Relational practices for meaningful inclusion in health research: Results of a deliberative dialogue study.

INTRODUCTION: The importance of including people affected by research (e.g., community members, citizens or patient partners) is increasingly recognized across the breadth of institutions involved in connecting research with action. Yet, the increasing rhetoric of inclusion remains situated in research systems that tend to reward traditional dissemination and uphold power dynamics in ways that centre particular (privileged) voices over others. In research explicitly interested in doing research with those most affected by the issue or outcomes, research teams need to know how to advance meaningful inclusion. This study focused on listening to voices often excluded from research processes to understand what meaningful inclusion looks and feels like, and asked what contributes to being or feeling tokenized. METHODS: In this deliberative dialogue study, 16 participants with experience of navigating social exclusions and contributing to research activities reflected on what makes for meaningful experiences of inclusion. Using a co-production approach, with a diversely representative research team of 15 that included patient and community partners, we used critically reflective dialogue to guide an inclusive process to study design and implementation, from conceptualization of research questions through to writing. RESULTS: We heard that: research practices, partnerships and systems all contribute to experiences of inclusion or exclusion; the insufficiency or absence of standards for accountability amplifies the experience of exclusion; and inclusive practices require intention, planning, reflection and resources. CONCLUSIONS: We offer evidence-informed recommendations for the deeply relational work and practices for inclusivity, focused on promising practices for cultivating welcoming systems, spaces and relationships. PATIENT OR PUBLIC CONTRIBUTION: This work reflects a co-production approach, where people who use and are affected by research results actively partnered in the research process, including study design, data-generating activities, analysis and interpretation, and writing. Several of these partners are authors of this manuscript.

Characterizing Canadian funded partnered health research projects between 2011 and 2019: a retrospective analysis.

BACKGROUND AND AIMS: Involving research users in collaborative research approaches may increase the relevance and utility of research findings. Our primary objectives were to (i) identify and describe characteristics of Canadian federally and provincially funded health research projects that included research users and were funded between 2011 and 2019; (ii) explore changes over time; and (iii) compare characteristics between funder required and optional partnerships. METHODS: Retrospective analysis. Inclusion criteria were projects that included research users. We analyzed publicly available project variables, and coded field and type of research using established classification systems. We summarized data with descriptive statistics and compared variables across three funding year blocks and partnership requirement status. RESULTS: We identified 1153 partnered health research projects, representing 137 fields of research and 37 types of research categories. Most projects included a required partnership (80%) and fell into health and social care services research (66%). Project length and funding amount increased from average of 24.8 months and $266 248 CAD in 2011-2013 to 31.6 months and $438 766 CAD in 2017-2019. There were significantly fewer required partnerships in 2017-2019. CONCLUSIONS: Between 2011 and 2019 Canadian federally and provincially funded partnered health research reflected primarily care services research across many fields. The observed breadth suggests that partnered health research approaches are applicable in many fields of research. Additional work to support partnered research across all types of health research (especially biomedical research) is warranted. The administration of larger grants that are funded for longer time periods may address previously identified concerns among research teams engaging in partnered research but may mean that fewer teams receive funding and risk delaying responding to time-sensitive data needs for users. Our process and findings can be used as a starting point for international comparison.

A scoping review of the globally available tools for assessing health research partnership outcomes and impacts.

BACKGROUND: Health research partnership approaches have grown in popularity over the past decade, but the systematic evaluation of their outcomes and impacts has not kept equal pace. Identifying partnership assessment tools and key partnership characteristics is needed to advance partnerships, partnership measurement, and the assessment of their outcomes and impacts through systematic study. OBJECTIVE: To locate and identify globally available tools for assessing the outcomes and impacts of health research partnerships. METHODS: We searched four electronic databases (Ovid MEDLINE, Embase, CINAHL + , PsychINFO) with an a priori strategy from inception to June 2021, without limits. We screened studies independently and in duplicate, keeping only those involving a health research partnership and the development, use and/or assessment of tools to evaluate partnership outcomes and impacts. Reviewer disagreements were resolved by consensus. Study, tool and partnership characteristics, and emerging research questions, gaps and key recommendations were synthesized using descriptive statistics and thematic analysis. RESULTS: We screened 36 027 de-duplicated citations, reviewed 2784 papers in full text, and kept 166 studies and three companion reports. Most studies originated in North America and were published in English after 2015. Most of the 205 tools we identified were questionnaires and surveys targeting researchers, patients and public/community members. While tools were comprehensive and usable, most were designed for single use and lacked validity or reliability evidence. Challenges associated with the interchange and definition of terms (i.e., outcomes, impacts, tool type) were common and may obscure partnership measurement and comparison. Very few of the tools identified in this study overlapped with tools identified by other, similar reviews. Partnership tool development, refinement and evaluation, including tool measurement and optimization, are key areas for future tools-related research. CONCLUSION: This large scoping review identified numerous, single-use tools that require further development and testing to improve their psychometric and scientific qualities. The review also confirmed that the health partnership research domain and its measurement tools are still nascent and actively evolving. Dedicated efforts and resources are required to better understand health research partnerships, partnership optimization and partnership measurement and evaluation using valid, reliable and practical tools that meet partners' needs.

