Maximising the impact of qualitative research in feasibility studies for randomised controlled trials: guidance for researchers

Women's and midwives' views on the optimum process for informed consent for research in a feasibility study involving an intrapartum intervention: a qualitative study

BACKGROUND

Recruitment to intrapartum research is complex. Women are expected to understand unfamiliar terminology and assess potential harm versus benefit to their baby and themselves, often when an urgent intervention is required. Time pressures of intrapartum interventions are a major challenge for recruitment discussions taking place during labour, with research midwives expected to present, discuss and answer questions whilst maintaining equipoise. However, little is known about these interactions. An integrated qualitative study (IQS) was used to investigate information provision for women invited to participate in the Assist II feasibility study investigating the OdonAssist™-a novel device for use in assisted vaginal birth with an aim to generate a framework of good practice for information provision.

METHODS

Transcripts of in-depth interviews with women participants (n = 25), with recruiting midwives (n = 6) and recruitment discussions between midwives and women (n = 21), accepting or declining participation, were coded and interpreted using thematic analysis and content analysis to investigate what was helpful to women and what could be improved.

RESULTS

Recruiting women to intrapartum research is complicated by factors that impact on women's understanding and decision-making. Three key themes were derived from the data: (i) a woman-centred recruitment process, (ii) optimising the recruitment discussion and (iii) making a decision for two.

CONCLUSION

Despite evidence from the literature that women would like information provision and the research discussion to take place in the antenatal period, intrapartum studies still vary in the recruitment processes they offer women. Particularly concerning is that some women are given information for the first time whilst in labour, when they are known to feel particularly vulnerable, and contextual factors may influence decision-making; therefore, we propose a framework for good practice for information provision for research involving interventions initiated in the intrapartum period as a woman centred, and acceptable model of recruitment, which addresses the concerns of women and midwives and facilitates fair inclusion into intrapartum trials.

TRIAL REGISTRATION

ISRCTN. This qualitative research was undertaken as part of the ASSIST II Trial (trial registration number: ISRCTN38829082. Prospectively registered on 26/06/2019).

Children's, parents', and teachers' experiences of the feasibility of a telerehabilitation intervention for children with acquired brain injury in the chronic phase - a qualitative study of acceptability and participation in the Child In Context Intervention (CICI)

BACKGROUND

This is a qualitative feasibility study of the Child in Context Intervention (CICI). The CICI is an individualized, goal-oriented and home-based tele-rehabilitation intervention which targets everyday functioning of children (6-16 years) with acquired brain injury in the chronic stage, and their families, one year or more after insult, who have ongoing challenges (physical, cognitive, behavioral, social and/or psychological). The aim of this study is to better understand how children, parents and teachers experienced participation and acceptability; to develop knowledge about the mechanisms of change, and to explore how the CICI was tailored to the context.

METHODS

Six families and schools participated in the intervention, which comprised seven tele-rehabilitation sessions in which the child and parent participated, one in-person parent seminar and four digital school meetings. A multidisciplinary team delivered the intervention to 23 participants over a 4- to 5-month period. The intervention involved psychoeducation about targeted acquired brain injury-related problems, such as fatigue, pain, or social challenges. All but one consented to participate in the current digital interview study. The data were analyzed using content analysis.

RESULTS

The experience of participation and acceptability varied among the children. Attendance was consistently high; the child participants felt mostly listened to and could influence goal setting and strategies. However, engaging and motivating the child participants proved somewhat challenging. The parents found the CICI rewarding, useful and relevant. However, they had different experiences regarding which intervention component they perceived as most helpful. Some argued in favor of the 'whole intervention', while others highlighted new knowledge, SMART goals or the school collaboration. The teachers found the intervention acceptable and useful but wanted a better meeting plan. They had difficulties in finding time for meetings, emphasized the involvement of school leaders, and appreciated the digital format.

CONCLUSIONS

Overall, the intervention was perceived as acceptable, and the participants felt that the various intervention components contributed to improvements. The CICI's flexibility facilitated tailoring to different contexts based on the children's functional level. The digital format saved time and provided flexibility regarding the amount of attendance but limited full participation from children with more severe cognitive impairments.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04186182.

Relax to Heal? Perspectives of Patients with Diabetic Foot Ulcers and Health Professionals on Relaxation Sessions for Wound Healing

OBJECTIVE

To explore patients' and healthcare professionals' (HPs') perspectives on the suitability/acceptability of a relaxation intervention, its effects on patients' well-being and diabetic foot ulcer (DFU) healing, and its incorporation into the multidisciplinary management of patients with diabetic foot.

METHODS

This qualitative study was nested within a three-arm pilot randomized controlled trial. Patients with a chronic DFU received four relaxation sessions. Investigators then interviewed patients, physicians, and nurses involved with diabetic foot consultations. Interviews were audio-recorded, transcribed, and analyzed using thematic content analysis.

RESULTS

Five themes emerged from patient's interviews about the suitability/acceptability of the relaxation intervention: perceptions regarding the psychological intervention, distress, the relaxation technique, changes in the patient's life, and changes in DFU/contribution to healing. Three themes emerged from interviews with HPs: perceptions regarding relaxation, changes in the patient, and changes in DFU/healing. Regarding the feasibility of the relaxation intervention, three themes emerged for both patients and HPs: suggested modifications, stressors/difficulties, and impact of COVID-19 pandemic. The utility theme emerged only in HP interviews, with subthemes of patients' distress, psychological interventions, relaxation intervention, and integration of the psychologist in the team.

CONCLUSIONS

These findings provide evidence for the suitability/acceptability, feasibility, and utility of a relaxation intervention in diabetic foot consultations.

The Feasibility and Acceptability of the Adverse Childhood Experiences Questionnaire in Danish Antenatal Care-A Qualitative Study of Midwives' Implementation Experiences

Adverse childhood experiences have a potential lifelong impact on health. A traumatic upbringing may increase antenatal health risks in mothers-to-be and impact child development in their offspring. Yet, little is known about the identification of adverse childhood experiences in antenatal care. The objective of this study was to explore the feasibility and acceptability of the adverse childhood experiences questionnaire among midwives and factors affecting its implementation. Three Danish maternity wards participated in the study. The data consisted of observations of midwifery visits and informal conversations with midwives, as well as mini group interviews and dialogue meetings with midwives. The data were analysed using systematic text condensation. Analysis of the data revealed three main categories; "Relevance of the adverse childhood experiences questionnaire", "Challenges related to use of the adverse childhood experiences questionnaire" and "Apprehensions, emotional strain, and professional support". The findings showed that the adverse childhood experiences questionnaire was feasible to implement in Danish antenatal care. Midwives' acceptability of the questionnaire was high. Training courses and dialogue meetings motivated the midwives to work with the questionnaire in practice. The main factors affecting the implementation process were time restrictions, worries of overstepping women's boundaries, and a lack of a specific intervention for women affected by their traumatic upbringing circumstances.

Is a dissonance-based group intervention targeting thin-ideal internalization a successful potential add-on for specialized eating disorder care? A randomized feasibility and acceptability pilot study

BACKGROUND

Dissonance-based eating disorder programs have successfully targeted body dissatisfaction by challenging the thin beauty ideal in the preventive context and in groups of patients with a subthreshold and full threshold DSM-5 eating disorder. As there is a need for interventions specifically targeting thin-ideal internalization in (highly) specialized treatment centres, the present study adapted Stice's et al.'s Body Project for its use as an add-on treatment for severe eating disorders with the aims to identify whether it was feasible and acceptable in this treatment context, to determine any necessary modifications with regard to the treatment and study procedures, and to test preliminary effectiveness.

METHODS

The study was a randomized controlled pilot/feasibility trial. Thirty patients started in the Body Project group and 25 in the Psycho-education group. Measurements took place pre- and post-intervention, and at three and six months follow-up. Patients and staff evaluated treatment and study procedures, and patients completed questionnaires on thin-ideal internalization, body dissatisfaction, self-objectification, negative affect and eating disorder pathology.

RESULTS

The Body Project group and Psycho-education group both proved highly feasible and acceptable, as well as preliminarily effective, based on quantitative scores and qualitative feedback. Preliminary analyses showed that treatment effects did not differ between treatment groups. As both groups were an add-on to standard treatment, treatment effects cannot be disentangled from effects resulting from standard treatment. Qualitative feedback for the Body Project group included several recommendations for future implementation: increasing the number of treatment sessions, creating homogeneous therapy groups, and optimizing timing of the treatment.

CONCLUSIONS

Future research should examine further modifications to the Body Project group for severe eating disorders, as well as for whom, and when in the course of treatment the intervention is most effective. The present study also showed the benefits of implementing a structured Psycho-education group. We tested the feasibility and acceptability of a group intervention targeting the thin beauty ideal (Body Project group) in patients with severe eating disorders and compared this intervention to a group intervention focusing on psycho-education about eating disorders (Psycho-education group). Both interventions were added to standard treatment. We adapted the protocol for patients with severe eating disorders. Both the Body Project group and the Psycho-education group were evaluated by patients as well as staff as highly feasible and acceptable, and effects were positive. Treatment effects did not differ between treatment groups. As both treatments were an add-on to standard treatment, treatment effects cannot be disentangled from effects resulting from standard treatment. The study suggested further modifications to the Body Project group. Future research should examine these modifications as well as for whom, and when in the course of treatment the intervention is most effective. The present study also showed the benefits of implementing a structured Psycho-education group.

The MATE trial: a multicentre, mixed-methodology, pilot, randomised controlled trial in neovascular age-related macular degeneration

BACKGROUND/OBJECTIVES

In healthcare research investigating complex interventions, gaps in understanding of processes can be filled by using qualitative methods alongside a quantitative approach. The aim of this mixed-methods pilot trial was to provide feasibility evidence comparing two treatment regimens for neovascular age-related macular degeneration (nAMD) to inform a future large-scale randomised controlled trial (RCT).

SUBJECTS/METHODS

Forty-four treatment-naïve nAMD patients were followed over 24 months and randomised to one of two treatment regimens: standard care (SC) or treat and extend (T&E). The primary objective evaluated feasibility of the MATE trial via evaluations of screening logs for recruitment rates, nonparticipation and screen fails, whilst qualitative in-depth interviews with key study staff evaluated the recruitment phase and running of the trial. The secondary objective assessed changes in visual acuity and central retinal thickness (CRT) between the two treatment arms.

RESULTS

The overall recruitment rate was 3.07 participants per month with a 40.8% non-participation rate, 18.51% screen-failure rate and 15% withdrawal/non-completion rate. Key themes in the recruitment phase included human factors, protocol-related issues, recruitment processes and challenges. Both treatment regimens showed a trend towards a visual acuity gain at month 12 which was not maintained at month 24, whilst CRT reduced similarly in both regimens over the same time period. These were achieved with one less treatment following a T&E regimen.

CONCLUSION

This mixed-methodology, pilot RCT achieved its pre-defined recruitment, nonparticipation and screen failure rates, thus deeming it a success. With some minor protocol amendments, progression to a large-scale RCT will be achievable.

