Abstract
Introduction
Global aging, inequalities, and climate change (Institut national de santé publique du Québec, 2024) require preparing occupational therapists (OTs) to promote health in increasingly diverse contexts (Aldrich et al., 2022), with high-quality training in evidence-based interventions (Ishikawa et al., 2023). Developed at the University of Southern California (USC), Lifestyle Redesign (LR; Clark et al., 2021) is an evidence-based intervention (Clark et al., 1997, 2012) supporting older adults in meaningful health-promoting routines. Offered primarily in groups for 6–9 months, the LR and its training were available only in English and U.S. cultural and healthcare norms, limiting transferability in other contexts (Seng et al., 2006).
Necessary for improving intervention effectiveness in diverse populations, cultural adaptation is defined as “the systematic modification of an evidence-based treatment or intervention protocol to consider language, culture, and context in such a way that it is compatible with the client's cultural patterns, meanings, and values” (Bernal et al., 2009, p. 362), and involves both content and process (Day et al., 2023). Despite numerous frameworks, few address training adaptation, often seen as peripheral (Stirman et al., 2013). Adapting and evaluating training is as critical as adapting the intervention (Asiimwe et al., 2023), and enhances implementation fidelity, clinician competency (Ishikawa et al., 2023) and willingness to adopt innovations (Marsiglia & Booth, 2015). Although LR's adaptation has been the focus of several studies (Hirvonen & Johansson, 2023; Levasseur et al., 2022; Schepens Niemiec et al., 2025), its training remains largely unexplored as a distinct component of cultural adaptation, a gap that is particularly salient in Quebec, where LR is still novel and implementation depends on clinicians’ readiness to engage with the approach.
In occupational therapy (OT), growing interest in lifestyle-based health-promoting interventions has prompted several cultural adaptations of the LR: Vivir mi vida for rural-dwelling U.S. Latinos (Schepens Niemiec et al., 2019), Temps d’accompagnement Prévention activités signifiantes et Santé (TaPasS) for frail community-living older adults in France (Morel-Bracq et al., 2023), and healthy and active ageing for older migrants in the Netherlands (Abma & Heijsman, 2015). In Vivir mi vida, community health workers received 12–40 hr of training from a bilingual team, along with ongoing weekly supervision and mentorship from an OT and a senior promotor reinforced culturally sensitive communication and behaviour change strategies. The training covered LR's foundations, content and delivery, as well as goal setting, motivational interviewing, documentation, and research foundations, and was supported by a structured Spanish manual (Schepens Niemiec et al., 2019). The TaPasS was culturally adapted in terms of thematic relevance, vocabulary, and sociocultural concerns such as ageism and digital literacy (Morel-Bracq et al., 2019). As French older adults perceived several themes were missing from Lifestyle Redesign® (e.g., financial resources, housing, use of digital tools, connection with the living world), the intervention was reconfigured through a community and territorial lens (Morel-Bracq et al., 2023). This ensured the program's adaptability to diverse territories, practice settings, and stakeholders, its alignment with community-based OT models, and its grounding in participants’ physical and sociocultural environments. Developed and delivered by the French National Association of OTs (ANFE), the structured training program includes a one-and-a-half-day in-person session, preceded by preparatory remote activities and followed by a one-day, remote group follow-up session 4 months later. The training prepares OTs for concrete implementation of the intervention, which is expected to be applied in the interim, though this is not always done in practice (ANFE, 2025). The follow-up allows participants to share experiences, discuss implementation challenges, and refine their project materials. In the Dutch adaptation, limited training, notably on cultural competence, may have hindered alignment between the intervention and participants’ values and expectations, contributing to misunderstandings, low engagement and early dropout (Abma & Heijsman, 2015). Overall, training adaptations varied considerably and were underreported. Without culturally adapted training, it may be difficult to ensure program successful implementation, to distinguish core from culturally adapted elements—or even to differentiate between an adapted intervention and an entirely new one—and to convey the meaning, value, and transformative power of occupation as a distinctive feature of OT (Lee Bunting et al., 