Selecting implementation models, theories, and frameworks in which to integrate intersectional approaches.

BACKGROUND: Models, theories, and frameworks (MTFs) provide the foundation for a cumulative science of implementation, reflecting a shared, evolving understanding of various facets of implementation. One under-represented aspect in implementation MTFs is how intersecting social factors and systems of power and oppression can shape implementation. There is value in enhancing how MTFs in implementation research and practice account for these intersecting factors. Given the large number of MTFs, we sought to identify exemplar MTFs that represent key implementation phases within which to embed an intersectional perspective. METHODS: We used a five-step process to prioritize MTFs for enhancement with an intersectional lens. We mapped 160 MTFs to three previously prioritized phases of the Knowledge-to-Action (KTA) framework. Next, 17 implementation researchers/practitioners, MTF experts, and intersectionality experts agreed on criteria for prioritizing MTFs within each KTA phase. The experts used a modified Delphi process to agree on an exemplar MTF for each of the three prioritized KTA framework phases. Finally, we reached consensus on the final MTFs and contacted the original MTF developers to confirm MTF versions and explore additional insights. RESULTS: We agreed on three criteria when prioritizing MTFs: acceptability (mean = 3.20, SD = 0.75), applicability (mean = 3.82, SD = 0.72), and usability (median = 4.00, mean = 3.89, SD = 0.31) of the MTF. The top-rated MTFs were the Iowa Model of Evidence-Based Practice to Promote Quality Care for the 'Identify the problem' phase (mean = 4.57, SD = 2.31), the Consolidated Framework for Implementation Research for the 'Assess barriers/facilitators to knowledge use' phase (mean = 5.79, SD = 1.12), and the Behaviour Change Wheel for the 'Select, tailor, implement interventions' phase (mean = 6.36, SD = 1.08). CONCLUSIONS: Our interdisciplinary team engaged in a rigorous process to reach consensus on MTFs reflecting specific phases of the implementation process and prioritized each to serve as an exemplar in which to embed intersectional approaches. The resulting MTFs correspond with specific phases of the KTA framework, which itself may be useful for those seeking particular MTFs for particular KTA phases. This approach also provides a template for how other implementation MTFs could be similarly considered in the future. TRIAL REGISTRATION: Open Science Framework Registration: osf.io/qgh64.

Development and usability testing of tools to facilitate incorporating intersectionality in knowledge translation.

BACKGROUND: The field of knowledge translation (KT) has been criticized for neglecting contextual and social considerations that influence health equity. Intersectionality, a concept introduced by Black feminist scholars, emphasizes how human experience is shaped by combinations of social factors (e.g., ethnicity, gender) embedded in systemic power structures. Its use has the potential to advance equity considerations in KT. Our objective was to develop and conduct usability testing of tools to support integrating intersectionality in KT through three key phases of KT: identifying the gap; assessing barriers to knowledge use; and selecting, tailoring, and implementing interventions. METHODS: We used an integrated KT approach and assembled an interdisciplinary development committee who drafted tools. We used a mixed methods approach for usability testing with KT intervention developers that included semi-structured interviews and the System Usability Scale (SUS). We calculated an average SUS score for each tool. We coded interview data using the framework method focusing on actionable feedback. The development committee used the feedback to revise tools, which were formatted by a graphic designer. RESULTS: Nine people working in Canada joined the development committee. They drafted an intersectionality primer and one tool that included recommendations, activities, reflection prompts, and resources for each of the three implementation phases. Thirty-one KT intervention developers from three countries participated in usability testing. They suggested the tools to be shorter, contain more visualizations, and use less jargon. Average SUS scores of the draft tools ranged between 60 and 78/100. The development committee revised and shortened all tools, and added two, one-page summary documents. The final toolkit included six documents. CONCLUSIONS: We developed and evaluated tools to help embed intersectionality considerations in KT. These tools go beyond recommending the use of intersectionality to providing practical guidance on how to do this. Future work should develop guidance for enhancing social justice in intersectionality-enhanced KT.

