Evaluating the Scalability of the ProMuscle Intervention for Community-Dwelling Older Adults: A Mixed Methods Study

Evaluating the Scalability of the ProMuscle Intervention for Community-Dwelling Older Adults: A Mixed Methods Study | 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 Evaluating the Scalability of the ProMuscle Intervention for Community-Dwelling Older Adults: A Mixed Methods Study Lara R Bos, Patricia J Laag, Berber G Dorhout, Aaron A Heeren, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7156488/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The global population is ageing, leading to an increase of older adults with sarcopenia, a condition associated with reduced quality of life and higher healthcare costs. ProMuscle, a 12-week intervention combining strength training and protein intake, has been shown to effectively improve physical functioning in older adults. Although ProMuscle has demonstrated promising results on a smaller scale, further scale up requires adapted strategies to address emerging challenges. This study aims to assess the scalability of ProMuscle, systematically guided by the Intervention Scalability Assessment Tool (ISAT). Methods A mixed-methods approach was used, combining a review of documents, interviews (n = 8), online surveys (n = 49), and consensus focus groups (n = 2), all involving key stakeholders. Each of the ISAT domains - the problem, the intervention, strategic and political context, effectiveness, costs, fidelity and adaptation, reach and acceptability, delivery setting and workforce, implementation infrastructure, and sustainability – were addressed during data collection. Findings of the scalability assessment were displayed for each of the ISAT domains in a radar plot. Results The ISAT indicates that ProMuscle holds strong potential for scale up. The demonstrated effectiveness, the relevance of sarcopenia prevention, its alignment with broader health priorities, and its potential to reduce healthcare costs were supported by both scientific evidence and stakeholder consensus. However, key challenges were identified in the strategic and political context and implementation infrastructure, which must be addressed before further scale up. Structural barriers, such as the lack of sustainable funding, limited awareness, and lack of prioritization of sarcopenia among policymakers and healthcare professionals were described as significant challenges. Conclusion ProMuscle shows strong potential for scale up but requires a guided and coordinated approach. Successful scaling depends on collaboration between researchers, policymakers, and healthcare professionals, with clear responsibilities for sustainable funding and integration into routine care. Future efforts should focus on equity, long-term effectiveness, and adaptability across settings to ensure broad and lasting impact. Lifestyle intervention Scalability Implementation Science Physical functioning Older Adults Figures Figure 1 Background Globally, the population aged 65 years or older is expected to more than double, from 761 million in 2021 to 1.6 billion in 2050. The population that is 80 years of age or older is increasing at an even quicker rate 1 . As people age, muscle mass and muscle strength decline 2 , 3 . A muscular disorder that is characterised by this decline in muscle mass, muscle strength, and overall physical functioning is called sarcopenia 4 – 6 . Sarcopenia is associated with decreased quality of life, loss of independence, increased need for care, morbidity, and even mortality 2 , 3 . In the Netherlands, the cost of healthcare for older adults with sarcopenia is 4325 euros every three months, which is significantly more than the 1533 euros for older adults without sarcopenia 7 , 8 . Therefore, preventing rather than delaying the onset of sarcopenia and other age-related problems should be a public health priority 9 . Strength training and protein intake are effective strategies to improve physical functioning and counteract sarcopenia in older adults. These approaches are particularly beneficial for those who are (pre-)frail or already experiencing a decline in strength during daily activities 10 , 11 . An effective intervention that combines resistance exercise training with an increased dietary protein intake is ProMuscle 2 , 3 , 11 . ProMuscle is a 12-week program for community-dwelling older adults (65 years and older) and delivered by physical therapists and dietitians in primary care 12 . ProMuscle is effective in enhancing muscle mass, muscle strength, and physical functioning 11 , 13 . Despite the proven effectiveness of this programme, ProMuscle is not yet widely used by primary care physical therapists and dietitians concerned with community-dwelling older adults. Recently, an implementation toolbox was developed in co-creation with physical therapists, dietitians, and implementation specialists to tailor context-specific implementation activities in a local context 2 , 14 – 16 . These implementation activities aim to remove barriers which hinder the adoption of ProMuscle, for instance, limited financial resources, support from local authorities, and collaboration between stakeholders 2 , 15 . So far, ProMuscle has been implemented on a smaller scale, with promising results regarding its effectiveness in local settings 3 , 12 . These findings provide valuable insights for the next step, scaling up the intervention to maximise the impact of ProMuscle on health outcomes in older adults. However, scaling up is not merely a matter of repeating previous efforts on a larger scale. It requires adapted strategies, as new contextual factors emerge, such as the need for sustainable financing, stronger collaborations, and alignment with policy 3 , 12 , 17 . To further enhance ProMuscle’s impact, it is essential to understand how scaling can be effectively achieved. The World Health Organization defines scaling up as “ deliberate efforts to increase the impact of successfully tested health interventions so as to benefit more people and to foster policy and program development on a lasting basis ” 18 , 19 . Evaluating the intervention’s readiness for scale-up is the first step towards a successful scale-up 17 , 20 , 21 . This step is particularly important, as a thorough evaluation helps determine whether the intervention is ready for scale-up and identifies necessary adaptations for broader application 11 – 13 . Successful scaling is essential to achieve meaningful improvements in muscle health and functioning among aging populations, while also reducing the burden on healthcare systems 7 , 9 , 22 . Without proper scaling, however, these potential benefits remain limited, and the investments in research and implementation may not lead to sustainable health impact 23 . By ensuring that research addresses the specific questions and criteria relevant to implementation, the likelihood of adoption and sustained use in practice increases 24 – 26 . This emphasizes how crucial it is to make sure that interventions like ProMuscle are both scalable and sustainable. One way to systematically assess the scalability of an intervention is by using the Intervention Scalability Assessment Tool (ISAT) 27 . The ISAT consists of ten domains, each with a set of questions tailored to evaluate an intervention’s readiness for scale-up 17 , 18 , 28 . In the past, the ISAT has been used to assess the scalability of various health interventions across different settings and policy environments 17 , 25 , 29 , 30 . The aim of this study is to assess the scalability of the ProMuscle intervention, using the ISAT. This involves determining to what extent ProMuscle can be widely deployed in primary care to improve older adults’ muscle strength and physical functioning while maintaining its effectiveness and efficiency. Methods Design A mixed methods study was conducted with sequential quantitative and qualitative approaches to assess the scalability of ProMuscle. A combination of document analysis, semi-structured interviews, surveys, and focus groups was used. To ensure transparency and completeness, the Good Reporting of A Mixed Methods Study (GRAMMS) guideline was used 31 , 32 . Data collection took place between February 2023 and July 2024. Population & Setting A wide range of stakeholders were invited to participate in the study, including individuals with prior experience administering or implementing ProMuscle or similar programs, as well as professionals who self-identified as working with the target population of community-dwelling older adults. This included, healthcare professionals (HCPs) (i.e. physical therapists, dietitians, and general practitioners), program coordinators and administrators, policy makers and public health officials, and researchers. Maximum variation was sought in terms of age, gender, occupation, and years of work experience 33 . Participants were recruited using purposive sampling to obtain a wide range of perspectives, providing a collection of rich, detailed data from those most experienced with the implementation of ProMuscle or similar lifestyle interventions in older adults 34 , 35 . Initially, professionals who had previously participated in ProMuscle or similar interventions were directly invited to fill in the online survey, to participate in the one-on-one interviews, or to take part in one of the two focus groups. To expand the number of participants, LinkedIn was used to recruit additional stakeholders who are professionally involved with improving the lifestyle of community-dwelling older adults. This study was conducted within the Region Foodvalley partnership, an alliance of eight municipalities in the Netherlands 36 . The Region Foodvalley partnership, including the PUMP-fit study within the theme ‘Nutrition and Health’, aims to maintain the fitness and functionality of older adults by effectively combining nutrition and exercise. The intervention: ProMuscle ProMuscle is a 12-week during program and consists of a combination of resistance exercise training and a diet intervention focused on increasing protein intake 12 . The exercise component entails twice a week, one-hour group sessions of progressive resistance training guided by a physical therapist. Each training consists of a warming-up, strength exercises, and a cooling-down 3 , 11 . The nutrition intervention consists of an individual intake and one to two evaluation consultations. During the intake, dietitians provide participants tailored advice on how to increase their protein intake using regular food products, which focuses on consuming at least 25 grammes of protein per main meal 3 , 11 . During the evaluation consultations, dietitians and participants discuss strategies on how to continue consuming protein-rich foods after the intervention period and potentially adjust the dietary advice 3 , 11 . Study outcome: Scalability of ProMuscle The ISAT was used as the guiding framework for the primary outcome of this study, the scalability of ProMuscle 27 . The ISAT guides users to assess the scalability of an intervention by identifying contextual factors that facilitate or hinder scale-up. It provides a structured framework to determine key scalability factors and the necessary resources for assessment 28 , 37 . The ISAT consists of ten domains. For each domain, different questions were asked to identify strengths and weaknesses that are important for scalability. The domains are divided into different parts (Table 1 ) 18 . Table 1 Description of each ISAT domain 28 ISAT domain Domain description Domain A1: The problem Describe the problem being addressed, who it affects, what it affects and how it is currently being addressed (if at all). When possible, support with recent data, such as population survey data at the local, regional or national level, to provide evidence of the problem and its impacts. Domain A2: The intervention Describe the proposed intervention aims, objectives, key elements, and methods of delivery to address the problem described in A1. Domain A3: Strategic/political context Consider the strategic, political, and environmental context, along with potential influences from industry, commercial players, or the non-government sector. Domain A4: Evidence of effectiveness Evaluate the evidence supporting the scale-up of the proposed intervention, considering sources such as scientific literature and results from previous evaluations, whether piloted locally or elsewhere. Domain A5: Intervention costs and benefits Assess the known costs of the intervention delivery and any measurable benefits. Using methods such as cost-effectiveness, cost-benefit, and cost-utility analyses. When costs are not fully known, estimates should be gathered. Domain B1: Fidelity and adaptation Identify any proposed changes to the intervention for scale-up, such as a reduction in the number of elements to be delivered. Document any known impacts of these changes. Domain B2: Reach and acceptability Evaluate the reach and acceptability of the intervention for the target population. Domain B3: Delivery settings and workforce Examine the intervention delivery setting (e.g., hospitals, primary care centers, community centers) and the delivery organisations, newly created or existing, responsible for implementation. The delivery workforce includes those directly administering the intervention. Domain B4: Implementation infrastructure Consider the potential implementation infrastructure needed for scale-up. Answers may be known or extrapolated from available information. Domain B5: Sustainability Consider the long-term outcomes of scale-up and the sustainability of the intervention over time. Some questions may be challenging or impossible to answer. [insert Table 1 here] Part A includes five domains that focus on background information on the public health problem, context of the proposed intervention and a description of the intervention. Part B also includes five domains and focuses on implementation and feasibility factors relating to all potential scale up aspects, including fidelity and adaptations, reach and acceptability, delivery setting and workforce, and implementation infrastructure and training. All the information gathered in Parts A and B is summarized in Part C, which concludes the readiness assessment questions. In this part, the overall score of each domain is used to generate a radar plot 18 , 28 . Ultimately, the ISAT results in a scalability report to summarize the scalability of ProMuscle. Data collection and analysis A variety of data sources was used to complete the assessment on scalability of ProMuscle. Data were collected and analysed through four consecutive, iterative steps 18 . First, a document analysis was conducted, reviewing policy documents and intervention related literature to answer the questions posed in the ISAT and identify gaps in information. Next, interviews with stakeholders were held to discuss each ISAT domain in detail. Hereafter, a survey was distributed among a wide range of stakeholders, allowing them to assign scores to the ISAT domains with additional space for open-ended answers. Finally, focus groups were conducted in which the survey results were presented to a diverse group of stakeholders, facilitating discussions to reach consensus on the final scores per domain. Stakeholders at the micro (physical therapists and dietitians), meso (program coordinators and the regional association of general practitioners), and macro levels (The Ministry of Health, Welfare, and Sport (VWS), the National Institute for Public Health and the Environment (RIVM), the Royal Dutch Society for Physical Therapy (KNGF), and Public Health Services) were involved throughout these stages of data collection. Step 1: document analysis A document analysis was conducted to answer contextual questions raised on background information on the public health problem, the context of ProMuscle