Discrepancies between qualitative and quantitative evaluation of randomised controlled trial results: achieving clarity through mixed methods triangulation

MulTI-domain self-management in older People wiTh OstEoarthritis and multi-morbidities: protocol for the TIPTOE randomised controlled trial

BACKGROUND

Four out of five people living with osteoarthritis (OA) also suffer with at least one other long-term health condition. The complex interaction between OA and multiple long-term conditions (MLTCs) can result in difficulties with self-care, restricted mobility, pain, anxiety, depression and reduced quality of life. The aim of the MulTI-domain Self-management in Older People wiTh OstEoarthritis and Multi-Morbidities (TIPTOE) trial is to evaluate the clinical and cost-effectiveness of the Living Well self-management support intervention, co-designed with people living with OA, integrated into usual care, in comparison to usual care alone.

METHODS

TIPTOE is a multi-centre, two-arm, individually randomised controlled trial where 824 individuals over 65 years old with knee and/or hip joint pain from their OA affected joint and at least one other long-term health condition will be randomised to receive either the Living Well Self-Management support intervention or usual care. Eligible participants can self-refer onto the trial via a website or be referred via NHS services across Wales and England. Those randomised to receive the Living Well support intervention will be offered up to six one-to-one coaching sessions with a TIPTOE-trained healthcare practitioner and a co-designed book. Participants will be encouraged to nominate a support person to assist them throughout the study. All participants will complete a series of self-reported outcome measures at baseline and 6- and 12-month follow-up. The primary outcome is symptoms and quality of life as assessed by the Musculoskeletal Health Questionnaire (MSK-HQ). Routine data will be used to evaluate health resource use. A mixed methods process evaluation will be conducted alongside the trial to inform future implementation should the TIPTOE intervention be found both clinically and cost-effective. An embedded 'Study Within A Project' (SWAP) will explore and address barriers to the inclusion of under-served patient groups (e.g. oldest old, low socioeconomic groups, ethnic groups).

DISCUSSION

TIPTOE will evaluate the clinical and cost-effectiveness of a co-designed, living well personalised self-management support intervention for older individuals with knee and/or hip OA and MLTCs. The trial has been designed to maximise inclusivity and access.

TRIAL REGISTRATION

ISRCTN 16024745 . Registered on October 16, 2023.

Acceptability of Four Intervention Components Supporting Medication Adherence in Women with Breast Cancer: a Process Evaluation of a Fractional Factorial Pilot Optimization Trial

Adjuvant endocrine therapy (AET) reduces mortality in early-stage breast cancer, but adherence is low. We developed a multicomponent intervention to support AET adherence comprising: text messages, information leaflet, acceptance and commitment therapy (ACT), and side-effect website. Guided by the multiphase optimization strategy, the intervention components were tested in the ROSETA pilot optimization trial. Our mixed-methods process evaluation investigated component acceptability. The pilot optimization trial used a 24-1 fractional factorial design. Fifty-two women prescribed AET were randomized to one of eight experimental conditions, containing unique component combinations. An acceptability questionnaire was administered 4 months post-randomization, and semi-structured interviews with 20 participants further explored acceptability. Assessments were guided by four constructs of the theoretical framework of acceptability: affective attitude, burden, perceived effectiveness, and coherence. Quantitative and qualitative findings were triangulated to identify agreements/disagreements. There were high overall acceptability scores (median = 14-15/20, range = 11-20). There was agreement between the qualitative and quantitative findings when triangulated. Most participants "liked" or "strongly liked" all components and reported they required low effort to engage in. Between 50% (leaflet) and 65% (SMS) "agreed" or "strongly agreed," it was clear how each component would help adherence. Perceived effectiveness was mixed, with 35.0% (text messages) to 55.6% (ACT) of participants "agreeing" or "strongly agreeing" that each component would improve their adherence. Interview data provided suggestions for improvements. The four components were acceptable to women with breast cancer and will be refined. Mixed-methods and triangulation were useful methodological approaches and could be applied in other optimization trial process evaluations.

A pragmatic cluster randomised controlled trial of air filtration to prevent symptomatic winter respiratory infections (including COVID-19) in care homes (AFRI-c) in England: Trial protocol

BACKGROUND

Respiratory tract infections are readily transmitted in care homes. Airborne transmission of pathogens causing respiratory tract illness is largely unmitigated. Portable high-efficiency-particulate-air (HEPA) filtration units capture microbial particles from the air, but it is unclear whether this is sufficient to reduce infections in care home residents. The Air Filtration to prevent symptomatic winter Respiratory Infections (including COVID-19) in care homes (AFRI-c) randomized controlled trial will determine whether using HEPA filtration units reduces respiratory infection episodes in care home residents.

METHODS

AFRI-c is a cluster randomized controlled trial that will be delivered in residential care homes for older people in England. Ninety-one care homes will be randomised to take part for one winter period. The intervention care homes will receive HEPA filtration units for use in communal areas and private bedrooms. Normal infection control measures will continue in all care homes. Anonymised daily data on symptoms will be collected for up to 30 residents. Ten to 12 of these residents will be invited to consent to a primary care medical notes review and (in intervention homes) to having an air filter switched on in their private room. The primary outcome will be number of symptomatic winter respiratory infection episodes. Secondary outcomes include specific clinical measures of infection, number of falls / near falls, number of laboratory confirmed infections, hospitalisations, staff sickness and cost-effectiveness. A mixed methods process evaluation will assess intervention acceptability and implementation.

DISCUSSION

The results of AFRI-c will provide vital information about whether portable HEPA filtration units reduce symptomatic winter respiratory infections in older care home residents. Findings about effectiveness, fidelity, acceptability and cost-effectiveness will support stakeholders to determine the use of HEPA filtration units as part of infection control policies.

A Hybrid Pragmatic and Factorial Cluster Randomized Controlled Trial for an Anti-racist, Multilevel Intervention to Improve Mental Health Equity in High Schools

Systemic racism is pervasive in US society and disproportionately limits opportunities for education, work, and health for historically marginalized and minoritized racial and ethnic groups, making it an urgent issue of social justice. Because systemic racism is a social determinant of health prevalent across multiple social and institutional structures, it requires multilevel intervention approaches using effective designs and analytic methods to measure and evaluate outcomes. Racism is a fundamental cause of poor health outcomes, including mental health outcomes; thus, mental health services and programs that address racism and discrimination are key to promoting positive mental health of racial and ethnic minority youth. While multilevel interventions are well-suited for improving outcomes like youth mental health disparities, their evaluation poses unique methodological challenges, requiring specialized design and analytic approaches. There has been limited methodological guidance provided to researchers on how to test multilevel interventions using approaches that balance methodological rigor, practicality, and acceptability across stakeholder groups, especially within communities most affected by systemic racism. This paper addresses this gap by providing an example of how to rigorously evaluate a hypothetical, theoretically based, multilevel intervention promoting mental health equity in three US school systems using an anti-racist approach intervening at the macro- (i.e., school system), meso- (i.e., school), and micro- (i.e., family and student) levels to improve mental health in adolescents. We describe the design, sample size considerations, and analytic methods to comprehensively evaluate its effectiveness while exploring the extent to which the components interact synergistically to improve outcomes. The methodological approach proposed can be adapted to other multilevel interventions that include strategies addressing macro-, meso-, and micro-levels of influence.

Autonomy, self-realization, and psychological empowerment: a prospective mixed methods study of the effects of residential immersive life skills programs for youth with physical disabilities

PURPOSE

To examine changes in self-determination associated with youth participation in residential immersive life skills (RILS) programs.

METHOD

In this prospective mixed methods study, the Arc's Self-Determination Scale was administered pre- and post-program, and at 3- and 12-month follow-ups, to 27 RILS youth and a comparison group of 11 youth enrolled in a non-residential life skills program. Ten RILS youth were interviewed 3 and 12 months post-program, with content analysis used to explore changes in autonomy, self-realization, and psychological empowerment.

RESULTS

RILS youth showed statistically significant increases in autonomy immediately after the program, which were maintained one year later, whereas the comparison group displayed increased autonomy only at 3 months post-program. Qualitatively, RILS youth emphasized changes in behavioral autonomy and psychological empowerment 3 months post-program, whereas at one year there was greater emphasis on changes in self-realization. Using a triangulation protocol, the mixed methods data were interpreted as showing agreement regarding changes in autonomy due to intervention, partial agreement regarding self-realization, and dissonance regarding psychological empowerment.

CONCLUSIONS

RILS programs can enhance the autonomy of youth with physical disabilities and contribute to their sense of confidence and understanding of themselves as they move forward in life.

Excellence in Antibiotic Stewardship: A Mixed-Methods Study Comparing High-, Medium-, and Low-Performing Hospitals

BACKGROUND

Despite antibiotic stewardship programs existing in most acute care hospitals, there continues to be variation in appropriate antibiotic use. While existing research examines individual prescriber behavior, contextual reasons for variation are poorly understood.

METHODS

We conducted an explanatory, sequential mixed-methods study of a purposeful sample of 7 hospitals with varying discharge antibiotic overuse. For each hospital, we conducted surveys, document analysis, and semi-structured interviews with antibiotic stewardship and clinical stakeholders. Data were analyzed separately and mixed during the interpretation phase, where each hospital was examined as a case, with findings organized across cases using a strengths, weaknesses, opportunities, and threats framework to identify factors accounting for differences in antibiotic overuse across hospitals.