How are health research partnerships assessed? A systematic review of outcomes, impacts, terminology and the use of theories, models and frameworks.

BACKGROUND: Accurate, consistent assessment of outcomes and impacts is challenging in the health research partnerships domain. Increased focus on tool quality, including conceptual, psychometric and pragmatic characteristics, could improve the quantification, measurement and reporting partnership outcomes and impacts. This cascading review was undertaken as part of a coordinated, multicentre effort to identify, synthesize and assess a vast body of health research partnership literature. OBJECTIVE: To systematically assess the outcomes and impacts of health research partnerships, relevant terminology and the type/use of theories, models and frameworks (TMF) arising from studies using partnership assessment tools with known conceptual, psychometric and pragmatic characteristics. METHODS: Four electronic databases were searched (MEDLINE, Embase, CINAHL Plus and PsycINFO) from inception to 2 June 2021. We retained studies containing partnership evaluation tools with (1) conceptual foundations (reference to TMF), (2) empirical, quantitative psychometric evidence (evidence of validity and reliability, at minimum) and (3) one or more pragmatic characteristics. Outcomes, impacts, terminology, definitions and TMF type/use were abstracted verbatim from eligible studies using a hybrid (independent abstraction-validation) approach and synthesized using summary statistics (quantitative), inductive thematic analysis and deductive categories (qualitative). Methodological quality was assessed using the Quality Assessment Tool for Studies with Diverse Designs (QATSDD). RESULTS: Application of inclusion criteria yielded 37 eligible studies. Study quality scores were high (mean 80%, standard deviation 0.11%) but revealed needed improvements (i.e. methodological, reporting, user involvement in research design). Only 14 (38%) studies reported 48 partnership outcomes and 55 impacts; most were positive effects (43, 90% and 47, 89%, respectively). Most outcomes were positive personal, functional, structural and contextual effects; most impacts were personal, functional and contextual in nature. Most terms described outcomes (39, 89%), and 30 of 44 outcomes/impacts terms were unique, but few were explicitly defined (9, 20%). Terms were complex and mixed on one or more dimensions (e.g. type, temporality, stage, perspective). Most studies made explicit use of study-related TMF (34, 92%). There were 138 unique TMF sources, and these informed tool construct type/choice and hypothesis testing in almost all cases (36, 97%). CONCLUSION: This study synthesized partnership outcomes and impacts, deconstructed term complexities and evolved our understanding of TMF use in tool development, testing and refinement studies. Renewed attention to basic concepts is necessary to advance partnership measurement and research innovation in the field. Systematic review protocol registration: PROSPERO protocol registration: CRD42021137932 https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=137932 .

'Doing' or 'using' intersectionality? Opportunities and challenges in incorporating intersectionality into knowledge translation theory and practice.

Intersectionality is a widely adopted theoretical orientation in the field of women and gender studies. Intersectionality comes from the work of black feminist scholars and activists. Intersectionality argues identities such as gender, race, sexuality, and other markers of difference intersect and reflect large social structures of oppression and privilege, such as sexism, racism, and heteronormativity. The reach of intersectionality now extends to the fields of public health and knowledge translation. Knowledge translation (KT) is a field of study and practice that aims to synthesize and evaluate research into an evidence base and move that evidence into health care practice. There have been increasing calls to bring gender and other social issues into the field of KT. Yet, as scholars outline, there are few guidelines for incorporating the principles of intersectionality into empirical research. An interdisciplinary, team-based, national health research project in Canada aimed to bring an intersectional lens to the field of knowledge translation. This paper reports on key moments and resulting tensions we experienced through the project, which reflect debates in intersectionality: discomfort with social justice, disciplinary divides, and tokenism. We consider how our project advances intersectionality practice and suggests recommendations for using intersectionality in health research contexts. We argue that while we encountered many challenges, our process and the resulting co-created tools can serve as a valuable starting point and example of how intersectionality can transform fields and practices.

Integrated Knowledge Translation Guiding Principles for Conducting and Disseminating Spinal Cord Injury Research in Partnership.

