Optimization of Multicomponent Behavioral and Biobehavioral Interventions for the Prevention and Treatment of HIV/AIDS

A Proposed Framework to Aid Primary Care Clinicians in Promoting Cardiovascular Health

Healthy lifestyle behaviors play a significant role in promoting cardiovascular health. Primary care clinicians (PCCs) are tasked with promoting cardiovascular health through the assessment of lifestyle behaviors and the use of behavior change counseling. However, PCCs face several barriers including a lack of training in counseling techniques. We propose a framework to guide the development of a patient-centered digital communication bundle that can aid PCCs in helping their patients create and sustain feasible lifestyle changes. Our framework proposes that this digital communication bundle contains the following features: assess and analyze an individual's cardiovascular health status; communicate personalized information in a health-literacy-friendly, visual format; assess behavioral components of change (e.g., motivation) that can inform the PCC's approach in guiding behavior change; provide PCCs with brief, behavior change counseling prompts that are grounded in motivational interviewing; and assess and address potential structural, socioeconomic, and environmental barriers, thereby fostering resilience in patients' lifestyle change efforts. We highlight the available research to support the need for such a tool and its potential ability to guide PCCs while also promoting behavior change in a patient-centered manner.

Primary Care Uptake Interventions in Taxi, App-Based, and Other For-Hire Vehicle Drivers: The HAILL Cluster Randomized Controlled Trial

BACKGROUND

Taxi, app-based, and other for-hire vehicle drivers have major health risks and poor healthcare access.

OBJECTIVE

Compare workplace interventions to improve driver healthcare access.

DESIGN

Taxi Health Access Intervention for Linkages and Lifestyle (HAILL) was a three-arm cluster randomized controlled trial (2015-2022; analyses 2024) with outcomes assessed at 12 months. Randomization was at the cluster (taxi garage) level.

PARTICIPANTS

We approached 97 taxi garages in New York City (garages with ≥ 100 drivers and app-based driver hubs), 32 were excluded, and 65 enrolled. Drivers attending workplace Health Fairs at the garages were consecutively screened for participation; 735 enrolled.

INTERVENTIONS

All sites received the Health Fair intervention (health history, screenings [blood pressure, etc.], clinician consult, and 3 months of primary care access facilitation follow-up). Arm 1 received the Health Fair only. Arm 2 received the Health Fair and Navigator case management for up to 12 months. Arm 3 received the Health Fair and up to 12 months of appointment reminder text messages and peer support.

MAIN MEASURES

Medical Expenditure Panel Survey items measured primary care uptake (primary outcome). A Behavioral Risk Factor Surveillance Survey item measured insurance enrollment (secondary outcome). Two independent-sample t tests compared arm 1 versus 2 and arm 1 versus 3 primary care uptake proportions.

KEY RESULTS

Sixty-one garages participated (arm 1, n = 20; arm 2, n = 22; arm 3, n = 19). In the cluster intention-to-treat analyses, primary care uptake was 44% in arm 1 versus 57% in arm 2 (P = .264) and versus 43% in arm 3 (P = .994); health insurance enrollment was 63% in arm 1 versus 58% in arm 2 (P = .627) and versus 50% in arm 3 (P = .197).

CONCLUSIONS

All interventions increased healthcare access, with a positive trend in primary care uptake between arms 1 and 2. Health Fairs and Navigator case management should be considered by policy makers.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02508363 ( https://clinicaltrials.gov/study/NCT02508363 ).

Interventions for subjective and objective social isolation among people living with HIV: A scoping review

Subjective and objective social isolation has been a globally significant public health issue for people living with HIV, yet little is known about the characteristics, effectiveness, and acceptability of available interventions. The purpose of this scoping review was to systematically identify and map the available evidence on interventions for subjective and objective social isolation among people living with HIV. We searched PubMed, Cochrane Library, Embase, Scopus, Social Sciences Citation Index, PsycArticles, CINAHL, ProQuest Dissertation & Theses Global, OpenGrey, Google Scholar, international trial registers, and websites for eligible studies from their inception to June 1, 2024. We included any studies that identified subjective or objective social isolation as a primary goal or outcome of an intervention for people living with HIV (≥18 years old). Two researchers independently conducted study selection, data extraction, and data analysis. A 'basic qualitative content analysis' approach was used to analyze the findings of the included studies. Of the 12762 records identified, 19 full-text studies involving 961 participants were included in this scoping review. Overall, we identified seven interventions for subjective and objective social isolation among people living with HIV, as well as their characteristics, including psychological therapy, support group intervention, online support community, peer mentorship, navigation-type intervention, activity intervention, and knowledge/skills development intervention. However, there was limited, mixed evidence on the effectiveness and acceptability of different interventions for subjective and objective social isolation among people living with HIV. More rigorously designed and large-scale randomized control trials are needed to support and enrich existing evidence further.

Twenty years of intervention optimization

In the classical paradigm for intervention research, the components that are to make up an intervention are identified, pilot tested, and then immediately assembled into a treatment package and subjected to an evaluation randomized controlled trial (RCT) to assess the performance of the entire package. Intervention optimization, which adapts ideas from technological fields to intervention science in order to hasten scientific progress, is an alternative to the classical paradigm. The first article introducing intervention optimization via the multiphase optimization strategy (MOST) was published in Annals of Behavioral Medicine in 2005. In this commentary, I reflect on the evolution of intervention optimization from that first publication to today, and on what the future could hold if the intervention science field continues to adopt the optimization paradigm. I propose that if intervention optimization became standard operating procedure, the field would accumulate a coherent base of knowledge about what specific intervention strategies work, for whom, under which circumstances, and why; every intervention produced would contain only components that contribute enough to justify their resource requirements; interventions would be readily implementable; and as the knowledge base grew, interventions would be improved continually.

Application of enhanced recovery after surgery based on multiphase optimization strategy in the nursing management of children with snoring disease day surgery

AIMS AND OBJECTIVES

This study aimed to investigate the effectiveness of applying a multiphase optimization strategy (MOST) to enhance recovery after surgery (ERAS) protocols within the nursing management of children undergoing day surgery for snoring disease.

BACKGROUND

While MOST has been applied to behavioral intervention research in smoking cessation, AIDS management, and weight loss by international scholars, its application in constructing nursing intervention projects remains relatively unexplored.

DESIGN

Using convenience sampling, randomised controlled trial.

METHODS

A convenience sampling method was employed. The study recruited 200 preschool children diagnosed with snoring who underwent day surgery at a specific hospital between January 2023 and January 2024. The participants were divided into two groups: a control group receiving standard nursing care and an experimental group receiving MOST-guided, integrated high-quality nursing plans specifically designed for children with snoring undergoing day surgery, adhering to established ERAS guidelines.

RESULTS

Children in the experimental group exhibited significantly lower anxiety levels compared to the control group, both in the preoperative waiting area and upon returning to the ward (p < 0.01). While the quality of discharge teaching scale (QDTS) scores did not reveal a statistically significant difference between the groups (p > 0.01), the content of discharge instructions and the perceived effectiveness and skill of nurse guidance differed significantly between the control and experimental groups(p < 0.01). Notably, the experimental group experienced a demonstrably lower incidence of thirst, hunger, crying, aspiration, pain, and conversion of day ward to routine hospitalization mode compared to the control group (all p < 0.01). There was no significant difference in the incidence of postoperative nausea and vomiting between the groups after rehydration (p > 0.01).

CONCLUSIONS

The implementation of ERAS protocols enhanced by MOST within the nursing management of children with snoring undergoing day surgery demonstrates significant efficacy. This approach can effectively reduce preoperative anxiety in children, improve the quality of discharge guidance provided to parents, and demonstrably decrease the occurrence of postoperative thirst, hunger, crying, aspiration, pain, and the need for unplanned hospitalization transitions within 6 h after surgery.

RELEVANCE TO CLINICAL PRACTICE

It is necessary to provide fast rehabilitation nursing for children with snoring during daytime operation. Nurses should adopt the theory of fast rehabilitation based on multi-stage optimization strategy to promote children's fast rehabilitation after operation.

Psychosocial Syndemic Burden, Sexual Behaviors, and Engagement in HIV Prevention Care Among Sexual and Gender Minority Youths: United States, 2022

Objectives. To examine linear and nonlinear associations between psychosocial syndemic factors and HIV risk and engagement in HIV prevention care among sexual and gender minority (SGM) youths. Methods. Between February and October 2022, we recruited 17 578 SGM youths aged 13 to 18 years in the United States for an online survey. We examined the relationship of syndemics (i.e., binge drinking, drug use, sexual victimization, and anti-lesbian, gay, bisexual, and transgender discrimination) with sexual behaviors (i.e., sexual initiation, condomless anal or vaginal sex, and number of sexual partners) and HIV prevention care (i.e., HIV testing, preexposure prophylaxis awareness and utilization) using regression. Results. Psychosocial syndemic burden (number of syndemic factors reported) was linearly and cubically associated with engagement in sexual behaviors. Psychosocial syndemic burden was linearly associated with higher HIV testing and preexposure prophylaxis awareness and cubically associated with higher preexposure prophylaxis utilization. Conclusions. Our findings are evidence of synergism across psychosocial syndemic factors regarding HIV risk and engagement in HIV prevention care among SGM youths in the United States. Public Health Implications. Multicomponent interventions may help reduce HIV risk and promote access to HIV prevention services among SGM individuals aged 13 to 18 years. (Am J Public Health. 2024;114(9):892-902. https://doi.org/10.2105/AJPH.2024.307753).

Enhancing Mission Wellness: Iterative Optimization and Stakeholder Engagement to Promote Sexual and Reproductive Health in the United States Military

INTRODUCTION

Sexual and reproductive health is critical for the readiness of the warfighter, as costs of sexually transmitted infections and unintended pregnancy result in added health care costs, lost mission time, and impact on morale. The Multiphase Optimization Strategy (MOST) is an engineering-inspired framework used to optimize biobehavioral interventions. The Military Active-Duty Reproductive and Sexual Health (MARSH) research team applied the MOST framework to develop "Mission Wellness"-an electronic health intervention to promote sexual and reproductive health within the U.S. Military.

