Population structure in a Philippines hot spring microbial mat

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Using qualitative research to explore intervention mechanisms: findings from the trial of the Learning Together whole-school health intervention.

BACKGROUND: This study reports on qualitative research conducted within a randomised controlled trial to explore possible intervention mechanisms. It focuses on the 'Learning Together' whole-school intervention delivered in secondary schools in England from 2014 to 2017 aiming to prevent bullying and aggression and improve student health. Intervention schools received staff training in restorative practice, a social and emotional learning curriculum, and an external facilitator and manual to convene and run a student/staff action group tasked with coordinating the intervention, focusing this on local needs. METHODS: Informed by realist approaches to evaluation, we analysed qualitative data to explore intervention mechanisms and how these might interact with school contexts to generate outcomes. Qualitative analysis drew on 45 interviews and 21 focus groups across three case-study schools and employed thematic content analysis to explore how intervention resources were taken up and used by local actors, how participants described the intervention mechanisms that then ensued, and how these might have generated beneficial outcomes. RESULTS: The thematic content analysis identified three social mechanisms that recurred in participant accounts: (1) building student commitment to the school community, (2) building healthy relationships by modelling and teaching pro-social skills, and (3) de-escalating bullying and aggression and enabling re-integration within the school community. CONCLUSIONS: Our analysis provides in-depth exploration of possible mechanisms and the contextual contingencies associated with these, allowing refinement of the initial intervention theory of change. TRIAL REGISTRATION: ISRCTN registry 10751359 . Registered on 11 March 2014

Using qualitative research to explore intervention mechanisms: findings from the trial of the Learning Together whole-school health intervention

Background: This study reports on qualitative research conducted within a randomised controlled trial to explore possible intervention mechanisms. It focuses on the ‘Learning Together’ whole-school intervention delivered in secondary schools in England from 2014 to 2017 aiming to prevent bullying and aggression and improve student health. Intervention schools received staff training in restorative practice, a social and emotional learning curriculum, and an external facilitator and manual to convene and run a student/staff action group tasked with coordinating the intervention, focusing this on local needs. / Methods: Informed by realist approaches to evaluation, we analysed qualitative data to explore intervention mechanisms and how these might interact with school contexts to generate outcomes. Qualitative analysis drew on 45 interviews and 21 focus groups across three case-study schools and employed thematic content analysis to explore how intervention resources were taken up and used by local actors, how participants described the intervention mechanisms that then ensued, and how these might have generated beneficial outcomes. / Results: The thematic content analysis identified three social mechanisms that recurred in participant accounts: (1) building student commitment to the school community, (2) building healthy relationships by modelling and teaching pro-social skills, and (3) de-escalating bullying and aggression and enabling re-integration within the school community. / Conclusions: Our analysis provides in-depth exploration of possible mechanisms and the contextual contingencies associated with these, allowing refinement of the initial intervention theory of change. / Trial registration: ISRCTN registry 10751359. Registered on 11 March 2014

Correction to: Using qualitative research to explore intervention mechanisms: findings from the trial of the learning together whole-school health intervention.

An amendment to this paper has been published and can be accessed via the original article

Locating and testing the healthy context paradox: examples from the INCLUSIVE trial

BACKGROUND: The healthy context paradox, originally described with respect to school-level bullying interventions, refers to the generation of differences in mental wellbeing amongst those who continue to experience bullying even after interventions successfully reduce victimisation. Using data from the INCLUSIVE trial of restorative practice in schools, we relate this paradox to the need to theorise potential harms when developing interventions; formulate the healthy context paradox in a more general form defined by mediational relationships and cluster-level interventions; and propose two statistical models for testing the healthy context paradox informed by multilevel mediation methods, with relevance to structural and individual explanations for this paradox. METHODS: We estimated two multilevel mediation models with bullying victimisation as the mediator and mental wellbeing as the outcome: one with a school-level interaction between intervention assignment and the mediator; and one with a random slope component for the student-level mediator-outcome relationship predicted by school-level assignment. We relate each of these models to contextual or individual-level explanations for the healthy context paradox. RESULTS: Neither model suggested that the INCLUSIVE trial represented an example of the healthy context paradox. However, each model has different interpretations which relate to a multilevel understanding of the healthy context paradox. CONCLUSIONS: Greater exploration of intervention harms, especially when those accrue to population subgroups, is an essential step in better understanding how interventions work and for whom. Our proposed tests for the presence of a healthy context paradox provide the analytic tools to better understand how to support development and implementation of interventions that work for all groups in a population. TRIAL REGISTRATION: Current Controlled Trials, ISRCTN10751359

Methodological reflections on using qualitative research to explore the causal mechanisms of complex health interventions

We reflect on how qualitative research can be used to develop or refine theories about how the mechanisms triggered by intervention enactment might generate outcomes, referring to examples from a ‘realist trial’ of a whole-school health intervention. Qualitative research can explore mechanisms directly, by asking participants how they think interventions work, or indirectly, by exploring participant experiences of intervention-related actions to understand the conditions and consequences of these actions. Both of these approaches can inform theorisation of how mechanisms are triggered and generate outcomes, and how this is contingent on context. We discuss methods for sampling, data collection and data analysis, and recommend dimensional analysis as a means to analyse qualitative data on mechanisms. We then consider how to draw on qualitative research to inform hypotheses to be tested statistically. </jats:p

Are realist randomised controlled trials possible? A reflection on the INCLUSIVE evaluation of a whole-school, bullying-prevention intervention.

