The spirit of the intervention: reflections on social effectiveness in public health intervention research

Systematic Review of Contemporary Theories Used for Co-creation, Co-design and Co-production in Public Health

BACKGROUND

There is a need to systematically identify and summarize the contemporary theories and theoretical frameworks used for co-creation, co-design and co-production in public health research.

METHODS

The reporting of this systematic review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Given substantial interest in and application of co-creation, co-design and co-production, we searched PubMed, CINAHL, Scopus and APA PsycINFO from 2012 to March-April 2022. A quality assessment and data extraction for theory content was performed.

RESULTS

Of the 3763 unique references identified through the comprehensive search strategy, 10 articles were included in the review: four articles named co-creation, two articles named co-creation and co-design, two articles named co-production and co-design, and two articles named co-design. Empowerment Theory was employed by two articles, whereas other theories (n = 5) or frameworks (n = 3) were employed by one article each. For the quality assessment, eight articles received a strong rating and two articles received a moderate rating.

CONCLUSION

There is little indication of theory applications for the approaches of co-creation, co-design and co-production in public health since 2012, given 10 articles were included in this review. Yet, the theories described in these 10 articles can be useful for developing such co-approaches in future public health research.

Activating the ‘peerness’ of youth leaders in a community sports programme through techne and phronesis

Peer-to-peer approaches engage groups of people considered to share one or more characteristics that identify them as peers and draw on rationales of credibility, identification and role modelling in peer-to-peer interactions. Despite the popularity of the approach, the ways in which the peer leadership component specifically contributes to health promotion is not thoroughly understood. We suggest that a first step for making use of peer leader characteristics is to make explicit what the peer leadership component is expected to bring to a programme. To approach such an understanding, we investigated how peer leaders can be supported in activating their ‘peerness’ in health promotion programmes, using as a case the peer leader education of a youth-led, peer-to-peer community sports programme, implemented by the non-profit street sports organization, GAME. We analysed the peer leader training programme’s learning objectives and field notes from observations of the training programme. The empirical material was analysed using an abductive approach by drawing upon contemporary interpretations of two forms of knowledge originally proposed by Aristotle. In so doing, this article explores how the development of techne (practical knowledge) and phronesis (practical wisdom) was supported in a peer leader training programme for young people. Findings suggest that supporting the development of both these types of knowledge can strengthen programme planners’ attention to the contribution of peers. Concurrently, an emphasis on promoting phronesis in peer leader training can support and encourage peer leaders in activating their ‘peerness’ in peer-to-peer health promotion programmes.

ASPHALT II: Study Protocol for a Multi-Method Evaluation of a Comprehensive Peer-Led Youth Community Sport Programme Implemented in Low Resource Neighbourhoods

To reduce inequalities in children's sport participation, studies are needed to explore ways in which children from low resource neighbourhoods can be engaged and retained in sport. GAME Community is a peer-led community sport programme which aims to promote physical activity through participation in inclusive street sports activities targeting 8-15-year-old children living in low resource neighbourhoods. The GAME Community intervention is implemented by the non-profit street sport organisation GAME. Five components support the implementation of GAME Community: (1) training of peer leaders; (2) a focus on inclusion of inactive girls; (3) parental involvement; (4) community engagement; (5) strengthened organisational support to peer leaders. In the ASPHALT II study, we aim to evaluate GAME Community and hence contribute to understanding how children growing up in low resource neighbourhoods can be engaged and retained in physical activity through participation in peer-led, community-based sport and to generate new understandings on the scale up of community interventions. The primary objective of the evaluation is to investigate the implementation of GAME Community and the programme's reach, and to establish the functioning and mechanisms of the programme. The secondary objective is to establish the health enhancing potential of the programme. The evaluation of GAME Community involves three linked but independent studies that investigate (1) the functioning (i.e., mechanisms and processes), (2) reach, and (3) outcomes. The functioning of the five intervention components is investigated using qualitative methodologies. Programme reach will be investigated based on participant registrations. Systematic observations using a novel combination of validated tools will provide information on outcomes (physical activity level and social behaviour) during GAME Community activities. Investigating functioning, reach, and outcomes of the GAME Community intervention by using multiple methods is a strength, as different data complement and inform each other. This study will provide in-depth insights into if and how children living in low resource neighbourhoods can be engaged and retained in physical activity through participation in peer-led, community-based sport. Contributions of this evaluation include new understanding of the mechanisms and scalability of a community-based street sport intervention.

Text Message Reminders to Improve Immunization Appointment Attendance in Alberta, Canada: The Childhood Immunization Reminder Project Pilot Study

BACKGROUND

Vaccine coverage for 18-month-old children in Canada is often below the recommended level, which may be partially because of parental forgetfulness. SMS text message reminders have been shown to potentially improve childhood immunization uptake but have not been widely used in Alberta, Canada. In addition, it has been noted that language barriers may impede immunization service delivery but continue to remain unaddressed in many existing reminder and recall systems.

OBJECTIVE

This study aimed to assess the effectiveness and acceptability of using SMS text messages containing a link to web-based immunization information in different languages to remind parents of their child's 18-month immunization appointment.