2024). While increasing responsiveness to local realities, few cultural adaptations were guided by frameworks, particularly for training. Concerns about fidelity also varied with the depth of adaptation, ranging from surface-level changes to more substantive transformations. Clearer methodological guidance is needed and, to ensure successful transfer to contexts like Quebec, it is essential to not only adapt content, but also the delivery. Studies on LR and similar interventions highlight the value of brief, workplace-integrated training (Smith et al., 2012), peer learning (Lévesque et al., 2019; Pyatak et al., 2022), case-based discussions (Ayton et al., 2017), face-to-face groups (Piché et al., 2019) and examples of real-world implementation (Baker et al., 2005). User-friendly materials (Baker et al., 2005), supervision and mentored experience (Pyatak et al., 2022) further support their integration into practice. While emphasizing practical aspects of training delivery, few studies explored if learning occurs. Recent developments in OT education have underscored the importance of disciplinary signature pedagogies, that is, relational, affective and contextually grounded active learning strategies (Schaber & Candler, 2024). Applied to LR original U.S. model relying on didactic presentations, these strategies call for experiential group facilitation, modelling of the facilitator role, and reflexive learning with flexible use of the approach's modules. Beyond knowledge and skills, training should foster professional identity aligned with LR's core beliefs (e.g., change potential), values (e.g., empowerment), and principles (e.g., foresight; Lévesque et al., 2024), while building agency to enact them in practice (Carrier et al., 2024). While many of them feel ill-equipped to act as change agents (Rochette et al., 2020), especially when implementing innovations like LR, enhancing OTs’ sense of competence remains key, as it drives motivation and engagement with evidence-based services (Carrier et al., 2024), dimensions yet unexplored. Little is also known on training effects on OTs’ knowledge, intention and experience (i.e., achievement of learning objectives, perception of the adaptation and appreciation of the pedagogical design), which are essential for designing relevant, high-quality continuing professional development (CPD) activities (Légaré et al., 2015). This study thus aimed to explore the influence of the training on OTs’ knowledge and behavioural intention to implement the approach [objective (O) 1], and the experience of French–Canadian OTs (O2).
Method
Study Design and Participants
This pilot study used a cross-cultural validation with expert committee (Epstein et al., 2015) and an action-research approach (Benjamin-Thomas & Laliberte Rudman, 2024) with a pre-experimental component (Figure 1). As an educational initiative in a pre-implementation phase, action-research was particularly suited to support knowledge translation and action and inform practice improvement (Cargo & Mercer, 2008). While completing one action-reflection cycle, a sufficient step to initiate and understand change in complex settings (Fortin & Gagnon, 2022), the pre-experimental and qualitative components informed the development of a contextually grounded implementation plan and guide future cycles. A purposive sample of 24 participants (20 OTs and four OT students) was adequate to detect a standardized difference of 0.6 or greater between two means using paired bilateral t tests based on a significance level of 5% and power of 80% (Machin et al., 2018). Aligned with previous studies (e.g., Piché et al., 2019), this sample reflected various practices, clinical settings, regions, and experience, and supported both in-depth exploration and data saturation. Eligibility criteria were: (a) being an OT and member of the Ordre des ergothérapeutes du Québec (OEQ; Quebec OTs’ board) or a ≥ third-year OT student, (b) having an interest in health promotion among older adults; (c) speaking French, and (d) participating in the in-person training and data collection in Quebec. Participants were recruited through private practice members of the Quebec association of OTs and OEQ, research team network and previous study participants (Lévesque et al., 2019), two Health and Social Services Centre (HSSC) of the Quebec regions, and two Facebook groups (Ergothérapie Québec and “Ergo Maîtrise 2017–2018”). The Research Ethics Committee of the Eastern Townships HSSC approved the study (MP-31-2018-2482). All data were anonymized, coded, and stored securely and confidentially at the research centre (questionnaires and paper documents) or on password-protected computers (audio recordings and group transcripts). Data retention followed ethical standards based on sensitivity.
Plan, participants and process.
