The Assessment, Monitoring, and Enhancement of Treatment Fidelity In Public Health Clinical Trials

Treatment adherence and competency ratings among therapists, supervisors, study-related raters and external raters in a clinical trial of a 12-step facilitation for stimulant users

This study investigated the correspondence among four groups of raters on adherence to STAGE-12, a manualized 12-step facilitation (TSF) group and individual treatment targeting stimulant abuse. The four rater groups included the study therapists, supervisors, study-related ("TSF expert") raters, and non-project related ("external") raters. Results indicated that external raters rated most critically mean adherence - the mean of all the adherence items - and global performance. External raters also demonstrated the highest degree of reliability with the designated expert. Therapists rated their own adherence lower, on average, than did supervisors and TSF expert raters, but therapist ratings also had the poorest reliability. Findings highlight the challenges in developing practical, but effective methods of fidelity monitoring for evidence based practice in clinical settings. Recommendations based on study findings are provided.

Implementation of a nurse-led behaviour change intervention to support medication taking in type 2 diabetes: beyond hypothesised active ingredients (SAMS Consultation Study)

Background

Implementation of trial interventions is rarely assessed, despite its effects on findings. We assessed the implementation of a nurse-led intervention to facilitate medication adherence in type 2 diabetes (SAMS) in a trial against standard care in general practice. The intervention increased adherence, but not through the hypothesised psychological mechanism. This study aimed to develop a reliable coding frame for tape-recorded consultations, assessing both a priori hypothesised and potential active ingredients observed during implementation, and to describe the delivery and receipt of intervention and standard care components to understand how the intervention might have worked.

Methods

211 patients were randomised to intervention or comparison groups and 194/211 consultations were tape-recorded. Practice nurses delivered standard care to all patients and motivational and action planning (implementation intention) techniques to intervention patients only. The coding frame was developed and piloted iteratively on selected tape recordings until a priori reliability thresholds were achieved. All tape-recorded consultations were coded and a random subsample double-coded.

Results

Nurse communication, nurse-patient relationship and patient responses were identified as potential active ingredients over and above the a priori hypothesised techniques. The coding frame proved reliable. Intervention and standard care were clearly differentiated. Nurse protocol adherence was good (M (SD) = 3.95 (0.91)) and competence of intervention delivery moderate (M (SD) = 3.15 (1.01)). Nurses frequently reinforced positive beliefs about taking medication (e.g., 65% for advantages) but rarely prompted problem solving of negative beliefs (e.g., 21% for barriers). Patients’ action plans were virtually identical to current routines. Nurses showed significantly less patient-centred communication with the intervention than comparison group.

Conclusions

It is feasible to reliably assess the implementation of behaviour change interventions in clinical practice. The main study results could not be explained by poor delivery of motivational and action planning components, definition of new action plans, improved problem solving or patient-centred communication. Possible mechanisms of increased medication adherence include spending more time discussing it and mental rehearsal of successful performance of current routines, combined with action planning. Delivery of a new behaviour change intervention may lead to less patient-centred communication and possible reduction in overall trial effects.

Trial registration

ISRCTN30522359.

mHealth interventions for weight loss: a guide for achieving treatment fidelity

mHealth interventions have shown promise for helping people sustain healthy behaviors such as weight loss. However, few have assessed treatment fidelity, that is, the accurate delivery, receipt, and enactment of the intervention. Treatment fidelity is critical because the valid interpretation and translation of intervention studies depend on treatment fidelity assessments. We describe strategies used to assess treatment fidelity in mobile health (mHealth) interventions aimed at sustaining healthy behaviors in weight loss. We reviewed treatment fidelity recommendations for mHealth-based behavioral interventions and described how these recommendations were applied in three recent weight loss studies. We illustrate how treatment fidelity can be supported during study design, training of providers, treatment delivery, receipt of treatment, and enactment of treatment skills. Pre-planned strategies to ensure the treatment fidelity of mHealth interventions will help counter doubts concerning valid conclusions about their effectiveness and allow investigators and clinicians to implement robustly efficacious mobile health programs.

TRIAL REGISTRATION NUMBER

1F31 NR012599.

A cluster randomized controlled trial of a brief tobacco cessation intervention for low-income communities in India: study protocol

BACKGROUND

India has 275 million adult tobacco users and tobacco use is estimated to contribute to more than a million deaths in the country each year. There is an urgent need to develop and evaluate affordable, practicable and scalable interventions to promote cessation of tobacco use. Because tobacco use is so harmful, an increase of as little as 1 percentage point in long-term quit success rates can have an important public health impact. This protocol paper describes the rationale and methods of a large randomized controlled trial which aims to evaluate the effectiveness of a brief scalable smoking cessation intervention delivered by trained health professionals as an outreach programme in poor urban communities in India.

METHODS/DESIGN

This is a pragmatic, two-arm, community-based cluster randomized controlled trial focused on tobacco users in low-income communities. The treatment arm is a brief intervention comprising brief advice including training in craving control using simple yogic breathing exercises (BA-YBA) and the control arm is very brief advice (VBA). Of a total of 32 clusters, 16 will be allocated to the intervention arm and 16 to the control arm. Each cluster will have 31 participants, making a total of 992 participants. The primary outcome measure will follow the Russell Standard: self-report of sustained abstinence for at least 6 months following the intervention confirmed at the final follow-up by salivary cotinine.

DISCUSSION

This trial will inform national and international policy on delivery of scalable and affordable brief outreach interventions to promote tobacco use cessation in low resource settings where tobacco users have limited access to physicians and medications.

