Contamination in trials of educational interventions

Pain neuroscience education and graded exposure versus Pilates and postural education: A pilot study in an occupational context

INTRODUCTION

Pain neuroscience education (PNE) and graded exposure have not been explored in occupational settings for low back pain (LBP).

AIM

To pilot feasibility and assess preliminary effectiveness of PNE and graded exposure for LBP.

METHODS

A pilot study where workers were randomized to either PNE and graded exposure or Pilates and postural education. Both interventions consisted of weekly individual face-to-face sessions for 8 weeks (a total of 8 sessions). The primary outcome was pain intensity. Secondary outcomes were disability, catastrophizing, fear-avoidance, sleep, endurance of back extensor muscles, and patient's perceived impression of change.

RESULTS

Seventeen participants entered the PNE and graded exposure group and 20 the Pilates and postural education group. PNE and graded exposure were feasible to implement. Between-group comparisons suggest higher improvements in the PNE group for extensor muscle endurance (p < .001, η2p = .29), pain catastrophizing (p < .001; η2p = .56) and fear-avoidance related to physical activity (p < .001; η2p = .48) and work (p < .001; η2p = .47). In the PNE group, at least 13 (76.5%) participants reported being at least "moderately better" against 6 (30%) participants in the Pilates group.

CONCLUSION

PNE and graded exposure can be successfully implemented in an occupational context and is potentially more beneficial than Pilates and postural education for extensor muscle endurance, catastrophizing, and fear avoidance and similarly as beneficial for pain intensity and disability. Further studies are needed to confirm these results.

The Báa nnilah Program: Results of a Chronic-Illness Self-Management Cluster Randomized Trial with the Apsáalooke Nation

Indigenous people in Montana are disproportionately affected by chronic illness (CI), a legacy of settler colonialism. Existing programs addressing CI self-management are not appropriate because they are not consonant with Indigenous cultures in general and the Apsáalooke culture specifically. A research partnership between the Apsáalooke (Crow Nation) non-profit organization Messengers for Health and Montana State University co-developed, implemented, and evaluated a CI self-management program for community members. This article examines qualitative and quantitative program impacts using a pragmatic cluster randomized clinical trial design with intervention and waitlist control arms. The quantitative and qualitative data resulted in different stories on the impact of the Báa nnilah program. Neither of the quantitative hypotheses were supported with one exception. The qualitative data showed substantial positive outcomes across multiple areas. We examine why the data sets led to two very different stories, and provide study strengths and limitations, recommendations, and future directions.

A video-based intervention to overcome pregnancy smoking stigma among healthcare students: a randomised controlled trial

OBJECTIVES

This study tests a video intervention to reduce pregnancy smoking stigma among French healthcare students.

DESIGN

The participants were randomly selected to watch online either an experimental video (presenting educational content regarding stigma and contact with pregnant smokers) or a control video (presenting standard educational content about the risks of smoking). The students completed scales assessing stigma, intention to address smoking cessation and self-efficacy to do so, before the intervention (T0, n = 252), one week after the intervention (T1, n = 187), and one month after the intervention (T2, n = 131).

RESULTS

Compared to the medical students, especially men, the midwifery students reported lower derogative cognitions (η2p = .18), negative behaviours (η2p = .07) and personal distress (η2p = .06). However, the midwifery students also reported lower levels of intention to address smoking (η2p = .02) than the medical students. The experimental video decreased derogative cognitions to a greater extent than the control video (η2p = .23) in both the short and medium term. This study is the first intervention designed to reduce the stigmatisation of pregnant smokers by healthcare students. We recommend that the issue of stigma should receive more attention in the medical curriculum.

Self-sampling tools to increase cancer screening among underserved patients: a pilot randomized controlled trial

BACKGROUND

Screening can reduce cancer mortality, but uptake is suboptimal and characterized by disparities. Home-based self-sampling can facilitate screening for colorectal cancer (with stool tests, eg, fecal immunochemical tests) and for cervical cancer (with self-collected human papillomavirus tests), especially among patients who face barriers to accessing health care. Additional data are needed on feasibility and potential effects of self-sampling tools for cancer screening among underserved patients.

METHODS

We conducted a pilot randomized controlled trial with patients (female, ages 50-65 years, out of date with colorectal and cervical cancer screening) recruited from federally qualified health centers in rural and racially segregated counties in Pennsylvania. Participants in the standard-of-care arm (n = 24) received screening reminder letters. Participants in the self-sampling arm (n = 24) received self-sampling tools for fecal immunochemical tests and human papillomavirus testing. We assessed uptake of screening (10-week follow-up), self-sampling screening outcomes, and psychosocial variables. Analyses used Fisher exact tests to assess the effect of study arm on outcomes.

RESULTS

Cancer screening was higher in the self-sampling arm than the standard-of-care arm (colorectal: 75% vs 13%, respectively, odds ratio = 31.32, 95% confidence interval = 5.20 to 289.33; cervical: 79% vs 8%, odds ratio = 72.03, 95% confidence interval = 9.15 to 1141.41). Among participants who returned the self-sampling tools, the prevalence of abnormal findings was 24% for colorectal and 18% for cervical cancer screening. Cancer screening knowledge was positively associated with uptake (P < .05).

CONCLUSIONS

Self-sampling tools can increase colorectal and cervical cancer screening among unscreened, underserved patients. Increasing the use of self-sampling tools can improve primary care and cancer detection among underserved patients.

CLINICAL TRIALS REGISTRATION NUMBER

STUDY00015480.

Interactive clinical supervision training added to self-education leads to small improvements in the effectiveness of clinical supervision of physiotherapists: a randomised trial

QUESTION

Does adding an interactive clinical supervision training program to self-education improve the effectiveness of clinical supervision of physiotherapists, reduce burnout, decrease intention to leave and increase participation in clinical supervision?

DESIGN

Randomised controlled trial with concealed allocation, assessor blinding and intention-to-treat analysis.

PARTICIPANTS

Physiotherapists (n = 58) working at a publicly funded health service.

INTERVENTION

Participants in both groups received a self-education clinical supervision training package. In addition, participants in the experimental group received interactive clinical supervision training consisting of three 90-minute workshops.

OUTCOME MEASURES

The primary outcome measure was effectiveness of clinical supervision 4 months after training measured using the Manchester Clinical Supervision Scale (MCSS-26). Secondary outcomes were the Maslach Burnout Inventory, the Intention to Leave Scale, and participation in supervision. Focus groups were also used to gauge impressions of the intervention.

RESULTS

The addition of interactive clinical supervision training slightly improved effectiveness of clinical supervision, with a between-group mean difference of 6.3 units (95% CI 0.3 to 12.3) on the MCSS-26. The estimate of the effect on the proportion of physiotherapists reporting effective clinical supervision (ie, MSCC-26 score ≥ 73) was unclear (OR 1.97, 95% CI 0.50 to 7.81). Physiotherapists in the experimental group reported slightly lower levels of depersonalisation (MD -3.0 units, 95% CI -4.6 to -1.3). There were negligible or uncertain effects on the other burnout domains, intention to leave and participation in clinical supervision. Qualitatively, participants reported that the workshops made them realise that supervisees could take greater ownership of where supervision focused.

CONCLUSION

Adding interactive clinical supervision training to self-education leads to small improvements in the effectiveness of clinical supervision of physiotherapists.

REGISTRATION

osf.io/yz3kx.

Supporting patients to prepare for total knee replacement: Evidence-, theory- and person-based development of a 'Virtual Knee School' digital intervention

INTRODUCTION

Digital delivery of pre-operative total knee replacement (TKR) education and prehabilitation could improve patient outcomes pre- and post-operatively. Rigorously developing digital interventions is vital to help ensure they achieve their intended outcomes whilst mitigating their potential drawbacks.

OBJECTIVE

To develop a pre-operative TKR education and prehabilitation digital intervention, the 'Virtual Knee School' (VKS).

METHODS

The VKS was developed using an evidence-, theory- and person-based approach. This involved a mixed methods design with four phases. The first three focused on planning the VKS. The final phase involved creating a VKS prototype and iteratively refining it through concurrent think-aloud interviews with nine patients who were awaiting/had undergone TKR. Meta-inferences were generated by integrating findings from all the phases. ISRCTN registration of the overall project was obtained on 24 April 2020 (ISRCTN11759773).

RESULTS

Most participants found the VKS prototype acceptable overall and considered it a valuable resource. Conversely, a minority of participants felt the prototype's digital format or content did not meet their individual needs. Participants' feedback was used to refine the prototype's information architecture, design and content. Two meta-inferences were generated and recommend: 1. Comprehensive pre-operative TKR education and prehabilitation support should be rapidly accessible in digital and non-digital formats. 2. Pre-operative TKR digital interventions should employ computer- and self-tailoring to account for patients' individual needs and preferences.

CONCLUSIONS

Integrating evidence, theory and stakeholders' perspectives enabled the development of a promising VKS digital intervention for patients awaiting TKR. The findings suggest future research evaluating the VKS is warranted and provide recommendations for optimising pre-operative TKR care.

PATIENT OR PUBLIC CONTRIBUTION

Patient and Public Involvement (PPI) was central throughout the project. For example, PPI representatives contributed to the project planning, were valued members of the Project Advisory Group, had key roles in developing the VKS prototype and helped disseminate the project findings.

The impact of an e-newsletter or animated video to disseminate outdoor free-play information in relation to COVID-19 guidelines in New South Wales early childhood education and care services: a randomised controlled trial

BACKGROUND

State-based Guidelines were issued for Early Childhood Education and Care (ECEC) services (caring for children 0-6 years) recommending greater time outdoors and inclusion of indoor-outdoor programs to facilitate social distancing to reduce spread of COVID-19. The aim of this 3-arm randomised controlled trial (RCT) was to examine the impact of different dissemination strategies on increasing ECEC service intentions to adopt recommendations from the Guidelines.

METHODS

This was a post-intervention only RCT. A sample of eligible ECEC services in New South Wales (n = 1026) were randomly allocated to one of three groups; (i) e-newsletter resource; (ii) animated video resource; or (iii) control (standard email). The intervention was designed to address key determinants of guideline adoption including awareness and knowledge. Following delivery of the intervention in September 2021, services were invited to participate in an online or telephone survey from October-December 2021. The primary trial outcome was the proportion of services intending to adopt the Guidelines, defined as intention to; (i) offer an indoor-outdoor program for the full day; or (ii) offer more outdoor play time. Secondary outcomes included awareness, reach, knowledge and implementation of the Guidelines. Barriers to Guideline implementation, cost of the dissemination strategies and analytic data to measure fidelity of intervention delivery were also captured.

