A conceptual framework for implementation fidelity

Supporting Looked After Children and Care Leavers In Decreasing Drugs, and alcohol (SOLID): protocol for a pilot feasibility randomised controlled trial of interventions to decrease risky substance use (drugs and alcohol) and improve mental health of looked after children and care leavers aged 12-20 years

BACKGROUND

Looked after children (LAC) and care leavers are young people who have been placed under the legal care of local authorities, in many instances due to a history of abuse and/or neglect. These young people have a significantly increased risk of substance use and mental disorder compared to their peers. The aim of the SOLID study is to assess the feasibility and acceptability of a definitive three-arm multi-centre randomised controlled trial (RCT) that compares the effectiveness of two interventions that aim to reduce risky drug and alcohol use and improve mental health among LAC aged 12 to 20 years with usual care.

METHODS

All LAC aged 12 to 20 years residing in four local authorities in North East England will be screened by their social worker for risky drug and alcohol use using the CRAFFT (Car, Relax, Alone, Forget, Friends and Trouble) screening tool. Those who score ≥2 will be invited to take part in the trial after further eligibility checks. Informed consent will be taken and baseline data collected. Participants will then be randomised into either (i) Motivational Enhancement Therapy, (ii) Social Behaviour and Network Therapy, or (iii) control-usual care. Follow-up data will be collected 12 months post-baseline. The baseline and follow-up questionnaires will measure self-reported drug and alcohol use, mental health and well-being and health-related quality of life. The follow-up will also collect data on placement stability and self-reported sexual, antisocial and criminal behaviour. Participants will also be asked about the use of health and social services. A detailed process evaluation, using both qualitative and quantitative methods, will be conducted and involve LAC, their carers, social workers and drug and alcohol practitioners.

DISCUSSION

Despite having an increased likelihood of risky substance misuse, there is a lack of evidence outlining specific interventions to decrease drug and alcohol use targeting LAC. This feasibility study will provide the information needed to develop a definitive trial. LAC will benefit from the results of this study and the further development of the interventions.

TRIAL REGISTRATION

ISRCTN80786829.

Music-based therapeutic interventions for people with dementia

BACKGROUND

Dementia is a clinical syndrome with a number of different causes which is characterised by deterioration in cognitive, behavioural, social and emotional functions. Pharmacological interventions are available but have limited effect to treat many of the syndrome's features. Less research has been directed towards non-pharmacological treatments. In this review, we examined the evidence for effects of music-based interventions as a treatment.

OBJECTIVES

To assess the effects of music-based therapeutic interventions for people with dementia on emotional well-being including quality of life, mood disturbance or negative affect, behavioural problems, social behaviour, and cognition at the end of therapy and four or more weeks after the end of treatment.

SEARCH METHODS

We searched ALOIS, the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (CDCIG) on 14 April 2010 using the terms: music therapy, music, singing, sing, auditory stimulation. Additional searches were also carried out on 3 July 2015 in the major healthcare databases MEDLINE, Embase, psycINFO, CINAHL and LILACS; and in trial registers and grey literature sources. On 12 April 2016, we searched the major databases for new studies for future evaluation.

SELECTION CRITERIA

We included randomized controlled trials of music-based therapeutic interventions (at least five sessions) for people with dementia that measured any of our outcomes of interest. Control groups either received usual care or other activities.

DATA COLLECTION AND ANALYSIS

Two reviewers worked independently to screen the retrieved studies against the inclusion criteria and then to extract data and assess methodological quality of the included studies. If necessary, we contacted trial authors to ask for additional data, including relevant subscales, or for other missing information. We pooled data using random-effects models.

MAIN RESULTS

We included 17 studies. Sixteen studies with a total of 620 participants contributed data to meta-analyses. Participants in the studies had dementia of varying degrees of severity, but all were resident in institutions. Five studies delivered an individual music intervention; in the others, the intervention was delivered to groups of participants. Most interventions involved both active and receptive musical elements. The methodological quality of the studies varied. All were at high risk of performance bias and some were at high risk of detection or other bias. At the end of treatment, we found low-quality evidence that music-based therapeutic interventions may have little or no effect on emotional well-being and quality of life (standardized mean difference, SMD 0.32, 95% CI -0.08 to 0.71; 6 studies, 181 participants), overall behaviour problems (SMD -0.20, 95% CI -0.56 to 0.17; 6 studies, 209 participants) and cognition (SMD 0.21, 95% CI -0.04 to 0.45; 6 studies, 257 participants). We found moderate-quality evidence that they reduce depressive symptoms (SMD -0.28, 95% CI -0.48 to -0.07; 9 studies, 376 participants), but do not decrease agitation or aggression (SMD -0.08, 95% CI -0.29 to 0.14; 12 studies, 515 participants). The quality of the evidence on anxiety and social behaviour was very low, so effects were very uncertain. The evidence for all long-term outcomes was also of very low quality.

AUTHORS' CONCLUSIONS

Providing people with dementia with at least five sessions of a music-based therapeutic intervention probably reduces depressive symptoms but has little or no effect on agitation or aggression. There may also be little or no effect on emotional well-being or quality of life, overall behavioural problems and cognition. We are uncertain about effects on anxiety or social behaviour, and about any long-term effects. Future studies should employ larger sample sizes, and include all important outcomes, in particular 'positive' outcomes such as emotional well-being and social outcomes. Future studies should also examine the duration of effects in relation to the overall duration of treatment and the number of sessions.

Music therapy for children and adolescents with behavioural and emotional problems: a randomised controlled trial

BACKGROUND

Although music therapy (MT) is considered an effective intervention for young people with mental health needs, its efficacy in clinical settings is unclear. We therefore examined the efficacy of MT in clinical practice.

METHODS

Two hundred and fifty-one child (8-16 years, with social, emotional, behavioural and developmental difficulties) and parent dyads from six Child and Adolescent Mental Health Service community care facilities in Northern Ireland were randomised to 12 weekly sessions of MT plus usual care [n = 123; 76 in final analyses] or usual care alone [n = 128; 105 in final analyses]. Follow-up occurred at 13 weeks and 26 weeks postrandomisation. Primary outcome was improvement in communication (Social Skills Improvement System Rating Scales) (SSIS) at 13 weeks. Secondary outcomes included social functioning, self-esteem, depression and family functioning.

RESULTS

There was no significant difference for the child SSIS at week 13 (adjusted difference in mean 2.4; 95% CI -1.2 to 6.1; p = .19) or for the guardian SSIS (0.5; 95% CI -2.9 to 3.8; p = .78). However, for participants aged 13 and over in the intervention group, the child SSIS communication was significantly improved (6.1, 95% CI 1.6 to 10.5; p = .007) but not the guardian SSIS (1.1; 95% CI -2.9 to 5.2; p = .59). Overall, self-esteem was significantly improved and depression scores were significantly lower at week 13. There was no significant difference in family or social functioning at week 13.

CONCLUSIONS

While the findings provide some evidence for the integration of music therapy into clinical practice, differences relating to subgroups and secondary outcomes indicate the need for further study. ISRCTN Register; ISRCTN96352204.

Addressing post-stroke care in rural areas with Peru as a case study. Placing emphasis on evidence-based pragmatism

Stroke is a major cause of death and disability, with most of its burden now affecting low- and middle-income countries (LMIC). People in rural areas of LMIC who have a stroke receive very little acute stroke care and local healthcare workers and family caregivers in these regions lack the necessary knowledge to assist them. Intriguingly, a recent rapid growth in cell-phone use and digital technology in rural areas has not yet been appropriately exploited for health care training and delivery purposes. What should be done in rural areas, at the community setting-level, where access to healthcare is limited remains a challenge. We review the evidence on improving post-stroke outcomes including lowering the risks of functional disability, stroke recurrence, and mortality, and propose some approaches, to target post-stroke care and rehabilitation, noting key challenges in designing suitable interventions and emphasizing the advantages mHealth and communication technologies can offer. In the article, we present the prevailing stroke care situation and technological opportunities in rural Peru as a case study. As such, by addressing major limitations in rural healthcare systems, we investigate the potential of task-shifting complemented with technology to utilize and strengthen both community-based informal caregivers and community healthcare workers.

Implementation of a Text-Based Content Intervention in Secondary Social Studies Classes

We describe teacher fidelity (adherence to the components of the treatment as specified by the research team) based on a series of studies of a multicomponent intervention, Promoting Acceleration of Comprehension and Content Through Text (PACT), with middle and high school social studies teachers and their students. Findings reveal that even with highly specified materials and implementing practices that are aligned with effective reading comprehension and content instruction, teachers' fidelity was consistently low for some components and high for others. Teachers demonstrated consistently high implementation fidelity and quality for the instructional components of building background knowledge (comprehension canopy) and teaching key content vocabulary (essential words), whereas we recorded consistently lower fidelity and quality of implementation for the instructional components of critical reading and knowledge application.

