characteristics of the DSPs and the people with moderate to profound ID supported by the participating teams are described in Table 2.
During the program, there were changes in the context that were not provoked by the implementation of the program. These changes were with regard to staff: decrease in staff at one (residential) facility (number 1) and additional education for two DSPs at one (residential) facility in order to become physical activity consultants (number 2). With regard to a healthy lifestyle, the following changes were made: decrease in budget for food at one (residential) facility (number 2), increasing offer of physical activity at one (residential) facility (number 4), and health related activities at two (residential) facilities (numbers 1 and 4), for example, receiving recommendations from a movement expert regarding physical activity, more indoor activities, a short class for people with ID about health, and a cooking activity 1 day per week for people with ID.
Dose delivered, dose received and fidelity
All program components (e-learning, three in-person sessions, and three assignments) were available, although not all DSPs completed all of the components of the program. The e-learning was completed by 26 out of the 32 DSPs. All of the three in-person sessions were attended by 18 DSPs. The remaining 14 DSPs attended one or two in-person sessions. Reasons for not participating in the in-person sessions were illness, vacation, time, or private circumstances. An overview of dose delivered and dose received is described in Table 3. With regards to completing the assignments, six DSPs completed all three assignments, 13 completed either one or two assignments, and 13 did not complete any assignments.
The quality of the submitted assignments (38 out of 96) was mostly positive (23 assignments); see Table 4. The quality of the assignments was considered not sufficient if not all parts of the assignment were completed (e.g. there was no consultation with colleagues), the link to the theme of the in-person session was missing, a question was not well understood, or the BCTs were not clear enough.
According to the DSPs, 13 out of 32 prepared all of the in-person sessions. Some DSPs prepared only partly for the sessions. Reasons for not preparing were illness, absence, time, and not remembered. The trainers indicated that DSPs from two (residential) facilities in particular prepared inadequately for the in-person sessions. However, the participation during the sessions at these two (residential) facilities was neutral to good. One (residential) facility had different expectations (working with more clear action points) for the in-person sessions. Additionally, the group size for one (residential) facility was large (n = 16), making the sessions less effective according to the reflection of the trainers. Overall, the execution of the in-person sessions in relation to theoretical methods and determinants was good (see Table 4).
Acceptability and suitability of the program
Table 4 shows the mean ratings of DSPs and the managers for the acceptability and fit of the program. It also indicates that, for two of the four (residential) facilities, the acceptability of the program was sufficient, and the fit of the program in daily practice was sufficient to good according to DSPs. For the other two (residential) facilities, the acceptability and suitability were insufficient to good; for one (residential) facility, the acceptability and relevance of the e-learning was considered insufficient whereas the satisfaction and relevance of the in-person sessions were good. The overall satisfaction about the preparation before the in-person sessions was insufficient according to DSPs. The satisfaction and the relevance of the in-person sessions was, for (residential) facility 2, statistically significantly lower in comparison to the other three (residential) facilities. The DSPs of (residential) facility 2 were overall less satisfied about the program and its relevance. All managers granted the program an eight as a rating (one manager could not answer this question), and three out of four were very positive about the content of the program (missing information for one manager).
Almost all of the interviewed DSPs (14 out of 17) indicated that they would recommend the program to colleagues. The DSPs mentioned that their recommendation depends on the status of the team in the domain of healthy lifestyle. Comments that were more critical by some of DSPs pertained to the lack of connection with the target group and the significant time investment of the program. In addition, all of the interviewed DSPs indicated that they were positive (n = 17) about the connection of the program to their support needs. Approximately half of them (n = 8) considered the awareness of a healthy lifestyle and communicating with each other in this context as positive. One DSP illustrates: ‘I thought it was good. We do a lot of things, but it is the awareness of just simple things, like housekeeping, that is also physical activity. Often, we take over activities of our clients which they can do by themselves’ (respondent 5:9). Beside the positive statements about the connection of the program to support needs, there were also DSPs who made neutral (n = 8) or negative (n = 7) comments. They indicated that the program was not necessary or that they expected more tips for daily practice.
Time and capacity to complete the program
Per DSP, the time investment of the program, including preparation and assignments, was an average of 11 h. The feasibility of the time investment of the e-learning was, according to the DSPs, slightly negative to neutral. The feasibility of the time investment of the in-person sessions was neutral to positive. They indicated that the number of sessions, the available time, and the time between the in-person sessions was good. The time investment of the program and the proceeds were rated neutral to positive. The experienced support from their manager was slightly negative to positive according to the DSPs (see Table 4 for their ratings). Overall, the managers indicated the time investment of the program was feasible with the exception of a single manager indicating that the time investment was too much, especially for the research element. The costs associated with the time investment were feasible according to the managers. They were positive about the time spent on the program and the outcomes (see Table 4 for the ratings of the managers). The capacity to complete the program as operationalized by DSPs’ participation in the activities during the meetings was sufficient (score 4.1 on a scale from 1 to 5).
