Implementation Fidelity Research Articles

Purpose of the studyReports concerning implementation of competency-based postgraduate medical education (CB-PGME) are mostly from high income countries where programs are nationally regulated. The present study evaluates implementation of CB-PGME as an institutional initiative in a low- middle-income country (LMIC) where it is not yet a formal accreditation requirement.Study designAn exploratory descriptive qualitative study in mid-2023, eighteen months after initiating transition, used focus group discussions to elicit and analyze program directors’ perceptions of the fidelity of CB-PGME implementation in five selected residency programs of the Aga Khan University (AKU) in Pakistan. Research trustworthiness criteria were duly addressed.ResultsThree themes emerged as relevant: understanding of and commitment to workplace-based assessment; integration of learning with clinical work; and alignment of institutional policies for effective governance. Early gains included drawing stakeholders’ attention to CB-PGME; effecting changes in curriculum and assessment; reinforcing the importance of the clinical learning environment; and providing governance at program and institution levels. Simultaneously, deficiencies were observed in faculty’s constructive feedback and timely documentation following workplace-based assessment (WPBA); holistic assessment of residents’ competencies; residents’ understanding of WPBA intent; administration of WPBAs in busy or extended service locations; longitudinal continuity of clinical postings; empowerment of program directors; and alignment of institutional policies.ConclusionThe deficiencies encountered during early implementation of CB-PGME at AKU were like those faced elsewhere and potentially reversible through institutional effort. So, it would be safe to assume that institutional initiatives to implement CB-PGME are feasible in LMIC, while awaiting formal national accreditation.

This study compared teacher’s preferences and implementation outcomes for two versions of a supplemental read-aloud curriculum that provides young children with vocabulary instruction and guides for teachers to ask open-ended questions and scaffold conversations. One curriculum was fully scripted and the other trained teachers to make structured adaptations. Kindergarten and Grade 1 teachers ( n = 54) were randomly assigned to the Scripted or Adaptive condition. Teacher exit interviews indicated 87.76% preferred the more efficient “softly scripted” version over the adaptive version that required time for teachers to plan modifications. Teachers in both conditions perceived similar and positive implementation outcomes in terms of appropriateness, feasibility, acceptability, and usability. For fidelity, we observed no group differences for adherence or dosage. Teachers’ baseline knowledge and skills for supporting language comprehension related to fidelity of implementation and their perceived appropriateness. These findings suggest that teachers with stronger initial competencies are better positioned to deliver curricular innovations.

ABSTRACTBackground and AimsHome‐based high‐intensity interval training (HIIT) could be feasible and useful for people with Parkinson's (PwP). However, no home‐based HIIT program for PwP has been undertaken. This trial was designed to obtain preliminary data regarding the feasibility, acceptability and safety of HIIT‐Home4Parkinson's (HH4P), a previously co‐created home‐based HIIT program for PwP, explore outcomes that may be sensitive to change, and inform the implementation of a potential full trial.MethodsA randomized, controlled feasibility trial was undertaken. Thirteen independently mobile PwP of Hoehn and Yahr stages 1–3 were randomized to the 12‐week, three times weekly HH4P HIIT program (n = 7), or usual care (n = 6). Feasibility and safety outcomes included aspects such as program completion, adherence, exercise intensity and adverse effects and events. Potential primary outcomes for a full trial were serum brain‐derived neurotrophic factor, maximal oxygen uptake and the Unified Parkinson's Disease Rating Scale part III. Process evaluation with a qualitative aspect explored implementation fidelity and participant thoughts and feelings.ResultsSix HIIT participants completed the program, with one withdrawing due to an unrelated back injury. Mean exercise adherence was 78.4%, while the mean exercise intensity was 77.2% HRmax per session, with three participants not achieving mean 75% HRmax. HIIT related adverse effects were minor and temporary, and the majority of exercise program and delivery procedures were deemed feasible and acceptable by participants. When compared to controls, the HIIT group did not experience benefits in any of the potential primary outcomes.ConclusionPreliminary data suggests that home‐based HIIT could be feasible, safe and acceptable for some PwP, although the capacity to stimulate the required exercise intensity, along with the potential benefits remain uncertain. Progression to a full HH4P trial cannot be recommended until further evaluation of aspects such as exercise type and model of support is undertaken.Trial RegistrationClinicalTrials.gov NCT05485428.

