A new framework for developing and evaluating complex interventions: update of Medical Research Council guidance

Strengthening teamwork and respect (STAR) in maternity units: developing a health system intervention in South Africa

Disrespect and abuse in maternity services in South Africa has been described over several decades and are rooted in the country's complex socio-political landscape and unequal health system which places strain on public sector health professionals. Strategies to improve the quality of health care typically involve once-off didactic teaching or outside technical consultants focused on improving specific health programmes. These approaches fail to encourage self-reflection or to establish learning cultures. Participatory learning processes, embedded in routine service delivery, are a potentially powerful way to improve ownership and accountability for health system performance. We describe the process followed to develop the Strengthening Teamwork and Respect (STAR) intervention which is being implemented in nine district hospitals in two rural districts of KwaZulu-Natal. The intervention approach draws on a conceptual framework for learning health systems, with intervention strategies informed by participatory learning and action theory. The intervention design was an iterative process informed by literature reviews, formative data collection, consultation with provincial, district and hospital management stakeholders, expert reviewer inputs and piloting of proposed activities. This process produced the STAR intervention approach and toolkit, consisting of: identification and training of champions, creation of STAR teams, convening of learning sessions to work through STAR toolkit activities, identification, implementation and monitoring of change projects, and onsite and virtual mentorship from the STAR development team. Endline cross-sectional surveys and a parallel process evaluation will advance the evidence base for interventions to improve respectful care and cultures of teamwork and learning within maternity units in rural low- and middle-income settings.

Development of a dyadic mindfulness self-compassion intervention for patients with lung cancer and their family caregivers: A multi-method study

Objective

Lung cancer and its prolonged treatment are profoundly unsettling for patients and their family caregivers, and developing dyadic measures to alleviate their negative affectivity is pivotal. This study aimed to develop a complex intervention to alleviate dyadic psychological stress among patients with lung cancer and their family caregivers.

Methods

A stepwise multi-method study was conducted following the Medical Research Council framework. Three phases were adopted, namely: (1) a preparation phase, a systematic review was conducted to identify the evidence base, (2) a development phase, empirical data from a quantitative study and a qualitative study were integrated to identify effective components, and (3) a modification phase, an online Delphi survey was carried out to refine the intervention.

Results

The dyadic Mindfulness Self-Compassion intervention developed in this study consists of six weekly sessions. The key components of the intervention include: (1) getting along with cancer (introductory session targets illness perception), (2) practising mindful awareness (core session for mindfulness), (3) defining dyadic relationships and introducing self-compassion (core session for self-compassion), (4) promoting dyadic communication (maintenance session targets communication skills), (5) promoting dyadic coping (maintenance session targets coping skills), and (6) a summary session reviewing the rewards and challenges of dyadic adaptation named embracing the future.

Conclusions

An evidence-based, theory-driven, and culturally appropriate dyadic Mindfulness Self-Compassion intervention was developed for patients with lung cancer and their family caregivers. Future studies are warranted to pilot and evaluate the usability, feasibility, acceptability, satisfaction, and effectiveness of this complex intervention.

Trial registration

ClinicalTrial.gov NCT04795700.

Therapists perspectives on the Early Intervention after Rape study: a qualitative process evaluation of a randomized controlled trial

ABSTRACTBackground: Early interventions using trauma-focused cognitive behavioural therapy have the potential to alleviate post-traumatic stress symptoms in individuals who have experienced recent sexual assault. Specialized Sexual Assault Centers (SACs) in Norway offers psychosocial support, however, this support varies across SACs and its efficacy has not been researched. The Early Intervention after Rape (EIR) study is a multisite randomized controlled trial designed to assess the efficacy and effectiveness of training SAC nurses and social workers to deliver a modified version of prolonged exposure therapy shortly after rape.Objective: This article aims to present a qualitative process evaluation of the implementation of the EIR study across three SACs in Norway, from the perspective of nurses and social workers.Method: We conducted semi-structured interviews with fifteen nurses and social workers, ten of whom received training in prolonged exposure therapy (mPE). We used Thematic Analysis to identify themes and subthemes.Results: Thematic analysis yielded four significant themes for process evaluation: (1) The quality of the new intervention modified prolonged exposure was considered satisfactory through training and supervision and delivered with good adherence to the manual, although some therapists perceived the manual as too rigid; (2) Adoption dynamics within the SACs are complex and include both enthusiasm for clinical research as well as resistance to change; (3) Narrow inclusion criteria and burden with participation for patients may limit reach and representativeness of the RCT; (4) Unintended consequences were identified, such as delayed start, conflicting advices and cross-contamination, underscoring the ongoing necessity for process evaluation alongside RCTs.Conclusion: This qualitative process evaluation offers insight into real-world clinical challenges with implementing a new intervention and conducting a multisite RCT within SACs in Norway. This study may inform opportunities to advance evidence-based practices for rape survivors seeking help.Trial registration: ClinicalTrials.gov identifier: NCT05489133..

Interventions facilitating the involvement of relatives of patients with acquired brain injury or malignant brain tumour: A scoping review

AIM

To identify and map the evidence on interventions facilitating the involvement of relatives of patients with an acquired brain injury (ABI) or a malignant brain tumour (MBT).

BACKGROUND

An ABI or a MBT are severe diseases that have profound impact on the lives of patients and their relatives. The well-being of the patient may be deteriorated, and relatives may experience a new role and changing caregiving tasks. Involvement of relatives seems essential, and there is a need for identifying interventions facilitating the involvement.

DESIGN

Scoping review.

METHODS

The Joanna Briggs Institute methodology was used in this review and the review was reported in accordance with the PRISMA extension for scoping reviews.

DATA SOURCES

The literature search was conducted in MEDLINE, Embase, CINAHL and Cochrane Library. Reference lists of included studies, Google Scholar and Web of Science were also searched.

RESULTS

In total, 46 studies were included of which 36 (78%) involved patients with stroke. Median duration of study interventions were 8 weeks, and nurses were involved as providers of the intervention in 23 (50%) studies. Thirty (65%) studies used a multicomponent intervention. Thirty-five unique outcomes were identified using 60 unique outcome measurements.

CONCLUSION

Interventions facilitating the involvement of relatives differed importantly in key characteristics of study interventions, and in relation to the context in which they were used. There was no consensus regarding choice of outcomes and outcome measurements. Our results highlight the complexity of interventions in this field.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

To our knowledge this is the first scoping review examining interventions facilitating the involvement of relatives of patients with an acquired brain injury or a malignant brain tumour. This review suggests a clear definition of 'involvement' in future research and there is a need of development of a core outcome set for use in interventions facilitating the involvement.

REPORTING METHOD

The scoping review was reported in accordance with the PRISMA extension for scoping reviews.

NO PATIENT OR PUBLIC CONTRIBUTION

The authors decided to undertake this scoping review without patient and public contribution. However, the protocol was published prior to review conduct and available to the public but we did not receive any comments on it.

Advance care planning intervention in chronic kidney care: A qualitative evaluation

BACKGROUND

Patients with chronic kidney disease and their families request early and continuous advance care planning. Based on user involvement, an advance care planning intervention was developed to support patients, family members and healthcare professionals (HCPs) in advance care planning conversations in a nephrology outpatient setting.

OBJECTIVE

To explore the experiences and perceptions of an advance care planning intervention among patients with chronic kidney disease, family members and healthcare professionals.

DESIGN

An exploratory qualitative study with a phenomenological-hermeneutic approach.

PARTICIPANTS

Six patients with chronic kidney disease, four family members and four healthcare professionals.

APPROACH

Semistructured interviews with patients and family members and a focus group interview with healthcare professionals were conducted. Data were analysed using Ricoeur's interpretation theory.

FINDINGS

Patients and their families were impacted in various ways when the patient received the diagnose of chronic kidney disease. The need for an advance care planning intervention was based on a range of individual needs. The intervention supported patients, their family members, and healthcare professionals through open dialogues and reflections about thoughts and concerns. Healthcare professionals' reflected that it might be too early to deliver an increased amount of care.

CONCLUSION

When the disease challenged family and everyday life, the advance care planning intervention was useable and facilitated an open dialogue and reflections. The advance care planning conversations developed awareness among the patients and family members about their values, preferences, and needs, and supported them in sharing them. There is a need for training in initiating and conducting advance care planning conversations among healthcare professionals.

Parents' Experiences of Raising 7- to 11-Year-Old Children With ADHD and Perception of a Proposed Parenting Program: A Qualitative Study

OBJECTIVE

To examine the experiences of Australian parents raising primary school-aged children with ADHD and gather feedback on a proposed ADHD parenting program.

METHODS

Reflexive thematic analysis of semi-structured interviews undertaken with 11 Australian parents of 7- to 11-year-old children with ADHD. Interviews were conducted over Webex, audio recorded, transcribed verbatim, and analyzed in NVivo Ltd. software.

RESULTS

We identified four themes: (1) "I love my child but their ADHD traits are challenging," (2) "Compliance, control, and completion," (3) "It's hard, burdensome, and exhausting and I can feel like I'm alone," and (4) "What a welcome relief."

CONCLUSION

Parents report that although raising neurotypical children is difficult, the presence of childhood ADHD increases the emotional and support burden placed on them. Parents were also very interested in and supportive of the proposed ADHD parenting program. The program aims to enhance parents' understanding of the neurocognitive implications of ADHD and to foster secure parent-child attachment, attuned parental responsiveness, and age-appropriate development of traits that promote well-being, adaption and recovery in people with ADHD.).

Frameworks for the design and reporting of anaesthesia interventions in perioperative clinical trials

Background

Interventions from RCTs can only be replicated and implemented if reported in sufficient detail. This study developed frameworks to assist researchers with describing, monitoring, and reporting the key components of anaesthetic interventions in trials.

Methods

This study comprised three phases: (1) initial framework development-text describing the delivery of anaesthetic interventions was coded and categorised into components using thematic analysis; (2) refinement of frameworks-facilitated structured group discussions were conducted with perioperative clinicians, researchers, and journal editors to elicit additional framework categories and consider clarity and feasibility; (3) framework testing and further refinement-cognitive interviews with professionals undertaking trials evaluating anaesthesia interventions to test the feasibility of using the frameworks in contemporary perioperative trials.

Results

Three frameworks were developed for general, regional, and sedation anaesthesia interventions. Data saturation of categories within the frameworks was reached after inclusion of 15 RCTs for general and regional anaesthesia, and 13 for sedation. Each framework is structured into three main sections: (1) professional(s) delivering the intervention; (2) setting; and (3) intervention components, with descriptions of the preoperative, intraoperative, and postoperative stages unique to each anaesthetic intervention. Each framework deconstructs an anaesthetic intervention into component parts to support researchers with the design and reporting of RCTs. Final frameworks are available at: https://anaesthesiaframeworks.blogs.bristol.ac.uk/.

