What Really Works in Intervention? Using Fidelity Measures to Support Optimal Outcomes

An intervention to address nurse educators' occupational well-being: A process evaluation

BACKGROUND

There is a global need for more support for the occupational well-being of educators working in nurse education, where nurse educators experience challenges when managing their own occupational well-being. However, there is a lack of research studies into occupational well-being interventions. Aim To evaluate the usability and utility of the Self-Help INtervention for Educators in nurse education.

DESIGN

A process evaluation was conducted after the intervention in Spring 2022.

SETTINGS

Educational organisations providing national regulated practical nurse education in Finland.

PARTICIPANTS

Nurse educators (n = 37), completing the 8-workweek intervention.

METHODS

Data were collected with the self-reported electronic feedback questionnaire consisting of three sections: 1) 10-item System Usability Scale, 2) 7-item Utility scale developed for this study and 3) 4 open ended questions. The data were analysed statistically and with content analysis.

RESULTS

The intervention was found to be usable; especially the easy learnability and usage of the digital Smart Break-SHINE program and the applicable exercises. It was estimated to be moderately useful as a well-being and break promoter at work. The utility of the intervention to promote physical activity and recovery during working hours was statistically more positive for educators with <5 years of work experience than those with over 15 years. Usability and utility barriers were found especially regarding workload issues.

CONCLUSIONS

The Self-Help INtervention for Educators supports the occupational well-being of nurse educators and includes well-being actions suitable for different work surroundings (e.g., remote working) without the need for constant facilitating. The intervention was found to be most beneficial for early career nurse educators. The Self-Help INtervention for Educators needs more development to overcome the usability and utility barriers related to workload issues.

Enabled to Stand: A Single-subject Research Design Study Exploring Pediatric Power Wheelchair Standing Device Use

PURPOSE

To investigate the influence of powered wheelchair standing device (PWSD) use on changes in activity/participation in children with neurodevelopmental conditions.

METHODS

A mixed methods A-B-A single-subject research design was replicated with participants. The target behavior was parental perceptions of changes in children's performance of activity/participation goals measured via the Canadian Occupational Performance Measure (COPM). Secondary outcome measures included the COPM with children, an interview, and a 3-measure implementation survey. COPM data related to the target behavior were analyzed using the split-middle celeration line method.

RESULTS

Four child-parent dyads participated in the study. All participants achieved statistically and clinically significant increases in COPM performance ratings for the 5 parent-identified activity/participation goals.

CONCLUSIONS

For the participant dyads in this study, use of the PWSD appeared to positively influence parental perceptions of improvements in their child's performance of activity/participation goals.

Existing psychological supportive care interventions for cervical cancer patients: a systematic review and meta-analysis

Cervical cancer patients commonly experience psychological supportive care needs, necessitating diverse interventions to enhance psychological well-being and alleviate physical symptoms. This systematic review, covering English-published articles from January 1999 to April 2023, assessed the impact of psychological supportive care interventions on anxiety and depression. Twenty-Six studies, including 11,638 patients, were analyzed, comprising randomized controlled trials; quasi-experimental, and pre-post-test designs from PubMed; Science Direct; Wiley online library; Google Scholar; Cochrane Library; and JSTOR. The extraction of data was done by two independent authors and a third independent author checked the data extraction. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), 2020 statement was adopted. The population, intervention, comparator, and outcomes (PICO) search strategy was applied. Effective Public Health Practice Project (EPHPP) tool was used to assess the quality of selected articles. Various interventions, such as psychological nursing, exercise, counselling, psycho-curative approaches, peer and family education, psychotherapy, and medication, were identified. Two studies incorporated homework sessions, predominantly administered by nursing staff. Self-Rating Depression Scale (SDS) and Self-Rating Anxiety Scale (SAS) were commonly used instruments. Statistical analysis revealed a significant difference in anxiety and depression scores between treatment and control groups (p < 0.005) post-intervention across all studies. A subsequent meta-analysis of eight homogeneous studies, utilizing a random-effects model, showed a moderate-to-high overall effect size (1.35, 95% CI: 0.75 to 1.94), indicating a statistically significant positive impact. Various studies exhibited variability in effect sizes ranging from low to high. While the meta-analysis included 936 participants, the forest plot visually represents individual study effect sizes and the combined effect size. Preliminary evidence supports the positive impact of psychological supportive care interventions on cervical cancer outcomes, urging further research, especially exploring long-term effects and employing rigorous study designs.

Waste not, want not: call to action for spinal manipulative therapy researchers

BACKGROUND

Research waste is defined as research outcomes with no or minimal societal benefits. It is a widespread problem in the healthcare field. Four primary sources of research waste have been defined: (1) irrelevant or low priority research questions, (2) poor design or methodology, (3) lack of publication, and (4) biased or inadequate reporting. This commentary, which was developed by a multidisciplinary group of researchers with spinal manipulative therapy (SMT) research expertise, discusses waste in SMT research and provides suggestions to improve future research.

MAIN TEXT

This commentary examines common sources of waste in SMT research, focusing on design and methodological issues, by drawing on prior research and examples from clinical and mechanistic SMT studies. Clinical research is dominated by small studies and studies with a high risk of bias. This problem is compounded by systematic reviews that pool heterogenous data from varying populations, settings, and application of SMT. Research focusing on the mechanisms of SMT often fails to address the clinical relevance of mechanisms, relies on very short follow-up periods, and has inadequate control for contextual factors.

CONCLUSIONS

This call to action is directed to researchers in the field of SMT. It is critical that the SMT research community act to improve the way research is designed, conducted, and disseminated. We present specific key action points and resources, which should enhance the quality and usefulness of future SMT research.

Magnus J, Assefa N, Wordofa MA. The protocol for a cluster randomized controlled trial to evaluate couple-based violence prevention education and its ability to reduce intimate partner violence during pregnancy in Southwest Ethiopia

BACKGROUND

A significant proportion of women in Ethiopia suffer from violence by their intimate partner during pregnancy, which has adverse maternal and newborn outcomes. Couple-focused interventions are effective in reducing and/or controlling violence between women and their intimate partners. However, interventions addressing intimate partners of the victims are not well studied, particularly in the Ethiopian setting. This study aims to assess the effect of couple-based violence prevention education on intimate partner violence during pregnancy.

