How does a school-based intervention impact students' social cognitions on reducing sedentary behavior over 14 months?

Despite sedentary behavior being ubiquitous in students and detrimental to health, interventions specifically targeting it are mostly restricted to leisure time screen time reduction. With six weekly sessions alongside a poster campaign and an additional teacher intervention, the Let's Move It trial delivered environmental and psychological strategies to increase physical activity (PA) and reduce sedentary behavior (SB) in vocational schools, an understudied environment for behavioral interventions. Participants in the intervention arm considerably reduced sedentary time post-intervention. To investigate how social cognitions about restricting SB, as defined by the Reasoned Action Approach, change in intervention and control arms, self-reported data on social cognitions was collected as part of a cluster-randomized controlled trial from 1166 students (59% female, mage = 18.7 years, range: 16-49) in six vocational schools before, post-intervention, and 14 months post-baseline. Data were analyzed using mixed between-within repeated measures ANOVA. We found greater improvements in intention (F(1, 833) = 9.69; η2p = 0.01; p = .018) and descriptive norms (F(1, 831) = 13.25; η2p = 0.016; p < .001) in the intervention than control arm, but these effects depended on the included control variables. Generally, intervention effects leveled off from post-intervention to follow-up. The Let's Move It intervention for SB reduction showed modest, short-lived effects on social cognitions, indicating that changes in behavior are likely due to other factors like changes to the classroom environment. Optimally, SB reduction interventions should not only change behavior but produce robust changes in conscious intentions to restrict one's sitting, so that positive effects generalize to other contexts.

How a group-based occupational therapy program works in woman with fibromyalgia: A process evaluation of the ADAPT program

BACKGROUND

The ADAPT Program have improved activities of daily living (ADL) in women with fibromyalgia. To understand the functioning of the program, it is relevant to evaluate how program theory components are linked to outcomes (mechanisms) and how the randomised controlled trial (RCT) context, influenced delivery and outcomes.

OBJECTIVE

To evaluate ADAPT in terms of dose, mechanisms of change and contextual factors.

MATERIAL/METHODS

Dose was recorded on the n = 21 participants receiving ADAPT in the IMPROvE trial (NCT01352052). A subsample of n = 16 attended one of three 2-hour focusgroups, evaluating mechanisms of change and contextual factors. Interview questions explored participants' interaction with four program components, i.e. how the 'client-centred approach', 'group-based peer-exchange format', 'teaching-learning strategies' and 'long-term program format' triggered mechanisms facilitating/hindering outcomes. Moreover, how randomisation procedures influenced delivery and outcomes.

RESULTS

Attending a long-term educational peer-exchange program, in which participants experienced met by a health professional that legitimised difficulties, facilitated participants knowledge, insights and motivation for changing habits. With time and support, participants experienced increased acceptance of their situation and began to implement more effective ways to perform ADL tasks.

CONCLUSIONS/SIGNIFICANCE

Results support previous findings of improved ADL ability post-ADAPT and provide initial evidence to support the ADAPT Program theory.

A grounded theory exploration of programme theory within waves of wellness surf therapy intervention

OBJECTIVE

Poor mental health represents a large proportion of disease burden faced by young Australians, which has been further exacerbated by the Covid-19 pandemic and the reluctance of this population to seek support. Surf therapy is a novel form of intervention targeting mental health. The objective of this study was to interrogate programme theory within surf therapy, as delivered by the Waves of Wellness Foundation (WOW) in Australia.

METHODS AND MEASURES

The study utilised grounded theory to understand or develop theoretical mediators for WOW surf therapy based on interviews exploring the experiences of previous intervention participants (n = 16; mean age = 18.4 years, SD = 2.8, range 14-24). Data were analysed through constant comparative analysis.

RESULTS

Five categories emerged from participant data as foundational to WOW programme theory: (a) Safe Space, (b) Social Support, (c) Sensory Grounding, (d) Mastery and (e) Respite. These categories have novel theoretical and practical implications for both surf therapy and wider clinical practice, especially around concepts such as delivering 'mental health by stealth' and fostering longer term 'mental health maintenance' for participants.

CONCLUSION

The study developed an initial WOW programme theory, highlighting the importance of foundational therapeutic structures beyond simply going surfing.

Improving child health service interventions through a Theory of Change: A scoping review

Background

The objective of this scoping review was to map how child health service interventions develop, utilise, and refine theories of change. A Theory of Change (ToC) is a tool for designing, implementing, and evaluating interventions that is being increasingly used by child health practitioners who are aiming to enact change in health services.