MATERIALS AND METHODS

From 2017 to 2022, the MARSH team implemented the first and second phases of MOST to develop and optimize "Mission Wellness." All phases received institutional review board approval. The first phase consisted of expert and literature review, qualitative interviews, and beta testing to identify intervention components and the optimization objective and to inform study design. The second phase consisted of a factorial trial.

RESULTS

Figures 1-4 outline the research program approach, demographics of the sample, and format of the app. Service members who used the application found it to be acceptable and, overall, reported that it would be easier to talk to a sexual partner about risk behaviors and history at the post-intervention assessment compared to baseline. This iterative optimization approach using both local and strategic engagement enhanced program development and set the stage for dissemination and implementation efforts.

CONCLUSIONS

In line with the iterative nature of MOST, the lessons learned during the optimization trial led the MARSH team to return "Mission Wellness" to the preparation phase. The utilization of mixed (i.e., qualitative and quantitative) research methods and engagement with stakeholders at multiple levels of the military enterprise provided the information necessary to further optimize "Mission Wellness." This programmatic approach also provides a blueprint for the development of research design and testing in military health care balancing rigor and agility.

Factorial Trial to Optimize an Internet-Delivered Intervention for Sexual Health After Breast Cancer: Protocol for the WF-2202 Sexual Health and Intimacy Enhancement (SHINE) Trial

BACKGROUND

Although most survivors of breast cancer report substantial sexual concerns following treatment, few receive support for these concerns. Delivering sexual health care to survivors of breast cancer via the internet could overcome many of the barriers to in-person treatment. Even when delivered remotely, survivor time constraints remain a leading barrier to sexual health intervention uptake.

OBJECTIVE

Guided by the multiphase optimization strategy methodological framework, the primary objective of this study is to identify the most efficient internet-delivered sexual health intervention package that is expected to provide survivors of breast cancer the greatest benefit with the fewest (and least-intensive) intervention components. This study aims to determine how intervention components work (mediators) and for whom they work best (moderators).

METHODS

Partnered, posttreatment adult female survivors of breast cancer (N=320) experiencing at least 1 bothersome sexual symptom (ie, pain with sex, vaginal dryness, low sexual desire, and difficulty with orgasm) related to their breast cancer treatment will be enrolled. Clinic-based recruitment will be conducted via the Wake Forest National Cancer Institute Community Oncology Research Program (NCORP) Research Base. Participants will be randomly assigned to 1 of 16 combinations of four intervention components with two levels each in this factorial trial: (1) psychoeducation about cancer-related sexual morbidity (receive either enhanced vs standard versions); (2) communication skills training for discussing concerns with health care providers (received vs not received); (3) communication skills training for discussing concerns with a partner (received vs not received); and (4) intimacy promotion skills training (received vs not received). Cores will be fully automated and implemented using a robust internet intervention platform with highly engaging elements such as animation, video, and automated email prompts. Survivors will complete web-based assessments at baseline (prerandomization time point) and again at 12 and 24 weeks later. The primary study aim will be achieved through a decision-making process based on systematically evaluating the main and interaction effects of components on sexual distress (Female Sexual Distress Scale-Desire, Arousal, Orgasm) and sexual functioning (Female Sexual Function Index) using a generalized linear model approach to ANOVA with effect coding. Mediation analyses will be conducted through a structural equation modeling approach, and moderation analyses will be conducted by extending the generalized linear model to include interaction effects.

RESULTS

This protocol has been reviewed and approved by the National Cancer Institute Central Institutional Review Board. Data collection is planned to begin in March 2024 and conclude in 2027.

CONCLUSIONS

By identifying the combination of the fewest and least-intensive intervention components likely to provide survivors of breast cancer the greatest sexual health benefit, this study will result in the first internet intervention that is optimized for maximum impact on the undertreated, prevalent, and distressing problem of breast cancer-related sexual morbidity.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06216574; https://clinicaltrials.gov/study/NCT06216574.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/57781.

Applying the multiphase optimization strategy to evaluate the feasibility and effectiveness of an online road safety education intervention for children and parents: a pilot study

BACKGROUND

Reports of children's engagement in active transportation outline low participation rates in many countries despite many associated mental, physical, and social health benefits. One of the main contributors to this phenomenon is a cited lack of education and knowledge among children regarding active travel (AT), specifically road safety. To address this issue, the aim of this study was to evaluate the feasibility and effectiveness of an online road safety education intervention to promote AT among children and their parents.

METHODS

Applying the Multiphase Optimization Strategy (MOST) for intervention development, implementation, and evaluation, we designed and assessed a four-module online road safety education intervention with a sample of 57 parent-child dyads using a 23 factorial design featuring both qualitative and quantitative analyses.

RESULTS

Main intervention feasibility findings include positive and critical feedback on the program's content and design, and moderate participant engagement as reflected by program retention and completion rates. With respect to the preliminary intervention effectiveness on children, a significant improvement in road safety knowledge scores was observed for groups that feature the "wheeling safety and skills" module. Slight improvements in AT knowledge scores across all the intervention groups were observed, but were not of significance. Preliminary intervention effectiveness on select parental AT practices and perceptions saw significant improvements in some groups. Groups that featured the 'wheeling safety and skills' module exhibited significantly higher guided choice scores upon completion of the program than those who did not receive this component.

CONCLUSION

The MOST framework allowed us to design and evaluate the feasibility and preliminary effectiveness of an online road safety education intervention. The developed intervention has demonstrated that it has the potential to improve children's road safety knowledge and some areas of parental AT practices and perceptions, to which improvements may be attributed to the inclusion of the "wheeling safety and skills" module, suggesting that the targeted focus on cycling skills is a prioritized area. AT programming and practice implications are discussed. Future research is encouraged to refine modules to better reflect the priorities of children and parents and to test these refined components among larger samples.

WORD COUNT

9,391 (excludes abstract, tables, figures, abbreviations, and references).

Optimizing Interventions for Equitability: Some Initial Ideas

Interventions (including behavioral, biobehavioral, biomedical, and social-structural interventions) hold tremendous potential not only to improve public health overall but also to reduce health disparities and promote health equity. In this study, we introduce one way in which interventions can be optimized for health equity in a principled fashion using the multiphase optimization strategy (MOST). Specifically, we define intervention equitability as the extent to which the health benefits provided by an intervention are distributed evenly versus concentrated among those who are already advantaged, and we suggest that, if intervention equitability is acknowledged to be a priority, then equitability should be a key criterion that is balanced with other criteria (effectiveness overall, as well as affordability, scalability, and/or efficiency) in intervention optimization. Using a hypothetical case study and simulated data, we show how MOST can be applied to achieve a strategic balance that incorporates equitability. We also show how the composition of an optimized intervention can differ when equitability is considered versus when it is not. We conclude with a vision for next steps to build on this initial foray into optimizing interventions for equitability.

Optimizing smartphone psychotherapy for depressive symptoms in patients with cancer: Multiphase optimization strategy using a decentralized multicenter randomized clinical trial (J-SUPPORT 2001 Study)

AIM

Patients with cancer experience various forms of psychological distress, including depressive symptoms, which can impact quality of life, elevate morbidity risk, and increase medical costs. Psychotherapy and pharmacotherapy are effective for reducing depressive symptoms among patients with cancer, but most patients prefer psychotherapy. This study aimed to develop an efficient and effective smartphone psychotherapy component to address depressive symptom.

METHODS

This was a decentralized, parallel-group, multicenter, open, individually randomized, fully factorial trial. Patients aged ≥20 years with cancer were randomized by the presence/absence of three cognitive-behavioral therapy (CBT) skills (behavioral activation [BA], assertiveness training [AT], and problem-solving [PS]) on a smartphone app. All participants received psychoeducation (PE). The primary outcome was change in the patient health questionnaire-9 (PHQ-9) total score between baseline and week 8. Secondary outcomes included anxiety.

RESULTS

In total, 359 participants were randomized. Primary outcome data at week 8 were obtained for 355 participants (99%). The week 8 PHQ-9 total score was significantly reduced from baseline for all participants by -1.41 points (95% confidence interval [CI] -1.89, -0.92), but between-group differences in change scores were not significant (BA: -0.04, 95% CI -0.75, 0.67; AT: -0.16, 95% CI -0.87, 0.55; PS: -0.19, 95% CI -0.90, 0.52).

CONCLUSION

As the presence of any of the three intervention components did not contribute to a significant additive reduction of depressive symptoms, we cannot make evidence-based recommendations regarding the use of specific smartphone psychotherapy.

Acceptability, Feasibility, and Preliminary Impact of 4 Remotely-Delivered Interventions for Rural Older Adults Living with HIV

People living with HIV (PLH) who live in rural areas of the United States (US) face more challenges to obtaining medical care and suffer higher mortality rates compared to non-rural PLH. Compared with younger PLH, older PLH (age 50+) also face additional challenges to maintaining their health and wellbeing. Despite the heightened barriers to receiving care and remaining adherent to treatment among older rural PLH, few interventions to increase viral suppression and improve quality of life exist for this population. We pilot-tested four remotely-delivered interventions-group-based social support, group-based stigma-reduction, individual strengths-based case management, and individual technology detailing-aimed to improve care engagement and quality of life in rural older PLH in the southern US. Participants (N = 61, Mage = 58, 75% male) completed surveys and self-collected blood specimens at baseline and 3 months; in between, they were randomized to 0-4 interventions. We assessed feasibility, acceptability, and preliminary impact on medication adherence, viral suppression, quality of life, depressive symptoms, and hypothesized mediating mechanisms. More than 80% participated in assigned intervention(s), and 84% completed the study. Interventions were highly acceptable to participants, with more than 80% reporting they would recommend interventions to peers. More than 80% found the social support and case management interventions to be relevant and enjoyable. We found promising preliminary impact of interventions on quality of life, medication adherence, depressive symptoms, internalized stigma, and loneliness. Remotely-delivered interventions targeting rural older PLH are feasible to conduct and acceptable to participants. Larger scale study of these interventions is warranted.

Optimization of mHealth behavioral interventions for patients with chronic lymphocytic leukemia: the HEALTH4CLL study

PURPOSE

This pilot study of a diet and physical activity intervention (HEALTH4CLL) was conducted to reduce fatigue and improve physical function (PF) in patients with chronic lymphocytic leukemia (CLL).

