Design Of Improvement Interventions Research Articles

Factors Related to Rehabilitation Adherence in Pediatric Cancer: A Systematic Review

Background: Rehabilitation is crucial for improving the functional outcomes of children and adolescents with cancer. An understanding of factors related to rehabilitation adherence is needed to improve intervention design and effectiveness, and decrease healthcare costs. Therefore, this systematic review aims to identify factors related to pediatric cancer rehabilitation adherence. Methods: Based upon the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, a search of MEDLINE and CINAHL was completed in January 2023, including terms of pediatrics, cancer, rehabilitation, and adherence. Study eligibility included: (1) published after 2011, (2) English language, (3) a physical therapy, occupational therapy, speech-language pathology, cognitive or exercise intervention or service, (4) mean age ≤18 years old, within 5 years of a cancer diagnosis, and (5) measurement and reporting of adherence factors. Study quality was evaluated using the Joanna Briggs Critical Appraisal Tools. Results: The review included 13 studies providing interventions to 318 children. Most of the interventions were related to exercise. Adherence levels of supervised sessions ranged from 61% to 91%. Unsupervised intervention adherence was not a common outcome, but the reported measurements ranged widely (<1-72%). The classification of factors associated with adherence included organizational, treatment, and personal factors. Common barriers to adherence were fatigue, illness, time and motivation. Facilitators of adherence included peer or caregiver support and supervision. Conclusion: Additional research is needed to investigate the factors related to rehabilitation intervention adherence, especially factors beyond exercise and those associated with unsupervised interventions. Standardized measures are crucial to ensure the reliability and comparability of findings.

Intersectionality in Intervention Development: Insights From Formative Work on a Tailored Tobacco Cessation Program for LGBTQIA+ Young Adults.

Tailored tobacco cessation interventions focusing on minoritized communities are proliferating, but the extent to which these interventions address the needs of individuals with multiple minoritized social identities is unclear. We developed Empowered, Queer, Quitting, and Living (EQQUAL), an avatar-led digital smoking cessation intervention tailored for lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual, and more (LGBTQIA+) young adults based on acceptance and commitment therapy (ACT), via a multistage user-centered design process. The purpose was to evaluate feedback from EQQUAL development activities using an intersectional lens. Intersectionality is a paradigm created by Kimberlé Crenshaw illustrating the multiple social identities each person possesses along with the marginalization of these different social identities. We conducted a rapid deductive content analysis focused on intersectional design gaps using interviewer notes from user testing (n = 7), a diary study (n = 8), and treatment satisfaction responses from a single-arm trial of the EQQUAL intervention (n = 22). Feedback related to intersectional design fell under three broad themes: (a) inadequate representativeness of the avatar, (2) inadequate representativeness within the program broadly, and (3) non-inclusive ACT intervention content. Feedback on inclusiveness included reference to socioeconomic status, race/ethnicity, religious/cultural affiliation, and ability/disability. Although we previously found that EQQUAL was highly acceptable and showed promise in terms of efficacy in a single-arm pilot trial, we identified several gaps in intersectional design as the iterative intervention development proceeded. Because intersectional design is a critical part of developing interventions with a health equity focus, applying standardized procedures for intersectional design and analysis could improve intervention design and better address tobacco cessation treatment needs of individuals who may experience multiple forms of marginalization.

Barriers and facilitators to structured physical activity interventions in early childhood education and care centres: a systematic review

Introduction: Despite the importance of physical activity and motor competence for young children, many early childhood education and care (ECEC) centres struggle to successfully implement and sustain physical activity programs, especially those delivered by educators rather than physical education specialists. This review aimed to identify factors (barriers and facilitators) reported by educators that may influence their implementation of structured physical activity interventions in ECEC and synthesise these factors according to the 14 domains of the “Theoretical Domains Framework” (TDF). Methods: A systematic search in five scientific databases was undertaken for articles published between 2009 and July 2019 that investigated educator reported barriers and/ or facilitators to implementing structured physical activity programs in ECEC centres. Duplicate abstracts were removed, and selection criteria applied. Data from included studies was extracted and coded in two stages. Extracted factors were mapped and synthesised using the TDF. Results: Of the 1903 identified citations, 12 studies met the inclusion criteria (4 qualitative, 8 mixed methods). Across studies, barriers and facilitators were identified in 11 of the 14 domains of the TDF, with the most frequently reported domains for both barriers and facilitators being “knowledge”, “skills”, and “environmental context and resources”. Within these domains, common themes were educator training, organisational policies and readiness, physical environment and space, supporting resources and time. Relatively few factors were identified in the remaining domains and none were reported for three domains: “intentions”, “memory, attention and decision processes” and “behavioural regulation”. Discussion: This evidence synthesis may help guide development of policy, programs, and implementation strategies that improve uptake and sustainability of structured physical activity interventions in ECEC settings. Greater investigation and reporting of training to build educator knowledge, skills and confidence is warranted. Implementation science frameworks may provide a means to improve intervention design, including involving educators in co-design, whereby potential organisational and educator-level implementation barriers are identified and addressed. Additionally, use of theoretical frameworks in evaluating program implementation may identify a wider range of factors that influence educator behaviour than is currently reported in the literature. Conflict of interest statement: My co-authors and I acknowledge that we have no conflict of interest of relevance to the submission of this abstract.

