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

A personalised health intervention to maintain independence in older people with mild frailty: a process evaluation within the HomeHealth RCT

Background

Frailty is common in later life and can lead to adverse health outcomes. Services aimed at preventing decline in early stages of frailty may support older people to remain independent for longer. We developed and tested a new service, HomeHealth, in a randomised controlled trial. HomeHealth was a multidomain behaviour change service based in the voluntary sector in England targeting mobility, socialising, nutrition and psychological well-being.

Objective

To describe the population reach, fidelity, acceptability, context and mechanisms of impact of the HomeHealth service.

Design and methods

Mixed-methods process evaluation of a randomised trial.

Setting and participants

HomeHealth trial participants (older people aged 65+ years with mild frailty) and service providers.

Data sources and analysis

Population reach was evaluated through comparison to local census data. Fidelity of audio-recorded appointments was assessed by two independent raters using a structured checklist. Using data from appointments attended, types of goals set and progress towards goals, we described appointment characteristics, goals and signposting, and evaluated three mechanisms of impact: (1) effect of appointment attendance on independence, (2) effect of goal progress on independence and (3) whether selecting a particular goal type led to improvements in the corresponding intermediate outcome. We thematically analysed qualitative interviews with 49 older people, 7 HomeHealth workers and 8 stakeholders to explore acceptability and context.

Results

HomeHealth participants were similar with regards to deprivation, education and housing status to the local older population but with lower rates of minority ethnic groups. HomeHealth was delivered with good fidelity (81.7%) in voluntary sector organisations. Appointments were well attended (mean 5.33 out of the 6 intended), but attendance was not associated with better independence scores at 12 months [mean difference 1.29 (-8.20 to 10.78)]. Participants varied in progress towards goals within appointments (mean progress 1.15/2.00), but greater goal progress was not associated with improved independence scores at 12 months [mean difference -0.40 (-2.38 to 1.58)]. Mobility goals were most frequently selected (49%), but type of goal had no impact on independence and little impact on intermediate outcomes. Forty-one per cent were signposted or referred to other supportive services, with ongoing support where needed throughout this process. Qualitative data indicated that HomeHealth was acceptable, empowering for those who saw a need for change and fitted well within host voluntary sector organisations.

Limitations

Census data were only available for all adults aged over 65 in local areas rather than a mildly frail population, who are likely to be older, female and less diverse, and therefore population reach calculations may be less accurate. Goal progress was assessed using a simple scale rather than a validated instrument.

Conclusions

HomeHealth represents an acceptable and implementable intervention for older people with mild frailty but may work via different mechanisms than those intended.

Future work

Future work should explore how to best screen older people with mild frailty for readiness to change to maximise benefits from similar services and identify other possible mechanisms of effects.

Funding

This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number NIHR128334.

Feasibility and acceptability of PDConnect, a multi-component intervention to support physical activity in people with Parkinson's disease: A mixed methods study

BackgroundPhysical activity (PA) is beneficial for people with Parkinson's (PwP); however, many are classed as sedentary. PDConnect is an online multicomponent intervention combining 1:1 physiotherapy and group-based PA combined with education, behavior change and self-management strategies, promoting PA and self-management among PwP.ObjectiveTo assess feasibility and acceptability of PDConnect.MethodsMixed methods study involving 31 PwP randomly allocated to: (i) usual care: physiotherapy once a week for six weeks, and (ii) PDConnect: physiotherapy once a week for six weeks, followed by 12 weekly sessions of group-based PA, followed by three monthly Teams calls to support engagement. Outcomes included intervention feasibility and acceptability (primary) assessed via survey and interviews; PA, motor, non-motor symptoms, and health and well-being (secondary) assessed at baseline, and at six, 18, and 30 weeks. Fidelity was accessed by post hoc video analysis.ResultsOnline delivery of PDConnect was feasible and safe. Participant retention was 74%. Response rate of self-reported measures was 97%. 95% of participants returned completed activity diaries. Attendance was high, with all participants recommending PDConnect. PDConnect participants reported improved flexibility, muscle strength, and endurance as well as increased PA confidence, PA levels and knowledge of Parkinson's disease. Half of PDConnect participants reported that they were much improved compared to 10% of usual care participants. Small to large effect sizes in PA (d = 0.03) and UPDRS (d = 0.96) ES) were reported, which warrant further exploration in an appropriately powered study.ConclusionsPDConnect is feasible and acceptable among PwP. A future large-scale trial is required to determine the effectiveness of PDConnect.

Healthy Mom Zone Adaptive Intervention With a Novel Control System and Digital Platform to Manage Gestational Weight Gain in Pregnant Women With Overweight or Obesity: Study Design and Protocol for a Randomized Controlled Trial

BACKGROUND

Regulating gestational weight gain (GWG) in pregnant women with overweight or obesity is difficult, particularly because of the narrow range of recommended GWG for optimal health outcomes. Given that many pregnant women show excessive GWG and considering the lack of a "gold standard" intervention to manage GWG, there is a timely need for effective and efficient approaches to regulate GWG. We have enhanced the Healthy Mom Zone (HMZ) 2.0 intervention with a novel digital platform, automated dosage changes, and personalized strategies to regulate GWG, and our pilot study demonstrated successful recruitment, compliance, and utility of our new control system and digital platform.

OBJECTIVE

The goal of this paper is to describe the study protocol for a randomized controlled optimization trial to examine the efficacy of the enhanced HMZ 2.0 intervention with the new automated control system and digital platform to regulate GWG and influence secondary maternal and infant outcomes while collecting implementation data to inform future scalability.

METHODS

This is an efficacy study using a randomized controlled trial design. HMZ 2.0 is a multidosage, theoretically based, and individually tailored adaptive intervention that is delivered through a novel digital platform with an automated link of participant data to a new model-based predictive control algorithm to predict GWG. Our new control system computes individual dosage changes and produces personalized physical activity (PA) and energy intake (EI) strategies to deliver just-in-time dosage change recommendations to regulate GWG. Participants are 144 pregnant women with overweight or obesity randomized to an intervention (n=72) or attention control (n=72) group, stratified by prepregnancy BMI (<29.9 vs ≥30 kg/m2), and they will participate from approximately 8 to 36 weeks of gestation. The sample size is based on GWG (primary outcome) and informed by our feasibility trial showing a 21% reduction in GWG in the intervention group compared to the control group, with 3% dropout. Secondary outcomes include PA, EI, sedentary and sleep behaviors, social cognitive determinants, adverse pregnancy and delivery outcomes, infant birth weight, and implementation outcomes. Analyses will include descriptive statistics, time series and fixed effects meta-analytic approaches, and mixed effects models.

RESULTS

Recruitment started in April 2024, and enrollment will continue through May 2027. The primary (GWG) and secondary (eg, maternal and infant health) outcome results will be analyzed, posted on ClinicalTrials.gov, and published after January 2028.

CONCLUSIONS

Examining the efficacy of the novel HMZ 2.0 intervention in terms of GWG and secondary outcomes expands the boundaries of current GWG interventions and has high clinical and public health impact. There is excellent potential to further refine HMZ 2.0 to scale-up use of the novel digital platform by clinicians as an adjunct treatment in prenatal care to regulate GWG in all pregnant women.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/66637.

Secure care hospital evaluation of manualised interpersonal art-psychotherapy (SCHEMA): A randomised controlled trial protocol

Background

Within the criminal Justice System in the UK one-third of prisoners self-identified as having a learning difficulty and/or disability. This is broadly consistent with formal assessment of the needs of offenders, with 29% of the offender population having a learning disability. In the UK, NHS and private/independent sector secure care (Forensic) provides assessment and treatment for men and women who have come into contact within the Criminal Justice System and have mental health needs, a personality disorder, and/a learning disability. Patients in these services are often detained under the Mental Health Act (1983) and/or have licence conditions that have been set by the Ministry of Justice.Interpersonal art psychotherapy was developed within secure care as an accessible psychological intervention for adults with mild intellectual disabilities or borderline intellectual functioning. A feasibility randomised controlled trial of interpersonal art psychotherapy showed that assessment of key feasibility objectives were met and the trial procedures were acceptable, indicating progression to a definitive trial.

Methods

This is a two-arm single blind randomised controlled trial of effectiveness comparing manualised interpersonal art psychotherapy and Usual Care (UC) to UC. The Randomised Controlled Trial (RCT) will be conducted in a minimum of 10 secure care hospitals (NHS & Independent) with secure care (Forensic) facilities and will recruit 150 participants. The trial design includes an integrated assessment of cost-effectiveness.

Results

Individuals with intellectual disabilities and borderline intellectual functioning were involved in the design and set up of the trial. The trial is currently open to recruitment for participants from eight NHS and private/independent secure care sites in the UK.

Conclusions

A full report of study results will be published on completion of the trial.

The trial has been registered

ISRCTN57406593 ( ISRCTN registry, 2024). This published protocol corresponds with version 6, dated 12.08.2024.

Telehealth Programme for the Education and Enrichment of Relational Skills (PEERS) for adolescents with acquired and congenital brain injuries: a protocol for mixed-methods randomised trial

INTRODUCTION

For adolescents with brain injury, challenges with social function often persist into adulthood, impacting social participation and quality of life. The Programme for the Education and Enrichment of Relational Skills (PEERS) is a manualised group-based intervention with preliminary evidence demonstrating improved social knowledge and participation for adolescents with acquired brain injury or cerebral palsy when delivered face to face. The recent COVID-19 pandemic and challenges for families living outside metropolitan centres to access the programme suggest a telehealth delivered PEERS should be explored. This study aims to compare telehealth PEERS to usual care in a mixed-methods randomised waitlist-controlled trial to determine preliminary efficacy to improve social functioning and secondarily to determine acceptability, feasibility, cost and contextual factors impacting the implementation.

METHODS AND ANALYSIS

In this single-centre mixed-methods randomised waitlist-controlled trial, 32 adolescents with brain injury, aged 11-17 years attending mainstream high school and their caregivers will be randomised to receive either (a) telehealth PEERS once/week for 1.5 hours for 14 weeks or (b) usual care (UC). UC is highly variable in Australia but often comprises fortnightly occupational therapy, physiotherapy or speech therapy. The waitlist group will then receive PEERS following the 26-week retention time point. Measures will be administered at baseline, 14 weeks (immediately post) and then 26 and 52 weeks post baseline. The primary outcome is self-reported performance and satisfaction with social goals on the Canadian Occupational Performance Measure at 14 weeks. Secondary outcomes include self and parent-reported social competence, frequency of get-togethers with peers, self-report knowledge of social skills, frequency of peer victimisation and quality of life. An implementation evaluation will be done to determine acceptability, feasibility, cost and identify barriers and facilitators in the implementation of the intervention and map these against the Consolidated Framework for Implementation Research. This study will assess the unit costs of implementing the PEERS from an Australian health system perspective.

ETHICS AND DISSEMINATION

The Children's Health Queensland Hospital and Health Service and The University of Queensland Human Research Ethics Committees have approved this study. Findings will be disseminated in peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

ACTRN1263000082606.