METHODS

The HEALTH4CLL study used a randomized factorial design based on the multiphase optimization strategy (MOST). Patients received diet, exercise, and body weight management instructional materials plus a Fitbit and were randomized to undergo one of 16 combinations of 4 evidence-based mHealth intervention strategies over 16 weeks. Patients' fatigue, PF, health-related quality of life, behavior changes, and program satisfaction and retention were assessed. Paired t-tests were used to examine changes in outcomes from baseline to follow-up among patients. Factorial analysis of variance examined effective intervention components and their combinations regarding improvement in fatigue and PF scores.

RESULTS

Among 31 patients, we observed significant improvements in fatigue (+ 11.8; t = 4.08, p = 0.001) and PF (+ 2.6; t = 2.75, p = 0.01) scores. The combination of resistance and aerobic exercise with daily self-monitoring was associated with improved fatigue scores (β = 3.857, SE = 1.617, p = 0.027). Analysis of the individual components of the MOST design demonstrated greater improvement in the PF score with resistance plus aerobic exercise than with aerobic exercise alone (β = 2.257, SE = 1.071, p = 0.048).

CONCLUSIONS

Combined aerobic and resistance exercise and daily self-monitoring improved PF and reduced fatigue in patients with CLL.

IMPLICATIONS FOR CANCER SURVIVORS

This pilot study supported the feasibility of a low-touch mHealth intervention for survivors of CLL and provided preliminary evidence that exercising, particularly resistance exercise, can improve their symptoms and quality of life.

Optimization of a mHealth Physical Activity Promotion Intervention With Mindful Awareness for Young Adult Cancer Survivors: Design and Methods of Opt2Move Full Factorial Trial

Background

Opt2Move is a theory-guided moderate and vigorous physical activity (MVPA) promotion trial that uses multiphase optimization strategy (MOST) methodology to evaluate the individual and combined effects of four intervention components in a full factorial experiment among young adult cancer survivors (YACS; N = 304). All participants will receive the core mHealth MVPA intervention, which includes a Fitbit and standard self-monitoring Opt2Move smartphone application. YACS will be randomized to one of 16 conditions to receive between zero and four additional components each with two levels (yes v. no): E-Coach, buddy, general mindfulness, and MVPA-specific mindfulness.

Objective

The primary aim is to determine the individual and combined effects of the components on MVPA post-intervention (12-weeks) and at 24-week follow-up. The secondary aim is to examine how changes in MVPA are associated with patient-reported outcomes, light-intensity activity, sedentary time, and sleep duration and quality. Potential mediators and moderators of component effects will also be examined.

Results

Results will support the selection of a package of intervention components optimized to maximize MVPA to be tested in a randomized controlled trial.

Conclusion

Opt2Move represents the first systematic effort to use MOST to design an optimized, scalable mHealth MVPA intervention for YACS and will lead to an improved understanding of how to effectively change YACS' MVPA and ultimately, improve health and disease outcomes.

Impact of a livelihood intervention on gender roles and relationship power among people with HIV

OBJECTIVE

To evaluate the impact of an agricultural livelihood intervention on gender role conflict and sexual relationship power among people with HIV (PWH) in western Kenya.

DESIGN

Study participants were enrolled in Shamba Maisha , a cluster randomized controlled trial of an agricultural intervention conducted among PWH across 16 health facilities during 2016-2020. Intervention participants received a water pump, seeds, and agricultural and financial training; control participants received standard of HIV care.

METHODS

We assessed men's views on masculinity and gender roles via the validated gender role conflict score (GRCS; range 18-78, higher = greater gender role conflict). We measured gender power imbalances among women via the validated Sexual Relationship Power Scale (SRPS), which combines subscales of relationship control and decision-making dominance (range 1-4, higher = female holds more power). We compared changes over the study period by arm using longitudinal multilevel difference-in-difference linear regression models accounting for clustering of facilities using the intention-to-treat cohort.

RESULTS

We enrolled 720 participants (366 intervention, 354 control); 2-year retention was 94%. Median age was 40 and approximately 55% of participants were female. Among men, after 24-months the decrease in GRCS scores was 4.3 points greater in the intervention than the control arm ( P  < 0.001). Among women, the intervention resulted in 0.25 points greater increase in the SRPS compared to the control arm ( P  < 0.001).

CONCLUSIONS

Shamba Maisha resulted in less gender role conflict in men and greater sexual relationship power for women. Agricultural livelihood interventions may be a powerful tool to improve gender power imbalances, which may subsequently mitigate poverty and food insecurity.

Overall, Direct, Spillover, and Composite Effects of Components of a Peer-Driven Intervention Package on Injection Risk Behavior Among People Who Inject Drugs in the HPTN 037 Study

We sought to disentangle effects of the components of a peer-education intervention on self-reported injection risk behaviors among people who inject drugs (n = 560) in Philadelphia, US. We examined 226 egocentric groups/networks randomized to receive (or not) the intervention. Peer-education training consisted of two components delivered to the intervention network index individual only: (1) an initial training and (2) "booster" training sessions during 6- and 12-month follow up visits. In this secondary data analysis, using inverse-probability-weighted log-binomial mixed effects models, we estimated the effects of the components of the network-level peer-education intervention upon subsequent risk behaviors. This included contrasting outcome rates if a participant is a network member [non-index] under the network exposure versus under the network control condition (i.e., spillover effects). We found that compared to control networks, among intervention networks, the overall rates of injection risk behaviors were lower in both those recently exposed (i.e., at the prior visit) to a booster (rate ratio [95% confidence interval]: 0.61 [0.46-0.82]) and those not recently exposed to it (0.81 [0.67-0.98]). Only the boosters had statistically significant spillover effects (e.g., 0.59 [0.41-0.86] for recent exposure). Thus, both intervention components reduced injection risk behaviors with evidence of spillover effects for the boosters. Spillover should be assessed for an intervention that has an observable behavioral measure. Efforts to fully understand the impact of peer education should include routine evaluation of spillover effects. To maximize impact, boosters can be provided along with strategies to recruit especially committed peer educators and to increase attendance at trainings. Clinical Trials Registration Clinicaltrials.gov NCT00038688 June 5, 2002.

Optimization of an Information Leaflet to Influence Medication Beliefs in Women With Breast Cancer: A Randomized Factorial Experiment

BACKGROUND

Adherence to adjuvant endocrine therapy (AET) is low in women with breast cancer. Negative beliefs about the necessity of AET and high concerns are barriers to adherence.

PURPOSE

To use the multiphase optimization strategy to optimize the content of an information leaflet intervention, to change AET beliefs.

METHODS

We conducted an online screening experiment using a 25 factorial design to optimize the leaflet. The leaflet had five components, each with two levels: (i) diagrams about AET mechanisms (on/off); (ii) infographics displaying AET benefits (enhanced/basic); (iii) AET side effects (enhanced/basic); (iv) answers to AET concerns (on/off); (v) breast cancer survivor (patient) input: quotes and photographs (on/off). Healthy adult women (n = 1,604), recruited via a market research company, were randomized to 1 of 32 experimental conditions, which determined the levels of components received. Participants completed the Beliefs about Medicines Questionnaire before and after viewing the leaflet.

RESULTS

There was a significant main effect of patient input on beliefs about medication (β = 0.063, p < .001). There was one significant synergistic two-way interaction between diagrams and benefits (β = 0.047, p = .006), and one antagonistic two-way interaction between diagrams and side effects (β = -0.029, p = .093). There was a synergistic three-way interaction between diagrams, concerns, and patient input (β = 0.029, p = .085), and an antagonistic four-way interaction between diagrams, benefits, side effects, and concerns (β = -0.038, p = .024). In a stepped approach, we screened in four components and screened out the side effects component.

CONCLUSIONS

The optimized leaflet did not contain enhanced AET side effect information. Factorial experiments are efficient and effective for refining the content of information leaflet interventions.

Refocusing of Attention on Positive Events Using Monitoring-Based Feedback and Microinterventions for Patients With Chronic Musculoskeletal Pain in the PerPAIN Randomized Controlled Trial: Protocol for a Microrandomized Trial

BACKGROUND

Chronic musculoskeletal pain (CMSP) affects between 13% and 47% of the population, with a global growth rate of 20.3% within the last 15 years, suggesting that there is a high need for effective treatments. Pain diaries have long been a common tool in nonpharmacological pain treatment for monitoring and providing feedback on patients' symptoms in daily life. More recently, positive refocusing techniques have come to be used, promoting pain-free episodes and positive outcomes rather than focusing on managing the pain.

OBJECTIVE

This study aims to evaluate the feasibility (ie, acceptability, intervention adherence, and fidelity) and initial signals of efficacy of the PerPAIN app, an ecological momentary intervention for patients with CMSP. The app comprises digitalized monitoring using the experience sampling method (ESM) and feedback. In addition, the patients receive 3 microinterventions targeted at refocusing of attention on positive events.

METHODS

In a microrandomized trial, we will recruit 35 patients with CMSP who will be offered the app for 12 weeks. Participants will be prompted to fill out 4 ESM monitoring questionnaires a day assessing information on their current context and the proximal outcome variables: absence of pain, positive mood, and subjective activity. Participants will be randomized daily and weekly to receive no feedback, verbal feedback, or visual feedback on proximal outcomes assessed by the ESM. In addition, the app will encourage participants to complete 3 microinterventions based on positive psychology and cognitive behavioral therapy techniques. These microinterventions are prompts to report joyful moments and everyday successes or to plan pleasant activities. After familiarizing themselves with each microintervention individually, participants will be randomized daily to receive 1 of the 3 exercises or none. We will assess whether the 2 feedback types and the 3 microinterventions increase proximal outcomes at the following time point. The microrandomized trial is part of the PerPAIN randomized controlled trial (German Clinical Trials Register DRKS00022792) investigating a personalized treatment approach to enhance treatment outcomes in CMSP.

RESULTS

Approval was granted by the Ethics Committee II of the University of Heidelberg on August 4, 2020. Recruitment for the microrandomized trial began in May 2021 and is ongoing at the time of submission. By October 10, 2022, a total of 24 participants had been enrolled in the microrandomized trial.

CONCLUSIONS

This trial will provide evidence on the feasibility of the PerPAIN app and the initial signals of efficacy of the different intervention components. In the next step, the intervention would need to be further refined and investigated in a definitive trial. This ecological momentary intervention presents a potential method for offering low-level accessible treatment to a wide range of people, which could have substantial implications for public health by reducing disease burden of chronic pain in the population.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/43376.

