Training of Peer Coaches to Assist Individuals with Knee Osteoarthritis Prepare and Recover From Total Knee Replacement

Abstract

Objective

The objective of this study is to outline the training of peer coaches in the Moving Well intervention, which was designed to reduce anxiety, depression, and pain catastrophizing in patients before and after total knee replacement (TKR).

Methods

Selected peer coaches had a history of knee osteoarthritis (KOA), a TKR of 12 months or more before training, and were 60 or older. Training was primarily conducted virtually, with a later addition of one in‐person session. Training centered on developing skills in motivational interviewing (MoI), encompassing techniques like open‐ended questions, affirmations, reflective listening, and summarization. It also covered the MoI processes of engagement, focus, evocation, and planning. Coaches were required to discuss at least 90% of session‐specific topics, which were monitored using checklists for each certification, and to complete individual MoI training, which was not graded. The evaluation of peer coach training involved surveys and a focus group.

Results

Three women and two men, averaging 75 years in age, completed the peer coach training for the Moving Well intervention. An in‐person training session was added to address technology and MoI skill concerns, greatly enhancing their grasp of MoI skills and their ability to guide others through the program effectively. Peer coaches stressed the importance of live feedback, in‐person training, and incorporating personal experiences into the program content during their training.

Conclusion

To effectively train older adults as peer coaches for the Moving Well intervention, flexibility in learning formats, personalized guidance, peer support, and regular evaluations were essential in building the necessary MoI competencies to guide research participants in the program.

INTRODUCTION

Knee osteoarthritis (KOA) is a common form of arthritis that leads to joint degeneration, worsening pain, limited mobility, and loss of function.¹ Once a patient reaches end-stage KOA, total knee replacement (TKR) is recommended to restore mobility. Although TKR typically decreases pain and increases function, up to 30% of patients continue to experience pain post-TKR.^2–4 Poor outcomes are associated with low preoperative knee function and high levels of anxiety, depression, and pain catastrophizing.^2–15

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SIGNIFICANCE & INNOVATIONS

• This article introduces the Moving Well intervention, a comprehensive 12-week program that integrates principles of cognitive behavioral therapy, exercise, and social support for individuals undergoing total knee replacement (TKR). This approach goes beyond traditional prehabilitation methods, addressing not only physical aspects, but also psychological factors such as anxiety, depression, and pain catastrophizing.
• In contrast to other research focusing on enhancing TKR recovery, this study uses peer coaches—individuals with firsthand experience of TKR—to administer the intervention. This approach provides a cost-effective and personalized support system, boosting patient engagement and potentially leading to enhanced post-TKR outcomes.
• The paper details a successful training program, empowering older adults (with an average age of 75) to actively contribute to their peers’ well-being. Emphasizing a dual-beneficial relationship, the flexible learning format, interactive instruction, and periodic evaluations ensure the completion and certification of peer coaches. This approach not only fosters a sense of community among the coaches but also underscores the mutual benefits derived from integrating older adults into society.

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Improving knee strength before surgery, ie, prehabilitation, has been suggested to enhance postoperative outcomes. A randomized control trial by Calatayud et al found that an eight-week, high-intensity prehabilitation program improved early postoperative knee pain, mobility, and strength.¹⁶ Specifically, the average Western Ontario and McMaster Universities Osteoarthritis Index scores, measuring pain, stiffness, and physical functioning, showed a reduction with a between-group difference of 18.6 before surgery, 14.0 at one month postsurgery, and 5.8 at three months postsurgery. However, a systematic review and meta-analysis found that prehabilitation for TKR resulted in small and nonsignificant improvements in postoperative pain and anxiety.¹⁷

Other studies have shown higher success in addressing anxiety, depression, and pain catastrophizing through cognitive behavioral therapy (CBT).^18–20 CBT teaches individuals to modify dysfunctional thinking patterns.^21,22 One randomized controlled trial found that pre-TKR CBT reduced pain catastrophizing by 15% in the experimental group compared with 8% in the control group after a four-week telehealth CBT.²⁰ Although CBT can reduce pain catastrophizing and improve knee function, its minimal use (≤4 weeks) and the high cost of health care specialists raise questions about the long-term effectiveness of such programs.^23–25

A systematic review by Baumeister et al found that the effectiveness of structured online CBT interventions is not influenced by the professional qualifications of the coaches.²⁶ Thus, training lay individuals as peer coaches using CBT principles could improve TKR outcomes. Peer coaches who have undergone TKR themselves bringing personal experience as well as enhancing patient engagement and trust.