METHODS

We will use a cluster randomized controlled trial to evaluate the effectiveness of couple-based violence prevention education compared to routine care in reducing intimate partner violence during pregnancy. Sixteen kebeles will be randomly assigned to 8 interventions and 8 control groups. In the trial, 432 couples whose wife is pregnant will participate. Health extension workers (HEWs) will provide health education. Data will be collected at baseline and endline. All the collected data will be analyzed using Stata version 16.0 or SPSS version 25.0. We will use the McNemar test to assess the differences in outcomes of interest in both intervention and control groups before and after the intervention for categorical data. A paired t-test will be used to compare continuous outcome of interest in the intervention and the control groups after and before the intervention. The GEE (Generalized Estimating Equation), will be used to test the independent effect of the intervention on the outcome of the interest. Data analysis will be performed with an intention-to-treat analysis approach. During the analysis, the effect size, confidence interval, and p-value will be calculated. All tests will be two-sided, and statistical significance will be declared at p < 0.05.

DISCUSSION

We expect that the study will generate findings that can illuminate violence prevention strategies and practices in Ethiopia.

TRIAL REGISTRATION

It has been registered on ClinicalTrials.gov as NCT05856214 on May 4, 2023.

Treatment Fidelity in 94 Randomized Controlled Trials of Physical Rehabilitation in the ICU: A Scoping Review

OBJECTIVES

Recent reviews demonstrated discordant effects of ICU-based physical rehabilitation on physical function. These inconsistencies may be related to differences in treatment fidelity-the extent to which a protocol is delivered as planned. Before evaluating the association of fidelity with outcomes, we must first understand the extent of treatment fidelity reporting in ICU-based physical rehabilitation randomized controlled trials (RCTs).

DATA SOURCES

Six electronic databases from inception to December 2022.

STUDY SELECTION

We included RCTs enrolling adults or children admitted to the ICU, if greater than or equal to 50% were invasively mechanically ventilated greater than 24 hours, and underwent an ICU-based physical rehabilitation intervention, with no limitation to comparators or outcomes.

DATA EXTRACTION

We screened and extracted data independently and in duplicate, with a third reviewer as needed. Extracted data included study characteristics, treatment descriptions, and the presence of National Institutes of Health Behaviour Change Consortium (NIH-BCC) treatment fidelity tool components. Treatment fidelity scores were calculated as the proportion of reported (numerator) out of total NIH-BCC components (denominator). We calculated scores across studies and by treatment group (intervention vs. comparator). We used linear regression to assess for a time trend in study treatment fidelity scores.

DATA SYNTHESIS

Of 20,433 citations, 94 studies met inclusion criteria. Authors reported a median (first-third quartiles) of 19% (14-26%) of treatment fidelity components across studies. Intervention group scores were higher than comparator groups (24% [19-33%] vs. 14% [5-24%], p < 0.01). We found a mean increase in study treatment fidelity scores by 0.7% (0.3 points) per year.

CONCLUSIONS

Only 19% of treatment fidelity components were reported across studies, with comparator groups more poorly reported. Future research could investigate ways to optimize treatment fidelity reporting and determine characteristics associated with treatment fidelity conduct in ICU-based physical rehabilitation RCTs.

Consolidated guidance for behavioral intervention pilot and feasibility studies

BACKGROUND

In the behavioral sciences, conducting pilot and/or feasibility studies (PFS) is a key step that provides essential information used to inform the design, conduct, and implementation of a larger-scale trial. There are more than 160 published guidelines, reporting checklists, frameworks, and recommendations related to PFS. All of these publications offer some form of guidance on PFS, but many focus on one or a few topics. This makes it difficult for researchers wanting to gain a broader understanding of all the relevant and important aspects of PFS and requires them to seek out multiple sources of information, which increases the risk of missing key considerations to incorporate into their PFS. The purpose of this study was to develop a consolidated set of considerations for the design, conduct, implementation, and reporting of PFS for interventions conducted in the behavioral sciences.

METHODS

To develop this consolidation, we undertook a review of the published guidance on PFS in combination with expert consensus (via a Delphi study) from the authors who wrote such guidance to inform the identified considerations. A total of 161 PFS-related guidelines, checklists, frameworks, and recommendations were identified via a review of recently published behavioral intervention PFS and backward/forward citation tracking of a well-known PFS literature (e.g., CONSORT Ext. for PFS). Authors of all 161 PFS publications were invited to complete a three-round Delphi survey, which was used to guide the creation of a consolidated list of considerations to guide the design, conduct, and reporting of PFS conducted by researchers in the behavioral sciences.

RESULTS

A total of 496 authors were invited to take part in the three-round Delphi survey (round 1, N = 46; round 2, N = 24; round 3, N = 22). A set of twenty considerations, broadly categorized into six themes (intervention design, study design, conduct of trial, implementation of intervention, statistical analysis, and reporting) were generated from a review of the 161 PFS-related publications as well as a synthesis of feedback from the three-round Delphi process. These 20 considerations are presented alongside a supporting narrative for each consideration as well as a crosswalk of all 161 publications aligned with each consideration for further reading.

CONCLUSION

We leveraged expert opinion from researchers who have published PFS-related guidelines, checklists, frameworks, and recommendations on a wide range of topics and distilled this knowledge into a valuable and universal resource for researchers conducting PFS. Researchers may use these considerations alongside the previously published literature to guide decisions about all aspects of PFS, with the hope of creating and disseminating interventions with broad public health impact.

Development and Feasibility of an eHealth Diabetes Prevention Program Adapted for Older Adults-Results from a Randomized Control Pilot Study

Lifestyle programs that reduce health risks and support weight loss (WL) in older adults face adherence and attendance challenges due to reduced energy requirements, impaired mobility, lack of transportation, and low social support. Tailored lifestyle and weight management programs are needed to better support healthy aging for older adults. Here, we developed and piloted an age-adapted, remotely delivered modification of the Diabetes Prevention Program (DPP). The modification includes age-appropriate goals, visuals, and examples; flexible dietary composition; remote classroom and fitness-monitoring technology; and standardized online classroom materials employing pedagogical and behavior change theory. The modifications were designed to safeguard fidelity and to boost adherence, engagement, and knowledge integration, with the convenience of a fully remote WL program for diverse older adults. Six-month pilot data are presented from older adults (55-85 years, body mass index (BMI) 27-39.9 kg/m2, N = 20) randomly allocated to an online DPP intervention with weight, diet, and activity monitored remotely, or into a waitlisted control. The intervention achieved 100% attendance and adherence to self-monitoring. The intervention group mean (±SD) body weight change was -9.5% (±4.1); 90% lost ≥ 5%. By contrast, the control group gained 2.4% (±1.8). Once thought incompatible with older adults, remote interventions are feasible for older adults and can support fidelity, adherence, engagement, and clinically significant WL. Standardized materials are provided for future implementation.

