Confirmatory factor analysis of the Evidence-Based Practice Attitude Scale (EBPAS) in a large and representative Swedish sample: is the use of the total scale and subscale scores justified?

BACKGROUND: There is a call for valid and reliable instruments to evaluate implementation of evidence-based practices (EBP). The 15-item Evidence-Based Practice Attitude Scale (EBPAS) measures attitude toward EBP, incorporating four lower-order factor subscales (Appeal, Requirements, Openness, and Divergence) and a Total scale (General Attitudes). It is one of a few measures of EBP attitudes evaluated for its psychometric properties. The reliability of the Total scale has been repeatedly supported, but also the multidimensionality of the inventory. However, whether all of the items contribute to the EBPAS Total beyond their subscales has yet to be demonstrated. In addition, the Divergence subscale has been questioned because of its low correlation with the other subscales and low inter-item correlations. The EBPAS is widely used to tailor and evaluate implementation efforts, but a Swedish version has not yet been validated. This study aimed to contribute to the development and cross-validation of the EBPAS by examining the factor structure of t a Swedish-language version in a large sample of mental health professionals. METHODS: The EBPAS was translated into Swedish and completed by 570 mental health professionals working in child and adolescent psychiatry settings spread across Sweden. The factor structure was examined using first-order, second-order and bifactor confirmatory factor analytic (CFA) models. RESULTS: Results suggested adequate fit for all CFA models. The EBPAS Total was strongly supported in the Swedish version. Support for the hierarchical second-order model was also strong, while the bifactor model gave mixed support for the subscales. The Openness and Requirements subscales came out best, while there were problems with both the Appeal (e.g. not different from the General Attitudes factor) and the Divergence subscales (e.g. low reliability). CONCLUSIONS: Overall, the psychometric properties were on par with the English version and the total score appears to be a valid measure of general attitudes towards EBP. This is the first study supporting this General Attitudes factor based on a bifactor model. Although comparatively better supported in this Swedish sample, we conclude that the use of the EBPAS subscale scores may result in misleading conclusions. Practical implications and future directions are discussed.

"It is something that gives us hope": Lived experience among parents to children with cerebral palsy who are non-ambulant of the phenomenon physical activity, with or without the use of a novel dynamic standing device.

Introduction: Regular physical activity confers health benefits for all. Parents commonly want their children to be physically active, and want to be physically active themselves, but children with cerebral palsy (CP) who are non-ambulant face challenges, and they need support to be physically active. Dynamic standing in the novel motorized assistive device Innowalk has positive effects in children who are non-ambulant-it gives them a chance to be physically active. The aim of this study was to explore the lived experience of physical activity of parents themselves and for their children with cerebral palsy who are non-ambulant. Methods: A descriptive inductive design with a hermeneutic phenomenological approach was used for the analysis of interviews with 11 parents of children with CP who are non-ambulant who participated in a study of exercise effects of dynamic standing. Results: The parents experienced physical activity for their children as being important but difficult, especially for their child, as described in Theme 1: "Being aware of health benefits while struggling with family time." The children were perceived as being dependent on other people, the environment, and equipment for participating in physical activity, referring to Theme 2: "Being dependent." The opportunity for their children to become physically active on a regular basis through an assistive device gave the parents hope for a better life, which formed Theme 3: "Getting hope in a challenging life situation." Conclusion: Physical activity for children with CP who are non-ambulant is possible through an elaborate network of social relations and environmental conditions. Limiting the degree of dependence and containing the negative consequences of high a degree of dependence are vital in the support of physical activity. Relations, support, and assistive devices that strengthen empowerment and autonomy should be prioritized, and if this works, the experience of physical activity can be positive, giving families hope.

Health Care Professionals' Experiences and Views of eHealth in Pediatric Care: Qualitative Interview Study Applying a Theoretical Framework for Implementation.

