Ethnocultural adaptation of an effective health-promoting intervention for Punjabi-speaking older adults: Choose to Move ਆਓ ਚੰਗੀ ਸਿਹਤ ਵੱਲ ਚਲੀਏ

Ethnocultural adaptation of an effective health-promoting intervention for Punjabi-speaking older adults: Choose to Move ਆਓ ਚੰਗੀ ਸਿਹਤ ਵੱਲ ਚਲੀਏ | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Ethnocultural adaptation of an effective health-promoting intervention for Punjabi-speaking older adults: Choose to Move ਆਓ ਚੰਗੀ ਸਿਹਤ ਵੱਲ ਚਲੀਏ Heather Macdonald, Thea Franke, Diya Chowdhury, Heather McKay, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8264715/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background South Asians are the largest and fastest-growing racialized group in Canada but are underrepresented in health research and underserved in health-promoting initiatives. In this paper we: 1) describe the systematic process by which we ethnoculturally adapted Choose to Move (CTM) – an effective health-promoting model for older adults – for South Asian Punjabi-speaking older adults and organizations that serve them, 2) describe the adapted CTM model, and 3) evaluate implementation of the adapted CTM model. Methods Using community-based participatory research methods, we followed a multi-step adaptation process: 0) review existing CTM Phase 4 data; 1) engage community partners and Punjabi-speaking older adults; 2) conduct needs assessment; 3) develop and 4) validate a prototype adapted CTM model; 5) finalize adapted model; and 6) pilot implementation. We coded adaptations using the FRAME and FRAME-IS frameworks. Four organizations piloted the adapted CTM model (4 coaches, 5 programs, 68 older adults). Following program delivery, we assessed implementation indicators and outcomes through questionnaires and semi-structured interviews with organizations, activity coaches and participants. Results We proposed 23 updates to the CTM model after Step 0 (e.g., modified activity coach training content) and 32 ethnocultural adaptations after Steps 1–3 (e.g., increased length of group meetings, translated promotion and recruitment materials). During the pilot, 72% of participants completed the CTM program and provided post-program feedback. Organizations and coaches rated the program as acceptable, appropriate and feasible. Dose delivered, dose received and participant responsiveness were high (> 84% for all). Fidelity to core functions ranged from 62–100%. Four themes emerged from qualitative data to support these findings: 1) provide structure and support, 2) foster cultural and linguistic resonance, 3) make goals matter and 4) facilitate engagement. Coaches were satisfied with strategies they used (usage ranged from 25% to 100% across available resources) and made few adaptations. Qualitative data supported these findings through three themes: 1) build relationship-centered partnerships, 2) provide tailored and culturally appropriate support, and 3) tailored training. Conclusions We integrated implementation science approaches with ethnogerontology to generate a blueprint for implementing an evidence-based and ethnoculturally grounded health-promoting for Punjabi-speaking older adults. Clinical Trials Registration NCT06252259; Registration date: February 1, 2024 healthy aging health promotion implementation science physical activity South Asian people program evaluation Background In Canada, racialized immigrant older adults have a higher prevalence of chronic conditions, poorer self-reported physical and mental health, and greater difficulties with instrumental activities of daily living than non-racialized and Canadian-born older adults [ 1 – 3 ]. Immigrant status among older adults is also associated with lower levels of physical activity [ 4 ] and higher levels of loneliness [ 5 ] as compared with Canadian-born older adults. Among the Canadian immigrant population, South Asians are the largest and fastest-growing racialized group. In British Columbia (BC), South Asians are the largest racialized immigrant group (24.8% of immigrants) [ 6 ]. Yet, South Asians remain underrepresented in health research and underserved by health-promoting initiatives [ 7 ]. This underrepresentation is often sustained by power imbalances and structural inequities within research and health systems that frequently exclude these communities from the research process [ 8 ]. Over the past decade we used a phased approach to scale-up an effective health-promoting model for older adults (Choose to Move; CTM) in British Columbia, Canada [ 9 , 10 ]. Through a series of systematic adaptations, we demonstrated that CTM could be implemented with fidelity at increasingly larger scale [ 11 , 12 ], virtually [ 13 ], and at lower cost [ 14 , 15 ]. We define adaptation as the “process of thoughtful and deliberate alteration to the design or delivery of an intervention, with the goal of improving its fit or effectiveness in a given context” [ 16 ]). We and others [ 17 ] contend that adaptation of an evidence-based intervention (EBI) during scale-up is both inevitable and appropriate. Adaptations to CTM to date did not compromise program effectiveness (i.e., health benefits for older adult participants were retained) [ 12 , 14 ]. Although we, and our government and community partners, deemed scale-up of CTM across Phases 1–4 a success (based on reach), programs attracted relatively few racially minoritized and immigrant older adult populations [ 9 , 12 , 14 ]. This is not unlike many health-promoting initiatives that are implemented with a “one (cultural) size fits all’’ approach [ 18 ] and therefore often fail to reach marginalized or underrepresented populations [ 19 ]. Community-based organizations that serve these populations may lack the necessary staff, financial resources or specialized skillsets to support EBI implementation [ 20 – 22 ]. Cultural adaptation has been defined as “the systematic modification of an EBI to consider language, culture, and context in such a way that is compatible with the client’s cultural patterns, meanings, and values” [ 23 ]. Cultural adaptation does not rely solely on “superficial” changes such as language translation of EBI materials that increase an EBI’s acceptability [ 24 ]. Instead, it aims for “deep level” changes that reflect the “target populations’ values, culture, and social and historical forces that influence health behaviours” [ 24 , 25 ]. We use the term “ethnocultural” adaptation to intentionally emphasize both the shared ethnic heritage and the deeper cultural elements, such as values, beliefs, traditions, norms, and ways of knowing, that define a group [ 26 ]. Ethnocultural adaptation of EBIs for racialized immigrant older adults is crucial, as age-related changes (e.g., mobility), sociocultural values (e.g., collectivism, gendered expectations), and migration legacies (e.g., trauma, systemic exclusion) converge to create both barriers to healthy aging and opportunities to apply 21st century health promotion practice [ 27 , 28 ]. Although cultural adaptation increased acceptability and effectiveness of several EBIs among South Asian populations [ 29 ], few [ 30 – 32 ] described the adaptation process and none focused specifically on ethnocultural adaptation of an EBI for South Asian older adults. Therefore, we adopted a health equity lens [ 33 ] to ethnoculturally adapt CTM for racialized immigrant older adults. Specifically, we aimed to address the following three objectives: 1) describe the process by which we ethnoculturally adapted the CTM model for South Asian Punjabi-speaking older adults and organizations that serve them, 2) describe the adapted CTM model, and 3) evaluate implementation of the adapted CTM model. Methods The Intervention: Choose to Move We have described Choose to Move (CTM; https://choosetomove.ca ), associated health outcomes, and our phased approach to scale-up elsewhere [ 9 , 10 ]. Briefly, CTM is a flexible, choice-based model, co-designed with older adults and community partners [ 9 , 10 ]. During the 3-month CTM program (CTM Phase 4), trained activity coaches (“coaches”) guide low active community dwelling older adults ( ≥ 55 years) to set physical activity goals, address barriers, and choose physical activities in their communities that suit their personal preferences, abilities and resources. CTM effectively enhanced physical activity and mobility, and diminished social isolation and loneliness in older adult participants [ 9 , 12 ]; some but not all benefits were maintained up to 12 months after participants completed the program [ 12 , 34 ]. Implementation [ 35 , 36 ] and scale-up [ 37 ] frameworks and principles (e.g., community partnerships) guided implementation and scale-up of CTM across 10 years (2015-present). Large (e.g., YMCA) and small (e.g., neighbourhood houses) delivery partner organizations (“organizations”) offer the CTM program in person or virtually (e.g., on Zoom™). With government funding, the Active Aging Society (AAS; https://www.activeagingsociety.org ) supports organizations to hire or train coaches to deliver CTM. Our implementation support team (“support team” [ 38 ]), is housed within the AAS and uses a suite of implementation strategies (“strategies”) [ 39 ] to build capacity (e.g., provides tools, training and ongoing support) among organizations to adopt and implement the CTM program. Ethnocultural adaptation process Our approach to ethnocultural adaptation is grounded in intersectionality theory, and we acknowledged the need to be ethnoculturally competent and attuned to the needs and preferences of diverse communities [ 40 , 41 ]. We integrated collaborative, iterative, community-based participatory research (CBPR) methods [ 42 ] to engage Punjabi-speaking older adults and community organizations. CBPR nurtures long-term partnerships and relies upon co-operation among organizations and across sectors. We aimed to: 1) ensure that language, ethnocultural values, and lived experiences between older adults and community organizations who served them were aligned, 2) assess the need for capacity building [ 43 ], and 3) co-identify key priorities [ 44 , 45 ]. Cultural insiders are a key component of ethnocultural research [ 46 , 47 ]. Therefore, our immediate actions were to: 1) hire a South Asian, Punjabi-speaking program coordinator and cultural insider (BA, female) who through shared language and cultural awareness was instrumental in program and strategy adaptations and evaluation. They engaged with organizations, coaches and participants bi-weekly and maintained these relationships throughout the lifecycle of CTM; 2) recruit a post-doctoral fellow with a South Asian background (female), proficient in several South Asian languages (Punjabi, Urdu, Hindi, Bengali), and 3) contract a Punjabi-speaking consultant (female) to assist with qualitative data collection. The ethnocultural sensitivity of team members honored cultural norms [ 40 ]. Our project team (cultural insiders, support team, members of the research team) collaborated on all aspects of qualitative data collection, analysis, interpretation, and made final decisions on necessary adaptations. Similar to our previous adaptations of CTM [ 11 , 14 ], ethnocultural adaptation of CTM for Punjabi-speaking older adults sought to systematically adapt for ‘best fit’ while maintaining fidelity to CTM’s ‘core functions’ (i.e., the specific behaviour change techniques [ 48 ]). Briefly, we followed a systematic six-step adaptation process, informed by the Planned Adaptation Model [ 49 ], the National Cancer Institute adaptation framework [ 50 ] and integrated knowledge translation principles [ 51 ]. We added a seventh step (Step 0) that involved reviewing feedback on the original CTM Phase 4 model from organizations, coaches and older adult participants. We describe Steps 0 to 6, below. We recorded changes to the CTM program and strategies against Stirman et al.’s Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) [ 16 ] and FRAME-IS [ 52 ], respectively. Importantly, we carefully noted adaptations that were made for ethnocultural reasons. All methods were performed in accordance with the ethical standards of the University of British Columbia’s Behavioural Research Ethics Board [H22-03385] and with the 1964 Helsinki Declaration and its later amendments. We obtained informed consent from all participants. Ethnocultural adaptation of CTM for Punjabi-speaking older adults Step 0 – Review CTM Phase 4 data and respond to feedback In March 2023, the project team reviewed feedback from organizations, coaches, and older adult participants collected during CTM Phase 4 (2020–2022) and proposed initial adaptations to update the Phase 4 model. Step 1 - Engage : Between October 2022 and March 2023, the project team held three virtual meetings (approx. 60 min) with three organizations who were long-term CTM delivery partners. The aims of these meetings were to: 1) broadly examine barriers and facilitators to implementing CTM for Punjabi-speaking older adults; and 2) identify community organizations that serve this target population in Metro Vancouver and could partner to deliver the adapted CTM program. Next, a member of the project team used purposeful sampling [ 53 ] and contacted two of the identified organizations by phone or email and invited representatives to attend a ‘meet and greet’ (in-person at the organization, 60–75 min, conducted in English; July and December 2023). All invitees agreed to participate, and no other attendees were present. The project team introduced attendees (n = 4) to the CTM model and discussed with them whether CTM was a potential fit for their organization. Field notes were taken during each meeting. Step 2 – Needs Assessment Organizations contacted in Step 1 agreed to participate in a focus group with members of the project team. During 90-min in-person sessions, the project team provided a detailed overview of the CTM model, answered questions, elicited feedback on the CTM model, and aimed to understand the needs, preferences and capacities of each organization and the population they serve. These meetings were audio recorded via Zoom™, transcribed using Otter.ai™ and anonymized. The project team developed the interview guide (Additional File 1); H.B. used a structured meeting guide to take notes. We offered honoraria ( $ 75 CDN per organization) to compensate for organizational representatives’ time. We also considered field note data obtained by H.B. who attended both the information session and seven of the eight group meetings of one CTM Phase 4 program (Fall 2023) delivered by one small DPO to 19 Punjabi-speaking older adults prior to our formal adaptation process. Older adults were aware of H.B.’s role in collecting data and were invited to participate in an in-person interview to provide feedback on the CTM program (e.g., program components and suggested adaptations). The project team developed the interview guide (Additional File 1), and our cultural insiders conducted a mock interview to translate the guide into Punjabi and ensure use of culturally relevant language. We translated the invitation letter and consent forms using Amazon Web Services ( https://aws.amazon.com ); H.B. reviewed the translated forms for accuracy. Seven older adults participated in interviews (60–90 min; 3 individual, 2 paired; conducted in Punjabi by H.B. with field notes taken by the contracted Punjabi-speaking consultant at the small DPO where they attended the CTM program). Participants received an honorarium ( $ 25 gift card). At a follow-up meeting two team members (H.B. and T.F.) reviewed detailed field notes for analysis (accurate and reliable translation and transcription software for Punjabi was not available). Step 3 – Develop Prototype The project team reviewed the results from Steps 0–2, incorporated additional adaptations based on the lived experience of our cultural insiders, and drafted a prototype CTM model for Punjabi-speaking older adults. Step 4 – Validate Prototype The support team and H.B. met (45–60 min, on Zoom) with each organization that participated in Step 1 and 2 to share the prototype and invite feedback. These meetings were informal and not recorded via Zoom. One team member documented these informal meetings via field notes. Step 5 – Create a Final Adapted Model The project team reviewed data from Step 4 and made any necessary changes to create the final CTM model for Punjabi-speaking older adults. Step 6 – Implement the Adapted Model : We pilot tested implementation of the adapted model developed in Step 5 with 4 organizations (2 organizations previously delivered CTM Phase 4 programs, 2 organizations were new to CTM) between August and December 2024. To assess implementation of the program we selected implementation indicators from a proposed minimum data set [ 54 ] (acceptability, appropriateness and feasibility (4 items each Acceptability of Intervention, Intervention Appropriateness, and Feasibility of Intervention Measures (AIM/IAM/FIM) [ 55 ]); fidelity; dose delivered; adaptation). To this list we added dose received (to capture varying attendance levels across older adult participants), participant responsiveness ("the degree to which the program stimulates the interest or holds the attention of participants" [ 35 ]) and facilitators and barriers to delivery. As in our previous studies [ 9 , 12 , 14 ] coaches completed: 1) program feedback surveys and 2) participant engagement surveys (one per participant). All coaches (n = 4) completed questionnaires electronically via REDCap [ 56 , 57 ] at the end of the program (3 months). Older adults completed a program feedback questionnaire at the end of the program (3 months; dose received of core functions, participant responsiveness). Participants completed paper-based questionnaires in Punjabi or English. To assess use of implementation strategies we evaluated coaches’ self-efficacy, and adoption/use, satisfaction, and adaptation of provided resources and materials [ 54 ]. Coaches completed a questionnaire after training (one per coach to assess self-efficacy to deliver CTM) and an implementation support questionnaire (one per coach to assess adoption/use, satisfaction and any adaptation of provided resources and materials). Following delivery of the adapted CTM model, two members of the project team (one researcher (PhD), one support team member; both female) conducted interviews (approx. 