Amanda S. Newton

Systematic review of knowledge translation strategies in the allied health professions

BackgroundKnowledge translation (KT) aims to close the research-practice gap in order to realize and maximize the benefits of research within the practice setting. Previous studies have investigated KT strategies in nursing and medicine; however, the present study is the first systematic review of the effectiveness of a variety of KT interventions in five allied health disciplines: dietetics, occupational therapy, pharmacy, physiotherapy, and speech-language pathology.MethodsA health research librarian developed and implemented search strategies in eight electronic databases (MEDLINE, CINAHL, ERIC, PASCAL, EMBASE, IPA, Scopus, CENTRAL) using language (English) and date restrictions (1985 to March 2010). Other relevant sources were manually searched. Two reviewers independently screened the titles and abstracts, reviewed full-text articles, performed data extraction, and performed quality assessment. Within each profession, evidence tables were created, grouping and analyzing data by research design, KT strategy, targeted behaviour, and primary outcome. The published descriptions of the KT interventions were compared to the Workgroup for Intervention Development and Evaluation Research (WIDER) Recommendations to Improve the Reporting of the Content of Behaviour Change Interventions.ResultsA total of 2,638 articles were located and the titles and abstracts were screened. Of those, 1,172 full-text articles were reviewed and subsequently 32 studies were included in the systematic review. A variety of single (n = 15) and multiple (n = 17) KT interventions were identified, with educational meetings being the predominant KT strategy (n = 11). The majority of primary outcomes were identified as professional/process outcomes (n = 25); however, patient outcomes (n = 4), economic outcomes (n = 2), and multiple primary outcomes (n = 1) were also represented. Generally, the studies were of low methodological quality. Outcome reporting bias was common and precluded clear determination of intervention effectiveness. In the majority of studies, the interventions demonstrated mixed effects on primary outcomes, and only four studies demonstrated statistically significant, positive effects on primary outcomes. None of the studies satisfied the four WIDER Recommendations.ConclusionsAcross five allied health professions, equivocal results, low methodological quality, and outcome reporting bias limited our ability to recommend one KT strategy over another. Further research employing the WIDER Recommendations is needed to inform the development and implementation of effective KT interventions in allied health.

Antipsychotics in Adults With Schizophrenia: Comparative Effectiveness of First-Generation Versus Second-Generation Medications: A Systematic Review and Meta-analysis

BACKGROUND Debate continues about the comparative benefits and harms of first-generation antipsychotics (FGAs) and second-generation antipsychotics (SGAs) in treating schizophrenia. PURPOSE To compare the effects of FGAs with those of SGAs in the treatment of adults aged 18 to 64 years with schizophrenia and related psychosis on illness symptoms, diabetes mellitus, mortality,tardive dyskinesia, and a major metabolic syndrome. DATA SOURCES English-language studies from 10 electronic databases to March 2012, reference lists of relevant articles, and gray literature. STUDY SELECTION Randomized trials for efficacy and cohort studies at least 2 years in duration for adverse events. DATA EXTRACTION Two independent reviewers extracted data from 114 studies involving 22 comparisons and graded the strength of evidence for primary outcomes as insufficient, low, moderate, or high using the Grading of Recommendations Assessment, Development and Evaluation approach. DATA SYNTHESIS Few differences of clinical importance were found for core illness symptoms; lack of precision in effect estimates precluded firm conclusions for many comparisons. Moderate-strength evidence showed a clinically important benefit of haloperidol over olanzapine for improving positive symptoms, but the benefit was scale-dependent: It was seen when the Scale for the Assessment of Positive Symptoms was used but not when the Positive and Negative Syndrome Scale (PANSS) was used. Moderate-strength evidence showed a clinically important benefit of olanzapine over haloperidol in improving negative symptoms when the PANSS and the Scale for the Assessment of Negative Symptoms were used. Low-strength evidence showed no difference in mortality for chlorpromazine verus clozapine or haloperidol versus aripiprazole,increased incidence of the metabolic syndrome for olanzapine versus haloperidol (risk differences, 2% and 22%), and higher incidence of tardive dyskinesia for chlorpromazine versus clozapine (risk differences, 5% and 9%). Evidence was insufficient to draw conclusions for diabetes mellitus. LIMITATIONS All studies had high or unclear risk of bias. Length of study follow-up was often too brief to adequately measure adverse events. Medication comparisons, dosage, and outcome measurement were heterogenous for head-to-head comparisons. Selective patient populations limit generalizability. CONCLUSION Clear benefits of FGAs versus SGAs for treating schizophrenia remain inconclusive because of variation in assessing outcomes and lack of clinically important differences for most comparisons. The strength of evidence on safety for major medical events is low or insufficient. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality.