RESULTS

Of the 154 services that provided post-intervention data, 58 received the e-newsletter (37.7%), 50 received the animated video (32.5%), and 46 received the control (29.9%). Services who received the animated video had nearly five times the odds (OR: 4.91 [1.03, 23.34] p = 0.046) than those in the control group, to report having intentions to adopt the Guidelines. There were no statistically significant differences in awareness or knowledge of the Guidelines between either intervention or control services. Development costs were greatest for the animated video. The extent to which the dissemination strategy was viewed in full, were similar for both the e-newsletter and animated video.

CONCLUSION

This study found potential for the inclusion of interactive strategies to disseminate policy and guideline information within the ECEC setting, in the context of the need for rapid communication. Further research should explore the added benefits of embedding such strategies within a multi-strategy intervention.

TRIAL REGISTRATION

Retrospectively registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) on the 23/02/2023 (ACTRN 12,623,000,198,628).

Effect of smoking-related COVID-19 risk messaging on smoking cessation in community smokers: A pragmatic randomized controlled trial

INTRODUCTION

Observational and experimental studies have suggested that messaging on smoking-related COVID-19 risk may promote smoking abstinence, but evidence from randomized clinical trials (RCTs) is lacking.

METHODS

This was a pragmatic RCT in Hong Kong, China, to compare the effectiveness of communicating smoking-related COVID-19 risk with generic cessation support on abstinence. Both groups received brief cessation advice at baseline. The intervention group received messaging on smoking-related COVID-19 risk and cessation support via instant messaging for three months (16 messages in total), which highlighted the increased risk of severe COVID-19 and deaths, and potentially higher risk of viral exposure (e.g. due to mask removal) for smokers. The control group received generic text messaging support for three months (16 messages). The primary outcomes were biochemically validated 7-day point prevalence abstinence (PPA) at 3 and 6 months. Intention to treat analyses was used.

RESULTS

Between 13 June and 30 October 2020, 1166 participants were randomly assigned to an intervention (n=583) or control (n=583) group. By intention-to-treat, validated 7-day PPA did not significantly differ between the intervention and control groups at three months (9.6% and 11.8%, relative risk, RR=0.81; 95% CI: 0.58-1.13, p=0.22) or six months (9.3% and 11.7%, RR=0.79; 95% CI: 0.57-1.11, p=0.18). A higher perceived severity of COVID-19 in smokers at baseline was associated with a greater validated 7-day PPA at six months, and a marginally significant intervention effect on changes in perceived severity from baseline through 6 months was found (p for group × time interaction = 0.08).

CONCLUSIONS

Communicating smoking-related COVID-19 risk via instant messaging was not more effective in increasing smoking abstinence than generic cessation support.

TRIAL REGISTRATION

The study is registered on ClinicalTrials.gov Identifier: NCT04399967.

Increasing the use of experimental methods in nursing and midwifery education research

AIM

To consider how more use could be made of experimental research in nursing and midwifery education.

BACKGROUND

Much use has been made in nursing and midwifery educational research of pre- and post-, within-subjects research. While this has its place and has been a valuable design for testing educational interventions, there has been a distinct lack of more rigorous experimental designs.

DESIGN

Discussion paper to consider the use of experimental designs in nursing and midwifery education research.

METHODS

A review of within-subjects designs, between-subjects designs and new approaches to experimental research such as pragmatic designs, non-inferiority designs and the framework offered by complex interventions.

RESULTS

Recommendations for implementing experimental designs in nursing and midwifery education research have been drawn.

CONCLUSIONS

Within-subjects designs have dominated experimental research in nursing and midwifery education. While suitable for preliminary studies, they should be augmented by more rigorous designs based on between-subjects designs. These do not have to be strictly randomised controlled trials and there are many reasons why these are hard to implement in nursing and midwifery education research. However, a range of alternatives is available.

Community sharing: Contextualizing Western research notions of contamination within an Indigenous research paradigm

Báa nnilah is a chronic illness self-management program designed by and for the Apsáalooke (Crow) community. Arising from a collaboration between an Indigenous nonprofit organization and a university-based research team, Báa nnilah's development, implementation, and evaluation have been influenced by both Indigenous and Western research paradigms (WRPs). Báa nnilah was evaluated using a randomized wait-list control group design. In a WRP, contamination, or intervention information shared by the intervention group with the control group, is actively discouraged as it makes ascertaining causality difficult, if not impossible. This approach is not consonant with Apsáalooke cultural values that include the encouragement of sharing helpful information with others, supporting an Indigenous research paradigm's (IRP) goal of benefiting the community. The purpose of this paper is to address contamination and sharing as an area of tension between WRP and IRP. We describe how the concepts of contamination and sharing within Báa nnilah's implementation and evaluation are interpreted differently when viewed from these contrasting paradigms, and set forth a call for greater exploration of Indigenous research approaches for developing, implementing, and evaluating intervention programs in Indigenous communities. (Improving Chronic Illness Management with the Apsáalooke Nation: The Báa nnilah Project.: NCT03036189), ClinicalTrials. gov: NCT03036189).

Influence of a Survival Swimming Training Programme on Water Safety Knowledge, Attitudes and Skills: A Randomized Controlled Trial among Young Adults in Sri Lanka

Drowning among young adults is high in Sri Lanka. Water safety education is a recommended strategy for drowning prevention but is often overlooked for young adults. This study aimed to evaluate the effectiveness of an adapted educational intervention, "Swim for Safety" on improving water safety knowledge, attitudes and survival swimming skills among undergraduates (19-28 years) in Sri Lanka. This study employed a parallel-group, two-arm randomized controlled trial design. The intervention group (n = 78) received a face-to-face, 12-lesson education programme, and the control group (n = 78) received a brochure and weekly mobile phone messages for six consecutive weeks. Baseline, post-intervention and three-month follow-up knowledge, attitudes and skills were evaluated. Knowledge and attitudes were assessed using a self-administered questionnaire and skills were evaluated following a skills assessment protocol. In total 116 participants, 60 intervention group and 56 control group, completed the study. At baseline there were no differences between groups in median scores of water safety knowledge, attitudes and survival swimming skills. The intervention group demonstrated statistically significant increases in median water safety knowledge, attitudes and survival swimming skill scores compared with the control group, following the intervention and maintained at three-month follow-up (p < 0.05). The adapted Swim for Safety programme significantly improved water safety knowledge, attitudes, and survival swimming skills among young adults in Sri Lanka. Therefore, it is recommended that the SfS programme be implemented widely to prevent drowning in young adults.

Rational and Design of the SIMULATOR Study: A Multicentre Randomized Study to Assess the Impact of SIMULation-bAsed Training on Transoesophageal echocardiOgraphy leaRning for Cardiology Residents

Introduction: Simulation-based training in transesophageal echocardiography (TEE) seems promising. However, data are limited to non-randomized or single-center studies. To assess the impact of simulation-based vs. traditional teaching on TEE knowledge and performance for medical residents in cardiology. Materials and Methods: Nationwide prospective randomized multicenter study involving 43 centers throughout France allowing for the inclusion of >70% of all French cardiology residents. All cardiology residents naive from TEE will be included. Randomization with stratification by center will allocate residents to either a control group receiving theoretical knowledge by e-learning only, or to an intervention group receiving two simulation-based training sessions on a TEE simulator in addition. Results: All residents will undergo both a theoretical test (0-100 points) and a practical test on a TEE simulator (0-100 points) before and 3 months after the training. Satisfaction will be assessed by a 5-points Likert scale. The primary outcomes will be to compare the scores in the final theoretical and practical tests between the two groups, 3 months after the completion of the training. Conclusion: Data regarding simulation-based learning in TEE are limited to non-randomized or single-center studies. The randomized multicenter SIMULATOR study will assess the impact of simulation-based vs. traditional teaching on TEE knowledge and performance for medical residents in cardiology, and whether such an educational program should be proposed in first line for TEE teaching.

Pilot Randomized Clinical Trial of a Text Messaging-Based Intervention for Smoking Cessation Among Young People Experiencing Homelessness

INTRODUCTION

Smoking rates are alarmingly high among young people experiencing homelessness (YEH), yet there are no evidence-based cessation programs for this population. This paper presents results from a pilot evaluation of a text messaging-based smoking cessation treatment, as an adjunct to brief group cessation counseling, to improve abstinence rates among 18-25 year old smokers experiencing homelessness. The goal of this study was to estimate effect sizes for a larger trial and it was not powered to detect group differences.

METHODS

YEH smokers who had a working cell phone with them at recruitment were randomized to receive a group counseling session, nicotine patches, and written material on quitting (n=37) or a similar program that also included a 6-week automated text messaging intervention (TMI) to provide ongoing support for quitting (n=40). Smoking outcomes were evaluated through a 90-day follow-up.

RESULTS

7-day point prevalence abstinence at 90-day follow-up was higher in the TMI condition than standard condition (17.50% vs. 8.11%, respectively; Cohen's h=.37); however, the 90-day continuous abstinence rate was not statistically different from zero in either condition. Reductions in the number of days smoked in the past 30 days from baseline to follow-up were greater in the TMI condition than the standard condition (-14.24 vs. -8.62, respectively; Cohen's d=.49).

CONCLUSIONS

Adding a 6-week TMI support to a brief group counseling and pharmacotherapy protocol holds promise for smoking reduction and abstinence among YEH smokers. Results indicate that further development and evaluation of the TMI in this population is warranted.

IMPLICATIONS

This is the first study to evaluate the feasibility of using a text messaging-based intervention (TMI) for behavior change with 18-25 year olds experiencing homelessness, and more specifically, the first to test a TMI to provide ongoing support for smoking cessation. Small to medium effect sizes for the TMI are promising in terms of implementing a TMI using participants' own cell phones, as well as the efficacy of this approach as an adjunct to standard care (brief group counseling and pharmacotherapy) for smoking cessation among young people experiencing homelessness.

Contamination within trials of community-based public health interventions: lessons from the HENRY feasibility study

Introduction

Contamination occurs when participants allocated to trial control arms receive elements of the active intervention. Randomisation at cluster level, rather than individual level, may reduce or eliminate contamination, avoiding the dilution of intervention effectiveness that it may cause. However, cluster randomisation can result in selection bias and may not be feasible to deliver. We explored the extent of contamination in a qualitative study nested within a feasibility study of HENRY (Health, Exercise and Nutrition for the Really Young); a UK community-based child obesity prevention programme. We aimed to determine the nature and impact of contamination to inform a larger planned trial and other trials in community based public health settings.

Method

We invited participants to take part in the nested qualitative study who were already involved in the HENRY feasibility study. Semi-structured interviews/focus groups were conducted with children’s centre managers (n=7), children’s centre staff (n=15), and parents (n=29). Data were transcribed and analysed using an integrative approach. First, deductively organised using a framework guided by the topic guide and then organised using inductive thematic analysis.

