Developing and evaluating complex interventions: the new Medical Research Council guidance

Development of a dyadic mindfulness self-compassion intervention for patients with lung cancer and their family caregivers: A multi-method study

Objective

Lung cancer and its prolonged treatment are profoundly unsettling for patients and their family caregivers, and developing dyadic measures to alleviate their negative affectivity is pivotal. This study aimed to develop a complex intervention to alleviate dyadic psychological stress among patients with lung cancer and their family caregivers.

Methods

A stepwise multi-method study was conducted following the Medical Research Council framework. Three phases were adopted, namely: (1) a preparation phase, a systematic review was conducted to identify the evidence base, (2) a development phase, empirical data from a quantitative study and a qualitative study were integrated to identify effective components, and (3) a modification phase, an online Delphi survey was carried out to refine the intervention.

Results

The dyadic Mindfulness Self-Compassion intervention developed in this study consists of six weekly sessions. The key components of the intervention include: (1) getting along with cancer (introductory session targets illness perception), (2) practising mindful awareness (core session for mindfulness), (3) defining dyadic relationships and introducing self-compassion (core session for self-compassion), (4) promoting dyadic communication (maintenance session targets communication skills), (5) promoting dyadic coping (maintenance session targets coping skills), and (6) a summary session reviewing the rewards and challenges of dyadic adaptation named embracing the future.

Conclusions

An evidence-based, theory-driven, and culturally appropriate dyadic Mindfulness Self-Compassion intervention was developed for patients with lung cancer and their family caregivers. Future studies are warranted to pilot and evaluate the usability, feasibility, acceptability, satisfaction, and effectiveness of this complex intervention.

Trial registration

ClinicalTrial.gov NCT04795700.

Evaluation of person-centred care within the Stepstones transition program for adolescents with congenital heart disease - a document analysis

Background

Transition programs are pivotal in ensuring successful transition to adulthood and transfer to adult care for adolescents with chronic conditions. Healthcare providers must therefore support adolescents in increasing their empowerment to gain active participation in health and care. The Stepstones transition program is based on a person-centred care approach and has been evaluated in a randomized controlled trial. However, the extent to which the person-centred care approach was implemented needs further exploration.

Objective

To evaluate how a person-centred care approach was implemented based on a documentation analysis of the Stepstones transition program for adolescents with congenital heart disease.

Design

A deductive qualitative design employing analysis of the documentation used in the Stepstones transition program.

Settings

The documentation derives from the consultations in the two interventions centres in the Stepstones randomized controlled trial. The trial was conducted between 2017 and 2021. Data sources included in this study were: The adolescents' written narratives, documentation of the person-centred conversations, and goalsetting in the transition plans.

Participants

Documentation for adolescents with congenital heart disease, randomized to the intervention group (n = 59) at the two intervention centres was included.

Methods

Directed content analysis was used to evaluate how person-centred care was described in the documentation. The analysis was based on the three cornerstones of person-centred care: initiating, establishing and safeguarding partnership, in this study between the adolescent and the transition coordinator during the transition program. The data were deductively sorted into aspects of relevance for person-centred care and adolescent health. For the written narratives an inductive analysis was thereafter undertaken.

Results

A partnership between the transition coordinator and the adolescent was initiated through the adolescents' written narrative and established using a psychosocial interview guide. This outlined a spectrum of aspects important to person-centred and adolescent-oriented approach, such as resources, risks/obstacles, and needs. The goalsetting process describes goals commonly agreed upon and how to accomplish them. A solid foundation of self-awareness regarding personal capacities and learning needs contributed to the development of knowledge, understanding, and fostered independence to various degrees.

Conclusions

The Stepstones transition program for adolescents with congenital heart disease implemented several person-centred components, such as eliciting narratives, collaborative goal setting, and tailoring support needs. The documentation had limitations in fully reflecting the person-centred practices employed, highlighting opportunities for improvement in person-centred documentation.

Tweetable abstract

"The study delves into the implementation of person-centred care in the Stepstones transition program for adolescents with congenital heart disease, revealing strengths and areas for improvement in documentation."

Surviving and Thriving in Medicine: Developing Theory-Based Interventions for Students From Widening Access Backgrounds

The challenges facing students from widening participation (WP) backgrounds do not simply disappear upon entering medicine. Accordingly, it is imperative that in promoting equity in medicine, we understand how WP students may be best supported to thrive in their studies. This research aimed to develop an evidence-based and theory-informed intervention strategy to target student support amongst undergraduate WP students in medicine. Workshops were conducted with staff working in the medical school and students from WP backgrounds. Participants generated potential intervention ideas and critically considered the feasibility of implementation. Data analysis and intervention development were supported by the Theoretical Domains Framework (TDF) and Behaviour Change Wheel (BCW). The TDF and BCW were successfully conceptualised to structure an intervention strategy to enhance student support amongst WP students in medicine. Workshop participants identified support needs of students from WP backgrounds, and these were prioritised and used to drive intervention development. We outline two interventions that were developed from the research: adaptation of the existing personal tutor scheme and implementation of a WP peer network. The theory-based intervention strategy outlines a foundation that could be utilised to develop and evaluate interventions to support students from WP backgrounds in medicine. This study has demonstrated how an intervention development framework (BCW) using a theoretical base can be used to develop interventions for students from WP backgrounds. Two intervention ideas were developed from the research and were designed to promote support seeking, social connection and a sense of belonging in students from WP backgrounds.

Therapists' perspectives on the Maudsley model anorexia nervosa treatment for adolescents and young adults (MANTRa): A qualitative interview study

OBJECTIVES

A rising incidence of eating disorders in the young population and limited effectiveness of available treatment approaches underscore the need for innovative therapies. This study explores therapists' perspectives regarding a promising new manualized psychotherapeutic treatment (MANTRa) for adolescents and young adults with anorexia nervosa (AN).

METHODS

Semi-structured qualitative interviews were conducted with 10 therapists (nine female) who provided 24-34 sessions of MANTRa per patient. Interview topics included positive and negative experiences with MANTRa in general, with the workbook and other components. Reflexive thematic analysis was used to interpret the data. Furthermore, written notes taken by the therapists after each sessions were analysed.

RESULTS

The thematic analysis revealed five overarching themes: (1) Variety of therapeutic tools and content elements included in the workbook; (2) Getting the therapeutic process going; (3) Flexibility in use of the workbook; (4) Impact of the scientific and multidisciplinary framework on quality assurance; (5) Formal design of the workbook. Therapists' case formulation letters to the patients were regarded as powerful tools to strengthen therapeutic alliance and promote recovery. In-depth therapists' training, regular supervision and a multi-professional treatment setting were important factors to ensure high treatment quality.

CONCLUSIONS

The findings suggest how the MANTRa content (e.g. inclusion of additional therapeutic tools), the therapists' training and the format (e.g. provision of a digital version) can be improved to reach maximum impact. Therapists' formulation letters may be an effective therapeutic tool not only for AN but also across the spectrum of psychiatric disorders in adolescents and young adults.

The Role of Health Psychology in Surgical Prehabilitation: Insights From REST, a Preoperative Sleep Intervention for Total Knee Replacement Patients

BACKGROUND

Approximately 10%-34% of people experience chronic pain after total knee replacement (TKR) surgery. Prehabilitation approaches that address pre-operative risk factors for chronic post-surgical pain are a key area for research. To be effective, prehabilitation requires substantial engagement and behaviour change by patients, which can be challenging in the pre-operative period. Health psychology theory plays a valuable role in understanding how best to support behaviour change to achieve maximum patient benefit. This study provides insights from REST, a pre-operative sleep intervention for TKR patients.

METHODS

In-depth semi-structured interviews were conducted with eight TKR patients who took part in the REST feasibility trial. An abductive analysis approach was used to identify the applicability of existing health psychology theories, and to explore new insights into the relationships between stages of behaviour change.

RESULTS

Three thematic areas related to intervention engagement and enactment were identified: (i) health beliefs and readiness to change; (ii) from contemplation to enactment: the role of behaviour change techniques; (iii) and behavioural maintenance.

CONCLUSION

Findings highlighted three key stages of behaviour change that participants need to be supported in to benefit fully from prehabilitation intervention. Complex behaviour change interventions that include aspects of tailoring should consider the boundaries of acceptable adaption while maintaining core causal mechanisms, and include methods to explore real-world implementation and usability during the development process. These findings are important for surgeons and multidisciplinary teams to consider when developing new prehabilitation care pathways or when implementing evidence-based prehabilitation practices.

Telemedicine-supported hospital-at-home for acutely admitted patients at Nordsjaellands Hospital, Denmark: a study protocol for a randomised controlled trial

INTRODUCTION

The combination of a reduction in the Danish hospital bed count, the shortage of hospital staff and demographic changes challenges the Danish hospital capacity. This was further highlighted during the COVID-19 pandemic when hospitals worldwide were overwhelmed by infected patients requiring acute hospital care. To address these challenges, a hospital-at-home (HaH) programme offers an alternative to conventional in-hospital admission. Furthermore, HaH has the potential to improve patient outcomes, reduce costs and increase patient satisfaction. However, few studies have evaluated HaH in a Scandinavian setting, and this article describes the protocol for a randomised controlled trial (RCT) comparing an HaH model with continued conventional in-hospital admission. The main aim of the trial is to evaluate physical activity level and mental wellbeing in patients admitted at home compared with conventionally admitted patients.

METHODS AND ANALYSIS

110 clinically stable patients from two internal medical wards at Nordsjaellands Hospital in Denmark will be included and randomised in a ratio of 1:1 to either continued conventional in-hospital admission (control group) or virtual HaH model (intervention group). The control group will receive standard hospital treatment, and the intervention group will be transferred home for continued treatment (eg, intravenous antibiotics or oxygen treatment). The primary outcome measures are physical activity assessed using daily step count (during the first 24 hours after inclusion, as an intermediary indicator of the risk of adverse events) and treatment satisfaction (assessed using a patient satisfaction survey). Secondary outcome measures are adverse events of special interest, escalation of care, readmission rate postdischarge (30 days and 90 days), mortality (associated and 7 days, 30 days and 90 days postdischarge), process data (eg, the number of teleconsultations) and a health economic evaluation.

ETHICS AND DISSEMINATION

The study was approved by the Danish Research Ethics Committees (no. 2303051) and the Danish Medicines Agency (CIV-23-03-042542) and will be monitored by the Copenhagen University Hospital Good Clinical Practice unit. Results will be published in peer-reviewed journals and presented at relevant national and international conferences. We also plan to communicate the results to relevant stakeholders in the Danish healthcare system.

TRIAL REGISTRATION NUMBER

NCT05920304.

Professional-Facing Digital Health Technology for the Care of Patients With Chronic Pain: Scoping Review

BACKGROUND

Chronic pain is a highly prevalent condition, estimated to affect as many as 30% of people worldwide. The need for more innovative solutions for chronic pain management is clear, and digital health technology (DHT) may be the best way to address this challenge. Much of the digital health research focusing on chronic pain focuses on patient-facing solutions; however, DHT for health care professionals (HCPs) is equally important to support evidence-based practice, which, in turn, improves patient outcomes. Despite this, no review has investigated the availability of professional-facing DHT for chronic pain management.

