Framework for design and evaluation of complex interventions to improve health

Nurse-led task-shifting strategies to substitute for mental health specialists in primary care: A systematic review

AIM

The study aimed to synthesize evidence comparing task-shifting interventions led by general practice nurses and mental health specialists in improving mental health outcomes of adults in primary care.

DESIGN

This study used a systematic review of randomized controlled trials.

DATA SOURCES

Articles from the databases CINAHL, MEDLINE, APA PsycInfo, PubMed, EMBASE, Cochrane EBM Reviews, Web of Science Core Collection, and ProQuest Dissertation and Thesis published between 2000 and 2020 were included.

REVIEW METHODS

The review was arranged based on the Cochrane Collaboration guidelines and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

RESULTS

Twelve articles met the eligibility criteria. Eight studies revealed that nurse-led intervention was significantly superior to its comparator. The review identified three major themes: training and supervision, single and collaborative care and psychosocial treatments.

CONCLUSION

Nurses could be temporarily employed to provide mental health services in the absence of mental health specialists as long as appropriate training and supervision was provided. This finding should be interpreted with caution due to the high risk of bias in the studies reviewed and the limited generalisability of their findings.

Using self-determination theory in research and evaluation in primary care

BACKGROUND

Multimorbidity (the co-existence of two or more long-term conditions within an individual) is a complex management challenge, with a very limited evidence base. Theories can help in the design and operationalization of complex interventions.

OBJECTIVE

This article proposes self-determination theory (SDT) as a candidate theory for the development and evaluation of interventions in multimorbidity.

METHODS

We provide an overview of SDT, its use in research to date, and its potential utility in complex interventions for patients with multimorbidity based on the new MRC framework.

RESULTS

SDT-based interventions have mainly focused on health behaviour change in the primary prevention of disease, with limited use in primary care and chronic conditions management. However, SDT may be a useful candidate theory in informing complex intervention development and evaluation, both in randomized controlled trials and in evaluations of 'natural experiments'. We illustrate how it could be used multimorbidity interventions in primary care by drawing on the example of CARE Plus (a primary care-based complex intervention for patients with multimorbidity in deprived areas of Scotland).

CONCLUSIONS

SDT may have utility in both the design and evaluation of complex interventions for multimorbidity. Further research is required to establish its usefulness, and limitations, compared with other candidate theories.

PATIENT OR PUBLIC CONTRIBUTION

Our funded research programme, of which this paper is an early output, has a newly embedded patient and public involvement group of four members with lived experience of long-term conditions and/or of being informal carers. They read and commented on the draft manuscript and made useful suggestions on the text. They will be fully involved at all stages in the rest of the programme of research.

Building staff capability, opportunity, and motivation to provide smoking cessation to people with cancer in Australian cancer treatment centres: development of an implementation intervention framework for the Care to Quit cluster randomised controlled trial

Few rigorous studies provide a clear description of the methodological approach of developing an evidence-based implementation intervention, prior to implementation at scale. This study describes the development, mapping, rating, and review of the implementation strategies for the Care to Quit smoking cessation trial, prior to application in nine cancer services across Australia. Key stakeholders were engaged in the process from conception through to rating, reviewing and refinement of strategies and principles. An initial scoping review identified 21 barriers to provision of evidence-based smoking cessation care to patients with cancer, which were mapped to the Theoretical Domains Framework and Behaviour Change Wheel (BCW) to identify relevant intervention functions. The mapping identified 26 relevant behaviour change techniques, summarised into 11 implementation strategies. The implementation strategies were rated and reviewed against the BCW Affordability, Practicality, Effectiveness and cost-effectiveness, Acceptability, Side-effects/safety, and Equity criteria by key stakeholders during two interactive workshops to facilitate a focus on feasible interventions likely to resonate with clinical staff. The implementation strategies and associated intervention tools were then collated by form and function to provide a practical guide for implementing the intervention. This study illustrates the rigorous use of theories and frameworks to arrive at a practical intervention guide, with potential to inform future replication and scalability of evidence-based implementation across a range of health service settings.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10742-022-00288-6.

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.

A Tailored Approach: A model for literature searching in complex systematic reviews

Our previous work identified that nine leading guidance documents for seven different types of systematic review advocated the same process of literature searching. We defined and illustrated this process and we named it ‘the Conventional Approach’. The Conventional Approach appears to meet the needs of researchers undertaking literature searches for systematic reviews of clinical interventions. In this article, we report a new and alternate process model of literature searching called ‘A Tailored Approach’. A Tailored Approach is indicated as a search process for complex reviews which do not focus on the evaluation of clinical interventions. The aims of this article are to (1) explain the rationale for, and the theories behind, the design of A Tailored Approach; (2) report the current conceptual illustration of A Tailored Approach and to describe a user’s interaction with the process model; and (3) situate the elements novel to A Tailored Approach (when compared with the Conventional Approach) in the relevant literature. A Tailored Approach suggests investing time at the start of a review, to develop the information needs from the research objectives, and to tailor the search approach to studies or data. Tailored Approaches should be led by the information specialist (librarian) but developed by the research team. The aim is not necessarily to focus on comprehensive retrieval. Further research is indicated to evaluate the use of supplementary search methods, methods of team-working to define search approaches, and to evaluate the use of conceptual models of information retrieval for testing and evaluation.

The feasibility of triggers for the integration of Standardised, Early Palliative (STEP) Care in advanced cancer: A phase II trial

Background

While multiple clinical trials have demonstrated benefits of early palliative care for people with cancer, access to these services is frequently very late if at all. Establishing evidence-based, disease-specific ‘triggers’ or times for the routine integration of early palliative care may address this evidence-practice gap.

Aim

To test the feasibility of using defined triggers for the integration of standardised, early palliative (STEP) care across three advanced cancers.

Method

Phase II, multi-site, open-label, parallel-arm, randomised trial of usual best practice cancer care +/- STEP Care conducted in four metropolitan tertiary cancer services in Melbourne, Australia in patients with advanced breast, prostate and brain cancer. The primary outcome was the feasibility of using triggers for times of integration of STEP Care, defined as enrolment of at least 30 patients per cancer in 24 months. Triggers were based on hospital admission with metastatic disease (for breast and prostate cancer), or development of disease recurrence (for brain tumour cohort). A mixed method study design was employed to understand issues of feasibility and acceptability underpinning trigger points.

Results

The triggers underpinning times for the integration of STEP care were shown to be feasible for brain but not breast or prostate cancers, with enrolment of 49, 6 and 10 patients across the three disease groups respectively. The varied feasibility across these cancer groups suggested some important characteristics of triggers which may aid their utility in future work.

Conclusions

Achieving the implementation of early palliative care as a standardized component of quality care for all oncology patients will require further attention to defining triggers. Triggers which are 1) linked to objective points within the illness course (not dependent on recognition by individual clinicians), 2) Identifiable and visible (heralded through established service-level activities) and 3) Not reliant upon additional screening measures may enhance their feasibility.

A protocol for monitoring fidelity of a preconception-life course intervention in a middle-income setting: the Healthy Life Trajectories Initiative (HeLTI), South Africa

Introduction

Despite the importance of intervention fidelity in interpreting the outcomes of complex public health interventions, there is a lack of both reporting fidelity trial protocols and uniformity. In evaluating complex, adaptable/pragmatic interventions in resource-strapped settings with systemic issues, unique challenges to intervention adherence and monitoring are introduced, increasing the importance of a fidelity protocol. We aim to describe the intervention fidelity and monitoring protocol for the Healthy Life Trajectories Initiative (HeLTI) South Africa, a complex four-phase intervention set in urban Soweto, starting preconceptionally and continuing through to pregnancy, infancy, and early childhood to improve the health of young women and reduce the intergenerational risk of obesity.

Methods

The HeLTI SA fidelity protocol was based on the NIH Behaviour Change Consortium (NIH BCC) Treatment Fidelity Framework, outlining the following components of intervention fidelity: study design, provider training, intervention delivery, intervention receipt, and intervention enactment. Context-specific fidelity challenges were identified. The intervention fidelity components and associated monitoring strategies were developed to align with HeLTI SA. Strategies for fidelity monitoring include, amongst others, qualitative process evaluation methods, reviewing observed and recorded intervention sessions, monitoring of activity logs, standardized training, and intervention session checklists. Possible challenges to fidelity and fidelity monitoring include high provider turnover, lack of qualification amongst providers, difficulty tracing participants for follow-up sessions, participant health literacy levels, and the need to prioritize participants’ non-health-related challenges. Solutions proposed include adapting intervention delivery methods, recruitment methods, and provider training methods.

Discussion

The NIH BCC Treatment Fidelity Framework provided a solid foundation for reporting intervention fidelity across settings to improve intervention validity, ability to assess intervention effectiveness, and transparency. However, context-specific challenges to fidelity (monitoring) were identified, and transparency around such challenges and possible solutions in low- and middle-income settings could help foster solutions to improve adherence, reporting, and monitoring of intervention fidelity in this setting.