Results

Potential for contamination between treatment arms was recognised by all stakeholder groups. Staff within the intervention centres presented the greatest risk of contamination, predominantly because they were often asked to work in other children centre’s (including control group centres). ‘Sharing of best practice’ by staff was reported to be a common and desirable phenomenon within community based settings. Parental sharing of HENRY messages was reported inconsistently; though some parents indicated a high degree of knowledge transfer within their immediate circles.

Conclusions

The extent of contamination identified has influenced the design of a future effectiveness trial of HENRY which will be clustered at the centre level (with geographically distinct clusters). The common practice of knowledge sharing amongst community teams means that this clustering approach is also likely to be most suitable for other trials based within these settings. We provide recommendations (e.g. cluster randomisation, training intervention facilitators on implications of contamination) to help reduce the impact of contamination in public health intervention trials with or without clustering, whilst enabling transfer of knowledge where appropriate.

Trial registration

ClinicalTrials.gov Identifier NCT03333733 registered 6th November 2017

Effects of Message Framing and Time Discounting on Health Communication for Optimum Cardiovascular Disease and Stroke Prevention (EMT-OCSP): a protocol for a pragmatic, multicentre, observer-blinded, 12-month randomised controlled study

INTRODUCTION

Primary prevention of cardiovascular disease (CVD) and stroke often fails due to poor adherence among patients to evidence-based prevention recommendations. The proper formatting of messages portraying CVD and stroke risks and interventional benefits may promote individuals' perception and motivation, adherence to healthy plans and eventual success in achieving risk control. The main objective of this study is to determine whether risk and intervention communication strategies (gain-framed vs loss-framed and long-term vs short-term contexts) and potential interaction thereof have different effects on the optimisation of adherence to clinical preventive management for the endpoint of CVD risk reduction among subjects with at least one CVD risk factor.

METHODS AND ANALYSIS

This trial is designed as a 2×2 factorial, observer-blinded multicentre randomised controlled study with four parallel groups. Trial participants are aged 45-80 years and have at least one CVD risk factor. Based on sample size calculations for primary outcome, we plan to enrol 15 000 participants. Data collection will occur at baseline, 6 months and 1 year after randomisation. The primary outcomes are changes in the estimated 10-year CVD risk, estimated lifetime CVD risk and estimated CVD-free life expectancy from baseline to the 1-year follow-up.

ETHICS AND DISSEMINATION

This study received approval from the Ethical Committee of West China Hospital, Sichuan University and will be disseminated via peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT04450888.

Nurturing and quiet intervention (NeuroN-QI) on preterm infants' neurodevelopment and maternal stress and anxiety: A pilot randomized clinical trial protocol

OBJECTIVES

Primary objective of this pilot study is to evaluate the feasibility and acceptability of the NeuroN-QI and the study procedures. Secondary objectives are to assess the feasibility and acceptability of the NeuroN-QI by the nurses, assess the nurses' training needs about the components of the NeuroN-QI, and estimate the preliminary effects of the NeuroN-QI on infants' neurodevelopment as well as maternal stress and anxiety at infants' 36 weeks of gestational age.

DESIGN

A two-group pilot parallel randomized clinical trial stratified by center.

METHODS

The pilot study will be conducted in two neonatal intensive care units (NICUs). A sample of 24 mother-infant dyads born between 26 and 31^6/7 gestational age will be randomized into an experimental or control group. Fifty nurses will be recruited. The NeuroN-QI consists of four 2-hour skin-to-skin contact sessions/week with a 15-minute auditory stimulation by mothers with controlled ambient levels of light and noise. A 1-hour quiet period will follow where infants will rest in their incubator/crib with their mother's milk for olfactory stimulation and where the light and noise control will be continued. In the control group, mother-infant dyads will do four skin-to-skin contacts per week and receive standard care. Acceptability and feasibility of the NeuroN-QI in addition to maternal stress and anxiety will be measured through questionnaires, while infants' neurodevelopment will be assessed with Assessment of Preterm Infant Behaviour and General Movement Assessment.

CONCLUSIONS

This pilot trial will address knowledge gaps and generate evidence in neonatal care by evaluating the feasibility and acceptability of a multi-component developmental care intervention.

IMPACT

This project is an innovative step towards optimizing the neurodevelopmental trajectory of infants in NICUs and consequently promoting their long-term health outcomes.

TRIAL REGISTRATION

NCT04593095.

A community-based nurse-led medication self-management intervention in the improvement of medication adherence in older patients with multimorbidity: protocol for a randomised controlled trial

Background

Older patients suffering from multimorbidity are at high risk of medication nonadherence. It has been well established that self-management support is an effective strategy to enhance medication adherence for patients with chronic conditions. However, little is known about the effect of the medication self-management intervention in older patients with multimorbidity. This paper presents the protocol for a study that aims to evaluate the effectiveness of a nurse-led medication self-management intervention in improving medication adherence and health outcomes for community-dwelling older patients with multimorbidity.

Methods

The study protocol follows the recommendations of the Standard Protocol Items: Recommendations for Interventional Trials 2013 statement. This study is a multicentre, single-blind, two-arm randomised controlled trial. Older patients with multimorbidity will be recruited from three community health centres in Changsha, China. A total of 136 participants will be randomly allocated to receive usual care or usual care plus the medication self-management intervention. The intervention will be delivered by community nurses. The 6-week intervention includes three face-to-face education sessions and two weekly follow-up phone calls. Participants in the control group continue to receive all respects of usual care offered by community healthcare providers, including chronic disease management, drug prescription, referral to hospital specialists, health education and consultations regarding patients’ diseases and treatments during centre visits. The primary outcome is medication adherence as measured by the 5-item Medication Adherence Report Scale. Secondary outcomes include medication self-management capacity (medication knowledge, medication beliefs, medication social support, medication skills, and medication self-efficacy), treatment experiences (medication treatment satisfaction and treatment burden), quality of life, and utilisation of healthcare services. All outcomes will be measured at baseline, immediately post-intervention, and at 3-month post-intervention.

Discussion

This study will provide evidence about the effectiveness of a medication self-management intervention, delivered by nurses, for older patients with multimorbidity and adherence problems. It is expected that the results of the study, if proven effective in improving patients’ adherence and health outcomes, will provide evidence-based self-management support strategies for healthcare providers in routine chronic disease management in community settings.

Trial registration

The trial is registered at ChiCTR.org.cn (ChiCTR2000030011; date February 19, 2020).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02097-x.

Designing and undertaking randomised implementation trials: guide for researchers

Implementation science is the study of methods to promote the systematic uptake of evidence based interventions into practice and policy to improve health. Despite the need for high quality evidence from implementation research, randomised trials of implementation strategies often have serious limitations. These limitations include high risks of bias, limited use of theory, a lack of standard terminology to describe implementation strategies, narrowly focused implementation outcomes, and poor reporting. This paper aims to improve the evidence base in implementation science by providing guidance on the development, conduct, and reporting of randomised trials of implementation strategies. Established randomised trial methods from seminal texts and recent developments in implementation science were consolidated by an international group of researchers, health policy makers, and practitioners. This article provides guidance on the key components of randomised trials of implementation strategies, including articulation of trial aims, trial recruitment and retention strategies, randomised design selection, use of implementation science theory and frameworks, measures, sample size calculations, ethical review, and trial reporting. It also focuses on topics requiring special consideration or adaptation for implementation trials. We propose this guide as a resource for researchers, healthcare and public health policy makers or practitioners, research funders, and journal editors with the goal of advancing rigorous conduct and reporting of randomised trials of implementation strategies.

Building capacity in mental health care in low- and middle-income countries by training primary care physicians using the mhGAP: a randomized controlled trial

To address the rise in mental health conditions in Tunisia, a training based on the Mental Health Gap Action Programme (mhGAP) Intervention Guide (IG) was offered to primary care physicians (PCPs) working in the Greater Tunis area. Non-specialists (such as PCPs)' training is an internationally supported way to target untreated mental health symptoms. We aimed to evaluate the programme's impact on PCPs' mental health knowledge, attitudes, self-efficacy and self-reported practice, immediately following and 18 months after training. We conducted an exploratory trial with a combination of designs: a pretest-posttest control group design and a one-group pretest-posttest design were used to assess the training's short-term impact; and a repeated measures design was used to assess the training's long-term impact. The former relied on a delayed-intervention strategy: participants assigned to the control group (Group 2) received the training after the intervention group (Group 1). The intervention consisted of a weekly mhGAP-based training session (totalling 6 weeks), comprising lectures, discussions, role plays and a support session offered by trainers. Data were collected at baseline, following Group 1's training, following Group 2's training and 18 months after training. Descriptive, bivariate and ANOVA analyses were conducted. Overall, 112 PCPs were randomized to either Group 1 (n = 52) or Group 2 (n = 60). The training had a statistically significant short-term impact on mental health knowledge, attitudes and self-efficacy scores but not on self-reported practice. When comparing pre-training results and results 18 months after training, these changes were maintained. PCPs reported a decrease in referral rates to specialized services 18 months after training in comparison to pre-training. The mhGAP-based training might be useful to increase mental health knowledge and self-efficacy, and decrease reported referral rates and negative mental health attitudes among PCPs in Tunisia and other low- and middle-income countries. Future studies should examine relationships among these outcome variables.

Effect of monitoring surgical outcomes using control charts to reduce major adverse events in patients: cluster randomised trial

OBJECTIVE

To determine the effect of introducing prospective monitoring of outcomes using control charts and regular feedback on indicators to surgical teams on major adverse events in patients.

DESIGN

National, parallel, cluster randomised trial embedding a difference-in-differences analysis.

SETTING

40 surgical departments of hospitals across France.

PARTICIPANTS

155 362 adults who underwent digestive tract surgery. 20 of the surgical departments were randomised to prospective monitoring of outcomes using control charts with regular feedback on indicators (intervention group) and 20 to usual care only (control group).

INTERVENTIONS

Prospective monitoring of outcomes using control charts, provided in sets quarterly, with regular feedback on indicators (intervention hospitals). To facilitate implementation of the programme, study champion partnerships were established at each site, comprising a surgeon and another member of the surgical team (surgeon, anaesthetist, or nurse), and were trained to conduct team meetings, display posters in operating rooms, maintain a logbook, and devise an improvement plan.

MAIN OUTCOME MEASURES

The primary outcome was a composite of major adverse events (inpatient death, intensive care stay, reoperation, and severe complications) within 30 days after surgery. Changes in surgical outcomes were compared before and after implementation of the programme between intervention and control hospitals, with adjustment for patient mix and clustering.

