A causal modelling approach to the development of theory-based behaviour change programmes for trial evaluation

Use of oral health care services among older home care clients in the context of an intervention study

BACKGROUND

An increasing number of care-dependent older people living at home need external support to receive regular dental care.

OBJECTIVES

To investigate the use of oral health care services among old home care clients who participated in an intervention study focusing on oral self-care and nutrition.

MATERIALS AND METHODS

This study employed data from the multidisciplinary Nutrition, Oral Health and Medication (NutOrMed) intervention study with a population-based sample of 245 home care clients (74% female) aged 75 or more divided in intervention (n = 140) and two control groups (n = 105). The data were collected through interviews at baseline and 6-month follow-up.

RESULTS

At baseline, 43% of participants reported visits to oral health care within the previous year. At 6-month follow-up, this proportion was 51%. In the intervention group, the corresponding figures were 46% and 53%, and in the controls 39% and 48%. Adjusted regression analyses showed that this change was statistically significant (p = 0.008). In addition, higher education and toothache or other discomfort related to teeth or dentures at baseline were associated with increased use after the 6-month follow-up (OR = 1.1, 95% CI = 1.0-1.2; OR = 3.4, 95% CI = 1.5-7.9) but being edentulous indicated the opposite (OR = 0.2, 95% CI = 0.1-0.4). Belonging to the intervention group was not associated with increased use.

CONCLUSIONS

In older adults, any efforts to raise awareness of oral health are of great potential to increase use of services.

An ontology of mechanisms of action in behaviour change interventions

Background

Behaviour change interventions influence behaviour through causal processes called "mechanisms of action" (MoAs). Reports of such interventions and their evaluations often use inconsistent or ambiguous terminology, creating problems for searching, evidence synthesis and theory development. This inconsistency includes the reporting of MoAs. An ontology can help address these challenges by serving as a classification system that labels and defines MoAs and their relationships. The aim of this study was to develop an ontology of MoAs of behaviour change interventions.

Methods

To develop the MoA Ontology, we (1) defined the ontology's scope; (2) identified, labelled and defined the ontology's entities; (3) refined the ontology by annotating (i.e., coding) MoAs in intervention reports; (4) refined the ontology via stakeholder review of the ontology's comprehensiveness and clarity; (5) tested whether researchers could reliably apply the ontology to annotate MoAs in intervention evaluation reports; (6) refined the relationships between entities; (7) reviewed the alignment of the MoA Ontology with other relevant ontologies, (8) reviewed the ontology's alignment with the Theories and Techniques Tool; and (9) published a machine-readable version of the ontology.

Results

An MoA was defined as "a process that is causally active in the relationship between a behaviour change intervention scenario and its outcome behaviour". We created an initial MoA Ontology with 261 entities through Steps 2-5. Inter-rater reliability for annotating study reports using these entities was α=0.68 ("acceptable") for researchers familiar with the ontology and α=0.47 for researchers unfamiliar with it. As a result of additional revisions (Steps 6-8), 23 further entities were added to the ontology resulting in 284 entities organised in seven hierarchical levels.

Conclusions

The MoA Ontology extensively captures MoAs of behaviour change interventions. The ontology can serve as a controlled vocabulary for MoAs to consistently describe and synthesise evidence about MoAs across diverse sources.

Co-construct, implement and evaluate a multi-level intervention to prevent a sedentary lifestyle in children-Study protocol of the CIPRES study

BACKGROUND

A sedentary lifestyle is commonly associated with a higher risk of chronic disease development. Among school-aged children from European countries, screen-time represents a significant portion of sedentary time with 39.8% of children spending more than 2h/day in front of a screen on average. Therefore, effective solutions to reduce sedentary behavior (SB) must be found. Multilevel interventions based on the socio-ecological model (SEM) are particularly relevant to take into account influences of the social environment on individuals' SB. Moreover, the trans-contextual model (TCM) can offer complementary levers for individuals' behavior change. The CIPRES study is a theory-based multilevel intervention designed to decrease the SB in French primary school children aged 8-10 years. The present paper describes the protocol of a randomized controlled study to evaluate the effectiveness of the CIPRES multilevel intervention on SB.

METHODS

The CIPRES study is a cluster-randomized controlled trial comparing intervention vs control groups. A total of 700 children are targeted for inclusion, distributed in four municipalities considered as clusters. The study consists of two successive phases: 1) co-building of a SB prevention intervention by using a participatory approach involving representatives of each level of the SEM (e.g., children, parents, staff from municipalities, teachers) and 2) implementation and evaluation of the intervention. The intervention will last for 6 weeks in each involved class. Primary outcome will be the sedentary time of children per week, assessed by accelerometry. In addition, children and their parents will be asked to fill out questionnaires concerning children's physical activity level, screen time, quality-of-life and variables of the TCM.

DISCUSSION

This study will give information on the effectiveness of a theory-based intervention, involving multiple levels of actors in the co-construction and the implementation of the intervention, that may interest schools and public health officers looking for innovative sedentary prevention programs.

Systematic Review Examining the Behavior Change Techniques in Medication Adherence Intervention Studies Among People With Type 2 Diabetes

BACKGROUND

Although previous systematic reviews have studied medication adherence interventions among people with Type 2 diabetes (PwT2D), no intervention has been found to improve medication adherence consistently. Furthermore, inconsistent and poor reporting of intervention description has made understanding, replication, and evaluation of intervention challenging.

PURPOSE

We aimed to identify the behavior change techniques (BCTs) and characteristics of successful medication adherence interventions among PwT2D.

METHODS

A systematic search was conducted on Medline, Embase, CINAHL, PsycINFO, Cochrane Central Register of Controlled Trials, Web of Science, and Scopus. Studies were included if they were randomized controlled trials with BCT-codable interventions designed to influence adherence to anti-diabetic medication for PwT2D aged 18 years old and above and have medication adherence measure as an outcome.

RESULTS

Fifty-five studies were included. Successful interventions tend to target medication adherence only, involve pharmacists as the interventionist, contain "Credible source" (BCT 9.1), "Instruction on how to perform the behaviour" (BCT 4.1), "Social support (practical)" (BCT 3.2), "Action planning" (BCT 1.4), and/ or "Information about health consequences" (BCT 5.1). Very few interventions described its context, used theory, examined adherence outcomes during the follow-up period after an intervention has ended, or were tailored to address specific barriers of medication adherence.

CONCLUSION

We identified specific BCTs and characteristics that are commonly reported in successful medication adherence interventions, which can facilitate the development of future interventions. Our review highlighted the need to consider and clearly describe different dimensions of context, theory, fidelity, and tailoring in an intervention.

Designing complex interventions: A description of the development of an intervention to reduce inequalities in planned dental visiting

There are multifaceted reasons for a social gradient in planned dental visiting involving various psycho-social variables that interact with each other and the environment. Interventions in this area are therefore inevitably complex interventions. While guidance recommends undertaking theory and modelling work before experimental work is done, there is a shortage of descriptions of how this is done, especially in the field of oral health.

OBJECTIVES

To describe theory, qualitative and public engagement work, and identification of behaviour change techniques (BCTs) to define features of an opportunistic dental visiting intervention for adult users of urgent dental care services.

METHODS

A systematic review and synthesis of theory, qualitative and quantitative work, along with expert input, generated a list of psycho-social determinants linked to planned dental visiting intentions. Modelling involved ethnographic work in urgent dental care settings and work with members of the community from the targeted demographic. This enabled verification, in the context of their idiosyncratic expression for the target population in question, of behavioural determinants (BDs) identified in the theory phase. It also facilitated generating intervention material which was infused with the identity of the end user. BDs identified were then mapped to BCTs using an accepted BCT taxonomy and an intervention prototype developed. The prototype then underwent iterative testing with target users before it was ready for a feasibility trial.

RESULTS

Theory and modelling identified five key intervention focuses: affordable resources (time/ cost), the importance of oral health, trust in dentists, embarrassment of having poor oral health and dental anxiety. Short videos were developed to incorporate role modelling which were well received. Prototype testing resulted in shifting from 'if-then' plans to action planning.

CONCLUSIONS

Complex intervention development involves an iterative rather than sequential process of combining theory, empirical work and user involvement, of which the article provides an example.

Effectiveness of double ABCX-based psychotherapy for psychological distress among women undergoing in vitro fertilization-embryo transfer: a three-arm randomized controlled trial

OBJECTIVE

This study aimed to evaluate the effectiveness of double ABCX-based psychotherapy for psychological distress during in vitro fertilization-embryo transfer (IVF-ET) among a female group (FG), couple group (CoG) and control group (CG).

METHODS

A total of 201 women undergoing their first IVF-ET cycle were randomized into three groups. The 6-session intervention was delivered at each visit to the IVF clinic. The primary outcomes were depression and anxiety, and the secondary outcomes included sleep quality, serum cortisol (nmol/L) levels and the clinical pregnancy rate, which were assessed before and after the intervention.

RESULTS

The group-by-time effects were significant for depression, anxiety, sleep quality and serum cortisol levels, with larger effect sizes in the FG than in the CoG. There was no significant difference in the pregnancy rate among the three groups.

CONCLUSION

Psychotherapy effectively mitigated psychological distress, suggesting greater effectiveness for couples undergoing IVF couples than for women only. It is structured and easy to use during the IVF treatment cycle.

TRIAL REGISTRATION NUMBER

https://register.clinicaltrials.gov (NCT03931187, retrospectively registered on April 23, 2019).

Applying the Behaviour Change Wheel to UK Local Authority Policy Documents: A Content Analysis in the Context of Financial Behaviour

Local authorities in the UK often try to improve their residents' financial well-being by promoting changes in behaviour. The extent to which these behaviour change activities are based on relevant theory or evidence is unknown. This research aims to retrospectively analyse the content of local authorities' policies to identify opportunities for improvement. The Action, Actor, Context, Target, Time (AACTT) framework was used to assess the specification of target behaviours. The Behaviour Change Wheel (BCW) process was used to assess intervention content. Within the policy documents, target behaviours were not consistently specified in terms of the AACTT criteria. Descriptions of interventions lacked detail with 28% unable to be categorised and there was a reliance on Education (46%) to change financial behaviour. The designing and reporting of interventions to change residents' financial behaviour were not always aligned with behavioural science evidence and utilising systematic frameworks could help local authorities achieve policy objectives.