Delta Studies: Expanding the Concept of Deviance Studies to Design More Effective Improvement Interventions.

The effects of improvement (implementation and de-implementation) interventions are often modest. Although positive and negative deviance studies have been extensively used in improvement science and quality improvement efforts, conceptual and methodological innovations are needed to improve our ability to use information about variation in quality to design more effective interventions. We describe a novel mixed methods extension of the deviance study we term "delta studies." Delta studies seek to quantitatively identify sites that have recently changed from low performers to high performers, or vice versa, in order to qualitatively learn about active strategies that produced recent change, challenges change agents faced and how they overcame them, and where applicable, the causes of recent deterioration in performance-information intended to inform the design of improvement interventions for deployment in low performing sites. We provide examples of lessons learned from this method that may have been missed with traditional positive or negative deviance designs. Considerations for quantitatively identifying delta sites are described including which quality metrics to track, over what timeframe to observe change, how to account for reliability of observed change, consideration of patient volume and initial performance as implementation context factors, and how to define clinically meaningful change. Methods to adapt qualitative protocols by integrating quantitative information about change in performance are also presented. We provide sample data and R code that can be used to graphically display distributions of initial status, change, and volume that are essential to delta studies. Patients and facilities of the US Veterans Health Administration. As an example, we discuss what decisions we made regarding the delta study design considerations in a funded study of low-value preoperative testing. The method helped us find sites that had recently reduced the burden of low-value testing, and learn about the strategies they employed and challenges they faced. The delta study concept is a promising mixed methods innovation to efficiently and effectively identify improvement strategies and other factors that have actually produced change in real-world settings.

The Adaptive Behavioral Components (ABC) Model for Planning Longitudinal Behavioral Technology-Based Health Interventions: A Theoretical Framework.

A growing number of interventions incorporate digital and social technologies (eg, social media, mobile phone apps, and wearable devices) into their design for behavior change. However, because of a number of factors, including changing trends in the use of technology over time, results on the efficacy of these interventions have been mixed. An updated framework is needed to help researchers better plan behavioral technology interventions by anticipating the needed resources and potential changes in trends that may affect interventions over time. Focusing on the domain of health interventions as a use case, we present the Adaptive Behavioral Components (ABC) model for technology-based behavioral interventions. ABC is composed of five components: basic behavior change; intervention, or problem-focused characteristics; population, social, and behavioral characteristics; individual-level and personality characteristics; and technology characteristics. ABC was designed with the goals of (1) guiding high-level development for digital technology–based interventions; (2) helping interventionists consider, plan for, and adapt to potential barriers that may arise during longitudinal interventions; and (3) providing a framework to potentially help increase the consistency of findings among digital technology intervention studies. We describe the planning of an HIV prevention intervention as a case study for how to implement ABC into intervention design. Using the ABC model to plan future interventions might help to improve the design of and adherence to longitudinal behavior change intervention protocols; allow these interventions to adapt, anticipate, and prepare for changes that may arise over time; and help to potentially improve intervention behavior change outcomes. Additional research is needed on the influence of each of ABC’s components to help improve intervention design and implementation.

Continued Decline in Obesity and Severe Obesity Prevalence Among New York City Public School Youth in Grades K-8: 2011-2017.