Factors during implementation
Factors for implementation were addressed when developing the program and designing the study, for example, continuous communication about the program . The primary researcher was able to manage the conditions to facilitate the implementation of the study and the program. The willingness to participate was good, however, despite careful discussions of expectations, the time for the DSPs to participate in the study and the program was limited. In addition, according to two of the four managers, the implementation of the program requires improvement, for example. With respect to the alignment of mutual expectations before the beginning of the program.
Evaluation of the data collection process
Based on the goals of the program, the overall sensitivity of the outcome measures to the changes after the program was good. The DSPs understood the questions and guidelines to complete the data collection. They were requested to fill in questionnaires, participate in interviews, and track food intake and physical activities of people with ID. This data collection process appeared, as noted before, time consuming for the participating teams which resulted in missing data. Regarding the missing data for the food diaries, at T2, 6 days of six people with ID were missing. Additionally, part of the diaries or details were missing which could not be included. For physical activity at T0, six people with ID did not wear the Actigraph for at least 4 days for 10 h, and one of them lost the Actigraph. Additionally, at T2, three people with ID did not wear the Actigraph.
Changes after the program
Figure 1 and Table 1 provide an overview of the design and the indicators for the changes after the program. The outcomes will be described based on the indicators: goal achievement of the program, actual application in practice, attitude of the DSPs, food intake of people with ID, and physical activity of people with ID.
Improving knowledge and skills
Overall, the DSPs’ goals of the program have been achieved for both the e-learning and the in-person sessions; see Table 4. They rated their knowledge about physical activity and nutrition for people with ID; these ratings were a 6.6 and a 7.2, respectively, at T0 and T1. This shows an improvement in knowledge directly after the program (Z = -2.923, p = 0.003).
Actual application in practice
The change in daily practice following the program was sufficient to good for two of the four (residential) facilities according to DSPs. For one (residential) facility, the change was insufficient and, for one (residential) facility, just the change in daily practice from the e-learning was insufficient. For (residential) facility 2, the in-person sessions made statistically significantly less change on daily practice. See Table 4 for the ratings.
The actual applications in practice mentioned by the DSPs were: ‘awareness about a healthy lifestyle’ (n = 16); a DSP illustrated: ‘It is in the little things. I am more aware that I let people with ID clean up themselves after dinner instead of doing that for them’ (respondent 3.33); ‘introducing more physical activities’ (n = 14); using the BCTs (n = 13); prepare or offer healthy nutrition (n = 12); and let people with ID choose themselves (n = 12). Almost all of the DSPs (n = 15) indicated nothing has changed in involving family and others in a healthy lifestyle of people with ID. Besides these comments, 11 DSPs had some neutral comments. They indicated the use of the BCTs depends on the people with ID (n = 6), and the actual application in practice is dependent on the attitude of the DSP (n = 5).
Overall, the managers indicated that the teams spent more attention on a healthy lifestyle in daily practice (see Table 4 for the ratings of the managers). Despite the improvement, the DSPs still struggle with the integration of healthy lifestyle behaviour into working processes.
Attitude of DSPs on supporting healthy lifestyle
There is a significant increase over time on the attitudes of nutrition and physical activity of the DSPs between T0 and T2 (3 months after the program), resulting from a mixed model analysis with random effects for DSPs; see Table 5 which is illustrated in Fig. 2. At T1, the change in attitude after the program is not statistically significant for physical activity and, for nutrition, the change is borderline significant.
Food intake of people with ID
The food intake of people with ID who were supported by the participating DSPs was measured before (T0) and three months after the program (T2). A statistical difference was ascertained between T0 and T2 for food intake from the recommended nutrition guidelines (Z = -1.979, p = 0.047). Table 6 shows the descriptives from T0 and T2. For the mean percentages of food intake from the recommended nutrition guidelines, this guideline is not reached.
Physical activity of people with ID
The physical activity of people with ID who were supported by the participating DSPs was measured before (T0) and three months after the program (T2). Table 7 shows the mean levels of activity of the people with ID who are able to walk. No significant differences between T0 and T2 were found (% Sedentary: Z = -0.459, p = 0.695; % Light: Z = -0.357, p = 0.770; % Moderate: Z = -0.357, p = 0.750; % Vigorous: Z = -1.604, p = 0.250; % Very Vigorous: Z = -1.414, p = 0.500). The percentages demonstrate that people with ID spend most of their time in a sedentary state. Table 8 shows the percentages of time spent in activities for people with ID who use a wheelchair; the percentage of time in activities before and after the program is almost the same. During the measurements, two Actigraphs were lost, and one participant did not accept wearing the Actigraph. In addition, the daily activity programs before and after the program were compared. No statistical differences were determined between T0 (Mean: 22.75, SD: 23.77) and T2 (Mean: 24.79, SD: 34.01): Z = -0.280, p = 0.844.
Differences in outcomes for the four participating (residential) facilities
For the differences in outcomes between the four participating (residential) facilities, statistically significant variances were ascertained for the changes after the in-person sessions (actual application in practice)(F = 5.848; p = 0.004) and for the relevance (F = 11.606; p = 0.000) and satisfaction (F = 14.004; p = 0.000) of the in-person sessions (acceptability/suitability). No statistical differences between the four participating (residential) facilities were found for goal achievement, the attitude of DSPs, food intake, and physical activity of people with ID.
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