Treatment fidelity of brief motivational interviewing and health education in a randomized clinical trial to promote dental attendance of low-income mothers and children: Community-Based Intergenerational Oral Health Study "Baby Smiles"

BACKGROUND

Fidelity assessments are integral to intervention research but few published trials report these processes in detail. We included plans for fidelity monitoring in the design of a community-based intervention trial.

METHODS

The study design was a randomized clinical trial of an intervention provided to low-income women to increase utilization of dental care during pregnancy (mother) or the postpartum (child) period. Group assignment followed a 2 × 2 factorial design in which participants were randomly assigned to receive either brief Motivational Interviewing (MI) or Health Education (HE) during pregnancy (prenatal) and then randomly reassigned to one of these groups for the postpartum intervention. The study setting was four county health departments in rural Oregon State, USA. Counseling was standardized using a step-by-step manual. Counselors were trained to criteria prior to delivering the intervention and fidelity monitoring continued throughout the implementation period based on audio recordings of counselor-participant sessions. The Yale Adherence and Competence Scale (YACS), modified for this study, was used to code the audio recordings of the counselors' delivery of both the MI and HE interventions. Using Interclass Correlation Coefficients totaling the occurrences of specific MI counseling behaviors, ICC for prenatal was .93, for postpartum the ICC was .75. Participants provided a second source of fidelity data. As a second source of fidelity data, the participants completed the Feedback Questionnaire that included ratings of their satisfaction with the counselors at the completion of the prenatal and post-partum interventions.

RESULTS

Coding indicated counselor adherence to MI protocol and variation among counselors in the use of MI skills in the MI condition. Almost no MI behaviors were found in the HE condition. Differences in the length of time to deliver intervention were found; as expected, the HE intervention took less time. There were no differences between the overall participants' satisfaction ratings of the HE and MI sessions by individual counselor or overall (p > .05).

CONCLUSIONS

Trial design, protocol specification, training, and continuous supervision led to a high degree of treatment fidelity for the counseling interventions in this randomized clinical trial and will increase confidence in the interpretation of the trial findings.

Does treatment fidelity predict client outcomes in 12-Step Facilitation for stimulant abuse?

OBJECTIVE

This study examined the relationships between treatment fidelity and treatment outcomes in a community-based trial of a 12-Step Facilitation (TSF) intervention.

METHOD

In a prior multi-site randomized clinical trial, 234 participants in 10 outpatient drug treatment clinics were assigned to receive the Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) intervention. A secondary analysis reviewed and coded all STAGE-12 sessions for fidelity to the protocol, using the Twelve Step Facilitation Adherence Competence Empathy Scale (TSF ACES). Linear mixed-effects models tested the relationship between three fidelity measures (adherence, competence, empathy) and six treatment outcomes (number of days of drug use and five Addiction Severity Index (ASI) composite scores) measured at 3 months post-baseline.

RESULTS

Adherence, competence and empathy were robustly associated with improved employment status at follow up. Empathy was inversely associated with drug use, as was competence in a non-significant trend (p=.06). Testing individual ASI drug composite score items suggested that greater competence was associated with fewer days of drug use and, at the same time, with an increased sense of being troubled or bothered by drug use.

CONCLUSIONS

Greater competence and empathy in the delivery of a TSF intervention were associated with better drug use and employment outcomes, while adherence was associated with employment outcomes only. Higher therapist competence was associated with lower self-report drug use, and also associated with greater self-report concern about drug use. The nature of TSF intervention may promote high levels of concern about drug use even when actual use is low.

Comparison of error-based and errorless learning for people with severe traumatic brain injury: study protocol for a randomized control trial

BACKGROUND

Poor skills generalization poses a major barrier to successful outcomes of rehabilitation after traumatic brain injury (TBI). Error-based learning (EBL) is a relatively new intervention approach that aims to promote skills generalization by teaching people internal self-regulation skills, or how to anticipate, monitor and correct their own errors. This paper describes the protocol of a study that aims to compare the efficacy of EBL and errorless learning (ELL) for improving error self-regulation, behavioral competency, awareness of deficits and long-term outcomes after TBI.

METHODS/DESIGN

This randomized, controlled trial (RCT) has two arms (EBL and ELL); each arm entails 8 × 2 h training sessions conducted within the participants' homes. The first four sessions involve a meal preparation activity, and the final four sessions incorporate a multitasking errand activity. Based on a sample size estimate, 135 participants with severe TBI will be randomized into either the EBL or ELL condition. The primary outcome measure assesses error self-regulation skills on a task related to but distinct from training. Secondary outcomes include measures of self-monitoring and self-regulation, behavioral competency, awareness of deficits, role participation and supportive care needs. Assessments will be conducted at pre-intervention, post-intervention, and at 6-months post-intervention.

DISCUSSION

This study seeks to determine the efficacy and long-term impact of EBL for training internal self-regulation strategies following severe TBI. In doing so, the study will advance theoretical understanding of the role of errors in task learning and skills generalization. EBL has the potential to reduce the length and costs of rehabilitation and lifestyle support because the techniques could enhance generalization success and lifelong application of strategies after TBI.

TRIAL REGISTRATION

ACTRN12613000585729.

Therapist predictors of treatment delivery fidelity in a community-based trial of 12-step facilitation

BACKGROUND AND AIMS

Therapist characteristics may be associated with variation in consistency, quality and effectiveness of treatment delivery. We examined associations between treatment fidelity and therapist education, experience, treatment orientation and perceived skills in a randomized, multi-site trial of Twelve Step Facilitation (TSF).

