Comparison of intervention fidelity between COPE TEEN and an attention-control program in a randomized controlled trial

The evidence-based COPE program: Reducing the time between diagnosing and treating depression and anxiety in youth

ABSTRACT

The soaring prevalence of depression and anxiety in children, teenagers, and young adults is now a public health epidemic, yet access to timely evidence-based mental health treatment is often lacking due to a severe shortage of mental health providers. This article provides an overview of the current state of depression and anxiety in children and adolescents as well as first-line evidence-based treatment. The Creating Opportunities for Personal Empowerment (COPE) program, a cognitive-behavioral skills-building intervention, is highlighted as an evidence-based intervention for timely treatment that can be delivered by NPs, physicians, and physician associates/assistants in primary care settings, school-based health centers, and chronic care clinics with reimbursement as well as in schools and universities as a preventive mental health intervention.

Implementing Home-Based Clinical Research for Caregivers and Persons with Stroke: Lessons Learned

Conducting research in the home environment presents challenges related to setting, study participants, methods, and researchers. Researchers should be aware of potential challenges to ensure rigor and improve planning for future studies. This paper describes difficulties experienced and lessons learned when conducting a two-group, randomized pilot study (n = 32) of a web-based intervention (Carepartner and Constraint-Induced Therapy [CARE-CITE]) designed to foster positive carepartner engagement in home-based activities to improve upper extremity function in persons with stroke. Challenges and issues included: 1) recruitment and referral, 2) data collection in the home setting, 3) participants' understanding of the rationale for adhering to constraint-induced movement therapy principles (wearing mitt on the less-affected limb), 4) tracking adherence of upper extremity practice time, 5) participant-driven goal setting, 6) potentially unsafe participant practice activities, 7) home visit safety, 8) encouraging versus controlling-using autonomy support, 9) participant needs beyond study scope, and 10) ethical safeguards for addressing depressive symptoms. Researchers can incorporate suggested strategies to support methodological rigor and facilitate interventions engaging carepartners in the rehabilitation process when planning for research in the home environment.

Features of effective staff training programmes within school-based interventions targeting student activity behaviour: a systematic review and meta-analysis

BACKGROUND

Evaluations of school-based activity behaviour interventions suggest limited effectiveness on students' device-measured outcomes. Teacher-led implementation is common but the training provided is poorly understood and may affect implementation and student outcomes. We systematically reviewed staff training delivered within interventions and explored if specific features are associated with intervention fidelity and student activity behaviour outcomes.

METHODS

We searched seven databases (January 2015-May 2020) for randomised controlled trials of teacher-led school-based activity behaviour interventions reporting on teacher fidelity and/or students' device-measured activity behaviour. Pilot, feasibility and small-scale trials were excluded. Study authors were contacted if staff training was not described using all items from the Template for Intervention Description and Replication reporting guideline. Training programmes were coded using the Behaviour Change Technique (BCT) Taxonomy v1. The Effective Public Health Practice Project tool was used for quality assessment. Promise ratios were used to explore associations between BCTs and fidelity outcomes (e.g. % of intended sessions delivered). Differences between fidelity outcomes and other training features were explored using chi-square and Wilcoxon rank-sum tests. Random-effects meta-regressions were performed to explore associations between training features and changes in students' activity behaviour.

RESULTS

We identified 68 articles reporting on 53 eligible training programmes and found evidence that 37 unique teacher-targeted BCTs have been used (mean per programme = 5.1 BCTs; standard deviation = 3.2). The only frequently identified BCTs were 'Instruction on how to perform the behaviour' (identified in 98.1% of programmes) and 'Social support (unspecified)' (50.9%). We found moderate/high fidelity studies were significantly more likely to include shorter (≤6 months) and theory-informed programmes than low fidelity studies, and 19 BCTs were independently associated with moderate/high fidelity outcomes. Programmes that used more BCTs (estimated increase per additional BCT, d: 0.18; 95% CI: 0.05, 0.31) and BCTs 'Action planning' (1.40; 0.70, 2.10) and 'Feedback on the behaviour' (1.19; 0.36, 2.02) were independently associated with positive physical activity outcomes (N = 15). No training features associated with sedentary behaviour were identified (N = 11).

CONCLUSIONS

Few evidence-based BCTs have been used to promote sustained behaviour change amongst teachers in school-based activity behaviour interventions. Our findings provide insights into why interventions may be failing to effect student outcomes.

