Randomized controlled trial of a coordinated care intervention to improve risk factor control after stroke or transient ischemic attack in the safety net: Secondary stroke prevention by Uniting Community and Chronic care model teams Early to End Disparities (SUCCEED).

BackgroundRecurrent strokes are preventable through awareness and control of risk factors such as hypertension, and through lifestyle changes such as healthier diets, greater physical activity, and smoking cessation. However, vascular risk factor control is frequently poor among stroke survivors, particularly among socio-economically disadvantaged blacks, Latinos and other people of color. The Chronic Care Model (CCM) is an effective framework for multi-component interventions aimed at improving care processes and outcomes for individuals with chronic disease. In addition, community health workers (CHWs) have played an integral role in reducing health disparities; however, their effectiveness in reducing vascular risk among stroke survivors remains unknown. Our objectives are to develop, test, and assess the economic value of a CCM-based intervention using an Advanced Practice Clinician (APC)-CHW team to improve risk factor control after stroke in an under-resourced, racially/ethnically diverse population.Methods/designIn this single-blind randomized controlled trial, 516 adults (≥40 years) with an ischemic stroke, transient ischemic attack or intracerebral hemorrhage within the prior 90 days are being enrolled at five sites within the Los Angeles County safety-net setting and randomized 1:1 to intervention vs usual care. Participants are excluded if they do not speak English, Spanish, Cantonese, Mandarin, or Korean or if they are unable to consent. The intervention includes a minimum of three clinic visits in the healthcare setting, three home visits, and Chronic Disease Self-Management Program group workshops in community venues. The primary outcome is blood pressure (BP) control (systolic BP <130 mmHg) at 1 year. Secondary outcomes include: (1) mean change in systolic BP; (2) control of other vascular risk factors including lipids and hemoglobin A1c, (3) inflammation (C reactive protein [CRP]), (4) medication adherence, (5) lifestyle factors (smoking, diet, and physical activity), (6) estimated relative reduction in risk for recurrent stroke or myocardial infarction (MI), and (7) cost-effectiveness of the intervention versus usual care.DiscussionIf this multi-component interdisciplinary intervention is shown to be effective in improving risk factor control after stroke, it may serve as a model that can be used internationally to reduce race/ethnic and socioeconomic disparities in stroke in resource-constrained settings.Trial registrationClinicalTrials.gov Identifier NCT01763203

Decision makers\u27 experience of participatory dynamic simulation modelling: Methods for public health policy

Background: Systems science methods such as dynamic simulation modelling are well suited to address questions about public health policy as they consider the complexity, context and dynamic nature of system-wide behaviours. Advances in technology have led to increased accessibility and interest in systems methods to address complex health policy issues. However, the involvement of policy decision makers in health-related simulation model development has been lacking. Where end-users have been included, there has been limited examination of their experience of the participatory modelling process and their views about the utility of the findings. This paper reports the experience of end-user decision makers, including senior public health policy makers and health service providers, who participated in three participatory simulation modelling for health policy case studies (alcohol related harm, childhood obesity prevention, diabetes in pregnancy), and their perceptions of the value and efficacy of this method in an applied health sector context. Methods: Semi-structured interviews were conducted with end-user participants from three participatory simulation modelling case studies in Australian real-world policy settings. Interviewees were employees of government agencies with jurisdiction over policy and program decisions and were purposively selected to include perspectives at different stages of model development. Results: The ‘co-production’ aspect of the participatory approach was highly valued. It was reported as an essential component of building understanding of the modelling process, and thus trust in the model and its outputs as a decision-support tool. The unique benefits of simulation modelling included its capacity to explore interactions of risk factors and combined interventions, and the impact of scaling up interventions. Participants also valued simulating new interventions prior to implementation in the real world, and the comprehensive mapping of evidence and its gaps to prioritise future research. The participatory aspect of simulation modelling was time and resource intensive and therefore most suited to high priority complex topics with contested options for intervening. Conclusion: These findings highlight the value of a participatory approach to dynamic simulation modelling to support its utility in applied health policy settings

Turning conceptual systems maps into dynamic simulation models: An Australian case study for diabetes in pregnancy