METHODS

Raters scored audio-recorded, TSF sessions (n = 966; 97% of TSF sessions) from 32 community-based, trained therapists for adherence, competence, empathy and global session performance.

RESULTS

Therapists with graduate degrees had significantly higher adherence and global performance fidelity ratings. Therapists reporting more positive attitudes toward 12-Step groups had lower adherence ratings. Being in recovery was associated with lower fidelity in univariate tests, but higher adherence in multivariate analysis. Fidelity was higher for therapists reporting self-efficacy in basic counseling skills and lower for self-efficacy in addiction-specific counseling skills. Fidelity was also superior in group relative to individual TSF sessions.

CONCLUSIONS

Results have implications for therapist selection, training and supervision in community-based, effectiveness trials and community implementation of evidence-based treatments. To obtain high fidelity and improve outcomes, it may be preferable to choose masters level therapists who are open to learning new treatments and have good, general counseling skills.

Theory-based interventions for contraception

BACKGROUND

The explicit use of theory in research helps expand the knowledge base. Theories and models have been used extensively in HIV-prevention research and in interventions for preventing sexually transmitted infections (STIs). The health behavior field uses many theories or models of change. However, educational interventions addressing contraception often have no stated theoretical base.

OBJECTIVES

Review randomized controlled trials (RCTs) that tested a theoretical approach to inform contraceptive choice; encourage contraceptive use; or promote adherence to, or continuation of, a contraceptive regimen.

SEARCH METHODS

Through June 2013, we searched computerized databases for trials that tested a theory-based intervention for improving contraceptive use (MEDLINE, POPLINE, CENTRAL, PsycINFO, ClinicalTrials.gov, and ICTRP). Previous searches also included EMBASE. For the initial review, we wrote to investigators to find other trials.

SELECTION CRITERIA

Trials tested a theory-based intervention for improving contraceptive use. We excluded trials focused on high-risk groups and preventing sexually transmitted infections or HIV. Interventions addressed the use of one or more contraceptive methods for contraception. The reports provided evidence that the intervention was based on a specific theory or model. The primary outcomes were pregnancy, contraceptive choice or use, and contraceptive adherence or continuation.

DATA COLLECTION AND ANALYSIS

The primary author evaluated abstracts for eligibility. Two authors extracted data from included studies. For the dichotomous outcomes, the Mantel-Haenszel odds ratio (OR) with 95% CI was calculated using a fixed-effect model. Cluster randomized trials used various methods of accounting for the clustering, such as multilevel modeling. Most reports did not provide information to calculate the effective sample size. Therefore, we presented the results as reported by the investigators. No meta-analysis was conducted due to differences in interventions and outcome measures.

MAIN RESULTS

We included three new trials for a total of 17. Ten randomly assigned individuals and seven were cluster-randomized. Eight trials showed some intervention effect.Two of 12 trials with pregnancy or birth data showed some effect. A theory-based group was less likely than the comparison group to have a second birth (OR 0.41; 95% CI 0.17 to 1.00) or to report a pregnancy (OR 0.24 (95% CI 0.10 to 0.56); OR 0.27 (95% CI 0.11 to 0.66)). The theoretical bases were social cognitive theory (SCT) and another social cognition model.Of 12 trials with data on contraceptive use (non-condom), six showed some effect. A theory-based group was more likely to consistently use oral contraceptives (OR 1.41; 95% CI 1.06 to 1.87), hormonal contraceptives (reported relative risk (RR) 1.30; 95% CI 1.06 to 1.58) or dual methods (reported RR 1.36; 95% CI 1.01 to 1.85); to use an effective contraceptive method (reported effect size 1.76; OR 2.04 (95% CI 1.47 to 2.83)) or use more habitual contraception (reported P < 0.05); and were less likely to use ineffective contraception (OR 0.56; 95% CI 0.31 to 0.98). Theories and models included the Health Belief Model (HBM), SCT, SCT plus another theory, other social cognition, and motivational interviewing (MI).For condom use, a theory-based group had favorable results in 5 of 11 trials. The main differences were reporting more consistent condom use (reported RR 1.57; 95% CI 1.28 to 1.94) and more condom use during last sex (reported results: risk ratio 1.47 (95% CI 1.12 to 1.93); effect size 1.68; OR 2.12 (95% CI 1.24 to 3.56); OR 1.45 (95% CI 1.03 to 2.03)). The theories were SCT, SCT plus another theory, and HBM.Nearly all trials provided multiple sessions or contacts. SCT provided the basis for seven trials focused on adolescents, of which five reported some effectiveness. Two others based on other social cognition models had favorable results with adolescents. Of six trials including adult women, five provided individual sessions. Some effect was seen in two using MI and one using the HBM. Two based on the Transtheoretical Model did not show any effect.

AUTHORS' CONCLUSIONS

Eight trials provided evidence of high or moderate quality. Family planning researchers and practitioners could adapt the effective interventions, although most provided group sessions for adolescents. Three were conducted outside the USA. Clinics and low-resource settings need high-quality evidence on changing behavior. Thorough use of single theories would help in identifying what works, as would better reporting on research design and intervention implementation.

A tutorial on sensitivity analyses in clinical trials: the what, why, when and how

BACKGROUND

Sensitivity analyses play a crucial role in assessing the robustness of the findings or conclusions based on primary analyses of data in clinical trials. They are a critical way to assess the impact, effect or influence of key assumptions or variations--such as different methods of analysis, definitions of outcomes, protocol deviations, missing data, and outliers--on the overall conclusions of a study.The current paper is the second in a series of tutorial-type manuscripts intended to discuss and clarify aspects related to key methodological issues in the design and analysis of clinical trials.

