Developing theory-informed interventions to implement evidence into practice: a systematic approach using the Theoretical Domains Framework

Background: There is little systematic operational guidance about how best to develop complex interventions to reduce the gap between practice and evidence. This article is one in a series of articles documenting the development and use of the Theoretical Domains Framework (TDF) to advance the science of implementation research. Methods: The intervention was developed considering three main components: theory, evidence, and practical issues. We used a four-step approach, consisting of guiding questions, to direct the choice of the most appropriate components of an implementation intervention: Who needs to do what, differently? Using a theoretical framework, which barriers and enablers need to be addressed? Which intervention components (behaviour change techniques and mode(s) of delivery) could overcome the modifiable barriers and enhance the enablers? And how can behaviour change be measured and understood? Results: A complex implementation intervention was designed that aimed to improve acute low back pain management in primary care. We used the TDF to identify the barriers and enablers to the uptake of evidence into practice and to guide the choice of intervention components. These components were then combined into a cohesive intervention. The intervention was delivered via two facilitated interactive small group workshops. We also produced a DVD to distribute to all participants in the intervention group. We chose outcome measures in order to assess the mediating mechanisms of behaviour change. Conclusions: We have illustrated a four-step systematic method for developing an intervention designed to change clinical practice based on a theoretical framework. The method of development provides a systematic framework that could be used by others developing complex implementation interventions. While this framework should be iteratively adjusted and refined to suit other contexts and settings, we believe that the four-step process should be maintained as the primary framework to guide researchers through a comprehensive intervention development process

From NCLB to ESSA: Implications for Teacher Preparation and Policy

With the 2001 reauthorization of the Elementary and Secondary Education Act (ESEA), the term highly qualified teacher (HQT) became an important component of teacher licensure, including for special educators. However, when ESEA was reauthorized in 2015 as the Every Student Succeeds Act (ESSA), the highly qualified regulations were removed. The purpose of this study was to look back at the historical record of policy implementation of HQT and compare the record across states to provide implications for teacher preparation and licensure policy in the era of ESSA. This was accomplished through a review of the history of special education teacher licensure and completion of a comprehensive analysis of state licensure requirements under the Individuals with Disabilities Education Improvement Act. Despite a general consistency across three domains (i.e., degree, examination, and licensure) of the highly qualified statute, inconsistencies among states at both the elementary and secondary levels of special educator licensure may yield significant challenges related to the impact of teacher quality on student outcomes. Better understanding of these challenges is important as policymakers will be better able to make decisions regarding what teachers need to know prior to entering the field to meet students’ needs and generate student achievement

Investigation of bias in meta-analyses due to selective inclusion of trial effect estimates:empirical study

OBJECTIVE: To explore whether systematic reviewers selectively include trial effect estimates in meta-analyses when multiple are available, and what impact this may have on meta-analytic effects. DESIGN: Cross-sectional study. DATA SOURCES: We randomly selected systematic reviews of interventions from 2 clinical specialties published between January 2010 and 2012. The first presented meta-analysis of a continuous outcome in each review was selected (index meta-analysis), and all trial effect estimates that were eligible for inclusion in the meta-analysis (eg, from multiple scales or time points) were extracted from trial reports. ANALYSIS: We calculated a statistic (the Potential Bias Index (PBI)) to quantify and test for evidence of selective inclusion. The PBI ranges from 0 to 1; values above or below 0.5 are suggestive of selective inclusion of effect estimates more or less favourable to the intervention, respectively. The impact of any potential selective inclusion was investigated by comparing the index meta-analytic standardised mean difference (SMD) to the median of a randomly constructed distribution of meta-analytic SMDs (representing the meta-analytic SMD expected when there is no selective inclusion). RESULTS: 31 reviews (250 trials) were included. The estimated PBI was 0.57 (95% CI 0.50 to 0.63), suggesting that trial effect estimates that were more favourable to the intervention were included in meta-analyses slightly more often than expected under a process consistent with random selection; however, the 95% CI included the null hypothesis of no selective inclusion. Any potential selective inclusion did not have an important impact on the meta-analytic effects. CONCLUSION: There was no clear evidence that selective inclusion of trial effect estimates occurred in this sample of meta-analyses. Further research on selective inclusion in other clinical specialties is needed. To enable readers to assess the risk of selective inclusion bias, we recommend that systematic reviewers report the methods used to select effect estimates to include in meta-analyses

Recruitment difficulties in a primary care cluster randomised trial:investigating factors contributing to general practitioners' recruitment of patients