RESULTS

Surveys included 85 respondents. Interviews included 90 respondents (31 hospitalists, 33 clinical pharmacists, 14 stewardship leaders, 12 hospital leaders). On surveys, clinical pharmacists at hospitals with lower antibiotic overuse were more likely to report feeling: respected by hospitalist colleagues (P = .001), considered valuable team members (P = .001), and comfortable recommending antibiotic changes (P = .02). Based on mixed-methods analysis, hospitals with low antibiotic overuse had 4 distinguishing characteristics: (1) robust knowledge of and access to antibiotic stewardship guidance; (2) high-quality clinical pharmacist-physician relationships; (3) tools and infrastructure to support stewardship; and (4) highly engaged infectious diseases physicians who advocated stewardship principles.

CONCLUSIONS

This mixed-methods study demonstrates the importance of organizational context for high performance in stewardship and suggests that improving antimicrobial stewardship requires attention to knowledge, interactions, and relationships between clinical teams and infrastructure that supports stewardship and team interactions.

Programme theories to describe how different general practitioner service models work in different contexts in or alongside emergency departments (GP-ED): realist evaluation

BACKGROUND

Addressing increasing patient demand and improving ED patient flow is a key ambition for NHS England. Delivering general practitioner (GP) services in or alongside EDs (GP-ED) was advocated in 2017 for this reason, supported by £100 million (US$130 million) of capital funding. Current evidence shows no overall improvement in addressing demand and reducing waiting times, but considerable variation in how different service models operate, subject to local context.

METHODS

We conducted mixed-methods analysis using inductive and deductive approaches for qualitative (observations, interviews) and quantitative data (time series analyses of attendances, reattendances, hospital admissions, length of stay) based on previous research using a purposive sample of 13 GP-ED service models (3 inside-integrated, 4 inside-parallel service, 3 outside-onsite and 3 with no GPs) in England and Wales. We used realist methodology to understand the relationship between contexts, mechanisms and outcomes to develop programme theories about how and why different GP-ED service models work.

RESULTS

GP-ED service models are complex, with variation in scope and scale of the service, influenced by individual, departmental and external factors. Quantitative data were of variable quality: overall, no reduction in attendances and waiting times, a mixed picture for hospital admissions and length of hospital stay. Our programme theories describe how the GP-ED service models operate: inside the ED, integrated with patient flow and general ED demand, with a wider GP role than usual primary care; outside the ED, addressing primary care demand with an experienced streaming nurse facilitating the 'right patients' are streamed to the GP; or within the ED as a parallel service with most variability in the level of integration and GP role.

CONCLUSION

GP-ED services are complex . Our programme theories inform recommendations on how services could be modified in particular contexts to address local demand, or whether alternative healthcare services should be considered.

Evaluation of different models of general practitioners working in or alongside emergency departments: a mixed-methods realist evaluation

Background

Emergency healthcare services are under intense pressure to meet increasing patient demands. Many patients presenting to emergency departments could be managed by general practitioners in general practitioner-emergency department service models.

Objectives

To evaluate the effectiveness, safety, patient experience and system implications of the different general practitioner-emergency department models.

Design

Mixed-methods realist evaluation.

Methods

Phase 1 (2017-8), to understand current practice: rapid realist literature review, national survey and follow-up key informant interviews, national stakeholder event and safety data analysis. Phase 2 (2018-21), to collect and analyse qualitative (observations, interviews) and quantitative data (time series analysis); cost-consequences analysis of routine data; and case site data for 'marker condition' analysis from a purposive sample of 13 case sites in England and Wales. Phase 3 (2021-2), to conduct mixed-methods analysis for programme theory and toolkit development.

Results

General practitioners commonly work in emergency departments, but delivery models vary widely in terms of the scope of the general practitioner role and the scale of the general practitioner service. We developed a taxonomy to describe general practitioner-emergency department service models (Integrated with the emergency department service, Parallel within the emergency department, Outside the emergency department on the hospital site) and present a programme theory as principal output of the study to describe how these service models were observed to operate. Routine data were of variable quality, limiting our analysis. Time series analysis demonstrated trends across intervention sites for: increased time spent in the emergency department; increased emergency department attendances and reattendances; and mixed results for hospital admissions. Evidence on patient experience was limited but broadly supportive; we identified department-level processes to optimise the safety of general practitioner-emergency department models.

Limitations

The quality, heterogeneity and extent of routine emergency department data collection during the study period limited the conclusions. Recruitment was limited by criteria for case sites (time series requirements) and individual patients (with 'marker conditions'). Pandemic and other pressures limited data collection for marker condition analysis. Data collected and analysed were pre pandemic; new approaches such as 'telephone first' and their relevance to our findings remains unexplored.

Conclusion

Findings suggest that general practitioner-emergency department service models do not meet the aim of reducing the overall emergency department waiting times and improving patient flow with limited evidence of cost savings. Qualitative data indicated that general practitioners were often valued as members of the wider emergency department team. We have developed a toolkit, based on our findings, to provide guidance for implementing and delivering general practitioner-emergency department services.

Future work

The emergency care data set has since been introduced across England to help standardise data collection to facilitate further research. We would advocate the systematic capture of patient experience measures and patient-reported outcome measures as part of routine care. More could be done to support the development of the general practitioner in emergency department role, including a core set of competencies and governance structure, to reflect the different general practitioner-emergency department models and to evaluate the effectiveness and cost effectiveness to guide future policy.

Study registration

This study is registered as PROSPERO CRD42017069741.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 15/145/04) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 10. See the NIHR Funding and Awards website for further award information.

Reducing the risk of criminal exploitation using multi-systemic therapy (the RESET Study): study protocol for a feasibility study and process evaluation

BACKGROUND

Child criminal exploitation is a form of child abuse that poses a serious risk to the welfare, safety, and wellbeing of young people. Multisystemic therapy (MST) is an intensive family and community-based intervention for young people with anti-social behavioral problems, many of whom will be at risk of criminal exploitation. This protocol describes a pilot feasibility study and process evaluation, designed to examine MST for children at risk of criminal exploitation.

METHODS

This pilot feasibility study and process evaluation involves two phases with associated subphases: phase 1.1 involved the collaborative refinement of the logic model adapting MST for children at risk of criminal exploitation; phase 1.2 involved pre-pilot interviews with MST therapists, families, and young people; phase 2.1 is a pilot modeling study of MST for children at risk of criminal exploitation, and; Phase 2.2 is a process evaluation that will involve interviewing stakeholders, MST therapists and employees, families, and young people. The dataset for the process evaluation will include questionnaires completed by parents and young people at baseline, mid-treatment, end of treatment, and 6 months after treatment. We will supplement these data with participant-level data linkage from MST sites and services.

RESULTS

Accrual to the pilot stage of this project opened on 6th August 2021 and is due to close on 31st May 2022. We aim to publish the results of this feasibility study and process evaluation in 2023.

CONCLUSIONS

The results of this feasibility study and process evaluation will inform the decision as to whether it is advisable to progress to a pilot clinical trial of MST for children at risk of criminal exploitation.

TRIAL REGISTRATION

Trial registration: ISRCTN registry, ISRCTN16164816 on 25th January 2021- https://doi.org/10.1186/ISRCTN16164816 .

Behavioral Activation for Comorbid Depression in People With Noncommunicable Disease in India: Protocol for a Randomized Controlled Feasibility Trial

BACKGROUND

The increasing burden of depression and noncommunicable disease (NCD) is a global challenge, especially in low- and middle-income countries, considering the resource constraints and lack of trained human resources in these settings. Effective treatment of depression in people with NCDs has the potential to enhance both the mental and physical well-being of this population. It will also result in the effective use of the available health care resources. Brief psychological therapies, such as behavioral activation (BA), are effective for the treatment of depression. BA has not been adapted in the community health care services of India, and the feasibility of using BA as an intervention for depression in NCD and its effectiveness in these settings have not been systematically evaluated.

OBJECTIVE

Our objective is to adapt BA for the Indian NCD context and test the acceptability, feasibility, and implementation of the adapted BA intervention (BEACON intervention package [BIP]). Additionally, we aim to test the feasibility of a randomized controlled trial evaluation of BIP for the treatment of depression compared with enhanced usual care.

METHODS

Following well-established frameworks for intervention adaptation, we first adapted BA (to fit the linguistic, cultural, and resource context) for delivery in India. The intervention was also adapted for potential remote delivery by telephone. In a randomized controlled trial, we will be testing the acceptability, feasibility, and implementation of the adapted BA intervention (BIP). We shall also test if a randomized controlled feasibility trial can be delivered effectively and estimate important parameters (eg, recruitment and retention rates and completeness of follow-up) needed to design a future definitive trial.

RESULTS

Following the receipt of approval from all the relevant agencies, the development of the BIP was started on November 28, 2020, and completed on August 18, 2021, and the quantitative data collection was started on August 23, 2021, and completed on December 10, 2021. Process evaluation (qualitative data) collection is ongoing. Both the qualitative and quantitative data analyses are ongoing.

CONCLUSIONS

This study may offer insights that could help in closing the gap in the treatment of common mental illness, particularly in nations with limited resources, infrastructure, and systems such as India. To close this gap, BEACON tries to provide BA for depression in NCDs through qualified NCD (BA) counselors integrated within the state-run NCD clinics. The results of this study may aid in understanding whether BA as an intervention is acceptable for the population and how feasible it will be to deliver such interventions for depression in NCD in South Asian countries such as India. The BIP may also be used in the future by Indian community clinics as a brief intervention program.

TRIAL REGISTRATION

Clinical Trials Registry of India CTRI/2020/05/025048; https://tinyurl.com/mpt33jv5.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/41127.

Applying machine-learning to rapidly analyze large qualitative text datasets to inform the COVID-19 pandemic response: comparing human and machine-assisted topic analysis techniques

Introduction

Machine-assisted topic analysis (MATA) uses artificial intelligence methods to help qualitative researchers analyze large datasets. This is useful for researchers to rapidly update healthcare interventions during changing healthcare contexts, such as a pandemic. We examined the potential to support healthcare interventions by comparing MATA with "human-only" thematic analysis techniques on the same dataset (1,472 user responses from a COVID-19 behavioral intervention).