RESULTS

75 047 patients were analysed in the intervention hospitals (37 579 before and 37 468 after programme implementation) versus 80 315 in the control hospitals (41 548 and 38 767). After introduction of the control chart, the absolute risk of a major adverse event was reduced by 0.9% (95% confidence interval 0.4% to 1.4%) in intervention compared with control hospitals, corresponding to 114 patients (70 to 280) who needed to receive the intervention to prevent one major adverse event. A significant decrease in major adverse events (adjusted ratio of odds ratios 0.89, 95% confidence interval 0.83 to 0.96), patient death (0.84, 0.71 to 0.99), and intensive care stay (0.85, 0.76 to 0.94) was found in intervention compared with control hospitals. The same trend was observed for reoperation (0.91, 0.82 to 1.00), whereas severe complications remained unchanged (0.96, 0.87 to 1.07). Among the intervention hospitals, the effect size was proportional to the degree of control chart implementation witnessed. Highly compliant hospitals experienced a more important reduction in major adverse events (0.84, 0.77 to 0.92), patient death (0.78, 0.63 to 0.97), intensive care stay (0.76, 0.67 to 0.87), and reoperation (0.84, 0.74 to 0.96).

CONCLUSIONS

The implementation of control charts with feedback on indicators to surgical teams was associated with concomitant reductions in major adverse events in patients. Understanding variations in surgical outcomes and how to provide safe surgery is imperative for improvements.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02569450.

Risk-based, 6-monthly and 24-monthly dental check-ups for adults: the INTERVAL three-arm RCT

BACKGROUND

Traditionally, patients are encouraged to attend dental recall appointments at regular 6-month intervals, irrespective of their risk of developing dental disease. Stakeholders lack evidence of the relative effectiveness and cost-effectiveness of different recall strategies and the optimal recall interval for maintenance of oral health.

OBJECTIVES

To test effectiveness and assess the cost-benefit of different dental recall intervals over a 4-year period.

DESIGN

Multicentre, parallel-group, randomised controlled trial with blinded clinical outcome assessment at 4 years and a within-trial cost-benefit analysis. NHS and participant perspective costs were combined with benefits estimated from a general population discrete choice experiment. A two-stratum trial design was used, with participants randomised to the 24-month interval if the recruiting dentist considered them clinically suitable. Participants ineligible for 24-month recall were randomised to a risk-based or 6-month recall interval.

SETTING

UK primary care dental practices.

PARTICIPANTS

Adult, dentate, NHS patients who had visited their dentist in the previous 2 years.

INTERVENTIONS

Participants were randomised to attend for a dental check-up at one of three dental recall intervals: 6-month, risk-based or 24-month recall.

MAIN OUTCOMES

Clinical - gingival bleeding on probing; patient - oral health-related quality of life; economic - three analysis frameworks: (1) incremental cost per quality-adjusted life-year gained, (2) incremental net (societal) benefit and (3) incremental net (dental health) benefit.

RESULTS

A total of 2372 participants were recruited from 51 dental practices; 648 participants were eligible for the 24-month recall stratum and 1724 participants were ineligible. There was no evidence of a significant difference in the mean percentage of sites with gingival bleeding between intervention arms in any comparison. For the eligible for 24-month recall stratum: the 24-month (n = 138) versus 6-month group (n = 135) had an adjusted mean difference of -0.91 (95% confidence interval -5.02 to 3.20); the risk-based (n = 143) versus 6-month group had an adjusted mean difference of -0.98 (95% confidence interval -5.05 to 3.09); the 24-month versus risk-based group had an adjusted mean difference of 0.07 (95% confidence interval -3.99 to 4.12). For the overall sample, the risk-based (n = 749) versus 6-month (n = 737) adjusted mean difference was 0.78 (95% confidence interval -1.17 to 2.72). There was no evidence of a difference in oral health-related quality of life between intervention arms in any comparison. For the economic evaluation, under framework 1 (cost per quality-adjusted life-year) the results were highly uncertain, and it was not possible to identify the optimal recall strategy. Under framework 2 (net societal benefit), 6-month recalls were the most efficient strategy with a probability of positive net benefit ranging from 78% to 100% across the eligible and combined strata, with findings driven by the high value placed on more frequent recall services in the discrete choice experiment. Under framework 3 (net dental health benefit), 24-month recalls were the most likely strategy to deliver positive net (dental health) benefit among those eligible for 24-month recall, with a probability of positive net benefit ranging from 65% to 99%. For the combined group, the optimal strategy was less clear. Risk-based recalls were more likely to be the most efficient recall strategy in scenarios where the costing perspective was widened to include participant-incurred costs, and in the Scottish subgroup.

LIMITATIONS

Information regarding factors considered by dentists to inform the risk-based interval and the interaction with patients to determine risk and agree the interval were not collected.

CONCLUSIONS

Over a 4-year period, we found no evidence of a difference in oral health for participants allocated to a 6-month or a risk-based recall interval, nor between a 24-month, 6-month or risk-based recall interval for participants eligible for a 24-month recall. However, people greatly value and are willing to pay for frequent dental check-ups; therefore, the most efficient recall strategy depends on the scope of the cost and benefit valuation that decision-makers wish to consider.

FUTURE WORK

Assessment of the impact of risk assessment tools in informing risk-based interval decision-making and techniques for communicating a variable recall interval to patients.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN95933794.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme [project numbers 06/35/05 (Phase I) and 06/35/99 (Phase II)] and will be published in full in Health Technology Assessment; Vol. 24, No. 60. See the NIHR Journals Library website for further project information.

Digital Training for Non-Specialist Health Workers to Deliver a Brief Psychological Treatment for Depression in Primary Care in India: Findings from a Randomized Pilot Study

Introduction: Task sharing holds promise for scaling up depression care in countries such as India, yet requires training large numbers of non-specialist health workers. This pilot trial evaluated the feasibility and acceptability of a digital program for training non-specialist health workers to deliver a brief psychological treatment for depression. Methods: Participants were non-specialist health workers recruited from primary care facilities in Sehore, a rural district in Madhya Pradesh, India. A three-arm randomized controlled trial design was used, comparing digital training alone (DGT) to digital training with remote support (DGT+), and conventional face-to-face training. The primary outcome was the feasibility and acceptability of digital training programs. Preliminary effectiveness was explored as changes in competency outcomes, assessed using a self-reported measure covering the specific knowledge and skills required to deliver the brief psychological treatment for depression. Outcomes were collected at pre-training and post-training. Results: Of 42 non-specialist health workers randomized to the training programs, 36 including 10 (72%) in face-to-face, 12 (86%) in DGT, and 14 (100%) in DGT+ arms started the training. Among these participants, 27 (64%) completed the training, with 8 (57%) in face-to-face, 8 (57%) in DGT, and 11 (79%) in DGT+. The addition of remote telephone support appeared to improve completion rates for DGT+ participants. The competency outcome improved across all groups, with no significant between-group differences. However, face-to-face and DGT+ participants showed greater improvement compared to DGT alone. There were numerous technical challenges with the digital training program such as poor connectivity, smartphone app not loading, and difficulty navigating the course content-issues that were further emphasized in follow-up focus group discussions with participants. Feedback and recommendations collected from participants informed further modifications and refinements to the training programs in preparation for a forthcoming large-scale effectiveness trial. Conclusions: This study adds to mounting efforts aimed at leveraging digital technology to increase the availability of evidence-based mental health services in primary care settings in low-resource settings.

Study protocol for a group-based motivational interviewing brief intervention to reduce substance use and sexual risk behavior among young adults experiencing homelessness

BACKGROUND

Young people experiencing homelessness have alarmingly high rates of alcohol and other drug (AOD) use, which is associated with sexual risk behaviors such as unprotected sex, trading sex, and sex with multiple casual partners. Few risk reduction programs for this population have been developed and rigorously evaluated, particularly those that address both of these interrelated behaviors, use a collaborative and non-judgmental approach, and are feasible to deliver in settings where homeless young people seek services. This paper describes the protocol of a study evaluating a four-session Motivational Interviewing (MI)-based group risk reduction intervention for this population. The protocol has been shown to be efficacious in pilot work over 3 months with 200 homeless young adults [1]. The current study seeks to refine the intervention protocol and evaluate the program on a larger scale.

METHODS/DESIGN

In a cluster-cross-over randomized controlled trial, 18-25 year olds will receive the AWARE risk reduction program (n = 200) or standard care (n = 200) at one of three drop-in centers serving homeless youth in the Los Angeles area. We will evaluate intervention effects on primary outcomes of AOD use and sexual risk behavior, as well as secondary outcomes of health-related quality of life and social stability, over a 12-month period.

DISCUSSION

This project has the potential to fill a significant gap in prevention services by demonstrating that a brief intervention, feasible to deliver within settings where young people experiencing homelessness typically seeks services, can significantly reduce the interrelated problems of AOD use and sexual risk behavior. Trial registration ClinicalTrials.gov Identifier: NCT03735784. Registered November 18, 2018, https://clinicaltrials.gov/ct2/show/record/NCT03735784 (retrospectively registered).

Effectiveness of the Ready to Reduce Risk (3R) complex intervention for the primary prevention of cardiovascular disease: a pragmatic randomised controlled trial

BACKGROUND

Cardiovascular disease is responsible for 31% of all global deaths. Primary prevention strategies are needed to improve longer-term adherence to statins and healthy lifestyle behaviours to reduce risk in people at risk of cardiovascular disease.

METHODS

Pragmatic randomised controlled trial recruited between May 2016 and March 2017 from primary care practices, England. Participants (n = 212) prescribed statins for primary prevention of cardiovascular disease with total cholesterol level ≥ 5 mmol/l were randomised: 105 to the intervention group and 107 to the control group, stratified by age and sex. The 3R intervention involved two facilitated, structured group education sessions focusing on medication adherence to statins, lifestyle behaviours and cardiovascular risk, with 44 weeks of medication reminders and motivational text messages and two supportive, coaching phone calls (at approximately 2 weeks and 6 months). The control group continued with usual clinical care. Both groups received a basic information leaflet. The primary outcome was medication adherence to statins objectively measured by a biochemical urine test. Self-reported adherence and practice prescription data provided additional measures. Secondary outcomes included cholesterol profile, blood pressure, anthropometric data, cardiovascular risk score, and self-reported lifestyle behaviours and psychological measures (health/medication beliefs, quality of life, health status). All outcomes were assessed at 12 months.

