Designing and evaluating complex interventions to improve health care

Complex interventions are “built up from a number of components, which may act both independently and interdependently.”1 2 Many health service activities should be considered as complex. Evaluating complex interventions can pose a considerable challenge and requires a substantial investment of time. Unless the trials illuminate processes and mechanisms they often fail to provide useful information. If the result is negative, we are left wondering whether the intervention is inherently ineffective (either because the intervention was inadequately developed or because all similar interventions are ineffective), whether it was inadequately applied or applied in an inappropriate context, or whether the trial used an inappropriate design, comparison groups or outcomes. If there is a positive effect, it can be hard to judge how the results of the trial might be applied to a different context (box 1)

The Effect of an Early Education Program on Adult Health: The Carolina Abecedarian Project Randomized Controlled Trial

Objectives. We explored whether a successful randomized controlled trial of early education, the Carolina Abecedarian Project (ABC), which enrolled infants from 1972 to 1977 at the Frank Porter Graham Child Development Institute in Chapel Hill, North Carolina, improved health outcomes and behaviors by 21 years of age. Methods. ABC randomized 111 infants to receive an intensive early education program or nutritional supplements and parental counseling alone; participants have been followed to the present day. We examined the effect of ABC on health outcomes and behavioral risk factors when participants were aged 21 years, and then explored the mediators of this relationship. Results. Relative to the control group, the ABC treatment group was previously found to have improved cognition and educational attainment. We found that the intervention also improved heath (P = .05) and health behaviors (P = .03) when participants were aged 21 years. These improvements in behaviors were not mediated by IQ, math and reading scores at 15 years of age, educational attainment, or health insurance. Conclusions. Effective early education programs may improve health and reduce risky health behaviors in adulthood

Rich Collections, Scarce Resources: Conundrum of Digital Curation in the Caribbean

Digital archiving presents a ready solution to the problem of hidden special collections. The availability of information and communication technology solutions provide libraries, archives and museums with a way forward. However, cost constraints present a real challenge to institutions, especially in the developing world where digitization projects must compete for scarce resources with many other pressing services. In the competition for resources special collections sometimes play second fiddle to immediate services, for example user facilities. The Library of the University of the West Indies (UWI), Mona, faced with limited and declining financial resources, yet recognizing the value of its growing but hidden special collections especially to scholarship at the university, as well as to the cultural and historical significance of the Caribbean region, sought cost-effective and innovative solutions to address the situation and to go ‘global’ with these collections. This paper uses a case study approach and details the strategies employed by a team at the University of the West Indies, Mona Library, including the acquisition of equipment, selection of collections to be included, and digitization of thirty collections of varied formats as well as deliberate collaborative initiatives at training of staff to ensure sustainability. It discusses challenges in the on-going process, and complications alluded to by Prochaska (2009) especially those of legal issues, politics, ownership, and values involved in stewardship of the collections. The paper posits solutions against a background of scarce resources as well as opportunities for far reaching and effective services

Do Gender Differences Exist in the Academic Identification of African American Elementary School-Aged Children?

The disidentification hypothesis predicts that African-American boys achieve less in school than African-American girls do because boys have less personal investment in doing well academically (i.e., they are disidentified). When do such gender differences emerge? Using self-perception and achievement data from longitudinal studies of children (N = 113) at high-risk for academic problems because they come from low-income families, the authors examined whether elementary school-aged and early adolescent African-American boys are more prone to low achievement and disidentification than African-American girls. Multiple regression analyses indicated no gender differences in reading or mathematics achievement between boys and girls at age 8 or at age 12. At 12, African-American boys’ self-esteem was predicted by academic performance in ways similar to that of African-American girls. Thus, no gender differences emerged in elementary school achievement and no gender-specific disengagement patterns were confirmed among at-risk African-American students

Archean (3.33 Ga) microbe-sediment systems were diverse and flourished in a hydrothermal context