and a description of ProMuscle (Part A, ISAT). Document analysis is a form of indirect data analysis, which is useful for exploring texts such as policy documents, legislation and protocols 38 . The selection of potentially useful documents was suggested by two researchers (AH and BD). Different types of documents were included and used to answer the questions posed in the ISAT, such as public records, and personal documents (Table 2 ). The answers to these questions posed in the ISAT described the current context, implementation, and required modifications to ProMuscle for scale up. Answering these questions also provided an opportunity to make sure that any potential knowledge gaps were considered and whether these gaps needed to be addressed during the continued implementation and scale up of ProMuscle. Table 2 Documents included in the document analysis Type of document Details Policy documents Integral Care Agreement 39 Partnership Agreement: Foodvalley 36 The Public Health Foresight study 2024 40 General lifestyle literature ProMuscle intervention adaptation, implementation and effectiveness 3 , 8 , 11 , 41 , 42 ProMuscle benefits, effects and cost-effectiveness 12 , 13 , 43 ProMuscle implementation: scoping review and pilot study 2 , 44 Centre for Healthy Living 10 National Health Care Institute 45 Step 2: interviews with stakeholders Subsequent to document analysis, online one-to-one interviews were conducted by one researcher (AH) with key stakeholders who were involved in the implementation and deployment of ProMuscle. Stakeholders from micro (physical therapists and dietitians), meso (program coordinators and the regional association of general practitioners), and macro levels (Public Health Services, the Royal Dutch Society for Physical Therapy (KNGF), and the Ministry of Health, Welfare and Sport (VWS)) were included to ensure a comprehensive perspective on implementation. The objective of the interviews was to gain more information on for example details of ProMuscle, potential scale-up of ProMuscle, fidelity and adaptation, reach and acceptability, delivery settings and workforce, and implementation infrastructure (Part B, ISAT) 18 . Based on the ISAT structure, the knowledge gaps identified by document analyses (step 1), and the interview questions employed by Calnan et al., an interview guide (Additional file 1) was developed in advance of the semi-structured interviews 17 . During each interview, specific domains of the ISAT were highlighted based on the kind of knowledge, expertise, and experience of the participant. All interviews were transcribed verbatim, and transcripts were coded using a deductive approach based on qualitative content analysis 46 , 47 . First, transcripts were read line by line, and emerging concepts were coded according the domains of the ISAT. The coding process was done by two researchers (LB and PL) and codes were discussed until consensus was reached. For this analysis, Atlas.ti version 25 was used 48 . Step 3: online survey In the third step, an online questionnaire was distributed to diverse stakeholders to rate scalability of the ProMuscle intervention. In addition to the stakeholders involved in step 2, additional stakeholders at macro level (the Ministry of Health, Welfare and Sport (VWS), the National Institute for Public Health and the Environment (RIVM), and the Royal Dutch Society for Physical Therapy (KNGF)) who had not yet participated were invited to contribute in step 3. The questionnaire was based on the readiness assessment questions provided by the ISAT framework, designed to assess the readiness for scale-up 17 , 18 . For each domain a short summary of the findings from the document analysis (step 1) and the semi-structured interviews (step 2) was presented. Participants were then asked to rate the scalability of each domain, based on their interpretation of the presented information and their professional experience. The questions were rated using a four-point scale (not at all (0), to a small extent (1), somewhat (2), and to a large extent (3)) 18 , 28 . Additional space was provided for open-ended responses to comment on the reasoning behind the given score. The final survey questions are accessible in Additional file 2. The surveys were analysed in line with the methodology outlined in the ISAT guidelines 18 . The total sum of scores per question was averaged over the number of scores given, resulting in an average score between 0 and 3. The answer ‘not applicable’ was removed from the dataset, as well as missing data. Average scores were rounded because the scores could only be submitted as an integer. Additionally, descriptive statistics were used to describe the demographics of the participants, including gender, age, occupation, and years of work experience. Quantitative analysis was conducted using SPSS version 29.0.1 49 . After the analysis of the online surveys, the ISAT scoring sheet (in Excel) was used to rate the scalability 50 . This scoresheet created a visual representation of the intervention’s performance across the domains, a radar plot, of the final scores. The scores were categorized by the research group as low (0–1.0), moderate (1.1–2.0), or high (2.1–3.0). This categorization helped identifying the domains in which the intervention performs reasonably well (high scores) and areas that may require improvement (low scores), thus illustrating the summation of the participants’ views of each scalability domain 18 , 28 , 51 . Step 4: focus groups to rate scalability The final step to assess the scalability of ProMuscle involved presenting and discussing the scalability report with a diverse and deliberately selected group of stakeholders. In step 4, participants from step 2 were personally invited to join an online focus group. Four more stakeholders who had not participated in previous steps of the study were invited to ensure diversity in the participating stakeholders in this step. This scalability report includes the radar plot, a summary for each ISAT domain, and a conclusion on overall scalability of ProMuscle. The primary study results were presented (in PowerPoint format) at the two online focus groups. To facilitate participants involvement in the subsequent discussion, a brief synopsis of each domain and its corresponding score were sent to participants in a document prior to the focus group (Additional file 3). This document was based on the ISAT Part C: summary of scalability assessment 28 . Participants were then given the opportunity to provide feedback based on their experiences and knowledge, identifying potential gaps or barriers in the results during online focus groups. Focus groups were conducted by two researchers (LB and PL), one acted as the moderator and the other as observer. This allowed for the recording of memos and initial suggestions 33 . The focus groups were audio-recorded and transcribed verbatim to ensure accuracy in data analysis. Finally, all findings were compared to predefined scalability criteria using the ISAT, leading to conclusions and recommendations for improving the scalability of the ProMuscle intervention, and were described using the available template in the ISAT 28 . For this analysis, Atlas.ti version 25 was used 48 . Results Different stakeholders participated in the different steps of this study. In step 2 of the scalability assessment, a total of 8 stakeholders took part in one-to-one online interviews. As shown in Table 3, interview participants included researchers involved in similar interventions, policy makers related to the intervention, and stakeholders engaged in the execution and implementation of the intervention. The interviews lasted between 34 and 52 minutes, with an average duration of 44 minutes. To complete the surveys in step 3, a total of 34 stakeholders were personally invited, and additional participants were recruited via LinkedIn, resulting in 49 participants that completed the surveys. Ten of the twelve stakeholders (83%) invited in step 4 participated in one of the two online focus groups. Focus groups lasted between 53 to 68 minutes (mean 61 minutes). Characteristics of participants are presented in Table 3. Table 3. Baseline characteristics of participants in step 2, 3 and 4 Age , N (%) <25 years 25-35 years 36-45 years 46-55 years 56-65 years Interview participants (ISAT step 2) N=8 Survey participants (ISAT step 3) N=49 Focus group participants (ISAT step 4) N=10 1 (12.5) 1 (12.5) 3 (37.5) 3 (37.5) - 1 (2) 11 (22.4) 19 (38.8) 8 (16.3) 10 (20.4) 1 (10) 2 (20) 2 (20) 3 (30) 2 (20) Gender , N (%) Female Male Rather not say 6 (75) 2 (25) - 38 (77.6) 10 (20.4) 1 (2) 10 (100) - - Occupation , N (%) Healthcare professional Physical therapist Dietician Policy maker Researcher Government official Manager 3 (37.5) 2 1 4 (50) 1 (12.5) - - 21 (42.9) 12 9 10 (20.4) 7 (14.3) 2 (4.1) 3 (6.1) 3 (30) 2 1 2 (20) 3 (30) 1 (10) 1 (10) Years of work experience , N (%) 0-5 years 6-10 years 11-15 years 16-20 years >20 years 2 (25) 2 (25) 2 (25) - 2 (25) 7 (14.3) 7 (14.3) 11 (22.4) 7 (14.3) 17 (34.7) 4 (40) 2 (20) 2 (20) - 2 (20) ISAT domains Data gathered from the surveys (step 3) was used to generate the radar plot in Figure 1, while insights from document analysis (step 1), interviews (step 2), and focus groups (step 4) provided additional context for interpretation. The radar plot displays the findings of the scalability assessment. Domains with higher scores and thus considered more ready for scalability are indicated by the points on the outer portion (e.g. A2 The program/intervention) of the radar plot, domains requiring further consideration are indicated by points closer to the center (e.g. B4 Implementation infrastructure). A comprehensive explanation of the findings is provided for each ISAT domain. Domain A1: the problem The problem being addressed by the intervention (domain A1) scored high (3.0) in the online survey, with most participants agreeing that the prevention of sarcopenia is of importance, as a great number of older adults are affected by it. This importance was underlined by the numbers and trends on sarcopenia found during the document analysis. In 2045, the prevalence of sarcopenia is expected to rise from 12.9% to 22.3%, according to estimations from Europe 42 . Participants of the focus groups indicated that while sarcopenia prevention is not always a top priority, HCPs and researchers pay more attention to sarcopenia than policymakers do at the moment. “The prevention of sarcopenia helps to delay and prevent a significant amount of suffering in the elderly, which is beneficial for their quality of life, for extending their longevity in good health, and for avoiding unneeded medical care and expenses.” - Physical therapist Domain A2: the intervention The intervention (domain A2), ProMuscle, was found to be effective in improving muscle strength, muscle mass, and physical functioning 11,12 . As a result, this domain scores high (3.0). However, survey participants questioned the perceived awareness of the intervention among older adults and HCPs. Awareness often arises only after experiencing sarcopenia related issues, such as falls or hospitalization. Participants in the interviews suggest that emphasizing daily life benefits of muscle strength exercises combined with a protein-enriched diet is more effective than solely promoting the prevention of sarcopenia. Additionally, participants during the focus groups stressed the importance of reaching older adults with a lower socioeconomic position. “I believe that a lot of senior individuals are unaware that functional decline is something that may be actively addressed and is not always an inevitable aspect of ageing. […] I believe that individuals did not know they needed it [ProMuscle] until after the program. From an outsider’s perspective, I believe that such a program is necessary, but not that a significant portion of the target population itself has an inherent need for it.” - Policymaker Domain A3: strategic and political context The strategic and political context (domain A3) scores moderate (2.0). Policy documents showed that current policies in the Netherlands, such as the Ministry of Health, public health agencies, and local governments are stressing priority on prevention. The focus is mainly on broader goals such as independent living, healthy ageing, promoting a healthy lifestyle, and fall prevention, rather than specific conditions such as sarcopenia 39,40 . ProMuscle aligns well with these goals but lacks recognition as a validated fall prevention intervention 10 . Moreover, participants in the interviews and focus groups consider the program to fall into a niche in terms of insured care in the Netherlands. Their experience is that fall prevention interventions are reimbursed by insurance companies, as are lifestyle programs for people with obesity. An intervention like ProMuscle, which indirectly contributes to fall prevention and could be seen as a lifestyle program for community-dwelling older people is currently not reimbursed by health insurance. Increasing ProMuscle’s visibility and highlighting its additional benefits, such as fall prevention, to address loneliness, and facilitating independent living, could enhance its value, adoption and scale-up according to the participants in the focus groups. “[…] The only thing that does not entirely match the current situation is your intervention [ProMuscle]. That is to say, there is broad support, the reason it [ProMuscle] does not align with the current strategic and political context is that ProMuscle’s outcomes does not fit the guidelines.” - Policymaker Domain A4: evidence of effectiveness ProMuscle received a high rating (3.0) when it came to the evidence of effectiveness of the intervention (domain A4). The existing scientific evidence and the participants’ personal observations, that older adults perform better on a variety of physical tests and report fewer challengers in their daily lives, support this high rating 8,11,13,42 . While the survey feedback confirms this score, focus group participants question the existence of any equivalent, less expensive, but just as effective interventions to address sarcopenia in older adults. Other participants also brought up the possible connection to other interventions, such as walking programs and fall prevention initiatives, highlighting how crucial it is to emphasize the interventions’ additional value in order to effectively market ProMuscle and optimize collaboration and impact. “It [ProMuscle] works fine, but there might be other, cheaper options, like walking or something. […]. So, to what extent do you need to specify this problem [sarcopenia], and how necessary is this particular solution, and could other options work as well?” – Physical therapist Domain A5: intervention costs and benefits Survey respondents gave a high score (3.0) to the question of whether the benefits of the intervention could potentially outweigh its costs (domain A5). According to their responses in the qualitative feedback of the survey, the benefits are evident, such as reducing healthcare costs through fall prevention and promoting healthy ageing. However, interview participants indicated that the cost of ProMuscle is often too high at individual level, which could discourage participation of older adults. Particularly for older adults with less financial resources, the costs of the intervention potentially widen health disparities. The interviewees stated that obtaining support from funding providers and collaborating with other professionals (e.g., exercise coaches or community workers) is crucial. Such collaboration may help address cost-related challenges by allowing other professionals to deliver parts of the ProMuscle intervention, thereby reducing dependency on more costly HCPs. Additionally, maintaining long-term behavioural change is challenging, and ensuring the intervention’s