2.1 The cooperative planning approach

The CP is a research-driven participatory approach that engages various actors (e.g., researchers, policymakers, health promotion practitioners, population group representatives) in jointly designing, planning, and implementing tailored PA actions (or interventions) that fit to the preconditions of the setting and needs of the population group addressed [19]. The CP process typically consists of 6–8 meetings, which includes an initial assessment, brainstorming potential PA promotion actions, prioritizing ideas, and adopting an action plan for implementation. Action plans may include specific PA offers and sport activities (e.g., swimming classes), but also advocate changes to infrastructures or regulations that help promote PA.

In the German PA and health promotion field, the CP approach has been extensively used, and quite a few projects have succeeded in implementing such actions on a long-term basis [16,20]. The implementation experiences of projects gathered in the last two decades show how versatile the CP process – it changes the context in which it takes place, but also may get changed by the context, see CP’s methodological flexibility in the study of Abu-Omar and colleagues [21]. As such, one can see CP as a method to co-develop actions for promoting PA, such as sport offers, which are ultimately referred to as “PA interventions”. Due to its complexity [19], CP can also be considered an intervention in its own right [22], as the process has the potential “to transform the system due to its interaction with the context and the capability created from this interaction” [23]. However, the widespread use of CP across multiple projects, as either method or intervention, poses challenges for scaling up participatory projects using CP. It becomes difficult to determinate which elements belong to CP and are applicable to broader contexts, and which are context-dependent [23]. The question arises as to whether the CP approach itself represents an innovation that can be scaled up, along with its step-by-step implementation guidelines. Alternatively, we need to consider if the PA actions developed through the CP are the primary innovations that should be scaled up. In other words, is the focus on transferring that CP methodology, or should we prioritize scaling context-specific actions for promoting PA that emerge from this process?

2.2 The Capital4Health consortium

In response to the national objective of sustainably adopting and transferring innovative approaches, the German Federal Ministry of Education and Research provided political support by launching the Health Research Program, Action Plan for Prevention and Nutrition Research. This initiative offered funding for three years, with the possibility of an additional three years, to support research consortia focused on primary prevention and health promotion [24].

Capital4Health (C4H) is one of the research consortium that received funding in two phases: from 2015 to 2018 (Pilot project phase) and 2018–2023 (Scale-up phase), with a total of 2,8 million Euros as part of an effort to strengthen national research on prevention. Its four empirical projects – A4M (“Action for men”), health.eduPLUS (“Health-related Education”), PArC-AVE (“PA-related Health Competence in Apprenticeship and Vocational Education”), and QueB (“Qualität entwickeln mit und durch Bewegung/Developing Quality with and through PA“) – focused on promoting PA. As shown in Table 1, the projects varied in setting, population groups, goals, and outcomes.

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Table 1. Overview of projects, intervention settings, sites, target groups, and pilot phase-developed actions and outcomes.

https://doi.org/10.1371/journal.pone.0326737.t001

In the pilot phase (2015–2018), the four projects used the participatory CP approach to co- design and co-develop tailored PA-promoting actions, such as media campaigns, infrastructure improvements, group-specific PA, health programs or courses, and capacity building among key stakeholders (i.e., teachers) [19,32,33]. The participatory nature of the projects allowed various groups (e.g., target group, stakeholders, researchers, professionals) to work together, developing various for PA promotion that reflected their unique resources, expectations and visions for enhancing local PA promotion within their settings. Given the effectiveness of the CP approach in fostering engagement and generating impactful actions, it was further recommended for use in the second phase of the consortium.

In the scale-up phase (2018–2022), the projects aimed to scale the CP approach and/or components of their pilot projects to broader population groups and further settings. As shown in Table 1, the types of setting remained broadly the same (i.e., community, school, childcare center, car mechatronics), but varied in their specific forms (e.g., transitioning from elementary to primary school, or from private to state nursing schools). These differences introduced new underlying conditions for scaling up within the new sites compared to those in the pilot phase. Given the varied setting and their distinct conditions and capacities for promoting PA, the projects prioritized designing and planning the process in close collaboration with the local policymakers, professionals, and population groups of each new implementation setting, rather than simply “transferring” the innovations form the pilot phase. This approach aimed to ensure that both the scale-up process and the PA promotion strategies would be well-suited to the unique contextual conditions of each new site.

