A conceptual framework for implementation fidelity

A study protocol to engage religious leaders to reduce blood pressure in Tanzanian communities: A cluster randomized trial

BACKGROUND

Most people with hypertension in Sub-Saharan Africa are unaware of their status. Low perceived need for hypertension screening, low trust in biomedical health care, unhealthy norms for diet and exercise, and prioritization of spiritual over physical health are key barriers to blood pressure (BP) control in Tanzanian communities. We seek to determine whether engaging religious leaders to screen for hypertension and educate communities on cardiovascular health can lead to a sustained community BP reduction.

METHODS

This trial aims to determine the efficacy of an intervention that engages religious leaders to reduce BP in Tanzanian communities. After refinement of the intervention following pilot testing, a hybrid type I randomized control trial will be conducted across 20 rural communities (10 intervention and 10 control communities). The intervention will consist of educational sessions for religious leaders, equipping them to provide community cardiovascular health teachings, and BP screening organized jointly by religious leaders and health care workers. We will measure the reduction in mean community BP and changes in hypertension awareness and treatment, diet, physical activity, body mass index, and waist circumference after one year. Key elements that contribute to the intervention's implementation and effectiveness to strengthen its adoption and broader use during and after the intervention up to 24 months will be evaluated.

DISCUSSION

Community-level barriers to BP control inhibit awareness and treatment of hypertension in Tanzania. Through innovative partnerships with trusted religious leaders, we seek to study an intervention with the potential to reduce BP and improve overall community health.

Adoption, Implementation, and Maintenance of Evidence-Based Falls Prevention Programs

We evaluate the implementation of evidence-based falls prevention programs (EBFPPs) of the Administration for Community Living (ACL) Grantees by (1) describing adoption; (2) evaluating implementation through participant adherence; and (3) describing program maintenance. Secondary data analysis of a national data repository included forty-four ACL grantees spanning 31 states who were funded between September 2014 and December 2019 and provided information on over 80,000 older adult participants. Descriptive statistics including frequencies, percentages, and means were used to describe adoption, implementation (adherence), and maintenance of EBFPPs. Senior centers were the most common organizations to adopt EBFPPs. Most programs were maintained at their respective organizational site through repeat offerings, with several programs (60%) being offered greater than 10 times. Information regarding adoption, implementation, and maintenance of EBFPPs is valuable in identifying the best programs suited for different organizations and their clientele, which can inform policy for scaling and sustaining EBFPPs across the nation.

Effects of internet-based mindfulness interventions on anxiety and depression symptoms in cancer patients: A meta-analysis

OBJECTIVE

This meta-analysis aimed to evaluate the effectiveness of internet-based mindfulness interventions on anxiety and depression symptoms in patients with cancer.

METHODS

Eight databases (Cochrane Library, PubMed, Embase, and PsycINFO CNKI, Wanfang, VIP, and CBM) were systematically searched from the inception of databases to August 2023 for randomized controlled trials (RCTs). Two independent reviewers rigorously assessed the risk of bias and extracted data using a pre-established form. The meta-analysis, conducted using Stata version 16, calculated pooled effect sizes and 95% confidence intervals (CIs). Sensitivity analysis was employed to find the source of heterogeneity, and potential publication bias was evaluated through funnel plot analysis and the Egger test.

RESULTS

This study included 10 studies, involving a total of 1314 patients. The results of the meta-analysis showed that Internet-based mindfulness interventions were effective in reducing anxiety [SMD = -0.38, 95% CI (-0.51, -0.25), P < 0.01] and depression [SMD = -0.36, 95% CI (-0.49, -0.23), P < 0.01], particularly when the duration of the program was within 8 weeks and each session lasted <45 min. Interventions guided by therapists proved to be more effective than those without therapist guidance in improving anxiety and depression in cancer patients, and synchronous online interaction with therapists were found to yield the most noticeable improvements in anxiety and depression.

CONCLUSION

Internet-based mindfulness interventions, especially synchronous online interaction with therapists, contribute to alleviating anxiety and depression symptoms in cancer patients. The effectiveness is more pronounced when the intervention duration per session is limited to 45 min and the overall intervention duration is within 8 weeks. The medium to long-term efficacy of the intervention needs further validation through more high-quality research.

The impact of a school garden program on children's food literacy, climate change literacy, school motivation, and physical activity: A study protocol

OBJECTIVE

FoodACT aims to investigate how school gardens affect children's food literacy (FL), climate change literacy (CCL), school motivation (SM), and physical activity (PA).

DESIGN

It comprises a multimethod, quasi-experimental inquiry into an existing Danish school garden program, Gardens to Bellies (GtB). Data will be collected using surveys, accelerometry, semi-structured and focus-group interviews. The study is preregistered with ClinicalTrials.gov (#NCT05839080).

SETTING

Six GtB school garden locations across Region Zealand and Region of Southern Denmark.

PARTICIPANTS

Fourth grade pupils attending GtB (approx. 1600) are recruited to the intervention group. Fourth grade pupils from schools not attending GtB (approx. 1600) are recruited to the control group.

INTERVENTION

Pupils grow, prepare and cook foods for meals in the school garden during eight garden sessions.

MAIN OUTCOME MEASURES

FL, CCL and SM are measured using pre- and post-intervention surveys in both groups. Pupils participating in GtB have their PA assessed using accelerometery, and acute SM by text-message-surveys. Semi-structured and focus-groups interviews are held with garden facilitators and pupils focusing on the implementation of GtB and mechanisms related to developing FL and CCL.

ANALYSIS

The effect on FL, CCL and SM is assessed using linear mixed models. PA and acute SM are assessed by comparing data on days with and without GtB in a subsample of 900 pupils. Qualitative data will be analysed using thematic analysis.

Understanding implementation, adoption, and acceptability of the WHO package of essential noncommunicable (PEN) disease interventions in FIJI: Evidence for scale-up

The Package of Essential Noncommunicable (PEN) disease interventions in response to the high prevalence of cardiovascular diseases and diabetes was implemented in Fiji commencing in 2012. This study aimed to understand implementation outcomes, and its contextual influences. Semi-structured interviews with health workers and patients across Fiji was conducted. Thematic analysis was mapped to the health system building blocks to understand PEN service delivery. The PEN program was well received by health workers formally trained. The frequency of use of PEN guidelines was influenced at the individual level by motivation, capability and capacity as well as external factors outside of the health workers' control. The key challenges to routine use were lack of essential medicines and equipment for CVD risk screening and management, shortage of health workers, high turnover of staff, limited formal training, and no designated focal person. However, at the country level, the PEN program improved the quality of care by providing patients with regular follow-up visits depending on their CVD risk levels. The patients found care to be comprehensive when they were also seen by dieticians and physiotherapists. In most instances, the barrier to access to care were cost and distance of travel and non-availability of essential medicines. To improve use of PEN program requires strengthening health system components: 1) need for efficient supply chain system for medicines and equipment, 2) improving healthcare workforce retention, 3) establishing accountability mechanisms embedded within the health centres, 4) health information system to track patient level data and 5) multi-level governance structures across the health system.

DEprescribing and Care to reduce Antipsychotics in DEmentia (DECADE)-A Hybrid Effectiveness-Implementation Pilot Study

OBJECTIVES

The aim of DEprescribing and Care to reduce Antipsychotics in Dementia (DECADE) was to evaluate a multifaceted intervention to reduce antipsychotic use among nursing home residents with dementia without medication shifts (increase in the use of other psychotropic medications) or worsening Behavioral and Psychological Symptoms of Dementia (BPSD).

METHODS

From June 2022 to January 2024, a type 2 hybrid effectiveness-implementation pilot study was conducted across six Danish nursing homes. The intervention included education for general practitioners and healthcare professionals, medication reviews, and individualized care plans for 40 residents with dementia using antipsychotic medications. The data collection focused on implementation, antipsychotic use, psychotropic medication use, and BPSD. Implementation was assessed through fidelity analysis and surveys assessing providers' perceptions of the models' acceptability, appropriateness, feasibility, and healthcare providers' self-reported knowledge and competence. Changes in antipsychotic use, medication shifts, and BPSD scores measured effectiveness.

RESULTS

Fidelity was generally high, but participation in education was low. About half of the respondents considered the model appropriate and feasible. The intervention led to a significant reduction in antipsychotic use among the 40 included residents, with a decrease of 97.6 mg in olanzapine equivalents corresponding to a daily mean use of 5.9 mg olanzapine equivalents at baseline to a daily mean use of 4.8 mg, at study end (averaged reduction of 1.1 mg/day). In total, 36% of the residents achieved ≥50% reductions, and without an increase in the use of other psychotropic drugs or worsening of BPSD.

CONCLUSIONS

DECADE reduced antipsychotic use without worsening BPSD, highlighting its potential for broader applications. Multidisciplinary collaboration and ongoing education regarding antipsychotic use in dementia care are essential.

Self-management versus usual care for greater trochanteric pain syndrome (the HIPS trial): study protocol for a randomised controlled trial

INTRODUCTION

Greater trochanteric pain syndrome (GTPS) is a common and disabling condition characterised by lateral hip pain. The condition often persists for several months, and there is low evidence for any superior treatment. The aim of this study protocol is to describe a randomised controlled trial (RCT) investigating the effectiveness of a self-management programme versus usual care for patients with GTPS.

METHODS AND ANALYSIS

The study is designed as an observer-blinded, parallel group, superiority RCTcomparing a self-management programme (n=55) with usual care (n=55). Eligible patients with GTPS will be included based on reproduction of pain on palpation in the greater trochanteric region and at least one positive clinical provocation test. The self-management programme includes 3-5 individual sessions with a physiotherapist over 12 weeks, addressing physical, emotional and behavioural factors deemed relevant by the patient. Usual care will receive general information about GTPS, activity management and are free to seek further treatment in primary care as wanted. The primary outcome measure is the Norwegian version of the Victorian Institute of Sports Assessment for gluteal tendinopathy questionnaire (VISA-G-Norwegian). Outcomes will be assessed at baseline, 3, 6 and 12 months. A longitudinal mixed effects model will be used to assess the effectiveness of treatment on pain and disability across all time points, with the primary endpoint at 6 months. Cost-effectiveness will be expressed by mean incremental cost-effectiveness ratios (ICERs) from a societal and healthcare perspective. Bootstrapping will be used to estimate ICER uncertainty.

ETHICS AND DISSEMINATION

The Norwegian Regional Committees for Medical and Health Research Ethics have approved the project (2023/590816), and it will be in accordance with recommendations from the Data Inspectorate at Oslo University Hospital (22/26396). The results from the study will be disseminated through publications in peer-reviewed journals, in conference presentations and through the user representative.

