Feasibility of a Virtual Health-Promoting Intervention (Choose to Move) for Older Adults: A Rapid Adaptation in Response to COVID-19.

To support older adults during the first wave of COVID-19, we rapidly adapted our effective health-promoting intervention (Choose to Move [CTM]) for virtual delivery in British Columbia, Canada. The intervention was delivered (April-October 2020) to 33 groups of older adults ("programs") who were a convenience sample (had previously completed CTM in person; n = 153; 86% female; 73 [6] years). We compared implementation outcomes (recruitment, dose received, retention, and completion of virtual data collection) to predetermined feasibility targets. We assessed mobility, physical activity, and social health outcomes pre- and postintervention (3 months) with validated surveys. We met most (dose received, retention, and virtual data collection), but not all (recruitment), feasibility targets. Approximately two thirds of older adults maintained or improved mobility, physical activity, and social health outcomes at 3 months. It was feasible to implement and evaluate CTM virtually. In future, virtual CTM could help us reach homebound older adults and/or serve as support during public health emergencies.

What is the 'voltage drop' when an effective health promoting intervention for older adults-Choose to Move (Phase 3)-Is implemented at broad scale?

BACKGROUND: Choose to Move (CTM), an effective health-promoting intervention for older adults, was scaled-up across British Columbia, Canada. Adaptations that enable implementation at scale may lead to 'voltage drop'-diminished positive effects of the intervention. For CTM Phase 3 we assessed: i. implementation; ii. impact on physical activity, mobility, social isolation, loneliness and health-related quality of life (impact outcomes); iii. whether intervention effects were maintained; iv) voltage drop, compared with previous CTM phases. METHODS: We conducted a type 2 hybrid effectiveness-implementation pre-post study of CTM; older adult participants (n = 1012; mean age 72.9, SD = 6.3 years; 80.6% female) were recruited by community delivery partners. We assessed CTM implementation indicators and impact outcomes via survey at 0 (baseline), 3 (mid-intervention), 6 (end-intervention) and 18 (12-month follow-up) months. We fitted mixed-effects models to describe change in impact outcomes in younger (60-74 years) and older (≥ 75 years) participants. We quantified voltage drop as percent of effect size (change from baseline to 3- and 6-months) retained in Phase 3 compared with Phases 1-2. RESULTS: Adaptation did not compromise fidelity of CTM Phase 3 as program components were delivered as intended. PA increased during the first 3 months in younger (+1 days/week) and older (+0.9 days/week) participants (p<0.001), and was maintained at 6- and 18-months. In all participants, social isolation and loneliness decreased during the intervention, but increased during follow-up. Mobility improved during the intervention in younger participants only. Health-related quality of life according to EQ-5D-5L score did not change significantly in younger or older participants. However, EQ-5D-5L visual analog scale score increased during the intervention in younger participants (p<0.001), and this increase was maintained during follow-up. Across all outcomes, the median difference in effect size, or voltage drop, between Phase 3 and Phases 1-2 was 52.6%. However, declines in social isolation were almost two times greater in Phase 3, compared with Phases 1-2. CONCLUSION: Benefits of health-promoting interventions-like CTM-can be retained when implemented at broad scale. Diminished social isolation in Phase 3 reflects how CTM was adapted to enhance opportunities for older adults to socially connect. Thus, although intervention effects may be reduced at scale-up, voltage drop is not inevitable.

Visual hindsight bias for abnormal mammograms in radiologists.

