When and how do 'effective' interventions need to be adapted and/or re-evaluated in new contexts? The need for guidance

Process Evaluation and Investigation of Cultural Adaptations for an Online Parent-Based Intervention Using a Mixed-Method Approach

Most alcohol intervention research focuses on program efficacy, yet few studies have investigated the acceptability of a program's design and implementation to the target population or adapting existing alcohol interventions to different populations. To address these gaps in the literature, we (1) examined participant responsiveness to and implementation quality of FITSTART+, a web-app delivered parent-based alcohol intervention designed for incoming first-year college students in the United States, and (2) gathered feedback on how this intervention could be adapted to other populations of parents. A sample of U.S. parents of 17-20-year-old first-year college students (N = 109) participated in FITSTART+ during their child's first year of college and completed a survey about parents' responsiveness to the app and its quality. Next, a sample of non-U.S. parents of adolescents aged 13 to 19 (N = 44) participated in one of 11 focus groups in which they briefly explored the app and then discussed how it could be adapted to be applicable and culturally relevant for them and their context. Results revealed that U.S. parents rated the intervention's quality as high and parents were responsive to the web-app's content, but some did not visit one of the most critical aspects of the intervention (i.e., alcohol-related parenting resources). Non-U.S. participants provided a range of suggestions for adapting the intervention to their context, which varied by culture. Results identify areas for improvement, particularly regarding the use of alcohol-related parenting resources, in this intervention and for web-delivered PBIs more broadly.

The Logic of Generalization From Systematic Reviews and Meta-Analyses of Impact Evaluations

Systematic reviews and meta-analyses are viewed as potent tools for generalized causal inference. These reviews are routinely used to inform decision makers about expected effects of interventions. However, the logic of generalization from research reviews to diverse policy and practice contexts is not well developed. Building on sampling theory, concerns about epistemic uncertainty, and principles of generalized causal inference, this article presents a pragmatic approach to generalizability assessment for use with systematic reviews and meta-analyses. This approach is applied to two systematic reviews and meta-analyses of effects of "evidence-based" psychosocial interventions for youth and families. Evaluations included in systematic reviews are not necessarily representative of populations and treatments of interest. Generalizability of results is limited by high risks of bias, uncertain estimates, and insufficient descriptive data from impact evaluations. Systematic reviews and meta-analyses can be used to test generalizability claims, explore heterogeneity, and identify potential moderators of effects. These reviews can also produce pooled estimates that are not representative of any larger sets of studies, programs, or people. Further work is needed to improve the conduct and reporting of impact evaluations and systematic reviews, and to develop practical approaches to generalizability assessment and guide applications of interventions in diverse policy and practice contexts.

Empowering School Staff to Support Pupil Mental Health Through a Brief, Interactive Web-Based Training Program: Mixed Methods Study

BACKGROUND

Schools in the United Kingdom and elsewhere are expected to protect and promote pupil mental health. However, many school staff members do not feel confident in identifying and responding to pupil mental health difficulties and report wanting additional training in this area.

OBJECTIVE

We aimed to explore the feasibility of Kognito's At-Risk for Elementary School Educators, a brief, interactive web-based training program that uses a simulation-based approach to improve school staff's knowledge and skills in supporting pupil mental health.

METHODS

We conducted a mixed methods, nonrandomized feasibility study of At-Risk for Elementary School Educators in 6 UK primary schools. Our outcomes were (1) school staff's self-efficacy and preparedness to identify and respond to pupil mental health difficulties, (2) school staff's identification of mental health difficulties and increased risk of mental health difficulties, (3) mental health support for identified pupils (including conversations about concerns, documentation of concerns, in-class and in-school support, and referral and access to specialist mental health services), and (4) the acceptability and practicality of the training. We assessed these outcomes using a series of questionnaires completed at baseline (T1), 1 week after the training (T2), and 3 months after the training (T3), as well as semistructured qualitative interviews. Following guidance for feasibility studies, we assessed quantitative outcomes across time points by comparing medians and IQRs and analyzed qualitative data using reflexive thematic analysis.

RESULTS

A total of 108 teachers and teaching assistants (TAs) completed T1 questionnaires, 89 (82.4%) completed T2 questionnaires, and 70 (64.8%) completed T3 questionnaires; 54 (50%) completed all 3. Eight school staff members, including teachers, TAs, mental health leads, and senior leaders, participated in the interviews. School staff reported greater confidence and preparedness in identifying and responding to mental health difficulties after completing the training. The proportion of pupils whom they identified as having mental health difficulties or increased risk declined slightly over time (medianT1=10%; medianT2=10%; medianT3=7.4%), but findings suggested a slight increase in accuracy compared with a validated screening measure (the Strengths and Difficulties Questionnaire). In-school mental health support outcomes for identified pupils improved after the training, with increases in formal documentation and communication of concerns as well as provision of in-class and in-school support. Referrals and access to external mental health services remained constant. The qualitative findings indicated that school staff perceived the training as useful, practical, and acceptable.

CONCLUSIONS

The findings suggest that brief, interactive web-based training programs such as At-Risk for Elementary School Educators are a feasible means to improve the identification of and response to mental health difficulties in UK primary schools. Such training may help address the high prevalence of mental health difficulties in this age group by helping facilitate access to care and support.

Effectiveness of Linkage to Care and Prevention Interventions Following HIV Self-Testing: A Global Systematic Review and Meta-analysis

Over 38.4 million people were living with HIV globally in 2021. The HIV continuum includes HIV testing, diagnosis, linkage to combined antiretroviral therapy (cART), and retention in care. An important innovation in the HIV care continuum is HIV self-testing. There is a paucity of evidence regarding the effectiveness of interventions aimed at linking self-testers to care and prevention, including pre-exposure prophylaxis (PrEP). To bridge this gap, we carried out a global systematic review and meta-analysis to ascertain the effectiveness of interventions post-HIV self-testing regarding: (1) linkage to care or ART, (2) linkage to PrEP, and (3) the impact of HIV self-test (HIVST) interventions on sexual behaviors. We searched PubMed, Web of Science, SCOPUS, Cochrane Library, CINAHL Plus (EBSCO), MEDLINE (Ovid), Google Scholar, and ResearchGate. We included only published randomized controlled trials (RCTs) and quasi-experiment that compared HIVST to the standard of care (SoC). Studies with sufficient data were aggregated using meta-analysis on RevMan 5.4 at a 95% confidence interval. Cochrane's Q test was used to assess heterogeneity between the studies, while Higgins and Thompson's I2 was used to quantify heterogeneity. Subgroup analyses were conducted to identify the source of heterogeneity. Of the 2669 articles obtained from the databases, only 15 studies were eligible for this review, and eight were included in the final meta-analysis. Overall, linkage to care was similar between the HIVST arm and SoC (effect size: 0.92 [0.45-1.86]; I2: 51%; p: 0.04). In the population subgroup analysis, female sex workers (FSWs) in the HIVST arm were significantly linked to care compared to the SoC arm (effect size: 0.53 [0.30-0.94]; I2: 0%; p: 0.41). HIVST interventions did not significantly improve ART initiation in the HIVST arm compared to the SoC arm (effect size: 0.90 [0.45-1.79]; I2: 74%; p: < 0.001). We found that more male partners of women living with HIV in the SoC arm initiated PrEP compared to partners in the HIVST arm. The meta-analysis showed no difference between the HIVST and SoC arm regarding the number of clients (effect size: - 0.66 [1.35-0.02]; I2: 64%; p: 0.09) and non-clients FSWs see per night (effect size: - 1.45 [- 1.45 to 1.38]; I2: 93%; p: < 0.001). HIVST did not reduce the use of condoms during insertive or receptive condomless anal intercourse among MSM. HIVST does not improve linkage to care in the general population but does among FSWs. HIVST intervention does not improve linkage to ART nor significantly stimulate healthy sexual behaviors among priority groups. The only RCT that linked HIVST to PrEP found that PrEP uptake was higher among partners of women living with HIV in the SoC arm than in the HIVST arm. More RCTs among priority groups are needed, and the influence of HIVST on PrEP uptake should be further investigated.

Implementing interventions to start HPV vaccination at age 9: Using the evidence we have

Human papillomavirus (HPV) vaccination is routinely recommended for adolescents aged 11 or 12 years but can begin at age 9. On-time HPV vaccination by the thirteenth birthday has proven to be effective in preventing HPV cancer and pre-cancer. However, HPV coverage rates continue to lag behind other routinely recommended vaccinations for adolescents. A promising approach to improving coverage is to start HPV vaccination at age 9. This approach has been endorsed by the American Academy of Pediatrics and the American Cancer Society. Benefits of this approach include increased time to complete vaccination series by the thirteenth birthday, additional spacing of recommended vaccines, and a more concentrated focus on cancer prevention messaging. While promising, little is known about how and if existing evidence-based interventions and approaches can be used to promote starting HPV vaccination at age 9. Implementation science frameworks offer scientific direction in how to adapt current and develop new interventions to promote starting HPV vaccination at age 9 and accelerate dissemination and prevent HPV cancers.

Characteristics and Components of Self-Management Interventions for Improving Quality of Life in Cancer Survivors: A Systematic Review

Self-management can improve clinical and psychosocial outcomes in cancer survivors. Which intervention characteristics and components are beneficial is unclear, hindering implementation into practice. We systematically searched six databases from inception to 17 November 2021 for studies evaluating self-management interventions for adult cancer survivors post-treatment. Independent reviewers screened for eligibility. Data extraction included population and study characteristics, intervention characteristics (TIDieR) and components (PRISMS), (associations with) quality of life (QoL), self-efficacy, and economic outcomes. Study quality was appraised, and narrative synthesis was conducted. We identified 53 papers reporting 32 interventions. Studies had varying quality. They were most often randomised controlled trials (n = 20), targeted at survivors of breast (n = 10), prostate (n = 7), or mixed cancers (n = 11). Intervention characteristics (e.g., provider, location) varied considerably. On average, five (range 1-10) self-management components were delivered, mostly "Information about condition and its management" (n = 26). Twenty-two studies reported significant QoL improvements (6 also reported significant self-efficacy improvements); these were associated most consistently with combined individual and group delivery. Economic evaluations were limited and inconclusive. Self-management interventions showed promise for improving QoL, but study quality was variable, with substantial heterogeneity in intervention characteristics and components. By identifying what to adapt from existing interventions, these findings can inform development and implementation of self-management interventions in cancer.