continuity is essential to achieve sustainable benefits. “It’s a difficult question. Who gains from the expenses? When considering this from the standpoint of the elderly, wealthy and well-educated individuals will be willing to pay for this [ProMuscle], but a significant number of older adults will not be able to pay for this [ProMuscle]. From the standpoint of public health, ProMuscle contributes to cost saving since it is a successful intervention that prevents falls and promotes healthy ageing.” – Government official Domain B1: fidelity and adaptation In terms of the fidelity and adaptation of ProMuscle (domain B1), the online survey showed a high score (2.3). The document analysis indicated that the intervention is deemed acceptable and feasible to implement in daily practice of physical therapists and dietitians. ProMuscle was implemented with high fidelity, supported by the extensive support, including the training of physical therapists and dietitians, and the close relationship to practice 3,41,42 . To achieve the documented benefits of ProMuscle when scaled up, interview participants stressed the importance of ensuring the intervention’s core elements, including twice-weekly strength training and increased protein intake. Professionals other than physical therapists and dietitians as potential deliverers of ProMuscle was discussed in the qualitative survey feedback and focus groups, raising some concerns about control and regulation of the intervention. While regulated professionals have quality systems in place, exercise coaches, for example, do not subject to these formal requirements. Therefore, focus group participants stressed the need for process evaluation and documentation when changes to the intervention are made. While less intensive adjustments, such as the involvement of movement professionals other than physical therapists and dietitians, may reduce the intervention’s effectiveness, alternative forms of support may work if they are customized to the target population. Finally, the need to monitor compliance and the quality of the intervention providers was highlighted across all steps of the scalability assessment. “You try your best to provide the professionals with the tools and training they need. In reality, however, you see that things occasionally change or are done differently. Then the question is, how horrible is that? And to what extent can you control that?” - Researcher Domain B2: reach and acceptability The reach and acceptability of the intervention for the target population (domain B2) also scored high (2.5). ProMuscle targets community-dwelling older adults aged 65 or older who are (pre-)frail or experience muscle strength loss in daily activities and are motivated to participate for at least 12 weeks 10 . According to survey and interview participants, it is essential that older adults themselves recognize the urgency of preventing age-related issues if ProMuscle is to be scaled up and is offered to a broader population. The program’s cost, frequently cited as a barrier across all data collection - especially for older adults with low incomes - highlights the need for funding and partnerships to improve reach and acceptability. Focus group participants suggested that collaboration with general practitioners and their assistants is essential for referring individuals to the intervention and may help encourage participation. In addition, partnering with local fitness- and municipal exercise professionals was considered as a possibility to reach more older adults. This is due to the fact that these professionals have a lower hourly rate, which would make ProMuscle more affordable. In terms of acceptability, research shows that older adults and HCPs rated the intervention positively, with satisfaction scores of 8.3 and 7.8 3 . Interview participants also reported positive experiences with the target group following their involvement in the intervention. “We observed that many older adults do not seek assistance as long as they are not experiencing any issues. Committing to a program on a weekly or more frequent basis is often too much for them. Additionally, financial costs are a common barrier. Although I still see several obstacles, I believe the program is suitable for the target population.” – Physical therapist Domain B3: delivery setting and workforce The delivery setting and workforce (domain B3) received a high score (2.5). Based on research found in the document analysis, ProMuscle is implemented by physical therapists and dietitians, focusing on strength training and nutrition 10 . The program was deemed compatible with regular workflows by primary care practices according to focus group participants. They expressed interest in continued involvement, as long as they have enough time to implement the intervention and access to the target population for recruitment 3 . Respondents in both the survey feedback and interviews endorsed dietitians and physical therapists for the program but suggested partnering with other professionals in sport and physical activity. For instance, participants described opportunities to expand ProMuscle to gyms, municipal sports programs, and broader healthcare settings, offering low-threshold access and more affordable for older adults. Focus group participants also deemed these collaborations helpful in more effectively reaching more vulnerable groups. However, reimbursement of prevention activities as well as the increased time pressure on HCPs were cited as potential factors reducing the acceptability of the intervention providers. Some focus group participants suggested that ProMuscle might be better suited to the social domain, with support from municipalities or health insurers to broaden its reach and make participation more affordable. “When the general practitioner, physical therapist and fitness instructors work together well, we see that the general practitioner, who now refers to the physical therapist far too frequently in our opinion, is referring more often to the network as a whole. At that point, you will realise that you can actually change things!” – Policy maker Domain B4: implementation infrastructure A moderate score (2.0) was given to the implementation infrastructure required for scale-up (domain B4). According to the survey feedback, interviews, and focus groups, ProMuscle has potential to contribute to healthy ageing and preventive care. However, its successful integration depends on addressing key barriers. Several respondents emphasized the need for additional (partial) funding to ensure accessibility for all older adults, regardless their financial status. Participants across all steps suggested that without financial support from insurers or government entities, the program might not gain broad acceptance. Competing programs, such as walking clubs, exercise groups for community-dwelling older adults, and fall prevention programs, offer alternatives with lower costs, making municipalities possibly hesitant to adopt a program without clear advantages. For HCPs to dedicate time and energy to the implementation of ProMuscle, funding and collaboration with other HCPs, was also considered essential by participants of the focus groups. They also emphasized that, like other initiatives, ProMuscle’s success relies on general practitioners and local care providers recognizing the interventions’ value. A structured approach, with the support tools for municipalities and healthcare providers, could facilitate implementation. Additionally, they suggested that building partnerships with community centers and sports facilities could further embed ProMuscle into local structures, enhancing both accessibility and sustainability. They mentioned that this approach may ensure that the program is not only preventive but also integrated into the broader social support systems, such as those addressing fall prevention and overall well-being. By involving the social domain, ProMuscle could also reach more vulnerable populations. “As soon as interventions or programs receive structured implementation support, the focus on these initiatives is maintained. But the main problem is that we have twenty programs like that and creating that kind of support structure for all of them is not feasible. This is where the public health service could play a role.” – Policy maker Domain B5: sustainability of the intervention The final domain of the ISAT addressed the perceived sustainability of the intervention, which also scored high (2.3). Further emphasis on the need for funding, improving accessibility, general support and sustainable implementation was raised in the survey feedback, interviews, and focus groups. Focus group participants raised concerns about the long-term maintenance of lifestyle changes promoted by the intervention. They emphasized the importance of sustaining these changes to prevent sarcopenia and extend physical independence over time. Lastly, focus group participants determined that to sustain outcomes and ensure lasting behavioural change among older adults, follow-up sessions, ongoing support, and an integrated approach are required. “The challenge is that these initiatives are often temporary, and this raises questions about their long-term effectiveness. Ultimately, it is about finding a sustainable place for the program and connecting it with existing efforts, whether in politics or the broader field of prevention.” – Government official Discussion The aim of this study was to assess the scalability of ProMuscle, a combined lifestyle intervention for community-dwelling older adults. The scalability assessment of ProMuscle indicates strong potential for scale-up. The high prevalence of sarcopenia among older adults highlighted the importance of its prevention, making it a key priority for the scale-up of ProMuscle. The intervention is considered effective, aligns with broader health goals such as fall prevention, and its benefits are deemed to outweigh the costs. Domains related to implementation, such as reach and acceptability, and delivery setting and workforce indicated that ProMuscle was well-received and deemed appropriate in primary care settings. However, some important barriers for larger-scale implementation are identified as well, such as the strategic and political context and implementation infrastructure. Addressing these threats is essential before proceeding with large-scale implementation. First, the limited prioritization of sarcopenia prevention among HCPs and policymakers, as well as the general lack of awareness among older adults, are important barriers for scaling the intervention. While sarcopenia was officially recognised as a medical condition in 2016, many stakeholders remain unfamiliar with its implications and the preventive measures necessary to address sarcopenia 5 , 6 . Targeted advocacy and educational campaigns could be used to raise awareness among the stakeholders to address this issue 25 . Aligning ProMuscle with broader health strategies and emphasising its cost-effectiveness through economic evaluations can strengthen its position within policy frameworks 23 . Research shows that policymakers are more likely to use evidence when it is timely, relevant, and presented with clear recommendations 52 , 53 . The lack of prioritization of sarcopenia prevention is often reinforced by barriers such as limited access to applicable research, mistrust, and poor timing, whereas facilitators such as personal contact and collaboration with researchers can help increase its visibility 52 , 53 . Building strong relationships, through an integrated approach that aligns with existing policies, health initiatives, and funding mechanisms, could promote successful scale-up. A relevant example is the attention for fall prevention, which has been successfully scaled up due to government endorsement and reimbursement through basic health insurance. Its integration into national policy has enabled widespread implementation in primary care 17 . Second, the required implementation infrastructure, particularly structural funding and sustainable collaboration across healthcare and other domains, hinders large-scale implementation of ProMuscle. Considering ProMuscle’s proven effectiveness, the availability of cheaper, more generalised healthy aging programs may make ProMuscle less appealing to policymakers and funders 15 , 43 , 54 . While aerobic exercise supports overall health, resistance training combined with nutritional support is essential for preventing sarcopenia and maintaining independence in older adults 11 , 54 . This study identified financial constraints as a frequently mentioned, persistent barrier among participants, aligning with existing literature that highlights cost as a key obstacle for older adults to participate in health interventions 15 . Affordability concerns, particularly among older adults with less financial resources, further emphasise the necessity of securing sustainable funding. Older adults in this group are more likely to experience health disparities, highlighting both the need and the potential for targeted interventions to advance health equity and improve health outcomes 55 – 57 . Implementing cost-effective strategies, such as resource optimisation, economies of scale, and cost minimisation, could enhance financial sustainability while preserving intervention quality 23 . By addressing these barriers, interventions could increase their reach and effectiveness within aging populations. To support scale up, demonstrating ProMuscle’s value and long-term impact is crucial to establish partnerships with stakeholders and securing sustainable funding. Furthermore, to ensure both scalability and quality, collaborations with other HCPs and alternative settings, such as fitness or community centers, are considered necessary. These foreseeable adaptations to ProMuscle, as part of the development of implementation infrastructure, are also based on the goal to reach a larger population. One strategy proposed in this study to address workforce limitations is the inclusion of movement professionals, such as sports coaches, lifestyle coaches, and fitness instructors, as deliverers of selected components if scaled up. This approach could help reduce costs and attract older adults with lower incomes, as these professionals typically have lower hourly wages and are more accessible than specialized facilities, thereby improving overall accessibility 15 , 23 . Some concerns about this approach were raised as well, assigning this intervention to lower-skilled staff may affect the quality of the program delivery. Therefore, a tailored delivery model could further enhance scalability by differentiating support based on the needs of older adults. For instance, younger, fitter participants requiring minimal supervision could be guided by fitness instructors, while older adults with more complex health conditions or frailty could receive more specialized support from physical therapists and dietitians. Such a stratified approach could optimize resource allocation, ensuring that those with greater care needs receive appropriate expertise while maintaining cost-effectiveness for the broader population 23 . A similar model has been successfully applied in osteoarthritis treatment, where individuals are screened and referred to the most suitable level of care. This model emphasizes matching care intensity to patient needs, promoting efficient resource use and enhancing patient engagement in decision-making 58 , 59 . Strengths and limitations One of the main strengths of this study is the use of the structured approach ISAT offers to assess scalability. The ISAT allowed for a detailed analysis of various domains, offering valuable insights into the intervention’s current positioning and areas that require improvement, enhancing the reliability of the findings. However, a notable limitation of