Conclusions

We provide novel frameworks to be used during the design of perioperative trials to facilitate the design, delivery, and reporting of anaesthesia interventions.

Economic Evaluations of Non-Pharmacological Interventions for Treating Disorders of Gut-Brain Interaction: A Scoping Review

BACKGROUND AND OBJECTIVES

Disorders of gut-brain interaction are highly prevalent and burdensome conditions for both patients and healthcare systems. Given the limited effectiveness of pharmacotherapy in treating disorders of gut-brain interaction, non-pharmacological interventions are increasingly used; however, the value for money of non-pharmacological treatments is uncertain. This is the first review to assess the economic evaluation evidence of non-pharmacological interventions for disorders of gut-brain interaction.

METHODS

A scoping review was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. Reporting adhered to ISPOR's good practices for systematic reviews with cost and cost-effectiveness outcomes. Comprehensive searches were performed on 24 October, 2023, and an updated search was run on 18 May, 2024 in PubMed/MEDLINE, Embase, Web of Science, Scopus and the International HTA database, with two reviewers screening studies in parallel. The novel Criteria for Health Economic Quality Evaluation (CHEQUE) framework was used to assess methodological and reporting quality. Reporting quality was further assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022.

RESULTS

Fifteen studies were included. Most studies examined treatments for irritable bowel syndrome. Cognitive behavioural therapy, dietary interventions and sacral neuromodulation were cost effective. Acupuncture and physiotherapy were not. CHEQUE assessment showed 12 studies met at least 70% of the methodological criteria, and 14 studies achieved 70% or more for reporting quality.

CONCLUSIONS

This review highlights gaps in the current evidence base, particularly in the robustness and generalisability of results due to methodological inconsistencies. Future research should incorporate longer follow-ups, comprehensive cost assessments, subgroup analyses, equity considerations and clearer justifications for modelling assumptions.

Development and implementation of a physiotherapy exercise intervention with tailored support for exercise adherence for people with vertebral fragility fractures (OPTIN trial)

OBJECTIVES

The OsteoPorosis Tailored exercise adherence INtervention (OPTIN) trial is a two-arm, multi-centre randomised controlled trial. It compares the effectiveness of physiotherapy exercise rehabilitation with integrated support for exercise adherence, to physiotherapy exercise rehabilitation alone, for people with vertebral fragility fracture (VFF) and back pain. This paper describes the development of the physiotherapist-led adherence enhanced intervention.

METHODS

We used an intervention mapping approach and followed Medical Research Council guidelines for developing complex interventions. We co-created the intervention involving expert clinicians, service managers, researchers, and adults with long-term musculoskeletal conditions, including osteoporosis. We identified a theoretical framework, reviewed the evidence, used a feasibility study, and considered clinical practice and deliverability within UK National Health Service (NHS) outpatient physiotherapy secondary care. Through a collaborative workshop, we refined the intervention, involved patients again and re-tested the intervention. Finally, we manualised the intervention, produced patient and physiotherapist materials and trained physiotherapists for delivery.

RESULTS

The OPTIN intervention uses a motivational interviewing approach and captures information about patient goals, barriers, and facilitators to exercise. Physiotherapists assess exercise capability, opportunities and motivation and utilise at least three behaviour change approaches, selecting from an intervention toolkit of nine approaches to support exercise behaviour. Ninety minutes of additional physiotherapy are provided to deliver the intervention, integrated within the assessment and six follow-up visits.

CONCLUSIONS

A theory-informed intervention to support exercise adherence was developed and delivered by physiotherapists trained in the intervention to older adults with VFF and back pain in the intervention arm (n = 63) of the OPTIN trial.

TRIAL REGISTRATION NUMBER

ISRCTN 14465704. CONTRIBUTION OF PAPER.

Effectiveness of behavioural and psychological interventions for managing obesity in children and adolescents: A systematic review and meta-analysis framed using minimal important difference estimates based on GRADE guidance to inform a clinical practice guideline

OBJECTIVE

Conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) of behavioural and psychological interventions for managing paediatric obesity.

METHODS

Eligible studies, published between 1985 and 2022, included 0 to 18 year olds with outcomes reported ≥3 months post-baseline, including patient-reported outcome measures (PROMs), cardiometabolic and anthropometric outcomes, and adverse events (AEs). We pooled data using a random effects model and assessed certainty of evidence (CoE) related to minimally important difference estimates for outcomes using GRADE.

RESULTS

We included 73 unique RCTs (n = 6305 participants, 53% female). Intervention types included physical activity (n = 1437), nutrition (n = 447), psychological (n = 1336), technology-based (n = 901) or multicomponent (≥2 intervention types, n = 2184). Physical activity had a small effect on health-related quality of life (HRQoL), varying effects ranging from moderate to very large on blood pressure, lipids and insulin resistance, and a small effect on BMIz. Nutrition had a small effect on lipids, insulin resistance and BMIz. Psychological interventions showed a small effect on HRQoL and triglycerides and moderate benefits on depressive symptoms, while technology interventions showed small benefits on blood pressure and BMIz. Multicomponent interventions had a large benefit on anxiety, small benefit on depressive symptoms, with large to very large benefits on lipids, and small benefits for diastolic blood pressure, insulin resistance and BMIz. AEs were reported infrequently, and when reported, were described as mild.

CONCLUSION

Physical activity and multicomponent interventions showed improvements in PROMs, cardiometabolic and anthropometric outcomes. Future trials should consistently measure PROMs, evaluate outcomes beyond the intervention period, and study children <6 years of age.

Digital and nurse-led support intervention in primary care during the first year after curative intent treatment for breast or prostate cancer: study protocol of two cluster randomised controlled pilot trials

INTRODUCTION

The period directly after primary treatment for breast or prostate cancer is a time when patients feel unprepared about how to manage life and address unexpected health challenges. Supportive care should focus on identifying symptoms and concerns and involving survivors in their self-care. Interventions using a blended model encompassing remote and in-person components may inform how supportive care can be organised. This protocol describes two pilot randomised controlled trials with the aim to investigate the acceptability, feasibility and potential effects of a 6 month digital and nurse-led support intervention in primary care for patients with breast or prostate cancer during the first year after primary treatment.

METHODS AND ANALYSIS

Two cluster randomised pilot trials including patients with breast or prostate cancer during the first year after ending primary treatment will run from 2023 in primary care centres in Region Stockholm. The trials will have an estimated sample size of 20 patients in each arm. The intervention groups receive a digital and nurse-led support intervention in combination with standard care, and the control groups receive standard care alone. To assess acceptability and feasibility, the participants in the intervention groups and the study nurses will be interviewed. Furthermore, digitally logged data and field notes by study-specific nurses will be analysed. Data collection for the potential effects of the intervention is conducted through self-reported standardised and validated questionnaires at baseline, and at 3, 6, 12, 18 and 24 months. Data entry and analyses will be blinded to the researchers. Qualitative data will be analysed with content analysis, quantitative data will be evaluated by comparing changes within and between groups.

ETHICS AND DISSEMINATION

This project was reviewed and approved by the Swedish Ethical Review Authority. Study results will be published in peer-reviewed journals and presented at scientific and professional meetings.

TRIAL REGISTRATION NUMBERS

ClinicalTrials.gov, NCT06471452 and NCT05100121.

Experiences of participation in an education and support group for carers of people with longer-term psychosis: a qualitative study

BACKGROUND

It is well-established that carers of people with psychosis require support given the stress, social isolation and health problems commonly associated with their caring role. However, interventions for carers are under-researched and underprovided. Psychoeducation and support groups can improve carers' experiences of caregiving, but there is insufficient evidence to inform an optimal intervention. Furthermore, the limited existing literature tends to focus on carer groups provided within early intervention services. We designed and implemented an education and support group programme for carers of people with longer term psychosis. The group ran twice, online in 2021 and face-to-face in 2023. We conducted a qualitative service evaluation to explore participants' experiences of participation in the group and inform its further refinement.

METHODS

We conducted in-depth, semi-structured interviews before and after each group programme which explored carers' experiences of caring and of group participation, in order to understand its impact, potential mechanisms of effect, and any helpful or challenging aspects. Facilitators also provided written reflective notes. Data were analysed using reflexive thematic analysis.

RESULTS

Seventeen carers and four facilitators participated. The group programme received highly positive feedback. Four main themes were identified regarding its impact on the experience of caring: 1) isolated versus connected and supported; 2) disempowered versus empowered; 3) grief, guilt, worry versus acceptance; 4) unmet needs: the challenges associated with participants' caring roles which were not addressed by group participation. The group's mechanisms of effect included: building connections between carers, building carers' connections with services, and providing psychoeducation that improved carers' confidence and increased their empathy for their relative. Key components of the group's design were: attendees having similar experiences of caring attendees receiving clear information about the group's purpose and format, and facilitation by senior mental professionals who enabled discussion. The main area for improvement was to increase accessibility to carers from minority groups.

CONCLUSIONS

This study explored participants' experiences of a psychoeducation and support group for carers of people with longer-term psychosis and showed that it was largely acceptable and received positively by participants. The results may explain why recent trials of carer focussed interventions that have relied on digital contact were not effective. Further research is needed, including clinical trials, to investigate the clinical and cost effectiveness of face-to-face carer groups.

Implementation of hospital-initiated complex interventions for adult people with multiple long-term conditions: a scoping review

BACKGROUND

The increasing prevalence of multiple long-term conditions (MLTC) presents significant challenges to healthcare delivery globally. Although interventions for long-term conditions have predominantly been designed and evaluated in primary care settings, there is a growing recognition of the need to address the management of MLTC within secondary care. This scoping review aims to comprehensively evaluate hospital-initiated complex interventions for people with MLTC.

METHODS

We searched MEDLINE, Embase, PsycINFO, CINAHL Plus and Cochrane Library to identify published studies from Jan 1, 2010, evaluating hospital-initiated interventions initiated for adults (aged ≥ 18 years) with MLTC (PROSPERO: CRD42024498448). Studies reporting patients with frailty only, one long-term condition or orthogeriatric studies that did not focus solely on people with MLTC were excluded. The primary outcome measures were the characteristics of these complex interventions measured as: (i) intervention components, (ii) stakeholders involved; and (iii) implementation strategies, reported according to a theoretical framework (Expert Recommendations for Implementing Change). Secondary outcome measures were clinical and cost implications of these complex interventions, feasibility and sustainability, defined according to the World Health Organisation implementation framework.