Methods

In MATA, an unsupervised topic-modeling approach identified latent topics in the text, from which researchers identified broad themes. In human-only codebook analysis, researchers developed an initial codebook based on previous research that was applied to the dataset by the team, who met regularly to discuss and refine the codes. Formal triangulation using a "convergence coding matrix" compared findings between methods, categorizing them as "agreement", "complementary", "dissonant", or "silent".

Results

Human analysis took much longer than MATA (147.5 vs. 40 h). Both methods identified key themes about what users found helpful and unhelpful. Formal triangulation showed both sets of findings were highly similar. The formal triangulation showed high similarity between the findings. All MATA codes were classified as in agreement or complementary to the human themes. When findings differed slightly, this was due to human researcher interpretations or nuance from human-only analysis.

Discussion

Results produced by MATA were similar to human-only thematic analysis, with substantial time savings. For simple analyses that do not require an in-depth or subtle understanding of the data, MATA is a useful tool that can support qualitative researchers to interpret and analyze large datasets quickly. This approach can support intervention development and implementation, such as enabling rapid optimization during public health emergencies.

Factors That Enhance and Hinder the Retention and Transfer of Online Pre-Clinical Skills Training to Facilitate Blended Learning

Purpose

During the SARS-CoV-2 pandemic, various online instructional strategies in clinical skills training were piloted. The sudden transition to the remote platform circumvented the rigorous planning associated with curriculum reform. This study aimed to explore students' and tutors' perceptions of factors that promoted or hindered successful learning transfer and to propose a blended conceptual model to guide affective, cognitive, and psychomotor clinical skills training in the pre-clinical phase of medical education.

Methods

A mixed-method quasi-experimental study assessed third-year students' transfer of clinical skills and knowledge following online learning in 2021. Students and their tutors completed online surveys that included open and closed-ended questions regarding factors influencing their experience of the adapted teaching methods. Descriptive statistical analysis was used for the quantitative data. Qualitative responses were thematically analyzed.

Results

One hundred fourteen students (48%) and seven tutors (100%) responded to the surveys. The questionnaires' internal consistency and construct validity were determined using Cronbach's α-Coefficient. There was an overall positive response (86%) to the acceptability of the online platform in clinical skills training. Using online simulations with targeted onsite practice was reported as effective in clinical skills training. Tutors perceived students as well-prepared for the skills laboratory. Five emergent themes, qualified by a linear model of asynchronous and synchronous online and onsite teaching with the evaluation of the instructional design and institutional support, informed the proposed blended learning guide for clinical skills training in the pre-clinical phase.

Conclusion

Blended clinical skills learning that included the flipped classroom concept was well-accepted. Virtual patients proved a convenient cognitive preparation tool for skills training and potentially optimized teaching delivery. The study found that the adapted teaching frameworks incorporating an online clinical skills component into a modified onsite curriculum augmented learners' ability to transfer knowledge to the clinical skills laboratory. An integrated five-step blended model is proposed for future interventions.

Inclusion of adults with conditions that have the potential to affect capacity and or communication in research: triangulation from a mixed-methods study of current practice and values across multiple stakeholders

OBJECTIVES

We aimed to: (A) describe researcher decision-making when including or excluding adults with conditions that have the potential to affect capacity and/or communication in research and (B) explore the underlying values and reasoning of stakeholders in research which falls under the provisions of the Mental Capacity Act, 2005.

DESIGN

The mixed-methods design included semistructured interviews with adults with conditions that have the potential to affect capacity and/or communication, supporters, researchers, research ethics committee members and an online survey with researchers. Triangulation was used to integrate the data and examine the complementarity of the findings.

SETTING

England and Wales.

PARTICIPANTS

There were 61 participants who took part in semistructured interviews, of which 39 were adults with conditions with potential to affect capacity and/or communication, 6 were in support roles for adults with conditions with potential to affect capacity and/or communication (including family members and professionals in advocacy organisations), 8 were members of research ethics committees flagged under the Mental Capacity Act to review research where there could be issues of mental capacity and 8 were researchers with experience of working with adults with conditions that have the potential to affect capacity and/or communication. The online survey had 128 participants, researchers with experience of working with adults with conditions that have the potential to affect capacity and/or communication.

RESULTS

All stakeholders were supportive of the genuine inclusion of adults with conditions that have the potential to affect capacity and/or communication in research, and exclusion was seen as a form of discrimination. Many researchers were daunted by meeting the threshold within the legislation for including participants who may lack capacity.

CONCLUSION

Further training, expertise and resources are required to promote the successful inclusion in research of adults with conditions that have the potential to affect capacity and/or communication.

Understanding tailoring to support the implementation of evidence-based interventions in healthcare: The CUSTOMISE research programme protocol

Although there are effective evidence-based interventions (EBIs) to prevent, treat and coordinate care for chronic conditions they may not be adopted widely and when adopted, implementation challenges can limit their impact.  Implementation strategies are "methods or techniques used to enhance the adoption, implementation, and sustainment of a clinical program or practice". There is some evidence to suggest that to be more effective,  strategies should be tailored; that is, selected and designed to address specific determinants which may influence implementation in a given context. Despite the growing popularity of tailoring the concept is ill-defined, and the way in which tailoring is applied can vary across studies or lack detail when reported. There has been less focus on the part of tailoring where stakeholders prioritise determinants and select strategies, and the way in which theory, evidence and stakeholders' perspectives should be combined to make decisions during the process. Typically, tailoring is evaluated based on the effectiveness of the tailored strategy, we do not have a clear sense of the mechanisms through which tailoring works, or how to measure the "success" of the tailoring process. We lack an understanding of how stakeholders can be involved effectively in tailoring and the influence of different approaches on the outcome of tailoring. Our research programme, CUSTOMISE (Comparing and Understanding Tailoring Methods for Implementation Strategies in healthcare) will address some of these outstanding questions and generate evidence on  the feasibility, acceptability, and efficiency of different tailoring approaches, and build capacity in implementation science in Ireland, developing and delivering training and supports for, and network of, researchers and implementation practitioners. The evidence generated across the studies conducted as part of CUSTOMISE will bring greater clarity, consistency, coherence, and transparency to tailoring, a key process in implementation science.

Experiencing COVID-19, home isolation and primary health care: A mixed-methods study

Objectives

Although the vast majority of COVID-19 cases are treated in primary care, patients' experiences during home isolation have been little studied. This study aimed to explore the experiences of patients with acute COVID-19 and to identify challenges after the initial adaptation of the German health system to the pandemic (after first infection wave from February to June 2020).

Methods

A mixed-method convergent design was used to gain a holistic insight into patients experience. The study consisted of a cross-sectional survey, open survey answers and semi-structured telephone interviews. Descriptive analysis was performed on quantitative survey answers. Between group differences were calculated to explore changes after the first infection wave. Qualitative thematic analysis was conducted on open survey answers and interviews. The results were then compared within a triangulation protocol.

Results

A total of 1100 participants from all German states were recruited by 145 general practitioners from August 2020 to April 2021, 42 additionally took part in qualitative interviews. Disease onset varied from February 2020 to April 2021. After the first infection wave, more participants were tested positive during the acute disease (88.8%; 95.2%; P < 0.001). Waiting times for tests (mean 4.5 days, SD 4.1; 2.7days, SD 2.6, P < 0.001) and test results (mean 2.4 days, SD 1.9; 1.8 days, SD 1.3, P < 0.001) decreased. Qualitative results indicated that the availability of repeated testing and antigen tests reduced insecurities, transmission and related guilt. Although personal consultations at general practices increased (6.8%; 15.5%, P < 0.001), telephone consultation remained the main mode of consultation (78.5%) and video remained insignificant (1.9%). The course of disease, the living situation and social surroundings during isolation, access to health care, personal resilience, spirituality and feelings of guilt and worries emerged as themes influencing the illness experience. Challenges were contact management and adequate provision of care during home isolation. A constant contact person within the health system helped against feelings of care deprivation, uncertainty and fear.

Conclusions

Our study highlights that home isolation of individuals with COVID-19 requires a holistic approach that considers all aspects of patient care and effective coordination between different care providers.

Development, implementation and evaluation of the digital transformation of renal services in Wales: the journey from local to national

BACKGROUND

Treatment for people with kidney disease is often associated with complicated combinations of medicines. Logistical challenges with traditiona paper-based prescribing means that these patients are particularly susceptible to medication-relation errors and harm.

AIM

To improve the quality of care that people with kidney disease receive across Wales through a Value-Based digital transformation programme.

SETTING

Renal units within the National Welsh Renal Clinical Network (WRCN).

DEVELOPMENT

A novel Electronic Prescribing & Medicines Administration (EPMA) system, integrated into a patient care record and linked to a patient portal was developed in South West Wales (SWW) region of the WRCN, enabled by the Welsh Government (WG) Efficiency Through Technology Fund. National upscale was enabled through the WG Transformation Fund.

IMPLEMENTATION

EPMA was designed and rolled out initially in SWW region of the WRCN (2018). A dedicated delivery team used the blueprint to finalise and implement a strategy for successful national roll-out eventually across all Wales (completed 2021).

EVALUATION

A multi-factorial approach was employed, as both the technology itself and the healthcare system within which it would be introduced, were complex. Continuous cycles of action research involving informal and formal qualitative interviews with service-users ensured that EPMA was accessible and optimally engaging to all target stakeholders (patients and staff). Results confirmed that EPMA was successful in improving the quality of care that people with kidney disease receive across Wales, contributed to Value-Based outcomes, and put people who deliver and access care at the heart of transformation.

CONCLUSION

Key findings of this study align directly with the national design principles to drive change and transformation, put forward by the WG in their plan for Health and Social Care: prevention and early intervention; safety; independence; voice; seamless care.