Trial registration

Pan African Clinical Trials Registry PACTR201903750173871. Registered on 27 March 2019

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06696-w.

Using a qualitative sub-study to inform the design and delivery of randomised controlled trials on medicinal cannabis for symptom relief in patients with advanced cancer

BACKGROUND

Recruitment for randomised controlled trials in palliative care can be challenging; disease progression and terminal illness underpin high rates of attrition. Research into participant decision-making in medicinal cannabis randomised controlled trials (RCTs) is very limited. Nesting qualitative sub-studies within RCTs can identify further challenges to participation, informing revisions to study designs and recruitment practices. This paper reports on findings from a qualitative sub-study supporting RCTs of medicinal cannabis for symptom burden relief in patients with advanced cancer in one Australian city.

METHODS

Semi-structured qualitative interviews were conducted with 48 patients with advanced cancer, eligible to participate in a medicinal cannabis RCT (n=28 who consented to participate in an RCT; n=20 who declined). An iterative and abductive approach to thematic analysis and data collection fostered exploration of barriers and enablers to participation.

RESULTS

Key enablers included participants' enthusiasm and expectations of medicinal cannabis as beneficial (to themselves and future patients) for symptom management, especially after exhausting currently approved options, and a safer alternative to opioids. Some believed medicinal cannabis to have anti-cancer effects. Barriers to participation were the logistical challenges of participating (especially due to driving restrictions and fatigue), reluctance to interfere with an existing care plan, cost, and concerns about receiving the placebo and the uncertainty of the benefit. Some declined due to concerns about side-effects or a desire to continue accessing cannabis independent of the study.

CONCLUSIONS

The findings support revisions to subsequent medicinal cannabis RCT study designs, namely, omitting a requirement that participants attend weekly hospital appointments. These findings highlight the value of embedding qualitative sub-studies into RCTs. While some challenges to RCT recruitment are universal, others are context (population, intervention, location) specific. A barrier to participation found in research conducted elsewhere-stigma-was not identified in the current study. Thus, findings have important implications for those undertaking RCTs in the rapidly developing context of medical cannabis.

A self-help version of the New Forest Parenting Programme for parents of children with attention deficit hyperactivity disorder: a qualitative study of parent views and acceptability

BACKGROUND

Although parent interventions are recommended as a frontline treatment approach for children with attention deficit hyperactivity disorder (ADHD), a number of practical and situational barriers can impact accessibility and availability. Self-help parent interventions offer a potential alternative to therapist-led interventions when barriers prevent access to face-to-face treatment. This qualitative study aims to explore participant views and acceptability of self-help parent interventions.

METHOD

Semi-structured interviews were conducted with parents/carers of 12 children (age 6-10 years) with ADHD who received the self-help version of the New Forest Parenting Programme (NFPP-SH) as part of a randomised controlled trial. Thematic analysis (as proposed by Braun and Clarke) was used to analyse the data.

RESULTS

Overall, participants had favourable views of the self-help intervention but also experienced some barriers to treatment adherence. Six key themes were identified in parent interviews related to parental desire to learn more; acquisition of new skills; the flexibility of the intervention; self-help intervention vs. traditional therapist-led formats; barriers to engagement in the home environment; and need for earlier access to help.

CONCLUSIONS

NFPP-SH was an acceptable intervention for parents. However, some parents may need additional support to overcome barriers associated with completing an intervention at home. Implications for healthcare providers and researchers developing self-help parent interventions for ADHD and child behaviour are discussed.

The Feasibility, Acceptability, and Efficacy of Positive Search Training for Irritable Youth: A Single-Case Experimental Design

Although irritability is common in youth, research on treatment is in its infancy. Threat biases are more pronounced in irritable compared to low irritable youth, similar to evidence found in anxious youth. Therefore, interventions targeting these biases may be promising for reducing irritability. This study utilised a multiple baseline case series design to determine the feasibility, acceptability, and efficacy of positive search training (PST) for irritable children. Three children were included who met criteria for a principal diagnosis of Disruptive Mood Dysregulation Disorder (DMDD), and a secondary diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) or Major Depressive Disorder (MDD). PST was feasible with two of the three participants; one child refused to continue after one session. For the two participants who completed PST, acceptability was stable with moderate-to-high ratings of engagement and enjoyment, and high and stable treatment-relevant verbalisations of the key strategies. Both cases showed declines in DMDD severity across treatment and no longer met criteria at post-treatment. Both participants met criteria for Oppositional Defiant Disorder (ODD) at post-treatment (considered less severe for irritability than DMDD). Declines in parent-reported irritability occurred for both cases, however some returns to baseline were observed. Overall, PST for irritable youth shows promise as an acceptable and feasible intervention. Further studies are needed combining PST with strategies for secondary diagnoses, given its high comorbidity with disruptive behaviour disorders.

Application of a Realistic Evaluation Approach on Three Public Health Programs Aiming at Prevention of Obesity

Rich literature abounds concerning the clinical effectiveness of programs aiming to produce weight gain/obesity prevention outcomes. However, there is very little evidence on how these outcomes are produced, and what interplay of factors made those programs effective (or not) in the environment that produced those effects. This study aims to describe the application of realistic evaluation in the field of obesity prevention, as an approach to unravel those components that influence the capacity of a program to produce its effects and to examine its significance in an effort to understand those components. The concepts of critical realism have informed the development of an interview topic guide, while three European programs were selected as case studies after a rigorous selection process. In total, 26 in-depth semi-structured interviews were taken, paired with personal observation and secondary data research. Several grounded context-mechanisms-outcomes (CMO) configurations were described within the respective context of each location, with the mechanisms introduced from each project resulting in distinctive outcomes. This study highlights the potential of realistic evaluation as a comprehensive framework to explain in which contextual circumstances of each program’s effects are produced, how certain underlying mechanisms produce those effects, and how to explicitly connect the context and the acting mechanisms into distinct outcome patterns, which will ultimately form unique configuration sets for each of the analyzed projects.

Implementation of a Health Promotion Practice Using Individually Targeted Lifestyle Interventions in Primary Health Care: Protocol for the "Act in Time" Mixed Methods Process Evaluation Study

Background

There is growing evidence that noncommunicable diseases (NCDs) can be attributable to unhealthy lifestyle habits. However, there has been little application of this knowledge in primary health care (PHC).

Objective

This study aims to evaluate the process and outcomes of a multifaceted implementation strategy for a healthy lifestyle-promoting practice in a PHC setting. This practice is based on national guidelines targeting unhealthy lifestyle habits with a potential risk for NCDs.

Methods

A pre-post implementation study design with a control group is used in a PHC setting in central Sweden. The Medical Research Council guidelines for process evaluation of complex interventions will be applied. The implementation process and outcomes will be assessed using a mix of qualitative and quantitative methods. A strategic sample of up to 6 PHC centers will be included as intervention centers, which will receive a 12-month multifaceted implementation strategy. Up to 6 matched PHC centers will serve as controls. Core components in the implementation strategy are external and internal facilitators in line with the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework and the Astrakan change leadership model. Data will be collected at baseline, during the implementation phase, and 4-6 months after the implementation strategy. Questionnaires will be sent to roughly 500 patients in every PHC center and 200 health care professionals (HCPs) before and after implementation. In addition, purposeful sampling will be used for interviews and focus group discussions with managers, HCPs, patient representatives, and internal and external facilitators. Use of data from medical records and activity logs will be an additional data source.

Results

Recruitment of PHC centers began in March 2021 and ended in Spring 2022. Based on the planned timeline with the 12-month implementation strategy and 4-6-month follow-up, we expect to collect the final data in Summer 2023.

Conclusions

This study will explain implementation process and outcomes using a multifaceted implementation strategy for a healthy lifestyle-promoting practice in a real-world PHC context. The study is expected to provide new knowledge about the role of facilitators and their contribution to implementation outcomes. These findings can guide policy makers, managers, and PHC staff to integrate health promotion and disease prevention in PHC and provide methodological support to facilitators.

Trial Registration

ClinicalTrials.gov NCT04799860; https://clinicaltrials.gov/ct2/show/NCT04799860

International Registered Report Identifier (IRRID)

DERR1-10.2196/37634

Enrolling people of color to evaluate a practice intervention: lessons from the shared decision-making for atrial fibrillation (SDM4AFib) trial

BACKGROUND

Trial recruitment of Black, indigenous, and people of color (BIPOC) is key for interventions that interact with socioeconomic factors and cultural norms, preferences, and values. We report on our experience enrolling BIPOC participants into a multicenter trial of a shared decision-making intervention about anticoagulation to prevent strokes, in patients with atrial fibrillation (AF).

METHODS

We enrolled patients with AF and their clinicians in 5 healthcare systems (three academic medical centers, an urban/suburban community medical center, and a safety-net inner-city medical center) located in three states (Minnesota, Alabama, and Mississippi) in the United States. Clinical encounters were randomized to usual care with or without a shared decision-making tool about anticoagulation.