While group, task-oriented, community-based exercise programs (CBEPs) delivered in-person can increase exercise and social participation in people with mobility limitations, challenges with transportation, cost and human resources, threaten sustainability. A virtual delivery model may help overcome challenges with accessing and delivering in-person CBEPs. The study objective is to estimate the short-term effect of an 8-week, virtual, group, task-oriented CBEP called TIME™ (Together in Movement and Exercise) at Home compared with a waitlist control on improving everyday function in community-dwelling adults with mobility limitations. A randomised controlled trial incorporating a type 1 effectiveness-implementation hybrid design is being conducted in four Canadian metropolitan centres. We aim to stratify 200 adults with self-reported mobility limitations by site, participation alone or with a partner, and functional mobility level, and randomise them using REDCap software to either TIME™ at Home or a waitlist control group. During TIME™ at Home classes (2 classes/week, 1.5 hours/class), two trained facilitators stream a 1-hour exercise video and facilitate social interaction prevideo and postvideo using Zoom. A registered healthcare professional at each site completes three e-visits to monitor and support implementation. Masked evaluators with physical therapy training evaluate participants and their caregivers at 0, 2 and 5 months using Zoom. The primary outcome is the change in everyday function from 0 to 2 months, measured using the physical scale of the Subjective Index of Physical and Social Outcome. The study is powered to detect an effect size of 0.4, given α=0.05, power=80% and a 15% attrition rate. Secondary outcomes are mobility, well-being, reliance on walking aids, caregiver assistance, caregiver mood, caregiver confidence in care-recipient balance and cost-effectiveness. A multimethod process evaluation is proposed to increase understanding of implementation fidelity, mechanisms of effect and contextual factors influencing the complex intervention. Qualitative data collection immediately postintervention involves interviewing approximately 16 participants and 4 caregivers from the experimental group, and 8 participants and 4 caregivers from the waitlist control group, and all healthcare professionals, and conducting focus groups with all facilitators to explore experiences during the intervention period. A directed content analysis will be undertaken to help explain the quantitative results. TIME™ at Home has received ethics approval at all sites. Participants provide verbal informed consent. A data safety monitoring board is monitoring adverse events. We will disseminate findings through lay summaries, conference presentations, reports and journal articles. NCT06245135.

This study examined the effectiveness of AI-based educational technology through a case study of JindanMath, an AI-driven tool designed to support personalized mathematics instruction. JindanMath incorporated features such as real-time feedback, personalized learning pathways, and error note recommendations, aimed at enhancing teaching practices and student engagement. The study employed the Fidelity of Implementation (FOI) framework and a logic model to assess how the tool’s design and implementation influenced classroom outcomes, as opposed to using a traditional group comparison design. Data collection included teacher interviews, student usage logs, and a Delphi survey to evaluate key aspects of pedagogical effectiveness. The findings revealed that JindanMath significantly improved teacher efficiency through automated task manage- ment, personalized feedback, and student performance monitoring. Teachers benefited from streamlined grading, which al- lowed more time for instructional planning and student engagement activities. The tool also enhanced student learning by fos- tering autonomy and personalized learning experiences. However, sustaining long-term student participation posed a challenge, as some students showed decreased engagement over time. This finding underscored the importance of ongoing motivation and adaptive instructional strategies tailored to diverse learner needs. The study concluded that AI-based tools like JindanMath could have a profound impact when aligned with clear instructional goals and continuously optimized based on classroom contexts. By offering empirical evidence, this research informed educators and developers of effective practices for evaluating the impact of AI-based tools in educational settings.

Introduction: Virtual learning environments (VLEs) have become central to English language teaching (ELT), although persistent disengagement suggests that design must go beyond content delivery. Gamification and personalised learning (PL) contribute to enhanced user experience (UX) and better learning outcomes, but evidence on their combined effects remains fragmented. Purpose: This systematic literature review (SLR) explains how gamification and PL influence UX, motivation, engagement and achievement in ELT-oriented VLEs, identifies effective design practices, and maps the implementation challenges that constrain them. Method: Following PRISMA-2020 guidelines, 46 empirical studies (2015-2024) were retrieved from Scopus, Web of Science, ERIC, and Dialnet. Two extraction matrices captured bibliographic, contextual and analytical data; methodological quality was appraised with MMAT-2018. Comparative and narrative syntheses linked design features to four outcome clusters: motivation/engagement, UX, academic performance, and learner satisfaction. Results: Challenge-based game mechanics, points and rewards reliably increased motivation and engagement, especially when integrated with adaptive feedback. PL strategies (adaptive difficulty, learner-directed paths and tailored content) produced the strongest dual gains in satisfaction and achievement. High UX emerged only when interfaces minimised cognitive load and feedback was timely. Gaps persist between short-term motivational spikes and durable learning, and competitive elements induce anxiety in novices. Key obstacles include limited digital literacy, bandwidth constraints and sparse reporting on implementation fidelity. Conclusion: Gamification and PL can substantially enhance UX and selected learning outcomes in ELT-oriented VLEs, but only when designs align with curricular goals, resource realities and learner profiles. Future research should pursue longer mixed-method trials, transparent adaptivity and scalable models for low-resource contexts.