60 min each, Additional File 1) with each organization and coach. Through these interviews, we aimed to assess implementation determinants (acceptability, feasibility, appropriateness) and outcomes (participant responsiveness, dose received, fidelity) of the adapted CTM model in more depth. Interviews were audio recorded via Zoom, transcribed and anonymized. Field notes were taken during interviews. All interviews were conducted by trained members of the project team with prior experience in qualitative methods and implementation research. Interviewers were not directly involved in program delivery, which minimized potential role-related bias. The team acknowledged shared interests in supporting community-based health promotion for older adults and maintained reflexive awareness of how these values might shape data interpretation. Regular team debriefs and analytic discussions were used to identify and critically reflect on assumptions, thereby enhancing transparency and analytic rigour. While transcripts were not returned to participants for review, trustworthiness was strengthened through ongoing validation discussions among the project team, and opportunities for member reflections during each interview [ 58 ]. This approach enabled participants to confirm, refine, or elaborate on their perspectives, enhancing the rigour and credibility of the data. Analysis Steps 0–5 Using Nvivo (NVivo Pro Version 11.4.1 for Mac, QSR International (Americas) Inc., Burlington, MA, USA), T.F. and D.C. conducted a preliminary, descriptive analysis of data collected from focus groups, individual and paired interviews, internal and external meetings, and field observations. Salient observations that reflected the need for, or rationale behind, specific adaptations were extracted and summarized in a Microsoft Excel matrix (Additional File 2; adapted from [ 59 ]). Each row in the matrix represents a discrete update or adaptation. We used the FRAME [ 16 ] and FRAME-IS [ 52 ] to capture what was modified, the nature and timing of the modification, the level of delivery affected (e.g., participant-facing materials, program delivery), and the goal of the modification and the rationale (e.g., cultural relevance, resource constraints, participant needs). We also examined data through an intersectional lens to identify ethnocultural and age-based complexity. This analytic approach enabled the project team to synthesize a wide range of qualitative inputs from diverse sources into a consolidated record of potential ethnoculturally appropriate adaptations to the CTM model and rapidly review suggested adaptations. Throughout the analysis process, the project team met regularly to review and refine the Excel matrix, resolve inconsistencies, and ensure consensus on adaptation classification. Step 6 We describe quantitative implementation indicators using percentages, means and ranges where appropriate. Interview transcripts and field notes were analysed using a six-step thematic analysis [ 60 ] and qualitative findings were reported following the consolidated criteria for reporting qualitative research (COREQ) checklist [ 61 ] (Additional File 3). We began with familiarization and initial coding using Nvivo (NVivo Pro Version 11.4.1 for Mac, QSR International (Americas) Inc., Burlington, MA, USA). We used an inductive approach to develop codes, applying both intersectional and ethnogerontology perspectives. Our analysis focused on how the interplay of age, ethnicity and culture, family dynamics, and migration experiences shaped key implementation determinants (feasibility, acceptability and appropriateness) of the adapted CTM model. We aimed to understand how factors related to aging (such as mobility, sensory changes) combined with ethnocultural values (such as collectivism, gendered experiences) and broader societal and systemic barriers to shape unique pathways for engagement and delivery within this population of Punjabi-speaking older adults. Similar codes were grouped into preliminary themes, which were reviewed and refined through iterative team discussions using a constant comparative method. Themes were substantiated with direct participant quotations that captured the range and depth of perspectives shared. Diverse perspectives and minor themes were included to capture the range of participant experiences. These variations were retained and reported to illustrate contextual influences and enhance the richness and credibility of the analysis. Although described sequentially, analysis was recursive and iterative. This process ensured that the analytic interpretations remained closely aligned with the data, thereby enhancing the credibility and trustworthiness of the findings. Data collection and analysis concluded when the team reached data sufficiency—when no new themes or insights emerged—within the context of the study’s scope and the limited number of participating organizations. Results Adaptation of the CTM Phase 4 Model (step 0) We proposed 23 updates to the CTM model after Step 0 (Additional File 2); we incorporated all proposed updates into the new CTM Phase 4 model. Examples include updates to implementation strategies such as coach training content (e.g., add required and optional modules; add or update examples), the CTM community of practice for coaches (focused topics; make attendance mandatory to maintain certification), and CTM program materials (content and format). In Table 1 , we highlight the differences between the original and updated CTM Phase 4 models. Ethnocultural adaptations of the updated CTM Phase 4 Model (steps 1–5) We proposed 32 adaptations to the updated CTM Phase 4 model after Steps 1 to 3: 22 program adaptations and 10 implementation strategy adaptations (Additional File 2). We incorporated all proposed adaptations into the prototype adapted CTM model. CTM program adaptations integrated South Asian cultural practices (e.g., chair sharing ritual) into group meeting content and were mindful of religious practices. Adaptations captured cultural-age intersections in two ways: 1) considered program-centered Punjabi cultural norms, including multigenerational dynamics and gender roles (e.g., organizations were encouraged to involve family members in participant recruitment); and 2) incorporated low-impact, ethnoculturally relevant physical activities aligned with participants' abilities and preferences (e.g., physical activity videos with South Asian instructors speaking in Punjabi). Key ethnocultural adaptations to implementation strategies were: added images of South Asian older adults being active to resources (e.g., recruitment and promotion materials and group meeting slides), translated participant-facing materials into Punjabi and phonetically translated (Punjabi rendered in English characters) to accommodate those who speak Punjabi but cannot read Gurmukhi script, adapted program materials to include larger multilingual fonts to address vision and language barriers, simplified health messaging without losing accuracy, engaged families to help recruit participants, encouraged organizations to schedule sessions around important holidays and cultural events, and added culturally relevant physical activity examples and discussion questions to group meeting slides. Key adaptations to evaluation materials were to remove items that were deemed not culturally relevant/sensitive, simplify language of questionnaire items, translate questionnaire text into Punjabi, add pictures to improve comprehension and provide in-person support to participants to complete the questionnaires. Across all adaptations, our Punjabi-speaking consultant reviewed all translated materials to ensure accuracy, appropriateness and readability. Implementation of the Adapted CTM Model (step 6) Four coaches delivered five adapted CTM programs for 68 Punjabi-speaking participants (August to December 2024). All four coaches and 65 participants (96%) volunteered for the evaluation. Of these participants, 47 (72%) completed the CTM program and the post-program feedback questionnaire; (38%) participants required assistance from either a project team member or a coach to complete the questionnaire. We provide descriptive characteristics of these participants in Table 2 . Quantitative Program implementation Acceptability, appropriateness and feasibility Organization staff rated the adapted CTM program acceptable, appropriate, and feasible (median score 5/5 for all). Coaches rated the adapted CTM program acceptable (median score 4.5/5), appropriate, and feasible (median score 5/5 for both). Dose delivered Coaches delivered all (8/8) group meetings in each of the five programs. Dose received Of the 65 participants who consented to be evaluated, attendance data were available for 64 of them. Sixty-three participants (98.4%) attended one or more group meetings; 54 (84%) participants attended 4 ( ≥ 50%) or more of the group meetings. Adaptation One coach skipped the welcome activity at two group meetings and increased the length of movement breaks to allow participants more time to exercise and chat with each other. Participant responsiveness Coaches deemed participants to be somewhat to extremely interactive; participants were enthusiastic, interested, and engaged with CTM content and each other at most or all group meetings. Of those participants who completed the post-CTM program feedback survey, most (n = 46, 98%) reported feeling satisfied or very satisfied with the program. Fidelity to core functions At 100% of group meetings, coaches provided opportunities for peer or group check-ins to revisit goals, educational content, and opportunities to share resources. At all group meetings, coaches encouraged peer check-ins (CTM Dost). From the participant perspective (n = 47), there were opportunities during most (4–7) or all group meetings to revisit goals with another member of the group (66%), learn about a health topic (77%) and share resources (62%). Across all programs, 83% (n = 39) of participants connected with a CTM Dost outside of group meetings. Of these participants, 46% reported checking in with their CTM Dost more than twice/month while others checked in twice (18%), once (13%) or less than once (18%) per month. Implementation strategies Self-efficacy All coaches were satisfied with the CTM training (rated all modules 4 or 5 out of 5) and felt confident they could apply what they learned in training to delivery of CTM (rated 4 or 5 out of 5). Adoption, acceptability and adaptation Promotion and recruitment materials : One coach reported using two of 22 promotion and recruitment materials; they were unaware of the other materials. Three coaches used between 6 and 11 different promotion and recruitment materials. Of the 22 materials, 1 was used by all 4 coaches (customizable English CTM poster), 3 were used by 3 coaches (English and Punjabi brochures and CTM logos), 4 were each used by 2 coaches (generic English poster, customizable Punjabi poster, CTM brand guidelines and promotional videos) and each of 5 materials were used by only 1 coach (English bookmark, English and Punjabi social media templates, Punjabi customizable rack card, guide for creating a poster, CTM program description). Eight promotion and recruitment materials were not used by any coaches (e.g., news release, generic rack card in English). Most coaches (3 of 4) were either satisfied or extremely satisfied with the promotion and recruitment materials. Two coaches used additional promotion and recruitment materials; one reported that their organization’s media team created advertisements and the other reported that their organization created a separate organization-specific poster in English and Punjabi. One coach required support to develop and implement a recruitment plan; however, all coaches used two or more of the six suggested recruitment strategies (e.g., traditional media, social media posts, referrals from other organizations). All coaches were either satisfied or extremely satisfied with the recruitment actions. Program delivery administrative materials : Of the 11 program administrative documents available to coaches, 5 documents were used by all coaches (e.g., one-on-one consultation sign-up form, group meeting topics), 5 other documents were used by three coaches (e.g., CTM delivery checklist, activity inventory), and the remaining document (provincial resources) was used by 2 coaches. All coaches were satisfied or extremely satisfied with the administrative documents and none of the coaches adapted any of the documents. Participant-facing program documents : Of the eight participant-facing program documents, seven were used by all coaches (e.g., Get Active Questionnaire in English and Punjabi, CTM information form in English and Punjabi), and one document (certificate of completion) was used by three coaches. All coaches were satisfied or extremely satisfied with the participant-facing documents and none of the coaches adapted any of the documents. Qualitative A representative from each organization (n = 4, on Zoom in English) and each coach (n = 4, on Zoom in English) participated in semi-structured interviews at the end of the adapted CTM program. Program implementation Four themes emerged that reflect key implementation determinants (feasibility, acceptability and appropriateness) of the adapted CTM program for Punjabi-speaking older adults: 1) provide structure and support, 2) foster cultural and linguistic resonance, 3) make goals matter through culturally responsive action planning, and 4) facilitate engagement through culturally tailored group delivery. We expand on these themes and provide supporting quotes, below. Provide structure and support Organizations and coaches thought CTM was highly feasible and acceptable to implement, largely due to well-structured, ready-to-use materials and the strong implementation support provided to coaches. Coaches emphasized that the program required minimal planning, with clearly organized slides, step-by-step guides, and comprehensive resources—including translated materials and promotional content—that simplified delivery and outreach. Organizations noted that CTM aligned well with existing programming and infrastructure, particularly in organizations already serving Punjabi-speaking older adults. Everything was ready… just for me to prepare the session. As compared to other programs where I had no training or resources, CTM was very, very easy. AC1 This was the group I enjoyed the most—it was all in Punjabi, easy for me to communicate… there was no language barrier. AC2 Ethnocultural and linguistic resonance Coaches and organizations considered the program to be ethnoculturally appropriate and meaningful. They emphasized the importance of well-executed Punjabi translations, not only for accessibility but for reinforcing learning. Ethnocultural adaptations—including familiar examples, culturally resonant movement breaks, and the use of Punjabi music and community stories—fostered engagement and helped participants relate personally to program content. I think the adapted model is very thoughtful, and it's culturally sensitive. And it meets the unique needs of the South Asian community, the Punjabi speaking Seniors, because they can easily relate to the program. … I also find it very, very successful programming, because, all the slides and the resources they were in in their own language, and very culturally and linguistically appropriate. AC1 I feel like they did really incorporate all the insights that we've shared, and especially that cultural component. I think the team did a fantastic job of collecting that information and trying to understand what really works for the community. Because sometimes standardized programming, it doesn't necessarily work for all communities. Org1 Sometimes the translation gets a bit heavy… but the phonetic version really helped, especially for those who speak Punjabi but aren’t comfortable reading it. AC3 Make goals matter through ethnoculturally responsive action planning Implementation of CTM core functions (e.g., goal setting and action planning) with Punjabi-speaking older adults posed unique challenges. Coaches saw these core functions as central to the program’s intent yet delivering them in a meaningful way required significant time, cultural sensitivity, and linguistic adaptation. Participants generally understood the idea of having a goal, but their understanding tended to be broad and non-specific—often centered on general well-being (e.g., being “healthy” or “happy”) rather than on specific, measurable behaviour changes. Coaches received structured action planning tools, but they were rarely used in a formal way. Instead, coaches relied on informal, conversational approaches to support goal setting, adapting their language to better align with participants’ cultural and linguistic contexts. Terms like “action plan” did not always translate meaningfully with participants’ cultural orientations toward relational and fluid approaches to health. Health actions emerged organically through dialogue rather than through rigid individual planning. Cultural values of sangat (collective wisdom) and seva (service through relationship) honor how health behaviours are negotiated within social contexts rather than prescribed individually. One-on-one consultations were the primary mechanism for introducing and reinforcing goals. Coaches and participants valued these sessions. However, coaches found sessions logistically demanding and time-intensive—they often took an hour to translate needs and explain program concepts. Additional time was required for data collection. Despite the time