Neighborhood physical activity opportunities for inner-city children and youth

The purpose of this study was to assess perceived physical activity (PA) opportunities and barriers for inner-city youth. Data were collected via interviews with 59 children, 8 school staff, and 13 youth workers plus objective neighborhood data. Analyses revealed three themes that influenced PA: neighborhood characteristics, family involvement, and adult-supervised programs. The neighborhood was highly walkable and multiple play spaces were available, but safety concerns restricted access. Children were rarely allowed out alone, but family accompaniment facilitated PA. Organized programs provided adult-supervised PA, but programs faced staffing problems that served to limit the provision of PA opportunities. Multiple ecological factors constrain or enable PA among inner-city youth.

Predictors of severe H1N1 infection in children presenting within Pediatric Emergency Research Networks (PERN): retrospective case-control study.

Objective To identify historical and clinical findings at emergency department presentation associated with severe H1N1 outcome in children presenting with influenza-like illness. Design Multicentre retrospective case-control study. Setting 79 emergency departments of hospitals associated with the Pediatric Emergency Research Networks in 12 countries. Participants 265 children (<16 years), presenting between 16 April and 31 December 2009, who fulfilled Centers for Disease Control and Prevention criteria for influenza-like illness and developed severe outcomes from laboratory confirmed H1N1 infection. For each case, two controls presenting with influenza-like illness but without severe outcomes were included: one random control and one age matched control. Main outcome measures Severe outcomes included death or admission to intensive care for assisted ventilation, inotropic support, or both. Multivariable conditional logistic regression was used to compare cases and controls, with effect sizes measured as adjusted odds ratios. Results 151 (57%) of the 265 cases were male, the median age was 6 (interquartile range 2.3-10.0) years, and 27 (10%) died. Six factors were associated with severe outcomes in children presenting with influenza-like illness: history of chronic lung disease (odds ratio 10.3, 95% confidence interval 1.5 to 69.8), history of cerebral palsy/developmental delay (10.2, 2.0 to 51.4), signs of chest retractions (9.6, 3.2 to 29.0), signs of dehydration (8.8, 1.6 to 49.3), requirement for oxygen (5.8, 2.0 to 16.2), and tachycardia relative to age). Conclusion These independent risk factors may alert clinicians to children at risk of severe outcomes when presenting with influenza-like illness during future pandemics.

Prevalence and Effect of Cyberbullying on Children and Young People: A Scoping Review of Social Media Studies

IMPORTANCE Social media has had a profound effect on how children and adolescents interact. While there are many benefits to the use of social media, cyberbullying has emerged as a potential harm, raising questions regarding its influence on mental health. OBJECTIVE To review existing publications that examine the health-related effects of cyberbullying via social media among children and adolescents. EVIDENCE REVIEW We searched 11 electronic databases from January 1, 2000, through January 17, 2012 (updated June 24, 2014). Studies were screened by 2 independent reviewers and were included if they reported primary research, described or evaluated the use of a social media tool in the context of cyberbullying, and were conducted with children or adolescents. Data were extracted by 1 reviewer and verified by a second. All studies were assessed by 2 reviewers for methodological quality using the Mixed Methods Appraisal Tool. Results were not pooled owing to heterogeneity in study objectives and outcomes; a narrative analysis is presented. FINDINGS Thirty-six studies in 34 publications were included. Most were conducted in the United States (21 [58.3%]), sampled middle and high school populations (24 [66.7%]), and included adolescents who were 12 to 18 years of age (35 [97.2%]). The median reported prevalence of cyberbullying was 23.0% (interquartile range, 11.0%-42.6%). Five studies reported inconsistent and/or weak correlations between cyberbullying and anxiety. Ten studies found a statistically significant association between cyberbullying and report of depression. Five studies investigated self-harm or suicidality, with conflicting results. Results indicate that the most common reason for cyberbullying is relationship issues, with girls most often being the recipients. Responses to cyberbullying are most often passive, with a pervasive lack of awareness or confidence that anything can be done. CONCLUSIONS AND RELEVANCE There is a consistent relationship across studies between cyberbullying and depression among children and adolescents; however, the evidence of the effect of cyberbullying on other mental health conditions is inconsistent. This review provides important information that characterizes cyberbullying within the context of social media, including attributes of the recipients and perpetrators, reasons for and the nature of bullying behaviors, and how recipients react to and manage bullying behaviors. This information is critical to the development of effective prevention and management strategies.