FINDINGS

This scoping review identified 70 studies (56,111 participants). Twelve intervention components were identified in 52 combinations; the most common were medication review and optimisation (n = 39), chronic disease management (n = 34) and providing detailed care plans (n = 23). Majority of studies included two or more interventions components (n = 49) delivered by multiple stakeholders (n = 38). Of eleven implementation strategies reported, training and educating stakeholders, establishing integrated wards or clinics and regular multidisciplinary team meetings were the most common. Majority of combinations of intervention groups were associated with improved clinical outcomes for patients with MLTC (n = 43/70, 61.4%), yet eight studies reported on costs. However, embedding training and education or integrated clinics in delivering these intervention groups were associated with improved clinical outcomes, irrespective of the number of healthcare professionals involved. Majority of studies were evaluated in single centre settings, with limited evaluation of broader implementation measures.

INTERPRETATION

Hospital-initiated complex interventions that involve multiple stakeholders may be feasible and appear to be clinically useful for people with MLTC. To strengthen impact and support wider scale-up across health systems, closing knowledge gaps around cost-implications and strategies to improve implementation of these complex interventions through training and education or integrated clinics will be crucial.

Patients' and providers' perspectives of a dose administration aid strategy to improve cardiovascular disease prevention in Australian primary healthcare

BACKGROUND

Hypertension is the most commonly managed problem in general practice in Australia, but blood pressure control is not achieved for most patients. An important factor to consider in hypertension control is patient medication adherence. Use of dose administration aids (DAAs) could increase adherence to medicines and reduce the frequency of medication errors. We conducted a trial to evaluate adherence to DAAs in real-world conditions. This study is a process evaluation of the main trial. This stydy aims to understand the acceptability of DAAs from patients, providers, and carers perspectives and examine implementation barriers and facilitators of trial processes.

METHODS

In-depth, semi structured interviews were conducted in an Australian general practice participating in a pilot randomised controlled trial evaluating a DAA-based strategy for people with high-risk primary and secondary cardiovascular disease. Interview topics included DAA acceptability, factors affecting adherence and trial implementation. Transcribed interview data were analysed thematically and interpretively. The consolidated framework for implementation research was used to guide our analysis.

RESULTS

Nineteen interviews were conducted (16 participants or carers, 1 physician, 1 pharmacist and 1 DAA packaging company representative). All trial participants reported improved adherence, especially in those with prior poor adherence. Key barriers to DAA use included inertia to change, resistance from the pharmacist with regards to repackaging by an external provider, logistics of direct home delivery and lack of communication. A key facilitator to trial implementation was the therapeutic relationship of patients with the health care professionals.

CONCLUSION

The DAA strategy was generally acceptable to patients and the physician as a cardiovascular preventative strategy. Participants suggested a DAA-based strategy as particularly appropriate for those with prior poor adherence to medications.

TRIAL REGISTRATION

ACTRN12620001239954. 19/11/2020.

Engaging South Asian Communities in the United Kingdom to Explore Infant Feeding Practices and Inform Intervention Development: Application of the REPLACE Approach

Breastfeeding in UK Pakistani and Bangladeshi communities is positively and negatively influenced by cultural beliefs and practices. The LIFT (Learning about Infant Feeding Together) project aimed to understand the determinants of infant feeding in these target communities and to engage them in the development of a culturally specific and acceptable infant feeding intervention to support breastfeeding. Reported here is phase one of the LIFT project guided by the REPLACE approach (a framework for the development of community-based interventions). The project involved an initial lengthy period of engagement with the target communities, using methods such as a community outreach event and identification of community peer group champions to help build trust. This was followed by iterative community workshops used to explore and build an understanding of infant feeding practices and the social norms and beliefs underlying these, and to assess community readiness to change. Consistent with previous research, the six key practices and beliefs identified from the workshops were: (1) Disparities between personal views versus cultural and normative barriers, (2) Family relationships and the influence on infant feeding decisions, (3) Pardah (modesty) and being unable to breastfeed in front of others, (4) Discarding colostrum (first breast milk), (5) Pre-lacteal feeds (feeds within a few hours of birth and before any breast or formula milk has been given) and complementary feeding before the baby is 6 months old, and (6) The belief that bigger babies are better and that formula helps babies to grow. Participants perceived that Pakistani and Bangladeshi communities would be amenable to intervention that aimed to change some but not all of the infant feeding behaviours identified. Findings informed the co-development of a culturally appropriate intervention toolkit to optimise infant feeding behaviour.

Readiness for scale up following effectiveness-implementation trial: results of scalability assessment of the Community Partnership Program for diabetes self-management for older adults with multiple chronic conditions

BACKGROUND

Implementation research should assess the feasibility of scale up to bridge the evidence-practice gap for integrated care programs in the prevention and management of chronic conditions. Scalability assessment is the first critical step of scale up to determine the potential suitability of a promising health program to be adopted into routine practice and the fit of the program within local contexts. The Community Partnership Program (CPP), an integrated care intervention for older adults with diabetes and multiple chronic conditions, was designed at the outset with scale up in mind, and evaluated in an implementation-effectiveness randomized controlled trial across three Canadian provinces. The final phase of this program of research was to assess scalability and determine the critical factors and next steps for the development of a scale up plan.

METHODS

Multiple methods were used to assess the scalability of the CPP including collection and analysis of publicly available documents, synthesis of qualitative and quantitative evidence from studies of the CPP, semi-structured interviews with key informants, feedback and recommendations arising from working group meetings and knowledge exchange workshops to discuss and rate the scalability of the program. Data collection and analysis was informed by the Intervention Scalability Assessment Tool (ISAT); developed to support practitioners and policy makers in conducting systematic assessments of the suitability of health interventions for population scale-up in high-income countries.

RESULTS

Overall, the CPP received high scalability ratings from participants. A phased, horizontal implementation and scale up process was recommended, facilitating local adaptations, on-going program evaluation, and accumulation of evidence. Challenges to scale up were identified, including the need for further evidence of program effectiveness in other diverse settings and populations, and designated funding and adequate health human resources.

CONCLUSIONS

Participants agreed the CPP meets the needs of many older adults with diabetes and multiple chronic conditions; however, they suggested further tailoring of the program to support different ethnocultural groups and targeting the CPP to older adults with higher needs. The scalability assessment process was a practical method to generate concrete strategies to facilitate the uptake of the CPP into practice.

TRIAL REGISTRATION

Clinical Trials.gov Identifier NCT03664583. Registration date: September 10, 2018.

Feasibility study of a co-designed, evidence-informed and community-based incentive intervention to promote healthy weight and well-being in disadvantaged communities in Scotland

OBJECTIVES

To feasibility test a novel community-based financial incentive scheme to promote healthy weight and well-being.

DESIGN

Single-arm, prospective feasibility study using mixed methods.

SETTING

Two communities in Scotland experiencing high levels of disadvantage according to the Scottish Index for Multiple Deprivation (SIMD). Community C1 is in a large rural area with a small town centre (population~1.5K) and community C2 is a small and urban community (population~9K), enabling contextual comparison.

PARTICIPANTS

Eligible adult (18 years or over) community members recruited through community outreach.

INTERVENTION

The Enjoy Life LocallY (ELLY) intervention comprised free soup twice weekly (café/delivery/pickup); loyalty card stamped for engagement in community assets (such as local activities, groups and clubs) exchanged for a £25 shopping card when a participant attends a minimum of 9 assets over 12 weeks; goal setting; information resources; self-monitoring of weight and well-being.

OUTCOMES

Primary outcomes-feasibility of recruitment, retention and engagement. Acceptability of intervention components was assessed by self-reported questionnaires and interviews. Secondary outcomes-feasibility of collecting outcomes prioritised by communities for a future trial: health-related quality of life (EQ-5D-5L), mental well-being (WEMWBS), connectedness (Social Connectedness Scale) and weight-related measures (weight, body mass index (BMI)).

RESULTS

Over 3 months, 75 community citizens (35 citizens in C1, 40 citizens in C2) were recruited (125% of target recruitment of 60 participants (117% of 30 participants C1 target, 133% of 30 participants C2 target), 84% female, baseline weight mean (SD)=84.8 kg (20) and BMI mean (SD)=31.9 kg/m2 (7.3), 65/75 (87%) living in disadvantaged areas (SIMD quintiles 1-3)). Retention at 12 weeks, defined by completion of outcome measures at 12 weeks, was 65 (87%). Participation in at least one asset for a minimum of 9 out of 12 weeks of the intervention was achieved by 55 (73%). All intervention components were acceptable, with the loyalty card being the most popular and the soup cafés the least popular. The mean average cost of the soup ingredients, per participant, over the 12 weeks was £12.02. Outcome data showed a small decrease in weight and BMI and a small increase in health-related quality of life, mental well-being and social connectedness.

CONCLUSIONS

The ELLY study recruited and retained participants from two disadvantaged communities in Scotland. The study was acceptable to participants and feasible to deliver. A full trial is warranted to determine effectiveness and cost-effectiveness, with consideration of scalability.

TRIAL REGISTRATION NUMBER

The ELLY feasibility study was not pre-registered.

Improving awareness of rabies and free-roaming dogs in schools of Guwahati, Assam, India: exploring the educators' perspective

BACKGROUND

Rabies poses a significant threat to public health in India, with schoolchildren comprising approximately 40% of mortality due to this zoonotic disease. Despite ongoing interventions in schools to increase awareness about rabies and free-roaming dogs (FRD), the incidence of dog bites and rabies cases among schoolchildren continues to rise. This study addresses the limitations of existing awareness programs by exploring educators' perspectives and proposing innovative, feasible, and cost-effective interventions in schools.

METHODS

A three-day workshop involving 19 teachers from seven schools representing diverse socio-economic backgrounds by adopting a modified Delphi method to achieve consensus on interventions identified during the process.

RESULTS

The workshop recommends (a) promoting awareness in morning assemblies, (b) starting a wall magazine on One Health, (c) distributing and displaying information, education, and communication (IEC) materials, (d) encouraging infographics, paintings, sketches, and reels, (e) integrating rabies-related topics in co-curricular activities, (f) initiating interdisciplinary projects focusing on rabies awareness (g) displaying in rabies awareness stalls during exhibitions/school functions, and (h) discussing in parent-teachers meets.

CONCLUSIONS

This study identifies sustainable and pedagogically sound interventions to raise awareness about rabies and FRD in schools, contributing to the broader goal of reducing rabies-related mortality among school children.