Effect of double duty interventions on the frequency of morbidity among adolescents in Debre Berhan Regiopolitan City, Ethiopia: a cluster randomized controlled trial

BACKGROUND

Morbidity is an immediate predictor of malnutrition. However, nutritional interventions to reduce frequent morbidities in adolescents were not conducted well based on behavioral models in low-income countries like Ethiopia. Hence, the aim of this study was to examine the effect of selected double-duty interventions on frequency of morbidities among adolescents based on health belief model in Debre Berhan Regiopolitan City, Central Ethiopia.

METHODS

A two-arm parallel cluster randomized controlled trial was conducted from October 13, 2022, to June 30, 2023, involving 356 adolescents in the intervention group (IG) and 352 adolescents in the control group (CG). The frequency of morbidity (FoM) was assessed through self-reported responses provided by the adolescents. To evaluate the impact of the intervention, a difference-in-differences analysis was employed along with a Generalized Estimating Equation (GEE) model using a Negative Binomial regression approach, which is suitable for analyzing count data with overdispersion. The statistical significance of the study was determined by setting a threshold of p-value less than 0.05.

RESULTS

The mean (± SD) score of FoM among IG and CG was - 4.5 (-1.82) and - 1.0 (-0.12), respectively. After the intervention had implemented, the IG had better reduction of mean score of FoM than CG. Moreover, adolescents in the endline measurements had 68% less likely to have higher FoM compared to the baseline measurements [IRR = 0.32, 95% CI (0.27, 0.37)]. Similarly, adolescents in the IG had 82.6% less likely to have higher FoM than CG [IRR = 0.72, 95% CI (0.12, 0.14)]. Likewise, adolescents in the time and treatment interaction category had 24.6% less likely to have higher FoM than adolescents who were not in the interaction category [IRR = 0.75, 95% CI (0.73, 0.78)].

CONCLUSION

The results showed that selected double-duty intervention packages based on the health belief model are effective in reducing FoM among adolescents. The findings suggest the need for integrating the double-duty intervention packages accompanied with behavioral models to the adolescent nutrition guideline and food and nutrition policy and strategy.

Feasibility and preliminary effects of a socio-spiritual intervention for adults with cancer and their family caregivers: a pilot randomised controlled trial

Background

Despite significant psychosocial-spiritual needs adversely affecting the health-related quality of life (HRQoL) of adults living with cancer and their family caregivers in sub-Saharan Africa, there is a dearth of culturally tailored interventions to address these needs. This study evaluates the feasibility of a socio-spiritual intervention designed for adults with cancer and their family caregivers in sub-Saharan Africa, and preliminarily examines its impact on family/social support, spiritual needs, information needs, health literacy and HRQoL.

Methods

This study employed a single-site randomised controlled trial design. Eighty-eight dyads were randomly assigned to either a socio-spiritual intervention (n = 44 dyads) or usual care (n = 44 dyads). The intervention group participated in a 4-week face-to-face training programme with usual care, whereas the control group received only usual care over the same period.

Result

A total of 82 dyads completed the study (40 dyads in the intervention group and 42 dyads in the control group). The eligibility and acceptance rates were >85%, retention was >90% and treatment fidelity was high (between 88.5% and 94.6%). In terms of intervention effects, the intervention was helpful in reducing needs and improving HRQoL of adults with cancer (F (13, 65) = 24.50, p < 0.001; Wilks' Lambda = 0.17) and their family caregivers (F (13, 65) = 14.27, p < 0.001; Wilks' Lambda = 0.26).

Conclusion

This pilot study established the feasibility of a face-to-face training programme for adults with cancer and their families, as well as its potential for improving HRQoL of this population.This study's findings imply that by supporting individuals with cancer and their family caregivers as a unit of care, both individual needs and components of HRQoL can be maintained or even improved. In current practice in Nigeria, only patients' needs are routinely addressed; caregivers often are left on their own to obtain information and support to deliver complex care in the home.

Fidelity of the Guided Self-Determination program in the MyHealth study during breast cancer follow-up

BACKGROUND AND PURPOSE

MyHealth is a new follow-up program including individual nurse-led sessions based on Guided Self-Determination (GSD), which has been shown to improve health and psychological outcomes in patients after treatment for breast cancer. Fidelity assessment is important to support the implementation of GSD in clinical practice. The purpose of this study was thus to investigate fidelity and acceptance of the GSD program in the MyHealth study and whether sociodemographic and psychological factors were associated with patients' completion of the GSD program and completion of reflection sheets.

MATERIAL AND METHODS

We assessed fidelity quantitatively by examining patients' completion of the GSD program (i.e. ≥3 sessions), completion of the reflection sheets and their associations with sociodemographic and psychological factors among 239 patients, and nurse-reported acceptance qualitatively through a focus group interview with all five nurses providing the GSD program.

RESULTS

A total of 81% of patients completed the GSD program, while 71% of the reflection sheets were completed. Including a relative in a GSD session and lower education were significantly associated with completion of the program. Younger age and including a relative in a GSD session were significantly associated with completion of reflection sheets. Nurses found GSD highly applicable and especially appreciated a values-clarifying GSD reflection sheet and the inclusion of a relative.

INTERPRETATION

The GSD program was applied with moderate-to-high fidelity, and the inclusion of relatives is potentially valuable. The GSD program indicates high usability and potential for being translated into clinical practice.

Developing intervention fidelity strategies for a behaviour change intervention delivered in primary care dental practices: the RETURN fidelity strategy

BACKGROUND

Behaviour change interventions delivered in real-world settings could be vulnerable to threats to internal and external validity if methodological considerations are overlooked. The primary dental care setting is a difficult environment within which to deliver research protocols presenting unique challenges for robust scientific research delivery. Intervention fidelity strategies are an important mechanism to improve the scientific rigor of such studies. Feasibility studies provide a vital opportunity to refine and optimise research processes and implementation strategies before embarking on larger scale projects. This paper sets out the development of a comprehensive intervention fidelity strategy guided by The National Institutes of Health Behavior Change Consortium.(BCC) recommendations.

METHOD

Using observations (53 h) and qualitative interviews (17 patient interviews and 2 staff interviews) conducted during the delivery of the RETURN feasibility study (InteRventions to rEduce inequaliTies in the Uptake of Routine deNtal care), an intervention fidelity strategy was developed for use in the RETURN main trial.

RESULTS

A comprehensive intervention fidelity strategy was developed, structured around the five domains of the BCC's recommendations (design, training, delivery, receipt, enactment) and attending to the goals pertaining to each of those domains. This paper sets out the fidelity strategy implemented in the RETURN main trial.

IMPLICATIONS AND CONCLUSIONS

The RETURN fidelity strategy was influenced by the unique research environment the primary dental care setting presents. The strategy could serve as a blueprint to other researchers conducting research in similar settings. It is also intended that this strategy is read alongside the RETURN results upon their publication.

TRIAL REGISTRATION

ISRCTN10853330, registered: 07/10/2019.

Effect of double duty interventions on dietary diversity score of adolescents using a cluster randomized controlled trial in Debre Berhan Regiopolitan City, Ethiopia

Improving the dietary quality of adolescents is crucial in public health, especially in low-income countries like Ethiopia. Despite numerous nutritional interventions, those interventions targeting adolescents were inconsistent due to fragmented implementation. Thus, this study aimed to evaluate the effect of selected double-duty interventions on the dietary diversity scores (DDS) of adolescents in Debre Berhan Regiopolitan City, Central Ethiopia. A two-arm parallel cluster randomized controlled study involved 708 adolescents (356 for intervention group (IG) and 352 for control group (CG)) was conducted from October 13, 2022 to June 30, 2023. The study found a 30.4% reduction in the proportion of adolescents with low DDS in the IG along with an 18.4% increase in high DDS compared to the CG as measured by the minimum dietary diversity score indicator. The generalized estimating equation (GEE) model revealed that adolescents in the IG were nearly twice as likely to achieve a high DDS compared to the CG [AOR = 1.91, 95% CI (1.85, 1.97)]. This study highlights the effectiveness of double-duty interventions supported by behavioral models in enhancing dietary diversity and advocates for their integration into nutritional policies.Clinical Trials: The trial was prospectively registered at ClinicalTrials.gov (NCT05574842) and was first posted on October 12, 2022.

Protocol of an adaptive mobile health intervention for the management of gestational weight gain: The LEAP cluster randomized controlled trial

BACKGROUND

More than half of pregnant patients with overweight or obesity exceed national gestational weight gain (GWG) guidelines, increasing their risk of adverse outcomes. There is an urgent need to develop effective and scalable interventions to improve GWG.

OBJECTIVE

To describe the protocol of Lifestyle, Eating, and Activity in Pregnancy (LEAP), a cluster randomized controlled trial evaluating a mobile health (mHealth) intervention promoting appropriate GWG in an integrated healthcare system.

METHODS

LEAP is a cluster randomized trial with randomization at the clinician level. Patient eligibility includes a pre-pregnancy BMI of 25.0-40.0 kg/m2 and singleton pregnancy. Consented patients receive standard care or standard care plus mHealth intervention per their clinician's randomization. The patient adaptive intervention provides personalized, automated feedback on GWG and physical activity using 1) a smartphone application, 2) a Wi-Fi scale and activity tracker; 3) weekly educational topics; and 4) step-wise support (added when GWG is >75th percentile of the GWG guidelines). Intervention clinicians receive newsletters with motivational interviewing tips to facilitate discussing GWG. Primary outcomes are total GWG (last measured weight - pre-pregnancy weight) and weekly rate of GWG (total GWG/gestational weeks at delivery) as continuous variables and categorized per the IOM GWG guidelines. Secondary outcomes include trimester-specific rate of GWG, GWG trajectory, diet and physical activity, postpartum weight retention, birthweight, infant size for gestational age, and infant growth to 12 months.

CONCLUSIONS

LEAP addresses gaps in the implementation of GWG interventions in healthcare settings. The adaptive and mHealth nature of the intervention may enhance scalability.

TRIAL REGISTRATION

ClinicalTrials.govNCT03880461.

Early detection and a treatment bundle strategy for postpartum haemorrhage: a mixed-methods process evaluation

BACKGROUND

Postpartum haemorrhage is a leading cause of maternal mortality. A multicountry, cluster-randomised trial (E-MOTIVE) demonstrated a 60% reduction in adverse postpartum haemorrhage outcomes. The E-MOTIVE intervention included early postpartum haemorrhage detection using calibrated blood-collection drapes, followed by a postpartum haemorrhage treatment bundle (ie, uterine massage, oxytocics, tranexamic acid, intravenous fluids, examination and escalation [MOTIVE]), supported by implementation strategies. We report a mixed-methods process evaluation assessing the implementation of the E-MOTIVE intervention in Kenya, Nigeria, South Africa, and Tanzania.