Recommendations for progression criteria during external randomised pilot trial design, conduct, analysis and reporting

BACKGROUND

External randomised pilot trials aim to assess whether a future definitive Randomised Controlled Trial (RCT) is feasible. Prespecified progression criteria help guide the interpretation of pilot trial findings to decide whether, and how, a definitive RCT should be conducted. This commentary presents a set of proposed recommendations for progression criteria to guide researchers when (i) designing, (ii) conducting, (iii) analysing and (iv) reporting external randomised pilot trials.

METHODS

Recommendations were developed following a mixed methods approach. This involved (i) a methodological review of pilot trial publications, (ii) a cross-sectional study of pilot trial research funding applications, (iii) qualitative interviews with pilot trial researchers and (iv) a survey of corresponding authors of identified pilot trial publications. Initial recommendations were refined following two consultation stakeholder workshops held in July 2022. Recommendations for progression criteria for external randomised pilot trials: i.

DESIGN

consider progression criteria from the earliest opportunity; map progression criteria to feasibility objectives; consider quantitative and qualitative interpretations of feasibility; provide justification; develop guidelines rather than rules; seek input from relevant stakeholders. ii. Conduct: regularly monitor pilot trial data against progression criteria. iii.

ANALYSIS

avoid considering each progression criterion in isolation; engage in discussion with relevant stakeholders; consider context and other factors external to the pilot trial; consider feasibility (can we?) and progression (will we?). iv. Reporting: we propose a reporting checklist in relation to progression criteria and recommend reporting in a table format for clarity.

CONCLUSION

These recommendations provide a helpful resource for researchers to consider progression criteria at different stages of external randomised pilot trials. We have produced a simple infographic tool to summarise these recommendations for researchers to refer to. Further research is needed to evaluate whether these proposed recommendations should inform future development, or update, of established guidelines for the design, conduct, analysis and reporting of external randomised pilot trials.

"I've got a spring in my step" participants experience of action observation therapy and eccentric exercises, a telehealth study for mid-portion Achilles Tendinopathy: a qualitative study

BACKGROUND

Quantitative research has dominated the field of Achilles Tendinopathy. The use of qualitative research allows in-depth exploration of participants' perspectives, offering great insight in the evaluation of a trial's processes, particularly when exploring a novel intervention such as Action Observation Therapy combined with eccentric exercises which has not been previously researched. This study aimed to qualitatively explore participants' experiences of partaking in a telehealth study including the acceptability of the intervention, motivators for participation, and perspectives on the trial processes.

METHOD

A thematic analysis as guided by Braun and Clarke was used to analyse the semi-structured interviews conducted on a purposive sample of participants with mid-portion Achilles Tendinopathy who recently completed a pilot feasibility study. The study adhered to the criteria for reporting qualitative research guidelines (COREQ).

RESULTS/DISCUSSION

Sixteen participants were interviewed. The five themes identified were: (i) The impact of Achilles Tendinopathy is commonly not prioritised with 'The acceptance and minimisation of pain' as a sub-theme (ii) Therapeutic alliance has the greatest impact on support (iii) Factors which influenced adherence (iv) Action Observation Therapy is valued and recommended (v) Recommendations for future interventions.

CONCLUSION

This study provides insightful recommendations around; exploring the use of Action Observation Therapy in Achilles Tendinopathy, the relative importance of therapeutic alliance rather than mode of therapy delivery, and that sufferers of Achilles Tendinopathy may not prioritise health seeking for this condition.

Considerations When Designing and Implementing Pragmatic Clinical Trials That Include Older Hispanics

Introduction

Pragmatic clinical trials (PCTs) are designed to connect researchers with clinicians to assess the real-world effectiveness and feasibility of interventions, treatments, or health care delivery strategies in routine practice. Within PCTs larger, more representative sampling is possible to improve the external validity of the research. Older adults from underrepresented groups can benefit from PCTs given their historically lower engagement in clinical research. The current article focuses on older Hispanic adults with Alzheimer disease and related dementias (ADRDs). Older Hispanic adults represent 19% of the US population and have a higher prevalence of ADRDs than Whites. We provide data from 2 PCTs about the recruitment of older Hispanics with ADRDs and discuss unique challenges associated with conducting PCTs and propose strategies to overcome challenges.

Data and Methods

The first PCT outlined is the Patient Priorities Care for Hispanics with Dementia (PPC-HD) trial. PPC-HD is testing the feasibility of implementing a culturally adapted version of the Patient Priorities Care approach for older Hispanic adults with multiple chronic conditions and dementia. The second PCT is the Dementia Care (D-CARE) Study, which is a multisite pragmatic study comparing the effectiveness of a health care system-based approach and a community-based approach to dementia care to usual care in patients with ADRDs and their family caregivers.

Lessons Learned and Recommendations for Future Studies

The lessons learned are summarized according to the various stakeholders that need to work together to effectively recruit diverse participants for PCTs: individuals, health care systems, research teams, and communities. Individual-level considerations include communication, priorities, and flexibility. Health care system-level considerations are grounded in 4 principles of Community-Based Participatory Research and include collaboration/partnership, available resources, priorities of the health care system, and sustainability. Research team-level considerations include team members, intentionality, and communication. Community-level considerations highlight the importance of partnerships, community members, and appropriate incentives.

Discussion

PCTs provide a unique and potentially impactful opportunity to test interventions in real-world settings that must be culturally appropriate to reach underrepresented groups. Collectively, considering variables at multiple levels to address the needs of older adults with ADRDs is crucial, and the examples and suggestions provided in this report are a foundation for future research.

Feasibility of a theoretically grounded, multicomponent, physiotherapy intervention aiming to promote autonomous motivation to adopt and maintain physical activity in patients with lower-limb osteoarthritis: protocol for a single-arm trial

BACKGROUND

Lower-limb osteoarthritis (OA) causes high levels of pain and disability in adults over 45 years of age. Adopting and maintaining appropriate levels of physical activity (PA) can help patients with lower-limb OA self-manage their symptoms and reduce the likelihood of developing secondary noncommunicable diseases. However, patients with lower-limb OA are less active than people without musculoskeletal pain. This single-arm feasibility trial seeks to determine the feasibility and acceptability of a complex multicomponent physiotherapy behaviour change intervention that aims to aid patients with lower-limb OA to adopt and maintain optimal levels of PA.

METHODS

This trial will be conducted at one site in a National Health Service physiotherapy outpatient setting in the West Midlands of England. Up to thirty-five participants with lower-limb OA will be recruited to receive a physiotherapy intervention of six sessions that aims to optimise their PA levels during phases of behavioural change: adoption, routine formation and maintenance. The intervention is underpinned by self-determination theory (and other motivational frameworks) and seeks to foster a motivationally optimal (empowering) treatment environment and implement behaviour change techniques (BCTs) that target PA behaviours across the three phases of the intervention. Physiotherapists (n = 5-6) will receive training in the why and how of developing a more empowering motivational environment and the delivery of the intervention BCTs. Participants will complete patient-reported and performance-based outcome measures at baseline and 3-month (to reflect behavioural adoption) and 6-month (maintenance) post-baseline. Feasibility and acceptability will be primarily assessed through semi-structured interviews (purposively recruiting participants) and focus groups (inviting all physiotherapists and research staff). Further evaluation will include descriptive analysis of recruitment rates, loss of follow-up and intervention fidelity.

DISCUSSION

A novel complex, multicomponent theoretical physiotherapy behaviour change intervention that aims to create a more empowering motivational treatment environment to assist patients with lower-limb OA to adopt and maintain optimal PA levels has been developed. Testing the feasibility and acceptability of the intervention and its associated physiotherapist training and related trial procedures is required to determine whether a full-scale parallel group (1:1) randomised controlled trial to evaluate the interventions effectiveness in clinical practice is indicated.

TRIAL REGISTRATION

Trial register: International Standard Randomised Controlled Trial identification number: ISRCTN12002764 . Date of registration: 15 February 2022.

Serial prophylactic exchange blood transfusion in pregnant women with sickle cell disease (TAPS-2): statistical and qualitative analysis plan for a randomised controlled feasibility trial

BACKGROUND

There are significant knowledge gaps regarding the effectiveness of serial prophylactic exchange blood transfusion (SPEBT) for pregnant women with sickle cell disease (SCD). The protocol for the randomised feasibility trial assessing SPEBT versus usual care in women with SCD (TAPS2 trial) has previously been published. This publication outlines the statistical and qualitative analysis plan for the study.

METHODS AND DESIGN

TAPS2 is a randomised two-arm phase 2 feasibility trial with a nested qualitative study and health economic evaluation. Up to 50 pregnant women with SCD and a singleton pregnancy will be recruited and individually randomised to either SPEBT approximately every 6-10 weeks until delivery (intervention arm) or to usual care (control arm). Information will be collected on a range of feasibility and clinical outcomes.

RESULTS

Due to the impact of COVID-19 on study recruitment, the initial study period of 24 months was extended to 48 months. Other protocol updates designed to mitigate the impact of COVID-19-related disruption included allowing for remote consent and conducting all qualitative interviews by telephone. The primary outcome for the trial is the overall recruitment rate. The number of women screened, eligible, consented, randomised and withdrawn will be summarised as a CONSORT flow diagram. Differences in clinical outcomes will additionally be presented as an initial assessment of efficacy and to inform sample size calculations for a future definitive trial. Qualitative interviews with trial participants and clinicians will be analysed using reflexive thematic analysis; data from interviews with participants who declined to participate in the trial will be extracted and incorporated into summary tables to report key findings. The health economic analysis plan is not covered by this update.

CONCLUSION

The publication of this analysis plan is designed to aid transparency and to reduce the potential for reporting bias.

TRIAL REGISTRATION

NIH registry ( www.

CLINICALTRIALS

gov ), registration number NCT03975894 (registered 05/06/19); ISRCTN ( www.isrctn.com ), registration number ISRCTN52684446 (retrospectively registered 02/08/19).

Phase III, two arm, multi-centre, open label, parallel-group randomised designed clinical investigation of the use of a personalised early warning decision support system to predict and prevent acute exacerbations of chronic obstructive pulmonary disease: 'Predict & Prevent AECOPD' - study protocol

INTRODUCTION

With 65 million cases globally, chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death and imposes a heavy burden on patients' lives and healthcare resources worldwide. Around half of all patients with COPD have frequent (≥2 per year) acute exacerbations of COPD (AECOPD). Rapid readmissions are also common. Exacerbations impact significantly on COPD outcomes, causing significant lung function decline. Prompt exacerbation management optimises recovery and delays the time to the next acute episode.

METHODS/ANALYSIS

The Predict & Prevent AECOPD trial is a phase III, two arm, multi-centre, open label, parallel-group individually randomised clinical trial investigating the use of a personalised early warning decision support system (COPDPredict) to predict and prevent AECOPD. We aim to recruit 384 participants and randomise each individual in a 1:1 ratio to either standard self-management plans with rescue medication (RM) (control arm) or COPDPredict with RM (intervention arm).The trial will inform the future standard of care regarding management of exacerbations in COPD patients. The main outcome measure is to provide further validation, as compared with usual care, for the clinical effectiveness of COPDPredict to help guide and support COPD patients and their respective clinical teams in identifying exacerbations early, with an aim to reduce the total number of AECOPD-induced hospital admissions in the 12 months following each patient's randomisation.