What do we want to get out of this? a critical interpretive synthesis of the value of process evaluations, with a practical planning framework

BACKGROUND

Process evaluations aim to understand how complex interventions bring about outcomes by examining intervention mechanisms, implementation, and context. While much attention has been paid to the methodology of process evaluations in health research, the value of process evaluations has received less critical attention. We aimed to unpack how value is conceptualised in process evaluations by identifying and critically analysing 1) how process evaluations may create value and 2) what kind of value they may create.

METHODS

We systematically searched for and identified published literature on process evaluation, including guidance, opinion pieces, primary research, reviews, and discussion of methodological and practical issues. We conducted a critical interpretive synthesis and developed a practical planning framework.

RESULTS

We identified and included 147 literature items. From these we determined three ways in which process evaluations may create value or negative consequences: 1) through the socio-technical processes of 'doing' the process evaluation, 2) through the features/qualities of process evaluation knowledge, and 3) through using process evaluation knowledge. We identified 15 value themes. We also found that value varies according to the characteristics of individual process evaluations, and is subjective and context dependent.

CONCLUSION

The concept of value in process evaluations is complex and multi-faceted. Stakeholders in different contexts may have very different expectations of process evaluations and the value that can and should be obtained from them. We propose a planning framework to support an open and transparent process to plan and create value from process evaluations and negotiate trade-offs. This will support the development of joint solutions and, ultimately, generate more value from process evaluations to all.

Complex multidisciplinary intervention to improve Initial Medication Adherence to cardiovascular disease and diabetes treatments in primary care (the IMA-cRCT study): mixed-methods process evaluation protocol

INTRODUCTION

Medication non-initiation, or primary non-adherence, is a persistent public health problem that increases the risk of adverse clinical outcomes. The initial medication adherence (IMA) intervention is a complex multidisciplinary intervention to improve adherence to cardiovascular and diabetes treatments in primary care by empowering the patient and promoting informed prescriptions based on shared decision-making. This paper presents the development and implementation strategy of the IMA intervention and the process evaluation protocol embedded in a cluster randomised controlled trial (the IMA-cRCT) to understand and interpret the outcomes of the trial and comprehend the extent of implementation and fidelity, the active mechanisms of the IMA intervention and in what context the intervention is implemented and works.

METHODS AND ANALYSIS

We present the protocol for a mixed-methods process evaluation including quantitative and qualitative methods to measure implementation and fidelity and to explore the active mechanisms and the interactions between the intervention, participants and its context. The process evaluation will be conducted in primary care centres and community pharmacies from the IMA-cRCT, and participants include healthcare professionals (general practitioners, nurses and community pharmacists) as well as patients. Quantitative data collection methods include data extraction from the intervention operative records, patient clinical records and participant feedback questionnaires, whereas qualitative data collection involves semistructured interviews, focus groups and field diaries. Quantitative and qualitative data will be analysed separately and triangulated to produce deeper insights and robust results.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Research Ethics Comittee (CEIm) at IDIAP Jordi Gol (codeCEIm 21/051 P). Findings will be disseminated through publications and conferences, as well as presentations to healthcare professionals and stakeholders from healthcare organisations.

TRIAL REGISTRATION NUMBER

NCT05026775.

Nationwide implementation of online communication skills training to reduce overprescribing of antibiotics: a stepped-wedge cluster randomized trial in general practice

Objectives

Primary care is responsible for a large proportion of unnecessary antibiotic use, which is one of the main drivers of antibiotic resistance. Randomized trials have found that online communication skills training for GPs reduces antibiotic prescribing for respiratory infections. This study assesses the real-world effect of implementing online communication skills training in general practice.

Methods

In a closed cohort stepped-wedge cluster randomized trial all Belgian GPs were invited to participate in online communication skills training courses (TRACE and INTRO) and provided with linked patient information booklets. The primary outcome was the antibiotic prescribing rate per 1000 patient contacts. Intention-to-treat and per protocol analyses were performed. Trial registration at ClinicalTrials.gov: NCT03265028.

Results

In total, 118 487 observations from 10 375 GPs were included in the analysis. Overall, 299 (2.88%) GPs completed TRACE and 93 (0.90%) completed INTRO, 30 of which completed both. There was no effect of the national implementation of TRACE and INTRO on the population-level antibiotic prescribing rate (prescribing rate ratio [PRR] = 0.99 [95% CI: 0.97–1.02]). GPs who actually completed TRACE prescribed fewer antibiotic prescriptions (PRR = 0.93 [95% CI: 0.90–0.95]).

Conclusions

Inviting GPs to complete an online communication skills training course and providing them with the linked patient information booklets did not reduce antibiotic prescribing. However, GPs who completed TRACE prescribed 7% fewer antibiotics, especially during winter. This suggests a significant decrease in population-wide antibiotic consumption could be achieved by focusing on increasing the uptake of this intervention by identifying and overcoming barriers to participation.

How can behavioural science contribute to qualitative research on antimicrobial stewardship in primary care?

Antibiotic use (and misuse) accelerates antimicrobial resistance (AMR), and addressing this complex problem necessitates behaviour change related to infection prevention and management and to antibiotic prescribing and use. As most antibiotic courses are prescribed in primary care, a key focus of antimicrobial stewardship (AMS) is on changing behaviours outside of hospital. Behavioural science draws on behaviour change theories, techniques and methods developed in health psychology, and can be used to help understand and change behaviours related to AMR/AMS. Qualitative methodologies can be used together with a behavioural science approach to explore influences on behaviour and develop and evaluate behavioural interventions. This paper provides an overview of how the behavioural science approach, together with qualitative methods, can contribute and add value to AMS projects. First, it introduces and explains the relevance of the behavioural science approach to AMR/AMS. Second, it provides an overview of behaviour change 'tools': behaviour change theories/models, behavioural determinants and behaviour change techniques. Third, it explains how behavioural methods can be used to: (i) define a clinical problem in behavioural terms and identify behavioural influences; (ii) develop and implement behavioural AMS interventions; and (iii) evaluate them. These are illustrated with examples of using qualitative methods in AMS studies in primary care. Finally, the paper concludes by summarizing the main contributions of taking the behavioural science approach to qualitative AMS research in primary care and discussing the key implications and future directions for research and practice.

HALO: Study protocol for a single-case experimental design study evaluating the moderating impact of a befriending intervention on the association between loneliness and health in older adults

Background: Loneliness in later life is often addressed with befriending interventions, yet evidence for their effectiveness is limited. Meanwhile it is known that loneliness has a deleterious impact on health. The aim of the study is to evaluate whether a befriending service for older adults mitigates the impact of loneliness on health outcomes, and to identify mechanisms through which befriending interventions might impact upon health. Methods: A mixed methods design is used. The quantitative component utilises an AB single-case experimental design, to gather intensive longitudinal data. These data will be analysed using a generalised additive modelling approach. The qualitative component of the study uses semi-structured dyadic interviews, structured and analysed according to the principles of constructivist grounded theory. Findings will then be triangulated according to an existing mixed methods integration protocol. Discussion: This mixed methods design has the potential to inform national and international policy in relation to befriending interventions for older adults. In addition, there is the potential for study results to inform our theoretical understanding of the nature of the relationship between loneliness and health. Trial registration: ClinicalTrials.gov identifier NCT04301167 (10 th March 2020). Protocol version 1.1, 26 th June 2020.

Using Integrative Career Construction Counselling to Promote Autobiographicity and Transform Tension into Intention and Action

This article reports on the use of integrative career counselling to promote autobiographical reasoning in a purposively sampled gifted 16-year-old female learner with moratorium career identity status. I implemented an explanatory, mixed-methods (QUALITATIVE-quantitative; uppercase denoting the bigger weighting given to the qualitative aspect) research design and used qualitative and quantitative career construction counselling techniques and methods and quantitative career construction counselling techniques and methods and strategies to construct data. The Maree Career Matrix (MCM) was used to gather the participant’s career interests (“scores”) quantitatively, and the Career Interest Profile (CIP) was used to elicit her micro-narratives (“stories”) qualitatively. An adapted version of thematic data analysis was used to analyse the data. The intervention promoted the participant’s (self-)reflection and reflexivity, transformed her tension into intention, led to an increase in her career options, and helped her revitalise her sense of meaning, purpose, and positivity. While the findings are encouraging, future (longitudinal) research is needed to establish the long-term influence of the intervention espoused here.

Brain-In-Hand technology for adults with acquired brain injury: A convergence of mixed methods findings

Introduction

Individuals with acquired brain injury may find it difficult to self-manage and live independently. Brain-in-Hand is a smartphone app designed to support psychological problems and encourage behaviour change, comprised of a structured diary, reminders, agreed solutions, and traffic light monitoring system.

Aim

To evaluate the potential use and effectiveness of Brain-in-Hand for self-management in adults with acquired brain injury.

Methods

A-B mixed-methods case-study design. Individuals with acquired brain injury ( n = 10) received Brain-in-Hand for up to 12 months. Measures of mood, independence, quality of life, cognition, fatigue, goal attainment, participation administered at baseline, 6 and 12 months. Semi-structured interviews conducted with acquired brain injury participants ( n = 9) and healthcare workers ( n = 3) at 6 months.

Results

Significant increase in goal attainment after 6 months use (t(7) = 4.20, p = .004). No significant improvement in other outcomes. Qualitative data suggested improvement in anxiety management. Contextual (personal/environmental) factors were key in influencing the use and effectiveness of Brain-in-Hand. Having sufficient insight, appropriate support and motivation facilitated use.

Conclusions

Brain-in-Hand shows potential to support acquired brain injury, but further work is required to determine its effectiveness. Context played a pivotal role in the effectiveness and sustained use of Brain-in-Hand, and needs to be explored to support implementation.