Background: System science approaches are increasingly used to explore complex public health problems. Quantitative methods, such as participatory dynamic simulation modelling, can mobilise knowledge to inform health policy decisions. However, the analytic and practical steps required to turn collaboratively developed, qualitative system maps into rigorous and policy relevant quantified dynamic simulation models are not well described. This paper reports on the processes, interactions and decisions that occurred at the interface between modellers and end-user participants in an applied health sector case study focusing on diabetes in pregnancy. Methods: An analysis was conducted using qualitative data from a participatory dynamic simulation modelling case study in an Australian health policy setting. Recordings of participatory model development workshops and subsequent meetings were analysed and triangulated with field notes and other written records of discussions and decisions. Case study vignettes were collated to illustrate the deliberations and decisions made throughout the model development process. Results: The key analytic objectives and decision-making processes included: defining the model scope; analysing and refining the model structure to maximise local relevance and utility; reviewing and incorporating evidence to inform model parameters and assumptions; focusing the model on priority policy questions; communicating results and applying the models to policy processes. These stages did not occur sequentially; the model development was cyclical and iterative with decisions being re-visited and refined throughout the process. Storytelling was an effective strategy to both communicate and resolve concerns about the model logic and structure, and to communicate the outputs of the model to a broader audience. Conclusion: The in-depth analysis reported here examined the application of participatory modelling methods to move beyond qualitative conceptual mapping to the development of a rigorously quantified and policy relevant, complex dynamic simulation model. The analytic objectives and decision-making themes identified provide guidance for interpreting, understanding and reporting future participatory modelling projects and methods

On the level. Evidence for action on type 2 diabetes

Type 2 diabetes is a serious condition. It doubles the risk of cardiovascular disease, is the most common reason for severe kidney disease and is the second most common cause of blindness in working age adults. The disease is a major public health challenge, with many people not knowing they have diabetes and many more are at risk of developing it.NIHR research provides important insights throughout the patient pathway, from prevention to early identification to management of the disease and treating complications. These findings are helping to shape practice and policy. <br/

Using theoretical frameworks of behaviour to understand and improve health care delivery

PhD ThesisThe development of new knowledge about patient care continues to progress at an ever-increasing rate but its transfer into clinical practice can be slow and unpredictable. This doctoral statement provides a critical overview of a substantial programme of work that has explored the utility of theoretical models of behaviour for promoting the uptake of research findings into routine care. Guided by the MRC Framework for the design and evaluation of complex interventions, the supporting publications describe the development and testing of an innovative and systematic approach to intervention design. As well as providing methods for identifying and applying behavioural theory, this work has also set standards for transparency in the intervention development processes. The work demonstrates that psychological theories of behaviour do have an important function for improving healthcare delivery by supporting clinical behaviour change, but important limitations remain. In my critical reflection of this body of work I discuss these challenges, considering in particular the omission of the patient perspective and the dynamic influence of the patient-professional interaction during the clinical encounter. I go on to propose an extended dual-perspective model supported by theory and evidence from other improvement literatures, epistemologies and disciplinary perspectives. The dual perspective model functions at the very core of healthcare delivery and illustrates the interdependency of professional and patient behaviour in determining healthcare decision making and patient outcomes. By formally including the patient perspective the revised model encompasses all three dimensions of the EBM paradigm. I argue for a focus on better understanding of the interactional and relational processes that are generated during the clinical encounter as an essential step forward for implementation and improvement science. The paradigm of patient-centred care is then revisited through the lens of capabilities thinking and is proposed as a vital mechanism for supporting the uptake of appropriate, evidence-based healthcare

Researching Across Two Cultures: Shifting Positionality

Embodied and creative research methods provoke honesty, emotion, and vulnerability in participants, which add to the richness of the stories they tell and are willing to share. The positionality of the researcher is less of “interviewer” and more “co-producer” or participant in a dialogue. Visual and creative approaches invite participants to share in ways in which they are not able or willing through words alone. The data and outputs they produce, with film, art, or objects, can in turn affect those who see it more than written text and need to be analysed and disseminated along with more traditional transcripts, articles, and presentations. In the context of investigating sensitive issues such as those around embodied identity, these methods, which use embodied methods to explore embodied research questions, may feel the most appropriate. These approaches lie along the boundary of therapy and research, asking much of researchers who are unlikely to have received therapeutic training or ongoing support. Due to this deficit, the researched may find that their experience is not held or contained in a way that the content would demand. Similarly, the data themselves lie on the boundary of art and research, in that they can be seen as more than a tool to facilitate reflection, but as artifacts in their own right. What are the implications in this scenario? Where should we position ourselves and our work along these boundaries? Who holds the space for the researcher and the researched if both are made vulnerable