using the ISAT is that some important aspects, such as the integrated approach, collaborations, scaled-up harms, and health inequities, are not explicitly addressed within the tool. These aspects were instead categorised under the next most appropriate domain. Another strength of this study lies in the diverse group of participants involved in the data collection. The participants included individuals with varying levels of experience, expertise, and professional backgrounds, which enriched the data with a broad range of perspectives. However, the differences in experience and timing of data collection across participants could also introduce some variability, which may have affected the consistency of responses and interpretations. Lastly, the mixed methods design of the study provided several advantages, providing a rich, multifaceted understanding of the intervention’s scalability. By combining both quantitative and qualitative data, the study provided complementary perspectives and a deeper analysis. However, the complexity inherent in a mixed methods design also posed challenges in data integration. Ensuring that quantitative and qualitative results were appropriately integrated required careful attention, especially when discrepancies arose between the two types of data. These challenges highlight the need for caution in drawing conclusions. Conclusion and implications This scalability assessment shows that the ProMuscle intervention holds strong potential, but further planning is needed to enable successful scale up. For complex interventions like ProMuscle, a guided process, rather than spontaneous diffusion, should be prioritized before scale up. To support this process, researchers, policymakers, and HCPs each play key roles. Research should identify what works and how to implement effectively, ensuring interventions are both effective and acceptable to the target population, and to drive selection by policymakers. To achieve structural and sustainable funding for interventions like ProMuscle, clear responsibility must be taken by policymakers, health insurers, and, where appropriate, older adults themselves. Policymakers in particular play a critical role in selecting, financing, and embedding effective interventions, while HCPs are essential for implementation and delivery in practice. Participants involved in this study showed a strong commitment to sustaining the intervention and are motivated to explore funding and collaboration opportunities to further embed ProMuscle into care for older adults. Further research should explore the scalability of ProMuscle in diverse settings and delivered by a variety of HCPs. Particular attention should be given to equity, to ensure that the intervention is accessible to underserved populations who may benefit most. Additionally, long-term health outcomes should be evaluated to assess whether ProMuscle remains effective and sustainable over time. Abbreviations ISAT = Intervention Scalability Assessment Tool HCP = Healthcare Professional GRAMMS = Good Reporting of A Mixed Methods Study GGD = Gemeentelijke GezondheidsDienst / Public Health Service VWS = Ministerie van Volksgezondheid, Welzijn en Sport / Ministry of Health, Welfare and Sport RIVM = Rijksinstituut voor Volksgezondheid en Milieu / National Institute for Public Health and the Environment KNGF = Koninklijke Nederlands Genootschap voor Fysiotherapie / Royal Dutch Society for Physical Therapy Declarations Ethics approval and consent to participate Ethical approval for the overarching study was granted by the Medical Committee University Utrecht (22/050). All participants gave written or verbal consent for participation in this study. All methods were performed in accordance with the relevant guidelines and regulations. Consent for publication Not applicable. Availability of data and materials The datasets used and analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This research was financially supported by a grant from the Regiodeal Foodvalley (162135). Author’s contributions This study was set up by PL and BD under the supervision of DB. Document analysis was conducted and analysed by BD and AH, interviews were conducted by AH, surveys were distributed by PL, and focus groups were conducted by LB and PL. Interviews, surveys, and focus groups were coded, analysed and interpreted by LB and PL. The manuscript was written by LB. PL, BD, AH, CV, DB, and LS critically read the manuscript and provided feedback. All authors read and approved the manuscript for submission. Acknowledgements Not applicable. References United Nations. Leaving No One Behind In An Ageing World. World Social Report 2023. [Internet]. 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09:31:10","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":20576,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-7156488/v1/fcf0060b6900aebdf5520895.docx"},{"id":87811992,"identity":"e0564e7a-cde8-463f-8c25-1f27ca7a88b7","added_by":"auto","created_at":"2025-07-29 09:31:10","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":17259,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile3.docx","url":"https://assets-eu.researchsquare.com/files/rs-7156488/v1/00109b54dfe30d6cb03ff91f.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluating the Scalability of the ProMuscle Intervention for Community-Dwelling Older Adults: A Mixed Methods Study","fulltext":[{"header":"Background","content":"\u003cp\u003eGlobally, the population aged 65 years or older is expected to more than double, from 761\u0026nbsp;million in 2021 to 1.6\u0026nbsp;billion in 2050. The population that is 80 years of age or older is increasing at an even quicker rate\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. As people age, muscle mass and muscle strength decline\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. A muscular disorder that is characterised by this decline in muscle mass, muscle strength, and overall physical functioning is called sarcopenia\u003csup\u003e\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e–\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Sarcopenia is associated with decreased quality of life, loss of independence, increased need for care, morbidity, and even mortality\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. In the Netherlands, the cost of healthcare for older adults with sarcopenia is 4325 euros every three months, which is significantly more than the 1533 euros for older adults without sarcopenia\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Therefore, preventing rather than delaying the onset of sarcopenia and other age-related problems should be a public health priority\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eStrength training and protein intake are effective strategies to improve physical functioning and counteract sarcopenia in older adults. These approaches are particularly beneficial for those who are (pre-)frail or already experiencing a decline in strength during daily activities\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. An effective intervention that combines resistance exercise training with an increased dietary protein intake is ProMuscle\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. ProMuscle is a 12-week program for community-dwelling older adults (65 years and older) and delivered by physical therapists and dietitians in primary care\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. ProMuscle is effective in enhancing muscle mass, muscle strength, and physical functioning\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eDespite the proven effectiveness of this programme, ProMuscle is not yet widely used by primary care physical therapists and dietitians concerned with community-dwelling older adults. Recently, an implementation toolbox was developed in co-creation with physical therapists, dietitians, and implementation specialists to tailor context-specific implementation activities in a local context \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e–\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. These implementation activities aim to remove barriers which hinder the adoption of ProMuscle, for instance, limited financial resources, support from local authorities, and collaboration between stakeholders\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. So far, ProMuscle has been implemented on a smaller scale, with promising results regarding its effectiveness in local settings\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. These findings provide valuable insights for the next step, scaling up the intervention to maximise the impact of ProMuscle on health outcomes in older adults. However, scaling up is not merely a matter of repeating previous efforts on a larger scale. It requires adapted strategies, as new contextual factors emerge, such as the need for sustainable financing, stronger collaborations, and alignment with policy\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eTo further enhance ProMuscle’s impact, it is essential to understand how scaling can be effectively achieved. The World Health Organization defines scaling up as “\u003cem\u003edeliberate efforts to increase the impact of successfully tested health interventions so as to benefit more people and to foster policy and program development on a lasting basis\u003c/em\u003e”\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Evaluating the intervention’s readiness for scale-up is the first step towards a successful scale-up\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. This step is particularly important, as a thorough evaluation helps determine whether the intervention is ready for scale-up and identifies necessary adaptations for broader application\u003csup\u003e\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e–\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Successful scaling is essential to achieve meaningful improvements in muscle health and functioning among aging populations, while also reducing the burden on healthcare systems\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. Without proper scaling, however, these potential benefits remain limited, and the investments in research and implementation may not lead to sustainable health impact\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. By ensuring that research addresses the specific questions and criteria relevant to implementation, the likelihood of adoption and sustained use in practice increases\u003csup\u003e\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e–\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. This emphasizes how crucial it is to make sure that interventions like ProMuscle are both scalable and sustainable.\u003c/p\u003e\u003cp\u003eOne way to systematically assess the scalability of an intervention is by using the Intervention Scalability Assessment Tool (ISAT)\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. The ISAT consists of ten domains, each with a set of questions tailored to evaluate an intervention’s readiness for scale-up\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. In the past, the ISAT has been used to assess the scalability of various health interventions across different settings and policy environments\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e,\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e. The aim of this study is to assess the scalability of the ProMuscle intervention, using the ISAT. This involves determining to what extent ProMuscle can be widely deployed in primary care to improve older adults’ muscle strength and physical functioning while maintaining its effectiveness and efficiency.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cb\u003eDesign\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA mixed methods study was conducted with sequential quantitative and qualitative approaches to assess the scalability of ProMuscle. A combination of document analysis, semi-structured interviews, surveys, and focus groups was used. To ensure transparency and completeness, the Good Reporting of A Mixed Methods Study (GRAMMS) guideline was used\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e,\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e. Data collection took place between February 2023 and July 2024.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePopulation \u0026amp; Setting\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA wide range of stakeholders were invited to participate in the study, including individuals with prior experience administering or implementing ProMuscle or similar programs, as well as professionals who self-identified as working with the target population of community-dwelling older adults. This included, healthcare professionals (HCPs) (i.e. physical therapists, dietitians, and general practitioners), program coordinators and administrators, policy makers and public health officials, and researchers. Maximum variation was sought in terms of age, gender, occupation, and years of work experience\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eParticipants were recruited using purposive sampling to obtain a wide range of perspectives, providing a collection of rich, detailed data from those most experienced with the implementation of ProMuscle or similar lifestyle interventions in older adults\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e,\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e. Initially, professionals who had previously participated in ProMuscle or similar interventions were directly invited to fill in the online survey, to participate in the one-on-one interviews, or to take part in one of the two focus groups. To expand the number of participants, LinkedIn was used to recruit additional stakeholders who are professionally involved with improving the lifestyle of community-dwelling older adults.\u003c/p\u003e\u003cp\u003eThis study was conducted within the Region Foodvalley partnership, an alliance of eight municipalities in the Netherlands\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e. The Region Foodvalley partnership, including the PUMP-fit study within the theme ‘Nutrition and Health’, aims to maintain the fitness and functionality of older adults by effectively combining nutrition and exercise.\u003c/p\u003e\u003cp\u003e\u003cb\u003eThe intervention: ProMuscle\u003c/b\u003e\u003c/p\u003e\u003cp\u003eProMuscle is a 12-week during program and consists of a combination of resistance exercise training and a diet intervention focused on increasing protein intake\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. The exercise component entails twice a week, one-hour group sessions of progressive resistance training guided by a physical therapist. Each training consists of a warming-up, strength exercises, and a cooling-down\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. The nutrition intervention consists of an individual intake and one to two evaluation consultations. During the intake, dietitians provide participants tailored advice on how to increase their protein intake using regular food products, which focuses on consuming at least 25 grammes of protein per main meal\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. During the evaluation consultations, dietitians and participants discuss strategies on how to continue consuming protein-rich foods after the intervention period and potentially adjust the dietary advice\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStudy outcome: Scalability of ProMuscle\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe ISAT was used as the guiding framework for the primary outcome of this study, the scalability of ProMuscle\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. The ISAT guides users to assess the scalability of an intervention by identifying contextual factors that facilitate or hinder scale-up. It provides a structured framework to determine key scalability factors and the necessary resources for assessment\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e. The ISAT consists of ten domains. For each domain, different questions were asked to identify strengths and weaknesses that are important for scalability. The domains are divided into different parts (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDescription of each ISAT domain\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eISAT domain\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDomain description\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDomain A1: The problem\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDescribe the problem being addressed, who it affects, what it affects and how it is currently being addressed (if at all). When possible, support with recent data, such as population survey data at the local, regional or national level, to provide evidence of the problem and its impacts.