ETHICS AND DISSEMINATION

This study protocol is reported in accordance with the guidance set out in the Standard Protocol Items: Recommendations for Interventional Trials statement. Predict & Prevent AECOPD has obtained ethical approval in England (19/LO/1939). On completion of the trial and publication of results a lay findings summary will be disseminated to trial participants.

TRIAL REGISTRATION NUMBER

NCT04136418.

S110-Opioid-free analgesia after outpatient general surgery: A qualitative study focused on the perspectives of patients and clinicians involved in a pilot trial

BACKGROUND

Opioid-free analgesia (OFA) may mitigate opioid-related harms after outpatient general surgery; however, the comparative effectiveness of this approach should be assessed in robust randomized controlled trials (RCTs). Undertaking an RCT on OFA raises important practical concerns, including surgeon and patient hesitation regarding pain management without opioids. We conducted a qualitative study to explore patients' and clinicians' perspectives and experiences with a pilot trial focused on OFA after outpatient general surgery.

METHODS

Patients undergoing outpatient abdominal and breast procedures were randomized to receive post-discharge opioid analgesia (OA) or OFA. Semi-structured interviews with patients and clinicians involved in the trial were conducted to elicit personal perspectives and experiences. Purposive sampling for maximum variation was used to recruit participants with diverse characteristics. Transcribed interviews were assessed using inductive thematic analysis.

RESULTS

Ten patients (5 abdominal, 5 breast) and 10 clinicians (6 surgeons, 2 anesthesiologists, 2 nurses) were interviewed. Five major themes emerged: readiness for trial engagement, pre-trial thoughts about the interventions, postoperative pain experiences, intervention acceptability, and trial refinement. Most patients were open to OFA. Clinicians expressed willingness to prescribe OFA, particularly after less invasive procedures and when using peripheral nerve blocks (PNBs). Concerns were raised regarding the adequacy of pain control and side effects of non-opioid drugs (e.g., NSAID-induced bleeding, kidney injury). Overall, participants were enthusiastic about the trial and recognized its relevance; clinicians praised the study design and organization; and patients valued the use of electronic questionnaires. Suggestions for improvements included preventing potential bias arising from the use of PNBs (i.e., via standardization or stratification) and reducing patient burden (i.e., decreasing postoperative questionnaires).

CONCLUSION

Patients and clinicians who participated in a pilot RCT generally accept the clinical equipoise between OA versus OFA after outpatient general surgery and recognize the need for methodologically robust trials to inform evidence-based analgesia prescribing.

Feasibility of a remotely supervised home-based group eHealth Fitness and Mobility Exercise program for stroke: French-Canadian version preliminary study

BACKGROUND

The numerous barriers to community-based physical activity programs have been exacerbated by the COVID-19 pandemic, especially among individuals with disabilities. eHealth programs may provide an alternative approach to address the physical activity needs of stroke survivors, but little is known about their feasibility or acceptance.

OBJECTIVE

The aims of this study were to 1) evaluate the feasibility of a remotely supervised home-based group eHealth program called Fitness and Mobility Exercise (FAME@home); 2) explore the influence of FAME@home on physical condition, mobility, self-efficacy, depression and anxiety; and 3) describe participants' satisfaction and experiences.

METHODS

A pre-post pilot study was used to recruit stroke survivors (>1 y post stroke) to complete a 12-week (2 days/week) eHealth program in small groups (n = 3). Feasibility indicators were assessed for process (e.g. inclusion criteria), resources (e.g. ability to use technology), management (e.g. major challenges), and treatment (e.g. influence on clinical outcomes and adverse events).

RESULTS

Nine participants were recruited with a mean (SD) of 60 (13) years of age and 7 (4) years post-stroke; eight completed the program. FAME@home was feasible for indicators of process, management, and treatment. Minor considerations to improve resources were suggested (i.e. support for technology use). There were statistically significant improvements in mobility after completion of FAME@home and 100% of the participants reported satisfaction. No adverse events occurred.

CONCLUSION

FAME@home was feasible to deliver as a remotely supervised group exercise program to community-dwelling stroke survivors, with high levels of retention and adherence. FAME@home improved accessibility to exercise and facilitated engagement by having a class schedule and social interaction.

A qualitative process evaluation of universal free school meal provision in two London secondary schools

BACKGROUND

In the UK, one in five households with children experienced food insecurity in 2022, defined as a household-level economic and social condition of limited or uncertain access to adequate food. Free school meals are a public health intervention aimed at reducing food insecurity amongst children. The provision of universal free school meals (UFSM) to secondary school-aged children is a novel and untested intervention in the UK. This study is a process evaluation of a pilot of UFSM in two secondary schools in England. The aim was to understand the feasibility, acceptability, cost implications and lessons for the implementation of UFSM.

METHODS

20 parents, 28 students and 8 school staff from two intervention schools participated in online qualitative interviews, as well as 4 staff from non-intervention schools. The Framework Method of thematic analysis was applied. These data were supplemented with student-led observations of school meal times, and school lunch uptake-data and cost information provided by the local authority delivering the pilot.

RESULTS

UFSM in secondary schools is a feasible and acceptable intervention, with coherent goals of increased access to a healthy meal, reduced food insecurity and better nutrition. All participants perceived these goals were met. Acceptability was further enhanced by the perception that UFSM were supporting a greater proportion of low-income families than the national, targeted Free School Meal scheme, as well as being easier to implement. Potential barriers to implementation include limited school kitchen and dining infrastructure, meal quality and choice, and increased queuing times. Participants' concerns that UFSM may benefit middle- and high- income families not in need were not as prevalent as the perception that UFSM was an effective way to support all families with secondary-aged children experiencing food insecurity.

CONCLUSION

This small-scale pilot study suggests that UFSM in secondary schools is feasible and acceptable, but more evidence is required from larger studies on the impact on long-term health, psychosocial and educational outcomes. Future, larger studies should also include detailed economic evaluations so this approach can be compared with other possible interventions.

Clinical pharmacists' intervention on pain management in cancer patients (PharmaCAP trial): study protocol for a randomized controlled trial

INTRODUCTION

Evidence-based services to support cancer patients with pain via clinical pharmacy services are currently lacking. Therefore, there is a need to undertake a randomized controlled trial (RCT) to explore the effectiveness of clinical pharmacists (CPs)' input into the multidisciplinary team (MDT) in providing better therapeutic outcomes for cancer pain management.

OBJECTIVES

The main aim of this pilot RCT is to determine the feasibility and preliminary efficacy of integrating CPs into the MDT for cancer pain management on the clinical outcomes of cancer patients experiencing pain.

METHODS

This study protocol outlines two-armed multicenter pilot RCT. Cancer patients suffering from pain will be randomly allocated to receive either clinical pharmacy services, i.e., PharmaCAP trial intervention from the CP, or the usual standard care (i.e., control group). Patients will be recruited consecutively from two hospitals in Kathmandu valley, Nepal. The outcomes will be assessed at baseline (pre-intervention) and 4 weeks post-intervention. The primary feasibility outcomes will include eligibility rate, recruitment rate, willingness to participate, acceptability of screening procedures and random allocation, possible contamination between the groups, intervention fidelity and compliance, treatment satisfaction, and patient understanding of the provided interventions. Subsequently, the primary clinical outcome, i.e., pain intensity of cancer patients, will be assessed. The secondary clinical outcomes will include health-related quality of life (HRQoL), anxiety, depression, adverse drug reactions, and patient medication compliance following the integration of CP into the healthcare team.

DISCUSSION

The feasibility and potential for integrating CP involvement in MDT to improve clinical outcomes of cancer patients with pain will be evaluated through the PharmaCAP trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05021393. Registered on 25th August 2022.

A continuity of care programme for women at risk of preterm birth in the UK: Process evaluation of a hybrid randomised controlled pilot trial

BACKGROUND

The development and evaluation of specific maternity care packages designed to address preterm birth remains a public health priority. We aim to evaluate the implementation, context, and potential mechanisms of action, of a new care pathway that combined midwifery continuity of care with a specialist obstetric clinic for women at risk of preterm birth (POPPIE) in London (UK).

METHODS

We did a multiphase mixed method triangulation evaluation nested within a hybrid type 2, randomised controlled trial in London (United Kingdom). Pregnant women with identified risk factors for preterm birth were eligible for trial participation and randomly assigned (1:1) to either midwifery continuity of care linked to a specialist obstetric clinic (POPPIE group) or standard maternity care. The primary outcome was a composite of appropriate and timely interventions for the prevention and/or management of preterm labour and birth, analysed according to intention to treat. Clinical and process outcome data were abstracted from medical records and electronic data systems, and coded by study team members, who were masked to study group allocation. Implementation data were collected from meeting records and key documents, postnatal surveys (n = 164), semi-structured interviews with women (n = 30), healthcare providers and stakeholders (n = 24) pre-, mid and post implementation. Qualitative and quantitative data from meeting records and key documents were examined narratively. Qualitative data from interviews were analysed using three thematic frameworks: Proctor's (for implementation outcomes: appropriateness, adoption, feasibility, acceptability, fidelity, penetration, sustainability), the Consolidated Framework for Implementation Research (for determinants of implementation), and published program theories of continuity models (for potential mechanisms). Data triangulation followed a convergent parallel and pragmatic approach which brought quantitative and qualitative data together at the interpretation stage. We averaged individual implementation measures across all domains to give a single composite implementation strength score which was compared to the primary outcome.

RESULTS

Between May 9, 2017, and Sep 30, 2018, 553 women were assessed for eligibility and 334 were enrolled with less than 6% of loss to follow up (169 were assigned to the POPPIE group; 165 were to the standard group). There was no difference in the primary outcome (POPPIE group 83·3% versus standard group 84·7%; risk ratio 0·98 [95% CI 0·90 to 1·08]). Appropriateness and adoption: The introduction of the POPPIE model was perceived as a positive fundamental change for local maternity services. Partnership working and additional funding were crucial for adoption. Fidelity: More than 75% of antenatal and postnatal visits were provided by a named or partner midwife, and a POPPIE midwife was present in more than 80% of births. Acceptability: Nearly 98% of women who responded to the postnatal survey were very satisfied with POPPIE model. Quantitative fidelity and acceptability results were supported by the qualitative findings. Penetration and sustainability: Despite delays (likely associated with lack of existing continuity models at the hospital), the model was embedded within established services and a joint decision was made to sustain and adapt the model after the trial (strongly facilitated by national maternal policy on continuity pathways). Potential mechanisms of impact identified included e.g. access to care, advocacy and perceptions of safety and trust. There was no association between implementation measures and the primary outcome.

CONCLUSIONS

The POPPIE model of care was a feasible and acceptable model of care that was implemented with high fidelity and sustained in maternity services. Larger powered trials are feasible and needed in other settings, to evaluate the impact and implementation of continuity programmes in other communities affected by preterm birth and women who experience social disadvantage and vulnerability.

TRIAL REGISTRATION

UKCRN Portfolio Database (prospectively registered, 24 April 2017): 31951. ISRCTN registry (retrospectively registered, 21 August 2017): ISRCTN37733900.

