Sustainable Change Research Articles

How interventions to maintain services during the COVID-19 pandemic strengthened systems for delivery of maternal and child health services: a case-study of Wakiso District, Uganda

ABSTRACT Background Health systems are resilient if they absorb, adapt, and transform in response to shocks. Although absorptive and adaptive capacities have been demonstrated during the COVID-19 response, little has been documented about their transformability and strengthened service delivery systems. We aimed to describe improvements in maternal and child health service delivery as a result of investments during the COVID-19 response. Methods This was a descriptive case study conducted in Wakiso District in central Uganda. It included 21 nurses and midwives as key informants and 32 mothers in three focus group discussions. Data were collected using an interview guide following the Systems Engineering Initiative for Patient Safety theoretical framework for service delivery. Results Maternal and child health service delivery during the pandemic involved service provision without changes, service delivery with temporary changes and outcomes, and service delivery that resulted into sustained changes and outcomes. Temporary changes included patient schedule adjustments, community service delivery and negative outcomes such as increased workload and stigma against health workers. Sustained changes that strengthened service delivery included new infrastructure and supplies such as ambulances and equipment, new roles involving infection prevention and control, increased role of community health workers and outcomes such as improved workplace safety and teamwork. Conclusions In spite of the negative impact the COVID-19 pandemic had on health systems, it created the impetus to invest in system improvements. Investments such as new facility infrastructure and emergency medical services were leveraged to improve maternal and child health services delivery. The inter-departmental collaboration during the response to the COVID-19 pandemic resulted into an improved intra-hospital environment for other service delivery. However, there is a need to evaluate lessons beyond health facilities and whether these learnings are deliberately integrated into service delivery. Future responses should also address the psychological and physical impacts suffered by health workers to maintain service delivery.

Demanding Change of Colonial Child Protection Systems Through Good Trouble: A Community‑Based Commentary of Resistance and Advocacy

Aboriginal and Torres Strait Islander communities, led particularly by Grandmothers and Aunties, have persistently challenged statutory child protection systems and the harms they inflict on our children, families, and communities. Reflecting on our own experiences advocating for Aboriginal families and communities at the practice and systems level, this paper explores a reflective commentary approach concerning opportunities and challenges of community-based advocacy toward substantive sustained change. We note how the voices, experiences, and expertise of Aboriginal and Torres Strait Islander people continue to be marginalised or ignored by non-Indigenous authorities, colonial systems, and practice. Despite the apologies and promises of successive governments, contemporary systems continue to reflect “past” approaches. In this context, we honour the strong women who have, and continue, to stand up for their children, families, and communities, further rallying for ongoing resistance and reform.

Advanced Manufacturing for Sustainable Fashion. Developing Interdisciplinary Educational Experiences

As a creative industry with high cultural, social, and environmental impacts, Fashion is crucially demanding a paradigmatic shift through digital transformation toward a positive, sustainable change. Therefore, fashion education needs to nurture professionals able to tackle increasingly complex challenges, delving into technological systems and aiming at meaningful environmental, economic, cultural, and societal transformations. New learning paths, approaches, and tools should prepare future fashion designers with a hybrid set of skills placed halfway between design, technology, science, and arts. This paper presents the lessons learned from the Advanced Manufacturing for Sustainable Fashion (ASMF) module conducted at Politecnico di Milano (Design School) in the course Design for the Fashion System. While exploring digital fabrication and smart wearable technologies, students delve into prototyping activities aiming at reflecting on sustainability and fashion design practices’ impacts. The paper describes the used learning tools and approaches and reports on instructional and pedagogical learning outcomes, problems, and future implementation of interdisciplinary educational experiences toward a systemic design paradigm.

Changes in pupil size track self-control failure.