Our program proposes the use of peer coaches to deliver the Moving Well intervention, a 12-week telephone-based program combining CBT principles, exercise, and social support, aimed at improving anxiety, depression, knee function, and pain catastrophizing in patients who are undergoing TKR.²⁷ Moving Well was adapted from the Living Healthy intervention, an intervention that was effective in using exercise to reduce joint pain in Black women with diabetes in rural Alabama.^28–30 The objective of this article was to present our approach in training older adults as peer coaches in delivering the Moving Well intervention, motivational interviewing (MoI), and principles of CBT.

METHODS

Moving Well peer coach recruitment

We recruited peer coach candidates from participants in a series of focus groups that constituted the needs assessment qualitative study (Institutional Review Board [IRB] #2018-0585) conducted at the Hospital for Special Surgery (HSS) that guided the adaptation of Living Healthy into Moving Well. Seventeen participants from this study consented to being contacted for future studies, and all 17 were reached via email. Seven candidates responded, met the initial inclusion criteria, and were interviewed.

Inclusion criteria required candidates to have had a successful TKR at the HSS at least 12 months before training, with a Knee Injury and Osteoarthritis Outcome Score (KOOS) for activities of daily living (ADL) subscale greater than 90. The KOOS ADL scores range from 0 to 100, with higher scores, particularly greater than 65, indicating excellent knee health.³¹ Candidates had to be at least 60 years old, have access to a phone and internet, be interested in becoming a peer coach, and be willing to help other patients prepare for and recover from TKR.

Interviews assessed their leadership experience, motivation, communication skills, and availability. Peer coaches were considered study participants and provided informed consent per HSS IRB guidelines. After consent, and to manage their compensation for training and subsequent work with participants of the Moving Well intervention, they were hired as part-time employees at Weill Cornell Medicine (WCM) at an hourly rate of $21, completing the required Collaborative Institutional Training Initiative (CITI) courses  and WCM human resources onboarding procedures. We collected a demographics survey and conducted a pretraining survey to assess peer coaches’ knowledge on KOA and MoI, as well as their personal exercise behaviors. The study was approved by both the HSS IRB (protocol #2019-1298) and WCM IRB (protocol #19-08020638).

Moving Well peer coach training

The peer coach training originally consisted of 15 online sessions over 24 weeks. The training followed the “listen, discuss, practice, and certify” structure, adapted from Living Healthy and the Cardiovascular risk assessment for rheumatoid arthritis (CARE RA) program.^28–30,32

In the “listen” phase, peer coaches listened to two audio recordings of simulated interactions, one depicting an ideal scenario and the other a nonideal situation. During the “discuss” phase, guided by an experienced research team member, peer coaches engaged in group discussions to explore themes from the recordings, asked questions, and brainstormed approaches to challenges heard in the recorded scenarios.

In the “practice” phase, coaches role-played a participant and a peer coach for a specific segment of a Moving Well session, with two research team members observing and assessing. Afterward, they received feedback from both the research team and the other peer coaches. Paired coaches then switched roles, completed a second itiration of the role-play, and repeated the feedback session. Coaches were instrcuted to practice the entire session independently after the training session. Once coaches felt prepared, they scheduled a certification session for the Moving Well session reviewed that week.

