From evidence to action: contextual determinants for the pre-implementation of a foot-ankle exercise program for diabetes in primary care

BACKGROUND: Diabetes mellitus (DM) is a significant public health challenge, associated with progressive chronic complications such as visual, renal, and foot-related impairments. Diabetic polyneuropathy is a major contributor to foot ulcers, infections, and lower-limb amputations. The FOot CAre and Exercises ImplementatioN for People with Diabetes in Primary Care (FOCAIN) project was developed to implement a foot and ankle exercise program, combined with self-care education, aimed at reducing risk factors for foot ulcers in individuals with DM within primary care in Limeira, São Paulo, Brazil. This study reports findings from the pre-implementation phase, focused on context analysis and identification of implementation barriers and facilitators. METHODS: Eighty-four primary health care professionals were invited to participate in a brainstorming activity using a semi-structured interview guide based on the Consolidated Framework for Implementation Research (CFIR). Rapid analysis, as described by Nevedal et al., was used to identify key barriers and facilitators. Staff adoption and representativeness were evaluated using the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, Maintenance). RESULTS: A total of 71.8% of primary care units and 100% of multidisciplinary teams were represented, with participation from 54 professionals (21 nurses, 21 community health workers, 3 nutritionists, 3 social workers, 2 psychologists, 2 physical therapists, and 1 nursing technician), resulting in an adoption rate of 65.8% (RE-AIM). Of the 24 CFIR constructs explored, 17 were identified as key implementation determinants. Barriers included limited resources, lack of targeted public policies, physician-centered care culture, and inadequate infrastructure. Facilitators included strong and credible evidence supporting the intervention, institutional support, and high professional engagement. CONCLUSIONS: The pre-implementation analysis revealed a promising context for FOCAIN implementation in Limeira. Professional commitment and municipal support were crucial facilitators. However, workforce limitations, especially in multidisciplinary teams, present ongoing challenges. Strengthening collaboration between academic institutions and local health system leadership is critical for overcoming barriers and enabling sustainable implementation.