Scalability evaluation of a complex community-based falls prevention intervention in Australian stroke rehabilitation.

Implementing medicare education for medication access: A review of the literature using the RE-AIM framework.

Peer support and social network groups among people living with epilepsy: A scoping review

Using Digital Health Technology to Prevent and Treat Diabetes.

The RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework was used to describe the implementation of the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) Initiative (2018-2021) for screening and assessing all older adults ≥65 years for falls risk across 34 outpatient rehabilitation clinics within a large health system. We described the Implementation process and strategies. Using Electronic Health Records (EHRs), we identified Reach, Adoption, and Maintenance of screenings and physical assessments to identify fall risk among older adults. STEADI Implementation strategies included health system mandates, EHR revisions, email instructions, educational sessions and resources, clinical leads and champions, and chart audits. Reach: 76.4% (50,023) had a completed screening, and 44.1% screened at risk for falls. Adoption: Clinic-level adoption varied, with most performing screenings. Profession-level adoption was highest for physical therapists (PTs; 94.2% initiated, 80.6% completed) and lowest for speech-language pathologists (SLPs; 79.8% initiated, 55.9% completed). Reach and Adoption of functional outcomes measures (FOM): PTs completed an FOM on 59.5% of at-risk patients, occupational therapists on 11.6%, and SLPs on 7.9%. Maintenance: All measures declined 1%-10% annually between 2018 and 2021. STEADI screening and FOMs were implemented systemwide in 34 outpatient rehabilitation clinics, reaching over 50,000 older adults. Screening adoption rates varied by clinic. PTs had the highest adoption rate. All adoption rates declined over time. Future research should consider an implementation science approach with input from key partners before implementation to identify barriers and develop strategies to support STEADI in outpatient rehabilitation.

BackgroundPublished evaluations of successful interventions to prevent falls in people with sight impairment (SI) are limited. The aim of this feasibility study is to optimise the design and investigation of home safety (HS) and home exercise (HE) programmes to prevent falls in older people with SI.MethodsA community-based feasibility study in north-west England comprising a three-arm randomised controlled trial (RCT) allocated participants to (1) a control group receiving usual care and social visits, (2) an experimental group receiving the HS programme and (3) an experimental group receiving the HS + HE programme. Participants were community-dwelling, aged 65 years and older and sight impaired. Primary outcome data on falls were collected continuously over 6 months. Secondary outcomes on physical activity (self-report and instrumented) and adherence were collected at baseline and 3 and 6 months for HE and at 6 months for the HS programme. Costs for the HS and HS + HE groups were calculated from logs of time spent on home visits, telephone calls and travel. The research assistant and statistician were blinded to group allocation.ResultsAltogether, 49 people were recruited over a 9-month period (randomised: 16 to control, 16 to HS, 17 to HS + HE). The interventions were implemented over 6 months by an occupational therapist at a cost per person (pounds sterling, 2011) of £249 (HS) and £674 (HS + HE). Eighty-eight percent (43/49) completed the trial and 6-month follow-up. At 6-month follow-up, 100 % reported partially or completely adhering to HS recommendations but evidence for adherence to HE was equivocal. Although self-reported physical activity increased, instrumented monitoring showed a decrease in walking activity. There were no statistically significant differences in falls between the groups; however, the study was not powered to detect a difference.ConclusionIt is feasible and acceptable for an occupational therapist to deliver HS and HE falls prevention programmes to people with SI living independently in the community. Future studies could access Local Authority Registers of people with SI to improve recruitment rates. Further research is required to identify how to improve adherence to HE and to measure changes in physical activity before conducting a definitive RCT.Trial registrationISRCTN53433311, registered on 8 May 2014.

