Fidelity monitoring in complex interventions: a case study of the WISE intervention

Systematic review of contemporary interventions for improving discharge support and transitions of care from the patient experience perspective

AIM

To synthesize the impact of improvement interventions related to care coordination, discharge support and care transitions on patient experience measures.

METHOD

Systematic review. Searches were completed in six scientific databases, five specialty journals, and through snowballing. Eligibility included studies published in English (2015-2023) focused on improving care coordination, discharge support, or transitional care assessed by standardized patient experience measures as a primary outcome. Two independent reviewers made eligibility decisions and performed quality appraisals.

RESULTS

Of 1240 papers initially screened, 16 were included. Seven studies focused on care coordination activities, including three randomized controlled trials [RCTs]. These studies used enhanced supports such as improvement coaching or tailoring for vulnerable populations within Patient-Centered Medical Homes or other primary care sites. Intervention effectiveness was mixed or neutral relative to standard or models of care or simpler supports (e.g., improvement tool). Eight studies, including three RCTs, focused on enhanced discharge support, including patient education (e.g., teach back) and telephone follow-up; mixed or neutral results on the patient experience were also found and with more substantive risks of bias. One pragmatic trial on a transitional care intervention, using a navigator support, found significant changes only for the subset of uninsured patients and in one patient experience outcome, and had challenges with implementation fidelity.

CONCLUSION

Enhanced supports for improving care coordination, discharge education, and post-discharge follow-up had mixed or neutral effectiveness for improving the patient experience with care, compared to standard care or simpler improvement approaches. There is a need to advance the body of evidence on how to improve the patient experience with discharge support and transitional approaches.

Tracking activities and adaptations in a multi-site stepped wedge pragmatic trial of a cancer symptom management intervention

Background

Pragmatic trials may need to adapt interventions to enhance local fit, and adaptation tracking is critical to evaluation. This study describes the tracking approach for a multisite, stepped-wedge hybrid pragmatic trial testing implementation and effectiveness of a cancer symptom management intervention.

Methods

Study activities were documented in a spreadsheet by date and category. Intervention adaptations were tracked across multiple workgroups in a database structured around the Framework for Reporting Adaptations and Modifications-Expanded (FRAME) domains, e.g., reasons for change. Implementation strategies were tracked longitudinally and by cluster in a database using the Longitudinal Implementation Strategy Tracking System (LISTS) method. A logic model was created at the end of the study to describe core intervention components and implementation strategies with dates of adaptations.

Results

Between January 2019 and January 2023, 187 study activities were documented. Most intervention activities took place early, but there were important intervention refinements during the course of the trial, including the expansion of interventionist roles to add two new disciplines. Eleven intervention adaptations were documented. Most were unplanned and aimed at improving fit or increasing engagement. Thirty-three implementation strategies were documented, the largest number of which were related to educating stakeholders. Most (but not all) component and strategy additions were consistent with the mechanisms of change as hypothesized at trial launch.

Conclusions

A multifaceted approach to adaptation tracking, combined with a logic model, supported identification of meaningful changes for use in evaluation, but further work is needed to minimize burden and ensure robust and practical systems that inform both evaluation and timely decision-making.

Trial

Registration: ClinicalTrials.gov, NCT03892967. Registered on March 25, 2019. https://www.clinicaltrials.gov/.

Development and evaluation of a concise nurse-driven non-pharmacological delirium reduction workflow for hospitalized patients: An interrupted time series study

We created a concise nurse-driven delirium reduction workflow with the aim of reducing delirium rates and length of stay for hospitalized adults. Our nurse-driven workflow included five evidence-based daytime "sunrise" interventions (patient room lights on, blinds up, mobilization/out-of-bed, water within patient's reach and patient awake) and five nighttime "turndown" interventions (patient room lights off, blinds down, television off, noise reduction and pre-set bedtime). Interventions were also chosen because fidelity could be quickly monitored twice daily without patient interruption from outside the room. To evaluate the workflow, we used an interrupted time series study design between 06/01/17 and 05/30/22 to determine if the workflow significantly reduced the unit's delirium rate and average length of stay. Our workflow is feasible to implement and monitor and initially significantly reduced delirium rates but not length of stay. However, the reduction in delirium rates were not sustained following the emergence of the COVID-19 pandemic.