Purpose: Hindsight bias-where people falsely believe they can accurately predict something once they know about it-is a pervasive decision-making phenomenon, including in the interpretation of radiological images. Evidence suggests it is not only a decision-making phenomenon but also a visual perception one, where prior information about an image enhances our visual perception of the contents of that image. The current experiment investigates to what extent expert radiologists perceive mammograms with visual abnormalities differently when they know what the abnormality is (a visual hindsight bias), above and beyond being biased at a decision level. Approach: N=40 experienced mammography readers were presented with a series of unilateral abnormal mammograms. After each case, they were asked to rate their confidence on a 6-point scale that ranged from confident mass to confident calcification. We used the random image structure evolution method, where the images repeated in an unpredictable order and with varied noise, to ensure any biases were visual, not cognitive. Results: Radiologists who first saw an original image with no noise were more accurate in the max noise level condition [area under the curve (AUC)=0.60] than those who first saw the degraded images (AUC=0.55; difference: p=0.005), suggesting that radiologists' visual perception of medical images is enhanced by prior visual experience with the abnormality. Conclusions: Overall, these results provide evidence that expert radiologists experience not only decision level but also visual hindsight bias, and have potential implications for negligence lawsuits.

Outcome domains measured in randomized controlled trials of physical activity for older adults: a rapid review.

BACKGROUND: Toward development of a core outcome set for randomized controlled trials (RCTs) of physical activity (PA) interventions for older adults, the purpose of this study was to identify outcome domains and subdomains ('what' was measured) in previously published RCTs of PA for older adults. METHODS: We conducted a rapid review and searched Ovid MEDLINE for recently- published (2015-2021), English-language, RCTs of PA interventions for older adults (mean age 60+ yrs). We limited to articles published in Web of Science top-10 journals in general and internal medicine, geriatrics and gerontology, rehabilitation, and sports science. Two reviewers independently completed eligibility screening; two other reviewers abstracted trial descriptors and study outcomes. We classified study outcomes according to the standard outcome classification taxonomy endorsed by the Core Outcome Measures in Effectiveness Trials Initiative. RESULTS: Our search yielded 548 articles; 67 articles were eligible to be included. Of these, 82% were efficacy/effectiveness trials, 85% included both male and female participants, and 84% recruited community-dwelling older adults. Forty percent of articles reported on interventions that involved a combination of group and individual PAs, and 60% involved a combination of PA modes (e.g., aerobic, resistance). Trial sample size ranged from 14 to 2157 participants, with median (IQR) of 94 (57-517); 28,649 participants were included across all trials. We identified 21 unique outcome domains, spanning 4/5 possible core areas (physiological/clinical; life impact; resource use; adverse events). The five most commonly reported outcome domains were physical functioning (included in n=51 articles), musculoskeletal and connective tissue (n=30), general (n=26), cognitive functioning (n=16), and emotional functioning/wellbeing (n=14). Under these five outcome domains, we further identified 10 unique outcome subdomains (e.g., fall-related; body composition; quality of life). No outcome domains or subdomains were reported consistently in all RCTs. CONCLUSIONS: We found extensive variability in outcome domains and subdomains used in RCTs of PA for older adults, reflecting the broad range of potential health benefits derived from PA and also investigator interest to monitor a range of safety parameters related to adverse events. This study will inform development of a core outcome set to improve outcome reporting consistency and evidence quality.

Timescale reverses the relationship between host density and infection risk.

Host density shapes infection risk through two opposing phenomena. First, when infective stages are subdivided among multiple hosts, greater host densities decrease infection risk through 'safety in numbers'. Hosts, however, represent resources for parasites, and greater host availability also fuels parasite reproduction. Hence, host density increases infection risk through 'density-dependent transmission'. Theory proposes that these phenomena are not disparate outcomes but occur over different timescales. That is, higher host densities may reduce short-term infection risk, but because they support parasite reproduction, may increase long-term risk. We tested this theory in a zooplankton-disease system with laboratory experiments and field observations. Supporting theory, we found that negative density-risk relationships (safety in numbers) sometimes emerged over short timescales, but these relationships reversed to 'density-dependent transmission' within two generations. By allowing parasite numerical responses to play out, time can shift the consequences of host density, from reduced immediate risk to amplified future risk.

Rapidly adapting an effective health promoting intervention for older adults-choose to move-for virtual delivery during the COVID-19 pandemic.

