Improving the translation of health promotion interventions using effectiveness-implementation hybrid designs in program evaluations

Research outcomes informing the selection of public health interventions and strategies to implement them: A cross-sectional survey of Australian policy-maker and practitioner preferences

BACKGROUND

A key role of public health policy-makers and practitioners is to ensure beneficial interventions are implemented effectively enough to yield improvements in public health. The use of evidence to guide public health decision-making to achieve this is recommended. However, few studies have examined the relative value, as reported by policy-makers and practitioners, of different broad research outcomes (that is, measures of cost, acceptability, and effectiveness). To guide the conduct of research and better inform public health policy and practice, this study aimed at describing the research outcomes that Australian policy-makers and practitioners consider important for their decision-making when selecting: (a) public health interventions; (b) strategies to support their implementation; and (c) to assess the differences in research outcome preferences between policy-makers and practitioners.

METHOD

An online value-weighting survey was conducted with Australian public health policy-makers and practitioners working in the field of non-communicable disease prevention. Participants were presented with a list of research outcomes and were asked to select up to five they considered most critical to their decision-making. They then allocated 100 points across these - allocating more points to outcomes perceived as more important. Outcome lists were derived from a review and consolidation of evaluation and outcome frameworks in the fields of public health knowledge translation and implementation. We used descriptive statistics to report relative preferences overall and for policy-makers and practitioners separately.

RESULTS

Of the 186 participants; 90 primarily identified as policy-makers and 96 as public health prevention practitioners. Overall, research outcomes of effectiveness, equity, feasibility, and sustainability were identified as the four most important outcomes when considering either interventions or strategies to implement them. Scores were similar for most outcomes between policy-makers and practitioners.

CONCLUSION

For Australian policy-makers and practitioners working in the field of non-communicable disease prevention, outcomes related to effectiveness, equity, feasibility, and sustainability appear particularly important to their decisions about the interventions they select and the strategies they employ to implement them. The findings suggest researchers should seek to meet these information needs and prioritize the inclusion of such outcomes in their research and dissemination activities. The extent to which these outcomes are critical to informing the decision of policy-makers and practitioners working in other jurisdictions or contexts warrants further investigation.

Assessing the properties of patient-specific treatment effect estimates from causal forest algorithms under essential heterogeneity

BACKGROUND

Treatment variation from observational data has been used to estimate patient-specific treatment effects. Causal Forest Algorithms (CFAs) developed for this task have unknown properties when treatment effect heterogeneity from unmeasured patient factors influences treatment choice - essential heterogeneity.

METHODS

We simulated eleven populations with identical treatment effect distributions based on patient factors. The populations varied in the extent that treatment effect heterogeneity influenced treatment choice. We used the generalized random forest application (CFA-GRF) to estimate patient-specific treatment effects for each population. Average differences between true and estimated effects for patient subsets were evaluated.

RESULTS

CFA-GRF performed well across the population when treatment effect heterogeneity did not influence treatment choice. Under essential heterogeneity, however, CFA-GRF yielded treatment effect estimates that reflected true treatment effects only for treated patients and were on average greater than true treatment effects for untreated patients.

CONCLUSIONS

Patient-specific estimates produced by CFAs are sensitive to why patients in real-world practice make different treatment choices. Researchers using CFAs should develop conceptual frameworks of treatment choice prior to estimation to guide estimate interpretation ex post.

The Digital Therapeutics Real-World Evidence Framework: An Approach for Guiding Evidence-Based Digital Therapeutics Design, Development, Testing, and Monitoring

Digital therapeutics (DTx) are a promising way to provide safe, effective, accessible, sustainable, scalable, and equitable approaches to advance individual and population health. However, developing and deploying DTx is inherently complex in that DTx includes multiple interacting components, such as tools to support activities like medication adherence, health behavior goal-setting or self-monitoring, and algorithms that adapt the provision of these according to individual needs that may change over time. While myriad frameworks exist for different phases of DTx development, no single framework exists to guide evidence production for DTx across its full life cycle, from initial DTx development to long-term use. To fill this gap, we propose the DTx real-world evidence (RWE) framework as a pragmatic, iterative, milestone-driven approach for developing DTx. The DTx RWE framework is derived from the 4-phase development model used for behavioral interventions, but it includes key adaptations that are specific to the unique characteristics of DTx. To ensure the highest level of fidelity to the needs of users, the framework also incorporates real-world data (RWD) across the entire life cycle of DTx development and use. The DTx RWE framework is intended for any group interested in developing and deploying DTx in real-world contexts, including those in industry, health care, public health, and academia. Moreover, entities that fund research that supports the development of DTx and agencies that regulate DTx might find the DTx RWE framework useful as they endeavor to improve how DTxcan advance individual and population health.

Co-Production of a Flexibly Delivered Relapse Prevention Tool to Support the Self-Management of Long-Term Mental Health Conditions: Co-Design and User Testing Study

BACKGROUND

Supported self-management interventions, which assist individuals in actively understanding and managing their own health conditions, have a robust evidence base for chronic physical illnesses, such as diabetes, but have been underused for long-term mental health conditions.

OBJECTIVE

This study aims to co-design and user test a mental health supported self-management intervention, My Personal Recovery Plan (MyPREP), that could be flexibly delivered via digital and traditional paper-based mediums.

METHODS

This study adopted a participatory design, user testing, and rapid prototyping methodologies, guided by 2 frameworks: the 2021 Medical Research Council framework for complex interventions and an Australian co-production framework. Participants were aged ≥18 years, self-identified as having a lived experience of using mental health services or working in a peer support role, and possessed English proficiency. The co-design and user testing processes involved a first round with 6 participants, focusing on adapting a self-management resource used in a large-scale randomized controlled trial in the United Kingdom, followed by a second round with 4 new participants for user testing the co-designed digital version. A final round for gathering qualitative feedback from 6 peer support workers was conducted. Data analysis involved transcription, coding, and thematic interpretation as well as the calculation of usability scores using the System Usability Scale.

RESULTS

The key themes identified during the co-design and user testing sessions were related to (1) the need for self-management tools to be flexible and well-integrated into mental health services, (2) the importance of language and how language preferences vary among individuals, (3) the need for self-management interventions to have the option of being supported when delivered in services, and (4) the potential of digitization to allow for a greater customization of self-management tools and the development of features based on individuals' unique preferences and needs. The MyPREP paper version received a total usability score of 71, indicating C+ or good usability, whereas the digital version received a total usability score of 85.63, indicating A or excellent usability.

CONCLUSIONS

There are international calls for mental health services to promote a culture of self-management, with supported self-management interventions being routinely offered. The resulting co-designed prototype of the Australian version of the self-management intervention MyPREP provides an avenue for supporting self-management in practice in a flexible manner. Involving end users, such as consumers and peer workers, from the beginning is vital to address their need for personalized and customized interventions and their choice in how interventions are delivered. Further implementation-effectiveness piloting of MyPREP in real-world mental health service settings is a critical next step.

Design, implementation, and inferential issues associated with clinical trials that rely on data in electronic medical records: a narrative review

Real world evidence is now accepted by authorities charged with assessing the benefits and harms of new therapies. Clinical trials based on real world evidence are much less expensive than randomized clinical trials that do not rely on "real world evidence" such as contained in electronic health records (EHR). Consequently, we can expect an increase in the number of reports of these types of trials, which we identify here as 'EHR-sourced trials.' 'In this selected literature review, we discuss the various designs and the ethical issues they raise. EHR-sourced trials have the potential to improve/increase common data elements and other aspects of the EHR and related systems. Caution is advised, however, in drawing causal inferences about the relationships among EHR variables. Nevertheless, we anticipate that EHR-CTs will play a central role in answering research and regulatory questions.

Designing a virtual mental health consultation program to support and strengthen childcare centers impacted by COVID-19: A randomized controlled trial protocol

BACKGROUND

The COVID-19 pandemic has had negative psychosocial impacts on young children; teachers in childcare centers continue to be overwhelmed by how to address the downstream psychological effects children are experiencing. This randomized controlled trial will study the role of a community-based, childcare center-support system in improving resilience and mitigating the long-term impacts of COVID-19 on children's development.

