Experimental and quasi-experimental designs in implementation research

Harnessing Implementation Science in Clinical Psychology: Past, Present, and Future

Implementation science aspires to equitably accelerate the uptake of clinical research into practice to improve population health. The focus of implementation science includes individual behavior change mechanisms that are similar to those that drive the field of clinical psychology. For this reason, clinical psychologists are well-suited to take up implementation science methods in pursuit of improving the quality of behavioral health care. To do so, clinical psychologists must expand beyond individual behavior change to include a focus on organizations and systems. In this review, we reflect on ways that clinical psychologists can lead in the integration of implementation science principles and approaches into clinical psychology research and practice. We discuss the role clinical psychologists play in closing know-do gaps in behavioral health and describe how clinical psychologists can build implementation science competencies. We end with current controversies and opportunities for innovation to further improve the quality of behavioral health care.

Implementation of a High-Reliability Organization Framework in a Large Integrated Health Care System: A Pre-Post Quasi-Experimental Quality Improvement Project

INTRODUCTION

The purpose of this quality improvement (QI) project was to evaluate outcomes across Veterans Health Administration (VHA) hospital facilities engaged in an enterprise-wide implementation of a high-reliability organization (HRO) framework.

MATERIALS AND METHODS

This QI project relied on primary data drawn from 139 facilities nationwide from 2019 to 2023. Data sources included the All Employee Survey Patient Safety Culture (PSC) Module and patient safety reporting data derived from the Joint Patient Safety Reporting system. The project design applied a pre-post quasi-experimental design that examined within-cohort changes at pre-intervention, intervention, and 2 post-intervention follow-up timepoints. HRO interventions included a combination of training, leadership coaching, site assessments, and experiential learning. HRO interventions were initiated at 18 facilities beginning in 2019 (Cohort 1), 54 facilities in 2020 (Cohort 2), and 67 facilities in 2021 (Cohort 3). For between-cohort analyses, the relative degree of change within Cohort 1 sites was compared with all other sites.

RESULTS

There were broad positive within-group trends for PSC scores across all sites, and domain-specific between-group differences in PSC Dimension 2-Risk Identification and Just Culture-and Dimension 4-Error Transparency and Risk Mitigation. For patient safety reporting, total events reported, and close calls increased for Cohort 1. The ratio of close calls to adverse events also increased for both Cohort 1 and all other VHA sites at post-intervention year 2.

CONCLUSIONS

The results of this QI project will inform further refinements to VHA's efforts to implement HRO principles and practices in the nation's largest integrated health system. In addition, the implementation practices may inform other large-scale, multi-level efforts to improve quality and patient safety.

Intensive End-of-Life Care: Implementation of a Canadian Guideline-Based Order Set for the Withdrawal of Life-Sustaining Therapy in the Intensive Care Unit

Background

An increasing number of patients receive end-of-life care in the intensive care unit (ICU). Death often occurs in the ICU after a decision has been made to withdraw life-sustaining therapies. In 2016, Downar et al. published Canadian consensus guidelines to standardize practices for withdrawal of life-sustaining therapy in the ICU. In this study, we sought to understand the feasibility and acceptability of implementing an order set, nursing flowsheet, and nursing care plan based on these guidelines in two ICUs in Saskatchewan, Canada.

Methods

We used a hybrid effectiveness-implementation design, engaging a steering committee of ICU health care providers and leadership to guide implementation. We conducted a six-month pilot implementation. We collected data in the three months pre-implementation, during the six-month implementation period, and for three months post-implementation. To evaluate implementation outcomes, we used the Consolidated Framework for Implementation Research to develop semi-structured interviews and feasibility surveys. To measure effectiveness outcomes, bedside nurses completed Quality of Death and Dying surveys, and we performed a patient chart review.

Results

The intervention materials added to the burden of paperwork of bedside health care providers but helped them provide quality end-of-life care, meet the needs of patients and their families, and lessen ethical tensions between symptom control and hastening death. There was no difference in cumulative sedative dosing and time to death after extubation in the pre-implementation, implementation, or post-implementation periods. A significant increase in symptom assessment (pain, dyspnea, and agitation) using standardized tools was observed during the implementation and post-implementation periods. There was an improvement in holistic care outcomes post-implementation.

Conclusions

We implemented current Canadian best-practice guidelines for providing end-of-life care in the ICU using a multidisciplinary approach. This study offers insight into how standardized symptom assessment and medication titration can be incorporated into the complex ICU environment.

Big Talks for Little People: A Pilot Study of a Classroom Based Mental Health Program

BACKGROUND

Schools are important settings for the promotion, implementation and education of mental health and well-being. The present study piloted and evaluated a classroom based mental health and well-being programme for use in primary schools.

METHODS

A mixed-method quasi-hybrid design methodology was utilised. An online survey was completed by students from five schools pretest (n = 173) and three schools matched post-test (n = 68) with semi-structured interviews with teachers (n = 4) and a focus group of students (n = 18) conducted at the completion of the programme. Student questionnaire data was gathered including the use of three standardised and internationally used measures of well-being.

RESULTS

Students at post-test self-reported significant improvements in positive emotional state (p < 0.05, moderate effect size), recognising (p < 0.001, large effect size) and expressing emotions (p < 0.001, moderate effect size) and reductions in anxiety (p < 0.001, moderate effect size).

CONCLUSIONS

The findings suggest the programme was effective in relation to promoting aspects of student well-being, emotional development and in reducing elements of anxiety. Shortcomings in the design including a lack of a control group must lead to caution in interpreting the outcomes.

SO WHAT

Further research with a larger student population which addresses the identified shortcomings of the present pilot study appears warranted.

Challenges and Considerations in Naming True and Quasi-Experimental Research Designs: A Methodological Discussion

Background: Novice researchers may face challenges in choosing names for true and quasi-experimental designs due to complexity in terminology and variety of experimental designs used in nursing. Addressing these issues is crucial for ensuring clarity and accuracy in experimental nursing research. Aim: To discuss the complexities, challenges, and considerations involved in naming true and quasi-experimental research designs and propose a decision tree for researchers to guide them in accurately and consistently naming these designs. Design: A methodological discussion. Methods: Research texts, the Public Health Agency of Canada Critical Appraisal Tool Kit, and articles from various scientific journals were chosen to illustrate the challenges and characteristics of different experimental and quasi-experimental study designs. Discussion: Key characteristics of true and quasi-experimental designs such as nature of experimental and control groups and process of random allocation are outlined and illustrated with examples. Conclusion: A decision tree is offered to help researchers and reviewers in the precise and consistent labeling of true and quasi-experimental designs. By providing a structured way for decision-making, it enhances the accuracy and reliability of classification processes.

Multicomponent Deimplementation Strategy to Reduce Low-Value Preoperative Testing

Importance

Routine preoperative blood tests and electrocardiograms before low-risk surgery do not prevent adverse events or change management but waste resources and can cause patient harm. Given this, multispecialty organizations recommend against routine testing before low-risk surgery.

Objective

To determine whether a multicomponent deimplementation strategy (the intervention) would reduce low-value preoperative testing before low-risk general surgery operations.

Design, Setting, and Participants

This study had a pre-post quality improvement interventional design using interrupted time series and difference-in-difference analytic approaches. The setting was a single academic, quaternary referral hospital with 2 freestanding ambulatory surgery centers and a central preoperative clinic. Included in the study were adult patients undergoing nonurgent outpatient inguinal hernia repairs, lumpectomy, or laparoscopic cholecystectomy between June 2022 and August 2023. Eligible clinicians included those treating at least 1 patient during both the preintervention and postintervention periods.

Interventions

All clinicians were exposed to the multicomponent deimplementation intervention, and their testing practices were compared before and after the intervention. The strategy components were evidenced-based decisional support, multidisciplinary stakeholder engagement, educational sessions, and consensus building with surgeons and physician assistants staffing a preoperative clinic.

Main Outcomes and Measures

The primary end point of the trial was the rate of unnecessary preoperative tests across each trial period.

Results

A total of 1143 patients (mean [SD] age, 58.7 [15.5] years; 643 female [56.3%]) underwent 261 operations (23%) in the preintervention period, 510 (45%) in the intervention period, and 372 (33%) in the postintervention period. Unnecessary testing rates decreased over each period (intervention testing rate, -16%; 95% CI, -4% to -27%; P = .01; postintervention testing rate, -27%; 95% CI, -17% to -38%; P = .003) and within each test category. The decrease in overall testing was not observed at other hospitals in the state on adjusted difference-in-difference analysis.

Conclusions and Relevance

In this quality improvement study, a multicomponent deimplementation strategy was associated with a reduction in unnecessary preoperative testing before low-risk general surgery operations. The resulting changes in testing practice patterns were not associated with temporal trends within or outside the study hospital. Results suggest that this intervention was effective, applicable to common general surgery operations, and adaptable for expansion into appropriate clinical settings.

The Effect of Integrated Simulation Experiential Learning Disaster Nursing for Enhancing Learning Outcomes Among Undergraduate Nursing Students: A Quasi-Experimental Study

Background

Traditional classroom-based learning often lacks the depth of experience to develop the practical skills and decision-making abilities needed in disaster situations. Integrated Simulation Experiential Learning Disaster Nursing (ISEL-DN) is an innovative approach that combines simulation technology with experiential learning, providing a more immersive and interactive learning experience for students.