METHODS

The Childhood Immunization Reminder Project was a pilot intervention at 2 public health centers, one each in Lethbridge and Edmonton, Alberta, Canada. Two SMS text message reminders were sent to parents: a booking reminder 3 months before their child turned 18 months old and an appointment reminder 3 days before their scheduled appointment. Booking reminders included a link to the study website hosting immunization information in 9 languages. To evaluate intervention effectiveness, we compared the absolute attendance no-show rates before the intervention and after the intervention. The acceptability of the intervention was evaluated through web-based surveys completed by parents and public health center staff. Google Analytics was used to determine how often web-based immunization information was accessed, from where, and in which languages.

RESULTS

Following the intervention, the health center in Edmonton had a reduction of 6.4% (95% CI 3%-9.8%) in appointment no-shows, with no change at the Lethbridge Health Center (0.8%, 95% CI -1.4% to 3%). The acceptability surveys were completed by 222 parents (response rate: 23.9%) and 22 staff members. Almost all (>95%) respondents indicated that the reminders were helpful and provided useful suggestions for improvement. All surveyed parents (222/222, 100%) found it helpful to read web-based immunization information in their language of choice. Google Analytics data showed that immunization information was most often read in English (118/207, 57%), Punjabi (52/207, 25.1%), Arabic (13/207, 6.3%), Spanish (12/207, 5.8%), Italian (4/207, 1.9%), Chinese (4/207, 1.9%), French (2/207, 0.9%), Tagalog (1/207, 0.5%), and Vietnamese (1/207, 0.5%).

CONCLUSIONS

The study's findings support the use of SMS text message reminders as a convenient and acceptable method to minimize parental forgetfulness and potentially reduce appointment no-shows. The diverse languages accessed in web-based immunization information suggest the need to provide appropriate translated immunization information. Further research is needed to evaluate the impact of SMS text message reminders on childhood immunization coverage in different settings.

Evidence in public health: An integrated, multidisciplinary concept

AIMS

Traditionally, evidence in public health has been founded in health sciences using the hierarchy of evidence. In this Commentary, we argue that we need a combination of evidence based on a broad range of scientific disciplines and methodologies to best translate research into improved public health.

METHODS

Using existing concepts of evidence such as the hierarchy of evidence and the evidence typology, we discuss their pitfalls in public health science and suggest a way forward. We use the case of the MAMAACT intervention to exemplify our claims.

RESULTS

Public health does not apply an either/or perspective, but an integrated, theoretically informed approach based on mixed and multiple methods to understand complex health problems and how to tackle them. Ideally, public health decisions should always incorporate scientific evidence, although we need to fully acknowledge that the quality of evidence is defined by more than just being placed highest in the hierarchy of evidence. No method or study design is superior in obtaining evidence, but we need the combined and supplemented contributions from a range of scientific approaches to form a whole. Thus, we propose an integrated, multidisciplinary concept of evidence in the form of cogwheels, where the public health problem followed by the research question(s) will guide the components to be studied and the use of method(s) in an interplay with the decisions of the scientific perspective(s) that include choice of theories.

CONCLUSIONS

We cannot understand or solve public health challenges without multidisciplinary approaches in a complimentary formation.

Association Between Urban Regeneration and Healthcare-Seeking Behavior of Affected Residents: A Natural Experiment in two Multi-Ethnic Deprived Housing Areas in Denmark

Area regeneration of deprived neighborhoods is being used to reduce health inequality, socioeconomic deprivation and ethnic segregation. This quasi-experimental study examines if long-term graded exposure to urban regeneration is associated with primary healthcare-seeking behavior among residents. We compared general practitioner (GP) contacts from 2015-2020 in two adjacent, deprived social housing areas, one exposed to area regeneration. Populations were into Western and non-Western males and females aged 15 years and older (N = 3,960). Mean annual GP contact frequency for each group were estimated and a difference-in-difference (DiD) analysis was conducted with adjustments for propensity scores based on baseline characteristics. GP contact frequency increased for all groups across time with a systematically higher level and faster increase in the control groups. In particular, the mean difference between the exposed and control area for non-Western women more than doubled from -0.61 to -1.47 annual contacts across the period. The mean differences in contact frequency increased for all groups but results of the DiD analyses were insignificant. In conclusion, an emerging gap in GP contact frequency, with the highest levels in the control area, was observed for all comparisons across time. More long-term research is needed to understand how the emerging gaps evolve.

Peer mentors' role in school-based health promotion: qualitative findings from the Young & Active study

Peer-led interventions are highlighted as promising strategies to promote health among adolescents, but little is known about the mechanisms underlying this approach. To better understand the role of peer mentors (PMs) as implementers in school-based health promotion, we combined participant observations, focus group interviews and video recordings to explore high school students' reception of a peer-led intervention component (Young & Active). Young & Active aimed to increase well-being among first-year high school students (∼16 years of age) through the promotion of movement and sense of community and was implemented during the school year 2016-2017 in a larger school-based intervention study, the Healthy High School study in Denmark. The Healthy High School study was designed as a cluster-randomized controlled trial with 15 intervention schools and 15 control schools. At each intervention school, university students in Sports Science and Health (members of the research group) facilitated an innovation workshop aiming at inspiring all first-year students to initiate movement activities at schools. The findings illustrate potentials and challenges implied in the PM role. The peer mentors' profound commitment, as well as their response and sensibility to situational contingencies, were found to be significant for the students' reception and experience of the intervention. In conclusion, the specific job of PMs as implementers seems to consist of simultaneously following a manual and situationally adjusting in an emerging context balancing commitment and identification to the target group and the intervention project.