People are more likely to perform poorly on a self-control task following a previous task requiring self-control (ego-depletion), but the mechanism for this effect remains unclear. We used pupillometry to test the role of attentional effort in ego-depletion. We hypothesized that an elevated pupil diameter (PD)-a common physiological measure of effort-during an initial task requiring self-control should be negatively associated with performance on a subsequent control task. To test this hypothesis, participants were first assigned to either a high- or low-demand attention task (manipulation; a standard ego-depletion paradigm), after which all participants completed the same Stroop task. We then separately extracted both sustained (low-frequency) and phasic (high-frequency) changes in PD from both tasks to evaluate possible associations with lapses of cognitive control on the Stroop task. We first show that in the initial task, sustained PD was larger among participants who were assigned to the demanding attention condition. Furthermore, ego-depletion effects were serially mediated by PD: an elevated PD response emerged rapidly among the experimental group during the manipulation, persisted as an elevated baseline response during the Stroop task, and predicted worse accuracy on incongruent trials, revealing a potential indirect pathway to ego-depletion via sustained attention. Secondary analyses revealed another, independent and direct pathway via high levels of transient attentional control: participants who exhibited large phasic responses during the manipulation tended to perform worse on the subsequent Stroop task. We conclude by exploring the neuroscientific implications of these results within the context of current theories of self-control.

The Work Environment of the School Leader in Australia: The Case for Sustained Change in Role and Practice

The questions addressed in this essay are (1) how has the work environment of school leaders changed in the early years of the 21st century, (2) how have these changes affected the role of the school leader, (3) what is the association between an evident deterioration in the work environment and the trend to more autonomy for schools and their leaders, and (4) how can school systems be more effective in supporting school leaders? The essay is organised into three domains that emerged from a review of the literature on changes in the work environment: intensification–intimidation, autonomy–accountability and system–support. Six recommendations are derived from the evidence: principals should have greater control over their work environment, system leaders should remove many reporting requirements from schools, there should be “organised abandonment” of outdated practices, the potential benefits of AI should be realised, there should be more engagement in planning for the future, and there should be further research on processes and outcomes through randomised controlled trials of new practices. It is not so much new theories in leadership but rather new roles and new practices within different arrangements for governance, informed by ongoing research as the context changes, amid evidence of deterioration in professional wellbeing.

Potential impacts of climate change on renewable energy in Egypt

The need for renewable energy sources is recently necessitated by attaining sustainability and climate change mitigation. Accordingly, the use of renewable energy sources has been growing rapidly during the last two decades. Yet, the potentials of renewable energy sources are generally influenced by several climatic factors that either determine the source of energy such as wind speed in the case of wind power or affect the performance of system such as the reduction in solar PV power production due to temperature increase. This highlights the need for assessing climate change impacts on renewable energy sources in the future to ensure their reliability and sustainability.This paper is intended to assess impacts of climate change on wind and solar potential energy in Egypt by the year 2065 under RCP 8.5 scenario. For this purpose, a GIS-based methodology of three main steps was applied. The results revealed that solar energy potential in Egypt is expected to be relatively less vulnerable to climate change compared to wind energy. In this respect, it was found that while wind energy potential was estimated to range ± 12%. By the year 2065 under RCP 8.5 scenario, PV module power is expected to decrease by about 1.3% on average. Such assessment can assist in developing more sustainable and flexible renewable energy policy in Egypt.

How to Optimize Carbon Sinks and Biodiversity in the Conversion of Norway Spruce to Beech Forests in Austria?

Assessments of synergies and trade-offs between climate change mitigation and forest biodiversity conservation have focused on set-aside areas. We evaluated a more comprehensive portfolio of silvicultural management adaptations to climate change and conservation measures exemplary for managed European beech forests. Based on the available literature, we assessed a range of common silvicultural management and conservation measures for their effects on carbon sequestration in forest and wood products and for substituting more carbon-intensive products. We complemented this review with carbon sequestration simulations for a typical mountainous beech forest region in Austria. We propose three priority actions to enhance the synergies between climate change mitigation and biodiversity. First, actively increase the proportion of European beech in secondary Norway spruce forests, even though beech will not be unaffected by expected water supply limitations. Secondly, optimize the benefits of shelterwood systems and promote uneven-aged forestry, and thirdly, enhance mixed tree species. Targeted conservation measures (deadwood, habitat trees, and old forest patches) increase the total C storage but decrease the annual C sequestration in forests, particularly in wood products. The establishment of a beech wood market with an extended product portfolio to reduce the use of fuelwood is essential for sustainable climate change mitigation. Since there are limitations in the production of saw timber quality beech wood on low fertility sites, C accumulation, and biodiversity can be emphasized in these areas.

Exploring Patients' and Chaplains' Perspectives About a Spiritual Care Program in the Primary Care Setting.