Local initiatives to access emergency obstetric and neonatal care in Burkina Faso

OBJECTIVE

To describe the various local initiatives to access emergency obstetric and neonatal care in Burkina Faso.

METHODS

An existing framework was used to review the three processes for local initiatives: emergence, formulation, and implementation. Multiple case studies were conducted, followed by literature review and semi-structured interviews with key informants.

RESULTS

Sixteen districts had implemented local initiatives, including cost sharing, free care for women and children, and free care for delivery and cesareans. Most districts (n=10) had implemented the cost-sharing intervention. These initiatives were initiated by local actors as well as nongovernmental organizations. The profile of those involved led to different ways of handling the emergence and formulation processes. At implementation, these initiatives faced many issues including late payment of contributions, low involvement of local governments, and equity in participation.

CONCLUSION

There are some issues in the implementation and sustainability of the local initiatives. Although many initiatives exist, these are unable to fully address the financial barriers to care. However, these initiatives highlight context-based financial barriers that must be taken into account to accelerate universal access to health care.

Patients' Perceptions of a Pressure Ulcer Prevention Care Bundle in Hospital: A Qualitative Descriptive Study to Guide Evidence-Based Practice

BACKGROUND

Pressure ulcers place a significant burden on patients and hospitals. Our team developed and tested a pressure ulcer prevention care bundle (PUPCB) in a cluster randomized trial. As part of the process evaluation conducted alongside the trial, we explored patients' perceptions of the intervention.

AIMS

To identify patients' perceptions and experiences of a PUPCB in hospital.

METHODS

This qualitative descriptive study explored the perceptions of a subset of patients who participated in a trial testing the PUPCB across four intervention hospitals. A trained interviewer conducted semistructured interviews, which were digitally recorded, transcribed, and analyzed using thematic analysis.

FINDINGS

Nineteen patients were interviewed across the four hospitals. Three main themes emerged: (a) importance of personal contact in PUPCB delivery; (b) understanding pressure ulcer prevention (PUP) enhances participation; and (c) individual factors impact patients' engagement in PUP.

DISCUSSION

The extent to which patients adopted the intervention appeared to be influenced by the complexity of education materials, compatibility with patients' existing knowledge and beliefs, and perceived advantage of the intervention; ability for human interaction; and patient-related facilitators and barriers to participating in PUP care.

LINKING EVIDENCE TO ACTION

This study found patients accepted a PUPCB that encouraged participation in care, particularly as it involved personal and positive interactions with nurses and provision of information that was easy to understand and resonated with patients.

A formative evaluation of the recovery public works programme in Blantyre City, Malawi

Public works programmes (PWPs) are popular social protection instruments in the context of chronic poverty but very little has been published in the way of implementation and outcomes of these programmes. This paper presents a formative process and outcome evaluation of the recovery PWP in Blantyre City, Malawi. The evaluation used longitudinal household survey data of PWP beneficiaries, programme records and interview responses from programme staff and community leaders. Largely, the process evaluation findings showed an agreement between actual and planned activities. The outcome evaluation found indications that the PWP community assets offered some potential benefits to the communities, and that PWP wages allowed the beneficiaries to purchase some food. This however, did not translate into more meals per day, nor did the earnings prevent the decline in household assets as expected. Given a plausible PWP theory and high implementation fidelity, the PWP wage rate or number of days was either just enough to smooth participant income, or insufficient altogether, to enable achievement of more distal outcomes.

Steps Towards Alcohol Misuse Prevention Programme (STAMPP): a school- and community-based cluster randomised controlled trial

Background

Alcohol use in young people remains a public health concern, with adverse impacts on outcomes such as health, well-being, education and relationships.

Objectives

To assess the effectiveness and cost-effectiveness of a combined classroom curriculum and parental intervention on self-reported alcohol use [heavy episodic drinking (HED)] and alcohol-related harms (indicators such as getting into fights after drinking, poorer school performance and trouble with friends and family).

Design

A two-arm, cluster randomised controlled trial with schools as the unit of randomisation.

Setting

A total of 105 post-primary schools in Northern Ireland (NI) and Glasgow/Inverclyde Educational Authority areas.

Participants

A total of 12,738 male and female secondary school students (intervention delivered when students were in school year 9 in NI or S2 in Scotland in the academic year 2012–13 and aged 12–13 years) were randomised. Randomisation and baseline (T0) surveys took place when children were in school year 8 or S1. Schools were randomised (1 : 1) by an independent statistician to the Steps Towards Alcohol Misuse Prevention Programme (STAMPP) or to education as normal (EAN). All schools were stratified by free school meal provision. Schools in NI were also stratified by school type (male/female/coeducational).

Interventions

STAMPP combined a school-based alcohol harm reduction curriculum [an adapted version of the School Health and Alcohol Harm Reduction Project (SHAHRP)] and a brief parental intervention designed to support parents in setting family rules around drinking. The classroom component comprised two phases delivered over 2 years, and the parental component comprised a standardised presentation delivered by a trained facilitator at specially arranged parent evenings on school premises. This was followed up a few weeks later by an information leaflet mailed to all intervention pupils’ parents highlighting the main points of the evening.

Main outcome measures

(1) Self-reported HED (defined as self-reported consumption of ≥ 6 units in a single episode in the previous 30 days for male students and ≥ 4.5 units for female students) assessed at 33 months from baseline (T3); and (2) the number of self-reported harms (harms caused by own drinking) assessed at T3.

Data sources

Self-completed pupil questionnaires.

Results

At final follow-up (T3), data were available for 5160 intervention and 5073 control pupils for the HED outcome, and for 5234 intervention and 5146 control pupils for the self-reported harms outcome. The intervention reduced self-reported HED compared with EAN (p < 0.001), but did not reduce self-reported harms associated with own drinking. The odds ratio for the intervention effect on HED was 0.596 (standard error 0.0596, 95% confidence interval 0.490 to 0.725). The mean cost of delivery per school was £818 and the mean cost per individual was £15. There were no clear cost savings in terms of service utilisation associated with the intervention. The process evaluation showed that the classroom component engaged and was enjoyed by pupils, and was valued by teachers. Schools, students, intervention trainers and delivery staff (teachers) were not blind to study condition. Data collection was undertaken by a team of researchers that included the trial manager and research assistants, some of whom were not blinded to study condition. Data analysis of primary and secondary outcomes was undertaken by the trial statistician, who was blinded to the study condition.

Limitations

Although the classroom component was largely delivered as intended, there was very low attendance at the parent/carer event; however, all intervention pupils’ parents/carers received an intervention leaflet.

Conclusions

The results of this trial provide some support for the effectiveness and cost-effectiveness of STAMPP in reducing heavy episodic (binge) drinking, but not in reducing self-reported alcohol-related harms, in young people over a 33-month follow-up period. As there was low uptake of the parental component, it is uncertain whether or not the intervention effect was accounted for by the classroom component alone.

Trial registration

Current Controlled Trials ISRCTN47028486.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full inPublic Health Research; Vol. 5, No. 2. See the NIHR Journals Library website for further project information. The Public Health Agency of NI and Education Boards of Glasgow/Inverclyde provided some intervention costs. Diageo provided funds to print some workbooks. The remaining intervention costs were internally funded.

An evolving approach to delirium: A mixed-methods process evaluation of a hospital-wide delirium program in New Zealand

OBJECTIVE

A process evaluation was carried out to assess and potentially improve the design and implementation of a hospital-wide delirium program.

METHODS

A mixed-methods sequential-explanatory design was used; retrospective chart reviews for 100 older (75+) medical inpatients were conducted to measure nurses', doctors' and coders' adherence to key program processes following which interviews were conducted to identify potential barriers to implementation.

RESULTS

Delirium occurred in 49% of patients. Chart reviews revealed suboptimal adherence to the delirium risk assessment (66%), the Short Confusion Assessment Method (50% on admission, 58% during admission), documentation of delirium in clinical records (80%) and discharge letters (38%) and coding for delirium (49%). The major barriers to implementation identified were failure to recruit non-nursing staff, unclear goals and instructions, difficulties using the Short-CAM, time constraints with competing priorities and lack of outcome expectancy.

CONCLUSION

A new delirium program was needed based on these findings.

