Action, actor, context, target, time (AACTT): a framework for specifying behaviour

BACKGROUND: Designing implementation interventions to change the behaviour of healthcare providers and other professionals in the health system requires detailed specification of the behaviour(s) targeted for change to ensure alignment between intervention components and measured outcomes. Detailed behaviour specification can help to clarify evidence-practice gaps, clarify who needs to do what differently, identify modifiable barriers and enablers, design interventions to address these and ultimately provides an indicator of what to measure to evaluate an intervention's effect on behaviour change. An existing behaviour specification framework proposes four domains (Target, Action, Context, Time; TACT), but insufficiently clarifies who is performing the behaviour (i.e. the Actor). Specifying the Actor is especially important in healthcare settings characterised by multiple behaviours performed by multiple different people. We propose and describe an extension and re-ordering of TACT to enhance its utility to implementation intervention designers, practitioners and trialists: the Action, Actor, Context, Target, Time (AACTT) framework. We aim to demonstrate its application across key steps of implementation research and to provide tools for its use in practice to clarify the behaviours of stakeholders across multiple levels of the healthcare system. METHODS AND RESULTS: We used French et al.'s four-step implementation process model to describe the potential applications of the AACTT framework for (a) clarifying who needs to do what differently, (b) identifying barriers and enablers, (c) selecting fit-for-purpose intervention strategies and components and (d) evaluating implementation interventions. CONCLUSIONS: Describing and detailing behaviour using the AACTT framework may help to enhance measurement of theoretical constructs, inform development of topic guides and questionnaires, enhance the design of implementation interventions and clarify outcome measurement for evaluating implementation interventions

Clinical Indications and Compassionate Use of Phage Therapy: Personal Experience and Literature Review with a Focus on Osteoarticular Infections.

The history of phage therapy started with its first clinical application in 1919 and continues its development to this day. Phages continue to lack any market approval in Western medicine as a recognized drug, but are increasingly used as an experimental therapy for the compassionate treatment of patients experiencing antibiotic failure. The few formal experimental phage clinical trials that have been completed to date have produced inconclusive results on the efficacy of phage therapy, which contradicts the many successful treatment outcomes observed in historical accounts and recent individual case reports. It would therefore be wise to identify why such a discordance exists between trials and compassionate use in order to better develop future phage treatment and clinical applications. The multitude of observations reported over the years in the literature constitutes an invaluable experience, and we add to this by presenting a number of cases of patients treated compassionately with phages throughout the past decade with a focus on osteoarticular infections. Additionally, an abundance of scientific literature into phage-related areas is transforming our knowledge base, creating a greater understanding that should be applied for future clinical applications. Due to the increasing number of treatment failures anticipatedfrom the perspective of a possible post-antibiotic era, we believe that the introduction of bacteriophages into the therapeutic arsenal seems a scientifically sound and eminently practicable consideration today as a substitute or adjuvant to antibiotic therapy

Fluxes and distribution of dissolved iron in the eastern (sub-) tropical North Atlantic Ocean

Aeolian dust transport from the Saharan/Sahel desert regions is considered the dominant external input of iron (Fe) to the surface waters of the eastern (sub-) tropical North Atlantic Ocean. To test this hypothesis, we investigated the sources of dissolved Fe (DFe) and quantified DFe fluxes to the surface ocean in this region. In winter 2008, surface water DFe concentrations varied between <0.1 nM and 0.37 nM, with an average of 0.13 ± 0.07 nM DFe (n = 194). A strong correlation between mixed layer averaged concentrations of dissolved aluminum (DAl), a proxy for dust input, and DFe indicated dust as a source of DFe to the surface ocean. The importance of Aeolian nutrient input was further confirmed by an increase of 0.1 nM DFe and 0.05 ?M phosphate during a repeat transect before and after a dust event. An exponential decrease of DFe with increasing distance from the African continent, suggested that continental shelf waters were a source of DFe to the northern part of our study area. Relatively high Fe:C ratios of up to 3 × 10?5 (C derived from apparent oxygen utilization (AOU)) indicated an external source of Fe to these African continental shelf waters. Below the wind mixed layer along 12°N, enhanced DFe concentrations (>1.5 nM) correlated positively with apparent oxygen utilization (AOU) and showed the importance of organic matter remineralization as an DFe source. As a consequence, vertical diffusive mixing formed an important Fe flux to the surface ocean in this region, even surpassing that of a major dust event