Outcome, Variables, and Tools
Participants first completed a sociodemographic questionnaire, followed by the same pre- and post-training measures to assess changes in knowledge and behavioural intention (O1). Knowledge was assessed with 60 multiple-choice questions covering all training objectives, some of which were created or adapted from the 72 original questions of the American OT Association (AOTA) training. Behavioural intention was measured with the French-adapted CPD Reaction (Légaré et al., 2015), a 12-item self-report questionnaire evaluating five constructs: intention, social influence, beliefs about capabilities, beliefs about consequences, and moral norms (Figure 2; O1). Grounded in theories of planned behaviour (Ajzen, 1991) and Triandis (1977), the questionnaire presents acceptable test–retest reliability (k 0.4–0.6), good internal consistency (α 0.77–0.85) and sufficient sensitivity to detect changes in healthcare professionals’ behavioural intentions (Legare et al., 2014, 2017). Scores are calculated by construct on a 7-point Likert scale, with higher scores indicated greater intention to adopt the behaviour following a CPD activity. To explore LR training's experience (O2), that is, strengths, gaps, necessary adjustments, and ability to meet OTs’ needs while preparing them for implementation, a semi-structured interview guide validated by one qualitative research expert and pretested with one OT was used.
Integrated model for explaining health professionals’ clinical behaviour.
Data Collection Procedures
Participants were recruited until the sample size was reached. Three weeks before the training (T1), participants attended a hybrid (in person/virtual) group session to complete all questionnaires (approximately 75 min; Figure 1). Following the training, participants answered the same outcome questionnaires (T2). About 2 weeks later, they had an in-person semi-directed focus group lasting about 150 min, 60–90 focused on the training, and the remaining time on facilitators and barriers to implementation, with results presented elsewhere (Lévesque et al., 2025). All groups were digitally audiotaped, transcribed and verified with respect to the participants’ wording. Preliminary results were summarized at the end of each focus group for initial validation.
Intervention
The French–Canadian LR training was translated and culturally adapted by five trained individuals (four students and one academic) and validated by six researchers with extensive knowledge of the intervention and expertise in aging, health promotion and OT. The translation process focused on semantic, functional, and experiential equivalence (Corbière & Fraccaroli, 2014), and was harmonized with the manual (Clark et al., 2021). Based on this validation process, experts recommended a hybrid training, combining online and in-person components. Consistent with cultural adaptation guidelines, minimal changes were made (Marsiglia & Booth, 2015) to the training scripts and knowledge tests for semantic equivalence; the adaptation of handouts (e.g., replacing U.S. holidays with Canadian ones), the replacement of examples and resources with Quebec-specific ones, and the subtitling of training videos using culturally appropriate terminology. The training was led by the two authors, one research master student experienced OT in primary care and one academic OT specializing in health promotion and clinical research. They were both involved in the first experimentation of the intervention (Levasseur et al., 2019; Lévesque et al., 2020), and in the translation and cultural adaptation of the USC 6-hr online introductory course (309 PowerPoint slides, 92 pages of scripted narration, 72 multiple-choice questions and 19 subtitled videos of individual and group sessions illustrated OTs’ role, process and strategies used to engage clients, including establishing a dialogue, offering constructive feedback, linking content to personal situations, and responding to specific needs; Figure 3) distributed by the AOTA. Based on the five theoretical chapters and 12 modules from the second edition of the LR manual, the training included 8 hr of in-person session over 2 consecutive days, along with a 1.5-hr asynchronous online assignment between sessions (Figure 3). The training also included examples of activities, outings and questions for each module. Each participant received the PowerPoint presentation.
Pedagogical scenario.
Data Analysis
To enhance transferability (Miles et al., 2020), the participants’ sociodemographic and main outcomes were analyzed using descriptive statistics. Pre- and posttest scores and questions were respectively compared with the Wilcoxon signed-rank and McNemar tests (O1), with minimally important difference (MID) thresholds were calculated similarly to the method proposed by Norman et al. (2004). Interview transcripts underwent thematic content analysis using mixed extraction grids (Miles et al., 2020; O2), and including: (a) data reading; (b) segmentation into meaning units; (c) reorganization based on pedagogical design components using the Scénarisation des connaissances et des compétences éducatives numériques ontology (SCEN; designed to model relationships among knowledge, competencies, learning activities and digital resources; Paquette, 2022), cultural adaptation and improvement suggestions (Figure 3), and (d) synthesis of results. To ensure credibility, reliability and confirmability (Miles et al., 2020), one third of the data first exhaustively analyzed by the first author was co-coded, and the senior author supervised and refined analysis until consensus. Mind maps and memos documented team reflections. To strengthen interpretation, qualitative and quantitative results were juxtaposed in a joint display, deepening contextualization and explanations. Analyses were conducted using SPSS (v25.0) or NVivo (v12).