Exploring why a complex intervention piloted in general practices did not result in an increase in chlamydia screening and diagnosis: a qualitative evaluation using the fidelity of implementation model

BACKGROUND

Chlamydia trachomatis (chlamydia) is the most commonly diagnosed sexually transmitted infection (STI) in England; approximately 70% of diagnoses are in sexually active young adults aged under 25. To facilitate opportunistic chlamydia screening in general practice, a complex intervention, based on a previously successful Chlamydia Intervention Randomised Trial (CIRT), was piloted in England. The modified intervention (3Cs and HIV) aimed to encourage general practice staff to routinely offer chlamydia testing to all 15-24 year olds regardless of the type of consultation. However, when the 3Cs (chlamydia screening, signposting to contraceptive services, free condoms) and HIV was offered to a large number of general practitioner (GP) surgeries across England, chlamydia screening was not significantly increased. This qualitative evaluation addresses the following aims: a) Explore why the modified intervention did not increase screening across all general practices. b) Suggest recommendations for future intervention implementation.

METHODS

Phone interviews were carried out with 26 practice staff, at least 5 months after their initial educational workshop, exploring their opinions on the workshop and intervention implementation in the real world setting. Interview transcripts were thematically analysed and further examined using the fidelity of implementation model.

RESULTS

Participants who attended had a positive attitude towards the workshops, but attendee numbers were low. Often, the intervention content, as detailed in the educational workshops, was not adhered to: practice staff were unaware of any on-going trainer support; computer prompts were only added to the female contraception template; patients were not encouraged to complete the test immediately; complete chlamydia kits were not always readily available to the clinicians; and videos and posters were not utilised. Staff reported that financial incentives, themselves, were not a motivator; competing priorities and time were identified as major barriers.

CONCLUSION

Not adhering to the exact intervention model may explain the lack of significant increases in chlamydia screening. To increase fidelity of implementation outside of Randomised Controlled Trial (RCT) conditions, and consequently, improve likelihood of increased screening, future public health interventions in general practices need to have: more specific action planning within the educational workshop; computer prompts added to systems and used; all staff attending the workshop; and on-going practice staff support with feedback of progress on screening and diagnosis rates fed back to all staff.

Enhanced recovery after elective caesarean: a rapid review of clinical protocols, and an umbrella review of systematic reviews

BACKGROUND

The rate of elective Caesarean Section (CS) is rising in many countries. Many obstetric units in the UK have either introduced or are planning to introduce enhanced recovery (ER) as a means of reducing length of stay for planned CS. However, to date there has been very little evidence produced regarding the necessary components of ER for the obstetric population. We conducted a rapid review of the composition of published ER pathways for elective CS and undertook an umbrella review of systematic reviews evaluating ER components and pathways in any surgical setting.

METHODS

Pathways were identified using MEDLINE, EMBASE and the National Guideline Clearing House, appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool and their components tabulated. Systematic reviews were identified using the Cochrane Library and Database of Abstracts of Reviews of Effects (DARE) and appraised using The Grading of Recommendations Assessment, Development and Evaluation (GRADE). Two reviewers aggregated summaries of findings for Length of Stay (LoS).

RESULTS

Five clinical protocols were identified, involving a total of 25 clinical components; 3/25 components were common to all five pathways (early oral intake, mobilization and removal of urinary catheter). AGREE II scores were generally low. Systematic reviews of single components found that minimally invasive Joel-Cohen surgical technique, early catheter removal and post-operative antibiotic prophylaxis reduced LoS after CS most significantly by around half to 1 and a half days. Ten meta-analyses of multi-component Enhanced Recovery after Surgery (ERAS) packages demonstrated reductions in LoS of between 1 and 4 days. The quality of evidence was mostly low or moderate.

CONCLUSIONS

Further research is needed to develop, using formal methods, and evaluate pathways for enhanced recovery in elective CS. Appropriate quality improvement packages are needed to optimise their implementation.

Implementation of Integrated Service Networks under the Quebec Mental Health Reform: Facilitators and Barriers associated with Different Territorial Profiles

INTRODUCTION

This study evaluates implementation of the Quebec Mental Health Reform (2005-2015), which promoted the development of integrated service networks, in 11 local service networks organized into four territorial groups according to socio-demographic characteristics and mental health services offered.

METHODS

Data were collected from documents concerning networks; structured questionnaires completed by 90 managers and by 16 respondent-psychiatrists; and semi-structured interviews with 102 network stakeholders. Factors associated with implementation and integration were organized according to: 1) reform characteristics; 2) implementation context; 3) organizational characteristics; and 4) integration strategies.

RESULTS

While local networks were in a process of development and expansion, none were fully integrated at the time of the study. Facilitators and barriers to implementation and integration were primarily associated with organizational characteristics. Integration was best achieved in larger networks including a general hospital with a psychiatric department, followed by networks with a psychiatric hospital. Formalized integration strategies such as service agreements, liaison officers, and joint training reduced some barriers to implementation in networks experiencing less favourable conditions.

CONCLUSION

Strategies for the implementation of healthcare reform and integrated service networks should include sustained support and training in best-practices, adequate performance indicators and resources, formalized integration strategies to improve network coordination and suitable initiatives to promote staff retention.

Recommendations for surgical safety checklist use in Canadian children's hospitals

BACKGROUND

There is ample evidence that avoidable harm occurs in patients, including children, who undergo surgical procedures. Among a number of harm mitigation strategies, the use of surgical safety checklists (SSC) is now a required organizational practice for accreditation in all North American hospitals. Although much has been written about the effects of SSC on outcomes of adult surgical patients, there is a paucity of literature on the use and role of the SSC as an enabler of safe surgery for children.

METHODS

The Pediatric Surgical Chiefs of Canada (PSCC) advocates on behalf of all Canadian children undergoing surgical procedures. We undertook a survey of the use of SSC in Canadian children's hospitals to understand the variability of implementation of the SSC and understand its role as both a measure and driver of patient safety and to make specific recommendations (based on survey results and evidence) for standardized use of the SSC in Canadian children's hospitals.

RESULTS

Survey responses were received from all 15 children's hospitals and demonstrated significant variability in how the checklist is executed, how compliance is measured and reported, and whether or not use of the checklist resulted in specific instances of error prevention over a 12-month observation period. There was near unanimous agreement that use of the SSC contributed positively to the safety culture of the operating room.

CONCLUSION

Based on the survey results, the PSCC have made 5 recommendations regarding the use of the SSC in Canadian children's hospitals.

Feasibility of a cognitive strategy training intervention for people with Parkinson's disease

PURPOSE

To investigate the feasibility of a novel client-centered cognitive strategy training intervention for people with Parkinson's disease (PD).

MATERIALS AND METHODS

This was a case series of seven people with PD without dementia but with subjective cognitive decline. The intervention involved ≥5 treatment sessions at the participant's home. Participant acceptance and engagement were assessed by the Credibility/Expectancy Questionnaire (CEQ), Client Satisfaction Questionnaire (CSQ), enjoyment and effort ratings, and homework completion. Logistical information was tracked, and the Canadian Occupational Performance Measure (COPM) was an exploratory outcome measure. Data analysis was descriptive.

RESULTS

CEQ scores were positive and increased over time. CSQ scores were high (M = 30.8, SD = 0.75), with all participants rating all items positively. Almost all (95%) effort and enjoyment ratings were ≥3 (Much), and homework completion rates averaged 84% (SD = 18). Intervention duration was 6-15 weeks (M = 9.2, SD = 2.8), with treatment sessions averaging 1.7 h (SD = 0.5). Group and most individual COPM ratings improved ≥2 points.

CONCLUSIONS

These findings support the feasibility of the intervention for people with PD. It was acceptable, engaging, and promising in terms of its effect on self-identified functional cognitive problems. Implications for Rehabilitation People with Parkinson's disease (PD) without dementia can experience cognitive decline that negatively impacts function and quality of life. Strategy-based interventions that explicitly train for transfer may mitigate the negative functional consequences of cognitive decline in this population. We developed a client-centered cognitive strategy training intervention for people with PD. This small case series supports its feasibility, indicating that it is acceptable and engaging for people with PD and promising in terms of its effect on self-identified functional cognitive problems.

Potential in-class strategies to increase children’s vegetable consumption

Objective

The Crunch&Sip programme is a school-based nutrition initiative designed to increase the fruit, vegetable and water intakes of primary-school children. In recognition of the notable deficits in children’s vegetable consumption, the present study explored the receptivity of school staff to a realignment of the Crunch&Sip programme to feature a primary focus on vegetable consumption. This involved investigating school staff members’ perceptions of relevant barriers, motivators and facilitators.