Health promotion innovations scale up: combining insights from framing and actor-network to foster reflexivity

There are numerous hurdles down the road for successfully scaling up health promotion innovations into formal programmes. The challenges of the scaling-up process have mainly been conceived in terms of available resources and technical or management problems. However, aiming for greater impact and sustainability involves addressing new contexts and often adding actors whose perspectives may challenge established orientations. The social dimension of the scaling-up process is thus critical. Building on existing conceptualizations of interventions as dynamic networks and of evolving framing of health issues, this paper elaborates a social view of scaling up that accounts for the transformations of innovations, using framing analysis and the notion of 'expanding scaling-up networks'. First, we discuss interventions as dynamic networks. Second, we conceptualize scaling-up processes as networks in expansion within which social learning and change occur. Third, we propose combining a 'representational approach' to frame analysis and an 'interactional approach' that illustrates framing processes related to the micro-practices of leading public health actors within expanding networks. Using an example concerning equity in early childhood development, we show that this latter approach allows documenting how frames evolve in the process. Considering the process in continuity with existing conceptualizations of interventions as actor-networks and transformation of meanings enriches our conceptualization of scaling up, improves our capacity to anticipate its outcomes, and promotes reflexivity about health promotion goals and means.

Next Level Health: a holistic health and wellbeing program to empower New Zealand women

Improving equity in women's health requires gender-specific and empowering approaches. However, health programs often disempower women by adopting a 'one-size-fits-all' approach that emphasizes diet, exercise and weight loss over other important aspects like sleep and mental wellbeing. This article reports on the design of Next Level Health (NLH), a program that aims to empower women through developing a wide range of health behaviors to support their holistic wellbeing. NLH is grounded by ethics, theory and evidence to support women to make achievable, sustainable changes that are relevant to their everyday lives. Women utilized the NLH framework to develop an integrative health routine across six domains: physical activity, sleep, nutrition, eating behavior, self-care and stress management. The framework guided them to set small, incremental goals that were adaptive to their needs and built from their existing circumstances. Participants reflected on their progress with a facilitator during monthly meetings, accessed a social media support page and received monthly text messages. Health programs remain an essential approach to improving women's health alongside community- and policy-level strategies. The development of NLH exemplifies how evidence may partner with modern health promotion values to inform relevant and ethical program design for women.

Negotiating Engagement, Worthiness of Care and Cultural Identities Through Intersubjective Recognition: Migrant Patient Perspectives on the Cultural Formulation Interview in Danish Mental Healthcare

This qualitative study presents migrant patient perspectives on using the Cultural Formulation Interview (CFI) in mental health assessments in Denmark. Empirical data consisted of 20 recorded CFI sessions and 16 patient interviews, coded with a constructivist grounded theory approach. Empirical findings prompted us to draw on the theoretical framework of intersubjective recognition in the analytical process. Our analysis showed how patients had multiple previous experiences of misrecognition in life and healthcare. This seemed to restrain their self-esteem and available positions for expressing preferences and reservations during the CFI and led to negotiations of worthiness of care. Despite occasional lack of flow and information in the recorded CFI sessions, patients subsequently recounted how they felt the CFI recognised the complexity and context of their cultural identities and illness narratives. Patients described how the CFI-guided provider approach of curiosity and empowerment carried significant meaning and left them feeling dignified, hopeful and engaged in future care. Intersubjective recognition is fundamental in all human interaction, but we argue that the recognising CFI approach is particularly important in vulnerable and asymmetrical mental health assessment encounters where access to care is determined and when working with migrants or other marginalised groups.

Ethnography and user-centered design to inform context-driven implementation

Despite pervasive findings pointing to its inextricable role in intervention implementation, context remains poorly understood in implementation science. Existing approaches for describing context (e.g., surveys, interviews) may be narrow in scope or superficial in their elicitation of contextual data. Thus, in-depth and multilevel approaches are needed to meaningfully describe the contexts into which interventions will be implemented. Moreover, many studies assess context without subsequently using contextual information to enhance implementation. To be useful for improving implementation, though, methods are needed to apply contextual information during implementation. In the case example presented in this paper, we embedded an ethnographic assessment of context within a user-centered design approach to describe implementation context and apply that information to promote implementation. We developed a patient-reported outcome measure-based clinical intervention to assess and address the pervasive unmet needs of young adults with cancer: the Needs Assessment & Service Bridge (NA-SB). In this paper, we describe the user-centered design process that we used to anticipate context modifications needed to deliver NA-SB and implementation strategies needed to facilitate its implementation. Our ethnographic contextual inquiry yielded a rich understanding of local implementation context and contextual variation across potential scale-up contexts. Other methods from user-centered design (i.e., translation tables and a design team prototyping workshop) allowed us to translate that information into specifications for NA-SB delivery and a plan for implementation. Embedding ethnographic methods within a user-centered design approach can help us to tailor interventions and implementation strategies to their contexts of use to promote implementation.

