Effectiveness of aquatic exercise for musculoskeletal conditions: a meta-analysis

Objective To investigate the effectiveness of aquatic exercise in the management of musculoskeletal conditions. Data Sources A systematic review was conducted using Ovid MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Embase, and The Cochrane Central Register of Controlled Trials from earliest record to May 2013. Study Selection We searched for randomized controlled trials (RCTs) and quasi-RCTs evaluating aquatic exercise for adults with musculoskeletal conditions compared with no exercise or land-based exercise. Outcomes of interest were pain, physical function, and quality of life. The electronic search identified 1199 potential studies. Of these, 1136 studies were excluded based on title and abstract. A further 36 studies were excluded after full text review, and the remaining 26 studies were included in this review. Data Extraction Two reviewers independently extracted demographic data and intervention characteristics from included trials. Outcome data, including mean scores and SDs, were also extracted. Data Synthesis The Physiotherapy Evidence Database (PEDro) Scale identified 20 studies with high methodologic quality (PEDro score ≥6). Compared with no exercise, aquatic exercise achieved moderate improvements in pain (standardized mean difference [SMD]=-.37; 95% confidence interval [CI], -.56 to -.18), physical function (SMD=.32; 95% CI,.13-.51), and quality of life (SMD=.39; 95% CI,.06-.73). No significant differences were observed between the effects of aquatic and land-based exercise on pain (SMD=-.11; 95% CI, -.27 to.04), physical function (SMD=-.03; 95% CI, -.19 to.12), or quality of life (SMD=-.10; 95% CI, -.29 to.09). Conclusions The evidence suggests that aquatic exercise has moderate beneficial effects on pain, physical function, and quality of life in adults with musculoskeletal conditions. These benefits appear comparable across conditions and with those achieved with land-based exercise. Further research is needed to understand the characteristics of aquatic exercise programs that provide the most benefit

Acceptability of the 6-PACK falls prevention program: A pre-implementation study in hospitals participating in a cluster randomized controlled trial

There is limited evidence to support the effectiveness of falls prevention interventions in the acute hospital setting. The 6-PACK falls prevention program includes a fall-risk tool; 'falls alert' signs; supervision of patients in the bathroom; ensuring patients' walking AIDS are within reach; toileting regimes; low-low beds; and bed/chair alarms. This study explored the acceptability of the 6-PACK program from the perspective of nurses and senior staff prior to its implementation in a randomised controlled trial. A mixed-methods approach was applied involving 24 acute wards from six Australian hospitals. Participants were nurses working on participating wards and senior hospital staff including: Nurse Unit Managers; senior physicians; Directors of Nursing; and senior personnel involved in quality and safety or falls prevention. Information on program acceptability (suitability, practicality and benefits) was obtained by surveys, focus groups and interviews. Survey data were analysed descriptively, and focus group and interview data thematically. The survey response rate was 60%. Twelve focus groups (n = 96 nurses) and 24 interviews with senior staff were conducted. Falls were identified as a priority patient safety issue and nurses as key players in falls prevention. The 6-PACK program was perceived to offer practical benefits compared to current practice. Nurses agreed fall-risk tools, low-low beds and alert signs were useful for preventing falls (>70%). Views were mixed regarding positioning patients' walking aid within reach. Practical issues raised included access to equipment; and risk of staff injury with low-low bed use. Bathroom supervision was seen to be beneficial, however not always practical. Views on the program appropriateness and benefits were consistent across nurses and senior staff. Staff perceived the 6-PACK program as suitable, practical and beneficial, and were open to adopting the program. Some practical concerns were raised highlighting issues to be addressed by the implementation plan

Barriers and enablers to the implementation of the 6-PACK falls prevention program: A preimplementation study in hospitals participating in a cluster randomised controlled trial