METHODS

In this mixed-methods process evaluation, data sources were observations of health workers providing clinical care to pregnant women and pregnant people during vaginal birth and postpartum haemorrhage at intervention sites, and surveys and qualitative interviews with health workers at intervention and control sites. Intervention sites received the calibrated drapes, MOTIVE bundle, and implementation strategies and control sites used uncalibrated drapes. Primary implementation outcomes included fidelity, adoption, adaptation, acceptability, feasibility, and contamination to the calibrated drape, MOTIVE bundle, and implementation strategies.

FINDINGS

Between June 1, 2022, and Jan 31, 2023, 2578 births were observed, 295 pregnant women and people had postpartum haemorrhage, 47 qualitative interviews were done, and 889 surveys were completed. Fidelity to calibrated drape use was high (birth observations 2578 [100%] of 2578; survey 451 [98·3%] of 459). Among health workers, calibrated drape acceptability was high; however, they reported barriers to pregnant women's and people's acceptability. Fidelity to postpartum haemorrhage treatment bundle delivery was high (birth observations 286 [96·9%] of 295), with moderate to high fidelity in median time from postpartum haemorrhage diagnosis to final treatment initiation (≤15 min initiation time in 191 [66·8%] of 295 birth observations, 16-20 min in 42 [14·7%] birth observations), and high acceptability and feasibility. Research midwives participated in clinical assessments after birth and bundle delivery in some sites (mixed fidelity).

INTERPRETATION

This process evaluation shows generally high levels of fidelity, feasibility, and acceptability of the calibrated drape and treatment bundle across evaluation methods and countries. The E-MOTIVE intervention should be included in national policies, with consideration for health workforce, supplies, and medication issues, which might need addressing for successful implementation.

FUNDING

The Bill and Melinda Gates Foundation and the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction, a co-sponsored programme of WHO.

TRANSLATION

For the Swahili translation of the abstract see Supplementary Materials section.

Psychotherapy research in the deaf community: pilot clinical trial lessons learned

At the time of publication, there are no evidence-based psychotherapies to treat any behavioral health condition with Deaf clients. This article describes unique study design considerations for psychotherapy clinical trials conducted in the U.S. Deaf community. We synthesized emergent themes from participant exit interviews with feasibility data and real-life challenges that our team encountered when implementing the Signs of Safety pilot clinical trial, conducted from 2019 to 2022. Particularly illustrative participant accounts were selected to demonstrate five major lessons learned-expanding reach for recruitment; formally assessing participants' ASL fluency; selecting ethically-sound control groups; streamlining video fidelity monitoring; and making crystallized outcome assessments ASL-accessible. These lessons learned informed the design of the first-ever full-scale psychotherapy trial in the U.S. Deaf community, to be conducted from late autumn 2024 through 2028. This trial will potentially validate the first evidence-based therapy for Deaf people and provide a vital roadmap for conducting Deaf community-engaged clinical trials.

Optimising physiotherapist delivery fidelity of exercise and physical activity advice for achilles tendinopathy: A prospective repeated-measures observational study

OBJECTIVES

To assess physiotherapist delivery fidelity and identify factors optimising delivery fidelity of an intervention based on recommended guidelines for Achilles tendinopathy.

DESIGN

A prospective repeated-measures observational study of physiotherapist delivery fidelity with carefully defined exercise and physical activity advice.

SETTING

An inter-disciplinary clinic in Melbourne, Australia, embedded in a randomised controlled trial.

PARTICIPANTS

Two physiotherapists delivering the intervention to five participants each, at three timepoints.

INTERVENTION

All participants were expected to receive the same intervention. Feedback at timepoint one, guided boost-training to optimise delivery fidelity.

MAIN OUTCOME MEASURES

Proportion of exercise and physical activity advice components delivered as intended (high ≥80%; moderate 51-79%; low≤50%), with relationships between variables analysed using chi-square tests.

RESULTS

Physiotherapist delivery fidelity improved significantly between timepoint one and two (χ2 = 83.3, p < 0.001), then sustained at timepoint three. At timepoint one, seven (70%) of intervention components were delivered with high fidelity, one (10%) with moderate fidelity and two (20%) with low fidelity. At timepoint two, after boost-training, nine (90%) were delivered with high fidelity and one (10%) with moderate fidelity. At timepoint three, all intervention components (100%) were delivered with high fidelity by both physiotherapists.

CONCLUSION

Physiotherapist delivery fidelity can be optimised with feedback, collaboration and boost-training.

Implementation-effectiveness of the power over pain portal for patients awaiting a tertiary care consultation for chronic pain: A pilot feasibility study

Background

The Power Over Pain (POP) Portal is a digital platform that provides people living with pain (PLWP) flexible access to chronic pain self-management resources.

Aims

To (1) determine the feasibility of an adequately-powered multisite trial of the POP Portal in tertiary settings; (2) understand the acceptability and usability of the POP Portal; and (3) explore clinical effectiveness among PLWP awaiting a first visit to a tertiary care pain clinic.

Methods

Mixed-methods pilot-feasibility study to inform a future definitive trial. Feasibility was assessed using recruitment and retention rates. Acceptability, usability, and patient outcomes were measured using validated surveys completed at baseline and 3-month follow-up, and semistructured interviews conducted after 3-month follow-up.

Results

Forty-one participants completed follow-up surveys and nine completed interviews. We reached a recruitment and retention rate of 83.75% and 61.19%, respectively. There was a reduction in pain interference (p = .024) and belief in a medical cure (p = .033) after using POP for 3 months. Surveys and interviews indicate PLWP were satisfied with the POP Portal, and it had good usability. Some participants indicated that POP was overwhelming, and certain resources were difficult to access, indicating that modifications could be made to improve ease of use.

Conclusions

The POP Portal was deemed acceptable with good usability; however, modification may be made for improvement. A definitive trial can proceed with enhancements to the portal, modification of the protocol, and close monitoring.

Effect of low- and moderate-intensity endurance exercise on physical functioning among breast cancer survivors: a randomized controlled trial

PURPOSE

Compare the effects of low-intensity and moderate-intensity exercise on physical functioning in breast cancer survivors.

METHODS

Women aged 50 + years and post-primary treatment for stage 0 to III breast cancer were randomly assigned to a 6-month low-intensity (LIG) or moderate-intensity (MIG) exercise group. Participants were instructed to walk (low- or moderate-intensity) for 30 min five days a week, followed by flexibility exercises, and do strengthening and balance exercises twice weekly. Exercise adherence was facilitated with seven individual counseling sessions tapered over six months and a Theory of Planned Behavior-based booklet. Assessments occurred at baseline, 6 months (post-intervention), and 12 months. Primary measures were PROMIS Physical Functioning, PROMIS Global Health, and six-minute walk test (6MWT).

RESULTS

Of 101 women randomized, 65 (64.4%) completed the study. No statistically significant between-group differences occurred at post-intervention or 12 months. Compared to baseline, within-group improvements in PROMIS physical functioning occurred (LIG increased from 45.87 ± 7.58 to 48.37 ± 7.13 post-intervention (p = 0.01); MIG increased from 45.26 ± 7.27 to 49.53 ± 8.80 post-intervention (p = 0.002) and 48.91 ± 9.29 at 12 months (p = 0.02)). Similarly, Global Health physical health improved (LIG increased from 46.04 ± 5.00 to 49.19 ± 5.76 post-intervention (p = 0.001); MIG increased from 45.06 ± 6.59 to 48.20 ± 7.33 post-intervention (p = 0.005) and 48.49 ± 7.89 at 12 months (p = 0.007)). 6MWT improved between post-intervention and 12 months for the LIG (469.99 ± 64.69 m to 492.19 ± 68.64 m, p = 0.008) and between baseline and post-intervention for the MIG (471.01 ± 62.69 m to 495.88 ± 66.64 m, p = 0.006).

CONCLUSION

Both low and moderate-intensity exercise led to significant improvement in physical functioning. When feasible and acceptable, prescribing low-intensity exercise can yield important benefits.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov identifier: NCT02982564.

A physiotherapist-led biopsychosocial education and exercise programme for patients with chronic low back pain in Ghana: a mixed-methods feasibility study

BACKGROUND

Low back pain is a common musculoskeletal condition which causes substantial disability globally. The biopsychosocial model of management has been recommended in national and international guidelines for the management of patients with chronic low back pain (CLBP). However, biopsychosocial approaches are predominantly delivered in high income countries (HICs), although the prevalence of LBP is substantially higher in low- and middle-income countries (LMICs) especially in Africa (39%; 95% CI 30-47). Understanding the effectiveness of BPS interventions in LMICs especially in Africa is underexplored, with substantial inequity between research from HICs and LMICs. Ghana is a LMIC where the effectiveness of biopsychosocial interventions has been underexplored. Therefore, the aim of this study was to explore the feasibility of delivering a physiotherapist-led BPS programme for the management of patients with CLBP in Ghana.

METHODS

This was a mixed-methods, sequential, pretest-posttest feasibility study. Participants involved thirty patients with CLBP. The biopsychosocial intervention involved an exercise and patient education programme based on principles of cognitive behavioural strategies with emphasis on self-management. The biopsychosocial intervention was delivered for six weeks for each participant. Feasibility outcomes regarding management and processes were captured pre-intervention, post-intervention, and three-months post intervention. Semi-structured interviews were conducted post-intervention to explore participants' experiences with the biopsychosocial intervention. Patients' demographics were collected at baseline. Patient reported outcome measures such as intensity of pain, disability, pain catastrophising, kinesiophobia, self-efficacy, and general quality of life, were collected pre-intervention, post-intervention and at three-months follow-up. Qualitative analysis explored participants' experiences regarding the acceptability of the biopsychosocial intervention.

RESULTS

The results of this feasibility study demonstrated that the training programme was acceptable to physiotherapists. Recruitment rate (5 patient participants per week - 100% recruitment met), retention rate post-intervention (90%), data completion rate post-intervention (99.8%) and intervention fidelity (83.1%), all met feasibility thresholds. There were no adverse events. Qualitative data also demonstrated that the biopsychosocial intervention was acceptable to participants.

CONCLUSION

This study has established the potential to deliver a biopsychosocial intervention programme in a Ghanaian hospital setting. This biopsychosocial intervention therefore shows promise, and the result of the study provides a platform to develop future clinical studies.

Progressive resisted exercise program combined with aerobic exercise on osteoporotic systemic lupus erythematous patients: a prospective randomized controlled trial

PURPOSE

To investigate the effect of progressive resisted exercise (PRE) and aerobic exercise (AE) on bone mineral density (BMD), muscular strength, exercise capacity, and health related quality of life (HRQoL) in patients with osteoporotic systemic lupus erythematous (SLE).

METHODS

This study was a single blinded randomized controlled trail. Eighty SLE participants, 30-50 years old, were randomly allocated into four equal groups. Group A received PRE and AE, group B received AE, group C received PRE, and group D received traditional medical treatment only. The intervention was implemented three days/week for six months. BMD was measured by Dual Energy X-ray Absorptiometry, muscle strength was measured by an isokinetic device, exercise capacity was measured by 6-min walk test, and HRQoL was measured by short form 36(SF-36). Every outcome was assessed at baseline, six months, and nine months.