DISCUSSION

In this paper we will provide a detailed exploration of the key aspects of sensitivity analyses including: 1) what sensitivity analyses are, why they are needed, and how often they are used in practice; 2) the different types of sensitivity analyses that one can do, with examples from the literature; 3) some frequently asked questions about sensitivity analyses; and 4) some suggestions on how to report the results of sensitivity analyses in clinical trials.

SUMMARY

When reporting on a clinical trial, we recommend including planned or posthoc sensitivity analyses, the corresponding rationale and results along with the discussion of the consequences of these analyses on the overall findings of the study.

Measuring fidelity to a culturally adapted HIV prevention intervention for men in substance abuse treatment

A fidelity measure was developed for use with Real Men Are Safe-Culturally Adapted (REMAS-CA), an HIV prevention intervention for ethnically diverse men in substance abuse treatment. The aims of this analysis were to: 1) assess the reliability of the Fidelity Rating and Skill Evaluation (FRASE); 2) measure improvement in therapist competence and adherence over time while delivering REMAS-CA; and 3) identify which modules of REMAS-CA were most difficult to deliver. Results showed that, 1) the FRASE was a reliable instrument; 2) therapists achieved adequate adherence and competence after training and demonstrated significant improvement over time in Global Empathy; and 3) Sessions 4 and 5 of REMAS-CA contained the most challenging modules for therapists to deliver. Recommendations for future REMAS-CA therapist trainings and fidelity monitoring are made.

Strategies for communicating contraceptive effectiveness

BACKGROUND

Knowledge of contraceptive effectiveness is crucial to making an informed choice. The consumer has to comprehend the pros and cons of the contraceptive methods being considered. Choice may be influenced by understanding the likelihood of pregnancy with each method and factors that influence effectiveness.

OBJECTIVES

To review all randomized controlled trials comparing strategies for communicating to consumers the effectiveness of contraceptives in preventing pregnancy.

SEARCH METHODS

Through February 2013, we searched the computerized databases of MEDLINE, POPLINE, CENTRAL, PsycINFO and CINAHL, ClinicalTrials.gov, and ICTRP. Previous searches also included EMBASE. We also examined references lists of relevant articles. For the initial review, we wrote to known investigators for information about other published or unpublished trials.

SELECTION CRITERIA

We included randomized controlled trials that compared methods for communicating contraceptive effectiveness to consumers. The comparison could be usual practice or an alternative to the experimental intervention.Outcome measures were knowledge of contraceptive effectiveness, attitude about contraception or toward any particular contraceptive, and choice or use of contraceptive method.

DATA COLLECTION AND ANALYSIS

For the initial review, two authors independently extracted the data. One author entered the data into RevMan, and a second author verified accuracy. For the update, an author and a research associate extracted, entered, and checked the data.For dichotomous variables, we calculated the Mantel-Haenszel odds ratio with 95% confidence intervals (CI). For continuous variables, we computed the mean difference (MD) with 95% CI.

MAIN RESULTS

Seven trials met the inclusion criteria and had a total of 4526 women. Five were multi-site studies. Four trials were conducted in the USA, while Nigeria and Zambia were represented by one study each, and one trial was done in both Jamaica and India.Two trials provided multiple sessions for participants. In one study that examined contraceptive choice, women in the expanded program were more likely to choose sterilization (OR 4.26; 95% CI 2.46 to 7.37) or use a modern contraceptive method (OR 2.35; 95% CI 1.82 to 3.03), i.e., sterilization, pills, injectable, intrauterine device or barrier method. For the other study, the groups received educational interventions with differing format and intensity. Both groups reportedly had increases in contraceptive use, but they did not differ significantly by six months in consistent use of an effective contraceptive, i.e., sterilization, IUD, injectable, implant, and consistent use of oral contraceptives, diaphragm, or male condoms.Five trials provided one session and focused on testing educational material or media. In one study, knowledge gain favored a slide-and-sound presentation versus a physician's oral presentation (MD -19.00; 95% CI -27.52 to -10.48). In another trial, a table with contraceptive effectiveness categories led to more correct answers than a table based on pregnancy numbers [ORs were 2.42 (95% CI 1.43 to 4.12) and 2.19 (95% CI 1.21 to 3.97)] or a table with effectiveness categories and pregnancy numbers [ORs were 2.58 (95% CI 1.5 to 4.42) and 2.03 (95% CI 1.13 to 3.64)]. Still another trial provided structured counseling with a flipchart on contraceptive methods. The intervention and usual-care groups did not differ significantly in choice of contraceptive method (by effectiveness category) or in continuation of the chosen method at three months. Lastly, a study with couples used videos to communicate contraceptive information (control, motivational, contraceptive methods, and both motivational and methods videos). The analyses showed no significant difference between the groups in the types of contraceptives chosen.

AUTHORS' CONCLUSIONS

These trials varied greatly in the types of participants and interventions to communicate contraceptive effectiveness. Therefore, we cannot say overall what would help consumers choose an appropriate contraceptive method. For presenting pregnancy risk data, one trial showed that effectiveness categories were better than pregnancy numbers. In another trial, audiovisual aids worked better than the usual oral presentation. Strategies should be tested in clinical settings and measured for their effect on contraceptive choice. More detailed reporting of intervention content would help in interpreting results. Reports could also include whether the instruments used to assess knowledge or attitudes were tested for validity or reliability. Follow-up should be incorporated to assess retention of knowledge over time. The overall quality of evidence was considered to be low for this review, given that five of the seven studies provided low or very low quality evidence.