BackgroundThe Coronavirus (COVID-19) pandemic has exacerbated the risk for poor physical and mental health outcomes among vulnerable older adults. Multicomponent interventions could potentially prevent or reduce the risk of becoming frail; however, there is limited evidence about utilizing alternative modes of delivery where access to in-person care may be challenging. This randomized feasibility trial aimed to understand how a multicomponent rehabilitation program can be delivered remotely to vulnerable older adults with frailty during the pandemic.MethodsParticipants were randomized to either a multimodal or socialization arm. Over a 12-week intervention period, the multimodal group received virtual care at home, which included twice-weekly exercise in small group physiotherapy-led live-streamed sessions, nutrition counselling and protein supplementation, medication consultation via a videoconference app, and once-weekly phone calls from student volunteers, while the socialization group received only once-weekly phone calls from the volunteers. The RE-AIM (Reach, Effectiveness, Adoption, Implementation and Maintenance) framework was used to evaluate the feasibility of the program. The main clinical outcomes were change in the 5-times sit-to-stand test (5 × STS) and Depression, Anxiety and Stress Scale (DASS-21) scores. The feasibility outcomes were analyzed using descriptive statistics and expressed as frequencies and mean percent with corresponding confidence intervals (CI). Analysis of covariance (ANCOVA) was used for the effectiveness component.ResultsThe program enrolled 33% (n = 72) of referrals to the study (n = 220), of whom 70 were randomized. Adoption rates from different referral sources were community self-referrals (60%), community organizations (33%), and healthcare providers (25%). At the provider level, implementation rates varied from 75 to 100% for different aspects of program delivery. Participant’s adherence levels included virtual exercise sessions 81% (95% CI: 75–88%), home-based exercise 50% (95% CI: 38–62%), protein supplements consumption 68% (95% CI: 55–80%), and medication optimization 38% (95% CI: 21–59%). Most participants (85%) were satisfied with the program. There were no significant changes in clinical outcomes between the two arms.ConclusionThe GERAS virtual frailty rehabilitation study for community-dwelling older adults living with frailty was feasible in terms of reach of participants, adoption across referral settings, adherence to implementation, and participant’s intention to maintain the program. This program could be feasibly delivered to improve access to socially isolated older adults where barriers to in-person participation exist. However, trials with larger samples and longer follow-up are required to demonstrate effectiveness and sustained behavior change.Trial registrationClinicalTrials.gov NCT04500366. Registered August 5, 2020, https://clinicaltrials.gov/ct2/show/NCT04500366

BackgroundAccurate data on adherence and sexual behaviour are crucial in microbicide (and other HIV-related) research. In the absence of a “gold standard” the collection of such data relies largely on participant self-reporting. The Microbicides Development Programme has developed a mixed method/triangulation model for generating more accurate data on adherence and sexual behaviour.Methodology/Principal FindingsData were collected from a random subsample of 725 women using structured case record form (CRF) interviews, coital diaries (CD) and in-depth interviews (IDI). Returned used and unused gel applicators were counted and additional data collected through focus group discussions and ethnography. The model is described in detail in a companion paper [1]. When CRF, CD and IDI are compared there is some inconsistency with regard to reporting of sexual behaviour, gel or condom use in more than half. Inaccuracies are least prevalent in the IDI and most prevalent in the CRF, where participants tend to under-report frequency of sex and gel and condom use. Women reported more sex, gel and condom use than their partners. IDI data on adherence match the applicator-return data more closely than the CRF. The main reasons for inaccuracies are participants forgetting, interviewer error, desirability bias, problems with the definition and delineation of key concepts (e.g. “sex act”). Most inaccuracies were unintentional and could be rectified during data collection.Conclusions/SignificanceThe CRF – the main source of self-report data on behaviour and adherence in many studies – was the least accurate with regard to measuring sexual behaviour, gel and condom use. This has important implications for the use of structured questionnaires for the collection of data on sexual behaviour and adherence. Integrating in-depth interviews and triangulation into clinical trials could increase the richness and accuracy of behavioural and adherence data.

Objectives To assess the efficacy and cost effectiveness of a home safety programme and a home exercise programme to reduce falls and injuries in older people with low vision.Design Randomised...

More than 1,000 randomized controlled trials have been published examining the effectiveness of stroke rehabilitation interventions. The objective of this study was to explore the use and non-use of evidence-based stroke rehabilitation interventions in clinical practice among Occupational Therapists across various stroke rehabilitation settings in Canada. Participants were recruited from medical centres providing rehabilitation to stroke patients in each of the ten provinces across Canada (January-July 2021). Adult (18 + years) Occupational Therapists who provide direct rehabilitative care to individuals after a stroke completed a survey in either English or French. Therapists rated their awareness, use, and reasons for non-use of stroke rehabilitation interventions. 127 therapists (female = 89.8%), largely from Ontario or Quebec (62.2%) were included; most worked full-time (80.3%) in moderate-large (86.1%) cities. The greatest use of interventions were those applied to the body peripherally, without a technological component. Few individuals were aware of interventions applied to the brain (priming or stimulating) with a technological component, and they were rarely, if ever, used. Significant efforts should be made to increase the awareness of interventions which are supported by strong evidence through knowledge translation and implementation initiatives, particularly for those with a technological component.