RESULTS

There were statistically significant differences among the groups in knee muscle strength, exercise capacity, and HRQol after 6 months (p < 0.05) in favor of the combined group. BMD increased significantly in the combined and PRE groups compared to the AE and control groups (p < 0.05).

CONCLUSION

PRE combined with AE were more beneficial than either exercise alone in improving knee muscle strength, exercise capacity, and HRQoL.

Scoping review of fidelity strategies used in behaviour change trials delivered in primary dental care settings

BACKGROUND

Primary dental care settings are strategically important locations where randomised controlled trials (RCTs) of behaviour change interventions (BCIs) can be tested to tackle oral diseases. Findings have so far produced equivocal results. Improving treatment fidelity is posed as a mechanism to improve scientific rigour, consistency and implementation of BCIs. The National Institutes of Health Behaviour Change Consortium (NIH BCC) developed a tool to assess and evaluate treatment fidelity in health behaviour change interventions, which has yet to be applied to the primary dental care BCI literature.

METHOD

We conducted a scoping review of RCTs delivered in primary dental care by dental team members (in real-world settings) between 1980 and 2023. Eligible studies were coded using the NIH BCC checklist to determine the presence of reported fidelity strategies across domains: design, training, delivery, receipt and enactment.

RESULTS

We included 34 eligible articles, reporting 21 RCTs. Fidelity reporting variations were found both between and within NIH BCC domains: strategy reporting ranged from 9.5 to 85.7% in design, 9.5 to 57.1% in training, 0 to 66.7% in delivery, 14.3 to 36.8% in receipt and 13.3 to 33.3% in enactment. The most reported domain was design (M = 0.45), and the least reported domain was delivery (M = 0.21). Only one study reported over 50% of the recommended strategies in every domain.

CONCLUSIONS

This review revealed inconsistencies in fidelity reporting with no evidence that fidelity guidelines or frameworks were being used within primary dental care trials. This has highlighted issues with interpretability, reliability and reproducibility of research findings. Recommendations are proposed to assist primary dental care trialists with embedding fidelity strategies into future research.

Evaluating the Implementation of the Rapid Prenatal Exome Sequencing Service in England

INTRODUCTION

In October 2020, a national rapid prenatal exome sequencing (pES) service was rolled out across the English National Health Service (NHS). This service is delivered by multiple clinical and two laboratory teams. While there was high level national guidance to support implementation, it was unclear how the service had been delivered in practice. This study evaluated pES service implementation across England, using the major system change (MSC) framework to explore links between implementation approaches and outcomes.

METHODS

We conducted a national mixed-methods multi-site study of 17 clinical genomics services, their linked fetal medicine services and two laboratories delivering the pES service. The MSC framework informed the study. Key documents, semi-structured interviews (eight national service developers, 55 staff), and surveys (n = 159 staff) were analysed using inductive and deductive thematic analysis and descriptive statistics. Findings were integrated.

RESULTS

Implementation was influenced by a range of factors including evidence of benefit, laboratory service reconfiguration, and stakeholder support. Local implementation approaches varied; seven models of service delivery were identified. Key differences between models included leadership, staffing, and multidisciplinary team approaches. Local staff factors (e.g., time, capacity, attitudes), pES service factors (e.g., communication/collaboration, logistics), and organisational factors (e.g., infrastructure and previous experience) influenced implementation.

CONCLUSION

We have identified multiple barriers and facilitators that are associated with implementing a major change to genomic services in a complex national healthcare system. This study highlights which models of pES may work in practice and why. Findings will inform future development of the pES service.

Firm, yet flexible: a fidelity debate paper with two case examples

BACKGROUND

In healthcare research and practice, intervention and implementation fidelity represent the steadfast adherence to core components of research-supported interventions and the strategies employed for their implementation. Evaluating fidelity involves determining whether these core components were delivered as intended. Without fidelity data, the results of complex interventions cannot be meaningfully interpreted. Increasingly, the necessity for firmness and strict adherence by implementers and their organizations has been questioned, with calls for flexibility to accommodate contextual conditions. This shift makes contemporary fidelity a balancing act, requiring researchers to navigate various tensions. This debate paper explores these tensions, drawing on experiences from developing fidelity assessments in two ongoing effectiveness-implementation hybrid trials.

MAIN BODY

First, given often scarce knowledge about the core components of complex interventions and implementation strategies, decisions about fidelity requirements involve a degree of subjective reasoning. Researchers should make these decisions transparent using theory or logic models. Second, because fidelity is context-dependent and applies to both interventions and implementation strategies, researchers must rethink fidelity concepts with every study while balancing firmness and flexibility. This is particularly crucial for hybrid studies, with their differing emphasis on intervention and implementation fidelity. Third, fidelity concepts typically focus on individual behaviors. However, since organizational and system factors also influence fidelity, there is a growing need to define fidelity criteria at these levels. Finally, as contemporary fidelity concepts prioritize flexible over firm adherence, building, evaluating, and maintaining fidelity in healthcare research has become more complex. This complexity calls for intensified efforts to expand the knowledge base for pragmatic and adaptive fidelity measurement in trial and routine healthcare settings.

CONCLUSION

Contemporary conceptualizations of fidelity place greater demands on how fidelity is examined, necessitating the expansion of fidelity frameworks to include organizational and system levels, the service- and study-specific conceptualizations of intervention and implementation fidelity, and the development of pragmatic approaches for assessing fidelity in research and practice. Continuing to build knowledge on how to balance requirements for firmness and flexibility remains a crucial task within the field of implementation science.

The impact of the Dementia Care in Hospitals Program on hospital acquired complications - a non-randomised stepped wedge hybrid effectiveness-implementation study

BACKGROUND

Hospitalized older patients with cognitive impairment (CI) experience poor outcomes and high rates of hospital acquired complications (HACs). This study investigated the effectiveness of a multimodal hospital CI identification and education program.

METHOD

A prospective stepped-wedge, cross-sectional, continuous-recruitment, hybrid effectiveness-Implementation study was conducted in acute hospitals in four Australian states/territories. The intervention, the Dementia Care in Hospitals Program (DHCP) provided: clinical/ non-clinical hospital staff CI awareness support and education; CI screening for older patients and a bedside alert-the Cognitive Impairment Identifier (CII). The primary outcome was change in the rate of the combined risk of four HACs (urinary tract infection, pneumonia, new onset delirium, pressure injury).

RESULTS

Participants were patients aged 65 years and over admitted for 24 h or more over a 12-month period between 2015-2017 (n = 16,789). Of the 11,309 (67.4%) screened, 4,277 (37.8%) had CI. HACs occurred in 27.4% of all screened patients and were three times more likely in patients with CI after controlling for age and sex (RR = 3.03; 95%CI:2.74-3.27). There was no significant change in HAC rate for patients with CI (RR = 1.084; 95%CI: 0.93; 1.26). In the intervention period the raw HAC rate for all screened patients was 27.0%, which when adjusted for age and sex suggested a small reduction overall. However, when adjusted for hospital site, this reduction in HAC risk not statistically significant (RR = 0.968; 95%CI:0.865-1.083). There was considerable interhospital variation in intervention implementation and outcomes which explains the final non-significant effect.

CONCLUSION

For patient with CI the implementation of the DCHP did not result in a reduction in HAC rates. Education for hospital staff regarding cognitive impairment screening, care support, carer engagement and bedside alerts, using the DCHP, can be feasibly implemented in acute hospitals. Reducing high frequency HACs in older hospital patients with CI, warrants further research.

TRIAL REGISTRATION

The trial was registered retrospectively with the Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12615000905561 on 01/09/2015 with 92 patients (0.8% of total sample) recruited in the baseline and none in the intervention before registration submission.

Process evaluation of a complex intervention evaluating the effectiveness of home-based rehabilitation in the chronic phase of traumatic brain injury

PURPOSE

To perform a process evaluation of a randomized controlled trial (RCT) evaluating a manualized intervention aiming to ameliorate long-term symptoms of traumatic brain injury (TBI) by assessing implementation fidelity, delivery context and acceptability of the intervention.

METHODS

Data from 60 participants were collected during recruitment, intervention delivery and outcome data collection in the RCT. Enrollment records, logs and checklists documented the delivery of the intervention (implementation fidelity) and the collaboration with family members and outside collaborators (delivery context). Attendance-rate, self-reported acceptability and willingness to participate in future studies were used to assess the acceptability of the intervention.

RESULTS

The main elements and dose of the intervention were delivered as intended with an excellent adherence to the manual items. Family members co-participated in the intervention for 39 (65%) of the participants. Outside collaborators were contacted for 32 (53%) of the participants. Acceptability scores were high for participants, family members and therapists.

CONCLUSIONS

The intervention was successfully delivered with high acceptability. This process evaluation informs researchers, clinicians and stakeholders about important factors influencing the outcomes of the intervention that should be considered in clinical implementation of rehabilitation interventions.

TRIAL REGISTRATION

Pre-registered 4th of June 2018 at clinicaltrials.gov (NCT03545594).

TEleRehabilitation foR Aphasia (TERRA) phase II trial design

Background and purpose

Despite comprehensive evidence that supports the utility of aphasia therapy in persons with chronic (≥6 months) stroke-induced aphasia, the amount of therapy provided to patients in the United States is typically far less than what is likely necessary to maximize recovery. Two potential contributors to this discrepancy are limited access to rehabilitation services due to the availability of providers and logistical difficulties with transportation. One way to increase access to aphasia therapy is to rely on telerehabilitation.

Methods

The TEleRehabilitation foR Aphasia (TERRA) trial is a prospective, randomized, rater-blinded, multicenter phase II non-inferiority trial to evaluate telerehabilitation for aphasia therapy in persons with chronic post-stroke aphasia. Participants are randomized (1:1) to receive either aphasia remote therapy or in-clinic therapy for 30 total days of treatment (15 days of a semantically focused approach and 15 days of a phonologically focused approach) for 45 min per day. A total of 100 adults (ages 21-80) with a history of left hemisphere ischemic or hemorrhagic stroke incurred at least 12 months prior to study enrollment will be randomized. The trial will be conducted at the clinical research facilities at two sites: the Medical University of South Carolina and the University of South Carolina.

Conclusions

This paper details the design of the TERRA trial, which aims to test whether aphasia therapy delivered by a remote speech-language pathologist through videoconferencing (i.e., via telerehabilitation) is not clinically worse than in-clinic therapy for individuals with chronic post-stroke aphasia to provide an opportunity to move to a definitive phase III trial.