METHODS

This study will be modeled on a successful Early Childhood Mental Health Consultation (ECMHC) intervention which utilizes mental health consultants to deliver a Jump Start+: COVID 19 Support (JS + CS) virtual toolkit to childcare centers in Miami-Dade County via a Kubi robot. The toolkit comprises four strength-based strategies likely to be effective in improving resiliency following disasters: Safety Planning, Effective Communication, Adult Self-Care, and Trauma-Informed Behavior Support. Our first aim will utilize a cluster randomized trial to examine the effectiveness of JS + CS on improving the psychosocial functioning of young children, as compared to an obesity prevention intervention control group. Children will be followed at 6, 12, 18, and 24 months. The second aim will examine the mechanisms that contribute to effective uptake by teachers of the JS + CS support strategies on child outcomes. The third aim will explore implementation barriers/facilitators as well as potential societal contextual factors (e.g., vaccine uptake) to help centers serving disproportionately affected minority communities recover from and prepare for future crises.

CONCLUSION

This design will inform the refinement and scaling of JS + CS and generalize impacts to other childcare center interventions in the context of disasters.

Which strategies support the effective use of clinical practice guidelines and clinical quality registry data to inform health service delivery? A systematic review

BACKGROUND

Empirical evidence suggests data and insights from the clinical practice guidelines and clinical quality registries are not being fully utilised, leaving health service managers, clinicians and providers without clear guidance on how best to improve healthcare delivery. This lack of uptake of existing research knowledge represents low value to the healthcare system and needs to change.

METHODS

Five electronic databases (MEDLINE, Embase, CINAHL, Cochrane Central and Cochrane Database of Systematic Reviews) were systematically searched. Included studies were published between 2000 and 2020 reporting on the attributes, evidence usage and impact of clinical practice guidelines and clinical quality registries on health service delivery.

RESULTS

Twenty-six articles including one randomised controlled trial, eight before-and-after studies, eight case studies/reviews, five surveys and four interview studies, covering a wide range of medical conditions and conducted in the USA, Australia and Europe, were identified. Five complementary strategies were derived to maximise the likelihood of best practice health service delivery: (1) feedback and transparency, (2) intervention sustainability, (3) clinical practice guideline adherence, (4) productive partnerships and (5) whole-of-team approach.

CONCLUSION

These five strategies, used in context-relevant combinations, are most likely to support the application of existing high-quality data, adding value to health service delivery. The review highlighted the limitations of study design in opportunistic registry studies that do not produce clear, usable evidence to guide changes to health service implementation practices. Recommendations include exploration of innovative methodologies, improved coordination of national registries and the use of incentives to encourage guideline adherence and wider dissemination of strategies used by successful registries.

Methods to improve the translation of evidence-based interventions: A primer on dissemination and implementation science for occupational safety and health researchers and practitioners

Objective

A limited focus on dissemination and implementation (D&I) science has hindered the uptake of evidence-based interventions (EBIs) that reduce workplace morbidity and mortality. D&I science methods can be used in the occupational safety and health (OSH) field to advance the adoption, implementation, and sustainment of EBIs for complex workplaces. These approaches should be responsive to contextual factors, including the needs of partners and beneficiaries (such as employers, employees, and intermediaries).

Methods

By synthesizing seminal literature and texts and leveraging our collective knowledge as D&I science and/or OSH researchers, we developed a D&I science primer for OSH. First, we provide an overview of common D&I terminology and concepts. Second, we describe several key and evolving issues in D&I science: balancing adaptation with intervention fidelity and specifying implementation outcomes and strategies. Next, we review D&I theories, models, and frameworks and offer examples for applying these to OSH research. We also discuss widely used D&I research designs, methods, and measures. Finally, we discuss future directions for D&I science application to OSH and provide resources for further exploration.

Results

We compiled a D&I science primer for OSH appropriate for practitioners and evaluators, especially those newer to the field.

Conclusion

This article fills a gap in the OSH research by providing an overview of D&I science to enhance understanding of key concepts, issues, models, designs, methods and measures for the translation into practice of effective OSH interventions to advance the safety, health and well-being of workers.

Examining the sustainability and effectiveness of co-created physical activity interventions in vocational education and training: a multimethod evaluation

Background

Co-creation approaches are increasingly used in physical activity promotion to develop interventions tailored to the target group and setting. The resulting complexity of such interventions raises challenges in evaluation. Accordingly, little is known about the effectiveness of co-created interventions and the underlying processes that impact their sustainable implementation. In this study, we attempt to fill this gap by evaluating co-created multi-component physical activity interventions in vocational education and training in nursing care and automotive mechatronics regarding (1) their sustainable implementation at the institutional level and (2) the effectiveness of single intervention components at the individual level.

Methods

Following a multimethod design, we conducted a questionnaire survey (n = 7) and semi-structured interviews (n = 4) to evaluate the sustainability of the interventions. Quantitative data were analyzed descriptively, and qualitative data were analyzed using qualitative content analysis. To examine the interventions’ effectiveness, we conducted two non-randomized controlled trials (n = 111). Analysis of variance was used to examine differences between groups.

Results

At the institutional level, long-term implementation of single intervention components in nursing care was observed; in contrast, long-term implementation in automotive mechatronics was not observed. In this context, various factors at the outer contextual (e.g., COVID-19 pandemic), inner contextual (e.g., health-promoting leadership), intervention (e.g., acceptance), and personal levels (e.g., champion) influenced sustainability. At the individual level, no significant intervention effects were found for changes in physical activity behavior and physical activity-related health competence.

Conclusion

The role of co-creation on the effectiveness and sustainability of physical activity promotion in vocational education and training cannot be answered conclusively. Only in the nursing care sector, a co-creation approach appeared promising for long-term intervention implementation. Sustainable implementation depends on various influencing factors that should be considered from the outset. Demonstrating effectiveness at the individual level was challenging. To conclusively clarify both the role and impact of co-creation, methodologically complex and elaborate evaluation designs will be required in future research projects.

Trial registration

This study was retrospectively registered at clinicaltrials.gov on 24/08/2021 (NCT05018559).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13133-9.

Introducing the Practice Dive Approach: an extension of co-creation in physical activity promotion and health promotion

Recently, there has been increasing interest in co-creation utilized for physical activity (PA) promotion and health promotion. Co-creation involves researchers and non-academic stakeholders conjointly developing and implementing interventions. In addition to the frequently reported benefits of co-creation, critical voices highlight the associated challenges (e.g. different interests that inhibit interaction). So far, research has not identified concrete solutions to these challenges and the limitations of co-creation. This article aims to introduce the Practice Dive Approach as a potential way to strengthen cooperation between researchers and non-academic stakeholders. We build on real-life experiences from a German research project, in which researchers moved into practice to familiarize themselves with the settings and end-users. After conducting a literature search on related concepts in PA/health promotion, we developed a comprehensive approach to fostering multi-sectoral cooperation. The introduced Practice Dive Approach assumes that a significant contribution to better cooperation among co-creators is the temporal immersion of researchers in their setting of interest, which has the potential to improve the success of co-creation in the PA/health promotion field. A four-level typology characterizes the intensity of researcher interactions with the setting and the non-academic stakeholders. Potential beneficial effects for both researchers and non-academic stakeholders can be hypothesized (e.g. familiarity with the setting structures and increased understanding of the end-users), while simultaneously, some challenges need to be considered. Future research should aim to validate the concept and its postulated effects.

Collaboration among researchers and non-academic stakeholders is increasingly used to promote physical activity and health. For example, people involved in such collaborations jointly develop new interventions. Potential challenges include different interests or work routines that can complicate cooperation. This article aims to introduce the Practice Dive Approach as a potential way to improve cooperation between researchers and non-academic stakeholders. We developed the approach based on observations from a German research project and a literature search on related concepts. This approach assumes that the temporal involvement of researchers in their setting of interest can strengthen research-practice cooperation and improve its success. We describe different types of a Practice Dive and the requirements for conducting Practice Dive activities. Furthermore, we present the potential effects of a Practice Dive for the researchers and the non-academic stakeholders, such as increased familiarity between both groups. However, some challenges need to be considered when applying the Practice Dive Approach. Future research should test this approach and its potential effects.