Purpose

This study aimed to explore the effectiveness of the ISEL-DN model in enhancing knowledge, attitudes, satisfaction, and self-confidence among undergraduate nursing students.

Methods

A quasi-experimental study with a control group was conducted on 94 undergraduate nursing students (Intervention group: 47 and control group: 47). Samples were recruited using convenience sampling by inclusion and exclusion criteria. The intervention group was given learning based on ISEL-DN. The data were analyzed univariately by displaying the frequency distribution and central tendency, and comparisons were made using the Wilcoxon rank and Mann-Whitney U-tests.

Results

Significant improvements were observed in the control group across variables: knowledge (p<0.001), attitude (p=0.042), satisfaction (p=0.001), and overall self-confidence (p=0.009). In the intervention group, all variables and subcomponents showed significant improvements (p<0.05). The ISEL-DN model significantly increased knowledge and satisfaction, much greater than traditional learning (p<0.05).

Conclusion

This study showed that the ISEL-DN model significantly improved nursing students' knowledge and satisfaction, attitudes, and self-confidence compared to traditional learning. The knowledge and satisfaction variables observed the most significant improvement, indicating that the ISEL-DN model provided a more interactive and in-depth learning experience. This model can be innovative in disaster nursing education to improve students' preparedness to deal with emergency situations effectively.

The involvement of specialists in primary healthcare teams for managing diabetes: a systematic review and meta-analysis

BACKGROUND

Diabetes mellitus requires ongoing management and care coordination. The majority of patients with diabetes were managed in primary healthcare settings. Several quality improvement programs have introduced specialist involvement in primary healthcare teams. However, synthesized evidence is needed to support policy improvements regarding the impact of specialist-primary healthcare coordination on glycemic control in diabetes care.

OBJECTIVE

This systematic review and meta-analysis aimed to assess the effectiveness of specialist involvement in primary healthcare teams on glycemic control of patients with diabetes.

METHODS

A search of five electronic databases (PubMed, Embase, Web of Science Core Collection, CNKI, and Wanfang Database) was conducted to identify relevant studies published until October 21st, 2023. We assessed the methodological quality of the included studies using the suggested risk of bias criteria for EPOC (Cochrane Effective Practice and Organization of Care). We conducted the certainty assessment using the GRADE guideline. The outcome measured was the HbA1c level. Meta-analyses were performed using random-effects models.

RESULTS

A total of 12 studies (7 randomized controlled trials and 5 controlled before-after studies) were included in the meta-analysis. The involvement of specialists in primary healthcare teams was associated with a statistically significant reduction in HbA1c level compared to usual or standard care (mean difference - 0.57, 95% CI: -0.86 to -0.27, I2 = 88.17%).

CONCLUSION

The findings revealed that the interventions might improve the care delivered and patients' health outcomes. However, due to the very low certainty of evidence on the effectiveness on glycemic control, the interventions implemented in the included studies should be employed with caution in future policy-making to achieve improved HbA1c levels. Further research with a more rigorous design is needed to provide evidence of higher certainty and quality.

REGISTRATION

The systematic review and meta-analysis was registered in the PROSPERO International Prospective Register of Systematic Reviews (registration No. CRD42022384589 available at https://www.crd.york.ac.uk/prospero/#searchadvanced ).

Effects of socio-therapeutic interventions on cognitive functions among institutionalized elderly

Cognitive impairment affects over one billion people globally, with elderly individuals in institutions in China being particularly impacted. This study involved 60 elderly participants with mild cognitive impairment, who were randomly assigned to one of two groups: 30 in a control group receiving traditional programs from the elderly institution and 30 in an intervention group receiving socio-therapeutic methods. Cognitive function was assessed before the intervention, and at the end of the first, second, and third months (with unsupervised interventions in the third month). Initially, both groups had similar low MMSE scores. However, the socio-therapeutic intervention led to significant cognitive improvements in the intervention group after the first and second months, with results remaining higher than the control group by the end of the third month. The study highlights the effectiveness of socio-therapeutic interventions in enhancing cognitive function and suggests that such programs should be adopted in elderly care institutions. Further research is needed to explore long-term effects and optimal program components, with personalized interventions and family/community involvement recommended to maximize benefits.

A Scoping Review of Implementation Science Studies in the Field of Traumatic Brain Injury: State of the Science and Future Directions

OBJECTIVE

Implementation research is essential to accelerating the public health benefits of innovations in health settings. However, the US National Academies of Sciences, Engineering, and Medicine 2022 report identified a lag in published implementation research applied to traumatic brain injury (TBI). Our objectives were to characterize implementation science studies published to date in TBI clinical care and rehabilitation and provide recommendations for future directions.

METHODS

A scoping review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Articles published between 2011 and 2023 were identified (MEDLINE, PubMed, PsychInfo, and Web of Science), and included if the study focused on the TBI population, measured at least one Proctor (2011) implementation outcome and aligned with implementation research designs. Data were charted using an extraction template.

RESULTS

Of the 38 articles, 76% were published between 2018 and 2023. About 37% of articles were in the pre-implementation phase, and 57.9% were in the implementation phase. Over half of articles used a theory, model, or framework to guide the research. Fifteen studies were descriptive, 10 were qualitative, 7 were mixed methods, and 4 were randomized controlled trials. Most studies investigated implementation outcomes regarding national guidelines following TBI or TBI symptom management. Adoption (42.1%) and fidelity (42.1%) were the most commonly studied implementation outcomes, followed by feasibility (18.4%), acceptability (13.2%), and penetration (10.5%). Only 55% of studies used or tested the effectiveness of one or more implementation strategies, with training and education used most commonly, followed by data warehousing techniques.

CONCLUSIONS

Future research should prioritize the selection and investigation of implementation strategy effectiveness and mechanisms across contexts of care and use implementation research reporting standards to improve study rigor. Additionally, collaborative efforts between researchers, community partners, individuals with TBI, and their care partners could improve the equitable translation of innovations across service contexts.

Efficacy of community groups as a social prescription for senior health-insights from a natural experiment during the COVID-19 lockdown

Loneliness and associated physical and cognitive health decline among the aging population is an important medical concern, exacerbated in times of abnormal isolation like the 2020-2021 Covid-19 pandemic lockdown. In this backdrop, recent "social prescribing" based health policy initiatives such as community groups as a support structure for the aging population assumes great importance. In this paper, we evaluate and quantify the impact of such social prescribing policies in combatting loneliness and related health degeneration of the aging population in times of abnormal isolation. To this end, we conduct a natural experiment across a sample of 618 individuals aged 65 and over with varying access to community groups during the Covid-19 lockdown period. Using a random-effects, probit model to compare the differences in health outcomes of participants with access to community groups (target) with those without access (control), we find that the target group was 2.65 times less likely to suffer from loneliness as compared to the control group, along with lower incidences of reported cardiovascular and cognitive health decline. These initial findings provide preliminary support in favor of the interventional power of social prescription tools in mitigating loneliness and its consequent negative health impact on the aging population.

Comparison of Researcher-Led versus Teacher-Led effectiveness and fidelity: A Hybrid Type 1 study of Kids SIPsmartER in Appalachia middle schools

The implementation of school-based obesity-prevention programs is understudied. Kids SIPsmartER is a 6-month, school-based, behavioral intervention for Appalachian middle school students and includes a teacher implementation strategy. Kids SIPsmartER effectively reduced students' sugar-sweetened beverages (SSB) when Researcher-Led. However, Teacher-Led effectiveness and fidelity are unknown. To explore the relative SSB effects when Kids SIPsmartER was Researcher-Led versus Teacher-Led and to examine teacher fidelity. This study of secondary outcomes used a quasi-experimental analytic approach of a Hybrid Type 1 effectiveness-implementation and cluster randomized controlled tria (RCT) of Kids SIPsmartER. Student SSB behaviors and teacher self-rated fidelity were assessed, respectively, with the validated Beverage Intake Questionnaire (BEVQ-15) and lesson-specific checklists. Analyses included descriptive statistics and modified two-part models with time-fixed effects and school-year cohort cluster controls. The analytic sample included students from six control schools (n = 220), six Researcher-Led intervention schools (n = 306), and five Teacher-Led intervention schools (n = 218), as well as eight teachers. Teacher-Led intervention students decreased SSB by -14.3 ounces/day (95% confidence interval = -15.4, -13.2; P < .001). Relative to control and to Researcher-Led intervention, the Teacher-Led treatment effect among students was -11.6 ounces SSB/day (P < .001, effect size = 0.75) and -4.3 (P = .004, effect size = 0.25), respectively. Teachers returned fidelity checklists for 90% of planned lessons. Fidelity averaged 94% (SD = 4.0%) among returned forms and 85% (SD = 18.9%) when missing forms were counted as zeros. Teachers can implement Kids SIPsmartER with high fidelity and produce statistically and clinically meaningful improvements in students' SSB behaviors. Findings have implications for the sustained implementation of Kids SIPsmartER and other school-based obesity-prevention programs. Clinical Trial information: NCT03740113.