BACKGROUND: Recruitment of patients by health professionals is reported as one of the most challenging steps when undertaking studies in primary care settings. Numerous investigations of the barriers to patient recruitment in trials which recruit patients to receive an intervention have been published. However, we are not aware of any studies that have reported on the recruitment barriers as perceived by health professionals to recruiting patients into cluster randomised trials where patients do not directly receive an intervention. This particular subtype of cluster trial is commonly termed a professional-cluster trial. The aim of this study was to investigate factors that contributed to general practitioners recruitment of patients in a professional-cluster trial which evaluated the effectiveness of an intervention to increase general practitioners adherence to a clinical practice guideline for acute low-back pain. METHOD: General practitioners enrolled in the study were posted a questionnaire, consisting of quantitative items and an open-ended question, to assess possible reasons for poor patient recruitment. Descriptive statistics were used to summarise quantitative items and responses to the open-ended question were coded into categories. RESULTS: Seventy-nine general practitioners completed at least one item (79/94 = 84%), representing 68 practices (85% practice response rate), and 44 provided a response to the open-ended question. General practitioners recalled inviting a median of two patients with acute low-back pain to participate in the trial over a seven-month period; they reported that they intended to recruit patients, but forgot to approach patients to participate; and they did not perceive that patients had a strong interest or disinterest in participating. Additional open-ended comments were generally consistent with the quantitative data. CONCLUSION: A number of barriers to the recruitment of patients with acute low-back pain by general practitioners in a professional-cluster trial were identified. These barriers were similar to those that have been identified in the literature surrounding the recruitment of patients in individual patient randomised trials. To advance the evidence base for patient recruitment strategies in primary care settings, trialists undertaking professional-cluster trials need to develop and evaluate patient recruitment strategies that minimise the efforts required by practice staff to recruit patients, while also meeting privacy and ethical responsibilities and minimising the risk of selection bias. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN012606000098538 (date registered 14/03/2006)

Photospheric flux cancellation and associated flux rope formation and eruption

We study an evolving bipolar active region that exhibits flux cancellation at the internal polarity inversion line, the formation of a soft X-ray sigmoid along the inversion line and a coronal mass ejection. The evolution of the photospheric magnetic field is described and used to estimate how much flux is reconnected into the flux rope. About one third of the active region flux cancels at the internal polarity inversion line in the 2.5~days leading up to the eruption. In this period, the coronal structure evolves from a weakly to a highly sheared arcade and then to a sigmoid that crosses the inversion line in the inverse direction. These properties suggest that a flux rope has formed prior to the eruption. The amount of cancellation implies that up to 60% of the active region flux could be in the body of the flux rope. We point out that only part of the cancellation contributes to the flux in the rope if the arcade is only weakly sheared, as in the first part of the evolution. This reduces the estimated flux in the rope to $\sim\!30$ or less of the active region flux. We suggest that the remaining discrepancy between our estimate and the limiting value of $\sim\!10$ of the active region flux, obtained previously by the flux rope insertion method, results from the incomplete coherence of the flux rope, due to nonuniform cancellation along the polarity inversion line. A hot linear feature is observed in the active region which rises as part of the eruption and then likely traces out field lines close to the axis of the flux rope. The flux cancellation and changing magnetic connections at one end of this feature suggest that the flux rope reaches coherence by reconnection shortly before and early in the impulsive phase of the associated flare. The sigmoid is destroyed in the eruption but reforms within a few hours after a moderate amount of further cancellation has occurred.Comment: Astron. Astrophys., in pres

Nonthermal properties of supernova remnant G1.9+0.3

The properties of the - presumably - youngest Galactic supernova remnant (SNR) G1.9+0.3 are investigated within the framework of nonlinear kinetic theory of cosmic ray acceleration in SNRs. The observed angular size and expansion speed as well as the radio and X-ray emission measurements are used to determine relevant physical parameters of this SNR. Under the assumption that SNR G1.9+0.3 is the result of a Type Ia supernova near the Galactic center (at the distance d=8.5 kpc) the nonthermal properties are calculated. In particular, the expected TeV gamma-ray spectral energy density is predicted to be as low as $\epsilon_{\gamma}F_{\gamma} \approx 5\times 10^{-15}$ erg cm$^{-2}$ s$^{-1}$, strongly dependent ($F_{\gamma}\propto d^{-11}$) upon the source distance d.Comment: 7 pages, 5 figures, accepted for publication in Ap

