Causal mechanisms of a healthy lifestyle intervention for patients with musculoskeletal pain who are overweight or obese

PURPOSE

To assess the causal mechanisms of a healthy lifestyle intervention for patients with chronic low back pain and knee osteoarthritis, who are overweight or obese.

METHODS

We conducted causal mediation analyses of aggregated data from two randomized controlled trials (RCTs); which included 160 patients with chronic low back pain, and 120 patients with knee osteoarthritis. The intervention consisted of brief advice and referral to a six-month telephone-based healthy lifestyle coaching service. We used causal mediation to estimate the indirect, direct and path-specific effects of hypothesized mediators including: self-reported weight, diet, physical activity, and pain beliefs. Outcomes were pain intensity, disability, and quality of life (QoL).

RESULTS

The intervention did not reduce weight, improve diet or physical activity or change pain beliefs, and these mediators were not associated with the outcomes. Sensitivity analyses showed that our estimates were robust to the possible effects of unknown and unmeasured confounding.

CONCLUSIONS

Our findings show that the intervention did not cause a meaningful change in the hypothesized mediators, and these mediators were not associated with patient-reported outcomes.

A cluster randomised controlled trial of an intervention to increase the implementation of school physical activity policies and guidelines: study protocol for the physically active children in education (PACE) study

Background

In an attempt to improve children’s physical activity levels governments have introduced policies specifying the minimum time schools are to schedule physical activity each week. Despite this, the majority of schools in many jurisdictions fail to implement these policies. This study will assess the effectiveness of a multi-component implementation strategy on increasing the minutes of planned physical activity scheduled by primary school teachers each week.

Methods

A cluster randomised controlled trial will be conducted in 62 primary schools in the Hunter New England region of New South Wales, Australia. Schools will be randomly allocated to receive either a multi-component implementation strategy that includes; obtaining executive support, training in-school champions, provision of tools and resources, implementation prompts, reminders and feedback; or usual practice. The study will employ an effectiveness-implementation hybrid design, assessing both policy implementation and individual (student) behavioural outcomes. The primary trial outcome of mean minutes of physical activity scheduled by classroom teachers across the school week will be measured via teacher log-book at baseline and approximately 12 and 18 months post baseline. A nested evaluation of the impact of policy implementation on child physical activity will be undertaken of students in Grades 2 and 3. Analyses will be performed using an intention to treat framework. Linear mixed effects regression models will be used to assess intervention effects on the primary outcome at both follow-up periods.

Discussion

This study will be the one of the first well powered randomised trials internationally to examine the impact of an implementation strategy for a physical activity policy in primary schools and will address a fundamental research translation gap. Given the dearth of research, the findings will be important in informing future implementation efforts in this setting.

Trial registration

ANZCTR ACTRN12617001265369 version 1 registered 1st September 2017.

Australian university smoke-free policy implementation: a staff and student survey

Issue addressed Universities represent important settings for the implementation of public health initiatives such as smoke-free policies. The study aimed to assess staff and student attitudes towards policy enforcement and compliance as well as the acceptability of the provision of cessation support in this setting. Methods A cross-sectional study was conducted following the introduction of a designated-areas partial smoke-free policy at two campuses of one Australian university in 2014. Staff (n=533) and students (n=3060) completed separate online surveys assessing attitudes towards smoke-free policy enforcement and compliance, and acceptability of university-provided cessation support. Results Students held significantly stronger beliefs than staff that the smoke-free policy required staff enforcement (69% vs 60%) and violation penalties (67% vs 60%; both P's <0.01); however, most staff (66%) did not believe enforcement was part of their role. Only 55% of student smokers were aware that the university provided any cessation support. 'Free or cheap nicotine replacement therapy' (65%) and 'free stop smoking counselling service' (60%) were the most popular strategies student smokers thought the university should provide. Conclusions University staff and students hold conflicting views over the need for policy enforcement and who is responsible for enforcement roles. Students view the university as an acceptable setting for the provision of smoking cessation support. So what? Where staff are expected to enforce smoke-free policies, specific education and training should be provided. Ongoing monitoring of compliance and enforcement behaviour appears necessary to avoid the pervasive kind of non-compliance to smoke-free policies that have been seen in other settings.

Efficacy of a free-play intervention to increase physical activity during childcare: a randomized controlled trial

The primary aim of this study was to assess the efficacy of a childcare-based intervention in increasing child physical activity by allowing children unrestricted access to outdoor areas for free-play when structured activity is not taking place. A randomized controlled trial was conducted in six childcare services. Intervention services provided children unrestricted access outdoors for active free-play, while control services provided their usual scheduled periods of outdoor play. Consent was obtained from 231 children. Child moderate to vigorous activity (MVPA), the primary trial outcome, was assessed via accelerometer at baseline and 3 months post baseline. Intervention effects were examined using Generalised Linear Mixed Models. Controlling for child age, gender and baseline outcome measure, at follow-up there were no significant differences between groups in minutes of MVPA in-care (mean difference: 4.85; 95% CI: -3.96, 13.66; P = 0.28), proportion of wear time in-care spent in MVPA (mean difference: 1.52%; 95% CI: -0.50, 3.53; P = 0.14) or total physical activity in-care (mean difference in counts per minute: 23.18; 95% CI: -4.26, 50.61; P = 0.10), nor on measures of child cognition (P = 0.45-0.91). It was concluded that interventions addressing multiple aspects of the childcare and home environment might provide the greatest potential to improve child physical activity.

Economic evaluation of telephone-based weight loss support for patients with knee osteoarthritis: a randomised controlled trial

Background

The prevalence of knee osteoarthritis is increasing worldwide. Obesity is an important modifiable risk factor for both the incidence and progression of knee osteoarthritis. Consequently, international guidelines recommend all patients with knee osteoarthritis who are overweight receive support to lose weight. However, few overweight patients with this condition receive care to support weight loss. Telephone-based interventions are one potential solution to provide scalable care to the many patients with knee osteoarthritis. The objective of this study is to evaluate, from a societal perspective, the cost-utility and cost-effectiveness of a telephone-based weight management and healthy lifestyle service for patients with knee osteoarthritis, who are overweight or obese.

Methods

An economic evaluation was undertaken alongside a pragmatic randomised controlled trial. Between May 19 and June 30, 2015, 120 patients with knee osteoarthritis were randomly assigned to an intervention or usual care control group in a 1:1 ratio. Participants in the intervention group received a referral to an existing non-disease specific 6-month telephone-based weight management and healthy lifestyle service. Quality-adjusted life years (QALYs) was the utility measure and knee pain intensity, disability, weight, and body mass index (BMI) were the clinical measures of effect. Costs included intervention costs, healthcare utilisation costs (healthcare services and medication use) and absenteeism costs due to knee pain. Data was collected at baseline, 6 weeks and 26 weeks. The primary cost-effectiveness analysis was performed from the societal perspective.

Results

Mean cost differences between groups (intervention minus control) were $493 (95%CI: -3513 to 5363) for healthcare costs, $-32 (95%CI: -73 to 13) for medication costs, and $125 (95%CI: -151 to 486) for absenteeism costs. The total mean difference in societal costs was $1197 (95%CI: -2887 to 6106). For QALYs and all clinical measures of effect, the probability of the intervention being cost-effective compared with usual care was less than 0.36 at all willingness-to-pay values.

Conclusions

From a societal perspective, telephone-based weight loss support, provided using an existing non-disease specific 6-month weight management and healthy lifestyle service was not cost-effective in comparison with usual care for overweight and obese patients with knee osteoarthritis.

Trial registration number

ACTRN12615000490572, registered 18th May 2015

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6300-1) contains supplementary material, which is available to authorized users.

Factors associated with retention in a smoking cessation trial for persons with a mental illness: a descriptive study

Background

Exploring factors associated with retention in randomised trials provides insight into potential threats to internal and external study validity, and may inform the development of interventions to increase retention in future trials. Given a paucity of existing research in the field, a study was conducted to explore factors associated with retention in a smoking intervention trial involving persons with a mental illness, considering demographic and smoking characteristics, treatment condition and engagement in prior follow-up assessments.

Method

A descriptive study was undertaken using data derived from a RCT of a smoking cessation intervention initiated in four adult psychiatric inpatient units in New South Wales (NSW), Australia. Retention assessment was undertaken at 1, 6 and 12-months post-discharge. A Generalised Linear Mixed Model was adopted to explore associations between retention at any follow up time point and demographic and smoking characteristics. Chi square analyses explored the association between retention at all follow up time points and treatment condition, and binary logistic regression analyses assessed for relationships between retention at 12-month follow up and engagement in prior follow up assessments.

Results

Retention rates were 63, 56 and 60% at the 1, 6 and 12-month assessments, respectively. No association was found between retention at any follow-up time point and 13 of 15 demographic and smoking characteristics. Younger participants and those who identified to be Aboriginal and/or Torres Strait Islander were more likely to be retained (both ps > 0.05). Retention rates did not vary according to treatment condition at any follow-up time point. Participants who completed a prior assessment were more likely to complete the 12 month assessment (both prior assessments: OR 10.7, p < 0.001; 6 month assessment: OR 6.01, p < 0.001; and 1 month assessment: OR 1.8, p = 0.002).

Conclusion

The underrepresentation of younger participants and those identifying to be Aboriginal and/or Torres Strait Islander may limit the generalisability of findings. Findings suggest that inclusion of multiple contacts during a trial follow up period may increase retention at the final assessment. Interventions to improve retention, overall and for those sub-groups less likely to be retained, in smoking trials involving persons with a mental illness are needed. Further assessment of sample characteristics, and also trial design factors, associated with retention in this field is warranted.

Economic evaluation of a healthy lifestyle intervention for chronic low back pain: A randomized controlled trial

BACKGROUND

Economic evaluations which estimate cost-effectiveness of potential treatments can guide decisions about real-world healthcare services. We performed an economic evaluation of a healthy lifestyle intervention targeting weight loss, physical activity and diet for patients with chronic low back pain, who are overweight or obese.

METHODS

Eligible patients with chronic low back pain (n = 160) were randomized to an intervention or usual care control group. The intervention included brief advice, a clinical consultation and referral to a 6-month telephone-based healthy lifestyle coaching service. The primary outcome was quality-adjusted life years (QALYs). Secondary outcomes were pain intensity, disability, weight and body mass index. Costs included intervention costs, healthcare utilization costs and work absenteeism costs. An economic analysis was performed from the societal perspective.

RESULTS

Mean total costs were lower in the intervention group than the control group (-$614; 95%CI: -3133 to 255). The intervention group had significantly lower healthcare costs (-$292; 95%CI: -872 to -33), medication costs (-$30; 95%CI: -65 to -4) and absenteeism costs (-$1,000; 95%CI: -3573 to -210). For all outcomes, the intervention was on average less expensive and more effective than usual care, and the probability of the intervention being cost-effective compared to usual care was relatively high (i.e., 0.81) at a willingness-to-pay of $0/unit of effect. However, the probability of cost-effectiveness was not as favourable among sensitivity analyses.