Design

A multi-method approach was adopted that involved four focus groups and a survey (administered in paper and online formats) containing a mixture of open- and closed-ended items.

Setting

Western Australia.

Subjects

Staff from Western Australian schools participated in the focus groups (n37) and survey (n620).

Results

School staff were strongly supportive of modifying the Crunch&Sip programme to focus primarily on children’s vegetable consumption and this was generally considered to be a feasible change to implement. Possible barriers identified included children’s taste preferences and a perceived lack of parental support. Suggested strategies to overcome these barriers were education sessions for parents and children, teachers modelling vegetable consumption for their students and integrating vegetable-related topics into the school curriculum.

Conclusions

School staff are likely to support the introduction of school-based nutrition programmes that specifically encourage the consumption of vegetables. Potential barriers may be overcome through strategies to engage parents and children.

Implementation of a multicomponent Responsible Beverage Service programme in Sweden-a qualitative study of promoting and hindering factors

Aims

The objective of this study was to identify factors that either promote or hinder implementation of a multicomponent Responsible Beverage Service programme in Swedish municipalities.

Design

Forty semi-structured interviews were conducted in six municipalities and directed content analysis, guided by the Consolidated Framework for Implementation Research (CFIR), was performed.

Results

The CFIR framework was useful as an underlying theoretical model in this study. Importance of the following factors, described in the five domains of CFIR, was empirically supported in this study: local needs, evidence strength and advantages of the intervention, costs and available resources, clear goals, evaluation and feedback, access to knowledge and information, clear role definitions and cooperation, and enthusiastic key persons with high confidence in the effectiveness of the intervention. Hindering factors listed by the informants were lack of enthusiasm and opportunities to specialise, low degree of self-efficacy, unengaged decision-makers, complexities of the programme, and a top-down approach.

Conclusions

This study indicates that previously identified factors shown to promote and hinder implementation processes are also valid in the context of multicomponent community action programmes like RBS. Suggestions on how to elude some of the hindering factors are proposed, e.g. to develop long-time financial plans, to provide better information about the RBS program in full, and to stress the importance of collaboration between representatives from the municipalities, police authorities and owners of on-licenced premises.

The efficacy of a relationship building intervention in 5th grade

The present study reports initial efficacy data for a new school-based intervention - the Relationship Building Intervention (RBI) - that includes a series of teacher-facilitated, structured activities designed to promote positive peer relationships and inclusive classroom communities. The RBI was evaluated in fifth-grade classrooms by estimating multilevel model (MLM) analyses of covariance (ANCOVA) comparing 368 fifth-grade students in intervention classrooms with 259 fifth-graders in control classrooms on social behaviors, perceptions of classroom connectedness, and academic performance. Controlling for pretest scores, cohort, and demographic variables, findings revealed that students who participated in the RBI liked school more, felt a greater sense of classroom identification and inclusion, were perceived by teachers to be less aggressive, and performed better academically than students who were in control classrooms. Further, implementation data showed that students and teachers responded positively to the activities. These results suggest that the RBI is a promising approach for improving the social and learning environment in fifth-grade classrooms.

Training nurses in task-shifting strategies for the management and control of hypertension in Ghana: a mixed-methods study

BACKGROUND

Nurses in Ghana play a vital role in the delivery of primary health care at both the household and community level. However, there is lack of information on task shifting the management and control of hypertension to community health nurses in low- and middle-income countries including Ghana. The purpose of this study was to assess nurses' knowledge and practice of hypertension management and control pre- and post-training utilizing task-shifting strategies for hypertension control in Ghana (TASSH).

METHODS

A pre- and post- test survey was administered to 64 community health nurses (CHNs) and enrolled nurses (ENs) employed in community health centers and district hospitals before and after the TASSH training, followed by semi-structured qualitative interviews that assessed nurses' satisfaction with the training, resultant changes in practice and barriers and facilitators to optimal hypertension management.

RESULTS

A total of 64 CHNs and ENs participated in the TASSH training. The findings of the pre- and post-training assessments showed a marked improvement in nurses' knowledge and practice related to hypertension detection and treatment. At pre-assessment 26.9% of the nurses scored 80% or more on the hypertension knowledge test, whereas this improved significantly to 95.7% post-training. Improvement of interpersonal skills and patient education were also mentioned by the nurses as positive outcomes of participation in the intervention.

CONCLUSIONS

Findings suggest that if all nurses receive even brief training in the management and control of hypertension, major public health benefits are likely to be achieved in low-income countries like Ghana. However, more research is needed to ascertain implementation fidelity and sustainability of interventions such as TASSH that highlight the potential role of nurses in mitigating barriers to optimal hypertension control in Ghana.

TRIAL REGISTRATION

Trial registration for parent TASSH study: NCT01802372 . Registered February 27, 2013.

Process evaluation of a preschool physical activity intervention using web-based delivery

BACKGROUND AND PURPOSE

Preschool/childcare settings offer a practical target for physical activity interventions. Online learning programs have the potential for greater public health reach and impact. The SHAPES-Dissemination (SHAPES-D) project adapted the original SHAPES in-person intervention for online delivery to teachers. The purpose of this paper is to describe the implementation monitoring and process evaluation for the SHAPES-D project.

METHODS

Nine preschools with 26 classrooms participated. A total of 41 teachers were trained via online learning to implement the SHAPES-D program in their classrooms. The dose received, completeness, and fidelity of implementation were assessed through website metrics, teacher surveys and interviews, and classroom observations.

RESULTS

Dose received was adequate (73%). Observed completeness and physical activity enjoyment fidelity were high (100%), although moderate-to-vigorous physical activity fidelity and social environment fidelity were low (25% each). Overall implementation was high (91%).

DISCUSSION

Results indicate that the online method of delivery is viable for dissemination. The online delivery system provides an easy method of monitoring dose received. This may be the first structural intervention to monitor dose received through web metrics.

CONCLUSION

The adaptation of an in-person intervention to an online delivery system increases the potential for dissemination of a successful program to increase physical activity in preschool settings.

How Effective are Mindfulness-Based Interventions for Reducing Stress Among Healthcare Professionals? A Systematic Review and Meta-Analysis

Workplace stress is high among healthcare professionals (HCPs) and is associated with reduced psychological health, quality of care and patient satisfaction. This systematic review and meta-analysis reviews evidence on the effectiveness of mindfulness-based interventions (MBIs) for reducing stress in HCPs. A systematic literature search was conducted. Papers were screened for suitability using inclusion criteria and nine papers were subjected to review and quality assessment. Seven papers, for which full statistical findings could be obtained, were also subjected to meta-analysis. Results of the meta-analysis suggest that MBIs have the potential to significantly improve stress among HCPs; however, there was evidence of a file drawer problem. The quality of the studies was high in relation to the clarity of aims, data collection and analysis, but weaker in terms of sample size and the use of theoretical frameworks. MBIs have the potential to reduce stress among HCPs; however, more high-quality research is needed before this finding can be confirmed. Future studies would benefit from long-term follow-up measures to determine any continuing effects of mindfulness training on stress outcomes. Copyright © 2016 John Wiley & Sons, Ltd.

Educational intervention to improve effectiveness in treatment and control of patients with high cardiovascular risk in low-resource settings in Argentina: study protocol of a cluster randomised controlled trial

INTRODUCTION

Hypercholesterolaemia is estimated to cause 2.6 million deaths annually and one-third of the cases of ischaemic heart disease. In Argentina, the prevalence of hypercholesterolaemia increased between 2005 and 2013 from 27.9% to 29.8%. Only one out of four subjects with a self-reported diagnosis of coronary heart disease is taking statins. Since 2014, statins (simvastatin 20 mg) are part of the package of drugs provided free-of-charge for patients according to cardiovascular disease (CVD) risk stratification. The goal of this study is to test whether a complex intervention targeting physicians and pharmacist assistants improves treatment and control of hypercholesterolaemia among patients with moderate-to-high cardiovascular risk in Argentina.

METHODS AND ANALYSIS

This is a cluster trial of 350 patients from 10 public primary care centres in Argentina to be randomised to either the intervention or usual care. The study is designed to have 90% statistical power to detect a 0.7 mmol/L reduction in low-density lipoproteins cholesterol from baseline to 12 months. The physician education programme consists of a 2-day initial intensive training and certification workshop followed by educational outreach visits (EOVs) conducted at 3, 6 and 9 months from the outset of the study. An on-site training to pharmacist assistants during the first EOV is performed at each intervention clinic. In addition, two intervention support tools are used: an app installed in physician's smartphones to serve as a decision aid to improve prescription of statins according to patient's CVD risk and a web-based platform tailored to send individualised SMS messages to patients.