Patchy Reconnection in a Y-Type Current Sheet

We study the evolution of the magnetic field in a Y-type current sheet subject to a brief, localized magnetic reconnection event. The reconnection produces up- and down-flowing reconnected flux tubes which rapidly decelerate when they hit the Y-lines and underlying magnetic arcade loops at the ends of the current sheet. This localized reconnection outflow followed by a rapid deceleration reproduces the observed behavior of post-CME downflowing coronal voids. These simulations support the hypothesis that these observed coronal downflows are the retraction of magnetic fields reconnected in localized patches in the high corona.Comment: 4 pages, 3 figure

SIGN-R1 Contributes to Protection against Lethal Pneumococcal Infection in Mice

Rapid clearance of pathogens is essential for successful control of pyogenic bacterial infection. Previous experiments have shown that antibody to specific intracellular adhesion molecule-grabbing nonintegrin (SIGN)-R1 inhibits uptake of capsular polysaccharide by marginal zone macrophages, suggesting a role for SIGN-R1 in this process. We now demonstrate that mice lacking SIGN-R1 (a mouse homologue of human dendritic cell–SIGN receptor) are significantly more susceptible to Streptococcus pneumoniae infection and fail to clear S. pneumoniae from the circulation. Marginal zone and peritoneal macrophages show impaired bacterial recognition associated with an inability to bind T-independent type 2 antigens such as dextran. Our work represents the first evidence for a protective in vivo role for a SIGN family molecule

Observation of An Evolving Magnetic Flux Rope Prior To and During A Solar Eruption

Explosive energy release is a common phenomenon occurring in magnetized plasma systems ranging from laboratories, Earth's magnetosphere, the solar corona and astrophysical environments. Its physical explanation is usually attributed to magnetic reconnection in a thin current sheet. Here we report the important role of magnetic flux rope structure, a volumetric current channel, in producing explosive events. The flux rope is observed as a hot channel prior to and during a solar eruption from the Atmospheric Imaging Assembly (AIA) telescope on board the Solar Dynamic Observatory (SDO). It initially appears as a twisted and writhed sigmoidal structure with a temperature as high as 10 MK and then transforms toward a semi-circular shape during a slow rise phase, which is followed by fast acceleration and onset of a flare. The observations suggest that the instability of the magnetic flux rope trigger the eruption, thus making a major addition to the traditional magnetic-reconnection paradigm.Comment: 13 pages, 3 figure

Evidence-based care of older people with suspected cognitive impairment in general practice: protocol for the IRIS cluster randomised trial

Background: Dementia is a common and complex condition. Evidence-based guidelines for the management of people with dementia in general practice exist; however, detection, diagnosis and disclosure of dementia have been identified as potential evidence-practice gaps. Interventions to implement guidelines into practice have had varying success. The use of theory in designing implementation interventions has been limited, but is advocated because of its potential to yield more effective interventions and aid understanding of factors modifying the magnitude of intervention effects across trials. This protocol describes methods of a randomised trial that tests a theory-informed implementation intervention that, if effective, may provide benefits for patients with dementia and their carers. Aims: This trial aims to estimate the effectiveness of a theory-informed intervention to increase GPs’ (in Victoria, Australia) adherence to a clinical guideline for the detection, diagnosis, and management of dementia in general practice, compared with providing GPs with a printed copy of the guideline. Primary objectives include testing if the intervention is effective in increasing the percentage of patients with suspected cognitive impairment who receive care consistent with two key guideline recommendations: receipt of a i) formal cognitive assessment, and ii) depression assessment using a validated scale (primary outcomes for the trial). Methods: The design is a parallel cluster randomised trial, with clusters being general practices. We aim to recruit 60 practices per group. Practices will be randomised to the intervention and control groups using restricted randomisation. Patients meeting the inclusion criteria, and GPs’ detection and diagnosis behaviours directed toward these patients, will be identified and measured via an electronic search of the medical records nine months after the start of the intervention. Practitioners in the control group will receive a printed copy of the guideline. In addition to receipt of the printed guideline, practitioners in the intervention group will be invited to participate in an interactive, opinion leader-led, educational face-to-face workshop. The theory-informed intervention aims to address identified barriers to and enablers of implementation of recommendations. Researchers responsible for identifying the cohort of patients with suspected cognitive impairment, and their detection and diagnosis outcomes, will be blind to group allocation. Trial registration: Australian New Zealand Clinical Trials Registry: ACTRN12611001032943 (date registered 28 September, 2011)