Cluster-randomized Studies in Educational Research: Principles and Methodological Aspects

A mixed methods, cluster randomized control trial to examine assistive technology use to support early literacy in preschool children with disabilities

This mixed methods study examined the impact of a multi-faceted professional development (PD) program for preschool teachers and classroom assistants on teacher-supported assistive technology (AT) use and early literacy development of children with disabilities. Four special education preschools were randomized into intervention (2 schools, 9 teachers, 50 children) and waitlist control (2 schools, 17 teachers, 42 children) groups. The 24-week PD included online modules, coaching, and AT device kits. Pre-post gains in children's AT use and early literacy skills were analyzed using χ2 and repeated measures ANOVA. Teacher interviews and reflective commentaries were analyzed using Framework Analysis methodology. From pre- to post-test, the percent of children in the intervention group using some form of AT rose from 36 to 80%. The percent of children using AT in the control group went from 45 to 62%. The difference in change between the two groups was statistically significant, χ2 = 13.93, p=.001. Gains in early literacy skills were not significantly different across groups, F(1,90)=0.010, p=.922. Analysis of the qualitative data revealed three themes: the positive impact of AT on child engagement and participation, the importance of individualizing AT for each student, and barriers teachers faced in AT implementation. The PD program had a positive effect on children's AT use but not on gains in early literacy. Teachers' comments highlighted the nuanced relationship between AT use and literacy outcomes, suggesting the need for more targeted implementation of AT during literacy activities.

Promoting Mental Health and Well-Being Among Adolescent Young Carers in Europe: A Cross-National Randomized Controlled Trial Study

BACKGROUND/OBJECTIVES

This cross-national study focuses on adolescents who provide care and support to family members or significant others. Current evidence regarding their mental health and solutions to strengthen it is limited and mostly available in a few countries. The aim of this study is to evaluate the results of a primary prevention intervention for improving the mental health and well-being of adolescent young carers (AYCs) aged 15-17 years in six European countries. The intervention was based on a psychoeducational program and tools adapted from the Discoverer, Noticer, Advisor, and Values (DNA-V) model.

METHODS

We designed a randomized controlled trial with 217 AYCs participating in the study, either in the intervention or control group. Quantitative and qualitative data were collected via questionnaires at baseline, post-intervention, and a 3-month follow up.

RESULTS

The results were mixed, as positive improvements in primary (i.e., psychological well-being and skills) and secondary (school/training/work functioning) outcomes were shown by the experimental group but, in most cases, they were not statistically significant. The qualitative data supported positive claims about the intervention and its appropriateness for AYCs.

CONCLUSIONS

The study implementation during the peak of the COVID-19 pandemic forced the consortium to adapt the design and may have influenced the results. More long-term studies are needed to assess similar mental health programs with this hard-to-reach target group.

Study protocol of the OrkA project: orofacial and communicative activation in old age- a cluster randomized prevention study in long-term care facilities in Lower Saxony, Germany

BACKGROUND

The process of aging involves numerous changes in the body, influencing physical, mental, and emotional well-being. Age-related changes and degradation can impact various functions of the swallowing process and lead to delayed word retrieval. Individuals with limited linguistic stimulation may experience a more rapid decline in cognitive performance. Thus, this project explores a preventive training program targeting swallowing and linguistic-communicative skills, aimed at preserving the social participation of older individuals residing in nursing homes.

METHODS

A preventive intervention program, combining orofaciopharyngeal and linguistic-communicative components, will be offered twice weekly over 12 weeks in long-term care facilities in the greater Hanover area. The program will aim at: (a) activating sensitive and motor skills in the orofaciopharyngeal area to counter age-related swallowing disorders, and (b) enhancing communicative abilities through semantic-lexical activation. A cluster randomized controlled trial will be conducted to investigate whether the intervention program improves swallowing skills in older adults. Additionally, a secondary analysis will explore the impact on language skills and social participation, as well as program acceptance.

DISCUSSION

The results will provide valuable insight into the effectiveness of preventive measures addressing swallowing and speech issues in older individuals.

TRIAL REGISTRATION

The trial was registered with DRKS (German register for clinical trials) in June 2023 (study ID: DRKS00031594) and the WHO International Clinical Trail Registry Platform (secondary register).