RESULTS

Baseline adherence to statins was 47% (control) and 62% (intervention). No significant difference between the groups found for medication adherence to statins using either the urine test (OR 1.02, 95% CI 0.34 to 3.06, P = 0.968) or other measures. This may have been due to the higher than expected adherence levels at baseline. The adjusted mean difference between the groups (in favour of the intervention group) for diastolic blood pressure (- 4.28 mmHg (95% CI - 0.98 to - 1.58, P = 0.002)) and waist circumference (- 2.55 cm (95% CI - 4.55 to - 0.55, P = 0.012)). The intervention group also showed greater perceived control of treatment and more coherent understanding of the condition.

CONCLUSIONS

The 3R programme successfully led to longer-term improvements in important clinical lifestyle indicators but no improvement in medication adherence, raising questions about the suitability of such a broad, multiple risk factor approach for improving medication adherence for primary prevention of CVD.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number (ISRCTN16863160), March 11, 2006.

A self-management support intervention for patients with atrial fibrillation: a randomized controlled pilot trial

BACKGROUND

Atrial fibrillation (AF) is the most common arrhythmia worldwide. Despite effective treatment, it is characterized by frequent recurrences. Optimal therapeutic management of AF requires active participation and self-management from patients. Two major components of self-management are self-monitoring and sign-and-symptom management. Pulse self-palpation (PSP) is a method of self-monitoring; however, not all AF patients are capable of successfully performing PSP. Due to a lack of interventions on this topic, a nurse-led intervention for patients with AF (PSPAF intervention) was developed to foster self-monitoring and to enhance self-management through PSP. The purpose of this pilot study was to test the acceptability, feasibility, and potential effects of this intervention on the capability of patients' PSP and sign-and-symptom management. Moreover, we aimed at gathering data on the feasibility of applied research methods to aid in the design of future studies.

METHODS

The pilot trial involved 20 adult patients with AF, randomized to an intervention or usual care group. At baseline and during a home visit 3-5 weeks later, we collected data using questionnaires, checklists, field notes, a mobile ECG device, and a diary. Acceptability and feasibility measures were validated through predefined cut-off points. Effect size estimates were expressed as relative risks (RR) and the number needed to treat (NNT).

RESULTS

The PSPAF intervention seemed feasible, but only partly acceptable. There were limitations in terms of potential effectiveness, suitability, addressing participants' willingness to implement its content in daily life, and adherence. Estimations of effect sizes suggest a large effect of the intervention on patients' PSP capability (RR = 6.0; 95% CI = [0.83, 43.3]; NNT = 2.4), but almost no effect on sign-and-symptom management (RR = 1.5; 95% CI = [0.7, 3.1]; NNT = 4.0). The feasibility of applied research methods showed minor limitations on recruitment and participant burden.

CONCLUSIONS

Despite some limitations, the intervention seemed to be applicable and promising. Taking into account the suggestions and amendments we have made, we recommend conducting a full-scale trial to examine the efficacy of the PSPAF intervention.

TRIAL REGISTRATION

This pilot study was registered in the German Clinical Trials Register at September 4, 2017 (Main ID: DRKS00012808).

Reducing Both Food Insecurity and Excess Body Weight in Costa Rican Women: A Cluster Randomized Trial

INTRODUCTION

The coexistence of food insecurity and excess body weight has been well documented in women. Both food insecurity and excess body weight have multiple consequences for physical and mental health. Concerns have been raised about interventions aimed to reduce food insecurity because these interventions might contribute to excess body weight, particularly in adult women. The purpose of this study was to develop, implement, and evaluate an intervention to simultaneously reduce food insecurity and body weight through alleviating discouragement-which women described as feeling sad, depressed, hopeless, and lacking drive to do important activities, such as finding a job or studying more-by increasing women's empowerment.

STUDY DESIGN

This 2-armed cluster RCT was conducted from February to December 2017. Data were analyzed from January to July 2018.

SETTING/PARTICIPANTS

Participants were food-insecure women with excess body weight in the Central Canton of the province of Alajuela, Costa Rica.

INTERVENTION

The intensive intervention arm consisted of activities at the individual (12 sessions lasting 2 hours each, 3 follow-up monthly sessions, and 1 closing session), household (1 workshop with the participants' household and community members and homework with family participation), and community (2 brochures and 1 workshop) levels. The nonintensive control arm consisted of 3 sessions about healthy lifestyles lasting 1 hour each.

MAIN OUTCOME MEASURES

Outcome measures included BMI, waist circumference, and food insecurity.

RESULTS

A total of 171 participants were enrolled (83 in intensive and 88 in nonintensive control arms). At 6 months, the intensive arm had greater decreases from baseline in BMI (-0.648, p=0.019), waist circumference (-2.21, p=0.002), and food insecurity (-1.35, p=0.009) compared with the nonintensive control arm.

CONCLUSIONS

The intensive intervention was effective in simultaneously reducing food insecurity and excess body weight. Educational components should be added to interventions aimed to reduce food insecurity.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT03492619.

Mindfulness-based crisis interventions (MBCI) for psychosis within acute inpatient psychiatric settings; a feasibility randomised controlled trial

BACKGROUND

Inpatient psychiatric care is a scarce and expensive resource in the National Health Service (NHS), with chronic bed shortages being partly driven by high re-admission rates. Brief inpatient talking therapies for psychosis could help reduce re-admission rates. The primary aim was to assess feasibility and acceptability of a novel, brief, mindfulness-based intervention for inpatients with psychosis. The secondary aim was to collect pilot outcome data on readmission rate, at 6 and 12 months (m) post discharge, and self-report symptom measures at 6 m.

METHODS

The amBITION study (BrIef Talking therapIes ON wards) was a parallel group, feasibility randomised controlled trial (RCT). In addition to treatment as usual (TAU), eligible inpatients with psychotic symptoms were randomly allocated to receive either (Mindfulness-Based Crisis Intervention; MBCI) or a control intervention (Social Activity Therapy; SAT), for 1-5 sessions.

RESULTS

Fifty participants were recruited (26 MBCI; 24 SAT); all received at least 1 therapy session (mean = 3). Follow-up rates were 98% at 6 m and 96% at 12 m for service use data extracted from clinical notes, and 86% for self-report measures. At 6 m follow-up, re-admission rates were similar across groups (MBCI = 6, SAT = 5; odds ratio = 1.20, 95% CI: 0.312-4.61). At 12 m follow-up, re-admissions were lower in the MBCI group (MBCI = 7, SAT = 11; odds ratio = 0.46, 95% CI: 0.14-1.51). Three participants experienced adverse events; none was related to trial participation.

CONCLUSIONS

Delivering a brief mindfulness-based inpatient intervention for psychosis is feasible and acceptable, and may reduce risk of short-term readmission. These promising findings warrant progression to a larger clinical effectiveness trial.

TRIAL REGISTRATION

ISRCTN37625384.

Contamination in complex healthcare trials: the falls in care homes (FinCH) study experience

Background

Trials are at risk of contamination bias which can occur when participants in the control group are inadvertently exposed to the intervention. This is a particular risk in rehabilitation studies where it is easy for trial interventions to be either intentionally or inadvertently adopted in control settings. The Falls in Care Homes (FinCH) trial is used in this paper as an example of a large randomised controlled trial of a complex intervention to explore the potential risks of contamination bias. We outline the FinCH trial design, present the potential risks from contamination bias, and the strategies used in the design of the trial to minimise or mitigate against this. The FinCH trial was a multi-centre randomised controlled trial, with embedded process evaluation, which evaluated whether systematic training in the use of the Guide to Action Tool for Care Homes reduced falls in care home residents.

Data were collected from a number of sources to explore contamination in the FinCH trial. Where specific procedures were adopted to reduce risk of, or mitigate against, contamination, this was recorded. Data were collected from study e-mails, meetings with clinicians, research assistant and clinician network communications, and an embedded process evaluation in six intervention care homes.

During the FinCH trial, there were six new falls prevention initiatives implemented outside the study which could have contaminated our intervention and findings. Methods used to minimise contamination were: cluster randomisation at the level of care home; engagement with the clinical community to highlight the risks of early adoption; establishing local collaborators in each site familiar with the local context; signing agreements with NHS falls specialists that they would maintain confidentiality regarding details of the intervention; opening additional research sites; and by raising awareness about the importance of contamination in research among participants.

Conclusion

Complex rehabilitation trials are at risk of contamination bias. The potential for contamination bias in studies can be minimized by strengthening collaboration and dialogue with the clinical community. Researchers should recognise that clinicians may contaminate a study through lack of research expertise.

Testing effectiveness of the revised Cape Town modified early warning and SBAR systems: a pilot pragmatic parallel group randomised controlled trial

BACKGROUND

Nurses' recognition of clinical deterioration is crucial for patient survival. Evidence for the effectiveness of modified early warning scores (MEWS) is derived from large observation studies in developed countries.

METHODS

We tested the effectiveness of the paper-based Cape Town (CT) MEWS vital signs observation chart and situation-background-assessment-recommendation (SBAR) communication guide. Outcomes were: proportion of appropriate responses to deterioration, differences in recording of clinical parameters and serious adverse events (SAEs) in intervention and control trial arms. Public teaching hospitals for adult patients in Cape Town were randomised to implementation of the CT MEWS/SBAR guide or usual care (observation chart without track-and-trigger information) for 31 days on general medical and surgical wards. Nurses in intervention wards received training, as they had no prior knowledge of early warning systems. Identification and reporting of patient deterioration in intervention and control wards were compared. In the intervention arm, 24 day-shift and 23 night-shift nurses received training. Clinical records were reviewed retrospectively at trial end. Only records of patients who had given signed consent were reviewed.

RESULTS

We recruited two of six CT general hospitals. We consented 363 patients and analysed 292 (80.4%) patient records (n = 150, 51.4% intervention, n = 142, 48.6% control arm). Assistance was summoned for fewer patients with abnormal vital signs in the intervention arm (2/45, 4.4% versus (vs) 11/81, 13.6%, OR 0.29 (0.06-1.39)), particularly low systolic blood pressure. There was a significant difference in recording between trial arms for parameters listed on the MEWS chart but omitted from the standard observations chart: oxygen saturation, level of consciousness, pallor/cyanosis, pain, sweating, wound oozing, pedal pulses, glucose concentration, haemoglobin concentration, and "looks unwell". SBAR was used twice. There was no statistically significant difference in SAEs (5/150, 3.3% vs 3/143, 2.1% P = 0.72, OR 1.61 (0.38-6.86)).

CONCLUSIONS

The revised CT MEWS observations chart improved recording of certain parameters, but did not improve nurses' ability to identify early signs of clinical deterioration and to summon assistance. Recruitment of only two hospitals and exclusion of patients too ill to consent limits generalisation of results. Further work is needed on educational preparation for the CT MEWS/SBAR and its impact on nurses' reporting behaviour.

