Tensions and Paradoxes of Scaling Up: A Critical Reflection on Physical Activity Promotion
Abstract
:1. Introduction
2. Materials and Methods
Physical Activity Scale-Up Workshop
3. Results
3.1. Tensions in Scale-Up
3.2. Epistemological Tensions
3.2.1. Paradigms of Evidence Generation and Conceptualisations of ‘Successful’ Scale-Up
3.2.2. Literature Depictions of Translation versus Scale-Up in Practice
3.3. Methodological Tensions
3.3.1. Use of Appropriate Research Designs for Scale-Up
3.3.2. Contextual Adaptation during Scale-Up
3.3.3. Capturing Appropriate Outcomes at Scale
3.4. Tensions of Time
Scale-Up ‘Time Lag’ Impacting Decision-Making in a Rapidly Changing Environment
3.5. Partnership Tensions
3.5.1. ‘Ownership’ and Responsibility for Scale-Up
3.5.2. Funding, Costs and Benefits of Scale-Up
3.5.3. Obtaining Buy-In from Key Decision-Makers
3.6. Paradoxes of Scale-Up in Physical Activity Interventions
3.7. Reach without Scale
3.8. Planned Serendipity
3.9. Simple Complexity
4. Discussion
Insights and Considerations
- Broadening of theoretical approaches: Epistemological tensions demonstrate that our knowledge can co-exist in equilibrium and in conflict. There is no clear answer as to whether adopting a ‘best practice’ sequential approach to scale-up leads to greater population impact. If the field is to adopt new perspectives on scale-up, including systems approaches, then strategies to extend and enhance theoretical approaches will be necessary.Future considerations: The use of complexity and systems theory to understand and approach population health scale-up, on the basis that “we shift analysis from individual parts of a system to the system as a whole” [97]. Additionally, employ frameworks that incorporate a systems thinking perspective on the barriers and facilitators to scaling up (e.g., the PRACTIS Guide [21]) and tools to support assessing prospective scalability (i.e., ISAT [38]).
- Re-thinking data sources: Each scale-up process requires a matrix of data on outcomes, reach, adoption, fidelity/adaption, costs and sustainability at scale. These metrics are generated through a mix of research and performance monitoring processes. Multiple forms of data are required for governance and to inform different stakeholders-participants, implementers, decision makers/policy makers and political leaders.Future considerations: Refer to resources that describe key data sources for robust planning and evaluation of real-world implementation (e.g., CFIR [98]). Involve stakeholders in a participatory process to determine which additional evidence sources influence intervention uptake, political support and community sustainability. Obtain qualitative data on end user perspectives that can capture, for example, perceived evidence value, persuasiveness, and trustworthiness in the community [65].
- Co-creation for planning and design: Whilst scaling up does not have a single recommended design or evaluation approach, approaches that actively engage stakeholders from various system levels, early and throughout the research and process is essential.Future considerations: This can be achieved, for example, via co-creation, co-design and co-production [99] of evidence and interventions for scale-up. Research designs, partnerships and funding sources that can accommodate the length of time required to thoroughly evaluate impacts of scaling up (5+ years), may contribute to the generation of evidence that is more useful for evaluating scale-up outcomes.
- Shared values and shared evaluation approaches to scale-up: Over-reliance and dominance of measures of adoption and reach of scaled interventions misdirects our focus on what is required for true changes in population physical activity. We need a shared understanding of the values placed on different evidence when scaling, the limitations of data collection at-scale, what is appropriate for different audiences and the importance of adopting measures that are a priority for the sector(s).Future considerations: Facilitated discussions with stakeholder groups prior to and throughout the research process, such as via translational formative evaluation [100], is a way to capture nuances in differences in expectations for evidence generation and reporting. ‘PRACTIS Workshops’ (i.e., [101]) also offer a process to systematically identify and document key metrics for different groups, challenges/opportunities with data collection and values placed on different scale-up outcomes; beyond reach and adoption.
- Improving research-practice roles and partnerships: Contradictory expectations and value placed on different outcomes of scaling creates tensions for who is responsible for different aspects of program expansion. The existence of partnerships is fundamental for program integration across multiple sectors, yet the quality and maintenance of the partnerships is what leads to successful scale-up. The role of partnerships needs to start at the earliest planning stages of testing an intervention, involving policy, researcher and end-users in the scalability decisions. However, it’s important not to over-rely on single partnerships (either individuals or organizations) as over time, people change positions and organizational mandates shift.Future considerations: Partnership analysis tools (e.g., [102]) are a practical resource to assist with establishing, developing or maintaining partnerships in health promotion. The NSW Health Guide to scaling up [37] also provides a process for conducting a situational and stakeholder analysis, including when to consult with stakeholders.
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
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Koorts, H.; Bauman, A.; Edwards, N.; Bellew, W.; Brown, W.J.; Duncan, M.J.; Lubans, D.R.; Milat, A.J.; Morgan, P.J.; Nathan, N.; et al. Tensions and Paradoxes of Scaling Up: A Critical Reflection on Physical Activity Promotion. Int. J. Environ. Res. Public Health 2022, 19, 14284. https://doi.org/10.3390/ijerph192114284
Koorts H, Bauman A, Edwards N, Bellew W, Brown WJ, Duncan MJ, Lubans DR, Milat AJ, Morgan PJ, Nathan N, et al. Tensions and Paradoxes of Scaling Up: A Critical Reflection on Physical Activity Promotion. International Journal of Environmental Research and Public Health. 2022; 19(21):14284. https://doi.org/10.3390/ijerph192114284
Chicago/Turabian StyleKoorts, Harriet, Adrian Bauman, Nancy Edwards, William Bellew, Wendy J. Brown, Mitch J. Duncan, David R. Lubans, Andrew J. Milat, Philip J. Morgan, Nicole Nathan, and et al. 2022. "Tensions and Paradoxes of Scaling Up: A Critical Reflection on Physical Activity Promotion" International Journal of Environmental Research and Public Health 19, no. 21: 14284. https://doi.org/10.3390/ijerph192114284