Community pharmacist intervention to close statin gaps in diabetes care: The GuIDE-S study

BACKGROUND

Statin therapy is recommended for people with type 2 diabetes (T2D) to lower cardiovascular risk; however, evidence suggests that significant gaps in statin therapy exist.

OBJECTIVE

To evaluate (1) the impact of a community pharmacist-led model for initiating statin therapy in people with type 2 diabetes (T2D) on statin initiation and (2) pharmacists' self-reported perceptions of the intervention feasibility and fidelity to the intervention.

METHODS

This was a type 1 hybrid effectiveness-implementation study of 9 intervention and 18 control pharmacies within a community pharmacy chain. Pharmacy staff proactively identified patients with T2D not taking a statin and prescribed a statin via a collaborative practice agreement or facilitated acquisition of a prescription from the patient's preferred prescriber. The eligible population included patients aged 18-84 years with T2D, who had filled ≥60 days' supply of one, noninsulin, diabetes medication in a rolling 6-month period, and who had not filled a statin during the same period. A Cox proportional hazards model was used to compare time to statin initiation. Pharmacists at intervention pharmacies completed a survey at 6 and 12 months after implementation (March and August 2019, respectively) to assess intervention feasibility and fidelity.

RESULTS

For the statin initiation analysis, 1670 intervention patients were matched to 3358 control patients. Overall, 26.3% (n=442) of intervention patients and 25.4% (n=854) of control patients initiated a statin within 12 months of their index date. There was no difference in statin initiation likelihood between intervention and control patients (hazard ratio: 1.00; 95% CI: 0.83, 1.21). Fifteen pharmacists completed the 6-month survey (33% response rate), and 12 completed the 12-month survey (26%). The intervention's feasibility score was 4.0 at 6 months and 4.2 at 12 months, indicating an increase in perceived feasibility. Fidelity decreased from 6 to 12 months.

CONCLUSION

The community pharmacist-led intervention resulted in more patients initiating statin therapy as compared to usual care; however, the differences were not statistically significant. Pharmacists perceived the intervention to be feasible; however, fidelity decreased over time.

Predictors of sustainment of two distinct nutrition and physical activity programs in early care and education

Introduction

The goal of the present study was to investigate factors associated with sustainment of two evidence-based programs for nutrition promotion in early care and education (ECE) settings - Food Friends (FF) and Together, We Inspire Smart Eating (WISE).

Materials and methods

In a cross-sectional study design, ECE directors (N = 55) from centers that had previously been trained in WISE or FF completed a survey. Program-specific measures included Steckler's Perception of Innovations, the Program Sustainability Assessment Tool (PSAT), and the Organizational Readiness for Change Assessment (ORCA). For our primary outcomes, two measures of sustainment were examined: Nutrition Continued Practice (i.e., the use of or general focus on nutrition programs) and Program Fidelity (i.e., how well centers used specific evidence-based practices of WISE or FF). Multiple regression was used to determine the association of these outcomes with program, years since last implementation, and overall scores on predictors. Follow-up correlation analyses were used to investigate outcome relationships with context submeasures due to high intercorrelations between predictor submeasures.

Results

Nutrition Continued Practice was significantly predicted by program and overall PSAT score. WISE programs had significantly higher Nutrition Continued Practice scores than FF program (p = 0.03). All subscales of the PSAT (e.g., environmental support, funding stability, organizational capacity, program adaptation, communications, and strategic planning) were significantly correlated with Nutrition Continued Practice (all rs > 0.30, all ps < 0.03). Program Fidelity was significantly predicted by PSAT and Steckler Perception of Innovation scores. All subscales of the PSAT were strongly positively correlated with Program Fidelity (all rs > 0.48, all ps < 0.001); relative advantage (r = 0.54, p < 0.001) and level of institutionalization (r = 0.61, p < 0.001) were positively correlated with Program Fidelity.

Conclusion

This study suggests that factors associated with the continued practice of program principles are partially distinct from those that are associated with the sustainment of specific practices driving program fidelity. Results suggest capacity building strategies may be important for both continued attention to nutrition and physical activity as well as sustaining fidelity to specific evidence-based practices.