TRIAL REGISTRATION

Pan African Clinical Trials Registry, PACTR201406000838118. Registered on 2 June 2014, www.pactr.org.

Feasibility, Acceptability, and Preliminary Impacts of Web-Based Patient Education on Patients With Schizophrenia Spectrum Disorder: Quasi-Experimental Cluster Study

BACKGROUND

Web-based interventions are promising tools for increasing the understanding of illness and treatment among patients with serious mental disorders.

OBJECTIVE

This study aimed to test the feasibility and acceptability of a Web-based patient education intervention using a quasi-experimental cluster design to report feedback on patient education sessions and the website used and to report preliminary evidence of the intervention's impact on patients with schizophrenia spectrum disorder.

METHODS

A single-blind, parallel, quasi-experimental cluster study over a 6-month period comparing Web-based education (n=33) with a nonequivalent control group (treatment as usual, n=24) for people with schizophrenia spectrum disorder was conducted. Participants (N=57) were recruited from one psychiatric hospital (6 wards). Feasibility was assessed by participants' commitment (refusal rate, dropout rate) to the study. Acceptability was assessed as participants' commitment to the intervention. Patient education sessions and website feedback were assessed by the patients and health care professionals. The preliminary impact of the sessions on patients' self-efficacy, self-esteem, illness cognition, and knowledge level was measured at baseline and follow-ups (8 weeks, 6 months) with self-rated questionnaires.

RESULTS

The refusal rate among patients was high with no statistically significant difference (69% [74/107] in the intervention group, 76% [76/100] in the control group; P=.21). The same result was found for the dropout rates (48% [16/33] vs 58% [14/24]; P=.46). The acceptability of the intervention was good; 31 participants out of 33 (94%) completed all five sessions. Feedback on the intervention was mainly positive; three out of four subscales of session were rated above the midpoint of 4.0. Feedback on the website was also positive, with a grade of good for content (69%, 20/29 patients; 75%, 21/28 professionals), layout (62%, 18/29 patients; 61%, 17/28 professionals), and usability (62%, 18/29 patients; and 68%, 19/28 professionals). The patients using the intervention had significantly higher scores 6 months after the sessions in self-efficacy (baseline mean 26.12, SD 5.64 vs 6-month mean 29.24, SD 6.05; P=.003) and regarding knowledge level about schizophrenia (mean 11.39, SD 4.65 vs 6-month mean 15.06, SD 5.26; P=.002), and lower scores in the subscale of helplessness in illness cognition (mean 2.26, SD 0.96 vs 6-month mean 1.85, SD 0.59; P=.03). Differences from the control group were not significant. No differences were found in patients' self-esteem or other subscales in illness cognition.

CONCLUSIONS

The patients were reluctant to participate in the study and tended to drop out before the follow-ups. Once they had participated, their acceptance of the intervention was high. A more effective recruitment strategy and monitoring method will be needed in future studies. To assess the impact of the intervention, a more rigorous study design with an adequately powered sample size will be used in cooperation with outpatient mental health services.

Effect of a School-Based Hygiene Behavior Change Campaign on Handwashing with Soap in Bihar, India: Cluster-Randomized Trial

Changing hand hygiene behavior at scale in the community remains a challenge. The objective of this study was to estimate the effect of Unilever’s school-based “School of 5” handwashing campaign on handwashing with soap (HWWS) in schoolchildren and their mothers in the Indian state of Bihar. We conducted a cluster-randomized trial in two districts. We randomized a total of 32 villages with at least one eligible school to intervention and control groups (1:1) and recruited 338 households in each group for outcome measurement. We used structured observation in households to measure HWWS at target occasions (after defecation, soap use during bathing, and before each main meal) in schoolchildren and their mothers. Observers were blinded to intervention status. We observed 636 target occasions (297 in the intervention arm and 339 in the control arm) in mothers and school-going children. After the intervention, HWWS prevalence at target occasions was 22.4% in the control arm and 26.6% in the intervention arm (prevalence difference +4.4%, 95% confidence interval: −4.0, 12.8). The difference was similar in children and mothers. Observers appeared to be adequately blinded to intervention status, whereas observed households were successfully kept unaware of the purpose of observations. To conclude, we found no evidence for a health-relevant effect of the School of 5 intervention on HWWS in schoolchildren and their mothers. Qualitative research suggested that reasons for the low impact of the intervention included low campaign intensity, ineffective delivery, and a model possibly not well tailored to these challenging physical and social environments.

The impact of an online patient decision aid for women with breast cancer considering immediate breast reconstruction: study protocol of a multicenter randomized controlled trial

Background

Most breast cancer patients undergoing mastectomy are candidates for breast reconstruction. Deciding about breast reconstruction is complex and the preference-sensitive nature of this decision requires an approach of shared decision making between patient and doctor. Women considering breast reconstruction have expressed a need for decision support. We developed an online patient decision aid (pDA) to support decision making in women considering immediate breast reconstruction. The primary aim of this study is to assess the impact of the pDA in reducing decisional conflict, and more generally, on the decision-making process and the decision quality. Additionally, we will investigate the pDA’s impact on health outcomes, explore predictors, and assess its cost-effectiveness.

Methods

A multicenter, two-armed randomized controlled trial (1:1) will be conducted. Women with breast cancer or ductal carcinoma in situ who will undergo a mastectomy and are eligible for immediate breast reconstruction will be invited to participate. The intervention group will receive access to the online pDA, whereas the control group will receive a widely available free information leaflet on breast reconstruction. Participants will complete online questionnaires at: baseline (T0), 1 week after consultation with a plastic surgeon (T1), and 3 (T2) and 12 months (T3) after surgery. The primary outcome is decisional conflict. Secondary outcomes include other measures reflecting the decision-making process and decision quality (e.g., decision regret), patient-reported health outcomes (e.g., satisfaction with the breasts) and costs.

Discussion

This study will provide evidence about the impact of an online pDA for women who will undergo mastectomy and are deciding about breast reconstruction. It will contribute to the knowledge on how to optimally support women in making this difficult decision.

Trial registration

This study is retrospectively registered at ClinicalTrials.gov (NCT03791138).

Impact of a Web Program to Support the Mental Wellbeing of High School Students: A Quasi Experimental Feasibility Study

Little effort has been made to investigate the potential of web programs aimed to support the mental wellbeing of adolescents in school environments in middle-income countries. A quasi-experimental feasibility study was conducted in Thailand with adolescents (N = 180) in three conveniently sampled high schools and with teachers (N = 12) who acted as program tutors. The web program was used in small groups, independently, or it was not used at all. No statistically significant changes were found between the groups regarding depression, stress, or satisfaction. Differences between program users (n = 61) and non-users (n = 48) were not significant. Acceptance was higher among adolescents who used the program independently (n = 40, 73% vs. n = 21, 39%; p = 0.001). Usability feedback did not differ between the groups. Support should be provided in order for programs to be potentially used. More information is needed regarding factors associated with the use of web programs.

Positive behaviour support training for staff for treating challenging behaviour in people with intellectual disabilities: a cluster RCT

BACKGROUND

Preliminary studies have indicated that training staff in Positive Behaviour Support (PBS) may help to reduce challenging behaviour among people with intellectual disability (ID).

OBJECTIVE

To evaluate whether or not such training is clinically effective in reducing challenging behaviour in routine care. The study also included longer-term follow-up (approximately 36 months).

DESIGN

A multicentre, single-blind, two-arm, parallel-cluster randomised controlled trial. The unit of randomisation was the community ID service using an independent web-based randomisation system and random permuted blocks on a 1 : 1 allocation stratified by a staff-to-patient ratio for each cluster.

SETTING

Community ID services in England.

PARTICIPANTS

Adults (aged > 18 years) across the range of ID with challenging behaviour [≥ 15 Aberrant Behaviour Checklist - Community total score (ABC-C_T)].

INTERVENTIONS

Manual-assisted face-to-face PBS training to therapists and treatment as usual (TAU) compared with TAU only in the control arm.

MAIN OUTCOME MEASURES

Carer-reported changes in challenging behaviour as measured by the ABC-C_T over 12 months. Secondary outcomes included psychopathology, community participation, family and paid carer burden, family carer psychopathology, costs of care and quality-adjusted life-years (QALYs). Data on main outcome, service use and health-related quality of life were collected for the 36-month follow-up.

RESULTS

A total of 246 participants were recruited from 23 teams, of whom 109 were in the intervention arm (11 teams) and 137 were in the control arm (12 teams). The difference in ABC-C_T between the intervention and control arms [mean difference -2.14, 95% confidence interval (CI) -8.79 to 4.51; p = 0.528] was not statistically significant. No treatment effects were found for any of the secondary outcomes. The mean cost per participant in the intervention arm was £1201. Over 12 months, there was a difference in QALYs of 0.076 in favour of the intervention (95% CI 0.011 to 0.140 QALYs) and a 60% chance that the intervention is cost-effective compared with TAU from a health and social care cost perspective at the threshold of £20,000 per QALY gained. Twenty-nine participants experienced 45 serious adverse events (intervention arm, n = 19; control arm, n = 26). PBS plans were available for 33 participants. An independent assessment of the quality of these plans found that all were less than optimal. Forty-six qualitative interviews were conducted with service users, family carers, paid carers and service managers as part of the process evaluation. Service users reported that they had learned to manage difficult situations and had gained new skills, and carers reported a positive relationship with therapists. At 36 months' follow-up (n = 184), the mean ABC-C_T difference between arms was not significant (-3.70, 95% CI -9.25 to 1.85; p = 0.191). The initial cost-effectiveness of the intervention dissipated over time.

LIMITATIONS

The main limitations were low treatment fidelity and reach of the intervention.

CONCLUSIONS

Findings from the main study and the naturalistic follow-up suggest that staff training in PBS as delivered in this study is insufficient to achieve significant clinical gains beyond TAU in community ID services. Although there is an indication that training in PBS is potentially cost-effective, this is not maintained in the longer term. There is increased scope to develop new approaches to challenging behaviour as well as optimising the delivery of PBS in routine clinical practice.

TRIAL REGISTRATION

This study is registered as NCT01680276.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 15. See the NIHR Journals Library website for further project information.

Impact of psychologically tailored hand hygiene interventions on nosocomial infections with multidrug-resistant organisms: results of the cluster-randomized controlled trial PSYGIENE

Background

Professional hand hygiene compliance represents a multifaceted behaviour with various determinants. Thus, it has been proposed to apply psychological frameworks of behaviour change to its promotion. However, randomized controlled trials of such approaches, which also assess nosocomial infections (NIs), are rare. This study analyses data of the PSYGIENE-trial (PSYchological optimized hand hyGIENE promotion), which has shown improvements in compliance after interventions tailored based on the Health Action Process Approach (HAPA), on rates of NIs with multidrug-resistant organisms (MDROs).

