Process evaluation of a randomised controlled trial intervention designed to improve rehabilitation services for Aboriginal Australians after brain injury: the Healing Right Way Trial.

BACKGROUND: Healing Right Way (HRW) aimed to improve health outcomes for Aboriginal Australians with stroke or traumatic brain injury by facilitating system-level access to culturally secure rehabilitation services. Using a stepped-wedge randomised controlled trial (RCT) design (ACTRN12618000139279, 30/01/2018), a two-pronged intervention was introduced in four rural and four urban hospitals, comprising 1.Cultural security training (CST) for staff and 2.Training/employment of Aboriginal Brain Injury Coordinators (ABIC) to support Aboriginal patients for 6-months post-injury. Three-quarters of recruited patients lived rurally. The main outcome measure was quality-of-life, with secondary outcomes including functional measures, minimum processes of care (MPC); number rehabilitation occasions of service received, and improved hospital experience. Assessments were undertaken at baseline, 12- and 26-weeks post-injury. Only MPCs and hospital experience were found to improve among intervention patients. We report on the process evaluation aiming to support interpretation and translation of results. METHODS: Using mixed methods, the evaluation design was informed by the Consolidated Framework for Implementation Research. Data sources included minutes, project logs, surveys, semi-structured interviews, and observations. Four evaluation questions provided a basis for systematic determination of the quality of the trial. Findings from separate sources were combined to synthesise the emerging themes that addressed the evaluation questions. Three components were considered separately: the trial process, CST and ABIC. RESULTS: The complex HRW trial was implemented to a satisfactory level despite challenging setting factors, particularly rural-urban system dynamics. Patient recruitment constraints could not be overcome. The vulnerability of stepped-wedge designs to time effects influenced recruitment and trial results, due to COVID. Despite relatively high follow-up, including to rural/remote areas, data points were reduced. The lack of culturally appropriate assessment tools influenced the quality/completeness of assessment data. The ABIC role was deemed feasible and well-received. The CST involved complex logistics, but rated highly although online components were often incomplete. Project management was responsive to staff, patients and setting factors. CONCLUSIONS: Despite mostly equivocal results, the ABIC role was feasible within mainstream hospitals and the CST was highly valued. Learnings will help build robust state-wide models of culturally secure rehabilitation for Aboriginal people after brain injury, including MPC, workforce, training and follow-up.

How Many Terms Does It Take to Define Sexual Assault? Inconsistencies in U.S. Higher Education Sexual Misconduct Policies.

Campus sexual misconduct policies (SMPs) outline prohibited conduct. We sought to document the range of terms used to refer to forms of nonconsensual sexual contact in SMPs and to analyze the content of definitions provided for the term "sexual assault." We coded the 2016-2017 SMPs from a sample of 381 U.S. schools. We identified 125 unique terms and documented both a terminological and conceptual morass around sexual assault. Policy language may have implications for students' and administrators' evaluation of experiences and reports of sexual assault.

Parents, Partners, and Professions: Reproduction and Mobility in a Cohort of College Women.

This article draws on data from a twelve-year longitudinal qualitative interview study of forty-five white women who started college in 2004 at a public flagship university in the American Midwest. We compare the class position of women's parents (captured when women began college) to women's own adult class position at age 30. Despite substantial downward mobility and modest upward mobility, we find that white women's social class was relatively sticky; that is, even downwardly mobile white women from privileged families did not fall far, while upwardly mobile white women from less privileged families were blocked from the top of the class structure. We develop the concept of "class projects," or multigenerational approaches to obtaining desired and imaginable economic circumstances, to explain patterns of intergenerational mobility in our data. We document three distinct class projects-gender complementarity, professional partnership, and self-reliance. Women experienced better outcomes when they engaged in a project that was a fit with family resources and motivations, as well as the larger socio-economic context. In addition, not all projects-even if successfully executed-led to the same level of economic security.

Classed Pathways to Marriage: Hometown Ties, College Networks, and Life after Graduation.

Objective: This article identifies mechanisms through which social class background shapes the marital outcomes of college-going white American women. Background: Scholars are interested in the relative influences of ascriptive and achieved characteristics on mate selection. Research indicates that social class background continues to influence the marriage patterns of college-educated Americans but does not identify the mechanisms through which this occurs. Method: The study analyzes six waves of longitudinal interviews with 45 women from differing social class backgrounds. The first interview was conducted at age 18, when women started college at a Midwestern public university. The final interview was collected at age 30, and was supplemented by a survey collecting the income, education, occupation, and debt of women and their spouses. Results: Women from privileged backgrounds were more likely to marry and married men who earned substantially more than the partners of less privileged women. Differences resulted from lifelong variation in social networks, originating in childhood. College did not interrupt long-standing exclusionary class networks. After graduation, social class background shaped where women moved, as well as with whom they worked and socialized. Conclusion: Higher education in the contemporary US may reinforce rather than interrupt class homogamy in marriage, even when students attend the same schools. The role of higher education in shaping classed social networks is in need of further study.