Transporting an Evidence-based Youth Development Program to a New Country: A Narrative Description and Analysis of Pre-implementation Adaptation

There is a pressing need to prevent and address youth crime and violence owing to its prevalence, harms and cost to society. Interventions with proven effectiveness in doing this exist. Adopting and adapting them in new contexts is potentially cost-effective. However, more research is needed into how to make adaptations that enhance intervention implementation, effectiveness and maintenance in new settings. This article reports the pre-implementation adaptation work involved in transporting Becoming a Man (BAM) from the US to the UK. BAM is a selective school-based youth development program for 12-18 year-old boys that aims to improve school engagement and reduce interactions with the criminal justice system. We describe the nature of and rationale for adaptations and identify learning for future adaptation efforts. An adaptation team comprising the intervention developers, new providers and the evaluators met weekly for 10 weeks, applying a structured, pragmatic and evidence-informed approach to adapt the BAM curriculum and implementation process. Changes were informed by documentary analysis, group-based discussions and site visits. The group agreed 27 changes to the content of 17/30 lessons, at both surface (e.g., cultural references) and deep (key mechanisms or concepts) levels. Of 28 contextual factors considered, 15 discrepancies between the US and UK were identified and resolved (e.g., differences in staffing arrangements). Strengths of the process were the blend of expertise on the adaptation team in the program and local context, and constant reference to and ongoing refinement of the program theory of change. Limitations included the lack of involvement of school staff or students. Further research is needed into potential conflicts between stakeholder perspectives during adaptation and whose views to prioritise and when.

Reciprocal coproduction as a basis for the diffusion of global health innovations

Global health reciprocal innovations originate in low-income and middle-income countries as well as high-income countries before their developers communicate about them with potential adopters in other countries as a transnational team. While communication technology has enabled a more rapid and broader sharing of information about innovations to prevent disease and improve health, innovations of various types have spread among countries, at all levels of income, for many centuries. In this article, we introduce the idea of reciprocal coproduction as a basis for the international sharing of information about innovations that exhibit potential for improving global health. Reciprocal coproduction occurs through two relational team-based processes: developer-led reinvention of an innovation so that it retains its desirable causal effects and implementer-led adaptation of that innovation so that it is compatible with new contexts into which it is introduced. Drawing on research and our own experiences across a range of health issues, we discuss common barriers to reciprocal coproduction and the diffusion of reciprocal innovations. We conclude with lessons drawn from dissemination and implementation science about the effective translation of reciprocal innovations from country to country so that researchers, policy-makers and social entrepreneurs can best ensure equity, accelerate adoptions and heighten the likelihood that global health reciprocal innovations will make a positive difference in health.

'A Different Ball Game': Adaptation of a men's health program for implementation in rural Australia

BACKGROUND

Men residing in rural areas are less likely to participate in weight management interventions than women, and few men-specific programs target rural areas. Aussie-Fans in Training (Aussie-FIT) is an evidence-based weight management intervention that uses professional Australian Football club affiliations and settings as a 'hook' to engage urban-residing men. The aim of this study is to report on how findings from rural stakeholder focus groups were used to inform the adaptation of Aussie-FIT for implementation in rural areas.

METHODS

Seven focus groups with stakeholders (n = 24) in three rural towns explored existing weight management and physical activity provisions, barriers and facilitators to engaging men, and considerations for adapting Aussie-FIT for implementation in rural contexts. Qualitative data were analysed using the framework approach. Adaptations made to the Aussie-FIT program and strategies to implement the program in rural contexts were reported using a structured framework.

RESULTS

Themes generated from our analysis include limited appealing services for men, Australian Football as a 'common language', the influence of the 'smaller fishpond'(population), considerations for program inclusivity, and the importance of local partner organisations for sustainability. We adapted the recruitment and marketing strategies, delivery settings, football program theme and partnerships for rural implementation. Stakeholders advised that an Australian Football program theme without specific local club affiliations would be important to avoid alienating men with differing club allegiances or non-sporting backgrounds. A multi-component recruitment strategy utilising local trusted sources, and program marketing that aligns with masculine ideals were considered important by stakeholders in small communities where 'people talk'.

CONCLUSIONS

Rural areas were described as 'a different ball game' due to limited local services and resources in comparison to metropolitan areas. Study findings have synergies with previous studies undertaken in rural contexts including in relation to the power of word of mouth, the importance of trust, and local partner organisations. Findings have implications for engaging rural men in health interventions in rural contexts where professional sporting contexts are not available. Assessing the extent to which the adapted Aussie-FIT program can reach and engage men in rural Australia, and exploring the barriers and facilitators to delivering the program in rural contexts is required.

TRIPLE C reporting principles for case study evaluations of the role of context in complex interventions

BACKGROUND

Guidance and reporting principles such as CONSORT (for randomised trials) and PRISMA (for systematic reviews) have greatly improved the reporting, discoverability, transparency and consistency of published research. We sought to develop similar guidance for case study evaluations undertaken to explore the influence of context on the processes and outcomes of complex interventions.

METHODS

A range of experts were recruited to an online Delphi panel, sampling for maximum diversity in disciplines (e.g. public health, health services research, organisational studies), settings (e.g. country), and sectors (e.g. academic, policy, third sector). To inform panel deliberations, we prepared background materials based on: [a] a systematic meta-narrative review of empirical and methodological literatures on case study, context and complex interventions; [b] the collective experience of a network of health systems and public health researchers; and [c] the established RAMESES II standards (which cover one kind of case study). We developed a list of topics and issues based on these sources and encouraged panel members to provide free text comments. Their feedback informed development of a set of items in the form of questions for potential inclusion in the reporting principles. We circulated these by email, asking panel members to rank each potential item twice (for relevance and validity) on a 7-point Likert scale. This sequence was repeated twice.

RESULTS

We recruited 51 panel members from 50 organisations across 12 countries, who brought experience of a range of case study research methods and applications. 26 completed all three Delphi rounds, reaching over 80% consensus on 16 items covering title, abstract, definitions of terms, philosophical assumptions, research question(s), rationale, how context and complexity relates to the intervention, ethical approval, empirical methods, findings, use of theory, generalisability and transferability, researcher perspective and influence, conclusions and recommendations, and funding and conflicts of interest.

CONCLUSION

The 'Triple C' (Case study, Context, Complex interventions) reporting principles recognise that case studies are undertaken in different ways for different purposes and based on different philosophical assumptions. They are designed to be enabling rather than prescriptive, and to make case study evaluation reporting on context and complex health interventions more comprehensive, accessible and useable.

A peer-led, school-based social network intervention for young people in the UK, promoting sexual health via social media and conversations with friends: intervention development and optimisation of STASH

BACKGROUND

The quality of school-based sex and relationships education (SRE) is variable in the UK. Digitally-based interventions can usefully supplement teacher-delivered lessons and positively impact sexual health knowledge. Designed to address gaps in core SRE knowledge, STASH (Sexually Transmitted infections And Sexual Health) is a peer-led social network intervention adapted from the successful ASSIST (A Stop Smoking in Schools Trial) model, and based on Diffusion of Innovation theory. This paper describes how the STASH intervention was developed and refined.

METHODS

Drawing on the Six Steps in Quality Intervention Development (6SQuID) framework, we tested a provisional programme theory through three iterative stages -: 1) evidence synthesis; 2) intervention co-production; and 3) adaptation - which incorporated evidence review, stakeholder consultation, and website co-development and piloting with young people, sexual health specialists, and educators. Multi-method results were analysed in a matrix of commonalities and differences.

RESULTS

Over 21 months, intervention development comprised 20 activities within the three stages. 1) We identified gaps in SRE provision and online resources (e.g. around sexual consent, pleasure, digital literacy), and confirmed critical components including the core ASSIST peer nomination process, the support of schools, and alignment to the national curriculum. We reviewed candidate social media platforms, ruling out all except Facebook on basis of functionality restrictions which precluded their use for our purposes. 2) Drawing on these findings, as well as relevant behaviour change theories and core elements of the ASSIST model, we co-developed new content with young people and other stakeholders, tailored to sexual health and to delivery via closed Facebook groups, as well as face-to-face conversations. 3) A pilot in one school highlighted practical considerations, including around peer nomination, recruitment, awareness raising, and boundaries to message sharing. From this, a revised STASH intervention and programme theory were co-developed with stakeholders.

CONCLUSIONS

STASH intervention development required extensive adaptation from the ASSIST model. Although labour intensive, our robust co-development approach ensured that an optimised intervention was taken forward for feasibility testing. Evidencing a rigorous approach to operationalising existing intervention development guidance, this paper also highlights the significance of balancing competing stakeholder concerns, resource availability, and an ever-changing landscape for implementation.

TRIAL REGISTRATION

ISRCTN97369178.