Methods

A published protocol guided this scoping review. Relevant publications were identified through selected electronic databases and grey literature via a search strategy. The main inclusion criteria were any child health service intervention globally that described their ToC or ToC development process. These were applied by two independent reviewers. Data relevant to the research sub-questions were extracted, charted and discussed.

Findings

38 studies were included in the analysis. This scoping review highlights the disparate and inconsistent use, and reporting of ToCs in the child health service intervention literature.

Conclusion

A ToC may be a helpful tool to enact change in a child health service but careful consideration must be undertaken by the child health service regarding how to maximise the benefits of doing a ToC, and how to accurately report it.

A Low-Cost Method for Understanding How Nature-Based Early Learning and Childcare Impacts Children's Health and Wellbeing

Nature-based play and learning provision is becoming increasingly popular across the early learning and childcare (ELC) sector in Scotland. However, there remains a lack of understanding of how the program is expected to function. This has implications for program learning and may affect wider rollout of the program. Secondary data analysis of parent interviews (n = 22) and observations (n = 7) in Scottish ELC settings, and review of internationally published studies (n = 33) were triangulated to develop a program theory using the Theory of Change approach. This approach makes a program's underlying assumptions explicit by systematically demonstrating the relationship between each component: inputs, activities, outcomes, impact, and the contexts of the program. Findings suggested that location of outdoor nature space, affordances, availability of trained practitioners, and transport to location lead to activities such as free play, educator-led activities, and interactions with nature, resulting in longer durations of physical activity, interactions with peers and educators, and increased engagement with the natural environment. These activities are vital for supporting children's physical, cognitive, social, and emotional development. Our results demonstrate the value of using secondary data analysis to improve our understanding of the underlying theory of nature-based ELC which can support future evaluation designs. These findings will be of interest to program evaluators, researchers, practitioners, and funders, who find themselves with limited resources and want to better understand their program before investing in an evaluation. We encourage researchers and evaluators in the field of early years and outdoor play in other countries to refine this logic model in their own context-specific setting.

Using theory of change in child health service interventions: a scoping review protocol

Background: The objective of this scoping review is to map the evidence of how child health service interventions use their theory of change. A theory of change is a hypothesis of how and why an intervention is intended to bring about change. It can be used as a program design, implementation, and evaluation tool. This scoping review will provide an overview of the evidence base for, and identify the way in which, theories of change in child health service interventions are defined, rationalised, developed, presented, and refined. Methods: The inclusion criteria for this scoping review is any child health service intervention globally, that describes their theory of change or theory of change development process. Relevant exclusions include: logic models or logic frameworks that do not meet this review's definition of theory of change, systematic reviews, behavioural change interventions that target patient's behaviour, school-based interventions, and maternal health interventions not related to child health outcomes. This scoping review will follow the Joanna Briggs Institute Reviewer's manual. Relevant publications will be first searched on selected electronic databases and grey literature. A search strategy will be developed. The search will be limited to articles written in the English language. Results of the search will be curated using Endnote and duplicates removed. Results will be imported to Rayyan. The inclusion criteria will be applied during the process of title and abstract screening, by two independent reviewers and disagreements resolved by a third independent reviewer. Full-texts will have the inclusion criteria applied via the same reviewer process. Data relevant to the research sub-questions will be extracted, analysed, charted and discussed. Ethics and dissemination: Ethical approval is not required for this review as we will make use of already published data. We aim to publish the findings of our review in a peer-reviewed journal.

Theoretical conceptions of intervention research addressing cancer control issues

Population health intervention research (PHIR) involves the use of scientific methods to produce knowledge about policy and program interventions that operate within or outside of the health sector and have the potential to impact health at the population level. PHIR is a relatively new research field that has gained momentum internationally. When developing PHIR, it is important to have a program theory with the potential to increase intervention success by identifying underlying mechanisms, areas of failure and unintended outcomes. Since 2010, the French National Cancer Institute (Institut National du Cancer-INCa) has supported a national, competitive, dedicated call for proposals in PHIR to tackle cancer control issues. After 5 years of activity, specific analysis of the proposals submitted for funding and/or funded (n = 63) from descriptive and analytic perspectives was called for. Analysis of the data revealed diversity in terms of targeted populations, partnerships engaged and methodological approaches. Projects were more likely to be funded (n = 15) if presented with a robust methodological approach and diversity in methodology, and/or with research objectives at different levels of action. The analysis also revealed that researchers do not explicitly describe theoretical constructs underpinning their interventions to combat cancer. PHIR still needs improvement to better incorporate social, institutional and policy approaches to cancer control. Researchers should apply a theory-driven approach to distinguish between 'program failure' and 'theory failure'. Following up the funded projects will allow successes and failures to be evaluated with respect to the use (or non-use) of theory-driven approaches.