BACKGROUND: The COVID-19 (COVID) pandemic shifted way of life for all Canadians. 'Stay-at-home' public health directives counter transmission of COVID but may cause, or exacerbate, older adults' physical and social health challenges. To counter unintentional consequences of these directives, we rapidly adapted an effective health promoting intervention for older adults-Choose to Move (CTM)-to be delivered virtually throughout British Columbia (BC). Our specific objectives were to 1. describe factors that influence whether implementation of CTM virtually was acceptable, and feasible to deliver, and 2. assess whether virtual delivery retained fidelity to CTM's core components. METHODS: We conducted a 3-month rapid adaptation feasibility study to evaluate the implementation of CTM, virtually. Our evaluation targeted two levels of implementation within a larger socioeconomic continuum: 1. the prevention delivery system, and 2. older adult participants. We implemented 33 programs via Zoom during BC's 1st wave acute and transition stages of COVID (April-October 2020). We conducted semi-structured 30-45 min telephone focus groups with 9 activity coaches (who delivered CTM), and semi-structured 30-45 min telephone interviews with 30 older adult participants, at 0- and 3-months. We used deductive framework analysis for all qualitative data to identify themes. RESULTS: Activity coaches and older adults identified three key factors that influenced acceptability (a safe and supportive space to socially connect, the technological gateway, and the role of the central support unit) and two key factors that influenced feasibility (a virtual challenge worth taking on and CTM flexibility) of delivering CTM virtually. Activity coaches also reported adapting CTM during implementation; adaptations comprised two broad categories (time allocation and physical activity levels). CONCLUSION: It was feasible and acceptable to deliver CTM virtually. Programs such as CTM have potential to mitigate the unintended consequences of public health orders during COVID associated with reduced physical activity, social isolation, and loneliness. Adaptation and implementation strategies must be informed by community delivery partners and older adults themselves. Pragmatic, virtual health promoting interventions that can be adapted as contexts rapidly shift may forevermore be an essential part of our changing world.

Youth gun carrying and household firearm ownership in 22 US states.

Youth gun carrying is associated with a range of adverse outcomes, including increased risks for homicide, suicide, school disciplinary problems, and criminal legal involvement. In this study we examined the association between state-level household firearm ownership rates and the odds of past-year gun carrying among high-school-aged youth. Using survey-weighted multivariable logistic regression models, results showed that each 1% point increase in state-level gun ownership was associated with a 2.7% (95% confidence interval [CI] = [1.1%, 4.2%], p = 0.001) increased odds of youth gun carrying, controlling for histories of school-based victimization, physical fighting, and substance use. Among a subset of weapon-carrying youth, state-level firearm availability was a significant factor in determining whether the weapon carried was a gun or a less lethal (i.e., nonfirearm) weapon (odds ratio = 1.021, 95% CI = [1.005, 1.038], p = 0.01). These findings show that firearm availability confers additional risk for youth gun carrying beyond the psychosocial risks emphasized in prior research and efforts to restrict youth access to firearms might be particularly important, especially in communities with high levels of household gun ownership.

Development of an Index to Measure the Exposure Level of UN Peacekeeper-Perpetrated Sexual Exploitation/Abuse in Women/Girls in the Democratic Republic of Congo.

Sexual exploitation and abuse (SEA) of women and girls by United Nations (UN) peacekeepers is an international concern. However, the typical binary measurement of SEA (indicating that it occurred, or it did not) disregards varying exposure levels and the complex circumstances surrounding the interaction. To address this gap, we constructed an index to quantify the degree to which local women and girls were exposed to UN-peacekeeper perpetrated SEA. Using survey data (n = 2867) from the Democratic Republic of Congo (DRC), eight indicators were identified using a combination of qualitative (thematic analysis of narrative data) and quantitative variables. With further development, this index may offer a more comprehensive and nuanced perspective of peacekeeper-perpetrated SEA that can better inform SEA prevention and intervention efforts.

A cross-sectional study of community perceptions of stigmatization amongst women affected by UN-peacekeeper perpetrated sexual exploitation and abuse.