Assessing fidelity of delivery of smoking cessation behavioural support in practice

BACKGROUND

Effectiveness of evidence-based behaviour change interventions is likely to be undermined by failure to deliver interventions as planned. Behavioural support for smoking cessation can be a highly cost-effective, life-saving intervention. However, in practice, outcomes are highly variable. Part of this may be due to variability in fidelity of intervention implementation. To date, there have been no published studies on this. The present study aimed to: evaluate a method for assessing fidelity of behavioural support; assess fidelity of delivery in two English Stop-Smoking Services; and compare the extent of fidelity according to session types, duration, individual practitioners, and component behaviour change techniques (BCTs).

METHODS

Treatment manuals and transcripts of 34 audio-recorded behavioural support sessions were obtained from two Stop-Smoking Services and coded into component BCTs using a taxonomy of 43 BCTs. Inter-rater reliability was assessed using percentage agreement. Fidelity was assessed by examining the proportion of BCTs specified in the manuals that were delivered in individual sessions. This was assessed by session type (i.e., pre-quit, quit, post-quit), duration, individual practitioner, and BCT.

RESULTS

Inter-coder reliability was high (87.1%). On average, 66% of manual-specified BCTs were delivered per session (SD 15.3, range: 35% to 90%). In Service 1, average fidelity was highest for post-quit sessions (69%) and lowest for pre-quit (58%). In Service 2, fidelity was highest for quit-day (81%) and lowest for post-quit sessions (56%). Session duration was not significantly correlated with fidelity. Individual practitioner fidelity ranged from 55% to 78%. Individual manual-specified BCTs were delivered on average 63% of the time (SD 28.5, range: 0 to 100%).

CONCLUSIONS

The extent to which smoking cessation behavioural support is delivered as specified in treatment manuals can be reliably assessed using transcripts of audiotaped sessions. This allows the investigation of the implementation of evidence-based practice in relation to smoking cessation, a first step in designing interventions to improve it. There are grounds for believing that fidelity in the English Stop-Smoking Services may be low and that routine monitoring is warranted.

Creating Avenues for Parent Partnership (CAPP): an intervention for parents of children with epilepsy and learning problems

Caregivers of children with both epilepsy and learning problems need assistance to manage their child's complex medical and mental health problems. We tested the cognitive behavioral intervention "Creating Avenues for Parent Partnership" (CAPP) which was designed to help caregivers develop knowledge as well as the confidence and skills to manage their child's condition. The CAPP intervention consisted of a one-day cognitive behavioral program and three follow-up group sessions. The sample comprised 31 primary caregivers. Caregivers reported that the program was useful (mean = 3.66 on a 4-point scale), acceptable (mean = 4.28 on a 5-point scale), and "pretty easy" (mean = 1.97 on a 4-point scale). Effect sizes were small to medium in paired t tests (comparison of intervention to control) and paired analysis of key variables in the pre- and post-tests. The CAPP program shows promise in helping caregivers build skills to manage their child's condition.

Treatment adherence in a lay health adviser intervention to treat tobacco dependence

Lay health advisers (LHAs) are increasingly used to deliver tobacco dependence treatment, especially with low-socioeconomic status (SES) populations. More information is needed about treatment adherence to help interpret mixed evidence of LHA intervention effectiveness. This study examined adherence to behavioral counseling and nicotine patches in an LHA intervention with 147 Ohio Appalachian female daily smokers. Participants were randomly selected from clinics and randomized to the intervention condition of a randomized controlled trial. Overall, 75.5% of participants received all seven planned LHA visits, 29.3% used patches for >7 weeks and approximately half received high average ratings on participant responsiveness. Depressive symptoms and low nicotine dependence were associated with lower patch adherence while high poverty-to-income ratio was associated with high responsiveness. Compared with those with fewer visits, participants who received all visits were more likely to be abstinent (22.5 versus 2.8%, P=0.026) or have attempted quitting (85.0 versus 47.4%, P=0.009) at 3 months. High participant responsiveness was associated with 12-month abstinence. LHA interventions should focus on improving adherence to nicotine patches and managing depression because it is an independent risk factor for low adherence.

Implementation of a community-based secondhand smoke reduction intervention for caregivers of urban children with asthma: process evaluation, successes and challenges

Many children, including those with asthma, remain exposed to secondhand smoke. This manuscript evaluates the process of implementing a secondhand smoke reduction counseling intervention using motivational interviewing (MI) for caregivers of urban children with asthma, including reach, dose delivered, dose received and fidelity. Challenges, strategies and successes in applying MI are highlighted. Data for 140 children (3-10 years) enrolled in the School Based Asthma Therapy trial, randomized to the treatment condition and living with one or more smoker, were analyzed. Summary statistics describe the sample, process measures related to intervention implementation, and primary caregiver (PCG) satisfaction with the intervention. The full intervention was completed by 79% of PCGs, but only 17% of other smoking caregivers. Nearly all (98%) PCGs were satisfied with the care study nurses provided and felt the program might be helpful to others. Despite challenges, this intervention was feasible and well received reaching caregivers who were not actively seeking treatment for smoking cessation or secondhand smoke reduction. Anticipating the strategies required to implement such an intervention may help promote participant engagement and retention to enhance the program's ultimate success.