Results
Of the 24 participants assessed at T1, all were women and most held a bachelor's degree (Table 1). Aged between 22 and 60, the majority were clinicians in the public sector working with older adults, including four in mental health teams. Two-thirds already included preventive interventions in their practice (e.g., fall prevention) and most were familiar with LR through conferences or academic training (Table 1). Prior to training, over half sought to increase their knowledge, while nearly two-fifths aimed to apply the approach or assess its potential implementation. Experience of both the public (groups [G] 1 and 2) and the private sectors and OT students (G3) was explored, along with suggestions for improvement (Figure 3).
Characteristics of Participants (n = 24)
M = mean; SD = standard deviation; Md = median, SIR = semi interquartile range.
LR Knowledge and Behavioural Intention
Participants’ knowledge improved post-training with a 12-point increase exceeding the MID, indicating clinically meaningful change (Table 2). Although statistically and clinically significant, theoretical content (parts 1–2) remained less mastered than clinical (parts 3–6) at both T1 and T2 (p˂.001). For instance, knowledge related to the Well Elderly studies increased moderately, showing a trend toward clinical significance without reaching statistical significance (Table 2). Knowledge improved for eight of 12 modules, with no gain in community mobility, longevity, and relationships. “Navigating the healthcare system” declined post-training (Table 2). Higher post-test knowledge scores were obtained for in-person modules (parts 1–4) compared to online modules (parts 5–6; Z = −4.0, p˂ .001), which showed higher improvement rates for questions related to in-person training (Q1–40) than those related to online training (Q41–60). Changes in social influence were clinically meaningful, but no statistical differences were found in the five CPD-Reaction constructs (Table 2). Some items related to intention and beliefs about consequences also showed clinically meaningful improvement.
Comparisons of Knowledge and Behavioural Intention Scores Before and After Training (n = 24)
Notes. USC = University of Southern California.
* Median (semi-interquartile range).
** Wilcoxon signed rank test.
In
† Similarly to Norman et al. (2004), the minimal important difference (MID) was estimated using 0.5 × Q based on pre-intervention data.
(-) decrease between.
Target behaviour = offer LR to my older clientele over the next year.
Achieving Training Objectives
Participants reported improved understanding of the LR structure, process and application to older adults, as well as greater clarity on the OT's specific role. A period of appropriation and additional tools (e.g., participant's and facilitator's workbook) were needed before integrating LR into practice (Table 3). While questions remained about its use with other clienteles (e.g., chronic pain, mental health), some participants developed a clear vision of potential applications: “I easily saw how I could [apply LR] with certain types of clientele” (G1).
Main Themes from OTs and Students’ Evaluations of the Training, Their Relative Frequencies and Their Relation to Results on Knowledge and Behavioural Intention Questionnaires
Notes. ƒ = Frequency (i.e., number of coded references per subtheme across all focus group transcripts); N/A = no clear conceptual alignment with quantitative results; USC = University of Southern California.
* Aspects addressed concurrently during coding.
Total number of coded references (n = 85) is lower than the sum of individual subtheme frequencies
Cultural Adaptation to Quebec
Training adaptation focused on content, pedagogical tools, and language, with the greatest challenges arising from the training videos.
Content
LR themes were seen as universal and well suited to aging Quebecers: “The themes are well suited to our context” (G1; Table 3). To meet the specific needs of their clientele, OTs recognized their role in adapting content, but highlighted tensions between the time required for these adaptations and need to preserve key elements for effectiveness and fidelity. Training resources (e.g., references) should be Quebecized and content should better reflect local realities (Figure 3): “What was missing were alternatives for rural areas” (G1).