Feasibility and preliminary efficacy of behavioral activation for treatment of depression in autistic adolescents

LAY ABSTRACT

Depression is common among autistic youth and has a significant negative impact on quality of life and day-to-day functioning. Despite great need for efficacious treatments, there are currently limited research-supported interventions for depression symptoms in autistic young people. This study tested a novel, behavior-based approach or psychotherapy for treatment of depression symptoms in autistic adolescents without intellectual disability (i.e. Behavioral Activation for Autistic Adolescents, BA-A) with 15 youth (11-16 years old). BA-A is an individually delivered 12-session therapy that was developed for and to meet the needs of autistic youth with depression. Results found that autistic youth and their caregivers were able to participate in BA-A therapy sessions, and clinicians were able to deliver BA-A in accordance with the treatment manual. Notably, results demonstrated that autistic youth depression symptoms significantly improved after participating in BA-A. Furthermore, anxiety symptoms and social skills significantly improved following BA-A.

Digital health outreach to promote postpartum screening after gestational diabetes: A randomized factorial pilot study

Objective

We examined the acceptability and feasibility of a multi-component digital health outreach intervention to promote uptake of guideline-recommended postpartum screening for type 2 diabetes among patients with gestational diabetes (GDM).

Methods

We conducted a 24 randomized factorial experiment as part of the Multiphase Optimization Strategy (MOST) preparation phase for developing behavioral interventions. Participants with current or recent GDM in an integrated healthcare system were randomized to receive an outreach message with up to four intervention components, designed to be self-administered in about 10 min and efficiently delivered online via REDCap: a streamlined values affirmation, personalized information on diabetes risk, an interactive motivational interviewing-based component, and an interactive action planning component. Patient-reported acceptability and feasibility outcomes were assessed via survey.

Results

Among 162 participants, 72% self-identified with a racial/ethnic minority group. Across components, acceptability scores averaged 3.9/5; ≥91% of participants read most or all of the outreach message; ≥89% perceived the amount of information as "about right"; and ≥ 87% completed ≥1 interactive prompt.

Conclusion

Each intervention component was acceptable to diverse patients and feasible to deliver in a brief, self-directed, online format.

Innovation

These novel components target unaddressed barriers to patient engagement in guideline-recommended postpartum diabetes screening and adapt theory-based behavior change techniques for large-scale use.

Assessing fidelity of design and training of Making Every Contact Count (MECC) in a mental health inpatient setting

BACKGROUND

Making Every Contact Count (MECC) is a public health strategy which strives to enable brief interventions to be implemented through opportunistic healthy lifestyle conversations. In a mental health inpatient setting a bespoke MECC training package has been developed to encourage cascade training through a train the trainer model and to incorporate an additional regional health strategy A Weight Off Your Mind into Core MECC training to provide a focus on healthy weight management. This study evaluated the fidelity of design of MECC in the mental health inpatient setting and fidelity of the training package currently being cascaded across the region.

METHODS

Initially a documentary analysis of six documents shared through the mental health inpatient setting including MECC implementation guide, logic model, checklist and evaluation framework. Documents were analysed using the Template for Intervention Description and Replication (TIDieR) checklist and coded using the Behaviour Change Technique (BCT) Taxonomy version one (BCTTv1) and the Expert Recommendations for Implementing Change (ERIC) Taxonomy. Coding was compared against MECC guidance documents to complete the fidelity assessment. A training delivery guide, training slides and two recordings of both train the trainer and Core MECC + A Weight Off Your Mind training were analysed for behaviour change techniques (BCTs) and compared to conduct a fidelity training assessment.

RESULTS

Overall the implementation of MECC in the mental health inpatient setting had moderate fidelity to the MECC guidance, with a total of 31 BCTs identified across guidance and provider documents and a 77% adherence of provider documents to guidance. The highest level of fidelity applied to the MECC implementation guide where 86% of identified BCTs were also present. The training package showed high fidelity that both training programmes were being delivered as intended with 100% of BCT matched from training materials to training transcripts. Potential loss of fidelity through additional BCTs was present across provider documents and training transcripts.

CONCLUSION

The implementation of MECC across the mental health inpatient setting and the training package appear to be delivered as intended therefore demonstrating good fidelity and potential benefits to public health. Future research would benefit from assessing cascade training sessions from those who have completed train the trainer to evaluate ongoing fidelity of training across the trust.

Effect of double-duty interventions on double burden of malnutrition among adolescents in Debre Berhan Regiopolitan City, Ethiopia: a cluster randomised controlled trial

Combating the double burden of malnutrition (DBM) in adolescents is a critical public health challenge in low-income countries like Ethiopia. However, past efforts have lacked focus and exhibited diverse governance strategies. Therefore, this study assesses the effect of selected double-duty interventions (DDIs) on DBM among adolescents in Central Ethiopia. The DBM status (thinness, normal, overweight/obesity) was determined using WHO AnthroPlus software. A two-arm parallel cluster randomised controlled trial was used among 708 adolescents (356 for the intervention group [IG] and 352 for the control group [CG]) from 13 October 2022 to 30 June 2023. The intervention's effect was analysed through difference-in-difference (DID) analysis and a multivariable multinomial generalised estimating equation (GEE) model with significance set at P < 0.05. The overall DBM prevalence decreased by nearly 7% (4.7% for thinness, 2.2% for overweight/obesity) in the DID analysis. After adjusting for possible confounders, the GEE model indicated that adolescents in the IG were 34% less likely to have higher DBM than those in the CG (AOR = 0.66, 95% CI [0.46, 0.94]). Additionally, the probability of DBM decreased by 59% at the end line compared to baseline measurements (AOR = 0.41, 95% CI [0.03, 0.92]). Adolescents in the category of time and IG interaction were 44% less likely to have increased DBM (AOR = 0.56, 95% [CI 0.02, 0.38]). Thus, this study underscores the effectiveness of selected DDIs in addressing DBM among adolescents using a health belief model. These results advocate for the integration of DDI strategies into existing nutrition guidelines, programmes, and policies. The trial was registered prospectively in ClinicalTrials.gov with registration number NCT05574842.

Enhancing Teacher Gatekeeper Skills for Suicide: A Cluster-Randomized Controlled Trial Among School-Based Lay People in China

Gatekeeper training equips individuals with the skills to identify those exhibiting warning signs of suicide risk and refer them to appropriate services. However, enhancing gatekeepers' knowledge, efficacy, subsequent behaviors, and the broader implications of such interventions in school settings remain pressing concerns. To address these challenges, the Life Gatekeeper Training Program (LGTP) was developed. This 8-session program is designed to train school teachers in essential gatekeeper skills through case demonstrations, role-plays, and group discussions, by using a train-the-trainer model. A cluster randomized controlled trial, which randomly assigned 84 schools (including 223 trainers and 4,140 trainees) to intervention and waitlist control groups, was conducted from December 2022 to March 2024 to evaluate the 6- and 12-month outcomes of the LGTP in Yunfu, China. The primary outcomes were teachers' stigmatization, suicide literacy, perceived competence, and willingness to intervene. The secondary outcome measures were gatekeeper behaviors, including identifying students at risk, discussing potential suicide risk with them, or with their caregiver(s), and referring them to a mental health professional or a specialist clinic. The study was pre-registered with the Chinese Clinical Trial Registry, with a registration number of ChiCTR2200066142. Following the principle of intention to treat (ITT), the results of the generalized estimating equations showed LGTP intervention led to significant decreases in stigmatization (b = - 0.80, SE=0.04, P FDR 0.001), increases in suicide literacy (b = 0.98, SE=0.04, P FDR<0.001), perceived competence (b = 1.03, SE=0.04, P FDR<0.001), and willingness to intervene (b = 0.76, SE=0.04, P FDR<0.001) compared to the control group at post-intervention, and these effects were moderately maintained at the 6 and 12 months follow up. In addition, gatekeeper behavior outcomes (i.e., Identify risk students, Talk to the students, Talk to the parents, Refer to professional help) in the intervention group were significantly higher than those in the control group. The LGTP, a standardized program with a brief training format, demonstrated efficacy in increasing actual gatekeeper behaviors among school teachers in China. The delivery strategies of this program enabled rapid scalability to reach a large population within a short time frame, thereby offering opportunities to expand early intervention and prevention efforts.

Development and Piloting of Implementation Strategies to Support Delivery of a Clinical Intervention for Postpartum Hemorrhage in Four sub-Saharan Africa Countries

INTRODUCTION

Postpartum hemorrhage (PPH) remains the leading cause of maternal mortality. A new clinical intervention (E-MOTIVE) holds the potential to improve early PPH detection and management. We aimed to develop and pilot implementation strategies to support uptake of this intervention in Kenya, Nigeria, South Africa, and Tanzania.

METHODS

Implementation strategy development: We triangulated findings from qualitative interviews, surveys and a qualitative evidence synthesis to identify current PPH care practices and influences on future intervention implementation. We mapped influences using implementation science frameworks to identify candidate implementation strategies before presenting these at stakeholder consultation and design workshops to discuss feasibility, acceptability, and local adaptations. Piloting: The intervention and implementation strategies were piloted in 12 health facilities (3 per country) over 3 months. Interviews (n=58), case report forms (n=1,269), and direct observations (18 vaginal births, 7 PPHs) were used to assess feasibility, acceptability, and fidelity.

RESULTS

Implementation strategy development: Key influences included shortages of drugs, supplies, and staff, limited in-service training, and perceived benefits of the intervention (e.g., more accurate PPH detection and reduced PPH mortality). Proposed implementation strategies included a PPH trolley, on-site simulation-based training, champions, and audit and feedback. Country-specific adaptations included merging the E-MOTIVE intervention with national maternal health trainings, adapting local PPH protocols, and PPH trollies depending on staff needs. Piloting: Intervention and implementation strategy fidelity differed within and across countries. Calibrated drapes resulted in earlier and more accurate PPH detection but were not consistently used at the start. Implementation strategies were feasible to deliver; however, some instances of limited use were observed (e.g., PPH trolley and skills practice after training).

CONCLUSION

Systematic intervention development, piloting, and process evaluation helped identify initial challenges related to intervention fidelity, which were addressed ahead of a larger-scale effectiveness evaluation. This has helped maximize the internal validity of the trial.

High-load strength training compared with standard care treatment in young adults with joint hypermobility and knee pain: study protocol for a randomised controlled trial (the HIPEr-Knee study)

INTRODUCTION

Patients with generalised joint hypermobility, including knee hypermobility (GJHk), often experience knee pain and are typically managed with low-intensity strength training and/or proprioceptive training as part of standard care. However, not all patients experience satisfactory outcomes. High-load strength training may offer additional benefits, such as increased muscle cross-sectional area, neural drive and tendon stiffness, which may reduce pain and improve active knee joint stability during movement tasks and daily activities. So far, no randomised controlled trials (RCTs) have compared high-load strength training with traditional treatment strategies (standard care) for this patient group.