Protocol for the process evaluation for a cluster randomised controlled trial evaluating primary school-based screening and intervention delivery for childhood anxiety problems

INTRODUCTION

Anxiety problems are prevalent in childhood and, without intervention, can persist into adulthood. Effective evidence-based interventions for childhood anxiety disorders exist, specifically cognitive-behavioural therapy (CBT) in a range of formats. However, only a small proportion of children successfully access and receive treatment. Conducting mental health screening in schools and integrating evidence-based interventions for childhood anxiety problems may be an effective way to ensure support reaches children in need. The Identifying Child Anxiety Through Schools-Identification to Intervention (iCATS i2i) trial involves screening for childhood anxiety problems and offering a brief online parent-led CBT intervention. This paper presents the protocol for the process evaluation of the iCATS i2i trial, which aims to examine the implementation and acceptability of the study procedures, the mechanisms of change and whether any external factors had an impact on procedure engagement or delivery.

METHODS AND ANALYSIS

This process evaluation will use both quantitative and qualitative methods to evaluate the implementation and acceptability of and barriers/facilitators to engagement and delivery of the iCATS screening/intervention procedures. Quantitative data sources will include opt-out and completion rates of baseline measures and usage analytics extracted from the online intervention platform. Qualitative interviews will be conducted with children, parents, school staff, iCATS i2i clinicians and researchers delivering study procedures. The Medical Research Council framework for process evaluations will guide study design and analysis.

ETHICS AND DISSEMINATION

This study has received ethical approval from the University of Oxford Research Ethics Committee (R66068_RE003). Findings from the study will be disseminated via peer-reviewed publications in academic journals, conferences, digital and social media platforms and stakeholder meetings.

TRIAL REGISTRATION

ISRCTN76119074.

'We listened and supported and depended on each other': a qualitative study of how leadership influences implementation of QI interventions

BACKGROUND

There is growing recognition in the literature of the 'Herculean' efforts required to bring about change in healthcare processes and systems. Leadership is recognised as a critical lever for implementation of quality improvement (QI) and other complex team-level interventions; however, the processes by which leaders facilitate change are not well understood. The aim of this study is to examine 'how' leadership influences implementation of QI interventions.

METHODS

We drew on the leadership literature and used secondary data collected as part of a process evaluation of the Safer Care for Older Persons in residential Environments (SCOPE) QI intervention to gain insights regarding the processes by which leadership influences QI implementation. Specifically, using detailed process evaluation data from 31 unit-based nursing home teams we conducted a thematic analysis with a codebook developed a priori based on the existing literature to identify leadership processes.

RESULTS

Effective leaders (ie, those who care teams felt supported by and who facilitated SCOPE implementation) successfully developed and reaffirmed teams' commitment to the SCOPE QI intervention (theme 1), facilitated learning capacity by fostering follower participation in SCOPE and empowering care aides to step into team leadership roles (theme 2) and actively supported team-oriented processes where they developed and nurtured relationships with their followers and supported them as they navigated relationships with other staff (theme 3). Together, these were the mechanisms by which care aides were brought on board with the intervention, stayed on board and, ultimately, transplanted the intervention into the facility. Building learning capacity and creating a culture of improvement are thought to be the overarching processes by which leadership facilitates implementation of complex interventions like SCOPE.

CONCLUSIONS

Results highlight important, often overlooked, relational and sociocultural aspects of successful QI leadership in nursing homes that can guide the design, implementation and scaling of complex interventions and can guide future research.

The Effect of Patient Decision Aid Attributes on Patient Outcomes: A Network Meta-Analysis of a Systematic Review

BACKGROUND

Patient decision aids (PtDAs) are effective interventions to help people participate in health care decisions. Although there are quality standards, PtDAs are complex interventions with variability in their attributes.

PURPOSE

To determine and compare the effects of PtDA attributes (e.g., content elements, delivery timing, development) on primary outcomes for adults facing health care decisions.

DATA SOURCES

A systematic review of randomized controlled trials (RCTs) comparing PtDAs to usual care.

STUDY SELECTION

Eligible RCTs measured at least 1 primary outcome: informed values choice, knowledge, accurate risk perception, decisional conflict subscales, and undecided.

DATA ANALYSIS

A network meta-analysis evaluated direct and indirect effects of PtDA attributes on primary outcomes.

DATA SYNTHESIS

Of 209 RCTs, 149 reported eligible outcomes. There was no difference in outcomes for PtDAs using implicit compared with explicit values clarification. Compared with PtDAs with probabilities, PtDAs without probabilities were associated with poorer patient knowledge (mean difference [MD] -3.86; 95% credible interval [CrI] -7.67, -0.03); there were no difference for other outcomes. There was no difference in outcomes when PtDAs presented information in ways that decrease cognitive demand and mixed results when PtDAs used strategies to enhance communication. Compared with PtDAs delivered in preparation for consultations, PtDAs used during consultations were associated with poorer knowledge (MD -4.34; 95% CrI -7.24, -1.43) and patients feeling more uninformed (MD 5.07; 95% CrI 1.06, 9.11). Involving patients in PtDA development was associated with greater knowledge (MD 6.56; 95% CrI 1.10, 12.03) compared with involving health care professionals alone.

LIMITATIONS

There were no direct comparisons between PtDAs with/without attributes.

CONCLUSIONS

Improvements in knowledge were influenced by some PtDA content elements, using PtDA content before the consultation, and involving patients in development. There were few or no differences on other outcomes.

HIGHLIGHTS

This is the first known network meta-analysis conducted to determine the contributions of the different attributes of patient decision aids (PtDAs) on patient outcomes.There was no difference in outcomes when PtDAs used implicit compared with explicit values clarification.There were greater improvements in knowledge when PtDAs included information on probabilities, PtDAs were used in preparation for the consultation or development included patients on the research team.There was no difference in outcomes when PtDAs presented information in ways that decrease cognitive demand and mixed results when PtDAs used strategies to enhance communication.

Patient characteristics, behavior, and discharge locations of patients with dementia and very severe challenging behavior

OBJECTIVES

To gain insights into the characteristics, behavior, and discharge location of patients with dementia and very severe challenging behavior admitted to highly specialized units that are specialized in the diagnostics and treatment of this patient group.

METHOD

In this observational study, 11 units participated from 2020 - 2023. Measurements included demographics; dementia type; severity of cognitive decline; presence of delirium; location before admission; compulsory admission; medical history; drug use; and behavior during the first 2 weeks of admission, assessed by the Cohen-Mansfield Agitation Inventory and the Neuropsychiatric Inventory Questionnaire.

RESULTS

127 patients (67.7% males) participated. Nine in ten patients had moderately severe or severe cognitive decline. Behavior was rather heterogeneous, with agitation, general restlessness and verbal aggression present in 70% or more. Agitation was severely or extremely distressful for nursing staff in relation to one in four patients. Half of the patients were discharged to a regular dementia special care unit (DSCU), one in ten could not be discharged, and one-third died during their stay.

CONCLUSIONS

Despite heterogenous and highly prevalent behaviors of patients, about half of the patients could be discharged to DSCUs after treatment in a highly specialized unit. Future studies should explore whether and how treatment is effective.

Developing intervention fidelity strategies for a behaviour change intervention delivered in primary care dental practices: the RETURN fidelity strategy

BACKGROUND

Behaviour change interventions delivered in real-world settings could be vulnerable to threats to internal and external validity if methodological considerations are overlooked. The primary dental care setting is a difficult environment within which to deliver research protocols presenting unique challenges for robust scientific research delivery. Intervention fidelity strategies are an important mechanism to improve the scientific rigor of such studies. Feasibility studies provide a vital opportunity to refine and optimise research processes and implementation strategies before embarking on larger scale projects. This paper sets out the development of a comprehensive intervention fidelity strategy guided by The National Institutes of Health Behavior Change Consortium.(BCC) recommendations.

METHOD

Using observations (53 h) and qualitative interviews (17 patient interviews and 2 staff interviews) conducted during the delivery of the RETURN feasibility study (InteRventions to rEduce inequaliTies in the Uptake of Routine deNtal care), an intervention fidelity strategy was developed for use in the RETURN main trial.

RESULTS

A comprehensive intervention fidelity strategy was developed, structured around the five domains of the BCC's recommendations (design, training, delivery, receipt, enactment) and attending to the goals pertaining to each of those domains. This paper sets out the fidelity strategy implemented in the RETURN main trial.

IMPLICATIONS AND CONCLUSIONS

The RETURN fidelity strategy was influenced by the unique research environment the primary dental care setting presents. The strategy could serve as a blueprint to other researchers conducting research in similar settings. It is also intended that this strategy is read alongside the RETURN results upon their publication.

TRIAL REGISTRATION

ISRCTN10853330, registered: 07/10/2019.

Evaluating a whole-school approach to addressing gender-based violence in Scottish secondary schools (Equally Safe at School): a study protocol for a type I hybrid effectiveness-implementation trial

INTRODUCTION

Equally Safe at School (ESAS) is a whole-school intervention to reduce gender-based violence (GBV) in secondary school. ESAS comprises self-assessment, student-led action group, two-tier staff training, curriculum enhancement and policy review. Schools set up key activities in Year 1 and embed them in Year 2. GBV, including sexual harassment, is common in secondary schools and disproportionately affects young women and lesbian, gay, bisexual, transgender and queer youth.

METHODS AND ANALYSIS

We will evaluate the effectiveness, cost-effectiveness, mechanisms of action and implementation of ESAS. We will recruit 36 schools across Scotland. The evaluation comprises three linked studies:Study 1: Pragmatic cluster randomised trial with 1:1 school allocation to either immediate ESAS intervention start (intervention schools) or 12-month delayed intervention start (control schools). Our primary outcome of student experience of sexual harassment will be measured at 12 months post-randomisation. Analysis of primary and secondary outcomes (student and school level) will be conducted on an intention to treat (ITT) basis comparing schools according to their original allocation.Study 2: Mixed-methods evaluation. Study 2A: Longitudinal follow-up will assess primary, secondary and intermediate outcomes at baseline, 12 months and 24 months of follow-up. Study 2B: Systems and realist-informed process evaluation will assess intervention and control school context, fidelity, dose and reach, acceptability and actor response, and how this varies by school and students. We will also assess implementation processes and mechanisms of action (beneficial or harmful), including if and how change is embedded over time, and if and how ESAS helps schools leverage other assets and resources.Study 3: Economic evaluation to assess the within-trial and longer term cost-effectiveness of ESAS.The methods include surveys in three out of six year groups (Years 2, 4 and 6) in all schools (baseline, 12 months and 24 months of follow-up); interviews with staff, students and other stakeholders; activity observations; brief surveys with key actors and analysis of trial documentation.

ETHICS AND DISSEMINATION

Ethical approval by University of Glasgow MVLS Ethics Committee (200220268). Findings will be disseminated via multiple channels to researchers, GBV and education sector stakeholders, study participants and the public.

TRIAL REGISTRATION NUMBER

ISRCTN29792495.