Spirituality is an important component of social and cultural identity that influences health-related beliefs, decision-making, and coping behaviors. Despite the importance of addressing spirituality in healthcare, research about its impact is limited, especially in the primary care setting. This study aimed to explore patients' and chaplains' experiences of receiving or providing spiritual care in the primary care setting. We conducted an in-depth interview qualitative research study. Participants included patient informants, a chaplain, and chaplains-in-training who participated in a spiritual care program at a primary care clinic. Interviews were transcribed and coded. Conventional qualitative research content analysis was performed. Eleven interviews were conducted - 7 with patient informants, 1 with a chaplain, and 3 with chaplains-in-training. Informants reported that in their experience spiritual care increased trust in their provider, made them feel safe to ask or share anything, improved their satisfaction with care, helped sustain healthy behavior change, and improved coping with chronic illness. Participants specifically attributed these positive experiences to chaplains' ability to respect and attend to patients' spirituality, create a safe space, help patients see the connection between their spirituality and health, and help patients tap into their own spirituality as a healthy means of coping. Spiritual care, when integrated into the primary care setting, has the potential, according to the report of our informants, to help achieve important health-related objectives, such as increased trust in their providers, sustained healthy behavior change, and happiness in spite of chronic illness. Now, more than ever, when our society is hurting from mistrust of our profession secondary to disinformation and discrimination, spiritual care has an important role to play in our efforts to gain our patients' trust so that we can support their healing.

Impact of climate change on the future distribution of three Ferulago species in Iran using the MaxEnt model.

The decline of habitats supporting medicinal plants is a consequence of climate change and human activities. In the Middle East, Ferulago angulata, Ferulago carduchorum, and Ferulago phialocarpa are widely recognized for their culinary, medicinal, and economic value. Therefore, this study models these Ferulago species in Iran using the MaxEnt model under two representative concentration pathways (RCP4.5 and RCP8.5) for 2050 and 2070. The objective was to identify the most important bioclimatic (n = 6), edaphic (n = 4), and topographic (n = 3) variables influencing their distribution and predict changes under various climate scenarios. Findings reveal slope percentage as the most significant variable for F. angulata and F. carduchorum, while solar radiation was the primary variable for F. phialocarpa. MaxEnt modeling demonstrated good to excellent performance, as indicated by all the area under the curve values exceeding 0.85. Projections suggest negative area changes for F. angulata and F. carduchorum (i.e., predictions under RCP4.5 for 2050 and 2070 indicate -34.0% and -37.8% for F. phialocarpa, and -0.3% and -6.2% for F. carduchorum; additionally, predictions under RCP 8.5 for 2050 and 2070 show -39.0% and -52.2% for F. phialocarpa, and -1.33% and -9.8% for F. carduchorum), while for F. phialocarpa, a potential habitat increase (i.e., predictions under RCP4.5 for 2050 and 2070 are 23.4% and 11.2%, and under RCP 8.5 for 2050 and 2070 are 64.4% and 42.1%) is anticipated. These insights guide adaptive management strategies, emphasizing conservation and sustainable use amid global climate change. Special attention should be paid to F. angulata and F. carduchorum due to anticipated habitat loss. Integr Environ Assess Manag 2024;20:1046-1059. © 2024 SETAC.

Reflective Engagement With a Digital Physical Activity Intervention Among People Living With and Beyond Breast Cancer: Mixed Methods Study.