Educational tools
Videos were criticized for their lack of cultural adaptation. For OTs, staged interactions between clients and therapists felt artificial and overly optimistic, failing to reflect both their professional identity and real group dynamics, including those requiring adjustments in relational mode to ensure collective functioning: “I wish I’d seen the dynamics, the interactions and heard that the group brings a richness and gives ideas” (G3). “And both things that go well and things that don’t, a real group, not something staged” (G2). Participants also deplored the lack of diversity, as videos mainly featured active and independent older adults while overlooking the broader functional and socio-demographic profiles of their clientele (Figure 3, Table 3).
Linguistics
The translation quality was perceived positively, and all participants valued having access to a French version. They also found it aligned with the French-speaking and OT culture: “We recognize ourselves, it's a French-Canadian version that reflects our OT terminology” (G2). However, participants would have preferred original French videos instead of subtitled English ones (Figure 3).
Appreciation of the Pedagogical Scenario
Participants examined the training across several aspects: teaching system, learning activities, educational tools, temporal aspect of the training, content, benefits and instructors.
Teaching system
In-person teaching was preferred and seen as essential for promoting interest, comprehension, practical application, sharing, and reflective discussions, particularly for theoretical and historical content, where trainers’ explanations and examples supported comprehension: “It was really important that it [historical and scientific content] was delivered in person, because we wouldn’t be able to find this information without being in a group with a trainer who is there to explain it to us, [to whom] we can ask questions, [with whom] we can have discussions. That's helpful” (G3).
The addition of an online component was appreciated for accommodating individual learning rhythms and offering cost savings and replay options, but its lack of interaction affected participants’ attention and retention: “Online, it felt like a very lectured course where I was trying to hurry up to take notes […] I found it harder to stay engaged and the retention of information was more demanding” (G2). Online modules were also seen as a tool for optimizing classroom time before training and reactivating knowledge to support approach implementation afterward. Despite its benefits and usefulness, the length of a fully online format could discourage completion: “It's too long to do it entirely online” (G1). A hybrid model was suggested for future training (Figure 3).
Learning activities
Despite the lecture format, participants valued the trainers’ real-life examples and exchange opportunities that fostered reflection and deeper learning. They also called for more active and authentic learning activities (e.g., experimentation, role-playing, collaboration, interaction, reflexivity and sharing; Figure 3), aligning with LR foundations.
Educational tools
Design flaws in the workbook (e.g., visual layout) impeded learning, as participants reported being more inclined to take notes than to listen. For future training, participants felt that the French version of the manual (not available at the time) was a necessary complement to the workbook and believed it should be included in the training cost to allow annotation, easy reference, and quicker application of knowledge into practice (Figure 3, Table 3).
While videos were appreciated for illustrating professional reasoning in individual and group interventions and making the training more applied and authentic, their scripted nature—with actors instead of real clients and limited group dynamics—reduced their effectiveness in demonstrating the therapeutic use of the group and its socio-affective dimension. Consequently, participants felt that videos did not fully prepare them for group facilitation (Table 3).
Temporal aspect
Participants perceived an imbalance in time allocated to theoretical versus clinical content, making the training duration insufficient to cover clinical modules in depth. Extensive historical and scientific content, combined with discussions, created time pressure that compressed clinical the content, limiting retention, exploration, and future application (Table 3). To address this and allow for more active teaching methods, participants suggested extending in-person training over 2 non-consecutive days and providing early access to online content (Figure 3).
Training content
Theoretical, clinical and implementation aspects of the French LR training were viewed as relevant and well presented. Clinical content was helpful for both novice and experienced OTs to integrate concepts rooted in the occupational paradigm. While these resources provided a solid foundation, some modules still seemed essential: “I find the module on safety at home [and in the community] important and relevant to the majority of people” (G1). Some participants also found that group questions and activities could be adapted to individual practice. Compared with other CPD courses, the approach's group-based, preventive and evidence-supported OT content was seen as innovative and distinctive (Table 3). To improve the clinical content, participants suggested adding information on specific themes’ contribution to health maintenance, record keeping guidelines, respect of professional competencies, and group facilitation and management skills (Figure 3). Most felt a refresher on group facilitation was needed, as these skills were seldom used in their practice. While several wanted basic group facilitation content to be included in the LR training, others viewed it as a prerequisite: “When offering the training, it would be useful to know that group facilitation skills are needed” (G1).
