Implementation of group-based health education and exercise for individuals with knee osteoarthritis in brazilian primary health care: a mixed-methods study

BACKGROUND: Despite strong evidence supporting exercise and education for knee osteoarthritis, access to these interventions remains limited in low- and middle-income countries. Implementation studies are needed to evaluate whether evidence-based programs can be delivered within routine primary care. OBJECTIVES: To examine the feasibility of implementing a physical therapist-led, group-based exercise and education program for people with knee osteoarthritis in Brazilian primary health care, and to explore participants' perceived barriers and facilitators to implementation and exploratory clinical outcomes. METHODS: A mixed-methods implementation study was conducted in Brazilian Primary Health Care across municipalities with varying levels of the Human Development Index and health care contexts. Eighty-four adults with knee osteoarthritis participated in a 12-week group-based program combining structured physical exercise and health education, delivered by primary care physical therapists trained through the PEAK-Portuguese e-learning course. The intervention combined group-based structured physical exercise and health education. Implementation outcomes included recruitment, adherence, fidelity, acceptability, satisfaction, and adverse events. Qualitative interviews were analyzed using content analysis to identify participants' perceived barriers and facilitators to implementation. Exploratory clinical outcomes included pain intensity, knee-related health status, function, global perceived effect, medication use, physical activity participation, and use of assistive walking devices. RESULTS: Of 110 eligible individuals, 96 agreed to participate (recruitment 87.3%), 84 started the program, and 70 completed the 12-week program (retention of 83%). Adherence was high, with participants missing an average of 1.39 sessions (SD = 1.35). Intervention fidelity exceeded 90%. All participants reported being satisfied with the treatment. No intervention-related adverse events were reported. Three overarching themes were identified: (1) experiences and perceptions of treatment, including improved symptoms, psychological well-being, knowledge acquisition, reduced medication use, and weight loss; (2) implementation facilitators, including free access, proximity to home, professional support, educational materials, and a supportive group environment; and (3) implementation barriers, including scheduling conflicts, distance to the treatment site, initial difficulty performing some exercises, and transient pain during the first sessions, which were generally perceived as minor or temporary. Exploratory clinical outcomes suggested improvements in pain intensity, knee-related health status, function, global perceived effect, medication use, physical activity participation, and use of assistive walking devices after 12 weeks. CONCLUSIONS: The implementation of physical therapist-led, group-based exercise and health education programs for people with knee osteoarthritis was feasible and well accepted within Brazilian Primary Health Care. High recruitment, retention, adherence, fidelity, participants' satisfaction, and the absence of intervention-related adverse events support its integration into routine care, while exploratory clinical outcomes suggested improvements in health outcomes.