Evidence for effective falls prevention interventions in acute wards is limited. One reason for this may be suboptimal program implementation. This study aimed to identify perceived barriers and enablers of the implementation of the 6-PACK falls prevention program to inform the implementation in a randomised controlled trial. Strategies to optimise successful implementation of 6-PACK were also sought. A mixed-methods approach was applied in 24 acute wards from 6 Australian hospitals. Participants were nurses working on participating wards and senior hospital staff including Nurse Unit Managers; senior physicians; Directors of Nursing; and senior personnel involved in quality and safety or falls prevention. Information on barriers and enablers of 6-PACK implementation was obtained through surveys, focus groups and interviews. Questions reflected the COM-B framework that includes three behaviour change constructs of: capability, opportunity and motivation. Focus group and interview data were analysed thematically, and survey data descriptively. The survey response rate was 60% (420/702), and 12 focus groups (n = 96 nurses) and 24 interviews with senior staff were conducted. Capability barriers included beliefs that falls could not be prevented; and limited knowledge on falls prevention in patients with complex care needs (e.g. cognitive impairment). Capability enablers included education and training, particularly face to face case study based approaches. Lack of resources was identified as an opportunity barrier. Leadership, champions and using data to drive practice change were recognised as opportunity enablers. Motivation barriers included complacency and lack of ownership in falls prevention efforts. Motivation enablers included senior staff articulating clear goals and a commitment to falls prevention; and use of reminders, audits and feedback. The information gained from this study suggests that regular practical face-to-face education and training for nurses; provision of equipment; audit, reminders and feedback; leadership and champions; and the provision of falls data is key to successful falls prevention program implementation in acute hospitals

Implementation fidelity of a nurse-led falls prevention program in acute hospitals during the 6-PACK trial

Background: When tested in a randomized controlled trial (RCT) of 31,411 patients, the nurse-led 6-PACK falls prevention program did not reduce falls. Poor implementation fidelity (i.e., program not implemented as intended) may explain this result. Despite repeated calls for the examination of implementation fidelity as an essential component of evaluating interventions designed to improve the delivery of care, it has been neglected in prior falls prevention studies. This study examined implementation fidelity of the 6-PACK program during a large multi-site RCT. Methods: Based on the 6-PACK implementation framework and intervention description, implementation fidelity was examined by quantifying adherence to program components and organizational support. Adherence indicators were: 1) falls-risk tool completion; and for patients classified as high-risk, provision of 2) a ‘Falls alert’ sign; and 3) at least one additional 6-PACK intervention. Organizational support indicators were: 1) provision of resources (executive sponsorship, site clinical leaders and equipment); 2) implementation activities (modification of patient care plans; training; implementation tailoring; audits, reminders and feedback; and provision of data); and 3) program acceptability. Data were collected from daily bedside observation, medical records, resource utilization diaries and nurse surveys. Results: All seven intervention components were delivered on the 12 intervention wards. Program adherence data were collected from 103,398 observations and medical record audits. The falls-risk tool was completed each day for 75% of patients. Of the 38% of patients classified as high-risk, 79% had a ‘Falls alert’ sign and 63% were provided with at least one additional 6-PACK intervention, as recommended. All hospitals provided the recommended resources and undertook the nine outlined program implementation activities. Most of the nurses surveyed considered program components important for falls prevention. Conclusions: While implementation fidelity was variable across wards, overall it was found to be acceptable during the RCT. Implementation failure is unlikely to be a key factor for the observed lack of program effectiveness in the 6-PACK trial. Trial registration: The 6-PACK cluster RCT is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12611000332921 (29 March 2011)

Jumping into the deep-end: results from a pilot impact evaluation of a community-based aquatic exercise program