ANALYSIS

We analyzed BIPOC patient enrollment by site, categorized reasons for non-enrollment, and examined how enrollment of BIPOC patients was promoted across sites.

RESULTS

Of 2247 patients assessed, 922 were enrolled of which 147 (16%) were BIPOC patients. Eligible Black participants were significantly less likely (p < .001) to enroll (102, 11%) than trial-eligible White participants (185, 15%). The enrollment rate of BIPOC patients varied by site. The inclusion and prioritization of clinical practices that care for more BIPOC patients contributed to a higher enrollment rate into the trial. Specific efforts to reach BIPOC clinic attendees and prioritize their enrollment had lower yield.

CONCLUSIONS

Best practices to optimize the enrollment of BIPOC participants into trials that examined complex and culturally sensitive interventions remain to be developed. This study suggests a high yield from enrolling BIPOC patients from practices that prioritize their care.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT02905032).

A process evaluation of 'We Can Quit': a community-based smoking cessation intervention targeting women from areas of socio-disadvantage in Ireland

Background

Smoking poses a serious risk of early preventable death and disease especially for women living with socio-economic disadvantage (SED). A smoking cessation programme, ‘We Can Quit’, was developed in Ireland tailored to SED women. This includes group-based support delivered by trained lay local community facilitators (CFs) and free nicotine replacement therapy (NRT). The intervention was pilot tested in a cluster randomised controlled trial, ‘We Can Quit 2’. This paper reports on the WCQ2 process evaluation which assessed feasibility and acceptability of the programme and trial processes.

Methods

Embedded qualitative design using the UK Medical Research Council’s process evaluation framework. Semi-structured interviews with trial participants (N = 21) and CFs (N = 8). Thematic analysis was utilised.

Results

Peer-modelling, a non-judgemental environment, CFs facilitation of group support were viewed as acceptable programme related factors. Some participants expressed concerns about NRT side effects. Provision of free NRT was welcomed and accepted by participants, although structural barriers made access challenging. Pharmacists took on a role that became larger than originally envisaged – and the majority provided additional support to women in their quit attempts between group meetings which augmented and supplemented the intervention sessions provided by the CFs. Participants reported good acceptance of repeated measures for data collection, but mixed acceptability of provision of saliva samples. Low literacy affected the feasibility of some women to fully engage with programme and trial-related materials. This was despite efforts made by intervention developers and the trial team to make materials (e.g., participant intervention booklet; consent forms and participant information leaflets) accessible while also meeting requirements under 2018 European General Data Protection Regulation legislation. Hypothetical scenarios of direct (e.g., researcher present during programme delivery) and indirect (e.g., audio recordings of programme sessions) observational fidelity assessments for a future definitive trial (DT) were acceptable.

Conclusions

Intervention and trial-related processes were generally feasible and acceptable to participants and CFs. Any future DT will need to take further steps to mitigate structural barriers to accessing free NRT; and the established problem of low literacy and low educational attainment in SED areas, while continuing to comply within the contemporary legislative research environment.

Trial registration

WCQ2 pilot trial (ISRCTN74721694).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13957-5.

Novel device for assisted vaginal birth: using integrated qualitative case study methodology to optimise Odon Device use within a feasibility study in a maternity unit in the Southwest of England

OBJECTIVE

When novel devices are used 'in human' for the first time, their optimal use is uncertain because clinicians only have experience from preclinical studies. This study aimed to investigate factors that might optimise use of the Odon Device for assisted vaginal birth.

DESIGN

We undertook qualitative case studies within the ASSIST Study, a feasibility study of the Odon Device. Each 'case' was defined as one use of the device and included at least one of the following: observation of the attempted assisted birth, and an interview with the obstetrician, midwife or woman. Data collection and thematic analysis ran iteratively and in parallel.

SETTING

Tertiary referral National Health Service maternity unit in the Southwest of England.

PARTICIPANTS

Women requiring a clinically indicated assisted vaginal birth.

INTERVENTION

The Odon Device, an innovative device for assisted vaginal birth.

PRIMARY AND SECONDARY OUTCOME MEASURES

Determining the optimal device technique, device design and defining clinical parameters for use.

RESULTS

Thirty-nine cases involving an attempted Odon-assisted birth were included in this study, of which 19 resulted in a successful birth with the device. Factors that improved use included optimisation of device technique, device design and clinical parameters for use. Technique adaptations included: applying the device during, rather than between, contractions; having a flexible approach to the application angle; and deflating the air cuff sooner than originally proposed. Three design modifications were proposed involving the deflation button and sleeve. Although use of the device was found to be appropriate in all fetal positions, it was considered contraindicated when the fetal station was at the ischial spines.

CONCLUSIONS

Case study methodology facilitated the acquisition of rapid insights into device function in clinical practice, providing key insights regarding use, design and key clinical parameters for success. This methodology should be considered whenever innovative devices are introduced into clinical practice.

TRIAL REGISTRATION NUMBER

ISRCTN10203171.

Perspectives of Nursing Students towards Schizophrenia Stigma: A Qualitative Study Protocol

Aim: This study aims to explore fourth-year nursing students’ knowledge of schizophrenia and their attitudes, empathy, and intentional behaviours towards people with schizophrenia. Design: This will be a descriptive qualitative study using focus-group interviews. Methods: Fourth-year nursing students on clinical placement in a hospital in Hunan province will be invited for focus-group interviews. Snowball and purposive sampling will be used to recruit nursing students for this study. Five focus-group interviews, each including six participants, will be conducted to explore participants’ knowledge, attitudes, intentional behaviours, and empathy towards schizophrenia. The interview will be conducted through the online Tencent video conference platform and the interview data will be collected through the same platform. All interviews will be recorded and transcribed verbatim and analysed with the approach of the content analysis supported by NVivo 12. Simultaneous data collection and analysis will be performed, and the interviews will be continued until data saturation is met. The findings of this study will be helpful in developing effective interventions to decrease the stigma toward schizophrenia among nursing students and those who study healthcare disciplines.

Implementation of a Novel Pediatric Behavioral Health Integration Initiative

This study explores healthcare professionals' perspectives about the impact of behavioral health integration (BHI) on pediatric primary care delivery in community health centers (CHCs). A concurrent, qualitative-dominant mixed methods empirical study design was utilized, applying semi-structured interviews with healthcare professionals at the end of the implementation phase of a 3-year co-development, implementation, and evaluation process. Surveys were also administered at three time points. Via thematic analysis, emergent qualitative themes were mapped onto the Relational Coordination (RC) conceptual framework to triangulate and complement final qualitative results with quantitative results. Interview findings reveal five emergent themes aligning with RC domains. Survey results show that healthcare professionals reported increased behavioral healthcare integration into clinic practice (p = 0.0002) and increased clinic readiness to address behavioral health needs (p = 0.0010). Effective pediatric BHI and care delivery at CHCs may rely on strong professional relationships and communication. Additional research from the patient/caregiver perspective is needed.

Safe and Healthy Para sport project (SHAPE): a study protocol of a complex intervention within Para sport

Elite Para athletes report a high incidence of sports injuries, illnesses and other health issues. Despite this, there are few prevention programmes in Para sport, and many of the existing prevention programmes are not adapted to Para athletes. To improve the success of preventive measures, it has been suggested that sports safety work should facilitate health promotion, including athlete health education. Therefore, the overarching aim of this project is to evaluate an accessible health promotion web platform as part of a complex intervention that aims to improve knowledge of athlete health in Para sport. In this protocol, the development, future implementation and evaluation of the intervention are described. To inform the implementation and use of such interventions, it is recommended to involve end users in the development and implementation process. Therefore, a participatory design process, including athletes and the sports organisation, was used to develop an accessible health promotion web platform. To evaluate this complex intervention, a process evaluation combining quantitative evaluation assessing causal pathways with qualitative methods assessing multifaceted pathways will be used. The primary outcomes are injury/illness incidence, athlete health parameters, health literacy and user behaviour. A cohort of elite Para athletes (n=150) from Sweden and South Africa will be invited to participate. This project will be the first that aims to improve athlete health in Para sport through pragmatic and accessible health promotion. It is a boundary-crossing project that will be conducted in a real-world sport setting, including athletes with different socioeconomic backgrounds.

Acupuncture intervention for acute pain in the Emergency Department trial: a consensus process

PURPOSE

This document describes the consensus process and intervention for a National Institutes of Health (NIH)-funded multi-site feasibility study utilizing acupuncture for ACUte paIn in The EmergencY Department (ACUITY). The acupuncture intervention is designed to be flexible and responsive to the most common Emergency Department (ED) scenarios, including trauma, acute pain of the low back, abdomen and/or musculoskeletal system, renal colic and headache.

BACKGROUND

Opioids remain a primary treatment for acute ED pain with attendant risk of adverse effects, addiction liability, diversion and death. Effective/safer options for acute pain are needed. Although acupuncture therapy has shown promise for acute pain in the ED alone or in conjunction with usual care, pragmatic trials are needed to obtain definitive and generalizable evidence.