cost, these consultations were considered rich opportunities to connect and engage participants. Behaviour-change discussions were frequently interwoven with emotional support: They spent almost an hour, and a few went over because they got engaged in conversations… it also became emotional support, not just action planning.” AC1 Facilitate engagement through ethnoculturally tailored group delivery Group-based delivery was a key strength of the adapted CTM program. Participants valued the opportunity to socially interact, connect, and receive peer support. Mixed-gender groups fostered spaces of mutual respect and shared learning, particularly when facilitated with ethnocultural sensitivity and skill. In our South Asian community, usually men think these groups are meaningless… but they found it very knowledgeable and are looking forward to joining again.” AC1 Engagement was further enhanced using peer-led strategies such as WhatsApp groups and informal accountability check-ins (CTM Dost). These helped reinforce participation and adherence between sessions. Movement breaks were a highly valued element of the group experience. Most coaches incorporated two movement breaks per session—one structured (e.g., functional movements or resistance exercises) and one more relaxed or culturally familiar (e.g., dance, yoga). This variety kept sessions dynamic and engaging. To ensure accessibility and relatability, coaches often adapted movement break content using culturally relevant music or videos featuring older Punjabi-speaking individuals. When such content wasn’t available—due to the lack of Punjabi-language exercise resources online—coaches would either translate English-language videos live or lead the exercises themselves while providing instructions in Punjabi. “When we try to find exercises on YouTube or other social media like things are not in Punjabi language….so it was bit hard for me to find like exercises in Punjabi ...so I used to translate for them.” AC2 Implementation strategies Three themes emerged that reflect key implementation determinants (feasibility, acceptability and appropriateness) of the adapted strategies: 1) building relationship-centered partnerships, 2) providing tailored and culturally appropriate support, and 3) strengthening coach delivery skills through tailored training. We expand on these themes and provide supporting quotes, below. Build relationship-centered partnerships We grounded our approach in CBPR and emphasized relationship-building as a foundational first step. Early and ongoing engagement with organizations serving South Asian communities prioritized trust and reciprocity. In-person visits and iterative conversations were intentionally used to foster mutual understanding and position community partners as co-creators in the adaptation and implementation process and ensure long-term collaboration. “The in-person meeting developed more of a partnership, more of a bond… we could ask questions and feel heard.” Org1 “I think she’s definitely built enough of a rapport with us that it's just very easy to get in touch. I feel like, as the partners, we feel very comfortable… It's very easy for us to express the good stuff or the bad stuff, things that are not working well, and I feel like there's always someone that we can contact, and they'll support us right away.” Org2 Provide tailored and culturally appropriate support Strategies were tailored to fit the varying needs and contexts of each organization. For example, the support team worked with organizations to adjust staff time allocation where needed, streamline administrative paperwork, and offer guidance on integrating CTM alongside existing programs. For one organization, providing flexibility within the budget accommodated food incentives and more support hours, which increased their perceived feasibility to deliver CTM. “During that budget piece, something that we had discussed was that hospitality and refreshments piece. So what we noticed for programming was that food was always an incentive for seniors. So I remember initially when we were looking at the budget, we thought that that food part of the budget, that line item there wasn't really enough funds allocated there. So then we had a discussion with [the support team], and we kind of gave some justification as to you know how our programs usually work. We usually like to offer a little bit of a snack or coffee or whatnot, and so they got back to us fairly quickly, and they were able to give us some additional funds for that piece. So it was a very straightforward process.” Org1 Strengthen coach delivery skills through tailored training Training content for coaches was adapted to reflect both cultural context and common challenges. As some coaches were less confident in formal goal setting and behaviour change facilitation, the support team provided hands-on mentorship and guidance in motivational interviewing and delivery techniques. Flexibility in training delivery and ongoing, bi-weekly check-ins with H.B. were critical to reinforce learning, troubleshoot challenges, and when required for coaches whose first language was Punjabi, to simplify training materials and explain them in Punjabi. “It wasn’t just the training—H.B. would check in all the time and help me think through things like how to do the one-on-one consultation better.” AC1 Over time, coaches became more confident and could independently deliver the program. Initial reliance on one-on-one support decreased as coaches gained experience. Organizations noted increased familiarity, efficiency, and confidence among coaches after completing one program. “In the beginning, [name of AC], really valued that one-on-one time to ask questions. I think now that she's gone through a program once, she’s less reliant on that.” Org2 “I think we have a pretty good handle on it... When it comes to overall delivery of the program, I think we have it. She’s [AC] much more confident in delivering the sections, she knows what's going on, she knows what can be improved.” Org1 “Well, and it's like I said to AC, okay, now you've done it once. Some of this stuff likely won't take you as long.” Org3 Discussion We respond to the call for implementation science projects to explicitly address health equity [ 33 ]. Here we describe our systematic ethnocultural adaptation and implementation of CTM for a marginalized, ethnocultural group in British Columbia, Canada -- Punjabi-speaking South Asian older adults. Cornerstones of our approach include meaningful engagement with multiple interested and invested ethnocultural partners, partnerships based on reciprocity and shared goals, and an intentional focus on ensuring that EBI benefits and outcomes reflect a fair distribution of power between partners. As the best approach to meaningfully engage ethnoculturally diverse populations in research remains unclear [ 62 ], we contribute to the growing body of work that seeks to move beyond cursory adaptations (often only for language), to contextually and ethnoculturally ground the co-adaptation process of health-promoting EBIs. Ethnicity and culture permeate all aspects of health-promoting EBIs and determine how programs are designed, implemented, and sustained within communities [ 18 ]. Historically, culture has been narrowly defined - often reduced to race - and applied in ways that marginalize minoritized groups [ 63 ]. In health research, this has manifested in deficit-based frameworks that pathologize cultural differences and position racialized communities' practices and behaviours as problems that require correction [ 64 ]. This approach reinforces harmful hierarchies, framing whiteness as the normative standard and justifies oppressive policies under the guise of scientific objectivity [ 65 ]. This legacy persists in systemic barriers to equitable health-promotion activities and ethnoculturally misaligned interventions [ 66 ]. The current adaptation literature often treats cultural identity, aging, language, and other factors as isolated variables, missing how they intersect to shape lived experience and program engagement. This oversight has consequences when designing health-promoting EBIs for ethnoculturally diverse older adults, such as South Asian immigrants in Canada. Intersectionality theory [ 67 ] pushes us to ask: Whose aging is being centered? Whose realities are erased? Without this lens, adaptation frameworks risk superficial inclusion - what scholars have called “culture as a checkbox” - rather than offering meaningful structural change [ 68 ]. Recognizing this, our ethnogerontological approach to adapting the CTM model sought not merely to tailor, but to transform how EBIs are conceptualized and delivered to marginalized older adults. To our knowledge, CTM is the first health-promoting EBI to be ethnoculturally adapted for Punjabi-speaking South Asian older adults in Canada. Our approach aligns with key strategies associated with effectiveness of physical activity interventions for South Asian older adults [ 29 ]. This includes using participatory approaches to i. inform ethnocultural tailoring/adaptation of the intervention, ii. adapt intervention materials to account for characteristics of the target population (such as language), iii. utilize community health workers/cultural insiders, iv. deliver the program in community/neighborhood facilities, and v. include culture-specific dance as part of the intervention. Our approach aligns with six factors deemed essential for equitable implementation [ 69 ]: ethnocultural adaptation, trusting relationships, dismantling power structures, investments and decision making to advance equity, community-defined evidence, and critical perspectives implementation. These factors were the cornerstones that strengthened our partnership with community organizations and informed our CBPR approach. As evidenced in both our quantitative and qualitative findings, the adapted CTM program was widely perceived as feasible, acceptable, and appropriate by organizations and coaches. Adaptations—such as extending one-on-one consultations, integrating ethnoculturally resonant movement breaks (that included dance), and offering phonetic and simplified Punjabi translations—were critical to facilitate participation, engagement, and comprehension among older adults with diverse language and literacy needs. These adaptations centered the interconnected roles of culture, religion and spirituality in shaping health behaviours, and allowed us to respectfully engage with immigrant communities while addressing their contemporary realities. The use of ethnoculturally grounded implementation strategies and program delivery formats was particularly important. South Asian older adults face barriers to physical activity related to i. limited availability of ethnoculturally and linguistically tailored programs, ii. lack of knowledge about physical activity guidelines [ 70 ] and benefits of physical activity and exercise in later life [ 71 ], and iii. restrictive social norms—particularly among women [ 70 , 72 ]. The project team was aware of their own positions of privilege and how these ‘power dynamics’ impact interactions with Punjabi-speaking community members. A ‘cultural insider’—a Punjabi-speaking team member with linguistic and lived experience in the community—played a pivotal role in supporting organizations and coaches to adopt and implement the adapted CTM program. They created a more equitable research environment where the voices and experiences of racialized older adults were respected and valued. They fostered ethnocultural congruence and trust, which were evident in our findings. Our deliberate attention to power-sharing was central to fostering sustained engagement to ensure CTM was meaningful for older adult participants, coaches and organizations. Organizations offered insights to ensure that CTM and its implementation was ethnoculturally responsive and sensitive to the needs and preferences of the community. This collaborative approach served to redistribute power, and position partners and participants at the center of the research process [ 73 ]. Without confronting these power structures, ethnocultural adaptations remain superficial. In adapting CTM, we pursued systemic change through three actions: 1) removed colonial metrics (e.g., BMI) from the CTM evaluation; 2) redistributed power by training activity coaches from the Punjabi community thereby centering lived experience over institutional authority; and 3) rejected Eurocentric 'validated' practices [ 74 ] (e.g., Vancouver Index of Acculturation) from our evaluation. Importantly, adaptations reflected how intersecting sensory and linguistic challenges uniquely impact how older immigrants engaged in CTM. We endeavoured to bridge two typically siloed disciplines. We integrated implementation science approaches [that historically understudy older adults’ heterogeneity and health equity] with ethnogerontology [that typically lacks systematic methods for translating ethnocultural knowledge into implementable and scalable interventions]. This synergy generated a blueprint for implementing an evidence-based AND ethnoculturally grounded EBI for older adults. It also responds to the need to move beyond one-size-fits-all approaches in community-based care for ethnoculturally diverse older adults. Other strengths of our study were using established adaptation and implementation frameworks (FRAME, FRAME-IS), a multi-method evaluation approach, sustained community engagement, the prominent role of cultural insiders on the project team, and CBPR methods. We consider these strengths in the context of some limitations. First, we engaged only four community organizations that serve Punjabi-speaking older adults. To improve the health of this ethnocultural group, the adapted CTM model must be scaled up to more sites. Thus, our next steps are to monitor and assess scale-up, and to evaluate participant-level health outcomes to assess program effectiveness. Second, while our approach was systematic and rigorous, the time- and resource-intensive nature of this ethnocultural adaptation process may challenge scalability in contexts where adequate resources are not available. Conclusion The adaptation literature often treats ethnocultural factors (e.g. migration legacies; exclusion), aging-related factors (e.g., mobility), and language as isolated variables. However, they intersect to shape lived experience and how older adults engage in health-promoting programs. Studies that address these complexities and the nuanced nature of ethnoculturally appropriate health-promoting EBIs are needed. We adopted an equity-oriented process to develop an ethnoculturally relevant version of CTM for Punjabi-speaking older adults. Lessons learned about the adaptation process and adaptations to the CTM model may be used to engage other ethnocultural groups of older adults. That said, the diversity across and within cultures is vast; one size does NOT fit all. We highly recommend using participatory methods to further tailor health-promoting models for different groups. Abbreviations AC Activity coach AAS Active Aging Society BC British Columbia CBPR Community-based participatory research CTM Choose to Move EBI Evidence-based intervention FRAME Framework for Reporting Adaptations and Modifications to Evidence-based interventions FRAME-IS Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies YMCA Young Men’s Christian Association Declarations Ethics approval and consent to participate : All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study. Consent for publication: Not applicable. Availability of data and materials: De-identified data from this study are not available in a public archive. De-identified data from this study will be made available (as allowable according to institutional IRB standards) by emailing the corresponding author. Competing interests: The authors declare that they have no competing interests. Funding : The BC Ministry of Health provided funds to the AAS to support delivery of CTM. The Canadian Institutes of Health Research [HG2-185013] funded evaluation of the adapted CTM model. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication. Authors' contributions: HAM and JSG conceived the project and secured funding. All authors contributed to creation of the evaluation plan and oversaw data acquisition. TF and DC analyzed the qualitative data; HMM analyzed the quantitative data. HMM, TF and DC drafted the initial manuscript. All authors reviewed and critically revised the manuscript and have approved the final version. Acknowledgements: We are grateful for the ongoing support of CTM from the BC Ministry of Health, the AAS and delivery partner organizations involved in the adaptation of CTM for Punjabi-speaking older adults. We thank all older adults who contributed to the adaptation process, and who participated in the adapted CTM programs. Lastly, we acknowledge the dedication of staff and trainees from the Active Aging Research Team without whom we could not conduct this work. References Dunn JR, Dyck I. Social determinants of health in Canada's immigrant population: results from the National Population Health Survey. Soc Sci Med. 2000;51:1573–93. Wang L, Guruge S, Montana G. Older Immigrants' Access to Primary Health Care in Canada: A Scoping Review. Can J Aging. 2019;38:193–209. 