Using realist approaches in nutrition and dietetics research

AIM

The aim of this study was to explore the use and future potential of realist approaches to research in nutrition and dietetics.

METHODS

A targeted literature review was used to search key journals (n = 7) in nutrition and dietetics to identify existing research using a realist approach. A narrative synthesis was conducted to explore findings in relation to the research aim.

RESULTS

Nine research papers (four realist evaluations, five realist reviews) describing seven nutrition interventions were found, which revealed the application of realist research in nutrition and dietetics has focused on public health interventions. Realist research provided a deeper, more nuanced understanding of varied outcomes including the role of context, and contributed to the development of theory about how and why interventions work. As a theory-driven research method, realist research was able to assist in overcoming methodological shortcomings to contribute to meaningful, transferable findings.

CONCLUSION

The results highlight the potential contribution of the realist research in nutrition and dietetics to evaluate interventions and inform future practice.

Towards a Program Theory for Family-Focused Practice in Adult Mental Health Care Settings: An International Interview Study With Program Leaders

Objectives: In several high-income countries, family-focused practice programs have been introduced in adult mental health care settings to identify and support children whose parents live with mental health problems. Whilst their common goal is to reduce the impact of parental mental illness on children, the mechanisms by which they improve outcomes in different systems and settings are less well known. This kind of knowledge can importantly contribute to ensuring that practice programs achieve pre-defined impacts. Methods: The aim of this study was to develop knowledge about relationships between contextual factors, mechanisms and impact that could inform a program theory for developing, implementing, and evaluating family-focused practice. Principles of a realist evaluation approach and complex system thinking were used to conceptualize the design of semi-structured in-depth interviews with individuals who led the implementation of programs. Seventeen individuals from eight countries participated in the study. Results: Interviewees provided rich accounts of the components that programs should include, contextual factors in which they operated, as well as the behavior changes in practitioners that programs needed to achieve. Together with information from the literature, we developed an initial program theory, which illustrates the interconnectedness between changes that need to co-occur in practitioners, parents, and children, many of which related to a more open communication about parental mental health problems. Stigma, risk-focused and fragmented health systems, and a lack of management commitment were the root causes explaining, for example, why conversations about parents' mental illness did not take place, or not in a way that they could help children. Enabling practitioners to focus on parents' strengths was assumed to trigger changes in knowledge, emotions and behaviors in parents that would subsequently benefit children, by reducing feelings of guilt and improving self-esteem. Conclusion: To our knowledge, this is the first research, which synthesizes knowledge about how family-focused practice programs works in a way that it can inform the design, implementation, and evaluation of programs. Stakeholder, who fund, design, implement or evaluate programs should start co-developing and using program theories like the one presented in this paper to strengthen the design and delivery of family-focused practice.

Case Management in Primary Care for Frequent Users of Health Care Services: A Realist Synthesis

PURPOSE

Case management (CM) is a promising intervention for frequent users of health care services. Our research question was how and under what circumstances does CM in primary care work to improve outcomes among frequent users with chronic conditions?

METHODS

We conducted a realist synthesis, searching MEDLINE, CINAHL, Embase, and PsycINFO (1996 to September 2017) for articles meeting the following criteria: (1) population: adult frequent users with chronic disease, (2) intervention: CM in a primary care setting with a postintervention evaluation, and (3) primary outcomes: integration of services, health care system use, cost, and patient outcome measures. Academic and gray literature were evaluated for relevance and robustness. Independent reviewers extracted data to identify context, mechanism, and outcome (CMO) configurations. Analysis of CMO configurations allowed for the modification of an initial program theory toward a refined program theory.

RESULTS

Of the 9,295 records retrieved, 21 peer-reviewed articles and an additional 89 documents were retained. We evaluated 19 CM interventions and identified 11 CMO configurations. The development of a trusting relationship fostering patient and clinician engagement in the CM intervention was recurrent in many CMO configurations.

CONCLUSION

Our refined program theory proposes that in the context of easy access to an experienced and trusted case manager who provides comprehensive care while maintaining positive interactions with patients, the development of this relationship fosters the engagement of both individuals and yields positive outcomes when the following mechanisms are triggered: patients and clinicians feel supported, respected, accepted, engaged, and committed; and patients feel less anxious, more secure, and empowered to self-manage.