This study aimed to estimate population-level prevalence of obesity and severe obesity for New York City youth and examine the most recent trends over time. All public school youth in grades kindergarten through eighth (K-8) (2011-2012 through 2016-2017) with valid weight and height measures were included (N = 1,137,782 unique students; 3,720,297 observations). Age- and sex-specific BMI percentiles for obesity and severe obesity were estimated using Centers for Disease Control and Prevention growth charts. Repeated cross-sectional analyses were conducted using logistic regression, weighting for missing or invalid responses and accounting for clustering by students and schools to examine trends over time and by sociodemographics. Among youth in K-8 (aged 5-15 years, 48.8% girls), the prevalence of obesity and severe obesity in 2011-2012 was 21.5% and 6.4%, respectively, compared with 20.2% and 6.0%, respectively, in 2016-2017. Since 2011-2012, decreasing trends in obesity and severe obesity (relative declines: 6.0% and 6.3%, respectively, P < 0.001) have been observed. Significant decreases were observed for all subgroups (P < 0.001), although there remained disparities in relative declines over time by race/ethnicity and poverty. Decreasing trends in obesity and severe obesity among all New York City K-8 public school youth are promising; however, persistent disparities highlight the need to improve intervention design and implementation strategies for groups disproportionately burdened by obesity.

Understanding Long-Term Effects of Motivation Interventions in a Changing World.

As intervention science develops, researchers are increasingly attending to the long-term effects of interventions in academic settings. Currently, however, there is no common taxonomy for understanding the complex processes through which interventions can produce long-lasting effects. The lack of a common framework results in a number of challenges that limit the ability of intervention scientists to effectively work toward their goal of preparing students to effectively navigate a changing and uncertain world. A comprehensive framework is presented to aid understanding of how interventions that target motivational processes in education produce downstream effects years after implementation. This framework distinguishes between three types of processes through which interventions may produce long-term effects: recursive processes (feedback loops by which positive effects can build on themselves over time), non-recursive chains of effects ("domino effects" in which proximal outcomes affect distinct distal outcomes), and latent intrapersonal effects (changed habits, knowledge, or perceptions that affect how students respond in different situations in the future). The framework is applied to intervention research that has reported long-term effects of motivation interventions, evidence for the processes described in this framework is evaluated, and suggestions are presented for how researchers can use the framework to improve intervention design. The chapter concludes with a discussion of how application of this framework can help intervention scientists to achieve their goal of positively influencing students' lifelong trajectories, especially in times of change and uncertainty.

Substance misuse intervention research in remote Indigenous Australian communities since the NHMRC ‘Roadmap’

ObjectiveDescribe program theories of substance misuse interventions with Aboriginal and Torres Strait Islander (Indigenous) Australians funded by the National Health and Medical Research Council (NHMRC) since the ‘Roadmap’ for Indigenous health. MethodsProjects funded 2003–2013 were categorised by intervention strategies. Realist concepts informed the program theory: intended resources and responses; influence of context on outcomes; explicit and implicit program assumptions. ResultsSeven interventions were included. Three randomised controlled trials targeted tobacco using psychosocial interventions in primary health centres using the program theory: “Local Indigenous health workers extend and sustain the effects of conventional clinical brief intervention by engendering social and cultural resources”. Four pragmatic trials of multiple‐component, community‐based interventions using controlled, semi‐controlled or before‐and‐after designs used the program theory: “Discrete intervention components targeting locally defined substance misuse issues will activate latent capacities to create an environment that favours cessation.” Publications did not report clear effect, implementation fidelity or explicit mechanisms affecting participant thinking. ConclusionsRigorous intervention designs built on ‘Roadmap’ principles neither reduced substance use in the populations studied nor identified transferable mechanisms for behaviour change. Implications for public healthSubstance misuse impacts among Indigenous Australians remain severe. Theoretical mechanisms of behaviour change may improve intervention design.

The Challenge of Improving Breast Cancer Care Coordination in Safety-net Hospitals: Barriers, Facilitators, and Opportunities.

Minority breast cancer patients tend to have higher rates of adjuvant treatment underuse. We implemented a web-based intervention that closes referral loops between surgeons and oncologists at inner-city safety-net hospitals serving high volumes of minority breast cancer patients to assist these hospitals and improve care coordination. Following intervention implementation, we conducted interviews with key personnel to improve our understanding of the implementation process and to identify barriers, facilitators, and opportunities for improvement. We used the constant comparative method of analysis to code interview transcripts and identify common themes regarding intervention implementation. We interviewed 64 administrative and clinical key informants from 10 inner-city safety-net hospitals with high volumes of minority breast cancer patients. We found substantial barriers to implementing an intervention designed to support care coordination efforts, despite initial feedback that the intervention itself was both easy to use and in line with organizational goals. We also characterized facilitators and challenges of breast cancer care coordination in the safety-net environment, as well as opportunities to improve intervention design to support increased quality of breast cancer care. Coordination of care for women with breast cancer is extremely important, but safety-net hospitals face considerable resource constraints from lack of time, support, and information systems. As safety-net hospital networks grow across numerous care sites, the challenge of care coordination will likely increase, highlighting the importance of interventions that can be successfully implemented and used to promote better care.