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Differences across the original Choose to Move (CTM) Phase 4 program, updated Phase 4 program, and Phase 4 program adapted for Punjabi-speaking older adults. Original CTM Phase 4 (2020-2022) Updated CTM Phase 4 (2023-present) CTM Phase 4 for Punjabi-speaking older adults Program length 3 months 3 months 3 months Format Information session 1-2 weeks prior to program start Initial 30-min consultation between GMs 1 and 2 8 GMs; 60 minutes (in-person; virtual; hybrid) Participant-level evaluation in English at baseline and 3-months, online or paper-based Information session 1-2 weeks prior to program start Initial 30-min consultation between GMs 1 and 2 8 GMs; 60 minutes (in-person; virtual) Participant-level evaluation in English at baseline and 3-months, online or paper-based Information session 1-2 weeks prior to program start Initial 60-min consultation between GMs 1 and 2 8 GMs; 90 minutes (in-person) Participant-level evaluation in Punjabi or English at baseline and 3-months, paper-based. Evaluation modified to remove some items that were not culturally relevant or sensitive (e.g., self-reported height and weight). Several items added to capture details related to immigration (i.e., years in Canada). Intervention activity: Group meetings (GMs) Health topics covered in GMs Welcome & goal setting Physical activity & social connection Incidental physical activity Goals revisited Nutrition Falls prevention Stress management & brain health Goals & celebration Prescribed movement breaks: during meetings (in-person; 5-10 min); none prescribed during virtual delivery for safety reasons, though activity coaches invited participants to get up and move around at some point during the meeting. Group meeting slides: prescriptive for group and paired discussions; contact information formally included in each CTM participant group Group check-ins: Occur during group meetings Group challenges: included at the end of each group meeting Optional peer check-ins Optional ‘check-in’ newsletter (bi-weekly) Activity coaches required to deliver Phase 1 meeting topics 1, 2, 3 & 8; for GMs 4-7, activity coaches can use the standard topics listed below, or choose alternate topics from a list of 22 other meeting topics. Welcome & goal setting Physical activity & social connection Incidental physical activity Building your support team Nutrition Falls prevention Stress management Revisit goals & celebrate Prescribed movement breaks: Same as original Phase 4 program Group meeting slides, group challenges, peer checkins and newsletter: Same as original Phase 4 program. Activity coaches deliver 8 standard GM topics (see Additional File 1 for details on adaptations to meeting topics). Welcome & goal setting with an introduction to physical activity Physical activity Incidental physical activity Healthy connections Nutrition Falls prevention Self care Goals & celebration An expanded list of alternate GM topics will be explored in future. Prescribed movement breaks: 20-30 min total, facilitated in 2 separate breaks.; activity coaches can choose from a variety of culturally relevant and appropriate materials (e.g., Indian dance videos) Group meeting slides: Reduced text, simplified language and added phonetics, added imagery and culturally relevant examples, added Punjabi translation for keywords and themes, included group and paired discussions. Group check-ins: Occur during group meetings. Group challenges: Replaced with “Next Steps” – guidance for how participants can incorporate learnings from GM into their daily lives. Optional peer check-ins: Replaced with CTM “Dost” (dost = friend in Punjabi) Optional ‘check-in’ newsletter: available for participants, but only in English Implementation strategy: Activity coach training Qualification: anyone with experience in fitness leadership or with older adults Activity coaches hired by delivery partners Training hosted online at www.choosetomovetraining.info (separate from main CTM website) Training delivered in self-directed online platform with interactive practical component Qualification: Same as original Phase 4 model Activity coaches hired by delivery partners Training hosted online on main CTM website (https://choosetomove.ca) Training delivered in similar format to orginal Phase 4 model but with additional modules on physical activity and behavior change for coaches without a fitness background, and on facilitation skills Qualification: Same as original Phase 4 model Activity coaches hired by delivery partners Training hosted in hybrid format (virtual and in-person), supplemented online training with in-person or virtual Q&A session, and added training modules on CTM Delivery-Punjabi and CTM Evaluation-Punjabi Table 2. Characteristics of participants in adapted Choose to Move (CTM) Phase 4 programs for Punjabi-speaking older adults that completed the baseline evaluation and the 3-month CTM program, and those that completed the baseline evaluation but did not complete the CTM program and/or the post-CTM evaluation. Completed baseline evaluation and 3-month CTM program (n=47) Did not complete the 3-month CTM program and/or the post-CTM evaluation (n=18) Participants, n (%) Female Male Missing data 35 (74.5%) 12 (25.5%) --- 11 (61.1%) 5 (27.8%) 2 (11.1%) Age category, n (%) 75 years Missing data 35 (74.5%) 11 (23.4%) 1 (2.1%) 12 (66.7%) 3 (16.7%) 3 (16.7%) Primary language spoken at home, n (%) Punjabi Hindi English 41 (87.2%) 1 (2.1%) 5 (10.6%) 15 (83.3%) 1 (5.6%) 2 (11.1%) Born in Canada, n (%) No Yes Missing data 47 (100%) --- --- 10 (55.6%) --- 8 (44.4%) Time in Canada, years (mean (SD)) 34.9 (15.3) Living arrangement, n (%) Alone With spouse/partner With children With spouse, children, grandchildren Missing data 4 (8.5%) 18 (38.3%) 10 (21.3%) 13 (27.7%) 2 (4.3%) 1 (5.6%) 5 (27.8%) 4 (22.2%) 8 (44.4%) --- Educational attainment Secondary or less Some trade, technical school or college Some university Prefer not to answer 25 (53.2%) 7 (14.9%) 14 (29.8%) 1 (2.1%) 7 (38.9%) 5 (27.8%) 2 (11.1%) 4 (22.2%) Chronic conditions, n (%) 0 1 > 2 Prefer not to answer Missing data 13 (27.7%) 14 (29.8%) 17 (36.2%) 1 (2.1%) 2 (4.3%) 1 (5.6%) 2 (11.1%) 7 (38.9%) --- 8 (44.4%) Self-rated health, n (%) Very poor, poor or fair for age Good or very good for age 16 (34.0%) 31 (66.0%) 8 (44.4%) 10 (55.6%) SD=standard deviation Additional Declarations No competing interests reported. Supplementary Files MacdonaldBMCPublicHealthAdditionalFile120251202.docx MacdonaldBMCPublicHealthAdditionalFile220251202.xlsx MacdonaldBMCPublicHealthAdditionalFile320251202.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 13 Jan, 2026 Reviewers agreed at journal 06 Jan, 2026 Reviewers invited by journal 06 Jan, 2026 Editor invited by journal 10 Dec, 2025 Editor assigned by journal 07 Dec, 2025 Submission checks completed at journal 07 Dec, 2025 First submitted to journal 02 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Macdonald","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/ElEQVRIiWNgGAWjYBACAyBmhnEkgFiG4XgDGyEtjM3IWngYzhwgWcuNBPxazNmbnz8uqLjHoNt++OGNjzvsePhuvjF78IPBTh6XFsueY4bNM84UM5idSTO2nHkmmUfydo65YQ9DsmEDLofdSDBs5m1LYDA7kMMmzdvGzGNwO8dMmoHhACNOLfeff2zm/QfUcv4NSEs9j8HNM2At9rht4QHa0gDUcgNsy2EeoAhYSyJOLWdyCmfzHEvgMbvxDOiXtuM8kmfSyg17DJKTcWo5fnzDZ56aBDmz88nAEGurluM7fnjbgx8Vdra4tMAAD7pRBNSPglEwCkbBKMALAGCFVxKOSjgrAAAAAElFTkSuQmCC","orcid":"","institution":"University of British Columbia","correspondingAuthor":true,"prefix":"","firstName":"Heather","middleName":"","lastName":"Macdonald","suffix":""},{"id":570427686,"identity":"732e2d80-1f08-4d26-95ab-89ae2db5bbe8","order_by":1,"name":"Thea Franke","email":"","orcid":"","institution":"University of British 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13:49:16","extension":"xlsx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":35533,"visible":true,"origin":"","legend":"","description":"","filename":"MacdonaldBMCPublicHealthAdditionalFile220251202.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-8264715/v1/8b6604c1f60335f0bd99dec9.xlsx"},{"id":99799112,"identity":"cd4941ac-fec8-4f7e-b390-2c4098506c62","added_by":"auto","created_at":"2026-01-08 13:49:14","extension":"pdf","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":441754,"visible":true,"origin":"","legend":"","description":"","filename":"MacdonaldBMCPublicHealthAdditionalFile320251202.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8264715/v1/8d6cb1ca4e623bec2297842c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Ethnocultural adaptation of an effective health-promoting intervention for Punjabi-speaking older adults: Choose to Move ਆਓ ਚੰਗੀ ਸਿਹਤ ਵੱਲ ਚਲੀਏ","fulltext":[{"header":"Background","content":"\u003cp\u003eIn Canada, racialized immigrant older adults have a higher prevalence of chronic conditions, poorer self-reported physical and mental health, and greater difficulties with instrumental activities of daily living than non-racialized and Canadian-born older adults [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Immigrant status among older adults is also associated with lower levels of physical activity [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] and higher levels of loneliness [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] as compared with Canadian-born older adults. Among the Canadian immigrant population, South Asians are the largest and fastest-growing racialized group. In British Columbia (BC), South Asians are the largest racialized immigrant group (24.8% of immigrants) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Yet, South Asians remain underrepresented in health research and underserved by health-promoting initiatives [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This underrepresentation is often sustained by power imbalances and structural inequities within research and health systems that frequently exclude these communities from the research process [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOver the past decade we used a phased approach to scale-up an effective health-promoting model for older adults (Choose to Move; CTM) in British Columbia, Canada [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Through a series of systematic adaptations, we demonstrated that CTM could be implemented with fidelity at increasingly larger scale [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], virtually [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], and at lower cost [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. We define adaptation as the \u0026ldquo;process of thoughtful and deliberate alteration to the design or delivery of an intervention, with the goal of improving its fit or effectiveness in a given context\u0026rdquo; [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]). We and others [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] contend that adaptation of an evidence-based intervention (EBI) during scale-up is both inevitable and appropriate. Adaptations to CTM to date did not compromise program effectiveness (i.e., health benefits for older adult participants were retained) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough we, and our government and community partners, deemed scale-up of CTM across Phases 1\u0026ndash;4 a success (based on reach), programs attracted relatively few racially minoritized and immigrant older adult populations [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This is not unlike many health-promoting initiatives that are implemented with a \u0026ldquo;one (cultural) size fits all\u0026rsquo;\u0026rsquo; approach [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and therefore often fail to reach marginalized or underrepresented populations [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Community-based organizations that serve these populations may lack the necessary staff, financial resources or specialized skillsets to support EBI implementation [\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCultural adaptation has been defined as \u0026ldquo;the systematic modification of an EBI to consider language, culture, and context in such a way that is compatible with the client\u0026rsquo;s cultural patterns, meanings, and values\u0026rdquo; [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Cultural adaptation does not rely solely on \u0026ldquo;superficial\u0026rdquo; changes such as language translation of EBI materials that increase an EBI\u0026rsquo;s acceptability [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Instead, it aims for \u0026ldquo;deep level\u0026rdquo; changes that reflect the \u0026ldquo;target populations\u0026rsquo; values, culture, and social and historical forces that influence health behaviours\u0026rdquo; [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. We use the term \u0026ldquo;ethnocultural\u0026rdquo; adaptation to intentionally emphasize both the shared ethnic heritage and the deeper cultural elements, such as values, beliefs, traditions, norms, and ways of knowing, that define a group [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Ethnocultural adaptation of EBIs for racialized immigrant older adults is crucial, as age-related changes (e.g., mobility), sociocultural values (e.g., collectivism, gendered expectations), and migration legacies (e.g., trauma, systemic exclusion) converge to create both barriers to healthy aging and opportunities to apply 21st century health promotion practice [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough cultural adaptation increased acceptability and effectiveness of several EBIs among South Asian populations [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], few [\u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] described the adaptation process and none focused specifically on ethnocultural adaptation of an EBI for South Asian older adults. Therefore, we adopted a health equity lens [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] to ethnoculturally adapt CTM for racialized immigrant older adults. Specifically, we aimed to address the following three objectives: 1) describe the process by which we ethnoculturally adapted the CTM model for South Asian Punjabi-speaking older adults and organizations that serve them, 2) describe the adapted CTM model, and 3) evaluate implementation of the adapted CTM model.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eThe Intervention: Choose to Move\u003c/h2\u003e \u003cp\u003eWe have described Choose to Move (CTM; \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://choosetomove.ca\u003c/span\u003e\u003cspan address=\"https://choosetomove.ca\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e), associated health outcomes, and our phased approach to scale-up elsewhere [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Briefly, CTM is a flexible, choice-based model, co-designed with older adults and community partners [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. During the 3-month CTM program (CTM Phase 4), trained activity coaches (\u0026ldquo;coaches\u0026rdquo;) guide low active community dwelling older adults (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;55 years) to set physical activity goals, address barriers, and choose physical activities in their communities that suit their personal preferences, abilities and resources. CTM effectively enhanced physical activity and mobility, and diminished social isolation and loneliness in older adult participants [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]; some but not all benefits were maintained up to 12 months after participants completed the program [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eImplementation [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] and scale-up [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] frameworks and principles (e.g., community partnerships) guided implementation and scale-up of CTM across 10 years (2015-present). Large (e.g., YMCA) and small (e.g., neighbourhood houses) delivery partner organizations (\u0026ldquo;organizations\u0026rdquo;) offer the CTM program in person or virtually (e.g., on Zoom\u0026trade;). With government funding, the Active Aging Society (AAS; \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.activeagingsociety.org\u003c/span\u003e\u003cspan address=\"https://www.activeagingsociety.org\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) supports organizations to hire or train coaches to deliver CTM. Our implementation support team (\u0026ldquo;support team\u0026rdquo; [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]), is housed within the AAS and uses a suite of implementation strategies (\u0026ldquo;strategies\u0026rdquo;) [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] to build capacity (e.g., provides tools, training and ongoing support) among organizations to adopt and implement the CTM program.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthnocultural adaptation process\u003c/h3\u003e\n\u003cp\u003eOur approach to ethnocultural adaptation is grounded in intersectionality theory, and we acknowledged the need to be ethnoculturally competent and attuned to the needs and preferences of diverse communities [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. We integrated collaborative, iterative, community-based participatory research (CBPR) methods [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] to engage Punjabi-speaking older adults and community organizations. CBPR nurtures long-term partnerships and relies upon co-operation among organizations and across sectors. We aimed to: 1) ensure that language, ethnocultural values, and lived experiences between older adults and community organizations who served them were aligned, 2) assess the need for capacity building [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e], and 3) co-identify key priorities [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCultural insiders are a key component of ethnocultural research [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Therefore, our immediate actions were to: 1) hire a South Asian, Punjabi-speaking program coordinator and cultural insider (BA, female) who through shared language and cultural awareness was instrumental in program and strategy adaptations and evaluation. They engaged with organizations, coaches and participants bi-weekly and maintained these relationships throughout the lifecycle of CTM; 2) recruit a post-doctoral fellow with a South Asian background (female), proficient in several South Asian languages (Punjabi, Urdu, Hindi, Bengali), and 3) contract a Punjabi-speaking consultant (female) to assist with qualitative data collection. The ethnocultural sensitivity of team members honored cultural norms [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Our project team (cultural insiders, support team, members of the research team) collaborated on all aspects of qualitative data collection, analysis, interpretation, and made final decisions on necessary adaptations.