Implementing Brain Health PRO Across Diverse Settings: A Multi-Site Implementation Study (BHPRO-IMP)

All participating sites implement BHPRO, a six-month, web-based dementia risk reduction program, using tailored implementation toolkits co-developed during Phase 1. Eligible end users at each site are offered access to the intervention. The study employs a single-group assignment without randomization or masking. Implementation is staggered across ten to fourteen Canadian sites, including community organizations, clinical settings, and one public health agency. The primary focus of the study is evaluation of implementation outcomes (adoption, sustainability, reach), while participant-level effectiveness outcomes are measured concurrently.

A 6-month, web-based dementia-risk-reduction program consisting of eight modules addressing modifiable risk factors: physical activity, diet, cognitive engagement, sleep, social and psychological health, vascular health, and vision/hearing health. Upon registration, participants complete baseline lifestyle questionnaires that generate a personalized risk profile. Participants are instructed to prioritize three risk domains based on their profile and receive tailored content accordingly. Materials include narrated educational content, visual aids, quizzes, interactive exercises, and evidence-based recommendations. Content is delivered gradually (four 10-minute chapters per week). All modules remain accessible throughout participation. Program engagement metrics, including chapter completion, are automatically captured through the platform.

The delivery of the intervention by the sites. Measure: Site implementation logs and twice-monthly champion reports; quantitative questionnaires Benchmark: ≥70% of sites adopt within 3 months of rollout.

The extent to which the intervention continues to be delivered by the sites one year after starting implementation.

Measure: Site implementation logs; program delivery logs; site documentation; focus groups.

Benchmark: ≥64% of adopting sites.

Participants from the sites who start the program. Benchmark: ≥67%. BHPRO platform analytics (automated backend); Reach Reporter (site champions, every 6 months).

Multi-level barriers and facilitators to BHPRO adoption and sustainability. Measurements: Semi-structured focus groups with site staff (60-90 min, audio-recorded, transcribed verbatim); monthly online meetings with site champions; analyzed using reflexive thematic analysis (inductive + deductive CFIR/RE-AIM framework). NVivo. ~20% double-coded.

The perceived fit, relevance, and compatibility of Brain Health PRO and of the Brain Health PRO Implementation Toolkit for the setting, as perceived by providers and organizational staff.

Measurements: Intervention Appropriateness Measure (IAM); a validated 4-item questionnaire. Each item is rated on a 5-point Likert scale. Item responses are averaged to produce the scale score.

Unit of Measure: Mean Intervention Appropriateness Measure score (range 4-20; higher = greater perceived appropriateness).

The extent to which Brain Health PRO can be successfully used or carried out within a given setting, as perceived by providers and organizational staff.

Measurements: Feasibility of Intervention Measure (FIM); a validated 4-item questionnaire. Each item is rated on a 5-point Likert scale. Item responses are averaged to produce the scale score.

Unit of Measure: Mean Feasibility of Intervention Measure score (range 4-20; higher = greater perceived feasibility).

Change in dementia literacy following participation in the study, as measured by the Alzheimer's Disease Knowledge Scale (ADKS). The ADKS is designed to assess knowledge about Alzheimer's Disease (AD) among laypeople, patients, caregivers, and professionals.

Measurements: This self-report questionnaire contains 30 true/false items. Unit of measure: The total score is the sum of the scores from the 30 items, which is quantitative and ranges from 0-30, with a higher score indicating better knowledge about AD.

Change in self-efficacy following participation in the study, as measured by the General Self-Efficacy Scale (GSE). The GSE measures perceived competence in dealing with a range of stressful or challenging situations.

Measurements: his self-report questionnaire contains 10-items, each rated on a 4-point scale (not true at all, hardly true, moderately true, exactly true).

Unit of measure: Responses are provided on a Likert scale. The total score is the sum of the scores for the 10 items, which is quantitative and ranges from 10-40, with a higher score indicating more self-efficacy

Change in composite score across 7 BHPRO dementia-risk domains: physical activity, nutrition, sleep, cognitive engagement, social and psychological health, vascular health, and vision and hearing. Details for each questionnaire are provided under separate outcomes.