Investigation of Active Ingredients Within Internet-Delivered Cognitive Behavioral Therapy for Depression: A Randomized Optimization Trial

Importance

There is limited understanding of how complex evidence-based psychological interventions such as cognitive behavioral therapy (CBT) for depression work. Identifying active ingredients may help to make therapy more potent, brief, and scalable.

Objective

To test the individual main effects and interactions of 7 treatment components within internet-delivered CBT for depression to investigate its active ingredients.

Design, Setting, and Participants

This randomized optimization trial using a 32-condition, balanced, fractional factorial optimization experiment (IMPROVE-2) recruited adults with depression (Patient Health Questionnaire-9 [PHQ-9] score ≥10) from internet advertising and the UK National Health Service Improving Access to Psychological Therapies service. Participants were randomized from July 7, 2015, to March 29, 2017, with follow-up for 6 months after treatment until December 29, 2017. Data were analyzed from July 2018 to April 2023.

Interventions

Participants were randomized with equal probability to 7 experimental factors within the internet CBT platform, each reflecting the presence vs absence of specific treatment components (activity scheduling, functional analysis, thought challenging, relaxation, concreteness training, absorption, and self-compassion training).

Main Outcomes and Measures

The primary outcome was depression symptoms (PHQ-9 score). Secondary outcomes include anxiety symptoms and work, home, and social functioning.

Results

Among 767 participants (mean age [SD] age, 38.5 [11.62] years; range, 18-76 years; 635 women [82.8%]), 506 (66%) completed the 6-month posttreatment follow-up. On average, participants receiving internet-delivered CBT had reduced depression (pre-to-posttreatment difference in PHQ-9 score, -7.79 [90% CI, -8.21 to -7.37]; 6-month follow-up difference in PHQ-9 score, -8.63 [90% CI, -9.04 to -8.22]). A baseline score-adjusted analysis of covariance model using effect-coded intervention variables (-1 or +1) found no main effect on depression symptoms for the presence vs absence of activity scheduling, functional analysis, thought challenging, relaxation, concreteness training, or self-compassion training (posttreatment: largest difference in PHQ-9 score [functional analysis], -0.09 [90% CI, -0.56 to 0.39]; 6-month follow-up: largest difference in PHQ-9 score [relaxation], -0.18 [90% CI, -0.61 to 0.25]). Only absorption training had a significant main effect on depressive symptoms at 6-month follow-up (posttreatment difference in PHQ-9 score, 0.21 [90% CI, -0.27 to 0.68]; 6-month follow-up difference in PHQ-9 score, -0.54, [90% CI, -0.97 to -0.11]).

Conclusions and Relevance

In this randomized optimization trial, all components of internet-delivered CBT except absorption training did not significantly reduce depression symptoms relative to their absence despite an overall average reduction in symptoms. The findings suggest that treatment benefit from internet-delivered CBT probably accrues from spontaneous remission, factors common to all CBT components (eg, structure, making active plans), and nonspecific therapy factors (eg, positive expectancy), with the possible exception of absorption focused on enhancing direct contact with positive reinforcers.

Trial Registration

isrctn.org Identifier: ISRCTN24117387.

Effect of the Fit2Thrive Intervention on Patient-reported Outcomes in Breast Cancer Survivors: A Randomized Full Factorial Trial

BACKGROUND

Moderate to vigorous physical activity (MVPA) interventions improve patient-reported outcomes (PROs) of physical and psychological health among breast cancer survivors (BCS); however, the effects of specific intervention components on PROs are unknown.

PURPOSE

To use the Multiphase Optimization Strategy (MOST) to examine overall effects of the Fit2Thrive MVPA promotion intervention on PROs in BCS and explore whether there are intervention component-specific effects on PROs.

METHODS

Physically inactive BCS [n = 269; Mage = 52.5 (SD = 9.9)] received a core intervention (Fitbit + Fit2Thrive smartphone app) and were randomly assigned to one of 32 conditions in a full factorial experiment of five components ("on" vs. "off"): (i) support calls, (ii) deluxe app, (iii) text messages, (iv) online gym, and (v) buddy. Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaires assessed anxiety, depression, fatigue, physical functioning, sleep disturbance and sleep-related impairment at baseline, post-intervention (12-week), and 24-week follow-up. Main effects for all components at each time point were examined using an intention to treat mixed-effects model.

RESULTS

All PROMIS measures except sleep disturbance significantly improved (p's < .008 for all) from baseline to 12-weeks. Effects were maintained at 24-weeks. The "on" level of each component did not result in significantly greater improvements on any PROMIS measure compared to the "off" level.

CONCLUSIONS

Participation in Fit2Thrive was associated with improved PROs in BCS, but improvements did not differ for "on" vs. "off" levels for any component tested. The low-resource Fit2Thrive core intervention is a potential strategy to improve PROs among BCS. Future studies should test the core in an RCT and examine various intervention component effects in BCS with clinically elevated PROs.

The effect of relationship-based interventions for maltreated children and adolescents: a systematic review and meta-analysis

Child maltreatment is characterized by a harmful relational environment which can have negative cascading consequences for the child's development. Relationship-based interventions may improve maltreated children's functioning by addressing key aspects of the parent-child relationship at various stages of development. The objective of the current study was to perform a systematic review on relationship-based interventions for maltreated children and a meta-analysis on the impact of these interventions on observed parent-child relational behavior. Data collection consisted of a comprehensive literature search in six databases and contacting experts in the field and hand searching relevant publications. In total, 5,802 abstracts were screened, of which 81 relevant publications were identified, representing 4,526 participants. The meta-analysis found large improvements in observed parent interactive behavior (g = 0.888), smaller improvements in child attachment (g = 0.403) and child interactive behavior (g = 0.274). The effect on parent interactive behavior was larger in interventions addressing middle childhood. Risk of bias assessments showed that a large number of studies suffer from poor reporting, which limits the conclusions of the findings. Future research should examine parent-child relationship behavior across multiple developmental stages, as well as the impact of developmentally appropriate intervention elements on maltreated children.

Does virtual reality enhance the effects of inhibitory control training for loss-of-control eating? A pilot factorial experiment

Inhibitory control, one's ability to inhibit automatic responses to desirable stimuli, may be inadequately targeted in interventions for loss-of-control eating (LOC). Promising evidence has identified inhibitory control trainings (ICTs) as an avenue to target inhibitory control directly; however, effects of ICTs on real-world behavior are limited. Compared to typical computerized trainings, virtual reality (VR) presents several potential advantages that may address key shortcomings of traditional ICTs, i.e. poor approximation to everyday life. The present study utilized a 2 × 2 factorial design of treatment type (ICT vs sham) by treatment modality (VR vs standard computer), which allows for increased statistical power by collapsing across conditions. Our primary aim was to examine the feasibility and acceptability of six weeks of daily training among groups. A secondary aim was to preliminarily assess main and interactive effects of treatment type and modality on target engagement and efficacy (i.e., training compliance, change in LOC episodes, inhibitory control, and implicit liking of foods). Participants (N = 35) with ≥1×/weekly LOC were assigned to one of four conditions and completed ICTs daily for six weeks. The trainings were feasible and acceptable, evinced by high retention and compliance across time and condition. Although completing daily trainings across treatment types and modalities was associated with large decreases in LOC, there were no meaningful effects of either treatment type or modality, nor a significant interaction effect, on LOC or mechanistic variables. Future research should aim to increase the efficacy of ICT (both standard and VR-based) and test in fully-powered clinical trials.

CATCH-UP vaccines: protocol for a randomized controlled trial using the multiphase optimization strategy (MOST) framework to evaluate education interventions to increase COVID-19 vaccine uptake in Oklahoma

BACKGROUND

Oklahoma's cumulative COVID-19 incidence is higher in rural than urban counties and higher than the overall US incidence. Furthermore, fewer Oklahomans have received at least one COVID-19 vaccine compared to the US average. Our goal is to conduct a randomized controlled trial using the multiphase optimization strategy (MOST) to test multiple educational interventions to improve uptake of COVID-19 vaccination among underserved populations in Oklahoma.

METHODS

Our study uses the preparation and optimization phases of the MOST framework. We conduct focus groups among community partners and community members previously involved in hosting COVID-19 testing events to inform intervention design (preparation). In a randomized clinical trial, we test three interventions to improve vaccination uptake: (1) process improvement (text messages); (2) barrier elicitation and reduction (electronic survey with tailored questions/prompts); and (2) teachable moment messaging (motivational interviewing) in a three-factor fully crossed factorial design (optimization).

DISCUSSION

Because of Oklahoma's higher COVID-19 impact and lower vaccine uptake, identifying community-driven interventions is critical to address vaccine hesitancy. The MOST framework provides an innovative and timely opportunity to efficiently evaluate multiple educational interventions in a single study.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05236270, First Posted: February 11, 2022, Last Update Posted: August 31, 2022.

My Health, My Life, My Way-An Inclusive Web-Based Self-management Program for People With Disabilities Living With Chronic Conditions: Protocol for a Multiphase Optimization Strategy Study

BACKGROUND

Individuals with disabilities living with chronic health conditions require self-management programs that are accessible, sustainable, inclusive, and adaptable. Health coaching is an effective approach to promoting behavior change in self-management. Health coaching combined with telehealth technology has the potential to improve the overall quality of, and access to, health services.

OBJECTIVE

This protocol outlines the study design for implementing the My Health, My Life, My Way intervention. The study will assess the feasibility, acceptability, and preliminary efficacy of the intervention for people with disabilities and optimize it.

METHODS

The My Health, My Life, My Way study is a 4-arm randomized controlled trial evaluating the delivery of a 6-month intervention involving telecoaching, inclusive educational content, and technology access for 200 individuals with chronic conditions and physical disabilities. This study uses the engineering-inspired multiphase optimization strategy (MOST) framework to evaluate intervention components and assess whether a combination or lack of individual elements influences behavior. Participants will be randomized to 1 of 4 study arms: scheduled coaching calls and gamified rewards, no scheduled coaching calls and gamified rewards, scheduled coaching calls and flat rewards, and no scheduled coaching calls and flat rewards.