BACKGROUND: The development and evaluation of eHealth interventions in clinical care should be accompanied by a thorough assessment of their implementation. The NASSS (Non-adoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies) framework was designed to facilitate the implementation and scale-up of health technology programs, providing an option for analyzing the progression of these initiatives as they are implemented in real-time. Considering health care provider perspectives within the framework for implementation offers valuable insights into the early identification of barriers and facilitators in the implementation of potentially effective eHealth innovations. Nevertheless, there is a dearth of studies on eHealth interventions that encompass longer time frames and delve into the complexities of scaling up and sustaining such interventions within real-world health care environments. OBJECTIVE: This study aims to investigate the perspectives and insights of health care professionals (HCPs) regarding the implementation of an eHealth intervention in pediatric health care while applying the NASSS framework to theorize and evaluate the conditions influencing the implementation of eHealth solutions. METHODS: Semistructured interviews were performed with health care providers, including both staff and management personnel, within a university pediatric hospital (N=10). The data collection process occurred concurrently with a clinical trial focused on developing and assessing an eHealth app for self-management in pediatric care following hospital discharge. Using an abductive approach, the interviews were initially analyzed qualitatively and subsequently mapped onto the 7 domains of the NASSS framework to identify factors influencing implementation, encompassing facilitators, barriers, and varying levels of complexity. RESULTS: In the realm of pediatric care, the family was identified as the primary unit of care, and patient heterogeneity was a prominent feature. The implementation of eHealth tools, while deemed usable and flexible, was also seen as a delicate balance between safety and adaptability, highlighting challenges related to health care integration. Child participation and secrecy, especially for adolescents, contributed to the complexity of using eHealth. HCPs had high eHealth literacy, and thus challenges concerning adoption were related to work adaptations and the risk of "app overload." The readiness for implementation was experienced as induced through the research study and the pandemic situation. However, to move from research to implementation in clinical practice, organizational challenges identified a need to update the concept of care and ensure activity measurements. In a wider context, HCPs raised concerns related to regulatory requirements for documentation, public procurement, and data safety. Implementation became more complex due to a lack of overview in a large organization. CONCLUSIONS: Important perspectives for implementation were considerations of regulatory requirements, as well as the need for a shared vision of eHealth and the establishment of eHealth-related work as part of regular health care. Key contextual factors that support reach and impact are communication channels between different levels at the hospital and a need for paths and procedures compatible with legal, technological, and security concerns. Further research should focus on how eHealth interventions are perceived by children, adolescents, their parents, and other stakeholders. TRIAL REGISTRATION: ClinicalTrials.gov NCT04150120; https://clinicaltrials.gov/ct2/show/NCT04150120.

Behavioral and physiological effects of ocean acidification and warming on larvae of a continental shelf bivalve.

The negative impacts of ocean warming and acidification on bivalve fisheries are well documented but few studies investigate parameters relevant to energy budgets and larval dispersal. This study used laboratory experiments to assess developmental, physiological and behavioral responses to projected climate change scenarios using larval Atlantic surfclams Spisula solidissima solidissima, found in northwest Atlantic Ocean continental shelf waters. Ocean warming increased feeding, scope for growth, and biomineralization, but decreased swimming speed and pelagic larval duration. Ocean acidification increased respiration but reduced immune performance and biomineralization. Growth increased under ocean warming only, but decreased under combined ocean warming and acidification. These results suggest that ocean warming increases metabolic activity and affects larval behavior, while ocean acidification negatively impacts development and physiology. Additionally, principal component analysis demonstrated that growth and biomineralization showed similar response profiles, but inverse response profiles to respiration and swimming speed, suggesting alterations in energy allocation under climate change.

Implementing guidelines for interventions in Swedish substance abuse treatment: A national evaluation of outcomes from 2010 to 2014.