METHODS

An Acupuncture Advisory Panel was convened that included nine acupuncture experts with 5-44 years of experience in practice and 2-16 years of experience in the acute pain care setting. A modified Delphi process was used with provision of a literature review, surveys of our panel members, three online discussions and email discussion as needed. The STandards for Reporting Interventions in Controlled Trials (STRICTA) checklist was used as a guide.

RESULTS

A responsive acupuncture intervention was agreed on for ACUITY. Session forms were fashioned in REDCap (Research Electronic Data Capture program to capture essential treatment data, assess fidelity and inform our design for a future pragmatic multi-site randomized controlled trial (RCT) of acupuncture in the ED, and for use by other future researchers.

CONCLUSION

Development of a responsive manualization intervention provides the appropriate framework for conducting a future, pragmatic, multi-site, definitive RCT of acupuncture in the ED.

TRIAL REGISTRATION NUMBER

NCT04880733 (ClinicalTrials.gov).

Keyworker mediated enhancement of physical health in patients with first episode psychosis: A feasibility/acceptability study

AIM

Early intervention for people experiencing first episode psychosis is a priority, and keyworkers are vital to such services. However, keyworkers' roles in addressing first episode psychosis patients' physical health are under researched. This study addresses this knowledge gap by evaluating a keyworker-mediated intervention promoting physical health among first episode psychosis patients.

METHODS

The study was informed by the Medical Research Council's Framework for Complex Interventions to Improve Health. First episode psychosis participants were recruited from three Irish mental health services. The intervention was evaluated in terms of its feasibility/acceptability.

RESULTS

Feasibility outcomes were mixed (recruitment rate = 24/68 [35.3%]; retention rate = 18/24 [75%]). The baseline sample was predominantly male (M:F ratio = 13:6; Med age = 25 y; IQR = 23-42 y). Common health issues among participants included overweightness/obesity (n = 11) and substance use (smoking/alcohol consumption [n = 19]). Participants' initial health priorities included exercising more (n = 10), improving diet (n = 6), weight loss (n = 7) and using various health/healthcare services. The intervention's acceptability was evidenced by the appreciation participants had for physical health keyworkers' support, as well as the healthy lifestyle, which the intervention promoted. Acceptability was somewhat compromised by a low-recruitment rate, variable linkages between keyworkers and general practitioners (GPs) and COVID-19 restrictions.

CONCLUSIONS

Physical health-oriented keyworker interventions for first episode psychosis patients show promise and further evaluation of such initiatives is warranted. Future interventions should be mindful of participant recruitment challenges, strategies to enhance relationships between keyworkers and GPs, and if necessary, they should mitigate COVID-19 restrictions' impacts on care.

Mitigating structural racism to reduce inequities in sepsis outcomes: a mixed methods, longitudinal intervention study

BACKGROUND

Sepsis affects 1.7 million patients in the US annually, is one of the leading causes of mortality, and is a major driver of US healthcare costs. African American/Black and LatinX populations experience higher rates of sepsis complications, deviations from standard care, and readmissions compared with Non-Hispanic White populations. Despite clear evidence of structural racism in sepsis care and outcomes, there are no prospective interventions to mitigate structural racism in sepsis care, nor are we aware of studies that report reductions in racial inequities in sepsis care as an outcome. Therefore, we will deliver and evaluate a coalition-based intervention to equip health systems and their surrounding communities to mitigate structural racism, driving measurable reductions in inequities in sepsis outcomes. This paper presents the theoretical foundation for the study, summarizes key elements of the intervention, and describes the methodology to evaluate the intervention.

METHODS

Our aims are to: (1) deliver a coalition-based leadership intervention in eight U.S. health systems and their surrounding communities; (2) evaluate the impact of the intervention on organizational culture using a longitudinal, convergent mixed methods approach, and (3) evaluate the impact of the intervention on reduction of racial inequities in three clinical outcomes: a) early identification (time to antibiotic), b) clinical management (in-hospital sepsis mortality) and c) standards-based follow up (same-hospital, all-cause sepsis readmissions) using interrupted time series analysis.

DISCUSSION

This study is aligned with calls to action by the NIH and the Sepsis Alliance to address inequities in sepsis care and outcomes. It is the first to intervene to mitigate effects of structural racism by developing the domains of organizational culture that are required for anti-racist action, with implications for inequities in complex health outcomes beyond sepsis.

Interrogating intervention delivery and participants' emotional states to improve engagement and implementation: A realist informed multiple case study evaluation of Engager

Background

‘Engager’ is an innovative ‘through-the-gate’ complex care intervention for male prison-leavers with common mental health problems. In parallel to the randomised-controlled trial of Engager (Trial registration number: ISRCTN11707331), a set of process evaluation analyses were undertaken. This paper reports on the depth multiple case study analysis part of the process evaluation, exploring how a sub-sample of prison-leavers engaged and responded to the intervention offer of one-to-one support during their re-integration into the community.

Methods

To understand intervention delivery and what response it elicited in individuals, we used a realist-informed qualitative multiple ‘case’ studies approach. We scrutinised how intervention component delivery lead to outcomes by examining underlying causal pathways or ‘mechanisms’ that promoted or hindered progress towards personal outcomes. ‘Cases’ (n = 24) were prison-leavers from the intervention arm of the trial. We collected practitioner activity logs and conducted semi-structured interviews with prison-leavers and Engager/other service practitioners. We mapped data for each case against the intervention logic model and then used Bhaskar’s (2016) ‘DREIC’ analytic process to categorise cases according to extent of intervention delivery, outcomes evidenced, and contributing factors behind engagement or disengagement and progress achieved.

Results

There were variations in the dose and session focus of the intervention delivery, and how different participants responded. Participants sustaining long-term engagement and sustained change reached a state of ‘crises but coping’. We found evidence that several components of the intervention were key to achieving this: trusting relationships, therapeutic work delivered well and over time; and an in-depth shared understanding of needs, concerns, and goals between the practitioner and participants. Those who disengaged were in one of the following states: ‘Crises and chaos’, ‘Resigned acceptance’, ‘Honeymoon’ or ‘Wilful withdrawal’.

Conclusions

We demonstrate that the ‘implementability’ of an intervention can be explained by examining the delivery of core intervention components in relation to the responses elicited in the participants. Core delivery mechanisms often had to be ‘triggered’ numerous times to produce sustained change. The improvements achieved, sustained, and valued by participants were not always reflected in the quantitative measures recorded in the RCT. The compatibility between the practitioner, participant and setting were continually at risk of being undermined by implementation failure as well as changing external circumstances and participants’ own weaknesses.

Trial registration number

ISRCTN11707331, Wales Research Ethics Committee, Registered 02-04-2016—Retrospectively registered https://doi.org/10.1186/ISRCTN11707331.

Adapt or die: how the pandemic made the shift from EBM to EBM+ more urgent

Evidence-based medicine (EBM's) traditional methods, especially randomised controlled trials (RCTs) and meta-analyses, along with risk-of-bias tools and checklists, have contributed significantly to the science of COVID-19. But these methods and tools were designed primarily to answer simple, focused questions in a stable context where yesterday's research can be mapped more or less unproblematically onto today's clinical and policy questions. They have significant limitations when extended to complex questions about a novel pathogen causing chaos across multiple sectors in a fast-changing global context. Non-pharmaceutical interventions which combine material artefacts, human behaviour, organisational directives, occupational health and safety, and the built environment are a case in point: EBM's experimental, intervention-focused, checklist-driven, effect-size-oriented and deductive approach has sometimes confused rather than informed debate. While RCTs are important, exclusion of other study designs and evidence sources has been particularly problematic in a context where rapid decision making is needed in order to save lives and protect health. It is time to bring in a wider range of evidence and a more pluralist approach to defining what counts as 'high-quality' evidence. We introduce some conceptual tools and quality frameworks from various fields involving what is known as mechanistic research, including complexity science, engineering and the social sciences. We propose that the tools and frameworks of mechanistic evidence, sometimes known as 'EBM+' when combined with traditional EBM, might be used to develop and evaluate the interdisciplinary evidence base needed to take us out of this protracted pandemic. Further articles in this series will apply pluralistic methods to specific research questions.

Using COM-B model in identifying facilitators, barriers and needs of community pharmacists in implementing weight management services in Malaysia: a qualitative study

Background

Previous qualitative studies exploring the experiences of community pharmacists (CP) in implementing weight management services (WMS) often lack a theoretical underpinning. This study applied the capability, opportunity, motivation, behaviour (COM-B) model to factors associated with WMS implementation among CPs to develop and recommend better intervention strategies.

Methods

A qualitative study design was used by conducting in-depth, semi-structured interviews with CPs. All the interviews were audio-recorded and duly transcribed. The thematic analysis approach was used to analyse the data, and the themes generated were mapped onto COM-B model components.

Results

The themes that emerged were (1) motivation of pharmacists and (2) knowledge and skills, which were identified as both barriers and facilitators, and (3) the barriers to implementation in aspects of social norms and resources. Factors were subsequently categorised into the subcomponents of the model: physical capability (e.g., training), psychological capability (e.g., lack of knowledge), physical opportunity (e.g., product range), social opportunity (e.g., stigma), automatic motivation (e.g., remuneration) and reflective motivation (e.g., CPs extended roles).