The Wonder of Colors and the Principle of Ariadne

The Principle of Ariadne, formulated in 1988 ago by Walter Carnielli and Carlos Di Prisco and later published in 1993, is an infinitary principle that is independent of the Axiom of Choice in ZF, although it can be consistently added to the remaining ZF axioms. The present paper surveys, and motivates, the foundational importance of the Principle of Ariadne and proposes the Ariadne Game, showing that the Principle of Ariadne, corresponds precisely to a winning strategy for the Ariadne Game. Some relations to other alternative. set-theoretical principles are also briefly discussed

Understanding the Canadian adult CT head rule trial: use of the theoretical domains framework for process evaluation

BACKGROUND: The Canadian CT Head Rule was prospectively derived and validated to assist clinicians with diagnostic decision-making regarding the use of computed tomography (CT) in adult patients with minor head injury. A recent intervention trial failed to demonstrate a decrease in the rate of head CTs following implementation of the rule in Canadian emergency departments. Yet, the same intervention, which included a one-hour educational session and reminders at the point of requisition, was successful in reducing cervical spine imaging rates in the same emergency departments. The reason for the varied effect of the intervention across these two behaviours is unclear. There is an increasing appreciation for the use of theory to conduct process evaluations to better understand how strategies are linked with outcomes in implementation trials. The Theoretical Domains Framework (TDF) has been used to explore health professional behaviour and to design behaviour change interventions but, to date, has not been used to guide a theory-based process evaluation. In this proof of concept study, we explored whether the TDF could be used to guide a retrospective process evaluation to better understand emergency physicians’ responses to the interventions employed in the Canadian CT Head Rule trial. METHODS: A semi-structured interview guide, based on the 12 domains from the TDF, was used to conduct telephone interviews with project leads and physician participants from the intervention sites in the Canadian CT Head Rule trial. Two reviewers independently coded the anonymised interview transcripts using the TDF as a coding framework. Relevant domains were identified by: the presence of conflicting beliefs within a domain; the frequency of beliefs; and the likely strength of the impact of a belief on the behaviour. RESULTS: Eight physicians from four of the intervention sites in the Canadian CT Head Rule trial participated in the interviews. Barriers likely to assist with understanding physicians’ responses to the intervention in the trial were identified in six of the theoretical domains: beliefs about consequences; beliefs about capabilities; behavioural regulation; memory, attention and decision processes; environmental context and resources; and social influences. Despite knowledge that the Canadian CT Head Rule was highly sensitive and reliable for identifying clinically important brain injuries and strong beliefs about the benefits for using the rule, a number of barriers were identified that may have prevented physicians from consistently applying the rule. CONCLUSION: This proof of concept study demonstrates the use of the TDF as a guiding framework to design a retrospective theory-based process evaluation. There is a need for further development and testing of methods for using the TDF to guide theory-based process evaluations running alongside behaviour change intervention trials

Provence and the British Imagination

Although it resonates today with lavender fields, sunny heritage locations and the gentrified memory of Paul Cézanne’s pictorial turbulence, Provence has not always been the attractive territory of pacified leisure and festival culture. Since the seventeenth century, indeed, the region has inscribed its shifting geography, complex politics and the extraordinary diversity of its land and seascapes in the perception and imagination of British visitors