An online 5-week professional identity program for nursing student in clinical rotation practice during the first wave of COVID-19 pandemic: A two-arm randomized trial

AIM

Development and evaluation of the effectiveness of an online 5-week professional identity program among nursing students in clinical internship practice during the COVID-19 restrictions.

BACKGROUND

Nurse professional identity is a strong predictor of career commitment. Clinical internship practice is a key stage when nursing students build and rebuild their professional identity. Meanwhile, the COVID-19 restrictions has strongly influenced the professional identity of nursing students as well as nursing education. A well-designed online professional identity program may contribute to nursing students who are in clinical internship practice developing positive professional identity during the COVID-19 restrictions.

DESIGN

The study was a two-armed, randomised, controlled trial conducted and reported based on Consolidated Standards of Reporting Trials (CONSORT) 2010 guidelines.

METHODS

A total of 111 nursing students undergoing clinical internship were randomised into an intervention group and a control group. The five-weekly session intervention was developed based on social identity theory and career self-efficacy theory. The primary outcomes were professional identity and professional self-efficacy and the second outcome was stress. Qualitative feedback was analysed by thematic analysis. Outcomes were assessed before and after the intervention and analysed using an intention-to-treat principle.

RESULTS

The generalised linear model showed that group-by-time effects were significant for the total score of professional identity and three factors of professional self-image, social comparison and self-reflection and independence of career choice, with small effect sizes (Cohen's d from 0.38 to 0.48). Only one factor of the capacity of information collection and planning in professional self-efficacy was significant (Wald χ² =0.4.82, P < 0.01) with a medium effect size (Cohen d=0.73). The group effect, time effect and group-by-time effect of stress were not significant. Three themes were: 'Gaining in professional identity, self-recognition and peer belonging'; 'Content, self-motivation and intervenor as participation facilitators'; and 'Combining offline and courses, setting group rules and building mutual trust as recommendations'.

CONCLUSIONS

The online 5-week professional identity program effectively promoted the development of professional identity and the capacity for information collection and career planning but did not significantly relieve pressure during the internship.

Challenges and opportunities in coproduction: reflections on working with young people to develop an intervention to prevent violence in informal settlements in South Africa

Coproduction is widely recognised as essential to the development of effective and sustainable complex health interventions. Through involving potential end users in the design of interventions, coproduction provides a means of challenging power relations and ensuring the intervention being implemented accurately reflects lived experiences. Yet, how do we ensure that coproduction delivers on this promise? What methods or techniques can we use to challenge power relations and ensure interventions are both more effective and sustainable in the longer term? To answer these questions, we openly reflect on the coproduction process used as part of Siyaphambili Youth ('Youth Moving Forward'), a 3-year project to create an intervention to address the social contextual factors that create syndemics of health risks for young people living in informal settlements in KwaZulu-Natal province in South Africa. We identify four methods or techniques that may help improve the methodological practice of coproduction: (1) building trust through small group work with similar individuals, opportunities for distance from the research topic and mutual exchanges about lived experiences; (2) strengthening research capacity by involving end users in the interpretation of data and explaining research concepts in a way that is meaningful to them; (3) embracing conflicts that arise between researchers' perspectives and those of people with lived experiences; and (4) challenging research epistemologies through creating spaces for constant reflection by the research team. These methods are not a magic chalice of codeveloping complex health interventions, but rather an invitation for a wider conversation that moves beyond a set of principles to interrogate what works in coproduction practice. In order to move the conversation forward, we suggest that coproduction needs to be seen as its own complex intervention, with research teams as potential beneficiaries.

The behaviour change behind a successful pilot of hypoglycaemia reduction with HYPO-CHEAT

Background

Children with hypoglycaemia disorders, such as congenital hyperinsulinism (CHI), are at constant risk of hypoglycaemia (low blood sugars) with the attendant risk of brain injury. Current approaches to hypoglycaemia detection and prevention vary from fingerprick glucose testing to the provision of continuous glucose monitoring (CGM) to machine learning (ML) driven glucose forecasting. Recent trends for ML have had limited success in preventing free-living hypoglycaemia, due to a focus on increasingly accurate glucose forecasts and a failure to acknowledge the human in the loop and the essential step of changing behaviour. The wealth of evidence from the fields of behaviour change and persuasive technology (PT) allows for the creation of a theory-informed and technologically considered approach.

Objectives

We aimed to create a PT that would overcome the identified barriers to hypoglycaemia prevention for those with CHI to focus on proactive prevention rather than commonly used reactive approaches.

Methods

We used the behaviour change technique taxonomy and persuasive systems design models to create HYPO-CHEAT (HYpoglycaemia-Prevention-thrOugh-Cgm-HEatmap-Assisted-Technology): a novel approach that presents aggregated CGM data in simple visualisations. The resultant ease of data interpretation is intended to facilitate behaviour change and subsequently reduce hypoglycaemia.

Results

HYPO-CHEAT was piloted in 10 patients with CHI over 12 weeks and successfully identified weekly patterns of hypoglycaemia. These patterns consistently correlated with identifiable behaviours and were translated into both a change in proximal fingerprick behaviour and ultimately, a significant reduction in aggregated hypoglycaemia from 7.1% to 5.4% with four out of five patients showing clinically meaningful reductions in hypoglycaemia.

Conclusions

We have provided pilot data of a new approach to hypoglycaemia prevention that focuses on proactive prevention and behaviour change. This approach is personalised for individual patients with CHI and is a first step in changing our approach to hypoglycaemia prevention in this group.

Australasian Genetic Counselors' Perceptions of Their Role in Supporting Clients' Behavior Change

Genetic testing does not always change health behavior. Effective behavior change requires a theory-driven coordinated set of activities (behavior change techniques). Genetic counselors are ideally positioned to facilitate behavior change. We aimed to explore genetic counselors' perceptions of their role in supporting clients' behavior change to inform the design of an intervention. Recruitment was via a professional organization and genetics services. Data were collected from 26 genetic counselors via qualitative focus groups/interview. Transcripts were analyzed using thematic analysis and mapped to the COM-B model. We identified three behaviors genetic counselors wanted clients to change: attend appointments, access information, and share information with family members. Strategies for changing clients' behavior included: assessing needs and capabilities, providing information and support, enabling and monitoring behavior change. Barriers included lack of behavior change skills and knowledge, lack of time, and beliefs about ownership of healthcare, directiveness of behavior change, and scope of practice. Equipping genetic counselors to deliver behavior change requires (i) education in behavior change theory and behavior change techniques, (ii) integration of capability, opportunity and motivation assessment into existing practice, and (iii) development of evidence-based strategies using behavior change tools to focus discussions and promote clients' agency to change their behavior.

The Codevelopment of "My Kidneys & Me": A Digital Self-management Program for People With Chronic Kidney Disease

BACKGROUND

Health care self-management is important for people living with nondialysis chronic kidney disease (CKD). However, the few available resources are of variable quality.

OBJECTIVE

This work describes the systematic codevelopment of "My Kidneys & Me" (MK&M), a theory-driven and evidence-based digital self-management resource for people with nondialysis CKD, guided by an established process used for the successful development of the diabetes education program MyDESMOND (Diabetes Education and Self-Management for Ongoing and Newly Diagnosed, DESMOND).

METHODS

A multidisciplinary steering group comprising kidney health care professionals and researchers and specialists in the development of complex interventions and digital health provided expertise in the clinical and psychosocial aspects of CKD, self-management, digital health, and behavior change. A patient and public involvement group helped identify the needs and priorities of MK&M and co-design the resource. MK&M was developed in 2 sequential phases. Phase 1 involved the codevelopment process of the MK&M resource (content and materials), using Intervention Mapping (IM) as a framework. The first 4 IM steps guided the development process: needs assessment was conducted to describe the context of the intervention; intervention outcomes, performance objectives, and behavioral determinants were identified; theory- and evidence-based change methods and practical strategies to deliver change methods were selected; and program components were developed and refined. Phase 2 involved the adoption and adaptation of the existing MyDESMOND digital platform to suit the MK&M resource.

RESULTS

The needs assessment identified that individuals with CKD have multiple differing needs and that delivering a self-management program digitally would enable accessible, tailored, and interactive information and support. The intended outcomes of MK&M were to improve and maintain effective self-management behaviors, including physical activity and lifestyle, improve knowledge, promote self-care skills, increase self-efficacy, and enhance well-being. This was achieved through the provision of content and materials designed to increase CKD knowledge and patient activation, reduce health risks, manage symptoms, and improve physical function. Theories and behavior change techniques selected include Self-Management Framework, Capability, Opportunity, Motivation Behavior model components of Behaviour Change Wheel and taxonomy of behavior change techniques, Health Action Process Approach Model, Common Sense Model, and Social Cognitive Theory. The program components developed comprised educational and behavior change sessions, health trackers (eg, monitoring blood pressure, symptoms, and exercise), goal-setting features, and forums for social support. The MyDESMOND digital platform represented an ideal existing platform to host MK&M; thus, the MyDESMOND interface and features were adopted and adapted for MK&M.

CONCLUSIONS

Applying the IM framework enabled the systematic application of theory, empirical evidence, and practical perspectives in the codevelopment of MK&M content and materials. Adopting and adapting a preexisting platform provided a cost- and time-efficient approach for developing our digital intervention. In the next stage of work, the efficacy of MK&M in increasing patient activation will be tested in a randomized controlled trial.

The unappreciated relevance of auxiliary assumptions for evaluating theory-based interventions in health psychology

The use of theory in health behavior change interventions has been recently questioned with mixed results found for theory-based intervention effectiveness. But theory testing in intervention depends on not only theoretical assumptions, but on auxiliary assumptions too. Specifically, auxiliary assumptions are required to traverse the distance from nonobservational terms in theories and observational terms at the level of the empirical hypotheses in interventions. We believe intervention failures are often due to flaws in auxiliary assumptions rather than assumptions at the theoretical level. We use the theory of planned behavior to illustrate how the consideration of these auxiliary assumptions is important to appraise the effectiveness of interventions informed by theory. We hope that bringing attention to the importance of auxiliary assumptions provides a more nuanced and accurate appraisal of theory utility.