ETHICS AND DISSEMINATION

Ethical approval was obtained from an independent ethics committee. Results of this study will be presented to the Ministry of Health of Argentina for potential dissemination and scale-up of the intervention programme to the entire national public primary care network in Argentina.

TRIAL REGISTRATION NUMBER

NCT02380911.

The Role of Participant Responsiveness on a Socio-Emotional Learning Program

The present study set out to evaluate participant responsiveness, one of the main dimensions of implementation quality, in a Socio-Emotional Learning after-school program using Educational Dance activities, Experiencing Emotions, and also to understand its influence on program outcomes. The sample involved 98 middle-school Portuguese pupils, 53 of whom participated in the program and 45 in after-school control sessions. Outcome measures included pre-test and post-test questionnaires of pupils' socio-emotional skills, well-being and school engagement. A self-report item measured pupils' satisfaction at the end of the program, and a checklist measuring attendance and homework completion was filled in by the facilitator at each session of the program and control condition. Results revealed (1) high levels of pupils' satisfaction and attendance, and a medium-high level of homework completion towards the program; (2) that pupils' higher attendance rate in the program predicted higher results in the self-management (p = .04, d = .57; p = .003, d = .87) and social awareness (p = .04, d = .59) SEL domains, emotional (p = .02, d = .67) and psychological (p = .009, d = .76) well-being and school engagement (p = .04, d = .56); (3) that pupils' higher rate of homework completion in the program predicted higher results in the relationship skills SEL area (p = .04, d = .59) and in school engagement (p = .005, d = 1.50); (4) that pupils' from the control condition higher rates of homework completion also predicted better school engagement (p = .006, d = .88). Implications for research and practice are discussed.

The "Critical" Elements of Illness Management and Recovery: Comparing Methodological Approaches

This study examined three methodological approaches to defining the critical elements of Illness Management and Recovery (IMR), a curriculum-based approach to recovery. Sixty-seven IMR experts rated the criticality of 16 IMR elements on three dimensions: defining, essential, and impactful. Three elements (Recovery Orientation, Goal Setting and Follow-up, and IMR Curriculum) met all criteria for essential and defining and all but the most stringent criteria for impactful. Practitioners should consider competence in these areas as preeminent. The remaining 13 elements met varying criteria for essential and impactful. Findings suggest that criticality is a multifaceted construct, necessitating judgments about model elements across different criticality dimensions.

Implementation of a consumer-focused eHealth intervention for people with moderate-to-high cardiovascular disease risk: protocol for a mixed-methods process evaluation

INTRODUCTION

Technology-mediated strategies have potential to engage patients in modifying unhealthy behaviour and improving medication adherence to reduce morbidity and mortality from cardiovascular disease (CVD). Furthermore, electronic tools offer a medium by which consumers can more actively navigate personal healthcare information. Understanding how, why and among whom such strategies have an effect can help determine the requirements for implementing them at a scale. This paper aims to detail a process evaluation that will (1) assess implementation fidelity of a multicomponent eHealth intervention; (2) determine its effective features; (3) explore contextual factors influencing and maintaining user engagement; and (4) describe barriers, facilitators, preferences and acceptability of such interventions.

METHODS AND ANALYSIS

Mixed-methods sequential design to derive, examine, triangulate and report data from multiple sources. Quantitative data from 3 sources will help to inform both sampling and content framework for the qualitative data collection: (1) surveys of patients and general practitioners (GPs); (2) software analytics; (3) programme delivery records. Qualitative data from interviews with patients and GPs, focus groups with patients and field notes taken by intervention delivery staff will be thematically analysed. Concurrent interview data collection and analysis will enable a thematic framework to evolve inductively and inform theory building, consistent with a realistic evaluation perspective. Eligible patients are those at moderate-to-high CVD risk who were randomised to the intervention arm of a randomised controlled trial of an eHealth intervention and are contactable at completion of the follow-up period; eligible GPs are the primary healthcare providers of these patients.

ETHICS AND DISSEMINATION

Ethics approval has been received from the University of Sydney Human Research Ethics Committee and the Aboriginal Health and Medical Research Council (AH&MRC) of New South Wales. Results will be disseminated via scientific forums including peer-reviewed publications and national and international conferences.

TRIAL REGISTRATION NUMBER

ANZCTR 12613000715774.

Implementation of the Community Health Assistant (CHA) Cadre in Zambia: A Process Evaluation to Guide Future Scale-Up Decisions

Universal health coverage requires an adequate health workforce, including community health workers (CHWs) to reach rural communities. To improve healthcare access in rural areas, in 2010 the Government of Zambia implemented a national CHW strategy that introduced a new cadre of healthcare workers called community health assistants (CHAs). After 1 year of training the pilot class of 307 CHAs deployed in September 2012. This paper presents findings from a process evaluation of the barriers and facilitators of implementation of the CHA pilot, along with how evidence was used to guide ongoing implementation and scale-up decisions. Qualitative inquiry was used to assess implementation during the first 6 months of the program rollout, with 43 in-depth individual and 32 small group interviews across five respondent types: CHAs, supervisors, volunteer CHWs, community members, and district leadership. Potential 'implementation moderators' were explored using deductive coding and thematic analysis of participant perspectives on community acceptance of CHAs, supervision support mechanisms, and coordination with volunteer CHWs, and health system integration of a new cadre. Community acceptance of CHAs was generally high, but coordination between CHAs and existing volunteer CHWs presented some challenges. The supervision support system was found to be inconsistent, limiting assurance of consistent quality care delivered by CHAs. Underlying health system weaknesses regarding drug supply and salary payments furthermore hindered incorporation of a new cadre within the national health system. Recommendations for implementation and future scale based on the process evaluation findings are discussed.

Preventing Patient-to-Worker Violence in Hospitals: Outcome of a Randomized Controlled Intervention

OBJECTIVE

To evaluate the effects of a randomized controlled intervention on the incidence of patient-to-worker (Type II) violence and related injury in hospitals.

METHODS

Forty-one units across seven hospitals were randomized into intervention (n = 21) and control (n = 20) groups. Intervention units received unit-level violence data to facilitate development of an action plan for violence prevention; no data were presented to control units. Main outcomes were rates of violent events and injuries across study groups over time.

RESULTS

Six months post-intervention, incident rate ratios of violent events were significantly lower on intervention units compared with controls (incident rate ratio [IRR] 0.48, 95% confidence interval [CI] 0.29 to 0.80). At 24 months, the risk for violence-related injury was lower on intervention units, compared with controls (IRR 0.37, 95% CI 0.17 to 0.83).

CONCLUSIONS

This data-driven, worksite-based intervention was effective in decreasing risks of patient-to-worker violence and related injury.

Fidelity of Implementation: An Overlooked Yet Critical Construct to Establish Effectiveness of Evidence-Based Instructional Practices

The discipline-based education research (DBER) community has been invested in the research and development of evidence-based instructional practices (EBIPs) for decades. Unfortunately, investigations of the impact of EBIPs on student outcomes typically do not characterize instructors' adherence to an EBIP, often assuming that implementation was as intended by developers. The validity of such findings is compromised, since positive or negative outcomes can be incorrectly attributed to an EBIP when other factors impacting implementation are often present. This methodological flaw can be overcome by developing measures to determine the fidelity of implementation (FOI) of an intervention, a construct extensively studied in other fields, such as healthcare. Unfortunately, few frameworks to measure FOI in educational settings exist, which likely contributes to a lack of FOI constructs in most impact studies of EBIPs in DBER. In this Essay, we leverage the FOI literature presented in other fields to propose an appropriate framework for FOI within the context of DBER. We describe how this framework enhances the validity of EBIP impact studies and provide methodological guidelines for how it should be integrated in such studies. Finally, we demonstrate the application of our framework to peer instruction, a commonly researched EBIP within the DBER community.

Building Sustainable Professional Development Programs: Applying Strategies From Implementation Science to Translate Evidence Into Practice

INTRODUCTION

Multisite and national professional development (PD) programs for educators are challenging to establish. Use of implementation science (IS) frameworks designed to convert evidence-based intervention methods into effective health care practice may help PD developers translate proven educational methods and models into successful, well-run programs. Implementation of the national Educational Scholars Program (ESP) is used to illustrate the value of the IS model.

METHODS

Four adaptable elements of IS are described: (1) replication of an evidence-based model, (2) systematic stages of implementation, (3) management of implementation using three implementation drivers, and (4) demonstration of program success through measures of fidelity to proven models and sustainability.