Making sense of the evidence in population health intervention research: building a dry stone wall

To effectively tackle population health challenges, we must address the fundamental determinants of behaviour and health. Among other things, this will entail devoting more attention to the evaluation of upstream intervention strategies. However, merely increasing the supply of such studies is not enough. The pivotal link between research and policy or practice should be the cumulation of insight from multiple studies. If conventional evidence synthesis can be thought of as analogous to building a wall, then we can increase the supply of bricks (the number of studies), their similarity (statistical commensurability) or the strength of the mortar (the statistical methods for holding them together). However, many contemporary public health challenges seem akin to herding sheep in mountainous terrain, where ordinary walls are of limited use and a more flexible way of combining dissimilar stones (pieces of evidence) may be required. This would entail shifting towards generalising the functions of interventions, rather than their effects; towards inference to the best explanation, rather than relying on binary hypothesis-testing; and towards embracing divergent findings, to be resolved by testing theories across a cumulated body of work. In this way we might channel a spirit of pragmatic pluralism into making sense of complex sets of evidence, robust enough to support more plausible causal inference to guide action, while accepting and adapting to the reality of the public health landscape rather than wishing it were otherwise. The traditional art of dry stone walling can serve as a metaphor for the more ‘holistic sense-making’ we propose.

Programme theory and realist evaluation of the 'Smoke-Free Vocational Schools' research and intervention project: a study protocol

INTRODUCTION

Smoke-free school hours (SFSHs) entails a smoking ban during school hours and might be an effective intervention to reduce the high smoking prevalence in vocational schools. For SFSH to be effective, the policy must be adequately implemented and enforced; this challenge for schools constitutes a research gap. The 'Smoke-Free Vocational Schools' research and intervention project has been developed to facilitate schools' implementation of SFSH. It is scheduled to run from 2018 to 2022, with SFSH being implemented in 11 Danish vocational schools. This study protocol describes the intervention project and evaluation design of the research and intervention project.

METHODS AND ANALYSIS

The intervention project aims to develop an evidence-based model for implementing SFSH in vocational schools and similar settings. The project is developed in a collaboration between research and practice. Two public health NGOs are responsible for delivering the intervention activities in schools, while the research partner evaluates what works, for whom, and under what circumstances. The intervention lasts one year per school, targeting different socioecological levels. During the first 6 months, activities are delivered to stimulate organisational readiness to implement SFSH. Then, SFSH is established, and during the next 6 months, activities are delivered to stimulate implementation of SFSH into routine practice. The epistemological foundation is realistic evaluation. The evaluation focuses on both implementation and outcomes. Process evaluation will determine the level of implementation and explore what hinders or enables SFSH becoming part of routine practice using qualitative and quantitative methods. Outcomes evaluation will quantitively assess the intervention's effectiveness, with the primary outcome measure being changes in smoking during school hours.

ETHICS AND DISSEMINATION

Informed consent will be obtained from study participants according to the General Data Protection Regulation (GDPR) and Danish data protection law. The study adheres to Danish ethics procedures. Study findings will be disseminated at conferences and further published in open-access peer-reviewed journals.

Viewing Sexual Health Education through the Lens of Critical Pedagogy: A Case Study in Chicago Public Schools

Comprehensive sexual health education (SHE) programs are being implemented in many state and local jurisdictions. Much research has focused on the strength and effectiveness of such programs. However, the experiences of teachers and students in their implementation is underexplored. A case study of the implementation of the SHE policy and curriculum in Chicago Public Schools sought to explore teachers' and students' experiences. Sixteen teachers were interviewed and five student focus groups, including 46 students, were conducted. Both teachers and students identified opportunities to improve upon the current program, including to (1) incorporate more student-centered learning opportunities and allow for tailoring to each specific group of students; (2) use discussion and dialogue to encourage students' exploration of their own opinions and identities and development of a sense of agency over their own learning; (3) shift focus from risk reduction to a more holistic focus on healthy sexual wellbeing; and (4) directly discuss current health inequities, contributing factors, and intersectionality. These findings align with a critical pedagogical approach and underscore the need to understand SHE implementation within its sociopolitical context. Implications of the use of critical pedagogy as a framework for SHE in Chicago and beyond are discussed.

Awareness of Sexual Rights and Empowerment: Quantitative and Qualitative Evaluation of a Sexual Health Intervention for Adults with Intellectual Disability

Young people with intellectual disability (ID) rarely have opportunities to form intimate relationships or receive long-term interventions promoting their sexual health and awareness of sexual rights. To promote sexual health in adults with ID in Taiwan, we utilized intervention research and inclusive research to introduce three interventions that involved adults with ID, their parents, and service workers. This paper primarily evaluates the outcomes of a two-year intervention to promote sexual and reproductive health knowledge/positive attitudes and quality of life for adults with ID. A non-equivalent multiple-groups with replications design was used to gather data from 87 adults with ID. In-depth interviews and focus groups were used to collect the experiences and perspectives of adults with ID, service workers and parents. Although the experimental groups did not show a strong quantitative increase in sexual knowledge and sexual attitudes, the qualitative data indicated that the dialogues with and among the participants transformed their perceptions of sexual needs from being sexual problems to being sexual rights, which was empowering for adults with ID. Involving parents and service workers in the intervention and facilitating dialogue between these groups are essential to transform sexual problems of adults with ID into sexual rights.