Program Impact Pathways and Contexts: A Commentary on Theoretical Issues and Research Applications to Support the EsIAN Component of Mexico's Conditional Cash Transfer Program

This commentary on the Integrated Strategy for Attention to Nutrition (EsIAN) journal supplement begins with a discussion about the challenges that implementation researchers confront with respect to analyzing complex impact pathways. We note that the research on the implementation of the EsIAN component of Mexico's conditional cash transfer program was based implicitly or explicitly on a program impact pathway approach, which used both quantitative and qualitative methods to examine bottlenecks in program implementation. We then identify 5 categories of contexts that affect the impact, implementation, and survival of intervention programs: 1) biological, 2) social-cultural, 3) delivery modalities and platforms, 4) bureaucratic, and 5) political. Each of these contexts presents theoretical and methodological challenges for investigators. In this commentary, we focus primarily on biological and social-cultural contexts, discussing the theoretical and methodological challenges the investigators faced and the research strategies they used to address them, which have produced a unique compilation of "learning by doing" studies. We also touch briefly on the political context in which the Prospera program research was conducted. We conclude with statements that highlight the exceptional value of the journal supplement, not only with respect to the analysis of the interventions the studies cover and the sustained examination of a long-term program but also as a major contribution to the literature in implementation science in nutrition.

A theory based evaluation of an intervention to promote positive health behaviors and reduce social isolation in people experiencing homelessness

Homelessness adversely affects an individual's ability to access healthcare, opportunities for social interaction and recreational activities such as physical activity. This study aimed to evaluate the impact of a community-based physical activity and peer support intervention on the health and wellbeing of homeless participants. This study employed semi-structured interviews to investigate the perceived impact of the Street Fit Scotland intervention on the health and wellbeing of 10 homeless adults. Interviews were audio recorded and transcribed verbatim. A thematic analysis was conducted. Participants reported that their health and wellbeing had improved since attending the intervention. This was attributed to improvements in self-esteem, social interaction and mental wellbeing. Participants generally felt that their physical activity had increased since attending Street Fit Scotland, and a number of individuals reported that they were making healthier choices with regards to health behaviors. A theory of change logic model was developed that demonstrated how each component of the intervention influences the observed and intended outcomes. Attendance of Street Fit Scotland had positive effects on participant's health and wellbeing, particularly concerning self-esteem, health behaviors, social interaction, and physical activity. More efforts should be made to evaluate small-scale interventions that are reaching vulnerable population groups.

Key Informants Specify Core Elements of Peer Supports for Parents With Serious Mental Illness

Background: Researchers have documented the lack of evidence-based interventions for parents with serious mental illness (SMI). Given the prevalence of parenthood among individuals with SMI, the value placed on parenthood, and their diverse vulnerabilities, a robust, theoretically sound and empirically tested model of peer supports would likely provide a valuable complement to psychiatric services. In this paper, we lay the groundwork for a model of peer supports using a program theory development process and guided by stages of evidence-informed innovation outlined by the National Implementation Research Network. Methods: This study employed a developmental design in the initial stage of a larger study of the development, implementation, and testing of peer supports to address three questions: (1) What needs of parents with SMI are particularly well-suited to peer supports? (2) What do peers have to offer parents? and (3) What is unique about peer supports for parents? A purposeful sampling strategy was used to recruit key informants (n = 22) familiar with peer supports, family-focused care and the experiences of families living with parental mental illness. Individual interviews were conducted face-to-face or on the telephone and a full-day group interview was conducted using a workshop format. Interview data were analyzed qualitatively to identify themes reflecting potential core program elements. Results: Consistent themes drawn from data comprise four core program elements: engage, explore, plan, and access and advocate. These core activities are likely founded on practice principles that include a focus on families and their strengths, cultural sensitivity, and acknowledgment of the trauma experienced by many parents. The findings raised a number of challenges in contemplating peer supports for parents with SMI, including the need for ongoing support for peers. Discussion: In developing this model, aspects of organizational context must be considered along with specification of the characteristics of parents with SMI suited to this approach and the attributes of peers providing support. A fully-articulated model must include parallel theories of change for the workforce, as well as for participating parents, to support well-being in the context of peer relationships and the success of parents with SMI in family life.