Certification sessions, lasting 60 to 90 minutes, were recorded and conducted virtually. During these sessions, research team members role-played patients who had undergone TKR, ensuring consistency by using the same staff and persona. Peer coaches would complete the session call with the mock persona played by the research team member. Postcertification, the research team provided verbal and written feedback, and coaches offered insights to ensure that the session content accurately reflected the TKR preparation and recovery experience. Coaches were certified for 9 of the 12 calls in the Moving Well intervention because the final 5 sessions did not introduce new content and had similar structured conversations. Certification 8 corresponded with session 8 (the first call after surgery), and certification 9 aligned with session 12 (the program's conclusion and future planning), eliminating the need for redundant recertification for sessions 9, 10, and 11 (Supplementary Table 1).

MoI training

Three experienced investigators (MB, YDP, and INM) led the training and certification of peer coaches in MoI, an evidence-based counseling method that promotes long-lasting behavior change. The main MoI skills include open-ended questions, affirmations, reflective listening, and summarization (OARS), and the main processes are engagement, focus, evocation, and planning. These skills help peer coaches motivate participants for successful TKR outcomes by creating a plan to achieve the goals of the Moving Well intervention.

Before the first training session, peer coaches watched educational videos on MoI skills and reviewed pamphlets adapted from the Motivational Interviewing Network of Trainers website. They implemented MoI training during practice rehearsals and completed two specific MoI training sessions. During these sessions, paired coaches role-played full-length intervention calls and received live feedback from the research team, who paused interactions to highlight areas for improvement and repeated the segment incorporating the feedback. Each session focused on one coach's performance, with a second session scheduled for the other coach to practice. All MoI sessions were recorded for review to ensure the consistent use of MoI throughout the intervention and to allow the research team to adapt training based on observed challenges.

Peer coach training evaluation

Certification sessions were used to determine whether peer coaches achieved the learning objectives for each session. A checklist (Supplementary File 2) assessed coaches’ session knowledge, MoI skills, and CBT application. The checklist comprised 26 items divided into three sections: Session Content (12 items), OARS Evaluation (10 items), and General Manner (4 items). Each item was marked as “Yes,” “Needs Improvement,” or “No” based on meeting the required competencies. To pass each session, coaches had to successfully discuss at least 90% of the session content items (11 of 12) and receive a mark of “Yes” or “Needs Improvement” on 90% of all other items (12 of 14).

Three research team members observed coaches during the certification sessions and completed the checklist. After the session, the checklist was reviewed with the coaches, along with suggestions for improvements. The research team then convened briefly to review each checklist and ensure competencies were accurately scored. A score of pass or fail was sent to coaches post certification with highlighted areas of improvements. Coaches had two attempts to pass the certification of each session before being required to repeat the training.

During MoI training sessions, coaches were not formally scored; instead, these sessions addressed gaps in knowledge on MoI and CBT principles. Coaches received written feedback on improvements needed. Throughout their certification, coaches faced tailored challenges designed to address areas of improvement identified during MoI and certification sessions.

Coaches were given opportunities to provide feedback on various aspects of the training and program materials or general comments throughout all stages of the program. Suggestions for changes were considered and discussed with the research team before implementation. Most feedback was provided via email or verbally during training sessions, certification processes, or office hours.

A formal program evaluation was conducted through a focus group at the end of the training to elicit peer coach feedback on the training curriculum, program content, and overall satisfaction with the training program. The focus group questionnaire was created by MB and refined by INM and YDP. The focus group was conducted by MB and YDP, recorded, and transcribed. Key quotes that stood out or were relevant to the research questions were highlighted and extracted by YDP. Quotes were then sorted into broad categories based on their content, and each group was labeled with a descriptive theme. MB, YDP, and INM worked on refining the themes. A post-training evaluation survey was also administered to gather additional insights and feedback.

RESULTS

Seven individuals were interviewed for peer coaching training, and all seven were offered the opportunity to train. Two peer coach candidates were unable to commit to the program because of time constraints. Five peer coaches completed the training and certification to be peer coaches of the Moving Well intervention. There were three women and two men with a mean age of 75; all were White and retired, and they had an average total KOOS of 97.6 (Table 1).