Co-Designing an Intervention to Prevent Overweight and Obesity among Young Children and Their Families in a Disadvantaged Municipality: Methodological Barriers and Potentials

Design-based research (DBR) is an innovative methodology for co-creation, but potentials, challenges, and differences between methodological ideals and the real-life intervention context are under-researched. This study analyzes the DBR process in which researchers, professionals, and families co-design a family-based intervention to prevent childhood overweight and obesity in a rural municipality. It involves interviews with six key stakeholders in the co-design process. Data were coded and analyzed using systematic text condensation, while the theory of the "social effectiveness of interventions" developed by Rod et al. (2014) was used as an analytical tool for unpacking the co-creation process and exploring methodological barriers and potentials. The DBR approach contributed with a feeling that everyone's perspective was important, and the professionals got a new perspective on the families' experiences with healthy living they did not previously consider. We also found that the iterative design process did not fully align with the organizational structures in the municipality or with the needs of stakeholders, leading to friction in the partnership. This study emphasizes the complexity of using an anti-hierarchical approach within a hierarchical context, and the importance of being aware of how the DBR approach shapes the partnership, as well as of how the social dynamics within the partnership shape the design process.

Do the key functions of an intervention designed from the same specifications vary according to context? Investigating the transferability of a public health intervention in France

Background

The processes at play in the implementation of one program in different contexts are complex and not yet well understood. In order to facilitate both the analysis and transfer of interventions, a “key functions/implementation/context” (FIC) model was developed to structure the description of public health interventions by distinguishing their potentially transferable dimensions (their “key functions”) from those associated with their translation within a specific context (their “form”). It was used to describe and compare preschool preventative nutrition interventions routinely implemented across three territories, in accordance with same national specifications.

Methods

The interventions were independently described by researchers and intervention’s implementers using the FIC model, during several workshops. Their key functions were then classified into 12 themes and compared to assess the extent to which the three interventions were similar.

Results

Despite being produced from the same set of specifications and having similar objectives, the key functions of the interventions in the three departments mostly reflected the same major themes, they did not overlap and were in some cases very different. In one of the three departments, the intervention was markedly different from those of the other two departments. The historical context of the interventions and the specificities of the local actors appear highly determinant of the key functions described.

Conclusions

For the interventions that we studied, some of the key functions varied greatly and translated different concepts of health education and modes of intervention to the population. It now seems vital to improve the description of interventions on the ground in order to highlight the key functions on which they are based, which still often remain implicit. The FIC model could be used to complement other models and theories focusing on the description of the implementation process, its determinants or its evaluation. Its interest is to provide a structure for joint reflection by various actors on the transferable aspects of an intervention, its form and its interactions with the context, in order ultimately to analyse or to improve its potential transferability.

Do the key functions of an intervention designed from the same specifications vary according to context? Investigating the transferability of a public health intervention in France

BACKGROUND

The processes at play in the implementation of one program in different contexts are complex and not yet well understood. In order to facilitate both the analysis and transfer of interventions, a "key functions/implementation/context" (FIC) model was developed to structure the description of public health interventions by distinguishing their potentially transferable dimensions (their "key functions") from those associated with their translation within a specific context (their "form"). It was used to describe and compare preschool preventative nutrition interventions routinely implemented across three territories, in accordance with same national specifications.

METHODS

The interventions were independently described by researchers and intervention's implementers using the FIC model, during several workshops. Their key functions were then classified into 12 themes and compared to assess the extent to which the three interventions were similar.

RESULTS

Despite being produced from the same set of specifications and having similar objectives, the key functions of the interventions in the three departments mostly reflected the same major themes, they did not overlap and were in some cases very different. In one of the three departments, the intervention was markedly different from those of the other two departments. The historical context of the interventions and the specificities of the local actors appear highly determinant of the key functions described.

CONCLUSIONS

For the interventions that we studied, some of the key functions varied greatly and translated different concepts of health education and modes of intervention to the population. It now seems vital to improve the description of interventions on the ground in order to highlight the key functions on which they are based, which still often remain implicit. The FIC model could be used to complement other models and theories focusing on the description of the implementation process, its determinants or its evaluation. Its interest is to provide a structure for joint reflection by various actors on the transferable aspects of an intervention, its form and its interactions with the context, in order ultimately to analyse or to improve its potential transferability.

Effectiveness of the settings-based intervention Shaping the Social on preventing dropout from vocational education: a Danish non-randomized controlled trial

BACKGROUND

Lack of formal education is an important social determinant of health inequality and represents a public health problem. School dropout is particularly common in vocational education; however few prevention programs targeting dropout in the vocational school setting have been evaluated. The purpose of the present study was to test the effect on school dropout of a settings-based intervention program (named Shaping the Social) that targeted the school organization in order to create social and supportive learning environments.