We previously proposed that realist randomised controlled trials could be used to evaluate how, for whom and under what conditions complex interventions can be used to activate mechanisms to improve health. While this idea was accepted by some, it was also met with resistance, particularly from some realist evaluators who believe that trials are inextricably positivist and dependent on constant conjunctions to understand causation, and that realist trials are unfeasible because participants and contexts will be insufficiently diverse to enable the testing of context-mechanism-outcome configurations. In this paper, we reflect on analyses of qualitative and quantitative data from the Initiating Change Locally in Bullying and Aggression through the School Environment (INCLSUIVE) trial, and whether these are useful and aligned with realism. We summarise the concerns expressed by realists and reflect on the philosophical and practical challenges that we encountered and whether or not they are related to the trial's design. Finally, we reflect on the trial's weaknesses and highlight areas that future researchers might consider when running realist trials. We conclude that realist randomised controlled trials are philosophically coherent, practically feasible, and can produce nuanced findings

Moderated mediation analyses to assess intervention mechanisms for impacts on victimisation, psycho-social problems and mental wellbeing: Evidence from the INCLUSIVE realist randomized trial.

Realist evaluations aim to evaluate interventions by understanding the mechanisms they trigger, assessing not merely what works but what works for whom, under what conditions, and how. Significant disagreement in the literature exists as to whether randomized trials can be used as a tool for realist evaluation. INCLUSIVE, which was the first realist randomized trial explicitly designed as such, evaluated the impact of Learning Together, a school-based intervention for students aged 12-15 that included restorative practice, on bullying victimisation, mental wellbeing and psychological problems. Drawing on hypotheses generated through qualitative research, this analysis tested if school belonging was a mediator of intervention effects, and in which contexts. We estimated a series of fully longitudinal multilevel moderated mediation models including intervention allocation, student reports of school belonging at 24 months and victimisation and wellbeing outcomes at 36 months, and stratified on the basis of whether, at baseline, schools were: a) rated 'outstanding' for leadership, b) below the median for average levels of victimisation, and c) above the median on school inclusivity. Findings suggested that in unstratified models, belonging was not a mediator for any outcome; but in each of the strata defined above, belonging was a significant mediator at the student level. However, in the strata where belonging was not a mediator, the intervention still had a significant effect on each outcome. Analyses point to a strong but conditional role for belonging as a mediator of intervention pathways; in schools where belonging was not a mediator (e.g. above-median victimisation levels), other mechanisms may have been activated. This is consistent with a realist understanding of context-mechanism linkages generating outcomes. Our analyses suggest that realist evaluations can be pursued within randomized trials and that such analyses can offer more nuanced evidence regarding in which contexts interventions might effectively be implemented

Multiscale correlative tomography: an investigation of creep cavitation in 316 stainless steel

Creep cavitation in an ex-service nuclear steam header Type 316 stainless steel sample is investigated through a multiscale tomography workflow spanning eight orders of magnitude, combining X-ray computed tomography (CT), plasma focused ion beam (FIB) scanning electron microscope (SEM) imaging and scanning transmission electron microscope (STEM) tomography. Guided by microscale X-ray CT, nanoscale X-ray CT is used to investigate the size and morphology of cavities at a triple point of grain boundaries. In order to understand the factors affecting the extent of cavitation, the orientation and crystallographic misorientation of each boundary is characterised using electron backscatter diffraction (EBSD). Additionally, in order to better understand boundary phase growth, the chemistry of a single boundary and its associated secondary phase precipitates is probed through STEM energy dispersive X-ray (EDX) tomography. The difference in cavitation of the three grain boundaries investigated suggests that the orientation of grain boundaries with respect to the direction of principal stress is important in the promotion of cavity formation

Developing community-driven quality improvement initiatives to enhance chronic disease care in Indigenous communities in Canada : the FORGE AHEAD program protocol

BACKGROUND: Given the dramatic rise and impact of chronic diseases and gaps in care in Indigenous peoples in Canada, a shift from the dominant episodic and responsive healthcare model most common in First Nations communities to one that places emphasis on proactive prevention and chronic disease management is urgently needed. METHODS: The Transformation of Indigenous Primary Healthcare Delivery (FORGE AHEAD) Program partners with 11 First Nations communities across six provinces in Canada to develop and evaluate community-driven quality improvement (QI) initiatives to enhance chronic disease care. FORGE AHEAD is a 5-year research program (2013-2017) that utilizes a pre-post mixed-methods observational design rooted in participatory research principles to work with communities in developing culturally relevant innovations and improved access to available services. This intensive program incorporates a series of 10 inter-related and progressive program activities designed to foster community-driven initiatives with type 2 diabetes mellitus as the action disease. Preparatory activities include a national community profile survey, best practice and policy literature review, and readiness tool development. Community-level intervention activities include community and clinical readiness consultations, development of a diabetes registry and surveillance system, and QI activities. With a focus on capacity building, all community-level activities are driven by trained community members who champion QI initiatives in their community. Program wrap-up activities include readiness tool validation, cost-analysis and process evaluation. In collaboration with Health Canada and the Aboriginal Diabetes Initiative, scale-up toolkits will be developed in order to build on lessons-learned, tools and methods, and to fuel sustainability and spread of successful innovations. DISCUSSION: The outcomes of this research program, its related cost and the subsequent policy recommendations, will have the potential to significantly affect future policy decisions pertaining to chronic disease care in First Nations communities in Canada. TRIAL REGISTRATION: Current ClinicalTrial.gov protocol ID NCT02234973 . Date of Registration: July 30, 2014