Leveraging Single-Case Experimental Designs to Promote Personalized Psychological Treatment: Step-by-Step Implementation Protocol with Stakeholder Involvement of an Outpatient Clinic for Personalized Psychotherapy

Our objective is to implement a single-case experimental design (SCED) infrastructure in combination with experience-sampling methods (ESM) into the standard diagnostic procedure of a German outpatient research and training clinic. Building on the idea of routine outcome monitoring, the SCED infrastructure introduces intensive longitudinal data collection, individual effectiveness measures, and the opportunity for systematic manipulation to push personalization efforts further. It aims to empower psychotherapists and patients to evaluate their own treatment (idiographic perspective) and to enable researchers to analyze open questions of personalized psychotherapy (nomothetic perspective). Organized around the principles of agile research, we plan to develop, implement, and evaluate the SCED infrastructure in six successive studies with continuous stakeholder involvement: In the project development phase, the business model for the SCED infrastructure is developed that describes its vision in consideration of the context (Study 1). Also, the infrastructure's prototype is specified, encompassing the SCED procedure, ESM protocol, and ESM survey (Study 2 and 3). During the optimization phase, feasibility and acceptability are tested and the infrastructure is adapted accordingly (Study 4). The evaluation phase includes a pilot implementation study to assess implementation outcomes (Study 5), followed by actual implementation using a within-institution A-B design (Study 6). The sustainability phase involves continuous monitoring and improvement. We discuss to what extent the generated data could be used to address current questions of personalized psychotherapy research. Anticipated barriers and limitations during the implementation processes are outlined.

On the Relationship Between Frailty, Nutritional Status, Depression and Quality of Life Among Older People

BACKGROUND

Frailty is a multidimensional geriatric syndrome associated with physical, psychological and social changes. There is a paucity of research on frailty in Sub-Saharan African (SSA) countries, especially Ethiopia.

OBJECTIVES

To assess the initial correlations among frailty, nutritional status, depression and QOL (quality of life) in a group of older people in Ethiopia who are later enrolled in a study examining the effects of a nurse-led community intervention on frailty and related health outcomes.

METHODS

Data from 68 community-dwelling individuals 60 years of age, or over, were collected. Frailty was measured using the Amharic version of the Tilburg Frailty Indicator. The statistical analysis included Spearman's rank correlation coefficient for degrees of association, Mann-Whitney U-test for variables with two categories and Kruskal-Wallis for variables with three or more categories.

RESULTS

The mean frailty score for participants was 7.3 (±1.9). Participants with higher frailty scores had lower nutritional status (rs = -0.46, p < 0.01). There was a statistically significant relationship (positive) between frailty scores and depression (rs = 0.39, p < 0.01). Depressed (Md = 9, n = 23) and non-depressed frail older people (Md = 7, n = 45) showed a significant difference in their overall frailty score, U = 330.50, z = -2.49, p = 0.01, r = 0.30. There was an inverse significant association between the level of frailty across different domains in the QOL: physical (rs = -0.44, p < 0.01), psychological (rs = -0.45, p < 0.01), social relations (rs = -0.29, p < 0.05) and environmental (rs = -0.47, p < 0.01).

CONCLUSION

The findings from this study were consistent with those from across middle-income and high-income countries.

IMPLICATIONS FOR PRACTICE

This research indicates that older people living in communities who are identified as frail often suffer from a poor nutritional status, depression and reduced QOL. It suggests that healthcare professionals in Sub-Saharan countries would benefit from recognising the frailty in this population, and developing interventions aimed at enhancing nutrition, mental health and overall well-being.

Comparative analysis of breast and lung cancer survival rates and clinical trial enrollments among rural and urban patients in Georgia

Objectives

Rural patients have poor cancer outcomes and clinical trial (CT) enrollment compared to urban patients due to attitudinal, awareness, and healthcare access differential. Knowledge of cancer survival disparities and CT enrollment is important for designing interventions and innovative approaches to address the stated barriers. The study explores the potential disparities in cancer survival rates and clinical trial enrollments in rural and urban breast and lung cancer patients. Our hypotheses are that for both cancer types, urban cancer patients will have longer 5-year survival rates and higher enrollment rates in clinical trials than those in rural counties.

Methods

We compared breast and lung cancer patients' survival rates and enrollment ratios in clinical trials between rural (RUCC 4-9) and urban counties in Georgia at a Comprehensive Cancer Center (CCC). To assess these differences, we carried out a series of independent samples t-tests and Chi-Square tests.

Results

The outcomes indicate comparable 5-year survival rates across rural and urban counties for breast and lung cancer patients, failing to substantiate our hypothesis. While clinical trial enrollment rates demonstrated a significant difference between breast and lung cancer patients at CCC, no significant variation was observed based on rural or urban classification.

Conclusion

These findings underscore the need for further research into the representation of rural patients with diverse cancer types at CCC and other cancer centers. Further, the findings have considerable implications for the initiation of positive social change to improve CT participation and reduce cancer survival disparities.

Evaluation of the Centers for Disease Control and Prevention's Essentials for Parenting Toddlers and Preschoolers on parent behavioral outcomes

BACKGROUND

The Centers for Disease Control and Prevention's web-based behavioral parent training (BPT) program, Essentials for Parenting Toddlers and Preschoolers (EfP), uses a psychoeducational approach to promote positive parenting and address common parenting challenges. The purpose of this study was to assess the effects of EfP on parenting behavior and whether implementation format impacted behavioral outcomes.

METHODS

A sample of 200 parents of 2- to 4-year-old children were recruited via Internet advertising. Using a repeated single subject, multiple baseline design, parents were randomly assigned to guided navigation (GN; n = 100) or unguided navigation (UN; n = 100) study conditions. Parents were provided secure access to the EfP website and completed 18 weekly surveys. Latent growth curve modeling was used to determine intervention effectiveness on behavioral outcomes.

RESULTS

Latent growth curve modeling indicated both GN and UN study conditions significantly increased use of praise (β = 0.19, p = 0.038) and commands and consequences (β = 0.17, p < 0.001), and decreased corporal punishment use (β = -0.01, p = 0.017) and attitudes promoting corporal punishment (β = -0.01, p < 0.001) over the study period. The UN condition exhibited a significant initial decrease in time-out use that increased over time to match the GN condition.

CONCLUSIONS

This study provides evidence for the effectiveness of EfP in promoting non-violent parenting behavior and increasing positive parenting techniques. The format of EfP implementation made no difference in parenting behaviors over time. Digital BPT programs like EfP provide access to evidence-informed parenting resources and can enhance positive parenting.

Mixed reality technology for older adults: Evaluating the impact of a novel virtual humanoid coach in a community-based physical exercise program in the Philippines

Physical inactivity among older adults remains a global burden, leading to a variety of health challenges and even mortality. This study evaluated the impact of a novel virtual humanoid coach-driven physical exercise program among older adults. A non-randomized (quasi) experimental research was conducted in two community senior centers. The recruited participants (n = 130) were primarily female older adults with a mean age of 66.40 and agreed to be purposively assigned either experimental or control groups. Trained healthcare providers performed health assessments in three time points using valid and reliable tools. Descriptive statistics, t-tests, and RM-ANOVA were used to quantitatively analyze the data using SPSS version 22. There are significant mean differences between the groups across all functional capacity assessments and Time 2-3 assessment of sleep quality. RM-ANOVA revealed significant differences in physical assessment over time between the two groups. The analyses of time and group interaction revealed significant improvement in health assessments among the members of the mixed reality group compared to the traditional groups. The impact of virtual coaches in community-based enhancing physical activity programs is comparable to the traditional mode and introduces a novel approach to promoting physical activity among older adults.

Evaluation of a complex couplet care intervention in a neonatal intensive care unit: A mixed methods study protocol

Background

Families with an infant in need of intensive care most often experience a harmful separation after birth. This is due to a division of medical specialties into neonatal care and maternal care. Therefore, a couplet care intervention is implemented for mother-infant dyads in a neonatal intensive care unit. This study protocol provides a comprehensive evaluation of the intervention. The aim is to evaluate the effect and implementation of a complex couplet care intervention to promote zero separation between mother and infant.

Methods

The couplet care intervention is a family-centered model of care, where treatment-requiring mother-infant dyads will be admitted together and receive couplet care by neonatal nurses. The study adheres to the framework of the Medical Research Council and will use a mixed methods embedded design comprising a quasi-experimental trial and a qualitative process evaluation. Finally, a health economic evaluation will be conducted to assess the cost-effectiveness of this complex couplet care intervention.

Discussion

Separation of mother-infant dyads after birth has an adverse impact on family health and well-being. This study protocol evaluates a complex couplet care intervention. With this study, a first step is taken to help bridge the gap between current practices and a new care model to prevent the separation of mothers and their infants.

The impact of a mixed reality technology-driven health enhancing physical activity program among community-dwelling older adults: a study protocol

Background

Physical inactivity and a sedentary lifestyle among community-dwelling older adults poses a greater risk for progressive physical and cognitive decline. Mixed reality technology-driven health enhancing physical activities such as the use of virtual coaches provide an emerging and promising solution to support healthy lifestyle, but the impact has not been clearly understood.

