We conducted a mixed methods study based on the RE-AIM framework. A cross-sectional study design was adopted, combining quantitative and qualitative approaches.

Our study targeted two levels of participation: locals and professionals. 1) Primary Care Units (known in Brazil as UBS) in the Florianópolis with physical education professionals certified by the VAMOS Program's online training (n = 20) and 2) The physical education professionals working in UBS within the Florianópolis’ municipal network certified by the VAMOS Program's online training (n = 5). We point out that all physical education professionals in the Florianópolis municipal network were invited (n = 12) via electronic mail to participate in the 20-hour online training for VAMOS Program leaders and, subsequently, to offer the intervention at the UBS where they worked. However, only 5 conducted the training and received certification. Twenty UBS were eligible to adopt the VAMOS since each professional worked not only in a single UBS but between three and five units.

Physical education professionals working in public health in Florianópolis were identified through electronic contact with the Municipal Health Secretariat. In this way, an invitation was sent to participate in the training of the intervention. The trained professionals were invited to adopt and offer the VAMOS to users at the UBS where they worked. The professionals who adopted the program defined where (in which UBS) they would implement the VAMOS. They made the necessary adjustments with the management to implement the program. The research team offered all the support to the professionals who offered the program and those who worked at UBS to explain about the VAMOS and to solve possible implementation doubts.

We used the RE-AIM framework as an instrument to evaluate adoption (Almeida et al., 2013; Brito et al., 2018). The adoption dimension was assessed by the number of UBS that agreed to host the intervention and the number of professionals who chose to become program leaders and implement the VAMOS. Thus, we calculated two adoption rates. The first was the adoption rate of locations: dividing the number of UBS that offered the intervention by the number of eligible UBS in the city, multiplied by 100; and the second was the adoption rate of professionals: dividing the number of health professionals who offered the intervention by the number of eligible health professionals, multiplied by 100.

Furthermore, we collected qualitative data to identify factors that may have influenced the adoption of the intervention. We conducted 33 interviews (semi-structured) with UBS health professionals, including: physical education professionals – leaders of the VAMOS (PEF; n = 4), UBS managers (GE; n = 4), and professionals from other areas who were part of the health teams and who were, directly or indirectly, involved in the intervention (n = 25), including: community health workers (ACS; n = 11), nursing technicians (TE; n = 4), administrative technicians (TA; n = 3), physicians (ME; n = 2), nurses (EN; n = 2), oral health assistants (ASB; n = 2) and nursing residents (RE; n = 1).

The professionals who participated in the interviews were chosen at random. That is, they were approached at the workplace and invited to participate in the study. To verify the impact of adopting the VAMOS in the UBS, we considered both professionals who were directly involved with the intervention and professionals that did not participate in the intervention. In addition, we conducted a focus group with the program leaders to obtain additional information about the VAMOS and investigate adoption-related perceptions.

The interviews and the focus group addressed the following topics: opinion about the intervention adoption by the UBS, facts that motivated the adoption of the intervention, the importance of the intervention training (offered via distance education) for its adoption (specific question to the program leaders), among others. We also asked how the UBS’ routine changed with the adoption of the intervention, opinions about the inclusion of the intervention in the health service offered by the UBS, the UBS professionals’ qualifications and available time to offer the intervention, the most interesting and least interesting aspects of the intervention. We also asked the UBS managers for a cost-benefit analysis of the intervention.

Although the adoption dimension proposed by the RE-AIM framework considers only the organizational level of participation, we conducted focus groups (n = 5) with PHC users who participated in the intervention (P; n = 26). We asked about the reason that they chose to adopt the VAMOS, as well as why their UBS unit adopted the intervention.

The interviews were conducted individually by a research team member, with an average duration of 30 minutes each. The focus groups were conducted by three research team members, with an average duration of 50 minutes each. The interviews and focus groups were recorded and transcribed. All participants agreed to participate in the research by signing a consent form. After analyzing the data, the names of all participants were coded (example: PEF1; ME2...). The data were confidential, and only three members of the research team had access to the recordings, transcriptions, and data analysis.

We geo-referenced the eligible UBS units (n = 20) through their addresses using the Google Earth Pro platform. We established three network buffer sizes to verify the UBS surrounding characteristics based on the accessibility of walking routes near each UBS (Lopes, Hino, Moura, & Reis, 2018). The UBS socio-demographic characteristics were calculated based on the 2010 census (Instituto Brasileiro de Geografia e Estatística, 2011). We analyzed the number of households, number of residents, average household income per capita, racial and ethnic distributions, the proportion of men, proportion of women, proportion of adults, and proportion of older adults. Geospatial analyses were performed using the ArcGIS 10.5 software.