Music to Reduce Pain and Distress in the Pediatric Emergency Department: A Randomized Clinical Trial

IMPORTANCE Many medical procedures aimed at helping children cause them pain and distress, which can have long-lasting negative effects. Music is a form of distraction that may alleviate some of the pain and distress experienced by children while undergoing medical procedures. OBJECTIVE To compare music with standard care to manage pain and distress. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial conducted in a pediatric emergency department with appropriate sequence generation and adequate allocation concealment from January 1, 2009, to March 31, 2010. Individuals assessing the primary outcome were blind to treatment allocation. A total of 42 children aged 3 to 11 years undergoing intravenous placement were included. INTERVENTIONS Music (recordings selected by a music therapist via ambient speakers) vs standard care. MAIN OUTCOMES AND MEASURES The primary outcome was behavioral distress assessed blinded using the Observational Scale of Behavioral Distress-Revised. The secondary outcomes included child-reported pain, heart rate, parent and health care provider satisfaction, ease of performing the procedure, and parental anxiety. RESULTS With or without controlling for potential confounders, we found no significant difference in the change in behavioral distress from before the procedure to immediately after the procedure. When children who had no distress during the procedure were removed from the analysis, there was a significantly less increase in distress for the music group (standard care group = 2.2 vs music group = 1.1, P < .05). Pain scores among children in the standard care group increased by 2 points, while they remained the same in the music group (P = .04); the difference was considered clinically important. The pattern of parent satisfaction with the management of childrens pain was different between groups, although not statistically significant (P = .07). Health care providers reported that it was easier to perform the procedure for children in the music group (76% very easy) vs the standard care group (38% very easy) (P = .03). Health care providers were more satisfied with the intravenous placement in the music group (86% very satisfied) compared with the standard care group (48%) (P = .02). CONCLUSIONS AND RELEVANCE Music may have a positive impact on pain and distress for children undergoing intravenous placement. Benefits were also observed for the parents and health care providers. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00761033.

Physical education and sport programs at an inner city school: exploring possibilities for positive youth development

Background: School-based recreational opportunities for youth from low-income inner-city neighbourhoods are often lacking. School programs represent an ideal location for promoting youth development in low-income areas because they can provide safe, supervised, and structured activities. Such activities should include not only physical education (PE) programs, but other extra-curricular activities such as intramural sports and school sport teams. Because we were interested in how these programs were associated with youth development, we used the concept of positive youth development (PYD) to guide this study. Purpose: This case study examined school staff members’ and childrens perceptions of school PE, intramural sports, and sport teams with a view to establish factors that facilitated or impeded PYD. Method: Data were collected via individual interviews with eight teachers and 59 children from an inner-city school that had a mission to promote positive behaviors consistent with PYD. Interviews were transcribed verbatim and subjected to a categorical aggregation analysis procedure. Results: Findings showed factors that facilitated or impeded PYD varied across different contexts. In PE, the importance of a specialist PE teacher and establishing clear boundaries during lessons while providing children with perceptions of choice were important. Children enjoyed intramural sports, but there were few attempts to create an appropriate developmental atmosphere during these sessions. In fact, intramural sports were associated with negative student interactions. Coaches of the sport teams used techniques to promote social interactions and respect. Most notable student outcomes associated with PYD related to fostering empathy and social connections. Conclusion: These findings showed differences in contextual factors across the PE/sport programs that helped promote or impeded PYD. These differences revealed some practical suggestions for promoting PYD, which include focusing on the developmental orientation of PE classes, the fun of intramurals, and the ‘life skills’ focus of the sport teams. Furthermore, we suggest an integrated, school-wide approach is required to help promote PYD.

Brief emergency department interventions for youth who use alcohol and other drugs: a systematic review

Objective Brief intervention (BI) is recommended for use with youth who use alcohol and other drugs. Emergency departments (EDs) can provide BIs at a time directly linked to harmful and hazardous use. The objective of this systematic review was to determine the effectiveness of ED-based BIs. Methods We searched 14 electronic databases, a clinical trial registry, conference proceedings, and study references. We included randomized controlled trials with youth 21 years or younger. Two reviewers independently selected studies and assessed methodological quality. One reviewer extracted and a second verified data. We summarized findings qualitatively. Results Two trials with low risk of bias, 2 trials with unclear risk of bias, and 5 trials with high risk of bias were included. Trials evaluated targeted BIs for alcohol-positive (n = 3) and alcohol/other drug–positive youth (n = 1) and universal BIs for youth reporting recent alcohol (n = 4) or cannabis use (n = 1). Few differences were found in favor of ED-based BIs, and variation in outcome measurement and poor study quality precluded firm conclusions for many comparisons. Universal and targeted BIs did not significantly reduce alcohol use more than other care. In one targeted BI trial with high risk of bias, motivational interviewing (MI) that involved parents reduced drinking quantity per occasion and high-volume alcohol use compared with MI that was delivered to youth only. Another trial with high risk of bias reported an increase in abstinence and reduction in physical altercations when youth received peer-delivered universal MI for cannabis use. In 2 trials with unclear risk of bias, MI reduced drinking and driving and alcohol-related injuries after the ED visit. Computer-based MI delivered universally in 1 trial with low risk of bias reduced alcohol-related consequences 6 months after the ED visit. Conclusions Clear benefits of using ED-based BI to reduce alcohol and other drug use and associated injuries or high-risk behaviours remain inconclusive because of variation in assessing outcomes and poor study quality.