Perspectives on snakebite envenoming care needs across different sociocultural contexts and health systems: A comparative qualitative analysis among US and Brazilian health providers

With the advancements in therapeutics and available treatment options, almost all deaths and permanent disabilities from snakebite envenoming (SBE) are preventable. The challenge lies in implementing these evidence-based treatments and practices across different settings and populations. This study aims to compare data on provider perceptions of SBE care across health systems and cultural contexts to inform potential implementation science approaches. We hypothesize different health systems and cultural contexts will influence specific perceived needs to provide adequate snakebite care within central tenets of care delivery (e.g., cost, access, human resources). We previously conducted exploratory descriptive studies in the US and Brazil in order to understand the experience, knowledge, and perceptions of health professionals treating SBE. In the US, in-depth interviews were performed with emergency physicians from January 2020 to March 2020. In BR, focus group discussions were conducted with health professionals from community health centers at the end of June 2021. The focus group discussions (BR) were originally analyzed through an inductive thematic analysis approach. We conducted a secondary qualitative analysis in which this codebook was then applied to the interviews (US) in a deductive content analysis. The analysis concluded in August 2022. Brazil participants were physicians (n=5) or nurses (n=20) from three municipalities in the State of Amazonas with an average of three years of professional experience. US participants were emergency physicians (n=16) with an average of 15 years of professional experience. Four main themes emerged: 1) barriers to adequate care on the patient and/or community side and 2) on the health system side, 3) perceived considerations for how to address SBE, and 4) identified needs for improving care. There were 25 subthemes within the four themes. These subthemes were largely the same across the Brazil and US data, but the rationale and content within each shared subtheme varied significantly. For example, the subtheme "role of health professionals in improving care" extended across Brazil and the US. Brazil emphasized the need for task-shifting and -sharing amongst health care disciplines, whereas the US suggested specialized approaches geared toward increasing access to toxicologists and other referral resources. Despite similar core barriers to adequate snakebite envenoming care and factors to consider when trying to improve care delivery, health professionals in different health systems and sociocultural contexts identified different needs. Accounting for, and understanding, these differences is crucial to the success of initiatives intended to strengthen snakebite envenoming care. Implementation science efforts, with explicit health professional input, should be applied to develop new and/or adapt existing evidence-based treatments and practices for SBE.

Einflussfaktoren beim Aufbau von Präventionsketten in Neubaugebieten am Beispiel des Münchner Stadtteils Freiham – eine qualitative Studie

Einleitung

Präventionsketten sind integrierte kommunale Strategien zur Förderung von Gesundheit und sozialer Teilhabe von Kindern, Jugendlichen und Familien sowie zur Vermeidung der Folgen von Kinderarmut. Sie sind als intersektorale Netzwerke in mehreren Kommunen in Deutschland etabliert. Der Aufbau von Präventionsketten in Neubaugebieten wurde bislang noch nicht systematisch erforscht. Im Rahmen der Prozessevaluation zur Präventionskette Freiham, die in dem sich derzeit im Bau befindlichen gleichnamigen Münchner Stadtteil implementiert wird, wurde eine qualitative Interview- und Fokusgruppenstudie durchgeführt. Das Ziel war, relevante Einflussfaktoren für den Aufbau von Präventionsketten in einem neu entstehenden Stadtteil zu identifizieren.

Methoden

Für die Studie wurden wiederholt Interviews mit dem Netzwerkwerkmanagement der Präventionskette Freiham durchgeführt sowie eine Fokusgruppe mit Vertreter*innen der beteiligten städtischen Referate. Zudem fanden Interviews mit 12 lokalen Fachkräften aus den Sektoren Bildung, Soziales und Gesundheit statt. Die Auswertung erfolgte mit der Methode der qualitativen Inhaltsanalyse in Anlehnung an Mayring.

Ergebnisse

Wichtige Einflussfaktoren für eine gelingende Implementierung stellten aus Sicht der Teilnehmer*innen die Ausstattung mit finanziellen und personellen Ressourcen sowie die Unterstützung durch die kommunale Politik und Verwaltungsspitzen dar. Für eine erfolgreiche Arbeit im Netzwerk waren die zentrale Netzwerkkoordination, eine transparente Kommunikation, die Integration der unterschiedlichen Interessen der Akteur*innen und die Vermittlung eines Mehrwerts des Engagements entscheidend. Eine spezifische Herausforderung für das Setting eines Neubaugebiets war der Aufbau von bedarfs- und zielgruppenorientierten Netzwerkstrukturen angesichts einer zunächst geringen Anzahl an Bewohner*innen und noch nicht etablierter Unterstützungsstrukturen.

Schlussfolgerung

Ausreichende Finanzierung und Rückhalt in Politik und Verwaltung sind zentrale Einflussfaktoren für die Implementierung einer Präventionskette in Kommunen. Insbesondere in Neubaugebieten ohne gewachsene Infrastruktur erfordert der Aufbauprozess eine langfristig angelegte Unterstützung.

An Aboriginal Community-Controlled Health Organization model of service delivery: qualitative process evaluation of the Tulku wan Wininn mobile clinic

BACKGROUND

Mobile clinics have been implemented in diverse clinical and geographical settings to provide proximal health care for specific populations. Primary health care mobile clinics have been implemented widely for Indigenous populations, with a paucity of research evaluations around service delivery models internationally. To redress factors impeding service accessibility for Aboriginal and Torres Strait Islander Peoples, Budja Budja Aboriginal Cooperative (Aboriginal Community Controlled Health Organisation located in a small rural town in Victoria, Australia), developed and implemented the Tulku wan Wininn primary health mobile clinic.

METHODS

A qualitative process evaluation methodology was used to explore contextual factors mediating the implementation of the mobile clinic, including the acceptability of the service to health service personnel, external key informants, and Aboriginal and/or Torres Strait Islander clients. A synthesis of international ethical guidelines, (Consolidated Criteria for strengthening reporting of health research involving Indigenous peoples (CONSIDER statement), was prospectively applied to shape the study design and research process. Semi-structured interviews were conducted with participants. Data collection occurred from July 2019 to October 2021. Inductive thematic data analysis was undertaken concurrently with data collection.

RESULTS

Data was collected from 19 participants which included 12 health service personnel and key informants, and 7 Aboriginal clients. In total, data from 22 interviews were included as interviews with three clients were undertaken twice. Four themes were developed: considerations for early implementation, maintaining face-to-face services during COVID-19, acceptability as a model of service delivery, and maintaining the mobile clinic as a service delivery model.

CONCLUSION

Evidence supporting the acceptability of a primary health care mobile clinic for Aboriginal Peoples residing in rural Victoria is provided. Despite the experience of early implementation challenges and adaptations, the mobile clinic addressed known transport and cultural barriers to accessing primary health care services. In the context of COVID-19 lockdowns, the mobile clinic was valued for the provision of face-to-face care for Aboriginal clients. Key issues for maintaining the mobile clinic include health workforce and funding. Findings are of value to other organizations seeking to implement a primary health mobile clinic service delivery model to redress barriers to accessibility experienced by the communities they serve.

Tensions and Paradoxes of Scaling Up: A Critical Reflection on Physical Activity Promotion

Achieving system-level, sustainable 'scale-up' of interventions is the epitome of successful translation of evidence-based approaches in population health. In physical activity promotion, few evidence-based interventions reach implementation at scale or become embedded within systems for sustainable health impact. This is despite the vast published literature describing efficacy studies of small-scale physical activity interventions. Research into physical activity scale-up (through case-study analysis; evaluations of scale-up processes in implementation trials; and mapping the processes, strategies, and principles for scale-up) has identified barriers and facilitators to intervention expansion. Many interventions are implemented at scale by governments but have not been evaluated or have unpublished evaluation information. Further, few public health interventions have evaluations that reveal the costs and benefits of scaled-up implementation. This lack of economic information introduces an additional element of risk for decision makers when deciding which physical activity interventions should be supported with scarce funding resources. Decision-makers face many other challenges when scaling interventions which do not relate to formal research trials of scale-up; Methods: To explore these issues, a multidisciplinary two-day workshop involving experts in physical activity scale-up was convened by the University of Newcastle, Australia, and the University of Ottawa, Canada (February 2019); Results: In this paper we discuss some of the scale-up tensions (challenges and conflicts) and paradoxes (things that are contrary to expectations) that emerged from this workshop in the context of the current literature and our own experiences in this field. We frame scale-up tensions according to epistemology, methodology, time, and partnerships; and paradoxes as 'reach without scale', 'planned serendipity' and 'simple complexity'. We reflect on the implications of these scale-up tensions and paradoxes, providing considerations for future scale-up research and practice moving forward; Conclusions: In this paper, we delve deeper into stakeholders' assumptions, processes and expectations of scaling up, and challenge in what ways as stakeholders, we all contribute to desired or undesired outcomes. Through a lens of 'tensions' and 'paradoxes', we make an original contribution to the scale-up literature that might influence current perspectives of scaling-up, provide future approaches for physical activity promotion, and contribute to understanding of dynamic of research-practice partnerships.

Adapting population health interventions for new contexts: qualitative interviews understanding the experiences, practices and challenges of researchers, funders and journal editors

OBJECTIVES

Research on the adaptation of population health interventions for implementation in new contexts is rapidly expanding. This has been accompanied by a recent increase in the number of frameworks and guidance to support adaptation processes. Nevertheless, there remains limited exploration of the real-world experiences of undertaking intervention adaptation, notably the challenges encountered by different groups of stakeholders, and how these are managed. Understanding experiences is imperative in ensuring that guidance to support adaptation has practical utility. This qualitative study examines researcher and stakeholder experiences of funding, conducting and reporting adaptation research.

SETTING

Adaptation studies.

PARTICIPANTS

Participants/cases were purposefully sampled to represent a range of adapted interventions, types of evaluations, expertise and countries. Semistructured interviews were conducted with a sample of researchers (n=23), representatives from research funding panels (n=6), journal editors (n=5) and practitioners (n=3).

MEASURES

A case study research design was used. Data were analysed using the framework approach. Overarching themes were discussed within the study team, with further iterative refinement of subthemes.

RESULTS

The results generated four central themes. The first three relate to the experience of intervention adaptation (1) involving stakeholders throughout the adaptation process and how to integrate the evidence base with experience; (2) selecting the intervention and negotiating the mismatch between the original and the new context; and (3) the complexity and uncertainty when deciding the re-evaluation process. The final theme (4) reflects on participants' experiences of using adaptation frameworks in practice, considering recommendations for future guidance development and refinement.