The integration of Social Emotional Learning (SEL) principles across various school curricula contributes to the continuous process of enhancing learning through creating a caring and positive learning climate that foregrounds learners’ emotional well-being and emphasizes both academic growth and fundamental life skills. However, relatively few studies have been conducted to explore its impact on middle level students’ performance and its influence on the specific domain of FL/SL learning. The current quasi-experimental study investigates the influence of Strong Kids Curriculum on two of the core competencies of 21 Algerian middle school English as a Foreign Language (EFL) students, precisely optimistic thinking and relationship skills. The results indicate a major improvement in both competencies, with a highly notable difference between pre- and post-intervention values. Additionally, the research indicated major improvement in students’ social emotional knowledge as well as a high degree of the curriculum implementation fidelity. Most students perceived Strong Kids curriculum as socially valid. The findings offer informative data, which may assist EFL middle school teachers in Algeria to create a positive learning climate that nurtures the personal and academic development of their students in the future.

Purpose: The purpose of the article is to establish the influence of result-based monitoring on the performance of housing projects in Nairobi. Projects, including construction, aim to meet diverse stakeholder needs and are evaluated based on quality, time, and cost. The Project Management Institute (PMI) asserts that successful projects must be completed within budget, on schedule, and to the desired quality. Globally, many struggle to meet these benchmarks. Benchmarking evaluation approaches significantly influence housing project performance, yet their absence often leads to inefficiencies, cost overruns, delays, and quality issues. This study assessed the impact of benchmarking on housing projects in Nairobi, guided by Construction Management Theory. Methodology: A descriptive research design was used, targeting 127 projects by 15 real estate developers between 2019–2024. Data were collected from 254 registered architects using structured questionnaires and analyzed using SPSS to generate descriptive and inferential statistics. Findings: The findings underscore the widespread adoption and favorable perception of Result-Based Monitoring (RBM) as a project management approach in housing developments. The majority of respondents affirmed the use of RBM practices. The empirical evidence from the study aligns with international and regional findings on the positive relationship between RBM and housing project performance. While high levels of adoption and satisfaction prevail, the responses also highlight areas where targeted improvements in implementation fidelity, tool functionality, and feedback application could further enhance the impact of RBM systems. Unique Contribution to Theory, Policy and Practice: The study recommends the institutionalization of standardized RBM protocols across all housing projects. To address technical challenges, it is also recommended that organizations invest in modern monitoring tools and digital systems capable of real-time data tracking, analytics, and feedback generation. The unique contribution of the study is that Feedback loops should be institutionalized, with clear mechanisms for translating monitoring insights into actionable strategic decisions.

ABSTRACTEnvironmental sustainability innovations are essential because they have the potential to generate valuable change and address pressing environmental issues. However, not all innovations result in the development of new technologies, processes, and practices that improve environmental sustainability and efficiency. The diffusion of innovations theory emphasizes the role of perceived benefits and compatibility with existing practices in determining adoption rates. Furthermore, the theory has been applied to better understand the role of mediators in implementing sectoral innovations, as well as the factors that influence the acceptance of innovative practices inside businesses. Thus, this study focuses on the impact of innovative environmental sustainability practices on organizational performance via green supply, as well as the direct consequences of innovation on environmental carbon emissions in the textile industry. To measure these linkages, route analysis was performed on multisource data obtained from senior managers of 203 textile manufacturers using structural equation modeling. The findings suggest that innovations adapt to the perceived necessity of outcomes. In other words, whereas sustainability‐focused technologies do not directly reduce carbon emissions, green supply adapts them to improve organizational performance. This study significantly enhances literature by identifying critical gaps in sustainable supply chain innovation (SSCI) empirical evidence. Findings demonstrate the necessity of implementation fidelity for effective SSCI, providing practical strategies for firms to optimize sustainability outcomes.