Extending the Together, We Inspire Smart Eating Curriculum to Intergenerational Nutrition Education: A Pilot Study

The COVID-19 pandemic has made accessing nutritious foods difficult for older adults and children living in low-income households. The evidence-based preschool nutrition education curriculum Together, We Inspire Smart Eating (WISE) can be used to encourage children to try healthy foods. Written as a single generation curriculum, inviting older adult community members to WISE programming for an intergenerational experience may provide further supports and mutual benefits as participants cooperate towards a common goal. While creators have evaluated implementation of WISE, research has yet to explore factors that influence WISE adoption within an intergenerational setting. We conducted a pilot study using the implementation evaluation framework to explore WISE implementation within single generation and intergenerational settings by measuring five implementation outcomes (fidelity, acceptability, appropriateness, feasibility, and sustainability) through three methods: (1) direct assessment of program fidelity via video coding; (2) indirect assessment of stakeholders’ perceptions of WISE implementation, and (3) a directed qualitative content analysis on annual interview data. Fidelity scores were comparable between the two settings and stakeholder ratings of appropriateness, acceptability, and feasibility of WISE were high. Qualitative data revealed that aspects of WISE are less appropriate for older participants and reiterated known logistical barriers of intergenerational programming that may challenge program sustainability.

Iterative development and pilot testing of an intervention fidelity monitoring plan for the enhanced, electronic health record-facilitated pragmatic clinical trial: Implications for training and protocol integrity

Fidelity monitoring is the degree to which a clinical trial intervention is implemented as intended by a research protocol. Consistent implementation of research protocols supported with extant fidelity monitoring plans contribute rigor and validity of study results. Fidelity monitoring plans should be comprehensive yet practical to accommodate the realities of conducting research, particularly a pragmatic clinical trial, in dynamic settings with heterogeneous patient populations. The purposes of this paper are to describe the (1) iterative development and implementation of protocols for intervention fidelity monitoring, (2) pilot testing of the fidelity monitoring plan, (3) the identification of interventionist training deficiencies, and (4) opportunities to enhance protocol rigor for a cancer symptom management intervention delivered through the electronic health record patient portal and telephone as part of a complex, multi-component pragmatic clinical trial to uncover training deficits and bolster protocol integrity. The intervention focuses on prominent symptoms reported among medical oncology patients including sleep disturbance, pain, anxiety, depression, low energy (fatigue) and physical function. In this pragmatic trial, the role of interventionist is a registered nurse symptom care manager (RN SCM). A three-part fidelity monitoring plan with checklists audit: Part-1 RN SCM role training activities in research components, clinical training components, and protocol simulation training; Part-2 RN SCM adherence to the intervention core components delivered over the telephone; and Part-3 maintenance of adherence to core intervention components. The goal is ≥ 80% adherence to components of each of the three checklists. An initial pilot test of the fidelity monitoring plan was conducted to evaluate the checklists and the RN SCM adherence to core protocol components. RN SCM skills and training deficits were identified during the pilot phase, as were opportunities to improve protocol integrity. Overall, approximately 50% of the audited RN SCM telephone calls had ≥80% fidelity to the core components. There remains on-going need for RN SCM training and skill building in action planning. The content presented in this paper is intended to begin to fill the gap of fidelity monitoring plans for complex interventions tested in pragmatic clinical trials and delivered remotely in an effort to strengthen protocol integrity.

Implementation Science Strategies Promote Fidelity in the Food, Feeding, and Your Family Study

OBJECTIVE

Use of implementation science strategies to promote fidelity in the Food, Feeding, and Your Family study.

DESIGN

Cluster randomized controlled trial with 3 conditions: control, in-class, or online, delivered in English or Spanish. Observations of 20% of classes.

SETTING

Expanded Food and Nutrition Education Program (EFNEP) in 2 states.

PARTICIPANTS

EFNEP peer educators (n = 11).

INTERVENTION

Parental feeding content incorporated into EFNEP lessons (in-class) or through text with links to videos/activities (online). Extensive educator training, scripted curriculum, frequent feedback.

ANALYSIS

Assessment of fidelity compliance. Qualitative analysis of verbatim educator interviews and classroom observer comments.

RESULTS

During 128 class observations (40-45 per condition), peer educators followed scripted lesson plan 78% to 89% of the time. There was no evidence of cross-contamination of parental feeding content in control and only minor sharing in online conditions. Variations with fidelity were primarily tied to the EFNEP curriculum, not the parent feeding content. Educators (n = 7) expressed favorable opinions about the Food, Feeding, and Your Family study, thought it provided valuable information, and appreciated support from EFNEP leadership.