A RCT to explore the effectiveness of supporting adherence to nebuliser medication in adults with cystic fibrosis: fidelity assessment of study interventions

BACKGROUND

A multi-component self-management intervention 'CFHealthHub' was developed to reduce pulmonary exacerbations in adults with Cystic Fibrosis (CF) by supporting adherence to nebuliser medication. It was evaluated in a randomized controlled trial (RCT) involving 19 CF centres, with 32 interventionists, 305 participants in the intervention group, and 303 participants in the standard care arm. Ensuring treatment fidelity of intervention delivery was crucial to ensure that the intervention produced the expected outcomes.

METHODS

Fidelity of the CFHealthHub intervention and standard care was assessed using different methods for each of the five fidelity domains defined by the Borrelli framework: study design, training, treatment delivery, receipt, and enactment. Study design ensured that the groups received the intended intervention or standard care. Interventionists underwent training and competency assessments to be deemed certified to deliver the intervention. Audio-recorded intervention sessions were assessed for fidelity drift. Receipt was assessed by identifying whether participants set Action and Coping Plans, while enactment was assessed using click analytics on the CFHealthHub digital platform.

RESULTS

Design: There was reasonable agreement (74%, 226/305) between the expected versus actual intervention dose received by participants in the CFHealthHub intervention group. The standard care group did not include focused adherence support for most centres and participants. Training: All interventionists were trained. Treatment delivery: The trial demonstrated good fidelity (overall fidelity by centre ranged from 79 to 97%), with only one centre falling below the mean threshold (> 80%) on fidelity drift assessments. Receipt: Among participants who completed the 12-month intervention, 77% (205/265) completed at least one action plan, and 60% (160/265) completed at least one coping plan. Enactment: 88% (268/305) of participants used web/app click analytics outside the intervention sessions. The mean (SD) number of web/app click analytics per participant was 31.2 (58.9). Additionally, 64% (195/305) of participants agreed to receive notifications via the mobile application, with an average of 53.6 (14.9) notifications per participant.

CONCLUSIONS

The study demonstrates high fidelity throughout the RCT, and the CFHealthHub intervention was delivered as intended. This provides confidence that the results of the RCT are a valid reflection of the effectiveness of the CFHealthHub intervention compared to standard care.

TRIAL REGISTRATION

ISRCTN registry: ISRCTN55504164 (date of registration: 12/10/2017).

The IndieTrainer system: a small-scale trial exploring a new approach to support powered mobility skill acquisition in children

The IndieTrainer system, consisting of a mobility device and video-based gamified training modules, was developed to assist children in attaining power wheelchair (PWC) skills. The purposes of this small-scale trial were to explore the use of the IndieTrainer system to provide PWC skills training and document parental satisfaction with the IndieTrainer system. We hypothesized that PWC skills training provided using the IndieTrainer system would result in improvements in both children's understanding of how to use a PWC and their PWC skill execution, and that parental satisfaction would be high. An open-label, single-arm trial was conduct as follows: (a) Baseline testing (T0); (b) A 3-week intervention consisting of two, 60-min-PWC skills training sessions per week; (c) Post-intervention testing (T1); and (d) A single session retention trial held 4 weeks after completion of the intervention (T2). Outcome measures included the Assessment of Learning Powered mobility use (ALP), Wheelchair Skills Checklist (WSC), Canadian Occupational Performance Measure (COPM), and Client Satisfaction Questionnaire-8 (CSQ-8). 25 child/parent dyads participated. Between T0 and T1, statistically significant differences (p-value <.0001) with large effect sizes in mean ALP and WSC scores (ALP: d = 3.14; WSC: d = 3.25) and COPM performance and satisfaction scores (Performance: d = 4.66; Satisfaction: d = 3.24) were achieved. Mean T1 total CSQ-8 score was 31.52/32. At T2, all children maintained or improved their T1 ALP and WSC scores. This study provides initial support for the usability and feasibility of the IndieTrainer system. Futhermore, larger scaled studies using more rigorous research designs are indicated.

Feasibility and Preliminary Effectiveness of the INSPIRE Pilot Study for Adolescent Girls

INTRODUCTION

This pilot study evaluated the feasibility and preliminary effectiveness of the Intervention to Support Physical Activity Independence and Routine Everyday program.

METHOD

This quasi-experimental single-group pretest/posttest study included adolescent girls (n = 15) who received a Fitbit Inspire 2 wearable activity tracker and participated in the seven-week Intervention to Support Physical Activity Independence and Routine Everyday program on a college campus in the Midwest. Feasibility outcomes included intervention participation, fidelity, and satisfaction. Preliminary effectiveness outcomes included moderate-to-vigorous physical activity, cardiorespiratory fitness, and resting heart rate.

RESULTS

For intervention sessions, the mean attendance rate was 83.42%, the mean minutes of moderate-to-vigorous physical activity was 62.03, and the mean satisfaction score was 28.90. Moderate-to-vigorous physical activity and resting heart rate improved significantly from baseline to postintervention, but cardiorespiratory fitness did not.

DISCUSSION

Results suggest the need for a pilot randomized controlled trial to improve cardiorespiratory fitness and incorporating an objective measure of moderate-to-vigorous physical activity.

Expert Perspectives on Pilot and Feasibility Studies: A Delphi Study and Consolidation of Considerations for Behavioral Interventions

Background

In the behavioral sciences, conducting pilot and/or feasibility studies (PFS) is a key step that provides essential information used to inform the design, conduct, and implementation of a larger-scale trial. There are more than 160 published guidelines, reporting checklists, frameworks, and recommendations related to PFS. All of these publications offer some form of guidance on PFS, but many focus on one or a few topics. This makes it difficult for researchers wanting to gain a broader understanding of all the relevant and important aspects of PFS and requires them to seek out multiple sources of information, which increases the risk of missing key considerations to incorporate into their PFS. The purpose of this study was to develop a consolidated set of considerations for the design, conduct, implementation, and reporting of PFS for interventions conducted in the behavioral sciences.