\u003c/p\u003e \u003cp\u003eSimilar to our previous adaptations of CTM [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], ethnocultural adaptation of CTM for Punjabi-speaking older adults sought to systematically adapt for \u0026lsquo;best fit\u0026rsquo; while maintaining fidelity to CTM\u0026rsquo;s \u0026lsquo;core functions\u0026rsquo; (i.e., the specific behaviour change techniques [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]). Briefly, we followed a systematic six-step adaptation process, informed by the Planned Adaptation Model [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e], the National Cancer Institute adaptation framework [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e] and integrated knowledge translation principles [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. We added a seventh step (Step 0) that involved reviewing feedback on the original CTM Phase 4 model from organizations, coaches and older adult participants. We describe Steps 0 to 6, below. We recorded changes to the CTM program and strategies against Stirman et al.\u0026rsquo;s Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] and FRAME-IS [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e], respectively. Importantly, we carefully noted adaptations that were made for ethnocultural reasons.\u003c/p\u003e \u003cp\u003e All methods were performed in accordance with the ethical standards of the University of British Columbia\u0026rsquo;s Behavioural Research Ethics Board [H22-03385] and with the 1964 Helsinki Declaration and its later amendments. We obtained informed consent from all participants.\u003c/p\u003e\n\u003ch3\u003eEthnocultural adaptation of CTM for Punjabi-speaking older adults\u003c/h3\u003e\n\u003cp\u003e \u003cstrong\u003eStep 0 \u0026ndash; Review CTM Phase 4 data and respond to feedback\u003c/strong\u003e \u003cp\u003eIn March 2023, the project team reviewed feedback from organizations, coaches, and older adult participants collected during CTM Phase 4 (2020\u0026ndash;2022) and proposed initial adaptations to update the Phase 4 model.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eStep 1 - Engage\u003c/b\u003e: Between October 2022 and March 2023, the project team held three virtual meetings (approx. 60 min) with three organizations who were long-term CTM delivery partners. The aims of these meetings were to: 1) broadly examine barriers and facilitators to implementing CTM for Punjabi-speaking older adults; and 2) identify community organizations that serve this target population in Metro Vancouver and could partner to deliver the adapted CTM program. Next, a member of the project team used purposeful sampling [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e] and contacted two of the identified organizations by phone or email and invited representatives to attend a \u0026lsquo;meet and greet\u0026rsquo; (in-person at the organization, 60\u0026ndash;75 min, conducted in English; July and December 2023). All invitees agreed to participate, and no other attendees were present. The project team introduced attendees (n\u0026thinsp;=\u0026thinsp;4) to the CTM model and discussed with them whether CTM was a potential fit for their organization. Field notes were taken during each meeting.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStep 2 \u0026ndash; Needs Assessment\u003c/strong\u003e \u003cp\u003e Organizations contacted in Step 1 agreed to participate in a focus group with members of the project team. During 90-min in-person sessions, the project team provided a detailed overview of the CTM model, answered questions, elicited feedback on the CTM model, and aimed to understand the needs, preferences and capacities of each organization and the population they serve. These meetings were audio recorded via Zoom\u0026trade;, transcribed using Otter.ai\u0026trade; and anonymized. The project team developed the interview guide (Additional File 1); H.B. used a structured meeting guide to take notes. We offered honoraria (\u003cspan\u003e$\u003c/span\u003e75 CDN per organization) to compensate for organizational representatives\u0026rsquo; time.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eWe also considered field note data obtained by H.B. who attended both the information session and seven of the eight group meetings of one CTM Phase 4 program (Fall 2023) delivered by one small DPO to 19 Punjabi-speaking older adults prior to our formal adaptation process. Older adults were aware of H.B.\u0026rsquo;s role in collecting data and were invited to participate in an in-person interview to provide feedback on the CTM program (e.g., program components and suggested adaptations). The project team developed the interview guide (Additional File 1), and our cultural insiders conducted a mock interview to translate the guide into Punjabi and ensure use of culturally relevant language. We translated the invitation letter and consent forms using Amazon Web Services (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://aws.amazon.com\u003c/span\u003e\u003cspan address=\"https://aws.amazon.com\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e); H.B. reviewed the translated forms for accuracy. Seven older adults participated in interviews (60\u0026ndash;90 min; 3 individual, 2 paired; conducted in Punjabi by H.B. with field notes taken by the contracted Punjabi-speaking consultant at the small DPO where they attended the CTM program). Participants received an honorarium (\u003cspan\u003e$\u003c/span\u003e25 gift card). At a follow-up meeting two team members (H.B. and T.F.) reviewed detailed field notes for analysis (accurate and reliable translation and transcription software for Punjabi was not available).\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStep 3 \u0026ndash; Develop Prototype\u003c/strong\u003e \u003cp\u003eThe project team reviewed the results from Steps 0\u0026ndash;2, incorporated additional adaptations based on the lived experience of our cultural insiders, and drafted a prototype CTM model for Punjabi-speaking older adults.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStep 4 \u0026ndash; Validate Prototype\u003c/strong\u003e \u003cp\u003eThe support team and H.B. met (45\u0026ndash;60 min, on Zoom) with each organization that participated in Step 1 and 2 to share the prototype and invite feedback. These meetings were informal and not recorded via Zoom. One team member documented these informal meetings via field notes.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStep 5 \u0026ndash; Create a Final Adapted Model\u003c/strong\u003e \u003cp\u003eThe project team reviewed data from Step 4 and made any necessary changes to create the final CTM model for Punjabi-speaking older adults.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eStep 6 \u0026ndash; Implement the Adapted Model\u003c/b\u003e: We pilot tested implementation of the adapted model developed in Step 5 with 4 organizations (2 organizations previously delivered CTM Phase 4 programs, 2 organizations were new to CTM) between August and December 2024. To assess implementation of the \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eprogram\u003c/span\u003e we selected implementation indicators from a proposed minimum data set [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e] (acceptability, appropriateness and feasibility (4 items each Acceptability of Intervention, Intervention Appropriateness, and Feasibility of Intervention Measures (AIM/IAM/FIM) [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]); fidelity; dose delivered; adaptation). To this list we added dose received (to capture varying attendance levels across older adult participants), participant responsiveness (\"the degree to which the program stimulates the interest or holds the attention of participants\" [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]) and facilitators and barriers to delivery. As in our previous studies [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] coaches completed: 1) program feedback surveys and 2) participant engagement surveys (one per participant). All coaches (n\u0026thinsp;=\u0026thinsp;4) completed questionnaires electronically via REDCap [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e] at the end of the program (3 months).\u003c/p\u003e \u003cp\u003eOlder adults completed a program feedback questionnaire at the end of the program (3 months; dose received of core functions, participant responsiveness). Participants completed paper-based questionnaires in Punjabi or English.\u003c/p\u003e \u003cp\u003eTo assess use of implementation \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003estrategies\u003c/span\u003e we evaluated coaches\u0026rsquo; self-efficacy, and adoption/use, satisfaction, and adaptation of provided resources and materials [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. Coaches completed a questionnaire after training (one per coach to assess self-efficacy to deliver CTM) and an implementation support questionnaire (one per coach to assess adoption/use, satisfaction and any adaptation of provided resources and materials).\u003c/p\u003e \u003cp\u003eFollowing delivery of the adapted CTM model, two members of the project team (one researcher (PhD), one support team member; both female) conducted interviews (approx. 60 min each, Additional File 1) with each organization and coach. Through these interviews, we aimed to assess implementation determinants (acceptability, feasibility, appropriateness) and outcomes (participant responsiveness, dose received, fidelity) of the adapted CTM model in more depth. Interviews were audio recorded via Zoom, transcribed and anonymized. Field notes were taken during interviews.\u003c/p\u003e \u003cp\u003eAll interviews were conducted by trained members of the project team with prior experience in qualitative methods and implementation research. Interviewers were not directly involved in program delivery, which minimized potential role-related bias. The team acknowledged shared interests in supporting community-based health promotion for older adults and maintained reflexive awareness of how these values might shape data interpretation. Regular team debriefs and analytic discussions were used to identify and critically reflect on assumptions, thereby enhancing transparency and analytic rigour. While transcripts were not returned to participants for review, trustworthiness was strengthened through ongoing validation discussions among the project team, and opportunities for member reflections during each interview [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. This approach enabled participants to confirm, refine, or elaborate on their perspectives, enhancing the rigour and credibility of the data.\u003c/p\u003e\n\u003ch3\u003eAnalysis\u003c/h3\u003e\n\u003cp\u003e \u003cstrong\u003eSteps 0\u0026ndash;5\u003c/strong\u003e \u003cp\u003eUsing Nvivo (NVivo Pro Version 11.4.1 for Mac, QSR International (Americas) Inc., Burlington, MA, USA), T.F. and D.C. conducted a preliminary, descriptive analysis of data collected from focus groups, individual and paired interviews, internal and external meetings, and field observations. Salient observations that reflected the need for, or rationale behind, specific adaptations were extracted and summarized in a Microsoft Excel matrix (Additional File 2; adapted from [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]). Each row in the matrix represents a discrete update or adaptation. We used the FRAME [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] and FRAME-IS [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e] to capture what was modified, the nature and timing of the modification, the level of delivery affected (e.g., participant-facing materials, program delivery), and the goal of the modification and the rationale (e.g., cultural relevance, resource constraints, participant needs). We also examined data through an intersectional lens to identify ethnocultural and age-based complexity. This analytic approach enabled the project team to synthesize a wide range of qualitative inputs from diverse sources into a consolidated record of potential ethnoculturally appropriate adaptations to the CTM model and rapidly review suggested adaptations. Throughout the analysis process, the project team met regularly to review and refine the Excel matrix, resolve inconsistencies, and ensure consensus on adaptation classification.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStep 6\u003c/strong\u003e \u003cp\u003eWe describe quantitative implementation indicators using percentages, means and ranges where appropriate. Interview transcripts and field notes were analysed using a six-step thematic analysis [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e] and qualitative findings were reported following the consolidated criteria for reporting qualitative research (COREQ) checklist [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e] (Additional File 3). We began with familiarization and initial coding using Nvivo (NVivo Pro Version 11.4.1 for Mac, QSR International (Americas) Inc., Burlington, MA, USA). We used an inductive approach to develop codes, applying both intersectional and ethnogerontology perspectives. Our analysis focused on how the interplay of age, ethnicity and culture, family dynamics, and migration experiences shaped key implementation determinants (feasibility, acceptability and appropriateness) of the adapted CTM model. We aimed to understand how factors related to aging (such as mobility, sensory changes) combined with ethnocultural values (such as collectivism, gendered experiences) and broader societal and systemic barriers to shape unique pathways for engagement and delivery within this population of Punjabi-speaking older adults. Similar codes were grouped into preliminary themes, which were reviewed and refined through iterative team discussions using a constant comparative method. Themes were substantiated with direct participant quotations that captured the range and depth of perspectives shared. Diverse perspectives and minor themes were included to capture the range of participant experiences. These variations were retained and reported to illustrate contextual influences and enhance the richness and credibility of the analysis. Although described sequentially, analysis was recursive and iterative. This process ensured that the analytic interpretations remained closely aligned with the data, thereby enhancing the credibility and trustworthiness of the findings.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eData collection and analysis concluded when the team reached data sufficiency\u0026mdash;when no new themes or insights emerged\u0026mdash;within the context of the study\u0026rsquo;s scope and the limited number of participating organizations.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eAdaptation of the CTM Phase 4 Model (step 0)\u003c/h2\u003e\n \u003cp\u003eWe proposed 23 updates to the CTM model after Step 0 (Additional File 2); we incorporated all proposed updates into the new CTM Phase 4 model. Examples include updates to implementation strategies such as coach training content (e.g., add required and optional modules; add or update examples), the CTM community of practice for coaches (focused topics; make attendance mandatory to maintain certification), and CTM program materials (content and format). In Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e, we highlight the differences between the original and updated CTM Phase 4 models.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026lt;Insert\u003c/em\u003e Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e \u003cem\u003ehere\u0026gt;\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eEthnocultural adaptations of the updated CTM Phase 4 Model (steps 1\u0026ndash;5)\u003c/h3\u003e\n\u003cp\u003eWe proposed 32 adaptations to the updated CTM Phase 4 model after Steps 1 to 3: 22 program adaptations and 10 implementation strategy adaptations (Additional File 2). We incorporated all proposed adaptations into the prototype adapted CTM model.\u003c/p\u003e\n\u003cp\u003eCTM \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eprogram\u003c/span\u003e adaptations integrated South Asian cultural practices (e.g., chair sharing ritual) into group meeting content and were mindful of religious practices. Adaptations captured cultural-age intersections in two ways: 1) considered program-centered Punjabi cultural norms, including multigenerational dynamics and gender roles (e.g., organizations were encouraged to involve family members in participant recruitment); and 2) incorporated low-impact, ethnoculturally relevant physical activities aligned with participants\u0026apos; abilities and preferences (e.g., physical activity videos with South Asian instructors speaking in Punjabi).\u003c/p\u003e\n\u003cp\u003eKey ethnocultural adaptations to implementation \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003estrategies\u003c/span\u003e were: added images of South Asian older adults being active to resources (e.g., recruitment and promotion materials and group meeting slides), translated participant-facing materials into Punjabi and phonetically translated (Punjabi rendered in English characters) to accommodate those who speak Punjabi but cannot read Gurmukhi script, adapted program materials to include larger multilingual fonts to address vision and language barriers, simplified health messaging without losing accuracy, engaged families to help recruit participants, encouraged organizations to schedule sessions around important holidays and cultural events, and added culturally relevant physical activity examples and discussion questions to group meeting slides.