Burnout in medical education: interventions from a co-creation process

INTRODUCTION

The high prevalence of burnout in medical education indicates an urgent need to develop and implement effective interventions at both the individual and organisational levels. Currently, there is a shortage of studies that include perspectives from multiple stakeholders, such as medical students, trainees and university staff. Our objective is to identify and discuss interventions from various stakeholders using a bottom-up approach to guide future implementation.

METHODS

A co-creation methodology was adopted, including workshops and a Delphi session, engaging 96 participants. The study included 12 workshops with medical students and trainees in Flanders (Belgium): first-year bachelor students (n = 12), first-year master students (n = 13), first-year General Practice (GP) trainees (n = 14) and first-year specialist trainees (n = 39). Additionally, one Delphi session was held with 18 other relevant stakeholders, including university staff. All workshops were transcribed verbatim and thematically analysed using NVivo.

RESULTS

Our results identified interventions to prevent and mitigate burnout among medical students and trainees. On the individual level, participants discussed personalized coaching, annual health assessments and training sessions. On the organisational level, a distinction was made between interventions intended for universities, and those for hospitals and GPs involved in medical training. Six interventions focused on preventing burnout in all contexts (i.e., onboarding programs); three were meant for universities only (i.e., pass-fail system), and six were tailored for hospitals and GPs (i.e., flexibility in scheduling).

CONCLUSION

Through an iterative multistakeholder co-creation process, this study identified interventions to prevent and mitigate burnout within medical education. These interventions span individual and organisational levels, targeting universities, hospitals and GPs. While organisational interventions are increasingly recognized as crucial to address burnout, individual-focused interventions remain predominant in current research. There is a pressing need to further investigate organisational interventions and their combination with individual-focused strategies.

Experiences of rehabilitation one year after breast cancer diagnosis-A focus group study from the ReScreen randomized controlled trial

BACKGROUND

Treatment for breast cancer poses major challenges and leads to a variety of side-effects and problems that affect life for a long time. Experiences and symptoms vary, and research indicates a lack of structures for ensuring individualized rehabilitation. This qualitative focus group study aims to explore the experience of women with BC after participating in a complex randomized controlled trial (RCT) (Clinicaltrials.gov NCT03434717) focusing on cancer rehabilitation from a comprehensive perspective.

METHOD

Nine semi-structured focus group interviews with women (n = 30) who participated in the Rescreen RCT were conducted. The women were interviewed divided into three RCT groups (intervention, control, or observation group). Data were initially analyzed inductively using conventional content analysis, followed by a deductive approach, guided by the result from the inductive analysis.

RESULTS

The inductive analysis resulted in two categories and four sub-categories and showed a great variation in experiences and needs. Some women described a well-functioning process, while others described lack of individualized information, continuity with healthcare providers, and clear pathways for support. After the deductive analysis, a variation between the groups appeared. Women in the intervention group expressed that a proactive and individualized approach facilitated rehabilitation and they experienced a feeling of being recognized as a person, which they highlighted as important. On the contrary, women from the control group described feelings of being abandoned from healthcare, hindering rehabilitation. The observation group expressed that their needs had been fulfilled within the healthcare system.

CONCLUSIONS

This study adds important knowledge to the evaluation of the ReScreen model and contributes to existing research on how individualized rehabilitation after breast cancer can be applied in clinical practice. A proactive, person-centered approach in rehabilitation, aimed at those with extended needs, would potentially optimize rehabilitation and facilitate the recovery process after breast cancer treatment.

A Multi-Stakeholder Qualitative Evaluation of ED PLUS: A Physiotherapy-Led Transition to Home Intervention for Older Adults Following Emergency Department Discharge

Introduction

Older adults frequently attend Emergency Departments (EDs) and experience high rates of adverse outcomes, including functional decline, re-presentation, and unplanned hospital admissions. Developing effective interventions to prevent these outcomes is a priority. Healthcare providers (HCPs) are well positioned to create integrated care pathways for older adults discharged from the ED. ED PLUS is a physiotherapy-led, multidisciplinary model that bridges the care transition between the ED and the community. It initiates a Comprehensive Geriatric Assessment (CGA) in the ED and provides multidisciplinary follow-up to the patient for six weeks post-discharge.

Purpose

This study aimed to explore the views and experiences of older adults and HCPs involved in the ED PLUS intervention to inform the design of a future definitive trial.

Methods

A descriptive qualitative design was used. Older adults (n = 9) and HCPs (n = 10) who participated in the intervention arm of the ED PLUS trial were invited to participate in semi-structured interviews exploring their experience and perspective of the ED PLUS intervention. These interviews were audio-recorded, transcribed, and analysed using reflexive thematic analysis.

Results

Nine older adults and six HCPs consented to participate. The evaluation highlighted stakeholders' experiences and suggested modifications for optimising ED PLUS. Four themes emerged: ED PLUS bridged the transition between care settings for older adults.Stakeholder collaboration and investment were key enablers of implementation.Organisational, logistical, and personnel issues impeded the intervention's delivery.There is potential for service optimisation and expansion.

Conclusion

This evaluation emphasises the important role of physiotherapists and other HCPs in transitional care delivery for older adults. The findings will inform future trials of the ED PLUS model, aiming to improve outcomes for this population.

Investigating the safety of physical rehabilitation with critically ill patients receiving vasoactive drugs: An exploratory observational feasibility study

BACKGROUND

Physical rehabilitation of critically ill patients may improve physical outcomes; however, the relative benefits and risks with patients requiring vasoactive drugs is currently unknown. A feasibility study is needed to inform the design of a future trial required to address this issue.

METHODS

A two-phase exploratory observational feasibility study was carried out: A retrospective study to clarify the current practice of rehabilitation with patients receiving vasoactive drugs to inform future trial interventions and design.A prospective study exploring recruitment and outcome measurement. Intensive care patients receiving vasoactive drugs were recruited and asked about the acceptability of a future trial. The feasibility of using an adverse event tool was measured during rehabilitation. Patients were followed up after 60 days to describe the feasibility of measuring outcomes for a future trial.

RESULTS

Retrospective study (n = 78): Twenty-one percent of patients took part in physical rehabilitation whilst receiving vasoactive drugs. Of 321 days with vasoactive drugs administered, physical rehabilitation occurred on 27 days (8%). Prospective study (n = 40): Eighty-one percent of participants indicated acceptability of being recruited into a future trial (n = 37). Eighty-eight percent of clinicians found it acceptable to randomise patients into either early rehabilitation or standard care. The adverse event tool was implemented by researchers with 2% loss of information. Finally, a 100% follow-up rate at day 60 was achieved for mortality outcomes. Follow-up rates were 70% for the EQ-5D (5 level), 65% for the World Health Organisation's Disability Assessment Schedule 2.0 and RAND 36-item Health Survey 1.0 and 26% for the 6-minute walk test.

CONCLUSIONS

This study found a low frequency of physical rehabilitation occurring with intensive care patients receiving vasoactive drugs. A high proportion of clinicians and patients found a future RCT within this patient group acceptable. Mortality and patient-reported outcomes were the most feasible to measure.

Informal digital peer support for mental health: understanding the digital support practices of LGBTQ+ young people in Australia

This paper offers an analysis of informal digital peer support among LGBTQ+ young people in Australia, based on survey data from 660 young people (aged 16-25). Research on LGBTQ+ young people's mental health support commonly focuses on their professional support needs and connection to services, but there is also a need to understand informal peer support through everyday social media use. There are known benefits of having access to multiple forms of care and support, including the immediacy of friendship and peer-based support. This paper focuses on how LGBTQ+ young people participate in informal digital support practices for mental health and the values they attribute to this. This includes support that is not only sought and found but that which is offered and reciprocated through care networks. We highlight the need to consider where informal support comes from, who is involved, and what it offers to LGBTQ+ young people. Participants commonly experienced social media as environments that offered connection to supportive people, content, and spaces - providing mental health benefits. The community, connection, and solidarity of online platform spaces can benefit young people's mental health and wellbeing, thereby complementing formal healthcare programmes, policy and systems of care.

Music in Mind Training: Producing a theory of change model to evaluate the implementation of an improvisation-based music-making training programme for care home staff working with people with dementia

BACKGROUND

In the UK, care home staff are often involved in musical practices as part of their professional activities. However, to date there is a lack of relational evidence that underpins improvisational music-making programmes in care homes, as related to the wellbeing of care home staff and musicians who deliver such work. This process evaluation accesses Manchester Camerata's 20-week 'Music in Mind Training' programme for care home staff working with people living with dementia in care homes, with a focus on care home staff.

AIMS

(i) To produce a Theory of Change model outlining the core mechanisms of change for Music in Mind Training; (ii) To evaluate the 'in-the-moment' and prospective impact of Music in Mind Training on participating care home staff practice and wellbeing.

METHODS

Conducted in two care homes, the study employed online observation of hour-long training sessions (n = 18), semi structured interviews with participating staff and musicians (n = 4), and oral histories interviews with stakeholders involved in programme development (n = 18).

FINDINGS

Participating care home staff reported a general increase in their motivation, wellbeing, and confidence through taking part in the training programme, while indicating a drop in confidence related to future delivery at the programme end. The study also indicated how care home staff implemented change to their day-to-day practice by incorporating their learning into interactions with residents in structured music sessions, and more broadly in daily interactions.

CONCLUSION

The presented Theory of Change model details core interpersonal mechanisms of change for this musical training programme, centred on (1) collaboration, (2) shared values, (3) respect and validation, and (4) openness and reflection, outlining pathways for impact regarding practice change and staff wellbeing. Subject to further refinement and testing, the model could be applied to other contexts to help provide a more rounded account of education and training in dementia care settings.

A self-management intervention for newly diagnosed with inflammatory arthritis: a randomized controlled feasibility and fidelity study

BACKGROUND

Inflammatory arthritis affects approximately 2-3% of adults worldwide. For patients newly diagnosed with arthritis, effective self-management is crucial, as they often face several physiological, emotional, and social challenges. A self-management intervention called NISMA was thus developed to cater to this group. This study aimed to evaluate the feasibility and fidelity of this intervention before conducting a full-scale randomized controlled trial.

METHODS

This feasibility study was conducted as a single-center randomized controlled trial. Twenty participants were expected to be sufficient for assessing the feasibility outcomes. The control group received only the usual care, while the intervention group received the NISMA intervention in addition, which involved individual and group sessions in a multidisciplinary setting. Feasibility was evaluated based on the recruitment, data collection, retention, and randomization processes. The patient-reported outcome measures and clinical measures were collected to review their potential for inclusion in a future randomized controlled trial. Fidelity was assessed by using documentation sheets filled in by the health professionals and audio recordings of the sessions to examine whether the intervention's principles and components were adequately addressed.