Methods

To develop this consolidation, we undertook a review of the published guidance on PFS in combination with expert consensus (via a Delphi study) from the authors who wrote such guidance to inform the identified considerations. A total of 161 PFS-related guidelines, checklists, frameworks, and recommendations were identified via a review of recently published behavioral intervention PFS and backward/forward citation tracking of well-know PFS literature (e.g., CONSORT Ext. for PFS). Authors of all 161 PFS publications were invited to complete a three-round Delphi survey, which was used to guide the creation of a consolidated list of considerations to guide the design, conduct, and reporting of PFS conducted by researchers in the behavioral sciences.

Results

A total of 496 authors were invited to take part in the Delphi survey, 50 (10.1%) of which completed all three rounds, representing 60 (37.3%) of the 161 identified PFS-related guidelines, checklists, frameworks, and recommendations. A set of twenty considerations, broadly categorized into six themes (Intervention Design, Study Design, Conduct of Trial, Implementation of Intervention, Statistical Analysis and Reporting) were generated from a review of the 161 PFS-related publications as well as a synthesis of feedback from the three-round Delphi process. These 20 considerations are presented alongside a supporting narrative for each consideration as well as a crosswalk of all 161 publications aligned with each consideration for further reading.

Conclusion

We leveraged expert opinion from researchers who have published PFS-related guidelines, checklists, frameworks, and recommendations on a wide range of topics and distilled this knowledge into a valuable and universal resource for researchers conducting PFS. Researchers may use these considerations alongside the previously published literature to guide decisions about all aspects of PFS, with the hope of creating and disseminating interventions with broad public health impact.

Reporting Rigor of Cancer Rehabilitation Interventions: Application of the CReDECI-2 Guidelines

ABSTRACT

Clear reporting of cancer rehabilitation interventions is critical for interpreting and translating research into clinical practice. This study sought to examine the completeness of intervention reporting of cancer rehabilitation interventions addressing disability and to identify which elements are most frequently missing. This was a secondary analysis of randomized controlled trials included in two systematic reviews examining effectiveness of cancer rehabilitation interventions that address cancer-related disability, including functional outcomes. Eligible trials were reviewed for intervention reporting rigor using the Criteria for Reporting the Development and Evaluation of Complex Interventions in Healthcare 2 checklist. Intervention descriptions for cancer rehabilitation interventions were generally incomplete. Approximately 85% ( n = 157) of trials described ≤50% of Criteria for Reporting the Development and Evaluation of Complex Interventions in Healthcare 2 checklist items. Commonly underreported items included description of the intervention's underlying theoretical basis, fidelity, description of process evaluation or external conditions influencing intervention delivery, and costs or required resources for intervention delivery. The findings reveal that cancer rehabilitation intervention descriptions lacked necessary detail in this body of literature. Poor descriptions limit the translation of research to clinical practice. To ensure higher-quality study design and reporting, future intervention research should incorporate an intervention reporting checklist to ensure more complete descriptions for research and practice.

Fidelity of Delivery in a Multisite Randomized Clinical Trial of Intervention Efficacy for Infants With Unilateral Cerebral Palsy

PURPOSE

To investigate the reliability of a measure of fidelity of therapist delivery, quantify fidelity of delivery, and determine factors impacting fidelity in the Rehabilitation EArly for Congenital Hemiplegia (REACH) clinical trial.

METHODS

Ninety-five infants (aged 3-9 months) with unilateral cerebral palsy participated in the REACH clinical trial. The Therapist Fidelity Checklist (TFC) evaluated key intervention components. Video-recorded intervention sessions were scored using the TFC.

RESULTS

Inter- and intrarater reliability was percentage agreement 77% to 100%. Fidelity of delivery was high for 88.9% of sessions and moderate for 11.1% of sessions. Sessions with moderate scores included infants receiving infant-friendly bimanual therapy and occurred at the intervention midpoint or later. No significant relationships were found for TFC scores and infant age, manual ability, or parent engagement.

CONCLUSIONS

Fidelity of delivery was high for the REACH trial in most intervention sessions. Standardized therapist training with intervention manuals and monthly peer-to-peer support likely contributed to these results.

Understanding implementation of a complex intervention in a stroke rehabilitation research trial: A qualitative evaluation using Normalisation Process Theory

BACKGROUND

The Implicit Learning in Stroke study was a pilot cluster randomised controlled trial, investigating the use of different motor learning strategies in acute stroke rehabilitation. Participating Stroke Units (n = 8) were from the South East/West regions of the UK, with the experimental intervention (implicit learning) being delivered by clinical teams. It required therapists to change how they gave instructions and feedback to patients during rehabilitation. This paper reports the processes underpinning implementation of the implicit learning intervention. The evaluation aimed to i) understand how therapists made sense of, engaged with and interpreted the effects of the intervention; ii) compare this to the experience reported by patients; iii) extrapolate learning of broader relevance to the design and conduct of research involving complex interventions in stroke rehabilitation.

METHODS

Qualitative evaluation, with data collected through focus groups with clinical staff (n = 20) and semi structured interviews with people with stroke (n = 19). Mixed inductive and theory driven analysis, underpinned by Normalisation Process Theory.

RESULTS

How therapists made sense of and experienced the intervention impacted how it was implemented. The intervention was delivered by individual therapists, and was influenced by their individual values, beliefs and concerns. However, how teams worked together to build a shared (team) understanding, also played a key role. Teams with a more "flexible" interpretation, reported the view that the intervention could have benefits in a wide range of scenarios. Those with a more fixed, "rule based" interpretation, found it harder to implement, and perceived the benefits to be more limited. Therapists' concerns that the intervention may impair therapeutic relationships and patient learning were not reflected in how patients experienced it.

CONCLUSIONS

Changing practice, whether in a research study or in the "real world", is complex. Understanding the process of implementation is crucial to effective research delivery. Implementation frameworks facilitate understanding, and subsequently the systematic and iterative development of strategies for this to be addressed. How teams (rather than individuals) work together is central to how complex interventions are understood and implemented. It is possible that new complex interventions work best in contexts where there are 'flexible' cultures. Researchers should consider, and potentially measure this, before they can effectively implement and evaluate an intervention.