\u003c/p\u003e\n\u003cp\u003eKey adaptations to \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eevaluation materials\u003c/span\u003e were to remove items that were deemed not culturally relevant/sensitive, simplify language of questionnaire items, translate questionnaire text into Punjabi, add pictures to improve comprehension and provide in-person support to participants to complete the questionnaires. Across all adaptations, our Punjabi-speaking consultant reviewed all translated materials to ensure accuracy, appropriateness and readability.\u003c/p\u003e\n\u003ch3\u003eImplementation of the Adapted CTM Model (step 6)\u003c/h3\u003e\n\u003cp\u003eFour coaches delivered five adapted CTM programs for 68 Punjabi-speaking participants (August to December 2024). All four coaches and 65 participants (96%) volunteered for the evaluation. Of these participants, 47 (72%) completed the CTM program and the post-program feedback questionnaire; (38%) participants required assistance from either a project team member or a coach to complete the questionnaire. We provide descriptive characteristics of these participants in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lt;Insert\u003c/em\u003e Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e \u003cem\u003ehere\u0026gt;\u003c/em\u003e\u003c/p\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eQuantitative\u003c/h2\u003e\n \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\n \u003ch2\u003eProgram implementation\u003c/h2\u003e\n \u003cp\u003e\u003cstrong\u003eAcceptability, appropriateness and feasibility\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eOrganization staff rated the adapted CTM program acceptable, appropriate, and feasible (median score 5/5 for all). Coaches rated the adapted CTM program acceptable (median score 4.5/5), appropriate, and feasible (median score 5/5 for both).\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDose delivered\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eCoaches delivered all (8/8) group meetings in each of the five programs.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDose received\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eOf the 65 participants who consented to be evaluated, attendance data were available for 64 of them. Sixty-three participants (98.4%) attended one or more group meetings; 54 (84%) participants attended 4 (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;50%) or more of the group meetings.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eAdaptation\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eOne coach skipped the welcome activity at two group meetings and increased the length of movement breaks to allow participants more time to exercise and chat with each other.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eParticipant responsiveness\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eCoaches deemed participants to be somewhat to extremely interactive; participants were enthusiastic, interested, and engaged with CTM content and each other at most or all group meetings. Of those participants who completed the post-CTM program feedback survey, most (n\u0026thinsp;=\u0026thinsp;46, 98%) reported feeling satisfied or very satisfied with the program.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eFidelity to core functions\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eAt 100% of group meetings, coaches provided opportunities for peer or group check-ins to revisit goals, educational content, and opportunities to share resources. At all group meetings, coaches encouraged peer check-ins (CTM Dost). From the participant perspective (n\u0026thinsp;=\u0026thinsp;47), there were opportunities during most (4\u0026ndash;7) or all group meetings to revisit goals with another member of the group (66%), learn about a health topic (77%) and share resources (62%). Across all programs, 83% (n\u0026thinsp;=\u0026thinsp;39) of participants connected with a CTM Dost outside of group meetings. Of these participants, 46% reported checking in with their CTM Dost more than twice/month while others checked in twice (18%), once (13%) or less than once (18%) per month.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003eImplementation strategies\u003c/h2\u003e\n \u003cp\u003e\u003cstrong\u003eSelf-efficacy\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eAll coaches were satisfied with the CTM training (rated all modules 4 or 5 out of 5) and felt confident they could apply what they learned in training to delivery of CTM (rated 4 or 5 out of 5).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003eAdoption, acceptability and adaptation\u003c/h2\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ePromotion and recruitment materials\u003c/span\u003e: One coach reported using two of 22 promotion and recruitment materials; they were unaware of the other materials. Three coaches used between 6 and 11 different promotion and recruitment materials. Of the 22 materials, 1 was used by all 4 coaches (customizable English CTM poster), 3 were used by 3 coaches (English and Punjabi brochures and CTM logos), 4 were each used by 2 coaches (generic English poster, customizable Punjabi poster, CTM brand guidelines and promotional videos) and each of 5 materials were used by only 1 coach (English bookmark, English and Punjabi social media templates, Punjabi customizable rack card, guide for creating a poster, CTM program description). Eight promotion and recruitment materials were not used by any coaches (e.g., news release, generic rack card in English).\u003c/p\u003e\n \u003cp\u003eMost coaches (3 of 4) were either satisfied or extremely satisfied with the promotion and recruitment materials. Two coaches used additional promotion and recruitment materials; one reported that their organization\u0026rsquo;s media team created advertisements and the other reported that their organization created a separate organization-specific poster in English and Punjabi.\u003c/p\u003e\n \u003cp\u003eOne coach required support to develop and implement a recruitment plan; however, all coaches used two or more of the six suggested recruitment strategies (e.g., traditional media, social media posts, referrals from other organizations). All coaches were either satisfied or extremely satisfied with the recruitment actions.\u003c/p\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eProgram delivery administrative materials\u003c/span\u003e: Of the 11 program administrative documents available to coaches, 5 documents were used by all coaches (e.g., one-on-one consultation sign-up form, group meeting topics), 5 other documents were used by three coaches (e.g., CTM delivery checklist, activity inventory), and the remaining document (provincial resources) was used by 2 coaches. All coaches were satisfied or extremely satisfied with the administrative documents and none of the coaches adapted any of the documents.\u003c/p\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eParticipant-facing program documents\u003c/span\u003e: Of the eight participant-facing program documents, seven were used by all coaches (e.g., Get Active Questionnaire in English and Punjabi, CTM information form in English and Punjabi), and one document (certificate of completion) was used by three coaches. All coaches were satisfied or extremely satisfied with the participant-facing documents and none of the coaches adapted any of the documents.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003ch2\u003eQualitative\u003c/h2\u003e\n \u003cp\u003eA representative from each organization (n\u0026thinsp;=\u0026thinsp;4, on Zoom in English) and each coach (n\u0026thinsp;=\u0026thinsp;4, on Zoom in English) participated in semi-structured interviews at the end of the adapted CTM program.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\n \u003ch2\u003eProgram implementation\u003c/h2\u003e\n \u003cp\u003eFour themes emerged that reflect key implementation determinants (feasibility, acceptability and appropriateness) of the adapted CTM program for Punjabi-speaking older adults: 1) provide structure and support, 2) foster cultural and linguistic resonance, 3) make goals matter through culturally responsive action planning, and 4) facilitate engagement through culturally tailored group delivery. We expand on these themes and provide supporting quotes, below.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eProvide structure and support\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eOrganizations and coaches thought CTM was highly feasible and acceptable to implement, largely due to well-structured, ready-to-use materials and the strong implementation support provided to coaches. Coaches emphasized that the program required minimal planning, with clearly organized slides, step-by-step guides, and comprehensive resources\u0026mdash;including translated materials and promotional content\u0026mdash;that simplified delivery and outreach. Organizations noted that CTM aligned well with existing programming and infrastructure, particularly in organizations already serving Punjabi-speaking older adults.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eEverything was ready\u0026hellip; just for me to prepare the session. As compared to other programs where I had no training or resources, CTM was very, very easy. AC1\u003c/p\u003e\n \u003cp\u003eThis was the group I enjoyed the most\u0026mdash;it was all in Punjabi, easy for me to communicate\u0026hellip; there was no language barrier. AC2\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cstrong\u003eEthnocultural and linguistic resonance\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eCoaches and organizations considered the program to be ethnoculturally appropriate and meaningful. They emphasized the importance of well-executed Punjabi translations, not only for accessibility but for reinforcing learning. Ethnocultural adaptations\u0026mdash;including familiar examples, culturally resonant movement breaks, and the use of Punjabi music and community stories\u0026mdash;fostered engagement and helped participants relate personally to program content.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eI think the adapted model is very thoughtful, and it\u0026apos;s culturally sensitive. And it meets the unique needs of the South Asian community, the Punjabi speaking Seniors, because they can easily relate to the program. \u0026hellip; I also find it very, very successful programming, because, all the slides and the resources they were in in their own language, and very culturally and linguistically appropriate. AC1\u003c/p\u003e\n \u003cp\u003eI feel like they did really incorporate all the insights that we\u0026apos;ve shared, and especially that cultural component. I think the team did a fantastic job of collecting that information and trying to understand what really works for the community. Because sometimes standardized programming, it doesn\u0026apos;t necessarily work for all communities. Org1\u003c/p\u003e\n \u003cp\u003eSometimes the translation gets a bit heavy\u0026hellip; but the phonetic version really helped, especially for those who speak Punjabi but aren\u0026rsquo;t comfortable reading it. AC3\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cstrong\u003eMake goals matter through ethnoculturally responsive action planning\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eImplementation of CTM core functions (e.g., goal setting and action planning) with Punjabi-speaking older adults posed unique challenges. Coaches saw these core functions as central to the program\u0026rsquo;s intent yet delivering them in a meaningful way required significant time, cultural sensitivity, and linguistic adaptation. Participants generally understood the idea of having a goal, but their understanding tended to be broad and non-specific\u0026mdash;often centered on general well-being (e.g., being \u0026ldquo;healthy\u0026rdquo; or \u0026ldquo;happy\u0026rdquo;) rather than on specific, measurable behaviour changes. Coaches received structured action planning tools, but they were rarely used in a formal way. Instead, coaches relied on informal, conversational approaches to support goal setting, adapting their language to better align with participants\u0026rsquo; cultural and linguistic contexts. Terms like \u0026ldquo;action plan\u0026rdquo; did not always translate meaningfully with participants\u0026rsquo; cultural orientations toward relational and fluid approaches to health. Health actions emerged organically through dialogue rather than through rigid individual planning. Cultural values of \u003cem\u003esangat\u003c/em\u003e (collective wisdom) and \u003cem\u003eseva\u003c/em\u003e (service through relationship) honor how health behaviours are negotiated within social contexts rather than prescribed individually.\u003c/p\u003e\n \u003cp\u003eOne-on-one consultations were the primary mechanism for introducing and reinforcing goals. Coaches and participants valued these sessions. However, coaches found sessions logistically demanding and time-intensive\u0026mdash;they often took an hour to translate needs and explain program concepts. Additional time was required for data collection. Despite the time cost, these consultations were considered rich opportunities to connect and engage participants. Behaviour-change discussions were frequently interwoven with emotional support:\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eThey spent almost an hour, and a few went over because they got engaged in conversations\u0026hellip; it also became emotional support, not just action planning.\u0026rdquo; AC1\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cstrong\u003eFacilitate engagement through ethnoculturally tailored group delivery\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eGroup-based delivery was a key strength of the adapted CTM program. Participants valued the opportunity to socially interact, connect, and receive peer support. Mixed-gender groups fostered spaces of mutual respect and shared learning, particularly when facilitated with ethnocultural sensitivity and skill.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eIn our South Asian community, usually men think these groups are meaningless\u0026hellip; but they found it very knowledgeable and are looking forward to joining again.\u0026rdquo; AC1\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eEngagement was further enhanced using peer-led strategies such as WhatsApp groups and informal accountability check-ins (CTM Dost). These helped reinforce participation and adherence between sessions.\u003c/p\u003e\n \u003cp\u003eMovement breaks were a highly valued element of the group experience. Most coaches incorporated two movement breaks per session\u0026mdash;one structured (e.g., functional movements or resistance exercises) and one more relaxed or culturally familiar (e.g., dance, yoga). This variety kept sessions dynamic and engaging. To ensure accessibility and relatability, coaches often adapted movement break content using culturally relevant music or videos featuring older Punjabi-speaking individuals. When such content wasn\u0026rsquo;t available\u0026mdash;due to the lack of Punjabi-language exercise resources online\u0026mdash;coaches would either translate English-language videos live or lead the exercises themselves while providing instructions in Punjabi.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u0026ldquo;When we try to find exercises on YouTube or other social media like things are not in Punjabi language\u0026hellip;.so it was bit hard for me to find like exercises in Punjabi ...so I used to translate for them.\u0026rdquo; AC2\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\n \u003ch2\u003eImplementation strategies\u003c/h2\u003e\n \u003cp\u003eThree themes emerged that reflect key implementation determinants (feasibility, acceptability and appropriateness) of the adapted strategies: 1) building relationship-centered partnerships, 2) providing tailored and culturally appropriate support, and 3) strengthening coach delivery skills through tailored training. We expand on these themes and provide supporting quotes, below.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eBuild relationship-centered partnerships\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eWe grounded our approach in CBPR and emphasized relationship-building as a foundational first step. Early and ongoing engagement with organizations serving South Asian communities prioritized trust and reciprocity. In-person visits and iterative conversations were intentionally used to foster mutual understanding and position community partners as co-creators in the adaptation and implementation process and ensure long-term collaboration.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u0026ldquo;The in-person meeting developed more of a partnership, more of a bond\u0026hellip; we could ask questions and feel heard.\u0026rdquo; Org1\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;I think she\u0026rsquo;s definitely built enough of a rapport with us that it\u0026apos;s just very easy to get in touch. I feel like, as the partners, we feel very comfortable\u0026hellip; It\u0026apos;s very easy for us to express the good stuff or the bad stuff, things that are not working well, and I feel like there\u0026apos;s always someone that we can contact, and they\u0026apos;ll support us right away.\u0026rdquo; Org2\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cstrong\u003eProvide tailored and culturally appropriate support\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eStrategies were tailored to fit the varying needs and contexts of each organization. For example, the support team worked with organizations to adjust staff time allocation where needed, streamline administrative paperwork, and offer guidance on integrating CTM alongside existing programs. For one organization, providing flexibility within the budget accommodated food incentives and more support hours, which increased their perceived feasibility to deliver CTM.