TRIAL REGISTRATION

PROSPERO registration number: CRD42020180624.

School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6 to 18

BACKGROUND

Physical activity among children and adolescents is associated with lower adiposity, improved cardio-metabolic health, and improved fitness. Worldwide, fewer than 30% of children and adolescents meet global physical activity recommendations of at least 60 minutes of moderate to vigorous physical activity per day. Schools may be ideal sites for interventions given that children and adolescents in most parts of the world spend a substantial amount of time in transit to and from school or attending school.

OBJECTIVES

The purpose of this review update is to summarise the evidence on effectiveness of school-based interventions in increasing moderate to vigorous physical activity and improving fitness among children and adolescents 6 to 18 years of age. Specific objectives are: • to evaluate the effects of school-based interventions on increasing physical activity and improving fitness among children and adolescents; • to evaluate the effects of school-based interventions on improving body composition; and • to determine whether certain combinations or components (or both) of school-based interventions are more effective than others in promoting physical activity and fitness in this target population.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, BIOSIS, SPORTDiscus, and Sociological Abstracts to 1 June 2020, without language restrictions. We screened reference lists of included articles and relevant systematic reviews. We contacted primary authors of studies to ask for additional information.

SELECTION CRITERIA

Eligible interventions were relevant to public health practice (i.e. were not delivered by a clinician), were implemented in the school setting, and aimed to increase physical activity among all school-attending children and adolescents (aged 6 to 18) for at least 12 weeks. The review was limited to randomised controlled trials. For this update, we have added two new criteria: the primary aim of the study was to increase physical activity or fitness, and the study used an objective measure of physical activity or fitness. Primary outcomes included proportion of participants meeting physical activity guidelines and duration of moderate to vigorous physical activity and sedentary time (new to this update). Secondary outcomes included measured body mass index (BMI), physical fitness, health-related quality of life (new to this update), and adverse events (new to this update). Television viewing time, blood cholesterol, and blood pressure have been removed from this update.  DATA COLLECTION AND ANALYSIS: Two independent review authors used standardised forms to assess each study for relevance, to extract data, and to assess risk of bias. When discrepancies existed, discussion occurred until consensus was reached. Certainty of evidence was assessed according to GRADE. A random-effects meta-analysis based on the inverse variance method was conducted with participants stratified by age (children versus adolescents) when sufficient data were reported. Subgroup analyses explored effects by intervention type.

MAIN RESULTS

Based on the three new inclusion criteria, we excluded 16 of the 44 studies included in the previous version of this review. We screened an additional 9968 titles (search October 2011 to June 2020), of which 978 unique studies were potentially relevant and 61 met all criteria for this update. We included a total of 89 studies representing complete data for 66,752 study participants. Most studies included children only (n = 56), followed by adolescents only (n = 22), and both (n = 10); one study did not report student age. Multi-component interventions were most common (n = 40), followed by schooltime physical activity (n = 19), enhanced physical education (n = 15), and before and after school programmes (n = 14); one study explored both enhanced physical education and an after school programme. Lack of blinding of participants, personnel, and outcome assessors and loss to follow-up were the most common sources of bias.  Results show that school-based physical activity interventions probably result in little to no increase in time engaged in moderate to vigorous physical activity (mean difference (MD) 0.73 minutes/d, 95% confidence interval (CI) 0.16 to 1.30; 33 studies; moderate-certainty evidence) and may lead to little to no decrease in sedentary time (MD -3.78 minutes/d, 95% CI -7.80 to 0.24; 16 studies; low-certainty evidence). School-based physical activity interventions may improve physical fitness reported as maximal oxygen uptake (VO₂max) (MD 1.19 mL/kg/min, 95% CI 0.57 to 1.82; 13 studies; low-certainty evidence). School-based physical activity interventions may result in a very small decrease in BMI z-scores (MD -0.06, 95% CI -0.09 to -0.02; 21 studies; low-certainty evidence) and may not impact BMI expressed as kg/m² (MD -0.07, 95% CI -0.15 to 0.01; 50 studies; low-certainty evidence). We are very uncertain whether school-based physical activity interventions impact health-related quality of life or adverse events.

AUTHORS' CONCLUSIONS

Given the variability of results and the overall small effects, school staff and public health professionals must give the matter considerable thought before implementing school-based physical activity interventions. Given the heterogeneity of effects, the risk of bias, and findings that the magnitude of effect is generally small, results should be interpreted cautiously.