Methods and analysis

An observational explanatory sequential mixed-method research design was conceptualized to examine the potential impact of a user-preferred mixed reality technology-driven health enhancing physical activity program directed toward purposively selected community-dwelling older adults in two senior centers in the Philippines. Quantitative components of the study will be done through a discreet choice experiment and a quasi-experimental study. A total of 128, or 64 older adults in each center, will be recruited via posters at community senior centers who will undergo additional screening or health records review by a certified gerontologist to ensure safety and proper fit. Treatments (live coaching with video-based exercise and mixed reality technology-driven exercise) will be assigned to each of the two senior center sites for the quasi-experiment. The participants from the experimental group shall be involved in the discreet choice experiment, modeling, and usability evaluations. Finally, a qualitative sample of participants (n = 6) as key informants shall be obtained from the experimental group using purposive selection.

Discussion

This study protocol will examine the health impact of a promising mixed reality program in health promotion among older adults. The study utilizes a human-centered mixed method research design in technology development and evaluation in the context of developing nations.Clinical trial registration: ClinicalTrials.gov, identifier NCT06136468.

Building a sharable literature collection to advance the science and practice of implementation facilitation

Background

Implementation science seeks to produce generalizable knowledge on strategies that promote the adoption and sustained use of evidence-based innovations. Literature reviews on specific implementation strategies can help us understand how they are conceptualized and applied, synthesize findings, and identify knowledge gaps. Although rigorous literature reviews can advance scientific knowledge and facilitate theory development, they are time-consuming and costly to produce. Improving the efficiency of literature review processes and reducing redundancy of effort is especially important for this rapidly developing field. We sought to amass relevant literature on one increasingly used evidence-based strategy, implementation facilitation (IF), as a publicly available resource.

Methods

We conducted a rigorous systematic search of PubMed, CINAHL, and Web of Science citation databases for peer-reviewed, English-language articles with "facilitation" and a combination of other terms published from January 1996 to December 2021. We searched bibliographies of articles published from 1996 to 2015 and identified articles during the full text review that reported on the same study. Two authors screened 3,168 abstracts. After establishing inter-rater reliability, they individually conducted full-text review of 786 relevant articles. A multidisciplinary team of investigators provided recommendations for preparing and disseminating the literature collection.

Findings

The literature collection is comprised of 510 articles. It includes 277 empirical studies of IF and 77 other articles, including conceptual/theoretical articles, literature reviews, debate papers and descriptions of large-scale clinical initiatives. Over half of the articles were published between 2017 and 2021. The collection is publicly available as an Excel file and as an xml file that can be imported into reference management software.

Conclusion

We created a publicly accessible collection of literature about the application of IF to implement evidence-based innovations in healthcare. The comprehensiveness of this collection has the potential to maximize efficiency and minimize redundancy in scientific inquiry about this strategy. Scientists and practitioners can use the collection to more rapidly identify developments in the application of IF and to investigate a wide range of compelling questions on its use within and across different healthcare disciplines/settings, countries, and payer systems. We offer several examples of how this collection has already been used.

Adaptive Designs in Implementation Science and Practice: Their Promise and the Need for Greater Understanding and Improved Communication

The promise of adaptation and adaptive designs in implementation science has been hindered by the lack of clarity and precision in defining what it means to adapt, especially regarding the distinction between adaptive study designs and adaptive implementation strategies. To ensure a common language for science and practice, authors reviewed the implementation science literature and found that the term adaptive was used to describe interventions, implementation strategies, and trial designs. To provide clarity and offer recommendations for reporting and strengthening study design, we propose a taxonomy that describes fixed versus adaptive implementation strategies and implementation trial designs. To improve impact, (a) futureimplementation studies should prespecify implementation strategy core functions that in turn can be taught to and replicated by health system/community partners, (b) funders should support exploratory studies that refine and specify implementation strategies, and (c) investigators should systematically address design requirements and ethical considerations (e.g., randomization, blinding/masking) with health system/community partners.

Working Toward Recommended Terminology in the Canadian Preschool Speech-Language Pathology Context

PURPOSE

This quality improvement project aimed to address the inconsistent use of clinical labels across a preschool speech and language program in Ontario, Canada. The study investigated whether a multicomponent knowledge translation (KT) intervention could increase speech-language pathologists' (SLPs') knowledge about the recommended clinical labels, motivate their intentions to use the labels, and facilitate practice change during a 3-month pilot period.

METHOD

The diffusion of innovations theory was utilized to identify and address known and suspected barriers and facilitators that could influence the adoption of consistent terminology. The intervention was evaluated using a pre-experimental study design (with pre, post, and follow-up testing) and included two phases: Phase 1 involved the pretraining survey, KT intervention, and posttraining survey, and Phase 2 included an exit survey after a 3-month pilot period.

RESULTS

Five hundred twenty-nine SLPs in Phase 1 and 387 SLPs in Phase 2 participated. Following the web-based intervention, SLPs demonstrated improved knowledge about the recommended labels with most indicating intentions to communicate the labels going forward. SLPs also reported increased comfort using labels and positive views on their importance and value. After the 3-month pilot period, SLPs' reported use of most recommended labels decreased, as did ratings of comfort, value, and importance. However, most SLPs reported intentions to use the labels going forward.

CONCLUSIONS

Despite having intentions to adopt the recommended labels, the lack of implementation by SLPs suggests the presence of additional barriers impacting their use of the recommended clinical labels in practice. Future work should investigate clinician-identified barriers to inform future implementation efforts.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.25254940.

Measuring the effects of nurse-led frailty intervention on community-dwelling older people in Ethiopia: a quasi-experimental study

BACKGROUND

Despite the critical need, interventions aimed at frailty in sub-Saharan Africa are scarce, attributed to factors such as insufficient healthcare infrastructure, the pressing need to address infectious diseases, maternal and child health issues, and a general lack of awareness. Hence, the aim of this research was to develop, implement, and evaluate the effect of a nurse-led program on frailty and associated health outcomes in community-dwelling older individuals in Ethiopia.

METHODS

This study utilised a pre-test, post-test, and follow-up single-group quasi-experimental design. The main outcome measure was to determine changes in the frailty levels of older individuals living in communities at three different intervals: initially (T0), immediately after the intervention (T1), and 12 weeks following the intervention (T2). Secondary outcomes were the observed changes in daily living activities, nutritional status, depression levels, and quality of life (QOL), evaluated at each of these data collection points. To analyse changes in frailty and response variables over these periods, Friedman's ANOVA and Cochran's Q test were employed, setting the threshold for statistical significance at P < 0.05.

RESULTS

Sixty-six older people with a high adherence rate of 97% completed the intervention and the follow-up measurements. Participants had an average age of 66.7 ± 7.9 years, with females comprising 79.4% of the group. Notably, 12 weeks post-intervention, there was a marked decrease in frailty (χ2(2) = 101.05, p < 0.001) and depression scores (χ2(2) = 9.55, p = 0.008) compared to the baseline. However, the changes in depression, physical, mental, and environmental domains of QOL were not sustained for 12 weeks post-intervention. Study participants showed an improvement in nutritional status (χ2(2) = 25.68, p < 0.001), activity of daily living (χ2(2) = 6.00, p = 0.05), and global quality of life (χ2(2) = 20.64, p < 0.001).

CONCLUSIONS

The nurse-led intervention notably, 12 weeks post-intervention reduced frailty and depression. The intervention improved the nutritional status and some components of the quality of life of the participants. There is a need for further studies, especially with larger participant groups and stronger research designs such as randomized controlled trials (RCTs).

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05754398 (03/03/2023).

Multivariate mixed-effects ordinal logistic regression models with difference-in-differences estimator of the impact of WORTH Yetu on household hunger and socioeconomic status among OVC caregivers in Tanzania

BACKGROUND

Although most of the livelihood programmes target women, those that involve women and men have been evaluated as though men and women were a single homogenous population, with a mere inclusion of gender as an explanatory variable. This study evaluated the impact of WORTH Yetu (an economic empowerment intervention to improve livelihood outcomes) on household hunger, and household socioeconomic status (SES) among caregivers (both women and men) of orphaned and vulnerable children (OVC) in Tanzania. The study hypothesized that women and men respond to livelihood interventions differently, hence a need for gender-disaggregated impact evaluation of such interventions.

METHODS

This is a secondary analysis of longitudinal data, involving caregivers' baseline (2016-2019) and follow-up (2019-2020) data from the USAID Kizazi Kipya project in 25 regions of Tanzania. Two dependent variables (ie, outcomes) were assessed; household hunger which was measured using the Household Hunger Scale (HHS), and Socioeconomic Status (SES) using the Principal Component Analysis (PCA). WORTH Yetu, a livelihood intervention implemented by the USAID Kizazi Kipya project was the main independent variable whose impact on the two outcomes was evaluated using multivariate analysis with a multilevel mixed-effects, ordinal logistic regression model with difference-in-differences (DiD) estimator for impact estimation.