OBJECTIVE

This scoping review aims to identify the available professional-facing DHTs for chronic pain management. Specifically, the objectives were to investigate the components of the DHTs as well as development methods, user features, outcomes, and HCP perspectives on DHTs for chronic pain care.

METHODS

Databases, including MEDLINE, Embase, CINAHL, PsycINFO, and Inspec, were searched using comprehensive search strategies. Two independent reviewers screened titles and abstracts for inclusion of studies in the review and conducted full-text screening. Any conflicts in each stage of the screening process were first resolved through discussion and then through a third independent reviewer. Data extraction and quality assessment were completed using the Template for Intervention Description and Replication (TiDIER) checklist and Quality Assessment for Diverse Studies. Qualitative analysis involved inductive content analysis of user features and thematic synthesis of HCP perspectives.

RESULTS

In total, 52 studies were included in the review, reporting on 44 professional-facing DHTs. The included DHTs were intended for remote patient monitoring, clinical decision support, assessment and diagnosis, education of HCPs, or a combination. The most common target population for DHT use was multidisciplinary care teams; the most common setting for implementation was primary care. Approximately half (26/44, 59%) of the professional-facing DHTs had a connected patient-facing system. Inductive content analysis of the user features produced 4 themes: guiding initial consultation, supporting chronic pain management, facilitating ongoing patient management, and supporting routine clinical duties. The thematic synthesis of HCP perspectives produced the following 4 themes, reflecting factors affecting the use of DHTs in chronic pain care: additional value, integration into clinical workflow, ease of navigation, and trust in the DHTs. Most (43/52, 83%) of the included studies did not adequately report appropriate stakeholder involvement in a proper co-design of DHTs; only 7% (3/44) of the DHTs were reported to have been developed with guidance from a system development framework.

CONCLUSIONS

There are various DHTs available for HCPs to use in the management of chronic pain. The included studies neither reported adequate stakeholder involvement in the DHT development nor any specific frameworks to guide rigorous co-design. Therefore, future research should focus on developing professional-facing DHTs with active involvement of stakeholders in the design process.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/51311.

Design and evaluation of the "Feel Good" feasibility study - a multi-component fruit and vegetable intervention in children measuring cognitive and mental health outcomes

BACKGROUND

Observational evidence suggests that increasing fruit and vegetable (FV) intake has the potential to improve children's cognitive function and mental well-being, but this has not yet been empirically tested in intervention research. This study assessed the feasibility and acceptability of a multi-component FV intervention which measures mental and cognitive health outcomes in children.

METHODS

The 'Feel Good Study' was a cluster-randomised controlled feasibility study conducted in four New Zealand primary schools, with equal allocation of schools to intervention and wait-list control arms. The intervention group received a 10-week FV programme informed by behavioural theory, including school- and home-based components designed to improve FV availability and acceptance. The wait-list control group received a simplified 5-week version of the intervention. Dietary, cognitive, and mental health outcomes were completed by children and parents/caregivers at the start and end of the 10-week study period. Primary outcomes of this feasibility study were recruitment, retention, and data collection rates. Process evaluation captured measures of intervention fidelity and dose, acceptability, reach, and barriers or facilitators to implementation.

RESULTS

Seventy children were recruited (79% of target recruitment rate), with an average retention rate of 89%. Diet, cognitive, and mental health data collection procedures were feasible, with all data valid for analysis except for 6% of children's dietary questionnaires. All intervention components were delivered (100% dose delivered), with high levels of fidelity (82% - 100% of components implemented as planned). All teachers and parents strongly agreed that they would recommend other schools/families take part in the study, indicating high levels of acceptability. Process evaluation revealed areas for refinement including more cohesive connections between school- and home-based intervention components, strengthening or adding new intervention components, and simplifying enrolment procedures with longer recruitment periods.

CONCLUSION

Having satisfied key feasibility and acceptance measures in the Feel Good Study, we recommend intervention refinement and progression to a definitive trial where the efficacy of increased FV intake for mental health and cognitive function can be tested in children for the first time.

TRIAL REGISTRATION

The trial protocol was prospectively registered with the Australia and New Zealand Clinical Trials Registry (ACTRN12623000533695) on 2 May 2023, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=385829&isReview=true .

Outcomes and cost-effectiveness of an integrated holistic care package on persons affected by podoconiosis, lymphatic filariasis and leprosy and community members in north-western Ethiopia: an implementation research study

BACKGROUND

Most studies on integration of neglected tropical disease programmes have focused on mass drug administration or environmental measures rather than Disease Management, Disability and Inclusion (DMDI). The study reported here explored integration of a DMDI care package across three disabling, stigmatising neglected tropical diseases (podoconiosis, lymphatic filariasis and leprosy), across physical and mental health, and into the state health system.

METHODS

We conducted this pre-post study, the third phase of an implementation research project, in two predominantly rural districts in north-west Ethiopia in 2021. We assessed physical and mental health outcomes on 192 affected persons and 817 community members at baseline and 6 months after initiation of the integrated care package, implemented by nurses and health officers. Key outcomes measured were disability (using WHODAS-2.0), depression (Patient Health Questionnaire-9), discrimination (Discrimination and Stigma Scale), internalised stigma (Internalized Stigma Related to Lymphoedema), quality of life (Dermatology Life Quality Index) and social support (Oslo-3 Social Support Scale). Mixed effects linear regression models were used to estimate change in outcomes between baseline and 6 months after initiation of the care package. We also evaluated implementation feasibility and conducted cost-effectiveness analysis.

RESULTS

Among 221 patients, improvements were observed in foot (- 2.3 cm; 95% CI: - 2.2, - 1.8) and leg circumference (- 1.8 cm; - 2.0, - 1.7) and acute attacks (6.2; 0.0, 6.6); these were statistically significant at the 5% level. Reductions were seen in disability scores (- 6.5; - 7.6, - 5.5), depression (- 5.3; - 6.6, - 4.6), discrimination (- 3.3; - 4.2, - 2.3), internalised stigma (- 3.7; - 4.6, - 2.8), quality of life (- 4.0; - 4.8, - 3.2), and alcohol use (- 1.6; - 2.4, - 0.8). No notable changes were found in the presence of wounds or moss, or perceived social support. Across 817 community members, there was strong evidence that knowledge improved, and stigmatising attitudes and social distance reduced. The intervention was cost-effective in reducing depression and disability and improving health-related quality of life and feasible to implement.

CONCLUSION

The integrated intervention is feasible and cost-effective even in remote areas and appears ideal for scale-up to other endemic regions in Ethiopia and other countries.

Transforming healthcare by prioritizing qualitative and quantitative clinical trial evidence: evaluating the Aging, Community and Health Research Unit's Community Partnership Program for Older Adults (ACHRU-CPP)

BACKGROUND

This study aimed to test the effectiveness and implementation of a complex integrated care intervention for older adults. We collected both quantitative and qualitative data, which is recommended in evaluating complex interventions to gain a comprehensive understanding of key success factors. Often, congruence is sought and considered desirable when integrating the findings from both data types. However, data are not always congruent, nor is it suboptimal when incongruence occurs, as we illustrate in this case study. We present the divergent findings from a large community-based implementation-effectiveness hybrid type II trial, and how the struggle to reconcile incongruent results yielded rich insights informing the next steps for translational research on the intervention being tested.

METHODS

Previous foundational research, including a pilot study and randomized controlled trial (RCT), showed promising results and supported proceeding with a multi-site pragmatic hybrid type II effectiveness-implementation RCT. This recent RCT was undertaken and quantitative and qualitative data were collected to inform the effectiveness and implementation evaluation. To synthesize the findings and guide integration of this large body of evidence, we developed a conceptual model which combined two existing frameworks: the Consolidated Framework for Implementation Research and Quintuple Aim. We used this model to identify the evidence and relate it to relevant implementation and intervention determinants/outcomes. We then synthesized the evidence to distall the main messages regarding the future of the intervention, which involved reconciling apparently discrepant findings from the quantitative and qualitative approaches.

RESULTS

The current RCT showed no statistically significant effect for participants for the primary (or secondary) outcomes yet the implementation evaluation consistently found perceived benefits of the intervention for patients, providers, and the healthcare system. Qualitative evidence was critical in understanding contextual factors potentially responsible for the absence of a treatment effect (e.g., COVID-19), strategies to overcome challenges experienced in participant engagement and intervention delivery, and recent policy/practice setting changes which showed strong alignment with the intervention and supported its future implementation.

CONCLUSIONS

With the goal of the hybrid type II effectiveness and implementation study in mind, stakeholders encouraged proceeding with a scalability assessment to consider the evidence from the current trial within the context of our prior research, the broader literature for similar interventions, and the ever-changing policy context.

TRIAL REGISTRATION

clinicaltrials.gov NCT03664583. Registration date: September 10, 2018.

Using a Robot to Address the Well-Being, Social Isolation, and Loneliness of Care Home Residents via Video Calls: Qualitative Feasibility Study

Background

About 40,000 people are living in Norwegian care homes, where a majority are living with a dementia diagnosis. Social isolation and loneliness are common issues affecting care home residents' quality of life. Due to visitation restrictions during the pandemic, residents and family members started using digital solutions to keep in contact. There is no framework or guidelines to inform the uptake and use of technologies in the care home context, and this often results in non-adoption and a lack of use after the introduction phase. Hence, there is a great need for research on the feasibility of a robot that can facilitate video communication between residents and family members.

Objective

This study aimed to (1) introduce video communication through a robot to address social isolation and loneliness in a care home during a period of 6 weeks and (2) identify elements central to the feasibility concerning testing and evaluating the use of the robot.

Methods

Three focus group interviews were undertaken: 1 with family members (n=4) and 2 with care staff (n=2 each). The informants were purposely selected to ensure that they had the proper amount of experience with the robot to have the ability to inform this study's objectives. The focus group interviews were tape-recorded and transcribed verbatim, then subsequently analyzed using systematic text condensation.

Results

The data analysis of focus group interviews and individual interviews resulted in three categories: (1) organizing the facilitation of video calls, (2) using a robot in dementia care, and (3) user experience with the robot.

Conclusions

Video communication in care homes is a feasible alternative to face-to-face interactions, but it depends on organizational factors such as information flow, resources, and scheduling. In dementia care, the user-friendly robot supports person-centered care through tailored social interaction. Both family members and staff express enthusiasm for video calls as an option and see its potential for future use.

Opportunities and challenges for paediatricians requesting funded genomic tests for children

Genomic diagnosis for children with childhood syndromes can inform treatment, management and reproductive planning. Shortages in the clinical genetics workforce mean that practices are changing, with paediatricians likely requesting initial genomic investigations and clinical genetics services reserved for particularly complex cases or post-test genetic counselling. In Australia, paediatricians can request funded genomic testing for patients, yet ordering rates are less than a quarter predicted. Using a theory-informed approach, we aimed to understand barriers and enablers to general paediatricians' practice as the essential first step in developing complex interventions to support clinical practice. Maximum variation sampling was used to invite general paediatricians to complete a semi-structured interview. The interview guide used a process map of the steps involved in ordering funded genomic tests, with questions addressing the components of the Capability, Opportunity, Motivation - Behaviour (COM-B) model and the Theoretical Domains Framework. Twenty-six general paediatricians with diverse practice experience participated. Paediatricians described barriers related to capability, opportunity and motivation. Intuitive strategies general paediatricians suggested to overcome barriers aligned with theoretical strategies to implement practice change. These included: raising awareness using avenues paediatricians already access for clinical information; providing opportunities for experiential learning to build on foundational knowledge; having practical resources in one easily accessible location; family-friendly information materials to share with patients. This study provides evidence to inform a roadmap of strategies to effectively support general paediatricians in incorporating genomics into their practice and ultimately delivering faster, more equitable genomic medicine.