We performed absolute and relative frequency measures for categorical variables and mean and standard deviation measures for numerical variables. We used Student t-tests for independent samples and the Mann-Whitney U test to determine the significance of differences in characteristics between the UBS adopted and did not adopt the intervention with p < .05. We analyzed the data using SPSS 22.0 software.

Furthermore, we used the NVivo 12 software to assist us in analyzing the qualitative collected data. To analyze the information, we adopted the content analysis technique (Bardin, 1977). Three researchers categorized the information, performed the content analysis, and selected the reports, when necessary, a third researcher resolved disagreements.

Our study was approved by the Human Research Ethics Committee of the Federal University of Santa Catarina (No. 1.394.492) and is registered at ClinicalTrials.gov (NCT02823301).

We implemented the VAMOS in 2016-2019 in UBS settings in Florianópolis. The program is designed for people aged 18 or over and offers educational and motivational experiences in 12 weekly face-to-face meetings for three months. The maintenance phase is evaluated 12 months after the end of the intervention. The program addresses topics that develop strategies to change behaviors. The meetings last 90 to 120 minutes and are conducted by previously trained health professionals. In addition, 20-hour online training for VAMOS leaders is offered free of charge via distance education (José, Konrad, Ribeiro, & Benedetti, 2019).Details about the VAMOS can be found in previous studies (Benedetti et al., 2017; Tomicki et al., 2021).

There are 49 UBS in Florianópolis, 20 (40.8%) were considered eligible to participate in the study, and five offered the intervention. The UBS adoption rate was 25%. The intervention cost was covered for units that chose to implement it, and program leaders duties were adjusted to allow them to deliver the program without an overload of responsibilities. Overall, there were few significant differences between UBS that offered the program and those that did not (see Table 1). However, considering the coverage area of the eligible UBS, UBS that adopted the intervention had a lower proportion of white users when compared to UBS that did not adopt it (p < .05).

All physical education professionals were invited to participate in the training for the VAMOS Program (n = 12; 91.6% women). Five completed the training, and four adopted the intervention (one health professional implemented the program in two UBS locations). The adoption rate for health professionals was 80%. The professionals were not authorized to attend the training during working hours. They attended when they were not working, according to interest level and motivation. The lack of interest in the VAMOS, the reduction of working hours, and increased demands in some UBS was pointed out as reasons for not adopting the intervention. The program leaders’ reasons for choosing locations to implement the intervention were related to the support of health teams, knowledge of the UBS and surrounding areas, and having a bond with the community that uses the UBS and knowledge of their needs. Table 2 shows the characteristics of the eligible professionals who adopted and did not adopt the intervention.

From the interviews and focus groups, we identified three themes related to adoption. The first theme speaks to the vital role that program leaders/health professionals play in adopting of the program by the UBS. Their attitude towards starting a new program, opinions about the curriculum, new duties and responsibilities, and opportunities for self-care improvements were key adoption factors. The second theme raises implementation challenges and how they influence adoption. Shortage of professionals, high workload, and the UBS organizational structure adversely affected adoption. Lack of infrastructure and limited financial resources are also among the implementation challenges. The third theme highlights the importance of partnerships for adoption. The support obtained from researcher partners, including thoughtful training modules, was an essential part of adoption.

Table 1
Comparison of the sociodemographic characteristics of the population covered by the eligible Primary Care Units

p = significance level at 5%. n = number. % = percentage. a = Data presented as mean and standard

Theme 1:Adoption centered on health professionals’ perceptions. A positive perception of professionals towards a new health initiative was the most salient finding from the qualitative part of this study. This theme reflects a consensus among all interviews. The following quote illustrates their overall welcoming attitude: "[...] having people around, mobilizing the population and proposing new activities and other things for them to do is always good" (TA3).

In the search for ways to meet the population's needs, health professionals see the nature of new health promotion programs and interventions essential to adoption in public health contexts. The focus of the VAMOS on health education, physical activity, and healthy eating positively influenced its perception by health professionals. The following quote supports this: “[...] we perceive a need for programs like this, aimed at improving lifestyle; so, working with this in primary care makes perfect sense [...] it is a program that is in accordance with public health” (PEF3).

The innovative intervention curriculum and related materials also motivated the adoption of VAMOS by health professionals. The material was perceived as inclusive and following high pedagogic standards, as shown in this quote: “A complete behavior change program [...] that offers a complete training, basic material, didactic material” (PEF3).

The intervention provided a novel approach to work and new duties and responsibilities for program leaders. The example in the following fragment: “[...] we will be able to care for those who have problems, but especially for those who do not have them yet; the program covers well what the Family Health Strategy recommends, which is not our daily routine” (TE2).

The “behavioral change” component of the intervention presented an opportunity for the health professionals to reflect on their health, as we can see in the fragment: "I think it is an incentive to the population and also to us, professionals [...] to reflect on the health issue" (TE4).