CONCLUSIONS AND IMPLICATIONS

Incorporating implementation science strategies can help ensure successful adherence to research protocols. With proper training and support, EFNEP peer educators can deliver an evidence-based curriculum as part of a complex research study.

Embedding mentoring to support trial processes and implementation fidelity in a randomised controlled trial of vocational rehabilitation for stroke survivors

BACKGROUND

Little guidance exists regarding how best to upskill and support those delivering complex healthcare interventions to ensure robust trial outcomes and implementation fidelity. Mentoring was provided to occupational therapists (OTs) delivering a complex vocational rehabilitation (VR) intervention to stroke survivors. This study aimed to explore mentors' roles in supporting OTs with intervention delivery and fidelity, and to describe factors affecting the mentoring process and intervention delivery.

METHODS

Quantitative data (duration, mode and total time of mentoring support) was extracted from mentoring records and emails between mentors and OTs, alongside qualitative data on barriers and facilitators to intervention delivery. Semi-structured interviews with mentors (n = 6) and OTs (n = 19) explored experiences and perceptions of intervention training, delivery and the mentoring process. Mean total and monthly time spent mentoring were calculated per trial site. Qualitative data were analysed thematically.

RESULTS

Forty-one OTs across 16 sites were mentored between March 2018 and April 2020. Most mentoring was provided by phone or Microsoft Teams (range: 88.6-100%), with the remainder via email and SMS (Short Message Service) text messages. Mentors suggested strategies to enhance trial recruitment, improved OTs' understanding of- and adherence to trial processes, intervention delivery and fidelity, and facilitated independent problem-solving. Barriers to mentoring included OT non-attendance at mentoring sessions and mentors struggling to balance mentoring with clinical roles. Facilitators included support from the trial team and mentors having protected time for mentoring.

CONCLUSIONS

Mentoring supported mentee OTs in various ways, but it remains unclear to what extent the OTS would have been able to deliver the intervention without mentoring support, or how this might have impacted fidelity. Successful implementation of mentoring alongside new complex interventions may increase the likelihood of intervention effectiveness being observed and sustained in real-life contexts. Further research is needed to investigate how mentors could be selected, upskilled, funded and mentoring provided to maximise impact. The clinical- and cost-effectiveness of mentoring as an implementation strategy and its impact on fidelity also requires testing in a future trial.

TRIAL REGISTRATION

ISRCTN, ISRCTN12464275 . Registered on 13th March 2018.

Accountability in Intervention Research: Developing a Fidelity Checklist of a Mental Health Intervention in Prisons

Adherence to intervention content and delivery protocols is vital in establishing the efficacy of treatment programs for mental illnesses. Using a fidelity tool during interventions can substantially increase the likelihood of clients receiving the most scientifically rigorous treatment. This article outlines the steps taken to develop a fidelity checklist to measure treatment adherence of a two-part intervention delivered in a prison setting. Researchers followed the five-step guide by Feely et al. (Child and Adolescent Social Work Journal, 35(2), 139-152: 2018) and describe the process of developing a fidelity tool to measure treatment adherence to a newly adapted CBT-based intervention designed to maximize uptake for participants with serious mental illnesses. Key decision points are discussed, along with final decisions and contextual considerations. A 26-item checklist was developed to measure treatment adherence related to process, content, and adaptations of the intervention. The checklist follows the structure of the CBT intervention, as well as provides flexibility for the delivery adaptations. Pilot testing of the checklist revealed all sessions were implemented with at least 85% fidelity, and 90% of sessions were implemented with at least 90% fidelity. Raters agreed on the fidelity of a session in 99.6% of sessions. Contextual considerations included the highly secure study setting, reconciling the constant monitoring of a group and creating a treatment environment, the flexibility mandated by the intervention, the relative newness of the intervention, and the limitations based on study aims and resources. These results illustrate how study specific considerations and challenges can be successfully navigated in the development and deployment of a fidelity tool in a real-world setting. The fidelity checklist achieved our goal of measuring treatment adherence for this intervention. In the development of a fidelity tool, we recommend leaving space for raters to note specific considerations that disrupt facilitators' ability to deploy the intervention precisely. Measuring fidelity is imperative for mental health interventions to ensure that the treatment is responsible for the changes observed in clients.

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.

