Protocol development, treatment fidelity, adherence to treatment, and quality control

Ensuring fidelity: key elements to consider in disseminating a diabetes telemanagement program for underserved Hispanic/Latinos living with type 2 diabetes

Background

The Hispanic/Latino population has greater risk (estimated >50%) of developing type 2 diabetes (T2D) and developing it at a younger age. The American Diabetes Association estimates costs of diagnosed diabetes in 2017 was $327 billion; with medical costs 2.3x higher than patients without diabetes. The purpose of this manuscript is to describe the methodology utilized in a randomized controlled trial aimed at evaluating the efficacy of a diabetes telemanagement (DTM) program for Hispanic/Latino patients with T2D. The intent is to provide information for future investigators to ensure that this study can be accurately replicated.

Methods

This study was a randomized controlled trial with 240 participants. Eligible patients (Hispanic/Latino, aged 18+, living with T2D) were randomized to Comprehensive Outpatient Management (COM) or DTM. DTM was comprised of usual care, including routine clinic visits every three months, as well as: Biometrics (a tablet, blood glucose meter, blood pressure monitor, and scale); Weekly Video Visits (facilitated in the patient's preferred language); and Educational Videos (including culturally congruent diabetes self-management education and quizzes). COM consisted of usual care including routine clinic visits every three months. For this study, COM patients received a glucometer, glucose test strips, and lancets. Establishing a therapeutic nurse-patient relationship was a fundamental component of our study for both groups. First contact (post-enrollment) centered on ensuring that patients and caregivers understood the program, building trust and rapport, creating a non-judgmental environment, determining language preference, and establishing scheduling availability (including evenings and weekends). DTM were provided with a tablet which allowed for self-paced education through videos and weekly video visits. The research team and Community Advisory Board identified appropriate educational video content, which was incorporated in diabetes educational topics. Video visits allowed us to assess patient involvement, motivation, and nonverbal communication. Communicating in Spanish, and awareness of diverse Hispanic/Latino backgrounds was critical, as using relevant and commonly-used terms can increase adherence and improve outcomes. Shared decision-making was encouraged to make realistic health care choices.

Conclusion

Key elements discussed above provide a framework for future dissemination of an evidence-based DTM intervention to meet the needs of underserved Hispanic/Latino people living with T2D.

Development of an audit checklist to evaluate treatment fidelity of a complex rehabilitation intervention

PURPOSE

The process of examining treatment fidelity is critical to the successful implementation of rehabilitation interventions. Videotaping is considered the 'gold standard' assessment; however, may be considered resource-intensive and intrusive for intervention providers and patients. An audit checklist is an alternative approach recommended in the literature. The purpose of this study was to develop a documentation audit checklist for assessing treatment fidelity during delivery of SENSe therapy, a complex rehabilitation intervention targeting upper limb somatosensory impairment post-stroke.

METHODS

Checklist development comprised: content determination and design; checklist testing via audit of 38 therapy records from an existing data set; and exploration of rater agreement between two assessors, using a subset of 10 therapy records.

RESULTS

The developed audit checklist comprised 29 components core to the delivery of SENSe therapy. Six SENSe therapy records were delivered with high fidelity (>80% adherence to core components), and 32 with moderate fidelity (51-79%). Rater agreement was 80% across the subset of 10 records.

CONCLUSION

Findings highlight the importance of using a theoretically-guided approach to checklist development, with the use of rater agreement to identify areas for refinement. A documentation audit checklist was developed that can be used to evaluate treatment fidelity of complex rehabilitation interventions.IMPLICATIONS FOR REHABILITATIONDevelopment of an audit checklist that evaluates clinician documentation of therapy delivery, is feasible as one strategy to measure and enhance the treatment fidelity of complex rehabilitation interventions.The process of audit checklist development should be structured and based on conceptual frameworks, to ensure it accurately measures quality of delivery and adherence to core intervention components.Audit checklists can be used to support clinicians delivering complex rehabilitation interventions.

Dyadic interventions in older people with chronic diseases: An integrative review

This integrative review aims to explore the current state of dyadic interventions in older people with chronic diseases and to review how these interventions are developed and conducted. 'Older people' and 'dyadic intervention' were searched in six databases to include studies published before August 2021. The constant comparison method was used for data synthesis, combined with the Joanna Briggs Institute (JBI)¹ and mixed methods appraisal tool (MMAT)² to assess the quality of the literature. Nineteen studies were included and could be divided into four types in which caregivers could be seen as subordinators, directors, cooperators and collaborators. Dyadic interaction could be observed in all studies, including dyad coled, patient-led, and caregiver-led interactions. The outcome indicators included patient-, caregiver-, dyad-, and family-related indicators. It is important not only to include the dyad but also to consider the dyadic interactions. In the future, dyadic intervention can be guided by matching dyadic theories. NO PATIENT OR PUBLIC CONTRIBUTION: This study is an integrative review; the study population was not directly contacted. Data from included studies were analysed and interpreted.