TRIAL REGISTRATION

Clinical Trials - NCT03792126.

Building School-Based Capacity to Support Parenting: Challenges and Lessons Learned

Both schools and caregivers play an important role in supporting children's mental health, but there are few mechanisms for caregivers and school-based mental health providers to work collaboratively to address children's needs. Closures of schools during the first wave of the COVID-19 pandemic left gaps in mental health support services to children and increased the burden on caregivers to ensure their children's well-being. In this study, investigators explored the feasibility and acceptability of a motivational interviewing-based program in which school-based mental health providers were trained to connect directly to caregivers to assist them in supporting key aspects of their children's well-being, including sleep, coping, and academic behavior. Results indicated a high degree of satisfaction with the program and a perception that it was helpful to caregivers and children. However, major challenges in recruitment of providers, as well as qualitative interviews with those providers who participated, indicated that the feasibility of implementing such a program is limited without significant additional implementation infrastructure. Findings suggest that structured support of caregivers, accessed through their children's schools, has high potential for improving child outcomes and family well-being. Future research should explore what implementation infrastructure is needed for schools to effectively offer these types of supports.

Intervention Fidelity to VITAL Start (Video Intervention to Inspire Treatment Adherence for Life) in a Randomized Controlled Trial Among Women Living With HIV in Malawi

BACKGROUND

Intervention effectiveness in a randomized controlled trial is attributed to intervention fidelity. Measuring fidelity has increasing significance to intervention research and validity. The purpose of this article is to describe a systematic assessment of intervention fidelity for VITAL Start (Video intervention to Inspire Treatment Adherence for Life)-a 27-minute video-based intervention designed to improve antiretroviral therapy adherence among pregnant and breastfeeding women.

METHOD

Research Assistants (RAs) delivered VITAL Start to participants after enrolment. The VITAL Start intervention had three components: a pre-video orientation, video viewing, and post-video counseling. Fidelity assessments using checklists comprised self (RA assessment) and observer (Research Officers, also known as ROs) assessment. Four fidelity domains (adherence, dose, quality of delivery, and participant responsiveness) were evaluated. Score scale ranges were 0 to 29 adherence, 0 to 3 dose, 0 to 48 quality of delivery and 0 to 8 participant responsiveness. Fidelity scores were calculated. Descriptive statistics summarizing the scores were performed.

RESULTS

In total, eight RAs delivered 379 VITAL Start sessions to 379 participants. Four ROs observed and assessed 43 (11%) intervention sessions. The mean scores were 28 (SD = 1.3) for adherence, 3 (SD = 0) for dose, 40 (SD = 8.6) for quality of delivery, and 10.4 (SD = 1.3) for participant responsiveness.

CONCLUSION

Overall, the RAs successfully delivered the VITAL Start intervention with high fidelity. Intervention fidelity monitoring should be an important element of randomized control trial design of specific interventions to ensure having reliable study results.

Powered Mobility Device Use and Developmental Change of Young Children with Cerebral Palsy

Mobility is a fundamental human right and is supported by the United Nations and the ON Time Mobility framework. The purpose of this study was to understand the effect of a powered mobility intervention on developmental changes of children with cerebral palsy (CP). This study was a randomized, crossover clinical trial involving 24 children (12-36 months) diagnosed with CP or with high probability of future CP diagnosis based on birth history and current developmental status. Children received the Explorer Mini and a modified ride-on car in randomized order, each for 8 weeks. The Bayley Scales of Infant and Toddler Development-4th Edition was administered at baseline, mid-study, and end-of-study. Raw change scores were used for analysis. Total minutes of use per device was categorized as low or high use for analysis based on caregiver-reported driving diaries. Explorer Mini: The high use group exhibited significantly greater positive change scores compared to the low use group on receptive communication, expressive communication, and gross motor subscales (p < 0.05). Modified ride-on car: No significant differences between low and high use groups. Regardless of device, low use was associated with no significant developmental change and high use was associated with positive developmental changes. Mobility access is critical to maximize the development of children with CP and may be augmented by using powered mobility devices. Results may have implications for the development of evidence-based guidelines on dosage for powered mobility use.

Development and evaluation of a fidelity tool in a post-discharge responsive parenting intervention program for very preterm born children

The TOP program is a fully implemented responsive parenting intervention for very preterm born infants. Fidelity monitoring of interventions is important for preserving program adherence, impact outcomes and to make evidence-based adaptations. The aim of this study was to develop a fidelity tool for the TOP program following an iterative and co-creative process and subsequently evaluate the reliability of the tool. Three consecutive phases were carried out. Phase I: Initial development and pilot testing two methods namely self-report and video based observation. Phase II: Adaptations and refinements. Phase III: Evaluation of the psychometric properties of the tool based on 20 intervention videos rated by three experts.The interrater reliability of the adherence and competence subscales was good (ICC.81 to .84) and varied from moderate to excellent for specific items (ICC between .51 and .98). The FITT displayed a high correlation (Spearman's rho.79 to.82) between the subscales and total impression item. The co-creative and iterative process resulted in a clinical useful and reliable tool for evaluating fidelity in the TOP program. This study offers insights in the practical steps in the development of a fidelity assessment tool which can be used by other intervention developers.

The AERO study: A feasibility randomised controlled trial of individually tailored exercise adherence strategies based on a brief behavioural assessment for older people with musculoskeletal conditions

INTRODUCTION

Exercise is a widely used treatment modality for older people with musculoskeletal conditions. The effectiveness of exercise programmes is limited by adherence. The aims of this study were to examine the acceptability and feasibility of the AERO intervention in facilitating exercise adherence in older people with musculoskeletal conditions, and to inform the design of a future randomised controlled trial.

METHODS

A two arm feasibility randomised controlled trial with an embedded qualitative study conducted at one orthopaedic hospital in the South of England. Older adults referred to physiotherapy with musculoskeletal conditions were randomised to receive either usual care consisting of standard physiotherapy only, or the AERO intervention, consisting of usual care with the addition of tailored exercise adherence approaches based on a brief behavioural assessment. Feasibility outcomes included recruitment, randomisation, retention, acceptability, and fidelity to trial protocol. Secondary outcomes included exercise adherence, physical activity, and behavioural regulation.

