Intervention fidelity and adaptation in a multi-site exercise training intervention for adults with multiple sclerosis

BACKGROUND

Successful translation of evidence-based exercise training interventions from research to clinical practice depends on the balance of treatment fidelity and adaptability when delivering the exercise program across settings. The current paper summarizes fidelity of study design, provider training, and intervention delivery strategies from best practice recommendations, and reports challenges experienced and adaptations instrumented by behavioral coaches delivering the multi-site Supervised versus Telerehabilitation Exercise Programs for Multiple Sclerosis (STEP for MS) Trial.

METHODS

Using a reflexive thematic analysis approach, open-ended survey questions were analyzed to explore experiences of behavioral coaches, transcripts from team meetings among behavioral coaches, and notes from audits of one-on-one sessions between behavioral coaches and participants.

RESULTS

Themes related to the fidelity of study design and delivery of the STEP for MS Trial included adaptations to the intervention itself (e.g., completion of virtual supervised exercise sessions with behavioral coaches in place of face-to-face sessions during COVID-19 pandemic restrictions), modification of exercise equipment, and adjustments of program delivery. The adjustments of program delivery reported by behavioral coaches included increasing program fit, maintaining engagement, and addressing participant safety concerns; however, these adaptations did not jeopardize the content of the essential elements of the program model.

CONCLUSIONS

The current paper demonstrates that when best practice recommendations are implemented, it is possible to address challenges to study design and evidence-based intervention delivery in ways that adaptations to overcome real-world obstacles can be accomplished without compromising fidelity.

Smartphone pain app for assessment of radiation-induced oral mucositis pain

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Background: Oral Mucositis related pain is one of the most common radiation therapy (RT) related toxicities associated with the treatment of head and neck cancer (HNC). Questionnaire-based assessment of mucositis pain is based on a patient's recall which can be inaccurate sometimes. Therefore, real-time monitoring of patient-reported pain is required for better evaluation of mucositis pain. Methods: We performed a single-arm, observational study (NCT02727062) to investigate the feasibility of a smartphone-based pain app (OMP) in assessing mucositis pain in locally advanced HNC patients(pts) undergoing a course of definitive or adjuvant RT (> 50 Gy), +/- chemotherapy, for oral cavity or oropharynx cancer. The app prompted pts to input pain severity scores using a visual analog (0-10) scale (VAS) at multiple time points during a day throughout the study. OMP software-generated time-weighted average weekly summary measure of pain by integrating multiple serial daily pain assessments. In addition, pts completed weekly Brief pain inventory (BPI) and MD Anderson head & neck symptom inventory (MDASI-HN) questionnaires. Feasibility surveys were also collected to assess the ease of use of OMP and the burden of study participation. Responses to questions on this survey were scored on a scale of 0-3, with 0 standing for not at all and 3 for extremely. Linear mixed models (LMM) controlling for person random effects were used to evaluate association and quantify differences between average weekly pain (AWP) calculated by OMP and AWP recorded using VAS by BPI survey (question 5). LMM was also used to evaluate the association between AWP score from OMP and BPI pain score with MDASI-HN scores. Descriptive statistics, including averages and frequency, were used to analyze feasibility surveys. Results: We report results of 15 pts who have complete data out of 18 registered pts. Using LMM, we compared AWP score curves calculated from BPI and OMP. We observed that both curves followed a parallel trajectory. However, pain scores calculated from OMP were 0.40 units higher than BPI pain. The Bland-Altman plot also confirmed that BPI pain and OMP did not clearly agree. Additionally, AWP scores from OMP had a positive correlation with fatigue (p < 0.001), drowsiness (p < 0.001), decreased activity (p < 0.001), and interference with work (p < 0.001) related scores recorded in MDASI-HN. In terms of feasibility, most surveys indicated that it was extremely easy for subjects to enter responses and not at all difficult for them to use all features of OMP. Furthermore, study participation did not interfere with subjects’ usual activities. Conclusions: Our study showed that pain scores calculated through OMP were, on average higher than those reported by BPI. It also showed the correlation between pain and physical activity. Hence, utilization of OMP in conjunction with questionnaires may improve our understanding of the severity of mucositis-related pain. Clinical trial information: NCT02727062.

Who is wearing a mask? Gender-, age-, and location-related differences during the COVID-19 pandemic

Masks are an effective tool in combatting the spread of COVID-19, but some people still resist wearing them and mask-wearing behavior has not been experimentally studied in the United States. To understand the demographics of mask wearers and resistors, and the impact of mandates on mask-wearing behavior, we observed shoppers (n = 9935) entering retail stores during periods of June, July, and August 2020. Approximately 41% of the June sample wore a mask. At that time, the odds of an individual wearing a mask increased significantly with age and was also 1.5x greater for females than males. Additionally, the odds of observing a mask on an urban or suburban shopper were ~4x that for rural areas. Mask mandates enacted in late July and August increased mask-wearing compliance to over 90% in all groups, but a small percentage of resistors remained. Thus, gender, age, and location factor into whether shoppers in the United States wear a mask or face covering voluntarily. Additionally, mask mandates are necessary to increase mask wearing among the public to a level required to mitigate the spread of COVID-19.