Self-collection of hair samples during the COVID-19 pandemic

Purpose

Due to the COVID-19 Pandemic, public health restrictions were implemented that required study protocol revisions for our collection of hair cortisol samples from in-person to self-collection. The purpose is to provide descriptions of the protocol transition process from in-person hair cortisol sample collection to participant self-collection using written and video instructions as well as the acceptability and feasibility of this transition.

Main results

The protocol transition required revisions to the written instructions with a link to a newly developed video for hair sample self-collection. There was little difference in the initial participant agreement to provide a hair sample between in-person (79/114; 69.3%) versus self-collection (254/417; 60.9%) protocol methods. Some participants were initially hesitant to provide a self-collected hair sample but commented that self-collection was easier than they anticipated which supports the acceptability of this protocol change. However, regarding feasibility, 16.8% of participant self-collected hair samples were not received by study staff despite reminders (14.3%) or there was an issue with mail delivery or return (2.5%).

Major conclusions

The transition of our hair sample collection protocol from in-person to self-collection was acceptable and feasible. Providing instructions for hair sample self-collection in a variety of formats (oral, written, video) helped to decrease uncertainty and hesitancy regarding the process and promote agreement among participants. In addition, consistent follow-up communication was key to timely receipt of the hair samples from participants.

Prioritising the content and delivery of a work-focused intervention for women with breast cancer using the nominal group technique

BACKGROUND: Increased breast cancer survivorship has prompted a focus on optimising quality of life for this cohort, including re-integration into employment. Despite this, there remains a lack of work-focused interventions to support work outcomes for women living with and beyond breast cancer. OBJECTIVE: The aim of this study was to prioritise the content and delivery of a work-focused intervention for women living with and beyond breast cancer. METHODS: Twelve stakeholders including women living with and beyond breast cancer, healthcare professionals, cancer support centre staff, and policy informers were invited to participate in an online discussion using the Nominal Group Technique (NGT) to determine priorities for a work-focused intervention. The NGT seeks consensus through four steps; (i) idea generation, (ii) discussion among the group, (iii) refining ideas, and (iv) ranking preference for ideas through anonymised voting. RESULTS: Intervention content prioritised included managing cancer-related symptoms and work-specific factors. Consensus was made for a blended delivery format (mix of group and individual sessions), and blended delivery (face-to-face and online). Findings indicated a preference for a six-week intervention, with 90–120 minute sessions. Community-based settings were preferred over hospital-based services for the setting of a work-focused intervention. Zoom Video Communications Inc. was the preferred setting to deliver an online intervention. CONCLUSION: Stakeholder priorities informed the content and delivery of a work-focused intervention for women with breast cancer. A pilot of the proposed intervention will be conducted to test for feasibility and acceptability.

Supporting young adults with intellectual/developmental disabilities to deliver a peer mentoring intervention: Evaluating fidelity and resources required

BACKGROUND

Peer-delivered interventions are a best practice in mental health, yet no such intervention exists for young adults (YA) with intellectual/developmental disabilities with co-occurring mental health conditions. We evaluated YA with intellectual/developmental disabilities' ability to deliver a novel peer mentoring intervention with fidelity and the supports received.

METHODS

We coded audio-recorded mentoring sessions to evaluate if 4 mentors adhered to 'content' (e.g., psychoeducation) and 'quality' (e.g., validation) fidelity criteria (codes: yes/no). We conducted content analysis of mentor support logs and interviews with mentors', mentors' parents and teachers to describe the supports mentors received.

RESULTS

Average fidelity for content criteria (M = 73.3%) was higher than quality criteria (M = 60.0%). Weekly support addressed logistics, delivering content, interpersonal interactions, emotional support, professionalism, and organisation. Family members and teachers rarely provided additional support.

CONCLUSIONS

With support, YA can deliver a peer mentoring intervention addressing mental health. Additional training activities will be developed to improve fidelity.