Methods

A parallel-group cluster-randomized controlled trial was conducted on all 10 intensive care units and two hematopoietic stem cell transplantation units at Hannover Medical School, a German tertiary care hospital. Educational training sessions for physicians and nurses (individual-level intervention) and feedback discussions with clinical managers and head nurses (cluster-level) were implemented in 2013. In the “Tailoring”-arm (n = 6 wards), interventions were tailored based on HAPA-components, which were empirically assessed and addressed by behaviour change techniques. As active controls, n = 6 wards received untailored educational sessions of the local “Clean Care is Safer Care”-campaign (Aktion Saubere Hände: “ASH”-arm). From 2013 to 2015 compliance was assessed by observation following the World Health Organization, while alcohol-based hand rub usage (AHRU) and NIs with multidrug-resistant gram-negative bacteria, Methicillin-resistant Staphylococcus aureus or Vancomycin-resistant Enterococcus were assessed following national surveillance protocols. Data were analysed at cluster-level.

Results

In the “Tailoring”-arm, interventions led to a decrease of 0.497 MDRO-infections per 1000 inpatient days from 2013 to 2015 (p = 0.015). This trend was not found in the “ASH”-arm (− 0 . 022 infections; p = 0.899). These patterns corresponded inversely to the trends in compliance but not in AHRU.

Conclusions

While interventions tailored based on the HAPA-model did not lead to a significantly lower incidence rate of MDRO-infections compared to control wards, a significant reduction, compared to baseline, was found in the second follow-up year in the “Tailoring”- but not the "ASH"-arm. This indicates that HAPA-tailored hand hygiene interventions may contribute to the prevention of NIs with MDRO. Further research should focus on addressing compliance by interventions tailored not only to wards, but also leaders, teams, and individuals.

Trial registration

German Clinical Trials Register/International Clinical Trials Registry Platform, DRKS00010960. Registered 19 August 2016-Retrospectively registered, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00010960. http://apps.who.int/trialsearch/Trial2.aspx?TrialID=DRKS00010960.

Electronic supplementary material

The online version of this article (10.1186/s13756-019-0507-5) contains supplementary material, which is available to authorized users.

A scoping review of the problems and solutions associated with contamination in trials of complex interventions in mental health

Background

In a randomised controlled trial, contamination is defined as the receipt of active intervention amongst participants in the control arm. This review assessed the processes leading to contamination, its typical quantity, methods used to mitigate it, and impact of use of cluster randomisation to prevent it on study findings in trials of complex interventions in mental health.

Methods

This is a scoping review of trial design approaches and methods of study conduct to address contamination. Studies included were randomised controlled trials of complex interventions in mental health that described the process leading to, amount of, or solution used to counter contamination. The Medline, Embase, and PsycInfo databases were searched for trials published between 2000 and 2015. Risk of bias was assessed using the Jadad score and domains recommended by Cochrane plus some relevant to cluster randomised trials.

Results

Two hundred and thirty-four articles were included in the review. The main processes that led to contamination were health professionals delivering both active and comparator treatments and communication among clinicians and participants from the different trial arms. Twenty-three trials (10%) measured binary treatment receipt in the control arm with median 13% of participants found to be contaminated (IQR 5–33%). The most common design approach for dealing with contamination was the use of cluster randomisation (n = 93). In addition, many researchers used simple trial conduct methods to minimise contamination due to suspected contamination processes, such as organising for each clinician to provide only one treatment and separating trial arms spatially or temporally. There was little evidence for a relationship between cluster randomisation to avoid contamination and size of treatment effect estimate.

Conclusion

There was some evidence of modest levels of treatment contamination with a large range, although a minority of studies reported the amount of contamination. A limitation was that many trials described the problem in little detail. Overall there is a need for greater measurement and reporting of treatment receipt in the control arm of trials. Researchers should be aware of trial conduct methods that can be used to minimise contamination without resorting to cluster randomisation.

Electronic supplementary material

The online version of this article (10.1186/s12874-018-0646-z) contains supplementary material, which is available to authorized users.

Impact of a peer-review network on the quality of inpatient low secure mental health services: cluster randomised control trial

BACKGROUND

Peer-review networks aim to help services to improve the quality of care they provide, however, there is very little evidence about their impact. We conducted a cluster randomized controlled trial of a peer-review quality network for low-secure mental health services to examine the impact of network membership on the process and outcomes of care over a 12 month period.

METHODS

Thirty-eight low secure units were randomly allocated to either the active intervention (participation in the network n = 18) or the control arm (delayed participation in the network n = 20). A total of 75 wards were assessed at baseline and 8 wards dropped out the study before the data collection at 12 month follow up. The primary outcome measure was the quality of the physical environment and facilities of the services. The secondary outcomes included: safety of the ward, patient mental wellbeing and satisfaction with care, staff burnout, training and supervision. We hypothesised that, relative to control wards, the quality of the physical environment and facilities would be higher on wards in the active arm of the trial 12 months after randomization.

RESULTS

The difference in the primary outcome between the groups was not statistically significant (4.1; 95% CI [- 0.2, 8.3] p = 0.06). The median number of untoward incidents rose in control services and remained the same at the member of the network (Difference between members and non-members = 0.55; 95% IC [0.29, 1.07] p = 0.08). At follow up, a higher proportion of staff in the active arm of the trial indicated that they felt safe on the ward relative to those in the control services (p = 0.04), despite reporting more physical assaults (p = 0.04). Staff working in services in the active arm of the trial reported higher levels of burnout relative to those in the control group. No difference was seen in patient outcomes.

CONCLUSIONS

We did not find evidence that participation in a peer-review network led to marked changes in the quality of the physical environment of low secure mental health services at 12 months. Future research should explore the impact of accreditation schemes and examine longer term outcomes of participation in such networks.

TRIAL REGISTRATION

ISRCTN79614916 . Retrospectively registered 28 March 2014.

The effect of a care program and social support on anxiety level in mothers of late preterm infants in Sistan and Baluchestan, Iran

Late and moderate preterm (LAMP) neonates are at risk of developing severe complications that can lead to anxiety in mothers. The aim of this study was to determine the effectiveness of a care program on the anxiety level of mothers with LAMP babies and to determine the effectiveness of the care program on the level of anxiety of new mothers in the presence of social support. This quasi-experimental study was conducted on 80 mothers whose late preterm infants were admitted to neonatal intensive care unit at Ali-ibn Abi Talib Hospital, Zahedan. Data were gathered between July 10 and October 13, 2016. The intervention group received the care program. Anxiety and social support were evaluated using the State-Trait Anxiety Inventory and Multidimensional Scale of Perceived Social Support (MSPSS), respectively. After receiving the intervention, the mean MSPSS was higher for the mothers in the intervention group (p = .0025). Additionally, they experienced less state anxiety 72 hours after discharge and 1 month after delivery (p < .0025). Regression analysis showed that mothers with higher social support were 39 percent more likely to be in the "no to moderate STAI" (<51) group. Perceived social support can mediate the effect of care programs on diminishing anxiety.

The Ready to Reduce Risk (3R) Study for a Group Educational Intervention With Telephone and Text Messaging Support to Improve Medication Adherence for the Primary Prevention of Cardiovascular Disease: Protocol for a Randomized Controlled Trial

Background

Poor adherence to cardiovascular medications is associated with worse clinical outcomes. Evidence for effective education interventions that address medication adherence for the primary prevention of cardiovascular disease is lacking. The Ready to Reduce Risk (3R) study aims to investigate whether a complex intervention, involving group education plus telephone and text messaging follow-up support, can improve medication adherence and reduce cardiovascular risk.

Objective

This protocol paper details the design and rationale for the development of the 3R intervention and the study methods used.

Methods

This is an open and pragmatic randomized controlled trial with 12 months of follow-up. We recruited participants from primary care and randomly assigned them at a 1:1 frequency, stratified by sex and age, to either a control group (usual care from a general practitioner) or an intervention group involving 2 facilitated group education sessions with telephone and text messaging follow-up support, with a theoretical underpinning and using recognized behavioral change techniques. The primary outcome was medication adherence to statins. The primary measure was an objective, novel, urine-based biochemical measure of medication adherence. We also used the 8-item Morisky Medication Adherence Scale to assess medication adherence. Secondary outcomes were changes in total cholesterol, blood pressure, high-density lipoprotein, total cholesterol to high-density lipoprotein ratio, body mass index, waist to hip ratio, waist circumference, smoking behavior, physical activity, fruit and vegetable intake, patient activation level, quality of life, health status, health and medication beliefs, and overall cardiovascular disease risk score. We also considered process outcomes relating to acceptability and feasibility of the 3R intervention.

Results

We recruited 212 participants between May 2015 and March 2017. The 12-month follow-up data collection clinics were completed in April 2018, and data analysis will commence once all study data have been collected and verified.

Conclusions

This study will identify a potentially clinically useful and effective educational intervention for the primary prevention of cardiovascular disease. Medication adherence to statins is being assessed using a novel urine assay as an objective measure, in conjunction with other validated measures.

Trial Registration

International Standard Randomized Controlled Trial Number ISRCTN16863160; http://www.isrctn.com/ISRCTN16863160 (Archived by WebCite at http://www.webcitation.org/734PqfdQw)

International Registered Report Identifier (IRRID)

DERR1-10.2196/11289

Nurse-led psychological intervention for type 2 diabetes: a cluster randomised controlled trial (Diabetes-6 study) in primary care

BACKGROUND

Suboptimal glycaemic control in type 2 diabetes (T2D) is common and associated with psychological barriers.

AIM

To investigate whether it was possible to train practice nurses in six psychological skills (Diabetes-6 [D6]) based on motivational interviewing (MI) and basic cognitive behaviour therapy (CBT), and whether integrating these with diabetes care was associated with improved glycaemic control over 18 months compared with standard care.

DESIGN AND SETTING

Two-arm, single-blind, parallel cluster randomised controlled trial in primary care.

METHOD

Adult participants (n = 334) with T2D and persistent HbA1c ≥69.4 mmol/mol were randomised to receive 12 sessions of either the D6 intervention or standard care over 12 months. Practice nurses were trained in the six psychological skills and their competencies were measured by standardised rating scales. Primary outcome was a change in HbA1c level at 18 months from randomisation. Secondary outcomes were changes in systolic and diastolic blood pressure, body mass index, waist circumference, depressive symptoms, harmful alcohol intake, diabetes-specific distress, and cost-effectiveness.

RESULTS

Using intention-to-treat analysis, there was no significant difference between D6 intervention and standard care in HbA1c (mean difference -0.79 mmol/mol, 95% confidence interval [CI] = -5.75 to 4.18) or for any of the secondary outcomes. The competency level of D6 nurses was below the beginner proficiency level and similar to the standard-care nurses.