RESULTS

The My Health, My Life, My Way study was approved by the institutional review board of the University of Alabama at Birmingham, and recruitment and enrollment will begin in May 2023. Data analysis is expected to be completed within 6 months of ending data collection. This clinical trial protocol was developed based on the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) 2013 statement.

CONCLUSIONS

The My Health, My Life, My Way study will help to optimize and improve our understanding of the feasibility and efficacy of a web-based self-management program for people with physical disabilities and chronic conditions. More specifically, My Health, My Life, My Way will determine which combination of interventions (coaching calls and gamification) will result in increased participation in self-management programming. The My Health, My Life, My Way intervention has the potential to become a scalable and novel method to successfully manage chronic conditions in people with disabilities.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05481593; https://clinicaltrials.gov/ct2/show/NCT05481593.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/31694.

Acceptability, fidelity and trial experience of four intervention components to support medication adherence in women with breast cancer: A process evaluation protocol for a pilot fractional factorial trial

Background

The Refining and Optimising a behavioural intervention to Support Endocrine Therapy Adherence (ROSETA) programme has developed four intervention components aiming to improve medication adherence in women with early-stage breast cancer. These are (a) text messages, (b) information leaflet, (c) Acceptance and Commitment Therapy-based guided self-help (ACT), (d) side-effect management website. Guided by the Multiphase Optimisation Strategy, our pilot trial will use a fractional factorial design to evaluate the feasibility of undertaking a larger optimisation trial. The pilot will include a process evaluation to maximise learning regarding the fidelity and acceptability of the intervention components before proceeding with a larger trial. The trial process evaluation has three aims: to assess the (1) fidelity and (2) acceptability of the intervention components; and (3) to understand participant's trial experience, and barriers and facilitators to recruitment and retention.

Methods

The process evaluation will use multiple methods. Fidelity of the intervention components will be assessed using self-reported questionnaire data, trial data on intervention component adherence, and observations of the ACT sessions. Acceptability of the intervention components and trial experience will be explored using an acceptability questionnaire and interviews with patients and trial therapists. Trial experience will be assessed using a questionnaire and interviews with participants, while barriers and facilitators to recruitment and retention will be assessed using a questionnaire completed by research nurses and participant interviews. The pilot trial opened for recruitment on 20th May 2022 and was open at the time of submission.

Conclusions

This process evaluation will provide information regarding whether the intervention components can be delivered with fidelity within a national healthcare setting and are acceptable to participants. We will also better understand participant experience in a pilot trial with a fractional factorial design, and any barriers and facilitators to recruitment and retention.

Registration

ISRCTN registry ( ISRCTN10487576, 16/12/2021).

Exploring the Mechanisms in Cognitive Behavioural Therapy for Anxious Children: Does Change in Emotion Regulation Explain Treatment Effect?

Cognitive behavioural therapy (CBT) for childhood anxiety has shown moderate effects. However, inconsistency in findings during the last decades of treatment research and lack of measurable treatment gains over time has led to a call for optimizing interventions by identifying the active mechanisms involved and for whom such interventions are effective. It has been suggested that the moderate effects may be explained by the fact that emotion regulation rarely is directly targeted in CBT-interventions and that interventions may be more effective for children with a certain level of problems with emotion regulation. Using data from a randomized controlled trial with 160 children and their mothers at baseline (t1) and posttreatment (t2), we examined whether being randomized to CBT predicted change in anxiety symptoms from t1 to t2 and whether this change was mediated by change in emotion regulation from t1 to t2. We also investigated whether the strength of this indirect pathway depended on the level of emotion regulation problems at baseline. Latent baseline target moderated mediation analyses within a structural equation modelling framework were conducted. Results showed a significant indirect pathway between receiving CBT to improved emotion regulation, which again was significantly associated with reductions in anxiety symptoms. The findings suggest that the effect of CBT is similar for children irrespective of initial levels of emotion regulation measured broadly, whereas there was some evidence of a baseline moderation effect of the subdomain emotional control. Emotion regulation, and especially emotional control, seems to be an underlying mechanism for positive effects of CBT for anxiety disorders in children, possibly indicating that a greater emphasis on emotion regulation may optimize the intervention.

Successful Optimization of Tobacco Dependence Treatment in the Emergency Department: A Randomized Controlled Trial Using the Multiphase Optimization Strategy

STUDY OBJECTIVE

Tobacco dependence treatment initiated in the hospital emergency department (ED) is effective. However, trials typically use multicomponent interventions, making it difficult to distinguish specific components that are effective. In addition, interactions between components cannot be assessed. The Multiphase Optimization Strategy allows investigators to identify these effects.

METHODS

We conducted a full-factorial, 24 or 16-condition optimization trial in a busy hospital ED to examine the performance of 4 tobacco dependence interventions: a brief negotiation interview; 6 weeks of nicotine replacement therapy with the first dose delivered in the ED; active referral to a telephone quitline; and enrollment in SmokefreeTXT, a free short-messaging service program. Study data were analyzed with a novel mixed methods approach to assess clinical efficacy, cost-effectiveness, and qualitative participant feedback. The primary endpoint was tobacco abstinence at 3 months, verified by exhaled carbon monoxide using a Bedfont Micro+ Smokerlyzer.

RESULTS

Between February 2017 and May 2019, we enrolled 1,056 adult smokers visiting the ED. Odd ratios (95% confidence intervals) from the primary analysis of biochemically confirmed abstinence rates at 3 months for each intervention, versus control, were: brief negotiation interview, 1.8 (1.1, 2.8); nicotine replacement therapy, 2.1 (1.3, 3.2); quitline, 1.4 (0.9, 2.2); SmokefreeTXT, 1.1 (0.7, 1.7). There were no statistically significant interactions among components. Economic and qualitative analyses are in progress.

CONCLUSION

The brief negotiation interview and nicotine replacement therapy were efficacious. This study is the first to identify components of ED-initiated tobacco dependence treatment that are individually effective. Future work will address the scalability of the brief negotiation interview and nicotine replacement therapy by offering provider-delivered brief negotiation interviews and nicotine replacement therapy prescriptions.

Sleep Interventions for Informal Caregivers of Persons with Dementia: A Systematic Review

We conducted a systematic review on the state of the science related to sleep interventions for informal caregivers of persons with Alzheimer's disease or related dementia (ADRD). This review included English-written, peer-reviewed articles that studied the effect of an intervention on sleep health outcomes for informal caregivers of persons with ADRD. Our search yielded 15 articles that met our a priori inclusion criteria. We categorized interventions into four categories: environmental, physical, cognitive, and collaborative. Intervention effects were heterogeneous, with most yielding nonsignificant sleep health effects. There is a need for theoretically sound and robust sleep health interventions for informal caregiver samples. Future research in this area could benefit from the use of more controlled, pragmatic, and adaptive research designs, and the use of objective measures that conceptually represent the multiple domains of sleep health to enhance intervention quality.

Supporting adjuvant endocrine therapy adherence in women with breast cancer: the development of a complex behavioural intervention using Intervention Mapping guided by the Multiphase Optimisation Strategy

BACKGROUND

Adjuvant endocrine therapy (AET) reduces the risk of breast cancer recurrence and mortality. However, up to three-quarters of women with breast cancer do not take AET as prescribed. Existing interventions to support adherence to AET have largely been unsuccessful, and have not focused on the most salient barriers to adherence. This paper describes the process of developing four theory-based intervention components to support adherence to AET. Our aim is to provide an exemplar of intervention development using Intervention Mapping (IM) with guidance from the Multiphase Optimisation Strategy (MOST).

METHODS

Iterative development followed the six-stage IM framework with stakeholder involvement. Stage 1 involved a literature review of barriers to adherence and existing interventions, which informed the intervention objectives outlined in Stage 2. Stage 3 identified relevant theoretical considerations and practical strategies for supporting adherence. Stage 4 used information from Stages 1-3 to develop the intervention components. Stages 1-4 informed a conceptual model for the intervention package. Stages 5 and 6 detailed implementation considerations and evaluation plans for the intervention package, respectively.

RESULTS

The final intervention package comprised four individual intervention components: Short Message Service to encourage habitual behaviours surrounding medication taking; an information leaflet to target unhelpful beliefs about AET; remotely delivered Acceptance and Commitment Therapy-based guided self-help to reduce psychological distress; and a website to support self-management of AET side-effects. Considerations for implementation within the NHS, including cost, timing and mode of delivery were outlined, with explanation as to how using MOST can aid this. We detail our plans for the final stage of IM which involve feasibility testing. This involved planning an external exploratory pilot trial using a 24-1 fractional factorial design, and a process evaluation to assess acceptability and fidelity of intervention components.

CONCLUSIONS

We have described a systematic and logical approach for developing a theoretically informed intervention package to support medication adherence in women with breast cancer using AET. Further research to optimise the intervention package, guided by MOST, has the potential to lead to more effective, efficient and scalable interventions.

Using the multiphase optimization strategy (MOST) framework to optimize an intervention to increase COVID-19 testing for Black and Latino/Hispanic frontline essential workers: A study protocol

BACKGROUND

Among those at highest risk for COVID-19 exposure is the large population of frontline essential workers in occupations such food service, retail, personal care, and in-home health services, among whom Black and Latino/Hispanic persons are over-represented. For those not vaccinated and at risk for exposure to COVID-19, including frontline essential workers, regular (approximately weekly) COVID-19 testing is recommended. However, Black and Latino/Hispanic frontline essential workers in these occupations experience serious impediments to COVID-19 testing at individual/attitudinal- (e.g., lack of knowledge of guidelines), social- (e.g., social norms), and structural-levels of influence (e.g., poor access), and rates of testing for COVID-19 are insufficient.