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDomain A2: The intervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDescribe the proposed intervention aims, objectives, key elements, and methods of delivery to address the problem described in A1.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDomain A3: Strategic/political context\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eConsider the strategic, political, and environmental context, along with potential influences from industry, commercial players, or the non-government sector.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDomain A4: Evidence of effectiveness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEvaluate the evidence supporting the scale-up of the proposed intervention, considering sources such as scientific literature and results from previous evaluations, whether piloted locally or elsewhere.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDomain A5: Intervention costs and benefits\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAssess the known costs of the intervention delivery and any measurable benefits. Using methods such as cost-effectiveness, cost-benefit, and cost-utility analyses. When costs are not fully known, estimates should be gathered.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDomain B1: Fidelity and adaptation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIdentify any proposed changes to the intervention for scale-up, such as a reduction in the number of elements to be delivered. Document any known impacts of these changes.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDomain B2: Reach and acceptability\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEvaluate the reach and acceptability of the intervention for the target population.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDomain B3: Delivery settings and workforce\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eExamine the intervention delivery setting (e.g., hospitals, primary care centers, community centers) and the delivery organisations, newly created or existing, responsible for implementation. The delivery workforce includes those directly administering the intervention.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDomain B4: Implementation infrastructure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eConsider the potential implementation infrastructure needed for scale-up. Answers may be known or extrapolated from available information.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDomain B5: Sustainability\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eConsider the long-term outcomes of scale-up and the sustainability of the intervention over time. Some questions may be challenging or impossible to answer.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e[insert Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e here]\u003c/p\u003e\u003cp\u003ePart A includes five domains that focus on background information on the public health problem, context of the proposed intervention and a description of the intervention. Part B also includes five domains and focuses on implementation and feasibility factors relating to all potential scale up aspects, including fidelity and adaptations, reach and acceptability, delivery setting and workforce, and implementation infrastructure and training. All the information gathered in Parts A and B is summarized in Part C, which concludes the readiness assessment questions. In this part, the overall score of each domain is used to generate a radar plot\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. Ultimately, the ISAT results in a scalability report to summarize the scalability of ProMuscle.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData collection and analysis\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA variety of data sources was used to complete the assessment on scalability of ProMuscle. Data were collected and analysed through four consecutive, iterative steps\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. First, a document analysis was conducted, reviewing policy documents and intervention related literature to answer the questions posed in the ISAT and identify gaps in information. Next, interviews with stakeholders were held to discuss each ISAT domain in detail. Hereafter, a survey was distributed among a wide range of stakeholders, allowing them to assign scores to the ISAT domains with additional space for open-ended answers. Finally, focus groups were conducted in which the survey results were presented to a diverse group of stakeholders, facilitating discussions to reach consensus on the final scores per domain. Stakeholders at the micro (physical therapists and dietitians), meso (program coordinators and the regional association of general practitioners), and macro levels (The Ministry of Health, Welfare, and Sport (VWS), the National Institute for Public Health and the Environment (RIVM), the Royal Dutch Society for Physical Therapy (KNGF), and Public Health Services) were involved throughout these stages of data collection.\u003c/p\u003e\u003cp\u003e\u003cem\u003eStep 1: document analysis\u003c/em\u003e\u003c/p\u003e\u003cp\u003eA document analysis was conducted to answer contextual questions raised on background information on the public health problem, the context of ProMuscle and a description of ProMuscle (Part A, ISAT). Document analysis is a form of indirect data analysis, which is useful for exploring texts such as policy documents, legislation and protocols\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e. The selection of potentially useful documents was suggested by two researchers (AH and BD). Different types of documents were included and used to answer the questions posed in the ISAT, such as public records, and personal documents (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The answers to these questions posed in the ISAT described the current context, implementation, and required modifications to ProMuscle for scale up. Answering these questions also provided an opportunity to make sure that any potential knowledge gaps were considered and whether these gaps needed to be addressed during the continued implementation and scale up of ProMuscle.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDocuments included in the document analysis\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eType of document\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDetails\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePolicy documents\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntegral Care Agreement\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003ePartnership Agreement: Foodvalley\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe Public Health Foresight study 2024\u003csup\u003e40\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGeneral lifestyle literature\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eProMuscle intervention adaptation, implementation and effectiveness\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e,\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eProMuscle benefits, effects and cost-effectiveness\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eProMuscle implementation: scoping review and pilot study\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eCentre for Healthy Living\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eNational Health Care Institute\u003csup\u003e\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eStep 2: interviews with stakeholders\u003c/em\u003e\u003c/p\u003e\u003cp\u003eSubsequent to document analysis, online one-to-one interviews were conducted by one researcher (AH) with key stakeholders who were involved in the implementation and deployment of ProMuscle. Stakeholders from micro (physical therapists and dietitians), meso (program coordinators and the regional association of general practitioners), and macro levels (Public Health Services, the Royal Dutch Society for Physical Therapy (KNGF), and the Ministry of Health, Welfare and Sport (VWS)) were included to ensure a comprehensive perspective on implementation. The objective of the interviews was to gain more information on for example details of ProMuscle, potential scale-up of ProMuscle, fidelity and adaptation, reach and acceptability, delivery settings and workforce, and implementation infrastructure (Part B, ISAT)\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. Based on the ISAT structure, the knowledge gaps identified by document analyses (step 1), and the interview questions employed by Calnan et al., an interview guide (Additional file 1) was developed in advance of the semi-structured interviews\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. During each interview, specific domains of the ISAT were highlighted based on the kind of knowledge, expertise, and experience of the participant. All interviews were transcribed verbatim, and transcripts were coded using a deductive approach based on qualitative content analysis\u003csup\u003e\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e,\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u003c/sup\u003e. First, transcripts were read line by line, and emerging concepts were coded according the domains of the ISAT. The coding process was done by two researchers (LB and PL) and codes were discussed until consensus was reached. For this analysis, Atlas.ti version 25 was used\u003csup\u003e\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003e\u003cem\u003eStep 3: online survey\u003c/em\u003e\u003c/p\u003e\u003cp\u003eIn the third step, an online questionnaire was distributed to diverse stakeholders to rate scalability of the ProMuscle intervention. In addition to the stakeholders involved in step 2, additional stakeholders at macro level (the Ministry of Health, Welfare and Sport (VWS), the National Institute for Public Health and the Environment (RIVM), and the Royal Dutch Society for Physical Therapy (KNGF)) who had not yet participated were invited to contribute in step 3. The questionnaire was based on the readiness assessment questions provided by the ISAT framework, designed to assess the readiness for scale-up\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. For each domain a short summary of the findings from the document analysis (step 1) and the semi-structured interviews (step 2) was presented. Participants were then asked to rate the scalability of each domain, based on their interpretation of the presented information and their professional experience. The questions were rated using a four-point scale (not at all (0), to a small extent (1), somewhat (2), and to a large extent (3))\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. Additional space was provided for open-ended responses to comment on the reasoning behind the given score. The final survey questions are accessible in Additional file 2.\u003c/p\u003e\u003cp\u003eThe surveys were analysed in line with the methodology outlined in the ISAT guidelines\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. The total sum of scores per question was averaged over the number of scores given, resulting in an average score between 0 and 3. The answer ‘not applicable’ was removed from the dataset, as well as missing data. Average scores were rounded because the scores could only be submitted as an integer. Additionally, descriptive statistics were used to describe the demographics of the participants, including gender, age, occupation, and years of work experience. Quantitative analysis was conducted using SPSS version 29.0.1\u003csup\u003e49\u003c/sup\u003e. After the analysis of the online surveys, the ISAT scoring sheet (in Excel) was used to rate the scalability\u003csup\u003e\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u003c/sup\u003e. This scoresheet created a visual representation of the intervention’s performance across the domains, a radar plot, of the final scores. The scores were categorized by the research group as low (0–1.0), moderate (1.1–2.0), or high (2.1–3.0). This categorization helped identifying the domains in which the intervention performs reasonably well (high scores) and areas that may require improvement (low scores), thus illustrating the summation of the participants’ views of each scalability domain\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003e\u003cem\u003eStep 4: focus groups to rate scalability\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe final step to assess the scalability of ProMuscle involved presenting and discussing the scalability report with a diverse and deliberately selected group of stakeholders. In step 4, participants from step 2 were personally invited to join an online focus group. Four more stakeholders who had not participated in previous steps of the study were invited to ensure diversity in the participating stakeholders in this step. This scalability report includes the radar plot, a summary for each ISAT domain, and a conclusion on overall scalability of ProMuscle. The primary study results were presented (in PowerPoint format) at the two online focus groups. To facilitate participants involvement in the subsequent discussion, a brief synopsis of each domain and its corresponding score were sent to participants in a document prior to the focus group (Additional file 3). This document was based on the ISAT Part C: summary of scalability assessment\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. Participants were then given the opportunity to provide feedback based on their experiences and knowledge, identifying potential gaps or barriers in the results during online focus groups. Focus groups were conducted by two researchers (LB and PL), one acted as the moderator and the other as observer. This allowed for the recording of memos and initial suggestions\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e. The focus groups were audio-recorded and transcribed verbatim to ensure accuracy in data analysis. Finally, all findings were compared to predefined scalability criteria using the ISAT, leading to conclusions and recommendations for improving the scalability of the ProMuscle intervention, and were described using the available template in the ISAT\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. For this analysis, Atlas.ti version 25 was used\u003csup\u003e\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eDifferent stakeholders participated in the different steps of this study. In step 2 of the scalability assessment, a total of 8 stakeholders took part in one-to-one online interviews. As shown in Table 3, interview participants included researchers involved in similar interventions, policy makers related to the intervention, and stakeholders engaged in the execution and implementation of the intervention. The interviews lasted between 34 and 52 minutes, with an average duration of 44 minutes. To complete the surveys in step 3, a total of 34 stakeholders were personally invited, and additional participants were recruited via LinkedIn, resulting in 49 participants that completed the surveys. Ten of the twelve stakeholders (83%) invited in step 4 participated in one of the two online focus groups. Focus groups lasted between 53 to 68 minutes (mean 61 minutes). Characteristics of participants are presented in Table 3.