2.2 Research design

We used a qualitative research design to investigate the key elements of scale-up, particularly the innovations (see below) scaled within the empirical projects and strategies for transfer and institutionalization. For this, we relied on different types of data collected from various perspectives and at various points in time, thus ensuring a higher quality of results [34–41] The work by Tong and colleagues [35] guided our reporting of qualitative findings.

Based on our previous research on scale-up in PA promotion [36], we identified the WHO-ExpandNet framework [6], initially designed to help with planning scale-up, as a suitable framework to retrospectively analyze such processes [37,38]. The WHO-ExpandNet framework (see Fig 1) enables the identification of the following key elements: (a) the innovation (“What was actually transferred to other contexts?”); (b) the user organization(s) responsible for implementing the innovation on a larger scale (“Which entities adopted the innovation and how did this influence its scale-up?”); (c) the resource team that tested the innovation and sought to promote its wider use (“Which entities, familiar with the innovation from its pilot testing, supported its scale-up?”); (d) the context in which scale-up took place (“What was the socio-cultural-political and economic context in which scale-up occurred, i.e., roles, interactions, and relationships?”); and (e) the different strategies adopted for scale-up.

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Fig 1. The WHO-ExpandNet framework for scaling up (6, p.5).

https://doi.org/10.1371/journal.pone.0326737.g001

2.3 Data collection

We based our research on the consortium’s documentation (in particular, the grant proposal of the scale-up phase phase) and semi-structured focus group interviews (n = 15) with the researchers of the four projects scaling up the innovation. In total, 19 scientists participated in the study (n = 4 from A4M; n = 6 from health.eduPLUS; n = 4 from PArC-AVE; n = 5 from QueB). The authors of this study were also researchers within the Capital4Health consortium, who informed participants about study’s objectives and recruited them during collaborative work within the consortium.

The grant proposal included both a general description of the consortium’s focus as well as specific objectives and workplans of each project. Its analysis allowed for a systematic review of the projects’ intended scale-up targets and activities. One researcher (SF) conducted two rounds of interviews (n = 10) with project teams on different topics (e.g., project status, project’s collaboration partners, and key challenges associated with different research tasks). Participants were recruited from March 12^th until March 26^th, 2019, and the first round of face-to-face interviews (n = 5) lasted ∼60–85 min. For the second round of interviews (n = 5), participants were recruited from January 15^th until March 18^th, 2020. Due to the Covid-19 pandemic, the interviews were conducted in a web-based format, lasting ∼40–80 min. Conducting interviews at least twice allows for a full understanding of scale-up-related complexities and gives researchers the opportunity to revise their findings at a later time [40]. For the present study, only data related specifically to scale-up were analyzed. Results on scientific collaboration are reported elsewhere [39]. A third round of interviews (n = 5) was conducted online by two researchers (RS; LB) from August 6^th to October 11^th, 2021, and lasted ∼75–90 min. These interviews included specific questions about the choices made to achieve scale-up aims [41] to retrospectively assess to what extent the projects succeeded in reaching their goals for scaling up.

2.4 Data analysis

All interviews were audio-recorded and transcribed verbatim. RS performed a deductive content analysis [42] using MAXQDA software. RS created a codebook with a prime example for each code and translated all codes from German to English. LB analyzed the data, reviewed the codes, and verified translation accuracy. Discrepancies were discussed between RS and LB until agreement was reached. In the next step, the grant proposal was analyzed to identify the essential elements of scale-up and strategic scale-up choices for each project according to the WHO-ExpandNet framework [6]. Finally, all analyzed data were integrated into one set of results, which was discussed within the entire research group.

2.5 Ethical considerations

The Ethics Committee of the Friedrich-Alexander University Erlangen-Nuremberg granted ethical approval for this follow-up study (approval number: 390_18 B). All interviewees gave informed consent for the interview, the audio recording, and the scientific use of their data. All transcripts were anonymized so that no inferences could be drawn about the interviewees or others mentioned in the interview.