Parents as Agents of Change (PAC) in pediatric weight management: The protocol for the PAC randomized clinical trial

BackgroundThere is an urgent need to develop and evaluate weight management interventions to address childhood obesity. Recent research suggests that interventions designed for parents exclusively, which have been named parents as agents of change (PAC) approaches, have yielded positive outcomes for managing pediatric obesity. To date, no research has combined a PAC intervention approach with cognitive behavioural therapy (CBT) to examine whether these combined elements enhance intervention effectiveness. This paper describes the protocol our team is using to examine two PAC-based interventions for pediatric weight management. We hypothesize that children with obesity whose parents complete a CBT-based PAC intervention will achieve greater reductions in adiposity and improvements in cardiometabolic risk factors, lifestyle behaviours, and psychosocial outcomes than children whose parents complete a psycho-education-based PAC intervention (PEP).Methods/DesignThis study is a pragmatic, two-armed, parallel, single-blinded, superiority, randomized clinical trial. The primary objective is to examine the differential effects of a CBT-based PAC vs PEP-based PAC intervention on children’s BMI z-score (primary outcome). Secondary objectives are to assess intervention-mediated changes in cardiometabolic, lifestyle, and psychosocial variables in children and parents. Both interventions are similar in frequency of contact, session duration, group facilitation, lifestyle behaviour goals, and educational content. However, the interventions differ insofar as the CBT-based intervention incorporates theory-based concepts to help parents link their thoughts, feelings, and behaviours; these cognitive activities are enabled by group leaders who possess formal training in CBT. Mothers and fathers of children (8–12 years of age; BMI ≥85th percentile) are eligible to participate if they are proficient in English (written and spoken) and agree for at least one parent to attend group-based sessions on a weekly basis. Anthropometry, cardiometabolic risk factors, lifestyle behaviours, and psychosocial health of children and parents are assessed at pre-intervention, post-intervention, 6-, and 12-months follow-up.DiscussionThis study is designed to extend findings from earlier efficacy studies and provide data on the effect of a CBT-based PAC intervention for managing pediatric obesity in a real-world, outpatient clinical setting.Trial RegistrationClinicalTrials.gov identifier: NCT01267097

Emergency health care use and follow-up among sociodemographic groups of children who visit emergency departments for mental health crises

Background: Previous studies of differences in mental health care associated with children’s sociodemographic status have focused on access to community care. We examined differences associated with visits to the emergency department. Methods: We conducted a 6-year population-based cohort analysis using administrative databases of visits (n = 30 656) by children aged less than 18 years (n = 20 956) in Alberta. We measured differences in the number of visits by socioeconomic and First Nations status using directly standardized rates. We examined time to return to the emergency department using a Cox regression model, and we evaluated time to follow-up with a physician by physician type using a competing risks model. Results: First Nations children aged 15–17 years had the highest rate of visits for girls (7047 per 100 000 children) and boys (5787 per 100 000 children); children in the same age group from families not receiving government subsidy had the lowest rates (girls: 2155 per 100 000 children; boys: 1323 per 100 000 children). First Nations children (hazard ratio [HR] 1.64; 95% confidence interval [CI] 1.30–2.05), and children from families receiving government subsidies (HR 1.60, 95% CI 1.30–1.98) had a higher risk of return to an emergency department for mental health care than other children. The longest median time to follow-up with a physician was among First Nations children (79 d; 95% CI 60–91 d); this status predicted longer time to a psychiatrist (HR 0.47, 95% CI 0.32–0.70). Age, sex, diagnosis and clinical acuity also explained post-crisis use of health care. Interpretation: More visits to the emergency department for mental health crises were made by First Nations children and children from families receiving a subsidy. Sociodemographics predicted risk of return to the emergency department and follow-up care with a physician.