International audienceInteracting, diverse microbe-sediment systems exist in natural environments today but have not yet been recognized in the oldest records of life on Earth (older than 3.3 Ga) because of lack of distinctive biomarker molecules and patchy preservation of microbial paleocommunities. In an in-situ outcrop-to microbial-scale study, we have differentiated probable phototrophic, chemolithotrophic, and chemo-organotrophic fossil microbial signatures in a nearshore vol-canogenic sedimentary setting in 3.33 Ga rocks of the Josefsdal Chert, Barberton greenstone belt, South Africa, while demonstrating the importance of contemporaneous hydrothermal activity. Hydrothermal fluids, as a nutrient source, strongly controlled the development and distribution of the microbial communities and, as a silicifying agent, contributed to their rapid fossilization. We thus show that intricate microbe-sediment systems are deep-rooted in time and that at least some early life may indeed have been thermophilic. INTRODUCTION Microbial communities in natural environments exist as multispecies assemblages that interact directly with one another and with their surroundings, and thus can be viewed as distinctive systems (Nealson, 1997). For example, a wide diversity of organotrophic and lithotro-phic (chemotrophic) microorganisms has been described in present-day, carbon-rich hydrother-mally influenced basaltic sediments (Callac et al., 2013), similar to those described from early Earth. However, lack of specific biomarker preservation in very ancient rocks (Summons, 1993) and haphazard preservation of microbial communities in general (Campbell et al., 2001; Orange et al., 2009) make tracing such systems in fossilized form to the oldest records of life on Earth (early Archean, older than 3.3 Ga) very challenging. Nevertheless, phototrophic microbial communities in early to mid-Archean (ca. 3.5–3.2 Ga) strata of South Africa and Australia have been well documented (). On the other hand, no previous investigations have recognized and addressed the syngenetic diversity of Archean microbial paleocommunities—both phototrophs and che-motrophs —within their sedimentary habitats at the microbial scale and using in-situ methods. Here we describe a macroscopic to microscopic investigation of the sedimentary and geochemical settings of widespread, fossilized phototrophic and chemotrophic microorganisms in early to mid-Archean (3.33 Ga) coastal sediments from the Josefsdal Chert, Barberton greenstone belt, South Africa. We also emphasize the importance of contemporaneous hydrothermal activity both as a source of energy for biomass production and as the means of preserving the biosignatures

Improving Informed Consent: The Medium Is Not the Message

An important type of research on informed consent involves empirically testing interventions designed to improve the consent process. Here we report on the experience of eight teams that conducted research involving interventions designed primarily to impact one of three categories: decision-making, knowledge, and the therapeutic misconception

Protocol for the 'e-Nudge trial' : a randomised controlled trial of electronic feedback to reduce the cardiovascular risk of individuals in general practice [ISRCTN64828380]

Background: Cardiovascular disease (including coronary heart disease and stroke) is a major cause of death and disability in the United Kingdom, and is to a large extent preventable, by lifestyle modification and drug therapy. The recent standardisation of electronic codes for cardiovascular risk variables through the United Kingdom's new General Practice contract provides an opportunity for the application of risk algorithms to identify high risk individuals. This randomised controlled trial will test the benefits of an automated system of alert messages and practice searches to identify those at highest risk of cardiovascular disease in primary care databases. Design: Patients over 50 years old in practice databases will be randomised to the intervention group that will receive the alert messages and searches, and a control group who will continue to receive usual care. In addition to those at high estimated risk, potentially high risk patients will be identified who have insufficient data to allow a risk estimate to be made. Further groups identified will be those with possible undiagnosed diabetes, based either on elevated past recorded blood glucose measurements, or an absence of recent blood glucose measurement in those with established cardiovascular disease. Outcome measures: The intervention will be applied for two years, and outcome data will be collected for a further year. The primary outcome measure will be the annual rate of cardiovascular events in the intervention and control arms of the study. Secondary measures include the proportion of patients at high estimated cardiovascular risk, the proportion of patients with missing data for a risk estimate, and the proportion with undefined diabetes status at the end of the trial

Early Educational Intervention, Early Cumulative Risk, and the Early Home Environment as Predictors of Young Adult Outcomes Within a High-Risk Sample

The extent to which early educational intervention, early cumulative risk, and the early home environment were associated with young adult outcomes was investigated in a sample of 139 young adults (age 21) from high-risk families enrolled in randomized trials of early intervention. Positive effects of treatment were found for education attainment, attending college, and skilled employment; negative effects of risk were found for education attainment, graduating high school, being employed and avoiding teen parenthood. The home mediated the effects of risk for graduating high school, but not being employed or teen parenthood. Evidence for moderated mediation was found for educational attainment; the home mediated the association between risk and educational attainment for the control group, but not the treated group