METHODS AND ANALYSIS

In this RCT, we aim to recruit patients with GJHk and knee pain from primary care physiotherapy clinics in the Region of Southern Denmark and via social media. Patients with competing injuries or experience with high-load strength training will be excluded. Patients will be randomised (1:1 ratio) to either 2 weekly sessions of high-load strength training or standard care for 12 weeks. The primary outcome is self-reported knee pain during an activity nominated by the patient as the most aggravating for their present knee pain measured using the Visual Analogue Scale for Nominated Activity (VASNA, 0-100; 0=no pain and 100=worst imaginable pain). This will be collected at baseline, 6 weeks, 12 weeks and 12 months. Secondary outcomes include self-reported knee function and adverse events (collected at baseline, 12 weeks and 12 months), objective measurements including a 5-repetition maximum single-leg press, proprioception and single-leg-hop for distance (collected at baseline and 12 weeks), and a range of other outcome measures such as fear of movement, tendon stiffness and global perceived effect. We aim to recruit 90 patients in total to detect a 10 mm group difference in the primary outcome with 80% power.

ETHICS AND DISSEMINATION

This study was funded by Independent Research Fund Denmark (grant number 2034-00088B) on 14 June 2022; the Regional Committees on Health Research Ethics for Southern Denmark approved it (S-20230050) on 30 August 2023. The first recruitment site opened on 15 February 2024, and the final results will be submitted to a peer-reviewed journal to inform rehabilitation strategies for symptomatic GJHk.Protocol version 1, dated 4 July 2024.

TRIAL REGISTRATION NUMBER

NCT06277401.

Embedding Multimodal Rehabilitation Within Routine Cancer Care in Sheffield-The Active Together Service Evaluation Protocol

BACKGROUND

Approximately 3 million people in the United Kingdom are currently living with or beyond cancer. People undergoing treatment for cancer are at risk of complications following treatment. Increasing evidence supports the role of rehabilitation (including prehabilitation) in enhancing psychological and physical well-being in patients with cancer and improving outcomes. Active Together is an evidence-based, multimodal rehabilitation service for patients with cancer, providing support to help patients prepare for and recover from treatment. This paper presents the evaluation protocol for the Active Together service, aiming to determine its impact on patient-reported outcomes and clinical endpoints, as well as understand processes and mechanisms that influence its delivery and outcomes.

METHODS

This evaluation comprises an outcome and process evaluation, with service implementation data integrated into the analysis of outcome measures. The outcome evaluation will assess changes in outcomes of patients that attend the service and compare health care resource use against historical data. The process evaluation will use performance indicators, semistructured interviews, and focus groups to explore mechanisms of action and contextual factors influencing delivery and outcomes. Integrating psychological change mechanisms with outcome data might help to clarify complex causal pathways within the service.

CONCLUSIONS

Evidence to support the role of multimodal rehabilitation before, during, and after cancer treatment is increasing. The translation of that evidence into practice is less advanced. Findings from this evaluation will contribute to our understanding of the real-world impact of cancer rehabilitation and strengthen the case for widespread adoption of rehabilitation into routine care for people with cancer.

Palliative Care and Advance Care Planning Intervention Fidelity Monitoring: Methods and Lessons Learned From PCORI-Funded Large-Scale, Pragmatic Clinical Trials

Over the past decade, the Patient-Centered Outcomes Research Institute (PCORI) funded multiple large-scale, comparative effectiveness clinical trials evaluating palliative care and advance care planning interventions. These are complex multicomponent interventions that need robust but flexible fidelity monitoring. Fidelity is necessary to maintain both internal and external validity within palliative care intervention research and to ultimately evaluate the real-world impact of high-quality interventions. Different trials not only took varying approaches to fidelity monitoring but also uncovered both unique and common challenges and facilitators. This article summarizes 8 of these trials and highlights approaches, adaptations, barriers, and facilitators for intervention fidelity monitoring. Identifying and delivering core elements while simultaneously allowing adaptations of noncore elements is a vital part of fidelity monitoring. Dissemination of such experiences can inform both future palliative care research as well as ongoing implementation of palliative care and advance care planning interventions across diverse clinical practices. Adoption of rigorous intervention fidelity methods is critical to advancing the science and reproducibility of palliative care interventions.

The quality of reporting in randomized controlled trials investigating exercise for individuals with whiplash-associated disorders; a systematic review

BACKGROUND

Whiplash-associated disorders are a common sequela of road traffic accidents. Exercise therapy is considered an effective intervention, and it is recommended for the management of such condition. However, the application of research findings to everyday clinical practice is dependent on sufficient details being reported.

OBJECTIVES

To explore the quality of reporting in studies investigating the effectiveness of exercise for whiplash-associated disorders.

METHODS

A literature search was conducted to identify studies testing the effectiveness of exercise for whiplash-associated disorders. Two reporting checklists were used to evaluate reporting completeness. The median positive scores for each study and overall percentage of positive scores for each item were calculated. Percentage agreement and the Cohen's Kappa coefficient were calculated.

RESULTS

Twenty-one studies were included. According to the Template for Intervention Description and Replication checklist, items were reported appropriately with a median of 29% (range 0-95%, IQR 40.5). The median number of adequately reported items per study was 5 (range 1-10, IQR 3). For the Consensus on Exercise Reporting Template checklist, items were reported appropriately with a median of 29% (range 0-57%, IQR 29). The median number of adequately reported items per study was 4 (range 0-16, IQR 8). Percentage agreement ranged from 57% to 100% while Cohen's Kappa from -0.17 to 1.00.

CONCLUSIONS

The study reveals significant gaps in the quality of reporting in studies investigating exercise for whiplash-associated disorders as both checklists showed a median reporting adequacy of only 29%. Overall, the inter-rater agreement for both checklists was acceptable.

A pilot cluster randomised controlled trial, of an IMPlicit learning approach versus standard care, on recovery of mobility following stroke (IMPS)

OBJECTIVES

To evaluate the delivery of rehabilitation using implicit motor learning principles in an acute stroke setting.

DESIGN

Pilot, assessor-blind, cluster randomised controlled trial with nested qualitative evaluation.

SETTING

Eight inpatient stroke units, UK.

PARTICIPANTS

People within 14 days of stroke onset, presenting with lower limb hemiplegia.

INTERVENTIONS

Participants at control clusters received usual care. Participants at intervention clusters received rehabilitation using an Implicit Learning Approach (ILA); primarily consisting of reduced frequency instructions/feedback, and promotion of an external focus of attention. Video recording was used to understand the ability of intervention site therapists to adhere to the implicit learning principles, and to compare differences between groups.

MEASURES

Ability to recruit and retain clusters/participants; suitability and acceptability of data collection processes; appropriateness of fidelity monitoring methods; and appropriateness of chosen outcome measures.

RESULTS

Eight stroke units participated, with four assigned to each group (intervention/control). Fifty-one participants were enrolled (intervention group 21; control group 30). Mean time since stroke was 6 days (SD 3.42; 0-14); mean age was 73 years (SD 14, 25-94). Of those approached to take part, 72% agreed. We found clear differences between groups with respect to the frequency and type of instructional statement. The ILA was acceptable to both patients and therapists.

CONCLUSION

It is feasible to evaluate the application and effectiveness of motor learning principles within acute stroke rehabilitation, using a cluster randomised design. A larger study is required to evaluate the benefits of each approach; we provide a range of sample size estimates required for this.

Digitizing Survivorship Care Plans Through the POST-Treatment Health Outcomes of Cancer Survivors (POSTHOC) Mobile App: Protocol for a Phase II Randomized Controlled Trial

BACKGROUND

Survivorship care plans (SCPs) are provided at the completion of cancer treatment to aid in the transition from active treatment to long-term survivorship. They describe the details of a patient's diagnosis and treatment and offer recommendations for follow-up appointments, referrals, and healthy behaviors. The plans are currently paper-based and become outdated as soon as a patient's health status changes. There is a need to digitize these plans to improve their accessibility, modifiability, and longevity. With current technology, SCPs can be linked to mobile devices and activity trackers so that patients can track health behaviors and compare them to their clinical goals, taking charge of their own health.

OBJECTIVE

A mobile app, POSTHOC (POST-Treatment Health Outcomes of Cancer Survivors), that digitizes the SCP was developed, with goals of integrating it with wearable technologies and electronic medical records. Herein, we are conducting a randomized controlled trial that evaluates the POSTHOC app versus the traditional SCP on total symptom burden in the early posttreatment period.

METHODS

We will recruit 54 patients who have recently completed curative therapy for cancer (any type) in person and remotely. They will be randomized 2:1, POSTHOC:usual care (unblinded). Those randomized to the POSTHOC group will receive their SCP via the app and will choose to focus on nutrition or exercise for the duration of the study based on their individual plan and personal preferences. Those randomized to the control group will get a paper-based plan. At baseline, 6 weeks, and 12 weeks, we will evaluate patient-reported outcomes, including total symptom burden (web-based questionnaire), diet (24-hour Automated Self-Administered [ASA24]), and physical activity (Fitbit Charge 6 [Google LLC]). We will also collect quantitative and qualitative feedback on the usability of the app from those in the POSTHOC arm to improve the app for future implementation studies, with a specific focus on patient-provider communication. For feasibility, we will calculate the percentage of patients who used the POSTHOC app at least 3 times per week. We will use linear mixed models to evaluate the effects of the POSTHOC app versus those of usual care on other outcomes at weeks 6 and 12.

RESULTS

This trial is open to accrual in the University of Maryland Medical System as of March 2024, and as of July 3, 2024, a total of 20 participants have consented.

CONCLUSIONS

This study is among the first to digitize the SCP in a mobile app and test the effects of a mobile health-delivered behavioral health intervention on symptom burden in cancer survivors. Our results will provide evidence about the effects of health self-management on symptoms. This knowledge will be integral to larger randomized controlled studies, integration with the electronic medical record, and nationwide implementation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05499663; https://clinicaltrials.gov/ct2/show/NCT05499663.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/59222.

The TOTAL trial for weight management participation: A randomized controlled trial protocol

BACKGROUND

The three types of evidence-based treatment options for adults with overweight and obesity - behavioral weight management, anti-obesity medications (AOM), and bariatric surgery - are underutilized in the Veterans Health Administration (VHA) system. Our objective in this manuscript is to describe the study protocol for an adequately powered randomized controlled trial (RCT) of a behavioral intervention: TOTAL (Teaching Obesity Treatment Options to Adult Learners) to increase patient uptake of obesity treatment.

METHODS

In this multi-site, parallel, RCT, eligible Veterans with a body mass index [BMI] ≥ 27 who had not received obesity treatment within the past 12 months were randomly assigned to TOTAL or usual care. TOTAL involves watching an 18-min video that highlights obesity health risks, pros/cons of all three evidence-based obesity treatments, and expected treatment outcomes. It also includes motivational sessions delivered via televideo at 2 weeks, 6 months, and 12 months after the video (target n = 494 participants). The primary outcome is initiation of behavioral weight management treatment within 18 months of randomization. Secondary outcomes include sustained behavioral weight management treatment, initiation of AOM, bariatric surgery referral, and weight change across 18 months.

CONCLUSION

TOTAL, which seeks to increase delivery of weight management treatment within the largest integrated health system in the U.S., combines patient education with motivational interviewing components. If efficacious in this trial, further evaluation of intervention effectiveness and implementation throughout the VHA and other healthcare systems would be warranted.