OBJECTIVE: To address a gap between spinal cord injury (SCI) research and practice by rigorously and systematically co-developing integrated knowledge translation (IKT) guiding principles for conducting and disseminating SCI research in partnership with research users. DESIGN: The process was guided by the internationally accepted The Appraisal of Guidelines for REsearch & Evaluation (AGREE) II Instrument for evaluating the development of clinical practice guidelines. SETTING: North American SCI research system (ie, SCI researchers, research users, funders). PARTICIPANTS: The multidisciplinary expert panel (n=17) and end users (n=35) included individuals from a North American partnership of SCI researchers, research users, and funders who have expertise in research partnerships. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Clarity, usefulness, and appropriateness of the principles. RESULTS: Data regarding 125 principles of partnered research were systematically collected from 4 sources (review of reviews, scoping review, interviews, Delphi consensus exercise). A multidisciplinary expert panel held a 2-day meeting to establish consensus, select guiding principles, and draft the guidance. The panel reached 100% consensus on the principles and guidance document. The final document includes a preamble, 8 guiding principles, and a glossary. Survey data showed that the principles and guidance document were perceived by potential end users as clear, useful, and appropriate. CONCLUSIONS: The IKT Guiding Principles represent the first rigorously co-developed, consensus-based guidance to support meaningful SCI research partnerships. The principles are a foundational tool with the potential to improve the relevance and impact of SCI research, mitigate tokenism, and advance the science of IKT.

Design characteristics and inclusion of evidence-based exercise recommendation in fall prevention community exercise programs for older adults in Canada: a national descriptive self-report study.

BACKGROUND: Training balance through exercise is an effective strategy to reduce falls in community-dwelling older adults. Evidence-based fall prevention exercise recommendations have been proposed, specifying that exercise programs should: (1) provide a high challenge to balance, (2) be offered for a least three hours per week, (3) be provided on an ongoing basis. Community exercise programs have the potential to deliver effective fall prevention exercise; however, current design characteristics and whether they include the recommendations is not known. This study described design characteristics of fall prevention community exercise programs for older adults (50 years and older) across Canada, and explored whether these programs included the three evidence-based exercise recommendations. METHODS: Instructors of fall prevention community exercise programs completed electronic self-report questionnaires following a modified Dillman recruitment approach. Questions explored program characteristics, exercise content, target population, and program and instructor demographic information. Using a previously developed coding scheme based on recommendations, exercises were coded for balance challenge. RESULTS: One hundred fourty completed eligible questionnaires were analyzed (74% response rate). One hundred thirty-three programs (95%) included the challenge recommendation by prescribing mostly moderate or high challenge balance exercises, 16 programs (11%) included at least three hours of exercise a week, and 59 programs (42%) were offered on an ongoing basis. Eight programs (6%) included all three recommendations. CONCLUSIONS: Most programs included at least one recommendation for effective fall prevention exercise. Future studies should examine organizational barriers and facilitators to incorporating evidence-based exercise recommendations and explore the use of mixed home/in-class strategies to include the recommendations.

A prospective study to establish the minimal clinically important difference of the Mini-BESTest in individuals with stroke.

OBJECTIVE: To determine the minimal clinically important difference of the Mini-BESTest in individuals' post-stroke. DESIGN: Prospective cohort study. SETTING: Outpatient stroke rehabilitation. SUBJECTS: Fifty outpatients with stroke with a mean (SD) age of 60.8 (9.4). INTERVENTION: Outpatients with stroke were assessed with the Mini-BESTest before and after a course of conventional rehabilitation. Rehabilitation sessions occurred one to two times/week for one hour and treatment duration was 1.3-42 weeks (mean (SD) = 17.4(10.6)). MAIN MEASURES: We used a combination of anchor- and distribution-based approaches including a global rating of change in balance scale completed by physiotherapists and patients, the minimal detectable change with 95% confidence, and the optimal cut-point from receiver operating characteristic curves. RESULTS: The average (SD) Mini-BESTest score at admission was 18.2 (6.5) and 22.4 (5.2) at discharge (effect size: 0.7) (P = 0.001). Mean change scores on the Mini-BESTest for patient and physiotherapist ratings of small change were 4.2 and 4.3 points, and 4.7 and 5.3 points for substantial change, respectively. The minimal detectable change with 95% confidence for the Mini-BESTest was 3.2 points. The minimally clinical importance difference was determined to be 4 points for detecting small changes and 5 points for detecting substantial changes. CONCLUSIONS: A change of 4-5 points on the Mini-BEST is required to be perceptible to clinicians and patients, and beyond measurement error. These values can be used to interpret changes in balance in stroke rehabilitation research and practice.