Assessment of the Feasibility, Acceptability, and Impact of Implementing Seasonal Malaria Chemoprevention in Nampula Province, Mozambique: Protocol for a Hybrid Effectiveness-Implementation Study

Background

Malaria is a significant cause of morbidity and mortality in children aged under 5 years in Mozambique. The World Health Organization recommends seasonal malaria chemoprevention (SMC), the administration of four monthly courses of sulfadoxine-pyrimethamine (SP) and amodiaquine (AQ), to children aged 3-59 months during rainy season. However, as resistance to SP is widespread in East and Southern Africa, SMC has so far only been implemented across the Sahel in West Africa.

Objective

This protocol describes the first phase of a pilot project that aims to assess the protective effect of SP and AQ when used for SMC and investigate the levels of molecular markers of resistance of Plasmodium falciparum to antimalarial medicines in the study districts. In addition, it is important to understand whether SMC is a feasible and acceptable intervention in the context of Nampula Province, Mozambique.

Methods

This study will adopt a hybrid effectiveness-implementation design to conduct a mixed methods evaluation with six objectives: a molecular marker study, a nonrandomized controlled trial, an analysis of reported malaria morbidity indicators, a documentation exercise of the contextual SMC adaptation, an acceptability and feasibility assessment, and a coverage and quality assessment.

Results

Ethical approval for this study was granted by the Mozambican Ministry of Health National Bioethics Committee on September 15, 2020. Data collection began in October 2020, and data analysis is expected to be completed by August 2021.

Conclusions

This research will make a unique contribution to our understanding of whether the combination of SP and AQ, when used for SMC, can confer a protective effect against malaria in children aged 3-59 months in a region where malaria transmission is seasonal and SP resistance is expected to be high. If the project is successful, subsequent phases are expected to provide a more comprehensive assessment of the effectiveness and sustainability of SMCs.

International Registered Report Identifier (IRRID)

DERR1-10.2196/27855

Social Modeling and Eating Behavior-A Narrative Review

Social modeling of eating is the adjustment of the amount of food eaten to the intake of the accompanying person. In this paper we provide a narrative review of literature on social modeling of eating with a particular focus on recent studies. Firstly, we describe the structure of a typical modeling experiment. Secondly, we present a variety of research in this field: experiments with various types of confederates, experiments aimed at the evaluation of the influence of gender, partner’s body weight, type of food, hunger, personal characteristics, etc. Thirdly, we present practical implications of this knowledge. The common conclusion is that social modeling of eating occurs in different situations and consumption is adapted to the standards established by the eating partner, but is not their direct reflection. Social influence of eating is not restricted to "artificial" laboratory situations; social modeling and social norms manipulations may be used to change people’s dietary practices, especially in children and young adults. Within the home environment parental modeling has been shown to promote children’s snacking and fruit and vegetable consumption. Social modeling may be used in nutrition interventions aimed at the improvement of children’s diet and in obesity prevention programs.

App-Based Salt Reduction Intervention in School Children and Their Families (AppSalt) in China: Protocol for a Mixed Methods Process Evaluation

Background

The app-based salt reduction intervention program in school children and their families (AppSalt) is a multicomponent mobile health (mHealth) intervention program, which involves multiple stakeholders, including students, parents, teachers, school heads, and local health and education authorities. The complexity of the AppSalt program highlights the need for process evaluation to investigate how the implementation will be achieved at different sites.

Objective

This paper presents a process evaluation protocol of the AppSalt program, which aims to monitor the implementation of the program, explain its causal mechanisms, and provide evidence for scaling up the program nationwide.

Methods

A mixed methods approach will be used to collect data relating to five process evaluation dimensions: fidelity, dose delivered, dose received, reach, and context. Quantitative data, including app use logs, activity logs, and routine monitoring data, will be collected alongside the intervention process to evaluate the quantity and quality of intervention activities. The quantitative data will be summarized as medians, means, and proportions as appropriate. Qualitative data will be collected through semistructured interviews of purposely selected intervention participants and key stakeholders from local health and education authorities. The thematic analysis technique will be used for analyzing the qualitative data with the support of NVivo 12. The qualitative data will be triangulated with the quantitative data during the interpretation phase to explain the 5 process evaluation dimensions.

Results

The intervention activities of the AppSalt program were initiated at 27 primary schools in three cities since October 2018. We have completed the 1-year intervention of this program. The quantitative data for this study, including app use log, activity logs, and the routine monitoring data, were collected and organized during the intervention process. After completing the intervention, we conducted semistructured interviews with 32 students, 32 parents, 9 teachers, 9 school heads, and 8 stakeholders from local health and education departments. Data analysis is currently underway.

Conclusions

Using mHealth technology for salt reduction among primary school students is an innovation in China. The findings of this study will help researchers understand the implementation of the AppSalt program and similar mHealth interventions in real-world settings. Furthermore, this process evaluation will be informative for other researchers and policy makers interested in replicating the AppSalt program and designing their salt reduction intervention.

International Registered Report Identifier (IRRID)

DERR1-10.2196/19430

The Complex Quest of Preventing Obesity in Early Childhood: Describing Challenges and Solutions Through Collaboration and Innovation

Childhood obesity remains a major public health issue and priority area for action. Promisingly, obesity prevention interventions in the first 2000 days of life have shown modest effectiveness in improving health behaviours and healthy weight status in children. Yet, researchers in this field face several challenges. This can lead to research waste and impede progress towards delivering effective, scalable solutions. In this perspective article, we describe some of the key challenges in early childhood obesity prevention and outline innovative and collaborative solutions to overcome these. Combining these solutions will accelerate the generation of high-quality evidence that can be implemented into policy and practice.

A digital mental health intervention to reduce depressive symptoms among overseas Filipino workers: protocol for a pilot hybrid type 1 effectiveness-implementation randomized controlled trial

Background

The current pilot randomized controlled trial (RCT) protocol will comprehensively describe the implementation of a culturally adapted Filipino version of the World Health Organization Step-by-Step (SbS-F) program, unguided online psychological intervention for people with depression based on behavioral activation, among overseas Filipino workers (OFWs) in Macao (Special Administrative Region). The main objective of this pilot study is to explore the preliminary effectiveness of the SbS-F program to decrease participant-reported depressive symptoms compared to enhanced care as usual (ECAU); and the secondary objectives are to explore the preliminary effectiveness of the SbS-F to decrease participant-reported anxiety symptoms and improve wellbeing, and to evaluate the potential for SbS-F implementation in real-world settings.

Methods

This trial will follow an effectiveness-implementation hybrid type 1 trial design and utilize the Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to accelerate the translation of clinical research into more effective implementation strategies and policies. Participants will be randomized 1:1 to control and treatment groups. Control group participants will receive ECAU that consists of brief depression psychoeducation and referral to local community partners. Treatment group participants will receive a 5-session of digital intervention through a mobile phone application. The primary outcome (depression) and psychological secondary outcomes (anxiety symptoms and wellbeing) will be measured using validated instruments. To evaluate study implementation, an embedded mixed-methods design will be used to collect data from various stakeholders. Data then will be analyzed using intention to treat principle and reported following the Consolidated Standards of Reporting Trials (CONSORT) guideline.

Discussion

This study will provide important new knowledge about the preliminary effectiveness of SbS-F, a mobile application, as a digital mental health intervention and its scalability. If SbS-F shows positive results among OFWs in Macao, it has strong potential to be used by OFWs in other countries that may also experience depression and difficulty accessing mental health services.

Trial registration

Prospective registration, Chinese Clinical Trial Registry (ChiCTR2000034959) on 26/07/2020.