Stakeholder selected strategies for obesity prevention in childcare: results from a small-scale cluster randomized hybrid type III trial

BACKGROUND

Together, We Inspire Smart Eating (WISE) is an intervention for the early care and education setting to support children's exposure to and intake of fruits and vegetables. WISE emphasizes 4 evidence-based practices (EBPs): (1) use of a mascot; (2) educators' role modeling; (3) positive feeding practices; and (4) hands-on exposures. The current study reports on a small-scale implementation trial aimed at improving the use of WISE EBPs by teachers.

METHODS

A Hybrid Type III Cluster Randomized Design compared a Basic and Enhanced implementation strategy. The Basic Strategy included training and reminders only; the Enhanced strategy was a multi-faceted package of stakeholder-selected strategies including a leadership commitment, an implementation blueprint, a local champion, an environmental reminder of the EBPs, facilitation, and tailored educational resources and incentives. All study sites were Head Starts. Sites were randomized using a balancing technique that considered site characteristics; 4 sites (20 classrooms, 39 educators, 305 children) received Enhanced support; 5 sites (18 classrooms, 36 educators, 316 children) received Basic support. RE-AIM guided the evaluation, and implementation fidelity was the primary outcome. Strategies were assessed using examination of data distributions and unadjusted comparisons (t tests) as well as general linear and mixed effects models controlling for covariates.

RESULTS

For the primary outcome of fidelity, the Enhanced group had significantly higher means for 3 of 4 EBPs. Multivariate models explained a significant portion of variance for both mascot use and hands-on exposure with a significant positive effect observed for treatment condition. The Enhanced group also had higher rates of Appropriateness and Organizational Readiness for Implementing Change (as indicators of implementation and adoption, respectively). There was no significant difference between groups for indicators of Reach, Effectiveness or Maintenance. Formative interviews indicated key targets for iteration and potential mechanisms. Key events were catalogued to provide context for interpretation (e.g., 61% of classrooms with turnover).

CONCLUSIONS

Findings were mixed but suggested promise for the Enhanced strategy, especially considering key events of the study. Implementation fidelity improvements occurred mainly in the last 3 months of the school year; additional time may be needed to translate to improvements in child outcomes.

TRIAL REGISTRATION

NCT03075085 Registered 20 February 2017.

Autoregulated heavy slow resistance training combined with radial shockwave therapy for plantar heel pain: Protocol for a mixed-methods pilot randomised controlled trial

BACKGROUND

Plantar heel pain (PHP) is considered a tendinopathy and it affects up to 10% of the population. Both heavy slow resistance training (HSRT) and extracorporeal shockwave therapy (ESWT) have shown effectiveness for treating PHP in isolation. However, more comprehensive exercise protocols and progression methods are needed due to poor long-term outcomes, and better standardisation of ESWT protocols are required. Autoregulation of resistance training involves self-selecting exercise dosage based on individual factors. Although autoregulation has proven effective for strength gains in athletes, it has not been investigated in tendinopathy. Recent studies recommend that PHP should not be treated by one treatment intervention in isolation. However, there is a dearth of research investigating the feasibility and effectiveness of combined treatment interventions for PHP. Currently, no studies have investigated autoregulated HSRT combined with ESWT, despite their individual efficacy. The optimal treatment protocol for PHP is unknown, and there is a need to ascertain whether the addition of ESWT to autoregulated HSRT leads to better outcomes compared to either alone.

METHODS

A three-arm randomised controlled trial (RCT) comparing these groups would be the ideal way to investigate this question, with a pilot RCT testing trial procedures and process evaluation required prior to a definitive RCT. Patients expectations, feasibility and acceptability of combined ESWT and exercise for PHP also remain unknown. Therefore, the addition of qualitative interviews in a mixed-methods pilot RCT would help ascertain acceptability and help explain the intervention outcomes.

A mixed-methods protocol for identifying successful sustainability strategies for nutrition and physical activity interventions in childcare

BACKGROUND

Despite the importance of sustainability for nutrition and physical activity in public health interventions, limited studies have explored the factors that promote and inhibit evidence-based program sustainment in the childcare setting. This study protocol describes a mixed-methods approach to develop novel sustainability strategies based on real-world settings and stakeholder feedback, with the goal of providing support for future obesity prevention programs and related studies on intervention sustainability. Two interventions, Together, We Inspire Smart Eating (WISE) and The Food Friends' (FF) Fun with New Foods and Get Movin' with Might Moves, are studied to this end.