Behavioral interventions for improving contraceptive use among women living with HIV

BACKGROUND

Contraception services can help meet the family planning goals of women living with HIV as well as prevent mother-to-child transmission. Due to the increased availability of antiretroviral therapy, survival has improved for people living with HIV, and more HIV-positive women may desire to have a child or another child. This review examines behavioral interventions to improve contraceptive use, for family planning, among women who are HIV-positive.

OBJECTIVES

We systematically reviewed studies that examined behavioral interventions for HIV-positive women that were intended to inform contraceptive choice, encourage contraceptive use, or promote adherence to a contraceptive regimen.

SEARCH METHODS

Through October 2012, we searched MEDLINE, CENTRAL, POPLINE, EMBASE, CINAHL, PsycINFO, ClinicalTrials.gov and ICTRP. For other relevant papers, we examined reference lists and unpublished project reports, and contacted investigators in the field.

SELECTION CRITERIA

Studies evaluated a behavioral intervention for improving contraceptive use for contraception. The comparison could be another behavioral intervention, usual care, or no intervention. We also considered studies that compared HIV-positive women versus HIV-negative women. We included nonrandomized (observational) studies as well as randomized trials.Primary outcomes were pregnancy and contraception use, e.g., uptake of a new method, improved use or continuation of current method. Secondary outcomes were knowledge of contraceptive effectiveness and attitude about contraception in general or about a specific contraceptive method.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted the data. One author entered the data into RevMan and a second verified accuracy. We examined the quality of evidence using the Newcastle-Ottawa Quality Assessment Scale.Given the need to control for confounding factors in observational studies, we used adjusted estimates from the models when available. Where we did not have adjusted analyses, we calculated the odds ratio (OR) with 95% confidence interval (CI). Due to varied study designs, we did not conduct meta-analysis.

MAIN RESULTS

The seven studies meeting our inclusion criteria had a total of 8882 women. All were conducted in Africa. Three studies compared a special intervention versus standard services. In one, the special intervention site showed greater use of non-condom contraceptives per visit (OR 6.40; 95% CI 5.37 to 7.62) and reported a lower pregnancy incidence. In another study, use of modern contraceptives was more likely for women at sites with enhanced versus basic integrated services (OR 2.48; 95% CI 1.31 to 4.72), but the groups did not differ significantly in change from baseline. In the third study, new use of modern contraceptives, excluding condoms, was less likely for women with integrated services versus those with routine care (OR 0.56; 95% CI 0.42 to 0.75), but new use of condoms was more likely (OR 1.73; 95% CI 1.52 to 1.98).Four older studies compared HIV-positive women versus HIV-negative women. None showed any significant difference between the HIV-status groups in use of modern contraceptives. Two did not provide an intervention for the HIV-negative women. In the larger of the two studies, HIV-positive women were less likely to become pregnant (OR 0.55; 95% CI 0.43 to 0.69). HIV-positive women were more likely to discontinue their hormonal contraceptive (OR 2.52; 95% CI 1.53 to 4.14) but more likely to use condoms (OR 2.82; 95% CI 2.18 to 3.65) and spermicide (OR 2.36; 95% CI 1.69 to 3.30). Two studies provided the intervention to both HIV-status groups. One included many of the women from the study just mentioned, and also showed fewer pregnancies for HIV-positive women (OR 0.39; 95% CI 0.23 to 0.68). In the other study, the HIV-status groups were not significantly different for pregnancy or consistent condom use.

AUTHORS' CONCLUSIONS

Comparative research on contraceptive counseling for HIV-positive women has been limited. We found little innovation in the behavioral interventions. Our ability to make statements about overall results is hampered by varied study designs, interventions, and outcome assessments. The quality of evidence was moderate. Since some of these studies were conducted, improvements in HIV treatment have influenced the fertility intentions of HIV-positive people.The family planning field needs better ways to help women choose an appropriate contraceptive and continue using that chosen method. Women with HIV may have special concerns regarding family planning. Research could focus on assessing the woman's needs and training providers to address those issues rather than delivering standardized information.

Acceptance and Commitment Therapy (ACT) for Psychological Adjustment after Traumatic Brain Injury: Reporting the Protocol for a Randomised Controlled Trial

Following a severe traumatic brain injury (TBI) there is a complex presentation of psychological symptoms which may impact on recovery. Validated treatments addressing these symptoms for this group of people are limited. This article reports on the protocol for a single-centre, two-armed, Phase II Randomised Control Trial (RCT) to address the adjustment process following a severe TBI. Participants will be recruited from Liverpool Brain Injury Rehabilitation Unit and randomly allocated to one of two groups, Acceptance and Commitment Therapy (ACT) or an active control (Befriending). The active treatment group utilises the six core processes of ACT with the intention of increasing participation and psychological flexibility and reducing psychological distress. A number of primary and secondary outcome measures, administered at assessment, post-treatment and 1-month follow-up, will be used to assess clinical outcomes. The publication of the protocol before the trial results are available addresses fidelity criterion (intervention design) for RCTs. This ensures transparency in the RCT and that it meets the guidelines according to the CONSORT statement. The protocol has also been registered on the Australian New Zealand Clinical Trials Registry ACTRN12610000851066.

How well is intervention content described in published reports of smoking cessation interventions?

INTRODUCTION

Behavioral support interventions for smoking cessation are typically complex, involving multiple interacting component behavior change techniques (BCTs). Precise reporting of intervention content is important for progress in the field. This study assessed the adequacy of published descriptions of the content of smoking cessation behavioral support interventions.