A pilot, randomized, feasibility study to improve health self-management behaviors in older adults with multiple chronic conditions and functional limitations: Protocol for the Behavioral Activation and Occupational Therapy Trial (BA+OT)

Background

Approximately 45% of older adults in the U.S. have 2 or more chronic health conditions (e.g., arthritis, hypertension, diabetes) in addition to functional limitations that prevent performance of health self-management activities. Self-management continues to be the gold standard for managing MCC, but functional limitations create difficulty with these activities (e.g., physical activity, symptom monitoring). Restricted self-management accelerates the downward spiral of disability and accumulating chronic conditions which, in turn, increases rates of institutionalization and death by 5-fold. Currently, there are no tested interventions designed to improve independence in health self-management activities in older adults with MCC and functional limitations. Research suggests that older adults are more likely to change behavior with interventions that assist with planning health-promoting daily activities, especially when contending with complex medical regimens and functional limitations. Our team asserts that combining occupational therapy (OT) and behavioral activation (BA) shows promise to improve health self-management in populations with chronic conditions and/or functional limitations. This innovative combination uses the goal setting, scheduling/monitoring activities, and problem-solving components of the BA approach as well as the environmental modification, activity adaptation, and focus on daily routines from OT practice.

Objectives

We will test the effect of this combined approach in a Stage I, randomized controlled pilot feasibility study compared to enhanced usual care. We will recruit 40 older adults with MCC and functional limitation and randomize 20 to the PI- delivered BA-OT protocol. This research will inform modification and larger-scale testing of this novel intervention.

Exploring right ventricular function applicability in a prediction model to identify preterm infants with early bronchopulmonary dysplasia (REPORT-BPD study): a mixed-methods observational cohort feasibility study protocol

BACKGROUND

Bronchopulmonary dysplasia (BPD) is a chronic disease that affects the immature lungs of preterm infants. Infants born before 32 weeks of gestation are at a greater risk of developing BPD due to the need for respiratory support with higher oxygen requirement. Pulmonary vascular remodelling in early BPD can impose an additional burden on the right ventricle (RV) and RV dysfunction. This protocol outlines the study design and aims to formulate a prediction model to identify early BPD through the data generated from echo scans analysis.

METHODS

The mixed-methods observational cohort feasibility study, which comprises three work-packages (WPs), will be conducted at the regional neonatal unit, University Hospital Plymouth, Plymouth, UK. WP-I will recruit 40 preterm infants; each participant will have two heart scans performed in the first ten days after birth (DABs). WP-II will collect the documentation of the participating preterm infants' parents in the study neonatal unit diaries in the first 10 DABs. WP-III will involve semi-structured interviews of 10-15 parents of participating preterm infants and 10-15 health professionals who participated in WP-I. The study recruitment will be conducted over 18-months. The start date is 01 June 2022. WP-I and WP-II recruitment will occur during this period, while WP-III recruitment will occur during the second half. The results are expected to be submitted for publication by mid-2024.

DISCUSSION

This paper outlines the study design. If the study successfully identifies the most sensitive echo parameter in recognising the RV dysfunction associated with early BPD, it will be an important finding in constructing an early BPD prediction model.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier is NCT05235399.

Feasibility evaluation of psychosocial intervention for internally displaced youth in Kenya

BACKGROUND

There is limited evidence on the cultural appropriateness of first-stage psychosocial interventions for youth with mental health problems who experience conflict and disadvantage in low- and middle-income countries (LMIC).

AIMS

To evaluate the feasibility of such an intervention (Writing for Recovery - WfR) among youth with emerging emotional problems following internal displacement in Kenya.

METHOD

Fifty-four youth aged 14-17 years were randomly allocated to a six-session intervention or a waiting list control group. They completed measures of stressful life events; post-traumatic stress, depressive and anxiety symptoms; quality of life; and free text on their experience of the intervention.

RESULTS

Young participants reported high levels of trauma exposure and emotional problems. The intervention was perceived as flexible and culturally acceptable, with reported short-term impact. This was found to have promising post-intervention effect in reducing post-traumatic stress, but not depressive or anxiety symptoms; and in enhancing quality of life scores.

CONCLUSIONS

Similar psychosocial interventions that can be delivered by paraprofessionals are important for resource-constrained LMIC settings, but need to be integrated within a comprehensive scaled service model.

Barriers and facilitators to cervical cancer screening among under-screened women in Cuenca, Ecuador: the perspectives of women and health professionals

Background

Cervical cancer screening is a cost-effective method responsible for reducing cervical cancer-related mortality by 70% in countries that have achieved high coverage through nationwide screening strategies. However, there are disparities in access to screening. In Ecuador, although cervical cancer is the second most common cancer in women, only 58.4% of women of reproductive age have ever been screened for cervical cancer.

Methodology

A qualitative study was performed to understand the current barriers to screening and to identify strategies that could increase uptake in Azuay province, Ecuador. Seven focus group discussions (FGDs) were conducted with under-screened women and health professionals (HPs). The FGDs were recorded and transcribed. Content analysis was done using the socio-ecological framework to categorize and analyse the data.

Results

Overall, 28 women and 27 HPs participated in the study. The two groups perceived different barriers to cervical cancer screening. The HPs considered barriers to be mainly at the policy level (lack of a structured screening plan; lack of health promotion) and the individual level (lack of risk perception; personal beliefs). The women identified barriers mainly at organizational level, such as long waiting times, lack of access to health centres, and inadequate patient–physician communication. Both groups mentioned facilitators at policy level, such as national campaigns promoting cervical cancer screening, and at community and individual level, including health literacy and women’s empowerment.

Conclusions

The women considered access to health services the main barrier to screening, while the HPs identified a lack of investment in screening programmes and cultural patterns at the community level as major obstacles. To take an integrated approach to cervical cancer prevention, the perspectives of both groups should be taken into account. Additionally, new strategies and technologies, such as self-administered human papillomavirus (HPV) testing and community participation, should be implemented to increase access to cervical cancer screening.

A mixed-methods feasibility study of a new digital health support package for people after stroke: the Recovery-focused Community support to Avoid readmissions and improve Participation after Stroke (ReCAPS) intervention

BACKGROUND

Evidence for digital health programmes to support people living with stroke is growing. We assessed the feasibility of a protocol and procedures for the Recovery-focused Community support to Avoid readmissions and improve Participation after Stroke (ReCAPS) trial.

METHODS

We conducted a mixed-method feasibility study. Participants with acute stroke were recruited from three hospitals (Melbourne, Australia). Eligibility: Adults with stroke discharged from hospital to home within 10 days, modified Rankin Score 0-4 and prior use of Short Message System (SMS)/email. While in hospital, recruited participants contributed to structured person-centred goal setting and completed baseline surveys including self-management skills and health-related quality of life. Participants were randomised 7-14 days after discharge via REDCap® (1:1 allocation). Following randomisation, the intervention group received a 12-week programme of personalised electronic support messages (average 66 messages sent by SMS or email) aligned with their goals. The control group received six electronic administrative messages. Feasibility outcomes included the following: number of patients screened and recruited, study retainment, completion of outcome measures and acceptability of the ReCAPS intervention and trial procedures (e.g. participant satisfaction survey, clinician interviews). Protocol fidelity outcomes included number of goals developed (and quality), electronic messages delivered, stop messages received and engagement with messages. We undertook inductive thematic analysis of interview/open-text survey data and descriptive analysis of closed survey questions.

RESULTS

Between November 2018 and October 2019, 312 patients were screened; 37/105 (35%) eligible patients provided consent (mean age 61 years; 32% female); 33 were randomised (17 to intervention). Overall, 29 (88%) participants completed the12-week outcome assessments with 12 (41%) completed assessments in the allocated timeframe and 16 also completing the satisfaction survey (intervention=10). Overall, trial participants felt that the study was worthwhile and most would recommend it to others. Six clinicians participated in one of three focus group interviews; while they reported that the trial and the process of goal setting were acceptable, they raised concerns regarding the additional time required to personalise goals.

CONCLUSION

The study protocol and procedures were feasible with acceptable retention of participants. Consent and goal personalisation procedures should be centralised for the phase III trial to reduce the burden on hospital clinicians.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12618001468213 (date 31/08/2018); Universal Trial Number: U1111-1206-7237.

Modeling and analysis of barriers to ethics in online assessment by TISM and fuzzy MICMAC analysis

The pandemic of COVID-19 has altered the world canvas forever. The education sector, too, has been impacted by the same. There has been a phenomenal rise in e-platforms for teaching, learning, and evaluation. Teachers and students had to train themselves overnight to embrace the changing dynamics of the education sector. The change has been marked with challenges. In this new education landscape, online exams have occupied center stage. While the idea of giving exams from any part of the world welcomes freedom, it also raises concerns among faculty and students about academic integrity. Thus, as online studies and online assessment continue to expand, the paper aims to identify the factors responsible for unethical practices in online assessment. The paper further identifies the association between the identified factors. The paper proposes a four-level model that focuses on the lack of training for both faculty and students, interpersonal barriers, technological barriers, time management, personal ethics, and design of assessment as underlying reasons for unethical behavior in online assessments. The paper further explains the linkages using fuzzy MICMAC analysis. The results have both practical and social implications. Understanding the factors and their relationship with each other can help the instructors and administrators in their decision-making process regarding online evaluations and formulate policies that would instill strong ethical values, such as academic integrity and honesty, in their students throughout their academic journey.

Comparison of two skin protection regimes for the Prevention of Incontinence-associated Dermatitis in geriatric care (PID): a study protocol for an exploratory randomised controlled pragmatic trial

INTRODUCTION

The majority of aged long-term care receivers and patients in geriatric acute care are affected by some form of incontinence. These individuals are at risk of developing incontinence-associated dermatitis (IAD), a common type of irritant contact dermatitis caused by repeated and prolonged direct contact of the skin with urine and stool. The prevalence of IAD in these settings is high. Preventive measures include mild skin cleansing and the application of skin protecting leave-on products. Available evidence is weak regarding the comparative performance of different skin protection strategies and products due to a lack of confirmatory trials using relevant comparators and endpoints. Therefore, the overall aim of this exploratory trial is to compare the effects of three skin protection strategies to estimate effect sizes of the recently published core outcomes in IAD research.

METHODS AND ANALYSIS

A pragmatic three-arm, assessor-blinded, randomised controlled, exploratory trial with parallel group design will be performed, comparing film-forming and lipophilic skin protecting leave-on products for IAD prevention with standard incontinence care alone. The trial will be conducted in geriatric nursing homes and geriatric acute care settings in the federal state of Berlin, Germany. A total of n=210 participants being incontinent of urine and stool will be included. Outcomes include IAD incidence, erythema, erosion, maceration, IAD-related pain, patient satisfaction, safety, feasibility and compliance. IAD incidence of the control and intervention groups will be compared to estimate effect sizes, and the procedural feasibility of the intervention will be tested to plan a possible subsequent confirmatory randomised controlled trial.

ETHICS AND DISSEMINATION

The study received the approval of the ethics committee of Charité-Universitätsmedizin Berlin (EA4/043/22). Results will be disseminated through peer-reviewed open-access journals and international conferences.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov (NCT05403762) and German Clinical Trials Register (Deutsches Register Klinischer Studien, or DRKS) (DRKS00028954).