Effectiveness of Interventional Studies on Type 2 Diabetes: A Decade Systematic Review

Context: Educational interventions on type 2 diabetes can have life-saving effects. A closer analysis of studies in this area contributes to well-designed interventions. Objectives: We surveyed the effectiveness of interventional studies on type 2 diabetes in the last decade. Data Sources: The research papers were obtained from PubMed, Science Direct, Scopus, Web of Science, Google Scholar, SID, and Magiran for Persian and English language studies between 2010 and 2019. The PRISMA checklist was used to select the studies for systematic reviews. Study Selection: The criteria for article selection were experimental studies, quasi-experimental studies, clinical trials, and pre-treatment and post-treatment observations. Also, the exclusion criteria were case studies, short articles, cross-sectional studies, descriptive and analytic studies, letters to the editor, and systematic review papers. Finally, 24 studies (out of 1,374) were entered in our study. Data Extraction: An interventional study checklist was used to report the standard of studies: (1) consolidated standards of reporting trials with 25 items; (2) checklist for experimental design with nine items; (3) checklist for quasi-experimental studies with nine items; and (4) transparent reporting of evaluations with non-randomized designs with 22 items. Results: Twenty-four research papers entered the final analysis. Most studies were clinical trials with the intervention period ranging from one to 12 months. Patients were usually selected as the participants. The education interventions in most studies were lectures, questions/answers, group discussions, brainstorming, photo/film/slide display, group teaching, individual training, individual counseling, and group counseling. The main focus of the interventions was on physical activity and diet, with positive effects. Conclusions: Most interventions made on type 2 diabetes variables had positive effects. Therefore, it is recommended that in addition to diet and physical activity, other factors of type 2 diabetes be considered in educational interventions. Also, the most effective and appropriate teaching methods should be considered to prevent and control this disease.

A Novel Digital Self-management Intervention for Symptoms of Fatigue, Pain, and Urgency in Inflammatory Bowel Disease: Describing the Process of Development

Background

Empirical studies and systematic reviews have demonstrated the role of biological, cognitive, behavioral, and emotional factors in fatigue, pain, and urgency in inflammatory bowel disease (IBD). Behavioral management that addresses the cognitive, behavioral, and emotional factors offered alongside medical treatment is seldom available to people with IBD. Digital interventions provide a potentially scalable and cost-effective way of providing behavioral support to patients.

Objective

This paper aimed to describe the process of developing a supported digital self-management intervention for fatigue, pain, and urgency in IBD using theory and evidence-based approaches and stakeholder input.

Methods

The Medical Research Council framework for complex health interventions and a person-based approach were used to guide intervention development, consulting with 87 patients with IBD and 60 nurses. These frameworks informed the selection and use of a theoretical model that subsequently guided cognitive behaviorally based intervention content. They also guided the design of tailored digital intervention pathways for individuals with IBD that matched the predominant symptoms.

Results

A transsymptomatic cognitive behavioral framework of symptom perpetuation was developed for the symptoms of fatigue, pain, and urgency in IBD. A logic model was used to define the intervention techniques. Patient feedback and qualitative interviews refined the website content and functionalities, including the use of visual aids, email reminders, and graphical tracking of symptoms. Nurse focus groups informed the volume and delivery model of the therapist facilitator support. Ratings of acceptability out of 10 following feasibility testing (31/87, 36%) demonstrated accessibility (scoring 9.43, SD 1.040), ease (scoring 8.07, SD 3.205), clarity, and the relevant tone of the intervention. The final intervention comprised 12 web-based sessions (8 core and 4 symptom-specific), with one 30-minute facilitator phone call following session 1 and subsequent on-site messaging.

Conclusions

The use of theory and integration of stakeholders’ views throughout informed the development of an evidence-based digital intervention for fatigue, pain, and urgency in IBD. This is the first web-based self-management intervention designed to address these multiple symptoms with the aim of improving the quality of life and reducing the symptom burden of IBD. The intervention is being tested in a large multicenter randomized controlled trial.

Trial Registration

ISRCTN Registry ISRCTN71618461; https://www.isrctn.com/ISRCTN71618461

Self-management program for patients with chronic kidney disease (SMP-CKD) in Southern China: protocol for an ambispective cohort study

Background

Chronic kidney disease (CKD) is a major global health problem. Short-term self-management has been considered to effect some renal and psychological endpoints. However, there are currently very few studies about self-management for CKD that a) have been scientifically designed by a theory-based framework and b) that evaluate the long-term effects and working mechanism. This study presents the rationale and design of a theory-based cohort study to explore how this self-management intervention works and its effectiveness on the Chinese CKD population.

Methods

In this ambispective intervention cohort study,1,200 patients with CKD stages 1–5 will be recruited from July 2015 to July 2024 in 3 branches of Guangdong Provincial Hospital of Chinese Medicine (GPHCM) in Guangdong province, China. The patients in the self-management cohort will choose to receive an intervention that consists of education, nutrition/diet modification, lifestyle change recommendation, medication review, and psychology support based on Social Cognition Theory (SCT). The patients in the control cohort will do regular follow-ups based on the clinic rules. All the patients will be followed up for 5 years, or until the occurrence of a primary outcome. Detailed clinical, laboratory markers, nutritional status, psychological exposures and outcome questionaries will be collected semiannually in CKD stage 1–2 and trimonthly in stage 3–5 patients. The primary outcome is the occurrence of composite clinical endpoints (doubling of serum creatinine level, ESKD, loss of renal function (≥ 40% decline in GFR from baseline), death, major cardiovascular or cerebrovascular events). The main secondary outcomes include the absolute change and slope of eGFR, absolute changes of urinary protein creatinine ratio, 24-h urine proteinuria, intact parathyroid hormone level, and self-management adherence rate and quality of life from baseline to end of the study. The effectiveness of self-management will be analyzed and the association between longitudinal trajectories of self-management and renal outcomes will be evaluated.

Discussion

This study aims to provide further evidence for the effectiveness of theory-based self-management in CKD patients and to improve the lives of patients with CKD by slowing progression, improving psychological well-being and overall quality of life.

Trial registration

Chinese Clinical Trial Register (ChiCTR1900024633). 19 July, 2019. http://www.chictr.org.cn/showproj.aspx?proj=38378

Development and Theoretical Underpinnings of the PRIORITY Intervention: A Parenting Intervention to Prevent Disordered Eating in Children and Young People With Type 1 Diabetes

Children and young people (CYP) with type 1 diabetes (T1D) are twice as likely to develop disordered eating (T1DE) and clinical eating disorders than those without. This has significant implications for physical and mental health, with some eating disorders associated with repeated diabetic ketoacidosis and higher HbA1c levels, both of which are life threatening. There is currently limited psychological support for CYP and families with T1D but increasingly, policy and practice are suggesting disordered eating in T1D may be effectively prevented through psychological intervention. We describe the development and theoretical underpinnings of a preventative psychological intervention for parents of CYP aged 11-14, with T1D. The intervention was informed by psychological theory, notably the Information Motivation Behaviour Skills model and Behaviour Change Technique Taxonomy. The intervention was co-developed with an expert advisory group of clinicians, and families with T1D. The manualised intervention includes two online group workshops, and supplementary online materials. The intervention continues to evolve, and feasibility findings will inform how best to align the intervention with routine care in NHS diabetes teams. Early detection and intervention are crucial in preventing T1DE, and it is hoped that the current intervention can contribute to improving the psychological and physical wellbeing of young people and families managing T1D.

A Systematic Review of Nudge Interventions to Optimize Medication Prescribing

Background: The benefits of medication optimization are largely uncontroversial but difficult to achieve. Behavior change interventions aiming to optimize prescriber medication-related decisions, which do not forbid any option and that do not significantly change financial incentives, offer a promising way forward. These interventions are often referred to as nudges.

Objective: The current systematic literature review characterizes published studies describing nudge interventions to optimize medication prescribing by the behavioral determinants they intend to influence and the techniques they apply.

Methods: Four databases were searched (MEDLINE, Embase, PsychINFO, and CINAHL) to identify studies with nudge-type interventions aiming to optimize prescribing decisions. To describe the behavioral determinants that interventionists aimed to influence, data were extracted according to the Theoretical Domains Framework (TDF). To describe intervention techniques applied, data were extracted according to the Behavior Change Techniques (BCT) Taxonomy version 1 and MINDSPACE. Next, the recommended TDF-BCT mappings were used to appraise whether each intervention applied a sufficient array of techniques to influence all identified behavioral determinants.

Results: The current review located 15 studies comprised of 20 interventions. Of the 20 interventions, 16 interventions (80%) were effective. The behavior change techniques most often applied involved prompts (n = 13). The MINDSPACE contextual influencer most often applied involved defaults (n = 10). According to the recommended TDF-BCT mappings, only two interventions applied a sufficient array of behavior change techniques to address the behavioral determinants the interventionists aimed to influence.

Conclusion: The fact that so many interventions successfully changed prescriber behavior encourages the development of future behavior change interventions to optimize prescribing without mandates or financial incentives. The current review encourages interventionists to understand the behavioral determinants they are trying to affect, before the selection and application of techniques to change prescribing behaviors.

Systematic Review Registration: [https://www.crd.york.ac.uk/prospero/], identifier [CRD42020168006].

The Effects of Interdisciplinary Bedside Rounds on Patient Centeredness, Quality of Care, and Team Collaboration: A Systematic Review

BACKGROUND

Research indicates that having multiple healthcare professions and disciplines simultaneously at the patient's bedside improves interprofessional communication and collaboration, coordination of care, and patient-centered shared decision-making. So far, no review has been conducted, which included qualitative studies, explores the feasibility of the method, and looks at differences in definitions.

OBJECTIVES

The aim of the study was to explore available evidence on the effects of interdisciplinary bedside rounds (IBRs) on patient centeredness, quality of care and team collaboration; the feasibility of IBRs; and the differences in definitions.

DATA SOURCES

PubMed, Web of Science, and Cochrane databases were systematically searched. The reference lists of included articles and gray literature were also screened. Articles in English, Dutch, and French were included. There were no exclusion criteria for publication age or study design.