METHODS/DESIGN

The proposed community-engaged study uses the multiphase optimization strategy (MOST) framework and an efficient factorial design to test four candidate behavioral intervention components informed by an integrated conceptual model that combines critical race theory, harm reduction, and self-determination theory. They are A) motivational interview counseling, B) text messaging grounded in behavioral economics, C) peer education, and D) access to testing (via navigation to an appointment vs. a self-test kit). All participants receive health education on COVID-19. The specific aims are to: identify which components contribute meaningfully to improvement in the primary outcome, COVID-19 testing confirmed with documentary evidence, with the most effective combination of components comprising an "optimized" intervention that strategically balances effectiveness against affordability, scalability, and efficiency (Aim 1); identify mediators and moderators of the effects of components (Aim 2); and use a mixed-methods approach to explore relationships among COVID-19 testing and vaccination (Aim 3). Participants will be N = 448 Black and Latino/Hispanic frontline essential workers not tested for COVID-19 in the past six months and not fully vaccinated for COVID-19, randomly assigned to one of 16 intervention conditions, and assessed at 6- and 12-weeks post-baseline. Last, N = 50 participants will engage in qualitative in-depth interviews.

DISCUSSION

This optimization trial is designed to yield an effective, affordable, and efficient behavioral intervention that can be rapidly scaled in community settings. Further, it will advance the literature on intervention approaches for social inequities such as those evident in the COVID-19 pandemic.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05139927 ; Registered on 11/29/2021. Protocol version 1.0. May 2, 2022, Version 1.0.

Optimizing an mHealth Intervention to Improve Uptake and Adherence to HIV Pre-exposure Prophylaxis in Young Transgender Women: Protocol for a Multi-Phase Trial

BACKGROUND

Vulnerable adolescents and emerging adults (aged 18-29 years), particularly young transgender women, are among the fastest-growing HIV positive populations worldwide. Thailand has the highest adult HIV seroprevalence in Asia, with a rate of infection among this population of 18%. Widespread technology offers opportunities for innovative mobile health (mHealth) interventions. Pre-exposure prophylaxis (PrEP) is an efficacious HIV prevention strategy recommended for at-risk individuals. PrEP is highly effective when taken as prescribed, but uptake and adherence have been low, with high discontinuation rates among youth.

OBJECTIVE

We propose to develop and pilot a multi-component, technology-based intervention to promote PrEP usage. We will adapt an existing 2-session, technology-delivered, motivational interviewing-based intervention to focus on PrEP use in transgender women in Thailand. We call this the Motivational Enhancement System for PrEP Uptake and Adherence (MES-PrEP). We will also refine and enhance YaCool, a mobile app with integrated text messaging developed and used clinically by our Thai team. The new version of the app is called Enhanced YaCool, and it enables self-management of gender and sexual health (including PrEP). Our primary aim is to develop and assess the preliminary efficacy of this mHealth intervention.

METHODS

We will utilize a multiphase optimization strategy (MOST) to identify the most effective intervention component or combination of components to improve PrEP usage in Thai transgender women. The study includes two phases: phase I (R21) includes qualitative interviews with key stakeholders to explore barriers and facilitators of PrEP usage through thematic analysis to inform intervention adaptation. Following this, we will adapt and beta-test MES-PrEP and Enhanced YaCool for functionality and feasibility using a community advisory board of HIV-negative Thai transgender women. In phase II (R33), we will conduct a MOST design-based trial to evaluate the feasibility, acceptability, and preliminary efficacy of MES-PrEP and Enhanced YaCool. Eighty HIV-negative participants who are currently taking PrEP and 80 participants who are not will be randomized to four conditions: (1) standard PrEP counseling (the control condition); (2) MES-PrEP and standard PrEP counseling; (3) Enhanced YaCool and standard PrEP counseling; and (4) MES-PrEP, Enhanced YaCool, and standard PrEP counseling. Feasibility and acceptability of the intervention will be assessed through usage patterns and the System Usability Scale. Preliminary impact will be assessed by evaluating the proportion of participants who initiate PrEP and their level of adherence to PrEP. Assessments will be at baseline and 1, 3, 6, 9, and 12 months postintervention. Biomarkers of adherence to PrEP, HIV, and other sexually transmitted infections will be collected.

RESULTS

Upon project completion, we will have an optimized mHealth intervention to support the use of PrEP by transgender women that will be ready for testing in a larger efficacy trial.

CONCLUSIONS

Even though transgender women in Thailand face increasing risks of HIV, few interventions have targeted them. Effective developmentally and culturally tailored interventions are needed to prevent HIV transmission in this high-risk population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05262426; https://clinicaltrials.gov/ct2/show/NCT05262426.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/37659.

Asthma and technology in emerging African American adults (The ATHENA Project): Protocol for a trial using the Multiphase Optimization Strategy framework (Preprint)

Background

Asthma causes substantial morbidity and mortality in the United States, particularly among African American emerging adults (AAEAs; aged 18-30 years), but very few asthma programs have targeted this population. Interventions that provide education and address underlying motivation for managing asthma may be the most effective. However, intensive face-to-face interventions are often difficult to implement in this population.

Objective

The purpose of this study is to develop an effective mobile asthma management intervention to improve control among AAEAs.

Methods

We will assess the ability of multiple technologic components to assist and improve traditional asthma education. The first component is the Motivational Enhancement System for asthma management. It is a mobile 4-session intervention using supported self-regulation and motivational interviewing. Personalized content is based on each participant’s activity level, daily experiences, and goals. The second component is supportive accountability. It is administered by asthma nurses using targeted mobile support (Skype/voice calls) to provide education, promote self-efficacy, and overcome barriers through a motivational interviewing–based framework. The third component is SMS text messaging. It provides reminders for asthma education, medication adherence, and physical activity. The fourth component is physical activity tracking. It uses wearable technology to help meet user-defined physical activity goals. Using a multiphase optimization strategy (MOST) framework, we will test intervention components and combinations of components to identify the most effective mobile intervention. The MOST framework is an innovative, and cost- and time-effective framework that uses engineering principles to produce effective behavioral interventions. We will conduct a component selection experiment using a factorial research design to build an intervention that has been optimized for maximum efficacy, using a clinically significant improvement in asthma. Participants (N=180) will be randomized to 1 of 6 intervention arms. Participants will be recruited from multiple sites of the American Lung Association-Airway Clinical Research Centers network and ambulatory care clinics at the Detroit Medical Center. Data collections will occur at baseline, and 3, 6, and 12 months.

Results

At study completion, we will have an empirically supported optimized mobile asthma management intervention to improve asthma control for AAEAs. We hypothesize that postintervention (3, 6, and 12 months), participants with uncontrolled asthma will show a clinically significant improvement in asthma control. We also hypothesize that improvements in asthma management behaviors (including physical activity), quality of life, symptoms, adherence, and exacerbation (secondary outcomes) will be observed.

Conclusions

AAEAs are disproportionately impacted by asthma, but have been underrepresented in research. Mobile asthma management interventions may help improve asthma control and allow people to live healthier lives. During this project, we will use an innovative strategy to develop an optimized mobile asthma management intervention using the most effective combination of nurse-delivered asthma education, a smartphone app, and text messaging.

International Registered Report Identifier (IRRID)

PRR1-10.2196/37946

Advances in clinical trials methodology: Intervention optimization approaches in emergency medicine

The classical two-arm randomized clinical trial (RCT) is designed to test the efficacy or effectiveness of an intervention, which may consist of one or more components. However, this approach does not enable the investigator to obtain information that is important in intervention development, such as which individual components of the intervention are efficacious, which are not and possibly should be removed, and whether any components interact. The Multiphase Optimization Strategy (MOST) is a new framework for development, optimization, and evaluation of interventions. MOST includes the RCT for purposes of evaluation, but inserts a phase of research before the RCT aimed at intervention optimization. The optimization phase requires one or more separate trials similar in scope to an RCT, but employing a different experimental design. The design of the optimization trial is selected strategically so as to maximize the amount of scientific information gained using the available resources. One consideration in selecting this experimental design is the type of intervention to be optimized. If a fixed intervention, i.e. one in which the same intervention content and intensity is provided to all participants, is to be optimized, a factorial experiment is often appropriate. If an adaptive intervention, i.e. one in which intervention content or intensity is varied in a principled manner, is to be optimized, a sequential multiple-assignment randomized trial (SMART) is often a good choice. The objective of this article is to describe MOST and the scientific rationale for its use; describe two current applications of MOST in emergency medicine research, one using a factorial experiment and the other using a SMART; and discuss funding strategies and potential future applications in studying the care of individuals with acute illness, injury, or behavioral disorders.

Optimization of a technology-supported physical activity promotion intervention for breast cancer survivors: Results from Fit2Thrive

BACKGROUND

The benefits of moderate to vigorous physical activity (MVPA) for breast cancer survivors are well established. However, most are insufficiently active. Fit2Thrive used the Multiphase Optimization Strategy methodology to determine the effect of 5 intervention components on MVPA in this population.

METHODS

Two hundred sixty-nine participants (mean age, 52.5 years; SD, 9.9 years) received a core intervention (the Fit2Thrive self-monitoring app and Fitbit) and were randomly assigned to 5 intervention components set to on/off in a full factorial experiment: support calls, deluxe app, buddy, online gym, and text messages. The intervention was delivered over 12 weeks with a 12-week follow-up. MVPA was measured via accelerometry at the baseline (T1), at 12 weeks (T2), and at 24 weeks (T3). The main effects and interaction effects at each time point were examined for all components.

RESULTS

Trial retention was high: 91.8% had valid accelerometer data at T2 or T3. Across all conditions, there were significant increases in MVPA (+53.6 min/wk; P < .001) and in the proportion of survivors meeting MVPA guidelines (+22.3%; P < .001) at T2 that were maintained but attenuated at T3 (MVPA, +24.6 min/wk; P < .001; meeting guidelines, +12.6%; P < .001). No individual components significantly improved MVPA, although increases were greater for the on level versus the off level for support calls, buddy, and text messages at T2 and T3.

CONCLUSIONS

The Fit2Thrive core intervention (the self-monitoring app and Fitbit) is promising for increasing MVPA in breast cancer survivors, but the components provided no additional increases in MVPA. Future research should evaluate the core intervention in a randomized trial and determine what components optimize MVPA behaviors in breast cancer survivors.