TRIAL REGISTRATION NUMBER

NCT06297148.

Stakeholder perspectives of an experiential learning program at a children's museum to promote healthy eating and physical activity

BACKGROUND

Encouraging healthy eating and physical activity in children has long-term benefits for their health and development, however many do not meet the requirements for fruit and vegetable consumption, or physical activity. Experiential learning (EL) has been shown to improve children's healthy eating and physical activity-related knowledge, attitudes, and behaviour. Children's museums provide opportunities for hands-on EL activities that can engage families. This study examined stakeholder perspectives on the perceived feasibility, acceptability, fidelity and impact of an EL health-promoting program in a children's museum.

METHODS

A qualitative case study was conducted at the Early Start Discovery Space, a university-based children's museum, in Australia. The study involved implementing a 4-week Healthy Living program comprising EL activities related to food and movement for children aged 0-10 years. Perceived feasibility, acceptability, fidelity and impact were assessed through focus groups and observations. Focus groups (23 participants, 17 caregivers and 6 museum staff) were conducted post-implementation. Focus groups were audio-recorded, transcribed verbatim and analysed using thematic analysis. 15 HL sessions were observed throughout implementation.

RESULTS

Stakeholders perceived that the HL program was feasible and acceptable. As a result of consultation between researchers and museum staff, the HL program was easily implemented in the museum. Stakeholders suggested that children and their carers enjoyed the HL activities and were engaged in the HL activities. Aspects of fidelity were explored and showed that most sessions were delivered as intended, however, the delivery of the key messages was suboptimal. Perceived changes in children's knowledge, attitudes behaviour relating to healthy eating and physical activity were minimal.

CONCLUSIONS

Key stakeholders (museum staff and caregivers) provided insights regarding perceived feasibility and acceptability of the HL program delivered in the children's museum. Preliminary findings highlight the potential of children's museums as a setting for EL health eating and physical activity programs. Further, this study highlights the significance of stakeholder engagement, collaboration, and incorporation of hands-on and enjoyable activities to promote healthy habits in children. Future studies, with larger sample sizes, should be conducted to extend the results from this study.

Evaluation of risk stratification and problem management plus (PM+) for pregnant women with HIV in Kenya (Tatua study): Protocol paper

BACKGROUND

While many pregnant and postpartum women with HIV (PPWH) in the African Region successfully engage in HIV care, a substantial number still face significant barriers, including poor mental health and HIV stigma. These psychosocial barriers contribute to poor medication and clinic visit adherence, poor health outcomes, including unsuppressed viral load, and increased risk of perinatal transmission of HIV. To efficiently improve health outcomes within a resource-constrained health system, responsive and effective interventions are urgently needed to support women who are at the highest risk of sub-optimal outcomes.

OBJECTIVE

To determine whether risk stratification of PPWH in conjunction with an evidence-based, tailored, lay health worker-delivered psychological intervention can optimize health outcomes for PPWH and their infants.

METHODS

Using human-centered design, we will adapt Problem Management Plus (PM+) with PPWH for in-person and mobile delivery formats to prevent sub-optimal treatment adherence and HIV care disengagement among PPWH in Kisumu, Kenya. We will test the adapted PM+ intervention among 120 PPWH randomized 1:1:1 to standard of care, in-person PM+, or mobile PM+ in a hybrid type 2 implementation effectiveness pilot trial. Implementation outcomes, including feasibility, acceptability, and intervention satisfaction, as well as preliminary effectiveness outcomes in mental health and HIV, will be evaluated.

EXPECTED STUDY OUTCOMES

We anticipate that the adapted PM+ intervention will be highly acceptable and feasible to implement and have the potential to be effective at reducing care disengagement, viremia, and psychological distress in PPWH.

Validity Evidence for an Observational Fidelity Measure to Inform Scale-Up of Evidence-Based Interventions

As evidence-based interventions are scaled, fidelity of implementation, and thus effectiveness, often wanes. Validated fidelity measures can improve researchers' ability to attribute outcomes to the intervention and help practitioners feel more confident in implementing the intervention as intended. We aim to provide a model for the validation of fidelity observation protocols to guide future research studying evidence-based interventions scaled-up under real-world conditions. We describe a process to build evidence of validity for items within the Session Review Form, an observational tool measuring fidelity to interactive drug prevention programs such as the Botvin LifeSkills Training program. Following Kane's (2006) assumptions framework requiring that validity evidence be built across four areas (scoring, generalizability, extrapolation, and decision), confirmatory factor analysis supported the hypothesized two-factor structure measuring quality of delivery (seven items assessing how well the material is implemented) and participant responsiveness (three items evaluating how well the intervention is received), and measurement invariance tests suggested the structure held across grade level and schools serving different student populations. These findings provide some evidence supporting the extrapolation assumption, though additional research is warranted since a more complete overall depiction of the validity argument is needed to evaluate fidelity measures.

Protocol for a randomized controlled dose response trial to combat accelerated summer BMI gain in children: The Determining the Optimal amount of Structured Environments (DOSE) study

BACKGROUND

Summer is a period of accelerated body mass index (BMI) gain for elementary school-aged children. Summer day camps may provide a structured environment, which has been shown to mitigate accelerated summer BMI gain. Many of these programs have a fee-for-service structure, creating a financial barrier for families with low-income. Providing vouchers to pay for these programs may be an effective strategy for addressing this barrier and mitigating accelerated summer BMI gain but requires further investigation on the optimal dose - the minimum exposure needed to see meaningful results while not overextending resources.

METHODS

This study will use a multi-arm randomized controlled trial with three treatment levels. Children (n = 360) ages 5-12 years from participating schools (n = 4) will be randomly assigned to either summer as usual (comparison group) or to receive a voucher to attend an existing summer day camp for 4-, 6-, or 8-, weeks. BMI will be objectively measured at baseline (i.e., ∼May), 3-months (i.e., ∼August), and 12-months (i.e., ∼May of following school year). Obesogenic behaviors (e.g., physical activity, diet, screen time, and sleep) will be assessed in spring (i.e., late May) and summer (i.e., late June and July). Implementation factors, such as content, attendance frequency, duration, and coverage, relationship with children's summer BMI gain and obesogenic behaviors will also be evaluated. The study will also evaluate the cost-effectiveness of each duration.

DISCUSSION

The study's findings will identify the optimal dose of summer programming to mitigate excess summer BMI gain, informing effective public health initiatives to combat childhood obesity.

TRIAL REGISTRATION

NCT06158594 https://clinicaltrials.gov/study/NCT06158594?titles=determining%20optimal%20amount%20of%20structured%20environments&rank=1.

Core elements of the perioperative medicine for older people undergoing surgery (POPS) model of care

PURPOSE

Hospital surgical services that utilise the approach of the perioperative medicine for older people undergoing surgery (POPS) model of care improve outcomes for older people contemplating and undergoing surgery. Complex models of care like POPS may be difficult to implement without understanding the elements that comprise that model of care. Logic models can be used to aid implementation by visually depicting theoretical relationships between the elements of the model of care. Our objective was to understand the core elements of the POPS model of care at health services other than where it was first developed.

METHODS

A qualitative case study at three contextually different health services in England with POPS models of care of varying implementation maturity was undertaken. We conducted semi-structured interviews with clinicians and managers involved in POPS (n = 56). The interviews were analysed using inductive and deductive methods.

RESULTS

We developed a logic model with seven domains and themes that described the core elements of the POPS model of care compared and contrasted across the three health services. We found POPS could be adapted to 'fit' the local contexts of our study and still achieve its desired outcomes if it remained true to the principles of comprehensive geriatric assessment and optimisation and was delivered by staff with expert skills and attitudes.

CONCLUSION

Our logic model provides potentially generalisable information about the core elements of the POPS service in three health services. This information can be used to aid the implementation of the POPS model of care in healthcare settings similar to our study. Further research may be required to test the logic model in other healthcare contexts.

Internet-Based Cognitive Rehabilitation for Working Cancer Survivors: A Process Evaluation

OBJECTIVE

The aim of the study was to evaluate the process of an online cognitive rehabilitation program aimed at supporting cancer survivors experiencing cognitive problems at work.

METHODS

Cancer survivors ( N = 279) were randomized to one of the intervention groups (ie, basic and extensive online cognitive rehabilitation) or waitlist control group. Recruitment, reach, dosage, implementation, perceived usefulness, and experiences with the program were evaluated using questionnaires and logbooks.

RESULTS

Implementation (ie, reach multiplied by dosage) was acceptable for both versions of the program (range 63%-76%). Cancer survivors and cognitive therapists perceived the overall program as moderately to highly useful and generally reported positive experiences.

CONCLUSIONS

Both a basic and extensive versions of the online cognitive rehabilitation program were successfully implemented in the context of a randomized controlled trial, suggesting their feasibility as intervention to support cancer survivors with cognitive problems at work.

Fidelity to an early childhood home visitation program model's prenatal physical activity curriculum modules: A convergent parallel mixed-methods investigation

Prenatal physical activity (PA) has been associated with health benefits with the potential to affect both mother and baby; however, a matter of conjecture remains regarding the fidelity with which different early childhood home visitation program models' prenatal PA modules are delivered. Therefore, this mixed-methods study investigated the fidelity with which the Maternal Infant Health Outreach Worker program's prenatal PA curriculum modules were delivered to clients. Data sources were: four focus groups ( n = 2, n = 3, n = 4, and n = 1) with community health workers, termed Outreach Workers (OWs); five interviews with Site Leaders; and existing client records for 109 clients (e.g., checklists of curriculum modules completed for clients). One key finding was that eight OWs discussed delivering the prenatal PA curriculum modules at multiple, most, or all of the home visits whereas the checklist data revealed that only 19.3 % of clients received two or more home visits where "prenatal PA" and/or "other" curriculum modules were delivered. Findings can be applied to enhance fidelity assessment and the fidelity with which the prenatal PA curriculum modules are delivered.

Implementation of thirst management in the immediate postoperative period guided by knowledge translation and exchange

OBJECTIVE

To evaluate the implementation of the Thirst Management Model in the immediate postoperative period guided by the Knowledge Translation framework.

METHOD

A quasi-experimental study, in the Post Anesthesia Care Unit of a large university hospital in northern Paraná. Implementation took place in two phases: preparation and implementation and change. Data was collected by observing the practice of nursing professionals. The implementation process was evaluated by measuring adoption and aspects of fidelity, using descriptive analysis of the level of adherence to the evidence in the continuous improvement cycles and the reach of the target audience. The adoption of the Thirst Management Model at pre- and post-implementation times was compared using Chi-square.