Protocol for a feasibility randomised controlled trial of the 'Outdoor' mobility intervention for older adults after hip fracture

BACKGROUND

A high proportion of patients do not regain outdoor mobility after hip fracture. Rehabilitation explicitly targeting outdoor mobility is needed to enable these older adults to recover activities which they value most. The overarching aim of this study is to determine the feasibility of a randomised controlled trial which aims to assess the clinical- and cost-effectiveness of an intervention designed to enable recovery of outdoor mobility among older adults after hip fracture (the OUTDOOR intervention).

METHODS

This is a protocol for a multi-centre pragmatic parallel group (allocation ratio 1:1) randomised controlled assessor-blinded feasibility trial. Adults aged 60 years or more, admitted to hospital from- and planned discharge to- home, with self-reported outdoor mobility in the three-months pre-fracture, surgically treated for hip fracture, and who are able to consent and participate, are eligible. Individuals who require two or more people to support mobility on discharge will be excluded. Screening and consent (or consent to contact) will take place in hospital. Baseline assessment and randomisation will follow discharge from hospital. Participants will then receive usual care (delivered by physiotherapy, occupational therapy, or therapy assistants), or usual care plus the OUTDOOR intervention. The OUTDOOR intervention includes a goal-orientated outdoor mobility programme (supported by up to six in-person visits), therapist-led motivational dialogue (supported by up to four telephone calls), supported by a past-patient led video where recovery experiences are shared, and support to transition to independent ongoing recovery. Therapists delivering the OUTDOOR intervention (distinct from those supporting usual care) will receive training in motivational interviewing and behaviour change techniques. Baseline demographics will be collected. Patient reported outcome measures including health related quality of life, activities of daily living, pain, community mobility, falls related self-efficacy, resource use, readmissions, and mortality will be collected at baseline, 6-weeks, 12-weeks, and 6-months (for those enrolled early in the trial) post-randomisation. Exercise adherence (6- and 12- weeks) and intervention acceptability (12-weeks) will be collected. A subset of 20 participants will also support accelerometery data collection for 10 days at each time point.

DISSEMINATION

The trial findings will be disseminated to patients and the public, health professionals and researchers through publications, presentations and social media channels.

TRIAL REGISTRATION

The trial has been registered at ISRCTN16147125.

PROTOCOL VERSION

3.0.

A Systematic Review of the Optimal Management of Pediatric Distal Radius Displacement Fractures: Open Reduction and Internal Fixation Versus Cast Placement

Distal radius fractures are among the most common pediatric injuries, affecting thousands of children each year. These fractures often require clinical intervention to reduce displacement and ensure the proper healing of the growth plate and wrist bone. The primary objective of this comprehensive analysis is to compare the effectiveness of open reduction and internal fixation (ORIF) versus cast placement in the treatment of pediatric distal radius fractures, with the aim of identifying the optimal treatment approach. Therefore, a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted on pediatric distal radius displacement fractures using extensive database searches from 2000 to 2024 for specific keywords, ensuring transparency and reproducibility. Our findings indicate that higher displacement necessitates ORIF to minimize long-term complications and ensure better functional outcomes for pediatric patients. Rare studies comparing ORIF and cast placement are analyzed, emphasizing the advantages and limitations of each approach. The document concludes that the choice between ORIF and casting depends on factors such as fracture severity, patient's age, and specific characteristics of the injury to ensure optimal outcomes in pediatric distal radius fracture management. In conclusion, our data suggests that ORIF and cast placement each have pros and cons for pediatric distal radius fractures, with the best treatment depending on fracture specifics and patient factors, but neither method is clearly superior for long-term outcomes.

Exploring fidelity of enactment in a cluster randomised controlled trial testing the effectiveness of 'gatekeeper' training for pesticide vendors in reducing self-poisoning in rural Sri Lanka: protocol for a multimethod qualitative study

INTRODUCTION

Pesticide self-poisoning causes severe health and socioeconomic hardship in low- and middle-income countries, including Sri Lanka. A stepped-wedge cluster randomised controlled trial (cRCT) has been designed to test whether 'gatekeeper' training for pesticide vendors reduces pesticide self-poisoning in rural Sri Lanka (Vendor cRCT). Ensuring intervention fidelity in RCTs is essential for consistently replicating interventions, accurately assessing their impact and improving outcomes. Thus, the overarching goal of this proposed study is to explore to what extent the pesticide vendors use the 'gatekeeper' strategies.

METHODS AND ANALYSIS

A multimethod qualitative research design is being used to explore the pesticide-selling behaviours of vendors after the 'gatekeeper' training. A subsample of the Vendor cRCT Study population is being recruited using a stratified purposive sampling method in all six intervention districts in Sri Lanka to ensure that the sample is representative of the pesticide vendors in the study area. Participant diaries, observations and focus group discussions are being adopted to collect data. Data triangulation will be performed and data will be analysed thematically.

ETHICS AND DISSEMINATION

The study was approved by the Ethics and Research Committee, Faculty of Medicine and Allied Sciences, at the Rajarata University of Sri Lanka (ERC/2023/09). All participants will provide informed consent. Findings will be disseminated in scientific peer-reviewed journals and conference presentations.

The Use of Internet of Things (IoT) Technology to Promote Children's Oral Health: A Scoping Review

Dental treatments and oral health promotion are now more mobile and versatile thanks to the Internet of Things (IoT)-based healthcare services. This scoping review aims to compile the available data and outline the aims, design, assessment procedures, efficacy, advantages, and disadvantages of the implementation of IoT to improve children's oral health. Articles for this review were gathered from PubMed, Scopus, and Ebscohost databases to identify and construct the keywords and primary research topic. The selected studies were published between 2000 and 2022 and focused on children aged 1 to 18 and/or parents/caregivers of children who received oral health promotion and/or dental disease preventive treatments utilizing the IoT. Each study topic required data extraction. A total of nine papers were included in this review. Two of the nine publications were quasi-experimental, while the remaining six papers were randomized control trials. The nine papers considered in this appraisal have a range of interventions and follow-up periods. Mobile-Health (m-Health), home healthcare, hospital/clinical management, and electronic-Health applications (e-Health) are the most common IoT architecture used as interventions. Three studies assessed oral health knowledge and behavior scores, whereas the bulk of studies (6/7) used m-Health treatments focusing on dental plaque buildup as well as gingival health evaluation to assess oral hygiene. IoT is one of the mediums or instruments that might be used to encourage children's dental health. The studies suggest that the use of IoT could help in improving oral hygiene and oral health, which can further improve children's oral health.

Completeness of intervention reporting of nutrition-focused weight management interventions adjunct to metabolic and bariatric surgery: effect of the TIDieR checklist

Nutrition-focused interventions are essential to optimize the bariatric care process and improve health and weight outcomes over time. Clear and detailed reporting of these interventions in research reports is crucial for understanding and applying the findings effectively in clinical practice and research replication. Given the importance of reporting transparency in research, this study aimed to use the Template for Intervention Description and Replication (TIDieR) checklist to evaluate the completeness of intervention reporting in nutritional weight management interventions adjunct to metabolic and bariatric surgery (MBS). The secondary aim was to examine the factors associated with better reporting. A literature search in PubMed, PsychINFO, EMBASE, Scopus, and the Cochrane Controlled Register of Trials was conducted to include randomized controlled trials (RCT), quasi-RCTs and parallel group trials. A total of 22 trials were included in the final analysis. Among the TIDieR 12 items, 6.6 ± 1.9 items were fully reported by all studies. None of the studies completely reported all intervention descriptors. The main areas where reporting required improvement were providing adequate details of the materials and procedures of the interventions, intervention personalization, and intervention modifications during the study. The quality of intervention reporting remained the same after vs. before the release of the TIDieR guidelines. Receiving funds from industrial organizations (p = 0.02) and having the study recorded within a registry platform (p = 0.08) were associated with better intervention reporting. Nutritional weight management interventions in MBS care are still below the desirable standards for reporting. The present study highlights the need to improve adequate reporting of such interventions, which would allow for greater replicability, evaluation through evidence synthesis studies, and transferability into clinical practice.

Developing an international consensus Reporting guideline for intervention Fidelity in Non-Drug, non-surgical trials: The ReFiND protocol

BACKGROUND

Inadequate reporting of fidelity to interventions in trials limits the transparency and interpretation of trial findings. Despite this, most trials of non-drug, non-surgical interventions lack comprehensive reporting of fidelity. If fidelity is poorly reported, it is unclear which intervention components were tested or implemented within the trial, which also hinders research reproducibility. This protocol describes the development process of a reporting guideline for fidelity of non-drug, non-surgical interventions (ReFiND) in the context of trials.

METHODS

The ReFiND guideline will be developed in six stages. Stage one: a guideline development group has been formed to oversee the guideline methodology. Stage two: a scoping review will be conducted to identify and summarize existing guidance documents on the fidelity of non-drug, non-surgical interventions. Stage three: a Delphi study will be conducted to reach consensus on reporting items. Stage four: a consensus meeting will be held to consolidate the reporting items and discuss the wording and structure of the guideline. Stage five: a guidance statement, an elaboration and explanation document, and a reporting checklist will be developed. Stage six: different strategies will be used to disseminate and implement the ReFiND guideline.

DISCUSSION

The ReFiND guideline will provide a set of items developed through international consensus to improve the reporting of intervention fidelity in trials of non-drug, non-surgical interventions. This reporting guideline will enhance transparency and reproducibility in future non-drug, non-surgical intervention research.

Effectiveness of technology-aided education on self-efficacy among individuals post pulmonary surgery: A randomized controlled trial

BACKGROUND

Patient education is an effective tool in enhancing compliance and comprehension to therapy. Preoperative video-based education (VBE) on knowledge and understanding of surgical procedures and physical therapy provides an insight into the essential need for treatment adherence and early post-operative recovery. Self-efficacy (SE) is an individual self-belief about one's ability to cope and is denoted as a sign of healthy behavior and empowerment. Although little is known about VBE and self-efficacy (SE) in rehabilitation of pulmonary surgery patients. The objective was to assess the influence of VBE in pulmonary rehabilitation on SE post pulmonary surgery patients using the Manipal Self Efficacy Questionnaire (MSEQ).

METHODS

Study design: Mixed methods pilot study. The MSEQ and educational video were designed and developed for this study. Piloting was conducted with the MSEQ (CVI = 0.95) and educational video (CVI = 1). After approval from the ethics committee, written informed consent was obtained from twenty preoperative pulmonary surgery patients were randomized to two groups. The control group (n = 30) received routine post-operative exercises and experimental group (n = 30) received preoperative VBE along with exercises.

RESULTS

Validation of MSEQ and educational video was derived as per content validation index. Mann- Whitney U test and Wilcoxon signed rank test were used to compare the groups. SE scores in the experimental group was higher than the control (p = 0.004).

DISCUSSION AND CONCLUSION

VBE on PR improved SE of the patients after pulmonary surgery. The study's main limitation was the difficulty in attaining the desired sample size because it was a time-bound study.