CONCLUSIONS

The healthy lifestyle intervention seems to be cost-effective from the societal perspective. However, variability in the sensitivity analyses indicates caution is needed when interpreting these findings.

SIGNIFICANCE

This is an economic evaluation of a randomized controlled trial of a healthy lifestyle intervention for chronic low back pain. The findings suggest that a healthy lifestyle intervention may be cost-effective relative to usual care.

Barriers to implementation of a healthy canteen policy: A survey using the theoretical domains framework

ISSUE ADDRESSED

Improving implementation of school healthy canteen policies requires a comprehensive understanding of implementation barriers. Therefore, the aim of this study was to assess a range of barriers, as reported by canteen managers, using a quantitative survey instrument developed based on a theoretical framework.

METHODS

A cross sectional survey of primary school canteen managers from the Hunter New England region of New South Wales was conducted of eligible schools in the study region identified as having an operational canteen. Survey items assessed canteen manager employment status, canteen characteristics and potential barriers to healthy canteen policy implementation, aligned to the 14 domains of the theoretical domains framework via a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). The mean domain scores of canteen managers were calculated, less than four indicating the canteen manager considered the domain was a barrier. Canteen managers were also asked to provide the current canteen menu for audit by a dietitian.

RESULTS

Of the 184 participants, 20% (n = 36) were assessed as having menus compliant with the state policy. The five most common domains identified as potential barriers to policy implementation were behavioural regulation (n = 117, 65%), skills (n = 105, 57%), beliefs about capabilities (n = 100, 55%), reinforcement (n = 95, 52%) and goals (n = 95, 52%). Canteen managers who reported optimism as a barrier had significantly lower odds of having a menu compliant with the state policy (OR = 0.39; 95% CI 0.16-0.95, P = 0.038).

CONCLUSIONS

This study provides further evidence of perceived and actual barriers that canteen managers face when attempting to implement a healthy canteen policy, and highlights the need to address differences in canteen characteristics when planning implementation support. SO WHAT?: For public health benefits of nutrition policies within schools to be realised, the barriers to implementation need to be identified and used to help guide implementation support strategies.

Strategies to improve the implementation of workplace-based policies or practices targeting tobacco, alcohol, diet, physical activity and obesity

BACKGROUND

Given the substantial period of time adults spend in their workplaces each day, these provide an opportune setting for interventions addressing modifiable behavioural risk factors for chronic disease. Previous reviews of trials of workplace-based interventions suggest they can be effective in modifying a range of risk factors including diet, physical activity, obesity, risky alcohol use and tobacco use. However, such interventions are often poorly implemented in workplaces, limiting their impact on employee health. Identifying strategies that are effective in improving the implementation of workplace-based interventions has the potential to improve their effects on health outcomes.

OBJECTIVES

To assess the effects of strategies for improving the implementation of workplace-based policies or practices targeting diet, physical activity, obesity, tobacco use and alcohol use.Secondary objectives were to assess the impact of such strategies on employee health behaviours, including dietary intake, physical activity, weight status, and alcohol and tobacco use; evaluate their cost-effectiveness; and identify any unintended adverse effects of implementation strategies on workplaces or workplace staff.

SEARCH METHODS

We searched the following electronic databases on 31 August 2017: CENTRAL; MEDLINE; MEDLINE In Process; the Campbell Library; PsycINFO; Education Resource Information Center (ERIC); Cumulative Index to Nursing and Allied Health Literature (CINAHL); and Scopus. We also handsearched all publications between August 2012 and September 2017 in two speciality journals: Implementation Science and Journal of Translational Behavioral Medicine. We conducted searches up to September 2017 in Dissertations and Theses, the WHO International Clinical Trials Registry Platform, and the US National Institutes of Health Registry. We screened the reference lists of included trials and contacted authors to identify other potentially relevant trials. We also consulted experts in the field to identify other relevant research.

SELECTION CRITERIA

Implementation strategies were defined as strategies specifically employed to improve the implementation of health interventions into routine practice within specific settings. We included any trial with a parallel control group (randomised or non-randomised) and conducted at any scale that compared strategies to support implementation of workplace policies or practices targeting diet, physical activity, obesity, risky alcohol use or tobacco use versus no intervention (i.e. wait-list, usual practice or minimal support control) or another implementation strategy. Implementation strategies could include those identified by the Effective Practice and Organisation of Care (EPOC) taxonomy such as quality improvement initiatives and education and training, as well as other strategies. Implementation interventions could target policies or practices directly instituted in the workplace environment, as well as workplace-instituted efforts encouraging the use of external health promotion services (e.g. gym membership subsidies).

DATA COLLECTION AND ANALYSIS

Review authors working in pairs independently performed citation screening, data extraction and 'Risk of bias' assessment, resolving disagreements via consensus or a third reviewer. We narratively synthesised findings for all included trials by first describing trial characteristics, participants, interventions and outcomes. We then described the effect size of the outcome measure for policy or practice implementation. We performed meta-analysis of implementation outcomes for trials of comparable design and outcome.

MAIN RESULTS

We included six trials, four of which took place in the USA. Four trials employed randomised controlled trial (RCT) designs. Trials were conducted in workplaces from the manufacturing, industrial and services-based sectors. The sample sizes of workplaces ranged from 12 to 114. Workplace policies and practices targeted included: healthy catering policies; point-of-purchase nutrition labelling; environmental supports for healthy eating and physical activity; tobacco control policies; weight management programmes; and adherence to guidelines for staff health promotion. All implementation interventions utilised multiple implementation strategies, the most common of which were educational meetings, tailored interventions and local consensus processes. Four trials compared an implementation strategy intervention with a no intervention control, one trial compared different implementation interventions, and one three-arm trial compared two implementation strategies with each other and a control. Four trials reported a single implementation outcome, whilst the other two reported multiple outcomes. Investigators assessed outcomes using surveys, audits and environmental observations. We judged most trials to be at high risk of performance and detection bias and at unclear risk of reporting and attrition bias.Of the five trials comparing implementation strategies with a no intervention control, pooled analysis was possible for three RCTs reporting continuous score-based measures of implementation outcomes. The meta-analysis found no difference in standardised effects (standardised mean difference (SMD) -0.01, 95% CI -0.32 to 0.30; 164 participants; 3 studies; low certainty evidence), suggesting no benefit of implementation support in improving policy or practice implementation, relative to control. Findings for other continuous or dichotomous implementation outcomes reported across these five trials were mixed. For the two non-randomised trials examining comparative effectiveness, both reported improvements in implementation, favouring the more intensive implementation group (very low certainty evidence). Three trials examined the impact of implementation strategies on employee health behaviours, reporting mixed effects for diet and weight status (very low certainty evidence) and no effect for physical activity (very low certainty evidence) or tobacco use (low certainty evidence). One trial reported an increase in absolute workplace costs for health promotion in the implementation group (low certainty evidence). None of the included trials assessed adverse consequences. Limitations of the review included the small number of trials identified and the lack of consistent terminology applied in the implementation science field, which may have resulted in us overlooking potentially relevant trials in the search.

AUTHORS' CONCLUSIONS

Available evidence regarding the effectiveness of implementation strategies for improving implementation of health-promoting policies and practices in the workplace setting is sparse and inconsistent. Low certainty evidence suggests that such strategies may make little or no difference on measures of implementation fidelity or different employee health behaviour outcomes. It is also unclear if such strategies are cost-effective or have potential unintended adverse consequences. The limited number of trials identified suggests implementation research in the workplace setting is in its infancy, warranting further research to guide evidence translation in this setting.

Feasibility and acceptability of strategies to address mental health and mental ill-health in the Australian coal mining industry

Background

To evaluate the feasibility, acceptability and effectiveness of implementing a peer-based, multi-component mental health program in the Australian coal mining industry.

Methods

The multicomponent program included MATES in mining (a peer-based mental health and suicide prevention program) and supervisor training. Eight Australian coal mines participated in the research, with four mines receiving the mental health program. Primary outcome variables including mental health stigma, help-seeking behaviour and perception of the workplace commitment to mental health were measured prior to program implementation, and then again 10 months following using a paper based survey. Process evaluation of the mental health program was measured using a pre-test/post-test survey.

Results

MATES in mining 1275 miners participated in the MATES general awareness and connector training. Participants were more confident that they could identify a workmate experiencing mental ill-health; help a workmate, family member or themselves identify where to get support and were more willing to start a conversation with a workmate about their mental health. Supervisor training 117 supervisors completed the supervisor training and were subsequently more confident that they could: identify someone experiencing mental ill-health in the workplace; identify and recommend support services to a person experiencing mental ill-health; and have an effective conversation about performance issues that may be due to mental ill-health.

Conclusions

Our findings show evidence to support the use of peer-based mental health programs in the mining industry, and for male-dominated industry more broadly.

A randomised trial of real-time video counselling for smoking cessation in regional and remote locations: study protocol

BACKGROUND

Real-time video communication technology (e.g. Skype) may be an effective mode for delivering smoking cessation treatment to regional and remote residents. This randomised trial examines the effectiveness of real-time video counselling compared to: 1) telephone counselling; and 2) written materials (control) in achieving smoking abstinence in regional and remote residents.

DESIGN

A three-arm, parallel group, randomised trial will be conducted with smokers residing in regional and remote areas of New South Wales, Australia. Potential participants will complete an online screening survey and if eligible an online baseline survey. Participants will be randomly allocated into: 1) real-time video counselling; 2) telephone counselling; or 3) written materials (control). In the video counselling intervention an advisor will deliver up to six video sessions (e.g. via Skype) to participants. Those who nominate a quit date within a month during the initial video session will be offered sessions on the quit date, 3-, 7-, 14- and 30-days after the quit date. Those not ready to set a quit date within a month during the initial video session will be offered sessions 2-, 4- and 6-weeks later. Other than delivery mode, the video counselling and telephone counselling will be identical in content and callback schedules. Control group participants will be mailed one-off written materials. Follow-up surveys will occur at 4-months, 7-months and 13-months post-baseline. The primary outcome will be 7-day point prevalence abstinence at 13-months post-baseline.

DISCUSSION

Real-time video counselling may be an effective strategy for smoking cessation that could be integrated into quitlines globally.

Whole-of-community interventions to reduce population-level harms arising from alcohol and other drug use: a systematic review and meta-analysis

BACKGROUND AND AIMS

Whole-of-community interventions aim to reduce alcohol and other drug (AOD) use and harms by mobilizing community leaders, organizations and policy-makers to respond effectively to AOD use. The aim of this review is to estimate the effectiveness of whole-of-community interventions in reducing population-level harms arising from AOD use.

DESIGN

A systematic review of electronic databases CENTRAL, Embase, Medline, Medline in Process and PsycINFO was conducted from database inception to August 2017. Eligible trials had a parallel comparison group, implemented interventions in two or more community settings, and reported data on AOD use or harms.

SETTING

Intervention settings included schools, sporting clubs, police and law enforcement agencies, community centres, local media and retail premises.

PARTICIPANTS

Twenty-four trials from 63 publications were included (n = 249 125 participants).