STUDY APPRAISAL AND SYNTHESIS METHODS

The included (N = 33) articles were critically reviewed and assessed with the Downs and Black checklist. The selection and summarizing of the articles were performed in a 3-step procedure, in which each step was performed by 2 researchers separately with researcher triangulation afterward.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Interdisciplinary bedside round has potentially a positive influence on patient centeredness, quality of care, and team collaboration, but because of a substantial variability in definitions, design, outcomes, reporting, and a low quality of evidence, definitive results stay uncertain. Perceived barriers to use IBR are time constraints, lack of shared goals, varied responsibilities of different providers, hierarchy, and coordination challenges. Future research should primarily focus on conceptualizing IBRs, in specific the involvement of patients, before more empiric, multicentered, and longitudinal research is conducted.

Co-creation and prototyping of an intervention focusing on health literacy in management of malaria at community-level in Ghana

INTRODUCTION

Collaborating with end-users to develop interventions tailored to fit unique circumstances is proposed as a way to improve relevance and effectiveness of an intervention. This study used a local needs driven approach to develop a health literacy intervention for caregivers in Ghana concerning management of malaria in children under 5 years.

METHOD

For the period, November 2017-February 2019, we carried out the study using a three-phase framework including: 1) Needs assessment based on data from questionnaires, focus groups, individual interviews and observations, 2) Co-creation of a board game and brochures for health education at Child Welfare Clinics to address needs in health literacy concerning malaria and 3) Development of a prototype of the game, brochures as well as determining feasibility. In addition to the research team, health administrators, community health workers, designers and caregivers contributed to the development of the intervention.

FINDINGS

The needs assessment contributed to the development of interactive and useful materials including a board game and brochures, to help bridge the gaps in health literacy among caregivers. Co-creation of the materials and prototyping yielded a varying sense of ownership among stakeholders. End-users' engagement and participation in developing the intervention resulted in a high interest and adherence to interventions. However, high attrition rates of health workers and caregivers' inconsistent use of the Child Welfare Clinics challenged sustainability of this intervention.

CONCLUSION

Co-creation led to an interactive intervention. The interactive nature of the board game and brochures resulted in a better caregiver-health provider relationship and a sense of recognition of a more participatory approach to health delivery. We recommend co-creation as an approach to develop needs-driven interventions in a context like Ghana. Still, a stronger buy-in at the top-level of health management would improve sustainability and reach a larger audience.

Application of Integrated Behavioral Model (IBM) to measure intention to get early screening and treatment of Sexually Transmitted Infections (STIs) among HIV at- risk sub-populations in Ethiopia

Background

Sexually Transmitted Infections (STIs) increase the risk of contracting Human Immunodeficiency Virus (HIV). Hence, early screening and treatment of STIs as a behavioral practice will reduce the odds of HIV infection among at risk and vulnerable sub-populations. To that end, HIV prevention strategies need to design evidence-based interventions using behavioral models or theories to help at-risk individuals adopt early screening and treatment of STI as preventive health behavior. In this study, commercial sex workers were considered as HIV at-risk sub-populations.

Objective

Measuring to what extent that Integrated Behavioral Model constructs explain individuals' intention to practice early screening and treatment of sexually transmitted infections as healthy behavior of interest in HIV prevention.

Design

Integrated Behavioral Model (IBM) measurement survey was conducted using Respondent Driven Sampling (RDS) in six towns located in the main transport corridors of Ethiopia. Respondents' answers to model construct-based questions and intention to practice the health behavior of interest were measured using Likert Scale. Analysis was done to assess the correlation and level of association of model construct-based questions with intention to practice the preventive health behavior.

Results

Respondents' attitude explained 32%, perceived control 2%, normative influence 21%, and self-efficacy 53 % of their intention to get early screening and treatment of sexually transmitted infections.

Conclusion

Self-efficacy explained the variability of respondents' intention to get early screening and treatment of STIs most, while perceived control was the least. Hence, HIV prevention behavioral interventions targeting early screening and treatment of STIs should give high emphasis to self-efficacy.

Capability, opportunity, and motivation: an across contexts empirical examination of the COM-B model

BACKGROUND

There is limited evidence for successful weight gain prevention interventions targeting young adults. Developing effective interventions necessitates a theoretical model that can identify barriers and enablers for healthy eating and physical activity among young adults to support weight management. This study empirically examines the utility of the COM-B model as a framework for intervention planning across two behavioural contexts: eating and physical activity.

METHODS

A cross-sectional survey research design was employed to empirically test the COM-B model in the contexts of young adult's eating and physical activity behaviours. Informed by the Theoretical Domains Framework, pre-validated measures appropriate for capturing the latency of the COM (Capability, Opportunity, and Motivation) constructs were sourced. Both surveys (eating and physical activity) were administered online to two independent samples of young adults aged 18-35 years. Models were specified and tested using structural equation modelling.

RESULTS

A total of 582 (mean age = 22.8 years; 80.3% female) and 455 (mean age = 24.9 years; 80.8% female) participants were included in the physical activity and eating analyses, respectively. The COM-B model explained 31% of variance in physical activity behaviour and 23% of variance in eating behaviour. In the physical activity model (N = 582), capability and opportunity were found to be associated with behaviour through the mediating effect of motivation. In the eating model (N = 455), capability was found to be associated with behaviour through the mediating effect of motivation. Capability was also found to mediate the association between opportunity and motivation. Consistencies and variations were observed across both models in terms of COM indicators.

CONCLUSIONS

Findings support the COM-B model's explanatory potential in the context of young adult's physical activity and eating behaviours. Barriers and enablers underlying young adult's physical activity and eating behaviours were identified that represent potential targets for future intervention design. Further research is needed to validate present study findings across different populations and settings.

The theoretical basis of a nationally implemented type 2 diabetes prevention programme: how is the programme expected to produce changes in behaviour?

BACKGROUND

It is considered best practice to provide clear theoretical descriptions of how behaviour change interventions should produce changes in behaviour. Commissioners of the National Health Service Diabetes Prevention Programme (NHS-DPP) specified that the four independent provider organisations must explicitly describe the behaviour change theory underpinning their interventions. The nationally implemented programme, launched in 2016, aims to prevent progression to Type 2 diabetes in high-risk adults through changing diet and physical activity behaviours. This study aimed to: (a) develop a logic model describing how the NHS-DPP is expected to work, and (b) document the behaviour change theories underpinning providers' NHS-DPP interventions.

METHODS

A logic model detailing how the programme should work in changing diet and activity behaviours was extracted from information in three specification documents underpinning the NHS-DPP. To establish how each of the four providers expected their interventions to produce behavioural changes, information was extracted from their programme plans, staff training materials, and audio-recorded observations of mandatory staff training courses attended in 2018. All materials were coded using Michie and Prestwich's Theory Coding Scheme.

RESULTS

The NHS-DPP logic model included information provision to lead to behaviour change intentions, followed by a self-regulatory cycle including action planning and monitoring behaviour. None of the providers described an explicit logic model of how their programme will produce behavioural changes. Two providers stated their programmes were informed by the COM-B (Capability Opportunity Motivation - Behaviour) framework, the other two described targeting factors from multiple theories such as Self-Regulation Theory and Self-Determination Theory. All providers cited examples of proposed links between some theoretical constructs and behaviour change techniques (BCTs), but none linked all BCTs to specified constructs. Some discrepancies were noted between the theory described in providers' programme plans and theory described in staff training.

CONCLUSIONS

A variety of behaviour change theories were used by each provider. This may explain the variation between providers in BCTs selected in intervention design, and the mismatch between theory described in providers' programme plans and staff training. Without a logic model describing how they expect their interventions to work, justification for intervention contents in providers' programmes is not clear.

The stepwise development of an interactive web-based sex education programme for subfertile couples: the Pleasure & Pregnancy programme

STUDY QUESTION

Can we develop a web-based sex education programme (programme running in a web browser) that addresses the needs of subfertile couples who are advised expectant management for at least 6 months?

SUMMARY ANSWER

The 'Pleasure & Pregnancy' programme addresses couples' needs, is likely to improve couples' sexual functioning, and is subsequently hypothesised to improve the chance of natural pregnancy.

WHAT IS KNOWN ALREADY

According to professional guidelines (e.g. the Netherlands and UK) couples with unexplained subfertility and a good chance of natural pregnancy, should be advised at least 6 months of expectant management. Adherence to expectant management is challenging as couples and gynaecologist prefer a more active approach. Targeting sexuality may be useful as subfertility is a risk factor for decreased sexual functioning.

STUDY DESIGN, SIZE, DURATION

A novel programme was developed according to the three steps of the Medical Research Councils' (MRC) framework. First, relevant literature was explored. Second, an interdisciplinary expert panel developed a theory (based on a systematic literature review and patient interviews) on how the chance of natural conception can be improved. Third, the expected process and outcomes were modelled.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Two licenced clinical sexologists, two gynaecologists, a clinical embryologist and two midwife-researchers, all from Belgium and the Netherlands, proposed components for the sex education programme. PubMed was searched systematically for randomised controlled trials (RCTs) evaluating the proposed components in different patient populations. The needs of 12 heterosexual Dutch or Belgian couples who were advised expectant management were explored with in-depth interviews. The content and delivery characteristics of the novel programme were described in detail with the aid of 'Intervention Taxonomy'. To model the outcomes, a protocol for an RCT was designed, registered and submitted for publication.

MAIN RESULTS AND THE ROLE OF CHANCE

To help maintain or improve sexual functioning, mainly pleasure, and hence increase pregnancy rates, the web-based Pleasure & Pregnancy programme contains a combination of psychosexual education and couple communication, mindfulness and sensate focus exercises. Information on the biology of conception and interaction with fertility clinic staff and peers were added based on couples' needs to increase potential acceptability.

LIMITATIONS AND REASON FOR CAUTION

This paper outlines the development phase of a sex education programme according to the MRC-framework. Whether the Pleasure & Pregnancy programme actually is acceptable, improves sexual functioning, increases pregnancy rates and is cost-effective remains to be determined.

WIDER IMPLICATIONS OF THE FINDINGS

No previous interactive web-based sex education programme has aimed to increase the natural pregnancy rate of subfertile couples by targeting their sexual pleasure. The Pleasure & Pregnancy programme addresses couples' needs and its effect on sexual functioning and pregnancy rate is plausible but remains to be demonstrated by an RCT which is currently ongoing.