Measures implemented in the school setting to contain the COVID-19 pandemic: a scoping review

BACKGROUND

In response to the spread of SARS-CoV-2 and the impact of COVID-19, national and subnational governments implemented a variety of measures in order to control the spread of the virus and the associated disease. While these measures were imposed with the intention of controlling the pandemic, they were also associated with severe psychosocial, societal, and economic implications on a societal level. One setting affected heavily by these measures is the school setting. By mid-April 2020, 192 countries had closed schools, affecting more than 90% of the world's student population. In consideration of the adverse consequences of school closures, many countries around the world reopened their schools in the months after the initial closures. To safely reopen schools and keep them open, governments implemented a broad range of measures. The evidence with regards to these measures, however, is heterogeneous, with a multitude of study designs, populations, settings, interventions and outcomes being assessed. To make sense of this heterogeneity, we conducted a rapid scoping review (8 October to 5 November 2020). This rapid scoping review is intended to serve as a precursor to a systematic review of effectiveness, which will inform guidelines issued by the World Health Organization (WHO). This review is reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist and was registered with the Open Science Framework.

OBJECTIVES

To identify and comprehensively map the evidence assessing the impacts of measures implemented in the school setting to reopen schools, or keep schools open, or both, during the SARS-CoV-2/COVID-19 pandemic, with particular focus on the types of measures implemented in different school settings, the outcomes used to measure their impacts and the study types used to assess these.

SEARCH METHODS

We searched the Cochrane COVID-19 Study Register, MEDLINE, Embase, the CDC COVID-19 Research Articles Downloadable Database for preprints, and the WHO COVID-19 Global literature on coronavirus disease on 8 October 2020.

SELECTION CRITERIA

We included studies that assessed the impact of measures implemented in the school setting. Eligible populations were populations at risk of becoming infected with SARS-CoV-2, or developing COVID-19 disease, or both, and included people both directly and indirectly impacted by interventions, including students, teachers, other school staff, and contacts of these groups, as well as the broader community. We considered all types of empirical studies, which quantitatively assessed impact including epidemiological studies, modelling studies, mixed-methods studies, and diagnostic studies that assessed the impact of relevant interventions beyond diagnostic test accuracy. Broad outcome categories of interest included infectious disease transmission-related outcomes, other harmful or beneficial health-related outcomes, and societal, economic, and ecological implications.

DATA COLLECTION AND ANALYSIS

We extracted data from included studies in a standardized manner, and mapped them to categories within our a priori logic model where possible. Where not possible, we inductively developed new categories. In line with standard expectations for scoping reviews, the review provides an overview of the existing evidence regardless of methodological quality or risk of bias, and was not designed to synthesize effectiveness data, assess risk of bias, or characterize strength of evidence (GRADE).

MAIN RESULTS

We included 42 studies that assessed measures implemented in the school setting. The majority of studies used mathematical modelling designs (n = 31), while nine studies used observational designs, and two studies used experimental or quasi-experimental designs. Studies conducted in real-world contexts or using real data focused on the WHO European region (EUR; n = 20), the WHO region of the Americas (AMR; n = 13), the West Pacific region (WPR; n = 6), and the WHO Eastern Mediterranean Region (EMR; n = 1). One study conducted a global assessment and one did not report on data from, or that were applicable to, a specific country. Three broad intervention categories emerged from the included studies: organizational measures to reduce transmission of SARS-CoV-2 (n = 36), structural/environmental measures to reduce transmission of SARS-CoV-2 (n = 11), and surveillance and response measures to detect SARS-CoV-2 infections (n = 19). Most studies assessed SARS-CoV-2 transmission-related outcomes (n = 29), while others assessed healthcare utilization (n = 8), other health outcomes (n = 3), and societal, economic, and ecological outcomes (n = 5). Studies assessed both harmful and beneficial outcomes across all outcome categories.

AUTHORS' CONCLUSIONS

We identified a heterogeneous and complex evidence base of measures implemented in the school setting. This review is an important first step in understanding the available evidence and will inform the development of rapid reviews on this topic.

Nasal povidone-iodine implementation for preventing surgical site infections: Perspectives of surgical nurses

INTRODUCTION

Preoperative nasal decolonization of surgical patients with nasal povidone-iodine (PI) has potential to eliminate pathogenic organisms responsible for surgical site infections. However, data on implementation of PI for quality improvement in clinical practice is limited. The purpose of this study was to evaluate the implementation feasibility, fidelity and acceptability of intranasal PI solution application by surgical nurses using the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) conceptual framework.

