A RCT to explore the effectiveness of supporting adherence to nebuliser medication in adults with cystic fibrosis: fidelity assessment of study interventions

BACKGROUND

A multi-component self-management intervention 'CFHealthHub' was developed to reduce pulmonary exacerbations in adults with Cystic Fibrosis (CF) by supporting adherence to nebuliser medication. It was evaluated in a randomized controlled trial (RCT) involving 19 CF centres, with 32 interventionists, 305 participants in the intervention group, and 303 participants in the standard care arm. Ensuring treatment fidelity of intervention delivery was crucial to ensure that the intervention produced the expected outcomes.

METHODS

Fidelity of the CFHealthHub intervention and standard care was assessed using different methods for each of the five fidelity domains defined by the Borrelli framework: study design, training, treatment delivery, receipt, and enactment. Study design ensured that the groups received the intended intervention or standard care. Interventionists underwent training and competency assessments to be deemed certified to deliver the intervention. Audio-recorded intervention sessions were assessed for fidelity drift. Receipt was assessed by identifying whether participants set Action and Coping Plans, while enactment was assessed using click analytics on the CFHealthHub digital platform.

RESULTS

Design: There was reasonable agreement (74%, 226/305) between the expected versus actual intervention dose received by participants in the CFHealthHub intervention group. The standard care group did not include focused adherence support for most centres and participants. Training: All interventionists were trained. Treatment delivery: The trial demonstrated good fidelity (overall fidelity by centre ranged from 79 to 97%), with only one centre falling below the mean threshold (> 80%) on fidelity drift assessments. Receipt: Among participants who completed the 12-month intervention, 77% (205/265) completed at least one action plan, and 60% (160/265) completed at least one coping plan. Enactment: 88% (268/305) of participants used web/app click analytics outside the intervention sessions. The mean (SD) number of web/app click analytics per participant was 31.2 (58.9). Additionally, 64% (195/305) of participants agreed to receive notifications via the mobile application, with an average of 53.6 (14.9) notifications per participant.

CONCLUSIONS

The study demonstrates high fidelity throughout the RCT, and the CFHealthHub intervention was delivered as intended. This provides confidence that the results of the RCT are a valid reflection of the effectiveness of the CFHealthHub intervention compared to standard care.

TRIAL REGISTRATION

ISRCTN registry: ISRCTN55504164 (date of registration: 12/10/2017).

Bisphenols and alternative developers in thermal paper receipts from the U.S. market assessed by Fourier transform infrared spectroscopy

Cash register receipts made of thermal paper expose workers and shoppers to endocrine-disrupting chemicals and contaminate paper recycling streams. In 2022, 571 receipts were collected from retail stores in the United States and tested for developer chemicals using attenuated total reflection infrared spectroscopy. The results were compared to a 2017 study of 167 receipts to determine changes in color developer use over time. Receipts were tested as-is and a subset were additionally subjected to a simple extraction that improved detection of receipt chemicals. Bisphenol S was the most frequently detected developer (85% of tested receipts), followed by Pergafast 201 (12%), bisphenol A (1%); and Appvion Alpha Free, D-8, and NKK-1304 (each below 1%). NKK-1304 is reported here for the first time in a scientific journal. The frequency of bisphenol A usage in receipts decreased and the frequency of bisphenol S and Pergafast 201 increased between 2017 and 2022, particularly among large companies. National retailers were more likely than regional or local retailers to have adopted non-bisphenol alternatives. Potential health and environmental hazards of the detected developer chemicals and strategies for reduction are discussed.

Epilepsy Surgery in Adult Stroke Survivors with New-Onset Drug-Resistant Epilepsy

BACKGROUND

Despite its effectiveness, surgery for drug-resistant epilepsy is underutilized. However, whether epilepsy surgery is also underutilized among patients with stroke-related drug-resistant epilepsy is unclear. Therefore, our objectives were to estimate the rates of epilepsy surgery assessment and receipt among patients with stroke-related drug-resistant epilepsy and to identify factors associated with these outcomes.