People living with and beyond breast cancer can face internal barriers to physical activity (eg, fatigue and pain). Digital interventions that promote psychological acceptance and motivation may help this population navigate these barriers. The degree to which individuals (1) adhere to intervention protocols and (2) reflect on and internalize intervention content may predict intervention efficacy. The objective of this study was to characterize the nature of reflective processes brought about by an 8-week acceptance- and mindfulness-based physical activity intervention for insufficiently active survivors of breast cancer (n=75). Furthermore, we explored the potential utility of a metric of reflective processes for predicting study outcomes. Of the intervention's 8 weekly modules, 7 (88%) included an item that asked participants to reflect on what they found to be most useful. Two coders conducted directed content analysis on participants' written responses. They assessed each comment's depth of reflection using an existing framework (ranging from 0 to 4, with 0=simple description and 4=fundamental change with consideration of social and ethical issues). The coders identified themes within the various levels of reflection. We fit multiple linear regression models to evaluate whether participants' (1) intervention adherence (ie, number of modules completed) and (2) the mean level of the depth of reflection predicted study outcomes. Participants were aged on average 57.2 (SD 11.2) years, mostly non-Hispanic White (58/75, 77%), and mostly overweight or obese (54/75, 72%). Of the 407 responses to the item prompting personal reflection, 70 (17.2%) were rated as reflection level 0 (ie, description), 247 (60.7%) were level 1 (ie, reflective description), 74 (18.2%) were level 2 (ie, dialogic reflection), 14 (3.4%) were level 3 (ie, transformative reflection), and 2 (0.5%) were level 4 (ie, critical reflection). Lower levels of reflection were characterized by the acquisition of knowledge or expressing intentions. Higher levels were characterized by personal insight, commentary on behavior change processes, and a change of perspective. Intervention adherence was associated with increases in self-reported weekly bouts of muscle-strengthening exercise (B=0.26, SE 0.12, 95% CI 0.02-0.50) and decreases in sleep disturbance (B=-1.04, SE 0.50, 95% CI -0.06 to -2.02). The mean level of reflection was associated with increases in psychological acceptance (B=3.42, SE 1.70, 95% CI 0.09-6.75) and motivation for physical activity (ie, integrated regulation: B=0.55, SE 0.25, 95% CI 0.06-1.04). We identified a useful method for understanding the reflective processes that can occur during digital behavior change interventions serving people living with and beyond breast cancer. Intervention adherence and the depth of reflection each predicted changes in study outcomes. Deeper reflection on intervention content was associated with beneficial changes in the determinants of sustained behavior change. More research is needed to investigate the relations among digital behavior change intervention use, psychological processes, and intervention efficacy.

Using a Systems Thinking Approach to Increase Coastal Community Resilience against Environmental Shocks: A Case Study of Valiathura Coastal Area, India

Aim of the studyGlobally, the increasing environmental shocks in coastal zones of tropical regions are crippling human-ecological systems’ interactions that promote sustainable development. The uni-dimensional nature of environmental shocks is increasing the environmental vulnerabilities of coastal people who heavily depend on marine and environmental resources. Current policies on resilience are mainly linear thus negating coastal communities’ ability to develop synergies for adaptation and mitigation.Material and methodsWe used the Iceberg model of systems thinking to identify local system dynamics in relation to vulnerability to environmental shocks and the 3 Horizons framework to qualitatively identify the preferred options that can lead to a preferred future involving avenues for increasing women’s resilience to environmental shocks in coastal areas, using Valiathura in Kerala as a case study.Results and conclusionsWe developed a novel Three Horizon (3H) framework that links current system indicators in Valiathura, which could be used to understand environmental shocks and how to navigate through such shocks. Based on the developed framework, we identified possible pathways in Valiathura that can be used by coastal people and regions in other jurisdictions to promote sustainable change from Horizon 1, and 2 to Horizon 3 such as increasing women’s knowledge of environmental shocks and leveraging the historical strategies used by coastal women to increase resilience against environmental shocks. Therefore, to develop sustainable actions in coastal zones affected by environmental shocks, a focus on understanding the dynamics of the system is key to understanding system interactions and feedback that can inform actions, which promote transformative change, for instance, related to adaptation and mitigation.

Dupilumab Efficacy on Asthma Functional, Inflammatory, and Patient-Reported Outcomes across Different Disease Phenotypes and Severity: A Real-Life Perspective.

Dupilumab is currently approved for the treatment of Type 2 severe asthma and chronic rhinosinusitis with nasal polyps (CRSwNP). Few studies have specifically reported on dupilumab efficacy on asthma outcomes as a primary objective in a real-life setting, in patients with and without CRSwNP. Our study aimed to explore the efficacy of dupilumab on functional, inflammatory, and patient-reported outcomes in asthma patients across different disease phenotypes and severity, including mild-to-moderate asthma coexisting with CRSwNP. Data from 3, 6, and 12 months follow-up were analyzed. Asthma (FEV1%, Tiffeneau%, ACT, FeNO, oral steroid use, exacerbation rate, and blood eosinophilia) and polyposis (SNOT22, VAS, NPS) outcomes showed a rapid (3 months) and sustained (6 and 12 months) significant change from baseline, despite most of the patients achieving oral steroid withdrawal. According to the sensitivity analysis, the improvement was not conditioned by either the presence of polyposis or severity of asthma at baseline. Of note, even in the case of milder asthma forms, a significant further improvement was recorded during dupilumab treatment course. Our report provides short-, medium-, and long-term follow-up data on asthma outcomes across different diseases phenotypes and severity, contributing to the real-world evidence related to dupilumab efficacy on upper and lower airways T2 inflammation.