A pilot randomised controlled trial of a web-based implementation intervention to increase child intake of fruit and vegetables within childcare centres

Background

As dietary behaviours developed during early childhood are known to track into adulthood, interventions that aim to improve child nutrition at a population level are recommended. Whilst early childhood education and care (ECEC) is a promising setting for interventions targeting children’s nutrition behaviours, previous interventions have largely used high intensity, face-to-face approaches, limiting their reach, implementation and potential impact at a population level. Web-based modalities represent a promising means of supporting the delivery of childcare-based interventions whilst overcoming challenges of previous approaches; however, the feasibility of using such modalities to support implementation is largely unknown. As such, this study sought to collect feasibility and pilot data to inform the design of a web-based intervention together with health promotion officer support within childcare centres. Child dietary intake will also be assessed to provide an estimate of the impact of the implementation intervention.

Methods

A superiority cluster randomised controlled trial with repeat cross-sectional data collection employing an effectiveness-implementation type-II hybrid design will be conducted with childcare centres within the Hunter New England region of New South Wales, Australia. Type-II hybrid designs provide the opportunity to assess intervention efficacy whilst piloting the feasibility of the implementation strategies. Centres allocated to the intervention group will receive access to a web-based program together with health promotion officer support to implement targeted healthy eating practices to improve child diet in care. A number of outcomes will be assessed to inform the feasibility to conduct a larger trial, including childcare centre and parent recruitment and consent rates for each component of data collection, uptake of the implementation strategies, acceptability of the intervention and implementation strategies, appropriateness of the implementation strategies and the contextual factors influencing implementation.

Discussion

This study will provide high-quality evidence regarding the potential feasibility of a web-based intervention and the impact of healthy eating practices on child diet in care. Web-based modalities provide a promising approach for population-wide implementation support to childcare centres given their potential reach and consistency with existing infrastructure.

Trial registration

Prospectively registered with Australian New Zealand Clinical Trial Registry (ACTRN12619001158156).

Supplementary Information

Supplementary information accompanies this paper at 10.1186/s40814-020-00707-w.

Importance of congruence between communicating and executing implementation programmes: a qualitative study of focus group interviews

Background

The Ostrobothnia Depression Programme (ODP) in Finland was intended to implement two evidence-based brief psychotherapy interventions, namely motivational interview and behavioural activation, in several regional psychiatric teams. A simultaneous effectiveness study was conducted. Considerable tension was encountered between these two arms, causing resistance to change. We conducted a qualitative case study to better understand this tension and to discuss how managerial and executive practices may ensure the successful running of a hybrid design programme.

Methods

We conducted focus group interviews to evaluate the phases of preparation and practical execution of the ODP from the perspectives of management and the programme executives. To gather the data, we applied the revised Socratic approach for health technology assessment and focus group interviews. We analysed the data deductively according to the Normalization Process Theory.

Results

We identified two main critical issues: (1) The ODP programme plan ignored the team leaders’ crucial role in influencing the implementation climate and mobilizing organizational strategies. The ODP had a simplistic top-down design with minimal and delayed collaboration with its target groups in the preparation phase. (2) Incongruence occurred between what the project group had explicitly communicated about being the spearhead of the ODP and what they then actually enacted. These two issues caused tension between the implementation efforts and the effectiveness study as well as resistance to change among the staff.

Conclusion

Early, open collaboration with all prospective stakeholders towards a shared understanding about the programme is the first action the programme administrators should take. Agreement on goals and the means to achieve them would lower tension between the two arms of a hybrid design programme, thereby reducing resistance to change. Congruence between the goals communicated and the actual managerial and executive actions is of paramount importance in getting the programme recipients on board.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-020-00090-w.

Lifestyle behaviors and related health risk factors in a sample of Australian university students

Objective: To describe lifestyle behaviors (fruit and vegetable intake, alcohol intake, physical activity, sitting time, smoking, drug use, sleep, sexual health) and health risk factors (body mass index, food insecurity, mental health) in a sample of Australian university students. Participants: 3,077 students from the University of Newcastle (UON), Australia (mean age 27.1 ± 9.8 years, 69.4% female) were surveyed in September-October 2017. Methods: Cross-sectional self-report survey, the UON Student Healthy Lifestyle Survey 2017. Results: Participants with unhealthy lifestyle behaviors included; 89.5% not meeting vegetable recommendations, 50.3% exceeding lifetime risk guidelines for alcohol intake, and 38.1% insufficiently physically active. Rates of health risk factors included; 39.6% overweight/obese, 37.6% high or very high risk of psychological distress, and 22.0% food insecure. Conclusions: Rates of unhealthy lifestyle behaviors and related health risk factors were high within the study population, highlighting the importance of ongoing monitoring and prioritization of effective strategies to improve university student health.

An Implementation Science Framework to Develop a Clinical Decision Support Tool for Familial Hypercholesterolemia

Electronic health record (EHR)-based clinical decision support (CDS) can address the low awareness and undertreatment of familial hypercholesterolemia (FH), a disorder associated with a markedly increased risk of coronary heart disease. We aimed to incorporate provider perspectives into the development and implementation of a CDS tool for FH. An implementation science framework and a user-centered design process were used to create a CDS tool for FH. Primary care physicians and specialist physicians participated in qualitative interviews, usability testing and an implementation survey. The CDS was configured in two formats—a best practice alert (BPA) and an in-basket message and subsequently deployed in the EHR in silent mode. The key themes that emerged from the analysis of interview transcripts included understanding and awareness of FH, clinical workflow, physician preferences and value of CDS tools, perspectives on patient needs and values and dissemination and implementation. Recommendations related to usability included preferred CDS format and placement, content, timing and frequency, and level of alert urgency/prioritization. In response to the survey, 84.6% of physicians agreed that the CDS would improve early FH diagnosis and 92.3% agreed that it would help them identify and manage FH patients. Physician feedback led to iterative CDS refinement. In summary, we developed a CDS tool for FH using an implementation science framework and physician feedback. Initial deployment revealed a significant burden of FH and the potential for the CDS tool to have a large impact.

Protocol for a mixed methods process evaluation of a hybrid implementation-effectiveness trial of a scaled-up whole-school physical activity program for adolescents: Physical Activity 4 Everyone (PA4E1)

Background

Physical Activity 4 Everyone (PA4E1) is a physical activity program for secondary schools located in low-socioeconomic areas. Over a 24-month period, schools in the program arm of a cluster randomised controlled trial (n = up to 38 schools) will receive a multi-component implementation support strategy to embed the seven school physical activity practices of the PA4E1 program. This article describes the process evaluation of the PA4E1 hybrid implementation-effectiveness trial. The process evaluation aims to describe the fidelity and reach of the implementation support strategies using quantitative data; and to describe the acceptability, appropriateness and feasibility of the implementation support strategies and physical activity practices to school stakeholders using mixed methods.

Methods

Quantitative and qualitative data will be collected from participants (Physical Education teachers, in-School Champions, students) in the program arm. Data collection will involve semi-structured interviews, focus groups, a fidelity monitoring log, a fidelity checklist, surveys, and routinely collected administrative and website data. Quantitative data will be analysed descriptively and qualitative data will be analysed thematically within and across data sets. Triangulation between data sources will be used to synthesise findings regarding the implementation and potential mechanisms of impact of PA4E1 on school physical activity practice adoption, with respect to context.

Discussion

Results of the process evaluation will facilitate the interpretation of the findings of the trial outcomes. It will comprehensively describe what was actually implemented and identify the potential contribution of the various components of the implementation support strategy to the school physical activity practice adoption outcomes. Findings will inform future improvement and scale-up of PA4E1 and approaches to implementing secondary school-based physical activity programs more broadly.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12617000681358 registered 12 May 2017.

A systematic review of approaches to improve practice, detection and treatment of unhealthy alcohol use in primary health care: a role for continuous quality improvement

BACKGROUND

Unhealthy alcohol use involves a spectrum from hazardous use (exceeding guidelines but no harms) through to alcohol dependence. Evidence-based management of unhealthy alcohol use in primary health care has been recommended since 1979. However, sustained and systematic implementation has proven challenging. The Continuing Quality Improvement (CQI) process is designed to enable services to detect barriers, then devise and implement changes, resulting in service improvements.