Participants appreciated the theoretical content, including its historical and scientific dimensions, which they felt could support implementation. To improve the theoretical component, participants suggested adding complementary resources (e.g., OT lifestyle medicine) and references, sharing scientific evidence about the approach and updating certain content. Suggestions for expanding implementation content included clearer guidance on administrative aspects (e.g., absences, funding, service agreements) and concrete steps, methods, and conditions for successful implementation, particularly where and how to start.
Training benefits
Benefits ranged from increased awareness of prevention to practice transformation (Table 3). For some, it confirmed the alignment between their practice and scientific evidence. For others, it reinforced their intention to change both their practice and lifestyle (Table 3). Opportunities for exchanges and networking were also valued. Given its usefulness and applicability, the training seemed to adequately prepare participants for the approach's implementation.
Instructors
Participants highly valued the trainers’ dynamism, passion and expertise, including their subject mastery, clinical experience and research involvement, which enhanced their motivation and interest. Concrete examples bridging theory and practice, as well as the trainers’ ability in prompting reflection and discussion were major assets. Some emphasized the importance of training offered by and for OTs: “We now have doctors in occupational therapy who teach us. It's about time we had training given by and for OTs” (G3).
Connecting Qualitative and Quantitative Results
Integrating qualitative and quantitative results (Table 3) highlighted that the training was predominantly perceived positively with 259 coded references (f) rather than negatively (f = 59), with additional remarks raising questions or tensions (f = 99) or identifying missing elements (f = 77). Training benefits, usefulness and professional relevance were consistent with greater beliefs about consequences (Tables 2 and 3). Nevertheless, less frequent themes also offer valuable insights. For example, “Occupation and client-centred practice” aligns with a stronger moral norm, reflecting coherence with the professional ethos and reinforcing the disciplinary relevance of the training (Table 3). Additionally, participants described theoretical content as more difficult than clinical material and emphasized the importance of in-person delivery for such complex topics—an observation consistent with lower knowledge in theoretical modules and online training (Table 3). Finally, the frequent theme related to “Raises awareness” and rarely to “Practice change” might illustrate that the training has prompted reflection without immediately translating into behavioural intention, coherently with stable intention (Table 3).
Discussion
This pilot study explored the experience and influence of the French–Canadian LR training on OTs knowledge and behavioural intention. Globally, the training improved participants’ knowledge about the approach but not their intention to implement LR within the next year.
Results confirm the relevance of in-person training, echoing Piché et al. (2019) and Ayton et al. (2017) who highlight its role in the successful implementation of preventive approaches. As in medical education (Lindsay et al., 2017), participants unanimously preferred in-person sessions, which better fostered interaction, discussion, and social engagement—elements often lacking in online formats, limiting opportunities for collaborative learning, an important determinant of learners’ satisfaction (Valois et al., 2019). Since both relied on similar, script, and pedagogical tools (e.g., quizzes, videos), such preference did not seem to stem from structural differences. However, participants described richer interactions and collaborative reflection in the in-person format, which may have influenced their assessment. While online learning offers flexibility and can be equally effective, it risks decontextualizing learning making it unusable to solve real problems (Valois et al., 2019) and causing disengagement over time. Consistent with the post-COVID-19 shift toward hybrid models (Thibault, 2020), results support a blended approach, incorporating online components for preparation and reinforcement while prioritizing interactive in-person sessions, particularly for theoretical content and modules calling on skills of a different nature or rarely used in practice. A flipped classroom model could optimize training by reducing lecture time and increasing hands-on learning and discussion.