RESULTS

Implementation of the ESP was grounded on five established principles and methods for successful PD. The process was conducted in four IS stages over 10 years: Exploration, Installation, Initial Implementation, and Full Implementation. To ensure effective and efficient processes, attention to IS implementation drivers helped to manage organizational relationships, build competence in faculty and scholars, and address leadership challenges. We describe the ESP's fidelity to evidence-based structures and methods, and offer three examples of sustainability efforts that enabled achievement of targeted program outcomes, including academic productivity, strong networking, and career advancement of scholars.

DISCUSSION

Application of IS frameworks to program implementation may help other PD programs to translate evidence-based methods into interventions with enhanced impact. A PD program can follow systematic developmental stages and be operationalized by practical implementation drivers, thereby creating successful and sustainable interventions that promote the academic vitality of health professions educators.

Testing an Integrated Model of Program Implementation: the Food, Health & Choices School-Based Childhood Obesity Prevention Intervention Process Evaluation

Childhood obesity is a complex, worldwide problem. Significant resources are invested in its prevention, and high-quality evaluations of these efforts are important. Conducting trials in school settings is complicated, making process evaluations useful for explaining results. Intervention fidelity has been demonstrated to influence outcomes, but others have suggested that other aspects of implementation, including participant responsiveness, should be examined more systematically. During Food, Health & Choices (FHC), a school-based childhood obesity prevention trial designed to test a curriculum and wellness policy taught by trained FHC instructors to fifth grade students in 20 schools during 2012-2013, we assessed relationships among facilitator behaviors (i.e., fidelity and teacher interest); participant behaviors (i.e., student satisfaction and recall); and program outcomes (i.e., energy balance-related behaviors) using hierarchical linear models, controlling for student, class, and school characteristics. We found positive relationships between student satisfaction and recall and program outcomes, but not fidelity and program outcomes. We also found relationships between teacher interest and fidelity when teachers participated in implementation. Finally, we found a significant interaction between fidelity and satisfaction on behavioral outcomes. These findings suggest that individual students in the same class responded differently to the same intervention. They also suggest the importance of teacher buy-in for successful intervention implementation. Future studies should examine how facilitator and participant behaviors together are related to both outcomes and implementation. Assessing multiple aspects of implementation using models that account for contextual influences on behavioral outcomes is an important step forward for prevention intervention process evaluations.

Assessing the fidelity of delivery of an intervention to increase attendance at the English Stop Smoking Services

BACKGROUND

Implementation fidelity refers to the extent to which a proposed intervention is enacted as designed and is necessary to determine how much the intervention in question is the primary mechanism in any changes observed. Start2quit was a randomised controlled trial that aimed to improve attendance at the English Stop Smoking Service (SSS). The complex intervention combining computer-tailored personal risk letters and no-commitment ("taster") sessions aimed at encouraging attendance at the SSS doubled attendance at the SSS and significantly increased abstinence rates, although attendance and abstinence varied between participating SSSs. Assessment of the fidelity of the delivery of the taster sessions to the protocol was embedded into the trial and is the focus of this study.

METHODS

Eighteen SSSs participated in the study. Taster sessions were delivered by SSS advisors in the area. Of the 131 sessions delivered, 93 (71 %) were recorded and 41 (31.3 %) were selected for transcription and analysis. The taster session protocol contained 73 specified behaviours, which were independently classified into component behaviour change techniques (BCTs) using an established taxonomy for smoking cessation. All transcripts were coded by two authors with 25 % additionally coded by a third. The fidelity of each taster session was expressed as the percentage of overall protocol-specified behaviours that were delivered. Adherence to each BCT was measured as the number of behaviours applied by the advisors within each BCT divided by the total number classified within each.

RESULTS

Adherence of protocol-specified behaviours was relatively high (median 71.23 %), though there was considerable variation (28.76 to 95.89 %) in individual sessions. Median fidelity to specific BCTs across sessions also varied from 50 to 100 %. Shorter sessions, sessions run jointly by two advisors, by female advisors, or by advisors aged 45 to 54 were associated with higher levels of adherence. There was no association between adherence and subsequent attendance at the SSS.

CONCLUSIONS

These results suggest that the delivery of the intervention of this study is not likely to have been impacted by issues of fidelity. As such, we can have greater confidence that variability in the main outcome is not due to variability in SSS advisor adherence to the protocol of the taster sessions.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN76561916.

Assessing Variability and Implementation Fidelity of Suicide Prevention Safety Planning in a Regional VA Healthcare System

BACKGROUND

In 2008, the Veterans Health Administration (VHA) implemented the use of safety planning for suicide prevention. A safety plan is a list of strategies, developed collaboratively with a provider, for a patient to use when suicide risk is elevated. Despite the use of safety plans in VHA, little is known about implementation fidelity, the extent to which safety plans are delivered as intended, or patient-level outcomes of safety planning.

AIMS

This study aimed to explore the implementation fidelity of safety planning in a regional VHA hospital and examine the associations between safety plan quality and completeness with patient outcomes.

METHOD

A comprehensive chart review was conducted for patients who were flagged as high risk for suicide (N = 200). Completeness and quality were coded, as well as information about patient and provider interactions regarding safety plan use.

RESULTS

Safety plans were mostly complete and of moderate quality, although variability existed, particularly in quality. Limited evidence of follow-up regarding safety planning was found in the medical charts. Higher quality was associated with fewer subsequent psychiatric hospitalizations.

CONCLUSION

Variability in implementation fidelity and infrequent follow-up suggest a need for additional training and support regarding the use of safety plans for suicide prevention.

Trauma Center Based Youth Violence Prevention Programs: An Integrative Review

OBJECTIVE

Youth violence recidivism remains a significant public health crisis in the United States. Violence prevention is a requirement of all trauma centers, yet little is known about the effectiveness of these programs. Therefore, this systematic review summarizes the effectiveness of trauma center-based youth violence prevention programs.

METHODS

A systematic review of articles from MEDLINE, CINAHL, and PsychINFO databases was performed to identify eligible control trials or observational studies. Included studies were from 1970 to 2013, describing and evaluating an intervention, were trauma center based, and targeted youth injured by violence (tertiary prevention). The social ecological model provided the guiding framework, and findings are summarized qualitatively.

RESULTS

Ten studies met eligibility requirements. Case management and brief intervention were the primary strategies, and 90% of the studies showed some improvement in one or more outcome measures. These results held across both social ecological level and setting: both emergency department and inpatient unit settings.

CONCLUSIONS

Brief intervention and case management are frequent and potentially effective trauma center-based violence prevention interventions. Case management initiated as an inpatient and continued beyond discharge was the most frequently used intervention and was associated with reduced rearrest or reinjury rates. Further research is needed, specifically longitudinal studies using experimental designs with high program fidelity incorporating uniform direct outcome measures. However, this review provides initial evidence that trauma centers can intervene with the highest of risk patients and break the youth violence recidivism cycle.

Critical stakeholder determinants to the implementation of intersectoral community approaches targeting childhood obesity

Several intersectoral community approaches targeting childhood obesity (IACOs) have been launched in the Netherlands. Translation of these approaches into practice is however arduous and implementation. We therefore studied the implementation of five IACOs in the Netherlands for one-and-a-half years. IACO implementation was evaluated via an adapted version of the MIDI questionnaire, consisting of 18 theory-based constructs. A response rate of 62% was obtained. A hierarchical multivariate linear regression model was used to analyse our data; the final regression model predicted 65% of the variance in adherence. Higher levels of self-efficacy, being an implementer embedded in community B, and having more than 1 year of experience with IACO implementation were associated with higher degrees of adherence. Formal ratification of implementation by management and being prescribed a higher number of activities were related to lower degrees of adherence. We advise that, when designing implementation strategies, emphasis should be placed on the enhancement of professionals' self-efficacy, limitation of the number of activities prescribed and allocation of sufficient time to get acquainted and experienced with IACO implementation. Longitudinal studies are needed to further evaluate interaction between and change within critical determinants while progressing through the innovation process.

A review of electronic medical record keeping on mobile medical service trips in austere settings

INTRODUCTION

Electronic medical records (EMRs) may address the need for decision and language support for Western clinicians on mobile medical service trips (MSTs) in low resource settings abroad, while providing improved access to records and data management. However, there has yet to be a review of this emerging technology used by MSTs in low-resource settings. The aim of this study is to describe EMR systems designed specifically for use by mobile MSTs in remote settings, and accordingly, determine new opportunities for this technology to improve quality of healthcare provided by MSTs.