Conclusions

In conclusion, programs or training For Cps should develop their psychological capability to change their behaviour by being more proactive in promoting and providing weight management services, with a vital educational component. This behavioural change will improve the promotion of this service and will help many customers who were unaware of this service. Learning opportunities will leave CPs to feel more empowered and overcome barriers to implementing and maintaining WMS in primary care. The study findings provided essential insights into the factors that affect this provided service in Malaysia. The results will help to encourage the embedding of nutrition counselling in academic curricula.

The ReCoN intervention: a co-created comprehensive intervention for primary mental health care aiming to prevent involuntary admissions

BACKGROUND

Reducing involuntary psychiatric admissions is a global concern. In Norway, the rate of involuntary admissions was 199 per 100,000 people 16 years and older in 2020. Individuals' paths towards involuntary psychiatric admissions usually unfold when they live in the community and referrals to such admissions are often initiated by primary health care professionals. Interventions at the primary health care level can therefore have the potential to prevent such admissions. Interventions developed specifically for this care level are, however, lacking. To enhance the quality and development of services in a way that meets stakeholders' needs and facilitates implementation to practice, involving both persons with lived experience and service providers in developing such interventions is requested.

AIM

To develop a comprehensive intervention for primary mental health care aiming to prevent involuntary admissions of adults.

METHODS

This study had an action research approach with a participatory research design. Dialogue conferences with multiple stakeholders in five Norwegian municipalities, inductive thematic analysis of data material from the conferences, and a series of feedback meetings were conducted.

RESULTS

The co-creation process resulted in the development of the ReCoN (Reducing Coercion in Norway) intervention. This is a comprehensive intervention that includes six strategy areas: [1] Management, [2] Involving Persons with Lived Experience and Family Carers, [3] Competence Development, [4] Collaboration across Primary and Specialist Care Levels, [5] Collaboration within the Primary Care Level, and [6] Tailoring Individual Services. Each strategy area has two to four action areas with specified measures that constitute the practical actions or tasks that are believed to collectively impact the need for involuntary admissions.

CONCLUSIONS

The ReCoN intervention has the potential for application to both national and international mental health services. The co-creation process with the full range of stakeholders ensures face validity, acceptability, and relevance. The effectiveness of the ReCoN intervention is currently being tested in a cluster randomised controlled trial. Given positive effects, the ReCoN intervention may impact individuals with a severe mental illness at risk of involuntary admissions, as more people may experience empowerment and autonomy instead of coercion in their recovery process.

What Are Complex Interventions in Suicide Research? Definitions, Challenges, Opportunities, and the Way Forward

It has been argued that effective action towards addressing a complex concern such as suicide requires a combination of evidence-based strategies. While these complex public health approaches have recently gained importance, little is known about their characteristics and what contributes to their complexity. The use of interchangeable terms such as multilevel, multicomponent, community based, and inconsistent definitions of these approaches creates confusion around what it is and what it is not. In practice, this disorder is reflected in a substantial variation in the design, implementation, and evaluation of complex approaches in suicide research. While it is impossible to resolve all existing inconsistencies in terminology, this review explores a range of terms and definitions to connote complex interventions. It aims to unpack multiple meanings of these terms and their diverse usage in suicide literature. The potential implications of this fluidity and plausible pathways to make sense of this complexity for suicide research are also discussed. With a shared understanding of what constitutes a complex intervention, we can expect to see an improved representation of the real-world complexities in our efforts to address suicide. This common language can also contribute toward quality implementation and dissemination and thereby advance our understanding of complex interventions.

Generalizability and reach of a randomized controlled trial to improve oral health among home care recipients: comparing participants and nonparticipants at baseline and during follow-up

Background

The generalizability of randomized controlled trials (RCTs) with a low response can be limited by systematic differences between participants and nonparticipants. This participation bias, however, is rarely investigated because data on nonparticipants is usually not available. The purpose of this article is to compare all participants and nonparticipants of a RCT to improve oral health among home care recipients at baseline and during follow-up using claims data.

Methods

Seven German statutory health and long-term care insurance funds invited 9656 home care recipients to participate in the RCT MundPflege. Claims data for all participants (n = 527, 5.5% response) and nonparticipants (n = 9129) were analyzed. Associations between trial participation and sex, age, care dependency, number of Elixhauser diseases, and dementia, as well as nursing, medical, and dental care utilization at baseline, were investigated using multivariable logistic regression. Associations between trial participation and the probability of (a) moving into a nursing home, (b) being hospitalized, and (c) death during 1 year of follow-up were examined via Cox proportional hazards regressions, controlling for baseline variables.

Results

At baseline, trial participation was positively associated with male sex (odds ratio 1.29 [95% confidence interval 1.08–1.54]), high (vs. low 1.46 [1.15–1.86]) care dependency, receiving occasional in-kind benefits to relieve caring relatives (1.45 [1.15–1.84]), having a referral by a general practitioner to a medical specialist (1.62 [1.21–2.18]), and dental care utilization (2.02 [1.67–2.45]). It was negatively associated with being 75–84 (vs. < 60 0.67 [0.50–0.90]) and 85 + (0.50 [0.37–0.69]) years old. For morbidity, hospitalizations, and formal, respite, short-term, and day or night care, no associations were found. During follow-up, participants were less likely to move into a nursing home than nonparticipants (hazard ratio 0.50 [0.32–0.79]). For hospitalizations and mortality, no associations were found.

Conclusions

For half of the comparisons, differences between participants and nonparticipants were observed. The RCT’s generalizability is limited, but to a smaller extent than one would expect because of the low response. Routine data provide a valuable source for investigating potential differences between trial participants and nonparticipants, which might be used by future RCTs to evaluate the generalizability of their findings.

Trial registration

German Clinical Trials Register DRKS00013517. Retrospectively registered on June 11, 2018.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06470-y.

A pilot randomized controlled trial of group-based indoor gardening and art activities demonstrates therapeutic benefits to healthy women

Background

There is mounting anecdotal and empirical evidence that gardening and art-making afford therapeutic benefits.

Objectives

This randomly controlled pilot study tested the hypothesis that participation in group-based indoor gardening or art-making activities for one hour twice a week for four weeks would provide quantifiably different therapeutic benefits to a population of healthy women ages 26–49.

Methods

A population of 42 volunteers was randomly assigned to parallel gardening or art-making treatment groups. A total of 36 participants initiated the treatment protocol and 32 (Gardening n = 15 and Art n = 17) received the interventions and completed all assessments. Treatments included eight one-hour group-based gardening or art intervention sessions. Self-report psychometric assessments were conducted for anxiety, depression symptomatology, mood disturbance, stress, satisfaction with discretionary social activities, and quality of life measures. Cardiac physiological data were also collected. Outcomes were measured at baseline, during, and post-intervention.

Results

Engaging in both gardening and art-making activities resulted in apparent therapeutic improvements for self-reported total mood disturbance, depression symptomatology, and perceived stress with different effect sizes following eight one-hour treatment sessions. Gardening also resulted in improvements for indications of trait anxiety. Based on time-course evidence, dosage responses were observed for total mood disturbance, perceived stress, and depression symptomatology for both gardening and art-making. However, gardening or art-making did not have an apparent influence on heart rate or blood pressure or result in marked improvement for satisfaction with discretionary leisure activities.

Conclusion

The data did not support the hypothesis of differential therapeutic benefits of gardening and art-making for healthy women. When taken together, group-based gardening or art-making can provide quantitatively measurable improvements in healthy women’s psychosocial health status that imply potentially important public health benefits.

Trial registration

ClinicalTrials.gov NCT03266120.

Protocol for an intervention development and pilot implementation evaluation study of an e-health solution to improve newborn care quality and survival in two low-resource settings, Malawi and Zimbabwe: Neotree

INTRODUCTION

Every year 2.4 million deaths occur worldwide in babies younger than 28 days. Approximately 70% of these deaths occur in low-resource settings because of failure to implement evidence-based interventions. Digital health technologies may offer an implementation solution. Since 2014, we have worked in Bangladesh, Malawi, Zimbabwe and the UK to develop and pilot Neotree: an android app with accompanying data visualisation, linkage and export. Its low-cost hardware and state-of-the-art software are used to improve bedside postnatal care and to provide insights into population health trends, to impact wider policy and practice.

METHODS AND ANALYSIS

This is a mixed methods (1) intervention codevelopment and optimisation and (2) pilot implementation evaluation (including economic evaluation) study. Neotree will be implemented in two hospitals in Zimbabwe, and one in Malawi. Over the 2-year study period clinical and demographic newborn data will be collected via Neotree, in addition to behavioural science informed qualitative and quantitative implementation evaluation and measures of cost, newborn care quality and usability. Neotree clinical decision support algorithms will be optimised according to best available evidence and clinical validation studies.