Applying mixed methods to pilot feasibility studies to inform intervention trials

BACKGROUND

Pilot feasibility studies serve a uniquely important role in preparing for larger scale intervention trials by examining the feasibility and acceptability of interventions and the methods used to test them. Mixed methods (collecting, analyzing, and integrating quantitative and qualitative data and results) can optimize what can be learned from pilot feasibility studies to prepare rigorous intervention trials. Despite increasing use of mixed method designs in intervention trials, there is limited guidance on how to apply these approaches to address pilot feasibility study goals. The purpose of this article is to offer methodological guidance for how investigators can plan to integrate quantitative and qualitative methods within pilot feasibility studies to comprehensively address key research questions.

METHODS

We used an informal consensus-based process informed by key methodological resources and our team's complementary expertise as intervention researchers and mixed methodologists to develop guidance for applying mixed methods to optimize what can be learned from pilot feasibility studies. We developed this methodological guidance as faculty in the Mixed Methods Research Training Program (MMRTP) for the Health Sciences (R25MH104660) funded by the National Institutes of Health through the Office of Behavioral and Social Science Research.

RESULTS

We provide the following guidance for applying mixed methods to optimize pilot feasibility studies: (1) identify feasibility domain(s) that will be examined using mixed methods, (2) align quantitative and qualitative data sources for the domain(s) selected for mixing methods, (3) determine the timing of the quantitative and qualitative data collection within the flow of the pilot study, (4) plan integrative analyses using joint displays to understand feasibility, and (5) prepare to draw meta-inferences about feasibility and implications for the future trial from the integrated data.

CONCLUSIONS

By effectively integrating quantitative and qualitative data within pilot feasibility studies, investigators can harness the potential of mixed methods for developing comprehensive and nuanced understandings about feasibility. Our guidance can help researchers to consider the range of key decisions needed during intervention pilot feasibility testing to achieve a rigorous mixed methods approach generating enhanced insights to inform future intervention trials.

Randomised controlled pilot and feasibility study of multimodal agility-based exercise training (MAT) versus strength and endurance training (SET) to improve multiple sclerosis-related fatigue and fatigability during inpatient rehabilitation (ReFEx): study protocol

INTRODUCTION

Subjective fatigue and objectively assessed fatigability are common symptoms in persons with multiple sclerosis (pwMS). Recent work has suggested a positive effect of balance and motor control training (BMCT) in reducing fatigue. It is unclear whether this effect can also be attained during inpatient rehabilitation. Multimodal agility-based exercise training (MAT) has been developed as a framework that incorporates BMCT with added agility components but has not been applied to pwMS. Therefore, this study will evaluate the feasibility of a randomised controlled trial comparing MAT against strength and endurance training (SET) for the improvement of MS-related fatigue and fatigability in a German neurological rehabilitation centre.

METHODS AND ANALYSIS

A total of 24 pwMS (Expanded Disability Status Scale ≤5.0, Fatigue Scale for Motor and Cognitive Functions ≥53) will be randomly assigned to either SET or land and water-based MAT for 4-6 weeks during inpatient rehabilitation. Assessments of subjective fatigue, motor and cognitive fatigability, cognitive and cardiorespiratory performance, and balance confidence will be performed at admission and discharge. Subjective fatigue will also be assessed at 1, 4 and 12 weeks after discharge. Feasibility outcomes will include patients' acceptance of study procedures and interventions, recruitment rate, retention rate, time needed to complete baseline assessments, intervention adherence and fidelity. All quantitative outcomes will be reported descriptively. A total of 12 pwMS (6 per group) will be interviewed to gain insights into participants' experiences during study participation.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Ethics Committee of the University of Bonn (reference number: 543/20). Dissemination of findings is planned via peer-reviewed journals, conferences and media releases.

TRIAL REGISTRATION NUMBER

DRKS00023943.

'That would have been the perfect thing after diagnosis': development of a digital lifestyle management application in multiple sclerosis

Background

A multiple sclerosis (MS) diagnosis urges decision-making on immunotherapies, while persons with MS (PwMS) need to develop a coping concept in parallel. At this stage, PwMS ask how they themselves may contribute to controlling the disease. Evidence suggests that maintaining a healthy lifestyle (e.g. physical activity and stress management) is a key factor for healthy aging and preserving activity, while data on MS are complex.

Objectives

Following the Medical Research Council framework, this study aimed to develop and investigate the feasibility of a new digital health application that conveys evidence-based patient information about lifestyle factors in MS and engages PwMS in relevant behaviour change techniques.

Methods

Based on a digital health application promoting lifestyle management in breast cancer survivors, an MS-specific adaptation ('levidex') was developed. Feasibility was tested with 15 PwMS and eight MS experts. Subsequently, a six-week pilot study with eight PwMS was conducted. All participants provided feedback on practicability and acceptability via a questionnaire and took part in a semi-structured telephone interview. Levidex was revised after each test phase.

Results

The final levidex tool includes 16 modules, 177 references and several other functions. Feasibility results showed that PwMS and MS experts perceived levidex as understandable (14 out of 15; 6 out of 8), trustworthy (15 out of 15; 8 out of 8), and relevant (10 out of 15; 8 out of 8). Interviews revealed potential for improvement regarding the length and complexity of some content. Piloting of the revised version confirmed good feasibility and high acceptance. Most participants felt inspired to initiate (7 out of 8) or had already implemented (5 out of 8) lifestyle changes after working with levidex.

Conclusion

Results suggest that levidex is feasible and well-accepted by PwMS and MS experts. It might be a useful tool to support PwMS in adapting to their diagnosis and initiating health-promoting lifestyle changes.

Pilot study of physiotherapist-led versus music therapist-led breathing control exercises for young adults living with breathing pattern disorder: a randomised controlled trial protocol

INTRODUCTION

Breathing pattern disorder (BPD) is an abnormal breathing pattern associated with biochemical, biomechanical and psychophysiological changes. While physiotherapy is often offered, limited evidence-based therapies for BPD are available. Music therapy-based singing exercises have been shown to improve quality of life for individuals with respiratory conditions and may also be beneficial for individuals living with BPD. No study has previously compared these participatory interventions in the treatment of people living with BPD.

METHODS AND ANALYSIS

This is a study protocol for an assessor blinded 1:1 randomised controlled trial and qualitative interview study. Forty participants aged 18-40 years who score at least 19 on the Nijmegen Questionnaire (NQ) and do not have any underlying respiratory conditions will be recruited. Participants will be randomised to receive either physiotherapy-led or music therapy-led breathing exercises for 6 weeks. The primary outcome will be between-group difference in NQ post-intervention. Semistructured interviews with a purposive sample of participants will be performed. Qualitative data will be analysed using thematic analysis to better understand participants' intervention and trial experiences.

ETHICS AND DISSEMINATION

This study has received ethical approval by Brunel University London College of Health, Medicine and Life Science's Research Ethics Committee (32483-MHR-Mar/2022-38624-3). The anonymised completed dataset will be made available as an open-access file via Brunel University London Figshare and the manuscript containing anonymised patient data will be published in an open-access journal.

TRIAL REGISTRATION NUMBER

This trial is registered on the Open Science Framework Registry (https://osf.io/u3ncw).

Exploring the Feasibility of Virtually Delivered Auricular Point Acupressure in Self-Managing Chronic Pain: Qualitative Study

Background

Chronic pain remains highly prevalent. Current pharmacological and non-pharmacological strategies have not adequately managed chronic pain which has contributed to disability and high healthcare costs. With existing challenges in providing adequate pain care and access, we tested vAPA, a virtually delivered, self-management intervention using Auricular Point Acupressure (APA) by mobile app and virtual consultations (telehealth). Our key purpose was to evaluate the feasibility of the vAPA in self-managing chronic pain in preparation for a future randomized controlled trial.

Methods

We conducted a descriptive, qualitative study evaluating our 4-week vAPA intervention among 18 participants. We used directed qualitative content analysis. Results and Conclusion. Participants perceived that vAPA was feasible (acceptable, useable, practical, and beneficial). In addition, the following themes were gathered: better control of pain, less use of pain medications, self-management and motivation in pain, and expectations for pain relief. Refinements were recommended for the app, content, and delivery to improve study interventions. Findings are relevant in moving forward to a future randomized controlled trial and for wider implementation in a pragmatic clinical trial.

Enabling local political committees to support the implementation of evidence-based practice - a feasibility study

BACKGROUND

Local politicians can serve as enablers or barriers for health and social organizations to implement evidence, impacting the context of health and social service organizations. Increasing local politicians' knowledge about, and support for, evidence-based practice (EBP) could be a way to strengthen the conditions in social service organizations for EBP. The aim of the study was to describe the development and assess the perceived feasibility, acceptability, and appropriateness of an intervention to enable local political committees to support the implementation of EBP. Furthermore, the achievement of the learning outcomes was examined.

METHODS

Workshops and interviews were used to co-create the intervention with social service representatives (n = 8) and local politicians (n = 6). A single-arm, non-blinded feasibility study was conducted in a social welfare committee with local politicians (n = 14) and representatives from social services (n = 4). Interviews and pre-post questionnaires were used to assess the intervention's feasibility, acceptability, appropriateness, and learning outcomes. Progression criteria was set to > 80% of respondents judging the intervention to be feasible, acceptable, and appropriate. Thematic analysis and descriptive statistics were used for analysis.

RESULTS

The quantitative and qualitative results indicate that the intervention was perceived as acceptable and appropriate. However, the progression criteria for feasibility were not fully met. Qualitative findings show that the intervention was perceived as interesting, fun, and created curiosity to learn more about EBP. The discussions between the committee and the representatives from the social services department were much valued.

CONCLUSIONS

Careful anchoring of the intervention and comprehensive local adaptation regarding delivery format will be central to the delivery of this intervention if offered elsewhere. Furthermore, we recommend that skills training during the intervention should be included. The collaboration between local politicians and representatives from the social services department was a vital aspect of the intervention and should not be excluded. Collaboration between these actors will be of significance in further developing support for EBP implementation, as expressed by the interview participants.

Usability and feasibility assessment of a smartphone application (Suhriday) for heart failure self-care remote monitoring in an Indian tertiary health care setting: a pilot mixed-methods study

BACKGROUND/OBJECTIVES

Remote monitoring as a component of chronic heart failure (CHF) management programmes has demonstrated utility in reducing the risk of rehospitalisation and mortality. There is little evidence on mobile health app facilitated remote monitoring in India. We conducted a pilot usability and feasibility assessment of a smartphone-based application (Suhriday) to remotely monitor patients with CHF.

METHODS

We used a mixed-methods design. Usability testing consisted of the think-aloud approach followed by semistructured in-depth interviews (SSIs) and a satisfaction questionnaire. Feasibility testing was done using acceptability and user satisfaction questionnaires in addition to SSIs. We trained five purposively sampled patients with CHF (based on health literacy and gender) and their caregivers (n=10) in self-care monitoring and app use. Usability was assessed using metrics such as task completion, time required for task completion and user satisfaction using Brooke's System Usability Scale (SUS). Content analysis of the transcripts with deductive coding was performed for both usability and feasibility interviews. The number and types of medical alerts transmitted through the app were captured and escalated to the treating team.

RESULTS

Critical tasks involving (1) opening the app and identifying task list, (2) reporting blood pressure, weight, heart rate and fluid intake and (3) reporting symptoms were completed within 60 s by four patients. Median (IQR) SUS score was 85 (75-92.5) indicating high level of usability. There were 62 alerts from four patients over 4 weeks, with 36 (58.1%) excess fluid intake alerts and 16 (25.8%) blood pressure variations being the most frequent. One participant had challenges using the app and was monitored through active phone calls.

