Lessons from complex interventions to improve health

A systematic review of the main mechanisms of heart failure disease management interventions

OBJECTIVE

To identify the main mechanisms of heart failure (HF) disease management programmes based in hospitals, homes or the community.

METHODS

Systematic review of qualitative and quantitative studies using realist synthesis. The search strategy incorporated general and specific terms relevant to the research question: HF, self-care and programmes/interventions for HF patients. To be included, papers had to be published in English after 1995 (due to changes in HF care over recent years) to May 2014 and contain specific data related to mechanisms of effect of HF programmes. 10 databases were searched; grey literature was located via Proquest Dissertations and Theses, Google and publications from organisations focused on HF or self-care.

RESULTS

33 studies (n=3355 participants, mean age: 65 years, 35% women) were identified (18 randomised controlled trials, three mixed methods studies, six pre-test post-test studies and six qualitative studies). The main mechanisms identified in the studies were associated with increased patient understanding of HF and its links to self-care, greater involvement of other people in this self-care, increased psychosocial well-being and support from health professionals to use technology.

CONCLUSION

Future HF disease management programmes should seek to harness the main mechanisms through which programmes actually work to improve HF self-care and outcomes, rather than simply replicating components from other programmes. The most promising mechanisms to harness are associated with increased patient understanding and self-efficacy, involvement of other caregivers and health professionals and improving psychosocial well-being and technology use.

Balancing stakeholder needs in the evaluation of healthcare quality improvement

Quality improvement (QI) efforts affect a broader range of people than we often assume. These are the potential stakeholders for QI and its evaluation, and they have valuable perspectives to offer when they are consulted in planning, conducting and interpreting evaluations. QI practitioners are accustomed to consulting stakeholders to assess unintended consequences or assess patient experiences of care, but in many cases there are additional benefits to a broad inclusion of stakeholders. These benefits are better adherence to ethical standards, to assure that all legitimate interests take part, more useful and relevant evaluation information and better political buy-in to improve impact. Balancing various stakeholder needs for information requires skill for both politics and research management. These challenges have few pat answers, but several preferred practices, which are illustrated with practical examples.

Variations in schools' commitment to health and implementation of health improvement activities: a cross-sectional study of secondary schools in Wales

Background

Interventions to improve young people’s health are most commonly delivered via schools. While young people attending the lowest socioeconomic status (SES) schools report poorer health profiles, no previous studies have examined whether there is an ‘inverse care law’ in school health improvement activity (i.e., whether schools in more affluent areas deliver more health improvement). Nor have other factors that may explain variations, such as leadership of health improvement activities, been examined at a population level. This paper examines variability in delivery of health improvement actions among secondary schools in Wales, and whether variability is linked to organisational commitment to health, socioeconomic status and school size.

Methods

Of the 82 schools participating in the 2013/14 Health Behaviour in School-aged Children (HBSC) survey in Wales, 67 completed a questionnaire on school health improvement delivery structures and health improvement actions within their school. Correlational analyses explore associations of delivery of health improvement activity among schools in Wales with organisational commitment to health, socioeconomic context and school size.

Results

There is substantial variability among schools in organisational commitment to health, with pupil emotional health identified as a priority by 52 % of schools, and physical health by 43 %. Approximately half (49 %) report written action plans for pupil health. Based on composite measures, the quantity of school health improvement activity was greater in less affluent schools and schools reporting greater commitment to health. There was a consistent though non-significant trend toward more health improvement activity in larger schools. In multivariate analysis deprivation (OR = 1.06; 95 % CI = 1.01 to 1.12) and organisational commitment to health were significant independent predictors of the quantity of health improvement (OR = 1.60; 95 % CI = 1.15 to 2.22).

Conclusions

There is no evidence of an ‘inverse care law’ in school health, with some evidence of more comprehensive, multi-level health improvement activity in more deprived schools. This large-scale, quantitative analysis supports previous smaller scale, qualitative studies/process evaluations that suggest that senior management team commitment to delivering health improvement, and formulating and reviewing progress against written action plans, are important for facilitating the delivery of comprehensive interventions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-2763-0) contains supplementary material, which is available to authorized users.