Pilot optimization trial of a sexual and reproductive health program for Latina teens and their female caregivers: A study protocol

To explore how teachers’ beliefs and behaviour change throughout implementation processes, N = 47 teachers participated in a 6-month professional development (PD) programme, and then implemented a differentiated reading innovation over one school year (totalling 15 months). Teachers’ beliefs (acceptability, feasibility, self-efficacy) and behaviour (fidelity, innovation use, adaptivity) were assessed after PD (T2), after 3 (T3), 6 (T4), and 9 months (T5) of implementation. Multilevel models displayed that acceptability and feasibility remained stable over time. Teachers’ self-efficacy and adaptivity increased significantly, while innovation use and implementation fidelity decreased. Cluster analyses based on teachers’ individual and school-level pre-conditions at T1 revealed one cluster with moderate and one cluster with optimal pre-conditions. The two clusters showed a parallel development with clear level differences, but teachers with moderate pre-conditions showed a steeper decline in fidelity after 9 months. Results emphasise that teacher change is a dynamic process that should be tailored to underlying conditions.

This design-based research study examined the implementation fidelity and effectiveness of the SIMPLE Approach, a constructivist intervention integrating the bar model method with metacognitive scaffolding to enhance word problem-solving skills in Kosovo’s lower secondary classrooms. The study aims to address the research gap in that intervention studies in design-based research recognise the critical role of teachers but provide little insight into their actual work and the fidelity of their implementation. To address this research gap, the study investigated (1) alignment of the teachers’ implementation of the SIMPLE Approach and (2) teachers' and pupils' perceptions. Data from classroom observations, teacher diaries, and interviews revealed varying fidelity levels, improving over time. Teacher 1 showed the lowest fidelity, struggling with the bar model method and limiting group work, while Teacher 3 demonstrated the highest fidelity, effectively incorporating all aspects of the SIMPLE Approach and promoting active pupil engagement. Pupils reported initial difficulty with the bar model but ultimately expressed positive perceptions and a desire for continued use. While generalisability is limited, the findings suggest the SIMPLE Approach holds promise but highlights the need for comprehensive teacher training and ongoing support, particularly when introducing novel methods to ensure effective implementation and high fidelity.

This article presents a descriptive quantitative study examining the application of the Montessori method to the development of autonomy and self-regulation in children in early education (3–5 years) and preparatory/kindergarten (5–6/7 years). The proposal is grounded in empirical evidence linking Montessori pedagogy to improvements in academic, cognitive, and socioemotional outcomes, as well as to self-regulation trajectories during early childhood. The design entails purposive sampling of Montessori and non-Montessori centers; administration of validated instruments—including the Head-Toes-Knees-Shoulders (HTKS/HTKS-R) and an observational protocol focused on Practical Life—and descriptive analyses of indicators of functional autonomy, behavioral self-regulation, and independent work habits. The study aims to describe levels and profiles of autonomy/self-regulation by sublevel, sex, and school type, and to compare implementation fidelity of the prepared environment with self-regulation levels. Implications are discussed for teacher education and for preschool policies oriented toward holistic development and educational justice.

Few studies have analyzed the effectiveness of online music professional development (OMPD) on teachers’ pedagogical competencies. We evaluated the effectiveness of an OMPD designed to train kindergarten teachers in a music-and-movement intervention, drawing on the notion of implementation fidelity (i.e., level of accuracy with which an intervention is delivered). In addition, we investigated teachers’ perspectives on the factors that facilitated their learning. After 83 teachers from seven kindergartens took the OMPD, all Kindergarten 2 teachers ( N = 9) were observed implementing the intervention. In this mixed-methods study, we used implementation fidelity checklists completed by teachers and external observers and individual teacher interviews. Findings revealed consistently high implementation fidelity ratings by both teachers and external observers. School support, practice, preparation, sufficient time and space, and reflection were the facilitative factors identified in the interviews. The study highlights the potential of OMPD in fostering the music-specific pedagogical competencies of general classroom teachers.