"Patients Are Not Following the [Adherence] Club Rules Anymore": A Realist Case Study of the Antiretroviral Treatment Adherence Club, South Africa

There is growing evidence that differentiated care models employed to manage treatment-experienced patients on antiretroviral therapy could improve adherence to medication and retention in care. We conducted a realist evaluation to determine how, why, for whom, and under what health system context the adherence club intervention works (or not) in real-life implementation. In the first phase, we developed an initial program theory of the adherence club intervention. In this study, we report on an explanatory theory-testing case study to test the initial theory. We conducted a retrospective cohort analysis and an explanatory qualitative study to gain insights into the important mechanisms activated by the adherence club intervention and the relevant context conditions that trigger the different mechanisms to achieve the observed outcomes. This study identified potential mitigating circumstances under which the adherence club program could be implemented, which could inform the rollout and implementation of the adherence club intervention.

Getting Started: An Empirically Derived Logic Model for Age-Friendly Community Initiatives in the Early Planning Phase

Age-friendly community initiatives (AFCIs) foster efforts across stakeholders to make localities more supportive and inclusive of older adults, and potentially better for residents of all ages. This study drew on in-depth interviews with leaders of nine newly forming AFCIs in northern New Jersey to develop an empirically based logic model for the initiatives in the early planning phase. The results obtained from a conventional content analysis indicated three main activities in the early planning phase: assessing the community; meeting; and communicating with stakeholders; and facilitating communitywide communications. These activities worked toward two outputs: increased understanding of aging in the community and more engaged stakeholders in aging. Participants described leveraging the contributions of lead staff, consultants, elected officials, organizational partners, volunteers, interns, funders, and other AFCIs to engage in their focal activities. Based on these findings, a logic model for AFCIs in the early planning phase is presented. AFCI leaders can draw on this model to evaluate AFCI processes and outcomes in their formative stages, as well as to strategically plan for the start of an AFCI within a given locality. Findings also suggest important directions for future research on the development of AFCIs and the community changes that they seek to influence.

Program theory within policy-initiated evaluations: the Norwegian low-income family study

Using as an example a project where the Norwegian Labor and Welfare Directorate developed a comprehensive model for the follow-up of low-income families, this article demonstrates the process of developing a program theory for policy-initiated interventions. The data consist of interviews with program developers, political documents from early stages, and observations of the program's development. The results demonstrate that, although research inspired the program developers, the program was also the outcome of policy priorities, experiences from earlier projects, and input from the practice field. Multiple sources contributed to its relevance for the practice field, however, increasing its complexity. The program includes several intervention levels and follow-up areas and partially builds on elements found to be important across interventions. Although a program theory can be difficult to conceptualize within policy-initiated interventions, it is important to articulate it prior to evaluation and, if necessary, reassess it when data have been analyzed.

Promoting Sustained Breastfeeding of Infants at Risk for Asthma: Explaining the "Active Ingredients" of an Effective Program Using Intervention Mapping

Infants whose parents and/or siblings have a history of asthma or allergy may profit from receiving exclusive breastfeeding during the first 6 months of life. This is expected to diminish the chance of developing childhood asthma and/or atopic disease. Ongoing breastfeeding for 6 months seems challenging for many women. An educational program was developed using Intervention Mapping as a logic model to guide development and was found successful in improving breastfeeding rates at 6 months postpartum, improving knowledge and beliefs about breastfeeding for 6 months, after exposure to the program compared to controls. Intervention elements included an evidence- and theory-based booklet addressed during pre- and postnatal home visits by trained assistants. This paper elucidates the inner workings of the program by systematically describing and illustrating the steps for intervention development.

Interaction of Theory and Practice to Assess External Validity

BACKGROUND

Variations in local context bedevil the assessment of external validity: the ability to generalize about effects of treatments. For evaluation, the challenges of assessing external validity are intimately tied to the translation and spread of evidence-based interventions. This makes external validity a question for decision makers, who need to determine whether to endorse, fund, or adopt interventions that were found to be effective and how to ensure high quality once they spread.

OBJECTIVE

To present the rationale for using theory to assess external validity and the value of more systematic interaction of theory and practice.

METHODS

We review advances in external validity, program theory, practitioner expertise, and local adaptation. Examples are provided for program theory, its adaptation to diverse contexts, and generalizing to contexts that have not yet been studied. The often critical role of practitioner experience is illustrated in these examples. Work is described that the Robert Wood Johnson Foundation is supporting to study treatment variation and context more systematically.

RESULTS

Researchers and developers generally see a limited range of contexts in which the intervention is implemented. Individual practitioners see a different and often a wider range of contexts, albeit not a systematic sample. Organized and taken together, however, practitioner experiences can inform external validity by challenging the developers and researchers to consider a wider range of contexts. Researchers have developed a variety of ways to adapt interventions in light of such challenges.