MEASUREMENTS

Outcomes from AOD consumption (quantity and frequency), AOD-related crime and AOD-related accidents, injuries and hospital admissions. Data were pooled using random-effects inverse variance meta-analysis in Review Manager version 5.3.

FINDINGS

Risk of bias was mostly high, due to lack of random allocation, selective reporting and significant attrition. Meta-analyses indicated significant reductions in risky drinking [Alcohol Use Disorders Identification Scale (AUDIT) > 8; three trials (7 data points), relative risk (RR) = 0.78, 95% confidence interval (CI) = 0.62-0.99)], but found no impact on past-month alcohol use (five trials, RR = 0.95, 95% CI = 0.89-1.02), binge drinking (five trials, RR = 0.97, 95% CI = 0.89-1.06) or 12-month marijuana use (two trials, RR = 0.98, 95% CI = 0.86-1.11). Narrative synthesis indicated some reductions in AOD-related assault rates and arrests, but were equivocal for quantity of alcohol consumed, 12-month illicit drug use, assault or abuse, motor vehicle accidents and hospital admissions.

CONCLUSIONS

Interventions to reduce alcohol and other drug use and harms applied to whole communities have resulted so far in small reductions in risky alcohol consumption, but have had little impact upon past month alcohol use, binge drinking or 12-month marijuana use and the studies have been subject to high risk of bias.

Effectiveness of telephone-based interventions for managing osteoarthritis and spinal pain: a systematic review and meta-analysis

BACKGROUND

Osteoarthritis and spinal pain are common and burdensome conditions; however, the majority of patients with these conditions do not receive care that is consistent with clinical practice guidelines. Telehealth models of care have the potential to improve care for osteoarthritis and spinal pain patients. The aim of this review was to assess the effectiveness of verbal real-time telehealth interventions, including telephone-based and videoconferencing interventions to reduce pain intensity and disability in patients with osteoarthritis of the knee or hip and spinal pain (back or neck pain).

METHODS

We searched seven electronic databases from inception to May 2018. Randomised controlled trials (RCTs), cluster-RCTs, and non-randomised controlled trials were included. Two review authors independently extracted data for each included study. Primary outcomes were pain intensity and disability. We conducted primary meta-analyses combining all conditions with similar interventions and comparators. Standardised mean difference (SMD) and 95% confidence intervals (CIs) were calculated using random effects models. We used the Cochrane Risk of Bias tool to assess risk of bias, and GRADE to evaluate the quality of evidence.

RESULTS

We included 23 studies with 56 trial arms and 4,994 participants. All studies utilised telephone-based interventions. Only two studies used a telephone only approach and the remainder included educational materials and/or face-to-face components. We found no studies utilising videoconferencing. Meta-analysis showed telephone-based interventions (with educational materials) for osteoarthritis and spinal pain improved pain intensity (n = 5 trials, n = 1,357 participants, SMD -0.27, 95% CI [-0.53, -0.01], Tau2 = 0.06, I 2 = 74%; moderate-quality evidence) and disability (n = 7 trials, n = 1,537 participants, SMD -0.21, 95% CI [-0.40, -0.02], Tau2 = 0.03, I 2 = 56%; moderate-quality evidence) compared to usual care. Meta-analyses found telephone with face-to-face interventions does not improve pain and disability compared to usual care or face-to-face care alone.

DISCUSSION

We are moderately confident that telephone-based interventions reduce pain intensity and disability in patients with osteoarthritis and spinal pain compared to usual care, but telephone plus face-to-face interventions are no more effective than usual care or face-to-face interventions alone.

Promotion of healthy eating in clubs with junior teams in Australia: A cross-sectional study of club representatives and parents

ISSUES ADDRESSED

To: (i) describe the prevalence of policies and practices promoting healthy eating implemented by sports clubs with junior teams; (ii) examine differences in such practices across geographic and operational characteristics of clubs; and (iii) describe the attitudes of club representatives and parents regarding the acceptability of sports clubs implementing policies and practices to promote healthy eating.

METHODS

Cross-sectional telephone surveys of junior community football club management representatives and parents/carers of junior players were conducted in the states of New South Wales and Victoria, Australia in 2016.

RESULTS

Seventy-nine of the 89 club representatives approached to participate completed the telephone survey. All clubs (100%; 95% CI 96.2-100.0) reported recommending fruit or water be provided to players after games or at half-time, 24% (95% CI 14.4-33.7) reported promoting healthy food options through prominent positioning at point of sale and only 8% (95% CI 1.6-13.6) of clubs had a written healthy eating policy. There were no significant differences between the mean number of healthy eating policies and practices implemented by club socio-economic or geographic characteristics. Club representatives and parents/carers were supportive of clubs promoting healthy eating for junior players.

CONCLUSIONS

While there is strong support within sporting clubs with junior teams for policies and practices to promote healthy eating, their implementation is highly variable. SO WHAT?: A considerable opportunity remains for health promotion policy and practice improvement in clubs with junior teams, particularly regarding policies related to nutrition.

Patient receipt of smoking cessation care in four Australian acute psychiatric facilities

This study aimed to report the receipt of smoking care, and associated clinical and smoking characteristics among smokers admitted to four public psychiatric inpatient facilities in New South Wales, Australia. Between October 2012 and July 2014, adult smokers (N = 236) were surveyed during admission to and 1 month following discharge from the facilities. Measures of smoking care receipt were reported descriptively, and logistic regression analyses were used to explore characteristics associated with care receipt. The majority of participants were offered (78%) and used (78%) nicotine replacement therapy (NRT), with 66% of NRT-users reporting the amount provided was sufficient to reduce cravings. A minority of participants (16%) received information or advice to quit smoking, and 60% reported smoking throughout their admission. Patients not contemplating quitting and those with non-psychotic disorders were more likely to receive an offer of NRT. The findings suggest the provision of smoking care in Australian acute psychiatric units is sub-optimal overall, with an indication that care may be provided selectively to certain patients, rather than systematically to all. Development and dissemination of interventions to increase smoking care provision in inpatient psychiatry are needed.

Codesign of the Population Health Information Management System to measure reach and practice change of childhood obesity programs

INTRODUCTION

Childhood obesity prevalence is an issue of international public health concern and governments have a significant role to play in its reduction. The Healthy Children Initiative (HCI) has been delivered in New South Wales (NSW), Australia, since 2011 to support implementation of childhood obesity prevention programs at scale. Consequently, a system to support local implementation and data collection, analysis and reporting at local and state levels was necessary. The Population Health Information Management System (PHIMS) was developed to meet this need. Design and development: A collaborative and iterative process was applied to the design and development of the system. The process comprised identifying technical requirements, building system infrastructure, delivering training, deploying the system and implementing quality measures. Use of PHIMS: Implementation of PHIMS resulted in rapid data retrieval and reporting against agreed performance measures for the HCI. The system has 150 users who account for the monitoring and reporting of more than 6000 HCI intervention sites (early childhood services and primary schools).

LESSONS LEARNT

Developing and implementing PHIMS presented a number of complexities including: applying an information technology (IT) development methodology to a traditional health promotion setting; data access and confidentiality issues; and managing system development and deployment to intended timelines and budget. PHIMS was successfully codesigned as a flexible, scalable and sustainable IT solution that supports state-wide HCI program implementation, monitoring and reporting.

Strategies to improve the implementation of policies, practices or programmes in sporting organisations targeting poor diet, physical inactivity, obesity, risky alcohol use or tobacco use: a systematic review

OBJECTIVES

The primary aim for this review is to determine the effectiveness of strategies to improve the implementation of policies, practices or programmes in sporting organisations. The secondary aims are to describe the cost or cost-effectiveness and adverse effects of such strategies and to examine the effects of those implementation strategies on individual's diet, physical activity, obesity, alcohol use or tobacco use.

METHODS

We conducted searches of academic databases (eg, MEDLINE, EMBASE and CENTRAL), trial registers and hand searches of selected journals. Studies were included if they were conducted at a sporting venue; described a strategy to improve implementation of policies, practices or programmes focusing on one or more health risks (diet, physical inactivity, obesity, alcohol or tobacco use), and included a parallel control group. Two authors independently screened citations and extracted data. The results of included studies were synthesised narratively.

RESULTS

Of the 5926 citations screened three studies met the inclusion criteria. Two studies were randomised controlled trials. Two studies sought to improve the implementation of nutrition-related policy and practices and one study sought to improve implementation of alcohol-related policy and practices. Each study reported improvement in at least one measure of policy or practice implementation. Two studies reported individual-level outcomes and found a reduction in excessive alcohol consumption and an increase in purchase of fruits and vegetables at the sports club ground. Two studies assessed club revenue as a potential adverse effect, neither reported significant between-group differences on these measures.

CONCLUSION

There is a sparse evidence base regarding the effectiveness of strategies to improve the implementation of policies, practices or programmes targeting chronic disease risk factors in sporting clubs. While all studies reported some improvements in implementation, for some multistrategic implementation strategies it is difficult to determine the extent to which such effects are generalisable.

PROSPERO REGISTRATION NUMBER

CRD42016039490.

Differential intervention effectiveness of a universal school-based resilience intervention in reducing adolescent substance use within student subgroups: exploratory assessment within a cluster-randomised controlled trial

OBJECTIVES

Interventions addressing the individual and environmental protective factors of adolescents are suggested to have potential for reducing adolescent substance use. While universally delivered school-based substance use prevention interventions are common, previous studies have suggested variable effectiveness by subgroups of students. An exploratory study was undertaken to examine the differential effectiveness of a universal school-based resilience intervention on adolescent substance use and protective factors according to their sociodemographic and previous substance use.

DESIGN

Secondary analysis of data from a cluster-randomised controlled trial.

SETTING

32 Australian secondary schools.

PARTICIPANTS

Cohort of grade 7 students (n=3155) followed up in grade 10 (aged 15-16 years; 2014; n=2105).

INTERVENTION

Three-year universal school-based intervention implemented by school staff that targeted a range of student resilience protective factors (2012-2014).

MEASUREMENTS

Primary outcomes included: tobacco (recent, number of cigarettes) and alcohol (recent, 'risk' and number of drinks) use, and secondary outcomes included: marijuana (recent) and other illicit substance (recent) use, and aggregate individual and environmental protective factor scores. Generalised and linear mixed models examined interactions between treatment and student subgroups (gender; socioeconomic disadvantage (low/high); geographic location (major city/inner regional/outer regional-remote); and previous substance use (non-user/user)) at follow-up (36 models).

RESULTS

Analysis of student follow-up data showed no differential intervention effect for any substance use or protective factor outcome for any subgroup, with the exception of one differential effect found by socioeconomic status for the outcome of mean number of cigarettes smoked by recent smokers (p=0.003). There was no evidence of an intervention effect within the low (mean difference (MD) -12.89, 95% CI -26.00 to 0.23) or high (MD 16.36, 95% CI -1.03 to 33.76) socioeconomic subgroups.

CONCLUSIONS

No evidence of an intervention effect on substance use and protective factors was found according to student subgroups defined by sociodemographic characteristics or previous substance use.

TRIAL REGISTRATION NUMBER

ACTRN12611000606987.