RESULTS

In the pre-implementation period, 236 events in the care provided by nursing professionals related to thirst management were observed, and 198 in the post-implementation period. Adoption of the evidence went from 28.2% pre-implementation to 78.4% post-implementation (p<0.001). The level of adherence exceeded the 70% target in one of the three cycles: 61.1%, 66.6%, 84.0%. The target audience was reached 100% in the first rapid cycle.

CONCLUSION

The use of the theoretical framework and its multifaceted intervention significantly increased the adoption of the Thirst Management Model.

A protocol of a randomized control trial to test the feasibility and efficacy of the EMPOWER social-emotional learning curriculum for youth aged 11-14 years in after-school settings

INTRODUCTION

Promoting youth mental health and well-being is a global concern. Administering social-emotional learning programs in contexts that are familiar to youth have the potential to increase mental well-being by helping youth develop fundamental coping skills that may contribute to their resilience. Implementing social-emotional learning programs in after-school settings is a unique opportunity to improve mental well-being skills in communities that face inequities.

METHODS

The study is a partnership between investigators at an academic mental health hospital and an after-school program embedded within economically and socially vulnerable neighborhoods in a large metropolitan city in Ontario, Canada. This 20-week covariate-constrained randomized controlled trial will test the feasibility and preliminary efficacy of the EMPOWER social-emotional learning curriculum for youth aged 11-14 years in an after-school program. Twenty sites will be randomized to an intervention group or no-intervention control. Program staff in the intervention arm will receive training on the manualized curriculum and weekly coaching sessions to build capacity and support implementation over the 16-week program. Program staff and youth across both intervention and no-intervention control groups will be asked to participate in baseline and post-intervention data collection where they may complete questionnaires about youth's social-emotional learning skills, global quality of functioning, and resilience skills. The no-intervention control group will carry on with their regular programming while the intervention group implements the 16-week social-emotional learning curriculum, after the collection of baseline data. Program staff in the intervention group will be asked to complete weekly fidelity measures and monthly feasibility, acceptability, and appropriateness of implementation scales. Parents/caregivers of youth in the intervention group will be asked to participate in a brief interview to report their observations of their children's social-emotional learning skills.

DISSEMINATION

Results from this pilot study will be disseminated in a peer-reviewed journal and at community and academic conferences.

Assessing the feasibility, acceptability, and preliminary health behavior outcomes of a community-based virtual group health coaching for cancer survivors program

PURPOSE

The primary purpose was to assess the feasibility and acceptability of a group health coaching (GHC) program with cancer patients and survivors; secondarily, to determine the preliminary effects of GHC on several behavioral lifestyle factors.

METHODS

GHC was provided to people diagnosed with cancer via videoconference by trained health coaches across six GHC sessions over a 3-month period. Qualitative and quantitative data were collected. Data on recruitment, attrition, attendance, fidelity, retention, safety, and barriers and facilitators to implementation were assessed. Participant-reported outcomes collected via surveys included physical activity, eating habits, perceived stress, anxiety, depression, sleep, and quality of life, followed by post-program focus groups and in-depth interviews. Survey results were analyzed using repeated measures multilevel modeling. Qualitative data was analyzed using inductive thematic analysis.

RESULTS

Overall, 26 participants with a variety of cancer types attended an average of 74% of coaching sessions. The intervention was feasible to implement and found acceptable by participants and health coaches. Over the course of the intervention, there was a moderate increase in total weekly physical activity minutes (baseline = 365.25, follow-up = 510.30, p = 0.032, d = 0.50), and a small increase in weekly moderate-vigorous physical activity frequency (baseline = 4.07 bouts, follow-up = 5.44 bouts, p = 0.045, d = 0.39). Additionally, a moderate increase was found in functional well-being (baseline = 16.30, follow-up = 18.93, p < 0.001, d = 0.50). CONCLUSIONS AND IMPLICATIONS: GHC may be a feasible and acceptable way to promote behavior change for physical activity in cancer patients and survivors, reducing cancer burden and enhancing functional well-being.

Music-based therapeutic interventions for people with dementia

BACKGROUND

Dementia is a clinical syndrome with a number of different causes. It is characterised by deterioration in cognitive, behavioural, social and emotional functioning. Pharmacological interventions are available but have limited effect on many of the syndrome's features. However, receptivity to music may remain until the late phases of dementia, and music-based therapeutic interventions (which include, but are not limited to, music therapy) are suitable for people with advanced dementia. As there is uncertainty about the effectiveness of music-based therapeutic interventions, trials are being conducted to evaluate this. This review updates one last published in 2018 and examines the current evidence for the effects of music-based interventions for people with dementia.

OBJECTIVES

To assess the effects of music-based therapeutic interventions for people with dementia on emotional well-being (including quality of life), mood disturbance or negative affect (i.e. depressive symptoms and anxiety), behavioural problems (i.e. overall behavioural problems or neuropsychiatric symptoms, and more specifically agitation or aggression), social behaviour and cognition, at the end of therapy and four or more weeks after the end of treatment, and to assess any adverse effects.

SEARCH METHODS

We searched the Cochrane Dementia and Cognitive Improvement Group's Specialised Register, MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), CINAHL (EBSCOhost), Web of Science Core Collection (ISI Web of Science), LILACS (BIREME), ClinicalTrials.gov and the World Health Organisation's meta-register-the International Clinical Trials Registry Platform on 30 November 2023.

SELECTION CRITERIA

We included randomised controlled trials of music-based therapeutic interventions (of at least five sessions) for people with dementia that measured any of our outcomes of interest. Control groups either received usual care or other activities with or without music.

DATA COLLECTION AND ANALYSIS

Two review authors worked independently to screen the retrieved studies against the inclusion criteria and then to extract data from included studies and assess their risk of bias. If necessary, we contacted trial authors to ask for additional data, such as relevant subscales. We pooled data using the random-effects model. We assessed the certainty of the evidence for our two comparisons and our main outcomes of interest using GRADE.

MAIN RESULTS

We included 30 studies with 1720 randomised participants that were conducted in 15 countries. Twenty-eight studies with 1366 participants contributed data to meta-analyses. Ten studies contributed data to long-term outcomes. Participants had dementia of varying degrees of severity and resided in institutions in most of the studies. Seven studies delivered an individual intervention; the other studies delivered the intervention to groups. Most interventions involved both active and receptive elements of musical experience. The studies were at high risk of performance bias and some were at high risk of detection or other bias. For music-based therapeutic interventions compared to usual care, we found moderate-certainty evidence that, at the end of treatment, music-based therapeutic interventions probably improved depressive symptoms slightly (standardised mean difference (SMD) -0.23, 95% confidence interval (CI) -0.42 to -0.04; 9 studies, 441 participants), and we found low-certainty evidence that it may have improved overall behavioural problems (SMD -0.31, 95% CI -0.60 to -0.02; 10 studies, 385 participants). We found moderate-certainty evidence that music-based therapeutic interventions likely did not improve agitation or aggression (SMD -0.05, 95% CI -0.27 to 0.17; 11 studies, 503 participants). Low to very low certainty evidence showed that they did not improve emotional well-being (SMD 0.14, 95% CI -0.29 to 0.56; 4 studies, 154 participants), anxiety (SMD -0.15, 95% CI -0.39 to 0.09; 7 studies, 282 participants), social behaviour (SMD 0.22, 95% CI -0.14 to 0.57; 2 studies; 121 participants) or cognition (SMD 0.19, 95% CI -0.02 to 0.41; 7 studies, 353 participants). Low or very-low -certainty evidence showed that music-based therapeutic interventions may not have been more effective than usual care in the long term (four weeks or more after the end of treatment) for any of the outcomes. For music-based therapeutic interventions compared to other interventions, we found low-certainty evidence that, at the end of treatment, music-based therapeutic interventions may have been more effective than the other activities for social behaviour (SMD 0.52, 95% CI 0.08 to 0.96; 4 studies, 84 participants). We found very low-certainty evidence of a positive effect on anxiety (SMD -0.75, 95% CI -1.27 to -0.24; 10 studies, 291 participants). For all other outcomes, low-certainty evidence showed no evidence of an effect: emotional well-being (SMD 0.20, 95% CI -0.09 to 0.49; 9 studies, 298 participants); depressive symptoms (SMD -0.14, 95% CI -0.36 to 0.08; 10 studies, 359 participants); agitation or aggression (SMD 0.01, 95% CI -0.31 to 0.32; 6 studies, 168 participants); overall behavioural problems (SMD -0.08, 95% CI -0.33 to 0.17; 8 studies, 292 participants) and cognition (SMD 0.12, 95% CI -0.21 to 0.45; 5 studies; 147 participants). We found low or very-low certainty evidence that music-based therapeutic interventions may not have been more effective than other interventions in the long term (four weeks or more after the end of treatment) for any of the outcomes. Adverse effects were inconsistently measured or recorded, but no serious adverse events were reported.

AUTHORS' CONCLUSIONS

When compared to usual care, providing people with dementia with at least five sessions of a music-based therapeutic intervention probably improves depressive symptoms and may improve overall behavioural problems at the end of treatment. When compared to other activities, music-based therapeutic interventions may improve social behaviour at the end of treatment. No conclusions can be reached about the outcome of anxiety as the certainty of the evidence is very low. There may be no effects on other outcomes at the end of treatment. There was no evidence of long-term effects from music-based therapeutic interventions. Adverse effects may be rare, but the studies were inconsistent in their reporting of adverse effects. Future studies should examine the duration of effects in relation to the overall duration of treatment and the number of sessions.

Evaluation of Electronic Palliative Care Coordination Systems to support advance care planning for people living with life-threatening conditions (PREPARE): protocol for a multicentre observational study using routinely collected primary and secondary care data in England

INTRODUCTION

Electronic Palliative Care Coordination Systems (EPaCCS) are electronic registers that aim to facilitate documentation and sharing of up-to-date information about patients' end-of-life preferences and plans for care among different health services. They aim to improve patients' experiences and outcomes and mitigate costs linked to undesired aggressive care. However, evidence on the equitable delivery of EPaCCS and the extent to which advance care planning (ACP) enhances end-of-life care remains sparse. This study aims to explore the effect of EPaCCS on healthcare outcomes, service utilisation, and costs. It will also estimate the association between social determinants of health and the content and use of EPaCCS.