Table 1 Demographics of peer coaches who completed the training*

Peer coach demographics	Total (n = 5)
Age, mean, y	75
Sex
Female	3
Male	2
Race
White	5
Income
$51,000–100,000	2
>$100,000	3
Education
Associate degree	1
Bachelor's degree	2
Advance degree	2
Work status
Retired	5
Time after TKR, ya	4–6
Average total KOOS ADLb	97.6
Peer coach 1	98
Peer coach 2	99
Peer coach 3	100
Peer coach 4	92
Peer coach 5	99

The original training schedule consisted of 15 virtual sessions over 24 weeks. However, midway through the training, the research team substituted two virtual sessions with one extended in-person session to reinforce MoI skills. The training concluded after 22 weeks with 12 virtual sessions and one in-person five-hour session (Figure 1).

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The rationale for the addition of the in-person session and office hours was based on three main factors. First, peer coaches encountered various technological challenges, including email access, working with portable document format files, and participating in video conferences. Second, they had challenges incorporating OARS and MoI processes during training. Third, peer coaches in training were experiencing frustration given these challenges. The inclusion of an extra training session and office hours were intended to minimize the risk of peer coaches dropping out of the program.

During the in-person training, we provided physical copies of all training materials, addressed technological difficulties with each coach individually, completed the three steps of typical training (listen, discuss, practice), and created an opportunity for peer coaches to meet all team members involved in the program's creation (ie, physical therapists, research assistants, physicians, and researchers). There were improvements in their approaches to challenging mock participants, incorporating OARS into their mock sessions, interacting collaboratively with other coaches, and enthusiastically helping their co–peer coach in training to succeed. These changes sparked increased enthusiasm about the program. Table 2 provides details about the pre– and post–in-person training changes that were observed.

Table 2 Observed changes in the attitudes of peer coaches in training, both before and after the in-person training session*

Training activity	Before in-person training	After in-person training
Approaching challenging mock participants	Asked questions to try to assess what was “wrong” with the participant	Listened and acknowledged mock participant experiences and tied them back into the program
Wanted to “solve” all the mock participant's problems and used directive language such as “you should do…”	Began incorporating open-ended questions, affirmations, and summarizing from MoI to assess participant experiences and challenges, thus helping strategize how to approach participant dilemmas
Found it difficult to include examples of their own preparation and recovery from TKR	Began role-modeling their own personal experiences throughout their preparation and recovery from TKR, ie, discussing food preparation pre-TKR, suggesting changes to living arrangements for better walking post-TKR, adding information about the process of being scheduled for TKR, etc
Certification and MoI session	Became flustered or upset when receiving feedback by the research team on how to improve their MoI/CBT use	Became inquisitive on how to implement suggestions, took inspiration from co-peer coaches for similar situations, and sometimes suggested alternatives to the research team suggestions that added a personal twist
Role-playing with co-peer coaches	Only spoke about content in the present session being discussed	Foreshadowed materials to the mock participant to answer questions but still remained on-topic
Worked with mock participants as if getting a TKR was the end goal	Understood that there were different motivators for getting a TKR. Coaches thus focused on the participant's motivators throughout each conversation (ie, wanting to attend a wedding, new grandchild on the way, wanting to travel, sports/hobbies)
Coaches playing the mock participant created extremely challenging scenarios for their co-peer coach in training (ie, interrupting the coach, pretending to talk to another person during the call with the coach), which created conflict during the training sessions	Coaches playing the mock participant offered more realistic challenges that still encouraged learning how to problem-solve collaboratively

We created weekly virtual office hours during which the research team was available to address any challenges experienced by the peer coaches and provide support throughout their training. Participation was optional, and at least one coach attended every session, totaling 22 hours of office hours throughout the training period. Excluding these 22 hours, peer coaches, on average, completed around 145 hours of training (Figure 1). This exceeded the research team's initial estimate of 124 hours, representing a 14.5% increase in training time.