3.1 Case study 1: The “Action for men (A4M)” project

In the pilot phase, A4M used the participatory CP approach to improve PA in men over 50 in two rural communities. In the scale-up phase, the project aimed to transfer the CP process to a third community and engage local sports and non-sports associations (e.g., fire department) to jointly develop low-barrier PA offers for inactive men. The project collaborated with district and federal bodies (i.e., Health Administration of East Bavaria, Bavarian Medical Chamber) to disseminate new actions for PA promotion to other communities and regions.

3.2 Case study 2: The “health.eduPLUS” project

In the pilot phase, the project used the CP method to develop actions improving the sport-related health competencies of secondary school children, as well as the teaching competencies of physical education (PE) students. The scale-up phase focused solely on the scale-up of CP to four primary schools. Based on the experience from the pilot phase, the goal was to develop good practice examples for PE teachers to promote sport-related health competencies. The project also sought support from the Bavarian education authorities to disseminate these examples to PE teachers across Bavaria using a governmental PE teaching platform.

3.3 Case study 3: The “PArC-AVE” project

In the first funding phase, PArC-AVE used CP processes to address PA promotion in the vocational setting, namely in a car manufacturing company and a private nursing school. In the second phase, the project was extended to the production division of the car manufacturing company and two state-run nursing schools. One aim was to transfer the CP and use it to develop strategies to integrate PA promotion into regular work activities of the new organizations; the other was to include PA-related health competence into the curriculum of state nursing schools with support from Bavarian State Ministry of Education.

3.4 Case study 4: The “QueB” project

In the pilot phase, QueB intervened in twelve childcare centers located in two regions, where they applied the CP approach, followed by counseling and/or evaluation sessions on how those centers can promote PA among their staff and children. During the scale-up phase, QueB reached out to other childcare centers located in difficult social environments, characterized by challenging social circumstances, such as poverty and/or a large population of children with a migrant background. QueB aimed to scale-up the CP, but also actions developed within the pilot phase: a mobile app (the Check-App) and a certification procedure to annually assist centers on how PA-friendly they are. To achieve a wide roll-out, QueB established a close collaboration with a national platform for diet and PA promotion to create a network of stakeholders at the regional level. The project focused on training instructors by empowering them to facilitate PA promotion in other childcare centers in the region, especially those with low PA levels and hard to reach.

4.1 Central findings and implications for scaling up participatory projects

First of all, our results yielded useful insights regarding the “innovation” of participatory projects and strategies on how to transfer (horizontal scale-up) and institutionalize (vertical scale-up) them. In our study, most projects referred to the participatory CP method as the innovation planned to be scaled, but results show that other components of their pilot projects were also scaled to new sites. Most projects scaled up the CP process horizontally to new sites (different schools, company division, communities, childcare centers), but at the same time, many researchers utilized other components of their pilot projects (i.e., PA promotion actions successfully developed in the pilot phase – see examples in Table 2) to (a) transfer them directly to the new sites, and (b) subsequently scale them vertically within organizational structures and systems.

For example, in the A4M project, the CP approach was transferred to a third community, but instead of developing new low-barrier PA offers from scratch, local stakeholders opted to transfer and re-implement specific PA actions (i.e., the SportCard) that had been successfully implemented in the pilot communities of the project’s pilot phase. This strategy emerged from a collaborative decision-making process within the A4M project, involving the researchers and the other participants who were eager to transfer the successful PA strategy from the pilot phase. They collectively acknowledged that this strategy aligned with the capacities and needs of the new community. This result underscores the significant influence of context factors – such as cultural beliefs, local politics and/or available resources – can have on the scale-up process.

Such previously tested PA promotion actions may be less disruptive and easier to implement, and can thus have a substantial and immediate positive impact on the target setting. However, such a strategy bypasses a core tenet of CP and no longer aligns with its original goals (see Section 2.1.) regarding empowerment and structural changes [15].