METHODS AND ANALYSIS

The PREPARE project is a retrospective observational cohort study conducted in two phases. We will analyse routinely collected data from three EPaCCS registers from London, Bradford and Leeds. The first phase will use descriptive analysis to describe the completeness of EPaCCS, the content of EPaCCS, and socio-demographic and clinical characteristics of individuals with EPaCCS, and will model the relationship between social determinants of health and completion of ACP components and the creation of EPaCCS. The second phase will use a natural experiment to compare quality indicators (place of death and hospital use) between individuals with EPaCCS and those without. The control groups will be identified through the Leeds decedent dataset and through linking the London EPaCCS register to an electronic record used in North West London. Also, we will quantify healthcare costs and outcomes.

ETHICS AND DISSEMINATION

Research approval has been secured from the Health Research Authority (ref 24/LO/0194), London - South East Research Ethics Committee (ref 24/LO/0194) and Confidentiality Advisory Group (ref 24/CAG/0046). Dissemination of findings will occur through peer-reviewed publications, knowledge exchange events and collaborative efforts with patient and public involvement partners.

Protocol to evaluate the feasibility of the D-PRESCRIBE intervention adapted to the Belgian community setting (END-IT CS study)

INTRODUCTION

Benzodiazepine receptor agonists (BZRA) deprescribing interventions are needed to tackle high BZRA use in the older population. This study aims to assess the feasibility of the D-PRESCRIBE intervention, adapted from Canada to the Belgian community setting. This pharmacist-led intervention comprises a patient educational brochure and a pharmacist-to-prescriber communication tool.

METHODS AND ANALYSIS

We will conduct a feasibility study of a cluster randomised controlled trial involving 8-10 community pharmacies (clusters) and aiming to recruit 56-80 patients (≥65 years). Intervention pharmacies will deliver the adapted D-PRESCRIBE intervention and control pharmacies, usual care. Patients will be blinded to group allocation. Quantitative data will be collected at baseline, 3 months and 6 months through patients' and pharmacists' questionnaires, aiming: (1) to test the feasibility of the intervention, (2) to test the feasibility of the study design needed for its evaluation and (3) to perform an exploratory cost-effectiveness analysis. Hence, data about implementation outcomes, mechanisms of impact (ie, mechanisms through which the intervention is supposed to be effective) and contextual factors will be gathered. Patient-centred outcomes will also be collected as they would be in a full cost-effectiveness trial. The feasibility of the study design will be assessed through participation rate, completeness of the data and a satisfaction survey, sent to participants after the 6-month data collection. Data will be analysed using descriptive statistics. To gain a deeper understanding of pharmacists and patients' experience with the intervention, interviews will be conducted after the 6-month data collection and the Theoretical Domains Framework will be used as a deductive framework for analysis.

ETHICS AND DISSEMINATION

This study was approved by the Ethics Committee of CHU UCL Namur (NUB: B0392023000036). Participants will receive a summary of the results. Results will also be disseminated through the organisation of a local symposium and a peer-reviewed publication.

TRIAL REGISTRATION NUMBER

NCT05929417.

A process evaluation of the walking in ScHools (WISH) study using the RE-AIM framework

BACKGROUND

Physical inactivity in adolescents is a major public health issue. Schools are important settings for physical activity interventions. The WISH Study was a peer-led, school-based walking intervention that aimed to increase physical activity levels of adolescent girls. This study uses the RE-AIM Framework to present the process evaluation of the WISH Study with a focus on factors that affected participation, motivation, and enjoyment of the intervention.

METHODS

Pupils (n589 12-14 years) were recruited from 18 schools in the border region of Ireland and Northern Ireland. In intervention schools (n9), older pupils (15-18 years) were trained as walk leaders and led pupils (12-14 years) in brisk walks (10-15 min) during the school day, across the school year (2021-22). Questionnaires to measure self-efficacy for walking and physical activity, health-related quality of life and reasons for engaging in physical activity were administered throughout the intervention. At the end of the intervention focus groups were held with pupils, and interviews conducted with teachers and walk leaders. Attendance at walks was monitored by walk leaders. Quantitative data were analysed descriptively, and qualitative analysis was undertaken using thematic analysis. Themes were reported under RE-AIM indicators (reach, effectiveness, adoption, implementation, and maintenance).

RESULTS

Pupils in the intervention schools (n286) were representative of adolescent girls in Northern Ireland and Ireland, in terms of their activity level. At baseline, 15% of these pupils met the recommended physical activity guidelines of 60 min moderate-vigorous physical activity per day, as measured by accelerometers. The total number of walks reported per school ranged from 2 to 104 across intervention schools. One quarter of pupils (n74, 26%) never attended a walk and 15% (n23) of walk leaders did not lead a walk. Pupils and walk leaders self-reported improvements in their physical health, mental well-being, and social relationships, and walk leaders reported gaining transferrable skills. Implementation was aided by school support in some schools, although barriers such as COVID-19, lack of time, harsh weather, inadequate facilities for indoor walks, and walk leader availability, were identified. Staff engagement was a key driver for the maintenance of walks.

CONCLUSIONS

Despite a promising feasibility study and a comprehensive walk leader training programme, the extent to which the intervention was adopted and implemented varied, suggesting future school-based physical activity interventions need to consider individual school contexts to ensure intervention fidelity.

TRIAL REGISTRATION

ISRCTN 12847782.

Interventions on Fruit and Vegetable Intake in Low-, Middle-, and High-Income Countries: A Scoping Review of Evidence and Knowledge Gaps

BACKGROUND

Adequate fruit and vegetable (F&V) intake is important for health, yet populations globally are failing to meet recommendations.

OBJECTIVE

A scoping review to summarize available evidence of evaluations of interventions to increase F&V intake globally, focusing on target populations, intervention strategies, research methods, and summarizing their evaluated impacts.

METHODS

We searched PubMed and Web of Science in February 2023 for intervention studies in which dietary intake of fruit and/or vegetables were documented. Eligible studies included all age groups, excluding those targeting populations with specific disease-related conditions, such as cancer patients/survivors. Only articles published in English since 2012 were included in the review.

RESULTS

We identified 6338 articles, with 226 meeting inclusion criteria, comprising 223 unique studies and 284 intervention comparisons. Most comparisons occurred in high-income countries (n = 192) compared to low- and middle-income countries (n = 92). Randomized controlled trials (RCTs; 37.3%) and cluster RCTs (52.5%) were predominant. Interventions primarily targeted adults (31.7%), school-aged children (18.0%), children under-five (14.4%), and adolescents (13.7%), lasting an average of 24 weeks (range: 2 weeks to 20 years). Food-frequency questionnaires (59.2%) and 24-h recalls (26.8%) were the most used dietary assessment method. Health and nutrition education (75.9%) was the most common intervention, utilizing interpersonal communication, mass media, and information-communication technology, often in combinations. Positive impacts on fruit (43.9%), vegetable (40.2%), and combined F&V intake (53.0%) were observed in nearly half the intervention comparisons.

CONCLUSIONS

These findings highlight the predominance of health and nutrition education interventions, predominantly in high-income countries, showing mixed success in improving F&V intake, emphasizing the need for context-specific strategies and standardized methodologies to design sustainable, cost-effective interventions for better diet quality and health outcomes.

PLAIN LANGUAGE TITLE

A literature review assessing what we know and do not know about efforts to improve fruit and vegetable intake across the world.

Assessing competence of primary care respiratory healthcare professionals to deliver a psychologically-based intervention for people with COPD: results from the TANDEM study

Management of long-term conditions is a significant challenge in contemporary health care as people often require support for both physical and psychological symptoms. Assessing the competence of healthcare professionals delivering psychologically informed interventions informs decisions about future implementation. This is a comprehensive intervention fidelity assessment nested within a randomised controlled trial. We developed a bespoke intervention fidelity assessment framework to assess the competence of primary care respiratory nurses, physiotherapists and occupational therapists delivering a cognitive behavioural intervention for people with COPD. A total of 180 (representing 15% of trial cases) intervention audio files, from 36 intervention arm participants, were coded. The intervention was delivered with acceptable adherence for most components. Therapeutic competency was achieved and comparable with previous research studies. Interpersonal skills and focus had higher competency whilst guided discovery and application of appropriate change techniques was lower but still adequate. Skills improved over time and with an increased number of clients. With proper training and supervision, primary care respiratory nurses, physiotherapists and occupational therapists can deliver cognitive behavioural interventions with acceptable therapeutic competency but questioning and change techniques may need particular focus in training and greater practice.

Tuning in to Kids Together: Piloting an Emotion-Focused Coparenting Program

Group parenting programs, including emotion-focused programs, are effective at improving children's emotional and behavioral adjustment; however, the impact of these programs may be limited due to parents, typically mothers, attending sessions alone. It is expected that actively involving both caregivers in parenting programs will lead to superior outcomes given family systems are interconnected and when parents feel more supported by one another, they are more likely to have greater emotional availability for their children. Tuning in to Kids Together (TIK-Together) was developed to involve both caregivers and address the coparenting relationship. The current study examined the feasibility and pilot testing of TIK-Together when delivered in a real-world context, specifically assessing program adherence, reliability of measures, and program outcomes. TIK-Together was delivered to 57 participants (27 mother-father dyads, 1 triad) by community services in Australia in an intervention-only design. Facilitators completed attendance sheets and fidelity checklists after each session, and parents completed online questionnaires at pre-intervention, post-intervention, and 6-month follow-up. Adherence across services varied; however, parent attendance and the proportion of content delivered was high. The measures used to assess coparent outcomes demonstrated good to excellent internal consistency in the current sample. After attending the program, parents reported increased supportive/cooperative coparenting of children's emotions, greater dyadic coping, improved emotion coaching beliefs and practices, reduced undermining coparenting of children's emotions, lower emotion dismissing beliefs and practices, and less parent emotion dysregulation. Mothers and fathers reported improved child emotion regulation and decreased behavioral difficulties. The findings are consistent with prior TIK research and pave the way for future research exploring the benefits of integrating coparenting content into this parenting intervention.

Upskilling Rheumatology Occupational Therapists in Work Rehabilitation: An Evaluation of a Job Retention Vocational Rehabilitation Training Course (the Workwell Trial)

OBJECTIVES

The objectives were to assess current job retention vocational rehabilitation (JRVR) services for employed individuals with inflammatory arthritis (IA) in rheumatology therapy departments interested in participating in the Workwell trial. Additionally, to modify a JRVR training course to support therapists in delivering JRVR and to evaluate changes in therapists' knowledge, confidence, and ability following the training.