In 2009, the Swedish government launched a nationwide dissemination and implementation project regarding substance abuse treatment, Knowledge to Practice (KTP), which was commissioned by the Swedish National Board of Health and Welfare (SoS). AIM: The study aimed to evaluate the effectiveness of a national project to disseminate and implement evidence-based assessment instruments and treatment methods, and to promote cross-sectional collaboration in substance abuse treatment. DESIGN AND RECRUITMENT: This study was a naturalistic prospective follow-up study of a sample of 3063 participants in 203 municipalities via five consecutive online surveys. Of the 21 Swedish regions, we included 20. All participants, representing 79.5% of the population, were employed in substance abuse treatment/care within social work and psychiatry. We used individual background variables and factors in the organizational readiness for change (ORC) questionnaire for prediction. METHODS: We calculated descriptive statistics using SPSS 24.0. We applied latent profile analysis (LPA) to identify respondents with distinct growth profiles across five assessment points. Next, we calculated multilevel growth curve analyses using full information maximum likelihood analysis (FIML) in Mplus 8.3. In the analyses, we nested "within-person change" (level 1) in "between-persons analysis" (level 2). We, in turn, nested these in municipalities/regions (level 3). We included both respondents and organizational predictors in levels 2 and 3. We tested four statistical models in the multilevel analyses to predict the outcome. RESULTS: The annual response rate was 59% on average across the five years. Respondents were a homogenous group with regard to education and years of employment, and two thirds were women. We identified four different trajectories nationwide, which showed different growth profiles for the use of methods and assessment instruments. Our results showed a larger between-region variation than within-region variation in outcome indicators. Some regions were more successful than others over the five years. At the respondent level, the years of employment in treatment work was associated with increased use of assessment instruments, while the ORC factor, institutional resources, predicted decreased use of assessment instruments. Specialist competence and the ORC factors staff attributes (job satisfaction, efficacy, and influence) and institutional resources predicted increased use of psychosocial treatment methods. The ORC factor organizational climate was positively associated with increased cross-sectional collaboration activities.

Ocean acidification alters morphology of all otolith types in Clark's anemonefish (Amphiprion clarkii).

Ocean acidification, the ongoing decline of surface ocean pH and [CO 3 2 - ] due to absorption of surplus atmospheric CO2, has far-reaching consequences for marine biota, especially calcifiers. Among these are teleost fishes, which internally calcify otoliths, critical elements of the inner ear and vestibular system. There is evidence in the literature that ocean acidification increases otolith size and alters shape, perhaps impacting otic mechanics and thus sensory perception. Here, larval Clark's anemonefish, Amphiprion clarkii (Bennett, 1830), were reared in various seawater pCO2/pH treatments analogous to future ocean scenarios. At the onset of metamorphosis, all otoliths were removed from each individual fish and analyzed for treatment effects on morphometrics including area, perimeter, and circularity; scanning electron microscopy was used to screen for evidence of treatment effects on lateral development, surface roughness, and vaterite replacement. The results corroborate those of other experiments with other taxa that observed otolith growth with elevated pCO2, and provide evidence that lateral development and surface roughness increased as well. Both sagittae exhibited increasing area, perimeter, lateral development, and roughness; left lapilli exhibited increasing area and perimeter while right lapilli exhibited increasing lateral development and roughness; and left asterisci exhibited increasing perimeter, roughness, and ellipticity with increasing pCO2. Right lapilli and left asterisci were only impacted by the most extreme pCO2 treatment, suggesting they are resilient to any conditions short of aragonite undersaturation, while all other impacted otoliths responded to lower concentrations. Finally, fish settlement competency at 10 dph was dramatically reduced, and fish standard length marginally reduced with increasing pCO2. Increasing abnormality and asymmetry of otoliths may impact inner ear function by altering otolith-maculae interactions.

Organizational Readiness for Change (ORC) test used in the implementation of assessment instruments and treatment methods in a Swedish National study.