CONCLUSION

Training nurses in MI and basic CBT to support self-management did not lead to improvements in glycaemic control or other secondary outcomes in people with T2D at 18 months. It was also unlikely to be cost-effective. Furthermore, the increased contact with standard-care nurses did not improve glycaemic control.

Cut stroke in half: Polypill for primary prevention in stroke

This review summarizes the potential for polypill therapies for stroke prevention. While a number of studies applying different approaches regarding polypill have been performed, none of them has had a focus on stroke as the main outcome. A combination pill containing drugs such as statins, diuretics, and other antihypertensives is currently available in various formats. Estimates focusing mostly on primary prevention show that using such a combination drug a reduction in the 5-year stroke incidence by 50% can be achieved - especially in low- and middle-income countries with a high prevalence of risk factors even among people at young ages. A combination of a large supporting population-wide program with a registry-based quality control is the most likely perspective and can be achieved within a reasonable time frame and potentially have significant influence in young stroke populations.

Interventions to increase adherence in patients taking immunosuppressive drugs after kidney transplantation: a systematic review of controlled trials

BACKGROUND

Immunosuppressive drugs have to be taken through the whole duration of kidney transplant survival to avoid rejection. Low adherence can increase the risk of allograft rejection. The objective was to evaluate the effectiveness of adherence-enhancing interventions (AEI) in kidney transplantation recipients taking immunosuppressive drugs.

METHODS

A search was performed in Medline, Embase, CINAHL, and PsycINFO. The search was performed in May 2016. We included comparative studies on AEI for kidney transplant recipients taking immunosuppressive drugs. The primary outcome was medication adherence. All identified articles were screened according to the predefined inclusion criteria. The risk of bias was assessed with the Cochrane risk of bias tool. Study selection and risk of bias assessment were performed by two reviewers independently. Data were extracted in standardized tables. Data extraction was verified by a second reviewer. All discrepancies were resolved through discussion. Data were synthesized in a structured narrative way. There is no registered or published protocol for this systematic review.

RESULTS

We identified 12 studies. The number of participants ranged from 24 to 1830. Nine studies included adults, two children, and one adults and children. Risk of bias was high. The main reasons for high risk of bias were inadequate allocation sequence (confounding) and that studies were not blinded. Eleven studies evaluated AEI consisting of educational and/or behavioral components. All these studies showed an effect direction in favor of the intervention. Intervention effect was only moderate. Most adherence measures in studies on educational and behavioral interventions showed statistically significant differences. Studies that combined educational and behavioral intervention components showed larger effects. All studies that were statistically significant were multimodal. Studies that included an individualized component and more intensive interventions showed larger effects. One study evaluated a reminder system. Effect size was not reported. This study showed no statistical significant difference (p > 0.05).

CONCLUSION

Educational and behavioral AEI can increase adherence. In particular, multimodal and individualized interventions seem promising. However, because of the small effect, the high risk of bias, and the invalidity of adherence measures, the actual benefit of adherence interventions for an unselected patient population (i.e., including also adherent patients) seems limited. No conclusion is possible for interventions combining adherence-enhancing components that address intentional (behavioral) as well as unintentional adherence (reminder).

Pilot evaluation of a coping-oriented supportive program for people with spinal cord injury during inpatient rehabilitation

PURPOSE

To report the feasibility and preliminary effects of a psychosocial care program entitled "coping-oriented supportive program" (COSP) for people with spinal cord injury (SCI) during inpatient rehabilitation.

METHODS

This was a pilot test of the COSP using a convenience sample of 22 participants with SCI (11 participants per group) with pre- and post-test, comparison group design. The feasibility, acceptability, and preliminary effects of the COSP were examined.

RESULTS

Nine patients with SCI in the intervention group and 11 in the comparison group who completed five or more sessions of the intervention were included in the data analysis. The COSP was feasible with high levels of recruitment, retention and protocol adherence. Good acceptability was suggested by the participants' feedback on the intervention program. The intervention group had a statistically significant greater improvement in self-efficacy (z = -1.978, p = 0.048), life enjoyment and satisfaction (z = -2.801, p = 0.005), and satisfaction of social support (z = -2.298, p = 0.022) at post-test, when compared to the comparison group. Whereas, no significant improvement was found for coping.

CONCLUSIONS

Our findings support the feasibility and acceptability of the COSP, and suggest that this intervention is a promising psychosocial care program to enhance people's life satisfaction and well-being as well as the satisfaction of social support after SCI. Further testing of this program with a larger-sized and diverse sample of people with SCI is needed. Implications for Rehabilitation The Chinese culturally-sensitive psychosocial care program (coping-oriented supportive program) is feasible, and has the potential to enhance people's self-efficacy in coping with spinal cord injury, and improve their psychosocial well-being and life satisfaction. The conventional inpatient spinal cord injury rehabilitation services could be improved by providing this "first-line" psychosocial care program in line with the current medical rehabilitation service.

Impact of Latin Dance on Physical Activity, Cardiorespiratory Fitness, and Sedentary Behavior Among Latinos Attending an Adult Day Center

Objective: The aim of this study was to determine whether a Latin dance program with sedentary behavior information would have an impact on physical activity, cardiorespiratory fitness (CRF), and sedentary behavior among older Latinos attending an adult day center (ADC). Method: Participants ( N = 21, 75.4 ± 6.3 years old, Mini-Mental State Examination [MMSE] score = 22.4 ± 2.8) were randomized into a dance or wait-list control group. Participants wore an accelerometer and inclinometer and completed a sedentary behavior questionnaire, and a nonexercise equation was used to calculate CRF. Results: Findings indicate small to medium effect sizes in the desired direction during midpoint of the intervention for physical activity, sedentary behavior–related outcomes, CRF, and self-reported sedentary behavior in the dance group; however; dance participants did not maintain that trajectory for the remaining 2 months of the intervention. Discussion: Future studies may consider implementing behavioral strategies during midpoint of the intervention to encourage participants attending an ADC to maintain physical activity and sedentary behavior changes.

An online growth mindset intervention in a sample of rural adolescent girls

BACKGROUND

Students living in rural areas of the United States exhibit lower levels of educational attainment than their suburban counterparts. Innovative interventions are needed to close this educational achievement gap.

AIMS

We investigated whether an online growth mindset intervention could be leveraged to promote academic outcomes.

SAMPLE

We tested the mindset intervention in a sample of 222 10th-grade adolescent girls (M age = 15.2; 38% White, 25% Black, 29% Hispanic) from four rural, low-income high schools in the Southeastern United States.

METHODS

We conducted a randomized controlled trial to test the efficacy of the growth mindset intervention, relative to a sexual health programme. We used random sampling and allocation procedures to assign girls to either the mindset intervention (n = 115) or an attention-matched control programme (n = 107). We assessed participants at pre-test, immediate post-test, and 4-month follow-up.

RESULTS

Relative to the control condition, students assigned to the mindset intervention reported stronger growth mindsets at immediate post-test and 4-month follow-up. Although the intervention did not have a total effect on academic attitudes or grades, it indirectly increased motivation to learn, learning efficacy and grades via the shifts in growth mindsets.

CONCLUSIONS

Results indicate that this intervention is a promising method to encourage growth mindsets in rural adolescent girls.

Computer-generated reminders delivered on paper to healthcare professionals: effects on professional practice and healthcare outcomes

BACKGROUND

Clinical practice does not always reflect best practice and evidence, partly because of unconscious acts of omission, information overload, or inaccessible information. Reminders may help clinicians overcome these problems by prompting them to recall information that they already know or would be expected to know and by providing information or guidance in a more accessible and relevant format, at a particularly appropriate time. This is an update of a previously published review.

OBJECTIVES

To evaluate the effects of reminders automatically generated through a computerized system (computer-generated) and delivered on paper to healthcare professionals on quality of care (outcomes related to healthcare professionals' practice) and patient outcomes (outcomes related to patients' health condition).

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, six other databases and two trials registers up to 21 September 2016 together with reference checking, citation searching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We included individual- or cluster-randomized and non-randomized trials that evaluated the impact of computer-generated reminders delivered on paper to healthcare professionals, alone (single-component intervention) or in addition to one or more co-interventions (multi-component intervention), compared with usual care or the co-intervention(s) without the reminder component.

DATA COLLECTION AND ANALYSIS

Review authors working in pairs independently screened studies for eligibility and abstracted data. For each study, we extracted the primary outcome when it was defined or calculated the median effect size across all reported outcomes. We then calculated the median improvement and interquartile range (IQR) across included studies using the primary outcome or median outcome as representative outcome. We assessed the certainty of the evidence according to the GRADE approach.

MAIN RESULTS

We identified 35 studies (30 randomized trials and five non-randomized trials) and analyzed 34 studies (40 comparisons). Twenty-nine studies took place in the USA and six studies took place in Canada, France, Israel, and Kenya. All studies except two took place in outpatient care. Reminders were aimed at enhancing compliance with preventive guidelines (e.g. cancer screening tests, vaccination) in half the studies and at enhancing compliance with disease management guidelines for acute or chronic conditions (e.g. annual follow-ups, laboratory tests, medication adjustment, counseling) in the other half.Computer-generated reminders delivered on paper to healthcare professionals, alone or in addition to co-intervention(s), probably improves quality of care slightly compared with usual care or the co-intervention(s) without the reminder component (median improvement 6.8% (IQR: 3.8% to 17.5%); 34 studies (40 comparisons); moderate-certainty evidence).Computer-generated reminders delivered on paper to healthcare professionals alone (single-component intervention) probably improves quality of care compared with usual care (median improvement 11.0% (IQR 5.4% to 20.0%); 27 studies (27 comparisons); moderate-certainty evidence). Adding computer-generated reminders delivered on paper to healthcare professionals to one or more co-interventions (multi-component intervention) probably improves quality of care slightly compared with the co-intervention(s) without the reminder component (median improvement 4.0% (IQR 3.0% to 6.0%); 11 studies (13 comparisons); moderate-certainty evidence).We are uncertain whether reminders, alone or in addition to co-intervention(s), improve patient outcomes as the certainty of the evidence is very low (n = 6 studies (seven comparisons)). None of the included studies reported outcomes related to harms or adverse effects of the intervention.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that computer-generated reminders delivered on paper to healthcare professionals probably slightly improves quality of care, in terms of compliance with preventive guidelines and compliance with disease management guidelines. It is uncertain whether reminders improve patient outcomes because the certainty of the evidence is very low. The heterogeneity of the reminder interventions included in this review also suggests that reminders can probably improve quality of care in various settings under various conditions.