RESULTS

The analysis was based on 497,293 observations from 249,655 caregivers of OVC at baseline, and 247,638 of them at the follow-up survey. In both surveys, 70% were women and 30% were men. Their mean age was 49.3 (±14.5) years at baseline and 52.7 (±14.8) years at the follow-up survey. Caregivers' membership in WORTH Yetu was 10.1% at the follow-up. After adjusting for important confounders there was a significant decline in the severity of household hunger by 46.4% among WORTH Yetu members at the follow-up compared to the situation at the baseline (adjusted Odds Ratio (aOR) = 0.536, 95% Confidence Interval (CI) [0.521, 0.553]). The decline was 45.7% among women (aOR = 0.543 [0.524, 0.563]) and 47.5% among men (aOR = 0.525 [0.497, 0.556]). Regarding SES, WORTH Yetu members were 15.9% more likely to be in higher wealth quintiles at the follow-up compared to the situation at the baseline (aOR = 1.159 [1.128, 1.190]). This impact was 20.8% among women (aOR = 1.208 [1.170, 1.247]) and 4.6% among men (aOR = 1.046 [0.995, 1.101]).

CONCLUSION

WORTH Yetu was associated with a significant reduction in household hunger, and a significant increase in household SES among OVC caregivers in Tanzania within an average follow-up period of 1.6 years. The estimated impacts differed significantly by gender, suggesting that women and men responded to the WORTH Yetu intervention differently. This implied that the design, delivery, and evaluation of such programmes should happen in a gender responsive manner, recognising that women and men are not the same with respect to the programmes.

Mutual Aid Groups for Loneliness, Psychosocial Disability, and Continuity of Care

The objective of the present study was to evaluate the effectiveness of mutual help groups in continuity of care, loneliness and psychosocial disability in a Colombian context. For this, a quasi-experimental design is used, with pre- and post-intervention assessments due to non-randomized participant allocation. The study involved 131 individuals with mental disorders. The Psychosocial Disability Scale, The Alberta Scale of Continuity of Services in Mental Health, the UCLA Scale and the Zarit Caregiver Burden Scale were employed. The intervention was based on the core components of mutual aid groups. Significant differences (p < 0.001) were observed for the study variables, particularly in Loneliness, Continuity of Care, and various domains of psychosocial disability. A large effect size was found for these variables after the intervention. Most variables exhibited a moderate to large effect. This study demonstrates the effectiveness of mutual groups facilitated by mental health personnel at the primary care level.

Behavioral Interventions on Surgeons' Preoperative Decision-Making: A Scoping Review and Critical Analysis

INTRODUCTION

Consensus is lacking regarding the optimal strategy to influence surgeons' behaviors to reduce low-value surgical care. Comprehensively describing the existing body of literature that seeks to intervene on surgeons' preoperative decision-making may aid in structuring future behavior change strategies.

METHODS

We performed a scoping review using four databases (Medical Literature Analysis and Retrieval System Online, Embase, Web of Science, and Cumulated Index to Nursing and Allied Health Literature) for articles that tested the effect of behavioral-based interventions on any aspect of surgeons' decision-making in the preoperative setting. Abstracted data were characterized by summative descriptions and analyzed using the Tailored Implementation for Chronic Disease framework, mapping aspects of deimplementation strategies in the studies onto the determinant(s) that they altered. Data abstraction and mapping tools were piloted and iteratively revised before two researchers independently assessing studies and categorizing determinants, and then meeting to discuss their decisions.

RESULTS

There were 1460 articles identified from the initial search, with 17 full text articles ultimately included in the scoping review. Eight studies relied on a multidisciplinary preoperative conference to accomplish their aims, while five were multifaceted in their approach to deimplementation, and four studies used only a clinical decision support tool to accomplish their aims. Mapping determinants addressed in these studies onto the Tailored Implementation for Chronic Disease framework demonstrated that most strategies attempted to close knowledge gaps, leverage communication between providers, and broadcast institutional prioritization of change.

CONCLUSIONS

There is a small but growing field of implementation and deimplementation strategies in preoperative surgical decision-making, and different approaches may be equally effective in varied clinical contexts. Deliberate measurement and comparison of outcomes, as well as selection of control groups, are areas for improvement in future work.

Novice medical students' perception about bad news training with simulation and spikes strategy

Objective

To analyze the medical students' perception about simulated consultations before and after training using the SPIKES protocol.

Methods

Quasi-experimental study, with a qualitative approach. It counted with the participation of 20 students as Simulated Physicians (SF), and 20 students as Simulated Patients (SP), all belonging to a medical course. Data were obtained from the responses given to a reflective question, applied before and after training with the SPIKES. The treatment and the analysis of the data were guided by the stages of thematic analysis.

Results

In the category "Simulated Medical Student's Self-Perception", the subcategories "Nervousness and Insecurity" were predominant after the first consultation, while "Tranquility and Security" after the second consultation after training. In the category "Simulated Medical Student's Perception about the Educational Process", the subcategory "Reflective Learning" emerged in the students' speeches, especially after the second consultation. In the speeches of SP, it was evidenced the improvement of the care provided by SF after training.

Conclusion

The strategy used for the development of communication skills showed evidence of short-term effectiveness.

Innovation

The research resulted in a teaching protocol for students in pre-clinical stages that involves four stages: simulation, self-assessment, feedback and new simulations.

Study protocol: assessment of the usefulness and practicability of a psychoeducational intervention to prevent the negative psychological impact of the COVID-19 pandemic on primary care health workers

BACKGROUND

The COVID-19 pandemic has constituted an extraordinarily stressful situation for healthcare professionals and has led to psychological distress and an increase in various mental disorders. In the post-pandemic context, it is necessary to provide professionals with strategies and skills to manage this stressful situation and prevent or minimize its negative impact.

METHODS

Aims: To assess the feasibility and clinical effects of a group psychoeducational program focused on preventing the adverse psychological and emotional effects of the pandemic on primary care workers, and to explore the experience and perceptions of participants with regard to the program from a qualitative perspective.

DESIGN

A single-arm, before-and-after study conducted in primary care.

SETTING

The 332 primary care centers of the Catalan Institute of Health (Catalonia, Spain) Participants: The target population of the intervention is primary care workers, including clinical profiles (e.g., nurses and doctors), and non-clinical profiles (e.g., administrative staff). The implementation strategy will also involve community psychologists, who will lead the psychoeducational groups, and the health organization promoting the implementation.

INTERVENTION

A group psychoeducational program targeting primary care workers to promote emotional well-being and the ability to cope with stressful situations. Community psychologists will deliver it in the primary care centers they are linked to.

MEASURES

Mixed-methods evaluation, combining quantitative and qualitative research. A prospective assessment of the main outcomes (professional quality of life, psychological state, and resilience) will be performed using online questionnaires before and immediately after the intervention, and at 3 and 6 months. A qualitative study will be conducted, comprising focus groups and individual in-depth interviews with the participants in the intervention and the psychologists who provide it.

ETHICS

The Research Ethics Committee of the Jordi Gol Primary Care Research Institute (IDIAP) has approved the protocol (22/086-PCV).

DISCUSSION

This project proposes an intervention to promote mental health and psychological well-being in primary care workers by learning skills and integrating them into personal and professional life. The expected results will allow us to determine the usefulness and effectiveness of this psychoeducational intervention under the conditions of real clinical practice, provide data to model and perfect it, and promote its dissemination.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05720429; registered on 09/02/2023.

Enhancing Medical Students' Confidence and Knowledge in Antibiotic Prescription and Administration through Virtual Education: A Quasi-Experimental Study

BACKGROUND

Antibiotic resistance is a worldwide health concern that necessitates antibiotic stewardship. Medical students significantly impact future healthcare practices; thus, their trust in antibiotic prescription and administration is crucial. This research aims to assess medical students' levels of confidence and knowledge in these areas before and after exposure to virtual antibiotic stewardship education.

METHODS

A one-group pretest-posttest design was conducted with medical students from King Saud bin Abdulaziz University for Health Sciences in Jeddah, Saudi Arabia. Participants were enrolled in the WHO-online antibiotic stewardship course.

RESULTS

The group's baseline confidence and background knowledge were reported to be lower than what was offered after introducing the virtual course. The McNemar-Bowker test showed a significant difference in students' confidence in pre-course and post-course scores (Z = 20, p < 0.002); the matched paired t-test revealed a significant difference in students' knowledge scores (M = 7.66 verses M = 5.36, Z = 3.54, p = 0.001). In the sample, 70% of the students were unfamiliar with antibiotic stewardship; thus, the analysis revealed a significant difference in their familiarity before and after enrolling in the online course (30 vs. 100, p < 0.001).

CONCLUSION

Medical students experience low confidence in the safe practice of the antibiotic stewardship program. The WHO-online antibiotic stewardship course is considered a valuable resource that can be used in a formative medical curriculum. Thus, educators and the academic curriculum must promote practical strategies to minimize antibiotic stewardship literacy and increase antibiotic prescribing and administration quality. Introducing antibiotic stewardship across the medical curriculum and establishing educational courses are some strategies that can be undertaken to ensure that future doctors are well-educated in the principles and practices of the appropriate use of antibiotic stewardship.

The effectiveness of technology-based cognitive behavioral therapy on perinatal depression and anxiety: A systematic review and meta-analysis

BACKGROUND

Extensive literature has shown the effectiveness of cognitive behavioral therapy in treating perinatal depression, but little is known about the effectiveness of its technology-based version.

