A neighborhood’s built environment can challenge the mobility of older mobility-challenged adults (due to knee osteoarthritis and falls), reducing their participation and quality of life. The Built Environment in Falls and arthrITis (BE-FIT) study aims to understand the neighborhood influence on the mobility, participation, and psychosocial health of older adults with knee osteoarthritis and/or falls. BE-FIT comprises four work packages (WPs). WP1 quantitatively explores relationships among environmental-, social-, and person-related factors and participation outcomes of its intended population. WP2 employs qualitative methods to comprehend the relationships among WP1’s variables. Via a combination of wearable sensor technology and qualitative geospatial methods, WP3 aims to characterize its population’s movement behavior, mobility, functional activity of daily living, and lived experiences of residing in a mature neighborhood. Finally, WP4 engages crucial stakeholders to co-develop evidence-based recommendations to inform public health, urban planning, and aging policies and implementation. BE-FIT could benefit societies with rising incidence of knee osteoarthritis and falls by improving neighborhoods and lives of older mobility-challenged residents.

Objective: To evaluate the implementation process of a community-based, multidisciplinary intervention (CONNACT) through a randomized controlled trial (RCT) in order to contextualize the RCT outcomes and inform implementation opportunities. Methods: This study is an embedded qualitative process evaluation of the CONNACT effective-implementation hybrid RCT. Semi-structured interviews with 22 intervention patients and 14 healthcare professionals were conducted. Interviews were audio-recorded, transcribed and translated using framework analysis. Data was analysed thematically and the emergent themes were organised into the conceptual domains of RE-AIM. An explanatory sequential methods approach was used to discuss the Reach and Effectiveness domains of RE-AIM, whereby quantitative data (i.e. recruitment logs and published quantitative results) was discussed in relation to this study’s qualitative data. Results: Reach: 55.4% of the patients who met the inclusion criteria participated, while work or family commitments and disinterest in physiotherapy are the primary reasons for declining participation. Effectiveness: CONNACT intervention is not superior to control hospital-based usual care in terms of pain, function, and quality of life, but superior in physical performance, knee satisfaction, global perceived effect and positive dietary change. The results and effectiveness of CONNACT are presented and discussed in a related publication. Adoption: Healthcare professionals proposed changes for long-term sustainability (transdisciplinary approach, expert patients) despite their strong support for CONNACT. Implementation (context): A spectrum of passive-resigned and impatient-unrealistic mindsets, pain beliefs, and expectations was elucidated. Implementation (mechanism of impact): Focus on patient education and empowerment encouraged patients to actively accept their condition and practice self-efficacy. Although group classes are a source of support, motivation, and positive peer pressure, several patients preferred personalized treatments. CONNACT’s synergistic nature benefitted patients who are more complex. Maintenance (patient-level): Patients highlighted the importance of incorporating exercise into their regular routines, but lack of time and inertia remain as significant barriers. Conclusion: The themes have allowed a better understanding of the RCT primary and secondary outcomes and informed the next phase of implementation. CONNACT and similar interventions should identify and address reasons for refusing participation [Reach]; improve group classes with initial evaluations, equal attention paid to patients, tailored exercises, and acknowledge progress [Effectiveness, Implementation]; and adopt a streamlined resource-efficient transdisciplinary design [Maintenance]. Trial registration: This study, which primarily employs qualitative methods for data collection, is not a clinical trial (clinical trial number: not applicable). Ethics approval (NHG DSRB ref no: 2020/00067;) was obtained before commencement of this study.

Background: A treatment journey (TJ) outlines a patient’s needs, actions, and experiences when seeking treatment. In Singapore, the quality of knee osteoarthritis (KOA) care is suboptimal. Mapping the TJ of older KOA patients can identify gaps in care influencing treatment decision, experiences, timeliness, and effectiveness for optimizing care in Singapore. Methods: This qualitative study was embedded in a larger qualitative study conducted in an urban, referral-based tertiary hospital in Singapore that evaluated and explored KOA patients’ treatment experiences of a randomized controlled trial. The larger study conveniently sampled 46 patients (22 intervention, 24 control). Semi-structured interviews were conducted in a quiet private hospital room. Framework analysis was used to analyze all 24 control patients’ transcripts. There was sufficient information power to fulfill the study’s objectives. Findings: Eighteen participants described relatively linear TJs comprising five sequential stages. Themes and sub-themes related to the stages are discussed. Onset: Participants gained awareness as symptoms impacted their daily lives, alongside sense-making processes shaped by beliefs that KOA was an inevitable consequence of ageing. A strong need to cure their condition drove informal knowledge-seeking from social networks. Self-treatment: Participants experimented with topical agents, supplements, traditional Chinese medicine, analgesics, and exercise, often delaying formal care until symptoms worsened. Symptomatic exacerbation or persistence triggered treatment-seeking. Primary care: Many participants felt dissatisfied with and dismissed from receiving limited explanations, passive management, and gatekept from specialist care. Tertiary care: Orthopedic consultations gave participants hope in conservative physiotherapy treatment and position surgery as a last resort. Positive treatment experiences and symptom improvement fostered hope, confidence, and treatment engagement. Conversely, dissatisfactory experiences led some participants to disengage from treatment and question its relevance and value. Post-treatment: Participants transitioned to self-management. Engagement in exercise and physical activity was motivated by the desire to avoid pain, deterioration, and surgery, and to maintain independence. However, inertia and perceived lack of time emerged as barriers. Complex treatment journeys: Six participants experienced complex, non-linear TJs involving multiple and/or repeated healthcare touchpoints that caused confusion and frustration. Discussion: Improving community knowledge of KOA could meet older KOA patients’ strong need for treatment information, which influences sense-making, self-efficacy, decisions, and eventually treatment length, complexity, effectiveness, and experience. Healthcare providers could provide informative communication and feedback that fulfill their patients’ expectations for both information and care, as well as their need for hope confidence, reassurance, help, and relief. Inertia and a lack of time can be counteracted by providing meaningful, manageable, and adaptable care. Conclusion: Inadequate communication from healthcare providers are pain points in a TJ. Pain history and severity, and degree of physical functioning and KOA knowledge can influence a TJ’s length and complexity. Trial registration: This study, embedded in a larger study that qualitatively evaluated data from a randomized controlled trial (NHG DSRB ref no: 2020/00067) Tan et al. (BMC Musculoskelet Disord. 21(1):684, 2020) that explored the treatment experiences of KOA patients, is not a clinical trial (clinical trial number: not applicable).