Focus group results

The focus group discussion with the trained peer coaches highlighted several key themes regarding the training program's structure, virtual training, MoI skills, program development, and overall fulfillment (Table 3). Peer coaches emphasized the importance of live feedback in the training process, stating it was crucial for effective learning. One coach noted, “You have to have that kind of feedback. If you don't, then you're not going to learn your lessons very well.” Additionally, large group training sessions were valued for allowing coaches to learn techniques from one another and broaden their MoI experience.

Table 3 Themes and quotes from individuals who had TKR surgery, reflecting on their training experience as a Moving Well peer coach*

Theme	Peer coach quotes
Training structure	“I just thought that you have to have that kind of feedback [live feedback]. If you don't, then you're not going to learn your lessons very well” (peer coach 4, female, 78 years old).
“I felt that it [large group training sessions] offered the opportunity to pick up techniques that others had that we hadn't explored, and it offered an opportunity for us to broaden our own [motivational] interviewing experience” (peer coach 4, female, 78 years old).
Virtual training	“We aren't going to be doing in-person work with people anyway, so it [virtual training] gave us an opportunity to experience the remoteness of not being in-person so that when we talked to them on the phone it'll actually be easier” (peer coach 4, female, 78 years old).
“One of the big benefits is that when I wasn't home, when all of us weren't home, we were still able to get on the Zoom” (peer coach 3, male, 81 years old).
“I thought it went very well on Zoom, as a matter of fact I would recommend it” (peer coach 4, female, 78 years old).
“I think one [in-person meeting] is very necessary, but I do not think more is necessary” (peer coach 2, female, 75 years old).
MoI skills and positive thinking	“I never looked at it [positive thinking] objectively like this program forced me to, so it made me realize that the positive attitude, and the motivation to succeed, was a very important part for me, so it's important to get that across to somebody who's got this [TKR] upcoming” (peer coach 5, male, 72 years old).
“Learning these new skills and then knowing that we were going to have this session [certification and MoI sessions] that we would have to prove ourselves… not only did we learn these things in book form, but we had to be prepared to make the rubber meet the road” (peer coach 3, male, 81 years old).
Program development	“I think the fact that we have input into what's going to be in the real, the final product is important because all of us have had experiences [TKR]” (peer coach 2, female, 75 years old).
“It's clear that if you haven't had the experience [TKR], how do you craft something like that? You have this group of people who have lived it. For us, it was a lovely opportunity to offer suggestions to help you complete a successful program” (peer coach 4, female, 78 years old).
“For me, it builds ownership. I mean we were in this together, you were asking our opinions, we were offering advice, and so the program became a little bit of something that I felt a little ownership too” (peer coach 5, male, 72 years old).
Peer coach fulfillment	“I thought I was going into something where I was going to have a one-hour phone call with somebody once a week and that was it, so I've learned an awful lot” (peer coach 3, male, 81 years old).
“I don't know that I expected the program to be that intense. It's much more than I had originally expected, and I think it was just very well done” (peer coach 2, female, 75 years old).
“The program offered so much more than I anticipated, and I learned personal skills that I can utilize in all my life, and I just hadn't thought about it from that perspective” (peer coach 4, female, 78 years old).
“I thought the program was very well crafted and the best part is feeling like I could go out there and maybe really help somebody” (peer coach 4, female, 78 years old).

Coaches appreciated the virtual training format, acknowledging its alignment with the remote nature of their future interactions with participants of the trial. They found virtual sessions practical and beneficial, as illustrated by a coach's comment: “It gave us an opportunity to experience the remoteness of not being in-person so that when we talked to them on the phone it'll actually be easier.” The flexibility of virtual training was also highlighted, with one coach mentioning, “When all of us weren't home we were still able to get on the Zoom.”

The introduction of an in-person training session was received positively by the peer coaches. One coach emphasized the necessity of at least one in-person meeting, stating, “I think one [in-person meeting] is very necessary but I do not think more is necessary.” The training program, particularly the in-person session, helped coaches realize the importance of positive thinking and MoI skills. One coach reflected on their own experience with TKR and the training that they just completed, saying, “It made me realize that the positive attitude and the motivation to succeed was a very important part for me.” This suggests that training increased their self-awareness regarding their emotions at the time of their TKR and reenforced principles of CBT that they had learned. The certification sessions were seen as an important way to apply these skills because they ensured that coaches were prepared to deliver the intervention as intended, according to the Moving Well manual, and also allowed the flexibility for them to adapt themselves to the unique needs of the different participants. The certification sessions were viewed as a key platform for skill application.