CONCLUSION

This study highlights the range of complexities and challenges experienced in funding, conducting and reporting research on intervention adaptation. Moving forward, guidance can be helpful in systematising processes, provided that it remains responsive to local contexts and encourage innovative practice.

Monitoring unplanned sexual health curricula adaptations: Using results to improve fidelity and support implementation

Maintaining fidelity to an evidence-based curriculum is important, yet educators may need to adapt to unexpected situations or particular contexts. The purpose of this study is to identify the reasons for unplanned adaptations during implementation of an evidence-based sexual health education program in California. Evaluators reviewed fidelity checklists from the implementation of 571 cohorts for activities with reported unplanned adaptations. Reasons were qualitatively coded and compared across two phases of implementation and by setting. Educators reported 319 unplanned adaptations, affecting 21.5% of the 571 cohorts and 2.9% of 13,782 activities. The most common reasons for unplanned adaptations were due to time management issues, site logistic issues, and to increase participant engagement. Over time, health educators reported fewer unplanned adaptations, particularly those due to time management, resulting in a decrease in the cohorts and activities affected. Adaptations to evidence-based curricula are necessary and often occur during implementation to fit local conditions and populations. Ongoing review of adaptation data provides an opportunity to refine training and technical assistance efforts. Guidance about the types of permitted adaptations and how to anticipate and plan for adaptations for future implementation can ensure fidelity to the core curriculum components and responsiveness to youth participants.

Social, economic, political, and geographical context that counts: meta-review of implementation determinants for policies promoting healthy diet and physical activity

Background

This meta-review investigated the context-related implementation determinants from seven domains (geographical, epidemiological, sociocultural, economic, ethics-related, political, and legal) that were systematically indicated as occurring during the implementation of obesity prevention policies targeting a healthy diet and a physically active lifestyle.

Methods

Data from nine databases and documentation of nine major stakeholders were searched for the purpose of this preregistered meta-review (#CRD42019133341). Context-related determinants were considered strongly supported if they were indicated in ≥60% of the reviews/stakeholder documents. The ROBIS tool and the Methodological Quality Checklist-SP were used to assess the quality-related risk of bias.

Results

Published reviews (k = 25) and stakeholder documents that reviewed the evidence of policy implementation (k = 17) were included. Across documents, the following six determinants from three context domains received strong support: economic resources at the macro (66.7% of analyzed documents) and meso/micro levels (71.4%); sociocultural context determinants at the meso/micro level, references to knowledge/beliefs/abilities of target groups (69.0%) and implementers (73.8%); political context determinants (interrelated policies supported in 71.4% of analyzed reviews/documents; policies within organizations, 69.0%).

Conclusions

These findings indicate that sociocultural, economic, and political contexts need to be accounted for when formulating plans for the implementation of a healthy diet and physical activity/sedentary behavior policies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13340-4.

Follow-up after gestational diabetes: a qualitative study of perspectives from general practices

BACKGROUND

Women whose pregnancies are complicated by gestational diabetes mellitus are approximately eight times more likely to develop type two diabetes. Although regular participation in follow-up screening increases the chance of early detection of diabetes, participation rates are often suboptimal. A better understanding of general practice as a key contextual setting for screening could help inform the development and adoption of, for example, electronic reminder interventions to support women's participation.

AIM

To explore the perspectives of general practitioners and relevant staff members engaged in early detection of diabetes after gestational diabetes in order to identify barriers to and facilitators of follow-up screening.

DESIGN & SETTING

A qualitative interview study undertaken in general practices in the North Denmark Region.

METHOD

Based on a purposive sample strategy, 18 semi-structured interviews of 12 general practitioners and six staff members, who were either nurses or midwives, were analysed using a reflexive thematic analytical approach.

RESULTS

Three main themes were formulated: (1) Challenges of addressing women's risk; (2) Prioritisation of early detection of diabetes; (3) System influence on clinical procedures.

CONCLUSION

Follow-up screening was facilitated by knowledge of guidelines. We found professional collaboration and adaptation support to lead to successful implementation of guidelines in general practice. Supporting GPs and their staff's reflection and discussion of ways to engage in communication and decision-making processes with women is however important, hence it was found to create an important barrier to follow-up screening. Overall, our findings can help inform the future development of interventions to increase uptake.

A systematic review of adaptations and effectiveness of scaled-up nutrition interventions

CONTEXT

Public health nutrition interventions shown to be effective under optimal research conditions need to be scaled up and implemented in real-world settings.

OBJECTIVES

The primary aim for this review was to assess the effectiveness of scaled-up public health nutrition interventions with proven efficacy, as examined in a randomized controlled trial. Secondary objectives were to: 1) determine if the effect size of scaled-up interventions were comparable to the prescale effect, and; 2) identify any adaptations made during the scale-up process.

DATA SOURCES

Six electronic databases were searched and field experts contacted.

STUDY SELECTION

An intervention was considered scaled up if it was delivered on a larger scale than a preceding randomized controlled trial ("prescale") in which a significant intervention effect (P ≤ 0.05) was reported on a measure of nutrition.

DATA EXTRACTION

Two reviewers independently performed screening and data extraction. Effect size differences between prescale and scaled-up interventions were quantified. Adaptations to scale-up studies were coded according to the Adaptome model.

RESULTS

Ten scaled-up nutrition interventions were identified. The effect size difference between prescale trials and scaled-up studies ranged from -32.2% to 222% (median, 50%). All studies made adaptations between prescale to scaled-up interventions.

CONCLUSION

The effects of nutrition interventions implemented at scale typically were half that achieved in prior efficacy trials. Identifying effective scale-up strategies and methods to support retainment of the original prescale effect size is urgently needed to inform public health policy.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no.CRD42020149267.

Exploring the association between school-based peer networks and smoking according to socioeconomic status and tobacco control context: a systematic review

BACKGROUND

Whilst prevalence of youth smoking in middle and high income countries has decreased, inequality has prevailed. The introduction of legislation regulating tobacco use in public spaces varies across countries, impacting the tobacco control context. Thus reviewing our knowledge of how social networks may influence smoking differently within different contexts is required to facilitate the development of context-specific interventions.

METHODS

The search, conducted on 31st May 2019, included the following smoking-related terms; schools, adolescents, peers and social networks. Inclusion and exclusion criteria were applied throughout the title and abstract screening and full text screening. Quality assessment and synthesis followed. Studies were narratively synthesised to identify changes according to legislative context. This synthesis was conducted separately for findings relating to three categories: socioeconomic status; social selection and influence; and network position.

RESULTS

Thirty studies were included. Differences in the relationship between network characteristics and smoking according to socioeconomic status were measured in five out of fifteen studies in Europe. Results varied across studies, with differences in network characteristics and their association with smoking varying both between schools of a differing and those of a similar socioeconomic composition. For studies conducted both before and after the introduction of comprehensive smoking legislation, the evidence for selection processes was more consistent than influence, which varied according to reciprocity. Findings showed that isolates were more likely to smoke and in-degree and out-degree centrality were related to smoking both before and after the introduction of legislation. The relationship between popularity and smoking was contingent on school level smoking prevalence in studies conducted before the introduction of legislation, but not after.

CONCLUSIONS

Overall, effects according to socioeconomic status were underreported in the included studies and no consistent evidence of change after the introduction of a comprehensive smoking ban was observed. Further network analyses are required using more recent data to obtain a comprehensive understanding of how network processes may influence smoking differently according to socioeconomic status, and how adaptation could be used to enhance intervention effectiveness.

SYSTEMATIC REVIEW REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO) registration number: CRD42019137358 .

Innovations in implementing a health systems response to violence against women in 3 tertiary hospitals of Maharashtra India: Improving provider capacity and facility readiness

Background

Violence against women [VAW] is an urgent public health issue and health care providers [HCPs] are in a unique position to respond to such violence within a multi-sectoral health system response. In 2013, the World Health Organization (WHO) published clinical and policy guidelines (henceforth - the Guidelines) for responding to intimate partner violence and sexual violence against women. In this practical implementation report, we describe the adaptation of the Guidelines to train HCPs to respond to violence against women in tertiary health facilities in Maharashtra, India.

Methods

We describe the strategies employed to adapt and implement the Guidelines, including participatory methods to identify and address HCPs' motivations and the barriers they face in providing care for women subjected to violence. The adaptation is built on querying health-systems level enablers and obstacles, as well as individual HCPs' perspectives on content and delivery of training and service delivery.

Results

The training component of the intervention was delivered in a manner that included creating ownership among health managers who became champions for other health care providers; joint training across cadres to have clear roles, responsibilities and division of labour; and generating critical reflections about how gender power dynamics influence women's experience of violence and their health. The health systems strengthening activities included establishment of standard operating procedures [SOPs] for management of VAW and strengthening referrals to other services.

Conclusions

In this intervention, standard training delivery was enhanced through participatory, joint and reflexive methods to generate critical reflection about gender, power and its influence on health outcomes. Training was combined with health system readiness activities to create an enabling environment. The lessons learned from this case study can be utilized to scale-up response in other levels of health facilities and states in India, as well as other LMIC contexts.

Plain language summary

Violence against women affects millions of women globally. Health care providers may be able to support women in various ways, and finding ways to train and support health care providers in low and middle-income countries to provide high-quality care to women affected by violence is an urgent need. The WHO developed Clinical and Policy Guidelines in 2013, which provide guidance on how to improve health systems response to violence against women. We developed and implemented a series of interventions, including training of health care providers and innovations in service delivery, to implement the WHO guidelines for responding to violence against women in 3 tertiary hospitals of Maharashtra, India. The nascent published literature on health systems approaches to addressing violence against women in low and middle-income countries focuses on the impact of these interventions. This practical implementation report focuses on the interventions themselves, describes the processes of developing and adapting the intervention, and thus provides important insights for donors, policy-makers and researchers.