A practice change intervention to improve antenatal care addressing alcohol consumption by women during pregnancy: research protocol for a randomised stepped-wedge cluster trial

Background

Despite clinical guideline recommendations, implementation of antenatal care addressing alcohol consumption by pregnant women is limited. Implementation strategies addressing barriers to such care may be effective in increasing care provision. The aim of this study is to examine the effectiveness, cost and cost-effectiveness of a multi-strategy practice change intervention in increasing antenatal care addressing the consumption of alcohol by pregnant women.

Methods

The study will be a randomised, stepped-wedge controlled trial conducted in three sectors in a health district in New South Wales, Australia. Stepped implementation of a practice change intervention will be delivered to sectors in a random order to support the introduction of a model of care for addressing alcohol consumption by pregnant women. A staged process was undertaken to develop the implementation strategies, which comprise of: leadership support, local clinical practice guidelines, electronic prompts and reminders, opinion leaders, academic detailing (audit and feedback), educational meetings and educational materials, and performance monitoring. Repeated cross-sectional outcome data will be gathered weekly across all sectors for the study duration. The primary outcome measures are the proportion of antenatal appointments at ‘booking in’, 27–28 weeks gestation and 35–36 weeks gestation for which women report (1) being assessed for alcohol consumption, (2) being provided with brief advice related to alcohol consumption during pregnancy, (3) receiving relevant care for addressing alcohol consumption during pregnancy, and (4) being assessed for alcohol consumption and receiving relevant care. Data on resources expended during intervention development and implementation will be collected. The proportion of women who report consuming alcohol since knowing they were pregnant will be measured as a secondary outcome.

Discussion

This will be the first randomised controlled trial to evaluate the effectiveness, cost and cost-effectiveness of implementation strategies in improving antenatal care that addresses alcohol consumption by pregnant women. If positive changes in clinical practice are found, this evidence will support health service adoption of implementation strategies to support improved antenatal care for this recognised risk to the health and wellbeing of the mother and child.

Trial registrations

Australian and New Zealand Clinical Trials Registry, No. ACTRN12617000882325 (date registered: 16/06/2017).

Providing routine chronic disease preventive care in community substance use services: a pilot study of a multistrategic clinical practice change intervention

OBJECTIVES

To evaluate the potential effectiveness of a practice change intervention in increasing preventive care provision in community-based substance use treatment services. In addition, client and clinician acceptability of care were examined.

DESIGN

A pre-post trial conducted from May 2012 to May 2014.

SETTING

Public community-based substance use treatment services (n=15) in one health district in New South Wales (NSW), Australia.

PARTICIPANTS

Surveys were completed by 226 clients and 54 clinicians at baseline and 189 clients and 46 clinicians at follow-up.

INTERVENTIONS

A 12-month multistrategic clinician practice change intervention that aimed to increase the provision of preventive care for smoking, insufficient fruit and/or vegetable consumption and insufficient physical activity.

PRIMARY AND SECONDARY OUTCOME MEASURES

Client and clinician reported provision of assessment, brief advice and referral for three modifiable health risk behaviours: smoking, insufficient fruit and/or vegetable consumption and insufficient physical activity. Clinician-reported optimal care was defined as providing care to 80% of clients or more. Client acceptability and clinician attitudes towards preventive care were assessed at follow-up.

RESULTS

Increases in client reported care were observed for insufficient fruit and/or vegetable consumption including: assessment (24% vs 54%, p<0.001), brief advice (26% vs 46%, p<0.001), and clinicians speaking about (10% vs 31%, p<0.001) and arranging a referral (1% vs 8%, p=0.006) to telephone helplines. Clinician reported optimal care delivery increased for: assessment of insufficient fruit and/or vegetable consumption (22% vs 63%, p<0.001) and speaking about telephone helplines for each of the three health risk behaviours. Overall, clients and clinicians held favourable views regarding preventive care.

CONCLUSION

This study reported increases in preventive care for insufficient fruit and/or vegetable consumption; however, minimal increases were observed for smoking or insufficient physical activity. Further investigation of the barriers to preventive care delivery in community substance use settings is needed.

TRIALREGISTRATION NUMBER

ACTRN12614000469617.

Scale up of a multi-strategic intervention to increase implementation of a school healthy canteen policy: findings of an intervention trial

Background

Implementation interventions delivered in schools to improve food provision have been found to improve student diet and reduce child obesity risk. If the health benefits of food availability policies are to be realised, interventions that are effective need to be implemented at scale, across an entire population of schools. This study aims to assess the potential effectiveness of an intervention in increasing the implementation, at scale, of a healthy canteen policy by Australian primary schools.

Methods

A non-controlled before and after study was conducted in primary schools located in the Hunter New England region of New South Wales, Australia. Schools received a multi-component intervention adapted from a previous efficacious and cost-effective randomised control trial. The primary trial outcome was the proportion of canteen menus compliant with the state healthy canteen policy, assessed via menu audit at baseline and follow-up by dietitians. Secondary outcomes included policy reach and adoption and maintenance policy implementation.

Results

Of the 173 schools eligible for inclusion in the trial, 168 provided menus at baseline and 157 menus were collected at follow-up. At follow-up, multiple imputation analysis found 35% (55/157) of schools compared to 17% (29/168) at baseline (OR = 2.8 (1.6–4.7), p = < 0.001) had menus compliant with the state healthy canteen policy. As an assessment of the impact of the intervention on policy reach, canteen manager and principal knowledge of the policy increased from 64% (n = 76) and 38% (n = 44) respectively at baseline to 69% (n = 89) and 60% (n = 70) at follow-up (p = 0.393, p = 0.026). Adoption of the policy increased from 80% (n = 93) at baseline to 90% (n = 104) at follow-up (p = 0.005) for principals, and from 86% (n = 105) to 96% (n = 124) (p = 0.0001) for canteen managers. Multiple imputation analysis showed intervention effects were maintained six-months post intervention (33% of menus compliant OR = 2.6 (1.5–4.5), p = < 0.001 compared to baseline).

Conclusions

This study found school canteen compliance with a healthy food policy increased in association with a multi-strategy intervention delivered at scale. The study provides evidence for public health policy makers and practitioners regarding strategies and modes of support required to support improvement in nutrition policy implementation across entire populations of schools.

Impacts of licensed premises trading hour policies on alcohol-related harms

BACKGROUND AND AIM

Evaluations of alcohol policy changes demonstrate that restriction of trading hours of both 'on'- and 'off'-licence venues can be an effective means of reducing rates of alcohol-related harm. Despite this, the effects of different trading hour policy options over time, accounting for different contexts and demographic characteristics, and the common co-occurrence of other harm reduction strategies in trading hour policy initiatives, are difficult to estimate. The aim of this study was to use dynamic simulation modelling to compare estimated impacts over time of a range of trading hour policy options on various indicators of acute alcohol-related harm.

METHODS

An agent-based model of alcohol consumption in New South Wales, Australia was developed using existing research evidence, analysis of available data and a structured approach to incorporating expert opinion. Five policy scenarios were simulated, including restrictions to trading hours of on-licence venues and extensions to trading hours of bottle shops. The impact of the scenarios on four measures of alcohol-related harm were considered: total acute harms, alcohol-related violence, emergency department (ED) presentations and hospitalizations.

RESULTS

Simulation of a 3 a.m. (rather than 5 a.m.) closing time resulted in an estimated 12.3 ± 2.4% reduction in total acute alcohol-related harms, a 7.9 ± 0.8% reduction in violence, an 11.9 ± 2.1% reduction in ED presentations and a 9.5 ± 1.8% reduction in hospitalizations. Further reductions were achieved simulating a 1 a.m. closing time, including a 17.5 ± 1.1% reduction in alcohol-related violence. Simulated extensions to bottle shop trading hours resulted in increases in rates of all four measures of harm, although most of the effects came from increasing operating hours from 10 p.m. to 11 p.m.

CONCLUSIONS

An agent-based simulation model suggests that restricting trading hours of licensed venues reduces rates of alcohol-related harm and extending trading hours of bottle shops increases rates of alcohol-related harm. The model can estimate the effects of a range of policy options.

Alcohol management practices in community sporting clubs: Validation of an online self-report tool

INTRODUCTION AND AIMS

Those involved in organised sport have a high risk of excessive alcohol consumption and alcohol-related harm, the implementation of alcohol management practices have been proven to reduce these risks. Measuring alcohol management practice implementation by sporting clubs is impeded by a lack of valid tools. The aim of this study was to determine the validity of online self-report of alcohol-management practices by community football clubs via comparison with observational methods.

DESIGN AND METHODS

A cross-sectional study was undertaken with a sample of community football clubs within Australia. The implementation of 12 alcohol management practices was collected via: (i) an online survey; and (ii) observational audit at a clubs home ground. The prevalence of implementation of alcohol management practices for both data collection methods was calculated as was percent agreement and Kappa/Prevalence Adjusted and Bias Adjusted Kappa (PABAK) statistics.

RESULTS

Data were collected from 58 football clubs. For both assessment methods, implementation prevalence was greater than 80% for 6 of the 12 alcohol management practices. A total of 75% (n = 9) of practices had at least 70% agreement between the online and observation methods of assessment. Kappa/PABAK scores ranged from -0.08 (poor agreement) to 0.97 (almost perfect agreement).

DISCUSSION AND CONCLUSION

The online survey provided valid measure of assessing some but not all alcohol management practices in community sporting clubs. The validity of the measure may be improved by enhancements to the manner in which the self-report data are collected.

Do mental health consumers want to improve their long-term disease risk behaviours? A survey of over 2000 psychiatric inpatients

Policies and clinical guidelines acknowledge the role mental health services have in addressing the physical health of individuals with a mental illness; however, little research has explored interest in reducing health risk behaviours or the acceptability of receiving support to reduce such risks among psychiatric inpatients. This study estimated the prevalence of four long-term disease risk behaviours (tobacco smoking, hazardous alcohol consumption, inadequate fruit and/or vegetable consumption, and inadequate physical activity); patient interest in reducing these risks; and acceptability of being provided care to do so during a psychiatric inpatient stay. A cross-sectional survey was undertaken with 2075 inpatients from four inpatient psychiatric facilities in one health district in Australia (October 2012-April 2014). Prevalence of risk behaviours ranged from 50.2% (inadequate physical activity) to 94.8% (inadequate fruit and/or vegetable consumption). The majority of respondents (88.4%) had more than one risk behaviour, and most were seriously considering improving their risk behaviours (47.6% to 65.3%). The majority (80.4%) agreed that it would be acceptable to be provided support and advice to change such behaviours during their psychiatric inpatient stay. Some diagnoses were associated with smoking and hazardous alcohol consumption, interest in reducing alcohol consumption and increasing fruit and/or vegetable consumption, and acceptability of receiving advice and support. The findings reinforce the need and opportunity for psychiatric inpatient facilities to address the long-term disease risk behaviours of their patients.

Harnessing advances in computer simulation to inform policy and planning to reduce alcohol-related harms

OBJECTIVES

Alcohol misuse is a complex systemic problem. The aim of this study was to explore the feasibility of using a transparent and participatory agent-based modelling approach to develop a robust decision support tool to test alcohol policy scenarios before they are implemented in the real world.