BACKGROUND: Sexual exploitation and abuse (SEA) by UN peacekeepers perpetrated against local women and girls is a concern in the Democratic Republic of Congo (DRC). While stigma associated with sexual and gender-based violence is well documented more broadly, little is known about stigma associated with peacekeeper-perpetrated SEA. METHODS: The aim of this study was to examine how the degree of exposure to SEA affects community perceptions of a woman or girl's (1) social status (public stigma) and (2) institutional support in her community (structural stigma). Two poisson regression models with robust variance estimation were constructed utilizing community survey data of SEA experiences from eastern DRC (n = 2867) to quantify these associations. Relevant demographic variables were assessed for confounding and effect modification. RESULTS: The prevalence of public and structural stigma were 62.9 and 19.3% respectively across the sample. A positive relationship was demonstrated between level of exposure of SEA and diminished social status in which women and girls experiencing moderate levels of SEA were at the greatest risk of public stigmatization after adjusting for confounding (RR: 1.94; CI: 1.66-2.26). Similarly, a positive relationship between exposure to SEA and inadequate institutional support was shown for female narrators wherein women and girls experiencing a high degree of SEA were 6.53 times as likely to receive inadequate support (RR: 6.53; CI: 3.63, 11.73). This contrasted with male narrated stories for whom there was no significant association between the SEA exposure level and institutional support. CONCLUSIONS: Women/girls with high exposure levels to UN peacekeeper-perpetrated SEA are at the highest risk of public and structural stigmatization, which should be more routinely considered when conceptualizing the consequences of SEA in peacekeeping contexts. The frequent occurrence of both public and structural stigma, coupled with the varying perceptions by sex, demonstrates the need for a multi-faceted approach for stigma reduction.

Physical activity is good for older adults-but is programme implementation being overlooked? A systematic review of intervention studies that reported frameworks or measures of implementation.

OBJECTIVE: To examine older adult physical activity (PA) intervention studies that evaluated implementation and/or scale-up. Research question 1: What implementation and/or scale-up indicators (specific, observable and measurable characteristics that show the progress of implementation) were reported? Research question 2: What implementation and/or scale-up frameworks were reported? Research question 3: Did studies evaluate the relationship between implementation or scale-up of the intervention and individual level health/behaviour outcomes? If yes, how? DESIGN: Systematic review. DATA SOURCES: Publications from electronic databases and hand searches (2000 to December 2019). ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Any PA intervention studies with community-dwelling older adult participants (mean age ≥60 years). Required indicators: (a) Must report amount of PA as an outcome, with validated self-report or objective measures, and (b) Must have reported at least one implementation or scale-up framework and/or one implementation or scale-up indicator. RESULTS: 137 studies were included for research question 1, 11 for question 2 and 22 for question 3. 137 studies reported an implementation indicator: 14 unique indicators. None were specified as indicators for scale-up evaluation. 11 studies were guided by an implementation or scale-up framework. 22 studies described a relationship between an implementation indicator and an individual-level health outcome. CONCLUSION: There is need for implementation research that extends beyond analysis at the individual level, includes clearly defined indicators and provides a guiding framework to support PA initiatives in older adults. Such implementation studies should evaluate factors in the broader context (eg,political, environmental) that influence scale-up. PROSPERO REGISTRATION: CRD42018091839.

Mortality Among People With Opioid Use Disorder: A Systematic Review and Meta-analysis.