Applying an intersectionality lens to the theoretical domains framework: a tool for thinking about how intersecting social identities and structures of power influence behaviour.

BACKGROUND: A key component of the implementation process is identifying potential barriers and facilitators that need to be addressed. The Theoretical Domains Framework (TDF) is one of the most commonly used frameworks for this purpose. When applying the TDF, it is critical to understand the context in which behaviours occur. Intersectionality, which accounts for the interface between social identity factors (e.g. age, gender) and structures of power (e.g. ageism, sexism), offers a novel approach to understanding how context shapes individual decision-making and behaviour. We aimed to develop a tool to be used alongside applications of the TDF to incorporate an intersectionality lens when identifying implementation barriers and enablers. METHODS: An interdisciplinary Framework Committee (n = 17) prioritized the TDF as one of three models, theories, and frameworks (MTFs) to enhance with an intersectional lens through a modified Delphi approach. In collaboration with the wider Framework Committee, a subgroup considered all 14 TDF domains and iteratively developed recommendations for incorporating intersectionality considerations within the TDF and its domains. An iterative approach aimed at building consensus was used to finalize recommendations. RESULTS: Consensus on how to apply an intersectionality lens to the TDF was achieved after 12 rounds of revision. Two overarching considerations for using the intersectionality alongside the TDF were developed by the group as well as two to four prompts for each TDF domain to guide interview topic guides. Considerations and prompts were designed to assist users to reflect on how individual identities and structures of power may play a role in barriers and facilitators to behaviour change and subsequent intervention implementation. CONCLUSIONS: Through an expert-consensus approach, we developed a tool for applying an intersectionality lens alongside the TDF. Considering the role of intersecting social factors when identifying barriers and facilitators to implementing research evidence may result in more targeted and effective interventions that better reflect the realities of those involved.

Delivering Midwifery: A Scoping Review of Employment Models in Canada.

The majority of Canadian Provinces have regulated and publicly funded midwifery. No comprehensive review has summarized and compared the various types of employment models, practice organizations, and compensation for midwives across Canada. The aim of this scoping review was to gain an understanding of evidence related to funding models, organization of practice models, and compensation for midwives. The Arksey and O'Malley five-stage framework for conducting scoping reviews guided our methodology. The constructs of interest for inquiry related to Canadian midwifery were the following: (1) employment models, (2) organization of practice, and (3) compensation. The study selection was an iterative search process. After duplicates were removed from both database and grey literature sources, a total of 1540 records were initially screened. After final screening was complete, a total of 111 records were included that contained content related to constructs of interest. Currently, midwifery services are publicly funded in Alberta, British Columbia, Manitoba, Ontario, Québec, Nunavut, Nova Scotia, Northwest Territories, and Saskatchewan. The four types of employment models in which midwives work are private practice, private fee for service (deemed as course of care), course of care, and salaried. Compensation varies by province depending on the model of employment. This review of publicly available literature illustrates the range of employment, practice models, and compensation of regulated midwifery across Canada, as well as the evolution of the profession in the past 27 years. This type of information is relevant to inform health workforce planning for midwifery services across the country (Canadian Task Force Classification III).

Disseminating the Foundations of Knowledge Translation and Patient Engagement Science Through the KnowledgeNudge Blog and Twitter Profile: Quantitative Descriptive Evaluation.

BACKGROUND: There is a documented need to build capacity for theory- and evidence-informed knowledge translation (KT) and patient engagement (PE) practice in health research. Dissemination of foundational content online coupled with social media promotion may build capacity by increasing awareness, knowledge, and positive attitudes. OBJECTIVE: This retrospective study sought to (1) describe exposure and engagement of the KnowledgeNudge KT and PE dissemination strategy (online blog and Twitter profile) over 2 years and (2) identify and compare characteristics of individual posts with the most and least exposure and reach. METHODS: Exposure was assessed by blog site views per month and Twitter profile impressions per month. Engagement was assessed by Twitter profile interactions per month. Descriptive statistics were calculated for 6-month blocks and compared using one-way analysis of variance or Student t test. Individual post exposure was assessed by average post views per week. Individual post reach was assessed by average post reads per week. High- and low-profile blog posts with the highest and lowest 10th percentile for exposure and reach were identified. RESULTS: A total of 99 posts and 755 tweets were published during the study period. There was a significant increase in exposure (P=.004) and reach (P<.001) during the final 6 months. Seven high-profile and 6 low-profile posts were identified. High-profile posts had a significantly greater average word count than low-profile posts (P=.003). There were no other significant differences between posts. CONCLUSIONS: The increases in KnowledgeNudge exposure and engagement offer preliminary evidence in support of this dissemination strategy for the practice of KT and PE. Variation in individual post exposure and reach warrants further exploration to tailor content to user needs. Future work will include a prospective evaluation strategy to explore the effect of KnowledgeNudge on awareness, knowledge, attitudes, and behavior.