Organizational climate and related factors are associated with outcome and are as such of vital interest for healthcare organizations. Organizational Readiness for Change (ORC) is the questionnaire used in the present study to assess the influence of organizational factors on implementation success. The respondents were employed in one of 203 Swedish municipalities within social work and psychiatric substance/abuse treatment services. They took part in a nationwide implementation project organized by the Swedish Association of Local Authorities and Regions (SALAR), commissioned by the Swedish National Board of Health and Welfare. AIM: The aims were: (a) to identify classes (clusters) of employees with different ORC profiles on the basis of data collected in 2011 and (b) to investigate ORC profiles which predicted the use of assessment instruments, therapy methods and collaborative activities in 2011 and 2013. DESIGN AND RECRUITMENT: The evaluation study applied a naturalistic design with registration of outcome at consecutive assessments. The participants were contacted via official e-mail addresses in their respective healthcare units and were encouraged by their officials to participate on a voluntary basis. STATISTICS: Descriptive statistics were obtained using SPSS version 23. A latent profile analysis (LPA) using Mplus 7.3 was performed with a robust maximum likelihood estimator (MLR) to identify subgroups (clusters) based on the 18 ORC indexes. RESULTS: A total of 2402 employees responded to the survey, of whom 1794 (74.7%) completed the ORC scores. Descriptive analysis indicated that the respondents were a homogenous group of employees, where women (72.0%) formed the majority. Cronbach's alpha for the 18 ORC indexes ranged from α=0.67 to α=0.78. A principal component analysis yielded a four-factor solution explaining 62% of the variance in total ORC scores. The factors were: motivational readiness (α=0.64), institutional resources (α=0.52), staff attributes (α=0.76), and organizational climate (α=0.74). An LPA analysis of the four factors with their three distinct profiles provided the best data fit: Profile 3 (n=614), Profile 2 (n=934), and Profile 1 (n=246). Respondents with the most favorable ORC scores (Profile 3) used significantly more instruments and more treatment methods and had a better collaborating network in 2011 as well as in 2013 compared to members in Profile 1, the least successful profile. CONCLUSION: In a large sample of social work and healthcare professionals, ORC scores reflecting higher institutional resources, staff attributes and organizational climate and lower motivational readiness for change were associated with a successful implementation of good practice guidelines for the care and treatment of substance users in Sweden. Low motivational readiness as a construct may indicate satisfaction with the present situation. As ORC proved to be an indicator of successful dissemination of evidence-based guidelines into routine and specialist healthcare, it can be used to tailor interventions to individual employees or services and to improve the dissemination of and compliance with guidelines for the treatment of substance users.

An ethnographic observation study of the facilitator role in an implementation process.

BACKGROUND: Even though the importance of a facilitator during an implementation process is well described, the facilitator's role is rarely problematized in relation to the organizational context in terms of power and legitimacy; themes which have recently been brought to the fore when studying change in health care organizations. Therefore, in this article, we present a qualitative study with the aim of identifying key aspects of the experience of being in a facilitator role. The data collection involved ethnographic fieldwork encompassing observations and field notes, as well as two qualitative interviews with the facilitator. The data were analysed using a phenomenological hermeneutical method in order to formulate thematic aspects of the implementation process. The study was conducted in southern Sweden between January 2013 and August 2014. RESULTS: One main theme, "walking a tightrope", and four sub-themes, all of which involved balancing acts of different levels and different ways, were identified. These included: being in control, but needing to adjust; pushing for change, but forced to stand back; being accepted, but dependent; and being reasonable, but culturally sensitive. CONCLUSION: Instead of listing the desirable qualities and conditions of a facilitator, this study shows that being a facilitator can be described more completely by applying the concept of role, thus allowing a more holistic process of reflection and analysis. This in turn makes it possible to move from the reactive stance of balancing to a more proactive stance of negotiating.

Expanding our understanding of the trade in marine aquarium animals.

The trade of live marine animals for home and public aquaria has grown into a major global industry. Millions of marine fishes and invertebrates are removed from coral reefs and associated habitats each year. The majority are imported into the United States, with the remainder sent to Europe, Japan, and a handful of other countries. Despite the recent growth and diversification of the aquarium trade, to date, data collection is not mandatory, and hence comprehensive information on species volume and diversity is lacking. This lack of information makes it impossible to study trade pathways. Without species-specific volume and diversity data, it is unclear how importing and exporting governments can oversee this industry effectively or how sustainability should be encouraged. To expand our knowledge and understanding of the trade, and to effectively communicate this new understanding, we introduce the publically-available Marine Aquarium Biodiversity and Trade Flow online database (https://www.aquariumtradedata.org/). This tool was created to communicate the volume and diversity of marine fishes and/or invertebrates imported into the US over three complete years (2008, 2009, and 2011) and three partial years (2000, 2004, 2005). To create this tool, invoices pertaining to shipments of live marine fishes and invertebrates were scanned and analyzed for species name, species quantities, country of origin, port of entry, and city of import destination. Here we focus on the analysis of the later three years of data and also produce an estimate for the entirety of 2000, 2004, and 2005. The three-year aggregate totals (2008, 2009, 2011) indicate that just under 2,300 fish and 725 invertebrate species were imported into the US cumulatively, although just under 1,800 fish and 550 invertebrate species were traded annually. Overall, the total number of live marine animals decreased between 2008 and 2011. In 2008, 2009, and 2011, the total number of individual fish (8.2, 7.3, and 6.9 million individuals) and invertebrates (4.2, 3.7, and 3.6 million individuals) assessed by analyzing the invoice data are roughly 60% of the total volumes recorded through the Law Enforcement Management Information System (LEMIS) dataset. Using these complete years, we back-calculated the number of individuals of both fishes and invertebrates imported in 2000, 2004, and 2005. These estimates (9.3, 10.8, and 11.2 million individual fish per year) were consistent with the three years of complete data. We also use these data to understand the global trade in two species (Banggai cardinalfish, Pterapogon kauderni, and orange clownfish, Amphiprion ocellaris / percula) recently considered for Endangered Species Act listing. Aquariumtradedata.org can help create more effective management plans for the traded species, and ideally could be implemented at key trade ports to better assess the global trade of aquatic wildlife.