The effectiveness of an m-Health intervention on the sexual and reproductive health of in-school adolescents: a cluster randomized controlled trial in Nigeria

BACKGROUND

The implementation of the country-wide comprehensive sexuality education (CSE) curriculum among in-school adolescents remains abysmally low and mHealth-based interventions are promising. We assessed the effect of a mHealth-based CSE on the sexual and reproductive health (SRH) knowledge, attitude and behaviour of in-school adolescents in Ilorin, northcentral Nigeria.

METHODS

Using schools as clusters, 1280 in-school adolescents were randomised into intervention and control groups. Data was collected at baseline (T0), immediately after the intervention (T1) and 3 months afterwards (T2) on SRH knowledge, attitude and practice of risky sexual behaviour (RSB). Data analysis included test of associations using Chi-square, independent t-test and repeated measures ANOVA. Predictors were identified using binary logistic regression.

RESULTS

In the intervention group, there was a statistically significant main effect on mean knowledge score (F = 2117.252, p =  < 0.001) and mean attitude score (F = 148.493, p =  < 0.001) from T0 to T2 compared to the control group which showed no statistically significant main effects in knowledge (p = 0.073), attitude (p = 0.142) and RSB (p = 0.142). Though the mean RSB score declined from T0 to T2, this effect was not statistically significant (F = 0.558, p = 0.572). Post-intervention, being female was a positive predictor of good SRH knowledge; being male was a positive predictor of RSB while being in a higher-class level was a negative predictor of RSB.

CONCLUSION

The mHealth-based CSE was effective in improving SRH knowledge and attitude among in-school adolescents. This strategy should be strengthened to bridge the SRH knowledge and attitude gap among in-school adolescents. Trial registration Retrospectively registered on the Pan African Clinical Trial Registry (pactr.samrc.ac.za) on 19 October 2023. Identification number: PACTR202310485136014.

Can positive expectations help to improve the learning of risk literacy? A cluster-randomized study in undergraduate medical students

BACKGROUND

Risk literacy, i.e., the ability to calculate and apply risk parameters, represents a key competence for risk communication and medical decision making. However, risk literacy is reportedly low in medical students. The successful acquisition of statistical competencies is often difficult, and can be hampered by emotional learning obstacles, calling for interventions to support learning. In this cluster-randomized study, we aimed to translate findings from placebo research to medical education. Specifically, we tested if the acquisition of risk literacy during a seminar unit can be facilitated by positive expectations, induced by a positive and non-threatening framing of the content and learning goals.

METHODS

The study took place during a mandatory 2.5-h seminar on "risk literacy" for 2^nd year medical students. The seminar teaches both statistical knowledge and its application in patient communication. To test the effects of expectations on risk literacy acquisition, the (otherwise identical) seminar was framed either as "communication training" (positive framing condition) or "statistics seminar" (negative framing condition). All N = 200 students of the semester were invited to participate, and cluster-randomized to the positive or negative framing condition (4 seminar groups each condition). Risk literacy was assessed with the "Quick Risk Test" (QRT) at the beginning and end of the seminar, along with statistics anxiety and subjective learning success using questionnaires.

RESULTS

Data from N = 192 students were included. At the end of the seminar, risk literacy was increased in both framing conditions, with a significantly greater increase in QRT scores in the positive framing condition. Statistics anxiety was significantly decreased in both framing conditions, with no evidence of group differences. Subjective learning success was overall high and comparable between groups.

CONCLUSIONS

Supporting our hypothesis, positive framing led to a significantly greater increase in risk literacy (i.e., in QRT scores). Our data offer first support that positive framing of learning goals may help to facilitate the acquisition of statistical knowledge. Expectation-orientated interventions may thus offer a feasible tool to optimize learning settings and framing of learning objectives in medical statistics courses.

Effect Evaluation of Sahtak bi Sahnak, a Lebanese Secondary School-Based Nutrition Intervention: A Cluster Randomised Trial

Objective

To evaluate the effectiveness of Sahtak bi Sahnak on dietary knowledge and adherence to dietary guidelines in Lebanese adolescents.

Design/setting

A cluster randomised controlled trial was conducted in public and private secondary schools located in urban and rural regions in Lebanon.

Participants

Sixteen secondary schools including 1,572 adolescents were randomly assigned to the intervention (n = 739) or control group (n = 833).

Intervention

Sahtak bi Sahnak is an educational school-based intervention dedicated to improving dietary adherence to nutritional guidelines, increasing the level of dietary knowledge, and preventing the development of obesity during adolescence. It was systematically designed based on the Intervention Mapping framework. The total length of the intervention was around seven educational sessions, until all of the 11 lessons were covered. Each education session lasted 20-40 min.