CONCLUSIONS

In systematic programs of inquiry, as opposed to individual studies, the problems of context can be better addressed. Evaluators have advocated an interaction of theory and practice for many years, but the process can be made more systematic and useful. Systematic interaction can set priorities for assessment of external validity by examining the prevalence and importance of context features and treatment variations. Practitioner interaction with researchers and developers can assist in sharpening program theory, reducing uncertainty about treatment variations that are consistent or inconsistent with the theory, inductively ruling out the ones that are harmful or irrelevant, and helping set priorities for more rigorous study of context and treatment variation.

Applying a fidelity framework to understand adaptations in an occupational health intervention

BACKGROUND

Two objectives are central when implementing occupational health interventions: high intervention fidelity, i.e. alignment with existing theory/evidence, and the need for fit, i.e., matching organizational and employee needs. These objectives can be contradictory and there is little advice on how to successfully combine them.

OBJECTIVE

This study examines if an implementation fidelity framework can be used to categorize and describe how to adapt an occupational health intervention.

METHODS

Using an adapted version of the Conceptual Framework for Implementation Fidelity, we analyzed the implementation of a workplace-based physical exercise intervention and its contextualized adaptations. Adaptations are described in terms of content, dose, coverage and timeliness, each on three levels: individual, unit and organizational. Data sources include systematic project documentation and reflexive discussions.

RESULTS

The intervention was adapted across all aspects and levels of fidelity. Adaptations involved aligning the intervention with level characteristics: organizational level adaptations aligned health policies with cost/benefits, whereas unit level adaptations minimized interference with production and coordinated the intervention with employee preferences. On the individual level, the exercise type varied, which aligned individual needs with the intervention.

CONCLUSIONS

The Conceptual Framework for Implementation Fidelity can help describe the balance between adaptation and adherence at different organizational levels.

Strengthening prevention program theories and evaluations: contributions from social network analysis

A majority of school-based prevention programs target the modification of setting-level social dynamics, either explicitly (e.g., by changing schools' organizational, cultural or instructional systems that influence children's relationships), or implicitly (e.g., by altering behavioral norms designed to influence children's social affiliations and interactions). Yet, in outcome analyses of these programs, the rich and complicated set of peer network dynamics is often reduced to an aggregation of individual characteristics or assessed with methods that do not account for the interdependencies of network data. In this paper, we present concepts and analytic methods from the field of social network analysis and illustrate their great value to prevention science--both as a source of tools for refining program theories and as methods that enable more sophisticated and focused tests of intervention effects. An additional goal is to inform discussions of the broader implications of social network analysis for public health efforts.

Conceptual framework of the Controlling Asthma in American Cities Project

The Controlling Asthma in American Cities Project (CAACP) was designed to improve the control of asthma in inner-city populations of children with a disparate burden of symptoms and adverse outcomes. As with many chronic diseases, asthma is the manifestation of multiple biologic, environmental, and social determinants. In addition to appropriate medical management, individuals with asthma must have logistical, financial, and cultural access to environments that allow avoidance of asthma triggers and encourage good asthma management practices. In recognition of this complexity, the CAACP required the seven project sites to coordinate and synchronize multiple interventions (education, healthcare access, medical management, trigger reduction) at multiple levels (individual, home, school, community, and policy) through the collaboration of relevant groups, institutions, and individuals. This paper describes the "program theory" of the CAACP project-the assumptions about how the project worked, how the components were linked, and what outcomes were anticipated. It relates the subsequent papers in the supplement to the program theory and describes how the papers can inform and guide other community-based interventions, and advance the translation of scientific knowledge to effective interventions in communities of need.

Beyond the limitations of best practices: how logic analysis helped reinterpret dual diagnosis guidelines

The co-occurrence of mental health and substance use disorders is becoming increasingly recognized as a single problem, and professionals recognize that both should be addressed at the same time. Medical best practices recommend integrated treatment. However, criticisms have arisen, particularly concerning the difficulty of implementing integrated teams in specific health-care contexts and the appropriateness of the proposed model for certain populations. Using logic analysis, we identify the key clinical and organizational factors that contribute to successful implementation. Building on both the professional and organizational literatures on integrated services, we propose a conceptual model that makes it possible to analyze integration processes and places integrated treatment within an interpretative framework. Using this model, it becomes possible to identify key factors necessary to support service integration, and suggest new models of practice adapted to particular contexts.