METHODS

We used linked health administrative databases to conduct a population-based retrospective cohort study of adult Ontario, Canada residents discharged from an Ontario acute care institution following the treatment of a stroke between January 1, 1997, and December 31, 2020, without prior evidence of seizures. We excluded patients who did not subsequently develop drug-resistant epilepsy and those with other epilepsy risk factors. We estimated the rates of epilepsy surgery assessment and receipt by March 31, 2021. We planned to use Fine-Gray subdistribution hazard models to identify covariates independently associated with our outcomes, controlling for the competing risk of death.

RESULTS

We identified 265,081 patients who survived until discharge following inpatient stroke treatment, 1,902 (0.7%) of whom subsequently developed drug-resistant epilepsy (805 women; mean age: 67.0 ± 13.1 years). Fewer than six (≤0.3%) of these patients were assessed for or received epilepsy surgery before the end of follow-up (≤55.5 per 100,000 person-years). Given that few outcomes were identified, we could not proceed with the multivariable analyses.

CONCLUSIONS

Patients with stroke-related drug-resistant epilepsy are infrequently considered for epilepsy surgery that could reduce morbidity and mortality.

How is the Behavior Change Technique Content of the NHS Diabetes Prevention Program Understood by Participants? A Qualitative Study of Fidelity, With a Focus on Receipt

Background

The National Health Service (NHS) Diabetes Prevention Program (DPP) is a nationally implemented behavioral intervention for adults at high risk of developing Type 2 diabetes in England, based on a program specification that stipulates inclusion of 19 specific behavior change techniques (BCTs). Previous work has identified drift in fidelity from these NHS England specifications through providers’ program manuals, training, and delivery, especially in relation to BCTs targeting self-regulatory processes.

Purpose

This qualitative study investigates intervention receipt, i.e., how the self-regulatory BCT content of the NHS-DPP is understood by participants.

Methods

Twenty participants from eight NHS-DPP locations were interviewed; topics included participants’ understanding of self-monitoring of behavior, goal setting, feedback, problem solving, and action planning. Transcripts were analyzed thematically using the framework method.

Results

There was a wide variation in understanding among participants for some BCTs, as well as between BCTs. Participants described their understanding of “self-monitoring of behaviors” with ease and valued BCTs focused on outcomes (weight loss). Some participants learned how to set appropriate behavioral goals. Participants struggled to recall “action planning” or “problem solving” or found these techniques challenging to understand, unless additional support was provided (e.g., through group discussion).

Conclusions

Participants’ lack of understanding of some self-regulatory BCTs is consistent with the drift across fidelity domains previously identified from NHS design specifications. Behavioral interventions should build-in necessary support for participants to help them understand some BCTs such as action planning and problem solving. Alternatively, these self-regulatory BCTs may be intrinsically difficult to use for this population.

Differences in HIV testing and receipt of results between adolescent and non-adolescent women in Uganda

Despite notable increase in HIV testing among Uganda's women from 25% in 2006 to 71% in 2011, HIV testing among adolescent women remains very low at 45.5%. This study assesses differences in HIV testing and receipt of results (HTR) between adolescent and non-adolescent women in Uganda. The differences were decomposed into components attributed to variation in characteristics and variation in effects of characteristics in the two groups. The assessment was based on data sourced from 2011 Uganda Demographic Health Survey. Statistical analysis was done using a Non-linear Oaxaca' Blinder Multivariate Decomposition of the logistic regression. In the results, the difference in HIV testing and receipt of result between adolescent and non-adolescent women was significantly (P < 0.05) attributed to both variation in characteristics (57.2%) and variation in the effects of characteristics/coefficients (42.8%). In particular, the gap in HTR was mainly attributed to variation in characteristics such as ever had sex (34.7%) and ever given birth (31.6%) and variation in effects of characteristics such as education level (- 68.8%) and marital status (- 12.6%). Based on the findings of the study, government and other development partners need to scale up HIV testing programs targeting adolescents through tackling stigma, increasing on community outreach services and expanding adolescent friendly HIV services center.