ETHICS AND DISSEMINATION

This is a Wellcome Trust funded project (215742_Z_19_Z). Research ethics approvals have been obtained: Malawi College of Medicine Research and Ethics Committee (P.01/20/2909; P.02/19/2613); UCL (17123/001, 6681/001, 5019/004); Medical Research Council Zimbabwe (MRCZ/A/2570), BRTI and JREC institutional review boards (AP155/2020; JREC/327/19), Sally Mugabe Hospital Ethics Committee (071119/64; 250418/48). Results will be disseminated via academic publications and public and policy engagement activities. In this study, the care for an estimated 15 000 babies across three sites will be impacted.

TRIAL REGISTRATION NUMBER

NCT0512707; Pre-results.

Factors affecting the implementation of a complex health intervention to improve insulin management in primary care: A SWOT analysis

Background

In South Africa, initiating and managing insulin in primary care for people living with type 2 diabetes (PLWD) is a major challenge. To address these challenges, a multidisciplinary team from the University of Pretoria (South Africa) developed the Tshwane Insulin project (TIP) intervention.

Aim

To determine internal and external factors, either facilitators or barriers, that could influence the implementation of the TIP intervention and propose strategies to ensure sustainability.

Setting

Tshwane District, Gauteng province, South Africa.

Methods

We used the SWOT framework to qualitatively analyse the strengths, weaknesses, opportunities, and threats influencing the implementation of the TIP intervention. Four field researchers and three managers from the TIP team participated in an online group discussion. We also conducted semi-structured interviews with healthcare providers (HCPs) (seven nurses, five doctors) and patients with type 2 diabetes (n = 13).

Results

Regardless of the identified weaknesses, the TIP intervention was accepted by PLWD and HCPs. Participants identified strengths including app-enabled insulin initiation and titration, pro-active patient follow-up, patient empowerment and provision of glucose monitoring devices. Participants viewed insulin resistance and the attitudes of HCPs as potential threats. Participants suggested that weaknesses and threats could be mitigated by translating education material into local languages and using the lived experiences of insulin-treated patients to address insulin resistance. The procurement of glucose monitoring devices by national authorities would promote the sustainability of the intervention.

Conclusion

Our findings may help decision-makers and health researchers to improve insulin management for PLWD in resource-constrained settings by using telehealth interventions.

Muslim Communities Learning About Second-hand Smoke in Bangladesh (MCLASS II): a combined evidence and theory-based plus partnership intervention development approach

Introduction

Deaths from second-hand smoke (SHS) exposure are increasing, but there is not sufficient evidence to recommend a particular SHS intervention or intervention development approach. Despite the available guidance on intervention reporting, and on the role and nature of pilot and feasibility studies, partial reporting of SHS interventions is common. The decision-making whilst developing such interventions is often under-reported. This paper describes the processes and decisions employed during transitioning from the aim of adapting an existing mosque-based intervention focused on public health messages, to the development of the content of novel community-based Smoke-Free Home (SFH) intervention. The intervention aims to promote smoke-free homes to reduce non-smokers’ exposure to SHS in the home via faith-based messages.

Methods

The development of the SFH intervention had four sequential phases: in-depth interviews with adults in households in Dhaka, identification of an intervention programme theory and content with Islamic scholars from the Bangladesh Islamic Foundation (BIF), user testing of candidate intervention content with adults, and iterative intervention development workshops with Imams and khatibs who trained at the BIF.

Results

It was judged inappropriately to take an intervention adaptation approach. Following the identification of an intervention programme theory and collaborating with stakeholders in an iterative and collaborative process to identify barriers, six potentially modifiable constructs were identified. These were targeted with a series of behaviour change techniques operationalised as Quranic verses with associated health messages to be used as the basis for Khutbahs. Following iterative user testing, acceptable intervention content was generated.

Conclusion

The potential of this community-based intervention to reduce SHS exposure at home and improve lung health among non-smokers in Bangladesh is the result of an iterative and collaborative process. It is the result of the integration of behaviour change evidence and theory and community stakeholder contributions to the production of the intervention content. This novel combination of intervention development frameworks demonstrates a flexible approach that could provide insights for intervention development in related contexts.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01100-5.

Factors influencing the implementation of an intimate partner violence intervention in nurse home visiting: A qualitative descriptive study

AIMS

To identify factors that influenced: (1) integration of an intimate partner violence intervention into the Nurse-Family Partnership programme and (2) utilization of the intervention with fidelity to the clinical pathway by nurses in their home visits.

DESIGN

A qualitative descriptive study embedded in the intervention arm (n = 7 sites) of a 15-site cluster randomized clinical trial to evaluate the intimate partner violence intervention.

METHODS

Semi-structured interviews (n = 13) were conducted with supervisors. Nurses at the seven sites shared their experiences in focus groups conducted at two time points (n = 14 focus groups, 12 months after baseline and following collection of client trial data). Qualitative data were generated between May 2012 and September 2016, with this post hoc analysis completed in 2021. Focus group data were analysed using a rapid qualitative analysis technique. Conventional content analysis was used to categorize data from the supervisor interviews.

RESULTS

Integration was negatively impacted by: (1) a lack of centralized programme support and (2) competing programme demands. At the practice level, multiple factors related to supervisor capacity, preservation of the nurse-client relationship and nurse, client and intervention attributes influenced nurses' capacity to address intimate partner violence with fidelity to the clinical pathway. A lack of privacy in home visits was the most common barrier to addressing clients' experiences of violence. The need for increased time for nurses to develop clinical expertise prior to the evaluation of the intervention was also identified.

CONCLUSION

Before implementing an intimate partner violence intervention, home visitation programmes need to attend to site readiness, provide support to supervisors to facilitate implementation, and provide nurses with time to develop the expertise and clinical judgement required to use a complex intervention whilst also respecting clients' agency to determine when and how they will respond to the violence in their relationships.ImpactWhat problem did the study address? Given the positive impacts that participating in the Nurse-Family Partnership intimate partner violence education had on nurse home visitors' attitudes and confidence to address this type of violence experienced by first-time mothers, it was important to understand what factors contributed to the low fidelity of intervention implementation in practice, a factor that may help to explain the lack of client-level impacts on maternal outcomes. What were the main findings? Implementation of an intimate partner violence intervention in a nurse home visiting programme was influenced by contextual factors at both programme and practice levels. At the practice level, a lack of privacy in the home limited nurses' capacity to use the intervention. Supervisors were identified as having an important role to support nurses develop the expertise to use the intervention. Nurses also consistently balanced the intervention requirements to address intimate partner violence with an understanding of the complexity of this type of violence in young women's lives and respect for clients' agency to determine when and how they will respond to the violence in their relationships. Where and on whom will the research have an impact? These findings will be of interest to: (1) researchers developing and evaluating complex nursing interventions to address intimate partner violence in home visitation programmes and (2) stakeholders leading the implementation of novel innovations in the Nurse-Family Partnership programme.

Working with families of adults affected by eating disorders: uptake, key themes, and participant experiences of family involvement in outpatient treatment-as-usual

BACKGROUND

Eating disorders are associated with significant personal and family costs. Clinical guidelines recommend family members be involved and supported during care, but little has been reported regarding the preferences of adults around carer involvement in treatment. The necessary intensity of family work with adults is also unknown. A trial of a standardised brief family involvement method was conducted in an adult eating disorder service offering treatment-as-usual. Uptake and feasibility of implementing the approach as part of standard outpatient care and the preliminary impact on issues identified by adult patients and carers were evaluated.

METHODS

Eligible referrals at an adult eating disorders outpatient clinic were offered as needed family consultation to address presenting interpersonal problems identified by patients and their family members, and outcomes were evaluated 4 weeks later. Pre and post intervention surveys identified participant self-reported change in (i) problem frequency, (ii) distress and disruption caused, and (iii) confidence regarding presenting problems. Open text responses provided an overview of patient and carer goals for family involvement and revealed how the novel method impacted these areas as well as overall experience of, and feedback regarding, the brief family intervention.

RESULTS

Twenty-four female participants aged 18-53, and 22 carers participated in 31 consultations. Common concerns raised were eating disorder related interpersonal and communication issues. The focused sessions, offered on a one-at-a-time basis, showed preliminary effectiveness for reducing both patients and carer concerns. For example, adult patients reported that life interference from interpersonal problems was lower and confidence to deal with them was higher following family consultation. Carers also reported that frequency, level of worry, and life interference around presenting problems were lower after the structured family intervention.

CONCLUSIONS

Brief family consultation, with a single focus on issues identified by family members and adult patients, was a safe and feasible procedure with adults affected by eating disorders. Effective at meeting the needs of participants, the framework investigated in the current study may also be a useful direction for adult services to consider when looking to support families and meet recommendations for their routine involvement in the outpatient care.

TRIAL REGISTRATION

Australian Clinical Trials Register number: ACTRN12621000047897 (www.anzctr.org.au).