METHODS

A MEDLINE, EMBASE, and Scopus/IEEE search and supplementary Google search were performed for EMR systems specific to mobile MSTs. Information was extracted regarding EMR name, organization, scope of use, platform, open source coding, commercial availability, data integration, and capacity for linguistic and decision support. Missing information was requested by email.

RESULTS

After screening of 122 abstracts, two articles remained that discussed deployment of EMR systems in MST settings (iChart, SmartList To Go), and thirteen additional EMR systems were found through the Google search. Of these, three systems (Project Buendia, TEBOW, and University of Central Florida's internally developed EMR) are based on modified versions of Open MRS software, while three are smartphone apps (QuickChart EMR, iChart, NotesFirst). Most of the systems use a local network to manage data, while the remaining systems use opportunistic cloud synchronization. Three (TimmyCare, Basil, and Backpack EMR) contain multilingual user interfaces, and only one (QuickChart EMR) contained MST-specific clinical decision support.

DISCUSSION

There have been limited attempts to tailor EMRs to mobile MSTs. Only Open MRS has a broad user base, and other EMR systems should consider interoperability and data sharing with larger systems as a priority. Several systems include tablet compatibility, or are specifically designed for smartphone, which may be helpful given the environment and low resource context. Results from this review may be useful to non-government organizations (NGOs) considering modernization of their medical records practices as EMR use facilitates research, decreases paper administration costs, and improves perceptions of professionalism; however, most MST-specific EMRs remain in their early stages, and further development and research is required before reaching the stage of widespread adoption.

Using Compassion Focused Therapy as an adjunct to Trauma-Focused CBT for Fire Service personnel suffering with trauma-related symptoms

Individuals working for the emergency services often bear witness to distressing events. This outcome study examines therapeutic interventions for Fire Service personnel (FSP) experiencing symptoms of trauma, depression, anxiety and low levels of self-compassion. This study aims to investigate the effectiveness of using Compassion-Focused Therapy (CFT) as an adjunct to Trauma-Focused Cognitive Behavioural Therapy (TF-CBT) in reducing symptoms of trauma, anxiety and depression and increasing self-compassion. A convenience sample (n= 17) of participants, referred for therapy following a traumatic incident, were allocated to receive 12 sessions of either TF-CBT or TF-CBT coupled with CFT. The study employed a repeated-measures design. Data were gathered pre- and post-therapy, using three questionnaires: (1) Hospital Anxiety and Depression Scale; (2) Impact of Events Scale-R; (3) Self-Compassion Scale – Short Form. TF-CBT combined with CFT was more effective than TF-CBT alone on measures of self-compassion. Significant reductions in symptoms of depression, anxiety, hyperarousal, intrusion and avoidance and a significant increase in self-compassion occurred in both groups post-therapy. The study provides some preliminary evidence to suggest that FSP may benefit from therapeutic interventions aimed at cultivating self-compassion. Further research is warranted using a larger sample size and adequately powered randomized controlled trial, to detect statistically significant differences and to negate the risk of confound due to low numbers resulting in significant differences between groups at baseline. Using CFT as an adjunct to TF-CBT may help FSP, who bear witness to the distress of others, cultivate compassion for their own suffering.

Integrating Maternal and Children's Oral Health Promotion into Nursing and Midwifery Practice- A Systematic Review

BACKGROUND

Globally, oral diseases contribute to major disease problems and oral health disparities persistently exist amongst vulnerable population groups. Two contributory factors to these challenges are the shortage of dental practitioners and the characteristic separation between the medical and dental professions. Nurses and midwives, in particular, are in a potentially excellent position to assist in basic oral health services such as dental health education and intraoral screening. We aimed to assess the effectiveness of integrating promotion of oral health of young children and their mothers into nursing and midwifery practice.

METHODS AND FINDINGS

Seven electronic databases including CENTRAL, EMBASE, MEDLINE, GLOBAL HEALTH, CINHAL, Scopus, and Web of Science were systematically searched whereas conference proceedings and theses were retrieved via PROQUEST. Only randomized, non-randomized trials and observational studies on preventive oral health programs delivered by nurses or midwives in healthcare settings or through home visits were included. Two investigators reviewed full-text articles independently to decide on eligibility for inclusion. Quality assessment was done using Cochrane tool for risk of bias for randomized trials and Downs and Black assessment tool for all other studies. Out of 3162 retrieved records, twenty one trials on oral health interventions incorporated into standard nursing practice were reviewed. Eighteen programs reported significant positive outcomes including reduction in caries experience, better oral hygiene and dietary habits and increased rates of dental visits amongst young children as reported by their caregivers.

CONCLUSIONS

Incorporating oral health promotion into nursing practice is a promising initiative for reducing oral health disparities by contributing to a downward trend in caries experience and increased access to dental care especially amongst the poor disadvantaged communities.

Improving Fidelity of Translation of the Stepping On Falls Prevention Program through Root Cause Analysis

BACKGROUND

Fidelity monitoring is essential with implementation of complex health interventions, but there is little description of how to use results of fidelity monitoring to improve the draft program package prior to widespread dissemination. Root cause analysis (RCA) provides a systematic approach to identifying underlying causes and devising solutions to prevent errors in complex processes. Its use has not been described in implementation science.

METHODS

Stepping On (SO) is a small group, community-based intervention that has been shown to reduce falls by 31%. To prepare SO for widespread U.S. dissemination, we conducted a pilot of the draft program package, monitoring the seven SO sessions for fidelity of program delivery and assessing participant receipt and enactment through participant interviews after the workshop. Lapses to fidelity in program delivery, receipt, and enactment were identified. We performed a RCA to identify underlying causes of, and solutions to, such lapses, with the goal of preventing fidelity lapses with widespread dissemination.

RESULTS

Lapses to fidelity in program delivery were in the domains of group leader's role, use of adult learning principles, and introducing and upgrading the exercises. Lapses in fidelity of participant receipt and enactment included lack of knowledge about balance exercises and reduced adherence to frequency of exercise practice and advancement of exercise. Root causes related to leader training and background, site characteristics and capacity, and participant frailty and expectations prior to starting the program. The RCA resulted in changes to the program manual, the training program, and training manual for new leaders, and to the methods for and criteria for participant and leader recruitment. A Site Implementation Guide was created to provide information to sites interested in the program.

CONCLUSION

Disseminating complex interventions can be done more smoothly by first using a systematic quality improvement technique, such as the RCA, to identify how lapses in fidelity occur during the earliest stages of implementation. This technique can also help bring about solutions to these lapses of fidelity prior to widespread dissemination across multiple domain lapses.

Process evaluations in neurological rehabilitation: a mixed-evidence systematic review and recommendations for future research

OBJECTIVE

To systematically review how process evaluations are currently designed, what methodologies are used and how are they developed alongside or within neurological rehabilitation trials.

METHODS

This mixed-methods systematic review had two evidence streams: stream I, studies reporting process evaluations alongside neurorehabilitation trials research and stream II, methodological guidance on process evaluation design and methodology. A search strategy was designed for each evidence stream. Data regarding process evaluation core concepts and design issues were extracted using a bespoke template. Evidence from both streams was analysed separately and then synthesised in a final overarching synthesis proposing a number of recommendations for future research.

RESULTS

A total of 124 process evaluation studies, reporting on 106 interventions, were included in stream I evidence. 30 studies were included as stream II evidence. Synthesis 1 produced 9 themes, and synthesis 2 identified a total of 8 recommendations for process evaluation research. The overall synthesis resulted in 57 'synthesis recommendations' about process evaluation methodology grouped into 9 research areas, including the use of theory, the investigation of context, intervention staff characteristics and the delivery of the trial intervention.

CONCLUSIONS

There remains no consensus regarding process evaluation terminology within the neurological rehabilitation field. There is a need for process evaluations to address the nature and influence of context over time. Process evaluations should clearly describe what intervention staff bring to a trial, including skills and experience prior to joining the research. Process evaluations should monitor intervention staff's learning effects and the possible impact that these may have on trial outcomes.

Assessment of the implementation fidelity of the Arctic Char Distribution Project in Nunavik, Quebec

BACKGROUND

In September 2011, the Nunavik Regional Board of Health and Social Services began supporting the Arctic Char Distribution Project (AC/DP) for pregnant women. This initiative promoted consumption of the fish Arctic char-a traditional Inuit food-by pregnant women living in villages of Nunavik, an area in northern Quebec (Canada) inhabited predominantly by people of Inuit ethnicity. This intervention was intended to reduce exposure to contaminants and improve food security in Inuit communities.

METHODS

We assessed the project's implementation based on data collected from background documentation, field notes and qualitative interviews with project recipients and implementers. Themes emerging from the data are critically discussed in the light of the framework for implementation fidelity developed by Carroll et al in 2007.