Quality improvement strategies to prevent falls in older adults: a systematic review and network meta-analysis.

BACKGROUND: Falls are a common occurrence and the most effective quality improvement (QI) strategies remain unclear. METHODS: We conducted a systematic review and network meta-analysis (NMA) to elucidate effective quality improvement (QI) strategies for falls prevention. Multiple databases were searched (inception-April 2017). We included randomised controlled trials (RCTs) of falls prevention QI strategies for participants aged ≥65 years. Two investigators screened titles and abstracts, full-text articles, conducted data abstraction and appraised risk of bias independently. RESULTS: A total of 126 RCTs including 84,307 participants were included after screening 10,650 titles and abstracts and 1210 full-text articles. NMA including 29 RCTs and 26,326 patients found that team changes was statistically superior in reducing the risk of injurious falls relative to usual care (odds ratio [OR] 0.57 [0.33 to 0.99]; absolute risk difference [ARD] -0.11 [95% CI, -0.18 to -0.002]). NMA for the outcome of number of fallers including 61 RCTs and 40 128 patients found that combined case management, patient reminders and staff education (OR 0.18 [0.07 to 0.47]; ARD -0.27 [95% CI, -0.33 to -0.15]) and combined case management and patient reminders (OR, 0.36 [0.13 to 0.97]; ARD -0.19 [95% CI, -0.30 to -0.01]) were both statistically superior compared to usual care. CONCLUSIONS: Team changes may reduce risk of injurious falls and a combination of case management, patient reminders, and staff education, as well as case management and patient reminders may reduce risk of falls. Our results can be tailored to decision-maker preferences and availability of resources. SYSTEMATIC REVIEW REGISTRATION: PROSPERO (CRD42013004151).

To what extent do older adult community exercise programs in Winnipeg, Canada address balance and include effective fall prevention exercise? A descriptive self-report study.

BACKGROUND: Effective fall prevention exercise for community-dwelling older adults requires (i) challenging balance exercise, (ii) offered at least 3 hrs/ week, and (iii) on an ongoing basis, to reduce falls. Community exercise programs are a potential implementation strategy for fall prevention exercise; however, the extent to which they address balance and include effective fall prevention exercise is unknown. Study objectives were to describe program delivery, exercise design, and assessment characteristics of older adult community exercise programs in Winnipeg, Canada; determine if they included effective fall prevention exercise; determine the balance challenge and components of postural control addressed in the most- and least-frequently reported exercises. METHODS: A public inventory of older adult community exercise programs served as the sampling frame for cross-sectional telephone questionnaires exploring program, exercise, and assessment characteristics. Exercises were coded independently by two investigators for balance challenge level and components of postural control. Programs were categorized by number of effective fall prevention exercise components established by evidence-based recommendations. Descriptive statistics were calculated. RESULTS: Thirty-three eligible programs were identified and nine individuals participated. Most programs (n = 5, 56%) identified as general exercise, and two (22%) as fall prevention exercise. Most programs (n = 5, 56%) were offered two or more times/ week and reported exercise intensity as somewhat challenging. Exercise time offered ranged between 1 and 3 h/ week. Assessments were conducted in two programs (22%). Only one program (general exercise) included all components of effective fall prevention exercise. Two programs (22%) included the component of being offered at least 3 hrs/ week. Three programs (33%) included the component of being offered on an ongoing basis. Seven programs (78%) prescribed mostly moderate challenge balance exercise, and one program (11%) prescribed mostly high challenge exercise. Most of the 19 most-frequently prescribed exercises (n = 17, 89%) targeted static stability and none targeted reactive postural control. CONCLUSIONS: Most of the older adult community exercise programs participating in this study did not focus on fall prevention, and did not include all components of effective fall prevention exercise. Future studies should focus on fall prevention programs and explore factors influencing implementation of effective fall prevention exercise components to facilitate planning.

A theory-based multi-component intervention to increase reactive balance measurement by physiotherapists in three rehabilitation hospitals: an uncontrolled single group study.