STUDY FUNDING/COMPETING INTEREST(S)

Funding was provided by The Netherlands Organisation for Health Research and Development (ZonMw), Flanders Research Foundation and the University of Amsterdam. C.B.L. is editor-in-chief of Human Reproductionbut was blinded to all parts of the peer review process. The remaining authors have no conflict of interest to report.

TRIAL REGISTRATION NUMBER

Not applicable.

Development of an antimicrobial stewardship implementation model involving collaboration between general practitioners and pharmacists: GPPAS study in Australian primary care

Background:

Rising antimicrobial resistance (AMR) in primary care is a growing concern and a threat to community health. The rise of AMR can be slowed down if general practitioners (GPs) and community pharmacists (CPs) could work as a team to implement antimicrobial stewardship (AMS) programs for optimal use of antimicrobial(s). However, the evidence supporting a GP pharmacist collaborative AMS implementation model (GPPAS) in primary care remains limited.

Aim:

With an aim to design a GPPAS model in Australia, this paper outlines how this model will be developed.

Methods:

This exploratory study undertakes a systematic review, a scoping review, nationwide surveys, and qualitative interviews to design the model. Medical Research Council (MRC) framework and Normalization Process Theory are utilized as guides. Reviews will identify the list of effective GPPAS interventions. Two AMS surveys and paired interviews of GPs and CPs across Australia will explore their convergent and divergent views about the GPPAS interventions, attitudes towards collaboration in AMS and the perceived challenges of implementing GPPAS interventions. Systems Engineering Initiative for Patient Safety (SEIPS 2.0) model and factor analyses will guide the structure of GPPAS model through identifying the determinants of GPPAS uptake. The implementable GPPAS strategies will be selected based on empirical feasibility assessment by AMS stakeholders using the APEASE (Affordability, Practicability, Effectiveness and cost-effectiveness, Acceptability, Side-effects and safety, Equity) criteria.

Discussion:

The GPPAS model might have potential implications to inform how to better involve GPs and CPs in AMS, and, to improve collaborative services to optimize antimicrobial use and reduce AMR in primary care.

Caring for Persons With Intellectual Disabilities and Challenging Behavior: Staff Experiences With a Web-Based Training Program

Background: Clear and effective communication is a prerequisite to provide help and support in healthcare situations, especially in health, and social care services for persons with intellectual disabilities, as these clients commonly experience communication difficulties. Knowledge about how to communicate effectively is integral to ensuring the quality of care. Currently, however, there is a lack of such knowledge among staff working in the disabilities sector, which is exacerbated by challenges in the competence provision in municipal health and social care services. Therefore, the aim of the study was to explore staffs' experience of web-based training in relation to their professional caring for persons with intellectual disabilities and challenging behavior. The intention is to move toward well-evaluated and proven web-based training in order to contribute to competence provision in this specific context. Methods: Fourteen semi-structured interviews were carried out with individual staff members to gather data regarding their experiences with web-based training in relation to their profession. The collected data were analyzed using qualitative content analysis with a focus on both manifest and latent content. Results: The staff's experiences with the web-based training program were presented as a single main theme: "Web-based training for staff initiates a workplace learning process by promoting reflections on and awareness of how to better care for persons with intellectual disabilities and challenging behavior." This theme contained three categories which are based on eight sub-categories. Conclusion and clinical implications: The benefits of web-based training for workplace learning could clearly be observed in the strengthening of professional care for persons with intellectual disabilities and challenging behavior. Staff members claimed to have gained novel insights about how to better care for clients as well as about the importance of interactions in their encounters with clients. Professional teamwork is crucial to providing effective care for persons with intellectual disabilities and challenging behavior. Hence, future research aimed at investigating the views of other healthcare professionals, such as registered nurses, is recommended to improve the competence provision within municipal health and social care services and thereby enhance the quality of care.

Nonpharmacological interventions to improve the psychological well-being of women accessing abortion services and their satisfaction with care: A systematic review

How women perceive and experience abortion impacts their subsequent psychological well-being. This systematic review evaluated nonpharmacological interventions designed to support women undergoing abortion services and improve their psychological well-being and satisfaction with care. Searches were conducted in MEDLINE, CINAHL, the Cochrane Library, PsycINFO, Sociological Abstracts, Social Services Abstracts, and PTSD Pubs. All searches were limited to peer-reviewed articles published in English from January 2010 to February 2020. Two reviewers independently assessed study eligibility. Ten studies were included, involving four types of interventions: music therapy; social support; information support; and mandated waiting and counseling requirements on abortion access. Outcome measures were divided into four categories comprised of cognitive domains, emotional and psychological well-being, clinical symptoms, and satisfaction with care. However, there is limited evidence on intervention effects. Most studies report null or mixed intervention effects. Even though some positive effects on women's cognitive outcomes and satisfaction with care were seen, findings across studies were inconclusive. Findings also show that methodological limitations such as lack of theoretical basis, inadequate reporting and no power sample size calculation were apparent across studies. There is limited evidence about nonpharmacological interventions designed to improve women's satisfaction with abortion services or psychological outcomes subsequent to accessing abortion services. Well-designed interventions that meet the needs of service-users should be developed and rigorously tested.

Resistance Exercise and Art Therapy on Body Image in Breast Cancer: A Scoping Review

Background: Treatments for breast cancer are invasive, causing visible changes such as loss of the breast, body weight change, and hair loss. These changes in conjunction with the pressure for women to conform to societal beauty standards may lead to body image disturbance in breast cancer survivors (BCS). The aims of this scoping review were to explore the nature, characteristics, and extent of the literature examining resistance exercise or art therapy on body image in BCS; and examine how body image is defined and measured across the studies.

Methods: We searched the literature up to January 2020, which included conducting electronic searches of three major databases and checking references of screened articles.

Results: Ninety-three articles were identified, 28 underwent full-text screening, with 8 studies eligible for inclusion in the review. Five randomized control trials, one hybrid effectiveness-implementation trial, and two single group studies were found. All studies showed significant within-group difference in body image scores, with two studies showing a between-group difference in favor of resistance exercise. No studies were found combining resistance exercise and art therapy. None of the studies defined the aspect of body image they wished to measure, and only one used theory to inform their research.

Discussion: Preliminary evidence supports the benefit of resistance exercise and art therapy as single interventions to improve body image perception among BCS. Findings suggest the need for closer attention to the delivery format of interventions. Future research is needed that is theory-informed, with a clear definition of the aspect of body image of interest, and with body image as the primary outcome.

Identifying mechanisms of change in a magic-themed hand-arm bimanual intensive therapy programme for children with unilateral spastic cerebral palsy: a qualitative study using behaviour change theory

Background

There has been much research into how to promote upper-limb skills to achieve functional independence in children with unilateral spastic cerebral palsy (USCP). One researched intervention is the Breathe Magic programme, which follows the protocol of hand-arm bimanual intensive therapy (HABIT) whilst, incorporating magic tricks to develop children’s motor skills and bimanual skills. However, whilst research has found the programme to be effective, there has been little consideration of how the intervention leads to a positive outcome: what the psychological, social and physical mechanisms of action are.

Methods

Qualitative semi-structured interviews with 21 children with USCP who participated in the Breathe Magic HABIT intervention, and focus groups with 17 parents and/or carers were undertaken. Analysis was conducted through the lens of the COM-B behaviour change model using a combined deductive framework and inductive thematic analysis. Reliability of coding was confirmed through random extraction and double coding of a portion of responses and the calculation of inter-rater reliability.

Results

Breathe Magic brings about change and positive outcomes by increasing children’s psychological and physical capabilities, providing social opportunities, and enhancing reflective and automatic motivation. Additionally, a number of enablers to engaging in the intervention were identified, particularly under psychological capabilities, social opportunities and both reflective and automatic motivation. Very few barriers were raised; those that were raised were of relatively low frequency of reporting.

Conclusions

By conducting a theory-based qualitative process evaluation, this study demonstrated the mechanisms of change behind the Breathe Magic HABIT intervention for children with USCP. Breathe Magic was found to be a well-structured combination of intended and unintended mechanisms of change. Overall, the success of Breathe Magic was observed through not only its intended mechanisms to enhance hand skills, but also through unintended psychological improvements in children’s hand function, as well as social and motivational benefits resulting from interaction between children and parents.

Sequential Changes Advancing from Exercise-Induced Psychological Improvements to Controlled Eating and Sustained Weight Loss: A Treatment-Focused Causal Chain Model

INTRODUCTION

Behavioral (nonsurgical/nonpharmacologic) weight loss treatments have been overwhelmingly unsuccessful beyond the short term. Rather than incorporating accepted behavioral change theory, most have inadequately relied on providing exercise and nutrition information. Although adherence is a challenge, exercise has emerged as the most robust predictor of sustained weight reduction. However, exercise might be more associated with long-term weight loss through the relationship of its associated psychological changes with improved nutrition than through direct effects of energy expenditures, which are typically minimal in deconditioned individuals.

OBJECTIVE

To facilitate improved helping methods through a proposed theory-based causal chain model in which supported exercise predicts sustained weight loss through successive changes in exercise-related, then eating-related, self-regulation, self-efficacy, and mood.

RESULTS

Segments of the model predict that 1) exercise and eating behaviors will be sequentially improved through increased self-regulatory skill use and self-efficacy and 2) exercise-induced mood improvements will foster greater self-regulation and reduced emotional eating. Short-term psychosocial changes can be leveraged to carry over to longer-term changes and maintained weight reductions. Suggested interventions emerging from the model and supporting research include using self-regulation to enable a habit of regular moderate exercise, facilitating a transfer of self-regulatory skills from an exercise to eating context, and leveraging mood improvements associated with manageable volumes of exercise to improve eating behaviors.

CONCLUSION

The model presents an evidence-based explanation of the exercise-weight loss association through psychosocial mechanisms. It also informs the development of practical methods to facilitate sustainable reductions in weight and health risks in adults with obesity.

Intensive care unit clinicians identify many barriers to, and facilitators of, early mobilisation: a qualitative study using the Theoretical Domains Framework

QUESTION

From the perspective of intensive care unit (ICU) clinicians, what are the barriers to and facilitators of implementing early mobilisation?

DESIGN

A qualitative study using focus groups, with analysis using the Theoretical Domains Framework.

PARTICIPANTS

Physicians, nurses, respiratory therapists and physiotherapists from the ICUs of three university-affiliated hospitals in Montreal, Canada.