RESULTS

48 participants were recruited to the study with 27 randomised to usual care and 21 to AERO and usual care. On the basis of recruitment, retention, the acceptability to participants and physiotherapists and fidelity, the AERO intervention was determined to be feasible.

CONCLUSION

The AERO intervention in which participants received tailored adherence strategies based on a behavioural assessment plus standard physiotherapy is feasible and acceptable. It is now ready to be tested in an adequately powered randomised controlled trial.

CONTRIBUTION OF THE PAPER

CLINICAL TRIAL REGISTRATION NUMBER: This study was registered at clinicaltrials.gov REF: NCT03643432.

A Synthesis of the Conceptualization and Measurement of Implementation Fidelity in Mathematics Intervention Research

In intervention studies, high rates of implementation fidelity are important markers of a study's success; however, the definition of implementation fidelity is both complex and dynamic. In this synthesis, we examined the dimensions of implementation fidelity measured and reported in 99 studies in which researchers utilized a mathematics intervention for elementary students (i.e., Grades 1-5). We examined implementation fidelity following recommendations made by Dane and Schneider (1998), O'Donnell (2008), and DeFouw et al. (2009) to capture a comprehensive representation of the implementation fidelity data collected and reported within mathematics intervention studies. We organized our conceptualization of implementation fidelity into four overarching categories and nine dimensions within those categories: intervention design (i.e., theories of change and logistics), fidelity of implementor (i.e., adherence, quality of delivery, dosage, and implementor knowledge or experience), student engagement, and treatment analysis (i.e., treatment differentiation and analysis of implementation fidelity). Overall, findings indicate many author teams reported adherence data and dosage data, but significantly fewer studies reported quality of delivery data, student engagement data, or treatment differentiation data. In addition, author teams were more likely to report at least one form of logistics, such as implementor support, than theories of change. Implications for research and practice are discussed.

Insoles to ease plantar pressure in people with diabetes and peripheral neuropathy: a feasibility randomised controlled trial with an embedded qualitative study

BACKGROUND

Therapeutic footwear and insoles are preventative strategies to reduce elevated plantar pressures associated with diabetic foot ulcer risk. An insole intervention appropriate for chairside delivery optimising plantar foot pressure reduction in people with diabetes has been developed.

AIM

To explore the feasibility and acceptability of testing an optimised insole compared with an active control insole to reduce plantar pressures for people with diabetic peripheral neuropathy.

METHODS

A double-blinded multi-centre feasibility RCT with an embedded qualitative study. Participants were randomised to either an optimised insole group (intervention) or a standard cushioned insole group (active control). Participants were assessed at baseline, 3, 6, and 12 months with clinical outcomes of foot ulceration and mean peak plantar pressure (MPPP) reduction. An embedded qualitative study involved semi-structured interviews with 12 study participants and three podiatrists to explore their experiences of the intervention and trial procedures. Data were analysed using descriptive statistics (quantitative data) and thematic analysis (qualitative data).

RESULTS

Screened were142 patients from which 61 were recruited; 30 participants were randomised to the intervention group and 31 to the active control group. Forty-two participants completed the study. At 12 months, 69% of the patient-reported questionnaires were returned and 68% of the clinical outcomes were collected. There were 17 incidences of foot ulceration occurring in 7/31 of the active control group and 10/30 in the intervention group. Mean difference in MPPP between the intervention and active control groups for all regions-of-interest combined favoured the intervention. Thematic analysis revealed three themes; accepting the study, behaviour and support during study procedures, and impact from study participation.

CONCLUSION

The results of the feasibility RCT suggest that the optimised insole holds promise as an intervention, and that a full RCT to evaluate the clinical and cost-effectiveness of this intervention is feasible and warranted for people with diabetic peripheral neuropathy.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number: ISRCTN16011830 . Registered 9th October 2017.

The application and reporting of motivational interviewing in managing adolescent obesity: A scoping review and stakeholder consultation

Motivational interviewing (MI) is an evidence-based counseling approach that can help individuals make positive behavioral and cognitive changes for managing obesity. We conducted a scoping review to summarize evidence on fidelity and key elements of MI-based interventions for managing adolescent obesity and examine the reporting of these interventions. Ten electronic databases and gray literature were searched systematically and included literature from January 1983 to February 2022, and 26 studies were included. Data on MI features, delivery context, training, and fidelity to treatment were summarized. Fidelity was assessed using an assessment grid with five domains-theory, training, implementation, treatment receipt, and treatment enactment. The last step of the review involved stakeholder consultation with clinician-scientists and researchers with experience in MI and managing adolescent obesity. Thirteen stakeholders were interviewed about our review findings on MI and treatment fidelity. Our analyses revealed that MI-based interventions for managing adolescent obesity had "low treatment fidelity"; no studies had "high treatment fidelity" across all five domains. Fidelity strategies adhered to the most was theory, and treatment enactment was the lowest. Stakeholders mentioned that "low treatment fidelity" may be due to increased time to complete fidelity assessments and increased cost associated with treatment fidelity. These findings have implications for planning, implementing, and evaluating MI-based interventions for managing adolescent obesity.

A narrative review: Pharmacy intervention fidelity

BACKGROUND

There has been a significant increase in the literature surrounding community-based pharmacy interventions. However, less is known about how researchers assured these interventions were implemented consistently and faithfully to the established protocol.

OBJECTIVE

This narrative review aims to describe the nature and extent to which researchers reported intervention fidelity measures across depression and hypertension studies completed in community and ambulatory care settings.

METHODS

Two research assistants used defined literature search criteria to identify manuscripts involving community pharmacist interventions in hypertension or depression care management. These research assistants independently evaluated each manuscript based on the nature and extent to which the studies described intervention training to support intervention fidelity, the intervention structure and content, the tools used to document intervention fidelity, and the extent to which the intervention was performed as expected. Manuscript authors were contacted for clarification of any details not clear from their published works.

RESULTS

Of the 6 depression and 19 hypertension manuscripts, intervention training was described in only 2 and 9 depression and hypertension manuscripts, respectively. Other depression and hypertension manuscripts did not describe such training or gave unclear training information. Respectively, only 2 and 9 of the depression and hypertension manuscripts described a tool that was used to capture interventions made according to protocol. Two of the depression manuscripts and 6 of the hypertension manuscripts were known to have measured the extent to which the intervention was performed as expected.

