Looking inside the black box : a theory-based process evaluation alongside a randomised controlled trial of printed educational materials (the Ontario printed educational message, OPEM) to improve referral and prescribing practices in primary care in Ontario, Canada

Background: Randomised controlled trials of implementation strategies tell us whether (or not) an intervention results in changes in professional behaviour but little about the causal mechanisms that produce any change. Theory-based process evaluations collect data on theoretical constructs alongside randomised trials to explore possible causal mechanisms and effect modifiers. This is similar to measuring intermediate endpoints in clinical trials to further understand the biological basis of any observed effects (for example, measuring lipid profiles alongside trials of lipid lowering drugs where the primary endpoint could be reduction in vascular related deaths). This study protocol describes a theory-based process evaluation alongside the Ontario Printed Educational Message (OPEM) trial. We hypothesize that the OPEM interventions are most likely to operate through changes in physicians' behavioural intentions due to improved attitudes or subjective norms with little or no change in perceived behavioural control. We will test this hypothesis using a well-validated social cognition model, the theory of planned behaviour (TPB) that incorporates these constructs. Methods/design: We will develop theory-based surveys using standard methods based upon the TPB for the second and third replications, and survey a subsample of Ontario family physicians from each arm of the trial two months before and six months after the dissemination of the index edition of informed, the evidence based newsletter used for the interventions. In the third replication, our study will converge with the "TRY-ME" protocol (a second study conducted alongside the OPEM trial), in which the content of educational messages was constructed using both standard methods and methods informed by psychological theory. We will modify Dillman's total design method to maximise response rates. Preliminary analyses will initially assess the internal reliability of the measures and use regression to explore the relationships between predictor and dependent variable (intention to advise diabetic patients to have annual retinopathy screening and to prescribe thiazide diuretics for first line treatment of uncomplicated hypertension). We will then compare groups using methods appropriate for comparing independent samples to determine whether there have been changes in the predicted constructs (attitudes, subjective norms, or intentions) across the study groups as hypothesised, and will assess the convergence between the process evaluation results and the main trial results.The OPEM trial and OPEM process evaluation are funded by the Canadian Institute of Health Research (CIHR). The OPEM process evaluation study was developed as part of the CIHR funded interdisciplinary capacity enhancement team KT-ICEBeRG. Gaston Godin, Jeremy Grimshaw and France Légaré hold Canada Research Chairs. Louise Lemyre holds an R.S. McLaughlin Research Chair

The microstructure of coaching practice:Behaviours and activities of an elite rugby union head coach during preparation and competition

The activities and behaviours of a female head coach of a national rugby union team were recorded in both training and competition, across a whole rugby season, using the newly developed Rugby Coach Activities and Behaviours Instrument (RCABI). The instrument incorporates 24 categories of behaviour, embedded within three forms of activity (training form, playing form and competitive match) and seven sub-activity types. In contrast to traditional drill-based coaching, 58.5% of training time was found to have been spent in playing form activities. Moreover, the proportion of playing form activities increased to a peak average of 83.8% in proximity to the team’s annual international championship. Uniquely, one of the coach’s most prolific behaviours was conferring with associates (23.3%), highlighting the importance of interactions with assistant coaches, medical staff and others in shaping the coaching process. Additionally, the frequencies of key behaviours such as questioning and praise were found to vary between the different activity forms and types, raising questions about previous conceptions of effective coaching practice. The findings are discussed in the light of the Game Sense philosophy and the role of the head coach

Perfectionism and achievement goals in young Finnish ice-hockey players aspiring to make the Under-16 national team