CONCLUSION

Overall usability and satisfaction with Suhriday were good and we were able to remotely manage patients. However, patients with limited health literacy and those facing technological challenges required active structured telephone support.

Co-designed, culturally tailored cervical screening education with migrant and refugee women in Australia: a feasibility study

Background

Participation of culturally and linguistically diverse (CALD) women from migrant and refugee backgrounds in cervical screening is crucial to eliminate cervical cancer as a public health problem within the next 20 years. However, CALD women report low participation in cervical screening. Barriers to participation can be addressed with culturally tailored, community-based programs. There is a need for research to explore the process, feasibility, acceptability and barriers to cultural tailoring in the delivery and evaluation of cervical screening health education.

Methods

CALD community health workers took part in a 2 day training program then co-designed, culturally tailored and co-facilitated cervical screening health promotion forums within their communities. Forums were delivered to a total of seven groups, involving 12 sessions and 71 CALD women. The forums were evaluated for feasibility, acceptability, implementation and effectiveness using a survey, interviews and observations. Data were collected from CALD women, facilitators and researchers.

Results

The co-design and co-delivery of cervical screening health promotion forums was time and resource intensive however allowed for deeper cultural tailoring resulting in engagement with ‘hard to reach’ CALD women, improved health literacy and intention to screen. Flexibility in the intervention implementation was crucial to ensure forums were responsive to community interests and needs. Online delivery of the forums in response to the COVID-19 pandemic was acceptable to most groups.

Conclusions

Co-designed, culturally tailored cervical screening health promotion forums are feasible and acceptable to CALD women, in both face-to-face and online formats. Adjustments to the intervention protocol were recommended to improve future implementation.

A Novel Hospital-to-Home System for Children With Medical Complexities: Usability Testing Study

Background

Children with medical complexity (CMC) are a group of young people who have severe complex chronic conditions, substantial family-identified service needs, functional limitations, and high health care resource use. Technology-enabled hospital-to-home interventions designed to deliver comprehensive care in the home setting are needed to ease CMC family stress, provide proactive and comprehensive care to this fragile population, and avoid hospital admissions, where possible.

Objective

In this usability testing study, we aimed to assess areas of strength and opportunity within the DigiComp Kids system, a hospital-to-home intervention for CMC and their families and care providers.

Methods

Hospital-based clinicians, family members of medically complex children, and home-based clinicians participated in DigiComp Kids usability testing. Participants were recorded and tasked to think aloud while completing usability testing tasks. Participants were scored on the metrics of effectiveness, efficiency, and satisfaction, and the total usability score was calculated using the Single Usability Metric. Participants also provided insights into user experiences during the postusability testing interviews.

Results

A total of 15 participants (5 hospital-based clinicians, 6 family members, and 4 home-based clinicians) participated in DigiComp Kids usability testing. The participants were able to complete all assigned tasks independently. Error-free rates for tasks ranged from 58% to 100%; the average satisfaction rating across groups was ≥80%, as measured by the Single Ease Question. Task times of participants were variable compared with the task times of an expert DigiComp Kids user. Single Usability Metric scores ranged from 80.5% to 89.5%. In qualitative interviews, participants stressed the need to find the right fit between user needs and the effort required to use the system. Interviews also revealed that the value of the DigiComp Kids system was in its ability to create a digital bridge between hospital and home, enabling participants to foster and maintain connections across boundaries.

Conclusions

Usability testing revealed strong scores across the groups. Insights gained include the importance of tailoring the implementation of the system to match individual user needs, streamlining key system features, and consideration of the meaning attached to system use by participants to allow for insight into system adoption and sustainment.

Understanding the barriers to, and facilitators of, ovarian toxicity assessment in breast cancer clinical trials

BACKGROUND

Detailed toxicity data are routinely collected in breast cancer (BC) clinical trials. However, ovarian toxicity is infrequently assessed, despite the adverse impacts on fertility and long-term health from treatment-induced ovarian insufficiency.

OBJECTIVES

To determine the barriers to and facilitators of ovarian toxicity assessment in BC trials of anti-cancer drugs.

METHODS

Semi-structured interviews were conducted with purposively selected stakeholders from multiple countries involved in BC clinical trials (clinicians, consumers, pharmaceutical company representatives, members of drug-regulatory agencies). Participants were asked to describe the perceived benefits and barriers to evaluating ovarian toxicity. Interviews were transcribed verbatim, coded in NVivo software and analysed using inductive thematic analysis.

RESULTS

Saturation of the main themes was reached and the final sample size included 25 participants from 14 countries (9 clinicians, 7 consumers, 5 members of regulatory agencies, 4 pharmaceutical company representatives); half were female. The main reported barrier to ovarian toxicity assessment was that the issue was rarely considered. Reasons included that these data are less important than survival data and are not required for regulatory approval. Overall, most participants believed evaluating the impact of BC treatments on ovarian function is valuable. Suggested strategies to increase ovarian toxicity assessment were to include it in clinical trial design guidelines and stakeholder advocacy.

CONCLUSION

Lack of consideration about measuring ovarian toxicity in BC clinical trials that include premenopausal women suggest that guidelines and stronger advocacy from stakeholders, including regulators, would facilitate its more frequent inclusion in future trials, allowing women to make better informed treatment decisions.

ASSIST: a reablement program for older adults in Sweden - a feasibility study

Background

Western countries emphasise the provision of assistive home care by implementing reablement services. Reablement services are offered to a limited degree in Sweden, and systematic research regarding outcomes and how reablement can be tailored to maximize benefits for older adults has been lacking. This study aimed to evaluate the feasibility of a novel reablement program (ASSIST 1.0) regarding study design and outcome measures, as well as fidelity, adherence, and acceptability of the program in a Swedish context.

Method

A non-randomised, quasi-experimental, mixed-method, pre/post-test design was applied with an intervention group receiving ASSIST 1.0 (n = 7) and a control group receiving regular home care (n = 10). ASSIST 1.0 was developed to empower older adults to increase their perceived performance and satisfaction of performing activities in everyday life as well as increase their perceived health, self-efficacy, and well-being. ASSIST 1.0 was founded on the concept of reablement and included three components: i) goal setting with The Canadian Occupational Performance Measure (COPM), ii) provided support to home care staff to enhance their provision of reablement, and iii) explored the incorporation and use of an information- and communication technology (ICT) to facilitate information transfer.

Results

Using COPM for goal setting with older adults and providing support to the staff via workshops were valuable components in the delivery of ASSIST 1.0. The ICT product encountered several challenges and could not be evaluated. COPM and EQ-5D were deemed the most important instruments. Organisational and political barriers affected the feasibility. Although, the fidelity and adherence were complied the staff perceived the program to be acceptable.

Conclusion

The ASSIST 1.0 program was feasible in regard of study design, delivering the intervention, and evaluating instruments that detected a change. A logical progression would be to conduct a full-scale trial. In addition, a usability study to evaluate the technological component is also recommended. With minor improvements, the ASSIST 1.0 program has the potential to contribute to the development of a home care organisation that could enhance older adults possibility to age in place at home.

Trial registration number

NCT03505619

Heart Rehabilitation for All (HeRTA): Protocol for a feasibility study and pilot randomized trial

Introduction

Today, 50% of people with cardiac disease do not participate in rehabilitation. The HeRTA-study aims to develop and test a sustainable rehabilitation model supporting vulnerable patients in participating in rehabilitation and long-term physical activity.

Methods

A feasibility study with a non-blinded pilot randomized trial was developed in collaboration with partners and cardiac patients to test a multi-component rehabilitation intervention across hospital, municipality, and civil society. The study runs from January 2020 to December 2024. Eligibility criteria for participants: a) diagnosed with either ischemic heart disease, persistent atrial fibrillation, heart failure, or have had cardiac valve surgery, b) residents in Hvidovre Hospitals uptake area, c) cognitively functional, d) physically able to participate in rehabilitation. Patient recruitment will be located at Hvidovre Hospital, Capital Region of Denmark, data collection at Hvidovre Hospital, Rehabilitation Center Albertslund, the Danish Heart Association, and in two municipalities (Hvidovre and Brøndby). Patients in the control group have access to usual care at the hospital: rehabilitation-needs-assessment, patient education, and physical training. After or instead of hospital rehabilitation, the patient can be referred to municipal rehabilitation with patient education, and a total of 12 weeks of physical training across sectors. Patients in the intervention group will in addition to usual care, have access to an information book about cardiac disease, patient supporters from the Danish Heart Association, Information materials to inform employers about the employees’ rehabilitation participation, a rehabilitation goal setting plan, a support café for relatives, and follow-up phone calls from physiotherapists 1 and 3 months after rehabilitation to support physical activities. Patients with vulnerabilities will additionally receive patient education conducted in small groups, pro-active counselling by a cardiac nurse, psychologist, or social worker, paid transportation to rehabilitation, and paid membership in a sports association. Patients are computer block-randomized so patients with vulnerability are distributed evenly in the two study arms by stratifying on a) a cut-off score of ≥ 5 in the Tilburg Frailty Indicator questionnaire and/or b) need of language translator support. A power calculation, based on an estimated 20% difference in participation proportion between groups, 80% power, a type 1 error of 5% (two-tailed), results in 91 participants in each study arm. The primary outcome: rehabilitation participation (attending ≥ two activities: patient education, smoking cessation, dietary counseling, and physical training) and reaching at least 50% attendance. Secondary outcomes: health-related quality of life, coping strategies, level of physical activities, and sustainability regarding participation in active communities after rehabilitation. The study is registered at ClinicalTrials.gov (NCT05104658).

Results

Differences between changes in outcomes between groups will be analyzed according to the intention-to-treat principle. Sensitivity analysis and analysis of the effect of the combined activities will be made. A process evaluation will clarify the implementation of the model, the partnership, and patients’ experiences.

Conclusion

Cross-sectoral collaborations between hospitals, municipalities, and organizations in civil society may lead to sustainable and affordable long-term physical activities for persons with chronic illness. The results can lead to improve cross-sectoral collaborations in other locations and patient groups.

Development of a Multicomponent Intervention to Decrease Racial Bias Among Healthcare Staff

BACKGROUND

Real or perceived discrimination contributes to lower quality of care for Black compared to white patients. Some forms of discrimination come from non-physician and non-nursing (non-MD/RN) staff members (e.g., receptionists).

METHODS

Utilizing the Burgess Model as a framework for racial bias intervention development, we developed an online intervention with five, 30-min modules: (1) history and effects of discrimination and racial disparities in healthcare, (2) implicit bias and how it may influence interactions with patients, (3) strategies to handle stress at work, (4) strategies to improve communication and interactions with patients, and (5) personal biases. Modules were designed to increase understanding of bias, enhance internal motivation to overcome bias, enhance emotional regulation skills, and increase empathy in patient interactions. Participants were non-MD/RN staff in nine primary care clinics. Effectiveness of the intervention was assessed using Implicit Association Test and Symbolic Racism Scale, to measure implicit and explicit racial bias, respectively, before and after the intervention. Acceptability was assessed through quantitative and qualitative feedback.