METHODS

We conducted a systematic review of literature reporting on strategies to improve implementation of screening and interventions for unhealthy alcohol use in primary care (MEDLINE EMBASE, PsycINFO, CINAHL, the Australian Indigenous Health InfoNet). Additional inclusion criteria were: (1) pragmatic setting; (2) reporting original data; (3) quantitative outcomes related to provision of service or change in practice. We investigate the extent to which the three essential elements of CQI are being used (data-guided activities, considering local conditions; iterative development). We compare characteristics of programs that include these three elements with those that do not. We describe the types, organizational levels (e.g. health service, practice, clinician), duration of strategies, and their outcomes.

RESULTS

Fifty-six papers representing 45 projects were included. Of these, 24 papers were randomized controlled trials, 12 controlled studies and 20 before/after and other designs. Most reported on strategies for improving implementation of screening and brief intervention. Only six addressed relapse prevention pharmacotherapies. Only five reported on patient outcomes and none showed significant improvement. The three essential CQI elements were clearly identifiable in 12 reports. More studies with three essential CQI elements had implementation and follow-up durations above the median; utilised multifaceted designs; targeted both practice and health system levels; improved screening and brief intervention than studies without the CQI elements.

CONCLUSION

Utilizing CQI methods in implementation research would appear to be well-suited to drive improvements in service delivery for unhealthy alcohol use. However, the body of literature describing such studies is still small. More well-designed research, including hybrid studies of both implementation and patient outcomes, will be needed to draw clearer conclusions on the optimal approach for implementing screening and treatment for unhealthy alcohol use. (PROSPERO registration ID: CRD42018110475).

Assessing the Integrated Community-Based Health Systems Strengthening initiative in northern Togo: a pragmatic effectiveness-implementation study protocol

BACKGROUND

Over the past decade, prevalence of maternal and child morbidity and mortality in Togo, particularly in the northern regions, has remained high despite global progress. The causes of under-five child mortality in Togo are diseases with effective and low-cost prevention and/or treatment strategies, including malaria, acute lower respiratory infections, and diarrheal diseases. While Togo has a national strategy for implementing the integrated management of childhood illness (IMCI) guidelines, including a policy on integrated community case management (iCCM), challenges in implementation and low public sector health service utilization persist. There are critical gaps to access and quality of community health systems throughout the country. An integrated facility- and community-based initiative, the Integrated Community-Based Health Systems Strengthening (ICBHSS) initiative, seeks to address these gaps while strengthening the public sector health system in northern Togo. This study aims to evaluate the effect and implementation strategy of the ICBHSS initiative over 48 months in the catchment areas of 21 public sector health facilities.

METHODS

The ICBHSS model comprises a bundle of evidence-based interventions targeting children under five, women of reproductive age, and people living with HIV through (1) community engagement and feedback; (2) elimination of point-of-care costs; (3) proactive community-based IMCI using community health workers (CHWs) with additional services including family planning, HIV testing, and referrals; (4) clinical mentoring and enhanced supervision; and (5) improved supply chain management and facility structures. Using a pragmatic type II hybrid effectiveness-implementation study, we will evaluate the ICBHSS initiative with two primary aims: (1) determine effectiveness through changes in under-five mortality rates and (2) assess the implementation strategy through measures of reach, adoption, implementation, and maintenance. We will conduct a mixed-methods assessment using the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework. This assessment consists of four components: (1) a stepped-wedge cluster randomized control trial using a community-based household survey, (2) annual health facility assessments, (3) key informant interviews, and (4) costing and return-on-investment assessments for each randomized cluster.

DISCUSSION

Our research is expected to contribute to continuous quality improvement initiatives, optimize implementation factors, provide knowledge regarding health service delivery, and accelerate health systems improvements in Togo and more broadly.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT03694366 , registered 3 October 2018.

Accelerating the Pace of Science: Improving Parenting Practices in Parents with Opioid Use Disorder

A public health emergency exists in the United States as a result of rising overdose deaths related to Opioid Use Disorder (OUD). With the rise of OUD has also come an increase in the number of children exposed to parents who suffer from an OUD. There is a pressing need for parenting interventions for individuals with OUD to provide safe environments for the children being reared in the face of this epidemic. Research on parenting with an OUD is sparse, but it is impractical to move linearly from basic research to program development and implementation given the urgent need for intervention - a trajectory that prior research has established takes approximately 17 years. We have created an outline of strategies that can be used to accelerate the pace of science so that parenting practices are more immediately improved for this population. First, we summarize what is already known about OUD and parenting to characterize mechanisms that existing interventions have targeted and optimal settings for the wide dissemination of implementable interventions. Next, we identify existing interventions that either specifically target parents with OUD or mechanisms specific to parents with OUD. We describe four different approaches for accelerating the pace of science to improve the lives of parents with OUD and their children. By doing so, we hope to provide a roadmap for future researchers and practitioners to deliver more timely evidence-based interventions to address the additional burden placed on families and communities due to the rise in OUD in the United States.

Untangling the ethical intersection of epidemiology, human subjects research, and public health

PURPOSE

Members of the American College of Epidemiology (ACE) Ethics Committee identified current ethics and epidemiology topic areas to consider for further discussion, consultation, teaching opportunities, and conference presentation. This article reflects on the activities of the Committee at the ACE Annual Meeting in New Orleans, Louisiana, September 24-26, 2017.

METHODS

The overall aim for the Ethics Committee was to engage members of the College and other audiences and highlight the evolution of ethics and epidemiology since the inception of the original Ethics Guidelines published by the ACE Ethics and Standards of Practice Committee in 2000. The Ethics Committee organized a symposium session at the 2017 Annual Meeting of ACE on the ethics of human subjects research as it relates to specialized areas of epidemiology and the intersecting role of public health. This article presents a summary and further discussion of that symposium session.

RESULTS

Three topic areas were presented: an overview of ethics and epidemiology (E.S.P.), very high biomarker levels in environmental epidemiology research (S.M.P.), and the interface of epidemiology, human subjects research, and public health interventions (S.M.). This article begins by reviewing the foundations of epidemiology and public health and the well-known ethical principles of human subjects research. Then, it considers the ethical considerations in the use of population registry data in epidemiological research, environmental epidemiology, and epidemic surveillance and response. This article may form the basis of teaching of ethics principles related to epidemiology and public health and may serve as a companion piece to the original ACE Ethics Guidelines.

CONCLUSIONS

Researchers are increasingly faced with ethical considerations in diverse, nontraditional, and specialized areas of epidemiology and public health. This article illustrates these challenges with real-world examples of clinical and population registry data, the study of environmental biomarkers, and Zika virus epidemic; it also reviews relevant ethical principles underpinning these examples and identifies where gaps in knowledge may exist.

Barriers and opportunities in the translation of mobile phone and social media interventions between research and health promotion practice in Australia: a qualitative study of expert perspectives

Background

Newer technologies, such as smartphones and social networking sites, offer new opportunities for health promotion interventions. There is evidence to show that these technologies can be effectively and acceptably used for health promotion activities. However, most interventions produced in research do not end up benefitting non-research populations, while the majority of technology-facilitated interventions which are available outside of research settings are either undocumented or have limited or no evidence to support any benefit. We therefore aimed to explore the perspectives of researchers and health promotion experts on efforts to translate technology-facilitated prevention initiatives into practice, and the barriers to achieving translation.

Methods

We utilised a qualitative study design, involving in-depth interviews with researchers experienced with technology-facilitated prevention interventions and prominent health promotion experts.

Results

Some barriers mirror the findings of other studies into health promotion practice, which have found that competing priorities, resource limitations and organisational capacity are important in determining use of evidence in programme planning, engagement in translation and evaluation practice. We add to this literature by describing barriers that are more specifically related to technology-facilitated prevention, such as the pace of developments in technology, and how this clashes with the time taken to develop and ready evidence for translation.

Conclusions

In order to maximise the vast potential of technology-facilitated prevention interventions to promote population health, it is essential that translation is at the forefront of consideration for both researchers and practitioners. We suggest actions that can be taken by both researchers and practitioners to improve translation of technology-facilitated prevention interventions, and also highlight how funding schemes can be modified to facilitate translation.