A complex intervention to reduce hospital admissions for people living with dementia in shared-housing arrangements in Germany: results of the multicenter, cluster-randomized controlled DemWG-study

BACKGROUND

People living with dementia (PlwD) have a 1.4 times higher risk of hospitalization than people living without dementia. Hospital admissions lead to negative consequences for PlwD and people living with mild cognitive impairment (PlwMCI). Housing models such as shared-housing arrangements (SHAs), which are predominantly used by PlwD, enable care-dependent people to experience daily life as ordinary as possible. However, studies are needed to show how complex non-pharmacological interventions affect hospital admissions, especially in the SHAs setting.

METHODS

The longitudinal, multicenter, cluster-randomized, controlled, and prospective mixed methods study from April 1, 2019, to December 31, 2022, was part of the German DemWG study and included a waitlist control group design. The multicomponent complex intervention consisted of (a) education of nursing staff in the SHAs-at the beginning of the study, (b) digital education of general practitioners-at the beginning of the study, and (c) the multimodal, psychosocial group intervention MAKS-mk + -structured application of MAKS-mk + between t0 (baseline) and t1 (after 6 months). Longitudinal data were collected at three survey times t0-t2 (t2 at another 6 months follow-up). The primary outcome parameter-hospital admission-was assessed using the nursing documentation. Poisson-models with hierarchical random effects were used for statistical analysis.

RESULTS

Nationwide, 97 SHAs with 341 residents participated at t0. Within the longitudinal observation period (12 months, t0-t2), data from 236 participants at t1 and 168 participants at t2 with mild cognitive impairment or mild to moderate dementia were evaluated. In the intention-to-treat sample, the adjusted Poisson-model showed that participants in the intervention group (IG, n = 201) had a significantly lower number of hospital admissions at t1 than participants in the control group (CG, n = 140) (p-value = 0.048; CI = 0.22; 0.99). Beyond t1-"open phase" of the study, no further statistically significant long-term effects of the IG could be identified (p-value ≤ 0.498; CI = 0.25; 1.98).

CONCLUSIONS

The complex intervention significantly reduced the number of hospital admissions for PlwD and PlwMCI in the "structured phase" of DemWG. This leads to significant improvements in the nursing care and living situation for PlwD and PlwMCI. Since the intervention has been proven to have positive effects and can be easily integrated into SHAs, regular and nationwide integration into everyday care should be given greater consideration.

TRIAL REGISTRATION

ISRCTN89825211 (Registered prospectively, 16 July 2019).

Development of a complex palliative care intervention for patients with heart failure and their family carers: a theory of change approach

BACKGROUND

Patients with heart failure have significant palliative care needs but few receive palliative care. Guidance is lacking on how to integrate palliative care into standard heart failure care. Palliative care interventions often lack an underpinning theory and details on how key components interact to achieve an impact. Understanding how and why an intervention works enhances implementation. This study aimed to develop and refine a theory-based, complex palliative care intervention for patients with heart failure and their family carers.

METHODS

A preliminary theory that underlies the intervention and delineates its key components was co-designed, based upon a literature review, in three Theory of Change workshops with stakeholders from a hospital heart failure multidisciplinary team. The workshop discussions and analysis were informed by Normalisation Process Theory. Subsequently, analysis of secondary data on patient and carer experiences with palliative care services was presented to stakeholders to refine the proposed theory. Service users were consulted to provide feedback on the intervention components.

RESULTS

The agreed impact of the intervention was to meet the holistic palliative care needs of patients with heart failure and their families. Three long-term outcomes were identified: reduced unnecessary hospitalisations, symptom burden, and caregiving burden. Twelve preconditions on the patient, family, and healthcare professional levels and contextual assumptions were determined to achieve these outcomes. Proposed intervention activities include educating patients and heart failure teams on palliative care, completing a needs-assessment tool (NAT: PD-HF), addressing primary palliative care needs, sharing a summary of the tool with healthcare staff, and sharing experiences of using NAT: PD-HF in practice.

CONCLUSIONS

The study provided novel insights into complex intervention development and the potential mechanism of integrating palliative care in heart failure. It outlined how the complex intervention could work and identified the active ingredients necessary for replication. The developed Theory of Change serves as a model for researchers and policymakers to use in heart failure, but also as an example of how to develop interventions embedded in and co-produced from practice.

Processing the trauma of gynaecological cancer through reading and writing: Women's experiences from digital storytelling after treatment

In this article we explore the potential significance of illness stories in cancer rehabilitation by describing gynaecological cancer survivors' experiences from both reading other women's illness stories as well as writing their own. Individual texts were written by fifty-nine women who had recently finished primary cancer treatment while participating in an e-intervention. These texts were analyzed, inspired by Braun and Clark's method of analysis. Our analysis led to two main themes; "Recognition - understanding oneself through others" and "Processing and adapting to a changed everyday life." We found that reading and writing about cancer can pave the way for the individual woman's recognition, normalization, belonging, and path to acceptance. However, this work can be painful as it can trigger memories of going through the cancer experience. Health personnel must be aware of both potentials and pitfalls and be sure to give the support needed.

The Acceptability of Diagnostic Tests in the United Kingdom

Purpose

It is increasingly acknowledged that public acceptability should be considered when designing, evaluating, and implementing healthcare interventions; especially for vulnerable groups.

Patients and Methods

A voluntary, self-reported, anonymous questionnaire with ethical approval and patient and public involvement was distributed online through social media over a 6-month period to explore acceptability of diagnostic tests.

Results

Ninety-three individuals replied to the questionnaire, of which the majority were female (89.2%) heterosexual (92.4%) white (81.6%) and resided in England (94.6%). The most encountered diagnostic test was an X-ray (92.4%) and the least encountered test was a bone marrow biopsy with local anaesthetic (0%). A sputum sample test was the most perfectly acceptable investigation (83.8%). One percent of participants felt that the cervical smear test was perfectly acceptable With reference to hysteroscopy, 44% felt a hysteroscopy was perfectly acceptable under general anaesthesia, compared to no participants with local anaesthetic or sedation. Forty one percent of participants felt a diagnostic laparoscopy was perfectly acceptable.

Conclusion

The findings from this study provide insight into the acceptability of medical tests from a patient perspective and will inform a more explorative qualitative study to ensure researchers are aiming to produce tests that are sensitive, specific and importantly acceptable.

Co-designing interprofessional education in primary healthcare: an illustration from the Make My Day stroke prevention project

The aim of this paper is to describe a research process of actively engaging stakeholders using co-design in the development of interprofessional education and a health intervention program targeting stroke prevention. Stakeholders included potential patients, healthcare professionals, and healthcare experts/researchers. Collaborating through co-design can be utilized in developing primary healthcare interventions including educational strategies for interprofessional learning. In this paper, an intervention in primary healthcare (Make My Day) will be used to illustrate how co-design was applied, partly as a method for developing educational resources together with stakeholders, and partly by engaging interprofessional healthcare teams in adapting intervention materials to address the needs of groups more specifically at risk of stroke in local contexts. There is a need to actively involve stakeholders, build on user experiences, and integrate interprofessional knowledge in the design and evaluation of health interventions. However, there is a lack of detailed accounts about how this can be accomplished. This study illustrates collaborative research process components and thus contributes with knowledge about how co-design methods can be applied in health intervention design as well as in interprofessional education within primary healthcare settings.

"I think most people feel like healthcare professionals tell them to take their treatments and judge them for not taking them": reflexive thematic analysis of the views of adults with cystic fibrosis on how treatment adherence is discussed in healthcare

OBJECTIVE

Previous research exploring patient-practitioner communication in relation to adherence in cystic fibrosis (CF) is limited. This UK study explored the views of adults with CF on how treatment adherence (related to all CF treatments) is discussed in routine CF care.

METHODS

12 White British adults (ten females; aged 20-37 years; mean 30.1 years) with CF participated in semi-structured interviews.

RESULTS

Three overarching themes were developed through reflexive thematic analysis: (1) 'The power of language'; (2) 'Healthcare professionals do not recognise the importance of context'; and (3) '"Admitting" non-adherence is difficult'. The way in which adherence is discussed in adult CF care is viewed as paternalistic and infantilising. Participants reported that healthcare professionals do not always consider the desire to balance treatment-taking with living a normal life. Unwelcome responses from healthcare professionals, and the inability to accurately self-report the amount of treatment taken made it difficult to 'admit' non-adherence.

CONCLUSIONS

A culture change is needed in CF care such that people who struggle to take their treatments are not labelled as disobedient, wilfully disobeying orders from healthcare professionals in positions of authority. Instead, an open, honest, non-judgemental approach, as recommended by healthcare agencies for over a decade, should be adopted.

Qualitative focus group study of interprofessional healthcare providers to inform the development of a virtual psychoeducational training program for the treatment of childhood interpersonal trauma

The shortage of adequately trained healthcare providers (HCPs) able to treat adults who have experienced childhood interpersonal trauma (CIT) is a pressing concern. This study explored HCPs' training needs for a trauma-focused psychoeducational group intervention and the potential barriers and facilitators to accessing such training. Three 1-hour focus group sessions were conducted with HCPs (n = 17) from two urban and one rural community healthcare organization serving diverse populations in Ontario, Canada, including under-housed people, women struggling with mental health and addiction, and LGBTQ+ populations. On average, participants had 2.4 years in their current role and 18.1 years of mental health field experience. Thematic analysis revealed key findings: a strong clinical need for trauma services, accessible training programs, and broadly applicable interventions relevant for diverse populations. Notably, participants emphasized the clinical advantages and increased accessibility of a virtual training programs focused on psychoeducational treatment interventions, particularly within community-based healthcare settings. This study highlights the potential of a virtual psychoeducational training programs for HCPs to address this critical gap in healthcare provision for individual with CIT. It also underscores the need to move beyond training program development and focus on implementation and sustainability of interventions in clinical practice.

Examining the implementation of a multi-site evidence-based intervention to reduce fluoroquinolone usage: A qualitative content analysis of staff interviews to identify facilitators and barriers

Clostridioides difficile infection is the most common healthcare-associated infection, causing almost half a million infections in the United States annually. Inappropriate antibiotic usage is a known risk factor. Antibiotic stewardship efforts aim to optimize prescribing. Evidence supports pre-prescription authorization as a highly effective intervention. A pre-prescription intervention for fluoroquinolone antibiotics via a computerized clinical decision support tool called a "best practice alert" (BPA) embedded in the patient's electronic health records has high potential for improving antibiotic stewardship. However, information is scant about the factors that might impact the uptake and effectiveness of this BPA and other similar evidence-based interventions when spread and adopted across multiple independent sites. Therefore, we utilized the Consolidated Framework for Implementation Research (CFIR) to understand the facilitators and barriers to the implementation process that influence clinical and implementation outcomes. In doing so, we conducted semi-structured interviews with 18 healthcare professionals across four hospitals. Our research team performed a qualitative analysis to understand the contextual factors influencing the implementation outcomes, such as acceptability and sustainability.