RESULTS

Fifty-eight non-MD/RN staff enrolled. Out of these, 24 completed pre- and post-intervention assessments and were included. Among participants who reported characteristics, most were Black, with less than college education and average age of 43.2 years. The baseline implicit bias d-score was 0.22, indicating slight pro-white bias. After the intervention, the implicit bias score decreased to -0.06 (p=0.01), a neutral score indicating no pro-white or Black bias. Participant rating of the intervention, scored from 1 (strongly disagree) to 5 (strongly agree), for questions including whether "it was made clear how to apply the presented content in practice" and "this module was worth the time spent" was ≥4.1 for all modules.

CONCLUSIONS

There was a decrease in implicit pro-white bias after, compared with before, the intervention. Intervention materials were highly rated.

Managing Unusual Sensory Experiences in People with First-Episode Psychosis (MUSE FEP): a study protocol for a single-blind parallel-group randomised controlled feasibility trial

INTRODUCTION

Hallucinations (hearing or seeing things that others do not) are a common feature of psychosis, causing significant distress and disability. Existing treatments such as cognitive-behavioural therapy for psychosis (CBTp) have modest benefits, and there is a lack of CBTp-trained staff. Shorter, targeted treatments that focus on specific symptoms delivered by a non-specialist workforce could substantially increase access to treatment.Managing Unusual Sensory Experiences (MUSE) explains why people have hallucinations and helps the person to develop and use coping strategies to reduce distress. MUSE focuses only on hallucinations, and treatment is short (four to six, 1-hour sessions per week). It is a digital intervention, run on National Health Service (NHS) laptops, which provides information about hallucinations in an engaging way, using audio, video and animated content. Crucially, it is designed for use by non-specialist staff like community psychiatric nurses.

METHODS AND ANALYSIS

The study is a two-arm feasibility randomised controlled trial comparing MUSE and treatment as usual (TAU) (n=40) to TAU alone (n=40), recruiting across two NHS Trusts, using 1:1 allocation and blind assessments before and after treatment (2 months) and at follow-up (3 months). Quantitative information on recruitment rates, adherence and completion of outcome assessments will be collected. Qualitative interviews will capture service users' experience of therapy and clinicians' experiences of the training and supervision in MUSE. Clinicians will also be asked about factors affecting uptake, adherence and facilitators/barriers to implementation. Analyses will focus on feasibility outcomes and provide initial estimates of intervention effects. Thematic analysis of the qualitative interviews will assess the acceptability of the training, intervention and trial procedures.

ETHICS AND DISSEMINATION

The trial has received NHS Ethical and Health Research Authority approval. Findings will be disseminated directly to participants and services, as well as through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

ISRCTN16793301.

How to embed qualitative research in trials: insights from the feasibility study of the SAFER trial programme

Qualitative research can enhance the design, conduct and interpretation of trials. Despite this, few trials incorporate qualitative methods, and those that do may not realise their full potential. In this commentary, we highlight how qualitative research can contribute to the design, conduct and day-to-day running of a trial, outlining the working arrangements and relationships that facilitate these contributions. In doing so, we draw on (i) existing frameworks on the role of qualitative research alongside trials and (ii) our experience of integrated qualitative research conducted as part of the feasibility study of the SAFER trial (Screening for Atrial Fibrillation with ECG to Reduce stroke), a cluster randomised controlled trial of screening people aged 70 and above for atrial fibrillation in primary care in England. The activities and presence of the qualitative team contributed to important changes in the design, conduct and day-to-day running of the SAFER feasibility study, and the subsequent main trial, informing diverse decisions concerning trial documentation, trial delivery, timing and content of measures and the information given to participating patients and practices. These included asking practices to give screening results to all participants and not just to 'screen positive' participants, and greater recognition of the contribution of practice reception staff to trial delivery. These changes were facilitated by a 'one research team' approach that underpinned all formal and informal working processes from the outset and maximised the value of both qualitative and trial coordination expertise. The challenging problems facing health services require a combination of research methods and data types. Our experience and the literature show that the benefits of embedding qualitative research in trials are more likely to be realised if attention is given to both structural factors and relationships from the outset. These include sustained and sufficient funding for qualitative research, embedding qualitative research fully within the trial programme, providing shared infrastructure and resources and committing to relationships based on mutual recognition of and respect for the value of different methods and perspectives. We outline key learning for the planning of future trials.Trial registration: Screening for atrial fibrillation with ECG to reduce stroke ISRCTN16939438 (feasibility study); Screening for atrial fibrillation with ECG to reduce stroke - a randomised controlled trial ISRCTN72104369 .

Community-based exercise programs incorporating healthcare-community partnerships to improve function post-stroke: feasibility of a 2-group randomized controlled trial

Background

Despite the potential for community-based exercise programs supported through healthcare-community partnerships (CBEP-HCPs) to improve function post-stroke, insufficient trial evidence limits widespread program implementation and funding. We evaluated the feasibility and acceptability of a CBEP-HCP compared to a waitlist control group to improve everyday function among people post-stroke.

Methods

We conducted a 3-site, pilot randomized trial with blinded follow-up evaluations at 3, 6, and 10 months. Community-dwelling adults able to walk 10 m were stratified by site and gait speed and randomized (1:1) to a CBEP-HCP or waitlist control group. The CBEP-HCP involved a 1-h, group exercise class, with repetitive and progressive practice of functional balance and mobility tasks, twice a week for 12 weeks. We offered the exercise program to the waitlist group at 10 months. We interviewed 13 participants and 9 caregivers post-intervention and triangulated quantitative and qualitative results. Study outcomes included feasibility of recruitment, interventions, retention, and data collection, and potential effect on everyday function.

Results

Thirty-three people with stroke were randomized to the intervention (n = 16) or waitlist group (n = 17). We recruited 1–2 participants/month at each site. Participants preferred being recruited by a familiar healthcare professional. Participants described a 10- or 12-month wait in the control group as too long. The exercise program was implemented per protocol across sites. Five participants (31%) in the intervention group attended fewer than 50% of classes for health reasons. In the intervention and waitlist group, retention was 88% and 82%, respectively, and attendance at 10-month evaluations was 63% and 71%, respectively. Participants described inclement weather, availability of transportation, and long commutes as barriers to attending exercise classes and evaluations. Among participants in the CBEP-HCP who attended ≥ 50% of classes, quantitative and qualitative results suggested an immediate effect of the intervention on balance, balance self-efficacy, lower limb strength, everyday function, and overall health.

Conclusion

The CBEP-HCP appears feasible and potentially beneficial. Findings will inform protocol revisions to optimize recruitment, and program and evaluation attendance in a future trial.

Trial registration

ClinicalTrials.gov, NCT03122626. Registered April 21, 2017 — retrospectively registered.

Functional standing frame programme early after severe sub-acute stroke (SPIRES): a randomised controlled feasibility trial

BACKGROUND

Early mobilisation (> 24 h post-stroke) is recommended for people with stroke. However, there is a paucity of evidence about how to implement early mobilisation for people who have had a severe stroke. Prolonged standing and task-specific training (sit-to-stand repetitions) have separately been evaluated in the literature; however, these functionally linked tasks have not been evaluated in combination for people with severe sub-acute stroke.

METHODS

The objective was to determine the feasibility of conducting a randomised controlled trial (RCT) of a functional standing frame programme compared with usual physiotherapy for people with severe sub-acute stroke. An assessor-blinded feasibility RCT with nested qualitative component (interviews and focus group) and process evaluation was adopted. Participants were aged ≥ 18 years with new diagnosis of severe sub-acute stroke (modified Rankin Scale (mRS) 4/5) from four Stroke Rehabilitation Units across South West England. Participants were randomised to receive either: (1) functional standing frame programme (30 min. standing plus sit-to-stand repetitions) plus 15 min of usual physiotherapy daily (intervention); (2) usual physiotherapy (45 min) daily (control). Both programmes were protocolised to be undertaken a minimum of five sessions per week for 3 weeks. Feasibility indicators included process, resource, management, and safety. Adherence, fidelity, and acceptability of the trial and intervention were evaluated using data recorded by therapists, observation of intervention and control sessions, interviews and one focus group. Patient measures of motor impairment, activities/participation, and quality of life were carried out by blinded assessors at baseline, 3, 15, 29, and 55 weeks post-randomisation.

RESULTS

Forty-five participants (51-96 years; 42% male, mRS 4 = 80% 5 = 20%) were randomised (n = 22 to intervention). Twenty-seven (60%) participants were followed-up at all time points. Twelve participants (27%) died during the trial; no deaths were related to the trial. Adherence to the minimum number of sessions was low: none of the participants completed all 21 sessions, and only 8 participants (18%) across both groups completed ≥ 15 sessions, over the 3 weeks; 39% intervention; 51% control sessions were completed; mean session duration 39 min (SD 19) control, 37 min intervention (SD 11). Intervention group: mean standing time 13 min (SD 9); mean sit-to-stand repetitions/session 5 (SD 4). Interviews were conducted with 10 participants, four relatives and six physiotherapists. Five physiotherapists attended a focus group.

CONCLUSIONS

The majority of progression criteria for this feasibility trial were met. However, adherence to the interventions was unacceptably low. This aspect of the trial design needs to be addressed prior to moving to a definitive RCT of this standing frame intervention in people with severe sub-acute stroke. Solutions have been identified to address these concerns.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number ISRCTN15412695 . Registration 19 December 2016.

Development and feasibility testing of a physical activity intervention for youth with anxiety and depression: a study protocol

Background

Anxiety and depressive disorders in children and adolescents are highly prevalent and account for more than half of all youth psychiatric disorders. Left untreated, anxiety, and depression lead to numerous detrimental outcomes, including reduced quality of life, psychiatric, and somatic comorbidity and even reduced lifespan. This puts a large strain on child and adolescent mental healthcare services (CAMHS) to provide effective treatments. However, even when provided the best evidence-based treatment, between 40–50% of patients continue to report significant symptom burdens. Thus, there is an immediate need for supplemental and/or new treatment approaches. Physical activity as a supplementary treatment may be such an approach. However, research investigating this approach within this population is scant. This protocol paper describes the development and feasibility trial of a physical activity-based intervention targeting anxiety and depressive symptoms in youth treated in CAMHS.

Methods/design

The study is based on the UK Medical Council Research Framework (MRC) for developing and evaluating complex interventions. Feasibility and acceptability of the physical activity intervention (confident, active, and happy youth) will be evaluated in an uncontrolled open-label trial using qualitative and quantitative data. Twenty youths with anxiety and/or depressive symptoms will be recruited. Acceptability of assessment procedures, the intervention, and perceived benefits and barriers to participation will be assessed, and qualitative interviews with participants, caregivers, and referring specialists will explore contextual and practical factors associated with intervention delivery. Physical activity will be measured using the Actigraph GT3X+ monitor at baseline, and post-intervention and change in anxiety and depression will be assessed.

Discussion

This study will contribute to the development of supplementary physical treatment interventions for youth with anxiety and depression in contact with CAMHS. The goal is to examine new avenues of treatment that ultimately may improve upon current treatment outcomes of anxiety and depression. This work will be in preparation for a future definitive randomized controlled trial (RCT) of this approach, in line with the MRC Framework.

Trial registration

ClnicalTrials.gov, NCT05049759. Registered on August 19, 2021. Retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01010-6.