MATERIALS AND METHODS

Using the i-PARIHS framework to frame questions and guide interview content areas, we conducted 15 semi-structured interviews of pre- and post-operative care nurses in two facilities. We analyzed the data using deductive content analysis to evaluate nurses' experience and perceptions on preoperative intranasal PI solution decolonization implementation. Open coding was used to analyze the data to ensure all relevant information was captured.

RESULTS

Each facility adopted a different quality improvement implementation strategy. The mode of facilitation, training, and educational materials provided to the nurses varied by facility. Barriers identified included lack of effective communication, insufficient information and lack of systematic implementation protocol. Action taken to mitigate some of the barriers included a collaboration between the study team and nurses to develop a systematic written protocol. The training assisted nurses to systematically follow the implementation protocol smoothly to ensure PI administration compliance, and to meet the goal of the facilities. Nurses' observations and feedback showed that PI did not cause any adverse effects on patients.

CONCLUSIONS

We found that PI implementation was feasible and acceptable by nurses and could be extended to other facilities. However further studies are required to ensure standardization of PI application.

Challenges with study procedure fidelity when conducting household survey: reports from the field

Objectives

The aim of the study was to identify reasons for protocol deviations during conduct of large epidemiological surveys despite training of field workers, validating clinicians, and providing field supervisory support. Enquiries focused on breaches of recruitment procedures, privacy, confidentiality, and informed consent. The case study was a household survey conducted in Ile-Ife, Nigeria.

Results

The study reveals that despite training of field workers, providing supervisory support, and conducting validation exercises, protocol deviation still occurred. Measures to improve internal research validity during the conduct of surveys can minimise but not eliminate protocol deviations. Individual and environmental factors increase the risk for protocol deviation. Individual factors include personal bias against adherence to elements of the protocols, and pressure to meet personal recruitment targets to maximise remuneration. These pressures increase the risk of breaching study participants’ recruitment process. Environmental pressures resulted from low research literacy that made it possible for field workers not to consent participants and for participants not to prioritise privacy. The use of electronic data collection enhanced data security. A key recommendation from the study was that improved field supervision will reduce the risk for protocol violation.

Electronic supplementary material

The online version of this article (10.1186/s13104-019-4500-0) contains supplementary material, which is available to authorized users.

Control freaks: Towards optimal selection of control conditions for fMRI neurofeedback studies

fMRI Neurofeedback research employs many different control conditions. Currently, there is no consensus as to which control condition is best, and the answer depends on what aspects of the neurofeedback-training design one is trying to control for. These aspects can range from determining whether participants can learn to control brain activity via neurofeedback to determining whether there are clinically significant effects of the neurofeedback intervention. Lack of consensus over criteria for control conditions has hampered the design and interpretation of studies employing neurofeedback protocols. This paper presents an overview of the most commonly employed control conditions currently used in neurofeedback studies and discusses their advantages and disadvantages. Control conditions covered include no control, treatment-as-usual, bidirectional-regulation control, feedback of an alternative brain signal, sham feedback, and mental-rehearsal control. We conclude that the selection of the control condition(s) should be determined by the specific research goal of the study and best procedures that effectively control for relevant confounding factors.

Effect of a combined programme of dietary restriction and physical activity on the physical function and body composition of obese middle-aged and older adults with knee OA (DRPA): protocol for a feasibility study

INTRODUCTION

Knee osteoarthritis (OA) is the most common chronic illness among older adults. Up to the submission date of this protocol, there are no published UK studies reporting the efficacy of a combined intervention programme of physical activity and dietary restriction on the musculoskeletal function of obese older adults with knee OA in spite of the clinical recommendation for exercise and diet for people with knee OA. The aim of this study is to assess the feasibility and acceptability of a combined dietary restriction and physical activity intervention programme and collect preliminary data.

METHOD AND ANALYSIS

This single-arm intervention study is scheduled to begin in September 2017 and conclude in November 2018. It will take place at the Royal Orthopaedic Hospital (ROH), Birmingham and the School of Sport, Exercise and Rehabilitation Sciences (SportExR), University of Birmingham. Participants will receive a physiotherapy usual care programme for knee OA for 1 month, after which they will continue to exercise in their local gym/leisure facility for 3 months. Participants will also follow dietary restriction throughout the 4-month intervention. Mixed analysis techniques will be used to analyse the quantitative and qualitative outcome measures.

ETHICS AND DISSEMINATION

It is approved by ROH R&D Foundation Trust and the Health Research Authority. The Consort Guidelines and checklist will be reviewed prior to generating any publications for the trial to ensure they meet the standards required for submission to high-quality peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN12906938.