TAKEAWAYS

The following themes highlight the factors affecting the implementation of this healthcare innovation.

INTERVENTION CHARACTERISTICS DOMAIN

Designing interventions that are customizable and low maintenance.

INNER SETTING DOMAIN

Maturity level of the Antibiotic Stewardship Program.

INDIVIDUALS DOMAIN

Implementer's experience/attitudes in implementing healthcare innovations.

OUTER SETTING DOMAIN

The ability to prioritize initiatives as the organization responds to unintended circumstances (e.g., COVID).

PROCESS DOMAIN

Adapting implementation approaches and strategies as technology spreads.

Mobile Health Interventions for Modifying Indigenous Maternal and Child-Health Related Behaviors: Systematic Review

BACKGROUND

Mobile health (mHealth) interventions promoting healthy lifestyle changes offer an adaptable and inexpensive method for accessing health information but require cultural appropriateness and suitability for acceptance and effectiveness in Indigenous populations. No systematic review on effective mHealth interventions for Indigenous women during pregnancy and the early childhood years has been conducted.

OBJECTIVE

This review evaluated the effectiveness of mHealth interventions promoting healthy behaviors for Indigenous mothers and children from conception to 5 years post partum. It also aimed to explore the observed effectiveness differences based on participant engagement, intervention design, and provision of context. Further, the review explored if the interventions were co-designed.

METHODS

A systematic search of 5 databases was conducted: SCOPUS, MEDLINE, CINAHL, PsycINFO, and ProQuest (Dissertation or Thesis). Studies were included if they were either a randomized controlled trial, pre-post comparison, or a cohort study using mHealth with Indigenous women for maternal and child health following a preregistered PROSPERO protocol (CRD42023395710). HealthInfoNet was searched for gray literature and the reference lists of included studies were hand searched. The initial title and abstract screen for eligibility were performed by 1 reviewer. A full-text screen of eligible studies and a quality appraisal of included studies was performed by 2 reviewers independently. The appraisal tools used were the Mixed Methods Quality Appraisal Tool and the Centre of Excellence in Aboriginal Chronic Disease Knowledge Translation and Exchange (CREATE). A descriptive synthesis of the extracted data was performed.

RESULTS

Of the 663 articles screened, only 3 met the eligibility criteria. Each paper evaluated a different mHealth intervention: Remote Prenatal Education; the SMS Parent Action Intervention (two-way text messaging); and the Screening, Brief Intervention and Referral to Treatment (SBIRT) eCHECKUP To Go (web-based screening and intervention). Statistically significant changes were reported in some outcomes, including an increase in the parental participation rate in face-to-face prenatal education; increased rate of breastfeeding initiation and exclusive breastfeeding (2-12 months); improved overall children's behavior related to sleep, diet, physical activity, screen time, and intake of sugary beverages; improved individual children's behavior related to physical activity and sleep; and decrease in alcohol drinks per week and binge drinking episodes per 2 weeks due to time effect. However, no study provided a sample size calculation for the reported significant outcomes. Also, due to the small number of included studies and each study evaluating a different intervention, it was not possible to combine results to ascertain if the participant engagement, intervention design, or community context had any impact on the effectiveness.

CONCLUSIONS

Due to the lack of sample size calculation, it was not possible to establish whether differences in the effectiveness were due to the interventions or a type I statistical error. Therefore, caution is required in the interpretation of these findings.

TRIAL REGISTRATION

PROSPERO CRD42023395710; https://www.crd.york.ac.uk/PROSPERO/view/CRD42023395710.

Health literacy interventions for informal caregivers: systematic review

AIM

The aim of the systematic review was to identify conceptual models and interventions designed to improve health literacy in caregivers of adults with a chronic disease/disability.

METHODS

MEDLINE, CINAHL, PsycINFO and Embase were searched for relevant literature. Articles were included if they focused on adults who provided informal care to someone aged 18+ with a chronic disease/disability. Quantitative studies were included if they reported an intervention designed to improve caregiver health literacy (CHL) and assessed outcomes using a validated measure of health literacy. Qualitative and mixed method studies were included if they described a conceptual model or framework of CHL or developed/assessed the feasibility of an intervention. Study quality was appraised using the Mixed Methods Assessment Tool.

RESULTS

Eleven studies were included. Five studies used pre-post design to assess outcomes of an intervention; four described intervention development and/or pilot testing; two described conceptual models. Two of five studies reported pre-post intervention improvements in CHL; one reported an improvement in one of nine health literacy domains; two reported no improvements following intervention. Interventions predominantly aimed to improve: caregiver understanding of the disease, treatment and potential outcomes, day-to-day care, self-care and health provider engagement. Few interventions targeted broader interpersonal and health service factors identified as influencing CHL.

DISCUSSION

Evidence on the development and assessment of comprehensive CHL interventions is scarce. Recommendations include the development of interventions that are guided by a CHL framework to ensure they address individual, interpersonal and health service/provider factors that influence CHL.

The characteristics, components, and fidelity of interventions promoting physical activity in people living with musculoskeletal conditions: a systematic review

PURPOSE

Musculoskeletal disorders (MSKDs) create a significant burden on individuals and healthcare systems. Physical activity (PA) is recommended to support people with MSKDs. Limited understanding exists of the components, characteristics, and fidelity of interventions aiming to support transition to increased PA. Determining what works to support transition to increased PA is therefore difficult. This systematic review aims to address this gap and summarise the common traits of interventions that helped improve PA in people with MSKDs.

METHODS

Systematic search and review were undertaken to find effectiveness studies of PA interventions in MSKDs. The Template for Intervention Description and Replication (TIDieR) was used to extract intervention components and characteristics. Risk of bias was assessed. A narrative synthesis was deployed.

RESULTS

Searches retrieved 3027 studies. Thirty-four full texts were reviewed with 14 included. Interventions reporting positive PA outcomes all contained: exercise and behavioural change components, delivery by health care professionals, 13 or more exercise sessions, individual tailoring, and assessment of adherence.

CONCLUSIONS

The TIDieR framework creates standardisation to understand PA interventions for people with MSKDs. To ensure interventions meet the needs of populations, there is need to improve implementation design and understand which BC components are the most optimal.

How well does it fit? Process evaluation of a multidisciplinary pre- and postoperative metabolic bariatric surgery support programme: A patients' perspective

Multidisciplinary support can help patients improve health and cope with changes after metabolic and bariatric surgery (MBS). However, there is uncertainty regarding what intervention components, delivery methods and intensity are effective. To understand how intervention effects are achieved, we performed a process evaluation of a 15-session pre- and post-MBS programme comprising medical, dietary and psychological interventions delivered via group sessions until 9 months postsurgery. The evaluation examined programme relevance, perceived fit and practicability ('appropriateness') and satisfaction with content and delivery ('acceptability'). Interviews (n = 11) and focus groups (n = 2) were performed with 21 patients in different programme phases. Programme fidelity was assessed using administrative data on attendance in 1.396 patients. Presurgery, practicing with postoperative recommendations and multiple social components, was described as useful. Although participants found several postoperative components helpful (e.g. meal planning), the perceived fit was lower due to group delivery, session spacing and varying needs. Attended programme time postsurgery was lower than presurgery. Individual needs varied in terms of support intensity and type, and by gender, age and surgery type. Participants recommended greater session spacing, as maintaining behaviours >1 year postsurgery was expected to be most challenging. Participants requested additional information on negative lived experiences, exercise and coping with various postoperative changes. Programme fit can be improved by taking patients' varying needs into account in a flexible programme, with a duration beyond the first postoperative year, and more attention to negative lived experiences, exercise and coping with changes.

Stroke survivor and caregiver perspectives in the development of a community water-based therapeutic exercise program

BACKGROUND

Water-based therapeutic exercise (WBTE) is an effective approach for stroke survivors to regain strength, mobility, and quality of life. However, existing trials have not included stroke survivors' perspectives in intervention development, which are critical to ensure a WBTE program meets the needs of stroke survivors and provides supports to enable engagement in ongoing exercise.

METHODS

Qualitative semi-structured interviews were completed with stroke survivors and caregivers with the aim to have them (1) provide feedback on elements of the intervention resulting from a preceding scoping review and (2) identify barriers, facilitators and other considerations that may impact implementation. Literature on the development of complex health interventions and implementation science informed interview topics. Interviews were analyzed using generic coding and thematic analysis for open-ended and closed-ended questions, respectively.

RESULTS

Stroke survivor and caregivers largely confirmed findings from the scoping review regarding intervention characteristics. Four main considerations for implementation were identified in interview analysis: (1) safety, (2) knowledge and beliefs, (3) environment, and (4) individual characteristics.

CONCLUSION

It is essential to consider stroke survivor and caregiver perspectives when developing interventions to promote ongoing exercise following formal rehabilitation. The unique needs of each stroke survivor should be evaluated to optimize participation in WBTE.

Locomotive Syndrome Digital Therapeutics Provided via a Smartphone App: Protocol for a Single-Group Trial

BACKGROUND

Locomotive syndrome (LS) is a condition in which muscle weakness and reduced motor function due to musculoskeletal disorders cause reduced mobility and physical function. In Japan, musculoskeletal disorders are the most frequent reason for requiring home support or nursing care, and the prevention and amelioration of LS are thus being emphasized. However, it is difficult for older people to make a habit of exercise therapy, which is the mainstay of LS treatment. We investigated whether digital therapy could (1) lead to behavioral change in older people and (2) prevent or improve LS in older people.

OBJECTIVE

We sought to determine whether digital therapeutics (DTx) are useful for the prevention and amelioration of LS in older people, and we assessed the effects of DTx on the participants' exercise awareness and motor function.

METHODS

We conducted a multicenter, prospective, longitudinal, nonrandomized, single-group study of Japanese adults aged ≥40 years who were eligible for LS checks. Each participant underwent an 8-week locomotion training (LT) intervention, and their subjective and objective motor abilities and motor awareness were objectively assessed at the following time points: baseline (before the start of the DTx), interim (4 weeks after the start of the DTx), and end (8 weeks after the start of the DTx). We evaluated the participants' objective motor function using the timed up and go (TUG) test, and we compare the results using a 3-way ANOVA with the TUG test at the 3 evaluation time points as the dependent variable. The results of the 25-question Geriatric Locomotive Function Scale, which is a subjective measure of motor function, and the results of the Behavioural Regulation in Exercise Questionnaire 3, which assesses motor awareness, were also evaluated using an ANOVA in the same way as the TUG test. The significance level was set at .05 / 3 = .0167 after Bonferroni correction.

RESULTS

As of April 2025, this study had enrolled 47 participants, and complete data had been gathered from 45 participants for the proposed analysis. Study participation was ongoing as of April 2025.

CONCLUSIONS

The study cohort will be used as a basis for further observational and intervention studies. This research could lead to more efficient use of medical resources and a reduction in financial and medical burdens on individuals and the economy, and it could support the prevention and amelioration of LS and the establishment of exercise habits among older people.

TRIAL REGISTRATION

University Hospital Medical Information Network Clinical Trials Registry UMIN000053922; https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000061550.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/70163.