Systematic translation and adaptation of the FOCUS program, a USA-based supportive intervention for persons with cancer and their family caregivers, for use in six European countries

PURPOSE

Having advanced cancer presents many challenges for patients and family caregivers. The FOCUS program is a psychoeducational nurse-led intervention, developed in the USA, to support dyads of patients with cancer and their family caregivers to live with the illness. The program includes a conversation manual and information resources for dyads. We aimed to develop a version of the program for dyads facing advanced cancer in six European countries.

METHOD

The Participatory and Iterative Process Framework for Language Adaptation (PIPFLA) was used to guide the translation of the program to the local contexts of Belgium, Denmark, Ireland, Italy, the Netherlands, and the UK. In several rounds, potential program users (e.g., nurses, clinicians, patients, family caregivers) and researchers from all six countries reviewed program materials and advised on adaptations.

RESULTS

The PIPFLA process resulted in one European version of the program in different languages (FOCUS +). The FOCUS + conversation manual is uniform across all countries. The main adaptations included additional attention to both family caregiver and patient needs; more emphasis on self-management, advance care planning, and shared responsibilities; discussing the dyad's outlook rather than optimism; addressing the role of nurses as educational rather than therapeutic; and more suggestions to refer dyads to health care professionals for specific care needs. The information resources for dyads were adapted to fit with local contexts.

CONCLUSION

The PIPFLA methodology is an efficient and effective framework to thoroughly translate and culturally adapt a complex USA-based program for use in six European countries in collaboration with end users.

Context-specific adaptation of an eHealth-facilitated, integrated care model and tailoring its implementation strategies-A mixed-methods study as a part of the SMILe implementation science project

Background

Contextually adapting complex interventions and tailoring their implementation strategies is key to a successful and sustainable implementation. While reporting guidelines for adaptations and tailoring exist, less is known about how to conduct context-specific adaptations of complex health care interventions.

Aims

To describe in methodological terms how the merging of contextual analysis results (step 1) with stakeholder involvement, and considering overarching regulations (step 2) informed our adaptation of an Integrated Care Model (ICM) for SteM cell transplantatIon faciLitated by eHealth (SMILe) and the tailoring of its implementation strategies (step 3).

Methods

Step 1: We used a mixed-methods design at University Hospital Basel, guided by the Basel Approach for coNtextual ANAlysis (BANANA). Step 2: Adaptations of the SMILe-ICM and tailoring of implementation strategies were discussed with an interdisciplinary team (n = 28) by considering setting specific and higher-level regulatory scenarios. Usability tests were conducted with patients (n = 5) and clinicians (n = 4). Step 3: Adaptations were conducted by merging our results from steps 1 and 2 using the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME). We tailored implementation strategies according to the Expert Recommendations for Implementing Change (ERIC) compilation.

Results

Step 1: Current clinical practice was mostly acute-care-driven. Patients and clinicians valued eHealth-facilitated ICMs to support trustful patient-clinician relationships and the fitting of eHealth components to context-specific needs. Step 2: Based on information from project group meetings, adaptations were necessary on the organizational level (e.g., delivery of self-management information). Regulations informed the tailoring of SMILe-ICM`s visit timepoints and content; data protection management was adapted following Swiss regulations; and steering group meetings supported infrastructure access. The usability tests informed further adaptation of technology components. Step 3: Following FRAME and ERIC, SMILe-ICM and its implementation strategies were contextually adapted and tailored to setting-specific needs.

Discussion

This study provides a context-driven methodological approach on how to conduct intervention adaptation including the tailoring of its implementation strategies. The revealed meso-, and macro-level differences of the contextual analysis suggest a more targeted approach to enable an in-depth adaptation process. A theory-guided adaptation phase is an important first step and should be sufficiently incorporated and budgeted in implementation science projects.

Implementation of Self-Management Interventions in Cancer Survivors: Why Are We Not There Yet?

Despite the growing evidence base for supported self-management for the improvement of quality of life, there is a lack of widespread implementation of self-management interventions for cancer survivors. We propose five key areas that, if addressed, would optimise the development and evaluation of these interventions, namely: (1) improving intervention adaptability to different survivor populations; (2) establishing intervention acceptability (and feasibility); (3) ensuring systematic description of interventions, their content, and active ingredients; (4) conducting process evaluations; and (5) assessing cost-effectiveness. These areas are an essential prerequisite for translation of self-management interventions from research into routine cancer care.

A health promotion intervention to improve oral health of prisoners: results from a pilot study

PURPOSE

Prisoners have poorer oral health than the general population. Good oral health is essential for both social and physical well-being. For prisoners, poor oral health is also related to drug use after release, whereas good oral health is related to successful reintegration into society. The purpose of this study was twofold: to examine the effect of an intervention based on motivational interviewing (MI) on prisoners' oral health-related behavior and to assess if the intervention is a good fit for this population.

DESIGN/METHODOLOGY/APPROACH

In total, 16 prisoners in a Norwegian prison were offered a brief MI-based intervention focusing on changing their oral health-related behavior. An oral examination was also performed and the prisoners received a small package containing oral hygiene aids. Two weeks later, a second oral examination and a semi-structured interview were conducted to explore the effect of the intervention and examine the prisoners' responses to the intervention. Qualitative data analyzes were guided by thematic analysis.

FINDINGS

The findings indicate that the intervention had positive effects on both the prisoners' motivation to use oral health-related behavior and their performance of oral health-related behavior. The findings also indicate that the intervention was well adapted to the target population.

ORIGINALITY/VALUE

This is one of the first studies that explore the effect of an intervention in improving prisoners' oral health and bridges a knowledge gap in the literature. The findings may increase the understanding of how dental services should be organized and offered to provide dental health care to this vulnerable group.

Is the NHS Diabetes Prevention Programme Intervention Delivered as Planned? An Observational Study of Fidelity of Intervention Delivery

BACKGROUND

The NHS Diabetes Prevention Programme (NHS-DPP) has been delivered by four commercial organizations across England, to prevent people with impaired glucose tolerance developing Type 2 diabetes. Evidence reviews underpinning the NHS-DPP design specification identified 19 Behavior Change Techniques (BCTs) that are the intervention "active ingredients." It is important to understand the discrepancies between BCTs specified in design and BCTs actually delivered.

PURPOSE

To compare observed fidelity of delivery of BCTs that were delivered to (a) the NHS-DPP design specification, and (b) the programme manuals of four provider organizations.

METHODS

Audio-recordings were made of complete delivery of NHS-DPP courses at eight diverse sites (two courses per provider organization). The eight courses consisted of 111 group sessions, with 409 patients and 35 facilitators. BCT Taxonomy v1 was used to reliably code the contents of NHS-DPP design specification documents, programme manuals for each provider organization, and observed NHS-DPP group sessions.

RESULTS

The NHS-DPP design specification indicated 19 BCTs that should be delivered, whereas only seven (37%) were delivered during the programme in all eight courses. By contrast, between 70% and 89% of BCTs specified in programme manuals were delivered. There was substantial under-delivery of BCTs that were designed to improve self-regulation of behavior, for example, those involving problem solving and self-monitoring of behavior.

CONCLUSIONS

A lack of fidelity in delivery to the underlying evidence base was apparent, due to poor translation of design specification to programme manuals. By contrast, the fidelity of delivery to the programme manuals was relatively good. Future commissioning should focus on ensuring the evidence base is more accurately translated into the programme manual contents.

Evaluating complex interventions in context: systematic, meta-narrative review of case study approaches

BACKGROUND

There is a growing need for methods that acknowledge and successfully capture the dynamic interaction between context and implementation of complex interventions. Case study research has the potential to provide such understanding, enabling in-depth investigation of the particularities of phenomena. However, there is limited guidance on how and when to best use different case study research approaches when evaluating complex interventions. This study aimed to review and synthesise the literature on case study research across relevant disciplines, and determine relevance to the study of contextual influences on complex interventions in health systems and public health research.

METHODS

Systematic meta-narrative review of the literature comprising (i) a scoping review of seminal texts (n = 60) on case study methodology and on context, complexity and interventions, (ii) detailed review of empirical literature on case study, context and complex interventions (n = 71), and (iii) identifying and reviewing 'hybrid papers' (n = 8) focused on the merits and challenges of case study in the evaluation of complex interventions.

RESULTS

We identified four broad (and to some extent overlapping) research traditions, all using case study in a slightly different way and with different goals: 1) developing and testing complex interventions in healthcare; 2) analysing change in organisations; 3) undertaking realist evaluations; 4) studying complex change naturalistically. Each tradition conceptualised context differently-respectively as the backdrop to, or factors impacting on, the intervention; sets of interacting conditions and relationships; circumstances triggering intervention mechanisms; and socially structured practices. Overall, these traditions drew on a small number of case study methodologists and disciplines. Few studies problematised the nature and boundaries of 'the case' and 'context' or considered the implications of such conceptualisations for methods and knowledge production.

CONCLUSIONS

Case study research on complex interventions in healthcare draws on a number of different research traditions, each with different epistemological and methodological preferences. The approach used and consequences for knowledge produced often remains implicit. This has implications for how researchers, practitioners and decision makers understand, implement and evaluate complex interventions in different settings. Deeper engagement with case study research as a methodology is strongly recommended.

Industry Context as an Essential Tool for the Future of Healthy and Safe Work: Illustrative Examples for Occupational Health Psychology from the Hospitality Industry

Contextual nuance holds value for occupational health and safety, particularly as workplace challenges and solutions become more complex. However, disciplines that inform occupational safety and health vary in the degree to which they target breadth and depth of understanding. The future of work presents challenges related to work, the workplace, and the workforce, and an appreciation of the context of industry will ready researchers and practitioners with the most informed solutions. Broadly developed solutions for future of work challenges may flounder without an appreciation for the context of industry, as evidenced by two examples provided in this review. As occupational safety and health disciplines answer the call provided by the future of work, this review provides an account for the value of industry context and recommendations for achieving both breadth and depth of scientific inquiry and practical reach.