CONCLUSION

There is considerable variability in the nature and extent that intervention fidelity measures are reported in the literature. Researchers should be required to report key intervention fidelity measures when seeking publication of their research. Such additional reporting of fidelity results will enable the scientific community to have greater confidence in study results, conclusions, and implications.

Feasibility, acceptability, and fidelity of Physical Activity Routines After Stroke (PARAS): a multifaceted behaviour change intervention targeting free-living physical activity and sedentary behaviour in community-dwelling adult stroke survivors

BACKGROUND

Low levels of habitual physical activity and high levels of sedentary behaviour are commonly observed post-stroke. We aimed to assess the feasibility, acceptability and fidelity of a multifaceted, theory- and evidence-informed supported self-management intervention targeting physical activity and sedentary behaviour after stroke: Physical Activity Routines After Stroke (PARAS).

METHODS

Adult stroke survivors and healthcare professionals were recruited from North East England stroke services. Stroke survivor physical activity and sedentary behaviour were targeted by a self-management behavioural intervention supported by healthcare professionals trained in intervention delivery. The main outcomes were protocol and intervention acceptability and feasibility and fidelity of intervention delivery.

RESULTS

Eleven healthcare professionals (9 physiotherapists; 2 occupational therapists) participated in the study. Stroke survivor recruitment was lower than anticipated (19 versus target of up to 35). The healthcare professional training programme was feasible, with fidelity assessment of delivery supporting this finding. Data completeness was acceptable according to a priori criteria (>60%), except for stroke survivor questionnaire return rate (59%) and interview uptake (52%). No serious adverse events occurred. Healthcare professionals and stroke survivors perceived intervention delivery to be feasible and acceptable with minor modifications highlighted including the potential for earlier delivery in the stroke pathway.

CONCLUSIONS

The study protocol and intervention delivery were feasible and acceptable to stroke survivors and healthcare professionals with modifications required before large-scale evaluation.

TRIAL REGISTRATION

ISRCTN35516780 . Registered on October 24, 2018.

Supporting young adults with intellectual/developmental disabilities to deliver a peer mentoring intervention: Evaluating fidelity and resources required

BACKGROUND

Peer-delivered interventions are a best practice in mental health, yet no such intervention exists for young adults (YA) with intellectual/developmental disabilities with co-occurring mental health conditions. We evaluated YA with intellectual/developmental disabilities' ability to deliver a novel peer mentoring intervention with fidelity and the supports received.

METHODS

We coded audio-recorded mentoring sessions to evaluate if 4 mentors adhered to 'content' (e.g., psychoeducation) and 'quality' (e.g., validation) fidelity criteria (codes: yes/no). We conducted content analysis of mentor support logs and interviews with mentors', mentors' parents and teachers to describe the supports mentors received.

RESULTS

Average fidelity for content criteria (M = 73.3%) was higher than quality criteria (M = 60.0%). Weekly support addressed logistics, delivering content, interpersonal interactions, emotional support, professionalism, and organisation. Family members and teachers rarely provided additional support.

CONCLUSIONS

With support, YA can deliver a peer mentoring intervention addressing mental health. Additional training activities will be developed to improve fidelity.

The SIT-PT Trial Protocol: A Dose-Matched Randomized Clinical Trial Comparing 2 Physical Therapist Interventions for Infants and Toddlers With Cerebral Palsy

OBJECTIVE

Although early intervention for infants at risk for cerebral palsy is routinely recommended, the content of intervention is poorly described, varies widely, and has mixed supporting evidence. The purpose of this study was to compare efficacy of 2 interventions grounded in differing domains of the International Classification of Functioning, Disability and Health on developmental outcomes of infants with or at high risk of cerebral palsy.

METHODS

Infants who meet inclusion criteria will be randomized into either Sitting Together and Reaching To Play or Movement, Orientation, Repetition, Exercise Physical Therapy groups. Both groups will receive intervention twice weekly for 3 months and follow-up at 3, 6, 9, and 12 months from baseline. The primary objectives compare changes over time and between groups in sitting, gross motor, and cognitive development. The setting is the infant's home unless the caregiver requests otherwise. One hundred and fifty infants between 8 and 24 months of age will be enrolled in 3 geographically, racially, and ethnically diverse sites: Los Angeles, California; Omaha, Nebraska; and Seattle, Washington. Enrolled infants will demonstrate motor delays, emerging sitting skills, and signs of neurologic impairment. Sitting Together and Reaching To Play targets activities including sitting, reaching, and motor-based problem solving to improve global development. In contrast, Movement, Orientation, Repetition, Exercise Physical Therapy focuses on strengthening and musculoskeletal alignment while encouraging repeated movement practice. Outcome measures include the Gross Motor Function Measure, Bayley Scales of Infant Development-IV, Assessment of Problem Solving in Play, and a Parent Child Interaction assessment. Enrolled children will maintain usual intervention services due to ethical concerns with intervention withdrawal.

IMPACT

This will be the first study, to our knowledge, comparing efficacy of early physical therapy with dose-matched interventions and well-defined key principles. The outcomes will inform selection of key principle of intervention in this population.

Cultural Adaptation of the Mothers and Babies Intervention for Use in Tribal Communities

OBJECTIVE

While one in five women may experience mood and anxiety disorders during pregnancy and postpartum, Indigenous identity increases that risk by 62%, especially among younger Indigenous women. The need for evidence-based perinatal mental health interventions that provide culturally relevant well-being perspectives and practices is critical to improving maternal, child, and community outcomes for Indigenous peoples, and reducing health inequities.

METHODS

Through a collaboration between community maternal and child health professionals, intervention researchers, and a cultural consultant, our workgroup developed cultural adaptations to Mothers and Babies, an evidence-based perinatal depression prevention intervention. Applying a cultural interface model, the workgroup identified existing intervention content for surface adaptations, as well as deep, conceptual adaptations to incorporate traditional teachings into this evidence-based intervention.

RESULTS

This collaboration developed a culturally adapted facilitator manual for intervention providers, including guidance for implementation and further adaptation to represent local tribal culture, and a culturally adapted participant workbook for Indigenous perinatal women that reflects cultural teachings and traditional practices to promote well-being for mother and baby.