Development and Systematic Evaluation of a Progressive Web Application for Women With Cardiac Pain: Usability Study

BACKGROUND

Cardiac pain has been widely considered to be the primary indicator of coronary artery disease. The presentation of cardiac pain and associated symptoms vary in women, making it challenging to interpret as cardiac, possibly cardiac, or noncardiac. Women prefer to consult with family and friends instead of seeking immediate medical care.

OBJECTIVE

This study aimed to assess the user performance (ie, ease of use, efficiency, and errors) and user satisfaction (System Usability Scale; SUS) of a progressive web application for women with cardiac pain.

METHODS

Following ethics approval, a purposive sample of women aged >18 years with cardiac pain or associated symptoms lasting >3 months and able to speak and read English was recruited to participate in 2 iterative usability testing cycles. The first cycle assessed the performance of and satisfaction with at heart using a web application, and the second cycle assessed the performance of and satisfaction with at heart across various Android and iOS devices. In total, 2 investigators recorded user comments and documented problems. At the end of the testing session, the participants completed the SUS and 4 semistructured interview questions.

RESULTS

In total, 10 eligible women participated in usability testing from March 31, 2020, to April 17, 2020 (cycle 1), and from November 17, 2020, to November 30, 2020 (cycle 2). Women across usability testing cycles had a mean age of 55.6 (SD 7.3) years, and most (9/10, 90%) were well educated. In total, 50% (5/10) were employed full or part time, and 60% (6/10) earned >CAD $70,000 (US $48,881.80) annually. Participants across 2 testing cycles reported the overall usability of the at heart progressive web application as highly acceptable (mean SUS score 81.75, SD 10.41). In total, 90% (9/10) of participants rated the user-friendliness of at heart as good or excellent. All participants (10/10, 100%) thought at heart was easy to use and efficient. Only 2 testing errors were noted as high priority; these were low contrast or small font and clarification that the chatbot was not a real person. User satisfaction was assessed using themes that emerged from the debrief and 4 semistructured interview questions; at heart was engaging, comprehensive, understandable, credible, relevant, affirming, personalized, and innovative.

CONCLUSIONS

This study provides initial support for the at heart progressive web application for women living with cardiac pain and symptoms. Ongoing evaluations in phases 3 and 4 should aim to examine the feasibility and acceptability of and the extent of engagement with the at heart core feature set: Heart Check, Wellness Check, and the library. In addition to assessing effectiveness in the phase-4 effectiveness-implementation hybrid trial (type I), describing and better understanding the context for implementation (eg, race and ethnicity and geography) will be necessary.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2019-033092.

Telehealth Support From Cardiologists to Primary Care Physicians in Heart Failure Treatment: Mixed Methods Feasibility Study of the Brazilian Heart Insufficiency With Telemedicine Trial

BACKGROUND

Heart failure is a prevalent condition ideally managed through collaboration between health care sectors. Telehealth between cardiologists and primary care physicians is a strategy to improve the quality of care for patients with heart failure. Still, the effectiveness of this approach on patient-relevant outcomes needs to be determined.

OBJECTIVE

This study aimed to assess the feasibility of telehealth support provided by cardiologists for treating patients with heart failure to primary care physicians from public primary care practices in Rio de Janeiro, Brazil.

METHODS

We used mixed methods to assess the feasibility of telehealth support. From 2020 to 2022, we tested 2 telehealth approaches: synchronous videoconferences (phase A) and interaction through an asynchronous web platform (phase B). The primary outcome was feasibility. Exploratory outcomes were telehealth acceptability of patients, primary care physicians, and cardiologists; the patients' clinical status; and prescription practices. Qualitative methods comprised content analysis of 3 focus groups and 15 individual interviews with patients, primary care physicians, and cardiologists. Quantitative methods included the baseline assessment of 83 patients; a single-arm, before-and-after assessment of clinical status in 58 patients; and an assessment of guideline-directed medical therapy in 28 patients with reduced ejection fraction measured within 1 year of follow-up. We integrated qualitative and quantitative data using a joint display table and used the A Process for Decision-Making After Pilot and Feasibility Trials framework for feasibility assessment.

RESULTS

Telehealth support from cardiologists to primary care physicians was generally well accepted. As barriers, patients expressed concern about reduced direct access to cardiologists, primary care physicians reported work overload and a lack of relative advantage, and cardiologists expressed concern about the sustainability of the intervention. Quantitative analysis revealed an overall poor baseline clinical status of patients with heart failure, with 53% (44/83) decompensated, as expected. Compliance with guideline-directed medical therapy for the treatment of heart failure with reduced ejection fraction after telehealth showed a modest improvement for β-blockers (17/20, 85% to 18/19, 95%) and renin-angiotensin-aldosterone system inhibitors (14/20, 70% to 15/19, 79%) but a drop in the prescription of spironolactone (16/20, 80% to 15/20, 75%). Neprilysin and sodium-glucose cotransporter 2 inhibitors were introduced in 4 and 1 patient, respectively. Missing record data precluded a more precise analysis. The feasibility assessment was positive, favoring the asynchronous modality. Potential modifications include more effective patient and professional recruitment strategies and educational activities to raise awareness of collaborative support in primary care.

CONCLUSIONS

Telehealth was feasible to implement. Considering the stakeholders' views and insights on the process is paramount to attaining engagement. Missing data must be anticipated for future research in this setting. Considering the recommended adaptations, the intervention can be studied in a cluster-randomized trial.

The COMbined Physical and somatoSEnsory (COMPoSE) training intervention to improve upper limb recovery after stroke: a single-case experimental study

PURPOSE

The COMbined Physical and somatoSEnsory (COMPoSE) program is a novel intervention combining training of somatosensory and motor variables synchronously to improve upper limb recovery after stroke. The aim of this study was to evaluate the impact of COMPoSE on the upper limbs after stroke, using a single-case experimental study design.

METHODS

Five people with chronic stroke (62-89 years) completed the COMPoSE intervention trial (15 h, 10 sessions). Effects on participants were assessed using laboratory measures (maximal tactile pressures) and clinical motor and somatosensory measures.

RESULTS

Notable improvements were observed in measures of maximal tactile pressures in four out of five participants between baseline and post-intervention (range of change index: 12.0-62.5%; change in level: 2.3-10.6 KPa). Also, improvements were observed in the Wolf motor function test (score and time), box and block test, motor activity log, grip strength, wrist position sense test, tactile discrimination test, stroke impact scale at post-intervention (range of change index: 3.0-50.3%) compared to baseline.

CONCLUSION

Our findings suggest that COMPoSE could be beneficial to people with mild to severe somatosensory and motor deficits after stroke. The delivery of the COMPoSE intervention could be tailored to individual needs to maximize somatosensory and motor improvements in the upper limb after stroke.

CLINICAL TRIALS REGISTRY

This study was registered with the Australian New Zealand Clinical Trials Registry ACTRN12615001222538.

The Journey to First-Line Nursing Management: A Qualitative Study in a Spanish University Hospital

AIM

To explore nurse managers' perceptions at first-line, middle and executive levels regarding their transition to first-line management in two divisions of a highly specialised university hospital in Spain.

DESIGN

A qualitative descriptive study.

METHOD

A purposive sampling technique was employed to conduct four focus groups and two semi-structured interviews with 31 nurse managers across three hierarchical levels in two divisions of a highly specialised university hospital in Spain. Participants included two Chief Nursing Officers, four Nursing Directors and 25 first-line nurse managers. Data were analysed thematically.

RESULTS

Three themes emerged: 'Bridging the Readiness Gap: Training, Role Clarity, and Institutional Alignment', revealing the lack of structured transition plans, role ambiguity and gaps in managerial skills, such as human resources, financial management and leadership; 'Fighting Loneliness: A Common Challenge in Care Management', highlighting the isolation of first-line nurse managers due to the absence of structured mentorship and peer support; 'Clinical Expertise as a Cornerstone: The Role of Prior Experience in Nurse Management', examining how clinical expertise facilitates leadership transitions but also presents challenges, particularly for managers promoted within their teams, where authority negotiation and role redefinition become critical.

CONCLUSIONS

Findings underscore the need for structured training and mentorship to address role ambiguity, enhance managerial competencies and support nurse managers' transitions through targeted education.

IMPLICATIONS FOR PROFESSION AND PATIENT CARE

Structured transition programmes focusing on role clarity, training and institutional alignment can ease transitions, boost leadership confidence and enhance peer collaboration. Providing mentoring and training tailored to first-line nurse managers can improve team dynamics, support professional integration and strengthen organisational cohesion.

IMPACT

Tailored educational interventions are essential in supporting nurse managers' transitions. Structured mentorship and targeted training enhance leadership readiness, adaptability and institutional alignment, strengthening healthcare leadership, efficiency and patient care quality.

PATIENT AND PUBLIC CONTRIBUTION

No patient or public contribution.

Pain management training for people with persistent pain and their informal carers (JOINT SUPPORT): multicentre randomised controlled feasibility trial with embedded qualitative study in English musculoskeletal services

OBJECTIVES

To assess the feasibility of conducting a pragmatic, multicentre randomised controlled trial (RCT) to test the clinical and cost-effectiveness of a pain management training intervention to support people with persistent musculoskeletal pain and their informal carers.

DESIGN

Two-arm, multicentre, pragmatic, open, feasibility RCT with embedded qualitative study.

SETTING

National Health Service (NHS) providers in four English hospitals.

PARTICIPANTS

Adults receiving NHS care for persistent musculoskeletal pain and their informal carers.

INTERVENTION

Control: usual NHS care.

EXPERIMENTAL

usual NHS care plus a carer-patient pain management training intervention (JOINT SUPPORT), comprising five, 1-hour, group-based sessions for patients and carers, delivered by trained physiotherapists or occupational therapists. Content included understanding pain, pacing, graded activity, fear avoidance, goal-setting, understanding the benefits of physical activity and medication management. This was re-enforced with a workbook. After the group-based sessions, patients and carers were supported through three telephone sessions.

RANDOMISATION

Central randomisation was computer-generated (2:1 Experimental:Control), stratified by hospital and patient-participant age (≤65 years). There was no blinding.

MAIN OUTCOME MEASURES

Data collected at baseline and 3 months post-randomisation included screening logs, intervention logs, fidelity checklists and clinical outcomes on quality of life, physical and emotional outcomes, adverse events and resource use. Interviews with 14 patient-carer participants and six health professionals who delivered the intervention.

RESULTS

A total of 76 participants (38 patients; 38 carers) were enrolled. Sixty per cent (312/480) of patients screened were eligible with 12% consenting to be randomised (38/312). Fifty-four per cent (13/24) of the experimental group reached minimal compliance with the JOINT SUPPORT intervention. There was no evidence of treatment contamination. For patient-participant outcomes, within-group differences from baseline to 3 months favoured the control group when assessed by EQ-5D and Generalised Self-Efficacy total score, but favoured the intervention group when assessed by numerical rating scale pain, fatigue and Centre for Epidemiologic Studies Depression Scaletotal score. Qualitative data demonstrated the acceptability of the trial design and JOINT SUPPORT intervention with modifications to improve trial processes.

CONCLUSIONS

The JOINT SUPPORT intervention was acceptable to patient-carer dyads and health professionals. Modifications to trial design, particularly enhanced recruitment strategies, are required.

TRIAL REGISTRATION NUMBER

ISRCTN78169443.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author (TS) on reasonable request. This includes access to the full protocol, anonymised participant-level dataset and statistical code.