OUP accepted manuscript

In order to design appropriate antimicrobial stewardship (AMS) programmes, it is crucial to understand challenges to tackling antibiotic resistance (AMR) specific to each healthcare setting. Antibiotic prescribing in primary care accounts for most prescriptions with a significant proportion considered clinically inappropriate. Qualitative research has a long history in social sciences, but its value and contribution are still contested in medical journals including in the AMR/AMS field. However, through its focus on understanding, meaning making and explaining, qualitative research can offer insights in how to improve AMS efforts in primary care. This paper provides an overview of unique considerations, contributions and challenges related to using qualitative research in AMS to help the AMS community new to qualitative research to utilize its potential most fully. First, we discuss specific considerations for AMS in relation to the stages of conducting a qualitative study, including identifying a research question and choosing a suitable methodology; sampling appropriate participants; planning a recruitment strategy; choosing a method of data collection; and conducting data analysis. These are illustrated with examples of qualitative AMS studies in primary care. Second, we highlight the importance of patient and public involvement throughout all stages of the project and ensuring quality in qualitative AMS research. Finally, drawing on these considerations, we make a further case for the value and contribution of qualitative methodologies in AMS/AMR research while outlining future directions for both AMS and qualitative research, including the need for studies with diverse actors; interdisciplinary collaborations; and complex decisions on methodologies and timelines.

How should we evaluate sweetened beverage tax policies? A review of worldwide experience

Over 45 jurisdictions globally have implemented sweetened beverage taxes. Researchers and policymakers need to assess whether and how these taxes change beverage demand and supply, their intended and unanticipated health, economic and equity impacts. Lessons from such evaluations can maximise the policies' success and impact on non-communicable disease prevention globally. We discuss key theoretical, design and methodological considerations to help policymakers, funders and researchers commission and conduct rigorous evaluations of these policies and related disease prevention efforts. We encourage involving the perspectives of various stakeholders on what evaluations are needed given the specific context, what data and methods are appropriate, readily available or can be collected within time and budget constraints. A logic model /conceptual system map of anticipated implications across sectors and scales should help identify optimal study design, analytical techniques and measures. These models should be updated when synthesising findings across diverse methods and integrating findings across subpopulations using similar methods.

Factors Influencing Fidelity to a Calorie Posting Policy in Public Hospitals: A Mixed Methods Study

Background: Labelling menus with nutrition information has increasingly become an important obesity policy option. While much research to-date has focused on determining its effectiveness, few studies report the extent to which menu labelling is implemented as designed. The aim of this study was to explore factors influencing fidelity to a calorie posting policy in Irish acute public hospitals.

Methods: A mixed methods sequential explanatory study design was employed, with a nested case study for the qualitative component. Quantitative data on implementation fidelity at hospitals were analysed first and informed case sampling in the follow-on qualitative phase. Maximum variation sampling was used to select four hospitals with high and low levels of implementation and variation in terms of geographic location, hospital size, complexity of care provided and hospital type. Data were collected using structured observations, unstructured non-participant observations and in-depth semi-structured interviews. The Consolidated Framework for Implementation Research guided qualitative data collection and analysis. Using framework analysis, factors influencing implementation were identified. A triangulation protocol was used to integrate fidelity findings from multiple sources. Data on influencing factors and fidelity were then combined using joint displays for within and cross-case analysis.

Results: Quantitative fidelity data showed seven hospitals were categorised as low implementers and 28 hospitals were high implementers of the policy. Across the four hospitals selected as cases, qualitative analysis revealed factors influencing implementation and fidelity were multiple, and operated independently and in combination. Factors were related to the internal hospital environment (e.g., leadership support, access to knowledge and information, perceived importance of calorie posting implementation), external hospital environment (e.g., national policy, monitoring), features of the calorie posting policy (e.g., availability of supporting materials), and the implementation process (e.g., engaging relevant stakeholders). Integrated analysis of fidelity indicated a pattern of partial adherence to the calorie posting policy across the four hospitals. Across all hospitals, there was a consistent pattern of low adherence to calorie posting across all menu items on sale, low adherence to calorie information displayed per standard portion or per meal, low adherence to standardised recipes/portions, and inaccurate calorie information.

Conclusion: Efforts to maximise fidelity require multi-level, multi-component strategies in order to reduce or mitigate barriers and to leverage facilitators. Future research should examine the relative importance of calorie posting determinants and the association between implementation strategies and shifts in fidelity to intervention core components.

Formative research to design an implementation strategy for a postpartum hemorrhage initial response treatment bundle (E-MOTIVE): study protocol

BACKGROUND

Postpartum hemorrhage (PPH) is the leading cause of maternal death worldwide. When PPH occurs, early identification of bleeding and prompt management using evidence-based guidelines, can avert most PPH-related severe morbidities and deaths. However, adherence to the World Health Organization recommended practices remains a critical challenge. A potential solution to inefficient and inconsistent implementation of evidence-based practices is the application of a 'clinical care bundle' for PPH management. A clinical care bundle is a set of discrete, evidence-based interventions, administered concurrently, or in rapid succession, to every eligible person, along with teamwork, communication, and cooperation. Once triggered, all bundle components must be delivered. The E-MOTIVE project aims to improve the detection and first response management of PPH through the implementation of the "E-MOTIVE" bundle, which consists of (1) Early PPH detection using a calibrated drape, (2) uterine Massage, (3) Oxytocic drugs, (4) Tranexamic acid, (5) Intra Venous fluids, and (6) genital tract Examination and escalation when necessary. The objective of this paper is to describe the protocol for the formative phase of the E-MOTIVE project, which aims to design an implementation strategy to support the uptake of this bundle into practice.

METHODS

We will use behavior change and implementation science frameworks [e.g. capability, opportunity, motivation and behavior (COM-B) and theoretical domains framework (TDF)] to guide data collection and analysis, in Kenya, Nigeria, South Africa, Sri Lanka, and Tanzania. There are four methodological components: qualitative interviews; surveys; systematic reviews; and design workshops. We will triangulate findings across data sources, participant groups, and countries to explore factors influencing current PPH detection and management, and potentially influencing E-MOTIVE bundle implementation. We will use these findings to develop potential strategies to improve implementation, which will be discussed and agreed with key stakeholders from each country in intervention design workshops.

DISCUSSION

This formative protocol outlines our strategy for the systematic development of the E-MOTIVE implementation strategy. This focus on implementation considers what it would take to support roll-out and implementation of the E-MOTIVE bundle. Our approach therefore aims to maximize internal validity in the trial alongside future scalability, and implementation of the E-MOTIVE bundle in routine practice, if proven to be effective.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04341662.

What is good grief support? Exploring the actors and actions in social support after traumatic grief

Social support seems to enhance wellbeing and health in many populations. Conversely, poor social support and loneliness are a social determinant of poor health outcomes and can adversely affect physical, emotional, and mental well-being. Social support is especially important in traumatic grief. However, the ways in which grieving individuals interpret and define social support is not well understood, and little is known about what specific behaviours are perceived as helpful. Using qualitative description and content analysis, this study assessed bereaved individuals’ satisfaction of social support in traumatic grief, using four categories of social support as a framework. Findings suggest inadequate satisfaction from professional, familial, and community support. Pets emerged with the most satisfactory ratings. Further, findings suggest that emotional support is the most desired type of support following traumatic loss. Implications for supporting bereaved individuals within and beyond the context of the COVID-19 pandemic are discussed.

Implementing a digital intervention for managing uncontrolled hypertension in Primary Care: a mixed methods process evaluation

Background

A high proportion of hypertensive patients remain above the target threshold for blood pressure, increasing the risk of adverse health outcomes. A digital intervention to facilitate healthcare practitioners (hereafter practitioners) to initiate planned medication escalations when patients’ home readings were raised was found to be effective in lowering blood pressure over 12 months. This mixed-methods process evaluation aimed to develop a detailed understanding of how the intervention was implemented in Primary Care, possible mechanisms of action and contextual factors influencing implementation.

Methods

One hundred twenty-five practitioners took part in a randomised controlled trial, including GPs, practice nurses, nurse-prescribers, and healthcare assistants. Usage data were collected automatically by the digital intervention and antihypertensive medication changes were recorded from the patients’ medical notes. A sub-sample of 27 practitioners took part in semi-structured qualitative process interviews. The qualitative data were analysed using thematic analysis and the quantitative data using descriptive statistics and correlations to explore factors related to adherence. The two sets of findings were integrated using a triangulation protocol.

Results

Mean practitioner adherence to escalating medication was moderate (53%), and the qualitative analysis suggested that low trust in home readings and the decision to wait for more evidence influenced implementation for some practitioners. The logic model was partially supported in that self-efficacy was related to adherence to medication escalation, but qualitative findings provided further insight into additional potential mechanisms, including perceived necessity and concerns. Contextual factors influencing implementation included proximity of average readings to the target threshold. Meanwhile, adherence to delivering remote support was mixed, and practitioners described some uncertainty when they received no response from patients.

Conclusions

This mixed-methods process evaluation provided novel insights into practitioners’ decision-making around escalating medication using a digital algorithm. Implementation strategies were proposed which could benefit digital interventions in addressing clinical inertia, including facilitating tracking of patients’ readings over time to provide stronger evidence for medication escalation, and allowing more flexibility in decision-making whilst discouraging clinical inertia due to borderline readings. Implementation of one-way notification systems could be facilitated by enabling patients to send a brief acknowledgement response.

Trial registration

(ISRCTN13790648). Registered 14 May 2015.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-021-01123-1.