METHODS

A consortium of Australia's leading alcohol experts was engaged to collaboratively develop an agent-based model of alcohol consumption behaviour and related harms. As a case study, four policy scenarios were examined.

RESULTS

A 19.5 ± 2.5% reduction in acute alcohol-related harms was estimated with the implementation of a 3 a.m. licensed venue closing time plus 1 a.m. lockout; and a 9 ± 2.6% reduction in incidence was estimated with expansion of treatment services to reach 20% of heavy drinkers. Combining the two scenarios produced a 33.3 ± 2.7% reduction in the incidence of acute alcohol-related harms, suggesting a synergistic effect.

CONCLUSIONS

This study demonstrates the feasibility of participatory development of a contextually relevant computer simulation model of alcohol-related harms and highlights the value of the approach in identifying potential policy responses that best leverage limited resources.

Systematic review of interventions to increase the provision of care for chronic disease risk behaviours in mental health settings: review protocol

BACKGROUND

People with a mental illness experience a higher morbidity and mortality from chronic diseases relative to the general population. A higher prevalence of risk behaviours, including tobacco smoking, poor nutrition, harmful alcohol consumption and physical inactivity, is a substantial contributor to this health inequity. Clinical practice guidelines recommend that mental health services routinely provide care to their clients to address these risk behaviours. Such care may include the following elements: ask, assess, advise, assist and arrange (the '5As'), which has been demonstrated to be effective in reducing risk behaviours. Despite this potential, the provision of such care is reported to be low internationally and in Australia, and there is a need to identify effective strategies to increase care provision. The proposed review will examine the effectiveness of interventions which aimed to increase care provision (i.e. increase the proportion of clients receiving or clinicians providing the 5As) for the chronic disease risk behaviours of clients within the context of mental health service delivery.

METHODS

Eligible studies will be any quantitative study designs with a comparison group and which report on the effectiveness of an intervention strategy (including delivery arrangements, financial arrangements, governance arrangements and implementation strategies) to increase care provision specifically for chronic disease risk behaviours (tobacco smoking, poor nutrition, harmful alcohol consumption and physical inactivity). Screening for studies will be conducted across seven electronic databases: PsycINFO, MEDLINE, Excerpta Medica database (EMBASE), Psychology and Behavioural Sciences Collection, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL) and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Two authors will independently screen studies for eligibility and extract data from included studies. Where studies are sufficiently homogenous, meta-analysis will be performed. Where considerable heterogeneity exists (I 2  ≥ 75), narrative synthesis will be used.

DISCUSSION

This review will be the first to synthesise evidence for the effectiveness of intervention approaches to facilitate care provision for chronic disease risk behaviours in the context of mental health service delivery. The results have the potential to inform the development of evidenced-based approaches to address the health inequities experienced by this population group.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017074360 .

Impact of scheduling multiple outdoor free-play periods in childcare on child moderate-to-vigorous physical activity: a cluster randomised trial

Background

Increasing the frequency of periods of outdoor free-play in childcare may represent an opportunity to increase child physical activity. This study aimed to assess the efficacy of scheduling multiple periods of outdoor free-play in increasing the time children spend in moderate-to-vigorous physical activity (MVPA) while attending childcare.

Methods

The study employed a cluster randomised controlled trial design involving children aged 3 to 6 years, attending ten childcare services in the Hunter New England region of New South Wales, Australia. Five services were randomised to receive the intervention and five to a control condition. The intervention involved services scheduling three separate periods of outdoor free-play from 9 am to 3 pm per day, each at least 15 min in duration, with the total equivalent to their usual daily duration of outdoor play period. Control services implemented the usual single continuous period of outdoor free-play over this time. The primary outcome, children’s moderate-to-vigorous physical activity (MVPA) while in care per day, was measured over 5 days via accelerometers at baseline and at 3 months post baseline. Secondary outcomes included percentage of time spent in MVPA while in care per day, total physical activity while in care per day and documented child injury, a hypothesised potential unintended adverse event. Childcare services and data collectors were not blind to the experimental group allocation.

Results

Parents of 439 (71.6%) children attending participating childcare services consented for their child to participate in the trial. Of these, 316 (72.0%) children provided valid accelerometer data at both time points. Relative to children in control services, mean daily minutes of MVPA in care was significantly greater at follow-up among children attending intervention services (adjusted difference between groups 5.21 min, 95% CI 0.59–9.83 p = 0.03). Percentage of time spent in MVPA in care per day was also greater at follow-up among children in intervention services relative to control services (adjusted difference between groups 1.57, 95% CI 0.64–2.49 p < 0.001). Total physical activity while in care per day, assessed via counts per minute approached but did not reach significance (adjusted difference between groups 14.25, 95% CI 2.26–30.76 p = 0.09). There were no differences between groups in child injury nor subgroup interactions for the primary trial outcome by child age, sex, or baseline MVPA levels.

Conclusion

Scheduling multiple periods of outdoor free-play significantly increased the time children spent in MVPA while in attendance at childcare. This simple ecological intervention could be considered for broader dissemination as a strategy to increase child physical activity at a population level.

Trial registration

This trial was prospectively registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) (ACTRN1261000347460). Prospectively registered 17th March 2016.

Electronic supplementary material

The online version of this article (10.1186/s12966-018-0665-5) contains supplementary material, which is available to authorized users.

Telephone-based weight loss support for patients with knee osteoarthritis: a pragmatic randomised controlled trial

OBJECTIVE

To determine the effectiveness of telephone-based weight loss support in reducing the intensity of knee pain in patients with knee osteoarthritis, who are overweight or obese, compared to usual care.

DESIGN

We conducted a parallel randomised controlled trial (RCT), embedded within a cohort multiple RCT of patients on a waiting list for outpatient orthopaedic consultation at a tertiary referral hospital in NSW, Australia. Patients with knee osteoarthritis, classified as overweight or obese [body mass index (BMI) between ≥27 kg/m² and <40 kg/m²] were randomly allocated to receive referral to an existing non-disease specific government funded 6-month telephone-based weight management and healthy lifestyle service or usual care. The primary outcome was knee pain intensity measured using an 11-point numerical rating scale (NRS) over 6-month follow-up. A number of secondary outcomes, including self-reported weight were measured. Data analysis was by intention-to-treat according to a pre-published analysis plan.

RESULTS

Between May 19 and June 30 2015, 120 patients were randomly assigned to the intervention (59 analysed, one post-randomisation exclusion) or usual care (60 analysed). We found no statistically significant between group differences in pain intensity [area under the curve (AUC), mean difference 5.4, 95%CI: -13.7 to 24.5, P = 0.58] or weight change at 6 months (self-reported; mean difference -0.4, 95%CI: -2.6 to 1.8, P = 0.74).

CONCLUSIONS

Among patients with knee osteoarthritis who are overweight, telephone-based weight loss support, provided using an existing 6-month weight management and healthy lifestyle service did not reduce knee pain intensity or weight, compared with usual care.

TRIAL REGISTRATION NUMBER

ACTRN12615000490572.

Economic analysis of three interventions of different intensity in improving school implementation of a government healthy canteen policy in Australia: costs, incremental and relative cost effectiveness

Background

No evaluations of the cost or cost effectiveness of interventions to increase school implementation of food availability policies have been reported. Government and non-government agency decisions regarding the extent of investment required to enhance school implementation of such policies are unsupported by such evidence. This study sought to i) Determine cost and cost-effectiveness of three interventions in improving school implementation of an Australian government healthy canteen policy and; ii) Determine the relative cost-effectiveness of the interventions in improving school implementation of such a policy.

Methods

An analysis of the cost and cost-effectiveness of three implementation interventions of varying support intensity, relative to usual implementation support conducted during 2013–2015 was undertaken. Secondly, an indirect comparison of the trials was undertaken to determine the most cost-effective of the three strategies. The economic analysis was based on the cost of delivering the interventions by health service delivery staff to increase the proportion of schools ‘adherent’ with the policy.

Results

The total costs per school were $166,971, $70,926 and $75,682 for the high, medium and low intensity interventions respectively. Compared to usual support, the cost effectiveness ratios for each of the three interventions were: A$2982 (high intensity), A$2627 (medium intensity) and A$4730 (low intensity) per percent increase in proportion of schools reporting ‘adherence’). Indirect comparison between the ‘high’ and ‘medium intensity’ interventions showed no statistically significant difference in cost-effectiveness.

Conclusions

The results indicate that while the cost profiles of the interventions varied substantially, the cost-effectiveness did not. This result is valuable to policy makers seeking cost-effective solutions that can be delivered within budget.

Mechanisms of implementing public health interventions: a pooled causal mediation analysis of randomised trials

BACKGROUND

The World Health Organization recommends that nations implement evidence-based nutritional guidelines and policies in settings such as schools and childcare services to improve public health nutrition. Understanding the causal mechanism by which implementation strategies exert their effects could enhance guideline implementation. The aim of this study was to assess the mechanisms by which implementation strategies improved schools and childcare services' adherence to nutrition guidelines.

METHODS

We conducted a mechanism evaluation of an aggregated dataset generated from three randomised controlled trials conducted in schools and childcare services in New South Wales, Australia. Each trial examined the impact of implementation strategies that targeted Theoretical Domains Framework constructs including knowledge, skills, professional role and identity, environmental context and resources. We pooled aggregated organisation level data from each trial, including quantitative assessments of the Theoretical Domains Framework constructs, as well as measures of school or childcare nutrition guideline compliance, the primary implementation outcome. We used causal mediation analysis to estimate the average indirect and direct effects of the implementation strategies and assessed the robustness of our findings to varying levels of unmeasured and unknown confounding.

RESULTS

We included 121 schools or childcare services in the pooled analysis: 79 allocated to receive guideline and policy implementation strategies and 42 to usual practice. Overall, the interventions improved compliance (odds ratio = 6.64; 95% CI [2.58 to 19.09]); however, the intervention effect was not mediated by any of the four targeted Theoretical Domains Framework constructs (average causal mediation effects through knowledge = - 0.00 [- 0.05 to 0.04], skills = 0.01 [- 0.02 to 0.07], professional role and identity = 0.00 [- 0.03 to 0.03] and environmental context and resources = 0.00 [- 0.02 to 0.06]). The intervention had no significant effect on the four targeted Theoretical Domains Framework constructs, and the constructs were not associated with school or childcare nutrition guideline compliance. Potentially, this lack of effect could be explained by imprecise measurement of the mediators. Alternatively, it is likely that that the interventions were operating via alternative mechanisms that were not captured by the four Theoretical Domains Framework constructs we explored.

CONCLUSIONS

Even though public health implementation strategies led to meaningful improvements in school or childcare nutrition guideline compliance, these effects were not mediated by key targeted constructs of the Theoretical Domains Framework. Future research should explore the mechanistic role of other Theoretical Domains Framework constructs and evaluate system-level mechanisms informed by an ecological framework.

TRIAL REGISTRATION

All trials were prospectively registered with the Australian New Zealand Clinical Trials Registry ( ACTRN12613000543785 . Registered 15/05/2013; ACTRN12614001148662 . Registered 30/10/2014; ACTRN12615001032549 . Registered 1/10/2015).