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u0026ldquo;During that budget piece, something that we had discussed was that hospitality and refreshments piece. So what we noticed for programming was that food was always an incentive for seniors. So I remember initially when we were looking at the budget, we thought that that food part of the budget, that line item there wasn\u0026apos;t really enough funds allocated there. So then we had a discussion with [the support team], and we kind of gave some justification as to you know how our programs usually work. We usually like to offer a little bit of a snack or coffee or whatnot, and so they got back to us fairly quickly, and they were able to give us some additional funds for that piece. So it was a very straightforward process.\u0026rdquo; Org1\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cstrong\u003eStrengthen coach delivery skills through tailored training\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eTraining content for coaches was adapted to reflect both cultural context and common challenges. As some coaches were less confident in formal goal setting and behaviour change facilitation, the support team provided hands-on mentorship and guidance in motivational interviewing and delivery techniques. Flexibility in training delivery and ongoing, bi-weekly check-ins with H.B. were critical to reinforce learning, troubleshoot challenges, and when required for coaches whose first language was Punjabi, to simplify training materials and explain them in Punjabi.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u0026ldquo;It wasn\u0026rsquo;t just the training\u0026mdash;H.B. would check in all the time and help me think through things like how to do the one-on-one consultation better.\u0026rdquo; AC1\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eOver time, coaches became more confident and could independently deliver the program. Initial reliance on one-on-one support decreased as coaches gained experience. Organizations noted increased familiarity, efficiency, and confidence among coaches after completing one program.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u0026ldquo;In the beginning, [name of AC], really valued that one-on-one time to ask questions. I think now that she\u0026apos;s gone through a program once, she\u0026rsquo;s less reliant on that.\u0026rdquo; Org2\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;I think we have a pretty good handle on it... When it comes to overall delivery of the program, I think we have it. She\u0026rsquo;s [AC] much more confident in delivering the sections, she knows what\u0026apos;s going on, she knows what can be improved.\u0026rdquo; Org1\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;Well, and it\u0026apos;s like I said to AC, okay, now you\u0026apos;ve done it once. Some of this stuff likely won\u0026apos;t take you as long.\u0026rdquo; Org3\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe respond to the call for implementation science projects to explicitly address health equity [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Here we describe our systematic ethnocultural adaptation and implementation of CTM for a marginalized, ethnocultural group in British Columbia, Canada -- Punjabi-speaking South Asian older adults. Cornerstones of our approach include meaningful engagement with multiple interested and invested ethnocultural partners, partnerships based on reciprocity and shared goals, and an intentional focus on ensuring that EBI benefits and outcomes reflect a fair distribution of power between partners. As the best approach to meaningfully engage ethnoculturally diverse populations in research remains unclear [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e], we contribute to the growing body of work that seeks to move beyond cursory adaptations (often only for language), to contextually and ethnoculturally ground the co-adaptation process of health-promoting EBIs.\u003c/p\u003e \u003cp\u003eEthnicity and culture permeate all aspects of health-promoting EBIs and determine how programs are designed, implemented, and sustained within communities [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Historically, culture has been narrowly defined - often reduced to race - and applied in ways that marginalize minoritized groups [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]. In health research, this has manifested in deficit-based frameworks that pathologize cultural differences and position racialized communities' practices and behaviours as problems that require correction [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e]. This approach reinforces harmful hierarchies, framing whiteness as the normative standard and justifies oppressive policies under the guise of scientific objectivity [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e]. This legacy persists in systemic barriers to equitable health-promotion activities and ethnoculturally misaligned interventions [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe current adaptation literature often treats cultural identity, aging, language, and other factors as isolated variables, missing how they intersect to shape lived experience and program engagement. This oversight has consequences when designing health-promoting EBIs for ethnoculturally diverse older adults, such as South Asian immigrants in Canada. Intersectionality theory [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e] pushes us to ask: Whose aging is being centered? Whose realities are erased? Without this lens, adaptation frameworks risk superficial inclusion - what scholars have called \u0026ldquo;culture as a checkbox\u0026rdquo; - rather than offering meaningful structural change [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]. Recognizing this, our ethnogerontological approach to adapting the CTM model sought not merely to tailor, but to transform how EBIs are conceptualized and delivered to marginalized older adults.\u003c/p\u003e \u003cp\u003eTo our knowledge, CTM is the first health-promoting EBI to be ethnoculturally adapted for Punjabi-speaking South Asian older adults in Canada. Our approach aligns with key strategies associated with effectiveness of physical activity interventions for South Asian older adults [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. This includes using participatory approaches to i. inform ethnocultural tailoring/adaptation of the intervention, ii. adapt intervention materials to account for characteristics of the target population (such as language), iii. utilize community health workers/cultural insiders, iv. deliver the program in community/neighborhood facilities, and v. include culture-specific dance as part of the intervention. Our approach aligns with six factors deemed essential for equitable implementation [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e]: ethnocultural adaptation, trusting relationships, dismantling power structures, investments and decision making to advance equity, community-defined evidence, and critical perspectives implementation. These factors were the cornerstones that strengthened our partnership with community organizations and informed our CBPR approach.\u003c/p\u003e \u003cp\u003eAs evidenced in both our quantitative and qualitative findings, the adapted CTM program was widely perceived as feasible, acceptable, and appropriate by organizations and coaches. Adaptations\u0026mdash;such as extending one-on-one consultations, integrating ethnoculturally resonant movement breaks (that included dance), and offering phonetic and simplified Punjabi translations\u0026mdash;were critical to facilitate participation, engagement, and comprehension among older adults with diverse language and literacy needs. These adaptations centered the interconnected roles of culture, religion and spirituality in shaping health behaviours, and allowed us to respectfully engage with immigrant communities while addressing their contemporary realities. The use of ethnoculturally grounded implementation strategies and program delivery formats was particularly important. South Asian older adults face barriers to physical activity related to i. limited availability of ethnoculturally and linguistically tailored programs, ii. lack of knowledge about physical activity guidelines [\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e] and benefits of physical activity and exercise in later life [\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e], and iii. restrictive social norms\u0026mdash;particularly among women [\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e, \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe project team was aware of their own positions of privilege and how these \u0026lsquo;power dynamics\u0026rsquo; impact interactions with Punjabi-speaking community members. A \u0026lsquo;cultural insider\u0026rsquo;\u0026mdash;a Punjabi-speaking team member with linguistic and lived experience in the community\u0026mdash;played a pivotal role in supporting organizations and coaches to adopt and implement the adapted CTM program. They created a more equitable research environment where the voices and experiences of racialized older adults were respected and valued. They fostered ethnocultural congruence and trust, which were evident in our findings. Our deliberate attention to power-sharing was central to fostering sustained engagement to ensure CTM was meaningful for older adult participants, coaches and organizations.\u003c/p\u003e \u003cp\u003eOrganizations offered insights to ensure that CTM and its implementation was ethnoculturally responsive and sensitive to the needs and preferences of the community. This collaborative approach served to redistribute power, and position partners and participants at the center of the research process [\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e]. Without confronting these power structures, ethnocultural adaptations remain superficial. In adapting CTM, we pursued systemic change through three actions: 1) removed colonial metrics (e.g., BMI) from the CTM evaluation; 2) redistributed power by training activity coaches from the Punjabi community thereby centering lived experience over institutional authority; and 3) rejected Eurocentric 'validated' practices [\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e] (e.g., Vancouver Index of Acculturation) from our evaluation. Importantly, adaptations reflected how intersecting sensory and linguistic challenges uniquely impact how older immigrants engaged in CTM.\u003c/p\u003e \u003cp\u003eWe endeavoured to bridge two typically siloed disciplines. We integrated implementation science approaches [that historically understudy older adults\u0026rsquo; heterogeneity and health equity] with ethnogerontology [that typically lacks systematic methods for translating ethnocultural knowledge into implementable and scalable interventions]. This synergy generated a blueprint for implementing an evidence-based AND ethnoculturally grounded EBI for older adults. It also responds to the need to move beyond one-size-fits-all approaches in community-based care for ethnoculturally diverse older adults. Other strengths of our study were using established adaptation and implementation frameworks (FRAME, FRAME-IS), a multi-method evaluation approach, sustained community engagement, the prominent role of cultural insiders on the project team, and CBPR methods.\u003c/p\u003e \u003cp\u003eWe consider these strengths in the context of some limitations. First, we engaged only four community organizations that serve Punjabi-speaking older adults. To improve the health of this ethnocultural group, the adapted CTM model must be scaled up to more sites. Thus, our next steps are to monitor and assess scale-up, and to evaluate participant-level health outcomes to assess program effectiveness. Second, while our approach was systematic and rigorous, the time- and resource-intensive nature of this ethnocultural adaptation process may challenge scalability in contexts where adequate resources are not available.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe adaptation literature often treats ethnocultural factors (e.g. migration legacies; exclusion), aging-related factors (e.g., mobility), and language as isolated variables. However, they intersect to shape lived experience and how older adults engage in health-promoting programs. Studies that address these complexities and the nuanced nature of ethnoculturally appropriate health-promoting EBIs are needed. We adopted an equity-oriented process to develop an ethnoculturally relevant version of CTM for Punjabi-speaking older adults. Lessons learned about the adaptation process and adaptations to the CTM model may be used to engage other ethnocultural groups of older adults. That said, the diversity across and within cultures is vast; one size does NOT fit all. We highly recommend using participatory methods to further tailor health-promoting models for different groups.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eActivity coach\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAAS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eActive Aging Society\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBritish Columbia\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCBPR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCommunity-based participatory research\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCTM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eChoose to Move\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEBI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEvidence-based intervention\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFRAME\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFramework for Reporting Adaptations and Modifications to Evidence-based interventions\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFRAME-IS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFramework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eYMCA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eYoung Men\u0026rsquo;s Christian Association\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eAll procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e De-identified data from this study are not available in a public archive. De-identified data from this study will be made available (as allowable according to institutional IRB standards) by emailing the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e The BC Ministry of Health provided funds to the AAS to support delivery of CTM. The Canadian Institutes of Health Research [HG2-185013] funded evaluation of the adapted CTM model. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u0026nbsp;\u003c/strong\u003eHAM and JSG conceived the project and secured funding. All authors contributed to creation of the evaluation plan and oversaw data acquisition. TF and DC analyzed the qualitative data; HMM analyzed the quantitative data. HMM, TF and DC drafted the initial manuscript. All authors reviewed and critically revised the manuscript and have approved the final version.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eWe are grateful for the ongoing support of CTM from the BC Ministry of Health, the AAS and delivery partner organizations involved in the adaptation of CTM for Punjabi-speaking older adults. We thank all older adults who contributed to the adaptation process, and who participated in the adapted CTM programs. Lastly, we acknowledge the dedication of staff and trainees from the Active Aging Research Team without whom we could not conduct this work.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDunn JR, Dyck I. Social determinants of health in Canada's immigrant population: results from the National Population Health Survey. 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PLoS ONE. 2022;17:e0273266.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHorne M, Skelton DA, Speed S, Todd C. Perceived barriers to initiating and maintaining physical activity among South Asian and White British adults in their 60s living in the United Kingdom: a qualitative study. Ethn Health. 2013;18:626\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLawton J, Ahmad N, Hanna L, Douglas M, Hallowell N. I can't do any serious exercise': barriers to physical activity amongst people of Pakistani and Indian origin with Type 2 diabetes. Health Educ Res. 2006;21:43\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeatrice RE, Mar\u0026iacute;a R, Bachera A, Jessica Amegee Q, Ivy C, S\u0026oacute;nia D, et al. You want to deal with power while riding on power\u0026rsquo;: global perspectives on power in participatory health research and co-production approaches. BMJ Global Health. 2021;6:e006978.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu WM, Liu RZ, Garrison YL, Kim JYC, Chan L, Ho YCS, et al. Racial trauma, microaggressions, and becoming racially innocuous: The role of acculturation and White supremacist ideology. Am Psychol. 2019;74:143\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e. Differences across the original Choose to Move (CTM) Phase 4 program, updated Phase 4 program, and Phase 4 program adapted for Punjabi-speaking older adults.