Evaluation of a primary care intervention on body mass index: the Maine Youth Overweight Collaborative.

BACKGROUND: We evaluated the impact of a brief primary-care-based intervention, The Maine Youth Overweight Collaborative (MYOC), on BMI (kg/m(2)) z-score change among participants with obesity (BMI ≥95th percentile for age and sex), overweight (BMI ≥85th and <95th percentile), and healthy weight (≥50th and <85th percentile). METHODS: A quasi-experimental field trial with nine intervention and nine control sites in urban and rural areas of Maine, MYOC focused on improvements in clinical decision support, charting BMI percentile, identifying patients with obesity, appropriate lab tests, and counseling families/patients. Retrospective longitudinal record reviews assessed BMI z-scores preintervention (from 1999 through October 2004) and one postintervention time point (between December 2006 and March 2008). Participants were youth ages 5-18 having two visits before the intervention with weight percentile greater than or equal to 95% (N=265). Secondary analyses focused on youths who are overweight (N=215) and healthy weight youth (N=506). RESULTS: Although the MYOC intervention demonstrated significant provider and office system improvements, we found no significant changes in BMI z-scores in intervention versus control youth pre- to postintervention and significant flattening of upward trends among both intervention and control sites (p<0.001). CONCLUSIONS: This brief office-based intervention was associated with no significant improvement in BMI z-scores, compared to control sites. An important avenue for obesity prevention and treatment as part of a multisector approach in communities, this type of primary care intervention alone may be unlikely to impact BMI improvement given the limited dosage-an estimated 4-6 minutes for one patient contact.

Impact of a primary care intervention on physician practice and patient and family behavior: keep ME Healthy---the Maine Youth Overweight Collaborative.

OBJECTIVE: To evaluate the effect of a pediatric primary care-based intervention, on improved clinical decision support and family management of risk behaviors for childhood overweight. METHODS: An experimental field trial was conducted with 12 intervention sites in urban and rural areas of Maine and nonrandomized control sites. Change was assessed by using clinical and parent measures from 9 intervention and 10 control sites before and during the Maine Youth Overweight Collaborative intervention. Longitudinal information was collected from chart audits of patients aged 5-18 years (n = 600), systematic samples of parents collected before (n = 346) and during (n = 386) the intervention in 12 sites, and systematic samples of parents in 9 intervention (n = 235) and 10 control (n = 304) sites collected during the intervention. Surveys of health care providers (n = 14 and 17) before and during the intervention were also collected. Teams worked over 18 months to implement improvements in clinical decision support, including tracking BMI percentiles, identification of overweight patients, appropriate laboratory tests, counseling of families and patients use of a behavioral screening tool, and other improvements following the chronic-care model targeting patients aged 5 to 18 and their families. RESULTS: Large changes occurred in clinical practice from before to during the Maine Youth Overweight Collaborative: increases in assessment of BMI (38%-94%), BMI percentile for age and gender (25%-89%), use of the 5-2-1-0 behavioral screening tool (0%-82%), and weight classification (19%-75%). Parent surveys indicated improvements in providers' behavior and rates of counseling. Intervention providers reported improvements in knowledge, attitudes, self-efficacy, and practice. CONCLUSIONS: The Maine Youth Overweight Collaborative intervention improved clinical decision support and family management of risk behaviors, indicating a promising primary care-based approach to address overweight risk among children and youth.