Prevalence of electronic nicotine delivery systems (ENDS) use among youth globally: a systematic review and meta-analysis of country level data

OBJECTIVE

To describe the prevalence and change in prevalence of electronic nicotine delivery systems (ENDS) use in youth by country and combustible smoking status.

METHODS

Databases and the grey literature were systematically searched to December 2015. Studies describing the prevalence of ENDS use in the general population aged ≤20 years in a defined geographical region were included. Where multiple estimates were available within countries, prevalence estimates of ENDS use were pooled for each country separately.

RESULTS

Data from 27 publications (36 surveys) from 13 countries were included. The prevalence of ENDS ever use in 2013-2015 among youth were highest in Poland (62.1%; 95%CI: 59.9-64.2%), and lowest in Italy (5.9%; 95%CI: 3.3-9.2%). Among non-smoking youth, the prevalence of ENDS ever use in 2013-2015 varied, ranging from 4.2% (95%CI: 3.8-4.6%) in the US to 14.0% in New Zealand (95%CI: 12.7-15.4%). The prevalence of ENDS ever use among current tobacco smoking youth was the highest in Canada (71.9%, 95%CI: 70.9-72.8%) and lowest in Italy (29.9%, 95%CI: 18.5-42.5%). Between 2008 and 2015, ENDS ever use among youth increased in Poland, Korea, New Zealand and the US; decreased in Italy and Canada; and remained stable in the UK.

CONCLUSIONS

There is considerable heterogeneity in ENDS use among youth globally across countries and also between current smokers and non-smokers. Implications for public health: Population-level survey data on ENDS use is needed to inform public health policy and messaging globally.

Assessing the potential impact of a front-of-pack nutritional rating system on food availability in school canteens: A randomised controlled trial

BACKGROUND

Front-of-pack graphical nutritional rating of products is becoming an important strategy in many countries to improve healthy food purchases by consumers. Evidence of the effectiveness of such on facilitating healthy food choices by school food service providers has not been reported. The primary aim of the study was to assess the impact of providing front-of-pack nutritional rating information on school canteen managers' likely food selections. Secondary outcomes were canteen manager awareness, attitudes and reported barriers to using the front-of-pack information.

METHODS

A randomised controlled trial involving primary school canteen managers was conducted in a single region in New South Wales, Australia. Eligible participants were randomised to an intervention or control group and asked in a telephone interview which of 12 common food products sold in school canteens they would sell. Both groups received product name and brand information. The intervention group also received information regarding the nutritional rating of products.

RESULTS

Canteen managers in the intervention group were significantly more likely than those in the control group to indicate they would sell three of the six 'healthier' products (p = 0.036, 0.005, 0.009). There was no difference between groups in the likelihood of making available for sale any of the six 'less healthy' products. The majority of canteen managers who had heard of a product nutritional rating system agreed that it was helpful in identifying 'healthier' foods (88%, n = 31).

CONCLUSIONS

The inclusion of product nutritional rating information has the potential to improve the availability of some 'healthier' items on canteen menus and contribute to improving child dietary intake. Further research is required to determine whether the use of product nutritional rating information actually makes a difference to canteen manager choices.

Randomised controlled trial of a web-based programme in sustaining best practice alcohol management practices at community sports clubs: a study protocol

INTRODUCTION

Community-based interventions have been found to effectively increase the implementation of alcohol management practices and reduce excessive alcohol use and alcohol-related harm at sports clubs. However, once implementation support ceases there may be a reduction in such intervention effects. Thus, ongoing contribution to improving the health of the community is diminished; sustaining practice implementation is a key determinant to address this. One possible solution to the strategic and logistical challenges of sustainability involves the use of the web. The primary aim of this study is to assess the effectiveness of a web-based programme in sustaining the implementation of alcohol management practices by community football clubs. The secondary aim is to assess the effectiveness of the programme in preventing excessive alcohol consumption and alcohol-related harm among members of community football clubs.

METHODS AND ANALYSIS

The study will employ a repeat randomised controlled trial design and be conducted in regional and metropolitan areas within two states of Australia. Community level football clubs who are currently accredited with an existing alcohol management programme ('Good Sports') and implementing at least 10 of the 13 core alcohol management practices (eg, not serving alcohol to <18-year-olds) required by the programme will be recruited and randomised to either a web-based sustainability programme or a 'minimal contact' programme. The primary outcome measures are the proportion of football clubs implementing ≥10 of the 13 required alcohol management practices and the mean number of those practices being implemented at 3-year follow-up. Secondary outcomes include: the proportion of club members who report risky drinking at their club, the Alcohol Use Disorder Identification Test (AUDIT) score and mean AUDIT score of club members. Outcome data will be collected via observation at the club during a 1-day visit to a home game, conducted by trained research assistants at baseline and follow-up.

ETHICS AND DISSEMINATION

The study was approved by The University of Newcastle Human Research Ethics Committee (reference: H-2013-0429). Study findings will be disseminated widely through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

ACTRN12614000746639; Pre-results.

Cluster randomised controlled trial of a multicomponent intervention to support the implementation of policies and practices that promote healthier environments at junior sports clubs: study protocol

INTRODUCTION

A large proportion of children and adolescents participate in organised sport, making community sports clubs a promising setting to support healthy behaviours. To date, however, there have been few interventions conducted in junior sports clubs that have targeted health-promoting practices. The primary aim of this pilot study is to assess the potential effectiveness of an intervention to implement health-promoting policies and practices in junior sporting clubs targeting alcohol and tobacco practices, healthy food and beverage availability, and physical activity via participation in sport. A secondary outcome is to assess the impact of such strategies on child exposure to alcohol and tobacco use at the club, purchasing behaviours by/for children at the club canteen and child sports participation opportunities.

METHODS AND ANALYSIS

The study will employ a cluster randomised controlled trial design and be conducted in metropolitan and regional areas of two Australian states. Randomisation will occur at the level of the football league. Community football clubs with over 40 junior players (players under 18 years) within each league will be eligible to participate. The intervention will be developed based on frameworks that consider the social, cultural and environmental factors that influence health behaviours. Intervention clubs will be supported to implement 16 practices targeting alcohol management, tobacco use, nutrition practices, new player recruitment activity, equal participation for players and the development of policies to support these practices. Trained research staff will collect outcome data via telephone interviews at baseline and follow-up. Interviews will be conducted with both club representatives and parents of junior players.

ETHICS AND DISSEMINATION

The study has been approved by the University of Newcastle Human Research Ethics Committee (H-2013-0429). The results of the study will be disseminated via peer-reviewed publications and presentations at conferences.

TRIAL REGISTRATION NUMBER

ACTRN12617001044314; Pre-results.

Validity of four measures in assessing school canteen menu compliance with state-based healthy canteen policy

Issue addressed In order to assess the impact of healthy school canteen policies on food availability for students, valid methods of measuring compliance are needed that can be applied at scale. The aim of this study is to assess the validity and direct cost of four methods to assess policy compliance: 1) principal and 2) canteen manager self-report via a computer-assisted telephone interview; and 3) comprehensive and 4) quick menu audits by dietitians, compared with observations. Methods A cross-sectional study took place in the Hunter region of NSW, Australia, in a sample of 38 primary schools that had previously participated in a randomised controlled trial to improve healthy canteen policy compliance. Policy compliance was assessed using the four methods specified above. Percentage agreement, kappa, sensitivity and specificity compared with observations was calculated together with the direct time taken and costs of each method. Indirect costs (including set-up costs) for all measures have not been included. Results Agreement with observations was substantial for the quick menu audit (kappa=0.68), and moderate for the comprehensive menu audit (kappa=0.42). Principal and canteen manager self-report resulted in poor agreement and low specificity with the gold standard. The self-reported measures had the lowest cost, followed by the quick menu audit and lastly the comprehensive menu audit. Conclusion The quick menu audit represents a valid and potentially low-cost method of supporting policy implementation at scale. So what? This study demonstrates that a quick menu audit represents a valid measure of undertaking assessment of school canteen policy compliance at a population level.

Association between Australian adolescent alcohol use and alcohol use risk and protective factors in 2011 and 2014

INTRODUCTION AND AIMS

Changes in risk and protective factors of adolescent alcohol use may be contributing to the recent decline in Australian adolescents alcohol use. The study aimed to determine the: (i) prevalence of alcohol use, risk and protective factors in 2011 and 2014; and (ii) association between alcohol use and risk and protective factors in 2011 and 2014.

DESIGN AND METHODS

A repeat cross-sectional study was conducted. Grade 9-10 (aged 15-17 years) students from 32 Australian secondary schools were sampled in 2011 and 2014. A self-report survey collected data regarding alcohol use (ever, recent, 'binge drinking'), risk factors (e.g. alcohol use/permissive attitude to alcohol by friends/siblings/parents) and protective factors (e.g. self-efficacy; school/home/community support; peer caring relationships). Descriptive statistics were used to determine differences in alcohol use, risk and protective factors between 2011 and 2014. Adjusted multivariable logistic regression analyses examined associations between alcohol use, risk and protective factors separately in 2011 and 2014 (six models).

RESULTS

Fewer adolescents reported alcohol use in 2014 compared with 2011 (ever: 56.6% vs. 67.9%, recent: 17.3% vs. 21.2%, 'binge drinking': 20.0% vs. 23.5%; 2011: n = 4366; 2014: n = 5199). Significant differences between 2014 and 2011 were found for some risk (five lower; one higher) and protective factors (four lower). Risk factors that were significantly lower in 2014 compared to 2011 were amongst variables with the strongest associations with alcohol use.

DISCUSSION AND CONCLUSIONS

The strength of associations with alcohol use, and decrease in the prevalence of certain risk factors in 2014 compared to 2011, suggests such factors may be contributing to the decline in adolescent alcohol use.

Measurement of the translation and impact from a childhood obesity trial programme: rationale and protocol for a research impact assessment

Background

There is growing recognition amongst health and medical research funders and researchers that translation of research into policy and practice needs to increase and that more transparency is needed on how impacts are realised. Several approaches are advocated for achieving this, including co-production of research or academic-practitioner research. The Population Health Unit (PHU) within the Hunter New England Local Health District in regional Australia, as an early adopter of this model, has been working to increase the likelihood that its research is translated into community health benefits. With the New South Wales Ministry of Health, the PHU responded to the burden of child overweight and obesity by combining service delivery with research expertise. The ‘Good for Kids, Good for Life’ (Good for Kids) dissemination trial was developed and implemented in seven community settings in the Hunter region of Australia between 2006 and 2010. This study aims to undertake a retrospective impact assessment to measure the research translation and impact of Good for Kids.

Methods

The method will be based upon the application of the Framework to Assess the Impact from Translational health research (FAIT), comprising three core elements, namely quantified metrics, economic assessment and a narrative of the process by which the research in question translates and generates impact.

Discussion

Increasingly, funders are interested both in the outcomes resulting from investments in health research and in the expected return on their investments. FAIT was developed specifically for this purpose and its use is anticipated to provide transparency to the pathway to translation and potentially drive increased investment in translational research programmes such as Good for Kids.