Exploring the Potential of a Digital Intervention to Enhance Couple Relationships (the Paired App): Mixed Methods Evaluation

BACKGROUND

Despite the effects of poor relationship quality on individuals', couples', and families' well-being, help seeking often does not occur until problems arise. Digital interventions may lower barriers to engagement with preventive relationship care. The Paired app, launched in October 2020, aims to strengthen and enhance couple relationships. It provides daily questions, quizzes, tips, and detailed content and facilitates in-app sharing of question and quiz responses and tagged content between partners.

OBJECTIVE

To explore the potential of mobile health to benefit couple relationships and how it may do this, we examined (1) Paired's impact on relationship quality and (2) its mechanisms of action.

METHODS

This mixed methods evaluation invited Paired subscribers to complete (1) brief longitudinal surveys over 3 months (n=440), (2) a 30-item web-based survey (n=745), and (3) in-depth interviews (n=20). For objective 1, survey results were triangulated to determine associations between relationship quality measures and the duration and frequency of Paired use, and qualitative data were integrated to provide explanatory depth. For objective 2, mechanisms of action were explored using a dominant qualitative approach.

RESULTS

Relationship quality improved with increasing duration and frequency of Paired use. Web-based survey data indicate that the Multidimensional Quality of Relationship Scale score (representing relationship quality on a 0-10 scale) was 35.5% higher (95% CI 31.1%-43.7%; P=.002), at 7.03, among people who had used Paired for >3 months compared to 5.19 among new users (≤1 wk use of Paired), a trend supported by the longitudinal data. Of those who had used Paired for >1 month, 64.3% (330/513) agreed that their relationship felt stronger since using the app (95% CI 60.2%-68.4%), with no or minimal demographic differences. Regarding the app's mechanisms of action, interview accounts demonstrated how it prompted and habituated meaningful communication between partners, both within and outside the app. Couples made regular times in their day to discuss the topics Paired raised. Daily questions were sometimes lighthearted and sometimes concerned topics that couples might find challenging to discuss (eg, money management). Interviewees valued the combination of fun and seriousness. It was easier to discuss challenging topics when they were raised by the "neutral" app, rather than during stressful circumstances or when broached by 1 partner. Engagement seemed to be enhanced by users' experience of relationship benefits and by the app's design.

CONCLUSIONS

This study demonstrates proof of concept, showing that Paired may have the potential to improve relationship quality over a relatively short time frame. Positive relationship practices became embedded within couples' daily routines, suggesting that relationship quality improvements might be sustained. Digital interventions can play an important role in the relationship care ecosystem. The mixed methods design enabled triangulation and integration, strengthening our findings. However, app users were self-selecting, and methodological choices impact our findings' generalizability.

Use of sedative drugs in specialist palliative care (iSedPall): a multi-modal intervention pilot study protocol

BACKGROUND

The use of sedative drugs in specialist palliative care is common but presents challenges due to specific medical, ethical, and legal considerations. There is little to no assistance for administering adequate sedative drug doses, ensuring accurate documentation before and during sedation, or managing ethically and legally challenging situations. In 2021, the SedPall study group published recommendations on the use of sedative drugs in palliative care. The German Association for Palliative Medicine endorsed the dissemination of the recommendations nationwide. However, disseminating recommendations alone does not necessarily lead to changes in clinical practice. In the project "Development and piloting of a multi-modal intervention for the use of sedative drugs in specialist palliative care (iSedPall)", we will develop a multi-modal intervention that implements these national recommendations into practical tools for healthcare professionals in specialist inpatient and home care settings. In the pilot study described below, we aim to test the feasibility of the multi-modal intervention, its appropriateness, and acceptability as primary feasibility outcomes of the multi-modal intervention. Additionally, we aim to assess the feasibility of measuring healthcare professionals´ confidence in using sedative drugs as an outcome indicator for a possible subsequent study.

METHODS AND ANALYSIS

We will use a mixed-methods approach to develop and pilot a multi-modal intervention. The primary feasibility outcomes and formative evaluation of the implementation process will be explored using quantitative (retrospective cohort study, survey) and qualitative elements (focus groups, interviews). Additionally, we will pilot the measurement of healthcare professionals´ confidence in using sedative drugs as an outcome indicator through a pre-post survey. Four specialist palliative care services will pilot the complex intervention for nine months. Due to the complexity of the intervention, we will follow the principles of the MRC framework for complex interventions and will apply a Theory of Change approach. The intervention will include different elements to be used throughout the patients' treatment in inpatient and home specialist palliative care considering medical, ethical, and legal aspects for the use of sedative drugs and intentional sedation. The evaluation of the overall feasibility and the decision about proceeding to an implementation study will be based on the integration of quantitative and qualitative data, according to our mixed-methods approach.

DISCUSSION

This project is the first attempt to translate national recommendations on best practices for sedative drug use into a multi-modal intervention and tests its feasibility. The study group identified potential risks and challenges related to the intervention´s feasibility, acceptability, and appropriateness in advance. To mitigate these risks, the study protocol is based on a theoretical framework, developed through a Theory of Change approach. Participatory elements and the involvement of different stakeholders are expected to enhance user acceptance and feasibility, potentially improving the development of supporting materials for sedative drug use in specialist palliative care while considering the interests of non-professionals.

TRIAL REGISTRATION

Registered in the German Clinical Trials Register, DRKS-ID: DRKS00027241; Registered: 10/12/2021; https://www.drks.de/drks_web/setLocale_EN.do .

Efficacy of a theatre-based intervention in patients with Parkinson's disease

Background: This study aimed to evaluate the efficacy of a theatre-based intervention for patients with Parkinson's disease (PD). To this end, we assigned participants to two types of intervention: a) theatre-based, which included both active and passive participation activities (Teatre Lliure, Barcelona, Spain), and b) cognitive stimulation (memory and attention) at home (Barcelona, Spain).Method: Before and after the intervention, participants were assessed on cognition (memory, language, and executive functions), mood (depression and anxiety), emotional state (apathy and anhedonia), and quality of life (Parkinson's Disease Questionnaire, PDQ-39).Results: By comparing participants' performance pre- and post-intervention, it could be seen that they reported cognitive improvements on the PDQ-39. In addition, depressive symptoms and anxiety decreased significantly after the intervention in both groups. However, emotional well-being improved only in participants enrolled in the theatre-based intervention.Conclusions: In conclusion, our study findings demonstrated that theatre-based interventions have specific benefits for emotional well-being and non-specific benefits in terms of reducing depressive symptoms and anxiety, as well as self-perceived cognitive improvement.

Development of Digital Strategies for Reducing Sedentary Behavior in a Hybrid Office Environment: Modified Delphi Study

BACKGROUND

Hybrid work is the new modus operandi for many office workers, leading to more sedentary behavior than office-only working. Given the potential of digital interventions to reduce sedentary behavior and the current lack of studies evaluating these interventions for home office settings, it is crucial to develop digital interventions for such contexts involving all stakeholders.

OBJECTIVE

This study aimed to reach expert consensus on the most feasible work strategies and the most usable digital elements as a delivery method to reduce sedentary behavior in the home office context.

METHODS

A modified Delphi study including 3 survey rounds and focus groups was conducted to achieve consensus. The first Delphi round consisted of two 9-point Likert scales for assessing the feasibility of work strategies and the potential usefulness of digital elements to deliver the strategies. The work strategies were identified and selected from a scoping review, a systematic review, and 2 qualitative studies involving managers and employees. The median and mean absolute deviation from the median for each item are reported. The second round involved 2 ranking lists with the highly feasible strategies and highly useful digital elements based on round 1 responses to order the list according to experts' preferences. The weighted average ranking for each item was calculated to determine the most highly ranked work strategies and digital elements. The third round encompassed work strategies with a weight above the median from round 2 to be matched with the most useful digital elements to implement each strategy. In total, 4 focus groups were additionally conducted to gain a greater understanding of the findings from the Delphi phase. Focus groups were analyzed using the principles of reflexive thematic analysis.

RESULTS

A total of 27 international experts in the field of occupational health participated in the first round, with response rates of 86% (25/29) and 66% (19/29) in rounds 2 and 3, respectively, and 52% (15/29) in the focus groups. Consensus was achieved on 18 work strategies and 16 digital elements. Feedback on activity progress and goal achievement; creating an action plan; and standing while reading, answering phone calls, or conducting videoconferences were the most feasible work strategies, whereas wrist-based activity trackers, a combination of media, and app interfaces in smartphones were the most useful digital elements. Moreover, experts highlighted the requirement of combining multiple levels of strategies, such as social support, physical environment, and individual strategies, to enhance their implementation and effectiveness in reducing sedentary behavior when working from home.

CONCLUSIONS

This expert consensus provided a foundation for developing digital interventions for sedentary behavior in home office workers. Ongoing interventions should enable the evaluation of feasible strategies delivered via useful digital elements in home office or hybrid contexts.

Improving and supporting quality of care in Dutch nursing homes: a quantitative study

BACKGROUND

Previous research showed the potential of quality improvement programs in nursing home care. However, studies that quantitatively evaluate the effectiveness of quality of care improvement programs are scarce. In this study, we examine the results of a Dutch nation-wide programme that was established to support the implementation of the Quality Framework for Nursing Home care.

METHODS

The Dignity & Pride at every Facility (D&PF) program was accessible to all Dutch nursing home facilities. Problem analysis per facility was conducted by means of a quantitative Quality Scan targeting all eight themes of the quality framework. Based on the baseline measurements nursing home facilities received tailored support from an external expert coach. The Quality Scan was repeated at the end of the support trajectories, 9 to 24 months later depending on the type of support provided. Scan data of 331 nursing home facilities was used to quantify the effectiveness of the D&PF program, the contribution of tailored support and the influence of organizational factors on care outcomes.

RESULTS

The entire pool of participating facilities scored better on the final scan (M = 3.21, SD = 0.74) than on the baseline scan (M = 2.64, SD = 0.87, p < 0.001). Greater improvements on theme level were seen when (partial) support was provided by an external expert coach. The probability of achieving high scores on care outcomes (person-centred care, resident safety and well-being) was significantly increased with high scores on organizational conditions. A multilevel model demonstrated that the themes Learning and improvement, Responsive workforce and Use of resources were statistically significant associated with positive care outcomes.

CONCLUSION

This study demonstrates significant improvements across all themes of the quality framework and provides supporting evidence for the positive contribution of tailored on-site support of external expert coaches. This study also indicates that a supportive organizational environment and a learning-oriented culture are of significant importance for good care outcomes in terms of safety, person-centred care and resident well-being.

Applying co-design health literacy development in Australian prisons: protocol for system-wide application of the Optimising Health Literacy and Access (Ophelia) process

INTRODUCTION

Prisons present both unique opportunities and challenges for delivering healthcare to individuals who often experience significant vulnerabilities and often have poor health outcomes. Actions and solutions informed by the health literacy strengths and challenges (ie, health literacy-informed interventions) of people in prison offer an opportunity to build fit-for-purpose and effective interventions in this unique context. This study aims to adapt and apply the three-phase Optimising Health Literacy and Access (Ophelia) process in a state-wide prison context to generate codesigned improvements in information, resources and services for people in prison.