Main Outcome Measures

Dietary knowledge and adherence levels were measured at baseline and post-intervention using validated questionnaires.

Statistical Analysis

Multivariate multilevel regression models were used to examine intervention effects on outcomes, controlled for background characteristics (i.e., age, gender, location, type of school, grade, BMI z-score).

Results

The intervention group showed significant improvements in total dietary knowledge (B = 12.74, p < 0.001) and intake of healthy items (B = 1.89, p < 0.001), compared to the control group. Intake of unhealthy items decreased significantly (B = -1.43, p < 0.001), compared to the control group. These results were adjusted for age, gender, type of school, location, BMI z-score, study group, and score at baseline.

Conclusion and Implications

Sahtak bi Sahnak is an effective and culturally appropriate school-based intervention for targeting diet among a variety of Lebanese adolescents.

The Long-Term Effectiveness of Interventions Addressing Mental Health Literacy and Stigma of Mental Illness in Children and Adolescents: Systematic Review and Meta-Analysis

Objectives: This study aims to provide a systematic review and meta-analysis of the literature on the long-term effects of interventions addressing children’s and adolescents’ mental health literacy and/or stigmatizing attitudes.

Methods: Articles in English or German published between January 1997 and May 2020 were retrieved from five databases, leading to a total of 4,375 original articles identified.

Results: 25 studies were included after applying exclusion criteria, 13 of which were eligible for meta-analysis. The overall average of the follow-up period was about 5 months. Long-term improvements were sustained for mental health literacy, d = 0.48, 95% CI = (0.34, 0.62), as well as for stigmatizing attitudes, d = 0.30, 95% CI = (0.24, 0.36), and social distance, d = 0.16, 95% CI = (0.03, 0.29). The combination of educational and contact components within interventions led to worse results for mental health literacy, but not stigmatizing attitudes or social distance.

Conclusion: Interventions targeting children and adolescents generally have a brief follow-up period of an average of 5 months. They show a stable improvement in mental health literacy, but are to a lesser degree able to destigmatize mental illness or improve social distance.

Promoting Mental Health and Well-Being among Adolescent Young Carers in Europe: A Randomized Controlled Trial Protocol

It is estimated that 4-8% of youth in Europe carry out substantial care for a family member or significant other. To prevent adverse psychosocial outcomes in young carers (YCs), primary prevention resilience building interventions have been recommended. We describe the study protocol of an international randomized controlled trial (RCT) of an innovative group intervention designed to promote the mental health and well-being of adolescent YCs (AYCs) aged 15-17. The RCT will be conducted in six European countries in the context of the Horizon 2020 European funded research and innovation project "Psychosocial support for promoting mental health and well-being among adolescent young caregivers in Europe" ("ME-WE"). The ME-WE intervention is based on Hayes and Ciarrochi's psychoeducational model for adolescents and will consist of seven 2-h sessions in a group format, aimed to help AYCs build psychological flexibility and live according to their values. The control group will be a waitlist. Primary and secondary outcomes and control variables will be measured at baseline (T0), post-intervention (T1) and 3 months follow-up (T2). The COVID-19 pandemic has made amendments necessary to the original study protocol methodology, which we describe in detail. This study will contribute to building an evidence-based manualized program that educators and health and social care professionals can use to support AYCs in their transition to adulthood. From a research perspective, the outcomes of this study will contribute to evidence-based practices in primary prevention of psychosocial difficulties in AYCs and will gather novel knowledge on the effectiveness of Hayes and Ciarrochi's model for use with middle adolescents with caring responsibilities. The trial has been preregistered (registration number: NCT04114864).

Working conditions of healthcare workers and clients' satisfaction with care: study protocol and baseline results of a cluster-randomised workplace intervention

BACKGROUND

In the present investigation the study protocol and the results at baseline of a workplace intervention are reported. It is hypothesised that the reduction of the physical and psychosocial workload of healthcare workers increases 1 their self-assessed physical and mental work ability, and 2. clients' satisfaction with care.

METHODS

Two-arm, cluster-randomised trial. Outcome data on workers and clients are collected in questionnaires at baseline, and two follow-ups between 2019 and 2021. Participants of the interventions are healthcare workers of 11 healthcare providers in Germany. At baseline, the intervention arm comprised 22 clusters (n = 174 workers); the control arm, 47 clusters (n = 276). The intervention consists of interviews and workshops, in which employees propose measures aiming to reduce the physical and psychosocial load, and strengthen resources at work. The primary outcome is the workers' physical and mental work ability. The secondary outcome is the clients' satisfaction with care.