Online canteens: awareness, use, barriers to use, and the acceptability of potential online strategies to improve public health nutrition in primary schools

Issue addressed This study of primary school principals assessed the awareness, use, barriers to use and acceptability of online canteens. Methods A telephone survey of 123 primary school principals within the Hunter New England Region of New South Wales, Australia was conducted from September 2014 to November 2014. Results Fifty-six percent of principals were aware of the existence of online canteens, with 8% having implemented such a system, and 38% likely to do so in the future. Medium/large schools were more likely to be aware of or to use online canteens, however there were no differences in awareness or use in relation to school rurality or socioeconomic advantage. Principals cited parent internet access as the most commonly identified perceived barrier to online canteen use, and the majority of principals (71-93%) agreed that it would be acceptable to implement a range of consumer behaviour strategies via an online canteen. Conclusions Study findings suggest that despite relatively low levels of current use, online canteens have the potential to reach a large proportion of school communities in the future, across geographical and socioeconomic divides, and that the nutrition interventions which they have the capacity to deliver are considered acceptable to school principals. So what? Online canteens may represent an opportunity to deliver nutrition interventions to school communities. Future research should examine the feasibility and potential effectiveness of interventions delivered via this modality.

Factors that influence the implementation of dietary guidelines regarding food provision in centre based childcare services: A systematic review

Children attending centre based childcare services consume as much as two thirds of their daily dietary requirements while in care. However, such services often fail to provide foods that are consistent with guideline recommendations. Developing strategies to improve childcare service adherence to menu dietary guidelines requires a comprehensive understanding of factors that may impede or promote implementation. The primary aim of this systematic review is to describe factors (barriers and facilitators) that may influence the implementation of menu dietary guidelines regarding food provision in centre-based childcare services and to map these factors to a theoretical framework. Over 7000 citations were identified from all sources. Duplicate abstracts were removed and selection criteria applied. Twelve studies (1994-2015) were included in the review. Dual data extraction was conducted and the reported factors were synthesised using the theoretical domains framework (TDF). Barriers and facilitators identified in qualitative studies were classified into 8 and 10 of the 14 TDF domains. Barriers and facilitators reported in quantitative studies covered 6 and 3 TDF domains respectively. The most common domain of which both barriers and facilitators to the implementation of menu dietary guidelines were identified was 'environmental context and resources'. This is the first study that comprehensively assesses literature to identify factors that influence the implementation of menu dietary guidelines in childcare services utilising a theoretical framework. Findings provide guidance to support researchers and policy makers design strategies to improve menu dietary guideline implementation and, as such have the potential to improve food provision in care.

An RCT to Facilitate Implementation of School Practices Known to Increase Physical Activity

INTRODUCTION

Although comprehensive school-based physical activity interventions are efficacious when tested under research conditions, they often require adaptation in order for implementation at scale. This paper reports the effectiveness of an adapted efficacious school-based intervention in improving children's moderate to vigorous physical activity. The impact of strategies to support program implementation was also assessed.

DESIGN

A cluster RCT of low socioeconomic elementary schools in New South Wales, Australia.

SETTING/PARTICIPANTS

Consenting schools were randomized (25 intervention, 21 control) using a computerized random number function. Follow-up measures were taken at 6 months post-randomization (May-August 2015) by blinded research assistants. The multicomponent school-based intervention, based on an efficacious school-based physical activity program (Supporting Children's Outcomes using Rewards, Exercise and Skills), consisted of four physical activity strategies and seven implementation support strategies. The intervention was adapted for scalability and delivery by a local health service over 6 months. The primary outcome was accelerometer assessed, student mean daily minutes spent in moderate to vigorous physical activity. Physical education lesson quality and other school physical activity practices were also assessed.

RESULTS

Participants (n=1,139, 49% male) were third- through sixth-grade students at follow-up (May-August 2015). Valid wear time and analysis of data were provided for 989 (86%) participants (571 intervention, 568 control). At 6-month follow-up, there were no significant effects in overall daily minutes of moderate to vigorous physical activity between groups (1.96 minutes, 95% CI= -3.49, 7.41, p=0.48). However, adjusted difference in mean minutes of overall vigorous physical activity (2.19, 95% CI=0.06, 4.32, p=0.04); mean minutes of school day moderate to vigorous physical activity (2.90, 95% CI=0.06, 5.85, p=0.05); and mean minutes of school day vigorous physical activity (1.81, 95% CI=0.78, 2.83, p≤0.01) were significantly different in favor of the intervention group. Physical education lesson quality and school physical activity practices were significantly different favoring the intervention group (analyzed October 2015-January 2016).

CONCLUSIONS

The modified intervention was not effective in increasing children's overall daily minutes of moderate to vigorous physical activity, when adapted for implementation at scale. However, the intervention did improve daily minutes of vigorous physical activity and school day moderate to vigorous physical activity, lesson quality, and school physical activity practices.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12615000437561.

Strategies for enhancing the implementation of school-based policies or practices targeting risk factors for chronic disease

BACKGROUND

A number of school-based policies or practices have been found to be effective in improving child diet and physical activity, and preventing excessive weight gain, tobacco or harmful alcohol use. Schools, however, frequently fail to implement such evidence-based interventions.

OBJECTIVES

The primary aims of the review are to examine the effectiveness of strategies aiming to improve the implementation of school-based policies, programs or practices to address child diet, physical activity, obesity, tobacco or alcohol use.Secondary objectives of the review are to: Examine the effectiveness of implementation strategies on health behaviour (e.g. fruit and vegetable consumption) and anthropometric outcomes (e.g. BMI, weight); describe the impact of such strategies on the knowledge, skills or attitudes of school staff involved in implementing health-promoting policies, programs or practices; describe the cost or cost-effectiveness of such strategies; and describe any unintended adverse effects of strategies on schools, school staff or children.

SEARCH METHODS

All electronic databases were searched on 16 July 2017 for studies published up to 31 August 2016. We searched the following electronic databases: Cochrane Library including the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; MEDLINE In-Process & Other Non-Indexed Citations; Embase Classic and Embase; PsycINFO; Education Resource Information Center (ERIC); Cumulative Index to Nursing and Allied Health Literature (CINAHL); Dissertations and Theses; and SCOPUS. We screened reference lists of all included trials for citations of other potentially relevant trials. We handsearched all publications between 2011 and 2016 in two specialty journals (Implementation Science and Journal of Translational Behavioral Medicine) and conducted searches of the WHO International Clinical Trials Registry Platform (ICTRP) (http://apps.who.int/trialsearch/) as well as the US National Institutes of Health registry (https://clinicaltrials.gov). We consulted with experts in the field to identify other relevant research.

SELECTION CRITERIA

'Implementation' was defined as the use of strategies to adopt and integrate evidence-based health interventions and to change practice patterns within specific settings. We included any trial (randomised or non-randomised) conducted at any scale, with a parallel control group that compared a strategy to implement policies or practices to address diet, physical activity, overweight or obesity, tobacco or alcohol use by school staff to 'no intervention', 'usual' practice or a different implementation strategy.

DATA COLLECTION AND ANALYSIS

Citation screening, data extraction and assessment of risk of bias was performed by review authors in pairs. Disagreements between review authors were resolved via consensus, or if required, by a third author. Considerable trial heterogeneity precluded meta-analysis. We narratively synthesised trial findings by describing the effect size of the primary outcome measure for policy or practice implementation (or the median of such measures where a single primary outcome was not stated).

MAIN RESULTS

We included 27 trials, 18 of which were conducted in the USA. Nineteen studies employed randomised controlled trial (RCT) designs. Fifteen trials tested strategies to implement healthy eating policies, practice or programs; six trials tested strategies targeting physical activity policies or practices; and three trials targeted tobacco policies or practices. Three trials targeted a combination of risk factors. None of the included trials sought to increase the implementation of interventions to delay initiation or reduce the consumption of alcohol. All trials examined multi-strategic implementation strategies and no two trials examined the same combinations of implementation strategies. The most common implementation strategies included educational materials, educational outreach and educational meetings. For all outcomes, the overall quality of evidence was very low and the risk of bias was high for the majority of trials for detection and performance bias.Among 13 trials reporting dichotomous implementation outcomes-the proportion of schools or school staff (e.g. classes) implementing a targeted policy or practice-the median unadjusted (improvement) effect sizes ranged from 8.5% to 66.6%. Of seven trials reporting the percentage of a practice, program or policy that had been implemented, the median unadjusted effect (improvement), relative to the control ranged from -8% to 43%. The effect, relative to control, reported in two trials assessing the impact of implementation strategies on the time per week teachers spent delivering targeted policies or practices ranged from 26.6 to 54.9 minutes per week. Among trials reporting other continuous implementation outcomes, findings were mixed. Four trials were conducted of strategies that sought to achieve implementation 'at scale', that is, across samples of at least 50 schools, of which improvements in implementation were reported in three trials.The impact of interventions on student health behaviour or weight status were mixed. Three of the eight trials with physical activity outcomes reported no significant improvements. Two trials reported reductions in tobacco use among intervention relative to control. Seven of nine trials reported no between-group differences on student overweight, obesity or adiposity. Positive improvements in child dietary intake were generally reported among trials reporting these outcomes. Three trials assessed the impact of implementation strategies on the attitudes of school staff and found mixed effects. Two trials specified in the study methods an assessment of potential unintended adverse effects, of which, they reported none. One trial reported implementation support did not significantly increase school revenue or expenses and another, conducted a formal economic evaluation, reporting the intervention to be cost-effective. Trial heterogeneity, and the lack of consistent terminology describing implementation strategies, were important limitations of the review.

AUTHORS' CONCLUSIONS

Given the very low quality of the available evidence, it is uncertain whether the strategies tested improve implementation of the targeted school-based policies or practices, student health behaviours, or the knowledge or attitudes of school staff. It is also uncertain if strategies to improve implementation are cost-effective or if they result in unintended adverse consequences. Further research is required to guide efforts to facilitate the translation of evidence into practice in this setting.

Cluster randomized controlled trial of a consumer behavior intervention to improve healthy food purchases from online canteens

Background: School canteens represent an opportune setting in which to deliver public health nutrition strategies because of their wide reach and frequent use by children. Online school-canteen ordering systems, where students order and pay for their lunch online, provide an avenue to improve healthy canteen purchases through the application of consumer-behavior strategies that have an impact on purchasing decisions.Objective: We assessed the efficacy of a consumer-behavior intervention implemented in an online school-canteen ordering system in reducing the energy, saturated fat, sugar, and sodium contents of primary student lunch orders.Design: A cluster-randomized controlled trial was conducted that involved 2714 students (aged 5-12 y) from 10 primary schools in New South Wales, Australia, who were currently using an online canteen ordering system. Schools were randomized in a 1:1 ratio to receive either the intervention (enhanced system) or the control (standard online ordering only). The intervention included consumer-behavior strategies that were integrated into the online ordering system (targeting menu labeling, healthy food availability, placement, and prompting).Results: Mean energy (difference: -567.25 kJ; 95% CI: -697.95, -436.55 kJ; P < 0.001), saturated fat (difference: -2.37 g; 95% CI: -3.08, -1.67 g; P < 0.001), and sodium (difference: -227.56 mg; 95% CI: -334.93, -120.19 mg; P < 0.001) contents per student lunch order were significantly lower in the intervention group than in the control group at follow-up. No significant differences were observed for sugar (difference: 1.16 g; 95% CI: -0.50, 2.83 g; P = 0.17).Conclusions: The study provides strong evidence supporting the effectiveness of a consumer-behavior intervention using an existing online canteen infrastructure to improve purchasing behavior from primary school canteens. Such an intervention may represent an appealing policy option as part of a broader government strategy to improve child public health nutrition. This trial was registered at www.anzctr.org.au as ACTRN12616000499482.