AIM

The aim of this review was to examine the effectiveness of technology-based cognitive behavioral therapy in reducing depressive and anxiety symptoms in women suffering from or at risk of experiencing perinatal depression.

METHODS

Six electronic databases were searched until February 2023 for articles published in English. Random-effect meta-analyses were conducted. Heterogeneity was assessed using the I2 statistics and Cochran's Q chi-squared test. Sensitivity analyses and subgroup analyses were also performed, and quality appraisals at the study and outcome levels were conducted.

RESULTS

A total of 16 randomized controlled trials were included in the review. Results from meta-analyses suggest that technology-based cognitive behavioral therapy has a medium effect in reducing perinatal depressive symptoms and a small effect in reducing perinatal anxiety symptoms. Overall, women suffering from or at risk of perinatal depression may benefit from technology-based cognitive behavioral therapy.

LINKING EVIDENCE TO ACTION

Future interventions can be improved by addressing both perinatal depression and anxiety, paying more attention to antenatal women to prevent postnatal mental health issues, and using self-guided mobile applications for accessibility.

Telerehabilitation Intervention in Transitional Care for People with COVID-19: Pre-Post Study with a Non-Equivalent Control Group

SARS-CoV-2 infection and its resulting sequelae have increased the prevalence of people with respiratory symptoms, with impacts on functional capacity, quality of life, anxiety, depression, and mental health. To mitigate this problem, one challenge has been the design and implementation of interventions that simultaneously allow for education, rehabilitation, and monitoring of people with long COVID, at a time when health services were on the verge of rupture due to the volume of people with active COVID and in need of intensive care. Telerehabilitation emerged as a mode for providing rehabilitative care that brought professionals closer to patients and enabled continuity of care. The present study aimed to evaluate the results of a telerehabilitation intervention for people with injuries associated with SARS-CoV-2 infection in hospital-community transitions, considering their degree of dependence in performing activities of daily living, respiratory symptoms, fatigue, gait capacity, muscle strength, and experience with anxiety and depression. A pre-post study with a non-equivalent control group was carried out with a total of 49 participants (intervention group n = 24; control group n = 25). The post-intervention results showed an increase in saturation, a decrease in heart rate, an improvement in the impact of post-COVID functionality, a decrease in fatigue, a decrease in perceived effort, and a decrease in depressive and anxiety symptoms. The telerehabilitation intervention, which combined educational strategies with respiratory and motor rehabilitation, helped improve global functionality and self-care, with clinical and functional impacts.

Noninferiority Clinical Trial of Adapted START NOW Psychotherapy for Outpatient Opioid Treatment

Background

Medications for opioid use disorder (MOUD) such as buprenorphine is effective for treating opioid use disorder (OUD). START NOW (SN) is a manualized, skills-based group psychotherapy originally developed and validated for the correctional population and has been shown to result in reduced risk of disciplinary infractions and future psychiatric inpatient days with a dose response effect. We investigate whether adapted START NOW is effective for treating OUD in a MOUD office-based opioid treatment (OBOT) setting in this non-inferiority clinical trial.

Methods

Patients enrolled in once weekly buprenorphine/suboxone MOUD OBOT were eligible for enrollment in this study. Participants were cluster-randomized, individually-randomized, or not randomized into either START NOW psychotherapy or treatment-as-usual (TAU) for 32 weeks of therapy. Treatment effectiveness was measured as the number of groups attended, treatment duration, intensity of attendance, and overall drug use as determined by drug screens.

Results

137 participants were quasi-randomized to participate in SN (n = 79) or TAU (n = 58). Participants receiving START NOW psychotherapy, when compared to TAU, had comparable number of groups attended (16.5 vs. 16.7, p = 0.80), treatment duration in weeks (24.1 vs. 23.8, p = 0.62), and intensity defined by number of groups attended divided by the number of weeks to last group (0.71 vs. 0.71, p = 0.90). SN compared to TAU also had similar rates of any positive drug screen result (81.0% vs. 91.4%, p = 0.16). This suggests that adapted START NOW is noninferior to TAU, or the standard of care at our institution, for treating opioid use disorder.

Conclusion

Adapted START NOW is an effective psychotherapy for treating OUD when paired with buprenorphine/naloxone in the outpatient group therapy setting. Always free and publicly available, START NOW psychotherapy, along with its clinician manual and training materials, are easily accessible and distributable and may be especially useful for low-resource settings in need of evidence-based psychotherapy.

Effect evaluation of a tele-neurologic intervention in primary care in a rural area in Germany-the NeTKoH study protocol of a stepped-wedge cluster randomized trial

BACKGROUND

Neurological disorders account for a large and increasing proportion of the global burden of disease. Therefore, it is important to strengthen the management of neurologic care, particularly in rural areas. The use of tele-neurology in primary care in rural areas is internationally considered to have the potential to increase access to health care services and improve the quality of care in these underserved areas. NeTKoH aims to address the existing knowledge gap regarding the effects of a tele-neurologic intervention in primary care under real-world conditions in a rural area in Germany.

METHODS

NeTKoH is a cluster-randomized controlled trial with a stepped-wedge design involving 33 outpatient general practitioner's (GP) offices (clusters) in a rural area in Northeast Germany. During 11 predetermined steps, all clusters are randomized before they cross over into groups from the control to the intervention arm. The targeted sample size is 1,089 patients with neurologic symptoms that are continuously being recruited. In the intervention arm, tele-neurologic consultations will be provided via a face-to-face video conferencing system with a neurologic expert at a university hospital. The control arm will receive usual care. The primary outcome is the proportion of neurologic problems being solved at the GP's office. Secondary outcomes will comprise hospital stays and days, time until neurologic specialist appointments and diagnostics, patients' health status and quality of life, outpatient and inpatient referrals. A concurrent observational study, together with a process, implementation, and health economic evaluation, will also be conducted.

DISCUSSION

Using a stepped-wedge cluster design in a real-life situation can help with logistic challenges and enhance the motivation of the participating GPs, as all, at some point, will be in the intervention phase. With the additional implementation evaluation pertaining to external validity, an observational study, and a health economic evaluation, NeTKoH will be able to provide an extensive evaluation for health policy decision-makers regarding the uptake into standard care.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS00024492). Date registered: September 28, 2021. Date and protocol version: June 2023, version 1.

Bridging the "Know-Do" Gaps in Five Non-Communicable Diseases Using a Common Framework Driven by Implementation Science

According to the United Nations High-Level Meeting 2018, five non-communicable diseases (NCDs) including cardiovascular diseases, chronic respiratory diseases, diabetes mellitus, cancer, and mental health conditions accounted for two-thirds of global deaths. These five NCDs share five common risk factors including tobacco use, unhealthy diets, physical inactivity, alcohol use, and air pollution. Low- and middle-income countries (LMICs) face larger burden of NCDs than high-income countries (HICs), due to differences in ecological, technological, socioeconomic and health system development. Based on high-level evidence albeit mainly from HICs, the burden caused by NCDs can be reduced by affordable medicines and best practices. However, "know-do" gaps, ie, gaps between what we know in science and what we do in practice, has limited the impact of these strategies, especially in LMICs. Implementation science advocates the use of robust methodologies to evaluate sustainable solutions in health, education and social care aimed at informing practice and policies. In this article, physician researchers with expertise in NCDs reviewed the common challenges shared by these five NCDs with different clinical courses. They explained the principles of implementation science and advocated the use of an evidence-based framework to implement solutions focusing on early detection, prevention and empowerment, supplemented by best practices in HICs and LMICs. These successful stories can be used to motivate policymakers, payors, providers, patients and public to co-design frameworks and implement context-relevant, multi-component, evidence-based practices. In pursuit of this goal, we propose partnership, leadership, and access to continuing care as the three pillars in developing roadmaps for addressing the multiple needs during the journey of a person with or at risk of these five NCDs. By transforming the ecosystem, raising awareness and aligning context-relevant practices and policies with ongoing evaluation, it is possible to make healthcare accessible, affordable and sustainable to reduce the burden of these five NCDs.

An expert patient program to improve the empowerment and quality of life of people with multiple sclerosis: protocol for a multicenter pre-post intervention study

Introduction

Multiple sclerosis (MS) causes a progressive disability, which substantially impacts the quality of life (QoL). Health interventions that meet the needs and demands of people with MS are essential to minimize QoL impairment. Expert patient programs (EPPs) facilitate health-related empowerment through peer learning. Based on a previous focus group study, we designed an EPP for MS coordinated by nursing professionals for implementation in the different MS reference units of Catalonia (Southwestern Europe). This study aims to evaluate the effects on quality of life, disease-related knowledge, and self-management related to the health process of the participants of the Expert Patient Program Catalonia™ for people with multiple sclerosis (EPPC-MS).