RESULTS

Among 47 eligible patients, we recruited 23 participants during a period of 4 months. The recruitment rate was 47% and the retention rate 91%. Randomization, although accepted, led to some disappointment in the control group. Data collection was effective, with only minimal missing data (< 1%). The fidelity was considered as high, as results indicated that nurses effectively engaged in collaborative partnerships with patients, utilizing planned questioning techniques and self-management strategies for problem-solving and resource utilization. However, action planning was inconsistently applied.

CONCLUSION

The study demonstrated the feasibility and the overall high fidelity of delivering the NISMA intervention to patients newly diagnosed with inflammatory arthritis. The insights from the study are useful for identifying the areas that require modifications before initiating a randomized controlled trial.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT06063252. Registered 02 October 2023 - retrospectively registered.

The pre-exposure prophylaxis personal obstacle scale: measurement properties in English, German, and French

BACKGROUND

This study aimed to validate the Pre-Exposure Prophylaxis Personal Obstacle Scale (PPOS) across English, German, and French (PPOS-EN/DE/FR) for men who have sex with men (MSM). The PPOS measures perceived barriers related to knowledge and uncertainty surrounding PrEP use, which are particularly important factors in the early stages of the PrEP Care Continuum (PCC).

METHODS

The original PPOS was adapted and translated into German and French. Data were collected through an online survey in four European countries (N = 1124). Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) assessed the factor structure, while multigroup CFA (MGCFA) tested measurement invariance across language groups and adoption statuses.

RESULTS

EFA revealed a two-factor structure: (i) "Impact of PrEP on personal health" and (ii) "Knowledge about PrEP." CFA confirmed this structure, and measurement invariance was established across languages and adoption statuses with high reliability (α = 0·82, ω = 0·82).

CONCLUSIONS

The PPOS-EN/DE/FR is a valid and reliable tool for assessing personal obstacles to PrEP uptake among MSM across different languages. It supports public health efforts by identifying specific challenges to PrEP adoption, facilitating culturally sensitive interventions to improve uptake and reduce HIV transmission.

An App-Based Intervention With Behavioral Support to Promote Brisk Walking in People Diagnosed With Breast, Prostate, or Colorectal Cancer (APPROACH): Process Evaluation Study

BACKGROUND

The APPROACH pilot study explored the feasibility and acceptability of an app (NHS Active 10) with brief, habit-based, behavioral support calls and print materials intended to increase brisk walking in people diagnosed with cancer.

OBJECTIVE

Following UK Medical Research Council guidelines, this study assessed the implementation of the intervention, examined the mechanisms of impact, and identified contextual factors influencing engagement.

METHODS

Adults (aged ≥18 y) with breast, prostate, or colorectal cancer who reported not meeting the UK guidelines for moderate-to-vigorous physical activity (≥150 min/wk) were recruited from a single hospital site in Yorkshire, United Kingdom. They were randomly assigned to the intervention or control (usual care) arm and assessed via quantitative surveys at baseline (time point 0 [T0]) and 3-month follow-up (time point 1 [T1]) and qualitative exit interviews (36/44, 82%) at T1. The process evaluation included intervention participants only (n=44). Implementation was assessed using data from the T1 questionnaire exploring the use of the intervention components. The perceived usefulness of the app, leaflet, and behavioral support call was rated from 0 to 5. Behavioral support calls were recorded, and the fidelity of delivery of 25 planned behavior change techniques was rated from 0 to 5 using an adapted Dreyfus scale. Mechanisms of impact were identified by examining T0 and T1 scores on the Self-Reported Behavioural Automaticity Index and feedback on the leaflet, app, call, and planner in the T1 questionnaire and qualitative interviews. Contextual factors influencing engagement were identified through qualitative interviews.

RESULTS

The implementation of the intervention was successful: 98% (43/44) of the participants received a behavioral support call, 78% (32/41) reported reading the leaflet, 95% (39/41) reported downloading the app, and 83% (34/41) reported using the planners. The mean perceived usefulness of the app was 4.3 (SD 0.8) in participants still using the app at T1 (n=33). Participants rated the leaflet (mean 3.9, SD 0.6) and the behavioral support call (mean 4.1, SD 1) as useful. The intended behavior change techniques in the behavioral support calls were proficiently delivered (overall mean 4.2, SD 1.2). Mechanisms of impact included habit formation, behavioral monitoring, and support and reassurance from the intervention facilitator. Contextual factors impacting engagement included barriers, such as the impact of cancer and its treatment, and facilitators, such as social support.

CONCLUSIONS

The APPROACH intervention was successfully implemented and shows promise for increasing brisk walking, potentially through promoting habit formation and enabling self-monitoring. Contextual factors will be important to consider when interpreting outcomes in the larger APPROACH randomized controlled trial.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s40814-022-01028-w.

Keeping Active with Texting after Stroke (KATS): a single-arm feasibility and acceptability study of a behavioural intervention to promote community-based physical activity after stroke rehabilitation

OBJECTIVES

To test the feasibility and acceptability of a text-message-delivered behavioural intervention to promote and maintain physical activity and recovery after stroke rehabilitation.

DESIGN

A single-arm acceptability and feasibility study.

SETTING

Community rehabilitation services in two Health Board areas in Scotland.

PARTICIPANTS

People with stroke who could participate in physical activities and use a mobile phone were recruited during rehabilitation and community rehabilitation.

INTERVENTION

Keeping Active with Texting after Stroke (KATS) is an automated text message-delivered intervention informed by behaviour change theory. It delivers a structured sequence of 103 messages over 14 weeks to support the uptake and maintenance of physical activities following stroke rehabilitation.

OUTCOMES

Data on recruitment, retention and satisfaction were collected. Semistructured interviews explored intervention acceptability. Preintervention and postintervention measures provided preliminary information on step count, functional independence, mental well-being, self-efficacy and quality of life.

RESULTS

18 men and 13 women were recruited; three withdrew before intervention commencement. All 28 participants who received at least one text message completed the study, indicating 100% retention. Median satisfaction score was 23/25 (range 12-25). All but one participant read and responded to texts, indicating good engagement. Effect sizes (Cohen's d; per cent change) were demonstrated in step count (0.2; 13%), extended activities of daily living (0.24; 8.3%) and mental well-being (0.35; 7%). Participants perceived KATS as acceptable, valuing messages and motivational prompts, but personalised tailoring was desired by some.

CONCLUSIONS

Recruitment, retention and outcome measure completion were feasible, and KATS was perceived as acceptable. Findings suggest some modifications of messages and goal-setting processes are required to accommodate participants with diverse physical activity capabilities before a definitive trial. Promising indicators of effects were detected, although interpretation must be cautious because the study was not powered to determine efficacy, and there was no control group. Based on these findings, KATS will be further optimised before evaluating effectiveness in a randomised controlled trial.

TRIAL REGISTRATION NUMBER AND PROTOCOL AVAILABILITY

ISRCTN 13704805 https://www.hra.nhs.uk/planning-and-improving-research/application-summaries/research-summaries/keeping-active-with-texting-after-stroke-kats/Protocol available https://www.isrctn.com/ISRCTN13704805?q=13704805&filters=&sort=&offset=1&totalResults=1&page=1&pageSize=10.

Mindfulness-based (non-contact) boxing therapy (MBBT) for depression and anxiety: A feasibility study

OBJECTIVES

Mindfulness-Based (non-contact) Boxing Therapy (MBBT) is a novel intervention designed to empower and promote self-agency through behavioral interventions, while reducing barriers to exercise for individuals with mental disorders. MBBT is an instructor-led, manualized, non-contact boxing group-exercise program (delivered in 90 min sessions, twice a week, over 10 weeks) that blends principles of mindfulness, meditation and group therapy. The current study tested the acceptability and feasibility of delivering MBBT to adults with major depressive disorder (MDD) or generalized anxiety disorder (GAD).

METHODS

Nine adult outpatients with MDD or GAD were recruited from a psychiatric outpatient clinic in Toronto, Canada in a 10-week feasibility trial of MBBT using a pre-post design. Feasibility was assessed through recruitment and retention rates, while acceptability was assessed through the CSQ-8, and self-questionnaires. Secondary clinical outcomes included the PHQ-9, GAD-7, K10, CGI, and MAAS. Trial registry: ISRCTN23023309.

RESULTS

Eight participants (5 female, 3 male) were included in the final analysis. Results indicated a high user retention (89%), attendance (84%), and satisfaction (98%). The study observed a statistically significant mean percent reduction in depression (54%), anxiety (51%) and distress (36%), alongside a mean percent increase in mindfulness (79%). Post intervention qualitative feedback from participants revealed themes of inclusivity and accessibility, cathartic release and control of emotions, improved self-esteem and confidence, self-agency, community, and trust in leadership.

CONCLUSIONS

Given the limitation of the study, MBBT appeared to be feasible and acceptable as an exercise/behavioural intervention. Further well-designed randomized clinical trials are warranted to confirm the clinical benefits of MBBT.

Process evaluation of Project Daire: a food environment intervention that impacted food knowledge, wellbeing and dietary habits of primary school children

BACKGROUND

Project DAIRE was a randomised-controlled, factorial design trial which aimed to improve children's health-related quality of life, wellbeing, food knowledge and dietary habits via two multi-component interventions: Nourish and Engage. Nourish was an intervention aiming to alter the school food environment, provide food-based experiences and expose pupils to locally produced foods. Engage was an age-appropriate cross-curricular food education intervention incorporating food, agriculture, nutrition science and related careers. The purpose of this study was to conduct a process evaluation to evaluate DAIRE implementation, mechanisms of impact (MOI) and context to elucidate trial results, and inform scalable implementation of the DAIRE approach for successful future rollout.

METHODS

The Medical Research Council's (MRC) framework for process evaluation was followed. Formal (questionnaires designed for process evaluation) and informal (researcher records and communications) methods were used to collect quantitative and qualitative data during the DAIRE trial in relation to process evaluation. Quantitative data were analysed using descriptive statistics and qualitative data via thematic analysis to identify key themes.

RESULTS

Fifteen schools and 983 pupils (n = 495 6-7 year olds/Year 3 and n = 488 10-11 year olds/Year 7) were recruited for the 6-month DAIRE intervention; a 100% retention rate was observed at the school level and the interventions had a high level of pupil and teacher acceptability. Nourish schools delivered a higher mean dose of intervention elements (61.4%) than Engage (50%) schools but, overall, mixed implementation of both interventions occurred. DAIRE produced change through four key MOI: social learning, experimental learning, interactive engaging content and real-life connections. Lack of time was the main contextual barrier to implementation and lack of financial cost to schools indicated as a potential facilitator.