The Associations of Gender With Social Participation of Burn Survivors: A Life Impact Burn Recovery Evaluation Profile Study.

Burn injury can be debilitating and affect survivors' quality of life in a profound fashion. Burn injury may also lead to serious psychosocial challenges that have not been adequately studied and addressed. Specifically, there has been limited research into the associations of burn injury on community reintegration based on gender. This work analyzed data from 601 burn survivors who completed field testing of a new measure of social participation for burn survivors, the Life Impact Burn Recovery Evaluation (LIBRE) Profile. Differences in item responses between men and women were examined. Scores on the six LIBRE Profile scales were then compared between men and women using analysis of variance and adjusted linear multivariate regression modeling. Overall, men scored significantly better than women on four of the six LIBRE Profile scales: Sexual Relationships, Social Interactions, Work & Employment, and Romantic Relationships. Differences were not substantially reduced after adjustment for demographic characteristics and burn size. Men scored better than women in most of the areas measured by the LIBRE Profile. These gender differences are potentially important for managing burn patients during the post-injury recovery period.

A randomized controlled trial of very early rehabilitation in speech after stroke.

RATIONALE: The efficacy of rehabilitation therapy for aphasia caused by stroke is uncertain. AIMS AND HYPOTHESIS: The Very Early Rehabilitation of Speech (VERSE) trial aims to determine if intensive prescribed aphasia therapy (VERSE) is more effective and cost saving than non-prescribed, intensive (usual care-plus) and non-intensive usual care (UC) therapy when started within 15 days of stroke onset and continued daily over four weeks. We hypothesize that aphasia therapy when started very early after stroke and delivered daily could enhance recovery of communication compared with UC. SAMPLE SIZE ESTIMATES: A total of 246 participants (82 per arm) will provide 80% power to detect a 4.4% improvement on aphasia quotient between VERSE and UC plus at a significance level of α = 0.05. SETTING: Acute-care hospitals and accompanying rehabilitation services throughout Australia, 2014-2017. DESIGN: Three-arm, prospective, randomized, parallel group, open-label, blinded endpoint assessment (PROBE) trial. PARTICIPANTS: Acute stroke in previous 14 days and aphasia diagnosed by aphasia quotient (AQ) of the Western Aphasia Battery (WAB). RANDOMIZATION: Computer-generated blocked randomization procedure stratified by aphasia severity according to Western Aphasia Battery, to one of three arms. INTERVENTION: All participants receive UC-usual ward-based aphasia therapy. Arm 1: UC-no additional therapy; Arm 2: UC-plus usual ward-based therapy; Arm 3: VERSE therapy-a prescribed and structured aphasia therapy program. Arms 2 and 3 receive a total of 20 additional sessions (45-60 min, provided daily) of aphasia therapy. The additional intervention must be provided before day 50 post stroke. STUDY OUTCOME MEASURES: The aphasia quotient of Western Aphasia Battery at 12 weeks post stroke. Secondary outcomes include discourse measures, the Stroke and Aphasia Quality of Life Scale-39 and the Aphasia Depression Rating Scale at 12 and 26 weeks. ECONOMIC EVALUATION: Incremental cost-effectiveness ratios at 26 weeks will be reported. DISCUSSION: This trial is designed to test whether the intensive and prescribed VERSE intervention is effective in promoting maximum recovery and preventing costly health complications in a vulnerable population of survivors of stroke. It will also provide novel, prospective, aphasia specific cost-effectiveness data to guide future policy development for this population.

Women's negotiation of cunnilingus in college hookups and relationships.

Using in-depth interviews with 43 college women who were, on average, 21 years old (SD = 0.79), the authors explored women's attitudes toward and experiences of cunnilingus. The authors found that cunnilingus posed interactional challenges for women, but that these varied by relationship context. Drawing on scripting theory, the authors argue that the sexual scripts available to contemporary American college students assume cunnilingus in relationships, but not in hookups, where the incorporation of the practice is more contested. For individual women, tension emerged when their preferences for cunnilingus contradicted the sexual script of the relationship context. Women who desired cunnilingus in hookups had to be assertive to get it, whereas those who did not want cunnilingus in hookups were relieved that it was not expected. The taken-for-granted nature of cunnilingus in relationships was a source of pleasure for women who enjoyed it and of difficulty for women who wished to avoid it. In relationships, some women's reluctance about cunnilingus was transformed by men's enthusiasm. More generally, this study implies that ambiguity in sexual scripts may heighten the interactional challenges of sex by creating uncertainty about expectations and gaps between sexual scripts and individual preferences.