METHODS

This was a mixed-methods study. Current work services were explored with lead therapists through a cross-sectional survey about their work rehabilitation service; and one-to-one interviews. Feedback from previous course attendees and trainers informed modifications to the training course. Participating therapists completed mailed questionnaires pre-and post-training.

RESULTS

Lead therapists from 28 interested departments reported providing JRVR to a median of 7 patients per month (IQR 3-12) for an average of 60 min (IQR 41.25-90). Nine therapists participated in pre-trial interviews, with themes highlighting variability in referrals, the use of work assessment tools, and advice on ergonomic adjustments. The training course was shortened from three to 2 days by incorporating a pre-training self-study pack and reducing lecture time, while increasing practical content such as work assessment demonstrations and extended workshops. Following the training, 32 therapists showed significant improvements in their knowledge and confidence in delivering JRVR (p < 0.001).

DISCUSSION

The need for training in work assessment and delivery of complex JRVR was identified. The therapist training course provided was favourably received. Post-training, therapists' ability to assess and plan complex JRVR improved.

TRIAL REGISTRATION

WORKWELL Trial: ISRCTN: 61762297; Clinical Trials.Gov: NCT03942783.

Assessing the fidelity of the "photo-with-movement program" (PMP) for community-dwelling older adults with pain: A randomized controlled trial

PURPOSE

To measure intervention fidelity of the Photo-with-Movement Program (PMP) and to report the findings of the program.

METHODS

This study was a two-arm, pilot randomized controlled trial of the PMP. An intervention fidelity checklist and semi-structured interviews were utilize to evaluate the fidelity of the PMP. Twenty-four older adults and informal caregiver dyads enrolled in the study, with 12 dyads in the experimental group and another 12 in the control group. The PMP integrated visual stimulation, physical exercise, and digital-based activity to deliver a comprehensive, non-pharmacological pain relief syllabus to the participants in the experimental group. The control group received pain management pamphlets. The data collected were analyzed using SPSS to compare the outcomes between the experimental and control groups.

RESULTS

The PMP led to significant findings on reducing pain intensity and high scores on intervention fidelity. Participants showed great acceptance of this delivery format.

CONCLUSIONS

This study revealed the fidelity and effectiveness of a multimodal non-pharmacological intervention, suggesting that it could be used for pain management and caregiving.

Implementing the Eat, Sleep, Console Model of Care: A Scoping Review

OBJECTIVE

The Eat, Sleep, Console (ESC) model of care is an innovative care approach for infants diagnosed with neonatal abstinence syndrome, improving patient and health system outcomes for this equity-deserving population. Little is known about sustainably implementing this model into practice. The objective is to map evidence on implementing the ESC model into clinical practice, including strategies, barriers and facilitators to implementation, and evaluation outcomes.

METHODS

Data sources include MEDLINE, Embase, CINAHL, PsycINFO, Google Scholar, and websites identified by a Google search. The study selection included articles exploring the implementation or evaluation of the ESC model in clinical practice since its 2017 conception. Two reviewers independently screened each study using a predetermined screening tool. Data were extracted by 2 independent reviewers from included articles.

RESULTS

The review identified 34 studies. Barriers to implementing the ESC model include resource limitations and systemic oppression and bias. Facilitators include health care provider education and empowerment of parent engagement. The most reported cluster of strategies (31.6%) included training and educating stakeholders. Gaps were noted in the exploration of implementation outcomes/processes, and equity implications on implementation.

CONCLUSIONS

The ESC model of care has been successfully implemented in various settings with positive patient and health system outcomes, including decreased hospital stay and pharmacological treatment of infants. However, there is a gap in exploring implementation processes and outcomes. Future research should explore the contextual elements of the implementation by equitably examining implementation outcomes specific to the ESC model of care.

Understanding Implementation Fidelity of Physical Health Screening in Mental Health Nursing: A Mixed Methods Study

Physical health screening for patients with schizophrenia spectrum disorders is suboptimal despite patients' poor physical health and nurses' willingness to conduct assessments. However, this inadequate service provision is poorly understood. The purpose of this study was to describe nurses' adherence to conducting screening with the Finnish Health Improvement Profile and related factors. An explanatory, sequential two-phase mixed-methods design was used. A quantitative method was used to describe nurses' adherence and a qualitative approach to describe moderating factors. The data were collected and analyzed separately and later integrated into one dataset. Generally, screening was implemented as intended regarding content adherence despite very few nurses conducting the screening. Analysis identified four main themes related to adherence. Comprehensiveness of policy description included complexity and duration; strategies to facilitate implementation included fragmented information, instructions, nurses' fragmented work tasks, management and equipment; quality of delivery included preparedness and nurses' confidence and skills; and participant responsiveness included nurses' enthusiasm in screening, nurses' engagement in screening, patient willingness to participate, patient's refusal to participate, patient's cognitive capacity and collaborative screening. For successful screening, the utility and feasibility of the screening tool would need to be reevaluated after addressing some of the barriers identified as moderating factors.

Needs assessment and Acceptability of a Community First Aid Responder programme to increase Out-of-hospital capacity in Kinshasa, Democratic Republic of Congo: A qualitative study

Objective

Despite efforts in recent years to expand the availability of prehospital care in low- and middle-income countries, its availability remains limited in many regions. The World Health Organization advocates the development of layperson first responder programmes as a supportive step in building functioning prehospital systems. This study aimed to identify the need for, and acceptability of, a community first responder programme to increase out-of-hospital capacity in Kinshasa, Democratic Republic of Congo.

Methods

We conducted five focus group discussions using purposive sampling. We included health system planners, emergency care providers, community health volunteers, and community members in both urban and peri‑urban areas. Interviews were recorded and transcribed verbatim, validated, and subjected to inductive content analysis to identify themes and sub-themes.

Results

Several areas of the emergency care system were identified for improvement, starting with the initial response to emergencies in the community. Barriers included planning and governance issues; inadequate resources such as trained staff; cost; transportation issues; and reliance on alternative forms of care. There was a dominant view that sustainably addressing these barriers and building on identified facilitators requires a multi-pronged approach involving government, healthcare, and community members. Perspectives about the acceptability and sustainability of a community first responder programme were largely positive, and numerous actionable recommendations were provided.

Conclusion

A community first responder programme was deemed a useful and acceptable intervention to help increase out-of-hospital emergency care capacity in Kinshasa. Key potential facilitators and barriers to its implementation and sustainability were identified.

Implementing INTERACT in Veterans Health Administration Community Living Centers: A pragmatic randomized trial

BACKGROUND

Hospital transfers from VA Community Living Centers (CLCs) are common. The objective of this study was to evaluate the effect of introducing the Intervention to Reduce Acute Care Transfers (INTERACT) program into VA CLCs.

METHODS

Cluster randomized trial involving 16 pair-matched VA CLCs.

INTERVENTIONS

Intervention CLC nursing staff were trained in the use of INTERACT tools designed to identify early signs of a clinical change in condition and improve communication and documentation. One tool was embedded into the VA Electronic Medical Record. Intervention staff were supported by bi-weekly calls over 18 months to reinforce INTERACT tool use.

MEASUREMENTS

The primary outcome for intent-to-treat analyses was the rate of all-cause hospitalizations per 1000 person days. Secondary outcomes, assessed through structured record reviews and algorithms, were intervention CLCs change in 1) potentially inappropriate transfer decisions and 2) potentially preventable transfers. CLC staff implementation and engagement in INTERACT were documented.

RESULTS

Only five of the eight intervention CLCs substantially engaged in the intervention. Using a negative-binomial regression with random effects, adjusting for month, intervention, and the interaction of time and the intervention, we observed no statistically significant difference between intervention and control facilities in all-cause hospitalizations. This was confirmed with matched resident-level, as-treated, analyses among residents in the five engaged CLCs and their matched controls. Structured implicit review of intervention CLC's medical records revealed low rates of inappropriate transfer decisions both before and after the intervention.

CONCLUSIONS

Introducing INTERACT into volunteer VA CLCs did not reduce the rates of all-cause hospitalizations. In both the pre- and post-intervention periods, all-cause hospitalization rates were relatively higher, and inappropriate transfers lower in VA CLCs than commonly observed in community NHs. Low rates of potentially inappropriate transfers and higher nurse and physician staffing in CLCs may explain why INTERACT was not implemented as fully as planned.

AIIMS ICU Rehabilitation (AIR): development and description of intervention for home rehabilitation of chronically ill tracheostomized patients

Background

The paucity of state-supported rehabilitation for chronically ill patients with long-term tracheostomies has ramifications of prolonged hospital-stay, increased burden on acute-care resources, and nosocomial infections. Few interventions describe home rehabilitation of adult tracheostomized patients. Almost none involve stakeholders. This paper describes the All-India Institute of Medical Sciences (AIIMS) ICU rehabilitation (AIR) healthcare intervention developed to facilitate home rehabilitation of chronically ill tracheostomized patients.

Methods

The AIR intervention development was based on the experience-based codesign theory (EBCD). A core research-committee studied prevalent knowledge and gaps in the area. Patients-carer and health-care stakeholders' experiences of barriers and facilitators to home care resulted in an intervention with interlinked components: family-carer training, equipment bank, m-health application, and follow-up, guided by the Medical Research Council (MRC) framework. Healthcare stakeholders (doctors, nurses, medical equipment vendors) and patient-carer dyads were engaged to gather experiences at various stages to form smaller codesign teams for each component. Multiple codesign meetings iteratively allowed refinement of the intervention over one year. The Template for Intervention Description and Replication (TIDieR) checklist was used to report the AIR intervention.

Results

The first component comprised a minimum of three bedside hands-on training sessions for carers relating to tracheostomy suction, catheter care, monitoring oxygenation, enteral feeding, skincare, and physiotherapy, buttressed by pictorial-books and videos embedded in a mobile-application. The second was an equipment-bank involving a rental-retrieval model. The third component was a novel m-health tool for two-way communication with the core group and community of other patient-carers in the project for follow-up and troubleshooting. Home visits on days 7 and 21 post-discharge assessed patient hygiene, nutrition, physiotherapy, and established contact with the nearest primary healthcare facility for the future.

Conclusions

Findings support the EBCD-based development using active feedback from stakeholders. Assessment of feasibility, process and effectiveness evaluation will follow.