Are verbatim transcripts necessary in applied qualitative research: experiences from two community-based intervention trials in Ghana

Conducting qualitative research within public health trials requires balancing timely data collection with the need to maintain data quality. Verbatim transcription of interviews is the conventional way of recording qualitative data, but is time consuming and can severely delay the availability of research findings. Expanding field notes into fair notes is a quicker alternative method, but is not usually recommended as interviewers select and interpret what they record. We used the fair note methodology in Ghana, and found that where research questions are relatively simple, and interviewers undergo sufficient training and supervision, fair notes can decrease data collection and analysis time, while still providing detailed and relevant information to the study team. Interviewers liked the method and felt it made them more reflective and analytical and improved their interview technique. The exception was focus group discussions, where the fair note approach failed to capture the interaction and richness of discussions, capturing group consensus rather than the discussions leading to this consensus.

Components of case management in caring for patients with dementia: a mixed-methods study

BACKGROUND

Case management has shown improvements in some health outcomes for dementia patients and their families. However, despite its benefits the components of case management in order to provide effective patient and family care remain unknown at present. Thus, the aim of this study is to identify the specific components of case management in caring for patients with dementia and to determine the necessary intensity of its deployment to enhance outcomes for these patients and their caregivers.

METHODS

Mixed-methods study with a qualitative phase to characterise forms of service provision, according to the case management components involved, followed by a quantitative phase to analyse the correlations between different patterns of service provision, adverse events in patients and caregiver overload. This study will be based on the variables described in the RANGE.COM register.

DISCUSSION

This research is expected to achieve a reproducible, evaluable set of interventions that can be modelled to optimise case management effectiveness for patients with dementia. Interactions between patients with dementia, their family caregivers and case management healthcare services, the components of these interactions and their association with the conditions of the individuals concerned are issues of great interest in the field of case management, which is constantly evolving.

Scotland's "Incentivised Laparoscopy Practice" programme: Engaging trainees with take-home laparoscopy simulation

BACKGROUND

The transfer validity of portable laparoscopy simulation is well established. However, attempts to integrate take-home simulation into surgical training have met with inconsistent engagement worldwide, as for example in our 2014-15 study of an Incentivised Laparoscopy Practice programme (ILPv1). Drawing on learning from our subsequent multi-centre study examining barriers and facilitators, we revised the programme for 2018 onwards. We now report on engagement with the 2018-2022 versions of this home-based simulation programme (ILP v2.1-2.3).

METHODS

In ILP v2.1-2.3, three consecutive year-groups of new-start Core Surgical Trainees (n = 48, 46 and 53) were loaned portable simulators. The 6-month education programme included induction, technical support, and intermittent feedback. Six tasks were prescribed, with video instruction and charting of metric scores. Video uploads were required and scored by faculty. A pass resulted in an eCertificate, expected at Annual Review (but not mandatory for progression). ILP was set within a wider reform, "Improving Surgical Training".

RESULTS

ILP v2.1-2.3 saw pass rates of 94%, 76% and 70% respectively (45/48, 35/46 and 37/53 trainees), compared with only 26% (7/27) in ILP v1, despite now including some trainees not intending careers in laparoscopic specialties. The ILP v2.2 group all reported their engagement with the whole simulation strategy was hampered by the COVID19 pandemic.

CONCLUSIONS

Simply providing take-home simulators, no matter how good, is not enough. To achieve trainee engagement, a whole programme is required, with motivated learners, individual and group practice, intermittent feedback, and clear goals and assessments. ILP is a complex intervention, best understood as a "reform within a reform, within a context."

The Conceptual Framework for the International Food Policy Study: Evaluating the Population-Level Impact of Food Policy

An unhealthy diet is among the leading global causes of death and disability. Globally, a range of policies are being implemented to support healthy food choices at a population level, including novel polices in the areas of food marketing, nutrition labeling, and taxation of less healthy foods. There is a need to evaluate and inform the implementation of these policies, including their impacts on marginalized population subgroups. The International Food Policy Study (IFPS) consists of repeated cross-sectional surveys conducted in 5 high- and upper-middle-income countries: Australia, Canada, Mexico, the United Kingdom, and the United States. In each country, approximately 4000 adults and 1200 children and youth (aged 10-17) were recruited from a global commercial panel to complete an online survey using consistent measures and methodologies across countries. The first annual IFPS surveys were conducted in 2017 with adults; annual surveys for young people aged 10-17 were launched in 2019 in the same countries, as well as in Chile. The design of the IFPS surveys creates a framework for evaluating "natural experiments" in food policies, including comparisons over time within countries implementing the policy and comparisons with countries in which the policy was not implemented. IFPS surveys have 3 primary areas of focus: 1) knowledge, attitudes, and beliefs associated with specific policies; 2) diet-related behaviors; and 3) dietary intake, including 24-hour dietary recalls for adults in 4 of the 5 countries. Surveys also assess food insecurity, income adequacy, sex and gender, race/ethnicity, and a range of other measures to assess trends among priority subgroups. Overall, the IFPS project has the potential to address important gaps in national monitoring surveys for dietary patterns, and to evaluate the impacts of novel food policies implemented in any of the 5 countries over the study period.

Acceptability of A Virtual Mind-Body Group Intervention for Teen Siblings of Children with Autism Spectrum Disorder

Teenage siblings of children with autism spectrum disorder (ASD) are at risk of worse mental health outcomes than their peers, yet there have been few interventions focused on improving their psychosocial wellbeing. This study explored the acceptability of an 8-session virtual group mind-body resiliency intervention for teen siblings of children with ASD. We used mixed methods to assess quantitative and qualitative survey results. Participants reported that the intervention had the right amount of sessions (88%), structure (74%), and duration (89%). Most participants felt comfortable during sessions (74%), found it helpful to learn mind-body exercises (74%), and that the intervention helped in coping with stress (71%). Though participants were satisfied with the opportunity to meet peers, they desired more social connection.

Application of the Behavior Change Wheel Within the Context of Internet-Based Cognitive Behavioral Therapy for Tinnitus Management

PURPOSE

Although experiencing tinnitus can lead to many difficulties, these can be reduced by using techniques derived from cognitive behavioral therapy. Internet-based cognitive behavioral therapy (ICBT) has been developed to provide an accessible intervention. The aim of this study was to describe how ICBT can facilitate tinnitus management by identifying the active ingredients of the intervention from the perspective of health behavior change.

METHOD

The ICBT intervention was evaluated using the Behavior Change Wheel in eight steps across the following three stages: (1) understanding the behavior, (2) identifying intervention options, and (3) identifying content and implementation options.

RESULTS

Target behaviors identified to reduce tinnitus distress, as well as additional problems associated with tinnitus, included goal setting, an increased understanding of tinnitus, encouraging deep breathing and progressive muscle relaxation, identifying and restructuring unhelpful thoughts, engaging in positive imagery, and reducing avoidance behaviors. ICBT provided the required components for individuals to be physically and psychologically capable of adapting to tinnitus, providing social and environmental opportunities to manage hearing loss through practice and training, and facilitated automatic and reflective motivation.

CONCLUSION

Understanding ICBT in the context of the Behavior Change Wheel has helped identify how its effectiveness can be improved and can be used for future tinnitus intervention planning.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19555213.

Improving adaptive seamless designs through Bayesian optimization

We propose to use Bayesian optimization (BO) to improve the efficiency of the design selection process in clinical trials. BO is a method to optimize expensive black-box functions, by using a regression as a surrogate to guide the search. In clinical trials, planning test procedures and sample sizes is a crucial task. A common goal is to maximize the test power, given a set of treatments, corresponding effect sizes, and a total number of samples. From a wide range of possible designs, we aim to select the best one in a short time to allow quick decisions. The standard approach to simulate the power for each single design can become too time consuming. When the number of possible designs becomes very large, either large computational resources are required or an exhaustive exploration of all possible designs takes too long. Here, we propose to use BO to quickly find a clinical trial design with high power from a large number of candidate designs. We demonstrate the effectiveness of our approach by optimizing the power of adaptive seamless designs for different sets of treatment effect sizes. Comparing BO with an exhaustive evaluation of all candidate designs shows that BO finds competitive designs in a fraction of the time.

Process evaluations of mental health and psychosocial support interventions for populations affected by humanitarian crises

BACKGROUND

Randomised controlled trials (RCTs) have been increasingly used to test the effectiveness of mental health and psychosocial support(MHPSS) interventions for populations affected by humanitarian crises. Process evaluations are often integrated within RCTs of psychological interventions to investigate the implementation of the intervention, the impact of context, and possible mechanisms of action. We aimed to explore limitations and strengths of how process evaluations are currently conceptualised and implemented within MHPSS RCTs specifically.

METHODS

In April-June 2021 we conducted semi-structured interviews with 24 researchers involved in RCTs of MHPSS interventions in 23 different countries. Participants were selected based on systematic reviews of MHPSS interventions, funders' databases, and personal networks. Data were analysed using codebook thematic analysis.