METHODS

Four focus group meetings were conducted with 33 participating ICU clinicians. Two researchers independently performed thematic content analysis on verbatim transcriptions of the audio recordings using the Theoretical Domains Framework.

RESULTS

Data saturation was reached after the third focus group. Thirty-six barriers were categorised in 13 domains of the Theoretical Domains Framework. The key barriers to early mobilisation were: lack of conviction and knowledge regarding the available evidence about early mobilisation; lack of attention to the provision of optimal care; poor communication; the unpredictable nature of the ICU; and limited staffing, equipment, time and clinical knowledge. Twenty-five facilitators categorised in ten TDF domains were also identified. These included individual-level facilitators (intrinsic motivation, positive outcome expectations, conscious effort to mobilise early, good planning/coordination, the presence of ICU champions, and expert support by a physiotherapist) and organisational-level facilitators (reminder system, pro-early mobilisation culture, implementation of an early mobilisation protocol, and improved ICU organisation).

CONCLUSIONS

A broad array of barriers to and facilitators of early mobilisation in the ICU were identified in this study. Clinicians can consider whether these barriers and facilitators are operating in their ICU. These may inform the design of tailored knowledge translation interventions to promote early mobilisation in the ICU.

Effect of implementation interventions on nurses' behaviour in clinical practice: a systematic review, meta-analysis and meta-regression protocol

BACKGROUND

Practitioner-level implementation interventions such as audit and feedback, communities of practice, and local opinion leaders have shown potential to change nurses' behaviour in clinical practice and improve patients' health. However, their effectiveness remains unclear. Moreover, we have a paucity of data regarding the use of theory in implementation studies with nurses, the causal processes-i.e. mechanisms of action-targeted by interventions to change nurses' behaviour in clinical practice, and the constituent components-i.e. behaviour change techniques-included in interventions. Thus, our objectives are threefold: (1) to examine the effectiveness of practitioner-level implementation interventions in changing nurses' behaviour in clinical practice; (2) to identify, in included studies, the type and degree of theory use, the mechanisms of action targeted by interventions and the behaviour change techniques constituting interventions and (3) to examine whether intervention effectiveness is associated with the use of theory or with specific mechanisms of action and behaviour change techniques.

METHODS

We will conduct a systematic review based on the Cochrane Effective Practice and Organization of Care (EPOC) Group guidelines. We will search six databases (CINAHL, EMBASE, ERIC, PsycINFO, PubMed and Web of Science) with no time limitation for experimental and quasi-experimental studies that evaluated practitioner-level implementation interventions aiming to change nurses' behaviour in clinical practice. We will also hand-search reference lists of included studies. We will perform screening, full-text review, risk of bias assessment, and data extraction independently with the Covidence systematic review software. We will assess the quality of evidence using the GRADEpro software. We will code included studies independently for theory use (Theory Coding Scheme), mechanisms of action (coding guidelines from Michie) and behaviour change techniques (Behaviour Change Technique Taxonomy v1) with QSR International's NVivo qualitative data analysis software. Meta-analyses will be performed using the Review Manager (RevMan) software. Meta-regression analyses will be performed with IBM SPSS Statistics software.

DISCUSSION

This review will inform knowledge users and researchers interested in designing, developing and evaluating implementation interventions to support nurses' behaviour change in clinical practice. Results will provide key insights regarding which causal processes-i.e. mechanisms of action-should be targeted by these interventions, and which constituent components-i.e. behaviour change techniques-should be included in these interventions to increase their effectiveness.

SYSTEMATIC REVIEW REGISTRATION

The protocol has been registered at the International Prospective Register of Systematic Reviews (PROSPERO; registration number: CRD42019130446).

A systematic review of parent based programs to prevent or reduce alcohol consumption in adolescents

BACKGROUND

Adolescent alcohol consumption is an issue of ongoing concern and programs targeting parents have been identified as an important component in minimizing and preventing alcohol related harm in adolescents. This paper aims to evaluate existing parent based alcohol education programs with a focus on understanding parent specific outcomes including parental attitudes, parent-child communication, alcohol specific rule setting and parental monitoring; study quality, the extent of stakeholder engagement in program design and the level of theory application.

METHOD

A systematic review of electronic databases EBSCO, Emerald, ProQuest, PubMed, Ovid, ScienceDirect, Taylor and Francis and Web of Science was conducted from database inception to August 2019. A total of 4288 unique records were retrieved from the eight databases. Studies were included if they evaluated school based alcohol education programs that included a parent component and detailed outcome measures associated with parent data. The methodological quality of the included studies was assessed using the Effective Public Health Practice Project (EPHPP) quality assessment tool.

RESULTS

In total 17 studies qualified for assessment, detailing 13 individual parent programs. Of these, ten programs demonstrated positive effects in at least one parent reported outcome measure. Stakeholder engagement during the design of programs was lacking with the majority of programs. One third of the programs did not report theory use and when theory was used reporting was weak with three programs applying theory, five testing theory and none building theory. According to the EPHPP tool, overall ten programs were rated as weak, three as moderate and none as strong.

CONCLUSION

Future studies are recommended to further enhance the effectiveness of parental programs by improving study quality, increasing stakeholder engagement and increasing the level of theory application and reporting.

Behavior Change Content, Understandability, and Actionability of Chronic Condition Self-Management Apps Available in France: Systematic Search and Evaluation

Background

The quality of life of people living with chronic conditions is highly dependent on self-management behaviors. Mobile health (mHealth) apps could facilitate self-management and thus help improve population health. To achieve their potential, apps need to target specific behaviors with appropriate techniques that support change and do so in a way that allows users to understand and act upon the content with which they interact.

Objective

Our objective was to identify apps targeted toward the self-management of chronic conditions and that are available in France. We aimed to examine what target behaviors and behavior change techniques (BCTs) they include, their level of understandability and actionability, and the associations between these characteristics.

Methods

We extracted data from the Google Play store on apps labelled as Top in the Medicine category. We also extracted data on apps that were found through 12 popular terms (ie, keywords) for the four most common chronic condition groups—cardiovascular diseases, cancers, respiratory diseases, and diabetes—along with apps identified through a literature search. We selected and downloaded native Android apps available in French for the self-management of any chronic condition in one of the four groups and extracted background characteristics (eg, stars and number of ratings), coded the presence of target behaviors and BCTs using the BCT taxonomy, and coded the understandability and actionability of apps using the Patient Education Material Assessment Tool for audiovisual materials (PEMAT-A/V). We performed descriptive statistics and bivariate statistical tests.

Results

A total of 44 distinct native apps were available for download in France and in French: 39 (89%) were found via the Google Play store and 5 (11%) were found via literature search. A total of 19 (43%) apps were for diabetes, 10 for cardiovascular diseases (23%), 8 for more than one condition in the four groups (18%), 6 for respiratory diseases (14%), and 1 for cancer (2%). The median number of target behaviors per app was 2 (range 0-7) and of BCTs per app was 3 (range 0-12). The most common BCT was self-monitoring of outcome(s) of behavior (31 apps), while the most common target behavior was tracking symptoms (30 apps). The median level of understandability was 42% and of actionability was 0%. Apps with more target behaviors and more BCTs were also more understandable (ρ=.31, P=.04 and ρ=.35, P=.02, respectively), but were not significantly more actionable (ρ=.24, P=.12 and ρ=.29, P=.054, respectively).

Conclusions

These apps target few behaviors and include few BCTs, limiting their potential for behavior change. While content is moderately understandable, clear instructions on when and how to act are uncommon. Developers need to work closely with health professionals, users, and behavior change experts to improve content and format so apps can better support patients in coping with chronic conditions. Developers may use these criteria for assessing content and format to guide app development and evaluation of app performance.

Trial Registration

PROSPERO CRD42018094012; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=94012

Reported theory use in electronic health weight management interventions targeting young adults: a systematic review

This review assesses the extent of reported theory use in electronic health weight management interventions targeting young adults aged 18-35 years. Twenty-four eligible studies were identified. Two independent reviewers extracted data and coded for theory use using the Theory Coding Scheme. Overall, the mean total use of theory score was 6/23 (SD = 5; Min. = 0, Max. = 17); 17 studies were classified as having weak application of theory, five as moderate, and two as strong. The majority (N = 18) of studies mentioned theory, however, most (N = 14) did not report how intervention techniques related to theoretical base. No study used theory to select intervention recipients and only four used theory to tailor intervention techniques to recipients. Limited studies reported theory testing (N = 6) and no study used intervention results to build and/or refine theory. Results indicate that weight-related outcomes may be enhanced when at least one or more theoretical constructs are explicitly linked to an intervention technique and when theoretical constructs are included in evaluations. Increases in theory application and reporting are needed to assist the scientific research community in systematically identifying which theories work, for whom, how, why, and when; thereby delivering an advanced understanding of how best to apply theory to enhance intervention outcomes.

What works to increase attendance for diabetic retinopathy screening? An evidence synthesis and economic analysis

BACKGROUND

Diabetic retinopathy screening (DRS) is effective but uptake is suboptimal.

OBJECTIVES

To determine the effectiveness of quality improvement (QI) interventions for DRS attendance; describe the interventions in terms of QI components and behaviour change techniques (BCTs); identify theoretical determinants of attendance; investigate coherence between BCTs identified in interventions and determinants of attendance; and determine the cost-effectiveness of QI components and BCTs for improving DRS.

DATA SOURCES AND REVIEW METHODS

Phase 1 - systematic review of randomised controlled trials (RCTs) evaluating interventions to increase DRS attendance (The Cochrane Library, MEDLINE, EMBASE and trials registers to February 2017) and coding intervention content to classify QI components and BCTs. Phase 2 - review of studies reporting factors influencing attendance, coded to theoretical domains (MEDLINE, EMBASE, PsycINFO and sources of grey literature to March 2016). Phase 3 - mapping BCTs (phase 1) to theoretical domains (phase 2) and an economic evaluation to determine the cost-effectiveness of BCTs or QI components.