Participants also called for a less lecture-based and more constructivist approach, using experiential and authentic activities (Figure 3). Their request for a turnkey training, with clear implementation guidelines and Quebec-specific references, aligns with Grandes et al. (2008) who emphasize the importance of training professionals on the implementation process and Baker et al. (2005) who highlight the need accessible evidence. A practical guide could further support training uptake and clinical implementation by detailing required material and costs, potential partners for recruitment and logistics (e.g., community centres, refreshments), and offering tips to support older adults’ organization (e.g., transit access, weather, financial, sensory, or safety issues) and explore free community activities (e.g., yoga sessions). Sample letters could also ease resource requests (e.g., transportation vouchers). Such a guide might also include intervention and assessment tools, locally developed frameworks, documentation templates, and vignettes from Quebec practice, as well as more explicit guidance on the use of the Personalized Engagement Plan and the life history in individual sessions. In addition, the guide could integrate advanced notions in occupational science (e.g., meaning-making, life and occupational transitions, empowerment, healthy routine building), group facilitation (e.g., conflict management), communication (e.g., motivational interviewing, effective questioning), and clinical screening (e.g., suicidal risk, driving ability). Complementary resources (e.g., webinars) and recent evidence (e.g., mechanisms of action, adaptation for multimorbidity) could also be integrated to strengthen clinical adoption.
Knowledge and Behavioural Intention
Consistent with the idea that knowledge alone is insufficient to determine intention (Godin et al., 2008), knowledge gains did not immediately translate into stronger behavioural intention, as other determinants such as beliefs about one's capabilities, habits, and moral norms must also be addressed (Godin et al., 2008; Figure 2). Because beliefs and habits are also key determinants of behaviour, training should target these aspects. For example, by addressing areas where OTs feel less competent (e.g., systemic advocacy, group facilitation) and reinforcing habit formation through simulation and practical assignments between training sessions (Figure 2). The absence of change in intention may also reflect the complexity of the target behaviour and a more accurate understanding of facilitators and barriers (Lévesque et al., 2025). In this sense, the post-training decrease in belief score could represent a learning curve, where confidence dips before building over time (Woolcock, 2009). While no statistical change occurred at the construct level, some items related to intention, social influence, and beliefs about consequences were clinically meaningful, suggesting an initial shift among some participants. Overall, small or no changes in intention and its associated constructs point to limited behaviour change and, consequently, a lack of LR implementation, raising important implications for training and professional development.
Implications for Practice, Education and Future Research
Findings highlight the need to refine training design through iterative improvement. This involves updating learning objectives (e.g., group facilitation, record-keeping, implementation stages, rural-specific issues) and adopting teaching strategies that are more authentic, reflexive and collaborative (Radović et al., 2023). Training should also be grounded in need assessment to enhance knowledge transfer to practice (Grant, 2002). Our results suggest that knowledge is still acquired at the end of training, particularly regarding theoretical content. Consistent with Pyatak et al. (2022) and current trends in health professions education (Thibault, 2020), positioning LR training within a competency-based trajectory (from clinical teaching to CPD) could therefore support the progressive development of competencies in real-world contexts (Cruess et al., 2016). This could include ongoing learning opportunities (e.g., communities of practice), tailored support across expertise levels (Pyatak et al., 2022), and tools to monitor progress and confidence (e.g., portfolio). In the United States, a certification approach is emerging and could strengthen the approach's recognition and credibility (Young et al., 2011). While appealing, such model may exacerbate inequities in Quebec due to limited infrastructure for CPD, a small pool of trainers, and the need for institutional and political support. Given that the French–Canadian training is an official adaptation of the original American model rather than a derivative, further consideration is needed to balance recognition of existing expertise with accessibility, avoiding unnecessary barriers. Yet, beyond training and certification issues, successful adoption of LR also depends on transmitting its professional values and philosophical foundations. To support the development of a new professional identity fully integrated into practice, it is essential to promote the transmission of this preventive OT culture in both training and practice, while legitimizing such innovations across decision-making levels (Lévesque et al., 2025).
Strengths and Limitations
Using rigorous cross-cultural validation and action research design, this study is the first to explore LR training among French–Canadian OTs. The combination of questionnaires and group interviews provided nuanced explanations while enabling data triangulation, reinforcing internal validity (Miles et al., 2020). By exploring knowledge, behavioural intention and experiences of participants trained in French LR, this study followed a rarely adopted learner-centred approach (Paquette et al., 2022), helping clarify pedagogical needs, initial knowledge levels, content-related difficulties, and gaps between required and applied competencies. This user-centred approach could contribute to a more authentic, meaningful, culturally adapted, and clinician-responsive version of LR training.