Coaches deeply valued seeing their input incorporated in the intervention, or, as one coach said, “For us, it was a lovely opportunity to offer suggestions to help you complete a successful program.” This involvement fostered a sense of belonging, commitment, engagement in the intervention, collaboration among the coaches, and collaboration between the coaches and the research team.

Coaches expressed a high level of fulfillment from participating in the training. They were pleasantly surprised by the program's intensity and the personal skills they gained, which they could apply in various aspects of their lives. One coach remarked, “The program offered so much more than I anticipated, and I learned personal skills that I can utilize in all my life.” Overall, the training was well-received, and coaches felt empowered to help others and were eager to start work with participants immediately after their training.

DISCUSSION

Successfully training older adults (average age of 75 years) for the Moving Well program required flexible learning, interactive instruction, personalized guidance, peer support, and periodic evaluations. After successfully engaging several participants to train as peer coaches, five peer coaches completed the training and became certified Moving Well peer coaches.

The inclusion of an in-person training session was crucial. It tackled technological issues, strengthened key skills, and enhanced engagement. We believe these factors greatly influenced the program's high completion rate and overall success. It allowed peer coaches to develop stronger interpersonal relationships with each other and with the research staff. It also gave them the opportunity to meet the physical therapist responsible for the online Moving Well exercise program. Furthermore, it proved pivotal to acquiring the necessary MoI competencies to effectively use MoI skills and apply CBT principles in each session. After the in-person session, the research team noticed that peer coaches demonstrated an improved grasp of Moving Well content and actively shared their experiences regarding TKR preparation and recovery. During role-playing exercises, they effectively employed role modeling, a key concept in social cognitive theory. Furthermore, coaches displayed increased receptivity to feedback from both the research team and fellow peer coaches and showed a willingness to provide feedback and support to their peers, particularly during challenging scenarios presented during the session.

Our group previously published our experience in the virtually training of peer coaches for the CARE RA intervention.³² The differences between the training of CARE RA and Moving Well peer coaches demonstrate the importance of customizing peer coach training to match the specific population and the disease under consideration. For example, the CARE RA peer coaches found it easier to develop the necessary skills for role modeling than the Moving Well coaches. We believed this was because RA is a chronic symptomatic condition; CARE RA coaches had little difficulty recalling details of their lived experiences with RA. In contrast, TKR is a one-time event with substantial symptom improvement, posing challenges for Moving Well coaches in recalling specific details. We addressed this by prompting coaches to recall surgery-related memories to facilitate their understanding and use of MoI skills.

The use of weekly certification sessions further enhanced the learning experience for coaches by keeping them accountable, identifying individual needs and learning gaps, and adjusting the training program based on individual progress. If not for these certification sessions, the research team would not have discovered the needs that the peer coaches in training had with learning and applying MoI and CBT skills early on. Our experience underscores the benefits of formal session-by-session certification and modifying training accordingly. It is noteworthy that, despite early challenges, all our coaches succeeded in becoming fully certified because of our early recognition of specific training needs.

Another important factor to note when comparing the CARE RA coaches with the Moving Well coaches was their age differences. The CARE RA peer coaches were middle-aged individuals who had regular interactions with technology, making virtual training more feasible. In contrast, the Moving Well peer coaches were older and encountered challenges with technology, necessitating the inclusion of in-person training and the institution of office hours. These differences highlight the importance of considering the target population and their training requirements when training peer coaches to allow investigators to effectively meet training objectives.