RESULTS

Phase 1 - 7277 studies were screened, of which 66 RCTs were included in the review. Interventions were multifaceted and targeted patients, health-care professionals (HCPs) or health-care systems. Overall, interventions increased DRS attendance by 12% [risk difference (RD) 0.12, 95% confidence interval (CI) 0.10 to 0.14] compared with usual care, with substantial heterogeneity in effect size. Both DRS-targeted and general QI interventions were effective, particularly when baseline attendance levels were low. All commonly used QI components and BCTs were associated with significant improvements, particularly in those with poor attendance. Higher effect estimates were observed in subgroup analyses for the BCTs of 'goal setting (outcome, i.e. consequences)' (RD 0.26, 95% CI 0.16 to 0.36) and 'feedback on outcomes (consequences) of behaviour' (RD 0.22, 95% CI 0.15 to 0.29) in interventions targeting patients and of 'restructuring the social environment' (RD 0.19, 95% CI 0.12 to 0.26) and 'credible source' (RD 0.16, 95% CI 0.08 to 0.24) in interventions targeting HCPs. Phase 2 - 3457 studies were screened, of which 65 non-randomised studies were included in the review. The following theoretical domains were likely to influence attendance: 'environmental context and resources', 'social influences', 'knowledge', 'memory, attention and decision processes', 'beliefs about consequences' and 'emotions'. Phase 3 - mapping identified that interventions included BCTs targeting important barriers to/enablers of DRS attendance. However, BCTs targeting emotional factors around DRS were under-represented. QI components were unlikely to be cost-effective whereas BCTs with a high probability (≥ 0.975) of being cost-effective at a societal willingness-to-pay threshold of £20,000 per QALY included 'goal-setting (outcome)', 'feedback on outcomes of behaviour', 'social support' and 'information about health consequences'. Cost-effectiveness increased when DRS attendance was lower and with longer screening intervals.

LIMITATIONS

Quality improvement/BCT coding was dependent on descriptions of intervention content in primary sources; methods for the identification of coherence of BCTs require improvement.

CONCLUSIONS

Randomised controlled trial evidence indicates that QI interventions incorporating specific BCT components are associated with meaningful improvements in DRS attendance compared with usual care. Interventions generally used appropriate BCTs that target important barriers to screening attendance, with a high probability of being cost-effective. Research is needed to optimise BCTs or BCT combinations that seek to improve DRS attendance at an acceptable cost. BCTs targeting emotional factors represent a missed opportunity to improve attendance and should be tested in future studies.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016044157 and PROSPERO CRD42016032990.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

The "great live and move challenge": a program to promote physical activity among children aged 7-11 years. Design and implementation of a cluster-randomized controlled trial

BACKGROUND

Recent population-based surveys have reported that large majorities of children in France, Europe and in the US are not complying with international physical activity (PA) guidelines. There is, therefore, a need to find programs that will improve children's PA habits from an early age. Theory-based interventions that include school, family, and community involvement have the potential to generate a considerable increase in the PA level of children. The theory of planned behavior (TPB) is one of the most widely tested models of the factors influencing health-related behaviors. The Great Live and Move Challenge (GLMC) is an extended TPB-based intervention designed to promote PA in French primary school children aged 7-11 years. The objective of this paper is to describe the protocol of a randomized controlled trial to evaluate the effectiveness of the GLMC on the PA level of children.

METHODS

This is a two-year cluster-randomized controlled trial comparing an intervention group to a control group, randomized into clusters (community of communes) and stratified by department (Hérault, Gard, Aude) and residential environment (urban, rural). The goal is to recruit 4000 children. The GLMC involves children and their parents, and multiple local grassroots partners, such as school teachers, municipal officials and policy stakeholders. The intervention will be delivered over 3.5 months per year for a two-year period. Pre- and post-intervention, children and parents will be asked to fulfill a questionnaire concerning current PA level, TPB variables (i.e., intentions, attitudes, subjective norms, perceived behavioral control) and other psychosocial variables (e.g., perceptions of activity opportunities). A subsample of 400 children will be proposed to wear an accelerometer (i.e., the Actigraph GT3X+). The primary hypothesis is that the GLMC intervention will increase the proportion of children achieving the World Health Organization's recommended 60 min of moderate to vigorous PA per day by 15%.

DISCUSSION

This study will evaluate the effectiveness of a multilevel, theory-based PA program and potentially provide valuable information for schools and public health officers looking for innovative PA programs.

TRIAL REGISTRATION

ISRCTN:61116221 , 19/06/2018.

Brief Exercise Counseling and High-Intensity Interval Training on Physical Activity Adherence and Cardiometabolic Health in Individuals at Risk of Type 2 Diabetes: Protocol for a Randomized Controlled Trial

Background

Worldwide incidence of type 2 diabetes (T2D) is rapidly increasing. Given the numerous negative health consequences associated with T2D, prevention of this disease has become a priority. Lifestyle changes, including regular exercise, can reduce the onset of T2D in those at elevated risk. However, long-term adherence to exercise is often poor in this population. Existing lifestyle interventions targeting exercise are labor intensive and costly for staff and participants. Evidence-informed counseling delivered in a manner that reduces dependence on staff and facilitates self-regulatory skills could alleviate time and financial barriers while promoting independent exercise.

Objective

This protocol outlines the design, recruitment, and proposed analysis of a brief, 2-week evidence-informed exercise counseling intervention combined with either high-intensity interval training (HIIT) or traditional moderate-intensity continuous training (MICT).

Methods

Small Steps for Big Changes is a 2-arm randomized controlled trial that will examine the effectiveness of combining brief exercise counseling with HIIT or MICT on adherence to moderate and vigorous exercise over 1 year. Cardiorespiratory fitness will be assessed at baseline, post intervention (2 weeks), and at 6- and 12-month follow-up. Physical activity behavior will be examined at baseline, post intervention, and 3-, 6-, 9-, and 12-month follow-up. The impact of the intervention on psychosocial outcomes pertinent to exercise adherence will be examined.

Results

Data collection was complete in March 2017. Data analysis is currently underway, and the first results are expected to be submitted for publication in 2019.

Conclusions

The results of this brief intervention have the potential to inform future public health efforts designed to increase exercise in individuals at risk of T2D.

Trial Registration

ClinicalTrials.gov NCT02164474; https://clinicaltrials.gov/ct2/show/NCT02164474 (Archived by WebCite at http://www.webcitation.org/74Hx1ipj6)

International Registered Report Identifier (IRRID)

DERR1-10.2196/11226

Evidence of promoting prevention and the early detection of breast cancer among women, a hospital-based education and screening interventions in low- and middle-income countries: a systematic review protocol

BACKGROUND

Given the increasing burden of breast cancer in the low- and middle-income countries, cost-effective approaches are needed to improve the early detection of breast cancer in these continents. Global policies and guidelines are now placing much emphasis on promoting early detection of breast cancer through integrated education and screening interventions. The proposed systematic review aims to map evidence on hospital-based breast cancer education, breast self-examination, and clinical breast examination services for women in low- and middle-income countries.

METHODS/DESIGN

We will conduct a systematic review of peer-reviewed studies on hospital-based breast cancer prevention intervention (breast cancer education, breast self-examination, and clinical breast examination) for women in low- and middle-income countries. An electronic search will be conducted in the following electronic databases CINAHL Plus with full text (EBSCOhost), MEDLINE with full-text (EBSCOhost) PsychINFO (EBSCOhost), and PubMed. Articles will also be searched through the "Cited by" search and citations included in the reference list of included articles. A two-stage mapping approach will be conducted. The first stage will involve screening studies through assessing their titles. Also, we will screen abstracts of identified studies descriptively and by focus and methods as dictated by the inclusion and exclusion criteria. The second stage will include extraction of data from eligible studies. A parallel screening and data extraction will be conducted by two reviewers. The quality of included studies will be assessed using the mixed methods appraisal tool (MMAT). A narrative account of the data extracted from the included studies will be analyzed using the thematic analysis.

DISCUSSION

We hope to find relevant studies reporting evidence on promoting prevention and the early detection of breast cancer among women in a hospital-based education and screening interventions in low- and middle-income countries. The evidence obtained from the included studies when summarized will help guide future research. The study results will be disseminated electronically and in print. Also, it will be presented at conferences related to breast cancer.

SYSTEMATIC REVIEW REGISTRATION

The protocol has been registered with PROSPERO, with registration number CRD42017077818.

Improving medication adherence in stroke survivors: the intervention development process

Background

Medications targeting stroke risk factors have shown good efficacy, yet adherence is suboptimal. A lack of underlying theory may contribute to the ineffectiveness of eliciting or sustaining behaviour change in many existing interventions targeting medication adherence in stroke. Intervention effectiveness and implementation could be enhanced by consideration of evidence base and theory to drive development. The purpose of this study is to identify appropriate components for a theory-driven and evidence-based medication adherence intervention for stroke survivors.

Methods

The Behaviour Change Wheel (BCW), a guide to intervention development, informed our systematic process of intervention development. Our earlier systematic review had identified important determinants of medication adherence that were mapped into the Theoretical Domains Framework (TDF), with Knowledge, Beliefs about consequences and Emotions found to be more influential. Utilising the BCW facilitated selection of intervention options and behaviour change techniques (BCTs); the active ingredients within an intervention. To further refine BCT selection, APEASE criteria were employed, allowing evaluation of potential BCTs within context: The National Health Service (NHS), United Kingdom (UK).

Results

Five intervention functions (Education, Persuasion, Training, Environmental Restructuring and Enablement) and five policy categories (Communication/marketing, Guidelines, Regulation, Environmental/social planning and Service provision) were identified as potential intervention options, underpinned by our systematic review findings. Application of APEASE criteria led to an initial pool of 21 BCTs being reduced to 11 (e.g. Habit Formation, Information about Health Consequences and Action Planning) identified as potential intervention components that would both be feasible and directly target the underlying determinants of stroke survivors’ medication adherence.

Conclusions

Careful consideration of underlying evidence and theory to drive intervention design, facilitated by the BCW, enabled identification of appropriate intervention components. BCTs including Habit Formation, Information about Health Consequences and Self-monitoring of Behaviour were considered potentially effective and appropriate to deliver within the NHS. Having reduced the pool of potential intervention components to a manageable number, it will now be possible to explore the perceived acceptability of selected BCTs in interviews with stroke survivors and healthcare professionals. This approach to intervention development should be generalisable to other chronic conditions and areas of behaviour change (e.g. exercise adherence).