Enhancing the Behaviour Change Wheel with synthesis, stakeholder involvement and decision-making: a case example using the 'Enhancing the Quality of Psychological Interventions Delivered by Telephone' (EQUITy) research programme

Background

Using frameworks such as the Behaviour Change Wheel to develop behaviour change interventions can be challenging because judgement is needed at various points in the process and it is not always clear how uncertainties can be resolved. We propose a transparent and systematic three-phase process to transition from a research evidence base to a behaviour change intervention. The three phases entail evidence synthesis, stakeholder involvement and decision-making. We present the systematic development of an intervention to enhance the quality of psychological treatment delivered by telephone, as a worked example of this process.

Method

In phase 1 (evidence synthesis), we propose that the capabilities (C), opportunities (O) and motivations (M) model of behaviour change (COM-B) can be used to support the synthesis of a varied corpus of empirical evidence and to identify domains to be included in a proposed behaviour change intervention. In phase 2 (stakeholder involvement), we propose that formal consensus procedures (e.g. the RAND Health/University of California-Los Angeles Appropriateness Methodology) can be used to facilitate discussions of proposed domains with stakeholder groups. In phase 3 (decision-making), we propose that behavioural scientists identify (with public/patient input) intervention functions and behaviour change techniques using the acceptability, practicability, effectiveness/cost-effectiveness, affordability, safety/side-effects and equity (APEASE) criteria.

Results

The COM-B model was a useful tool that allowed a multidisciplinary research team, many of whom had no prior knowledge of behavioural science, to synthesise effectively a varied corpus of evidence (phase 1: evidence synthesis). The RAND Health/University of California-Los Angeles Appropriateness Methodology provided a transparent means of involving stakeholders (patients, practitioners and key informants in the present example), a structured way in which they could identify which of 93 domains identified in phase 1 were essential for inclusion in the intervention (phase 2: stakeholder involvement). Phase 3 (decision-making) was able to draw on existing Behaviour Change Wheel resources to revisit phases 1 and 2 and facilitate agreement among behavioural scientists on the final intervention modules. Behaviour changes were required at service, practitioner, patient and community levels.

Conclusion

Frameworks offer a foundation for intervention development but require additional elucidation at each stage of the process. The decisions adopted in this study are designed to provide an example on how to resolve challenges while designing a behaviour change intervention. We propose a three-phase process, which represents a transparent and systematic framework for developing behaviour change interventions in any setting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-021-01122-2.

Experiences and needs of persons living with a household member infected with SARS-CoV-2: A mixed method study

BACKGROUND

Households are important sites for transmission of SARS-CoV-2 and preventive measures are recommended. This study aimed to 1) investigate the impact of living with a person infected with SARS-CoV-2; 2) understand how household members implemented infection control recommendations in their home; and 3) identify the information and support needs of household members.

METHODS

For this observational mixed-methods study, households with a person with confirmed SARS-CoV-2 infection were recruited via drive-through testing sites of Municipal Health Services, healthcare worker screening or hospital emergency visits in the University Medical Centre Utrecht, the Netherlands and via primary care physicians, hospital emergency visits or preoperative screening in the University Hospital of Antwerp, Belgium. We recorded household characteristics, including characteristics of all household members, together with their views on prevention measures. In a subset of households one adult household member was asked to participate in an interview investigating their views on preventive measures. Survey data were analysed using descriptive statistics and interview data by rapid framework analysis. A triangulation protocol was used to integrate findings.

RESULTS

Thirty-four households (120 household members) were included in the quantitative survey. Twenty-two households were invited to be interviewed, of which 18 completed an interview (response 81.8%). Survey data showed that almost all households implemented some preventive measures, the use of face masks being least frequently reported. Measures taken depended on what was physically possible, the perceived severity of illness of the index patient and to what extent household members were willing to limit social interaction. Respondents did not believe in the effectiveness of wearing face masks within the house, and from the interviews this was explained by media coverage of face masks, impracticality and the stigma associated with wearing masks. Interviewees reported that quarantine had a high emotional burden and wished to have more information about the exact duration of quarantine, their own COVID-19 status, symptoms and when to seek medical help.

CONCLUSION

People were willing to implement prevention measures, however actual adherence depended on perceived severity of illness and the perceived risk of becoming infected. Homes are social environments and recommendations for infection prevention should account for this context. Incorporating our findings into policy making could provide households with more relevant and actionable advice.

Evaluating a large-scale online behaviour change intervention aimed at wildlife product consumers in Singapore

Interventions to shift the behaviour of consumers using unsustainable wildlife products are key to threatened species conservation. Whether these interventions are effective is largely unknown due to a dearth of detailed evaluations. We previously conducted a country-level online behaviour change intervention targeting consumers of the Critically Endangered saiga antelope (Saiga tatarica) horn in Singapore. To evaluate intervention impact, we carried out in-person consumer surveys with >2,000 individuals pre- and post-intervention (2017 and 2019), and 93 in-person post-intervention surveys with traditional Chinese medicine (TCM) shopkeepers (2019). The proportion of self-reported high-usage saiga horn consumers in the target audience (Chinese Singaporean women aged 35-59) did not change significantly from pre- to post-intervention (24.4% versus 22.6%). However, post-intervention the target audience was significantly more likely than the non-target audience to accurately recall the intervention message and to report a decrease in saiga horn usage (4% versus 1% reported a behaviour change). Within the target audience, high-usage consumers were significantly more likely than lower-usage consumers to recall the message and report a behaviour change. Across respondents who reported a decrease in saiga horn usage, they cited the intervention message as a specific reason for their behaviour change significantly more than other reasons. Additionally, across all respondents, the belief that saiga is a common species in the wild decreased significantly from pre- to post-intervention. TCM shopkeepers, however, cited factors such as price and availability as the strongest influences on saiga horn sales. In sum, the intervention did significantly influence some consumers but the reduction of high-usage consumer frequency was not significant at the population level. We explore reasons for these findings, including competing consumer influences, characteristics of the intervention, and evaluation timing. This work suggests our intervention approach has potential, and exemplifies a multi-pronged in-person evaluation of an online wildlife trade consumer intervention.

Implementing a new clinical pathway in a non-receptive context: Mixed methods evaluation of a new fracture pathway for older people in a hospital Trust in the West Midlands, UK

OBJECTIVES

This paper reports a mixed methods evaluation of a new pathway to improve clinical outcomes for older people with fractures treated at a hospital Trust in the West Midlands, UK. The paper focuses specifically on the context surrounding the translation of the new pathway into practice and the way that external and internal factors influenced its adaptation and implementation.

METHODS

Quantitative analysis used a controlled Interrupted Time Series (ITS) to estimate the effect of the new pathway on patient complication rate, median length of hospital stay and 30-day mortality by comparing the pre- and post-intervention periods. ITS data were extracted from the UK Trauma Audit and Research Network (TARN) database and a patient-level control group identified using propensity score matching. Parallel qualitative analysis aimed to examine the context surrounding the new pathway and how external and internal factors might influence its adaption and implementation into clinical practice. Data were collected via semi-structured interviews (n = 16) undertaken with staff and clinical stakeholders within the Trust and were analysed using the COM-B (Capability, Opportunity, Motivation) model of behaviour.

RESULTS

No statistically significant effects were found for any of the patient outcomes studied in the controlled ITS analysis. Qualitative data suggest that the lack of effectiveness of the new initiative can be explained with reference to the capability, opportunity and motivation of internal Trust stakeholders to engage with the pathway, which created a non-receptive environment within the Trust.

CONCLUSIONS

Successfully implementing new care pathways in environments that may be non-receptive to change requires efforts to be put into winning 'hearts and minds' within the organisation to ensure engagement from key stakeholders during intervention development. Evidence must be provided internally of the way that a given intervention will alleviate the problematic issues being experienced within the organisation, and external dissemination of results should be avoided until there is evidence of a positive effect within the organisation where the new care pathway is first implemented.

An evaluation of cascading mentorship as advocacy training in undergraduate medical education

BACKGROUND

Physicians are in a position of great influence to advocate for health equity. As such, it is important for physicians-in-training to develop the knowledge and skills necessary to fulfil this role. Although various undergraduate medical programs have implemented health advocacy training, they often lack experiential learning and physician involvement. These aspects are foundational to the Advocacy Mentorship Initiative (AMI) which utilizes cascading mentorship as a novel approach to advocacy training. Medical students develop advocacy competency as peer mentors to youth raised in at-risk environments, while also being mentored themselves by physician residents. We aim to determine whether there are specific advantages to utilizing cascading mentorship to facilitate the attainment of advocacy competencies in undergraduate medical education.

METHODS

Medical students participating in AMI between 2017 to 2020 completed pre- and post-exposure questionnaires. Questionnaires assessed confidence in advocacy-related skills and knowledge of youth advocacy concepts, as well as learning goals, skills gained, benefits of AMI and resident mentors, and impact on future career. Sign tests were utilized to analyze quantitative results, and content analysis was used for open-ended responses. A triangulation protocol was also utilized.

RESULTS

Fifty mentors participated, 24 (48%) of which completed both pre- and post-exposure questionnaires. Participants gained confidence in advocacy-related skills (p < 0.05) such as working with vulnerable populations and advocating for medical and non-medical needs. They also reported significant improvements (p < 0.01) in their understanding of social determinants of health and concepts related to children's health and development. Content analysis showed that participants built meaningful relationships with mentees in which they learned about social determinants of health, youth advocacy, and developed various advocacy-related skills. Participants greatly valued mentorship by residents, identifying benefits such as support and advice regarding relations with at-risk youth, and career mentorship. AMI impacted participants' career trajectories in terms of interest in working with youth, psychiatry, and advocacy.

CONCLUSIONS

AMI offers a unique method of advocacy training through cascading mentorship that engages medical students both as mentors to at-risk youth and mentees to resident physicians. Through cascading mentorship, medical students advance in their advocacy-related skills and understanding of social determinants of health.