"VID-KIDS" Video-Feedback Interaction Guidance for Depressed Mothers and Their Infants: Results of a Randomized Controlled Trial

VID-KIDS (Video-Feedback Interaction Guidance for Depressed Mothers and their Infants) is a positive parenting programme comprising three brief nurse-guided video-feedback sessions (offered in-person or virtually via Zoom) that promote "serve and return" interactions by helping depressed mothers to be more sensitive and responsive to infant cues. We examined whether mothers who received the VID-KIDS programme demonstrated improved maternal-infant interaction quality. The secondary hypotheses examined VID-KIDS' effects on maternal depression, anxiety, perceived parenting stress, infant developmental outcomes, and infant cortisol patterns. A parallel group randomized controlled trial (n = 140) compared the VID-KIDS programme to standard care controls (e.g., a resource and referral programme). The trial was registered in the US Clinical Trials Registry (number NCT03052374). Outcomes were assessed at baseline, nine weeks post-randomization (immediate post-test), and two months post-intervention. Maternal-infant interaction quality significantly improved for the intervention group with moderate to large effects. These improvements persisted during the post-test two months after the final video-feedback session. No significant group differences were detected for secondary outcomes. This study demonstrated that nurse-guided video-feedback can improve maternal-infant interaction in the context of PPD. These findings are promising, as sensitive and responsive parenting is crucial for promoting children's healthy development.

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.

A self-management intervention for newly diagnosed with inflammatory arthritis: a randomized controlled feasibility and fidelity study

BACKGROUND

Inflammatory arthritis affects approximately 2-3% of adults worldwide. For patients newly diagnosed with arthritis, effective self-management is crucial, as they often face several physiological, emotional, and social challenges. A self-management intervention called NISMA was thus developed to cater to this group. This study aimed to evaluate the feasibility and fidelity of this intervention before conducting a full-scale randomized controlled trial.

METHODS

This feasibility study was conducted as a single-center randomized controlled trial. Twenty participants were expected to be sufficient for assessing the feasibility outcomes. The control group received only the usual care, while the intervention group received the NISMA intervention in addition, which involved individual and group sessions in a multidisciplinary setting. Feasibility was evaluated based on the recruitment, data collection, retention, and randomization processes. The patient-reported outcome measures and clinical measures were collected to review their potential for inclusion in a future randomized controlled trial. Fidelity was assessed by using documentation sheets filled in by the health professionals and audio recordings of the sessions to examine whether the intervention's principles and components were adequately addressed.

RESULTS

Among 47 eligible patients, we recruited 23 participants during a period of 4 months. The recruitment rate was 47% and the retention rate 91%. Randomization, although accepted, led to some disappointment in the control group. Data collection was effective, with only minimal missing data (< 1%). The fidelity was considered as high, as results indicated that nurses effectively engaged in collaborative partnerships with patients, utilizing planned questioning techniques and self-management strategies for problem-solving and resource utilization. However, action planning was inconsistently applied.

CONCLUSION

The study demonstrated the feasibility and the overall high fidelity of delivering the NISMA intervention to patients newly diagnosed with inflammatory arthritis. The insights from the study are useful for identifying the areas that require modifications before initiating a randomized controlled trial.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT06063252. Registered 02 October 2023 - retrospectively registered.

Evaluating the feasibility of a community-adapted multi-domain intervention for dementia prevention in older adults

BACKGROUND

Dementia impacts individuals, families, and society, necessitating effective prevention strategies.

OBJECTIVE

To evaluate the feasibility of a community-adapted multi-domain intervention for dementia prevention among older adults in Obu City, Japan and how uncertainties in implementing definitive trials can be reduced.

METHODS

A 12-month one-arm intervention trial was conducted with 80 community-dwelling older adults aged 65-86 years from two district regions. The multi-domain intervention included physical exercise, nutrition guidance, cognitive training, social participation, and vascular risk management. The primary outcome was the continuation rate, defined as the proportion of participants attending >60% of classes from the initial assessment to 6 months. Secondary outcomes, such as fidelity, acceptability, and appropriateness, were assessed through qualitative and quantitative evaluations. Additionally, health outcomes, including cognitive function and overall lifestyle, were evaluated.

RESULTS

The study achieved continuation rates of 75% and 76% at 6 and 12 months, respectively, indicating high feasibility. Participants showed high program acceptability (average acceptance score, 4.4 of 5). Fidelity was high regarding content coverage and duration, although the frequency and coverage varied between study sites. Cognitive function remained stable; food-diversity status improved significantly over the study period, though the absence of a control group limits causal interpretation of these changes.

CONCLUSIONS

The community-adapted multi-domain intervention for dementia prevention demonstrated high feasibility and acceptability among older adults. Our findings can help reduce uncertainties and support planning future definitive trials to evaluate the effectiveness of community-based dementia-prevention programs.

Process Evaluations of Interventions for the Prevention of Type 2 Diabetes in Women With Gestational Diabetes Mellitus: Systematic Review

BACKGROUND

Gestational diabetes mellitus (GDM) is characterized by hyperglycemia in pregnancy and typically resolves after birth. Women with GDM have an increased risk of developing type 2 diabetes mellitus (T2DM) later in life compared to those with normoglycemic pregnancy. While diabetes prevention interventions (DPIs) have been developed to delay or prevent the onset of T2DM, few studies have provided process evaluation (PE) data to assess the mechanisms of impact, quality of implementation, or contextual factors that may influence the effectiveness of the intervention.

OBJECTIVE

This study aims to identify and evaluate PE data and how these link to outcomes of randomized controlled trials (RCTs) of T2DM prevention interventions for women with GDM.

METHODS

A systematic review was conducted to identify studies published from 2005 to 2020 aiming to capture the most recent DPIs. Five electronic bibliographic databases (Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, Embase, PubMed, and MEDLINE) were searched to identify relevant studies. Inclusion criteria were published (peer-reviewed) RCTs of DPIs in women with a current diagnosis or history of GDM. Exclusion criteria were studies not published in English; studies where the target population was women who had a family history of T2D or women who were menopausal or postmenopausal; and gray literature, including abstracts in conference proceedings. The Medical Research Council's PE framework of complex interventions was used to identify key PE components. The Mixed Method Appraisal Tool was used to assess the quality of included studies.

RESULTS

A total of 24 studies were included; however, only 5 studies explicitly reported a PE theoretical framework. The studies involved 3 methods of intervention delivery, including in person (n=7), digital (n=7), and hybrid (n=9). Two of the studies conducted pilot RCTs assessing the feasibility and acceptability of their interventions, including recruitment, participation, retention, program implementation, adherence, and satisfaction, and 1 study assessed the efficacy of a questionnaire to promote food and vegetable intake. While most studies linked PE data with study outcomes, it was unclear which of the reported PE components were specifically linked to the positive outcomes.

CONCLUSIONS

While the Medical Research Council's framework is a valuable source for conducting systematic reviews on PEs, it has been criticized for lacking practical advice on how to conduct them. The lack of information on PE frameworks in our review also made it difficult to categorize individual PE components against the framework. We need clearer guidance and robust frameworks for conducting PEs for the development and reporting of DPIs for women with GDM.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42020208212; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=208212.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-https://doi.org/10.1177/16094069211034010.

Adherence to institutional stroke alert criteria in an academic adult emergency department population

BACKGROUND

Timely recognition of acute ischemic stroke (AIS) is essential to identify patients who may be eligible for acute intervention. Protocols to streamline systems-based care, such as "stroke alerts" in the emergency department (ED) can safely reduce time-to-care while enhancing safety. However, clinician adherence to stroke alert criteria is poorly described. We sought to describe the adherence and secondarily the detection rate of stroke alerts initiated by both pre-hospital and ED providers in adult patients with neurologic symptoms concerning for AIS.

METHODS

We conducted a retrospective, observational, quality improvement study at a single, quaternary care academic ED in Nashville, Tennessee. We identified adult patients presenting with acute neurological deficits concerning for AIS who received a stroke alert consultation between 2018 and 2024. The primary outcome was the adherence to institutional stroke alert protocols informed by evidence-based stroke criteria. Secondary outcomes included stroke detection, imaging utilization, and treatment interventions.

RESULTS

There were 861 adult stroke alert consultations during the study period that met inclusion criteria; the median age (interquartile range [IQR]) was 62.8 (50.4, 73.0) years, 450 (52.3 %) were female, and 174 (20.2 %) were Black race. Overall, 560 (65.0 %) stroke alerts met institutional activation criteria, and of these, 153 (27.3 %) had either an ischemic or hemorrhagic stroke, and 90 (16.1 %) received either a thrombolytic medication or cerebral angiography. Of the 301 (35.0 %) stroke alert activations not meeting institutional eligibility criteria, 74 (24.6 %) of these had either an ischemic or hemorrhagic stroke, and 10 (3.3 %) received thrombolytic medication or cerebral angiography.

CONCLUSION

Nearly two-thirds of ED-initiated stroke alert consultations met institutional criteria. Non-adherent stroke alerts were frequently outside the time window for activation. Continued education directed toward clinical providers may enhance adherence, resource utilization, and patient outcomes for patients with suspected strokes.

Guidelines for evaluating and reporting social isolation and loneliness interventions

Given the unpleasant nature of social isolation and loneliness (SIL) and their negative effects on health and wellbeing, interventions are needed. However, persistent issues in the design, evaluation, and reporting of SIL interventions preclude conclusive evidence and commentary on the effectiveness of SIL interventions. Here, we propose guidelines for evaluating SIL interventions, firstly by operationalising them into two categories: (1) interventions aiming to reduce SIL as a primary outcome and (2) interventions aiming to improve non-SIL outcomes in the lives of individuals experiencing SIL. Secondly, we evaluate instruments for measuring SIL and research designs for studying intervention effectiveness. Thirdly, guidelines for reporting information about the intervention, study design, results, and discussion in SIL intervention studies are presented. These guidelines will help researchers to better and more consistently report on SIL interventions and improve comparability of SIL interventions, ultimately contributing to the improvement of interventions and to the mitigation of SIL.

What is fidelity? A systematic review of provider fidelity and its associations with engagement and outcomes in parenting programs

As developers and practitioners translate parenting interventions from research to practice, significant heterogeneity in provider fidelity and parent engagement with the program has contributed to observed declines in intervention effectiveness. Despite this, empirical investigations of the relationship between provider fidelity, parent engagement, and intervention outcomes are scarce and those that exist show discrepant outcomes. This is, in part, due to the variability in the way fidelity is defined, operationalized, and measured. Therefore, following PRISMA-P guidelines, this review elucidates the relationship between provider fidelity, parent engagement, and intervention outcomes in parenting interventions, with a particular emphasis on how provider fidelity is defined and measured. A systematic search revealed 264 articles, of which 25 met inclusion criteria. As anticipated, results suggest that there are inconsistencies in the relationship between provider fidelity, parent engagement, and intervention outcomes, and these inconsistencies appear related to how fidelity is defined. Across studies, definitions of fidelity were related to one or more dimensions, including adherence, competence/quality, and knowledge, with those measures that captured all three dimensions demonstrating the most consistency in the relation between fidelity and intervention outcomes. Although methodological limitations exist, increased precision in fidelity measurement will have positive implications for the widespread implementation of parenting programs.