Indigenous populations globally have significantly high rates of type 2 diabetes compared to their non-Indigenous counterparts. This study aims to implement and evaluate the effectiveness of a culturally and contextually informed Aboriginal Diabetes Workforce Training Program on Aboriginal primary health care workforce knowledge, attitude, confidence, skill and practice relating to diabetes care. A Cluster Randomised Crossover Control Trial with two arms (Group A and Group B) will be conducted with Aboriginal primary health care services in South Australia. These services primarily provide primary health care to Aboriginal and Torres Strait Islander people. All healthcare service sites will be randomised into groups A and B to receive the training program. The training program consists of three components: 1) Peer support network, 2) E-Learning modules and 3) onsite support. Aboriginal Health Workers of participating sites will be invited to participate in the monthly online peer support network and all chronic disease staff are eligible to participate in the E-Learning modules and onsite support. The Peer Support Network runs for the entirety of the study, 17 months. Training components 2 and 3 occur simultaneously and are 2.5 months in length, with a six-month washout period between the two randomised groups undertaking the training. All primary outcomes of the study relate to diabetes management in a primary health care settings and measure participants' knowledge, attitude, confidence, practice and skills. These will be collected at seven time points across the entire study. Secondary outcomes measure satisfaction of the peer support network using a survey, interviews to understand enablers and barriers to participation, health service systems characteristics through focus groups, and medical record review to ascertain diabetes patients' care received and their clinical outcomes up to 12 months post training intervention. The findings will explore the effectiveness of the training program on Aboriginal primary health care provider knowledge, attitude, confidence, skill and practice relating to diabetes care. The final findings will be published in 2027. The study was prospectively registered in The Australian New Zealand Clinical Trials Registry (ANZCTR), with registration number ACTRN12623000749606 at ANZCTR - Registration. Universal Trial Number (UTN) U1111-1283-5257.

The mean peak oxygen consumption level (VO2 peak) in chronically disabled stroke survivors is approximately half that of age-matched individuals, compromising capacity to perform activities of daily living (ADLs). We and others have previously reported modest improvements in this outcome after moderate intensity exercise training (60-70% of Heart Rate Reserve, HRR). Relative change in VO2 peak has averaged 13 ± 5% (mean ± SD) in the stroke studies conducted to date (n=10). PURPOSE: We sought to determine whether stroke survivors could tolerate a more aggressive treadmill training stimulus aimed at greater adaptation in VO2 peak. METHODS: Stroke participants with residual gait deficits were randomized to either higher intensity, shorter duration treadmill training (HI-TM) or a lower intensity, longer duration regimen (LO-TM). HI-TM progressed to 80% HRR but was capped at 30 minutes duration per session. LO-TM was limited to 50% HRR but progressed to 50 minutes each session. Both groups trained 3×/ week for 6 months. Peak aerobic capacity was assessed using open circuit spirometry (COSMED, Quark B2, Chicago, IL) before and after the training interventions. Participants underwent a constant velocity, progressively graded treadmill exercise test to volitional fatigue (peak effort). RESULTS: There was not a significant difference in VO2 peak between HI-TM (n=15) and LO-TM (n=9) at baseline (15.3 ± 7 vs. 15.9 ± 4 mls/kg/min, mean ± SD). Across the training intervention, HI-TM improved VO2 peak by 37% (15.3 ± 7 to 20.9 ± 8 mls/kg/min) compared to a negative 3% change in LO-TM (15.9 ± 4 to 15.4 ± 3 mls/kg/min). Between group differences resulted in a significant time by group interaction (p<0.01) by repeated measures ANOVA. Importantly, gains in VO2 peak during HI-TM were more than double those previously reported. Further, the gain in HI-TM moved the V02 peak exhaustion level above the range of oxygen consumption required for ADLs. Prior work suggests that this level of increase can prospectively predict lower non-fatal and fatal cardiac events in non-stroke populations. CONCLUSIONS: Disabled stroke survivors can successfully exercise train at levels requisite for much larger gains in VO2 peak than previously reported. Gains of this magnitude have clinical significance for stroke survivors in the chronic phase of recovery.

The work of occupational therapists (OTs) in municipal healthcare has become more consultative in recent years. The aim of this study is to explore the content of the OTs' consultative role in everyday activities in municipal healthcare. The study is based on data consisting of diary notes with additional reflections made by 23 OTs during three days. The data were subjected to content analysis. OTs are contacted via referrals (telephone calls or personal communication) to arrange consultations with patients, relatives, assistant staff, and colleagues. The OTs' consultative work consists of discussion, negotiation, information, or instruction, in relation to the advice and recommendations given. They also provide supervision and support to patients, relatives, and assistant staff. The advice and recommendations are evaluated. Thus, OTs' counselling consists of more than assessments and advice, as it also includes information, instruction, supervision, support, and evaluation. Further investigations are necessary in order to understand the competence that is needed and used in the consultative role of OTs in municipal healthcare. An implication for practice is that the healthcare managers need to support the OTs' possibility to provide supervision and support, especially in relation to assistant staff as they are responsible for everyday rehabilitation.