Assessing the feasibility and acceptability of a diabetes-specific nurse-led multicomponent smoking cessation intervention in diabetes education: study protocol for an open-label pragmatic randomised controlled trial

INTRODUCTION

Smoking cessation is an essential, but often overlooked aspect of diabetes management. Despite the need for tailored smoking cessation support for individuals with diabetes, evidence of effective interventions for this cohort is limited. Additionally, individuals with diabetes do not easily adopt such interventions, resulting in low uptake and abstinence rates. This protocol describes a study that aims to assess the feasibility and acceptability of a unique smoking cessation intervention, based on the best evidence, theory and the needs of individuals with diabetes, among patients and service providers, the diabetes nurse educators.

METHODS AND ANALYSIS

This is an open-label pragmatic randomised controlled trial. Between 80 and 100 individuals with type 1 or type 2 diabetes who smoke will be recruited from the diabetes outpatients at the main acute public hospital in Malta, starting in August 2023. Participants will be randomly assigned (1:1 ratio) to the intervention or control arm for 12 weeks. The experimental intervention will consist of three to four smoking cessation behavioural support sessions based on the 5As (Ask, Advise, Assess, Assist and Arrange) algorithm, and a 6-week supply of nicotine replacement therapy. The control intervention will consist of an active referral to the Maltese National Health Service's one-to-one smoking cessation support service, which is based on motivational interviewing. The primary feasibility and acceptability outcomes include the recruitment and participation rates, resources used, problems identified by the nurses, the nurses' perceived challenges and facilitators to implementation and the nurses' and patients' acceptability of the study intervention. Data analyses will be descriptive, with quantitative feasibility and acceptability outcomes reported with 95% confidence intervals.

ETHICS AND DISSEMINATION

Ethical clearance was obtained from the Faculty of Health Sciences Research Ethics Committee, University of Malta. The study results will be disseminated through conference presentations and a publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT05920096.

A feasibility randomised waitlist-controlled trial of a personalised multi-level language treatment for people with aphasia: The remote LUNA study

BACKGROUND

Stroke survivors with aphasia want to improve their everyday talking (discourse). In current UK practice, 90% of speech and language therapists believe discourse assessment and treatment is part of their role but are hampered by barriers in resources, time and expertise. There is a clinical need for well-articulated discourse assessment and treatments. LUNA is a multi-level treatment targeting words, sentences and discourse macrostructure in personal stories that addresses this clinical need.

OBJECTIVES

This study aimed to assess the feasibility and acceptability of LUNA trial procedures in a randomised waitlist-controlled trial; and to evaluate preliminary efficacy.

METHODS

This paper reports a phase II, waitlist-controlled, proof-of-concept feasibility trial. Participants with chronic aphasia (n = 28) were recruited from the community and randomised to an Immediate (n = 14) or Delayed (n = 14) group. LUNA treatment was delivered twice weekly for 10 weeks via the videoconferencing technology, Zoom. Feasibility was assessed in terms of participant recruitment and retention, adherence, missing data, and treatment fidelity. Preliminary treatment efficacy was assessed in terms of between group differences in outcome measures relating to discourse, language, and psychosocial state.

RESULTS

The remote LUNA trial was feasible: 85% of those eligible consented to the trial; trial retention was 86%; 87% of treatment sessions were delivered as scheduled, and 79% of participants completed 80%+ of the treatment programme; data was missing only for participants who withdrew; treatment fidelity was high at 92% adherence; and only one clinical outcome measure demonstrated ceiling effects. ANCOVA analysis of the clinical outcome measures revealed group differences with medium and large effect sizes, indicating, improvements in the production of words, sentences, discourse macrostructure, overall language functioning (WAB-R), and psychosocial state (VAMS) following LUNA treatment. For most outcomes measured, similar treatment benefits were suggested in a secondary, non-parametric analysis.

CONCLUSIONS

Large-scale evaluation of the clinical efficacy and cost-effectiveness of LUNA is warranted and supported by these findings.

TRIAL REGISTRATION

Clinical trials registration: NCT05847023 (clinical trials.gov).

Understanding the processes underpinning IMPlementing IMProved Asthma self-management as RouTine (IMP2ART) in primary care: study protocol for a process evaluation within a cluster randomised controlled implementation trial

BACKGROUND

Providing supported self-management for people with asthma can reduce the burden on patients, health services and wider society. Implementation, however, remains poor in routine clinical practice. IMPlementing IMProved Asthma self-management as RouTine (IMP2ART) is a UK-wide cluster randomised implementation trial that aims to test the impact of a whole-systems implementation strategy, embedding supported asthma self-management in primary care compared with usual care. To maximise opportunities for sustainable implementation beyond the trial, it is necessary to understand how and why the IMP2ART trial achieved its clinical and implementation outcomes.

METHODS

A mixed-methods process evaluation nested within the IMP2ART trial will be undertaken to understand how supported self-management was implemented (or not) by primary care practices, to aid interpretation of trial findings and to inform scaling up and sustainability. Data and analysis strategies have been informed by mid-range and programme-level theory. Quantitative data will be collected across all practices to describe practice context, IMP2ART delivery (including fidelity and adaption) and practice response. Case studies undertaken in three to six sites, supplemented by additional interviews with practice staff and stakeholders, will be undertaken to gain an in-depth understanding of the interaction of practice context, delivery, and response. Synthesis, informed by theory, will combine analyses of both qualitative and quantitative data. Finally, implications for the scale up of asthma self-management implementation strategies to other practices in the UK will be explored through workshops with stakeholders.

DISCUSSION

This mixed-methods, theoretically informed, process evaluation seeks to provide insights into the delivery and response to a whole-systems approach to the implementation of supported self-management in asthma care in primary care. It is underway at a time of significant change in primary care in the UK. The methods have, therefore, been developed to be adaptable to this changing context and to capture the impact of these changes on the delivery and response to research and implementation processes.

Fidelity to the acupuncture intervention protocol in the ACUpuncture In The EmergencY department for pain management (ACUITY) trial: Expanding the gold standard of STRICTA and CONSORT guidelines

Background

Acupuncture shows promise as an effective nonpharmacologic option for reduction of acute pain in the emergency department (ED). Following CONSORT and STRICTA guidelines, randomized controlled trials (RCTs) generally report intervention details and acupoint options, but fidelity to acupuncture interventions, critical to reliability in intervention research, is rarely reported.

Methods

ACUITY is an NCCIH-funded, multi-site feasibility RCT of acupuncture in 3 EDs (Cleveland, Nashville, and San Diego). ACUITY acupuncturists were trained in study design, responsive acupuncture manualization protocol, logistics and real-time recording of session details via REDCap forms created to track fidelity.

Results

Across 3 recruiting sites, 79 participants received acupuncture: 51 % women, 43 % Black/African American, with heterogeneous acute pain sites at baseline: 32 % low back, 22 % extremity, 20 % abdominal, 10 % head. Pragmatically, participants were treated in ED common areas (52 %), private rooms (39 %), and semi-private rooms (9 %). Objective tracking found 98 % adherence to the six components of the acupuncture manualization protocol: staging, number of insertion points (M = 13.2, range 2-22), needle retention time (M = 23.5 min, range 4-52), session length (M = 40.3 min, range 20-66), whether general recommendations were provided and completion of the session form.

Conclusion

To the best of our knowledge, this is the first RCT to assess and report fidelity to an acupuncture protocol. Fidelity monitoring will be fundamental for ACUITY2, which would be a future definitive, multi-site RCT. Furthermore, we recommend that fidelity to acupuncture interventions be added to CONSORT and STRICTA reporting guidelines in future RCTs.

Protocol registration

The protocol of this study is registered at clinicaltrials.gov: NCT04880733.

The HIV Empowering Adults' Decisions to Share: UK/Uganda (HEADS-UP) Study-A Randomised Feasibility Trial of an HIV Disclosure Intervention for Young Adults with Perinatally Acquired HIV

Young adults with perinatally acquired HIV (PAH) face numerous challenges, including antiretroviral therapy (ART) adherence, managing onward HIV transmission risks and maintaining wellbeing. Sharing one's HIV status with others (onward HIV disclosure) may assist with these challenges but this is difficult. We developed and tested the feasibility of an intervention to help HIV status sharing decision-making for young adults with PAH. The study used a randomised parallel group feasibility design with 18-25-year-olds in Uganda and 18-29 year-olds in the UK. Participants were randomly assigned to intervention or standard of care (SOC) condition. The intervention consisted of four sessions (3 group, 1 individual) with follow-up support, delivered in person in Uganda and remotely in the UK. Assessments were carried out at: Pre-intervention /baseline; Post-intervention (intervention group only); Six-month follow-up. 142 participants were recruited (94 Uganda, 48 UK; 89 female, 53 male). At six-month follow-up, 92/94 (98%) participants were retained in Uganda, 25/48 (52%) in the UK. Multivariate analysis of combined data from both countries, showed a non-significant effect of intervention condition on HIV disclosure cognitions and affect (p = 0.08) and HIV disclosure intention (p = 0.09). There was a significant intervention effect on well-being (p = 0.005). This study addressed important gaps in understanding acceptable and feasible ways of delivering HIV status sharing support for young people living with PAH across two very different settings. The intervention was acceptable in both countries and feasible in Uganda. In the UK, retention may have been affected by its remote delivery.Trial registration: ISRCTN Registry, ISRCTN31852047, Registered on 21 January 2019.

Effectiveness of a school-based Life Gatekeeper Training Program on suicide prevention in China: protocol for a randomized controlled trial

BACKGROUND

With suicide as a leading cause of death, the issue of children and adolescent suicide risks is in the spotlight today. To empower teachers in primary and secondary schools to serve as gatekeepers and to ensure the safety of children and adolescents, the systematically tailored and localized Life Gatekeeper suicide prevention program was designed for Chinese schools.

OBJECTIVE

With the ultimate goal of preventing child and adolescent suicide, we aim to outline a research protocol for examining outcomes of the recently created standardized school-based Life Gatekeeper program in reducing teachers' stigma, increasing their knowledge, willingness to intervene, and perceived competence.

METHODS

Participants will be recruited from eligible primary and secondary schools. Cluster sampling will be used to randomly assign each school to either the intervention group or the control group. The primary outcomes are stigma against suicide, suicide literacy, perceived competence, and willingness to intervene with suicidal individuals, which will be measured using the Stigma of Suicide Scale, the Literacy of Suicide Scale, and the Willingness to Intervene Against Suicide Questionnaire, respectively. Measurements will be taken at four time points, including pre-intervention, immediately after the intervention, 6-month follow-up, and 1-year follow-up.

CONCLUSIONS

The current study features innovative implementation in the real world, by using a randomized controlled trial design to examine the effectiveness of a school-based gatekeeper program among primary and secondary school teachers, following a sequence of defined and refined steps. The research will also investigate the viability of a school-based gatekeeper program for primary and secondary school teachers that could be quickly and inexpensively implemented in a large number of schools.