Methods

Pre-post intervention multicenter clinical study involving 12 groups of 12 participants: six groups including relapsing and six groups including progressive MS patients, with 144 participants from 7 MS reference units from all over Catalonia, organized in six teams. The intervention will consist of nine telematic learning peer-led sessions (one weekly session). The expert patient (EP) leading the sessions will be an individual with MS with disease-related knowledge, who will be further trained by nurses to lead the sessions. Study variables will be measured before and immediately after the intervention and 6 and 12 months after the end of the sessions and will include: QoL, emotional impact, activation of the person, MS-related knowledge, fatigue, habits and lifestyles, health services use, and program-related experience. Baseline characteristics considered will be sociodemographic data, date of MS diagnosis and type, family history, and treatment characteristics. Variables related to disease follow-up will be new relapses and characteristics and changes in the ongoing treatment. The number of sessions attended will also be collected. Study variables will be analyzed using a pre-post comparison.

Discussion

Peer-led learning programs led by EP help empower people with chronic conditions and offer them tools to improve their autonomy and QoL. This study's intervention will be performed remotely, offering advantages both for people with chronic conditions and the healthcare system regarding the facilitation of family and work conciliation, saving time, simplifying attendance to meetings, lowering costs, and using fewer material resources.

Trial registration

NCT04988880 on September 22, 2021.

Evidence for "Whole Family Approach" in accelerating uptake of COVID-19 and routine immunizations among integrated primary health services in Nigeria

The family is the simplest unit but possesses the strongest bond in society. These qualities - bond and proximity - that exist both within and across neighboring families, according to our research, can be instrumental in shaping a new kind of health promotion strategy that can transform health behaviors in communities. The Whole Family Approach (WFA) is a government-sanctioned approach to increase uptake of COVID-19 vaccines in Nigeria. The approach entails leveraging the high family-based demand for some primary health services, such as malaria, diabetes, hypertension, and reproductive services, to generate demand for COVID-19 and routine immunizations. However, since the announcement in 2021, there has been no available evidence to show the impact of the approach on COVID-19 vaccine uptake, though global literature generally favors family-centered health approaches. This study tests the effectiveness of the approach in increasing the utilization of target services in a Nigerian community and further provides a theoretical framework for the strategy. Two primary healthcare facilities were selected in two communities located in Abuja in a quasi-experimental design. After a small-sample landscape assessment of the communities and the facilities, family-targeting health promotion activities were facilitated in the intervention community (integrated health education by trained community health influencers) and facility (opportunistic health promotion through in-facility referrals) for one month. Anonymized service utilization data were acquired from both facilities over a period of four months to analyze their respective month-by-month service utilization trends. Time trend analysis was conducted and revealed that WFA significantly increased service utilization (N = 5870; p < 0.001, α = 0.01, 99% CI) across all the package services provided at the intervention facility. A supplementary Pearson's correlation analysis further presented a positive relationship (r = 0.432-0.996) among the services which favored the result. It can therefore be concluded that the "Whole Family Approach" of health promotion is efficacious in accelerating uptake of priority health services such as COVID-19 and routine immunizations. While there is more to be understood about this interesting approach, we recommend the improvement of communication and capacity gaps in Nigeria's primary healthcare system to ensure that promising strategies such as the WFA are adequately implemented at the community and facility levels.

Evaluating the impact of prescriptive authority for psychologists on the rate of deaths attributed to mental illness

BACKGROUND

Five states have enacted policies granting prescriptive authority to psychologists in an effort to increase access to psychoactive medications; however, little is known regarding the public health impact of these policies. Policies in two of these states, New Mexico and Louisiana, have had sufficient time to license more than a handful of prescribing psychologists. This study estimates the impact of psychologist prescriptive authority policies in New Mexico and Louisiana on deaths attributable to mental illness and suicides.

METHODS

State-level annual death rates from all 50 states were obtained for deaths with an underlying cause of death attributable to mental illness and to suicide (1999-2013) from the Centers for Disease Control and Prevention's WONDER database. State characteristics were collected for the pre-policy time period (1999-2004). We estimated the impact of the policy on the rates of deaths attributable to mental illness and to suicide using a comparative interrupted time series design, and policy effect estimates were generated for New Mexico and Louisiana separately. We used the synthetic control method to create synthetic New Mexico and synthetic Louisiana for use as the comparators.

RESULTS

Immediately following the start of psychologist prescribing, the rate of deaths attributable to mental illness declined by 4.55 deaths per 100,000 (95% CI: [-8.30, -0.79]) in New Mexico relative to the control, but there was no change in Louisiana. There was no immediate change in the suicide rate in either state; however, the annual change in the overall suicide rate was 0.12 suicides per 100,000 (95% CI: [-0.18, -0.06]) per year lower than expected in Louisiana following implementation.

CONCLUSIONS

These findings suggest that policies granting prescriptive authority to psychologists have the potential to reduce the mental health mortality gap, though considerable questions remain.

A quasi-experimental analysis on the causal effects of COVID-19 on urban park visits: The role of park features and the surrounding built environment

Although many studies have explored the correlations between mobility intervention policies and park use during COVID-19, only a few have used causal inference approaches to assessing the policy's treatment effects and how such effects vary across park features and surrounding built environments. In this study, we develop an interrupted time-series quasi-experimental design based on three-month mobile phone big data to infer the causal effects of mobility intervention policies on park visits in Shenzhen, including the first-level response (FLR) and return-to-work (RTW) order. The results show that the FLR caused an abrupt decline of 2.21 daily visits per park, with a gradual reduction rate of 0.54 per day, whereas the RTW order helped recover park visits with an immediate increase of 2.20 daily visits and a gradual growth rate of 0.94 visits per day. The results also show that the impact of COVID-19 on park visits exhibited social and spatial heterogeneities: the mobility-reduction effect was smaller in low-level parks (e.g., community-level parks) with small sizes but without sports facilities and water scenes, whereas parks surrounded by compact neighborhoods and land use were more impacted by the pandemic. These findings provide planners with important insights into resilient green space and sustainable neighborhood planning for the post-COVID era.

Effectiveness of Fluid and Caffeine Modifications on Symptoms in Adults With Overactive Bladder: A Systematic Review

Overactive bladder (OAB) is prevalent in men and women and negatively impacts physical and psychological health. Fluid and caffeine intake modifications, which are lifestyle modification interventions, are simple methods to manage OAB. However, studies that synthesized both interventions and found scientific evidence are scarce. This review aimed to synthesize scientific evidence on whether fluid and caffeine intake modifications are effective for OAB symptoms. PubMed, CINAHL (Cumulative Index for Nursing and Allied Health Literature), Embase, Scopus, the Cochrane Library, KoreaMed, and RISS (Research Information Sharing Service) were used to search for studies and 8 studies were included. The Cochrane risk of bias tool (RoB 2.0) and ROBINS-I (Risk Of Bias In Non-randomized Studies - of Interventions) were used to assess the quality of selected studies. Due to the heterogeneous outcome variables, a meta-analysis was not conducted. Among the 8 included, 7 studies were randomized controlled trials and one was a quasi-experimental study. Four studies assessed urgency. Caffeine reduction was statistically effective for urgency symptoms, but increasing fluid intake was not. Frequency was assessed in 5 studies, which showed decreasing caffeine and fluid intake was effective in treating the symptoms. Urinary incontinence episodes were assessed in 6 studies, and nocturia in 2. Restricting caffeine intake was effective in treating these 2 symptoms, but restricting both caffeine and fluid intake was not. Quality of life (QoL) was examined in 5 studies, and modifying fluid and caffeine intake significantly improved QoL in 2. Although there were limited studies, our review provides scientific evidence that fluid and caffeine intake modification effectively manages OAB symptoms. Further research should examine acceptability and sustainability of interventions in the long-term and enable meta-analysis.

Implementation of unassisted and community-based HIV Self-Testing (HIVST) during the COVID-19 pandemic among Men-who-have-sex-with-Men (MSM) and Transgender Women (TGW): A demonstration study in Metro Manila, Philippines

OBJECTIVE

The study aimed to demonstrate the feasibility of an unassisted and community-based HIV self-testing (HIVST) distribution model and to evaluate its acceptability among men-having-sex-with-men (MSM) and transgender women (TGW).

METHODS

Our demonstration study focused on implementing the HIVST distribution model in Metro Manila, Philippines. Convenience sampling was done with the following inclusion criteria: MSM or TGW, at least 18 years old, and had no previous HIV diagnosis. Individuals taking HIV pre-exposure prophylaxis, on antiretroviral therapy, or female sex at birth were excluded. The implementation of the study was done online using a virtual assistant and a delivery system via courier due to COVID-19-related lockdowns. Feasibility was measured by the number of HIVST kits successfully delivered and utilized and the HIV point prevalence. Moreover, acceptability was evaluated by a 10-item system usability scale (SUS). HIV prevalence was estimated with linkage to care prioritized for reactive participants.

RESULTS

Out of 1,690 kits distributed, only 953 (56.4%) participants reported their results. Overall, HIV point prevalence was 9.8%, with 56 (60.2%) reactive participants linked to further testing. Furthermore, 261 (27.4%) of respondents self-reported, and 35 (13.4%) of the reactive participants were first-time testers. The HIVST service had an overall median and interquartile range (IQR) SUS score of 82.5 (IQR: 75.0, 90.0), rendering the HIVST kits very acceptable.