A notable strength of this study is the evidence-based nature of the Moving Well curriculum, which is drawn from two successful interventions (CARE RA and Living Health). These studies informed the integration of peer coaches’ experiences into both the training and content refinement of the program. These findings align well with Adult Learning Theory, which emphasizes the importance of adult learners’ engagement in planning and evaluating their instruction.^33,34 The positive feedback received from peer coaches during the focus group indicates that peer coach training benefited the coaches themselves and would also benefit future Moving Well participants. This benefit could explain the growing use of peer coaching in older populations to enhance physical fitness and address common aging-related challenges such as social isolation, physical decline, and cognitive impairment.^35–40

The outlined training program serves to establish the foundation for training cohorts of peer coaches, not only for Moving Well, but also for other interventions that involve peer coaches. These interventions are crucial in assessing whether peer coaches can effectively fulfill the roles typically performed by licensed professionals, such as physical therapists and psychologists, with the goal of enhancing the well-being of individuals with KOA or upcoming TKR. Furthermore, we believe that once coaches complete their training and gain experience working as a peer coach, they possess the skills necessary to help train future peer coaches, thus fostering a self-sustaining and self-organizing peer coach network that can offer solutions to the needs of older adults and circumvent the costly implementation of previous TKR interventions studies that relied on trained health care professionals. This possibility will be investigated further during training of future peer coach cohorts for the Moving Well intervention.

One limitation of this study is the small, homogeneous sample, which makes it difficult to gauge the broader applicability of the Moving Well peer coach training. However, the study by Goldman et al demonstrated that peer coaches from low-income backgrounds or with limited educational attainment can effectively master evidence-based curricula, suggesting the potential for training a more diverse group of peer coaches for the Moving Well program and assessing its applicability to a wider audience.⁴¹ Moreover, the age demographic of peer coaches posed technology-related challenges, consistent with previous research highlighting themes of frustration, limitations, and usability concerns among older populations when using technology.^42,43 One way to address this is by using tools like the Wireless Network Proficiency Questionnaire, developed by Roque and Boot, to assess peer coaches’ technological proficiencies.⁴⁴ A deeper understanding of peer coaches’ technological proficiency might offer a chance to transition the training to a fully remote format, eliminating the need for in-person meetings and facilitating scalability. However, we successfully addressed technological familiarity gaps through office hours and an in-person training session, suggesting that older adults with limited technological skills can become trained peer coaches if in-person training is feasible. Such capacity building could be particularly valuable for reaching disadvantaged communities.

Although unrelated to formal training, the research team found that implementing weekly team meetings post-training while interacting with participants of the Moving Well intervention effectively kept peer coaches engaged. Initially, these meetings served as a means of open communication between coaches and the research staff, primarily focusing on recruitment progress for the trial. As participants were assigned to peer coaches, these weekly meetings facilitated discussions about participant progress and provided a platform for seeking guidance when facing challenges. This approach allowed coaches to learn from one another and address areas for improvement. Consistently conducting these meetings fostered a sense of community and collegial collaboration between peer coaches and investigators and proactively reduced the likelihood of peer coaches leaving the program and the need for retraining. Whether peer coach retention will be maintained throughout the duration of the study is yet to be assessed.

The Moving Well program successfully trained older adults as peer coaches for TKR preparation and recovery through a structured curriculum that included CBT principles, exercise, and social support. The inclusion of an in-person training session was crucial for addressing technological challenges, reinforcing key skills, fostering stronger interpersonal relationships among coaches and the research team, and the retention of peer coaches. Although the small, uniform sample size limits generalizability, the program's success suggests potential for broader application and scalability. Future research should explore training a more diverse group of peer coaches and assess the program's applicability in disadvantaged communities.

AUTHOR CONTRIBUTIONS

All authors contributed to at least one of the following manuscript preparation roles: conceptualization AND/OR methodology, software, investigation, formal analysis, data curation, visualization, and validation AND drafting or reviewing/editing the final draft. As corresponding author, Dr Navarro-Millán confirms that all authors have provided the final approval of the version to be published, and takes responsibility for the affirmations regarding article submission (eg, not under consideration by another journal), the integrity of the data presented, and the statements regarding compliance with institutional review board/Helsinki Declaration requirements.

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