Process Evaluation of a Hub-and-Spoke Model to Deliver Coordinated Care for Children with Medical Complexity across Ontario: Facilitators, Barriers and Lessons Learned

Background:

Complex Care for Kids Ontario (CCKO) is a multi-year strategy aimed at expanding a hub-and-spoke model to deliver coordinated care for children with medical complexity (CMC) across Ontario.

Objective:

This paper aims to identify the facilitators, barriers and lessons learned from the implementation of the Ontario CCKO strategy.

Method:

Alongside an outcome evaluation of the CCKO strategy, we conducted a process evaluation to understand the implementation context, process and mechanisms. Semi-structured interviews were conducted with 38 healthcare leaders, clinicians and support staff from four regions involved in CCKO care delivery and/or governance.

Results:

Facilitators to CCKO implementation were sustained engagement of system-wide stakeholders, inter-organizational partnerships, knowledge sharing and family engagement. Barriers to CCKO implementation were resources and funding, fragmentation of care, aligning perspectives between providers and clinical staff recruitment and retention.

Conclusion:

A flexible approach is required to implement a complex, multi-centre policy strategy. Other jurisdictions considering such a model of care delivery would benefit from attention to contextual variations in implementation setting, building cross-sector engagement and buy-in, and offering continuous support for modifications to the intervention as and when required.

Applying an Equity Lens to Characterizing the Process and Reasons for an Adaptation to an Evidenced-based Practice

Background

Adaptations to evidence-based practices (EBPs) are common but can impact implementation and patient outcomes. In our prior research, providers in routine care made a fidelity-inconsistent adaptation to an EBP that improved health outcomes in people with serious mental illness (SMI). The purpose of this study was to characterize the process and reasons for the adaptation using a framework for reporting adaptations and modifications to EBPs, with a focus on equity.

Methods

This study used qualitative data collected during a national implementation of the InSHAPE EBP addressing obesity in persons with SMI. We reviewed transcripts from five behavioral health organizations that made a successful fidelity-inconsistent adaptation to a core component of InSHAPE that was associated with cardiovascular risk reduction. We coded the data using the Framework for Reporting Adaptations and Modifications-Expanded (FRAME) with an emphasis on exploring whether the adaptation addressed inequities in using the EBP related to social determinants of health.

Results

Across the five agencies, the fidelity-inconsistent adaptation was characterized as unplanned and reactive in response to challenges InSHAPE teams experienced delivering the intervention in community fitness facilities as intended. In all cases, the goal of the adaptation was to improve intervention access, feasibility and fit. Social and economic disadvantage were noted obstacles to accessing fitness facilities or gyms among participants with SMI, which led agencies to adapt the program by offering sessions at the mental health center.

Conclusions

Findings from this study show the advantages of applying a health equity lens to evaluate how obstacles such as poverty and discrimination influence EBP adaptations. Recommendations can also assist researchers and community partners in making proactive decisions about allowable adaptations to EBPs.

Multiple Health Behavior Programs in School Settings: Strategies to Promote Transfer-of-Learning Through Life Skills Education

Typically, schools implement health promotion programs that focus on a single behavioral domain. Multiple related health topics may be addressed using separate interventions, potentially producing overlap in program content. However, integrative approaches in health promotion have the potential to produce interventions capable of improving multiple health behaviors. In particular, more research is needed to identify the conditions and the factors that can promote the transfer of learning to broaden the target outcomes of health promotion programs. The present study aims to identify the characteristics of an evidence-based life skills education program that can facilitate the transfer of learning to different health behaviors not initially targeted by the program, and the strategies for achieving successful transfer. A two round Delphi method was used with a diverse group of 21 experts in health promotion, life skills education, and methods of pedagogy for early adolescent students. Questionnaires with open and closed-ended questions were administered on-line. Content qualitative analysis was run, integrating codes, subcategories, and categories of the two rounds of the study. Results showed strong consensus among experts about the potential for promoting the transfer of skills from one health domain to another. Many elements were identified as important factors that facilitate the transfer of learning. Strategies for successful transfer were related to teaching methods, educational approaches, and consistency with the broader school curriculum. Findings suggest that the successful transfer of learning to a new health domain requires that educators recognize its importance and explicitly designate it as an educational aim.

Planning and optimising a digital intervention to protect older adults' cognitive health

BACKGROUND

By 2050, worldwide dementia prevalence is expected to triple. Affordable, scalable interventions are required to support protective behaviours such as physical activity, cognitive training and healthy eating. This paper outlines the theory-, evidence- and person-based development of 'Active Brains': a multi-domain digital behaviour change intervention to reduce cognitive decline amongst older adults.

METHODS

During the initial planning phase, scoping reviews, consultation with PPI contributors and expert co-investigators and behavioural analysis collated and recorded evidence that was triangulated to inform provisional 'guiding principles' and an intervention logic model. The following optimisation phase involved qualitative think aloud and semi-structured interviews with 52 older adults with higher and lower cognitive performance scores. Data were analysed thematically and informed changes and additions to guiding principles, the behavioural analysis and the logic model which, in turn, informed changes to intervention content.

RESULTS

Scoping reviews and qualitative interviews suggested that the same intervention content may be suitable for individuals with higher and lower cognitive performance. Qualitative findings revealed that maintaining independence and enjoyment motivated engagement in intervention-targeted behaviours, whereas managing ill health was a potential barrier. Social support for engaging in such activities could provide motivation, but was not desirable for all. These findings informed development of intervention content and functionality that appeared highly acceptable amongst a sample of target users.

CONCLUSIONS

A digitally delivered intervention with minimal support appears acceptable and potentially engaging to older adults with higher and lower levels of cognitive performance. As well as informing our own intervention development, insights obtained through this process may be useful for others working with, and developing interventions for, older adults and/or those with cognitive impairment.

Adapting a guided low-intensity behavioural activation intervention for people with dementia and depression in the Swedish healthcare context (INVOLVERA): a study protocol using codesign and participatory action research

INTRODUCTION

Dementia is a worldwide health concern with incident rates continuing to increase. While depression prevalence is high in people with dementia and psychological interventions such as cognitive behavioural therapy (CBT) are effective, access to psychological interventions remains limited. Reliance on traditional CBT for people with dementia and depression may present difficulties given it is a complex psychological approach, costly to deliver, and professional training time is lengthy. An alternative approach is behavioural activation (BA), a simpler psychological intervention for depression. The present study seeks to work with people with dementia, informal caregivers, community stakeholders, and healthcare professionals, to adapt a guided low-intensity BA intervention for people with dementia and depression, while maximising implementation potential within the Swedish healthcare context.

METHODS AND ANALYSIS

A mixed methods study using codesign, principles from participatory action research (PAR) and normalisation process theory to facilitate the cultural relevance, appropriateness and implementation potential of the intervention. The study will consist of four iterative PAR phases, using focus groups with healthcare professionals and community stakeholders, and semi-structured interviews with people with dementia and informal caregivers. A content analysis approach will be adopted to analyse the transcribed focus groups and semi-structured interviews recordings.

ETHICS AND DISSEMINATION

The study will be conducted in accordance with the Declaration of Helsinki and data handled according to General Data Protection Regulation. Written informed consent will be obtained from all study participants. In accordance with the Swedish Health and Medical Services Act, capacity to consent will be examined by a member of the research team. Ethical approval has been obtained from the Swedish Ethical Review Authority (Dnr: 2020-05542 and Dnr: 2021-00925). Findings will be published in an open access peer-reviewed journal, presented at academic conferences, and disseminated among lay and healthcare professional audiences.

The what, why and when of adapting interventions for new contexts: A qualitative study of researchers, funders, journal editors and practitioners' understandings

BACKGROUND

The adaptation of interventions for new contexts is a rapidly developing research area. To date there is no consensus-based guidance to support decision-making and recommend adaptation processes. The ADAPT study is developing such guidance. This aim of the qualitative component of the study was to explore stakeholders' understandings of adaptation, as to date there has limited consideration of how different concepts and meanings shape decision-making and practice.

METHODS

A case study research design was used. Participants/cases were purposefully sampled based on study outcome, study design, expertise, context and country. Semi-structured interviews were conducted with a sample of researchers (n = 23); representatives from research funding panels (n = 6); journal editors (n = 5) and practitioners (n = 3). Data were analysed using the Framework approach. Overarching themes were discussed with the ADAPT study team, with further iterative refinement of subthemes.

RESULTS

The results generated four central themes. Four themes related to stakeholders' understanding: 1) definitions of adaptation and related concepts; 2) rationales for undertaking adaptation; 3) the appropriate timing for adaptation; and 4) ensuring fidelity when implementing adapted interventions.

CONCLUSION

The findings highlight the lack of clarity around key concepts and uncertainty about central decision-making processes, notably why interventions should be adapted, when and to what extent. This has informed the ADAPT study's guidance, shaping the scope and nature of recommendations to be included and surfacing key uncertainties that require future consideration.

A systematic approach to context-mapping to prepare for health interventions: development and validation of the SETTING-tool in four countries

Effectiveness of health interventions can be substantially impaired by implementation failure. Context-driven implementation strategies are critical for successful implementation. However, there is no practical, evidence-based guidance on how to map the context in order to design context-driven strategies. Therefore, this practice paper describes the development and validation of a systematic context-mapping tool. The tool was cocreated with local end-users through a multistage approach. As proof of concept, the tool was used to map beliefs and behaviour related to chronic respiratory disease within the FRESH AIR project in Uganda, Kyrgyzstan, Vietnam and Greece. Feasibility and acceptability were evaluated using the modified Conceptual Framework for Implementation Fidelity. Effectiveness was assessed by the degree to which context-driven adjustments were made to implementation strategies of FRESH AIR health interventions. The resulting Setting-Exploration-Treasure-Trail-to-Inform-implementatioN-strateGies (SETTING-tool) consisted of six steps: (1) Coset study priorities with local stakeholders, (2) Combine a qualitative rapid assessment with a quantitative survey (a mixed-method design), (3) Use context-sensitive materials, (4) Collect data involving community researchers, (5) Analyse pragmatically and/or in-depth to ensure timely communication of findings and (6) Continuously disseminate findings to relevant stakeholders. Use of the tool proved highly feasible, acceptable and effective in each setting. To conclude, the SETTING-tool is validated to systematically map local contexts for (lung) health interventions in diverse low-resource settings. It can support policy-makers, non-governmental organisations and health workers in the design of context-driven implementation strategies. This can reduce the risk of implementation failure and the waste of resource potential. Ultimately, this could improve health outcomes.