In addition, individual factors appear to influence the adoption of interventions by the UBS units and their professionals. UBS users decided to participate in the VAMOS Program because they needed an incentive to change their lifestyle and take better care of their health. For example, the following fragments: “[...] I had a health problem, and I needed something to encourage me to change my lifestyle” (P1).

Table 2
Characteristics of eligible health professionals who adopted and did not adopt the VAMOS Program

PEF = Pysical Education Professional. MSc = Master's Degree.

Theme 2: Adoption influenced by implementation challenges.Shortage of professionals and the high workload at UBS impacted the adoption of interventions, as shown in these quotes: "Most of the employees here at the UBS, due to the flow of the movement, get medical certificates, sick leaves, because they are stressed out" (ACS11). "[...] we have a population that is always larger than we can handle" (GE4).

Organizational structure and policies at each UBS were also considered to be essential factors in program adoption. The example in the following fragment: "Maybe the teams should be required to participate [...] here we only do what we are obliged to do" (GE4). "It depends on the professional [...] from technician to doctor it is much more difficult" (ACS3). Despite this, many UBS professionals are willing to adopt new health promotion strategies, as we can see in the fragment: "[...] we are always open to these activities that promote health" (GE4).

Interventions were perceived as beneficial to compensate for the lack of care at UBS settings, as we can see in this quote: “I think it comes to add more [...] to help us when we cannot meet the demand, we have to choose either preventive or curative measures, promotion is still maintained only because we have these aids [...] because if we do not, it is unfeasible, no way” (GE4).However, the profile of assistance and services offered by UBS units is gradually changing, impacting the collective service that is provided, for example: “I analyze what SUS was like [...] almost six years ago and today [...] before, we had many more groups, our meetings were much more productive, now the management tends to break this [...] spaces for groups are very reduced. Multidisciplinary work is increasingly difficult” (PEF2).

The UBS professionals supported the adoption of the program. However, the degree to which professionals were able to become engaged varied. The example in the following fragment: "We have an internal routine, and we were unable to participate as much as we would like to" (TE4). “The involvement of the professionals was positive” (GE3).The UBS's choice to adopt the intervention dependent on the support of the professionals who worked in them. The following fragment is an example: "I knew it would work there and that in other UBS this support is precarious" (PEF2). However, due to restrictions on time available for new programming, VAMOS adoption was not always a priority in the UBS service. The example in the following fragment: “[...] the professionals that we have [...] with the demand that we have, they are already involved in other programs, in other services, and there is little time left” (ME1).

When the program was implemented, there was no adverse impact on the routine of UBS and its professionals. For example: "[...] we have a lot of activities, meetings, groups and this was one more, so this is all part of our work routine, it is just another one that was included in our routine" (ACS6).Furthermore, there is a shortage of adequate space in the UBS to offer group interventions. The following fragments illustrate these concerns: “[...] there is no suitable place to receive a large weekly demand, the difficulty would lie in structure” (ME1) "The auditorium is always reserved for other UBS activities" (ASB1).

The method by which the municipal government administers transfers of funds from the federal government was viewed as problematic: "This question of funds, I do not know what amount we have available" (GE4). "[...] the municipal government acquires some things [...] which sometimes are not used, so we should be consulted about it because there is not much need, the demand is low" (GE1).Despite this, investing in new forms of work aimed at promoting the population's health was seen as positive, as we can see in the fragments: "I think any money that comes to encourage a healthy lifestyle is welcome" (GE2). "[...] this reflects a public benefit, a benefit for public health [...] I think it would be worth investing" (GE3).

Theme 3: Partnerships promote adoption.It was viewed as essential to subsidize and support health professionals regarding the adoption of public health interventions, as shown in the following fragments: “[...] training to be able to participate is very interesting” (GE2). “[...] the more training we have, the more ideas we’ll have for the job, they always have something to contribute” (PEF1).

The VAMOS Program training was well accepted and met its primary objective of training health professionals to act as program leaders of the intervention and to promote its adoption: "It [the training] delivered the basic tools of the work to us" (PEF1). “With the training, it is likely to become a program that is part of the UBS strategies. Brought it to my practice, many strategies to approach behavior change in the most diverse spheres within my service [...] I realized that the [blinded for review] language ended up pervading other activities that I develop" (PEF3).

In addition, to the VAMOS Program training, some professionals understood that the researchers’ participation was fundamental. For example: “[...] the link with the University, I find it very interesting [...] the issue of evaluating an activity within the UBS, we have many difficulties and do not have time to see what we are achieving in each activity, so I thought that being monitored by the University was a very good proposal” (PEF1).

camitomicki@gmail.com