The Jigsaw cooperative learning strategy, a peer-teaching method, has been widely studied for its role in enhancing academic achievement and social skills across various educational levels. This meta-analytic review synthesizes findings from peer-reviewed studies published between 2000 and 2024, examining the magnitude and consistency of the Jigsaw strategy’s effects on student achievement and social skills. Results indicate a moderate to large positive effect on academic outcomes (Cohen’s d = 0.65) and social skills development (d = 0.59), with variations influenced by educational level, subject area, and cultural context. This review also identifies research gaps including inconsistent implementation fidelity and limited longitudinal studies. Keywords: Jigsaw strategy, cooperative learning, meta-analysis, student achievement, social skills, education levels

Professional development (PD) to help teachers learn to use curriculum materials can be effective in aiding fidelity of implementation and supporting student learning. PD may be particularly necessary for curricula focused on students' ethnic-racial identities, given educators' potential discomfort and limited formal training focused on strategies for discussing race/ethnicity in class. The Equipping Educators for Equity through Ethnic-Racial Identity (E⁴) PD prepares educators to implement an eight-lesson ethnic-racial identity curriculum with high school students. We tested whether fidelity of implementation of the ethnic-racial identity curriculum varied by two training modalities: in-person versus remote. Teachers' (N = 14) fidelity of implementation across 55 classrooms was assessed via 440 observations. Teachers' fidelity regarding curriculum adherence was high (76%) and did not vary significantly by training modality. Remote and in-person training resulted in similar fidelity of implementation, suggesting remote trainings may enable scaling up without sacrificing impact.

Abstract Background & Objective: International guidelines vary in recommendations on the starting age for mammography screening for women at average breast cancer risk; however, all note the importance of shared-decision making (SDM) from age 40 and older. Decision Aids (DAs) are evidence-based materials demonstrated to facilitate SDM and improve decisional conflict. The integration of SDM/DA into routine clinical practice is crucial to support patient-informed choice; however, little is known related to the implementation of SDM and/or DA into the clinical setting. Methods: This scoping review was conducted according to JBI guidelines and reported using PRISMA-ScR. [RF1] Nine bibliographic databases were searched from January 2010 to May 2023 to identify studies using any SDM and/or DA tool or intervention used to implement SDM/DA regarding breast cancer screening. The studies could target either care providers or women at average risk of developing breast cancer and must include at least one implementation outcome (acceptability, adoption, appropriateness, fidelity, feasibility, penetration, sustainability). Studies that focused primarily on the decision-making process were included, whereas those that aimed only to increase breast cancer screening were excluded. Study selection and data extraction were conducted using Covidence with two independent reviewers using the Oxford Implementation Index. We extracted information on study design, intervention details, primary outcome of the study, frameworks used to develop DAs, and all results related to implementation outcomes[MN2] . Each study was coded as efficacy, effectiveness, or implementation. Intervention strategies were coded using Expert Recommendations for Implementing Change (ERIC) and strategies used to change clinical behaviours and support implementation outcomes were coded using Behaviour Change Techniques (BCTs). Results: The search yielded 10,383 records of which 22 studies met the inclusion criteria, 2 targeting providers, 16, targeting patients, and 4 targeting both. Studies were classified as follows (provider cohort; patient cohort): efficacy studies (0/6, 0%; 8/20, 40%), effectiveness studies (4/6, 67%; 10/20, 50%), and primary implementation studies (1/6, 17%; 1/20, 5[MN3] %). In the provider cohort, acceptability was assessed in 6/6(100%), adoption in 2/6(33%), feasibility in 2/6(33%), appropriateness in 1/6(17%), and sustainability in 1/6(17%). In the patient cohort, acceptability was assessed in 20/20(100%), feasibility in 3/20(15%), appropriateness in 3/20(15%), adoption in 1/20(5%). In both cohorts, acceptability was the most evaluated implementation outcome(100%), while penetration and fidelity were never assessed. DAs demonstrated moderate-to-excellent acceptability, requiring the use of visual aids and plain language to facilitate understanding in patients. BCTs commonly employed to increase SDM/DA included shaping knowledge, natural consequences, and comparison of outcomes. ERIC strategies frequently used included developing and distributing educational materials; there were limited strategies related to increasing uptake amongst clinical providers. Common barriers to SDM/DA use in the provider cohort included time constraints and lack of SDM training. Conclusions: DAs are effective in assisting with SDM related to breast cancer screening and existing DA’s in the literature appear acceptable; however, these tools/techniques can only help if they are used as intended. More primary implementation studies, focused on implementation fidelity, adoption/penetration, and sustainability are required, especially targeting providers, to evaluate and understand the optimal strategies for implementation of SDM and DA in these healthcare settings. Citation Format: Rama Alkhaldi, Neha Pathak, Victoria Mintsopoulos, Rouhi Fazelzad, Sarina Schrager, Patricia Villain, Noah Ivers, Michelle B. Nadler. Implementing Decision Aid Use and Shared-Decision Making in Breast Cancer Screening: A Scoping Review [abstract]. In: Proceedings of the San Antonio Breast Cancer Symposium 2024; 2024 Dec 10-13; San Antonio, TX. Philadelphia (PA): AACR; Clin Cancer Res 2025;31(12 Suppl):Abstract nr P4-04-02.