Extreme Weather-driven Disasters and Children’s Health

Extreme weather events such as heat waves, extreme precipitation, and storm surges are likely to become more frequent and intense with climate change. Extreme weather-driven disasters (EWDDs) cause a substantial burden of childhood mortality and morbidity worldwide. We reviewed the published literature on EWDDs and their health impacts on children, and developed a conceptual model based on complex systems thinking to identify the health risks, vulnerabilities, and capacities of children in the context of EWDDs as a means of informing areas for adaptive intervention. We found that direct and indirect physical and mental impacts of EWDDs on child health are abundant and interrelate in complex ways. The literature review and modeling demonstrated the centrality of resilience at the level of the child and his or her direct environment, suggesting that mental health status may play a key role in a child’s experience of numerous other health outcomes of EWDDs. EWDDs interact with environmental and social systems and with individual children and their contexts in complex ways, the impacts of which are nonlinear and difficult to predict. Traditional perspectives on climate change-driven health impacts often overlook complex bio-psychosocial interactions, suggesting a need to work on preventive strategies to reduce vulnerability and build individual child resilience.

Intervention Component Analysis (ICA): a pragmatic approach for identifying the critical features of complex interventions

BACKGROUND

In order to enable replication of effective complex interventions, systematic reviews need to provide evidence about their critical features and clear procedural details for their implementation. Currently, few systematic reviews provide sufficient guidance of this sort.

METHODS

Through a worked example, this paper reports on a methodological approach, Intervention Component Analysis (ICA), specifically developed to bridge the gap between evidence of effectiveness and practical implementation of interventions. By (a) using an inductive approach to explore the nature of intervention features and (b) making use of trialists' informally reported experience-based evidence, the approach is designed to overcome the deficiencies of poor reporting which often hinders knowledge translation work whilst also avoiding the need to invest significant amounts of time and resources in following up details with authors.

RESULTS

A key strength of the approach is its ability to reveal hidden or overlooked intervention features and barriers and facilitators only identified in practical application of interventions. It is thus especially useful where hypothesised mechanisms in an existing programme theory have failed. A further benefit of the approach is its ability to identify potentially new configurations of components that have not yet been evaluated.

CONCLUSIONS

ICA is a formal and rigorous yet relatively streamlined approach to identify key intervention content and implementation processes. ICA addresses a critical need for knowledge translation around complex interventions to support policy decisions and evidence implementation.

Understanding the Role of Public Administration in Implementing Action on the Social Determinants of Health and Health Inequities

Many of the societal level factors that affect health - the 'social determinants of health (SDH)' - exist outside the health sector, across diverse portfolios of government, and other major institutions including non-governmental organisations (NGOs) and the private sector. This has created growing interest in how to create and implement public policies which will drive better and fairer health outcomes. While designing policies that can improve the SDH is critical, so too is ensuring they are appropriately administered and implemented. In this paper, we draw attention to an important area for future public health consideration - how policies are managed and implemented through complex administrative layers of 'the state.' Implementation gaps have long been a concern of public administration scholarship. To precipitate further work in this area, in this paper, we provide an overview of the scholarly field of public administration and highlight its role in helping to understand better the challenges and opportunities for implementing policies and programs to improve health equity.

COSMOS--improving the quality of life in nursing home patients: protocol for an effectiveness-implementation cluster randomized clinical hybrid trial

BACKGROUND

Nursing home patients have complex mental and physical health problems, disabilities and social needs, combined with widespread prescription of psychotropic drugs. Preservation of their quality of life is an important goal. This can only be achieved within nursing homes that offer competent clinical conditions of treatment and care. COmmunication, Systematic assessment and treatment of pain, Medication review, Occupational therapy, Safety (COSMOS) is an effectiveness-implementation hybrid trial that combines and implements organization of activities evidence-based interventions to improve staff competence and thereby the patients' quality of life, mental health and safety. The aim of this paper is to describe the development, content and implementation process of the COSMOS trial.

METHODS/DESIGN

COSMOS includes a 2-month pilot study with 128 participants distributed among nine Norwegian nursing homes, and a 4-month multicenter, cluster randomized effectiveness-implementation clinical hybrid trial with follow-up at month 9, including 571 patients from 67 nursing home units (one unit defined as one cluster). Clusters are randomized to COSMOS intervention or current best practice (control group). The intervention group will receive a 2-day education program including written guidelines, repeated theoretical and practical training (credited education of caregivers, physicians and nursing home managers), case discussions and role play. The 1-day midway evaluation, information and interviews of nursing staff and a telephone hotline all support the implementation process. Outcome measures include quality of life in late-stage dementia, neuropsychiatric symptoms, activities of daily living, pain, depression, sleep, medication, cost-utility analysis, hospital admission and mortality.

DISCUSSION

Despite complex medical and psychosocial challenges, nursing home patients are often treated by staff possessing low level skills, lacking education and in facilities with a high staff turnover. Implementation of a research-based multicomponent intervention may improve staff's knowledge and competence and consequently the quality of life of nursing home patients in general and people with dementia in particular.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02238652.