CONCLUSIONS

Our study suggests the acceptability and feasibility of HIVST among the MSM and TGW in Metro Manila, Philippines, regardless of their age or HIV testing experience. In addition, other platforms of information dissemination and service delivery of HIVST should be explored, including access to online instructional videos and printed materials, which may facilitate easier use and interpretation of results. Furthermore, due to our study's limited number of TGW respondents, a more targeted implementation strategy to reach the TGW population is warranted to increase their access and uptake of HIVST.

Quantifying the impact of the Grain-for-Green Program on ecosystem service scarcity value in Qinghai, China

Studying the impact of large-scale ecological projects, such as the Grain-for-Green Program (GGP), on ecosystem services (ES) is currently a frontier and hot topic of ecological research. The GGP can directly change land use and land cover, thus affecting ES. By comparing the changes of ecosystem service value (ESV) and ecosystem service scarcity value (ESSV) in Qinghai before and after the implementation of the GGP, this paper clarified the impact of the GGP on Qinghai from the angles of ecology and economics. This paper quantified and evaluated the land use dynamics, ESV, and ESSV in Qinghai from 1995 to 2020. The results showed that in the past 25 years, the total annual Normalized Difference Vegetation Index (NDVI) of Qinghai showed a trend of sustained growth. From 1995 to 2020, the ESV increased by 6.80%. After considering supply and demand, the ESSV showed a continuous upward trend, increasing by 719.38%. After implementation of the GGP, the increase of NDVI inhibited the increase of the ESSV. These findings from evaluation of the effect of the GGP implementation provide a theoretical basis for future policy implementation and, in particular, a reference for the evaluation of the ESV and the ESSV in Qinghai.

How has the COVID-19 pandemic affected the utilisation of online consultation and face-to-face medical treatment? An interrupted time-series study in Beijing, China

OBJECTIVE

The COVID-19 pandemic has had a major impact on healthcare utilisation. This study aimed to quantify how the online and face-to-face utilisation of healthcare services changed during this time and thus gain insights into the planning of future healthcare resources during the outbreak of infectious diseases.

DESIGN

This work is an interrupted time-series study.

SETTING

Monthly hospital-grade healthcare-service data from 22 tertiary first-class public hospitals managed by the Beijing Hospital Authority and online-consultation data from GoodDoctor were used in this study.

METHODS

This is an interrupted time-series study about the change in face-to-face and online healthcare utilisation before and after the COVID-19 outbreak. We compared the impact of COVID-19 on the primary outcomes of both face-to-face healthcare utilisation (outpatient and emergency visits, discharge volume) and online healthcare utilisation (online consultation volume). And we also analysed the impact of COVID-19 on the healthcare utilisation of different types of diseases.

RESULTS

The monthly average outpatient visits and discharges decreased by 36.33% and 35.75%, respectively, compared with those in 2019 in 22 public hospitals in Beijing. Moreover, the monthly average online consultations increased by 90.06%. A highly significant reduction occurred in the mean outpatients and inpatients, which dropped by 1 755 930 cases (p<0.01) and 5 920 000 cases (p<0.01), respectively. Online consultations rose by 3650 cases (p<0.05). We identified an immediate and significant drop in healthcare services for four major diseases, that is, acute myocardial infarction (-174, p<0.1), lung cancer (-2502, p<0.01), disk disease (-3756, p<0.01) and Parkinson's disease (-205, p<0.01). Otherwise, online consultations for disk disease (63, p<0.01) and Parkinson's disease (25, p<0.05) significantly increased. More than 1300 unique physicians provided online-consultation services per month in 2020, which was 35.3% higher than in 2019.

CONCLUSIONS

Obvious complementary trends in online and face-to-face healthcare services existed during the COVID-19 pandemic. Different changes in healthcare utilisation were shown for different diseases. Non-critically ill patients chose online consultation immediately after the COVID-19 lockdown, but critically ill patients chose hospital healthcare services first. Additionally, the volume of online physician services significantly rose as a result of COVID-19.

The 'Tasty School' model is feasible for food education in primary schools

BACKGROUND

The 'Tasty School' is a tailored teacher-delivered food education model for primary schools in Finland. The aim of the current study was to investigate the feasibility of the Tasty School model in primary schools. Furthermore, the aim was to assess changes during the intervention in the class teachers' perspectives and experiences related to food education and school dining.

METHODS

The method involved a quasi-experimental study with intervention and control groups. A total of 130 class teachers from 15 intervention and 10 control schools from five municipalities in Finland participated in the study during one school year. The theoretical framework of acceptability was utilised to evaluate feasibility using frequencies. The comparison data were analysed using a mixed-effects model for repeated measures to account for the intervention effects and selected standardising effects.

RESULTS

Teachers reported that the model was highly acceptable and easily integrated into the school environment. Support from principals and colleagues was the most important facilitator of food education, and lack of time was the barrier. Teachers in the intervention schools were more likely to consider school meals healthy after the intervention, and they reported having sufficient materials and supplies for food education.

CONCLUSIONS

The Tasty School was shown to be a feasible model for food education in primary schools. The current study especially found that the commitment of the whole school and principals' role are crucial in the implementation of food education. The factors that support the implementation must be strengthened, and efforts must be made to reduce the barriers.

Interventions to reduce loneliness among Chinese older adults: A network meta-analysis of randomized controlled trials and quasi-experimental studies

This meta-analytic study investigates the effectiveness of different interventions in alleviating loneliness among Chinese older adults aged 50 years and above. We searched eight English databases, four Chinese databases, and grey literature. Thirty-four studies, including four randomized controlled trials (RCTs) and 30 quasi-experimental studies, were eventually included in the meta-analysis (n = 3843). Quality appraisal indicated risks of bias in the included studies. The pooled effect size was large and significant (Hedge's g = 0.84, 95% CI [0.54, 1.15]), indicating the effectiveness of interventions in reducing loneliness. However, the effect size may be overestimated due to publication bias. Moderation analyses showed significant differences in effect sizes by study designs and regions of studies. Network meta-analysis (NMA) indicated that hybrid and psychological interventions appeared to be advantageous over others. In addition, group-based delivery modes can add extra benefits to the interventions. This study adds to the knowledge of the effectiveness of current interventions in reducing Chinese older people's loneliness. However, the findings need to be interpreted with caution due to the relatively low study quality, considerable heterogeneity, and publication bias. Despite the limitations, this study offers valuable insights for future research, practice, and policy-making in reducing older people's loneliness.

A systematic review of digital health technologies for the care of older adults during COVID-19 pandemic

Objective

During the Coronavirus Disease 2019 (COVID-19) pandemic, digital health technologies (DHTs) became increasingly important, especially for older adults. The objective of this systematic review was to synthesize evidence on the rapid implementation and use of DHTs among older adults during the COVID-19 pandemic.

Methods

A structured, electronic search was conducted on 9 November 2021, and updated on 5 January 2023, among five databases to select DHT interventional studies conducted among older adults during the pandemic. The bias of studies was assessed using Version 2 of the Cochrane Risk-of-Bias Tool for randomized trials (RoB 2) and Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I).

Results

Among 20 articles included in the review, 14 (70%) focused on older adults with chronic diseases or symptoms, such as dementia or cognitive impairment, type 2 diabetes, and obesity. DHTs included traditional telehealth interventions via telephone, video, and social media, as well as emerging technologies such as Humanoid Robot and Laser acupuncture teletherapy. Using RoB 2 and ROBINS-I, four studies (20%) were evaluated as high or serious overall risk of bias. DHTs have shown to be effective, feasible, acceptable, and satisfactory for older adults during the COVID-19 pandemic compared to usual care. In addition, some studies also highlighted challenges with technology, hearing difficulties, and communication barriers within the vulnerable population.

Conclusions

During the COVID-19 pandemic, DHTs had the potential to improve various health outcomes and showed benefits for older adults' access to health care services.

A new multidimensional group intervention for cognitive and psychosocial functioning for older adults: Background, content, and process evaluation

Introduction

An essential element of quality aging is the maintenance of cognitive and psychosocial functioning. The principal objective of the present paper was to present the theoretical framework, content and process evaluation of a newly developed multi-dimensional group intervention designed to strengthen/improve areas of cognitive and psychosocial functioning in adults over 65.

Methods

The intervention implements multiple methodologies aiming to facilitate contextual integration of learned concepts and strategies derived from clinical psychology and rehabilitation. It moves seamlessly on the cognition-emotion axes and consists of five active ingredients selected to address challenges associated with aging: Memory Compensatory Strategies, Problem-Solving, Emotion Regulation, Mindfulness, and Locus of Control. Thirty participants joined the intervention group aged 65-75  years (M = 69.03; SD = 3.04). All 30 participants who were included in the intervention group completed the program.

Results

Results from the Participant Satisfaction Scale indicate that the program was perceived very positively by participants, who also reported implementing their newly learned strategies in activities of daily life. Furthermore, there was high correlation between internal locus of control and the learned strategies.

Discussion

The outcomes of this analysis indicate that the intervention is feasible and well tolerated by our target group. This multidimensional intervention may offer a valuable contribution to public health care and dementia prevention for older adults.

Clinical Trial Registration

[https://clinicaltrials.gov/ct2/results?cond=NCT01481246], identifier [NCT01481246].