Preparing medical students how to learn during clerkships is vital to support their transition from preclinical to workplace learning. However, training programs fostering students' workplace learning skills are sparse. To address this gap, the 'Learning to Learn at the Workplace' training program was developed, combining strategies for informal workplace learning with self-regulated learning (SRL) techniques. Using the 'ADDIE' instructional design model, the training was developed, implemented and evaluated. It consists of four classroom sessions combined with workplace assignments, each addressing a different SRL theme for informal workplace learning: learning goals, asking questions, feedback, and reflection. Additionally, the influence of the clerkship context on SRL is addressed, with the aim to enable students to recognize and utilize informal workplace learning. The training was piloted with medical students during their second or third clerkship (n = 33). Students provided written feedback following each session and completed a final questionnaire (n = 21). Teachers evaluated implementation fidelity after each session. Students reported that the training effectively supported their self-regulated workplace learning. They particularly valued its relevance, practical tools, and the opportunity to exchange clerkship learning experiences. Students gained valuable insights into self-regulated informal workplace learning at clerkships. To further stimulate application of taught skills during clerkships, better integration of transfer tasks into the training is suggested. Involving numerous stakeholders and extensive literature in the developmental process ensured this training aligned with students' needs and received positive evaluations from students, teachers, and curriculum developers. Subsequently, the training will become a mandatory part of the current curriculum.

The initial medication adherence (IMA) intervention aims to improve adherence to cardiovascular disease (CVD) and diabetes treatments in primary care (PC) through standardised shared decision-making (SDM) and healthcare professional (HCP) collaboration (general practitioners (GPs), nurses and pharmacists). This study assessed the intervention's implementation (strategies, fidelity and integration into routine practice-based on the Normalisation Process Theory), mechanisms of action and the role of context. The IMA-cRCT was an effectiveness-implementation cluster-Randomised Controlled Trial involving 24 Spanish PC centres (>300 HCP; >3000 patients) based on real-world evidence. This nested process evaluation used quantitative (monitoring data; HCP questionnaires) and qualitative methods (field diaries; 36 semistructured individual interviews and two focus groups (19 patients, 28 HCPs)). Quantitative data explored implementation and context and were analysed descriptively, while qualitative data examined implementation, mechanisms of action and context and were analysed using framework analysis. Both analyses were integrated for interpretation. Intervention implementation fidelity (6.5/10) and normalisation into clinical practice (7.6/10) were adequate, particularly regarding SDM and use of decision aids. HCPs recognised the importance of SDM, although some assumed it was already part of routine practice. The anticipated mechanisms of action were moderately supported. HCPs' knowledge and attitudes towards SDM improved as they acknowledged its relevance to practice. Some patients reported participation in decision-making, while others preferred the GP to decide on their behalf. Patients found leaflets helpful for understanding information. Contextual factors influencing the intervention were mainly organisational, such as lack of time and familiarity with SDM. The interprofessional SDM-based IMA intervention was considered beneficial for patients and HCPs, with adequate implementation fidelity and normalisation into practice. The intervention was important for HCPs, and patients accepted it. However, greater effort is needed to extend SDM throughout healthcare, moving towards patient-centred care. These results have enhanced understanding of SDM interventions and support their refinement for future implementation. ClinicalTrials.gov, NCT05026775.

This systematic review aims to investigate the effectiveness of text structure instruction (TSI) on students' expository writing and, using the insights obtained from the review, to develop theoretical frameworks and instructional procedures for TSI that will mainly serve the types of learners targeted by the present study. With this in mind, inclusion and exclusion criteria were set, and 14 experimental and quasi-experimental studies conducted on primary school students were selected. The review revealed that TSI could improve the inclusion of main ideas in written summaries and enhance the quality of expository text structure writing. Specifically, it can improve students’ ability to identify the main ideas and supportive details from the source text. Moreover, the study revealed a lack of consistent reporting on the fidelity of implementation and comprehensiveness, which are limitations of the reviewed studies. The review also revealed that an explicit TSI that integrates reading and writing skills and encourages the gradual release of student responsibilities during the writing process may enhance the ability of primary school EFL learners to write expository texts.