Personalized Fitness and Diet Planner with Smartwatch Integration

This survey paper explores the intersection of technology and health by delving into the realm of personalized fitness and diet planning, with a focus on seamless integration with smartwatches. The paper reviews existing literature, methodologies, and advancements in the development of innovative solutions that leverage smartwatch capabilities to tailor fitness and dietary recommendations to individual needs. By examining the convergence of data analytics, artificial intelligence, and wearable technology, the survey sheds light on the potential benefits, challenges, and future prospects of adopting a personalized approach to health and wellness. The aim is to provide readers with a comprehensive overview of the current state-of-the-art, fostering a deeper understanding of how the integration of smartwatches into personalized health management systems can contribute to more effective and sustainable lifestyle changes. Key Words: NLU, NLP, SVM, BERT, API, BMI

A Qualitative Exploration of Postoperative Bariatric Patients' Psychosocial Support for Long-Term Weight Loss and Psychological Wellbeing.

There is a paucity of research exploring postoperative psychosocial interventions for bariatric surgery patients exceeding 2 years, and therefore, an interdisciplinary postoperative approach is warranted. This qualitative study explored the psychosocial support that bariatric surgery patients feel they need to sustain long-term weight loss and their psychological wellbeing. Fifteen postoperative patients participated in recorded semi-structured online interviews that were transcribed verbatim and analysed using a reflexive thematic analysis approach. Three themes and six subthemes emerged. Theme 1, Journey to surgery, has two subthemes: Deep roots and Breaking point. Theme 2, The precipice of change, has two sub-themes: Continuity of care and Can't cut the problem out. Theme 3, Bridging the Gap, has two subthemes: Doing it together and Taking back the reigns. The inconsistencies participants experienced in their pre- and postoperative care led to dissonance, and they felt unprepared for the demands of life postoperatively. Bariatric surgery is a catalyst for physical change, but surgery alone is insufficient to ensure sustained change. Surgical and psychosocial interventions are interdependent rather than mutually exclusive. Patients favour an integrative, personalised, stepped-care approach pre- and postoperatively, with active participation fostering autonomy and access to ongoing support extending into the long-term.

Toward a Theory of Organizational DNA: Routines, Principles, and Beliefs (RPBs) for Successful and Sustainable Organizational Change.

Organizational change is a key mechanism to ensure the sustainability of healthcare systems. However, healthcare organizations are persistently difficult to change, and literature is riddled with examples of failed change endeavors. In this chapter, we attempt to unravel the underlying causes for failed organizational change. We distinguish three types of change with different levels of depth that require different change approaches. Transformations are the deepest forms of change where beliefs and principles need to be modified to successfully influence routines. Renewals are deep forms of change where principles need to be modified to successfully influence routines. Improvements are shallow forms of change where only modifications at the level of routines are needed. Using deoxyribonucleic acid (DNA) as our metaphor, we propose a theory of "organizational DNA" to understand organizations and these three types of organizational changes. We posit that organizations are made up of a double helix consisting of a so-called "social string," which contains the "soft" interaction or communication among the organization's members, and a so-called "technical string," which contains "hard" organizational aspects such as structure and technology. Ladders of organizational nucleotides (i.e., Routines, Principles, and Beliefs) connect this double helix in various combinations. Together, the double helix and accompanying nucleotides make up the DNA of an organization. Without knowledge of the architecture of organizational DNA and whether a change addresses beliefs, principles, and/or routines, we believe that organizational change is constrained and based on luck rather than change management expertise. Following this metaphor, we show that organizational change fails when it attempts to change one part of the DNA (e.g., routines) in a way that renders it incompatible with the connecting components (e.g., principles and beliefs). We discuss how the theory can be applied in practice using an exemplar case.