Identifying opportunities to develop the science of implementation for community-based non-communicable disease prevention: A review of implementation trials

Implementation of interventions in community organisations such as schools, childcare centres, and sporting clubs are recommended to target a range of modifiable risks of non-communicable diseases. Poor implementation, however, is common and has contributed to the failure of non-communicable disease interventions globally. This study aimed to characterise experimental research regarding strategies to improve implementation of chronic disease prevention programs in community settings. The review used data collected in three comprehensive systematic reviews undertaken between August 2015 and July 2017. Randomised controlled trials, including cluster design, and non-randomised trials with a parallel control group were included. The data were extracted to describe trial characteristics, implementation strategies employed, implementation outcomes and study quality. Of the 40 implementation trials included in the study, unhealthy diet was the most common risk factor targeted (n = 20). The most commonly reported implementation strategies were educational meetings (n = 38, 95%), educational materials (n = 36, 90%) and educational outreach visits (n = 29, 73%). Few trials were conducted 'at-scale' (n = 8, 20%) or reported adverse effects (n = 5, 13%). The reporting of implementation related outcomes; intervention adoption (n = 13, 33%); appropriateness (n = 11, 28%); acceptability (n = 8, 20%); feasibility (n = 8, 20%); cost (n = 3, 8%); and sustainability (n = 2, 5%); was limited. For the majority of trials, risk of bias was high for blinding of study personnel/participants and outcome assessors. Testing of strategies to improve implementation of non-communicable disease prevention strategies in community settings, delivered 'at-scale', utilising implementation frameworks, including a comprehensive range of implementation outcomes should be priority areas for future research in implementation science.

Strategies to improve the implementation of workplace-based policies or practices targeting tobacco, alcohol, diet, physical activity and obesity

BACKGROUND

Given the substantial period of time adults spend in their workplaces each day, these provide an opportune setting for interventions addressing modifiable behavioural risk factors for chronic disease. Previous reviews of trials of workplace-based interventions suggest they can be effective in modifying a range of risk factors including diet, physical activity, obesity, risky alcohol use and tobacco use. However, such interventions are often poorly implemented in workplaces, limiting their impact on employee health. Identifying strategies that are effective in improving the implementation of workplace-based interventions has the potential to improve their effects on health outcomes.

OBJECTIVES

To assess the effects of strategies for improving the implementation of workplace-based policies or practices targeting diet, physical activity, obesity, tobacco use and alcohol use.Secondary objectives were to assess the impact of such strategies on employee health behaviours, including dietary intake, physical activity, weight status, and alcohol and tobacco use; evaluate their cost-effectiveness; and identify any unintended adverse effects of implementation strategies on workplaces or workplace staff.

SEARCH METHODS

We searched the following electronic databases on 31 August 2017: CENTRAL; MEDLINE; MEDLINE In Process; the Campbell Library; PsycINFO; Education Resource Information Center (ERIC); Cumulative Index to Nursing and Allied Health Literature (CINAHL); and Scopus. We also handsearched all publications between August 2012 and September 2017 in two speciality journals: Implementation Science and Journal of Translational Behavioral Medicine. We conducted searches up to September 2017 in Dissertations and Theses, the WHO International Clinical Trials Registry Platform, and the US National Institutes of Health Registry. We screened the reference lists of included trials and contacted authors to identify other potentially relevant trials. We also consulted experts in the field to identify other relevant research.

SELECTION CRITERIA

Implementation strategies were defined as strategies specifically employed to improve the implementation of health interventions into routine practice within specific settings. We included any trial with a parallel control group (randomised or non-randomised) and conducted at any scale that compared strategies to support implementation of workplace policies or practices targeting diet, physical activity, obesity, risky alcohol use or tobacco use versus no intervention (i.e. wait-list, usual practice or minimal support control) or another implementation strategy. Implementation strategies could include those identified by the Effective Practice and Organisation of Care (EPOC) taxonomy such as quality improvement initiatives and education and training, as well as other strategies. Implementation interventions could target policies or practices directly instituted in the workplace environment, as well as workplace-instituted efforts encouraging the use of external health promotion services (e.g. gym membership subsidies).

DATA COLLECTION AND ANALYSIS

Review authors working in pairs independently performed citation screening, data extraction and 'Risk of bias' assessment, resolving disagreements via consensus or a third reviewer. We narratively synthesised findings for all included trials by first describing trial characteristics, participants, interventions and outcomes. We then described the effect size of the outcome measure for policy or practice implementation. We performed meta-analysis of implementation outcomes for trials of comparable design and outcome.

MAIN RESULTS

We included six trials, four of which took place in the USA. Four trials employed randomised controlled trial (RCT) designs. Trials were conducted in workplaces from the manufacturing, industrial and services-based sectors. The sample sizes of workplaces ranged from 12 to 114. Workplace policies and practices targeted included: healthy catering policies; point-of-purchase nutrition labelling; environmental supports for healthy eating and physical activity; tobacco control policies; weight management programmes; and adherence to guidelines for staff health promotion. All implementation interventions utilised multiple implementation strategies, the most common of which were educational meetings, tailored interventions and local consensus processes. Four trials compared an implementation strategy intervention with a no intervention control, one trial compared different implementation interventions, and one three-arm trial compared two implementation strategies with each other and a control. Four trials reported a single implementation outcome, whilst the other two reported multiple outcomes. Investigators assessed outcomes using surveys, audits and environmental observations. We judged most trials to be at high risk of performance and detection bias and at unclear risk of reporting and attrition bias.Of the five trials comparing implementation strategies with a no intervention control, pooled analysis was possible for three RCTs reporting continuous score-based measures of implementation outcomes. The meta-analysis found no difference in standardised effects (standardised mean difference (SMD) -0.01, 95% CI -0.32 to 0.30; 164 participants; 3 studies; low certainty evidence), suggesting no benefit of implementation support in improving policy or practice implementation, relative to control. Findings for other continuous or dichotomous implementation outcomes reported across these five trials were mixed. For the two non-randomised trials examining comparative effectiveness, both reported improvements in implementation, favouring the more intensive implementation group (very low certainty evidence). Three trials examined the impact of implementation strategies on employee health behaviours, reporting mixed effects for diet and weight status (very low certainty evidence) and no effect for physical activity (very low certainty evidence) or tobacco use (low certainty evidence). One trial reported an increase in absolute workplace costs for health promotion in the implementation group (low certainty evidence). None of the included trials assessed adverse consequences. Limitations of the review included the small number of trials identified and the lack of consistent terminology applied in the implementation science field, which may have resulted in us overlooking potentially relevant trials in the search.

AUTHORS' CONCLUSIONS

Available evidence regarding the effectiveness of implementation strategies for improving implementation of health-promoting policies and practices in the workplace setting is sparse and inconsistent. Low certainty evidence suggests that such strategies may make little or no difference on measures of implementation fidelity or different employee health behaviour outcomes. It is also unclear if such strategies are cost-effective or have potential unintended adverse consequences. The limited number of trials identified suggests implementation research in the workplace setting is in its infancy, warranting further research to guide evidence translation in this setting.

Strategies to improve the implementation of policies, practices or programmes in sporting organisations targeting poor diet, physical inactivity, obesity, risky alcohol use or tobacco use: a systematic review

OBJECTIVES

The primary aim for this review is to determine the effectiveness of strategies to improve the implementation of policies, practices or programmes in sporting organisations. The secondary aims are to describe the cost or cost-effectiveness and adverse effects of such strategies and to examine the effects of those implementation strategies on individual's diet, physical activity, obesity, alcohol use or tobacco use.

METHODS

We conducted searches of academic databases (eg, MEDLINE, EMBASE and CENTRAL), trial registers and hand searches of selected journals. Studies were included if they were conducted at a sporting venue; described a strategy to improve implementation of policies, practices or programmes focusing on one or more health risks (diet, physical inactivity, obesity, alcohol or tobacco use), and included a parallel control group. Two authors independently screened citations and extracted data. The results of included studies were synthesised narratively.

RESULTS

Of the 5926 citations screened three studies met the inclusion criteria. Two studies were randomised controlled trials. Two studies sought to improve the implementation of nutrition-related policy and practices and one study sought to improve implementation of alcohol-related policy and practices. Each study reported improvement in at least one measure of policy or practice implementation. Two studies reported individual-level outcomes and found a reduction in excessive alcohol consumption and an increase in purchase of fruits and vegetables at the sports club ground. Two studies assessed club revenue as a potential adverse effect, neither reported significant between-group differences on these measures.