METHODS

About 152 trials of behavioral support were identified from Cochrane reviews. Authors were contacted up to 3 times requesting a copy of the intervention manual. Descriptions of intervention content in manuals and the corresponding publications were coded into component BCTs using an established taxonomy. The proportion of manual-specified content reported in subsequent trial reports was examined.

RESULTS

Manuals were received for 28 interventions published between 1992 and 2008. An average of 27 BCTs were identified per manual (range: 5-56), whereas published descriptions averaged only 12 (range: 3-26) (t[27] = 4.15, p < .001 for the difference).

CONCLUSIONS

Published reports of evaluations of smoking cessation behavioral support interventions typically mention fewer than half the behavior change techniques specified in the corresponding intervention manuals; this deficit in reporting could be remedied by journals insisting on full manuals being provided as supplementary electronic files.

Effectiveness of Maternal Counseling in Reducing Caries in Cree Children

This cluster-randomized pragmatic (effectiveness) trial tested maternal counseling based on Motivational Interviewing (MI) as an approach to control caries in indigenous children. Nine Cree communities in Quebec, Canada were randomly allocated to test or control. MI-style counseling was delivered in test communities to mothers during pregnancy and at well-baby visits. Data on outcomes were collected when children were 30 months old. Two hundred seventy-two mothers were recruited from the 5 test and 4 control communities. Baseline characteristics were comparable but not equivalent for both groups. At trial’s end, 241 children had follow-up. The primary analysis outcome was enamel caries with substance loss (d2); no statistically significant treatment effect was detected. Prevalence of treated and untreated caries at the d2 level was 76% in controls vs. 65% in test (p = 0.17). Exploratory analyses suggested a substantial preventive effect for untreated decay at or beyond the level of the dentin, d3 (prevalences: 60% controls vs. 35% test), and a particularly large treatment effect when mothers had 4 or more MI-style sessions. Overall, these results provide preliminary evidence that, for these young, indigenous children, an MI-style intervention has an impact on severity of caries (clinical trial registration ISRCTN41467632).

Assessing fidelity of treatment delivery in group and individual 12-step facilitation

Twelve step facilitation (TSF) is an emerging, empirically supported treatment, the study of which will be strengthened by rigorous fidelity assessment. This report describes the development, reliability and concurrent validity of the Twelve Step Facilitation Adherence Competence Empathy Scale (TSF ACES), a comprehensive fidelity rating scale for group and individual TSF treatment developed for the National Drug Abuse Treatment Clinical Trials Network study, Stimulant Abuser Groups to Engage in 12-Step. Independent raters used TSF ACES to rate treatment delivery fidelity of 966 (97% of total) TSF group and individual sessions. TSF ACES summary measures assessed therapist treatment adherence, competence, proscribed behaviors, empathy and overall session performance. TSF ACES showed fair to good overall reliability; weighted kappa coefficients for 59 co-rated sessions ranged from .31 to 1.00, with a mean of .69. Reliability ratings for session summary measures were good to excellent (.69-.91). Internal consistency for the instrument was variable (.47-.71). Relationships of the TSF ACES summary measures with each other, as well as relationships of the summary measures with a measure of therapeutic alliance provided support for concurrent and convergent validity. Implications and future directions for the use of TSF ACES in clinical trials and community treatment implementation are discussed.

The importance of an independent oversight committee to preserve treatment fidelity, ensure protocol compliance, and adjudicate safety endpoints in the ATACH II trial

In response to growing trends and accepted U.S. Food and Drug Administration (FDA) guidance, the ATACH II trial leadership developed the independent oversight committee (IOC) as a mechanism to adjudicate the trial safety endpoints and to evaluate treatment fidelity and protocol compliance. To accomplish these tasks, the IOC reviews the first three subjects enrolled at each study center and all serious adverse events that occur across all study centers. The IOC makes recommendations to the steering committee regarding the aggregation of, or trend in, adverse events at particular sites and discusses homogeneity, or lack thereof, in the principles and intensity of the overall care. Based on the IOC findings, the steering committee will contact individual sites, as needed, to discuss potential remedial measures.

Assessing fidelity to integrated motivational interviewing and CBT therapy for psychosis and substance use: the MI-CBT fidelity scale (MI-CTS)

BACKGROUND

Guidelines for the psychological treatment of psychosis and substance use suggest integrated treatments to address both problems are necessary. One such treatment combines cognitive-behaviour therapy (CBT) and motivational interviewing (MI). While there are a number of scales to assess treatment fidelity to CBT and MI separately, none, to date, assess fidelity to integrated MI and CBT (MI-CBT) for psychosis and substance use.

AIMS

This study aimed to develop a reliable and valid scale to assess fidelity to MI-CBT for people with psychosis and problematic substance use.

METHOD

Items for a new scale (the MI-CTS fidelity scale) were selected from multiple relevant sources. Inter-rater reliability and validity (against the CTS-Psy and Motivational Interviewing Treatment Integrity (MITI)) scales were investigated.

RESULTS

The scale had good inter-rater reliability when used to rate adherence versus non-adherence. In relation to validity, the scale related well to CBT and MI scales (the CTS-Psy and MITI).

CONCLUSIONS

The MI-CTS is useful for assessing adherence to integrated MI-CBT for psychosis and substance misuse and could aid training and implementation of the approach.

Optimizing acceptability and feasibility of an evidence-based behavioral intervention for obese adults with obesity-related co-morbidities or additional risk factors for co-morbidities: an open-pilot intervention study in secondary care

OBJECTIVE

To test and optimize the feasibility and acceptability of a physical activity (PA) and healthy eating behavior change intervention for obese adults with obesity-related co-morbidities or additional risk factors for co-morbidities.