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"903\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 238px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOriginal CTM Phase 4 (2020-2022)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 238px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUpdated CTM Phase 4 (2023-present)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 238px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCTM Phase 4 for Punjabi-speaking older adults\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eProgram length\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 238px;\"\u003e\n \u003cp\u003e3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 238px;\"\u003e\n \u003cp\u003e3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 238px;\"\u003e\n \u003cp\u003e3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFormat\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 238px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eInformation session 1-2 weeks prior to program start\u003c/li\u003e\n \u003cli\u003eInitial 30-min consultation between GMs 1 and 2\u003c/li\u003e\n \u003cli\u003e8 GMs; 60 minutes (in-person; virtual; hybrid)\u003c/li\u003e\n \u003cli\u003eParticipant-level evaluation in English at baseline and 3-months, online or paper-based\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 238px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eInformation session 1-2 weeks prior to program start\u003c/li\u003e\n \u003cli\u003eInitial 30-min consultation between GMs 1 and 2\u003c/li\u003e\n \u003cli\u003e8 GMs; 60 minutes (in-person; virtual)\u003c/li\u003e\n \u003cli\u003eParticipant-level evaluation in English at baseline and 3-months, online or paper-based\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 238px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eInformation session 1-2 weeks prior to program start\u003c/li\u003e\n \u003cli\u003eInitial 60-min consultation between GMs 1 and 2\u003c/li\u003e\n \u003cli\u003e8 GMs; 90 minutes (in-person)\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eParticipant-level evaluation in Punjabi or English at baseline and 3-months, paper-based. Evaluation modified to \u003cstrong\u003eremove\u003c/strong\u003e some items that were not culturally relevant or sensitive (e.g., self-reported height and weight). Several items \u003cstrong\u003eadded\u003c/strong\u003e to capture details related to immigration (i.e., years in Canada). \u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntervention activity: Group meetings (GMs)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 238px;\"\u003e\n \u003cp\u003eHealth topics covered in GMs\u003c/p\u003e\n \u003col\u003e\n \u003cli\u003eWelcome \u0026amp; goal setting\u003c/li\u003e\n \u003cli\u003ePhysical activity \u0026amp; social connection\u003c/li\u003e\n \u003cli\u003eIncidental physical activity\u003c/li\u003e\n \u003cli\u003eGoals revisited\u003c/li\u003e\n \u003cli\u003eNutrition\u003c/li\u003e\n \u003cli\u003eFalls prevention\u003c/li\u003e\n \u003cli\u003eStress management \u0026amp; brain health\u003c/li\u003e\n \u003cli\u003eGoals \u0026amp; celebration\u003c/li\u003e\n \u003c/ol\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003ePrescribed movement breaks: during meetings (in-person; 5-10 min); none prescribed during virtual delivery for safety reasons, though activity coaches invited participants to get up and move around at some point during the meeting.\u0026nbsp;\u003cul\u003e\n \u003cli\u003eGroup meeting slides: prescriptive for group and paired discussions; contact information formally included in each CTM participant group\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eGroup check-ins: Occur during group meetings\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eGroup challenges: included at the end of each group meeting\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eOptional peer check-ins\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eOptional \u0026lsquo;check-in\u0026rsquo; newsletter (bi-weekly)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 238px;\"\u003e\n \u003cp\u003eActivity coaches required to deliver Phase 1 meeting topics 1, 2, 3 \u0026amp; 8; for GMs 4-7, activity coaches can use the standard topics listed below, or choose alternate topics from a list of 22 other meeting topics.\u0026nbsp;\u003c/p\u003e\n \u003col\u003e\n \u003cli\u003eWelcome \u0026amp; goal setting\u003c/li\u003e\n \u003cli\u003ePhysical activity \u0026amp; social connection\u003c/li\u003e\n \u003cli\u003eIncidental physical activity\u003c/li\u003e\n \u003cli\u003eBuilding your support team\u003c/li\u003e\n \u003cli\u003eNutrition\u003c/li\u003e\n \u003cli\u003eFalls prevention\u003c/li\u003e\n \u003cli\u003eStress management\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eRevisit goals \u0026amp; celebrate\u003c/li\u003e\n \u003c/ol\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003ePrescribed movement breaks: Same as original Phase 4 program\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eGroup meeting slides, group challenges, peer checkins and newsletter: Same as original Phase 4 program.\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 238px;\"\u003e\n \u003cp\u003eActivity coaches deliver 8 standard GM topics (see Additional File 1 for details on adaptations to meeting topics).\u0026nbsp;\u003c/p\u003e\n \u003col\u003e\n \u003cli\u003eWelcome \u0026amp; goal setting with an introduction to physical activity\u003c/li\u003e\n \u003cli\u003ePhysical activity\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eIncidental physical activity\u003c/li\u003e\n \u003cli\u003eHealthy connections\u003c/li\u003e\n \u003cli\u003eNutrition\u003c/li\u003e\n \u003cli\u003eFalls prevention\u003c/li\u003e\n \u003cli\u003eSelf care\u003c/li\u003e\n \u003cli\u003eGoals \u0026amp; celebration\u003c/li\u003e\n \u003c/ol\u003e\n \u003cp\u003eAn expanded list of alternate GM topics will be explored in future.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003ePrescribed movement breaks: 20-30 min total, facilitated in 2 separate breaks.; activity coaches can choose from a variety of culturally relevant and appropriate materials (e.g., Indian dance videos)\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eGroup meeting slides: Reduced text, simplified language and added phonetics, added imagery and culturally relevant examples, added Punjabi translation for keywords and themes, included group and paired discussions.\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eGroup check-ins: Occur during group meetings.\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eGroup challenges: Replaced with \u0026ldquo;Next Steps\u0026rdquo; \u0026ndash; guidance for how participants can incorporate learnings from GM into their daily lives.\u003c/li\u003e\n \u003cli\u003eOptional peer check-ins: Replaced with CTM \u0026ldquo;Dost\u0026rdquo; (dost = friend in Punjabi)\u003c/li\u003e\n \u003cli\u003eOptional \u0026lsquo;check-in\u0026rsquo; newsletter: available for participants, but only in English\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eImplementation strategy: Activity coach training\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 238px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eQualification: anyone with experience in fitness leadership or with older adults\u003c/li\u003e\n \u003cli\u003eActivity coaches hired by delivery partners\u003c/li\u003e\n \u003cli\u003eTraining hosted online at www.choosetomovetraining.info (separate from main CTM website)\u003c/li\u003e\n \u003cli\u003eTraining delivered in self-directed online platform with interactive practical component\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 238px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eQualification: Same as original Phase 4 model\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eActivity coaches hired by delivery partners\u003c/li\u003e\n \u003cli\u003eTraining hosted online on main CTM website (https://choosetomove.ca)\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eTraining delivered in similar format to orginal Phase 4 model but with additional modules on physical activity and behavior change for coaches without a fitness background, and on facilitation skills\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 238px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eQualification: Same as original Phase 4 model\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eActivity coaches hired by delivery partners\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eTraining hosted in hybrid format (virtual and in-person), supplemented online training with in-person or virtual Q\u0026amp;A session, and added training modules on CTM Delivery-Punjabi and CTM Evaluation-Punjabi\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e Characteristics of participants in adapted Choose to Move (CTM) Phase 4 programs for Punjabi-speaking older adults that completed the baseline evaluation and the 3-month CTM program, and those that completed the baseline evaluation but did not complete the CTM program and/or the post-CTM evaluation.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCompleted baseline evaluation and 3-month CTM program\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=47)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDid not complete the 3-month CTM program and/or the post-CTM evaluation\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=18)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipants, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003cp\u003eMissing data\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e35 (74.5%)\u003c/p\u003e\n \u003cp\u003e12 (25.5%)\u003c/p\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e11 (61.1%)\u003c/p\u003e\n \u003cp\u003e5 (27.8%)\u003c/p\u003e\n \u003cp\u003e2 (11.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge category, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u0026lt; 75 years\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003cu\u003e\u0026gt;\u003c/u\u003e 75 years\u003c/p\u003e\n \u003cp\u003eMissing data\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e35 (74.5%)\u003c/p\u003e\n \u003cp\u003e11 (23.4%)\u003c/p\u003e\n \u003cp\u003e1 (2.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e12 (66.7%)\u003c/p\u003e\n \u003cp\u003e3 (16.7%)\u003c/p\u003e\n \u003cp\u003e3 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary language spoken at home, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003ePunjabi\u003c/p\u003e\n \u003cp\u003eHindi\u003c/p\u003e\n \u003cp\u003eEnglish\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e41 (87.2%)\u003c/p\u003e\n \u003cp\u003e1 (2.1%)\u003c/p\u003e\n \u003cp\u003e5 (10.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15 (83.3%)\u003c/p\u003e\n \u003cp\u003e1 (5.6%)\u003c/p\u003e\n \u003cp\u003e2 (11.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBorn in Canada, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eMissing data\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e47 (100%)\u003c/p\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10 (55.6%)\u003c/p\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003cp\u003e8 (44.4%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime in Canada, years (mean (SD))\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e34.9 (15.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLiving arrangement, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eAlone\u003c/p\u003e\n \u003cp\u003eWith spouse/partner\u003c/p\u003e\n \u003cp\u003eWith children\u003c/p\u003e\n \u003cp\u003eWith spouse, children, grandchildren\u003c/p\u003e\n \u003cp\u003eMissing data\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u0026nbsp;4 (8.5%)\u003c/p\u003e\n \u003cp\u003e18 (38.3%)\u003c/p\u003e\n \u003cp\u003e10 (21.3%)\u003c/p\u003e\n \u003cp\u003e13 (27.7%)\u003c/p\u003e\n \u003cp\u003e2 (4.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (5.6%)\u003c/p\u003e\n \u003cp\u003e5 (27.8%)\u003c/p\u003e\n \u003cp\u003e4 (22.2%)\u003c/p\u003e\n \u003cp\u003e8 (44.4%)\u003c/p\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducational attainment\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eSecondary or less\u003c/p\u003e\n \u003cp\u003eSome trade, technical school or college\u003c/p\u003e\n \u003cp\u003eSome university\u003c/p\u003e\n \u003cp\u003ePrefer not to answer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e25 (53.2%)\u003c/p\u003e\n \u003cp\u003e7 (14.9%)\u003c/p\u003e\n \u003cp\u003e14 (29.8%)\u003c/p\u003e\n \u003cp\u003e1 (2.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7 (38.9%)\u003c/p\u003e\n \u003cp\u003e5 (27.8%)\u003c/p\u003e\n \u003cp\u003e2 (11.1%)\u003c/p\u003e\n \u003cp\u003e4 (22.2%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChronic conditions, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e\u003cu\u003e\u0026gt;\u003c/u\u003e2\u003c/p\u003e\n \u003cp\u003ePrefer not to answer\u003c/p\u003e\n \u003cp\u003eMissing data\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e13 (27.7%)\u003c/p\u003e\n \u003cp\u003e14 (29.8%)\u003c/p\u003e\n \u003cp\u003e17 (36.2%)\u003c/p\u003e\n \u003cp\u003e1 (2.1%)\u003c/p\u003e\n \u003cp\u003e2 (4.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (5.6%)\u003c/p\u003e\n \u003cp\u003e2 (11.1%)\u003c/p\u003e\n \u003cp\u003e7 (38.9%)\u003c/p\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003cp\u003e8 (44.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSelf-rated health, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eVery poor, poor or fair for age\u003c/p\u003e\n \u003cp\u003eGood or very good for age\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e16 (34.0%)\u003c/p\u003e\n \u003cp\u003e31 (66.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8 (44.4%)\u003c/p\u003e\n \u003cp\u003e10 (55.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSD=standard deviation\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"healthy aging, health promotion, implementation science, physical activity, South Asian people, program evaluation","lastPublishedDoi":"10.21203/rs.3.rs-8264715/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8264715/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSouth Asians are the largest and fastest-growing racialized group in Canada but are underrepresented in health research and underserved in health-promoting initiatives. In this paper we: 1) describe the systematic process by which we ethnoculturally adapted Choose to Move (CTM) – an effective health-promoting model for older adults – for South Asian Punjabi-speaking older adults and organizations that serve them, 2) describe the adapted CTM model, and 3) evaluate implementation of the adapted CTM model.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUsing community-based participatory research methods, we followed a multi-step adaptation process: 0) review existing CTM Phase 4 data; 1) engage community partners and Punjabi-speaking older adults; 2) conduct needs assessment; 3) develop and 4) validate a prototype adapted CTM model; 5) finalize adapted model; and 6) pilot implementation. We coded adaptations using the FRAME and FRAME-IS frameworks. Four organizations piloted the adapted CTM model (4 coaches, 5 programs, 68 older adults). Following program delivery, we assessed implementation indicators and outcomes through questionnaires and semi-structured interviews with organizations, activity coaches and participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe proposed 23 updates to the CTM model after Step 0 (e.g., modified activity coach training content) and 32 ethnocultural adaptations after Steps 1–3 (e.g., increased length of group meetings, translated promotion and recruitment materials). During the pilot, 72% of participants completed the CTM program and provided post-program feedback. Organizations and coaches rated the program as acceptable, appropriate and feasible. Dose delivered, dose received and participant responsiveness were high (\u0026gt; 84% for all). Fidelity to core functions ranged from 62–100%. Four themes emerged from qualitative data to support these findings: 1) provide structure and support, 2) foster cultural and linguistic resonance, 3) make goals matter and 4) facilitate engagement. Coaches were satisfied with strategies they used (usage ranged from 25% to 100% across available resources) and made few adaptations. Qualitative data supported these findings through three themes: 1) build relationship-centered partnerships, 2) provide tailored and culturally appropriate support, and 3) tailored training.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe integrated implementation science approaches with ethnogerontology to generate a blueprint for implementing an evidence-based and ethnoculturally grounded health-promoting for Punjabi-speaking older adults.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trials Registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNCT06252259; Registration date: February 1, 2024\u003c/p\u003e","manuscriptTitle":"Ethnocultural adaptation of an effective health-promoting intervention for Punjabi-speaking older adults: Choose to Move ਆਓ ਚੰਗੀ ਸਿਹਤ ਵੱਲ ਚਲੀਏ","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-08 07:55:37","doi":"10.21203/rs.3.rs-8264715/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"337338320167545442175015965912424491696","date":"2026-01-13T07:44:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"157138801664127733937134077829989155634","date":"2026-01-06T20:17:32+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-06T17:25:15+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-10T09:05:41+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-08T03:51:06+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-08T03:50:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-12-03T00:58:04+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7e34a49d-5543-4b35-9a55-6fff22963869","owner":[],"postedDate":"January 8th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-08T07:55:37+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-08 07:55:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8264715","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8264715","identity":"rs-8264715","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}