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 3. Baseline characteristics of participants in step 2, 3 and 4\u003c/em\u003e\u003c/p\u003e\n\u003ctable style=\"width:470.55pt;border-collapse:collapse;border:none;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 205.3pt;border: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cstrong\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003eAge\u003c/span\u003e\u003c/strong\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003e, N (%)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:35.4pt;line-height:200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003e\u0026lt;25 years\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:35.4pt;line-height:200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003e25-35 years\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:35.4pt;line-height:200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003e36-45 years\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:35.4pt;line-height:200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003e46-55 years\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:35.4pt;line-height:200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003e56-65 years\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83.85pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003eInterview participants\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e(ISAT step 2)\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cem\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003eN=8\u0026nbsp;\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90.7pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003eSurvey participants\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e(ISAT step 3)\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cem\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003eN=49\u0026nbsp;\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90.7pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height:200%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003eFocus group participants\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height:200%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003e(ISAT step 4)\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cem\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003eN=10\u0026nbsp;\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 83.85pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e1 (12.5)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e1 (12.5)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e3 (37.5)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e3 (37.5)\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e-\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90.7pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e1 (2)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e11 (22.4)\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e19 (38.8)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e8 (16.3)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e10 (20.4)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90.7pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e1 (10)\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e2 (20)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e2 (20)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e3 (30)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e2 (20)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205.3pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cstrong\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003eGender\u003c/span\u003e\u003c/strong\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003e, N (%)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:35.4pt;line-height:200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003eFemale\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:35.4pt;line-height:200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003eMale\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:35.4pt;line-height:200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003eRather not say\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83.85pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e6 (75)\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e2 (25)\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e-\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90.7pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e38 (77.6)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e10 (20.4)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e1 (2)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90.7pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e10 (100)\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e-\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e-\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205.3pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cstrong\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003eOccupation\u003c/span\u003e\u003c/strong\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003e, N (%)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:35.4pt;line-height:200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003eHealthcare professional\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:70.8pt;line-height:200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cem\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003ePhysical therapist\u0026nbsp;\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:70.8pt;line-height:200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cem\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003eDietician\u0026nbsp;\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:35.4pt;line-height:200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003ePolicy maker\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:35.4pt;line-height:200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003eResearcher\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:35.4pt;line-height:200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003eGovernment official\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:35.4pt;line-height:200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003eManager\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83.85pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e3 (37.5)\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cem\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003e2\u0026nbsp;\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cem\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003e1\u0026nbsp;\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e4 (50)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e1 (12.5)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e-\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e-\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90.7pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e21 (42.9)\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cem\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003e12\u0026nbsp;\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cem\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003e9\u0026nbsp;\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e10 (20.4)\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e7 (14.3)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e2 (4.1)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e3 (6.1)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90.7pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e3 (30)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cem\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003e2\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cem\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003e1\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e2 (20)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e3 (30)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e1 (10)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e1 (10)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205.3pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cstrong\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003eYears of work experience\u003c/span\u003e\u003c/strong\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003e, N (%)\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:35.4pt;line-height:200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003e0-5 years\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:35.4pt;line-height:200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003e6-10 years\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:35.4pt;line-height:200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003e11-15 years\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:35.4pt;line-height:200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003e16-20 years\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:35.4pt;line-height:200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family:\"Arial\",sans-serif;'\u003e\u0026gt;20 years\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83.85pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e2 (25)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e2 (25)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e2 (25)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e-\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e2 (25)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90.7pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e7 (14.3)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e7 (14.3)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e11 (22.4)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e7 (14.3)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e17 (34.7)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90.7pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e4 (40)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e2 (20)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e2 (20)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e-\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height: 200%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:13px;line-height:200%;font-family: \"Arial\",sans-serif;'\u003e2 (20)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eISAT domains\u003c/p\u003e\n\u003cp\u003eData gathered from the surveys (step 3) was used to generate the radar plot in Figure 1, while insights from document analysis (step 1), interviews (step 2), and focus groups (step 4) provided additional context for interpretation. The radar plot displays the findings of the scalability assessment. Domains with higher scores and thus considered more ready for scalability are indicated by the points on the outer portion (e.g. A2 The program/intervention) of the radar plot, domains requiring further consideration are indicated by points closer to the center (e.g. B4 Implementation infrastructure). A comprehensive explanation of the findings is provided for each ISAT domain.\u003c/p\u003e\n\u003cp\u003eDomain A1: the problem\u003c/p\u003e\n\u003cp\u003eThe problem being addressed by the intervention (domain A1) scored high (3.0) in the online survey, with most participants agreeing that the prevention of sarcopenia is of importance, as a great number of older adults are affected by it. This importance was underlined by the numbers and trends on sarcopenia found during the document analysis. In 2045, the prevalence of sarcopenia is expected to rise from 12.9% to 22.3%, according to estimations from Europe\u003csup\u003e42\u003c/sup\u003e. Participants of the focus groups indicated that while sarcopenia prevention is not always a top priority, HCPs and researchers pay more attention to sarcopenia than policymakers do at the moment.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The prevention of sarcopenia helps to delay and prevent a significant amount of suffering in the elderly, which is beneficial for their quality of life, for extending their longevity in good health, and for avoiding unneeded medical care and expenses.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e- Physical therapist\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDomain A2: the intervention\u003c/p\u003e\n\u003cp\u003eThe intervention (domain A2), ProMuscle, was found to be effective in improving muscle strength, muscle mass, and physical functioning\u003csup\u003e11,12\u003c/sup\u003e. As a result, this domain scores high (3.0). However, survey participants questioned the perceived awareness of the intervention among older adults and HCPs. Awareness often arises only after experiencing sarcopenia related issues, such as falls or hospitalization. Participants in the interviews suggest that emphasizing daily life benefits of muscle strength exercises combined with a protein-enriched diet is more effective than solely promoting the prevention of sarcopenia. Additionally, participants during the focus groups stressed the importance of reaching older adults with a lower socioeconomic position.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I believe that a lot of senior individuals are unaware that functional decline is something that may be actively addressed and is not always an inevitable aspect of ageing. [\u0026hellip;] I believe that individuals did not know they needed it [ProMuscle] until after the program. From an outsider\u0026rsquo;s perspective, I believe that such a program is necessary, but not that a significant portion of the target population itself has an inherent need for it.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;- Policymaker\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDomain A3: strategic and political context\u003c/p\u003e\n\u003cp\u003eThe strategic and political context (domain A3) scores moderate (2.0). Policy documents showed that current policies in the Netherlands, such as the Ministry of Health, public health agencies, and local governments are stressing priority on prevention. The focus is mainly on broader goals such as independent living, healthy ageing, promoting a healthy lifestyle, and fall prevention, rather than specific conditions such as sarcopenia\u003csup\u003e39,40\u003c/sup\u003e. ProMuscle aligns well with these goals but lacks recognition as a validated fall prevention intervention\u003csup\u003e10\u003c/sup\u003e. Moreover, participants in the interviews and focus groups consider the program to fall into a niche in terms of insured care in the Netherlands. Their experience is that fall prevention interventions are reimbursed by insurance companies, as are lifestyle programs for people with obesity. An intervention like ProMuscle, which indirectly contributes to fall prevention and could be seen as a lifestyle program for community-dwelling older people is currently not reimbursed by health insurance. Increasing ProMuscle\u0026rsquo;s visibility and highlighting its additional benefits, such as fall prevention, to address loneliness, and facilitating independent living, could enhance its value, adoption and scale-up according to the participants in the focus groups.