BACKGROUND AND AIMS: Opioids are among the most commonly used class of illicit drugs. We aimed to produce pooled estimates of mortality risks among people with opioid use disorder (OUD), with a focus upon all-cause mortality, and also overdose-specific causes of death. DESIGN: Systematic review and meta-analysis of cohorts of people with OUD involving illicit opioids with data on all-cause or overdose-specific mortality. SETTING AND PARTICIPANTS: Of 4247 papers, 92 were eligible, reporting on 101 cohorts that measured all-cause mortality and opioid-overdose mortality. Cohorts (n = 101-229,274) were in North America, Australia, several Eastern and Western European countries, and Asia. MEASUREMENT: Titles/abstracts and full texts were independently screened by 2 reviewers, with discrepancies resolved via a third reviewer. We extracted data on crude mortality rates (CMRs) per 1000 person-years (PY); we imputed CMRs where possible if not reported by study authors. We also calculated mortality relative risks. Data were pooled using random-effects models; potential reasons for heterogeneity were explored using subgroup analyses and meta-regressions. FINDINGS: The overall all-cause CMR was 18.7 per 1000 PY (95% confidence interval [CI] 17.1-20.3). The overall overdose-specific CMR was 7.0 per 1000 PY (95% CI 6.1-8.0). All-cause and overdose-specific mortality were substantially higher in low/middle-income countries, among those with HIV, and among people who use injection drugs. CONCLUSIONS: Individuals with OUD carry a high risk of all-cause and overdose-specific mortality. Potentially modifiable risk factors, such as HIV and injection drug use, were predictive of mortality risk and are amenable to global efforts aiming to improve access to OUD treatment and targeted harm reduction efforts.

Getting Ready for Scale-Up of an Effective Older Adult Physical Activity Program: Characterizing the Adaptation Process.

To optimize public health impact, health interventions must be delivered widely to reach the population in need. Yet, few interventions are ever implemented at broad scale (scaled-up). Thus it is necessary to devise implementation strategies that support scale-up of effective interventions. Adapting an intervention and implementation strategies to the local context to improve "fit" at scale-up is critical to success. Therefore, our study responds to a call to build a database of systematic adaptations of evidence-based interventions across populations and contexts, including scaled-up designs. To do so, we focus on the process of adapting an effective physical activity program for older adults, called Choose to Move (CTM), for scale-up. Our objectives were to describe the systematic process of adapting CTM for scale-up across British Columbia (BC) and to report the actual changes made to CTM. We adopted a 6-step process: (1) identify stakeholders; (2) conduct needs assessment; (3) develop prototype of adaptations; (4) validate prototype with stakeholders; (5) create adapted program; and (6) pilot test adaptations. For the adaptation process, we described each step and organized data within an adaptation coding system. Results showed that adaptations to CTM span program content, program context, and the training modules. For example, to address the request by CTM participants for more opportunities to socially connect with others, we added more group meetings, reduced phone check-ins, and integrated aspects of training related to social cohesion. Our study extends the current literature by providing researchers a clear pathway toward adapting health promotion interventions for scale-up.

Factors that influence implementation at scale of a community-based health promotion intervention for older adults.

BACKGROUND: Despite the many known benefits of physical activity (PA), relatively few older adults are active on a regular basis. Older adult PA interventions delivered in controlled settings showed promising results. However, to achieve population level health impact, programs must be effectively scaled-up, and few interventions have achieved this. To effectively scale-up it is essential to identify contextual factors that facilitate or impede implementation at scale. Our aim is to describe factors that influence implementation at scale of a health promotion intervention for older adults (Choose to Move). This implementation evaluation complements our previously published study that assessed the impact of Choose to Move on older adult health indicators. METHODS: To describe factors that influenced implementation our evaluation targeted five distinct levels across a socioecological continuum. Four members of our project team conducted semi-structured interviews by telephone with 1) leaders of delivery partner organizations (n = 13) 2) recreation managers (n = 6), recreation coordinators (n = 27), activity coaches (n = 36) and participants (n = 42) [August 2015 - April 2017]. Interviews were audio-recorded and professionally transcribed and data were analyzed using framework analysis. RESULTS: Partners agreed on the timeliness and need for scaled-up evidence-based health promotion programs for older adults. Choose to Move aligned with organizational priorities, visions and strategic directions and was deemed easy to deliver, flexible and adaptable. Partners also noted the critical role played by our project team as the support unit. However, partners noted availability of financial resources as a potential barrier to sustainability. CONCLUSIONS: Even relatively simple evidence-based interventions can be challenging to scale-up and sustain. To ensure successful implementation it is essential to align with multilevel socioecological perspectives and assess the vast array of contextual factors that are at the core of better understanding successful implementation.