National burden of the pharmaceutical cost of wet compresses and its cost predictors: nationwide cross-sectional study in Japan

BACKGROUND

Although a high number of wet compresses are prescribed daily in medical institutions in Japan, our understanding of the national burden of the cost of wet compresses and the details regarding their prescription is far from complete. We investigated the national burden of the annual pharmaceutical cost of wet compresses prescribed in Japan and estimated the predictors of this cost using nationwide health insurance claims data.

METHODS

We extracted the records on wet compress products from summary table files obtained from the second version of the "NDB Open Data Japan" website and calculated the annual pharmaceutical cost of wet compresses by patients' 5-year age group, sex, and prefecture. We also conducted an ecological study treating each prefecture as an individual unit and multiple linear regression analyses using the age-standardized cost of wet compresses per resident as a dependent variable.

RESULTS

The annual pharmaceutical cost of wet compresses prescribed in Japan in fiscal year 2015 was 149.0 billion Japanese yen (1.18 billion euros; 1.33 billion USD). Multiple linear regression analyses showed that the number of orthopedists and rehabilitation physicians per 100,000 residents were significantly positively associated with the annual pharmaceutical cost of wet compresses per resident (P = 0.042 and P = 0.008, respectively).

CONCLUSIONS

The annual pharmaceutical cost of wet compresses prescribed in Japan has a considerable impact on the nation's limited healthcare resources. The number of orthopedists and rehabilitation physicians per 100,000 residents may be independent predictors of the wet compress cost in Japan.

Bisphenol A exposure through receipt handling and its association with insulin resistance among female cashiers

Bisphenol A (BPA) is one of the most widely used chemicals in various consumer products. In thermal papers such as receipts and tickets, BPA is used as a heat-activated developer. Cashiers are therefore suspected to be a vulnerable group of exposure to BPA, but neither contribution of receipt handling to the total body burden of BPA among cashiers, nor related health effects are well characterized. Female cashiers (n = 54) were recruited from seven retail shops of a major supermarket chain in Korea, and urinary levels of BPA and metabolic syndrome (MetS) related biomarkers were measured. In order to estimate the contribution of receipt handling to the body burden of BPA, an intervention was designed on the use of gloves: the subjects were asked not to wear gloves during the work for one week, and in the following week, to wear gloves. Urine samples were collected at pre-shift and post-shift for the first two consecutive days in each week, and urinary BPA concentrations were measured. In cashiers without gloves, about a two-fold increase in urinary BPA concentrations was observed after work-shift. When the cashiers wore gloves, however, urinary BPA levels showed no changes. Higher urinary BPA concentrations were associated with greater levels of fasting insulin and insulin resistance. Our observation shows that receipt handling among the cashiers could double the BPA exposure levels at post-shift compared to those at pre-shift, and use of simple protective equipment such as gloves could effectively reduce the BPA exposure levels.

Operationalizing a model to quantify implementation of a multi-component intervention in a stepped-wedge trial

BACKGROUND

It is challenging to interpret the results of multifaceted interventions due to complex program theories that are difficult to measure in a quantifiable manner. The aims of this paper were, first, to develop a model for a comprehensive quantitative implementation evaluation and, second, to operationalize it in the process evaluation of the stepped-wedge cluster randomized controlled trial: "Prevention of low back pain and its consequences among nurses' aides in elderly care" to investigate if implementation differed across intervention components, steps, and settings (workplaces).

METHODS

Operationalization of a quantifiable measure of implementation requires three steps: (1) development of a program logic and intervention protocol, (2) description of a complete and acceptable delivery of the intervention, and (3) description of what determines the receipt of the intervention. Program logic from a previously developed multifaceted stepped-wedge intervention was used. The optimal delivery of the intervention was defined as the deliverers' full understanding and following of the intervention protocol and that they performed their best and contributed to the participants' attention and motivation (fidelity). The optimal receipt of the intervention was defined as participants being fully present at all intervention activities (participation), being motivated and satisfied, and having a good social support (responsiveness). Measurements of the fidelity, participation, and responsiveness were obtained from logbooks and questionnaires. Fidelity was multiplied by participation to measure exposure of the intervention to the individual. The implementation was determined from optimal delivery and optimal receipt on a scale from 0 (no implementation) to 100 (full implementation) on individual and organizational level.