Thoroughness and Psychometrics of Fidelity Measures in Occupational and Physical Therapy: A Systematic Review

OBJECTIVE

This study evaluated the thoroughness and psychometric properties of fidelity measures used by or of relevance to occupational or physical therapy.

METHOD

A systematic review of the literature was completed. Assessments used to measure occupational or physical therapy intervention fidelity were evaluated for thoroughness, reliability, validity, and clinical utility.

RESULTS

Eight fidelity measures met inclusion criteria for this systematic review. Most of the measures had moderate levels of thoroughness in the coverage of key aspects of fidelity, reported adequate to excellent reliability and validity, and were highly variable in clinical utility.

CONCLUSION

Additional research is recommended to validate existing occupational or physical therapy fidelity measures and to develop novel measures for other occupational therapy and physical therapy interventions. Clinicians and researchers must place greater emphasis on the development and implementation of fidelity measures to ensure uniformity in intervention delivery and high-quality, evidence-based care.

Social participation of people with cognitive problems and their caregivers: a feasibility evaluation of the Social Fitness Programme

OBJECTIVE

We developed a tailor-made intervention aimed at improving social participation of people with cognitive problems and their caregivers. This programme consists of an integration of healthcare and welfare interventions: occupational therapy, physiotherapy and guidance by a welfare professional. This article describes the feasibility evaluation of this Social Fitness Programme.

METHODS

Feasibility in terms of acceptability, demand, implementation, practicability and limited efficacy was evaluated based on experiences from professionals (programme deliverers), people with cognitive problems and their caregivers (programme recipients). We used qualitative research methods (focus group discussions, interviews, collection of treatment records) and applied thematic analyses.

RESULTS

The intervention was feasible according to stakeholders, and limited efficacy showed promising results. However, we found feasibility barriers. First, an acceptability barrier: discussing declined social participation was difficult, hindering recruitment. Second, a demand barrier: some people with cognitive problems lacked motivation to improve declined social participation, sometimes in contrast to their caregivers' wishes. Third, implementation and practicability barriers: shared decision-making, focusing the intervention and interdisciplinary collaboration between healthcare and welfare professionals were suboptimal during implementation.

DISCUSSION

Although this intervention builds upon scientific evidence, expert opinions and stakeholder needs, implementation was challenging. Healthcare and welfare professionals need to overcome obstacles in their collaboration and focus on integrated intervention delivery. Also, they need to find ways to (empower caregivers to) motivate people with cognitive problems to participate socially. After modifying the intervention and additional training of professionals, a consecutive pilot study to assess feasibility of the research design and outcome measures is justified. Copyright © 2017 John Wiley & Sons, Ltd.

Teaching Nursing Students the Importance of Treatment Fidelity in Intervention Research: Students as Interventionists

BACKGROUND

Treatment fidelity is the extent to which a study team adheres to the dictates of a study protocol. It ensures that the intervention has been implemented as intended. Including and monitoring treatment fidelity reduces threats to validity and is vital to providing reputable, sound research.

METHOD

This article describes specific measures taken to teach nursing students the key concepts and methodologic issues associated with treatment fidelity in intervention research studies through active learning. Twelve senior-level nursing students participated as interventionists in a study that spanned 4 months.

RESULTS

Treatment fidelity strategies included development of a manual, proper training and supervision of interventionists, a follow-up meeting with the interventionists, checklists, and a controller.

CONCLUSION

The treatment fidelity strategies implemented throughout the study provided an opportunity for students to learn firsthand how such strategies are implemented and how they strengthened the confidence that study findings are indeed related to the intervention. [J Nurs Educ. 2016;55(5):288-291.].

Implementing a pressure ulcer prevention bundle in an adult intensive care

BACKGROUND

The incidence of pressure ulcers (PUs) in intensive care units (ICUs) is high and numerous strategies have been implemented to address this issue. One approach is the use of a PU prevention bundle. However, to ensure success care bundle implementation requires monitoring to evaluate the care bundle compliance rate, and to evaluate the effectiveness of implementation strategies in facilitating practice change.

AIMS

The aims of this study were to appraise the implementation of a series of high impact intervention care bundle components directed at preventing the development of PUs, within ICU, and to evaluate the effectiveness of strategies used to enhance the implementation compliance.

METHOD

An observational prospective study design was used. Implementation strategies included regular education, training, audit and feed-back and the presence of a champion in the ICU. Implementation compliance was measured along four time points using a compliance checklist.