RESULTS

The conduct of process evaluations was characterized by high heterogeneity in perceived function, implementation outcomes assessed, and methods used. While process evaluations were overwhelmingly considered as an important component of an RCT, there were different opinions on their perceived quality. This could be explained by the varying prioritization of effectiveness data over implementation data, confusion around the nature of process evaluations, and challenges in the collection and analysis of process data in humanitarian settings. Various practical recommendations were made by participants to improve future process evaluations in relation to: (i) study design (e.g., embedding process evaluations in study protocol and overall study objectives); (ii) methods (e.g., use of mixed methods); and (iii) increased financial and human resources dedicated to process evaluations.

CONCLUSION

The current state of process evaluations in MHPSS RCTs is heterogeneous. The quality of process evaluations should be improved to strengthen implementation science of the growing number of evidence-informed MHPSS interventions.

Encouraging older adults with pre-frailty and frailty to "MoveStrong": an analysis of secondary outcomes for a pilot randomized controlled trial

BACKGROUND

This 8-week pilot stepped-wedge randomized controlled trial evaluated the MoveStrong program for teaching adults who have frailty/pre-frailty about balance and functional strength training and sufficient protein intake to prevent falls and improve mobility.

METHODS

We recruited individuals aged 60 years and over, with a FRAIL scale score of 1 or higher and at least one chronic condition, who were not currently strength training. The program included 16 exercise physiologist-led hour-long group sessions and two dietitian-led hour-long nutrition sessions. We analyzed secondary outcomes-weight, gait speed, grip strength, physical capacity (fatigue levels), sit-to-stand functioning, dynamic balance, health-related quality of life (HRQoL), physical activity levels and protein intake-using a paired t test and a generalized estimating equation (GEE).

RESULTS

Of 44 participants (mean [SD] age 79 [9.82] years), 35 were pre-frail and 9 were frail. At follow-up, participants had significantly improved grip strength (1.63 kg, 95% CI: 0.62 to 2.63); sit-to-stand functioning (2 sit-to-stands, 95% CI: 1 to 3); and dynamic balance (1.68 s, 95% CI: 0.47 to 2.89). There were no significant improvements in gait speed, HRQoL index scores, self-rated health, physical activity levels (aerobic activity and strength training) or protein intake. GEE analysis revealed an interaction between exposure to MoveStrong and gait speed, sit-to-stand functioning, dynamic balance and HRQoL index scores. The total cost to administer the program and purchase equipment was CAD 14 700, equivalent to CAD 377 per participant.

CONCLUSION

Exploratory analyses suggest MoveStrong exercises may improve gait speed, sit-to-stand functioning, dynamic balance and HRQoL index scores in older individuals who are frail and pre-frail.

Fatigue self-management education in persons with disease-related fatigue: A comprehensive review of the effectiveness on fatigue and quality of life

OBJECTIVES

To systematically synthesize the effectiveness of fatigue self-management education (SME) on fatigue and quality of life (QoL) in persons with disease-related fatigue, and to describe the intervention characteristics.

METHODS

We systematically reviewed the literature on SMEs in people with disease-related fatigue. We included randomized controlled trials (RCT), which aimed to improve self-management skills for fatigue in daily life. We synthesized the effectiveness and mapped the intervention characteristics.

RESULTS

We included 26 RCTs studying samples from eight disease groups. At follow-up, 46% studies reported statistically significant improvements on fatigue and 46% on QoL. For persons with cancer 6/8 and multiple sclerosis 8/10 RCTs showed positive evidence in favor of SME. The range of effect sizes was wide (d: 0.0 ->0.8). Delivery modalities (inpatient, outpatient, home), interactions (individual, group, remote), and duration [range (h): 1-17.5] varied.

CONCLUSIONS

The overall evidence on the effectiveness of SMEs on fatigue and QoL is limited and inconsistent. For persons with cancer and multiple sclerosis, the evidence provides a positive effect. The RCTs with medium to large effect on QoL indicate the potential benefit of SMEs.

PRACTICAL IMPLICATION

Duration and peer interaction should be considered when tailoring SMEs to populations and contexts.

Consultations’ demand for a hospital palliative care unit: how to increase appropriateness? Implementing and evaluating a multicomponent educational intervention aimed at increase palliative care complexity perception skill

Background

Planned, multidisciplinary teams’ discussions of cases are common in cancer care, but their impact on patients’ outcome is not always clear. Palliative care (PC) needs might emerge long before the last weeks of life. Many palliative care patients could be managed from the usual care staff, if appropriately trained; specialist palliative care should be provided to patients with more complex needs. Staff needs adequate training, so that only patients presenting a higher complexity are properly referred to the second level (“specialized”) PC services. In the considered hospital setting, “tumour boards” (multidisciplinary discussions) refer often to a low number of patients. Overall complexity of patients’ needs is hardly considered.

Methods

A mixed method pilot study with data triangulation of professionals’ interviews and an independently structured evaluation of complexity of referred patients, before and after the intervention, using the PALCOM instrument. We trained four teams of professionals to deliver first-level palliation and to refer patients with complex needs detected in multidisciplinary discussions. A multicomponent, first level PC educational intervention, including information technology’s adaptation, a training course, and bedside training was offered from the specialized PC Services, to all the HPs involved in multidisciplinary pancreas, lung, ovarian, and liver tumour boards.

Results

While the level of complexity of referred patients did not increase, trainees seemed to develop a better understanding of palliative care and a higher sensitivity to palliative needs. The number of referred patients increased, but patients’ complexity did not. Qualitative data showed that professionals seemed to be more aware of the complexity of PC needs. A “meaning shift” was perceived, specifically on the referral process (e.g., “when” and “for what” referring to specialist PC) and on the teams’ increased focus on patients’ needs. The training, positively received, was adapted to trainees’ needs and observations that led also to organizational modifications.

Conclusions

Our multicomponent intervention positively impacted the number of referrals but not the patients’ complexity (measured with the PALCOM instrument). Hospital staff does not easily recognize that patients may have PC needs significantly earlier than at the end of life.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-00968-7.

Implementation of prehabilitation in colorectal cancer surgery: qualitative research on how to strengthen facilitators and overcome barriers

Purpose

Prehabilitation is increasingly offered to patients with colorectal cancer (CRC) undergoing surgery as it could prevent complications and facilitate recovery. However, implementation of such a complex multidisciplinary intervention is challenging. This study aims to explore perspectives of professionals involved in prehabilitation to gain understanding of barriers or facilitators to its implementation and to identify strategies to successful operationalization of prehabilitation.

Methods

In this qualitative study, semi-structured interviews were performed with healthcare professionals involved in prehabilitation for patients with CRC. Prehabilitation was defined as a preoperative program with the aim of improving physical fitness and nutritional status. Parallel with data collection, open coding was applied to the transcribed interviews. The Ottawa Model of Research Use (OMRU) framework, a comprehensive interdisciplinary model guide to promote implementation of research findings into healthcare practice, was used to categorize obtained codes and structure the barriers and facilitators into relevant themes for change.

Results

Thirteen interviews were conducted. Important barriers were the conflicting scientific evidence on (cost-)effectiveness of prehabilitation, the current inability to offer a personalized prehabilitation program, the complex logistic organization of the program, and the unawareness of (the importance of) a prehabilitation program among healthcare professionals and patients. Relevant facilitators were availability of program coordinators, availability of physician leadership, and involving skeptical colleagues in the implementation process from the start.

Conclusions

Important barriers to prehabilitation implementation are mainly related to the intervention being complex, relatively unknown and only evaluated in a research setting. Therefore, physicians’ leadership is needed to transform care towards more integration of personalized prehabilitation programs.

Implications for cancer survivors

By strengthening prehabilitation programs and evidence of their efficacy using these recommendations, it should be possible to enhance both the pre- and postoperative quality of life for colorectal cancer patients during survivorship.

Evolution of Therapeutic Patient Education: A Systematic Scoping Review and Scientometric Analysis

Therapeutic patient education (TPE) aims to empower the patients and their caregivers to effectively care for and manage their conditions. Such educational programs have been shown to improve health behaviors, disease outcomes, and quality of life among different patient populations. The field of TPE has evolved extensively over decades, owing to interdisciplinary research. No study so far has been done to map this field, to identify the stakeholders and gaps requiring future research. By leveraging the theory of co-citation, CiteSpace was used to visualize the bibliographic data pertaining to TPE research. A total of 54,533 articles published in English language were analyzed to identify influential funders, regions, and institutes contributing to this field. Besides these, significant theoretical and empirical contributions that shaped this field were mapped. Our analysis revealed several important insights. Most of the important theories that helped shape TPE were inspired from the social sciences. Five important research themes were identified: disorders, study designs utilized in TPE research, the scope of the TPE literature and outcomes, and populations. The research focused on improving perceptions, behaviors, and attitudes toward health promotion, reducing stigma, self-management and medication adherence. Most of the research was developed in the context of high-income countries. Future research should involve patients and use digital technology. Meta-analytical studies need to be done to identify the effectiveness and moderators of TPE interventions across different disorders. Further research should involve low and middle-income countries (LMIC) to ensure knowledge and technology transfer.