In terms of participatory research, one might argue that the process shifts from a bottom-up to a top-down approach when changing the perspective on the innovation to be scaled, i.e., when adopting tested PA promotion actions directly (innovation=actions for PA promotion; as described in the case of the A4M project) rather than involving population groups intensively in their planning and development (innovation=CP; as in the case of the PArC-AVE project). Also, it no longer aligns with the WHO’s recommendations on working multisectorally and transdisciplinarily in order to develop solutions that have the power to alter structures at a systemic level and are disruptive enough to trigger sustainable change processes [44]. On the other hand, it may be well-suited to the current era of complex problem situations and challenges (e.g., climate change, pandemics) that requires solutions leading to rapid change in population behavior. This desire for “simpler” actions that lead to quicker changes is apparent in the third community of A4M, which skipped much of the CP development phase to directly implement actions that provided people with faster access to PA. In addition, as participatory processes like the CP require substantial resource allocation to engage members of the population group, policymakers, and practitioners [33], the direct scale-up of specific actions may often be considered a much cheaper (and thus much more attractive) option by community leaders.

However, it must be noted that the experience from Capital4Health indicates that the CP should not be abandoned completely in favor of a direct scale-up of actions for PA promotion. Rather, the CP is merely given a slightly different role within the scale-up process: It is still used to facilitate the original participatory development of actions, and many projects will first repeat the process at new sites as intended by the original concept. However, as more and more successful actions become available, there may be a shift from repeating the process towards directly transferring actions to other, comparable sites, see for example the study of Herbert-Maul et al. [13]. This tradeoff may be considered acceptable as (a) the actions are rooted in a participatory process and (b) the transformation process is constantly gaining pace. One may conclude that it could be useful to build a gradual change of focus regarding the innovation (from the participatory process towards its actions) into the scale-up concept of future participatory projects right from the start.

Another important finding pertains to the relationship between horizontal and vertical scale-up in participatory projects. Available research emphasizes that horizontal scale-up alone is not sufficient to ensure that people benefit from the innovation on a long-term basis – vertical strategies are needed for “policy, political, legal, regulatory, budgetary, or other health systems changes” [6] to achieve sustainability. This was illustrated by health.eduPLUS and PArC-AVE, both of which transferred (i.e., scaled horizontally) the CP method to new sites but used specific actions (e.g., PE content lesson, PA promotion concepts) to try to institutionalize (i.e., scale vertically) these actions to the state teaching curriculum and good practice database, respectively. Experience from other projects also suggests that specific PA actions developed within participatory processes can only be successfully integrated into local health promotion structures if they are developed in a participatory manner [13]. However, as in the case of a direct transfer of actions to other sites, health promoters need to be aware that the increased reach of such institutionalized actions comes at the price of reduced “tailoring” to specific populations.

4.2 Strengths and limitations of the study

Several limitations to this study need to be mentioned: Generalizability of our results is limited, especially as some of our settings are unique to the German system (i.e., vocational training in companies, school types). Nonetheless, the similarity of our results to other studies [1,45] points towards essential aspects to consider in future strategic planning processes for enhancing scalability, regardless of country background [6,46,47].

Another shortcoming of our study relates to the quality criteria of reporting qualitative results [36]. During the interviews, some projects identified more key factors than others. By not returning our findings to the interviewees, we missed a chance for further improving our data. A possible solution for future research would be to send interviewees the questions in advance to enhance reflection of past events and help them better prepare for the interviews.

There are also some limitations related to our use of the WHO-ExpandNet framework. The ExpandNet was originally not developed for retrospective analysis, as done in this and other studies, e.g., [37], but as a prospective guideline for scaling interventions and increasing project impact. This presented several challenges for our analysis, particularly in terms of handling the complexity of the framework while considering the two purposes mentioned above. In our research, we had to streamline a part of the framework, focusing only on the key elements that were relevant for making affirmations related to the scaled innovation, the organizations and individuals responsible for implementation, their environments and scale-up strategies. Despite this decision, our results indicate that we were still able to provide a detailed description of the scale-up processes, mostly regarding the various ways of scaling participatory projects. However, it is worth noting that the ExpandNet framework has limitations in capturing the diversity of these strategies, necessitating conceptual adaptations when using the framework for participatory research.