BACKGROUND: Most implementation interventions in rehabilitation, including physiotherapy, have used passive, non-theoretical approaches without demonstrated effectiveness. The goal of this study was to improve an important domain of physiotherapy practice - reactive balance measurement - with a targeted theory-based multi-component intervention developed using the Theoretical Domains Framework. The primary objective was to determine documented reactive balance measure use in a 12-month baseline, during, and for three months post- intervention. METHODS: An uncontrolled before-and-after study was completed with physiotherapists at three urban adult rehabilitation hospitals in Ontario, Canada. The 12-month intervention included group meetings, local champions, and health record modifications for a validated reactive balance measure. The primary outcome was the proportion of records with a documented reactive balance measure when balance was assessed pre-, during- and post-intervention. Secondary outcomes were changes in use, knowledge, and confidence post-intervention, differences across sites, and intervention satisfaction. RESULTS: Reactive balance was not measured in any of 211 eligible pre-intervention records. Thirty-three physiotherapists enrolled and 28 completed the study. Reactive balance was measured in 31% of 300 eligible records during-intervention, and in 19% of 90 eligible records post-intervention (p < 0.04). Knowledge and confidence significantly increased post-intervention (all p < 0.05). There were significant site differences in use during- and post-intervention (all p < 0.05). Most participants reported satisfaction with intervention content (71%) and delivery (68%). CONCLUSIONS: Reactive balance measurement was greater among participants during-intervention relative to the baseline, and use was partially sustained post-intervention. Continued study of intervention influences on clinical reasoning and exploration of site differences is warranted.

Components of Standing Postural Control Evaluated in Pediatric Balance Measures: A Scoping Review.

OBJECTIVE: To identify measures of standing balance validated in pediatric populations, and to determine the components of postural control captured in each tool. DATA SOURCES: Electronic searches of MEDLINE, Embase, and CINAHL databases using key word combinations of postural balance/equilibrium, psychometrics/reproducibility of results/predictive value of tests, and child/pediatrics; gray literature; and hand searches. STUDY SELECTION: Inclusion criteria were measures with a stated objective to assess balance, with pediatric (≤18y) populations, with at least 1 psychometric evaluation, with at least 1 standing task, with a standardized protocol and evaluation criteria, and published in English. Two reviewers independently identified studies for inclusion. There were 21 measures included. DATA EXTRACTION: Two reviewers extracted descriptive characteristics, and 2 investigators independently coded components of balance in each measure using a systems perspective for postural control, an established framework for balance in pediatric populations. DATA SYNTHESIS: Components of balance evaluated in measures were underlying motor systems (100% of measures), anticipatory postural control (72%), static stability (62%), sensory integration (52%), dynamic stability (48%), functional stability limits (24%), cognitive influences (24%), verticality (9%), and reactive postural control (0%). CONCLUSIONS: Assessing children's balance with valid and comprehensive measures is important for ensuring development of safe mobility and independence with functional tasks. Balance measures validated in pediatric populations to date do not comprehensively assess standing postural control and omit some key components for safe mobility and independence. Existing balance measures, that have been validated in adult populations and address some of the existing gaps in pediatric measures, warrant consideration for validation in children.

A descriptive qualitative examination of knowledge translation practice among health researchers in Manitoba, Canada.

BACKGROUND: The importance of effective translation of health research findings into action has been well recognized, but there is evidence to suggest that the practice of knowledge translation (KT) among health researchers is still evolving. Compared to research user stakeholders, researchers (knowledge producers) have been under-studied in this context. The goals of this study were to understand the experiences of health researchers in practicing KT in Manitoba, Canada, and identify their support needs to sustain and increase their participation in KT. METHODS: Qualitative semi-structured interviews were conducted with 26 researchers studying in biomedical; clinical; health systems and services; and social, cultural, environmental and population health research. Interview questions were open-ended and probed participants' understanding of KT, their experiences in practicing KT, barriers and facilitators to practicing KT, and their needs for KT practice support. RESULTS: KT was broadly conceptualized across participants. Participants described a range of KT practice experiences, most of which related to dissemination. Participants also expressed a number of negative emotions associated with the practice of KT. Many individual, logistical, and systemic or organizational barriers to practicing KT were identified, which included a lack of institutional support for KT in both academic and non-academic systems. Participants described the presence of good relationships with stakeholders as a critical facilitator for practicing KT. The most commonly identified needs for supporting KT practice were access to education and training, and access to resources to increase awareness and promotion of KT. While there were few major variations in response trends across most areas of health research, the responses of biomedical researchers suggested a unique KT context, reflected by distinct conceptualizations of KT (such as commercialization as a core component), experiences (including frustration and lack of support), and barriers to practicing KT (for example, intellectual property concerns). CONCLUSIONS: The major findings of this study were the continued variations in conceptualization of KT, and persisting support needs that span basic individual to comprehensive systemic change. Expanding the study to additional regions of Canada will present opportunities to compare and contrast the state of KT practice and its influencing factors.