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;[\u0026hellip;] The only thing that does not entirely match the current situation is your intervention [ProMuscle]. That is to say, there is broad support, the reason it [ProMuscle] does not align with the current strategic and political context is that ProMuscle\u0026rsquo;s outcomes does not fit the guidelines.\u0026rdquo; - Policymaker\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDomain A4: evidence of effectiveness\u003c/p\u003e\n\u003cp\u003eProMuscle received a high rating (3.0) when it came to the evidence of effectiveness of the intervention (domain A4). The existing scientific evidence and the participants\u0026rsquo; personal observations, that older adults perform better on a variety of physical tests and report fewer challengers in their daily lives, support this high rating\u003csup\u003e8,11,13,42\u003c/sup\u003e. While the survey feedback confirms this score, focus group participants question the existence of any equivalent, less expensive, but just as effective interventions to address sarcopenia in older adults. Other participants also brought up the possible connection to other interventions, such as walking programs and fall prevention initiatives, highlighting how crucial it is to emphasize the interventions\u0026rsquo; additional value in order to effectively market ProMuscle and optimize collaboration and impact.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;It [ProMuscle] works fine, but there might be other, cheaper options, like walking or something. [\u0026hellip;]. So, to what extent do you need to specify this problem [sarcopenia], and how necessary is this particular solution, and could other options work as well?\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u0026ndash; Physical therapist\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDomain A5: intervention costs and benefits\u003c/p\u003e\n\u003cp\u003eSurvey respondents gave a high score (3.0) to the question of whether the benefits of the intervention could potentially outweigh its costs (domain A5). According to their responses in the qualitative feedback of the survey, the benefits are evident, such as reducing healthcare costs through fall prevention and promoting healthy ageing. However, interview participants indicated that the cost of ProMuscle is often too high at individual level, which could discourage participation of older adults. Particularly for older adults with less financial resources, the costs of the intervention potentially widen health disparities. The interviewees stated that obtaining support from funding providers and collaborating with other professionals (e.g., exercise coaches or community workers) is crucial. Such collaboration may help address cost-related challenges by allowing other professionals to deliver parts of the ProMuscle intervention, thereby reducing dependency on more costly HCPs. Additionally, maintaining long-term behavioural change is challenging, and ensuring the intervention\u0026rsquo;s continuity is essential to achieve sustainable benefits.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s a difficult question. Who gains from the expenses? When considering this from the standpoint of the elderly, wealthy and well-educated individuals will be willing to pay for this [ProMuscle], but a significant number of older adults will not be able to pay for this [ProMuscle]. From the standpoint of public health, ProMuscle contributes to cost saving since it is a successful intervention that prevents falls and promotes healthy ageing.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u0026ndash; Government official\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDomain B1: fidelity and adaptation\u003c/p\u003e\n\u003cp\u003eIn terms of the fidelity and adaptation of ProMuscle (domain B1), the online survey showed a high score (2.3). The document analysis indicated that the intervention is deemed acceptable and feasible to implement in daily practice of physical therapists and dietitians. ProMuscle was implemented with high fidelity, supported by the extensive support, including the training of physical therapists and dietitians, and the close relationship to practice\u003csup\u003e3,41,42\u003c/sup\u003e. To achieve the documented benefits of ProMuscle when scaled up, interview participants stressed the importance of ensuring the intervention\u0026rsquo;s core elements, including twice-weekly strength training and increased protein intake. Professionals other than physical therapists and dietitians as potential deliverers of ProMuscle was discussed in the qualitative survey feedback and focus groups, raising some concerns about control and regulation of the intervention. While regulated professionals have quality systems in place, exercise coaches, for example, do not subject to these formal requirements. Therefore, focus group participants stressed the need for process evaluation and documentation when changes to the intervention are made. While less intensive adjustments, such as the involvement of movement professionals other than physical therapists and dietitians, may reduce the intervention\u0026rsquo;s effectiveness, alternative forms of support may work if they are customized to the target population. Finally, the need to monitor compliance and the quality of the intervention providers was highlighted across all steps of the scalability assessment.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;You try your best to provide the professionals with the tools and training they need. In reality, however, you see that things occasionally change or are done differently. Then the question is, how horrible is that? And to what extent can you control that?\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;- Researcher\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDomain B2: reach and acceptability\u003c/p\u003e\n\u003cp\u003eThe reach and acceptability of the intervention for the target population (domain B2) also scored high (2.5). ProMuscle targets community-dwelling older adults aged 65 or older who are (pre-)frail or experience muscle strength loss in daily activities and are motivated to participate for at least 12 weeks\u003csup\u003e10\u003c/sup\u003e. According to survey and interview participants, it is essential that older adults themselves recognize the urgency of preventing age-related issues if ProMuscle is to be scaled up and is offered to a broader population. The program\u0026rsquo;s cost, frequently cited as a barrier across all data collection - especially for older adults with low incomes - highlights the need for funding and partnerships to improve reach and acceptability. Focus group participants suggested that collaboration with general practitioners and their assistants is essential for referring individuals to the intervention and may help encourage participation. In addition, partnering with local fitness- and municipal exercise professionals was considered as a possibility to reach more older adults. This is due to the fact that these professionals have a lower hourly rate, which would make ProMuscle more affordable. In terms of acceptability, research shows that older adults and HCPs rated the intervention positively, with satisfaction scores of 8.3 and 7.8\u003csup\u003e3\u003c/sup\u003e. Interview participants also reported positive experiences with the target group following their involvement in the intervention.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We observed that many older adults do not seek assistance as long as they are not experiencing any issues. Committing to a program on a weekly or more frequent basis is often too much for them. Additionally, financial costs are a common barrier. Although I still see several obstacles, I believe the program is suitable for the target population.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u0026ndash; Physical therapist\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDomain B3: delivery setting and workforce\u003c/p\u003e\n\u003cp\u003eThe delivery setting and workforce (domain B3) received a high score (2.5). Based on research found in the document analysis, ProMuscle is implemented by physical therapists and dietitians, focusing on strength training and nutrition\u003csup\u003e10\u003c/sup\u003e. The program was deemed compatible with regular workflows by primary care practices according to focus group participants. They expressed interest in continued involvement, as long as they have enough time to implement the intervention and access to the target population for recruitment\u003csup\u003e3\u003c/sup\u003e. Respondents in both the survey feedback and interviews endorsed dietitians and physical therapists for the program but suggested partnering with other professionals in sport and physical activity. For instance, participants described opportunities to expand ProMuscle to gyms, municipal sports programs, and broader healthcare settings, offering low-threshold access and more affordable for older adults. Focus group participants also deemed these collaborations helpful in more effectively reaching more vulnerable groups. However, reimbursement of prevention activities as well as the increased time pressure on HCPs were cited as potential factors reducing the acceptability of the intervention providers. Some focus group participants suggested that ProMuscle might be better suited to the social domain, with support from municipalities or health insurers to broaden its reach and make participation more affordable.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;When the general practitioner, physical therapist and fitness instructors work together well, we see that the general practitioner, who now refers to the physical therapist far too frequently in our opinion, is referring more often to the network as a whole. At that point, you will realise that you can actually change things!\u0026rdquo; \u0026ndash; Policy maker\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDomain B4: implementation infrastructure\u003c/p\u003e\n\u003cp\u003eA moderate score (2.0) was given to the implementation infrastructure required for scale-up (domain B4). According to the survey feedback, interviews, and focus groups, ProMuscle has potential to contribute to healthy ageing and preventive care. However, its successful integration depends on addressing key barriers. Several respondents emphasized the need for additional (partial) funding to ensure accessibility for all older adults, regardless their financial status. Participants across all steps suggested that without financial support from insurers or government entities, the program might not gain broad acceptance. Competing programs, such as walking clubs, exercise groups for community-dwelling older adults, and fall prevention programs, offer alternatives with lower costs, making municipalities possibly hesitant to adopt a program without clear advantages. For HCPs to dedicate time and energy to the implementation of ProMuscle, funding and collaboration with other HCPs, was also considered essential by participants of the focus groups. They also emphasized that, like other initiatives, ProMuscle\u0026rsquo;s success relies on general practitioners and local care providers recognizing the interventions\u0026rsquo; value. A structured approach, with the support tools for municipalities and healthcare providers, could facilitate implementation. Additionally, they suggested that building partnerships with community centers and sports facilities could further embed ProMuscle into local structures, enhancing both accessibility and sustainability. They mentioned that this approach may ensure that the program is not only preventive but also integrated into the broader social support systems, such as those addressing fall prevention and overall well-being. By involving the social domain, ProMuscle could also reach more vulnerable populations.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;As soon as interventions or programs receive structured implementation support, the focus on these initiatives is maintained. But the main problem is that we have twenty programs like that and creating that kind of support structure for all of them is not feasible. This is where the public health service could play a role.\u0026rdquo; \u0026ndash; Policy maker\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDomain B5: sustainability of the intervention\u003c/p\u003e\n\u003cp\u003eThe final domain of the ISAT addressed the perceived sustainability of the intervention, which also scored high (2.3). Further emphasis on the need for funding, improving accessibility, general support and sustainable implementation was raised in the survey feedback, interviews, and focus groups. Focus group participants raised concerns about the long-term maintenance of lifestyle changes promoted by the intervention. They emphasized the importance of sustaining these changes to prevent sarcopenia and extend physical independence over time. Lastly, focus group participants determined that to sustain outcomes and ensure lasting behavioural change among older adults, follow-up sessions, ongoing support, and an integrated approach are required.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The challenge is that these initiatives are often temporary, and this raises questions about their long-term effectiveness. Ultimately, it is about finding a sustainable place for the program and connecting it with existing efforts, whether in politics or the broader field of prevention.\u0026rdquo; \u0026ndash; Government official\u0026nbsp;\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe aim of this study was to assess the scalability of ProMuscle, a combined lifestyle intervention for community-dwelling older adults. The scalability assessment of ProMuscle indicates strong potential for scale-up. The high prevalence of sarcopenia among older adults highlighted the importance of its prevention, making it a key priority for the scale-up of ProMuscle. The intervention is considered effective, aligns with broader health goals such as fall prevention, and its benefits are deemed to outweigh the costs. Domains related to implementation, such as reach and acceptability, and delivery setting and workforce indicated that ProMuscle was well-received and deemed appropriate in primary care settings. However, some important barriers for larger-scale implementation are identified as well, such as the strategic and political context and implementation infrastructure. Addressing these threats is essential before proceeding with large-scale implementation.