RESULTS

Of the 60 registered nurses (RNs) working in the critical care setting, 11 participated in this study. Study participants demonstrated a high level of compliance towards the PU prevention bundle implementation (78.1%), with 100% participant acceptance. No significant differences were found between participants' demographic characteristics and the compliance score. There was a significant effect for time in the implementation compliance (Wilks Lambda=0.29, F (3, 8)=6.35, p<0.016), indicating that RNs needed time to become familiar with the bundle and routinely implement it into their practice. PU incidence was not influenced by the compliance level of participants.

CONCLUSION

The implementation strategies used showed a positive impact on compliance. Assessing and evaluating implementation compliance is critical to achieve a desired outcome (reduction in PU incidence). This study's findings also highlighted that while RNs needed time to familiarise themselves with the care bundle elements, their clinical practice was congruent with the bundle elements.

Identifying and Evaluating the Therapeutic Strategies Used During a Manualized Self- Advocacy Intervention for Transition-Age Youth

Prior to undertaking randomized control trials, pilot research should ensure that an intervention's active ingredients are operationalized in manuals or protocols. This study identified the strategies facilitators reported to use during the implementation of a problem-solving self-advocacy intervention, Project "Teens making Environment and Activity Modifications" (TEAM), with transition-age youth with developmental disabilities, and evaluated the alignment of strategies with the intervention's hypothesized mechanisms of change. An iterative process was used to conduct a content analysis of 106 field notes completed by six facilitators. Facilitators used 19 strategies. Findings suggest that facilitators used strategies simultaneously to ensure universal design for learning, maximize relevance for individual trainees, and maintain a safe and encouraging environment. Facilitators can individualize Project TEAM in a way that operationalizes the mechanisms of change underlying Project TEAM. The quality of the intervention may improve by explicitly incorporating these strategies into the intervention protocol. The strategies may also be applicable to therapists implementing interventions informed, by similar theoretical propositions.

A process evaluation of a home-based occupational therapy intervention for Parkinson's patients and their caregivers performed alongside a randomized controlled trial

OBJECTIVE

To evaluate fidelity, treatment enactment and the experiences of an occupational therapy intervention in Parkinson's disease, to identify factors that affect intervention delivery and benefits.

DESIGN

Mixed methods alongside a randomized controlled trial.

SUBJECTS

These include 124 home-dwelling Parkinson's disease patients and their primary caregivers (recipients), and 18 occupational therapists.

INTERVENTION

Ten-week home-based intervention according to the Dutch guidelines for occupational therapy in Parkinson's disease.

MAIN MEASURES

Data were collected on intervention dose, protocol process, content of treatment (fidelity), offered and performed strategies (treatment enactment), and recipients' experiences. Therapists' experiences were collected through case note analyses and focus group interviews.

RESULTS

Mean intervention dose was 9.3 (SD 2.3) hours. Mean protocol process adherence was high (93%; SD 9%), however the intervention did not (fully) address the goal for 268 of 617 treatment goals. Frequencies of offered and performed strategies appeared similar, apart from 'using other tools and materials' which showed a drop from 279 advised to 149 used. The recipients were satisfied overall with the intervention (mean score 8 out of 10). The therapists noted positive or negative influencing factors on both process and benefits: the research context, the socio-political healthcare context, the recipients' personal and contextual factors, and the therapists' competence.

CONCLUSION

We found some prerequisite factors in equipment provision and available dose important for treatment delivery. Other elicited factors related to, or affected, the required professional competencies and tools to tailor interventions to the complexity of interacting personal and contextual factors of patients and caregivers.

Recruitment, retention, and blinding in clinical trials

The recruitment and retention of participants and the blinding of participants, health care providers, and data collectors present challenges for clinical trial investigators. This article reviews challenges and alternative strategies associated with these three important clinical trial activities. Common recruiting pitfalls, including low sample size, unfriendly study designs, suboptimal testing locations, and untimely recruitment are discussed together with strategies for overcoming these barriers. The use of active controls, technology-supported visit reminders, and up-front scheduling is recommended to prevent attrition and maximize retention of participants. Blinding is conceptualized as the process of concealing research design elements from key players in the research process. Strategies for blinding participants, health care providers, and data collectors are suggested.

Special issue on the Accelerating Clinical Trials and Outcomes Research (ACTOR) Conference

This special issue of AJOT features papers from the Accelerating Clinical Trials and Outcomes Research (ACTOR) Conference, which took place December 1–2, 2011.