An overview of and recommendations for more accessible digital mental health services

Mental health concerns are common, and various evidence-based interventions for mental health conditions have been developed. However, many people have difficulty accessing appropriate mental health care and this has been exacerbated by the COVID-19 pandemic. Digital mental health services, such as those delivered by mobile phone or web-based platforms, offer the possibility of expanding the reach and accessibility of mental health care. To achieve this goal, digital mental health interventions and plans for their implementation must be designed with the end users in mind. In this Review, we describe the evidence base for digital mental health interventions across various diagnoses and treatment targets. Then, we explain the different formats for digital mental health intervention delivery, and offer considerations for their use across key age groups. We discuss the role that the COVID-19 pandemic has played in emphasizing the value of these interventions, and offer considerations for ensuring equity in access to digital mental health interventions among diverse populations. As healthcare providers continue to embrace the role that technology can play in broadening access to care, the design and implementation of digital mental healthcare solutions must be carefully considered to maximize their effectiveness and accessibility.

Optimization of an mHealth lifestyle intervention for families with hereditary cancer syndromes: Study protocol for a multiphase optimization strategy feasibility study

BACKGROUND

Individuals at increased hereditary risk of cancer are an important target for health promotion and cancer prevention interventions. Health-4-Families uses the Multiphase Optimization STrategy (MOST) framework and is designed to pilot digital delivery strategies for a distance-based, 16-week intervention to promote weight management, healthy diet, and increased physical activity among individuals with BRCA1/BRCA2 or DNA mismatch repair (MMR) pathogenic germline variants. This communication describes participant recruitment and the design of the Health-4-Families pilot study.

METHODS

Health-4-Families is a full-factorial (16 condition) randomized pilot study of four lifestyle intervention components: social networking, telephone or email coaching, text messaging, and self-monitoring. The primary outcome was feasibility and satisfaction with these study components. Participants with pathogenic germline variants were identified via clinic surveillance lists and advocacy organizations and were invited to participate with family members. All participants had to report meeting at least one of the following criteria: (1) having a BMI ≥ 25 kg/m2, (2) consuming <5 servings of fruit and vegetables per day, or (3) getting <150 min of moderate-to-vigorous intensity activity per week.

RESULTS

The majority of screened potential participants with pathogenic variants (83%) were eligible; 86% of those eligible provided informed consent and 79% (n = 104) completed baseline. A total of 206 family members were nominated by study participants and 49% (n = 102) completed baseline.

DISCUSSION

Recruitment data suggest that individuals with pathogenic germline variants, who are at increased risk for hereditary cancers, are motivated to participate in digital lifestyle interventions. This recruitment success highlights the importance of identifying and prioritizing effective and efficient intervention components for hereditary cancer families. We intend to use the outcomes of our pilot study to inform a fully-powered factorial study for this community.

A Multi-step Approach to Adapting a Mind-Body Resiliency Intervention for Fear of Cancer Recurrence and Uncertainty in Survivorship (IN FOCUS)

BACKGROUND

For cancer survivors, there is a paucity of fear of recurrence (FOR) interventions that integrate empirically supported mind-body and psychological skills for managing FOR and are delivered in scalable formats.

OBJECTIVE

To adapt an evidence-based resiliency intervention to address FOR among cancer survivors.

METHODS

A multidisciplinary team of researchers, clinicians, and patient stakeholders followed an iterative intervention adaptation process (ORBIT). In Step 1, we sought to define key FOR management skills through a literature review and feedback from stakeholders. In Step 2, we integrated findings into a treatment manual and refined procedures for in-person delivery to groups of cancer survivors, defined as adults who had completed primary cancer treatment for non-metastatic cancer. In Step 3, we conducted a single arm trial to assess initial acceptability and change in FOR severity with 23 cancer survivors (N=4 intervention groups). In Step 4, we conducted additional qualitative interviews with 28 cancer survivors (N=6 focus groups stratified by FOR severity, N=15 individual interviews) to define adaptive and maladaptive strategies for coping with FOR and to identify preferences for delivery. In Step 5, we refined the treatment manual and procedures for testing in a future pilot randomized feasibility trial.

RESULTS

We identified critical feedback using a combination of qualitative and quantitative methods. The single arm trial suggested preliminary feasibility and sustained reductions in FOR severity, yet need for refinement (i.e., eligibility, delivery modality), prompting additional qualitative interviews for further targeting. The resulting intervention (IN FOCUS) is comprised of virtual, synchronous, group-delivered sessions that offer an integrated approach to FOR management by teaching cognitive-behavioral techniques, meditation, relaxation training, adaptive health behaviors, and positive psychology skills. Sessions are targeted by applying skills to FOR and associated healthcare engagement.

CONCLUSIONS

IN FOCUS is a targeted intervention for teaching mind-body resiliency skills to groups of cancer survivors with elevated FOR. Next steps are testing feasibility in a pilot randomized trial.

Prevention of child mental health problems through parenting interventions in Southeastern Europe (RISE): study protocol for a multi-site randomised controlled trial

BACKGROUND

Childhood adversities, such as poor parental practices, exposure to violence, and risk behaviours strongly impact children's future mental and behavioural problems. Adversities affect families living in disadvantaged environments and low- and middle-income countries (LMICs) to a greater extent than in high-income countries. Parenting programmes are an effective way to alleviate them, although their outreach and scalability is still limited in LMICs.

METHODS/DESIGN

A multi-site randomised controlled trial will be conducted in North Macedonia, Republic of Moldova and Romania to test the efficacy and cost-effectiveness of an optimised version of the promising Parenting for Lifelong Health Programme for Young Children (PLH-YC, 5 sessions), against a standard lecture on parenting issues (control group, 1 session). At least 864 participants who report having children between 2 and 9 years old who display elevated levels of behavioural difficulties will be randomised on a 1:1 basis to the intervention and control groups. The primary outcome will consist of parent report of child oppositional aggressive behaviour. Post-test (four months) and follow-up (12 months) assessments will provide information on short- and longer-term effects of PLH-YC compared to the parenting lecture in the control group.

DISCUSSION

This randomised trial will test the efficacy of PLH-YC in alleviating child behavioural problems and assess the cost-effectiveness, transportability across three different cultural contexts, and potential for scalability of the programme.

TRIAL REGISTRATION

ClinicalTrials.gov ., Registration number: NCT04721730 ( https://clinicaltrials.gov/ct2/show/NCT04721730 ). Registered 13.01.2021.

Optimizing a mindfulness-based intervention to alleviate stress from discrimination among young sexual and gender minorities of color: A study protocol

Background

Young sexual and gender minorities (SGMs) of color may face unique experiences of discrimination based on their intersectional positions (eg, discrimination based on both racial or ethnic identity and sexual identity). Emerging evidence suggests that mindfulness practices may reduce stress from discrimination and improve overall well-being among young SGM. Moreover, the omnipresence of smartphone access among racial or ethnic and sexual minority communities provides a method through which to administer mindfulness-based interventions among young SGMs of color.

Objective

This paper outlines the protocol of the Optimizing a Daily Mindfulness Intervention to Reduce Stress from Discrimination among Young Sexual and Gender Minorities of Color (REDUCE) study, a pilot optimization trial of a smartphone-based mindfulness intervention that was developed in conjunction with the Healthy Minds Program (HMP) with the aim of reducing stress from discrimination among young SGMs.

Methods

In total, 80 young (ages 18-29 years) SGMs of color will be enrolled in the study. The HMP is a self-guided meditation practice, and participants will be randomized to either a control condition or an intervention that uses a neuroscience-based approach to mindfulness. We will use the multiphase optimization strategy to assess which combination of mindfulness interventions is the most effective at reducing stress from discrimination among young SGMs of color. A combination of mindfulness-based meditation intervention components will be examined, comprising mindfulness-based practices of awareness, connection, and purpose. Awareness refers to the practice of self-awareness, which reduces the mind’s ability to be distracted and instead be present in the moment. Connection refers to the practice of connection with oneself and others and emphasizes on empathy and compassion with oneself and others. Purpose encourages goal-making in accordance with one’s values and management of behavior in accordance with these goals. In addition, we will assess the feasibility and acceptability of the HMP application among young SGMs of color.

Results

The REDUCE study was approved by the Institutional Review Board of New York University, and recruitment and enrollment began in the winter of 2021. We expect to complete enrollment by the summer of 2022. The results will be disseminated via social media, journal articles, abstracts, or presentations, as well as to participants, who will be given the opportunity to provide feedback to the researchers.

Conclusions

This optimization trial is designed to test the efficacy, feasibility, and acceptability of implementing an application-based, mindfulness-based intervention to reduce stress from discrimination and improve well-being among young SGMs of color. Evidence from this study will assist in the creation of a sustainable, culturally relevant mobile app–based mindfulness intervention to reduce stress from discrimination among young SGMs of color.

Trial Registration

Clinicaltrials.gov NCT05131360; https://clinicaltrials.gov/ct2/show/NCT05131360

International Registered Report Identifier (IRRID)

DERR1-10.2196/35593

Good Theories in Need of Better Data: Combining Clinical and Social Psychological Approaches to Study the Mechanisms Linking Relationships and Health

The study of intimate relationships and health is a fast-growing discipline with numerous well-developed theories, many of which outline specific interpersonal behaviors and psychological pathways that may give rise to good or poor health. In this article, we argue that the study of relationships and health can move toward interrogating these mechanisms with greater precision and detail, but doing so will require a shift in the nature of commonly used research methods in this area. Accordingly, we draw heavily on the science of behavior change and discuss six key methodologies that may galvanize the mechanistic study of relationships and health: dismantling studies, factorial studies, experimental therapeutics, experimental mediation research, multiple assessments, and recursive modeling. We provide empirical examples for each strategy and outline new ways in which a given approach may be used to study the mechanisms linking intimate relationships and health. We conclude by discussing the key challenges and limitations for using these research strategies as well as novel ideas about how to integrate this work into existing paradigms within the field.

One view of the next decade of research on behavioral and biobehavioral approaches to cancer prevention and control: intervention optimization

As a new decade begins, we propose that the time is right to reexamine current methods and procedures and look for opportunities to accelerate progress in cancer prevention and control. In this article we offer our view of the next decade of research on behavioral and biobehavioral interventions for cancer prevention and control. We begin by discussing and questioning several implicit conventions. We then briefly introduce an alternative research framework: the multiphase optimization strategy (MOST). MOST, a principled framework for intervention development, optimization, and evaluation, stresses not only intervention effectiveness, but also intervention affordability, scalability, and efficiency. We review some current limitations of MOST along with future directions for methodological work in this area, and suggest some changes in the scientific environment we believe would permit wider adoption of intervention optimization. We propose that wider adoption of intervention optimization would have a positive impact on development and successful implementation of interventions for cancer prevention and control and on intervention science more broadly, including accumulation of a coherent base of knowledge about what works and what does not; establishment of an empirical basis for adaptation of interventions to different settings with different levels and types of resources; and, in the long run, acceleration of progress from Stage 0 to Stage V in the National Institutes of Health Model of Stages of Intervention Development.