\u003c/p\u003e\u003cp\u003eFirst, the limited prioritization of sarcopenia prevention among HCPs and policymakers, as well as the general lack of awareness among older adults, are important barriers for scaling the intervention. While sarcopenia was officially recognised as a medical condition in 2016, many stakeholders remain unfamiliar with its implications and the preventive measures necessary to address sarcopenia\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Targeted advocacy and educational campaigns could be used to raise awareness among the stakeholders to address this issue\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. Aligning ProMuscle with broader health strategies and emphasising its cost-effectiveness through economic evaluations can strengthen its position within policy frameworks\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. Research shows that policymakers are more likely to use evidence when it is timely, relevant, and presented with clear recommendations\u003csup\u003e\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e,\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u003c/sup\u003e. The lack of prioritization of sarcopenia prevention is often reinforced by barriers such as limited access to applicable research, mistrust, and poor timing, whereas facilitators such as personal contact and collaboration with researchers can help increase its visibility\u003csup\u003e\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e,\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u003c/sup\u003e. Building strong relationships, through an integrated approach that aligns with existing policies, health initiatives, and funding mechanisms, could promote successful scale-up. A relevant example is the attention for fall prevention, which has been successfully scaled up due to government endorsement and reimbursement through basic health insurance. Its integration into national policy has enabled widespread implementation in primary care\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eSecond, the required implementation infrastructure, particularly structural funding and sustainable collaboration across healthcare and other domains, hinders large-scale implementation of ProMuscle. Considering ProMuscle’s proven effectiveness, the availability of cheaper, more generalised healthy aging programs may make ProMuscle less appealing to policymakers and funders\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e,\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e\u003c/sup\u003e. While aerobic exercise supports overall health, resistance training combined with nutritional support is essential for preventing sarcopenia and maintaining independence in older adults\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e\u003c/sup\u003e. This study identified financial constraints as a frequently mentioned, persistent barrier among participants, aligning with existing literature that highlights cost as a key obstacle for older adults to participate in health interventions\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Affordability concerns, particularly among older adults with less financial resources, further emphasise the necessity of securing sustainable funding. Older adults in this group are more likely to experience health disparities, highlighting both the need and the potential for targeted interventions to advance health equity and improve health outcomes\u003csup\u003e\u003cspan additionalcitationids=\"CR56\" citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e–\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e\u003c/sup\u003e. Implementing cost-effective strategies, such as resource optimisation, economies of scale, and cost minimisation, could enhance financial sustainability while preserving intervention quality\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. By addressing these barriers, interventions could increase their reach and effectiveness within aging populations. To support scale up, demonstrating ProMuscle’s value and long-term impact is crucial to establish partnerships with stakeholders and securing sustainable funding.\u003c/p\u003e\u003cp\u003eFurthermore, to ensure both scalability and quality, collaborations with other HCPs and alternative settings, such as fitness or community centers, are considered necessary. These foreseeable adaptations to ProMuscle, as part of the development of implementation infrastructure, are also based on the goal to reach a larger population. One strategy proposed in this study to address workforce limitations is the inclusion of movement professionals, such as sports coaches, lifestyle coaches, and fitness instructors, as deliverers of selected components if scaled up. This approach could help reduce costs and attract older adults with lower incomes, as these professionals typically have lower hourly wages and are more accessible than specialized facilities, thereby improving overall accessibility\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. Some concerns about this approach were raised as well, assigning this intervention to lower-skilled staff may affect the quality of the program delivery. Therefore, a tailored delivery model could further enhance scalability by differentiating support based on the needs of older adults. For instance, younger, fitter participants requiring minimal supervision could be guided by fitness instructors, while older adults with more complex health conditions or frailty could receive more specialized support from physical therapists and dietitians. Such a stratified approach could optimize resource allocation, ensuring that those with greater care needs receive appropriate expertise while maintaining cost-effectiveness for the broader population\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. A similar model has been successfully applied in osteoarthritis treatment, where individuals are screened and referred to the most suitable level of care. This model emphasizes matching care intensity to patient needs, promoting efficient resource use and enhancing patient engagement in decision-making\u003csup\u003e\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e,\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStrengths and limitations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOne of the main strengths of this study is the use of the structured approach ISAT offers to assess scalability. The ISAT allowed for a detailed analysis of various domains, offering valuable insights into the intervention’s current positioning and areas that require improvement, enhancing the reliability of the findings. However, a notable limitation of using the ISAT is that some important aspects, such as the integrated approach, collaborations, scaled-up harms, and health inequities, are not explicitly addressed within the tool. These aspects were instead categorised under the next most appropriate domain. Another strength of this study lies in the diverse group of participants involved in the data collection. The participants included individuals with varying levels of experience, expertise, and professional backgrounds, which enriched the data with a broad range of perspectives. However, the differences in experience and timing of data collection across participants could also introduce some variability, which may have affected the consistency of responses and interpretations. Lastly, the mixed methods design of the study provided several advantages, providing a rich, multifaceted understanding of the intervention’s scalability. By combining both quantitative and qualitative data, the study provided complementary perspectives and a deeper analysis. However, the complexity inherent in a mixed methods design also posed challenges in data integration. Ensuring that quantitative and qualitative results were appropriately integrated required careful attention, especially when discrepancies arose between the two types of data. These challenges highlight the need for caution in drawing conclusions.\u003c/p\u003e"},{"header":"Conclusion and implications","content":"\u003cp\u003eThis scalability assessment shows that the ProMuscle intervention holds strong potential, but further planning is needed to enable successful scale up. For complex interventions like ProMuscle, a guided process, rather than spontaneous diffusion, should be prioritized before scale up. To support this process, researchers, policymakers, and HCPs each play key roles. Research should identify what works and how to implement effectively, ensuring interventions are both effective and acceptable to the target population, and to drive selection by policymakers. To achieve structural and sustainable funding for interventions like ProMuscle, clear responsibility must be taken by policymakers, health insurers, and, where appropriate, older adults themselves. Policymakers in particular play a critical role in selecting, financing, and embedding effective interventions, while HCPs are essential for implementation and delivery in practice. Participants involved in this study showed a strong commitment to sustaining the intervention and are motivated to explore funding and collaboration opportunities to further embed ProMuscle into care for older adults. Further research should explore the scalability of ProMuscle in diverse settings and delivered by a variety of HCPs. Particular attention should be given to equity, to ensure that the intervention is accessible to underserved populations who may benefit most. Additionally, long-term health outcomes should be evaluated to assess whether ProMuscle remains effective and sustainable over time.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eISAT = Intervention Scalability Assessment Tool\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHCP = Healthcare Professional\u003c/p\u003e\n\u003cp\u003eGRAMMS = Good Reporting of A Mixed Methods Study\u003c/p\u003e\n\u003cp\u003eGGD = Gemeentelijke GezondheidsDienst / Public Health Service\u003c/p\u003e\n\u003cp\u003eVWS = Ministerie van Volksgezondheid, Welzijn en Sport / Ministry of Health, Welfare and Sport\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRIVM = Rijksinstituut voor Volksgezondheid en Milieu / National Institute for Public Health and the Environment\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eKNGF = Koninklijke Nederlands Genootschap voor Fysiotherapie / Royal Dutch Society for Physical Therapy\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eEthics approval and consent to participate \u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for the overarching study was granted by the Medical Committee University Utrecht (22/050). All participants gave written or verbal consent for participation in this study. All methods were performed in accordance with the relevant guidelines and regulations.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConsent for publication \u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eAvailability of data and materials \u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analysed during the current study are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis research was financially supported by a grant from the Regiodeal Foodvalley (162135).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study was set up by PL and BD under the supervision of DB. Document analysis was conducted and analysed by BD and AH, interviews were conducted by AH, surveys were distributed by PL, and focus groups were conducted by LB and PL. Interviews, surveys, and focus groups were coded, analysed and interpreted by LB and PL. The manuscript was written by LB. PL, BD, AH, CV, DB, and LS critically read the manuscript and provided feedback. All authors read and approved the manuscript for submission.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eUnited Nations. Leaving No One Behind In An Ageing World. World Social Report 2023. [Internet]. Available from: https://desapublications.un.org/publications/world-social-report-2023-leaving-no-one-behind-ageing-world. 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Sax Institute. 2019. Available from: https://preventioncentre.org.au/resources/the-intervention-scalability-assessment-tool/. [Accessed 5th August 2024].\u003c/li\u003e\n\u003cli\u003eNorthwood M, Chambers T, Fisher K, Ganann R, Markle-Reid M, Yous ML, et al. Readiness for scale up following effectiveness-implementation trial: results of scalability assessment of the Community Partnership Program for diabetes self-management for older adults with multiple chronic conditions. BMC Health Serv Res. 2025 Feb 20;25(1):284. \u003c/li\u003e\n\u003cli\u003eGrady A, Jackson J, Wolfenden L, Lum M, Yoong SL. Assessing the scalability of healthy eating interventions within the early childhood education and care setting: Secondary analysis of a Cochrane systematic review. Public Health Nutrition. 2023;26.\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Cathain A, Murphy E, Nicholl J. The quality of mixed methods studies in health services research. 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Communities in Action: Pathways to Health Equity. 2017. \u003c/li\u003e\n\u003cli\u003eSmink AJ, Dekker J, Vliet Vlieland TPM, Swierstra BA, Kortland JH, Bijlsma JWJ, et al. Health care use of patients with osteoarthritis of the hip or knee after implementation of a stepped-care strategy: An observational study. Arthritis Care Res (Hoboken). 2014;66(6). \u003c/li\u003e\n\u003cli\u003eSmink AJ, Van Den Ende CHM, Vliet Vlieland TPM, Bijlsma JWJ, Swierstra BA, Kortland JH, et al. Effect of stepped care on health outcomes in patients with osteoarthritis: An observational study in Dutch general practice. British Journal of General Practice. 2014;64(626). \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Lifestyle intervention, Scalability, Implementation Science, Physical functioning, Older Adults","lastPublishedDoi":"10.21203/rs.3.rs-7156488/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7156488/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThe global population is ageing, leading to an increase of older adults with sarcopenia, a condition associated with reduced quality of life and higher healthcare costs. ProMuscle, a 12-week intervention combining strength training and protein intake, has been shown to effectively improve physical functioning in older adults. Although ProMuscle has demonstrated promising results on a smaller scale, further scale up requires adapted strategies to address emerging challenges. This study aims to assess the scalability of ProMuscle, systematically guided by the Intervention Scalability Assessment Tool (ISAT).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA mixed-methods approach was used, combining a review of documents, interviews (n\u0026thinsp;=\u0026thinsp;8), online surveys (n\u0026thinsp;=\u0026thinsp;49), and consensus focus groups (n\u0026thinsp;=\u0026thinsp;2), all involving key stakeholders. Each of the ISAT domains - \u003cem\u003ethe problem, the intervention, strategic and political context, effectiveness, costs, fidelity and adaptation, reach and acceptability, delivery setting and workforce, implementation infrastructure, and sustainability\u003c/em\u003e \u0026ndash; were addressed during data collection. Findings of the scalability assessment were displayed for each of the ISAT domains in a radar plot.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe ISAT indicates that ProMuscle holds strong potential for scale up. The demonstrated effectiveness, the relevance of sarcopenia prevention, its alignment with broader health priorities, and its potential to reduce healthcare costs were supported by both scientific evidence and stakeholder consensus. However, key challenges were identified in the strategic and political context and implementation infrastructure, which must be addressed before further scale up. Structural barriers, such as the lack of sustainable funding, limited awareness, and lack of prioritization of sarcopenia among policymakers and healthcare professionals were described as significant challenges.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eProMuscle shows strong potential for scale up but requires a guided and coordinated approach. Successful scaling depends on collaboration between researchers, policymakers, and healthcare professionals, with clear responsibilities for sustainable funding and integration into routine care. Future efforts should focus on equity, long-term effectiveness, and adaptability across settings to ensure broad and lasting impact.\u003c/p\u003e","manuscriptTitle":"Evaluating the Scalability of the ProMuscle Intervention for Community-Dwelling Older Adults: A Mixed Methods Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-29 09:31:05","doi":"10.21203/rs.3.rs-7156488/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"da5bb5ac-bd6f-453f-8157-372f886d4610","owner":[],"postedDate":"July 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-01T12:53:57+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-29 09:31:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7156488","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7156488","identity":"rs-7156488","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}