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Background Nudge interventions are those that seek to modify the social and physical environment to enhance capacity for subconscious behaviours that align with the intrinsic values of an individual, without actively restricting options. This study sought to describe the application and effects of nudge strategies on clinician implementation of health-related guidelines, policies and practices within studies included in relevant Cochrane systematic reviews. Methods As there is varied terminology used to describe nudge, this study examined studies within relevant systematic reviews. A two-stage screening process was undertaken where, firstly, all systematic reviews published in the Cochrane Library between 2016 and 2018 were screened to identify reviews that included quantitative studies to improve implementation of guidelines among healthcare providers. Secondly, individual studies within relevant systematic reviews were included if they were (i) randomised controlled trials (RCTs), (ii) included a nudge strategy in at least one intervention arm, and (iii) explicitly aimed to improve clinician implementation behaviour. We categorised nudge strategies into priming, salience and affect, default, incentives, commitment and ego, and norms and messenger based on the Mindspace framework. Synthesis The number and percentage of trials using each nudge strategy was calculated. Due to substantial heterogeneity, we did not undertake a meta-analysis. Instead, we calculated within-study point estimates and 95% confidence intervals, and used a vote-counting approach to explore effects. Results Seven reviews including 42 trials reporting on 57 outcomes were included. The most common nudge strategy was priming (69%), then norms and messenger (40%). Of the 57 outcomes, 86% had an effect on clinician behaviour in the hypothesised direction, and 53% of those were statistically significant. For continuous outcomes, the median effect size was 0.39 (0.22, 0.45), while for dichotomous outcomes the median Odds Ratio was 1.62 (1.13, 2.76). Conclusions This review of 42 RCTs included in Cochrane systematic reviews found that the impact of nudge strategies on clinician behaviour was at least comparable to other interventions targeting implementation of evidence-based guidelines. While uncertainty remains, the review provides justification for ongoing investigation of the evaluation and application of nudge interventions to support provider behaviour change. Trial registration This review was not prospectively registered.

Background Sustainment has been defined as the sustained use or delivery of an intervention in practice following cessation of external implementation support. This review aimed to identify and synthesise factors (barriers and facilitators) that influence the sustainment of interventions (policies, practices, or programmes) in schools and childcare services that address the leading risk factors of chronic disease. Methods Seven electronic databases and relevant reference lists were searched for articles, of any design, published in English, from inception to March 2020. Articles were included if they qualitatively and/or quantitatively reported on school or childcare stakeholders’ (including teachers, principals, administrators, or managers) perceived barriers or facilitators to the sustainment of interventions addressing poor diet/nutrition, physical inactivity, obesity, tobacco smoking, or harmful alcohol use. Two independent reviewers screened texts, and extracted and coded data guided by the Integrated Sustainability Framework, an existing multi-level sustainability-specific framework that assesses factors of sustainment. Results Of the 13,158 articles identified, 31 articles met the inclusion criteria (8 quantitative, 12 qualitative, 10 mixed-methods, and 1 summary article). Overall, 29 articles were undertaken in schools (elementary n =17, middle n =3, secondary n =4, or a combination n =5) and two in childcare settings. The main health behaviours targeted included physical activity ( n =9), diet ( n =3), both diet and physical activity ( n =15), and smoking ( n =4), either independently ( n =1) or combined with other health behaviours ( n =3). Findings suggest that the majority of the 59 barriers and 74 facilitators identified to impact on intervention sustainment were similar across school and childcare settings. Factors predominantly relating to the ‘inner contextual factors’ of the organisation including: availability of facilities or equipment, continued executive or leadership support present, and team cohesion, support, or teamwork were perceived by stakeholders as influential to intervention sustainment. Conclusions Identifying strategies to improve the sustainment of health behaviour interventions in these settings requires a comprehensive understanding of factors that may impede or promote their ongoing delivery. This review identified multi-level factors that can be addressed by strategies to improve the sustainment of such interventions, and suggests how future research might address gaps in the evidence base. Trial registration This review was prospectively registered on PROSPERO: CRD42020127869 , Jan. 2020.

This systematic review described the association between electronic nicotine delivery systems and electronic non-nicotine delivery systems (ENDS/ENNDS) use among non-smoking children and adolescents aged <20 years with subsequent tobacco use. We searched five electronic databases and the grey literature up to end of September 2020. Prospective longitudinal studies that described the association between ENDS/ENNDS use, and subsequent tobacco use in those aged < 20 years who were non-smokers at baseline were included. The Joanna Briggs Institute Critical Appraisal Checklist was used to assess risk of bias. Data were extracted by two reviewers and pooled using a random-effects meta-analysis. We generated unadjusted and adjusted risk ratios (ARRs) describing associations between ENDS/ENNDS and tobacco use. A total of 36 publications met the eligibility criteria, of which 25 were included in the systematic review (23 in the meta-analysis) after exclusion of overlapping studies. Sixteen studies had high to moderate risk of bias. Ever users of ENDS/ENNDS had over three times the risk of ever cigarette use (ARR 3·01 (95% CI: 2·37, 3·82; p<0·001, I2: 82·3%), and current cigarette use had over two times the risk (ARR 2·56 (95% CI: 1·61, 4·07; p<0·001, I2: 77·3%) at follow up. Among current ENDS/ENNDS users, there was a significant association with ever (ARR 2·63 (95% CI: 1·94, 3·57; p<0·001, I2: 21·2%)), but not current cigarette use (ARR 1·88 (95% CI: 0·34, 10·30; p = 0·47, I2: 0%)) at follow up. For other tobacco use, ARR ranged between 1·55 (95% CI 1·07, 2·23) and 8·32 (95% CI: 1·20, 57·04) for waterpipe and pipes, respectively. Additionally, two studies examined the use of ENNDS (non-nicotine devices) and found a pooled adjusted RR of 2·56 (95% CI: 0·47, 13·94, p = 0.035). There is an urgent need for policies that regulate the availability, accessibility, and marketing of ENDS/ENNDS to children and adolescents. Governments should also consider adopting policies to prevent ENDS/ENNDS uptake and use in children and adolescents, up to and including a ban for this group.