Fidelity of a peer-led asthma self-management intervention and its attention control in a multisite study of urban adolescents

In this paper we compare the fidelity of a Peer-Led Asthma Self-Management Program for Adolescents (PLASMA) and its attention control. A randomized controlled trial involving two groups-the PLASMA group and the attention control group-was conducted between 2015 and 2018. Adolescents 12-17 years old (N = 259) in three cities in the United States received asthma self-management education implemented at a day camp, followed by bi-monthly, follow-up contact for 12 months. Thirty-five peer leaders and six adult educators implemented education sessions for the PLASMA and the attention control groups, respectively. The intervention was the peer-led delivery of the content instead of the educational content itself. This study compares the extent to which the education sessions and follow-up contacts were implemented in accordance with the study protocol by the peer and adult educators. Most topics on asthma knowledge and skills (85-95%) were delivered as intended at an adequate pace in both groups. Peer leaders missed more content in the psychosocial domain than adult educators-14% versus 0%, respectively (t = -3.7; p = .010). PLASMA participants reported high content and time fidelity for all education sessions (94% to 97.6%). Greater success in bimonthly follow-up contacts was reported in the attention control groups, with 4.6 ( ± 1.5) contacts on average compared to 2.6 (±2.02) in the PLASMA groups (t = 9.02; p < .001). Most components of the asthma self-management program were implemented with high fidelity in both groups. The relatively low fidelity in delivering psychosocial content and performing follow-up contacts in the PLASMA groups underscores the need for intensive training to enhance peer leaders' competency with managing these aspects of PLASMA to maximize fidelity. Peer leaders can implement asthma self-management educational components of the intervention with high fidelity similar to adult educators.

Essential considerations in developing attention control groups in behavioral research

Attention control groups strengthen randomized controlled trials of behavioral interventions, but researchers need to give careful consideration to the attention control activities. A comparative effectiveness research framework provides an ideal opportunity for an attention control group as a supplement to standard care, so participants potentially receive benefit regardless of group assignment. The anticipated benefit of the control condition must be independent of the study outcome. Resources needed for attention control activities need to be carefully considered and ethical considerations carefully weighed. In this paper we address nine considerations for the design and implementation of attention control groups: (1) ensure attention control activities are not associated with the outcome; (2) avoid contamination of the intervention or control group; (3) design comparable control and intervention activities; (4) ensure researcher training to adequately administer both treatment arms; (5) design control activities to be interesting and acceptable to participants; (6) evaluate attention control activities; (7) consider additional resources needed to implement attention control activities; (8) quantifying the effects of attention control and intervention groups; and (9) ethical considerations with attention control groups. Examples from the literature and ongoing research are presented. Careful planning for the attention control group is as important as for the intervention group. Researchers can use the considerations presented here to assist in planning for the best attention control group for their study.

Twelve-Month Effects of the COPE Healthy Lifestyles TEEN Program on Overweight and Depressive Symptoms in High School Adolescents

BACKGROUND

We evaluated the 12-month effects of the COPE (Creating Opportunities for Personal Empowerment) Healthy Lifestyles TEEN (Thinking, Emotions, Exercise, Nutrition) program versus an attention control program (Healthy Teens) on overweight/obesity and depressive symptoms in high school adolescents.

METHODS

A cluster randomized controlled trial was conducted. Participants were 779 culturally diverse adolescents in the US Southwest. COPE is a cognitive-behavioral skills-building intervention with 20 min of physical activity integrated into a health course and taught by teachers once a week for 15 weeks. Outcome measures included body mass index (BMI) and depressive symptoms.

RESULTS

COPE teens had a significantly lower BMI at 12 months (F(1,698)  = 11.22, p = .001) than Healthy Teens (24.95 versus 25.48). There was a significant decrease in the proportion of overweight and obese COPE teens from baseline to 12 months (χ(2)  = 5.40, p = .02) as compared with Healthy Teens. For youth who began the study with extremely elevated depressive symptoms, COPE teens had significantly lower depression at 12 months compared with Healthy Teens (COPE M = 42.39; Healthy Teens M = 57.90); (F(1 ,12)  = 5.78, p = .03).

CONCLUSIONS

COPE can improve long-term physical and mental health outcomes in teens.