Research on perfectionism suggests that is it useful to differentiate between perfectionistic strivings and perfectionistic concerns. Regarding the 2 x 2 achievement goal framework, the usefulness of this differentiation was recently demonstrated in a study with university student athletes (Stoeber, Stoll, Pescheck, & Otto, 2008, Study 2), in which it was found that perfectionistic strivings were associated with mastery-approach and performance-approach goals and perfectionistic concerns with mastery-avoidance, performance-approach, and performance-avoidance goals. Because the study was largely exploratory and only used non-elite athletes, the aim of the present research was to replicate and extend these findings by investigating a sample of 138 young, elite ice-hockey players, while adding further measures of perfectionism and using structural equation modelling (SEM) to confirm the relationships between perfectionistic strivings, perfectionistic concerns,and the 2 x 2 achievement goals. The SEM results showed that, in elite athletes also, perfectionistic strivings are associated with mastery-approach and performance-approach goals, whereas perfectionistic concerns are associated with masteryavoidance, performance-approach, and performance-avoidance goals. Our findings corroborate the importance of differentiating between perfectionistic strivings and perfectionistic concerns when studying perfectionism in sports, because only perfectionistic concerns (and not perfectionistic strivings) are associated with maladaptive patterns of achievement goals

Rare copy number variants contribute to congenital left-sided heart disease

Left-sided congenital heart disease (CHD) encompasses a spectrum of malformations that range from bicuspid aortic valve to hypoplastic left heart syndrome. It contributes significantly to infant mortality and has serious implications in adult cardiology. Although left-sided CHD is known to be highly heritable, the underlying genetic determinants are largely unidentified. In this study, we sought to determine the impact of structural genomic variation on left-sided CHD and compared multiplex families (464 individuals with 174 affecteds (37.5%) in 59 multiplex families and 8 trios) to 1,582 well-phenotyped controls. 73 unique inherited or de novo CNVs in 54 individuals were identified in the left-sided CHD cohort. After stringent filtering, our gene inventory reveals 25 new candidates for LS-CHD pathogenesis, such as SMC1A, MFAP4, and CTHRC1, and overlaps with several known syndromic loci. Conservative estimation examining the overlap of the prioritized gene content with CNVs present only in affected individuals in our cohort implies a strong effect for unique CNVs in at least 10% of left-sided CHD cases. Enrichment testing of gene content in all identified CNVs showed a significant association with angiogenesis. In this first family-based CNV study of left-sided CHD, we found that both co-segregating and de novo events associate with disease in a complex fashion at structural genomic level. Often viewed as an anatomically circumscript disease, a subset of left-sided CHD may in fact reflect more general genetic perturbations of angiogenesis and/or vascular biology

On passion and moral behavior in achievement settings: The mediating role of pride

The Dualistic Model of Passion (Vallerand et al., 2003) distinguishes two types of passion: harmonious passion (HP) and obsessive passion (OP) that predict adaptive and less adaptive outcomes, respectively. In the present research, we were interested in understanding the role of passion in the adoption of moral behavior in achievement settings. It was predicted that the two facets of pride (authentic and hubristic; Tracy & Robins, 2007) would mediate the passion-moral behavior relationship. Specifically, because people who are passionate about a given activity are highly involved in it, it was postulated that they should typically do well and thus experience high levels of pride when engaged in the activity. However, it was also hypothesized that while both types of passion should be conducive to authentic pride, only OP should lead to hubristic pride. Finally, in line with past research on pride (Carver, Sinclair, & Johnson, 2010; Tracy et al., 2009), only hubristic pride was expected to negatively predict moral behavior, while authentic pride was expected to positively predict moral behavior. Results of two studies conducted with paintball players (N=163, Study 1) and athletes (N=296, Study 2) supported the proposed model. Future research directions are discussed in light of the Dualistic Model of Passion

Looking inside the black box: results of a theory-based process evaluation exploring the results of a randomized controlled trial of printed educational messages to increase primary care physicians' diabetic retinopathy referrals [Trial registration number ISRCTN72772651]