Empowering Environmental Consciousness: Creating High School E-Modules for Sustainable Change

This study aims to develop valid, practical, and effective e-modules in subjects related to environmental change-oriented biology. This study uses the Rowntree development model which consists of three stages, namely: (1) the planning stage; (2) writing preparation; (3) writing and editing stages. In the third stage, the evaluation is carried out by means of a timer evaluation (self-evaluation, expert review, one-to-one, small group and field tests). The subjects of this study were students grade X at a senior high school in Palembang. The data collection methods employed in this study encompassed observation, interviews, walkthroughs, questionnaires, and tests. The average validation score, based on the results of three validators, was 91%, indicating a high level of validity. The practicality test results from the one-to-one evaluation and the small group evaluation yielded a score of 91.3% (very valid) for the one-to-one test and 90.75% for the small group test, placing them in the highly practical category. The effectiveness test yielded an N-gain result of 0.796, indicating a high level of efficacy. Based on the collected results, it can be inferred that the designed E-Module is valid, practical, and effective.

Implementation and mixed-methods evaluation of "Walk with a Doc" program at Stony Brook.

Walking groups run by trained individuals, lasting under an hour in a natural environment, may be a cost-effective way by which to encourage sustainable changes in physical activity as well as foster companionship and a shared experience of wellness among participants. Walk with a Doc (WWaD) is a national program that provides a platform for medical professionals, including physicians and medical students, to deliver a short talk on a health topic prior to walking side by side with patients and community members. To evaluate the WWaD Chapter at Stony Brook following implementation, a questionnaire was designed utilizing a mixed-methods approach (i.e.,containing qualitative and quantitative items) and administered to all attendees monthly prior to the health discussion. The aim of the questionnaire was fourfold: first, to obtain participant demographics; second, to obtain information on attendees' own perceptions of their health status and the role exercise plays in their health; third, to gain data on physical activity levels, including lengths of exercise sessions and types of activities performed; and fourth, to learn more about attendees' motivations and goals for participating in the walks. We received an IRB exemption. Physician and medical student volunteers were recruited from Stony Brook University Hospital, a suburban tertiary care center, to oversee program logistics. WWaD was scheduled to take place on the third Sunday of every month for 1 h at Heritage Park in Mount Sinai, New York. The event was advertised by volunteers to colleagues, peers, patients, and community members utilizing word of mouth, printed flyers, emails to listservs, and social media outlets. Each month, a physician volunteer oversaw a brief discussion (approximately 10 min in length). Over the course of the 5 month evaluation period, 91individuals participated in the walks, including repeat attendees. After excluding duplicate or incomplete entries, data from 30 participants were included in this analysis. The majority of participants were female (n=24) with a mean age of 50 years (range, 23-98 years). Feedback on WWaD program elements was largely positive. Participants commended the monthly speakers for "informative talks" (n=6) on "interesting topics" (n=4), with plans to review the supplemental information in educational pamphlets following the walk (n=4). The brochures were also deemed "helpful." Overwhelmingly, patients referred to the community gathering and team building aspects of WWaD as the "most enjoyable" aspect of the program (n=8) and a key driver for participation. This mixed-methods study of the WWaD chapter at Stony Brook contributes to a growing body of evidence highlighting the value of walking groups as effective avenues for collaboration in producing accessible healthy behavior.

Reducing the environmental impact of inhalers in primary care

Climate change is having a negative effect on our health and on our planet. The NHS has made a commitment to achieve net zero greenhouse gas emissions (GHGE) by 2050 as a way of addressing this. Switching pressurised metered dose inhalers (pMDIs) to dry powder inhalers (DPIs) has the potential to significantly reduce GHGEs. The primary aim of this systematic review was to establish how to make sustainable inhaler changes in primary care that do not compromise patient care and outcomes. pMDI devices have a significantly higher global warming potential than DPIs, but the latter are not suited to everyone. In patients unsuited to DPI devices, changing prescribing habits can help to lower emissions. Returning inhalers to pharmacies for incineration also lowers global warming potential. DPI devices are easier to use and are linked with improved health outcomes. It is possible to lower the carbon footprint of inhalers by switching pMDI to DPI, and through education and changed prescribing habits.