Exercise-based cardiac rehabilitation for patients with atrial fibrillation receiving catheter ablation: protocol for a feasibility randomised controlled trial (RCT) with embedded process evaluation

INTRODUCTION

Atrial fibrillation (AF) affects approximately 2.5% of the UK population, with a risk of 1 in 3-5 individuals after the age of 45 years. The global prevalence has risen sharply in the past two decades, from 33.3 million to 59 million individuals living with AF, and is associated with stroke, heart failure and mortality. Catheter ablation is commonly used for symptomatic patients to restore normal rhythm. A recent Cochrane review of randomised clinical trials (RCTs) has demonstrated that exercise training may induce positive effects on AF burden, AF severity, exercise capacity, and quality of life. The aim was therefore to investigate the feasibility of delivering exercise-based cardiac rehabilitation for patients with AF receiving catheter ablation within usual care in the UK.

METHODS AND ANALYSIS

A two-armed feasibility RCT with embedded process evaluation will be undertaken as a phased programme of work. Patients on a waiting list for catheter ablation will be offered a referral to cardiac rehabilitation. The intervention consists of supervised exercise sessions run by a clinical exercise physiologist and psychoeducation sessions. The trial (n=60) will involve one National Health Service (NHS) research site enrolling patients to assess intervention and study design processes. Primary outcomes are recruitment rate, adherence to exercise-based cardiac rehabilitation and loss to follow-up. Semistructured interviews and focus groups with patients and clinicians will be used to gather data on the acceptability of the intervention and study procedures. Secondary outcome measures will be taken at baseline (pre-intervention), post-intervention and at 6-month follow-up and will consist of AF burden, AF recurrence, quality of life, exercise capacity measured by peak oxygen consumption and echocardiographic parameters.

ETHICS AND DISSEMINATION

The trial was approved in the UK by the Northwest-Preston Research Ethics Committee (24/NW/0061; IRAS project ID: 330155). Results will be published in peer-reviewed journals and presented at national and international scientific meetings, and summaries will be communicated to participants.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov identifier: NCT06401148.

Experiences of Peer Mentoring Sexual and Gender Minority Emerging Adults Who Are at Risk for Suicide: Mixed Methods Study

BACKGROUND

Sexual and Gender Diverse Youth (SGDY) are at increased risk for suicide due to unique experiences including discrimination, family or friend rejection, and low positive affect. Peer mentors (PMs) may offer a unique opportunity for intervention but are underutilized for suicide prevention among SGDY.

OBJECTIVE

Little is known about the training needed for PMs when working with SGDY at risk for suicide. We developed an intervention, Supporting Transitions to Adulthood and Reducing Suicide (STARS), to improve suicide prevention among SGDY and increase social support, coping, and positive effects. PMs were trained by a licensed clinical therapist and provided a manual. PMs meet virtually for 6 weeks, providing social support, strategies to diminish the impact of discrimination, connection to safe spaces, and reinforcement of intentions to use Safety Plans with mentees.

METHODS

To understand PMs' experiences in their role, including distress, fidelity to the manual, and perceptions of feasibility and acceptability of STARS and mentees' Safety Plan, we collected survey data from mentees and PMs as well as in-depth interviews with PMs after the completion of the intervention.

RESULTS

As of September 2024, all peer mentees (N=64) have completed the study and all PMs have finished providing sessions for peer mentees. PMs (n=5) reported overall high comfort (8.52) and low distress (1.93) during sessions. All 5 PMs had high fidelity (>90%) to the PM intervention training. All 5 PMs reported high feasibility (17.50), acceptability (20), and appropriateness (20) of the STARS intervention. Mentees (n=27) reported high confidence ratings (3.54) in speaking with their PMs.

CONCLUSIONS

Peer mentorship for SGDY who are at risk for suicide was feasible and acceptable by PMs and mentees alike. PMs reported that they felt comfortable and confident during the sessions. Mentees also reported confidence in working with their PMs. Future research should explore the optimal strategies to support PMs and mentees as they engage in suicide prevention work as well as incorporate feedback from the PMs in this study to ensure optimal outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05018143; https://clinicaltrials.gov/study/NCT05018143.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/48177.

Strategies for Fidelity Monitoring a Solution-Focused Brief Intervention in a Randomized Clinical Trial

Integrated Care (IC) models have increased, but the current mechanisms to analyze the efficacy and fidelity of behavioral interventions within IC models are limited. A mixed methods concurrent process evaluation was used within the context of a randomized clinical trial to assess intervention fidelity for a Solution-focused brief therapy (SFBT) intervention implemented within an IC model. A qualitative content analysis was conducted to develop a participant survey and charting template for the SFBT intervention. Quantitative data were collected through (1) participant surveys, (2) interventionist self-report surveys, and (3) data from participant charts. Descriptive statistics and repeated measures ANOVA were used to analyze quantitative data. Data triangulation was used to present findings. The average SFBT intervention was 24.6 min and 33/34 (97%) of participants in the intervention group completed all 3 SFBT sessions. Most visits were weekly follow-ups (53.9%), followed by biweekly (28.2%) and then 3-week follow-ups (5.1%). The interventionist used session templates and a self-report checklist to monitor intervention integrity. Those in the intervention group had increased growth regarding Solution-focused core constructs (a scale created by the authors) when compared to the treatment-as-usual group (F [1, 64] = 22.7, p < 0.001): mean difference, 15.1 [95% CI 11.2 to 18.9]. Our study examined fidelity comprehensively and provides a foundation for studies interested in fidelity monitoring of SFBT interventions as well as behavioral interventions within IC models. Trial Registration: The study was pre-registered at ClinicalTrials.gov Identifier: NCT05838222 on 01/05/2023.

Behavioural interventions targeting the prevention and treatment of young children's mental health problems in low- and middle-income countries: a scoping review

Background

Globally, 10% of children and adolescents live with mental health problems and often lack high-quality care. Over 80% of people facing mental health issues reside in low- and middle-income countries (LMICs). Failing to address children's mental health may prolong these challenges into adulthood, impeding their chances for a healthy life. This scoping review aims to describe the types, implementation strategies, effectiveness, and gaps of existing interventions for preventing and treating mental health problems in early childhood (<10 years) in LMICs.

Methods

The study employed a scoping review of experimental studies published 2007-2023. Major databases including PubMed, Embase, Web of Science, and PsycINFO were searched using key terms related to the population (children), intervention (mental and/or behavioural health programmes), and outcome (mental health problems). Three authors independently conducted search strategy, article screening, data extraction, and quality assessment. The findings were presented using descriptive analysis and narrative synthesis.

Results

Of 39 499 identified articles, 33 were included in the study, covering 7629 children and published between 2009-2022. Seventeen studies (51.5%) were from upper-middle-income countries, 13 (39.4%) were from lower-middle-income, and three (9.1%) were from low-income countries. Enrolment was community-based in 23 studies and health-facility based in 10 studies; the majority (79%) focused on children aged 3-8 years old. Almost two-third (63.6%) of studies were conducted in urban settings. Programmes encompassed various interventions such as parenting programmes (33.3%). A majority of studies (57.5%) employed group therapy for delivering the programme, with mental health professionals (21.2%) acting as the primary intervention providers. Interventions were primarily received by children (39.4%), followed by mothers/caregivers (33.3%). Most studies explored disruptive disorders (20 studies), social and behavioural problems (16 studies), and anxiety disorders (12 studies). Statistically significant intervention effects on child mental health outcomes were reported for 90% of published studies.

Conclusions

Diverse behavioural programmes that improve the mental health of young children are available and effective in LMICs. Most interventions were delivered in urban settings and focus was on the use of health care professionals. Diverse intervention approaches, including parenting programmes and group therapy, were effective in addressing various mental health issues among young children.

Looking under the hood of a hybrid two-way texting intervention to improve early retention on antiretroviral therapy in Malawi: an implementation fidelity evaluation

BACKGROUND

While key to interpreting findings and assessing generalizability, implementation fidelity is underreported in mobile health (mHealth) literature. We evaluated implementation fidelity of an opt-in, hybrid, two-way texting (2wT) intervention previously demonstrated to improve 12-month retention on antiretroviral therapy (ART) among people living with HIV (PLHIV) in a quasi-experimental study in Lilongwe, Malawi.

METHODS

Short message service (SMS) data and ART refill visit records were used to evaluate adherence to 2wT content, frequency and duration through the lens of the Conceptual Framework for Implementation Fidelity. Message delivery and 2wT participant interactions were considered across four core 2wT components: 1) weekly motivational SMS messages; 2) proactive SMS appointment reminders; 3) SMS reminders after missed appointments; and 4) interactive messaging with 2wT staff about transfers and appointment rescheduling. Using mixed-effects logistic regression models adjusted for participant demographics, we examined the effect of core 2wT component fidelity on a) on-time appointment attendance and b) timely return to care after a missed appointment, presenting adjusted odds ratios (aORs) and 95% confidence intervals (CIs).

RESULTS

The 468 2wT participants had a median of 52 study weeks (interquartile range [IQR] 34 - 52) with 6 ART appointments (IQR 4-7) of which 2 (IQR 1 - 3) were missed. On average, participants received a motivation message for 75% (IQR 56%-83%) of enrolled weeks, a reminder before 83% (IQR 67%-100%) of appointments, and after 67% (IQR 0%-100%) of missed appointments. Participants reported 9 transfers and rescheduled 46 appointments through 2wT prompts; 196 appointments were changed via unprompted interaction. Participants with 10% higher expected motivation message delivery were more likely to attend clinic appointments on time (aOR: 1.08; 95%CI: 1.01 - 1.16, p = 0.03). Receiving and responding to an appointment reminder in any way were also associated with increased on-time appointment attendance (aOR: 1.35; 95%CI: 1.03 - 1.79, p = 0.03 and aOR: 1.47, 95%CI: 1.16 - 1.87, p = 0.001, respectively). No associations were found for 2wT messages and timely return to care following a missed appointment.

CONCLUSION

Greater 2wT implementation fidelity was associated with improved care outcomes. Although implementation fidelity monitoring of mHealth interventions is complex, it should be integrated into study design.