Systematic Review of Universal Resilience-Focused Interventions Targeting Child and Adolescent Mental Health in the School Setting

OBJECTIVE

To examine the effect of universal, school-based, resilience-focused interventions on mental health problems in children and adolescents.

METHOD

Eligible studies were randomized controlled trials (RCTs) of universal, school-based interventions that included strategies to strengthen a minimum of 3 internal resilience protective factors, and included an outcome measure of mental health problems in children and adolescents aged 5 to 18 years. Six databases were searched from 1995 to 2015. Results were pooled in meta-analyses by mental health outcome (anxiety symptoms, depressive symptoms, hyperactivity, conduct problems, internalizing problems, externalizing problems, and general psychological distress), for all trials (5-18 years). Subgroup analyses were conducted by age (child: 5-10 years; adolescent: 11-18 years), length of follow-up (short: post-≤12 months; long: >12 months), and gender (narrative).

RESULTS

A total of 57 included trials were identified from 5,984 records, with 49 contributing to meta-analyses. For all trials, resilience-focused interventions were effective relative to a control in reducing 4 of 7 outcomes: depressive symptoms, internalizing problems, externalizing problems, and general psychological distress. For child trials (meta-analyses for 6 outcomes), interventions were effective for anxiety symptoms and general psychological distress. For adolescent trials (meta-analyses for 5 outcomes), interventions were effective for internalizing problems. For short-term follow-up, interventions were effective for 2 of 7 outcomes: depressive symptoms and anxiety symptoms. For long-term follow-up (meta-analyses for 5 outcomes), interventions were effective for internalizing problems.

CONCLUSION

The findings may suggest most promise for using universal resilience-focused interventions at least for short-term reductions in depressive and anxiety symptoms for children and adolescents, particularly if a cognitive-behavioral therapy-based approach is used. The limited number of trials providing data amenable for meta-analysis for some outcomes and subgroups, the variability of interventions, study quality, and bias mean that it is not possible to draw more specific conclusions. Identifying what intervention qualities (such as number and type of protective factor) achieve the greatest positive effect per mental health problem outcome remains an important area for future research.

SYSTEMATIC REVIEW PROTOCOL AND REGISTRATION

Systematic Review of Universal Resilience Interventions Targeting Child and Adolescent Mental Health in the School Setting; http://dx.doi.org/10.1186/s13643-015-0172-6; PROSPERO CRD42015025908.

A randomised controlled trial of an online menu planning intervention to improve childcare service adherence to dietary guidelines: a study protocol

INTRODUCTION

The implementation of dietary guidelines in childcare settings is recommended to improve child public health nutrition. However, foods provided in childcare services are not consistent with guidelines. The primary aim of the trial is to assess the effectiveness of a web-based menu planning intervention in increasing the mean number of food groups on childcare service menus that comply with dietary guidelines regarding food provision to children in care.

METHODS AND ANALYSIS

A parallel group randomised controlled trial will be undertaken with 54 childcare services that provide food to children within New South Wales, Australia. Services will be randomised to a 12-month intervention or usual care. The experimental group will receive access to a web-based menu planning and decision support tool and online resources. To support uptake of the web program, services will be provided with training and follow-up support. The primary outcome will be the number of food groups, out of 6 (vegetables, fruit, breads and cereals, meat, dairy and 'discretionary'), on the menu that meet dietary guidelines (Caring for Children) across a 1-week menu at 12-month follow-up, assessed via menu review by dietitians or nutritionists blinded to group allocation. A nested evaluation of child dietary intake in care and child body mass index will be undertaken in up to 35 randomly selected childcare services and up to 420 children aged approximately 3-6 years.

ETHICS AND DISSEMINATION

Ethical approval has been provided by Hunter New England and University of Newcastle Human Research Ethics Committees. This research will provide high-quality evidence regarding the impact of a web-based menu planning intervention in facilitating the translation of dietary guidelines into childcare services. Trial findings will be disseminated widely through national and international peer-reviewed publications and conference presentations.

TRIAL REGISTRATION

Prospectively registered with Australian New Zealand Clinical Trial Registry (ANZCTR) ACTRN12616000974404.

Dietary intake and physical activity levels of children attending Australian childcare services

AIM

The primary aim of this study was to describe the dietary intake and physical activity levels of children while attending childcare.

METHODS

A cross-sectional study was conducted with 18 centre-based childcare services in the Hunter region of New South Wales, Australia. Childcare service characteristics were assessed via telephone interview. Child dietary intake and physical activity levels were assessed during a one-day observation conducted at participating childcare services using previously validated tools.

RESULTS

Children consumed a mean of 0.2 serves of vegetables, 0.7 serves of fruit, 1.4 serves of grain (cereal) foods, 0.1 serves of lean meat and poultry, fish, eggs, nuts and seeds and legumes/beans, 0.6 serves of milk, yoghurt, cheese and alternatives, and 0.7 serves of discretionary foods during attendance at childcare. Of all child physical activity counts, 48.6% were classified as 'sedentary', and 22.3% classified as 'very active'. Bivariate analyses indicated that children attending services located in rural areas consumed significantly more serves of vegetables (0.3 serves (SD 0.7) vs 0.1 serves (SD 0.2), P = 0.05). Multivariate analyses indicated that services with large child enrolments had a significantly greater proportion of child counts classified as 'very active' (23.6% of child counts (95% CI 1.6, 29.5) vs 14.9% of child counts (95% CI 9.1, 20.6), P = 0.007).

CONCLUSIONS

There is considerable scope to improve the diet and activity behaviours of children during attendance at childcare. Future research is needed to identify effective strategies to best support childcare services in implementing policies and practices to improve such behaviours in children.

Increasing the provision of preventive care by community healthcare services: a stepped wedge implementation trial

Background

Although clinical guidelines recommend the provision of care to reduce client chronic disease risk behaviours, such care is provided sub-optimally by primary healthcare providers. A study was undertaken to determine the effectiveness of an intervention in increasing community-based clinician implementation of multiple elements of recommended preventive care for four risk behaviours.

Methods

A three-group stepped-wedge trial was undertaken with all 56 community-based primary healthcare facilities in one health district in New South Wales, Australia. A 12-month implementation intervention was delivered sequentially in each of three geographically and administratively defined groups of facilities. The intervention consisted of six key strategies: leadership and consensus processes, enabling systems, educational meetings and training, audit and feedback, practice change support, and practice change information and resources. Client-reported receipt of three elements of preventive care: assessment; brief advice; referral for four behavioural risks: smoking, inadequate fruit and/or vegetable consumption, alcohol overconsumption, and physical inactivity, individually, and for all such risks combined were collected for 56 months (October 2009–May 2014). Segmented logistic regression models were developed to assess intervention effectiveness.

Results

A total of 5369 clients participated in data collection. Significant increases were found for receipt of four of five assessment outcomes (smoking OR 1.53; fruit and/or vegetable intake OR 2.18; alcohol consumption OR 1.69; all risks combined OR 1.78) and two of five brief advice outcomes (fruit and/or vegetable intake OR 2.05 and alcohol consumption OR 2.64). No significant increases in care delivery were observed for referral for any risk behaviour, or for physical inactivity.

Conclusions

The implementation intervention was effective in enhancing assessment of client risk status but less so for elements of care that could reduce client risk: provision of brief advice and referral. The intervention was ineffective in increasing care addressing physical inactivity. Further research is required to identify barriers to the provision of preventive care and the effectiveness of practice change interventions in increasing its provision.

Trial registration

Australian Clinical Trials Registry ACTRN12611001284954. Registered 15 December 2011. Retrospectively registered.

Effectiveness of a pragmatic school-based universal resilience intervention in reducing tobacco, alcohol and illicit substance use in a population of adolescents: cluster-randomised controlled trial

OBJECTIVES

Initiation of tobacco, alcohol and illicit substance use typically occurs during adolescence, with the school setting recommended to reduce adolescent substance use. Strengthening individual (eg, problem solving) and environmental (eg, caring relationships at school) resilience protective factors of adolescents has been suggested as a strategy for reducing substance use by adolescents; however, few studies have examined this potential. A study was conducted to investigate the effectiveness of a pragmatic school-based universal 'resilience' intervention in reducing the prevalence of tobacco, alcohol and illicit substance use, and increasing the individual and environmental protective factors of students.

DESIGN

A cluster-randomised controlled trial.

SETTING

Thirty-two Australian secondary schools (20 intervention; 12 control).

PARTICIPANTS

Cohort of grade 7 students followed-up in grade 10 (2014; aged 15-16 years).

INTERVENTION

A pragmatic intervention involving school staff selection and implementation of available programmes and resources targeting individual and environmental 'resilience' protective factors for all grade 7-10 students was implemented in schools (2012-2014). School staff were provided implementation support.

MEASUREMENTS

An online survey collected baseline and follow-up data for primary outcomes: tobacco (ever, recent) and alcohol (ever, recent, 'risk') use, and secondary outcomes: marijuana and other illicit substance use, and individual (six-factor subscales, aggregate) and environmental (three-factor subscales, aggregate) protective factor scores. Generalised and linear mixed models examined follow-up differences between groups.

RESULTS

Follow-up data from 2105 students (intervention=1261; control=844; 69% of baseline cohort) were analysed. No significant differences were found between intervention and control students for any primary (ever tobacco: OR 1.25, 95% CI 0.92 to 1.68, p=0.14; recent tobacco: OR 1.39, 95% CI 0.84 to 2.31, p=0.19; recent ever alcohol: OR 1.11, 95% CI 0.83 to 1.48, p=0.46; alcohol: OR 1.13, 95% CI 0.78 to 1.62, p=0.51; 'risk' alcohol: OR 0.98, 95% CI 0.70 to 1.36, p=0.89) or secondary outcomes (marijuana: OR 1.12, 95% CI 0.74 to 1.68, p=0.57; other illicit substance: OR 1.19, 95% CI 0.67 to 2.10, p=0.54; individual protective factors: MD=0, 95% CI -0.07 to 0.06, p=0.89; environmental protective factors: MD: -0.02, 95% CI -0.09 to 0.06, p=0.65).

CONCLUSIONS

The universally implemented pragmatic school-based intervention was not effective in reducing the prevalence of tobacco, alcohol or illicit substance use, or in increasing the protective factors of students.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Register reference: ACTRN12611000606987.