This multi-center quasi-experimental pilot study aimed to evaluate changes in pain, joint stiffness, physical function, and quality of life over 12 weeks in adults with musculoskeletal conditions attending ‘Waves’ aquatic exercise classes. A total of 109 adults (mean age, 65.2 years; range, 24–93 years) with musculoskeletal conditions were recruited across 18 Australian community aquatic centers. The intervention is a peer-led, 45 min, weekly aquatic exercise class including aerobic, strength, flexibility, and balance exercises (n = 67). The study also included a control group of people not participating in Waves or other formal exercise (n = 42). Outcomes were measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and EuroQoL five dimensions survey (EQ-5D) at baseline and 12 weeks. Satisfaction with Waves classes was also measured at 12 weeks. Eighty two participants (43 Waves and 39 control) completed the study protocol and were included in the analysis. High levels of satisfaction with classes were reported by Waves participants. Over 90 % of participants reported Waves classes were enjoyable and would recommend classes to others. Waves participants demonstrated improvements in WOMAC and EQ-5D scores however between-group differences did not reach statistical significance. Peer-led aquatic exercise classes appear to improve pain, joint stiffness, physical function and quality of life for people with musculoskeletal conditions. The diverse study sample is likely to have limited the power to detect significant changes in outcomes. Larger studies with an adequate follow-up period are needed to confirm effects

A mixed methods process evaluation of a person-centred falls prevention program

Background RESPOND is a telephone-based falls prevention program for older people who present to a hospital emergency department (ED) with a fall. A randomised controlled trial (RCT) found RESPOND to be effective at reducing the rate of falls and fractures, compared with usual care, but not fall injuries or hospitalisations. This process evaluation aimed to determine whether RESPOND was implemented as planned, and identify implementation barriers and facilitators. Methods A mixed-methods evaluation was conducted alongside the RCT. Evaluation participants were the RESPOND intervention group (n=263) and the clinicians delivering RESPOND (n=7). Evaluation data were collected from participant recruitment and intervention records, hospital administrative records, audio-recordings of intervention sessions, and participant questionnaires. The Rochester Participatory Decision-Making scale (RPAD) was used to evaluate person-centredness (score range 0 (worst) - 9 (best)). Process factors were compared with pre-specified criteria to determine implementation fidelity. Six focus groups were held with participants (n=41), and interviews were conducted with RESPOND clinicians (n=6). Quantitative data were analysed descriptively and qualitative data thematically. Barriers and facilitators to implementation were mapped to the ‘Capability, Opportunity, Motivation – Behaviour’ (COM-B) behaviour change framework. Results RESPOND was implemented at a lower dose than the planned 10 hours over six months, with a median (IQR) of 2.9 hours (2.1, 4). The majority (76%) of participants received their first intervention session within one month of hospital discharge. Clinicians delivered the program in a person-centred manner with a median (IQR) RPAD score of 7 (6.5, 7.5) and 87% of questionnaire respondents were satisfied with the program. The reports from participants and clinicians suggested that implementation was facilitated by the use of positive and personally relevant health messages. Complex health and social issues were the main barriers to implementation. Conclusions RESPOND was person-centred and reduced falls and fractures at a substantially lower dose, using fewer resources, than anticipated. However, the low dose delivered may account for the lack of effect on falls injuries and hospitalisations. The results from this evaluation provide detailed information to guide future implementation of RESPOND of similar programs. Trial registration: This study was registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12614000336684 (27 March 2014)

A social and ecological assessment of tropical land uses at multiple scales: the Sustainable Amazon Network

Science has a critical role to play in guiding more sustainable development trajectories. Here, we present the Sustainable Amazon Network (Rede Amazonia Sustentavel, RAS): a multidisciplinary research initiative involving more than 30 partner organizations working to assess both social and ecological dimensions of land-use sustainability in eastern Brazilian Amazonia. The research approach adopted by RAS offers three advantages for addressing land-use sustainability problems: (i) the collection of synchronized and co-located ecological and socioeconomic data across broad gradients of past and present human use; (ii) a nested sampling design to aid comparison of ecological and socioeconomic conditions associated with different land uses across local, landscape and regional scales; and (iii) a strong engagement with a wide variety of actors and non-research institutions. Here, we elaborate on these key features, and identify the ways in which RAS can help in highlighting those problems in most urgent need of attention, and in guiding improvements in land-use sustainability in Amazonia and elsewhere in the tropics. We also discuss some of the practical lessons, limitations and realities faced during the development of the RAS initiative so far.Keywords: Social–ecological systems, Tropical forests, Land use, Interdisciplinary research, Sustainability, Trade-off