METHODS

The study will deploy an explanatory, sequential mixed-methods design. First, the research team will collect a quantitative survey to assess rates of sustainment among WISE and Food Friends sites. We expect to collect 150 surveys from WISE and FF sites combined. Data from these surveys will be used to purposively sample sites for 12 to 18 site visits. Specifically, we will purposively sample low, partial, and high sustaining sites where we will conduct key informant interviews and focus groups as well as validate self-reports on sustainability. Survey content, qualitative interviews, and coding will be based on the Dynamic Sustainability Framework. We will draw on findings from the quantitative survey on predictors of sustainment and the qualitative site visits to understand varying levels of program sustainment. Then, we will utilize evidence-based quality improvement sessions to engage stakeholders in developing a multi-component sustainability strategy.

DISCUSSION

This study will provide a stakeholder-informed sustainability strategy ready for testing in a full-scale trial examining effects on sustainment of evidence-based nutrition and physical activity practices in childcare. We expect this strategy to be relevant for educators and consistent with the views of administrators as a guide for future practice for the targeted nutrition and physical activity interventions and beyond.

Table Talk: revision of an observational tool to characterize the feeding environment in early care and education settings

Objective

The Table Talk tool is an observational assessment of early care and education teacher (ECET) mealtime practices. The Table Talk Revised (TT-R) tool incorporates new constructs that emerged from qualitative research and teases apart existing categories to improve nuance of data capture. The objective of this study was to evaluate the TT-R, document interrater reliability for the TT-R, and report on ECET feeding communications in broader settings than previously studied (i.e., beyond a single Lunch and Head Start only).

Methods

Trained observers conducted mealtime observations in classrooms (N_classroms = 63, 10 sites) during Breakfast and two Lunches for both Lead and Assistant ECETs (N = 126). Classrooms were spread across Head Start in an urban area (60%), Head Starts in a rural area (24%), and a state-funded preschool (16%).

Results

On average, there were 22.17 (SD = 10.92) total verbal feeding communications at Breakfast, 37.72 (SD = 15.83) at Lunch₁, and 34.39 (SD = 15.05) at Lunch₂ with meals averaging 25 min. The most commonly observed supportive statement category was Exploring Foods for Lead (Breakfast = 1.61, Lunch₁ = 3.23, Lunch₂ = 2.70) and Assistant ECETs (Breakfast = .89, Lunch₁ = 2.03) except for Lunch₂ which was Encourages Trying in a Positive Way (Lunch₂ = 1.30). The most commonly observed unsupportive statement category was Firm Behavioral Control for both Lead (Breakfast = 3.61, Lunch₁ = 5.84, Lunch₂ = 5.51) and Assistants ECETs (Breakfast = 3.11, Lunch₁ = 6.38, Lunch₂ = 4.32). The majority of Interclass Correlation Coefficients indicating interrater reliability were in the excellent range (64%) for commonly occurring statement categories, and 14 of the 19 low frequency statement categories had > 80% agreement.

Conclusions and implications

Overall, items added to the Table Talk tool performed well, and interrater reliability was favorable. Our study also documented differences between Lead and Assistant teachers in mealtime practices and illustrated differing patterns of interaction between lunches and breakfast, important findings to inform future research and practice. The TT-R may be a useful measurement tool for monitoring and evaluating ECET practices in mealtime environments as well as informing intervention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-10087-8.

De-implementation of detrimental feeding practices: a pilot protocol

BACKGROUND

Early childhood educators (ECEs) often use detrimental feeding practices and are slow to implement positive feeding practices. Nevertheless, few studies have aimed to understand and change ECEs' feeding practices. This gap needs to be addressed because implementation (i.e., adding new, evidence-based practices) and de-implementation (i.e., stopping low-value or harmful practices) are distinct processes that require unique strategies.

METHODS

We will develop a de-implementation strategy for detrimental feeding practices using evidence-based quality improvement (EBQI) sessions to engage stakeholders and draw on the Niven process model for de-implementation. Then, we will investigate the effects of the de-implementation strategy in a proof-of-principle study. The de-implementation strategy will be evaluated in 2 partnering childcare agencies using a pre-post, within-site design. For our primary outcome, we will interview educators throughout the school year to assess the feasibility and acceptability of the intervention and survey them with standard measures for assessing feasibility and acceptability. For secondary outcomes, we will investigate its effects on the use of detrimental and evidence-based feeding practices by teachers and impacts on child BMI and diet.