The challenges of evidence-based prehabilitation in a real-life context for patients preparing for colorectal surgery-a cohort study and multiple case analysis

BACKGROUND

Multimodal prehabilitation programs are effective at reducing complications after colorectal surgery in patients with a high risk of postoperative complications due to low aerobic capacity and/or malnutrition. However, high implementation fidelity is needed to achieve these effects in real-life practice. This study aimed to investigate the implementation fidelity of an evidence-based prehabilitation program in the real-life context of a Dutch regional hospital.

METHODS

In this observational cohort study with multiple case analyses, all patients who underwent colorectal surgery from January 2023 to June 2023 were enrolled. Patients meeting the criteria for low aerobic capacity or malnutrition were advised to participate in a prehabilitation program. According to recent scientific insights and the local care context, this program consisted of four exercise modalities and three nutrition modalities. Implementation fidelity was investigated by evaluating: (1) coverage (participation rate), (2) duration (number of days between the start of prehabilitation and surgery), (3) content (delivery of prescribed intervention modalities), and (4) frequency (attendance of sessions and compliance with prescribed parameters). An aggregated percentage of content and frequency was calculated to determine overall adherence.

RESULTS

Fifty-eight patients intended to follow the prehabilitation care pathway, of which 41 performed a preoperative risk assessment (coverage 80%). Ten patients (24%) were identified as high-risk and participated in the prehabilitation program (duration of 33-84 days). Adherence was high (84-100%) in five and moderate (72-73%) in two patients. Adherence was remarkably low (25%, 53%, 54%) in three patients who struggled to execute the prehabilitation program due to multiple physical and cognitive impairments.

CONCLUSION

Implementation fidelity of an evidence-based multimodal prehabilitation program for high-risk patients preparing for colorectal surgery in real-life practice was moderate because adherence was high for most patients, but low for some patients. Patients with low adherence had multiple impairments, with consequences for their preparation for surgery. For healthcare professionals, it is recommended to pay attention to high-risk patients with multiple impairments and further personalize the prehabilitation program. More knowledge about identifying and treating high-risk patients is needed to provide evidence-based recommendations and to obtain higher effectiveness.

TRIAL REGISTRATION

NCT06438484.

Sustainability of an evidence-based intervention supporting transition to independent care for youth living with HIV in Kenya

Integrating and sustaining evidence-based interventions (EBIs) in routine care is crucial to improving HIV treatment outcomes among youth living with HIV (YLH). However, EBIs are often not sustained post clinical trial. An Adolescent Transition Package (ATP) delivered by health care workers (HCWs) and tested in Kenya in 2021 significantly improved YLH readiness to transition to independent care. Post-trial, participating clinics could continue using the ATP. We conducted 30 in-depth interviews with health care workers to evaluate determinants of continued ATP implementation one-year post-trial. Interviews used semi-structured guides, informed by the Consolidated Framework for Implementation Research version 2.0 (CFIR v2.0). Transcripts were analyzed thematically to identify key influences of ATP sustainment and fidelity post-trial. Effective training during and after the trial, and continued internal and external support for implementation, were crucial for sustained acceptability and feasibility. In contrast, staff shortages and high turnover, lack of integration into the existing electronic medical system, and maintaining staff motivation were barriers to ATP sustainment. Implementation fidelity was limited by workforce constraints and HCW beliefs about the importance of individualizing content and delivery to be responsive to individual client needs. ATP adaptability afforded optimization of delivery to overcome workforce constraints and meet client needs, increasing HCW perceptions of feasibility and motivating continued use. Alignment between observed impact and care provision goals further motivated ongoing ATP utilization. Strategies to ensure continued training and integration of tools into existing systems have the potential to further enhance ATP sustainability.

Implementing a workplace participatory approach to support working caregivers in balancing their work, private life and informal care: results of a process evaluation

BACKGROUND

Many organizations are faced with growing numbers of employees who combine their jobs with informal caregiving responsibilities. To support working caregivers in maintaining a good balance between work, private life and informal care, a workplace participatory approach (PA) intervention was implemented in four Dutch organizations. This study's aims were to evaluate the degree of PA implementation, contextual factors influencing implementation, and stakeholder experiences with the PA.

METHODS

A mixed methods process evaluation was conducted alongside a randomized controlled trial among three stakeholder groups: caregiving employees, their supervisors, and trained occupational professionals who acted as PA process facilitators. The implementation frameworks of Steckler and Linnan (2002) and Carrol et al. (2007) were applied to evaluate recruitment, reach, dosage, fidelity and context, as well as stakeholders' satisfaction, experiences and perceived intervention outcomes. Data were collected after PA implementation (4-7 months) using questionnaires, semi-structured interviews, checklists and research logs.

RESULTS

Of the 57 caregivers in the intervention group, 48 participated in the stepwise intervention. Among them, 20 (42%) completed all seven steps of the PA, and 30 (63%) involved their supervisors. PA implementation and supervisor involvement varied based on personal factors (e.g. a need for balance-related improvements; preference to keep caregiving private), interpersonal factors (e.g. caregiver-supervisor relationship quality), and organizational factors (high work demands; a supportive workplace culture for caregivers). Caregivers, supervisors, and process facilitators reported positive experiences with the PA, finding it valuable for addressing informal caregiving, receiving support and working on balance-related changes in multiple life domains. Some caregivers, however, needed more than the standard 3 PA meetings to identify key issues and implement solutions.

CONCLUSIONS

Stakeholders found the PA helpful in addressing working caregivers' work-life balance, but PA implementation can be further stimulated by creating a supportive organizational culture in which it is encouraged and safe to discuss informal care. Moreover, to better support working caregivers in the long term, the PA should be viewed as an ongoing and iterative process taking into account their evolving balance and circumstances.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN15363783 (Registration date 21 November 2022; Retrospectively registered).

A Mixed Methods Evaluation of Implementation Outcomes of a Self-Regulation Strategy for Health Education: Perspectives of Clinicians and Older Adults With and Without Traumatic Brain Injury

PURPOSE

Effective self-management is key for older adults with and without traumatic brain injury (TBI) to maintain their health, safety, and independence. Self-regulation is one method of promoting self-management. However, it is essential to examine effective methods of self-regulation interventions to maximize the use of such health promotion.

METHOD

Forty-one older adults (19 with TBI; 22 without TBI) participated in an in-person or telepractice health education intervention for fall prevention with 15 speech-language pathology student clinicians. The intervention was a self-regulation strategy, mental contrasting with implementation intentions (MCII), for promoting fall prevention. This mixed methods study explored treatment adherence and evaluated implementation outcomes through acceptability, appropriateness, feasibility, modifications to treatment, and therapist adherence and client participation.

RESULTS

All participants demonstrated some behavior change. Participants without TBI evaluated the MCII protocol as more acceptable, F(1, 39) = 5.88, p = .018; appropriate, F(1, 39) = 5.34, p = .023; and feasible, F(1, 39) = 9.56, p = .003, than participants with TBI, although all ratings were perceived as neutral or positive. From clinician data, protocol adherence, F(1, 39) = 1.57, p = .22, and client participation, F(1, 39) = 0.10, p = .92, were similar across injury groups, but participants with TBI required more fidelity-consistent modifications to treatment, F(1, 39) = 6.88, p = .012. There were no differences between settings except that those in telepractice had more client participation, F(1, 39) = 21.02, p < .001. Clinicians felt MCII was equally appropriate for both groups in all settings, acceptability: F(1, 48) = 0.082, p = .78; appropriateness: F(1, 48) = 0.554, p = .46; feasibility: F(1, 48) = 0.197, p = .66.

CONCLUSION

MCII may be a feasible tool to provide health education as it offers enough structure and individualization to be considered appropriate and relevant for older adults, and for novice clinicians to administer and modify as needed based on client needs.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.28074443.

Outcomes Following Close Collaboration With Parents Intervention in Neonatal Intensive Care Units: A Nonrandomized Clinical Trial

Importance

Family-centered care (FCC) in neonatal intensive care units (NICUs) is critical for parental involvement and infant well-being, yet few studies have evaluated the impact of FCC interventions on practice or examined how implementation fidelity may affect these outcomes.

Objectives

To evaluate the association between the Close Collaboration With Parents intervention and FCC practices and how implementation fidelity may modify these outcomes.

Design, Setting, and Participants

This nonrandomized clinical trial had a before-and-after design. It was conducted between March 2021 and June 2023 at 6 NICUs in Estonia and included the parents of all newborns and all staff.

Intervention

Close Collaboration With Parents is an educational intervention for multiprofessional NICU staff including e-learning and bedside practices combined with reflection sessions. It aims to improve FCC culture by developing staff skills in communication and collaboration with parents and parenting support.

Main Outcomes and Measures

The quality of FCC was assessed using a 1-time questionnaire for the parents with 9 questions from the Digi Family-Centered Care-Parent version tool, and daily questions for the staff using Digi Family-Centered Care-Nurse version tool. The association between implementation fidelity, defined as the proportion of staff who completed the full education, and the quality of FCC was also analyzed.

Results

A total of 186 infants (with responses from 186 mothers and 22 fathers) were included in the preintervention period. The median (IQR) gestational age was 37.4 (34.0-39.9) weeks, 94 infants (50.5%) were male, and the median (IQR) parental age was 32 (28-36) years. A total of 208 infants (with responses from 208 mothers and 55 fathers) were included in the postintervention period. The median (IQR) gestational age was 38.1 (35.4-39.9) weeks, 114 infants (55.1%) were male, and median (IQR) parental age was 32 (27-35) years. From the staff, 7448 and 6717 daily responses were analyzed in the preintervention and postintervention periods, respectively. The total rating was significantly higher after the intervention than before, by both the parents (r = 0.07; P < .001) and the staff (r = 0.10; P < .001). The median ratings did not, however, change: the parents' median (IQR) overall rating before and after was 7.0 (6.0-7.0), and the staff's median (IQR) overall rating was 6.0 (5.0-7.0) before and 6.0 (6.0-7.0) after. Implementation fidelity ranged from 4 of 30 health care professionals (13.3%) to 37 of 45 (82.2%) at the NICUs. The NICUs with high fidelity, as opposed to low fidelity, had significantly greater improvement in FCC ratings by the staff after the intervention (β = 2.1 [95% CI, 0.8-3.4]; P = .002).

Conclusions and Relevance

In this nonrandomized clinical trial, FCC practices were rated higher by the staff and parents after the Close Collaboration With Parents intervention. Implementation fidelity was identified as an important factor.

Trial Registration

ClinicalTrials.gov Identifier: NCT06258655.