Moving towards a more inclusive patient and public involvement in health research paradigm: the incorporation of a trauma-informed intersectional analysis.

BACKGROUND: The concept of patient engagement in health research has received growing international recognition over recent years. Yet despite some critical advancements, we argue that the concept remains problematic as it negates the very real complexities and context of people's lives. Though patient engagement conceptually begins to disrupt the identity of "researcher," and complicate our assumptions and understandings around expertise and knowledge, it continues to essentialize the identity of "patient" as a homogenous group, denying the reality that individuals' economic, political, cultural, subjective and experiential lives intersect in intricate and multifarious ways. DISCUSSION: Patient engagement approaches that do not consider the simultaneous interactions between different social categories (e.g. race, ethnicity, Indigeneity, gender, class, sexuality, geography, age, ability, immigration status, religion) that make up social identity, as well as the impact of systems and processes of oppression and domination (e.g. racism, colonialism, classism, sexism, ableism, homophobia) exclude the involvement of individuals who often carry the greatest burden of illness - the very voices traditionally less heard in health research. We contend that in order to be a more inclusive and meaningful approach that does not simply reiterate existing health inequities, it is important to reconceptualize patient engagement through a health equity and social justice lens by incorporating a trauma-informed intersectional analysis. This article provides key concepts to the incorporation of a trauma-informed intersectional analysis and important questions to consider when developing a patient engagement strategy in health research training, practice and evaluation. In redefining the identity of both "patient" and "researcher," spaces and opportunities to resist and renegotiate power within the intersubjective relations can be recognized and addressed, in turn helping to build trust, transparency and resiliency - integral to the advancement of the science of patient engagement in health research.

Comparisons of Interventions for Preventing Falls in Older Adults: A Systematic Review and Meta-analysis.

Importance: Falls result in substantial burden for patients and health care systems, and given the aging of the population worldwide, the incidence of falls continues to rise. Objective: To assess the potential effectiveness of interventions for preventing falls. Data Sources: MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Ageline databases from inception until April 2017. Reference lists of included studies were scanned. Study Selection: Randomized clinical trials (RCTs) of fall-prevention interventions for participants aged 65 years and older. Data Extraction and Synthesis: Pairs of reviewers independently screened the studies, abstracted data, and appraised risk of bias. Pairwise meta-analysis and network meta-analysis were conducted. Main Outcomes and Measures: Injurious falls and fall-related hospitalizations. Results: A total of 283 RCTs (159 910 participants; mean age, 78.1 years; 74% women) were included after screening of 10 650 titles and abstracts and 1210 full-text articles. Network meta-analysis (including 54 RCTs, 41 596 participants, 39 interventions plus usual care) suggested that the following interventions, when compared with usual care, were associated with reductions in injurious falls: exercise (odds ratio [OR], 0.51 [95% CI, 0.33 to 0.79]; absolute risk difference [ARD], -0.67 [95% CI, -1.10 to -0.24]); combined exercise and vision assessment and treatment (OR, 0.17 [95% CI, 0.07 to 0.38]; ARD, -1.79 [95% CI, -2.63 to -0.96]); combined exercise, vision assessment and treatment, and environmental assessment and modification (OR, 0.30 [95% CI, 0.13 to 0.70]; ARD, -1.19 [95% CI, -2.04 to -0.35]); and combined clinic-level quality improvement strategies (eg, case management), multifactorial assessment and treatment (eg, comprehensive geriatric assessment), calcium supplementation, and vitamin D supplementation (OR, 0.12 [95% CI, 0.03 to 0.55]; ARD, -2.08 [95% CI, -3.56 to -0.60]). Pairwise meta-analyses for fall-related hospitalizations (2 RCTs; 516 participants) showed no significant association between combined clinic- and patient-level quality improvement strategies and multifactorial assessment and treatment relative to usual care (OR, 0.78 [95% CI, 0.33 to 1.81]). Conclusions and Relevance: Exercise alone and various combinations of interventions were associated with lower risk of injurious falls compared with usual care. Choice of fall-prevention intervention may depend on patient and caregiver values and preferences.