METHODS

Open-pilot intervention study using an uncontrolled pre and post design with ongoing measures on intervention acceptability and feasibility. Participants received 5 weekly nurse-led one-hour long group sessions. Acceptability and feasibility were assessed throughout. PA, dietary behavior and weight were measured before and after the intervention.

RESULTS

Of 74 consenting participants, 61 (82%) received and 47 (64%) completed the intervention. Average ratings of intervention materials and components by participants ranged between 4.1 and 4.9 out of 5. Average facilitator satisfaction rating was 90% (range 75-100%). The intervention delivery was feasible as indicated by ratings and comments from participants and the facilitator. Participants lost -0.86 kg of weight t(45)=3.84, p=0.0001, and increased PA by an additional 1.6 (SD=2.7) sessions/week, t(31)=-3.3, p=0.002. No significant dietary differences emerged.

CONCLUSION

The intervention was acceptable to the facilitator and participants and feasible for delivery. Several intervention aspects were further optimized.

PRACTICE IMPLICATIONS

The current study outlines a PA and dietary behavior change pilot intervention coupled with a systematic and transparent process of intervention optimization.

Fidelity and moderating factors in complex interventions: a case study of a continuum of care program for frail elderly people in health and social care

Background

Prior studies measuring fidelity of complex interventions have mainly evaluated adherence, and not taken factors affecting adherence into consideration. A need for studies that clarify the concept of fidelity and the function of factors moderating fidelity has been emphasized. The aim of the study was to systematically evaluate implementation fidelity and possible factors influencing fidelity of a complex care continuum intervention for frail elderly people.

Methods

The intervention was a systematization of the collaboration between a nurse with geriatric expertise situated at the emergency department, the hospital ward staff, and a multi-professional team with a case manager in the municipal care services for older people. Implementation was evaluated between September 2008 and May 2010 with observations of work practices, stakeholder interviews, and document analysis according to a modified version of The Conceptual Framework for Implementation Fidelity.

Results

A total of 16 of the 18 intervention components were to a great extent delivered as planned, while some new components were added to the model. No changes in the frequency or duration of the 18 components were observed, but the dose of the added components varied over time. Changes in fidelity were caused in a complex, interrelated fashion by all the moderating factors in the framework, i.e., context, staff and participant responsiveness, facilitation, recruitment, and complexity.

Discussion

The Conceptual Framework for Implementation Fidelity was empirically useful and included comprehensive measures of factors affecting fidelity. Future studies should focus on developing the framework with regard to how to investigate relationships between the moderating factors and fidelity over time.

Trial registration

ClinicalTrials.gov, NCT01260493.

Activity pacing for osteoarthritis symptom management: study design and methodology of a randomized trial testing a tailored clinical approach using accelerometers for veterans and non-veterans

BACKGROUND

Osteoarthritis (OA) is a prevalent chronic disease and a leading cause of disability in adults. For people with knee and hip OA, symptoms (e.g., pain and fatigue) can interfere with mobility and physical activity. Whereas symptom management is a cornerstone of treatment for knee and hip OA, limited evidence exists for behavioral interventions delivered by rehabilitation professionals within the context of clinical care that address how symptoms affect participation in daily activities. Activity pacing, a strategy in which people learn to preplan rest breaks to avoid symptom exacerbations, has been effective as part of multi-component interventions, but hasn't been tested as a stand-alone intervention in OA or as a tailored treatment using accelerometers. In a pilot study, we found that participants who underwent a tailored activity pacing intervention had reduced fatigue interference with daily activities. We are now conducting a full-scale trial.

METHODS/DESIGN

This paper provides a description of our methods and rationale for a trial that evaluates a tailored activity pacing intervention led by occupational therapists for adults with knee and hip OA. The intervention uses a wrist accelerometer worn during the baseline home monitoring period to glean recent symptom and physical activity patterns and to tailor activity pacing instruction based on how symptoms relate to physical activity. At 10 weeks and 6 months post baseline, we will examine the effectiveness of a tailored activity pacing intervention on fatigue, pain, and physical function compared to general activity pacing and usual care groups. We will also evaluate the effect of tailored activity pacing on physical activity (PA).

DISCUSSION

Managing OA symptoms during daily life activity performance can be challenging to people with knee and hip OA, yet few clinical interventions address this issue. The activity pacing intervention tested in this trial is designed to help people modulate their activity levels and reduce symptom flares caused by too much or too little activity. As a result of this trial, we will be able to determine if activity pacing is more effective than usual care, and among the intervention groups, if an individually tailored approach improves fatigue and pain more than a general activity pacing approach.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01192516.

A Framework for Implementing Sustainable Oral Health Promotion Interventions

The present paper addresses basic evaluation and procedural concepts that are involved in the process of implementing sustainable oral health behavioral and social interventions. It is part of a series of thematic articles describing cutting-edge methods for conducting oral health interventions research. Core components for effective intervention implementation are presented as part of a comprehensive model composed of four stages (training, adoption, implementation, and practice), along with sustaining influences involving preparation and maintenance. This model systematically addresses common barriers that can reduce innovation success and permanence. Special attention is given to the measurement and impact of organizational and related contextual influences across stages of the implementation process. Assessment tools and research strategies are recommended and illustrated based on evaluations of interventions implemented in addiction and mental health treatment systems. These tools and research strategies also hold promise for use within the National Institute of Dental and Craniofacial Research Practice-Based Research Networks, as well as other systems of oral health care delivery.