Background: Theory-based process evaluations conducted alongside randomized controlled trials provide the opportunity to investigate hypothesized mechanisms of action of interventions, helping to build a cumulative knowledge base and to inform the interpretation of individual trial outcomes. Our objective was to identify the underlying causal mechanisms in a cluster randomized trial of the effectiveness of printed educational materials (PEMs) to increase referral for diabetic retinopathy screening. We hypothesized that the PEMs would increase physicians’ intention to refer patients for retinal screening by strengthening their attitude and subjective norm, but not their perceived behavioral control. Methods: Design: A theory based process evaluation alongside the Ontario Printed Educational Material (OPEM) cluster randomized trial. Postal surveys based on the Theory of Planned Behavior were sent to a random sample of trial participants two months before and six months after they received the intervention. Setting: Family physicians in Ontario, Canada. Participants: 1,512 family physicians (252 per intervention group) from the OPEM trial were invited to participate, and 31.3% (473/1512) responded at time one and time two. The final sample comprised 437 family physicians fully completing questionnaires at both time points. Main outcome measures: Primary: behavioral intention related to referring patient for retinopathy screening; secondary: attitude, subjective norm, perceived behavioral control. Results: At baseline, family physicians reported positive intention, attitude, subjective norm, and perceived behavioral control to advise patients about retinopathy screening suggesting limited opportunities for improvement in these constructs. There were no significant differences on intention, attitude, subjective norm, and perceived behavioral control following the intervention. Respondents also reported additional physician- and patient-related factors perceived to influence whether patients received retinopathy screening. Conclusions: Lack of change in the primary and secondary theory-based outcomes provides an explanation for the lack of observed effect of the main OPEM trial. High baseline levels of intention to advise patients to attend retinopathy screening suggest that post-intentional and other factors may explain gaps in care. Process evaluations based on behavioral theory can provide replicable and generalizable insights to aid interpretation of randomized controlled trials of complex interventions to change health professional behavior

Altered surfactant homeostasis and recurrent respiratory failure secondary to TTF-1 nuclear targeting defect

Background: Mutations of genes affecting surfactant homeostasis, such as SFTPB, SFTPC and ABCA3, lead to diffuse lung disease in neonates and children. Haploinsufficiency of NKX2.1, the gene encoding the thyroid transcription factor-1 (TTF-1) - critical for lung, thyroid and central nervous system morphogenesis and function - causes a rare form of progressive respiratory failure designated brain-lung-thyroid syndrome. Molecular mechanisms involved in this syndrome are heterogeneous and poorly explored. We report a novel TTF-1 molecular defect causing recurrent respiratory failure episodes in an infant.Methods: The subject was an infant with severe neonatal respiratory distress syndrome followed by recurrent respiratory failure episodes, hypopituitarism and neurological abnormalities. Lung histology and ultrastructure were assessed by surgical biopsy. Surfactant-related genes were studied by direct genomic DNA sequencing and array chromatine genomic hybridization (aCGH). Surfactant protein expression in lung tissue was analyzed by confocal immunofluorescence microscopy. For kinetics studies, surfactant protein B and disaturated phosphatidylcholine (DSPC) were isolated from serial tracheal aspirates after intravenous administration of stable isotope-labeled 2H2O and 13C-leucine; fractional synthetic rate was derived from gas chromatography/mass spectrometry 2H and 13C enrichment curves. Six intubated infants with no primary lung disease were used as controls.Results: Lung biopsy showed desquamative interstitial pneumonitis and lamellar body abnormalities suggestive of genetic surfactant deficiency. Genetic studies identified a heterozygous ABCA3 mutation, L941P, previously unreported. No SFTPB, SFTPC or NKX2.1 mutations or deletions were found. However, immunofluorescence studies showed TTF-1 prevalently expressed in type II cell cytoplasm instead of nucleus, indicating defective nuclear targeting. This pattern has not been reported in human and was not found in two healthy controls and in five ABCA3 mutation carriers. Kinetic studies demonstrated a marked reduction of SP-B synthesis (43.2 vs. 76.5 \ub1 24.8%/day); conversely, DSPC synthesis was higher (12.4 vs. 6.3 \ub1 0.5%/day) compared to controls, although there was a marked reduction of DSPC content in tracheal aspirates (29.8 vs. 56.1 \ub1 12.4% of total phospholipid content).Conclusion: Defective TTF-1 signaling may result in profound surfactant homeostasis disruption and neonatal/pediatric diffuse lung disease. Heterozygous ABCA3 missense mutations may act as disease modifiers in other genetic surfactant defects