METHODS AND ANALYSIS

Health Literacy Questionnaire data from 471 people in prison will be analysed using descriptive and cluster analyses (Ophelia Phase 1). Clusters, with qualitative interview data, will then inform vignette development for use in ideas generation workshops and yarning circles with stakeholders to develop health literacy-informed interventions. Selection, prioritisation and testing of identified interventions will be undertaken (Phase 2), followed by implementation and evaluation (Phase 3). This project will advance intervention development in the prison context, enabling the voice of people in prison and service providers to be heard through codesign. The protocol will inform the development and implementation of interventions to systematically improve the delivery of information, services and resources for people in prison, which may be relevant to prison healthcare authorities globally.

ETHICS AND DISSEMINATION

Ethical approval to undertake Phase 1 of the Ophelia process has been granted from the following Human Research Ethics Committees: Swinburne University of Technology (Ref: 20236977-15461), Justice Health NSW (Ref: 2022/ETH01433), Aboriginal Health and Medical Research Council (Ref: 2007/22) and the Corrective Services Ethics Committee (Ref: D2022/1452326). Dissemination of the study findings will be the Justice Health NSW codesign process and ownership of the project through authentic engagement with people with lived experience and health and corrective staff. It will also be disseminated through publication in a PhD thesis, peer-reviewed research papers and conference presentations.

Implementation of a national AI technology program on cardiovascular outcomes and the health system

Coronary artery disease (CAD) is a major cause of ill health and death worldwide. Coronary computed tomographic angiography (CCTA) is the first-line investigation to detect CAD in symptomatic patients. This diagnostic approach risks greater second-line heart tests and treatments at a cost to the patient and health system. The National Health Service funded use of an artificial intelligence (AI) diagnostic tool, computed tomography (CT)-derived fractional flow reserve (FFR-CT), in patients with chest pain to improve physician decision-making and reduce downstream tests. This observational cohort study assessed the impact of FFR-CT on cardiovascular outcomes by including all patients investigated with CCTA during the national AI implementation program at 27 hospitals (CCTA n = 90,553 and FFR-CT n = 7,863). FFR-CT was safe, with no difference in all-cause (n = 1,134 (3.2%) versus 1,612 (2.9%), adjusted-hazard ratio (aHR) 1.00 (0.93-1.08), P = 0.97) or cardiovascular mortality (n = 465 (1.3%) versus 617 (1.1%), aHR 0.96 (0.85-1.08), P = 0.48), while reducing invasive coronary angiograms (n = 5,720 (16%) versus 8,183 (14.9%), aHR 0.93 (0.90-0.97), P < 0.001) and noninvasive cardiac tests (189/1,000 patients versus 167/1,000), P < 0.001). Implementation of an AI-diagnostic tool as part of a health intervention program was safe and beneficial to the patient pathway and health system with fewer cardiac tests at 2 years.

Mental Health Nurses Leading the Way in the Training of Lay People Working With Young Asylum Seekers: The APT4U2 Program

Worldwide non-health professionals and volunteers (NHPV) in humanitarian settings assist asylum seekers, and they need to be empowered to recognise and refer people with mental health problems and provide psychosocial support in multicultural contexts. The APT4U2 program, aligned with mental health nurses' competencies, addresses this gap. The aim of this study was to present the development of a standardised training program for NHVP work with young asylum seekers. Following the development phase of the Medical Research Council's Complex Interventions methodology, the study follows the main steps: I - Mapping existing evidence on mental health training programs for NHPV working with asylum seekers and refugees; II - Identifying NHPVs' training needs and experiences and III - Developing the APT4U2 Program. The program underwent validation by eight experts in mental and psychiatric nursing, education, public health and psychology. The APT4U2 Program is prepared for 11 h and consists of three modules and five lessons. The APT4U2 Program is an easy-to-use training program constructed and to be administered by mental health nurses to NHPV who want to work with young asylum seekers. This evidence can guide mental health nurses in training worldwide NHPV who work with asylum seekers.

Barriers and Facilitators to Medicines Use in Patients With Vision Impairment: A Theory-Informed Qualitative Study of Patients and Caregivers

INTRODUCTION

Previous studies have highlighted numerous challenges with medicines use for patients with vision impairment, but evidence is lacking on interventions to support safe and effective medicine use for this population. This study aimed to identify potential barriers/facilitators of medicines use from the viewpoint of patients/caregivers, to establish a theory-informed foundation for a future intervention.

METHODS

Semi-structured interviews were conducted with patients with vision impairment and their caregivers in Saudi Arabia. Participants were recruited from low-vision clinics and a non-profit organisation. The Theoretical Domains Framework (TDF) informed the topic guide and served as the theoretical basis for examining participants' behaviours. Interviews explored the barriers/facilitators to obtaining and taking medicines (i.e. the target behaviours). Data were analysed using the framework method and content analysis. Key TDF domains were identified by assessing the relative frequency of themes, the existence of conflicting themes and the perceived theme impact on target behaviours.

RESULTS

Twelve patient/caregiver dyads and 18 individual patients were interviewed. Patients' ages ranged from 19 to 88 years, with 21 females and 9 males. Patients/caregivers demonstrated good knowledge of medicines used, and resourcefulness in finding methods to manage medication use (Domains: 'Knowledge' and 'Skills'). 'Environmental context and resources (ECR)' and 'Social influences' were the two most coded domains. Participants reported the usefulness of several resources including pill organisers and smartphones but described problems with pharmacy environments (Domain: 'ECR'). Caregivers played a major role in assisting patients with medicines. Participants had some positive encounters with pharmacists but reported difficulties in discussing medication issues with them. Many participants had a narrow view of the pharmacist's role (Domain: 'Social influences'). Maintaining a routine was a major facilitator under the 'Memory, attention and decision processes' and 'Behavioural regulation' domains. Six TDF domains were considered 'key' to participants' behaviours.

CONCLUSIONS

This study is the first to utilise a theoretical approach to understand the behaviour of patients with vision impairment in relation to medication use. It provides a comprehensive understanding of the role of caregivers and what influences their own behaviours. Findings will inform the future development of an intervention to support safe and effective medicine use for patients with vision impairment.

PATIENT OR PUBLIC CONTRIBUTION

An author met with an administrator at the 'National Association of the Blind' (Kafeef) in Riyadh to enhance the research team's understanding of vision impairment, and the practicality and logistics for identifying and recruiting patients. A draft of the interview guides was piloted with two patients and their caregivers and they were asked for feedback on the questions with amendments made accordingly.

Consensus-Based Recommendations for Designing, Delivering, Evaluating, and Reporting Exercise Intervention Research Involving People Living With a Spinal Cord Injury

OBJECTIVES

To establish recommendations for designing, delivering, evaluating, and reporting exercise intervention research to improve fitness-related outcomes in people living with spinal cord injury (PwSCI).

DESIGN

International consensus process.

SETTING

(1) An expert panel was established consisting of 9 members of the governing panel of the International Spinal Cord Society Physical Activity Special Interest Group and 9 additional scientists who authored or co-authored ≥1 exercise randomized controlled trial paper involving PwSCI. (2) We invited the panelists to draft an outline of the recommendations for 1 intervention component. (3) The panel reviewed the draft outlines and determined whether they fit the scope and objectives of the project, whether they were evidence-based, and whether they were sufficiently detailed. (4) We interviewed 7 PwSCI who had participated in ≥1 exercise trial to gather insights on their experiences within the trials, what they liked, and what they would change. (5) A first draft of the recommendations was approved by the panel and circulated to the general members of the International Spinal Cord Society Physical Activity Special Interest Group to gather their suggestions and opinions via an online survey. (6) The member feedback was used to revise the recommendations and panel members approved a final version.

PARTICIPANTS

N/A.

INTERVENTIONS

N/A.

MAIN OUTCOME MEASURE(S)

N/A.

RESULTS

We generated 33 recommendations regarding participant recruitment, study sample size determination, outcome measurement, potential confounders, exercise intervention prescription and delivery, supporting adherence to the intervention, monitoring and reporting adherence and retention, fidelity of the delivery of the intervention, monitoring and reporting adverse events, study design, and registration of study protocol and preparation of a protocol paper.

CONCLUSIONS

International experts have come to consensus on recommendations for conducting exercise intervention research involving PwSCI. Adopting these recommendations will increase the quality of the research and the overall certainty of the evidence regarding the effects of exercise on health outcomes in PwSCI.

Drug repurposing: Clinical practices and regulatory pathways

Drug repurposing, also known as drug repositioning or reprofiling, involves identifying new therapeutic uses for existing drugs beyond their original indications. Historical examples include sildenafil citrate transitioning to an erectile dysfunction treatment and thalidomide shifting from a sedative to an immunomodulatory agent. Advocates tout its potential to address unmet medical needs by expediting development, reducing costs, and using drugs with established safety profiles. However, concerns exist regarding specificity for new indications, safety, and regulatory exploitation. Ethical considerations include equitable access, informed consent when using drugs off-label, and transparency. Recent advancements include artificial intelligence (AI) applications, network pharmacology, and omics technologies. Clinical trials explore repurposed drugs' efficacy, with regulatory agencies facilitating approval. Challenges include intellectual property protection, drug target specificity, trial design complexities, and funding limitations. Ethical challenges encompass patient autonomy, potential conflicts of interest due to financial incentives for industries, and resource allocation. Future directions involve precision medicine, AI, and global collaboration. In conclusion, drug repurposing offers a promising pathway for therapeutic innovation but requires careful consideration of its complexities and ethical implications to maximize benefits and minimize risks.

Considering Theory-Based Gamification in the Co-Design and Development of a Virtual Reality Cognitive Remediation Intervention for Depression (bWell-D): Mixed Methods Study

BACKGROUND

In collaboration with clinical domain experts, we developed a prototype of immersive virtual reality (VR) cognitive remediation for major depressive disorder (bWell-D). In the development of a new digital intervention, there is a need to determine the effective components and clinical relevance using systematic methodologies. From an implementation perspective, the effectiveness of digital intervention delivery is challenged by low uptake and high noncompliance rates. Gamification may play a role in addressing this as it can boost adherence. However, careful consideration is required in its application to promote user motivation intrinsically.

OBJECTIVE

We aimed to address these challenges through an iterative process for development that involves co-design for developing content as well as in the application of gamification while also taking into consideration behavior change theories. This effort followed the methodological framework guidelines outlined by an international working group for development of VR therapies.

METHODS

In previously reported work, we collected qualitative data from patients and care providers to understand end-user perceptions on the use of VR technologies for cognitive remediation, reveal insights on the drivers for behavior change, and obtain suggestions for changes specific to the VR program. In this study, we translated these findings into concrete representative software functionalities or features and evaluated them against behavioral theories to characterize gamification elements in terms of factors that drive behavior change and intrinsic engagement, which is of particular importance in the context of cognitive remediation. The implemented changes were formally evaluated through user trials.

RESULTS

The results indicated that feedback from end users centered on using gamification to add artificial challenges, personalization and customization options, and artificial assistance while focusing on capability as the behavior change driver. It was also found that, in terms of promoting intrinsic engagement, the need to meet competence was most frequently raised. In user trials, bWell-D was well tolerated, and preliminary results suggested an increase in user experience ratings with high engagement reported throughout a 4-week training program.