Evaluating the implementation of the SWITCH® school wellness intervention and capacity-building process through multiple methods

Background

School wellness programming is important for promoting healthy lifestyles and academic achievement in youth; however, research is needed on methods that can help schools implement and sustain such programs on their own. The purpose of this study was to investigate factors within and outside the school environment that influenced school capacity for implementation and potential sustainability of wellness programming.

Methods

As part of the School Wellness Integration Targeting Child Health (SWITCH®) intervention, elementary school wellness teams (N = 30) were guided through a capacity-building process focused on promoting the adoption of healthy lifestyle behaviors in students. Data on implementation were collected through three standardized surveys and interviews (pre-mid-post) and a post-implementation interview. Indicators of organizational capacity were assessed using the School Wellness Readiness Assessment (SWRA). Paired t-tests were run to assess changes in implementation (classroom, physical education, and lunchroom settings), capacity, and stakeholder engagement over time. One-way analysis of variance (ANOVA) tests were run to examine how implementation of best practices (low, moderate, high) explained differences in capacity gains. Qualitative data were analyzed through inductive and deductive analysis, following the Consolidated Framework for Implementation Research (CFIR).

Results

Paired t-tests showed non-significant increases in school and setting-specific capacity and implementation of SWITCH best practices over time, in addition to a consistent level of engagement from key stakeholders. ANOVA results revealed non-significant associations between implementation group and gains in school capacity (F [2, 24] = 1.63; p = .21), class capacity (F [2, 24]=0.20 p = .82), lunchroom capacity (F [2, 24]=0.29; p = .78), and physical education (F [2, 24]=1.45; p = .25). Qualitative data demonstrated that factors within the outer setting (i.e., engaging community partners) facilitated programming. Inner-setting factors (i.e., relationships with administration and staff) influenced implementation. Implementation process themes (e.g., planning, adaptation of resources to meet school capacity/needs, and engaging students as leaders) were cited as key facilitators. Schools discussed factors affecting sustainability, such as school culture and knowledge of school wellness policy.

Conclusions

The results from this implementation study document the importance of allowing schools to adapt programming to meet their local needs, and highlight the strengths of measuring multiple implementation outcomes. Increased support is needed for schools regarding the formation and improvement of wellness policies as a means to enhance sustainability over time.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-020-01070-y.

A New Approach to Teaching Emotional Design

Emotional design focuses on providing intended users with a positive emotional experience. Thus far, the concept of emotional design has primarily been restricted to the fields of research and industry. Most professionals using emotional design slowly acquired the required skills by experience and without direct education. Teaching emotional design to design students has been overlooked due to its difficulty. This research introduces a new approach to teaching emotional design, which aims to prevent negative influences from being added to the products created by design students. A systematic method is introduced to make it easier for inexperienced design students to grasp emotional design. Students are first taught proper methods of data collection to determine users’ emotional requirements. Students are then taught how to summarize the data, as well as develop feasibility testing strategies to obtain promising ideas. The proposed teaching approach for emotional design has been proven efficient in the case study course conducted in this research. Graduate-level design students learned how to design products according to users’ emotional requirements. The students successfully produced several designs that clearly provided positive user experiences.

HALO: Study protocol for a single-case experimental design study evaluating the moderating impact of a befriending intervention on the association between loneliness and health in older adults

Background: Loneliness in later life is often addressed with befriending interventions, yet evidence for their effectiveness is limited. Meanwhile it is known that loneliness has a deleterious impact on health. The aim of the study is to evaluate whether a befriending service for older adults mitigates the impact of loneliness on health outcomes, and to identify mechanisms through which befriending interventions might impact upon health. Methods: A mixed methods design is used. The quantitative component utilises an AB single-case experimental design, to gather intensive longitudinal data. These data will be analysed using a generalised additive modelling approach. The qualitative component of the study uses semi-structured dyadic interviews, structured and analysed according to the principles of constructivist grounded theory. Findings will then be triangulated according to an existing mixed methods integration protocol. Discussion: This mixed methods design has the potential to inform national and international policy in relation to befriending interventions for older adults. In addition, there is the potential for study results to inform our theoretical understanding of the nature of the relationship between loneliness and health. Trial registration: ClinicalTrials.gov identifier NCT04301167 (10 th March 2020). Protocol version 1.1, 26 th June 2020.

Development of an implementation and evaluation strategy for the Australian 'Zero Childhood Cancer' (Zero) Program: a study protocol

INTRODUCTION

Effective implementation of a research Program requires an actionable plan to guide execution. To assess the actionability and success of that plan, both scientific and implementation elements must be taken into account. The aim of this study is to assess the 'Zero Childhood Cancer Personalised Medicine Program' (the Zero Program), an Australian first-ever and most comprehensive personalised medicine programme for children with high-risk or relapsed cancer, in terms of its structure, process and implementational effect.

METHODS AND ANALYSIS

We will assess Program delivery mechanisms. The development of the implementation and evaluation strategy will concentrate on the work of the Zero Program as a complex whole. This includes the structure of collaborative links across stakeholder groups involved in Program development and delivery, changes to collaborative relationships over time and the impact of group working on Program outcomes. We are applying a mixed-methods design including: a rapid ethnography (observations of stakeholder interactions and informal conversations), Program professionals' completion of a rapid health implementation proforma and a social network analysis. Formative evaluations of the implementation science effects, applying feedback techniques, for example, Formative Evaluation Feedback Loops and the Zero Program professionals' feedback, will determine where Program tailoring may be needed. A repeat of the social network analysis downstream will examine network changes over time, followed by an expert panel using the expert recommendations for implementing change to assess the integration of implementation strategies into the Program structure. A summative evaluation of the Program will bring the research elements together, leading to comprehensive data triangulation and determining the sustainability and implementational effects of Program delivery.

ETHICS AND DISSEMINATION

Ethical approval for this study has been granted by Hunter New England Research Ethics Committee, New South Wales, Australia (approval ref: 2019/ETH12025). Knowledge translation will be achieved through publications, reports and conference presentations to healthcare professionals, patients, families and researchers.

TRIAL REGISTRATION

NCT03336931; Pre-results.

Evaluation of the MCAST, a multidisciplinary toolkit to improve mental capacity assessment

Purpose: To evaluate the usability and acceptability of the Mental Capacity Assessment Support Toolkit (MCAST) in healthcare settings and whether its use was associated with increased legal compliance and assessor confidence.Materials and methods: A mixed methods convergence triangulation model was used. Multidisciplinary professionals used the MCAST during mental capacity assessments for UK hospital patients with diagnoses of stroke or acute or chronic cognitive impairment. Changes in legal compliance were investigated by comparing scores on case note audits before and after implementation of the MCAST. Changes in assessor confidence and professionals' perceptions of the MCAST's usability and acceptability were explored using surveys. Patients' and family members' views on acceptability were determined using semi-structured interviews. Data were integrated using triangulation.Results: Twenty-one professionals, 17 patients and two family members participated. Use of the MCAST was associated with significant increases in legal compliance and assessor confidence. Most professionals found the MCAST easy to use and beneficial to their practice and patients. Patients and family members found the MCAST materials acceptable.Conclusions: The MCAST is the first toolkit to support the needs of individuals with communication disabilities during mental capacity assessments. It enables assessors to deliver high quality, legally compliant and confident practice.IMPLICATIONS FOR REHABILITATIONMental capacity assessment practice needs to be improved to maximise patient autonomy, safety and well-being.The MCAST is a paper-based toolkit designed to facilitate and improve mental capacity practice in England and Wales.This study suggests the MCAST would be easy and acceptable to use in healthcare settings and could lead to improvements in assessment quality and assessor confidence.

Rugby as a rehabilitation program in a United Kingdom Male Young Offenders' Institution: key findings and implications from mixed methods research

There is a growing body of research on the effectiveness of rehabilitation programs in a Young Offenders' Institution (YOI). The aim of the present study is to investigate the effectiveness of rugby training as a rehabilitation intervention in a YOI in the United Kingdom. Young adult males (n=46) currently serving sentences at the YOI were split into two groups, intervention (n=25; mean age, 19.64±0.81 years) and no intervention (n=21; mean age, 19.76±0.89). Participants completed the Criminal Attitudes and Associates (MCAA) instrument at three different time cycles and then pre/post for intervention group. Additionally, qualitative interviews (one to one and focus groups) were carried out with the intervention and no intervention groups during the same cycles of the study. The results of questionnaire analysis showed no significant difference in MCAA measures taken before and after rugby intervention. Interestingly, the intervention group showed more procriminal attitudes on their responses compared to the no intervention group. Finally, analysis of the 3 cycles of data collected showed that the time of the year the questionnaire was completed has a significant impact on the responses given. In contrast, the qualitative interviews showed a very positive change of attitude towards rehabilitation from the intervention group after rugby training. The implications of the results in relation to studies aimed at evaluation of the intervention programs in YOI are discussed.