Developing Behavior Change Interventions for Self-Management in Chronic Illness: An Integrative Overview

More people than ever are living longer with chronic conditions such as obesity, type 2 diabetes, and heart disease. Behavior change for effective self-management can improve health outcomes and quality of life in people living with such chronic illnesses. The science of developing behavior change interventions with impact for patients aims to optimize the reach, effectiveness, adoption, implementation, and maintenance of interventions and rigorous evaluation of outcomes and processes of behavior change. The development of new services and technologies offers opportunities to enhance the scope of delivery of interventions to support behavior change and self-management at scale. Herein, we review key contemporary approaches to intervention development, provide a critical overview, and integrate these approaches into a pragmatic, user-friendly framework to rigorously guide decision-making in behavior change intervention development. Moreover, we highlight novel emerging methods for rapid and agile intervention development. On-going progress in the science of intervention development is needed to remain in step with such new developments and to continue to leverage behavioral science's capacity to contribute to optimizing interventions, modify behavior, and facilitate self-management in individuals living with chronic illness.

The potential of alternatives to face-to-face consultation in general practice, and the impact on different patient groups: a mixed-methods case study

Background

There is international interest in the potential role of different forms of communication technology to provide an alternative to face-to-face consultations in health care. There has been considerable rhetoric about the need for general practices to offer consultations by telephone, e-mail or internet video. However, little is understood about how, under what conditions, for which patients and in what ways these approaches may offer benefits to patients and practitioners in general practice.

Objectives

Our objectives were to review existing evidence about alternatives to face-to-face consultation; conduct a scoping exercise to identify the ways in which general practices currently provide these alternatives; recruit eight general practices as case studies for focused ethnographic research, exploring how practice context, patient characteristics, type of technology and the purpose of the consultation interact to determine the impact of these alternatives; and synthesise the findings in order to develop a website resource about the implementation of alternatives to face-to-face consultations and a framework for subsequent evaluation.

Design

Mixed-methods case study.

Setting

General practices in England and Scotland with varied experience of implementing alternatives to face-to-face consultations.

Participants

Patients and practice staff.

Interventions

Alternatives to face-to-face consultations include telephone consultations, e-mail, e-consultations and internet video.

Main outcome measures

How context influenced the implementation and impact of alternatives to the face-to-face consultation; the rationale for practices to introduce alternatives; the use of different forms of consultation by different patient groups; and the intended benefits/outcomes.

Review methods

The conceptual review used an approach informed by realist review, a method for synthesising research evidence regarding complex interventions.

Results

Alternatives to the face-to-face consultation are not in mainstream use in general practice, with low uptake in our case study practices. We identified the underlying rationales for the use of these alternatives and have shown that different stakeholders have different perspectives on what they hope to achieve through the use of alternatives to the face-to-face consultation. Through the observation of real-life use of different forms of alternative, we have a clearer understanding of how, under what circumstances and for which patients alternatives might have a range of intended benefits and potential unintended adverse consequences. We have also developed a framework for future evaluation.

Limitations

The low uptake of alternatives to the face-to-face consultation means that our research participants might be deemed to be early adopters. The case study approach provides an in-depth examination of a small number of sites, each using alternatives in different ways. The findings are therefore hypothesis-generating, rather than hypothesis-testing.

Conclusions

The current low uptake of alternatives, lack of clarity about purpose and limited evidence of benefit may be at odds with current policy, which encourages the use of alternatives. We have highlighted key issues for practices and policy-makers to consider and have made recommendations about priorities for further research to be conducted, before or alongside the future roll-out of alternatives to the face-to-face consultation, such as telephone consulting, e-consultation, e-mail and video consulting.

Future work

We have synthesised our findings to develop a framework and recommendations about future evaluation of the use of alternatives to face-to-face consultations.

Funding details

The National Institute for Health Research Health Services and Delivery Research programme.

Development of the IMB Model and an Evidence-Based Diabetes Self-management Mobile Application

Objectives

This study developed a diabetes self-management mobile application based on the information-motivation-behavioral skills (IMB) model, evidence extracted from clinical practice guidelines, and requirements identified through focus group interviews (FGIs) with diabetes patients.

Methods

We developed a diabetes self-management (DSM) app in accordance with the following four stages of the system development life cycle. The functional and knowledge requirements of the users were extracted through FGIs with 19 diabetes patients. A system diagram, data models, a database, an algorithm, screens, and menus were designed. An Android app and server with an SSL protocol were developed. The DSM app algorithm and heuristics, as well as the usability of the DSM app were evaluated, and then the DSM app was modified based on heuristics and usability evaluation.

Results

A total of 11 requirement themes were identified through the FGIs. Sixteen functions and 49 knowledge rules were extracted. The system diagram consisted of a client part and server part, 78 data models, a database with 10 tables, an algorithm, and a menu structure with 6 main menus, and 40 user screens were developed. The DSM app was Android version 4.4 or higher for Bluetooth connectivity. The proficiency and efficiency scores of the algorithm were 90.96% and 92.39%, respectively. Fifteen issues were revealed through the heuristic evaluation, and the app was modified to address three of these issues. It was also modified to address five comments received by the researchers through the usability evaluation.

Conclusions

The DSM app was developed based on behavioral change theory through IMB models. It was designed to be evidence-based, user-centered, and effective. It remains necessary to fully evaluate the effect of the DSM app on the DSM behavior changes of diabetes patients.

A psychosocial intervention for the management of functional dysphonia: complex intervention development and pilot randomised trial

BACKGROUND

Medically unexplained loss or alteration of voice-functional dysphonia-is the commonest presentation to speech and language therapists (SLTs). Besides the impact on personal and work life, functional dysphonia is also associated with increased levels of anxiety and depression and poor general health. Voice therapy delivered by SLTs improves voice but not these associated symptoms. The aims of this research were the systematic development of a complex intervention to improve the treatment of functional dysphonia, and the trialling of this intervention for feasibility and acceptability to SLTs and patients in a randomised pilot study.

METHODS

A theoretical model of medically unexplained symptoms (MUS) was elaborated through literature review and synthesis. This was initially applied as an assessment format in a series of patient interviews. Data from this stage and a small consecutive cohort study were used to design and refine a brief cognitive behavioural therapy (CBT) training intervention for a SLT. This was then implemented in an external pilot patient randomised trial where one SLT delivered standard voice therapy or voice therapy plus CBT to 74 patients. The primary outcomes were of the acceptability of the intervention to patients and the SLT, and the feasibility of changing the SLT's clinical practice through a brief training. This was measured through monitoring treatment flow and through structured analysis of the content of intervention for treatment fidelity and inter-treatment contamination.

RESULTS

As measured by treatment flow, the intervention was as acceptable as standard voice therapy to patients. Analysis of treatment content showed that the SLT was able to conduct a complex CBT formulation and deliver novel treatment strategies for fatigue, sleep, anxiety and depression in the majority of patients. On pre-post measures of voice and quality of life, patients in both treatment arms improved.

CONCLUSION

These interventions were acceptable to patients. Emotional and psychosocial issues presented routinely in the study patient group and CBT techniques were used, deliberately and inadvertently, in both treatment arms. This CBT "contamination" of the voice therapy only arm reflects the chief limitation of the study: one therapist delivered both treatments.

TRIAL REGISTRATION

Registered with the ISRCTN under the title: Training a Speech and Language Therapist in Cognitive Behavioural Therapy to treat Functional Dysphonia - A Randomised Controlled Trial.Trial Identifier: ISRCTN20582523 Registered 19/05/2010; retrospectively registered. http://www.isrctn.com/ISRCTN20582523.

A telehealth intervention to promote healthy lifestyles after stroke: The Stroke Coach protocol

Rationale Recurrent stroke is prevalent and associated with high mortality rates, disability, and social and economic costs. Adequate management of risk factors may reduce recurrent stroke; however, many stroke survivors have poor control of risk factors. We have developed a theoretically sound and evidence-based lifestyle modification program called the Stroke Coach, a telephone-based self-management program to improve control of risk factors. Hypothesis Individuals who participate in Stroke Coach will achieve more lifestyle improvements than individuals in an attention controlled Memory Training Program. Design In this single blind randomized controlled trial, 126 community-living stroke survivors will be randomized to Stroke Coach or the attention control group. Participants randomized to the six-month Stroke Coach will receive seven telephone lifestyle coaching sessions, self-management education and practice, and a self-monitoring kit, comprised of a health report card, with blood pressure and activity monitors. Study Outcomes The primary outcome will be measured using the Health Promoting Lifestyle Profile II. Secondary outcomes include behavioral and physiological risk factors, quality of life, cognitive status, health and social service use. Measurements will be taken at baseline, immediately after the intervention and six-month post-intervention. Summary The results of this trial will add to our understanding of the use of self-management to improve control of risk factors, and may facilitate the development of a larger trial evaluating the effect of Stroke Coach on endpoints such as recurrent stroke or cardiac events as the primary outcome.

Increasing value and reducing waste by optimizing the development of complex interventions: Enriching the development phase of the Medical Research Council (MRC) Framework

BACKGROUND

In recent years there has been much emphasis on 'research waste' caused by poor question selection, insufficient attention to previous research results, and avoidable weakness in research design, conduct and analysis. Little attention has been paid to the effect of inadequate development of interventions before proceeding to a full clinical trial.

OBJECTIVE

We therefore propose to enrich the development phase of the MRC Framework by adding crucial elements to improve the likelihood of success and enhance the fit with clinical practice METHODS: Based on existing intervention development guidance and synthesis, a comprehensive iterative intervention development approach is proposed. Examples from published reports are presented to illustrate the methodology that can be applied within each element to enhance the intervention design.

RESULTS

A comprehensive iterative approach is presented by combining the elements of the MRC Framework development phase with essential elements from existing guidance including: problem identification, the systematic identification of evidence, identification or development of theory, determination of needs, the examination of current practice and context, modelling the process and expected outcomes leading to final element: the intervention design. All elements are drawn from existing models to provide intervention developers with a greater chance of producing an intervention that is well adopted, effective and fitted to the context.

CONCLUSION

This comprehensive approach of developing interventions will strengthen the internal and external validity, minimize research waste and add value to health care research. In complex interventions in health care research, flaws in the development process immediately impact the chances of success. Knowledge regarding the causal mechanisms and interactions within the intended clinical context is needed to develop interventions that fit daily practice and are beneficial for the end-user.