CONCLUSION

There is a sparse evidence base regarding the effectiveness of strategies to improve the implementation of policies, practices or programmes targeting chronic disease risk factors in sporting clubs. While all studies reported some improvements in implementation, for some multistrategic implementation strategies it is difficult to determine the extent to which such effects are generalisable.

PROSPERO REGISTRATION NUMBER

CRD42016039490.

The influence of contextual factors on implementation fidelity in a whole school approach to prevention of violence against women

ISSUE ADDRESSED

Implementation fidelity relates to the degree of adherence to implementation protocols and content and helps to guide replication of evidence-based programs. In settings-based research, notions of fidelity have been applied more often to delivery of education content rather than whole of setting change. The aims of this paper were firstly, to analyse how contextual factors influenced implementation of a whole school program on respectful relationships education, and secondly given the findings, discuss whether a more flexible approach to implementation fidelity may have yielded increased school engagement.

METHODS

The project was conducted in 19 secondary schools in Victoria in 2015. This paper reports on focus groups and interviews which were conducted with 81 school staff and 28 staff from the lead agency, community agency partners, and departmental staff to understand the contextual factors influencing implementation.

RESULTS

The program followed a traditional implementation fidelity approach of considering core elements and some minor scope for adaption which engaged some regions and schools but not others.

CONCLUSION

An alternative notion of implementation fidelity, "fidelity to function," may have permitted increased flexibility to tailor the intervention components to suit different school and community contexts and potentially, increasing both the reach and impact of the program. SO WHAT?: Understanding how to apply notions of fidelity to guide whole of setting change are important considerations if programs are to be replicated to have wider reach and greater impact and effectiveness.

Communicating health-Optimising young adults' engagement with health messages using social media: Study protocol

BACKGROUND

Obesity is a global health problem. Understanding how to utilise social media (SM) as a platform for intervention and engagement with young adults (YAs) will help the practitioners to harness this media more effectively for obesity prevention.

AIM

Communicating health (CH) aims to understand the use of SM by YAs, including Aboriginal YAs, and in doing so will improve the effectiveness of SM strategies to motivate, engage and retain YAs in interventions to reduce the risk of obesity, and identify and disseminate effective ways for health professionals to deliver obesity prevention interventions via SM.

METHODS

The present study describes the theoretical framework and methodologies for the CH study, which is organised into four interrelated phases, each building on the outcomes of preceding phases. Phase 1 is a mixed methods approach to understand how YAs use SM to navigate their health issues, including healthy eating. Phase 2 utilises co-creation workshops where YAs and public health practitioners collaboratively generate healthy eating messages and communication strategies. Phase 3 evaluates these messages in a real-world setting. Phase 4 is the translation phase where public health practitioners use outcomes from CH to inform future strategies and to develop tools for SM for use by stakeholders and the research community.

DISCUSSION

The outcomes will include a rich understanding of psychosocial drivers and behaviours associated with healthy eating and will provide insight into the use of SM to reach and influence the health and eating behaviours of YAs.

Organizational determinants of evaluation practice in Australian prevention agencies

Program evaluation is essential to inform decision making, contribute to the evidence base for strategies, and facilitate learning in health promotion and disease prevention organizations. Theoretical frameworks of organizational learning, and studies of evaluation capacity building describe the organization as central to evaluation capacity. Australian prevention organizations recognize limitations to current evaluation effectiveness and are seeking guidance to build evaluation capacity. This qualitative study identifies organizational facilitators and barriers to evaluation practice, and explores their interactions in Australian prevention organizations. We conducted semi-structured interviews with 40 experienced practitioners from government and non-government organizations. Using thematic analysis, we identified seven key themes that influence evaluation practice: leadership, organizational culture, organizational systems and structures, partnerships, resources, workforce development and training and recruitment and skills mix. We found organizational determinants of evaluation to have multi-level interactions. Leadership and organizational culture influenced organizational systems, resource allocation and support of staff. Partnerships were important to overcome resource deficits, and systems were critical to embed evaluation within the organization. Organizational factors also influenced the opportunities for staff to develop skills and confidence. We argue that investment to improve these factors would allow organizations to address evaluation capacity at multiple levels, and ultimately facilitate effective evaluation practice.

Cluster randomised controlled trial of a multicomponent intervention to support the implementation of policies and practices that promote healthier environments at junior sports clubs: study protocol

INTRODUCTION

A large proportion of children and adolescents participate in organised sport, making community sports clubs a promising setting to support healthy behaviours. To date, however, there have been few interventions conducted in junior sports clubs that have targeted health-promoting practices. The primary aim of this pilot study is to assess the potential effectiveness of an intervention to implement health-promoting policies and practices in junior sporting clubs targeting alcohol and tobacco practices, healthy food and beverage availability, and physical activity via participation in sport. A secondary outcome is to assess the impact of such strategies on child exposure to alcohol and tobacco use at the club, purchasing behaviours by/for children at the club canteen and child sports participation opportunities.

METHODS AND ANALYSIS

The study will employ a cluster randomised controlled trial design and be conducted in metropolitan and regional areas of two Australian states. Randomisation will occur at the level of the football league. Community football clubs with over 40 junior players (players under 18 years) within each league will be eligible to participate. The intervention will be developed based on frameworks that consider the social, cultural and environmental factors that influence health behaviours. Intervention clubs will be supported to implement 16 practices targeting alcohol management, tobacco use, nutrition practices, new player recruitment activity, equal participation for players and the development of policies to support these practices. Trained research staff will collect outcome data via telephone interviews at baseline and follow-up. Interviews will be conducted with both club representatives and parents of junior players.

ETHICS AND DISSEMINATION

The study has been approved by the University of Newcastle Human Research Ethics Committee (H-2013-0429). The results of the study will be disseminated via peer-reviewed publications and presentations at conferences.

TRIAL REGISTRATION NUMBER

ACTRN12617001044314; Pre-results.

Strategies for enhancing the implementation of school-based policies or practices targeting risk factors for chronic disease

BACKGROUND

A number of school-based policies or practices have been found to be effective in improving child diet and physical activity, and preventing excessive weight gain, tobacco or harmful alcohol use. Schools, however, frequently fail to implement such evidence-based interventions.

OBJECTIVES

The primary aims of the review are to examine the effectiveness of strategies aiming to improve the implementation of school-based policies, programs or practices to address child diet, physical activity, obesity, tobacco or alcohol use.Secondary objectives of the review are to: Examine the effectiveness of implementation strategies on health behaviour (e.g. fruit and vegetable consumption) and anthropometric outcomes (e.g. BMI, weight); describe the impact of such strategies on the knowledge, skills or attitudes of school staff involved in implementing health-promoting policies, programs or practices; describe the cost or cost-effectiveness of such strategies; and describe any unintended adverse effects of strategies on schools, school staff or children.

SEARCH METHODS

All electronic databases were searched on 16 July 2017 for studies published up to 31 August 2016. We searched the following electronic databases: Cochrane Library including the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; MEDLINE In-Process & Other Non-Indexed Citations; Embase Classic and Embase; PsycINFO; Education Resource Information Center (ERIC); Cumulative Index to Nursing and Allied Health Literature (CINAHL); Dissertations and Theses; and SCOPUS. We screened reference lists of all included trials for citations of other potentially relevant trials. We handsearched all publications between 2011 and 2016 in two specialty journals (Implementation Science and Journal of Translational Behavioral Medicine) and conducted searches of the WHO International Clinical Trials Registry Platform (ICTRP) (http://apps.who.int/trialsearch/) as well as the US National Institutes of Health registry (https://clinicaltrials.gov). We consulted with experts in the field to identify other relevant research.

SELECTION CRITERIA

'Implementation' was defined as the use of strategies to adopt and integrate evidence-based health interventions and to change practice patterns within specific settings. We included any trial (randomised or non-randomised) conducted at any scale, with a parallel control group that compared a strategy to implement policies or practices to address diet, physical activity, overweight or obesity, tobacco or alcohol use by school staff to 'no intervention', 'usual' practice or a different implementation strategy.