Although the training relied on a transmissive teaching model (Figure 3), which may have limited knowledge acquisition and active engagement, this was offset by the quality of interaction and facilitators’ expertise, who contextualized content with concrete examples and explicit clinical applications. For feasibility reasons (master project), we used a purposive sample, which may have introduced selection bias, with more motivated OTs potentially inflating outcomes—though representative of typical training participants. Due to feasibility constraints, final findings were not returned to participants for formal validation either. Similarly, to prioritize initial implementation the original material, cultural adaptation mainly focused on translation, which meant relying on original subtitled videos. These may have presented overly linear, turnkey scenarios, failing to capture Quebec practises and fostering unrealistic expectations about implementation. This underlines that translation-based adaptation, while useful for initial implementation, may be insufficient in other contexts requiring broader cultural and pedagogical changes. While the study's pre-implementation positioning supports long-term implementation success, the absence of a control group and pretest sensitization, may have threatened internal validity, though the risk was attenuated by the test's length (60 items) and comprehensive coverage of the training content. As the study measured intention to implement the LR within the following year, it could not assess whether participants went on to do so. This outcome may also have been too general to yield consistent insights (Légaré et al., 2015). As with any self-reported measure, the risk of social desirability and confirmation biases is increased. However, in this study, that risk was likely reduced by the explicit instruction given to participants to respond as honestly as possible, with no right or wrong answers, as well as by the absence of increased behavioural intention despite participants’ knowledge gains and overall satisfaction.
Conclusion
This study explored French–Canadian OTs’ and OT students’ experience of LR training and its influence on their knowledge and behavioural intention, aspects often overlooked in pedagogical design research (Basque, 2017) or emerging in medical education (Ayivi-Vinz et al., 2022). While results provide insight into what participants know and intend about the LR, they remain insufficient to determine what they can accomplish with this knowledge. Given that current data do not allow for an assessment of the impact of LR training and effective pedagogical strategies, future research should test various pedagogical methods—including mentoring—and explore how knowledge acquisition translates into sustained behaviour change and patient outcomes. This includes the use of a control group, longitudinal follow-up (Price, 2023), subgroup analysis (e.g., practice setting, experience levels), and involvement of other key actors (e.g., dissemination personnel, multidisciplinary teams, managers), including for preliminary validation of results. Although a hybrid mode appears conducive for learning, training also requires enhancement to fully achieve its goals. This includes the systematic planning of concrete clinical examples, integrating new occupation-based content (e.g., climate change adaptation), less familiar themes and their interconnections, and opportunities for reflection and collaboration. As cultural adaptation is a continuous process, future iterations should also integrate updated content, authentic supports, and real-life practice opportunities. Beyond translation, cultural adaptation should reflect local contexts, support professional identity, and prepare clinicians for implementation. Broader cultural perspectives—including those beyond Western cultural norms—and frameworks such as the Ecological Validity Model (Bernal et al., 1995) could help sustain the relevance of LR across diverse settings. In line with current disciplinary reflections (Schaber & Candler, 2024), articulating a culturally adapted signature pedagogy grounded in OT education is also needed. To ensure the sustainable and scalable adoption of LR in the French–Canadian context and strengthen its research framework, an interuniversity committee could help harmonize training tools and assessment without imposing rigid certification. Building on the model of Université de Sherbrooke, which offers an intensive 1-week optional course in the master's program in OT, a hybrid approach integrating students and clinicians could enhance accessibility, foster mutual enrichment, and optimize academic resources.
Key Messages
LR online training is flexible and accessible, well suited for preparation and review but less effective for complex content and socio-affective engagement. As knowledge alone is insufficient to sustain behavioural intention and change, cultural adaptation of content and pedagogy is required to strengthen other determinants. Since LR relies on complex skills, professional attitudes, and values, anchoring its training in a competency-based model with certification is logical but presents challenges in the French–Canadian context.
Footnotes
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This publication’s research was funded by the Fonds de recherche du Québec – Santé (scholarship to the first author), and Canadian Institutes of Health Research (CIHR; scholarship to the first author and grant #126315). At the time of the study, Mélanie Levasseur was a CIHR New Investigator (#360880) and she currently holds a Tier 1 Canadian Research Chair in Social Participation and Connection for Older Adults (CRC-2022-00331; 2023-2030).