METHODS

A non-randomized controlled design including four large intervention schools and six matched-control schools was used. The target population was students in technical and agricultural vocational education, which is provided to students from age 16. Students were enrolled at school start. Register-based data (n = 10,190) was used to assess the effect on school dropout during a 2-year period. Odds ratios (OR) and 95% confidence intervals (CI) were calculated in logistic regression models, adjusting for age, sex, ethnicity, parental income, prior school dropout and type of basic course. Student survey (n = 2396) at 10-week follow-up was used to examine wellbeing at school (four subscales: school connectedness, student support, teacher relatedness, and valuing the profession) which was the hypothesized proximal intervention effect. As a secondary aim, we examined how the student wellbeing factors were associated with school dropout, independently of the intervention, and we explored whether the student wellbeing factors were potential mediators.

RESULTS

The present study showed an intervention effect on school dropout with dropout rates lower in intervention schools (36%) than control schools (40%) (OR = 0.86, 95% CI: 0.74, 0.99). We had no attrition on the dropout outcome. School connectedness mediated the intervention effect; no significant mediation effects were found for student support, teacher relatedness, and valuing the profession. Independently of the intervention, each student wellbeing factor prevented dropout.

CONCLUSIONS

Findings from this study suggest that a comprehensive, multicomponent school-based intervention could prevent dropout from vocational education by promoting school connectedness; nevertheless, the dropout rate remained high. Our results point to the need to explore how to further improve the wellbeing at school among young people in vocational education.

TRIALS REGISTRATION

ISRCTN, ISRCTN57822968 . Registered 16 January 2013 (retrospective registered).

How the Consolidated Framework for Implementation Research Can Strengthen Findings and Improve Translation of Research Into Practice: A Case Study

PURPOSE/OBJECTIVES

To answer how the planned intervention was performed in routine care, which factors supported or distracted from its implementation, and how key organizational structures have been built and sustained.
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RESEARCH APPROACH

Mixed-methods process evaluation.
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SETTING

Two German outpatient cancer clinics.
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PARTICIPANTS

Purposive sampling of 297 recruited patients with gynecologic cancer, their treating oncology nurses, and their interprofessional healthcare team, and the clinical stakeholders of two different outpatient cancer clinics.
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METHODOLOGIC APPROACH

Guided by the Consolidated Framework for Implementation Research (CFIR), five distinct interrelated substudies were designed to evaluate intervention characteristics, inner and outer settings, characteristics of the individuals involved, and the process of implementation. Quantitative and qualitative data will be analyzed separately and then integrated into a framework analysis.
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FINDINGS

Oncology nurses found the regular process analytic sessions to be beneficial, not only for sharing their experience, but also for experiencing social support and social connectedness.
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INTERPRETATION

Key implementation facets of the nurse-led intervention will be examined systematically. The results can guide future implementation processes, which need to be tailored to interested facilities.
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IMPLICATIONS FOR NURSING

The CFIR framework is well established but not yet widely applied in supportive treatment research. The current study aims to apply and combine this framework with the concept of intervention fidelity.

Anticipating the potential for positive uptake and adaptation in the implementation of a publicly funded online STBBI testing service: a qualitative analysis

Background

Online health services are a rapidly growing aspect of public health provision, including testing for sexually transmitted and other blood-borne infections (STBBI). Generally, healthcare providers, policymakers, and clients imbue online approaches with great positive potential (e.g., encouraging clients’ agency; providing cost-effective services to more clients). However, the promise of online health services may vary across contexts and be perceived in negative or ambiguous ways (e.g., risks to ‘gold standard’ care provision; loss of provider control over an intervention; uncertainty related to budget implications). This study examines attitudes and perceptions regarding the development of a novel online STBBI testing service in Vancouver, Canada. We examine the perceptions about the intervention’s potential by interviewing practitioners and planners who were engaged in the development and initial implementation of this testing service.

Methods

We conducted in-depth interviews with 37 healthcare providers, administrators, policymakers, and community-based service providers engaged in the design and launch of the new online STBBI testing service. We also conducted observations during planning and implementation meetings for the new service. Thematic analysis techniques were employed to identify codes and broader discursive themes across the interview transcripts and observation notes.

Results

Some study participants expressed concern that the potential popularity of the new testing service might increase demand on existing sexual health services or become fiscally unsustainable. However, most participants regarded the new service as having the potential to improve STBBI testing in several ways, including reducing waiting times, enhancing privacy and confidentiality, appealing to more tech-savvy sub-populations, optimizing the redistribution of demands on face-to-face service provision, and providing patient-centred technology to empower clients to seek testing.

Conclusions

Participants perceived this online STBBI testing service to have the potential to improve sexual health care provision. But, they also anticipated actions-and-reactions, revealing a need to monitor ongoing implementation dynamics. They also identified the larger, potentially system-transforming dimension of the new technology, which enables new system drivers (consumers) and reduces the amount of control health care providers have over online STBBI testing compared to conventional in-person testing.