Measurements: Scores for each risk factor will be standardized (z-score transformation using cohort-wide mean and standard deviation at baseline). When necessary, scores will be multiplied by -1 so that positive scores reflect lower risk. The participant-level mean risk score will be calculated which reflects the average z-score for the participant across the modifiable risk factors.

Description: The International Physical Activity Questionnaire-Short Form is a brief 7-item self-report measure that captures types of and intensity of physical activity and sitting time.

Measurements: The total score is calculated by summing the accrued number of points assigned per question. The total score ranges between 0-9, with a higher score indicating more physical activity.

Description: Shorter 11-item version of the Eating Pattern Self-Assessment Questionnaire developed by CCNA Team 5.

Measurement: The total score is calculated by calculating the accrued number of points assigned per question. The total score ranges between 0 and 22, with a higher score indicating more healthy eating habits.

Description: Brief 10-item questionnaire developed by BHPro sleep module content leads that assesses sleep duration, sleep patterns, and difficulties and daytime fatigue over the past 3 months.

Measurement: The total score is calculated by summing the accrued number of points assigned per question. The total score ranges between 1 and 20, with a higher score indicating healthier sleep.

Description: A 6-item questionnaire assessing types and duration of cognitively engaging activities.

Measurement: The total score is calculated by summing the accrued number of points assigned per question. The total score ranges between 0 and 36, with a higher score indicating more cognitively stimulating activities.

Description: An 8-item questionnaire comprising 1 item on loneliness, 1 item on ageism, 1 item on subjective age, 1 item on essentialist beliefs of aging and 4 items on depression, anxiety, stress, and social support from STOP-D.

Measurement: The total score is calculated by summing the accrued number of points assigned per question. The total score ranges between -1 and 50, with a higher score indicating poorer social and psychological health.

Description: 12-item self-report questionnaire developed by the BHPro Vascular Health team based on the American Heart Association's Life's Simple Seven checklist of the main risk factors for heart disease and stroke.

Measurement: The total score is calculated by summing the accrued number of points assigned per question. The total score ranges between -4 and 8, with a higher score indicating better vascular health.

Description: 10-item questionnaire developed by BHSP Vision and Hearing Module content leads that assesses perceived visual and auditory ability and actions taken to address potential vision/hearing difficulties.

Measurement: The total score is calculated by summing the accrued number of points assigned per question. If a user selects "Yes" for example, they receive 2 points for that question. The total score ranges between 0 and 20 points, with a higher score indicating poorer vision and hearing.

Change in cognition as measured by the Cogniciti Brain Health Assessment after 6 months.

Description: The Cogniciti Brain Health Assessment (BHA) is a self-administered validated computerized cognitive assessment comprised of four tests (Spatial Working Memory, Stroop Interference, Face-Name Association, and Number-Letter Alternation).

Measurement: The overall Cogniciti Brain Health Assessment score ranges from 0-100 with a higher score indicating better cognition.

Proportion of BHPRO chapters completed. Target benchmark: ≥80% chapter completion.

Measurements: BHPRO platform engagement log (number of chapters completed out of total available).

Usability of the Brain Health PRO platform, assessed with the System Usability Scale (SUS).

Measurements: The SUS is a 10-item questionnaire; each item is rated on a 5-point Likert scale (from strongly disagree to strongly agree), worded in reference to Brain Health PRO. Item responses are transformed and summed to a raw score of 0-40, then multiplied by 2.5 to yield a total score ranging from 0 to 100. Benchmarks: scores above 68 indicate satisfactory usability; scores above 80 indicate excellent usability.

Unit of Measure: Total SUS score (range 0-100; higher = better usability).

Acceptance of the Brain Health PRO (BHPRO) platform will be assessed using the Technology Acceptance Model Questionnaire (TAMQ).

Measurements: The TAMQ is a 20-item questionnaire (adapted for BHPro) with 7-point scale.

Unit of Measure: Responses are provided on a Likert scale. The total score ranges between 0-120, with a higher score indicating greater acceptance and satisfaction with BHPro.