CONCLUSIONS

In this paper, we present a process for the application of gamification that includes characterizing what was applied in a standardized way and identifying the underlying mechanisms that are targeted. Typical gamification elements such as points and scoring and rewards and prizes target motivation in an extrinsic fashion. In this work, it was found that modifications suggested by end users resulted in the inclusion of gamification elements less commonly observed and that tend to focus more on individual ability. It was found that the incorporation of end-user feedback can lead to the application of gamification in broader ways, with the identification of elements that are potentially better suited for mental health domains.

Use of a violence risk prediction tool (Oxford Mental Illness and Violence) in early intervention in psychosis services: mixed methods study of acceptability, feasibility and clinical role

BACKGROUND

Scalable assessment tools for precision psychiatry are of increasing clinical interest. One clinical risk assessment that might be improved by such approaches is assessment of violence perpetration risk. This is an important adverse outcome to reduce for some people presenting to services for first-episode psychosis. A prediction tool (Oxford Mental Illness and Violence (OxMIV)) has been externally validated in these services, but clinical acceptability and role need to be examined and developed.

AIMS

This study aimed to understand clinical use of the OxMIV tool to support violence risk management in early intervention in psychosis services in terms of acceptability to clinicians, patients and carers, practical feasibility, perceived utility, impact and role.

METHOD

A mixed methods approach integrated quantitative data on utility and patterns of use of the OxMIV tool over 12 months in two services with qualitative data from interviews of 20 clinicians and 12 patients and carers.

RESULTS

The OxMIV tool was used 141 times, mostly in new assessments. Required information was available, with only family history items scored unknown to any notable degree. The OxMIV tool was deemed helpful by clinicians in most cases, especially if there were previous risk concerns. It was acceptable practically, and broadly for the service, for which its concordance with clinical judgement was important. Patients and carers thought it could improve openness. There was some limited impact on plans for clinical support.

CONCLUSIONS

The OxMIV tool met an identified clinical need to support clinical assessment for violence risk. Linkage to intervention pathways is a research priority.

Passive Remote Monitoring Technologies' Influence on Home Care Clients' Ability to Stay Home: Multiprovincial Randomized Controlled Trial

BACKGROUND

Researchers in Nova Scotia and Ontario, Canada, implemented a passive remote monitoring (PRM) model of home care unique to their health system contexts. Each PRM model integrated tailored PRM devices (eg, motion sensors, cameras, and door alarms) into home care patients' residences with the aim of linking patients, family and friend caregivers, and health care providers to support older adults' aging in place.

OBJECTIVE

The purpose of this study was to examine the use of PRM technologies in the home to support older adults' safe aging in place and avoidance or delay of higher levels of care.

METHODS

This multiprovincial pragmatic randomized controlled trial examined how PRM technologies support older adults to safely remain in their home and avoid or delay admission to higher levels of care. Pairs of home care patients and their family and friend caregivers were recruited in Ontario and Nova Scotia. Participant pairs were randomly assigned to one of two conditions: (1) standard home care (ie, control) or (2) standard home care plus study-provided PRM (ie, intervention). Participants provided their provincial health insurance numbers to link with provincial health administrative databases and identify if patients were admitted to higher levels of care after 1 year. Cox proportional hazards models were used to evaluate the primary outcome in each province.

RESULTS

In total, 313 patient-caregiver pairs were recruited: 174 pairs in Ontario (intervention: n=60; control: n=114) and 139 pairs in Nova Scotia (intervention: n=45; control: n=94). Results indicate PRM was associated with a nonsignificant 30% reduction in risk of patients being admitted to higher levels of care in Ontario (hazard ratio 0.7, 95% CI 0.3-1.4) and no reduction in risk in Nova Scotia (hazard ratio 1.1, 95% CI 0.3-3.7). Adjusting for patient sex had no impact on model estimates for either province.

CONCLUSIONS

Limitations related, in part, to the impact of the COVID-19 pandemic may have contributed to the effectiveness of the intervention. While our study did not yield statistically significant results (P=.30 and P=.90) regarding the effectiveness of the PRM model in prolonging home stays, the observed trends suggest that technology-assisted aging in place may be a valuable goal for older adults. Further study is required to understand if longer follow-up time allows more effects of PRM on patients' avoidance of higher levels of care to be detected.

TRIAL REGISTRATION

ISRCTN ISRCTN79884651; https://www.isrctn.com/ISRCTN79884651.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/15027.

The impact of aesthetic education on university students' psychological wellbeing: exploring mediating and moderating effects

With rising psychological concerns among college students, educators and scholars are increasingly emphasizing mental health. As a key component of university curricula, aesthetic education plays a significant role in enhancing the psychological wellbeing of college students. Grounded in Self-Determination Theory (SDT), which focuses on three fundamental psychological needs-autonomy, competence, and relatedness-this study explores how aesthetic education influences the psychological well-being of university students. Specifically, aesthetic education fosters autonomy through self-expression, enhances competence by promoting creative development, and nurtures relatedness by facilitating social interaction in collaborative artistic activities. The study examines the mediating role of basic psychological needs and the moderating effects of gender and age. A total of 513 college students from China were surveyed using convenience sampling. Descriptive statistics, correlation analysis, hierarchical regression and mediation analysis were conducted using SPSS 26.0 to assess key variables, including aesthetic education, basic psychological needs, and psychological well-being. The results reveal significant positive correlations between aesthetic education, students' psychological wellbeing, and the fulfillment of basic psychological needs. Furthermore, aesthetic education significantly predicts the psychological well-being, with the satisfaction of basic psychological needs partially mediating this relationship. Gender and age were found to moderate the relationship between aesthetic education and psychological wellbeing to varying extents. These findings elucidate important associational pathways between aesthetic education, college students' psychological wellbeing, and the satisfaction of basic psychological needs, contributing both to the understanding of SDT and to practical applications in the context of university-level aesthetic education.

Methods for the health technology assessment of complex interventions: A scoping review

INTRODUCTION

Health Technology Assessment (HTA) methods have been developed to support evidence-informed policy-making by assessing the comparative value and costs of health interventions and programs. However, the complexity of many health interventions presents challenges to the use of conventional HTA methods. This scoping review collated and synthesised international approaches to the HTA of complex interventions including identifying assessment criteria, types of evidence and the domains of value that are most favoured.

MATERIALS AND METHODS

A systematic scoping review was conducted using JBI guidelines, Arksey and O'Malley's six-stage framework and recent advances in scoping review methodology. Seven electronic databases, grey literature sources, three leading HTA journals and backward citation searching were used to search complex intervention HTA records written in English from January 2000 to December 2023. Supplementary searches were also conducted to identify actual HTA reports produced by certain countries. The Population (or Participants), Concept and Context framework guided the literature selection process, with a two-phase screening process and subsequent narrative synthesis. The PRISMA-ScR checklist guided reporting. Independent screening by two reviewers ensured accuracy of study selection, and data extraction followed a customised form grounded in the HTA-core model.

RESULTS

A total of 10684 references yielded 35 records from twelve countries. The review identified two clusters of research on HTA of complex interventions: methodological orientation and conceptual models (n = 19) and actual HTAs conducted on complex interventions (n = 16). Several evaluation criteria and domains were used or recommended for use that extended beyond the core HTA domains. Three distinct HTA approaches emerged: the integrative approach, highlighted in methodological guides and theoretical frameworks; and either sequential or concurrent approaches, emphasised in practical HTAs. In the theoretical literature, equal weight is given to various HTA domains for complex intervention assessment, but in practice, the scope and specificity of domains vary across reports, with countries exhibiting differing priorities. Cost-effectiveness, clinical effectiveness and organisational aspects predominated in complex intervention evaluation, albeit with gradually increasing emphasis on a technology's description, intended use, safety and patient and social aspects over the past decade. There was less focus on ethical and legal considerations. This trend is consistent with the evaluation of non-complex interventions in HTA. HTAs undertaken on complex interventions introduced unique domains like politics, implementation, early stakeholder engagement, outcome uncertainty, adaptive methods and real-world data, with expert opinion recommended when data were insufficient.

CONCLUSION

A shift towards considering broader contextual and implementation factors in the HTA of complex interventions was evident in this scoping review, extending beyond traditional HTA domains. However, discrepancies persist between theoretical and methodological guidance suggesting one approach and practical HTAs often adopting another. The implications of the shift towards contextual and implementation factors require exploration in future research. This could help to establish consensus on metrics and evidentiary elements, optimising HTA for complex health interventions.

Process Evaluation of Pragmatic Cluster-Randomized Trials of Digital Adherence Technologies for Tuberculosis Treatment Support: A Mixed-Method Study in Five Countries

Digital adherence technologies (DATs) could improve the person-centeredness of tuberculosis (TB) treatment. DATs are found to be acceptable, though evidence of their effectiveness is varied. Our objective was to understand the fidelity of DAT interventions within five cluster-randomized trials. Two DATs (smart pillbox, medication labels) were assessed, with real-time adherence data available to healthcare providers (HCPs) on a digital platform in Ethiopia, the Philippines, South Africa, Tanzania, and Ukraine. A framework assessed four components of implementation: inputs (training, support, mobile access), processes (SMS, home visits, platform usage), outputs (DAT engagement, manual dosing), and outcomes (people with TB (PwTB)-HCP relationship). Fidelity was evaluated by quantitative indicators, and content analysis of qualitative sub-studies supplemented some indicators. Engagement with DATs was high among PwTB. Pillbox users showed high levels of sustained engagement (box opening), with digitally recorded doses ranging from 82% to 91%. Differences were observed in login frequency by HCPs to the adherence platform. In Ethiopia, Tanzania, and Ukraine, there was at least one login to the platform on 71% of weekdays per facility compared with the Philippines and South Africa at 42% and 52%, respectively. Intervention fidelity varied among countries, suggesting a need for future work on optimizing implementation.

A feasibility study of the internet-based intervention "Strategies for Empowering activities in Everyday life" (SEE 1.0) applied for people with stroke

BACKGROUND

To enable people with stroke to achieve an active everyday life under altered conditions, the development of self-management programs is essential to facilitate the process of change that individuals must undergo. To improve access to self-management, internet-based solutions have been proposed. The aim of this study was to evaluate the feasibility of a novel internet-based intervention, "Strategies for Empowering activities in Everyday Life" (SEE, version 1.0), for clients with stroke.

METHODS

This feasibility study had a preposttest design without a control group and utilized a mixed-method approach. Data were collected through study-specific forms, outcome assessments, interviews, and field notes. Descriptive statistics and content analysis were subsequently applied.

RESULTS

The study involved fifteen clients and staff at clinics in a hospital-based open-care rehabilitation setting. The results indicate that SEE is feasible for clients with stroke. When adopted as expected, SEE has the potential to empower self-management and enhance engagement, balance, and values in everyday activities. The study also indicates that SEE is feasible in terms of adherent delivery of dosage, acceptability, and value, as perceived by clients, occupational therapists, and clinic managers. However, adjustments are needed in the study design, in terms of recruitment strategies, the selection of assessor-based outcome assessment, and the evaluation of adherence. Additionally, the educational program for professionals should be enhanced to better support the implementation of SEE.

CONCLUSION

After the study design, intervention, and educational program are refined, SEE can be prepared for a pilot randomized controlled trial.

TRIAL REGISTRATION

clinicaltrails.gov NCT04588116, date of registration: 8th October 2020.