Perfectionism, burnout and engagement in youth sport: The mediating role of basic psychological needs

© 2016 Elsevier Ltd. Recent research indicates perfectionistic concerns and perfectionistic strivings share divergent associations with athlete burnout and athlete engagement. Guided by self-determination theory, the present study examined whether these associations were explained by basic psychological needs. Youth athletes (n = 222, M age = 16.01, SD = 2.68) completed measures of multidimensional perfectionism, athlete burnout, athlete engagement, basic psychological need satisfaction and thwarting. Structural equation modelling revealed that basic psychological need satisfaction and thwarting mediated the perfectionism-engagement and perfectionism-burnout relationships. Perfectionistic concerns shared a negative relationship (via need satisfaction) with athlete engagement and a positive relationship (via need satisfaction and thwarting) with athlete burnout. In contrast, perfectionistic strivings shared a positive relationship (via need satisfaction) with athlete engagement and a negative relationship (via need satisfaction and thwarting) with athlete burnout. The findings highlight the role of basic psychological needs in explaining the differential associations that perfectionistic concerns and strivings share with athlete burnout and engagement

Bricoleurs Extraordinaire: Sports Coaches in Inter War Britain

In Inter War Britain, individuals exploited their athletic skills by pursuing professional careers, or adopting amateur roles, as instructors, trainers and coaches, invariably drawing from, and elaborating on, existing practices. The coach was the master of a body of specialist craft knowledge, the tacit nature of which was transmitted through ‘stealing with the eyes’ as the apprentice watched the master in action (Gamble, 2001). Professional coaches saw themselves as practical men whose experiential knowledge concerning diet, physiological and psychological preparation, stimulants, massaging, medical treatments, talent identification, and so on provided critical components in their coaching ‘toolbox’ (Nelson, 1924, 25-26). Craft knowledge was never static. Coaching expertise is a fluid, cyclical process with practitioners continuously redeveloping their competencies (Turner, Nelson and Potrac, 2012, 323), and part of traditional craft expertise was the ability to react positively to shifting circumstances. Coaches were constantly stimulated to experiment by competitors, commercialisation, and emerging technologies (Clegg, 1977, 244), and they exemplified the notion of the ‘Bricoleur’ in constantly trialling emerging knowledge, intuitively accepting or rejecting appropriate material. This paper explores the ways in which practitioners developed their coaching ‘toolbox’ in Inter War Britain by drawing on examples from newspaper reports, personal and public archives, and instructional texts (eg. Tilden, 1920; Gent, 1922; Nelson, 1924; Mussabini, 1926; Lowe and Porritt, 1929; Abrahams and Abrahams, 1936). The author highlights the range of knowledge that coaches had at their command, well before the emergence of sports science and coaching certification programmes, and questions assumptions that coaches can no longer rely solely on ‘learning the trade’ through experience (Evans and Light, 2007). As Winchester et al. (2013) have emphasised, knowledge, skills, attitudes, and insights are developed from daily experiences in sport, work and at home, as well as through exposure to the coaching environment, and contemporary coaches still employ a largely implicit form of knowledge, closely connected to past experiences, which shares similarities with Inter War craft knowledge (Smith and Cushion, 2006, 363; Jones, Armour and Potrac, 2003), while identifying experimentation and experience as key reference points (Irwin, Hanton and Kerwin, 2004, 436, 439; Potrac, Jones and Cushion, 2007)