Real-world nudging, pricing, and mobile physical activity coaching was insufficient to improve lifestyle behaviours and cardiometabolic health: the Supreme Nudge parallel cluster-randomised controlled supermarket trial

BackgroundContext-specific interventions may contribute to sustained behaviour change and improved health outcomes. We evaluated the real-world effects of supermarket nudging and pricing strategies and mobile physical activity coaching on diet quality, food-purchasing behaviour, walking behaviour, and cardiometabolic risk markers.MethodsThis parallel cluster-randomised controlled trial included supermarkets in socially disadvantaged neighbourhoods across the Netherlands with regular shoppers aged 30–80 years. Supermarkets were randomised to receive co-created nudging and pricing strategies promoting healthier purchasing (N = 6) or not (N = 6). Nudges targeted 9% of supermarket products and pricing strategies 3%. Subsequently, participants were individually randomised to a control (step counter app) or intervention arm (step counter and mobile coaching app) to promote walking. The primary outcome was the average change in diet quality (low (0) to high (150)) over all follow-up time points measured with a validated 40-item food frequency questionnaire at baseline and 3, 6, and 12 months. Secondary outcomes included healthier food purchasing (loyalty card-derived), daily step count (step counter app), cardiometabolic risk markers (lipid profile and HbA1c via finger prick, and waist circumference via measuring tape), and supermarket customer satisfaction (questionnaire-based: very unsatisfied (1) to very satisfied (7)), evaluated using linear mixed-models. Healthy supermarket sales (an exploratory outcome) were analysed via controlled interrupted time series analyses.ResultsOf 361 participants (162 intervention, 199 control), 73% were female, the average age was 58 (SD 11) years, and 42% were highly educated. Compared to the control arm, the intervention arm showed no statistically significant average changes over time in diet quality (β − 1.1 (95% CI − 3.8 to 1.7)), percentage healthy purchasing (β 0.7 ( − 2.7 to 4.0)), step count (β − 124.0 (− 723.1 to 475.1), or any of the cardiometabolic risk markers. Participants in the intervention arm scored 0.3 points (0.1 to 0.5) higher on customer satisfaction on average over time. Supermarket-level sales were unaffected (β − 0.0 (− 0.0 to 0.0)).ConclusionsCo-created nudging and pricing strategies that predominantly targeted healthy products via nudges were unable to increase healthier food purchases and intake nor improve cardiometabolic health. The mobile coaching intervention did not affect step count. Governmental policy measures are needed to ensure more impactful supermarket modifications that promote healthier purchases.Trial registrationDutch Trial Register ID NL7064, 30 May 2018, https://www.onderzoekmetmensen.nl/en/trial/20990

Handoff Education Interventions: A Scoping Review Focused on Sustaining Improvements.

Handoffs involve the transfer of patient information and responsibility for care between health care professionals. The purpose of the current scoping review was (1) to describe handoff studies with education as part of the intervention and (2) to explore the role of handoff educational interventions in sustaining handoff improvements. This scoping review utilized previously published systematic reviews and a structured, systematic search of 5 databases (January 2006-June 2020). Articles were identified, and data were extracted by pairs of trained, independent reviewers. The search identified 74 relevant articles, most published after 2015 (70%) and conducted in the United States (76%). Almost all of the studies (99%) utilized instruction, 66% utilized skills practice, 89% utilized a memory aid, and 43% utilized reinforcement. However, few studies reported using education theory or followed accepted tenets of curriculum development. There has been a substantial increase over time in reporting actual handoff behavior change (17%-68%) and a smaller but important increase in reporting patient outcomes (11%-18%). Thirty-five percent of studies (26/74) had follow-up for 6 months or more. Twelve studies met the criteria for sustained change, which were follow-up for 6 months or more and achieving statistically significant improvements in either handoff skills/processes or patient outcomes at the conclusion of the study. All 12 studies with sustained change used multi-modal educational interventions, and reinforcement was more likely to be used in these studies than all others (75%, 9/12) versus (37%, 23/62), P = 0.015. Future handoff intervention efforts that include education should use education theory to guide development and include needs assessment and goals and measurable objectives. Educational interventions should be multi-modal and include reinforcement. Future research studies should measure actual handoff behavior change (skills/process) and patient outcomes, include follow-up for more than 6 months, and use education reporting guidelines.