RESULTS

There was no evidence of substantial differences between trial arms at baseline concerning the outcomes. The design effect estimates for physical and mental work ability were 1.29 and 1.05, respectively. At the end of the trial, effect sizes of at least 0.30 and 0.27 at the 80% power and 5% significance levels can be attained.

CONCLUSIONS

The results suggest that the implementation of the study design has been satisfactory. The intervention is expected to provide evidence of relatively small to medium-size effects of the intervention activities on the work ability of healthcare workers and the clients' satisfaction with care.

TRIAL REGISTRATION

Registration trial DRKS00021138 on the German Registry of Clinical Studies (DRKS), retrospectively registered on 25 March, 2020.

Effect of practice exergames on the mood states and self-esteem of elementary school boys and girls during physical education classes: A cluster-randomized controlled natural experiment

Reduced physical exercise can impact children's mental health. Use of active electronic games can help promote psychological health. Physical education (PE class) uses different resources, methods, and contents to promote student health. We investigated the effect of exergames on the mood and self-esteem of children and compare it that of with traditional PE classes. From a sample of 213 children (7-11 years old), 140 from 10 classes of the fourth and fifth grades of elementary school (59 boys, 81 girls; mean age 9.41±0.48 years), allocated to an experimental group (EG; n = 68; five clusters) and a PE group (PE; n = 72; five clusters), participated in this experimental controlled study. The EG practiced exergames during three 40-minute classes, and the PE group held three routine curricular PE classes. Brunel's Mood Scale and Rosenberg's Self-Esteem Scale were applied. Repeated measures ANOVA identified differences between sexes and groups. The main results of the EG demonstrated reduced tension in girls (p <0.05; ES: 0.62; 95% CI: 0.17-1.05). Regarding sex comparisons, anger was lower in girls (F: 4.57; p <0.05; ES: 0.61; 95% CI: 0.11-1.11) in the EG. Vigor was higher in girls in the EG than in those in the PE group (F: 5.46; p <0.05; ES: 0.56; 95% CI: 0.12-1.01). The main results of the PE group indicated increased self-esteem in boys (p <0.05; ES: 0.58; 95% CI: 0.08-1.07) and reduction of girls' mental confusion (p <0.05; ES 0.58; 95% CI 0.15-1.06). Thus, exergames impact boys' and girls' self-esteem and mood, as well as traditional physical education classes. Further study on exergames in schools is essential, with long-term effects on physical and mental health. Exergames bring interesting, varied content, technology, and innovation that can increase the attractiveness of physical education.

Nutrition education in Southeast Sulawesi Province, Indonesia: A cluster randomized controlled study

This study evaluated the impact of a nutrition education intervention on child feeding practices and children's nutritional status. Using a randomized controlled trial, we conducted an intervention for 6 months among caregivers with children aged 6-17 months in two subdistricts of Kendari, SE Sulawesi Province, Indonesia. In all, 22 integrated health posts were randomly assigned to an educational intervention or control group with 266 participants in both groups. Participants in the intervention group attended four nutrition classes and received a monthly home visit by cadres (community volunteers), whereas participants in the control group only received standard monthly health care at the health post. The primary study outcome was children's dietary diversity scores (DDSs). Mixed model analysis was conducted to examine the intervention effects on DDS and children's growth adjusting for clustering within subvillages. The study showed the educational intervention had a significant effect on children's DDS. Children in the intervention group had a larger DDS compared with children in the control group (Beta [mean difference] = 0.34, 95% CI: 0.02 to 0.66, P = 0.038). The intervention effect on height-for-age z-score (HAZ) could not be shown (Beta = 0.24, 95% CI: -0.06 to 0.56, P = 0.112). However, stunting prevalence remained stable in the intervention group but increased in the control group. These results indicated nutrition education delivered through nutrition classes combined with regular home visits by cadres as influencers provided a great potential to be adopted to complement other nutrition programmes in community health centres.