Implementation and scale-up of physical activity and behavioural nutrition interventions: an evaluation roadmap.

BACKGROUND: Interventions that work must be effectively delivered at scale to achieve population level benefits. Researchers must choose among a vast array of implementation frameworks (> 60) that guide design and evaluation of implementation and scale-up processes. Therefore, we sought to recommend conceptual frameworks that can be used to design, inform, and evaluate implementation of physical activity (PA) and nutrition interventions at different stages of the program life cycle. We also sought to recommend a minimum data set of implementation outcome and determinant variables (indicators) as well as measures and tools deemed most relevant for PA and nutrition researchers. METHODS: We adopted a five-round modified Delphi methodology. For rounds 1, 2, and 3 we administered online surveys to PA and nutrition implementation scientists to generate a rank order list of most commonly used; i) implementation and scale-up frameworks, ii) implementation indicators, and iii) implementation and scale-up measures and tools. Measures and tools were excluded after round 2 as input from participants was very limited. For rounds 4 and 5, we conducted two in-person meetings with an expert group to create a shortlist of implementation and scale-up frameworks, identify a minimum data set of indicators and to discuss application and relevance of frameworks and indicators to the field of PA and nutrition. RESULTS: The two most commonly referenced implementation frameworks were the Framework for Effective Implementation and the Consolidated Framework for Implementation Research. We provide the 25 most highly ranked implementation indicators reported by those who participated in rounds 1-3 of the survey. From these, the expert group created a recommended minimum data set of implementation determinants (n = 10) and implementation outcomes (n = 5) and reconciled differences in commonly used terms and definitions. CONCLUSIONS: Researchers are confronted with myriad options when conducting implementation and scale-up evaluations. Thus, we identified and prioritized a list of frameworks and a minimum data set of indicators that have potential to improve the quality and consistency of evaluating implementation and scale-up of PA and nutrition interventions. Advancing our science is predicated upon increased efforts to develop a common 'language' and adaptable measures and tools.

Selumetinib in patients receiving standard pemetrexed and platinum-based chemotherapy for advanced or metastatic KRAS wildtype or unknown non-squamous non-small cell lung cancer: A randomized, multicenter, phase II study. Canadian Cancer Trials Group (CCTG) IND.219.

INTRODUCTION: Activation of the RAS/RAF/MEK/ERK pathway may confer resistance to chemotherapy in non-small cell lung cancer (NSCLC). Selumetinib (AZD6244, ARRY142886), a MEK1/2 inhibitor combined with chemotherapy in patients with NSCLC was evaluated in two schedules to evaluate efficacy and toxicity. METHODS: IND.219 was a three-arm study of first line pemetrexed/platinum chemotherapy with two schedules of selumetinib (Arm A: intermittent given on days 2-19; Arm B: continuous given on days 1-21) versus chemotherapy alone (Arm C). The primary endpoint was objective response rate (ORR); secondary objectives were tolerability, progression-free survival (PFS), overall survival (OS). The trial was stopped at the planned interim analysis. RESULTS: Arms A/B/C enrolled 20/21/21 patients, ORR was 35% (95% CI 15-59% median duration 3.8 months), 62% (95% CI 38-82%; median duration 6.3 months), 24% (95% CI 8-47%; median duration 11.6 months) respectively. The PFS (months Arm A, B, C) was 7.5, 6.7, 4.0 respectively (hazard ratio (HR) PFS Arm A over Arm C: 0.76 [95% CI, 0.38-1.51, 2-sided p = 0.42]; Arm B over Arm C 0.75 [95% CI 0.37-1.54, p = 0.43]. Skin and gastrointestinal adverse events were more common with the addition of selumetinib. A high incidence of venous thromboembolism was seen in all arms. CONCLUSIONS: Selumetinib combined with chemotherapy was associated with a higher response rate. Continuous selumetinib appeared to be superior to an intermittent schedule. PFS was prolonged with the addition of selumetinib, however this was not statistically significant.