Addressing complexity in population health intervention research: the context/intervention interface

Background

Public health interventions are increasingly being recognised as complex and context dependent. Related to this is the need for a systemic and dynamic conception of interventions that raises the question of delineating the scope and contours of interventions in complex systems. This means identifying which elements belong to the intervention (and therefore participate in its effects and can be transferred), which ones belong to the context and interact with the former to influence results (and therefore must be taken into account when transferring the intervention) and which contextual elements are irrelevant to the intervention.

Discussion

This paper, from which derives criteria based on a network framework, operationalises how the context and intervention systems interact and identify what needs to be replicated as interventions are implemented in different contexts. Representing interventions as networks (composed of human and non-human entities), we introduce the idea that the density of interconnections among the various entities provides a criterion for distinguishing core intervention from intervention context without disconnecting the two systems. This differentiates endogenous and exogenous intervention contexts and the mediators that connect them, which form the fuzzy and constantly changing intervention/context interface.

Conclusion

We propose that a network framework representing intervention/context systems constitutes a promising approach for deriving empirical criteria to delineate the scope and contour of what is replicable in an intervention. This approach should allow better identification and description of the entities that have to be transferred to ensure the potential effectiveness of an intervention in a specific context.

A lifestyle intervention study targeting individuals with low socioeconomic status of different ethnic origins: important aspects for successful implementation

Background

Evaluation of the implementation process of trials is important, because the way a study is implemented modifies its outcomes. Furthermore, lessons learned during implementation can inform other researchers on factors that play a role when implementing interventions described in research. This study evaluates the implementation of the MetSLIM study, targeting individuals with low socioeconomic status of different ethnic origins. The MetSLIM study was set up to evaluate the effectiveness of a lifestyle programme on waist circumference and other cardio-metabolic risk factors. The objective of this evaluation was to identify components that were essential for the implementation of the MetSLIM study and to inform other researchers on methodological aspects when working with inadequately reached populations in health research.

Methods

In this evaluation study the experiences of health professionals, study assistants, a community worker and regional research coordinators involved in the MetSLIM study were explored using semi-structured interviews. Questionnaires were used to evaluate participants’ satisfaction with the lifestyle intervention.

Results

Our analyses show that a flexible recruitment protocol eventually leads to recruitment of sufficient participants; that trust in the recruiter is an important factor in the recruitment of individuals with low socioeconomic status of different ethnic origins; and that health professionals will unavoidably shape the form of intervention activities. Furthermore, our evaluation shows that daily practice and research mutually influence each other and that the results of an intervention are a product of this interaction.

Conclusions

Health promotion research would benefit from a perspective that sees intervention activities not as fixed entities but rather as social interaction that can take on numerous forms. Analysing and reporting the implementation process of studies, like in this evaluation, will allow readers to get a detailed view on the appropriateness of the (intended) study design and intervention for the targeted population. Evaluation studies that shed light on the reasons for adaptations, rather than describing them as deviation from the original plan, would point out methodological aspects important for a study’s replication. Furthermore, they would show how various factors can influence the implementation, and therewith initiate a learning cycle for the development of future intervention studies.

Trial registration

Netherlands Trial Register NTR3721 (since November 27, 2012).

Effects of a settings-based intervention to promote student wellbeing and reduce smoking in vocational schools: A non-randomized controlled study

RATIONALE

School dropout and health risk behavior such as cigarette smoking represent major problems among students attending upper secondary vocational education. Modifications to the social environment may promote educational attainment as well as health and wellbeing of young people. However, there is a need for more evidence-based intervention programs.

OBJECTIVE

The aim of this study was to assess the effectiveness of an intervention targeting the socio-environmental setting at vocational schools on student wellbeing and smoking.

METHODS

We conducted a non-randomized controlled trial of 5794 students (mean age 21 years; 81% male) in 10 (four intervention and six comparison) large vocational schools in Denmark. The intervention involved changes in everyday school practices focusing on four themes: (i) introduction activities, (ii) daily class meetings, (iii) scheduled breaks and (iv) pleasant non-smoking environment. Outcomes were student wellbeing (four subscales: school connectedness, student support, teacher relatedness, positive valuing of the profession) and daily smoking measured at 10-week follow-up.

RESULTS

We found statistically significant between-group difference in school connectedness, but not in student support, teacher relatedness and valuing the profession. The intervention had no effect on daily smoking. However, we found a statistically significant interaction between baseline smoking status and condition. This interaction suggested that baseline occasional smokers in the intervention group had significantly reduced odds ratio (OR) of becoming a daily smoker compared to baseline occasional smokers in the control group (8% versus 16%; OR = 0.44).

CONCLUSION

The positive effects on school connectedness and in preventing occasional smokers becoming daily smokers indicate that it is possible to tackle school-related wellbeing and smoking in a high risk population through settings-based interventions.