Adapting Behavioral Interventions for a Changing Public Health Context: A Worked Example of Implementing a Digital Intervention During a Global Pandemic Using Rapid Optimisation Methods

Background: A rigorous approach is needed to inform rapid adaptation and optimisation of behavioral interventions in evolving public health contexts, such as the Covid-19 pandemic. This helps ensure that interventions are relevant, persuasive, and feasible while remaining evidence-based. This paper provides a set of iterative methods to rapidly adapt and optimize an intervention during implementation. These methods are demonstrated through the example of optimizing an effective online handwashing intervention called Germ Defense. Methods: Three revised versions of the intervention were rapidly optimized and launched within short timeframes of 1-2 months. Optimisations were informed by: regular stakeholder engagement; emerging scientific evidence, and changing government guidance; rapid qualitative research (telephone think-aloud interviews and open-text surveys), and analyses of usage data. All feedback was rapidly collated, using the Table of Changes method from the Person-Based Approach to prioritize potential optimisations in terms of their likely impact on behavior change. Written feedback from stakeholders on each new iteration of the intervention also informed specific optimisations of the content. Results: Working closely with clinical stakeholders ensured that the intervention was clinically accurate, for example, confirming that information about transmission and exposure was consistent with evidence. Patient and Public Involvement (PPI) contributors identified important clarifications to intervention content, such as whether Covid-19 can be transmitted via air as well as surfaces, and ensured that information about difficult behaviors (such as self-isolation) was supportive and feasible. Iterative updates were made in line with emerging evidence, including changes to the information about face-coverings and opening windows. Qualitative research provided insights into barriers to engaging with the intervention and target behaviors, with open-text surveys providing a useful supplement to detailed think-aloud interviews. Usage data helped identify common points of disengagement, which guided decisions about optimisations. The Table of Changes was modified to facilitate rapid collation and prioritization of multiple sources of feedback to inform optimisations. Engagement with PPI informed the optimisation process. Conclusions: Rapid optimisation methods of this kind may in future be used to help improve the speed and efficiency of adaptation, optimization, and implementation of interventions, in line with calls for more rapid, pragmatic health research methods.

[Establishing evidence-based prevention and health promotion: criteria for evidence-based interventions and necessary organizational requirements and capacities]

Für die Umsetzung des Präventionsgesetzes in einem sich entwickelnden System Prävention und Gesundheitsförderung (PGF) ist die Anforderung der Evidenzbasierung formuliert. Vor diesem Hintergrund stellt sich die Frage, welche Schritte, Prozesse und Vorgehensweisen in diesem System benötigt werden, um der Anforderung zunehmend gerecht zu werden. Dieser Übersichtsartikel diskutiert für Deutschland, wie evidenzbasierte Maßnahmen in der Praxis operationalisiert werden können und welche organisationalen Rahmenbedingungen und Kapazitäten für ein evidenzbasiertes Handeln von AkteurInnen notwendig sind.

Aufbauend auf internationalen wissenschaftlichen Erkenntnissen und dem Memorandum Evidenzbasierte Prävention und Gesundheitsförderung der Bundeszentrale für gesundheitliche Aufklärung (BZgA) wird zunächst das Verständnis von evidenzbasierten Maßnahmen erläutert und im Weiteren werden Elemente zur Umsetzung von mehr Evidenzbasierung skizziert.

Neben der transparenten und einheitlichen Darstellung in Datenbanken und Empfehlungen ist es notwendig, bei EntscheidungsträgerInnen in Praxis und Politik ein gemeinsames Verständnis von evidenzbasierten Interventionen und von Anforderungen für eine Evaluation, die Evidenzbasierung sichert, zu schaffen. Darüber hinaus kann evidenzbasiertes Handeln von EntscheidungsträgerInnen gefördert werden durch Wertschätzung gegenüber Evidenzbasierung in ihren Organisationen, durch Gewährleistung eines regelhaften Zugangs zu Evidenzdatenbanken, durch verbesserte Kompetenzen in Bezug auf Interpretation von Evidenz und durch eine systematische Zusammenarbeit mit der Wissenschaft.

Mehr Evidenzbasierung ist eine Voraussetzung für die nachhaltige Verankerung von PGF als fünfte Säule des Gesundheitssystems.

Sports Injury Prevention is Complex: We Need to Invest in Better Processes, Not Singular Solutions

In recent years, an understanding has developed that sports injuries are the emergent outcomes of complex, dynamic systems. Thus, the influence of local contextual factors on injury outcomes is increasingly being acknowledged. These realisations place injury prevention research at a crossroads. Currently, injury prevention researchers develop universally applicable injury prevention solutions, but the adoption of these solutions in practice is low. This occurs because implementation contexts are both unique and dynamic in nature, and as a result singular, static solutions are often incompatible. In contrast, practitioners address injury prevention through iterative cycles of trial and error, aiming to optimise the injury prevention process within their own unique contexts. The purpose of this critical review is to draw attention to the misalignment between research and practice-based approaches to injury prevention. In light of this, we propose alternative research approaches that acknowledge the process-driven nature of injury prevention in practice. We propose that a core focus of sport injury prevention research should be to provide practitioners with useful and relevant information to support their decision making around their localised injury prevention practice. Through this approach, injury prevention research ceases to be about what works, and begins to engage with understanding what works in what contexts and why?

Context matters when implementing patient centred rehabilitation models for persons with cognitive impairment: a case study

Background

There is a growing number of older adults with cognitive impairment (CI) that require inpatient rehabilitation, and as such patient centred rehabilitation models have been developed. However, implementing evidence-based models without attending to the fit of the model to the new context could lead to an unsuccessful outcome. Researchers collaborated with administrators and staff in one rural site to adapt a patient centred rehabilitation model of care in the Canadian province of Ontario. This paper reports on the contextual factors that influenced the implementation of the model of care.

Methods

The study takes a case study approach. One rural facility was purposefully selected for its interest in offering rehabilitation to persons with CI. Four focus group discussions were conducted to explore healthcare professionals’ perceptions on the contextual factors that could affect the implementation of the rehabilitation model of care in the facility. Twenty-seven professionals with various backgrounds were purposively sampled using a maximum diversity sampling strategy. A hybrid inductive-deductive approach was used to analyze the data using the Context and Implementation of Complex Interventions (CICI) Framework.

Results

Across the domains of the CICI framework, three domains (political, epidemiological, and geographical) and seven corresponding sub-domains of the context were found to have a major influence on the implementation process. Key elements within the political domain included effective teamwork, facilitation, adequate resources, effective communication strategies, and a vision for change. Within the epidemiological domain, a key element was knowing how to tailor rehabilitation approaches for persons with CI. Infrastructure, an aspect of the geographical domain, focused on the facility’s physical layout that required attention.

Conclusions

The CICI framework was a useful guide to identify key factors within the context that existed and were required to fully support the implementation of the model of care in a new environment. The findings suggest that when implementing a new program of care, strong consideration should be paid to the political, epidemiological, and geographical domains of the context and how they interact and influence one another.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06206-9.

Adapting evidence-informed population health interventions for new contexts: a scoping review of current practice

BACKGROUND

Implementing evidence-informed population health interventions in new contexts often requires adaptations. While the need to adapt interventions to better fit new contexts is recognised, uncertainties remain regarding why and when to adapt (or not), and how to assess the benefits (or not) of adaptation. The ADAPT Study aims to develop comprehensive guidance on adaptation. This scoping review informs guidance development by mapping and exploring how adaptation has been undertaken in practice, in public health and health services research.

METHODS

We searched seven databases from January 2000 and October 2018 to identify eligible studies for this scoping review and a related systematic review of adaptation guidance. We mapped the studies of adaptation by coding data from all eligible studies describing the methods, contexts, and interventions considered for adaptation. From this map, we selected a sample of studies for in-depth examination. Two reviewers extracted data independently into seven categories: description, key concepts, types, rationale, processes, evaluation methods, evaluation justification, and accounts of failures and successes.

RESULTS

We retrieved 6694 unique records. From 429 records screened at full text, we identified 298 eligible studies for mapping and selected 28 studies for in-depth examination. The majority of studies in our map focused on micro- (i.e., individual-) level interventions (84%), related to transferring an intervention to a new population group within the same country (62%) and did not report using guidance (73%). Studies covered a range of topic areas, including health behaviour (24%), mental health (19%), sexual health (16%), and parenting and family-centred interventions (15%). Our in-depth analysis showed that adaptation is seen to save costs and time relative to developing a new intervention, and to enhance contextual relevance and cultural compatibility. It commonly follows a structured process and involves stakeholders to help with decisions on what to adapt, when, and how.

CONCLUSIONS

Adaptation has been undertaken on a range of health topics and largely in line with existing guidance. Significant gaps relate to adaptation of macro- (e.g., national-) level interventions, consideration of programme theories, mechanisms and contexts (i.e., a functional view of interventions), nuances around stakeholder involvement, and evaluation of the adapted interventions. Registration Open Science Framework, 2019, osf.io/udzma.