Undertaking and using health service evaluations in the field

There is a great need for decision makers in healthcare to use robust and reliable evidence to support clinical and health policy choices that aim to improve the quality of healthcare and support the efficient use of scarce resources. This evidence is, however, often lacking in quality, quantity and reliability. While many health interventions hold good face validity, their implementation and use in practice may not always produce the desired improvements in patient care. This gap suggests that challenges exist in the production of such evidence. This thesis sought to respond to this challenge through the undertaking of two health service evaluations. Each evaluation representing an independent, discrete piece of work addressing the primary objective of this thesis—to evaluate the impact of specific complex health interventions —providing evidence for, or against, its ongoing use. These evaluation case studies then provided a platform for reflecting on the contextual issues of the evaluation, lessons learnt and challenges confronted, addressing the second objective of this thesis—to describe the methodological and practical challenges experienced when undertaking such health service evaluations. Case study 1 was a retrospective evaluation of a Telephone Support Program for elderly people with Chronic or Complex care needs. The intervention was developed and implemented by a private healthcare provider and commissioned by a private health insurer, aimed at reducing avoidable hospital admissions for elderly members living in the community. A non-randomised controlled study design was employed using propensity score matching. Compared to matched controls, the intervention was not observed to reduce hospital use of healthcare utilisation costs. However it was unclear if the finding of no effect was due to poor implementation fidelity, issues with data quality and integrity, methodological limitations of the evaluation or an ineffective intervention. Case study 2 was a comprehensive evaluation of the 6-PACK program, a falls prevention intervention specifically developed for acute hospital wards. It was undertaken as part of a rigorously designed cluster randomised control trial (RCT) involving six hospitals (24 acute wards) across Australia and included an economic evaluation, a cost of fall study and an examination of implementation fidelity. The program was found to be ineffective at reducing fall (IRR = 1.04, 95% CI, 0.78 to 1.37; P=0.796) or fall injuries (IRR, 0.96, 95% CI, 0.72 to 1.27; P=0.766), above that of usual care, as such an economic evaluation was not undertaken. The cost of fall study found that patients who experienced an in-hospital fall were observed to have a 7 day longer hospital stay (p<0.000) and an additional AUD$5,395 in hospitalisation costs (p<0.000), compared to those without a recorded fall. While patients who experienced a fall-related injury had an 11 day longer hospital stay (p<0.000) and an additional AUD$9,917 in hospitalisation costs (p=0.003), compared to those without a recorded fall. The examination of implementation fidelity found reasonable levels of implementation fidelity during the cluster RCT. Therefore implementation failure did not appear to have been a key factor for the observed no effect in the 6-PACK trial. These case studies highlighted some common challenges faced by evaluators when examining the impacts of an intervention in the ‘real-world’ setting. Three key themes emerged from the two case studies: 1) the challenges with designing and undertaking rigorous evaluations in the ‘real-world’ setting; 2) the use of secondary data sources, particularly with the measurement of outcome and confounding variables and the use of data across organisations and jurisdictions; and 3) the ability to define and examine implementation fidelity of complex health interventions. When examining complex health interventions determining the level of implementation fidelity is essential to the interpretation of study findings, particularly when conducted in the dynamic and complicated environment, that is, healthcare. In addition, to ensure a more rigorous approach to health service evaluation in the ‘real-world’ is taken, resources need to be dedicated to enhance existing data sources and systems that are more conducive to evaluation, improving the strength of measures and the ability for data linkage to occur easily across sites and jurisdictions

Measuring safety climate in acute hospitals:Rasch analysis of the safety attitudes questionnaire

Background: The Safety Attitudes Questionnaire (SAQ) is commonly used to assess staff perception of safety climate within their clinical environment. The psychometric properties of the SAQ have previously been explored with confirmatory factor analysis and found to have some issues with construct validity. This study aimed to extend the psychometric evaluations of the SAQ by using Rasch analysi