DISCUSSION

The current study will establish the feasibility and acceptability of our de-implementation approach and will provide preliminary data toward 3 predicted secondary outcomes: (1) decreased detrimental feeding practices by ECEs, (2) increased adoption of and fidelity to nutrition promotion practices, and (3) improved child dietary outcomes. These results are expected to contribute to the uptake and sustainability of mealtime interventions to improve the diets of young children. Results will also apply to the field of implementation science by informing processes for developing de-implementation approaches in a community setting.

A data-driven examination of which patients follow trial protocol

Protocol adherence in behavioral intervention clinical trials is critical to trial success. There is increasing interest in understanding which patients are more likely to adhere to trial protocols. The objective of this study was to demonstrate the use of a data-driven approach to explore patient characteristics associated with the lowest and highest rates of adherence in three trials assessing interventions targeting behaviors related to lifestyle and risk for cardiovascular disease. Each trial included a common set of baseline variables. Model-based recursive partitioning (MoB) was applied in each trial to identify participant characteristics of subgroups characterized by these baseline variables with differences in protocol adherence. Bootstrap resampling was conducted to provide optimism-corrected c-statistics of the final solutions. In the three trials, rates of protocol adherence varied from 56.9% to 87.5%. Evaluation of heterogeneity of protocol adherence via MoB in each trial resulted in trees with 2–4 subgroups based on splits of 1–3 variables. In two of the three trials, the first split was based on pain in the past week, and those reporting lower pain were less likely to be adherent. In one of these trials, the second and third splits were based on education and employment, where those with lower education levels and who were employed were less likely to be adherent. In the third trial, the two splits were based on smoking status and then marriage status, where smokers who were married were least likely to be adherent. Optimism-corrected c-statistics ranged from 0.54 to 0.63. Model-based recursive partitioning can be a useful approach to explore heterogeneity in protocol adherence in behavioral intervention trials. An important next step would be to assess whether patterns hold in other similar studies and samples. Identifying subgroups who are less likely to be adherent to an intervention can help inform modifications to the intervention to help tailor the intervention to these subgroups and increase future uptake and impact.

Trial registration

ClinicalTrials.gov identifiers: NCT01828567, NCT02360293, and NCT01838226.

A Mixed-Methods Exploration of Barriers and Facilitators to Evidence-Based Practices for Obesity Prevention in Head Start

OBJECTIVE

To identify positive and negative deviant cases using quantitative fidelity data from a previous implementation of a nutrition intervention, Together, We Inspire Smart Eating (WISE), and to determine barriers and facilitators to fidelity by conducting qualitative interviews with deviant cases.

DESIGN

Explanatory sequential mixed methods.

SETTING

Head Start Program agencies in 2 southern US states.

PARTICIPANTS

Quantitative fidelity data were collected in 42 Head Start classrooms. Recruitment for qualitative interviews prioritized those who were positive or negative deviants across fidelity components (African American, n = 21; white, n = 19; and Hispanic, n = 3).

INTERVENTION

WISE introduces children to fruits and vegetables using evidence-based practices of role modeling, positive feeding, mascot use, and hands-on exposure.

ANALYSIS

A directed content analysis approach informed by the integrated Promoting Action on Research Implementation in Health Service framework.

PHENOMENON OF INTEREST

Barriers and facilitators to WISE evidence-based practices implementation.

RESULTS

Qualitative analyses identified themes of culture, leadership support, and mechanisms for embedding change as key contextual factors. Key findings related to recipient characteristics were beliefs about what works, personalized strategies to use WISE, and classroom management. Primary themes for the innovation construct were time and preparation, degree of fit, and WISE advantage. Finally, findings relative to the construct of facilitation included trainer support and desire for additional training.

CONCLUSIONS AND IMPLICATIONS

The study of cases at the extreme ends of the fidelity spectrum can provide unique perspectives on barriers and facilitators to implementation of interventions.

Implementation Science and Nutrition Education and Behavior: Opportunities for Integration

Implementation science (IS) is the study of approaches designed to increase adoption and sustainability of research evidence into routine practice. This article provides an overview of IS and ideas for its integration with nutrition education and behavior practice and research. Implementation science application in nutrition education and behavior practice can inform real-word implementation efforts. Research opportunities include advancing common approaches to implementation measurement. In addition, the article provides suggestions for future studies (eg, comparative effectiveness trials comparing implementation strategies) to advance the knowledge base of both fields. An example from ongoing research is included to illustrate concepts and methods of IS.