The Effect of Counseling on Breast Cancer Awareness in Rural Iranian Women: a Randomized Controlled Clinical Trial

In a community such as Iran where late presentation is predominant and the majority of breast cancer patients are diagnosed at advanced stages of the disease, there is an urgent need for improving the level of awareness about breast cancer and early detection measures. Given that rural residents are at higher risk for late diagnosis of breast cancer because they have less education, income, and access to advanced screening technologies, this study was conducted to determine the effect of counseling on breast cancer awareness of rural Iranian women. This randomized clinical trial was conducted on 60 rural women from the Abish Ahmad area in northwestern Iran in 2017. The randomized cluster method was used for sampling. From 20 rural health houses and centers, about one third were selected randomly. From the six selected clusters, three were randomly allocated as the control group and three as the intervention group. Using convenience sampling, 30 women between the ages of 40 and 69 were selected from the control group and 30 from the intervention group. The intervention group attended six group counseling sessions. Data was gathered using a demographic and obstetrical information questionnaire and breast cancer awareness measures. The chi-square, independent t test and ANCOVA by controlling for the baseline scores were used to analyze the data. After counseling, the mean knowledge about breast cancer score was significantly higher in the intervention group than in the control group (adjusted mean difference, 17.02; confidence interval (CI) 95%, 15.44 to 18.59; p < 0.001). The mean barriers to breast cancer screening score showed a significant decrease in the intervention group compared to the control group (AMD, - 1.74; 95% CI - 3.12 to - 0.36, p < 0.001). After intervention, the frequency of breast self-exam showed a significant difference between groups (p < 0.001); but for confidence about noticing breast changes, no significant difference was observed between groups (p = 0.08). Group counseling had a significant effect on enhancing breast cancer awareness of rural Iranian women, except for confidence about noticing breast changes.

Efficacy of a Short Role-Play Training on Breaking Bad News in the Emergency Department

Introduction

Breaking bad news (BBN) in the emergency department (ED) represents a challenging and stressful situation for physicians. Many medical students and residents feel stressed and uncomfortable with such situations because of insufficient training. Our randomized controlled study aimed to assess the efficacy of a four-hour BBN simulation-based training on perceived self-efficacy, the BBN process, and communication skills.

Methods

Medical students and residents were randomized into a 160-hour ED clinical rotation without a formal BBN curriculum (control group [CG], n = 31) or a 156-hour ED clinical rotation and a four-hour BBN simulation-based training (training group [TG], n = 37). Both groups were assessed twice: once at the beginning of the rotation (pre-test) and again four weeks later. Assessments included a BBN evaluation via a simulation with two actors playing family members and the completion of a questionnaire on self-efficacy. Two blinded raters assessed the BBN process with the SPIKES (a delivery protocol for delivering bad news) competence form and communication skills with the modified BBN Assessment Schedule.

Results

Group-by-time effects adjusted by study year revealed a significant improvement in TG as compared with CG on self-efficacy (P < 0.001), the BBN process (P < 0.001), and communication skills (P < 0.001). TG showed a significant gain regarding the BBN process (+33.3%, P < 0.001). After the training, students with limited clinical experience prior to the rotation showed BBN performance skills equal to that of students in the CG who had greater clinical experience.

Conclusion

A short BBN simulation-based training can be added to standard clinical rotations. It has the potential to significantly improve self-efficacy, the BBN process, and communication skills.

Effect of data self-collection as an activating teaching method in a statistical software course in medical biometry - a pilot study

Background: Biostatistics is an integral part of the studies of human medicine. Students learn the basics of analyzing and interpreting study results. It is important to demonstrate the subject's relevance by means of appropriate measures to maximize learning success. We investigated whether an active involvement of students in the process of data collection may improve test performance and motivation among medical students. Methods: We conducted a pilot study comparing active involvement of students (n1=45) in the process of data collection and standard education (n2=26). All students of this pilot study participated in an observational study assessing their preferences regarding sweets or salty munchies, and students of the experimental group subsequently used this data set during the exercises throughout the semester. Primary and secondary endpoints were examination success and motivation respectively. Results: Superiority of the activating teaching method could not be demonstrated (intervention: 109.0 points (SD 8.8), control: 113.8 points (SD 6.5)). The course ratings were superior in the intervention group (median grade 1 vs. median grade 2 in the control group), although this was not a significant improvement (p=0.487). Conclusions: Biostatistics education should incorporate approaches contributing to a better understanding of learning contents. Possible reasons why this pilot study failed to prove superiority of the intervention were a lack of sample size as well as the good grades in the control group. The presented teaching concept has to be evaluated by means of a larger sample enabling more valid conclusions. Furthermore, the considered research question in the experimental group may be changed to a more relevant one for medical practice.