The Developing Role of Evidence-Based Environmental Health: Perceptions, Experiences, and Understandings From the Front Line

There has been renewed recognition that proactive strategies and interventions can address the social determinants of health, and the environmental health profession is well placed to effect positive change in many of these determinants. This qualitative research has revealed differences in the perceptions, experiences, and understandings of evidence-based practice among public health professionals from different backgrounds across different services in health care and local government in England. The absence of a strong tradition of evidence-based practice in environmental health appears to be a disadvantage in securing funding and playing a full role, as it has become the expectation in the new public health system. This has, at times, resulted in tensions between professionals with different backgrounds and frustration on the part of environmental health practitioners, who have a tradition of responding quickly to new challenges and "getting on with the job." There is generally a willingness to develop evidence-based practice in environmental health; however, this will take time and investment.

'The government cannot do it all alone': realist analysis of the minutes of community health committee meetings in Nigeria

Since the mid-1980s, the national health policy in Nigeria has sought to inspire community engagement in primary health care by bringing communities into partnership with service providers through community health committees. Using a realist approach to understand how and under what circumstances the committees function, we explored 581 meeting minutes from 129 committees across four states in Nigeria (Lagos, Benue, Nasarawa and Kaduna). We found that community health committees provide opportunities for improving the demand and supply of health care in their community. Committees demonstrate five modes of functioning: through meetings (as ‘village square’), reaching out within their community (as ‘community connectors’), lobbying governments for support (as ‘government botherers’), inducing and augmenting government support (as ‘back-up government’) and taking control of health care in their community (as ‘general overseers’). In performing these functions, community health committees operate within and through the existing social, cultural and religious structures of their community, thereby providing an opportunity for the health facility with which they are linked to be responsive to the needs and values of the community. But due to power asymmetries, committees have limited capacity to influence health facilities for improved performance, and governments for improved health service provision. This is perhaps because national guidelines are not clear on their accountability functions; they are not aware of the minimum standards of services to expect; and they have a limited sense of legitimacy in their relations with sub-national governments because they are established as the consequence of a national policy. Committees therefore tend to promote collective action for self-support more than collective action for demanding accountability. To function optimally, community health committees require national government or non-government organization mentoring and support; they need to be enshrined in law to bolster their sense of legitimacy; and they also require financial support to subsidise their operation costs especially in geographically large communities.

Shaping the Social: design of a settings-based intervention study to improve well-being and reduce smoking and dropout in Danish vocational schools

Background

The social environment at schools is an important setting to promote educational attainment, and health and well-being of young people. However, within upper secondary education there is a need for evidence-based school intervention programmes. The Shaping the Social intervention is a comprehensive programme integrating social and educational activities to promote student well-being and reduce smoking and dropout in upper secondary vocational education. The evaluation design is reported here.

Methods/design

The evaluation employed a non-randomised cluster controlled design, and schools were selected to either implement the intervention or continue with normal practice for comparison. In the baseline survey conducted 2011–2012, 2,329 students from four intervention schools and 3,371 students from six comparison schools answered a computer-based questionnaire during class, representing 73 % and 81 % of eligible students, and 22 % of all technical/agricultural vocational schools in Denmark. Follow-up assessment was conducted 10 weeks after baseline and at the same time teachers of the intervention classes answered a questionnaire about implementation. School dropout rates will be tracked via national education registers through a 2-year follow-up period.

Discussion

Shaping the Social was designed to address that students at Danish vocational schools constitute a high risk population concerning health behaviour as well as school dropout by modifying the school environment, alongside developing appropriate evaluation strategies. To address difficulties in implementing settings-based interventions, as highlighted in prior research, the strategy was to involve intervention schools in the development of the intervention. Baseline differences will be included in the effectiveness analysis, so will the impact of likely mediators and moderators of the intervention.

Trials registration

ISRCTN57822968. Date of registration: 16/01/2013

How can we strengthen students' social relations in order to reduce school dropout? An intervention development study within four Danish vocational schools

Background

This article describes the rationale and contents of an intervention program aimed at strengthening students’ social relations in order to reduce dropout from vocational schools in Denmark. Taking its theoretical cue from the concept of ‘social participation’, a qualitative study was performed to investigate the specific relationships between the social environment within the schools and the institutional structures in order to analyse reasons for school dropout and their relation to well-being, cigarette smoking and substance use.

Methods

The development study was based on ethnographic methods, including 22 qualitative interviews with students 17–19 years old and fieldwork with participant observations at four vocational schools over 40 days, including informal interviews and discussion meetings with managers, teachers, counselors and students. As part of the fieldwork, four additional qualitative interviews and four group interviews were conducted with students 16–25 years old.

Results

The qualitative data collection resulted in seven major themes to be addressed in the intervention: social relations, sole focus on professional skills, institutionalized individualization, importance of the introduction period, physical surroundings and schedules, tobacco and cannabis use and communication about drug use. The program addressing these themes incorporates suggestions that are meant to improve how teachers welcome new students, to enable greater integration of social and educational activities and to enhance the capacity of teachers and counselors to deal with drug use problems among students.

Conclusion

The development of new intervention programs might benefit from adopting a theoretical and methodological perspective that enables a closer exploration of the everyday social practices in which interventions are embedded. Thus, we aimed to create a comprehensive intervention that worked through organizational changes in everyday school practices. Intervention programs must be planned in dialogue and collaboration with practitioners in the field to ensure the pertinence and usability of the program.