BackgroundRegardless of geography or income, effective help for depression and anxiety only reaches a small proportion of those who might benefit from it. The scale of the problem suggests a role for effective, safe, anonymized public health–driven Web-based services such as Big White Wall (BWW), which offer immediate peer support at low cost.ObjectiveUsing Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) methodology, the aim of this study was to determine the population reach, effectiveness, cost-effectiveness, and barriers and drivers to implementation of BWW compared with Web-based information compiled by UK’s National Health Service (NHS, NHS Choices Moodzone) in people with probable mild to moderate depression and anxiety disorder.MethodsA pragmatic, parallel-group, single-blind randomized controlled trial (RCT) is being conducted using a fully automated trial website in which eligible participants are randomized to receive either 6 months access to BWW or signposted to the NHS Moodzone site. The recruitment of 2200 people to the study will be facilitated by a public health engagement campaign involving general marketing and social media, primary care clinical champions, health care staff, large employers, and third sector groups. People will refer themselves to the study and will be eligible if they are older than 16 years, have probable mild to moderate depression or anxiety disorders, and have access to the Internet.ResultsThe primary outcome will be the Warwick-Edinburgh Mental Well-Being Scale at 6 weeks. We will also explore the reach, maintenance, cost-effectiveness, and barriers and drivers to implementation and possible mechanisms of actions using a range of qualitative and quantitative methods.ConclusionsThis will be the first fully digital trial of a direct to public online peer support program for common mental disorders. The potential advantages of adding this to current NHS mental health services and the challenges of designing a public health campaign and RCT of two digital interventions using a fully automated digital enrollment and data collection process are considered for people with depression and anxiety.Trial RegistrationInternational Standard Randomized Controlled Trial Number (ISRCTN): 12673428; http://www.controlled-trials.com/ISRCTN12673428/12673428 (Archived by WebCite at http://www.webcitation.org/6uw6ZJk5a)

A remote (telephone and tool kit) chronic pain program was studied using the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework. This 6-week pilot took place in underserved communities in Cleveland, Ohio. We determined reach by the diversity of the population, nearly 50% Black and mostly low income. Effectiveness over 7weeks was shown with validated instruments (depression, pain, sleep, quality of life, self-rated health, and self-efficacy). Changes in pain, depression, and self-efficacy were significant. (p < .01). Remote implementation was accomplished by sending participants a box of materials (book, exercise and relaxation CDs, a self-test, and tip sheets). Participants also participated in peer-facilitated, weekly, scripted telephone calls. Maintenance was demonstrated as the study site has offered nine additional programs with more plan. In addition, 60 additional organizations are now offering the program. This proof-of-concept study offers an alternate to in-person chronic pain self-management program delivery.

BackgroundThere is a link between racial bias and poor health outcomes among Black, Indigenous, and People of Color (BIPOC). We aimed to design and evaluate a novel pilot virtual reality (VR) training program to reduce racial bias among healthcare providers in a university healthcare system.MethodsCULTIVATE (Combatting Unequal Treatment in Healthcare Through Virtual Awareness in Empathy) is a mixed-methods study utilizing virtual reality (VR) training to enhance healthcare providers’ empathy towards racially and linguistically discordant patients. Participants included White-identifying clinical providers and graduate-level healthcare students, excluding those not engaged in direct patient care, BIPOC providers, and individuals unable to participate in VR training. Empathy was measured using a situational empathy scale and the Jefferson Empathy Scale (JSE) before and after the intervention, which comprised two VR modules, empathy assessments, and a qualitative interview. Quantitative and qualitative analyses were performed using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework to evaluate the program. The RE-AIM model will structure a framework for understanding virtual reality’s utility in future healthcare practice.ResultsReach: 30 adults participated, mostly women (n = 21), 47% were physicians, and 8% had no prior implicit bias training. Eighteen participants completed pre- and post-VR empathy assessments and interviews. Effectiveness: There was no significant difference in mean JSE scores pre- (120.7) and post-intervention (122.2), but qualitative data indicated increased emotional responses. Adoption: Participants endorsed the intervention with a mean score of 8 (SD = 2) on a 10-point Likert scale for recommending it to others. Implementation: The program followed the pre-designed protocol. Maintenance: Participants reported improved clinical empathy towards BIPOC patients in qualitative analyses.ConclusionsIn this pilot study, participants found VR training to be acceptable and feasible. A larger sample needs to participate in the intervention to determine effectiveness. Qualitative results demonstrated that VR training enhanced empathy.