IMPLICATIONS

Committing to a culturally respectful process to adapt Mothers and Babies is likely to increase the reach of the intervention into Indigenous communities, reengage communities with cultural practice, improve health outcomes among parents, children, and the next generation's elders, and reduce disparities among Indigenous groups. Replication of this community-engaged process can further the science and understanding of cultural adaptations to evidence-based interventions, while also further reducing health inequities. Future steps include evaluating implementation of the culturally adapted intervention among tribal home visiting organizations.

Teaching With Picture Books on Deaf and Hard-of-Hearing Students'Creativity

Studies have shown that teaching with picture books can help improve creativity development of deaf and hard-of-hearing (DHH) students. A quasi-experimental research design was applied in this study. Deaf and hard-of-hearing students in grades 3-6 from two cities, B and T, were selected as the samples in a pilot study. The Evaluation of Potential Creativity (EPoC) test tool (Ver. A) was applied to measure creativity through student performance on individual tests of divergent and integrative thinking. Following thirty 40-min lessons over 10 weeks, the EPoC test tool (Ver. B) was used to measure student creativity in the experimental and control groups. The results showed the following: (1) the performance of DHH students was better on graphic divergence than on verbal divergence, (2) performance on the divergent dimensions of creativity was significantly higher for DHH students from the experimental group than the control group, and (3) there was no difference in integrative thinking between the two groups in the posttest. In practice, teachers could use picture books in their lesson plans to improve the creativity of DHH students that results from divergent thinking. Future research should focus on the development of creativity in DHH students through integrative thinking with a longer teaching intervention.

Measuring Early Problem-Solving in Young Children with Motor Delays: A Validation Study

AIM

There is a lack of evidence-based tools for measuring problem-solving in young children with motor delays. The purpose of this study was to evaluate the construct validity and responsiveness of the Assessment of Problem-Solving in Play.

METHODS

125 young children (10.72, SD 2.62 months) with mild, moderate, and severe motor delays were assessed with the Bayley Scales of Infant and Toddler Development, Third Edition Cognitive Scale and the Assessment of Problem-Solving in Play up to 4 times over 12 months. The baseline and change over time assessment scores were compared.

RESULTS

The Assessment of Problem-Solving in Play was strongly, positively correlated with the Bayley Scales of Infant and Toddler Development, Third Edition Cognitive Scale raw scores at baseline (r=.83, p<.001) and for changes in scores across time (r=.64, p<.001). On average, participants demonstrated positive change in problem-solving scores across time. Participants with severe motor delay scored lower at baseline and changed less as compared to other participants.

CONCLUSIONS

Results provide evidence for the construct validity and responsiveness of the Assessment of Problem-Solving in Play scores in quantifying problem-solving in young children with motor delays 7-27 months of age.

Developing a fidelity measure of early intervention programs for children with neuromotor disorders

AIM

To describe the development of an intervention-specific fidelity measure and its utilization and to determine whether the newly developed Sitting Together and Reaching to Play (START-Play) intervention was implemented as intended. Also, to quantify differences between START-Play and usual early intervention (uEI) services.

METHOD

A fidelity measure for the START-Play intervention was developed for children with neuromotor disorders by: (1) identifying key intervention components, (2) establishing a measurement coding system, and (3) testing the reliability of instrument scores. After establishing acceptable interrater reliability, 103 intervention videos from the START-Play randomized controlled trial were coded and compared between the START-Play and uEI groups to measure five dimensions of START-Play fidelity, including adherence, dosage, quality of intervention, participant responsiveness, and program differentiation.

RESULTS

Fifteen fidelity variables out of 17 had good to excellent interrater reliability evidence with intraclass correlation coefficients (ICCs) ranging from 0.77 to 0.95. The START-Play therapists met the criteria for acceptable fidelity of the intervention (rates of START-Play key component use ≥0.8; quality ratings ≥3 [on a scale of 1-4]). The START-Play and uEI groups differed significantly in rates of START-Play key component use and quality ratings.

INTERPRETATION

The START-Play fidelity measure successfully quantified key components of the START-Play intervention, serving to differentiate START-Play from uEI.

START-Play Physical Therapy Intervention Impacts Motor and Cognitive Outcomes in Infants With Neuromotor Disorders: A Multisite Randomized Clinical Trial

OBJECTIVE

Our objective was to evaluate the efficacy of the Sitting Together and Reaching to Play (START-Play) intervention in young infants with neuromotor disorders.

METHOD

This randomized controlled trial compared usual care early intervention (UC-EI) with START-Play plus UC-EI. Analyses included 112 infants with motor delay (55 UC-EI, 57 START-Play) recruited at 7 to 16 months of age across 5 sites. START-Play included twice-weekly home visits with the infant and caregiver for 12 weeks provided by physical therapists trained in the START-Play intervention; UC-EI was not disrupted. Outcome measures were the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley); the Gross Motor Function Measure; reaching frequency; and the Assessment of Problem Solving in Play (APSP). Comparisons for the full group as well as separate comparisons for infants with mild motor delay and infants with significant motor delay were conducted. Piecewise linear mixed modeling estimated short- and long-term effects.

RESULTS

For infants with significant motor delay, positive effects of START-Play were observed at 3 months for Bayley cognition, Bayley fine motor, and APSP and at 12 months for Bayley fine motor and reaching frequency outcomes. For infants with mild motor delay, positive effects of START-Play for the Bayley receptive communication outcome were found. For the UC-EI group, the only difference between groups was a positive effect for the APSP outcome, observed at 3 months.

CONCLUSION

START-Play may advance reaching, problem solving, cognitive, and fine motor skills for young infants with significant motor delay over UC-EI in the short term. START-Play in addition to UC-EI may not improve motor/cognitive outcomes for infants with milder motor delays over and above usual care.

IMPACT

Concepts of embodied cognition, applied to early intervention in the START-Play intervention, may serve to advance cognition and motor skills in young infants with significant motor delays over usual care early intervention.

LAY SUMMARY

If you have a young infant with significant delays in motor skills, your physical therapist can work with you to develop play opportunities to enhance your child's problem solving, such as that used in the START-Play intervention, in addition to usual care to help your child advance cognitive and motor skills.