The preparation phase in the multiphase optimization strategy (MOST): a systematic review and introduction of a reporting checklist

Multicomponent behavioral interventions developed using the multiphase optimization strategy (MOST) framework offer important advantages over alternative intervention development models by focusing on outcomes within constraints relevant for effective dissemination. MOST consists of three phases: preparation, optimization, and evaluation. The preparation phase is critical to establishing the foundation for the optimization and evaluation phases; thus, detailed reporting is critical to enhancing rigor and reproducibility. A systematic review of published research using the MOST framework was conducted. A structured framework was used to describe and summarize the use of MOST terminology (i.e., preparation phase and optimization objective) and the presentation of preparation work, the conceptual model, and the optimization. Fifty-eight articles were reviewed and the majority focused on either describing the methodology or presenting results of an optimization trial (n = 38, 66%). Although almost all articles identified intervention components (96%), there was considerable variability in the degree to which authors fully described other elements of MOST. In particular, there was less consistency in use of MOST terminology. Reporting on the MOST preparation phase is varied, and there is a need for increased focus on explicit articulation of key design elements and rationale of the preparation phase. The proposed checklist for reporting MOST studies would significantly advance the use of this emerging methodology and improve implementation and dissemination of MOST. Accurate reporting is essential to reproducibility and rigor of scientific trials as it ensures future research fully understands not only the methodology, but the rationale for intervention and optimization decisions.

Evaluating four motivation-phase intervention components for use with primary care patients unwilling to quit smoking: a randomized factorial experiment

AIMS

To assess the effectiveness of intervention components designed to increase quit attempts and promote abstinence in patients initially unwilling to quit smoking.

DESIGN

A four-factor, randomized factorial experiment.

SETTING

Sixteen primary care clinics in southern Wisconsin.

PARTICIPANTS

A total of 577 adults who smoke (60% women, 80% White) recruited during primary care visits who were currently willing to reduce their smoking but unwilling to try to quit. Interventions Four factors contrasted intervention components administered over a 1-year period: (i) nicotine mini-lozenge versus none; (ii) reduction counseling versus none; (iii) behavioral activation (BA) counseling versus none; and (iv) motivational 5Rs counseling versus none. Participants could request cessation treatment at any time.

MEASUREMENTS

The primary outcome was 7-day point-prevalence abstinence at 52 weeks post enrollment; secondary outcomes were point-prevalence abstinence at 26 weeks and making a quit attempt by weeks 26 and 52.

FINDINGS

No abstinence main effects were found but a mini-lozenge × reduction counseling × BA interaction was found at 52 weeks; P = 0.03. Unpacking this interaction showed that the mini-lozenge alone produced the highest abstinence rate (16.7%); combining it with reduction counseling produced an especially low abstinence rate (4.1%). Reduction counseling decreased the likelihood of making a quit attempt by 52 weeks relative to no reduction counseling (P = 0.01).

CONCLUSIONS

Nicotine mini-lozenges may increase smoking abstinence in people initially unwilling to quit smoking, but their effectiveness declines when used with smoking reduction counseling or other behavioral interventions. Reduction counseling decreases the likelihood of making a quit attempt in people initially unwilling to quit smoking.

Optimization Methods and Implementation Science: An Opportunity for Behavioral and Biobehavioral Interventions

This editorial introduces the multiphase optimization strategy (MOST), a principled framework for the development, optimization and evaluation of multicomponent interventions, to the field of implementation science. We suggest that MOST may be integrated with implementation science to advance the field, moving closer towards the ultimate goal of disseminating effective interventions to those in need. We offer three potential ways MOST may advance implementation science: (1) development of an effective and immediately scalable intervention; (2) adaptation of interventions to local contexts; and (3) optimization of the implementation of an intervention itself. Our goal is to inspire the integration of MOST with implementation science across a number of public health contexts.

A randomized iterative approach to optimizing an online substance use intervention for collegiate athletes

BACKGROUND

Rates of drug use among collegiate athletes are high, yet there are few evidence-based interventions for this population. myPlaybook, an online intervention for collegiate athletes, targets multiple predictors of drug use (i.e., norms, positive and negative expectancies about use, and harm prevention intentions).

PURPOSE

We aimed to optimize modules from myPlaybook.

METHOD

We evaluated modules through three sequential randomized factorial trials, using the Multiphase Optimization Strategy framework. We recruited and randomized 54 (Trial 1), 47 (Trial 2), and 42 (Trial 3) schools and invited all first-year and transfer collegiate athletes to participate. Athletes completed a baseline survey, their randomly assigned modules, and immediate posttest and 30-day follow-up surveys. Across trials, 3,244 (48.8% female), 2,837 (51.9% female), and 2,193 (51.4% female) athletes participated. In Trial 1, we evaluated and revised less effective modules (defined as d < 0.3-0.4 for targeted outcomes). In Trial 2, we re-evaluated and revised less effective modules. In Trial 3, we re-evaluated the revised modules.

RESULTS

Trial 1: All effects were d < 0.15, so we revised modules to target proximal outcomes (i.e., the hypothesized mediating variables in our conceptual model), rather than specific drug use behaviors. Trial 2: Most effects were d < 0.3, so we revised all modules. Trial 3: The norms module improved descriptive and injunctive norms (all d >0.35). The expectancies module improved alcohol positive expectancies (d = 0.3). The other modules were not effective.

CONCLUSIONS

After three trials, two myPlaybook modules substantially improved proximal outcomes, increasing the likelihood that the combined intervention will have a meaningful clinical impact on collegiate athletes' drug use.

The Past, Present, and Future of PrEP implementation Among People Who Use Drugs

PURPOSE OF REVIEW

Recent HIV outbreaks among people who use drugs (PWUD) necessitate additional HIV prevention tools. Pre-exposure prophylaxis (PrEP) is highly efficacious yet uptake among PWUD remains exceedingly low. To address multilevel, complex barriers to PrEP use among PWUD, a range of intervention strategies are needed.

RECENT FINDINGS

The literature on interventions to optimize PrEP use among PWUD is nascent, comprising small pilots and demonstration projects in early phases of intervention development. Initial studies suggest that structural, healthcare, interpersonal, and individual-level interventions can improve PrEP use for PWUD, and a number of efficacy trials are underway. Future studies are needed to optimize the use of new PrEP modalities (e.g., injectable PrEP), simultaneously target multilevel challenges to PrEP use, and evaluate the integration of PrEP into other service settings and substance use treatment modalities.

Applying the Multiphase Optimization Strategy for the Development of Optimized Interventions in Palliative Care

Recent systematic reviews and meta-analyses have reported positive benefit of multicomponent "bundled" palliative care interventions for patients and family caregivers while highlighting limitations in determining key elements and mechanisms of improvement. Traditional research approaches, such as the randomized controlled trial (RCT), typically treat interventions as "bundled" treatment packages, making it difficult to assess definitively which aspects of an intervention can be reduced or replaced or whether there are synergistic or antagonistic interactions between intervention components. Progressing toward palliative care interventions that are effective, efficient, and scalable will require new strategies and novel approaches. One such approach is the Multiphase Optimization Strategy (MOST), a framework informed by engineering principles, that uses a systematic process to empirically identify an intervention comprised of components that positively contribute to desired outcomes under real-life constraints. This article provides a brief overview and application of MOST and factorial trial design in palliative care research, including our insights from conducting a pilot factorial trial of an early palliative care intervention to enhance the decision support skills of advanced cancer family caregivers (Project CASCADE).

A Review of Recent HIV Prevention Interventions and Future Considerations for Nursing Science

ABSTRACT

As our knowledge of HIV evolved over the decades, so have the approaches taken to prevent its transmission. Public health scholars and practitioners have engaged in four key strategies for HIV prevention: behavioral-, technological-, biomedical-, and structural/community-level interventions. We reviewed recent literature in these areas to provide an overview of current advances in HIV prevention science in the United States. Building on classical approaches, current HIV prevention models leverage intimate partners, families, social media, emerging technologies, medication therapy, and policy modifications to effect change. Although much progress has been made, additional work is needed to achieve the national goal of ending the HIV epidemic by 2030. Nurses are in a prime position to advance HIV prevention science in partnership with transdisciplinary experts from other fields (e.g., psychology, informatics, and social work). Future considerations for nursing science include leveraging transdisciplinary collaborations and consider social and structural challenges for individual-level interventions.

Strengthening the Evidence for Maternal and Child Health: Implementing the New Performance Measurement Framework for the Title V Maternal and Child Health Block Grant

PURPOSE

The Health Resources and Services Administration's Maternal and Child Health Bureau (HRSA MCHB) developed a three-tiered performance measure framework for the Title V Maternal and Child Health Block Grant program (MCH Title V). The third tier, evidence-based/informed strategy measures (ESMs) are developed by states to address National Performance Measures (NPM) goals. To support states' efforts, MCHB funded the "Strengthen the Evidence for Maternal and Child Health" (STE) to: (1) define the concept of evidence for the field with an emphasis on strength; (2) identify available evidence for each NPM, (3) translate ESM research for use at the state level; and (4) provide technical assistance (TA) to states to facilitate implementation.

DESCRIPTION

The program conducted evidence reviews defining an "evidence continuum" emphasizing a continuum of strength, provided individual and group TA to MCH Title V grantees, launched a TA referral system, and reviewed state ESMs to assess use of evidence-based/informed strategies.

ASSESSMENT

Ten evidence reviews identified multiple strategies as having "emerging" or "moderate" evidence. TA reached all MCH Title V programs, encompassing 59 US states and jurisdictions, and the TA referral system effectively partnered with MCHB resources. All MCH Title V states and territories submitted ESMs for the Block Grant program's first year reporting requirement.

CONCLUSION

STE is the first program to review available evidence on effective strategies addressing NPMs for MCH Title V. Identifying actionable next steps responsive to state needs will be a key factor for continued implementation of ESMs and achieving improvements in MCH.