How are progression decisions made following external randomised pilot trials? A qualitative interview study and framework analysis

Background

External randomised pilot trials help researchers decide whether, and how, to do a future definitive randomised trial. The progression criteria are often prespecified to inform the interpretation of pilot trial findings and subsequent progression decision-making. We aimed to explore and understand the perspectives and experiences of key stakeholders when making progression decisions following external pilot trials.

Methods

Thirty-five remote semi-structured interviews with external randomised pilot trial team members including chief investigators, trial managers, statisticians and patient and public involvement (PPI) representatives. Questions focussed on experiences and perceptions of pilot trial progression decisions and whether and how progression criteria informed this decision. Data were analysed using the framework method approach to thematic analysis. Strategies to ensure trustworthiness and rigour were used.

Results

Interviews were conducted between December 2020 and July 2021. Six descriptive themes were developed to capture the experiences and perspectives of participants. These were (1) divided opinions on the value and development of progression criteria, (2) (avoiding) the potential for personal interest to influence progression criteria and progression decision-making, (3) stakeholder engagement in setting progression criteria and making progression decisions, (4) lessons learned from doing the pilot trial and their impact on progression criteria applicability, (5) other factors that inform the progression decision and (6) progression of external randomised pilot trials—funding considerations and constraints. These themes were underpinned by an overarching interpretative theme ‘a one-size approach to progression does not fit all’ to describe the highly nuanced and complex decision-making process that occurs following external randomised pilot trials. The progression criteria are rarely the only consideration informing the decision to progress to future research; unanticipated events, signals of efficacy and continuity of the research team are other factors that researchers consider.

Conclusions

One size does not fit all when it comes to the progression criteria and pilot trial progression. The progression criteria are only one of many considerations researchers have when deciding whether a pilot trial is feasible. External pilot trial progression is not guaranteed even when a pilot trial is considered feasible (based on the progression criteria and/or other considerations), indicating inefficiency and potential research waste.

Trial registration

Open Science Framework osf.io/5N2KZ

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06063-9.

Clinical research on COVID-19: perceptions and barriers to participation in The Gambia

INTRODUCTION

The need to rapidly identify safe and efficacious drug therapies for COVID-19 has resulted in the implementation of multiple clinical trials investigating potential treatment options. These are being undertaken in an unprecedented research environment and at a higher speed than ever before. It is unclear how West African communities perceive such activities and how such perceptions influence participation in COVID-19 clinical trials. This qualitative study was conducted to assess the level of acceptability of a clinical trial on the prevention and treatment of COVID-19 in The Gambia and identify strategies to better engage communities in participating in such a trial.

METHODS

Data were collected using digitally recorded semistructured interviews (SSIs) and focus group discussions (FGDs) in Brikama and Kanifing local government areas. These are two of the most densely populated administrative subdivisions in The Gambia, where the clinical trial was to be implemented by the MRC Unit The Gambia. 26 men and 22 women aged between 19 and 70 years, with diverse socioeconomic profiles, participated in 8 FGDs (n=36) and 12 SSIs (n=12). Thematic analysis was used to analyse the data.

RESULTS

Fear of stigmatisation of patients with COVID-19 was a recurring theme in most FGDs and SSIs, with detrimental effects on willingness to accept COVID-19 testing and home visits to follow up patients with COVID-19 and their household contacts. Preserving the privacy of individuals enrolled in the study was key to potentially increase trial participation. Trust in the implementing institution and its acknowledged expertise were facilitators to accepting the administration of investigational products to sick individuals and their close contacts.

CONCLUSION

COVID-19 is a stigmatising disease. Developing a research-participant collaboration through an ongoing engagement with community members is crucial to a successful enrolment in COVID-19 clinical trials. Trust and acknowledged expertise of the implementing institution are key facilitators to foster such collaboration.

Feasibility of deploying peer coaches to mentor frontline home health aides and promote mobility among individuals recovering from a stroke: pilot test of a randomized controlled trial

BACKGROUND

Each year, approximately 100,000 individuals receive home health services after a stroke. Evidence has shown the benefits of home-based stroke rehabilitation, but little is known about resource-efficient ways to enhance its effectiveness, nor has anyone explored the value of leveraging low-cost home health aides (HHAs) to reinforce repetitive task training, a key component of home-based rehabilitation. We developed and piloted a Stroke Homehealth Aide Recovery Program (SHARP) that deployed specially trained HHAs as "peer coaches" to mentor frontline aides and help individuals recovering from stroke increase their mobility through greater adherence to repetitive exercise regimens. We assessed the feasibility of SHARP and its readiness for a full-scale randomized controlled trial (RCT). Specifically, we examined (1) the practicability of recruitment and randomization procedures, (2) program acceptability, (3) intervention fidelity, and (4) the performance of outcome measures.

METHODS

This was a feasibility study including a pilot RCT. Target enrollment was 60 individuals receiving post-stroke home health services, who were randomized to SHARP + usual home care or usual care only. The protocol specified a 30-day intervention with four planned in-home coach visits, including one joint coach/physical therapist visit. The primary participant outcome was 60-day change in mobility, using the performance-based Timed Up and Go and 4-Meter Walk Gait Speed tests. Interviews with participants, coaches, physical therapists, and frontline aides provided acceptability data. Enrollment figures, visit tracking reports, and audio recordings provided intervention fidelity data. Mixed methods included thematic analysis of qualitative data and quantitative analysis of structured data to examine the intervention feasibility and performance of outcome measures.

RESULTS

Achieving the 60-participant enrollment target required modifying participant eligibility criteria to accommodate a decline in the receipt of HHA services among individuals receiving home care after a stroke. This modification entailed intervention redesign. Acceptability was high among coaches and participants but lower among therapists and frontline aides. Intervention fidelity was mixed: 87% of intervention participants received all four planned coach visits; however, no joint coach/therapist visits occurred. Sixty-day follow-up retention was 78%. However, baseline and follow-up performance-based primary outcome mobility assessments could be completed for only 55% of participants.

CONCLUSIONS

The trial was not feasible in its current form. Before progressing to a definitive trial, significant program redesign would be required to address issues affecting enrollment, coach/HHA/therapist coordination, and implementation of performance-based outcome measures.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04840407 . Retrospectively registered on 9 April 2021.

Using long-term predicted Quality of Life in ICU clinical practice to prepare patients for life post-ICU: A feasibility study

PURPOSE

To examine the feasibility of using the PREdicting PAtients' long-term outcome for Recovery (PREPARE) prediction model for Quality of Life (QoL) 1 year after ICU admission in ICU practice to prepare expected ICU survivors and their relatives for life post-ICU.

MATERIALS AND METHODS

Between June 2020 and February 2021, the predicted change in QoL after 1 year was discussed in 25 family conferences in the ICU. 13 physicians, 10 nurses and 19 patients and/or family members were interviewed to evaluate intervention feasibility in ICU practice. Interviews were analysed qualitatively using thematic coding.

RESULTS

Patients' median age was 68.0 years, five patients (20.0%) were female and seven patients (28.0%) died during ICU stay. Generally, study participants thought the intervention, which clarified the concept of QoL through visualization and served as a reminder to discuss QoL and expectations for life post-ICU, had merit. However, some participants, especially physicians, thought the prediction model needed more data on more severely ill ICU patients to curb uncertainty.

CONCLUSIONS

Using predicted QoL scores in ICU practice to prepare patients and family members for life after ICU discharge is feasible. After optimising the model and implementation strategy, its effectiveness can be evaluated in a larger trial.

CHoosing Active Role Models to INspire Girls (CHARMING): protocol for a cluster randomised feasibility trial of a school-based, community-linked programme to increase physical activity levels in 9-10-year-old girls

Background

In the UK, there is evidence that girls’ physical activity tends to decline to a greater extent than boys as they enter adolescence. ‘Role models’ could play a vital role in inspiring girls to become or remain physically active. The CHARMING Programme is a primary school-based community linked role-model programme, co-developed in 2016, with children, parents, schools and wider stakeholders. It involves different types of physical activity delivered for 1-h each week by a community provider and peer role models (e.g. older girls from secondary schools) joining in with the sessions. The programme ultimately aims to increase and sustain physical activity levels among 9–10-year-old girls. This study aims to assess the feasibility and acceptability of the CHARMING Programme and of evaluating it using a randomised trial.

Methods

This study is a feasibility cluster randomised controlled trial, with embedded process evaluation and health economic evaluation. Approximately 90 Year 5 (i.e. 9–10-year-old) girls will be recruited across six primary schools in Mid-South Wales. Participating schools will be allocated to the programme: control on a 2:1 basis; four intervention schools will run the CHARMING Programme and two will continue with usual practice. A survey and accelerometer will be administered at baseline and repeated at 12 months. Interviews and focus groups will be conducted post-intervention delivery. The primary aim is to assess feasibility of a future randomised trial via the recruitment of schools, participants and role models; randomisation; retention; reach; data collection completion rates; programme adherence; and programme fidelity, views on intervention acceptability and programme barriers and facilitators. Secondary aims are to evaluate established physical activity outcome measures for children plus additional health economic outcomes for inclusion in a future full-scale trial.

Discussion

The results of this study will inform decisions on whether and how to proceed to a full-scale evaluation of the effectiveness and cost-effectiveness of the CHARMING Programme to improve or sustain physical activity.

Trial registration

ClinicalTrials.gov ISRCTN36223327. Registered March 29, 2021

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00961-6.

A physiotherapy-led transition to home intervention for older adults following emergency department discharge: protocol for a pilot feasibility randomised controlled trial

Background

Older adults frequently attend the emergency department (ED) and experience high rates of adverse outcomes following ED presentation including functional decline, ED re-presentation and unplanned hospital admission. The development of effective interventions to prevent such outcomes is a key priority for research and service provision. This paper reports a protocol designed to evaluate the feasibility of conducting a three arm randomised controlled trial (RCT) within the ED setting and in the patient’s home. The interventions are comprehensive geriatric assessment (CGA), ED PLUS and usual care.

Methods

The ED PLUS pilot trial is designed as a feasibility RCT conducted in the ED and Acute Medical Assessment Unit of a university teaching hospital in the mid-west region of Ireland. We aim to recruit 30 patients, aged 65 years and over presenting to the ED with undifferentiated medical complaints and discharged within 72 h of index visit.

Patients will be randomised by a computer in a ratio of 1:1:1 to deliver usual care, CGA or ED PLUS during a 6-month study period. A randomised algorithm is used to perform randomization. CGA will include a medical assessment, medication review, nursing assessment, falls assessment, assessment of mobility and stairs, transfers, personal care, activities of daily living (ADLs), social supports and baseline cognition. ED PLUS, a physiotherapist led, multidisciplinary intervention, aims to bridge the transition of care between the index visit to the ED and the community by initiating a CGA intervention in the ED and implementing a 6-week follow-up self-management programme in the patient’s own home following discharge from the ED. The outcomes will be parameters of the feasibility of the intervention and trial methods and will be assessed quantitatively and qualitatively.

Discussion

Rising ED visits and an ageing population with chronic health issues render ED interventions to reduce adverse outcomes in older adults a research priority. This feasibility RCT will generate data and experience to inform the conduct and delivery of a definite RCT.

Trial registration

The trial was registered in Clinical Trials Protocols and Results System as of 21^st July 2021, with registration number NCT049836020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00954-5.