RESULTS

Out of 753 sessions, 95% were delivered. The sessions were delivered with 91% success (fidelity) across the organization. Average participation, fidelity, exposure, and responsiveness were 50, 93, 48, and 89% across all participants. The implementation of the intervention was uniform across steps (p = 0.252) and workplaces (p = 0.125) but not for intervention components (p = 0.000). However, participation, fidelity, exposure, and responsiveness varied between workplaces.

CONCLUSIONS

This study developed a quantifiable implementation evaluation measuring participation, fidelity, exposure, and responsiveness. The quantifiable implementation evaluation was suitable for comparing implementation across steps, components, and settings and can be applied in the analyses on the impact of implementation of complex interventions.

Methods used to address fidelity of receipt in health intervention research: a citation analysis and systematic review

BACKGROUND

The American Behaviour Change Consortium (BCC) framework acknowledges patients as active participants and supports the need to investigate the fidelity with which they receive interventions, i.e. receipt. According to this framework, addressing receipt consists in using strategies to assess or enhance participants' understanding and/or performance of intervention skills. This systematic review aims to establish the frequency with which receipt is addressed as defined in the BCC framework in health research, and to describe the methods used in papers informed by the BCC framework and in the wider literature.

METHODS

A forward citation search on papers presenting the BCC framework was performed to determine the frequency with which receipt as defined in this framework was addressed. A second electronic database search, including search terms pertaining to fidelity, receipt, health and process evaluations was performed to identify papers reporting on receipt in the wider literature and irrespective of the framework used. These results were combined with forward citation search results to review methods to assess receipt. Eligibility criteria and data extraction forms were developed and applied to papers. Results are described in a narrative synthesis.

RESULTS

19.6% of 33 studies identified from the forward citation search to report on fidelity were found to address receipt. In 60.6% of these, receipt was assessed in relation to understanding and in 42.4% in relation to performance of skill. Strategies to enhance these were present in 12.1% and 21.1% of studies, respectively. Fifty-five studies were included in the review of the wider literature. Several frameworks and operationalisations of receipt were reported, but the latter were not always consistent with the guiding framework. Receipt was most frequently operationalised in relation to intervention content (16.4%), satisfaction (14.5%), engagement (14.5%), and attendance (14.5%). The majority of studies (90.0%) included subjective assessments of receipt. These relied on quantitative (76.0%) rather than qualitative (42.0%) methods and studies collected data on intervention recipients (50.0%), intervention deliverers (28.0%), or both (22.0%). Few studies (26.0%) reported on the reliability or validity of methods used.

CONCLUSIONS

Receipt is infrequently addressed in health research and improvements to methods of assessment and reporting are required.

The science prior to the crime--August Hirt's career before 1941

August Hirt (1898-1945) has achieved macabre renown for atrocities perpetrated during his years as professor of anatomy at the Reichsuniversität Straßburg 1941-1945. Little, however, is known about his preceding scientific career. To fill this gap and to scrutinise whether he really was a mediocre scientist during his early years, as some have purported, we perused relevant historical archives and the available literature. In 1921, after medical school, Hirt started to research and teach at the Institute of Anatomy in Heidelberg, forging a steady career until becoming interim chair in 1935. He then became director of anatomical institutes in Greifswald 1936 and Frankfurt 1938 before going to Straßburg in 1941. Hirt seems to have been well-established in the community of anatomists. Some of his career advancements after 1933 were nevertheless facilitated by Nazi support. His main scientific fields were the autonomic nervous system, in which he produced a relevant contribution to anatomical knowledge, and fluorescence microscopy. His development of a special "luminescence microscope", in cooperation with pharmacologist Ellinger, was an important advancement in the history of microscopic technique. His early research was funded by national and international sponsoring bodies and was neither unethical nor racist. As Hirt did not publish anything after 1940, those who only knew his publications might think of him as a "good" scientist. To simply dismiss Hirt as a "pseudoscientist" would avoid the question-still difficult to answer-of how he could develop from an accepted, successful anatomist to a criminal "in the name of science".