CONCLUSIONS

This process evaluation helped to identify important findings related to implementation, MOI and context. The most effective elements of the interventions which should be maintained include provision of interactive and engaging intervention elements at no financial cost to the school. Findings also identified suggestions for improvement including provision of increased teacher training, support and planning time, content reduction to facilitate easy integration, and implementation across the full academic year. A sustainable funding and resourcing mechanism is required for successful future roll-out across the UK and beyond.

TRIAL REGISTRATIONS

The original trial referenced in this process evaluation is registered as follows: National Institute of Health (NIH) U.S. National Library of Medicine Clinical Trials.gov (ID: NCT04277312; retrospectively registered 11th February 2020).

Co-designing the FOotpaths foR Adolescent MAternal Mental HeAlth (FOR MAMA) intervention for pregnant teens in Malawi

BACKGROUND

This study aimed to gain insights into stakeholders' priorities and preferences for a scalable intervention for common mental problems among perinatal adolescents in Malawi.

METHODS

Participatory stakeholder workshops (n=9) were conducted iteratively according to the principles of the Person-Based Approach. Three stakeholder groups were recruited from one urban and one rural primary health centre in Zomba district, Malawi: perinatal adolescents (n=10), their family members (n=8) and healthcare workers (n=10). Framework analysis was conducted using intervention descriptors from the Template for Intervention Description and Replication checklist.

RESULTS

Participants emphasized the need for information on causes and symptoms of common mental problems and for developing coping strategies: a) those focused on external stressors-problem-solving, financial literacy and interpersonal skills-and b) emotion-focused approach behaviours-behavioural activation, relaxation and anger management. There was a strong preference for healthcare workers as intervention providers. Participants agreed on a brief antenatal intervention delivered weekly using both group and individual formats. There were positive views on both self-help and guided formats. All stakeholder groups felt there was a need for follow-up to ensure that adolescents correctly engaged with the intervention material.

CONCLUSIONS

Findings informed the design of a brief multicomponent guided intervention for adolescents in the antenatal period.

Refining the Make My Day stroke prevention intervention for primary healthcare through co-creation with stakeholders

OBJECTIVES

To describe and explore the refinement of a stroke prevention intervention and conditions for implementation in primary healthcare by utilising co-creation with stakeholders.

METHOD

This was an iterative co-creation process of five collaborative workshops engaging stakeholders; healthcare professionals (HP), and persons at risk for stroke, who participated in or delivered a stroke prevention intervention in primary healthcare.

RESULTS

Through co-creation with stakeholders key components for revision were identified in the Make My Day intervention. The overall pedagogics, which was recognised as overarching, and three additional key components: the HP education, the intervention sessions, and the digital tool were identified. Moreover, the co-creation process rendered refinements of the prevention program addressing the key components representing stakeholder experiences. Refinements encompass delivering and receiving the Make My Day intervention, material ownership, and the interprofessional team.

CONCLUSIONS

The co-creation process revealed the importance of applying a strategic pedagogic approach in a complex intervention. The process underscored the need to augment a sense of material ownership and to improve interprofessional collaboration in primary healthcare, ultimately enhancing the intervention experience and facilitating the change process for individuals at risk of stroke. Utelising a co-creation process in this current intervention allowed for creation of refinements to the intervention optimising conditions for implementation.

Integrating Remote Monitoring Into the Pregnancy Care: Perspectives of Pregnant Women and Healthcare Professionals

Remote monitoring has been proposed to provide new opportunities to monitor pregnancy in the home environment and reduce the number of follow-up visits to the maternity clinic. Still, the integration of remote monitoring into the pregnancy care process has not been achieved. This descriptive qualitative study aimed to explore pregnant women's and healthcare professionals' perceptions of integrating remote monitoring into pregnancy monitoring process. A convenience sample of 10 pregnant women and 11 healthcare professionals participated in the focus group interviews. The data were analyzed with reflexive thematic analysis. The results comprised a four-step pregnancy monitoring process organizing the issues to consider when integrating remote monitoring into these steps. According to pregnant women and healthcare professionals, remote pregnancy monitoring should allow a holistic assessment to ensure the well-being of the pregnant woman and the fetus. Clear criteria for monitoring should guide the adaptation of monitoring to the identified monitoring needs. Ideally, remote monitoring could enable more personalized maternity care, supporting the monitoring-related decision-making of both pregnant women and healthcare professionals and facilitating the early detection of pregnancy complications. However, integration of remote monitoring would require significant restructuring of current pregnancy care processes.

Barriers and enablers to medicine-taking behaviours in chronic obstructive pulmonary disease: a qualitative interview study

BACKGROUND

Chronic Obstructive Pulmonary Disease (COPD) is associated with low health-related quality of life and high costs to healthcare systems, particularly due to hospital admissions and exacerbations. Medicines, inhalers especially, reduce the risk of hospitalisations and exacerbations, but factors influencing medicine-taking behaviours are not fully understood.

AIM

To explore experiences of people with COPD related to medicines, and followingly identify and characterise any barriers and enablers related to medicine-taking behaviours using the Theoretical Domains Framework (TDF).

METHOD

Semi-structured qualitative interviews were conducted and included ten people with COPD who had previously been admitted to hospital. Systematic text condensation was used inductively in the primary analysis of the interviews. In the secondary analysis, meaning units from the primary analysis were mapped to the TDF and summarised as barriers and enablers.

RESULTS

Five major themes were developed in the primary analysis: (1) health literacy and information needs, (2) patient autonomy, (3) lack of access to medicines, (4) lack of effect from medicines, and (5) experiences of medicines-related issues. In the secondary analysis, thirteen barriers and nine enablers were mapped to nine out of the fourteen domains of the TDF.

CONCLUSION

People with COPD experience challenges related to medicines which need to be addressed by researchers and healthcare providers. The identified barriers and enablers mapped to the TDF can guide and inform future design of interventions and health care services.

Prehabilitation in surgery - an update with a focus on nutrition

PURPOSE OF THE REVIEW

Since the introduction of the prehabilitation concept for optimizing functional capacity before surgery 20 years ago, evidence and interest has grown considerably. This review summarizes the recent evidence and proposes questions for prehabilitation with special regard to the nutritional component.

RECENT FINDINGS

Several meta-analyses of multimodal prehabilitation (exercise, nutrition, and psychological support) have been published recently. These reviews suggest that preoperative conditioning can improve functional capacity and reduce the complication rate for many patient groups (risk of bias: moderate to low). A prerequisite is the identification of high-risk patients using suitable screening and assessment tools. Additionally, there are currently no standardized, clear recommendations for the organization and implementation of prehabilitation programs. The programs vary greatly in duration, content, and outcome measurement. Although the preoperative nutrition interventions enhanced outcomes consistently, there was no clear evidence for which nutritional intervention should be applied to whom over consistent time frame four to six weeks (timeframe consistent with most prehabilitation programs).

SUMMARY

To advance our understanding of which prehabilitation interventions work best, how they work, and for whom they work best, additional low risk of bias and adequately powered trials are required. Nevertheless, our review presents evidence that prehabilitation should be offered before major surgery on a risk-stratified basis.

A qualitative study exploring depressed participants' experiences of receiving Augmented Depression Therapy (ADepT)

OBJECTIVES

The current study aimed to explore participants' views on the acceptability, impact and mechanisms of change of Augmented Depression Therapy (ADepT), a novel wellbeing-focused and recovery-oriented psychological therapy for depression.

DESIGN

A semi-structured qualitative interview design was used, with data analysed using the framework approach.

PARTICIPANTS

20 participants with anhedonic depression who had received up to 20 sessions of ADepT, sampled from a pilot randomised controlled trial of ADepT versus Cognitive Behavioural Therapy (CBT).

SETTING

A primary care psychological therapy clinic in Devon, UK, with interviews occurring between May 2018 and February 2020.

RESULTS

Participants found the wellbeing focus of ADepT acceptable. Helpful aspects of therapy were a positive therapeutic bond, the structure and flow of therapy scaffolding the learning journey, the tools and techniques of therapy helping building wellbeing and booster sessions supporting long-term recovery. Negative aspects for some participants were therapy feeling too intense and triggering feelings of failure. Participants reported significant positive impacts of treatment on wellbeing, functioning and hope. Perceived mechanisms of change were reorienting to the positive, engaging with valued goals, taking a proactive life stance, gaining confidence and motivation for change, breaking down tasks into small steps, cultivating self-care and self-compassion, enhancing help seeking and interpersonal effectiveness, changing the relationship to depression, and rediscovering the self beyond depression.

CONCLUSIONS

Findings suggest that the wellbeing focus of ADepT is acceptable and leads to positive impacts, supports the logic model underpinning the intervention, and warrants continuation to a definitive trial.

TRIAL REGISTRATION NUMBER

ISRCTN85278228.

Bridging inequity gaps in healthcare through tailored support: implementation perspectives of the Social Health Bridge-Building Programme

BACKGROUND

Equity in access to and outcomes from healthcare is a fundamental pillar of universal healthcare systems. However, these systems have not eliminated social inequities in health. Significant socio-economic disparities persist in access to and utilisation of healthcare services, as well as in the quality and outcomes of care. The Social Health Bridge-Building Programme aims to enhance health equity by addressing multi-level barriers to healthcare. In this programme, healthcare student volunteers accompany individuals in a socially vulnerable situation to healthcare appointments, providing support before, during, and after these encounters. This reciprocal arrangement not only enhances the healthcare experience for the individuals involved but also offers student volunteers unique insights into the social determinants of health while fostering the development of essential communication skills. This study explores implementation perspectives of the programme, focusing on those accompanied to appointments.

METHODS

Individuals accompanied to a healthcare appointment from August 2021 to June 2022 were asked to complete a web-based questionnaire covering socio-demographics, health literacy, physical and mental health, and satisfaction with the support provided. The frequency of accompaniments over six months were collected through telephone calls.

RESULTS

A total of 187 users of the programme responded. The Individuals were characterised by short educational attainment, limited social support, unemployment, as well as poor physical and mental health. The majority reported difficulties comprehending health information and engaging with healthcare professionals. Forty percent of the accompaniments were to hospital visits and 23% to GP consultations, with most requesting multiple types of support such as emotional, transportation, communication, and way-finding. Most users (96%) reported that the student-volunteer accommodated their need for support. The additional number of accompaniments over six months ranged from 0 to 21.

CONCLUSIONS

The programme is successfully implemented for individuals in a socially vulnerable situation and succeeded in the delivery of a tailored programme that adresses the individuals' specific needs and request. High satisfaction rates and the positive impact on healthcare experiences highlight the programme's potential to bridge existing inequity gaps in healthcare.

The Optimal Physical Recovery After Hospitalization (OPRAH) intervention to improve physical activity and protein intake after oncological surgery: a feasibility study

PURPOSE

(1) To assess the feasibility of a blended intervention, combining a smartphone app for self-monitoring of physical activity and protein intake with coaching from a physiotherapist and dietician after hospitalization and (2) to evaluate the associated study procedures.