Vista D2.1 Supporting Data for Business and Regulatory Scenarios Report

Vista examines the effects of conflicting market forces on European performance in ATM, through the evaluation of impact metrics on four key stakeholders, and the environment. The review of regulatory and business factors is presented. Vista will model the current and future (2035, 2050) framework based on the impact of regulatory and business factors. These factors are obtained from a literature review of regulations, projects and technological and operational changes. The current value of those factors and their possible evolution are captured in this deliverable

Speckle tracking echocardiography: new ways of translational approaches in preeclampsia to detect cardiovascular dysfunction

Several studies have shown that women with a preeclamptic pregnancy exhibit an increased risk of cardiovascular disease. However, the underlying molecular mechanisms are unknown. Animal models are essential to investigate the causes of this increased risk and have the ability to assess possible preventive and therapeutic interventions. Using the latest technologies such as speckle tracking echocardiography (STE), it is feasible to map subclinical changes in cardiac diastolic and systolic function as well as structural changes of the maternal heart. The aim of this work is to compare cardiovascular changes in an established transgenic rat model with preeclampsia-like pregnancies with findings from human preeclamptic pregnancies by STE. The same algorithms were used to evaluate and compare the changes in echos of human and rodents. Parameters of functionality like global longitudinal strain (animal -23.54 ± 1.82 % vs. -13.79 ± 0.57 %, human -20.60 ± 0.47 % vs. -15.45 ± 1.55 %) as well as indications of morphological changes like relative wall thickness (animal 0.20 ± 0.01 vs. 0.25 ± 0.01, human 0.34 ± 0.01 vs. 0.40 ± 0.02) are significantly altered in both species after preeclamptic pregnancies. Thus, the described rat model simulates the human situation quite well and is a valuable tool for future investigations regarding cardiovascular changes. STE is a unique technique which can be applied in animal models and human with a high potential to uncover cardiovascular maladaptation and subtle pathologies

Changing behaviour, 'more or less': do implementation and de-implementation interventions include different behaviour change techniques?

Background Decreasing ineffective or harmful healthcare practices (de-implementation) may require different approaches than those used to promote uptake of effective practices (implementation). Few psychological theories differentiate between processes involved in decreasing, versus increasing, behaviour. However, it is unknown whether implementation and de-implementation interventions already use different approaches. We used the behaviour change technique (BCT) taxonomy (version 1) (which includes 93 BCTs organised into 12 groupings) to investigate whether implementation and de-implementation interventions for clinician behaviour change use different BCTs. Methods Intervention descriptions in 181 articles from three systematic reviews in the Cochrane Library were coded for (a) implementation versus de-implementation and (b) intervention content (BCTs) using the BCT taxonomy (v1). BCT frequencies were calculated and compared using Pearson’s chi-squared (χ2), Yates’ continuity correction and Fisher’s exact test, where appropriate. Identified BCTs were ranked according to frequency and rankings for de-implementation versus implementation interventions were compared and described. Results Twenty-nine and 25 BCTs were identified in implementation and de-implementation interventions respectively. Feedback on behaviour was identified more frequently in implementation than de-implementation (Χ2(2, n=178) = 15.693, p = .000057). Three BCTs were identified more frequently in de-implementation than implementation: Behaviour substitution (Χ2(2, n=178) = 14.561, p = .0001; Yates’ continuity correction); Monitoring of behaviour by others without feedback (Χ2(2, n=178) = 16.187, p = .000057; Yates’ continuity correction); and Restructuring social environment (p = .000273; Fisher’s 2-sided exact test). Conclusions There were some significant differences between BCTs reported in implementation and de-implementation interventions suggesting that researchers may have implicit theories about different BCTs required for de-implementation and implementation. These findings do not imply that the BCTs identified as targeting implementation or de-implementation are effective, rather simply that they were more frequently used. These findings require replication for a wider range of clinical behaviours. The continued accumulation of additional knowledge and evidence into whether implementation and de-implementation is different will serve to better inform researchers and, subsequently, improve methods for intervention design