Care-experienced cHildren and young people's Interventions to improve Mental health and wEll-being outcomes: Systematic review (CHIMES) protocol

INTRODUCTION

The mental health and well-being of children and young people who have been in care (ie, care-experienced) are a priority. There are a range of interventions aimed at addressing these outcomes, but the international evidence-base remains ambiguous. There is a paucity of methodologically robust systematic reviews of intervention effectiveness, with few considering the contextual conditions under which evaluations were conducted. This is important in understanding the potential transferability of the evidence-base across contexts. The present systematic review will adopt a complex systems perspective to synthesise evidence reporting evaluations of mental health and well-being interventions for care-experienced children and young people. It will address impact, equity, cost-effectiveness, context, implementation and acceptability. Stakeholder consultation will prioritise a programme theory, and associated intervention, that may progress to further development and evaluation in the UK.

METHODS AND ANALYSIS

We will search 16 bibliographic databases from 1990 to June 2020. Supplementary searching will include citation tracking, author recommendation, and identification of evidence clusters relevant to included evaluations. The eligible population is children and young people (aged ≤25 years) with experience of being in care. Outcomes are (1) mental, behavioural or neurodevelopmental disorders; (2) subjective well-being; (3) self-harm; suicidal ideation; suicide. Study quality will be appraised with methodologically appropriate tools. We will construct a taxonomy of programme theories and intervention types. Thematic synthesis will be used for qualitative data reporting context, implementation and acceptability. If appropriate, meta-analysis will be conducted with outcome and economic data. Convergent synthesis will be used to integrate syntheses of qualitative and quantitative data.

ETHICS AND DISSEMINATION

We have a comprehensive strategy for engagement with care-experienced children and young people, carers and social care professionals. Dissemination will include academic and non-academic publications and conference presentations. Ethical approval from Cardiff University's School of Social Sciences REC will be obtained if necessary.

PROSPERO REGISTRATION NUMBER

CRD42020177478.

Establishing a Theory-Based Multi-Level Approach for Primary Prevention of Mental Disorders in Young People

The increasing prevalence of mental health disorders and psychosocial distress among young people exceeds the capacity of mental health services. Social and systemic factors determine mental health as much as individual factors. To determine how best to address multi-level risk factors, we must first understand the distribution of risk. Previously, we have used psychometric methods applied to two epidemiologically-principled samples of people aged 14-24 to establish a robust, latent common mental distress (CMD) factor of depression and anxiety normally distributed across the population. This was linearly associated with suicidal thoughts and non-suicidal self-harm such that effective interventions to reduce CMD across the whole population could have a greater total benefit than those that focus on the minority with the most severe scores. In a randomised trial of mindfulness interventions in university students (the Mindful Student Study), we demonstrated a population-shift effect whereby the intervention group appeared resilient to a universal stressor. Given these findings, and in light of the COVID-19 pandemic, we argue that population-based interventions to reduce CMD are urgently required. To target all types of mental health determinants, these interventions must be multi-level. Careful design and evaluation, interdisciplinary work, and extensive local stakeholder involvement are crucial for these interventions to be effective.

Case study research for better evaluations of complex interventions: rationale and challenges

BACKGROUND

The need for better methods for evaluation in health research has been widely recognised. The 'complexity turn' has drawn attention to the limitations of relying on causal inference from randomised controlled trials alone for understanding whether, and under which conditions, interventions in complex systems improve health services or the public health, and what mechanisms might link interventions and outcomes. We argue that case study research-currently denigrated as poor evidence-is an under-utilised resource for not only providing evidence about context and transferability, but also for helping strengthen causal inferences when pathways between intervention and effects are likely to be non-linear.

MAIN BODY

Case study research, as an overall approach, is based on in-depth explorations of complex phenomena in their natural, or real-life, settings. Empirical case studies typically enable dynamic understanding of complex challenges and provide evidence about causal mechanisms and the necessary and sufficient conditions (contexts) for intervention implementation and effects. This is essential evidence not just for researchers concerned about internal and external validity, but also research users in policy and practice who need to know what the likely effects of complex programmes or interventions will be in their settings. The health sciences have much to learn from scholarship on case study methodology in the social sciences. However, there are multiple challenges in fully exploiting the potential learning from case study research. First are misconceptions that case study research can only provide exploratory or descriptive evidence. Second, there is little consensus about what a case study is, and considerable diversity in how empirical case studies are conducted and reported. Finally, as case study researchers typically (and appropriately) focus on thick description (that captures contextual detail), it can be challenging to identify the key messages related to intervention evaluation from case study reports.

CONCLUSION

Whilst the diversity of published case studies in health services and public health research is rich and productive, we recommend further clarity and specific methodological guidance for those reporting case study research for evaluation audiences.

How can we adapt complex population health interventions for new contexts? Progressing debates and research priorities

INTRODUCTION

The UK Medical Research Council and National Institute for Health Research have funded the ADAPT study (2018-2020), to develop methodological guidance for the adaptation of complex population health interventions for new contexts. While there have been advances in frameworks, there are key theoretical and methodological debates to progress. The ADAPT study convened a panel meeting to identify and enrich these debates. This paper presents the panel's discussions and suggests directions for future research.

METHODS

Sixteen researchers and one policymaker convened for a 1-day meeting in July 2019. The aim was to reflect on emerging study findings (systematic review of adaptation guidance; scoping review of case examples; and qualitative interviews with funders, journal editors, researchers and policymakers), progress theoretical and methodological debates, and consider where innovation may be required to address research gaps.

DISCUSSION

Despite the proliferation of adaptation frameworks, questions remain over the definition of basic concepts (eg, adaptation). The rationale for adaptation, which often focuses on differences between contexts, may lead to adaptation hyperactivity. Equal emphasis should be placed on similarities. Decision-making about intervention modification currently privileges the concept of 'core components', and work is needed to progress the use and operationalisation of 'functional fidelity'. Language and methods must advance to ensure meaningful engagement with diverse stakeholders in adaptation processes. Further guidance is required to assess the extent of re-evaluation required in the new context. A better understanding of different theoretical perspectives, notably complex systems thinking, implementation science and realist evaluation may help in enhancing research on adaptation.

An Evaluation of the Implementation of a UK School-Based Running Program

The adoption of school-based running programs has rapidly increased over the last five years in the UK and globally. However, there is currently a lack of information on how these initiatives are implemented, and whether they are generalizable and/or sustainable. This study evaluated the implementation (including reach, fidelity, and dose) of a school-based running program over seven months to inform future delivery. This observational study used a mixed-method, single-group, before-and-after design strengthened by multiple interim measurements to evaluate the implementation of an optional school-based running program. Five state-funded primary schools in Leicestershire, UK, participated, with 17 teachers and 189 (81 boys (47.4%) and 90 girls (52.6%)) Year 5 pupils (aged 9-10 years) from eight classes. During the 2016/2017 academic year, data were collected via several measures (including interviews, focus groups, observations, questionnaires, and teacher implementation logs) at multiple levels (i.e., school and individual) and at multiple time points during implementation. Follow up qualitative data were also collected during 2017/2018. The school-based running program achieved good reach, with 100% of pupils opting to participate at some point during the academic year. All schools implemented the program with good fidelity, although the level of implementation varied between schools and over time. The average number of sessions held per week ranged from 0.94-3.89 with the average distance accumulated per pupil per week ranging from 0.02 to 2.91 kilometers and boys being more likely than girls to be classed as high-level participators. Despite an initial drop off in participation over time, all schools remained engaged in the program and continued to implement it until the end of the school year. Contextual features (e.g., staff capacity and resources) differed between schools and influenced the quality of implementation and the frequency of delivery. The school-based running program is simple, inexpensive, and versatile and can be implemented by schools with relative ease. However, schools are diverse settings, with unique challenges to ongoing delivery. Thus, planned adaptations, specific to each school's context, are likely necessary to sustain participation in the longer term and should be considered prior to implementation.

Promoting Learning from Null or Negative Results in Prevention Science Trials

There can be a tendency for investigators to disregard or explain away null or negative results in prevention science trials. Examples include not publicizing findings, conducting spurious subgroup analyses, or attributing the outcome post hoc to real or perceived weaknesses in trial design or intervention implementation. This is unhelpful for several reasons, not least that it skews the evidence base, contributes to research “waste”, undermines respect for science, and stifles creativity in intervention development. In this paper, we identify possible policy and practice responses when interventions have null (ineffective) or negative (harmful) results, and argue that these are influenced by: the intervention itself (e.g., stage of gestation, perceived importance); trial design, conduct, and results (e.g., pattern of null/negative effects, internal and external validity); context (e.g., wider evidence base, state of policy); and individual perspectives and interests (e.g., stake in the intervention). We advance several strategies to promote more informative null or negative effect trials and enable learning from such results, focusing on changes to culture, process, intervention design, trial design, and environment.

ADAPT study: adaptation of evidence-informed complex population health interventions for implementation and/or re-evaluation in new contexts: protocol for a Delphi consensus exercise to develop guidance

INTRODUCTION

Complex population health interventions that are effective in one context may not be effective elsewhere, and may even be harmful. As such, an intervention may require adaptation to ensure it fits with a new context. To date, there is no overarching guidance to help researchers to adapt and evaluate interventions in new contexts, and no criteria to support research funders or journals assess proposed or reported adaptations or evaluation. There is limited assistance for policy-makers and practitioners to decide if evidence-informed interventions are appropriate to their context, or if adaptation and further evaluation is needed. This Delphi exercise will contribute to the development of guidance for these communities to support the adaptation, implementation and/or re-evaluation of complex population health interventions in new contexts.

METHODS

We will conduct a Delphi consensus exercise to gather expert opinion from researchers, research funders, journal editors and policy-makers. Expert opinion will be sought on: appropriate definitions and concepts, identifying key methodological considerations and establishing adaptations and processes to be undertaken during adaptation of complex population health interventions in new contexts.

ETHICS AND DISSEMINATION

Ethics approval for the Delphi exercise has been obtained from the University of Glasgow and and the RAND institutional research board. Dissemination of the results of this study will be through peer-reviewed publications, workshops at national and international conferences, and a summary of the guidance developed for key organisations and stakeholders.