RESULTS

Pregnant women fully embraced the initiative because of its cultural appropriateness. However, project implementation was incomplete: first because it did not cover all intended geographic areas, and second because of a recurring inconsistency in the supply and distribution of the fish. In addition, the initiative has been inconsistently funded and relies on multiple funding sources.

DISCUSSION

This work highlights the extent to which project complexity can impede successful implementation, particularly in terms of communication and coordination. We provide recommendations for improving project implementation and suggest amendments to the implementation fidelity framework.

Comparison of registered and published intervention fidelity assessment in cluster randomised trials of public health interventions in low- and middle-income countries: systematic review protocol

BACKGROUND

Cluster randomised trials (CRTs) are a key instrument to evaluate public health interventions, particularly in low- and middle-income countries (LMICs). Fidelity assessment examines study processes to gauge whether an intervention was delivered as initially planned. Evaluation of implementation fidelity (IF) is required to establish whether the measured effects of a trial are due to the intervention itself and may be particularly important for CRTs of complex interventions. Current CRT reporting guidelines offer no guidance on IF assessment. We will systematically review the scientific literature to study current practices concerning the assessment of IF in CRTs of public health interventions in LMICs.

METHODS

We will include CRTs of public health interventions in LMICs that planned or assessed IF in either the trial protocol or the main trial report (or an associated document). Search strategies use Medical Subject Headings (MESH) and text words related to CRTs, developing countries, and public health interventions. The electronic database search was developed first for MEDLINE and adapted for the following databases: EMBASE, CINAHL, PubMed, and EMB Reviews, to identify CRT reports in English, Spanish, or French published on or after January 1, 2012. To ensure availability of a study protocol, we will include CRTs reporting a registration number in the abstract. For each included study, we will compare planned versus reported assessment of IF, and consider the dimensions of IF studied, and data collection methods used to evaluate each dimension. Data will be synthesised using quantitative and narrative techniques. Risk of bias for individual studies will be assessed using the Cochrane Collaboration Risk of Bias Tool criteria and additional criteria related to CRT methods. We will investigate possible sources of heterogeneity by performing subgroup analysis. This review was not eligible for inclusion in the PROSPERO registry.

DISCUSSION

Fidelity assessment may be a key tool for making studies more reliable, internally valid, and externally generalizable. This review will provide a portrait of current practices related to the assessment of intervention fidelity in CRTs and offer suggestions for improvement. Results will be relevant to researchers, those who finance health interventions, and for decision-makers who seek the best evidence on public health interventions.

Protocol for a cluster randomised controlled trial of an intervention to improve the mental health support and training available to secondary school teachers - the WISE (Wellbeing in Secondary Education) study

BACKGROUND

Teachers are reported to be at increased risk of common mental health disorders compared to other occupations. Failure to support teachers adequately may lead to serious long-term mental disorders, poor performance at work (presenteeism), sickness absence and health-related exit from the profession. It also jeopardises student mental health, as distressed staff struggle to develop supportive relationships with students, and such relationships are protective against student depression. A number of school-based trials have attempted to improve student mental health, but these have mostly focused on classroom based approaches and have failed to establish effectiveness. Only a few studies have introduced training for teachers in supporting students, and none to date have included a focus on improving teacher mental health. This paper sets out the protocol (version 4.4 20/07/16) for a study aiming to address this gap.

METHODS

Cluster randomised controlled trial with secondary schools as the unit of randomisation. Intervention schools will receive: i) Mental Health First Aid (MHFA) training for a group of staff nominated by their colleagues, after which they will set up a confidential peer support service for colleagues ii) training in MHFA for schools and colleges for a further group of teachers, which will equip them to more effectively support student mental health iii) a short mental health awareness raising session and promotion of the peer support service for all teachers. Comparison schools will continue with usual practice. The primary outcome is teacher wellbeing measured using the Warwick Edinburgh Mental Wellbeing Scale (WEMWBS). Secondary outcomes are teacher depression, absence and presenteeism, and student wellbeing, mental health difficulties, attendance and attainment. Measures will be taken at baseline, one year follow up (teachers only) and two year follow up. Economic and process evaluations will be embedded within the study.

DISCUSSION

This study will establish the effectiveness and cost-effectiveness of an intervention that supports secondary school teachers' wellbeing and mental health, and improves their skills in supporting students. It will also provide information regarding intervention implementation and sustainability.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number: ISRCTN95909211 registered 24/03/16.

Measurement of adherence in a randomised controlled trial of a complex intervention: supported self-management for adults with learning disability and type 2 diabetes

Background

Reporting adherence to intervention delivery and uptake is a detailed way of describing what was actually delivered and received, in comparison to what was intended. Measuring and reporting adherence is not routinely done well in complex interventions. The OK Diabetes trial (ISRCTN41897033) aimed to develop and subsequently test the feasibility of implementing a supported self-management intervention in adults with a learning disability and type 2 diabetes. A key study objective was to develop a measure of adherence to the intervention.

Methods

We conducted a systematic review of published literature, extracting data from included papers using a standardised proforma. We undertook a narrative synthesis of papers to determine the form and content of methods for adherence measurement for self-management interventions in this population that had already been developed. We used the framework and data extraction form developed for the review as the basis for an adherence measurement tool that we applied in the OK Diabetes trial.

Results

The literature review found variability in the quality and content of adherence measurement and reporting, with no standardised approach. We were able to develop an adherence measure based upon the review, and populate it with data collected during the OK Diabetes trial. The adherence tool proved satisfactory for recording and measuring adherence in the trial.

Conclusion

There remains a need for a standardised approach to adherence measurement in the field of complex interventions. We have shown that it is possible to produce a simple, feasible measure for assessing adherence in the OK Diabetes trial.

Electronic supplementary material

The online version of this article (doi:10.1186/s12874-016-0236-x) contains supplementary material, which is available to authorized users.

Improving patient safety through the involvement of patients: development and evaluation of novel interventions to engage patients in preventing patient safety incidents and protecting them against unintended harm

Background

Estimates suggest that, in NHS hospitals, incidents causing harm to patients occur in 10% of admissions, with costs to the NHS of > £2B. About one-third of harmful events are believed to be preventable. Strategies to reduce patient safety incidents (PSIs) have mostly focused on changing systems of care and professional behaviour, with the role that patients can play in enhancing the safety of care being relatively unexplored. However, although the role and effectiveness of patient involvement in safety initiatives is unclear, previous work has identified a general willingness among patients to contribute to initiatives to improve health-care safety.

Aim

Our aim in this programme was to design, develop and evaluate four innovative approaches to engage patients in preventing PSIs: assessing risk, reporting incidents, direct engagement in preventing harm and education and training.

Methods and results

We developed tools to report PSIs [patient incident reporting tool (PIRT)] and provide feedback on factors that might contribute to PSIs in the future [Patient Measure of Safety (PMOS)]. These were combined into a single instrument and evaluated in the Patient Reporting and Action for a Safe Environment (PRASE) intervention using a randomised design. Although take-up of the intervention by, and retention of, participating hospital wards was 100% and patient participation was high at 86%, compliance with the intervention, particularly the implementation of action plans, was poor. We found no significant effect of the intervention on outcomes at 6 or 12 months. The ThinkSAFE project involved the development and evaluation of an intervention to support patients to directly engage with health-care staff to enhance their safety through strategies such as checking their care and speaking up to staff if they had any concerns. The piloting of ThinkSAFE showed that the approach is feasible and acceptable to users and may have the potential to improve patient safety. We also developed a patient safety training programme for junior doctors based on patients who had experienced PSIs recounting their own stories. This approach was compared with traditional methods of patient safety teaching in a randomised controlled trial. The study showed that delivering patient safety training based on patient narratives is feasible and had an effect on emotional engagement and learning about communication. However, there was no effect on changing general attitudes to safety compared with the control.

Conclusion

This research programme has developed a number of novel interventions to engage patients in preventing PSIs and protecting them against unintended harm. In our evaluations of these interventions we have been unable to demonstrate any improvement in patient safety although this conclusion comes with a number of caveats, mainly about the difficulty of measuring patient safety outcomes. Reflecting this difficulty, one of our recommendations for future research is to develop reliable and valid measures to help efficiently evaluate safety improvement interventions. The programme found patients to be willing to codesign, coproduce and participate in initiatives to prevent PSIs and the approaches used were feasible and acceptable. These factors together with recent calls to strengthen the patient voice in health care could suggest that the tools and interventions from this programme would benefit from further development and evaluation.

Trial registration

Current Controlled Trials ISRCTN07689702.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.