DATA COLLECTION AND ANALYSIS

Citation screening, data extraction and assessment of risk of bias was performed by review authors in pairs. Disagreements between review authors were resolved via consensus, or if required, by a third author. Considerable trial heterogeneity precluded meta-analysis. We narratively synthesised trial findings by describing the effect size of the primary outcome measure for policy or practice implementation (or the median of such measures where a single primary outcome was not stated).

MAIN RESULTS

We included 27 trials, 18 of which were conducted in the USA. Nineteen studies employed randomised controlled trial (RCT) designs. Fifteen trials tested strategies to implement healthy eating policies, practice or programs; six trials tested strategies targeting physical activity policies or practices; and three trials targeted tobacco policies or practices. Three trials targeted a combination of risk factors. None of the included trials sought to increase the implementation of interventions to delay initiation or reduce the consumption of alcohol. All trials examined multi-strategic implementation strategies and no two trials examined the same combinations of implementation strategies. The most common implementation strategies included educational materials, educational outreach and educational meetings. For all outcomes, the overall quality of evidence was very low and the risk of bias was high for the majority of trials for detection and performance bias.Among 13 trials reporting dichotomous implementation outcomes-the proportion of schools or school staff (e.g. classes) implementing a targeted policy or practice-the median unadjusted (improvement) effect sizes ranged from 8.5% to 66.6%. Of seven trials reporting the percentage of a practice, program or policy that had been implemented, the median unadjusted effect (improvement), relative to the control ranged from -8% to 43%. The effect, relative to control, reported in two trials assessing the impact of implementation strategies on the time per week teachers spent delivering targeted policies or practices ranged from 26.6 to 54.9 minutes per week. Among trials reporting other continuous implementation outcomes, findings were mixed. Four trials were conducted of strategies that sought to achieve implementation 'at scale', that is, across samples of at least 50 schools, of which improvements in implementation were reported in three trials.The impact of interventions on student health behaviour or weight status were mixed. Three of the eight trials with physical activity outcomes reported no significant improvements. Two trials reported reductions in tobacco use among intervention relative to control. Seven of nine trials reported no between-group differences on student overweight, obesity or adiposity. Positive improvements in child dietary intake were generally reported among trials reporting these outcomes. Three trials assessed the impact of implementation strategies on the attitudes of school staff and found mixed effects. Two trials specified in the study methods an assessment of potential unintended adverse effects, of which, they reported none. One trial reported implementation support did not significantly increase school revenue or expenses and another, conducted a formal economic evaluation, reporting the intervention to be cost-effective. Trial heterogeneity, and the lack of consistent terminology describing implementation strategies, were important limitations of the review.

AUTHORS' CONCLUSIONS

Given the very low quality of the available evidence, it is uncertain whether the strategies tested improve implementation of the targeted school-based policies or practices, student health behaviours, or the knowledge or attitudes of school staff. It is also uncertain if strategies to improve implementation are cost-effective or if they result in unintended adverse consequences. Further research is required to guide efforts to facilitate the translation of evidence into practice in this setting.

Effectiveness of a pragmatic school-based universal resilience intervention in reducing tobacco, alcohol and illicit substance use in a population of adolescents: cluster-randomised controlled trial

OBJECTIVES

Initiation of tobacco, alcohol and illicit substance use typically occurs during adolescence, with the school setting recommended to reduce adolescent substance use. Strengthening individual (eg, problem solving) and environmental (eg, caring relationships at school) resilience protective factors of adolescents has been suggested as a strategy for reducing substance use by adolescents; however, few studies have examined this potential. A study was conducted to investigate the effectiveness of a pragmatic school-based universal 'resilience' intervention in reducing the prevalence of tobacco, alcohol and illicit substance use, and increasing the individual and environmental protective factors of students.

DESIGN

A cluster-randomised controlled trial.

SETTING

Thirty-two Australian secondary schools (20 intervention; 12 control).

PARTICIPANTS

Cohort of grade 7 students followed-up in grade 10 (2014; aged 15-16 years).

INTERVENTION

A pragmatic intervention involving school staff selection and implementation of available programmes and resources targeting individual and environmental 'resilience' protective factors for all grade 7-10 students was implemented in schools (2012-2014). School staff were provided implementation support.

MEASUREMENTS

An online survey collected baseline and follow-up data for primary outcomes: tobacco (ever, recent) and alcohol (ever, recent, 'risk') use, and secondary outcomes: marijuana and other illicit substance use, and individual (six-factor subscales, aggregate) and environmental (three-factor subscales, aggregate) protective factor scores. Generalised and linear mixed models examined follow-up differences between groups.

RESULTS

Follow-up data from 2105 students (intervention=1261; control=844; 69% of baseline cohort) were analysed. No significant differences were found between intervention and control students for any primary (ever tobacco: OR 1.25, 95% CI 0.92 to 1.68, p=0.14; recent tobacco: OR 1.39, 95% CI 0.84 to 2.31, p=0.19; recent ever alcohol: OR 1.11, 95% CI 0.83 to 1.48, p=0.46; alcohol: OR 1.13, 95% CI 0.78 to 1.62, p=0.51; 'risk' alcohol: OR 0.98, 95% CI 0.70 to 1.36, p=0.89) or secondary outcomes (marijuana: OR 1.12, 95% CI 0.74 to 1.68, p=0.57; other illicit substance: OR 1.19, 95% CI 0.67 to 2.10, p=0.54; individual protective factors: MD=0, 95% CI -0.07 to 0.06, p=0.89; environmental protective factors: MD: -0.02, 95% CI -0.09 to 0.06, p=0.65).

CONCLUSIONS

The universally implemented pragmatic school-based intervention was not effective in reducing the prevalence of tobacco, alcohol or illicit substance use, or in increasing the protective factors of students.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Register reference: ACTRN12611000606987.

Effectiveness of a clinical practice change intervention in increasing the provision of nicotine dependence treatment in inpatient psychiatric facilities: an implementation trial

BACKGROUND

Despite clinical practice guidelines recommending the routine provision of nicotine dependence treatment to smokers in inpatient psychiatric facilities, the prevalence of such treatment provision is low. The aim of this study was to examine the effectiveness of a clinical practice change intervention in increasing clinician recorded provision of nicotine dependence treatment to patients in inpatient psychiatric facilities.

METHODS

We undertook an interrupted time series analysis of nicotine dependence treatment provision before, during and after a clinical practice change intervention to increase clinician recorded provision of nicotine dependence treatment for all hospital discharges (aged >18 years, N = 4175) over a 19 month period in two inpatient adult psychiatric facilities in New South Wales, Australia. The clinical practice change intervention comprised six key strategies: leadership and consensus, enabling systems and procedures, training and education, information and resources, audit and feedback and an on-site practice change support officer. Systematic medical record audit and segmented logistic regression was used to determine differences in proportions for each nicotine dependence treatment outcome measure between the 'pre', 'during' and 'post-intervention' periods.

RESULTS

The prevalence of all five outcome measures increased significantly between the pre and post-intervention periods, including clinician recorded: assessment of patient smoking status (36.43 to 51.95%; adjusted odds ratio [AOR] = 2.39, 99% Confidence Interval [CI]: 1.23 to 4.66); assessment of patient nicotine dependence status (4.74 to 11.04%; AOR = 109.67, 99% CI: 35.35 to 340.22); provision of brief advice to quit (0.85 to 8.81%; AOR = 97.43, 99% CI: 31.03 to 306.30); provision of nicotine replacement therapy (8.06 to 26.25%; AOR = 19.59, 99% CI: 8.17 to 46.94); and provision of nicotine dependence treatment on discharge (8.82 to 13.45%, AOR = 12.36; 99% CI: 6.08 to 25.14).

CONCLUSIONS

This is the first study to provide evidence that a clinical practice change intervention may increase clinician recorded provision of nicotine dependence treatment in inpatient psychiatric settings. The intervention offers a mechanism for psychiatric facilities to increase the provision of nicotine dependence treatment in accordance with clinical guidelines.