An interdisciplinary mixed-methods approach to developing antimicrobial stewardship interventions: Protocol for the Preserving Antibiotics through Safe Stewardship (PASS) Research Programme

Behaviour change is key to combating antimicrobial resistance. Antimicrobial stewardship (AMS) programmes promote and monitor judicious antibiotic use, but there is little consideration of behavioural and social influences when designing interventions.  We outline a programme of research which aims to co-design AMS interventions across healthcare settings, by integrating data-science, evidence- synthesis, behavioural-science and user-centred design. The project includes three work-packages (WP): WP1 (Identifying patterns of prescribing):  analysis of electronic health-records to identify prescribing patterns in care-homes, primary-care, and secondary-care. An online survey will investigate consulting/antibiotic-seeking behaviours in members of the public. WP2 (Barriers and enablers to prescribing in practice): Semi-structured interviews and observations of practice to identify barriers/enablers to prescribing, influences on antibiotic-seeking behaviour and the social/contextual factors underpinning prescribing. Systematic reviews of AMS interventions to identify the components of existing interventions associated with effectiveness. Design workshops to identify constraints influencing the form of the intervention. Interviews conducted with healthcare-professionals in community pharmacies, care-homes, primary-, and secondary-care and with members of the public. Topic guides and analysis based on the Theoretical Domains Framework.  Observations conducted in care-homes, primary and secondary-care with analysis drawing on grounded theory.  Systematic reviews of interventions in each setting will be conducted, and interventions described using the Behaviour Change Technique taxonomy v1. Design workshops in care-homes, primary-, and secondary care. WP3 (Co-production of interventions and dissemination). Findings will be integrated to identify opportunities for interventions, and assess whether existing interventions target influences on antibiotic use. Stakeholder panels will be assembled to co-design and refine interventions in each setting, applying the Affordability, Practicability, Effectiveness, Acceptability, Side-effects and Equity (APEASE) criteria to prioritise candidate interventions.  Outputs will inform development of new AMS interventions and/or optimisation of existing interventions.  We will also develop web-resources for stakeholders providing analyses of antibiotic prescribing patterns, prescribing behaviours, and evidence reviews.

Supporting survivors of sexual violence: protocol for a mixed-methods, co-research study of the role, funding and commissioning of specialist services provided by the voluntary sector in England

INTRODUCTION

The voluntary sector provides a range of specialist services to survivors of sexual violence, many of which have evolved from grass roots organisations responding to unmet local needs. However, the evidence base is poor in terms of what services are provided to which groups of survivors, how voluntary sector specialist (VSS) services are organised and delivered and how they are commissioned. This will be the first national study on the role of the voluntary sector in supporting survivors in England.

METHODS AND ANALYSIS

This study uses an explanatory sequential naturalistic mixed-methods design with two stages. For stage 1, two national surveys of providers' and commissioners' views on designing and delivering VSS services will facilitate detailed mapping of service provision and commissioning in order to create a taxonomy of VSS services. Variations in the national picture will then be explored in stage 2 through four in-depth, qualitative case studies using the critical incident technique to explain the observed variations and understand the key contextual factors which influence service provision. Drawing on theory about the distinctive service contribution of the voluntary sector, survivors will be involved as co-researchers and will play a central role in data collection and interpretation.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the University of Birmingham research ethics committee for stage 1 of the project. In line with the sequential and co-produced study design, further applications for ethical review will be made in due course. Dissemination activities will include case study and end-of-project workshops; good practice guides; a policy briefing; project report; bitesize findings; webinars; academic articles and conference presentations. The project will generate evidence about what survivors want from and value about services and new understanding about how VSS services should be commissioned and provided to support survivors to thrive in the long term.

Integrating quantitative and qualitative data and findings when undertaking randomised controlled trials

It is common to undertake qualitative research alongside randomised controlled trials (RCTs) when evaluating complex interventions. Researchers tend to analyse these datasets one by one and then consider their findings separately within the discussion section of the final report, rarely integrating quantitative and qualitative data or findings, and missing opportunities to combine data in order to add rigour, enabling thorough and more complete analysis, provide credibility to results, and generate further important insights about the intervention under evaluation. This paper reports on a 2 day expert meeting funded by the United Kingdom Medical Research Council Hubs for Trials Methodology Research with the aims to identify current strengths and weaknesses in the integration of quantitative and qualitative methods in clinical trials, establish the next steps required to provide the trials community with guidance on the integration of mixed methods in RCTs and set-up a network of individuals, groups and organisations willing to collaborate on related methodological activity. We summarise integration techniques and go beyond previous publications by highlighting the potential value of integration using three examples that are specific to RCTs. We suggest that applying mixed methods integration techniques to data or findings from studies involving both RCTs and qualitative research can yield insights that might be useful for understanding variation in outcomes, the mechanism by which interventions have an impact, and identifying ways of tailoring therapy to patient preference and type. Given a general lack of examples and knowledge of these techniques, researchers and funders will need future guidance on how to undertake and appraise them.

Introducing new point-of-care tests for common infections in publicly funded clinics in South Africa: a qualitative study with primary care clinicians

Broad-spectrum antibiotics are routinely prescribed empirically in the resource-poor settings for suspected acute common infections, which drive antimicrobial resistance. Point-of-care testing (POCT) might increase the appropriateness of decisions about whether and which antibiotic to prescribe, but implementation will be most effective if clinician's perspectives are taken into account.

OBJECTIVES

To explore the perceptions of South African primary care clinicians working in publicly funded clinics about: making antibiotic prescribing decisions for two common infection syndromes (acute cough, urinary tract infection); their experiences of existing POCTs; their perceptions of the barriers and opportunities for introducing (hypothetical) new POCTs.

DESIGN, METHOD, PARTICIPANTS, SETTING

Qualitative semistructured interviews with 23 primary care clinicians (nurses and doctors) at publicly funded clinics in the Western Cape Metro district, South Africa. Data were analysed using thematic analysis.

RESULTS

Clinicians reported that their antibiotic prescribing decisions were influenced by their clinical assessment, patient comorbidities, social factors (eg, access to care) and perceived patient expectations. Their experiences with currently available POCTs were largely positive, and they were optimistic about the potential for new POCTs to: support evidence-based prescribing decisions that might reduce unnecessary antibiotic prescriptions; reduce the need for further investigations; support effective communication with patients, especially when antibiotics were unlikely to be of benefit. Resources and workflow disruption were seen as the main barriers to uptake into routine care.

CONCLUSIONS

Clinicians working in publicly funded clinics in the Western Cape Metro of South Africa saw POCTs as potentially useful for positively addressing both clinical and social drivers of the overprescribing of broad-spectrum antibiotics, but were concerned about the resource implications and disruption of existing patient workflows.

Patients' understanding of cellulitis and views about how best to prevent recurrent episodes: mixed-methods study in primary and secondary care

BACKGROUND

Cellulitis is a common painful infection of the skin and underlying tissues that recurs in approximately one-third of cases. The only proven strategy to reduce the risk of recurrence is long-term, low-dose antibiotics. Given current concerns about antibiotic resistance and the pressure to reduce antibiotic prescribing, other prevention strategies are needed.

OBJECTIVES

To explore patients' views about cellulitis and different ways of preventing recurrent episodes.

METHODS

Adults aged ≥ 18 years with a history of first-episode or recurrent cellulitis were invited through primary care, hospitals and advertising to complete a survey, take part in an interview or both.

RESULTS

Thirty interviews were conducted between August 2016 and July 2017. Two hundred and forty surveys were completed (response rate 17%). Triangulation of quantitative and qualitative data showed that people who have had cellulitis have wide-ranging beliefs about what can cause cellulitis and are often unaware of risk of recurrence or potential strategies to prevent recurrence. Enhanced foot hygiene, applying emollients daily, exercise and losing weight were more popular potential strategies than the use of compression stockings or long-term antibiotics. Participants expressed caution about long-term oral antibiotics, particularly those who had experienced only one episode of cellulitis.

CONCLUSIONS

People who have had cellulitis are keen to know about possible ways to prevent further episodes. Enhanced foot hygiene, applying emollients daily, exercise and losing weight were generally viewed to be more acceptable, feasible strategies than compression or antibiotics, but further research is needed to explore uptake and effectiveness in practice.

The views of children and young people on the use of silk garments for the treatment of eczema: a nested qualitative study within the CLOTHing for the relief of Eczema Symptoms (CLOTHES) randomized controlled trial

Background

Many children suffer with skin diseases but to date most dermatological research has been done ‘on’ rather than ‘with’ children; in this study we actively sought the experiences of children and young people. Atopic eczema (AE) is a chronic, itchy, inflammatory skin condition that affects around 20% of children and can impact on the health and wellbeing of children and their families. The role of specialist clothing in the management of AE is poorly understood.

Objectives

The aim of this study, which was nested in a randomized controlled trial, was to qualitatively examine child participants’ experiences of using silk garments for the treatment of AE.

Methods

Eighteen children aged 5–15 years, who took part in the CLOTHing for the relief of Eczema Symptoms (CLOTHES) trial, participated in age‐appropriate individual interviews or focus groups.

Results

Thematic analysis generated four themes directly related to the silk garments: (i) expectations of the garments; (ii) wearing the garments; (iii) asking if the garments helped; and (iv) thoughts about the garments. The conclusions from this nested qualitative study are that there was some limited improvement in eczema for some children but that the hoped‐for ‘miracle cure’ did not transpire. A mixed picture of knowledge, beliefs and experiences of using the silk garments emerged.

Conclusions

Engaging children in the evaluation of the garments provided first‐hand nuanced insights that enhanced understanding of the CLOTHES study as a whole. This nested study demonstrates that children can and indeed want to be engaged in dermatological research in meaningful ways that add to our understanding of treatment options.

What's already known about this topic?

Eczema affects around 20% of children and can have a detrimental effect on the child and their family.

Adherence with topical treatments is often poor and can lead to treatment failure.

Although children are often end‐users of eczema treatments, they are rarely engaged in research involving these products beyond completing questionnaires.

What does this study add?

Children and young people can be meaningfully engaged in dermatology research and add new dimensions of understanding that would not be gained by proxy data.

Children told us about their expectations of the garments and their views once they had worn them.

The added value of child data lies in enhancing understanding of reasons for adherence and nonadherence, in facilitating interpretation of the trial results, and in ensuring selected objective outcome measures include factors important to children.

What are the clinical implications of the work?

This study illustrates the need to communicate effectively with children and young people to ascertain their thoughts and beliefs about treatment regimens and assess the likelihood of adherence.

Linked Comment: Teasdale. Br J Dermatol 2018; 178:25–26.

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