METHODS

A single-arm feasibility study was performed with adult patients scheduled for curative intent gastrointestinal or lung cancer surgery. Patients were provided with a smartphone app and accelerometer one week before surgery, which they used for six weeks following discharge. In addition, patients received coaching from a physiotherapist and dietician. Feasibility was assessed by evaluating participation and completion rates, user adherence, system usability score (SUS), as well as experiences and safety, based on predefined criteria.

RESULTS

In total, 32 patients were included, with participation and completion rates of 69 and 75%, respectively. User adherence to wearing the accelerometer was deemed satisfactory (91%), while user adherence to protein intake was suboptimal (59%). The mean SUS was acceptable (73.5). Patient experiences were predominantly positive, although some patients mentioned a lack of options in the protein registration tool.

CONCLUSION

The intervention is feasible for implementation in a larger study. To improve adherence, modifications are needed regarding self-recording of protein intake. Study procedures require minor modifications.

Adolescent girls' explanations of high rates of low mood and anxiety in their population: a co-produced qualitative study

BACKGROUND

From early adolescence, girls face greater risk of experiencing low mood and anxiety relative to boys, with recent evidence that this may be worsening. There is a paucity of mental health research that meaningfully progresses understanding of these gender disparities, including that engages adolescent girls' own perspectives, limiting our ability to direct further research and enhance intervention approaches.

AIMS

We examined low mood and anxiety from the perspective of adolescent girls, asking: What do adolescent girls perceive to be causing their population's high rates of low mood and anxiety?

METHODS

We adopted a co-produced qualitative design, guided by ecological systems theory, conducting focus groups in 2022 with 32 adolescent girls aged 16 to 18 years in England. Data were analysed using reflexive thematic analysis.

ANALYSIS

Participants framed low mood and anxiety among adolescent girls as "normal", and discussed potential explanations including persistent reiteration and expectation of gendered norms, intense educational pressures in ways that can be gendered, difficulties within peer relationships, and comparison and insecurity in social media contexts. Throughout, participants highlighted how complex these issues are, including nuances around individual differences, sociodemographic contexts, and societal contexts.

CONCLUSIONS

The study offers a critically important contribution to evidence on gendered inequalities in low mood and anxiety, drawing attention to the interwoven and complex nature of girls' lives and illuminating various aspects that would benefit from greater research. The insights gained through exploration with girls themselves hold policy and practical relevance to enhance systems to meet girls' needs.

Timely short-term specialised palliative home care for older people with frailty and their family: a mixed-methods pilot randomised controlled trial and process evaluation

OBJECTIVE

The primary study aims were to evaluate the implementation, mechanisms and context of a timely short-term specialised palliative care intervention for older people with frailty (Frailty+ intervention) as well as to assess the feasibility of a randomised controlled trial to evaluate Frailty+. Our secondary aim was to describe any preliminary effects of Frailty+.

DESIGN

Pilot randomised controlled trial with process evaluation.

SETTING/PARTICIPANTS

We aimed to recruit 50 adults (≥70 years) with Clinical Frailty Scale score 5-7, and complex care needs and their main family carer, if available, from two Belgian hospitals on discharge.

INTERVENTIONS

Patients were randomised to the Frailty+ intervention alongside standard care or standard care alone.

OUTCOME MEASURES

Implementation and trial feasibility were assessed through interviews, focus groups and quantitative data. The primary outcome to be used in a potential full-scale trial if the study is feasible and implementable was mean change in five palliative care symptoms over 8 weeks.

RESULTS

We enrolled 37 patients (19 intervention, 18 control) and 26 family carers (15 intervention, 11 control). Patients and family carers valued the home visits from palliative care nurses, and nurses saw value in Frailty+. But most patients received only one visit over 8 weeks, and nurses did not organise foreseen multidisciplinary meetings, referring to absence of urgent needs. Many aspects of the trial methods were feasible, but recruitment was challenging. The baseline mean score on the five palliative care symptoms was 6.0 and 5.6 in intervention and control group, respectively; and 4.5 and 4.1 at 8 weeks (adjusted ratio 1.0, ie, no effects on symptoms).

CONCLUSIONS

While Frailty+ was generally welcomed by older people with frailty, families and palliative care nurses, our process evaluation uncovered multiple barriers, mostly rooted in the current organisation of specialised palliative care that is tailored to advanced stages of illness. Ensuring timely access requires efforts beyond timely referral alone, and implies profound organisational and cultural change.

TRIAL REGISTRATION NUMBER

ISRCTN39282347.

A Bibliometric Analysis of Healthcare Intervention-Related Studies Reporting Patient and Public Involvement and Engagement

BACKGROUND/OBJECTIVES

Patient and public involvement and engagement (PPIE) has gained global recognition as an innovative healthcare research practice. PPIE engages end-users throughout the research process, improving intervention effectiveness, resource efficiency, and user satisfaction. Despite its increasing inclusion in studies, comprehensive bibliometric reviews of healthcare intervention-related studies reporting PPIE are scarce. This study aims to conduct a bibliometric analysis of healthcare intervention-related studies reporting PPIE in recent decades to identify key worldwide bibliometric features, themes, and trends.

METHODS

The analysis includes 10,624 relevant English articles published in the Web of Science (WoS) Core Collection up to 26 November 2024. Search terms were selected based on PPIE conceptualization, interventional types, and related healthcare terms. Using WoS descriptive analysis and CiteSpace, we examined bibliometric features and identified major international themes and trends.

RESULTS

There has been a significant increase in the number of healthcare intervention-related studies reporting PPIE over the past five years, especially from the United States and the United Kingdom, with a recent rise in Asia. However, cross-national collaboration remains limited. Key research themes identified include "community participation", "health equity", "coronary heart disease", "web-based patient empowerment", "mental illness", and "obesity prevention", with growing interest in "mobile health" and "digital health".

CONCLUSIONS

This study provides a comprehensive and up-to-date overview of the bibliometric characteristics and evolving trends in healthcare intervention-related studies reporting PPIE. It highlights global regions with limited PPIE implementation, suggests pathways for further development, and identifies key research themes. The study offers researchers and practitioners valuable insights into tracking PPIE trends in healthcare interventions and fostering collaborations on evidence-based PPIE studies with leading scholars and institutions worldwide. Additionally, the findings drive innovations aimed at improving patient and public healthcare outcomes.

Exploring how PRIME-Parkinson care is implemented and whether, how and why it produces change, for who and under what conditions: a protocol for an embedded process evaluation within the PRIME-UK randomised controlled trial

INTRODUCTION

The PRIME-UK randomised controlled trial (RCT) aims to establish whether a model of care that seeks to be proactive, integrated and empower participants, caregivers and healthcare professionals can improve outcomes in people with parkinsonism. Given that this intervention is novel and complex, understanding whether and how the intervention will be acceptable, implementable, cost-effective and scalable across contexts are key questions beyond that of whether 'it works'. We describe an embedded process evaluation to answer these questions, which aims to support interpretation of the trial results, refinement of the intervention and support future scaling of the PRIME-Parkinson model of care.

METHODS AND ANALYSIS

A mixed-methods approach will be used to collect data across four process evaluation domains: implementation, mechanism of change, acceptability and context. Quantitative data will be collected prospectively from all participants and analysed descriptively with exploratory tests of relationships as power allows. Qualitative data will be collected through semistructured interviews with a purposively sampled subpopulation of participants, caregivers and staff members as well as case studies where relevant. Interview transcripts will be analysed thematically using interpretive qualitative analysis. Synthesis of quantitative and qualitative data will also be performed to draw conclusions.

ETHICS AND DISSEMINATION

The quantitative data will be collected as part of the main PRIME-UK RCT which was been granted NHS REC approval (21/LO/0387) on 27 July 2021. The qualitative data will be collected as part of a substudy, 'PRIME-Qual', which was granted NHS REC approval (21/LO/0388) on 14 July 2021. The mixed-methods process evaluation will be published after the conclusion of the trial in addition to the main trial findings.

TRIAL REGISTRATION NUMBER

NCT05127057.

Failed implementation of a nursing intervention to support family caregivers: An evaluation study using Normalization Process Theory

AIM

To evaluate the failed implementation of the Carer Support Needs Assessment Tool Intervention for family caregivers in end-of-life care, within a trial context using Normalization Process Theory (NPT).

DESIGN

An evaluation study was conducted to learn lessons from our trial, which was not successful due to the low number of participants. The evaluation study utilized various data sources, including published data from interviews and questionnaires, and unpublished data derived from emails and conversation notes.

METHODS

Data were retrospectively collected. Thematic analysis was conducted guided by the NPT framework. This framework emphasizes that successful implementation of an intervention relies on its 'normalization', consisting of four constructs: coherence, cognitive participation, collective action and reflexive monitoring.

RESULTS

Coherence (sense making): Nurses felt the intervention could contribute to their competence in assessing family caregivers' needs, but some were unsure how it differed from usual practice. Cognitive participation (relational work): Nurse champions played a crucial role in building a community of practice. However, sustaining this community was challenging due to staff turnover and shortages. Collective action (work done to enable the intervention): Nurses felt the Carer Support Needs Assessment Tool training enabled them to improve their support of family caregivers. However, contextual factors complicated implementation, such as being used to a patient rather than a family-focused approach and a high workload. Reflexive monitoring (appraisal of the intervention): Positive experiences of the nurses with the intervention motivated them to implement it. However, the research context made nurses hesitant to recruit family caregivers because of the potential burden of participation.

CONCLUSION

Although the intervention demonstrated potential to assist nurses in providing tailored support to family caregivers, its integration into daily practice was not optimal. Contextual factors, such as a patient-focused approach to care and the research context, hampered normalization of the intervention.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Assessing and considering contextual factors that may influence implementation of a complex care intervention is needed. The NPT provided a valuable framework for evaluating the implementation process in our study.

IMPACT

What problem did the study address? This evaluation study analysed the factors that promoted or hindered the implementation of a nursing intervention to support family caregivers in end-of-life care. What were the main findings? Both the intervention and the intervention training have potential and value for nurses in providing tailored support to family caregivers. However, the implementation faced challenges due to organizational factors and the research context, including recruitment. Where and on whom will the research have an impact? This insight is valuable for all stakeholders involved in implementing complex nursing interventions, including researchers, nurses and funders.

REPORTING METHOD

This study has adhered to the relevant EQUATOR guidelines: Standards for Reporting Qualitative Research (SRQR).

PATIENT OR PUBLIC CONTRIBUTION

There was no patient or public involved.

TRIAL REGISTRATION

The trial was prospectively registered on the Dutch Trial Register (NL7702).