Trials that aim to optimise the implementation of an intervention are often complex, requiring multiple, combined strategies and requiring uptake on multiple levels. Previous implementation trials have optimised implementation strategies using multi-arm cluster randomised control trials (cRCTs) but can be inefficient and waste resources. Adaptive designs may potentially improve efficiency of these trials, but under what design features and trial properties is unknown. A simulation study was performed to assess under what conditions, if any, one or two interim adaptive designs offer increased efficiency compared to a ‘fixed trial’ approach for implementation cRCTs. A four-arm cRCT was simulated with varied trial properties, with a fixed design or an adaptive design (varying by number of interim analyses and timing of interim analyses) and modelled using Bayesian hierarchical models. The adaptive design allowed for stopping early for futility and dropping an arm for futility. The power, type 1 error rate, and adaptive design decisions were compared between the designs across trial properties. Both one and two interim adaptive designs offered power gains and a lower type 1 error rate compared to the fixed designs across most trial properties. A high intra-class correlation (ICC) of 0.2 led to adaptive trials dropping effective arms or incorrectly stopping for futility more frequently, with the incorrect decisions being compounded when two interim analyses were used. The rate of these incorrect decisions was reduced when the first interim analysis in the two interim designs was delayed. Adaptive designs can offer improved efficiency, more power, and reduce resource wastage for trials compared to fixed designs.

Background Sustainability is concerned with the long-term delivery and subsequent benefits of evidence-based interventions. To further this field, we require a strong understanding and thus measurement of sustainability and what impacts sustainability (i.e., sustainability determinants). This systematic review aimed to evaluate the quality and empirical application of measures of sustainability and sustainability determinants for use in clinical, public health, and community settings. Methods Seven electronic databases, reference lists of relevant reviews, online repositories of implementation measures, and the grey literature were searched. Publications were included if they reported on the development, psychometric evaluation, or empirical use of a multi-item, quantitative measure of sustainability, or sustainability determinants. Eligibility was not restricted by language or date. Eligibility screening and data extraction were conducted independently by two members of the research team. Content coverage of each measure was assessed by mapping measure items to relevant constructs of sustainability and sustainability determinants. The pragmatic and psychometric properties of included measures was assessed using the Psychometric and Pragmatic Evidence Rating Scale (PAPERS). The empirical use of each measure was descriptively analyzed. Results A total of 32,782 articles were screened from the database search, of which 37 were eligible. An additional 186 publications were identified from the grey literature search. The 223 included articles represented 28 individual measures, of which two assessed sustainability as an outcome, 25 covered sustainability determinants and one explicitly assessed both. The psychometric and pragmatic quality was variable, with PAPERS scores ranging from 14 to 35, out of a possible 56 points. The Provider Report of Sustainment Scale had the highest PAPERS score and measured sustainability as an outcome. The School-wide Universal Behaviour Sustainability Index-School Teams had the highest PAPERS score (score=29) of the measure of sustainability determinants. Conclusions This review can be used to guide selection of the most psychometrically robust, pragmatic, and relevant measure of sustainability and sustainability determinants. It also highlights that future research is needed to improve the psychometric and pragmatic quality of current measures in this field. Trial registration This review was prospectively registered with Research Registry (reviewregistry1097), March 2021.

Trials optimising implementation strategies are complex, assess multicomponent strategies, and cluster randomise. We define optimisation as identifying the best combination of components for multi-component implementation strategies. Multi-arm, fixed, cluster randomised control trials (cRCTs) can assess multiple implementation components but suffer from low power due to challenges of recruitment. Adaptive designs offer increased efficiency, when compared to “fixed trial” approaches. A simulation study was conducted to assess whether adaptive designs are feasible (acceptable operating characteristics and adaptive interim decisions) for implementation cRCTs with few clusters. A four-arm cRCT was simulated under varying trial properties. The trials were simulated using fixed design and adaptive design parameters (number of interim analyses, timing of interim analysis, actions at interim e.g. allowing for early stopping for futility, arm dropping) and modelled using Bayesian hierarchical models. The power and type 1 error were compared between the fixed and adaptive designs, and the number of correct interim decisions under the adaptive design were examined. When the intra-class correlation (ICC) was high, the proportion of trials that incorrectly dropped the most effective arm increased. There were small power gains for adaptive designs, without increasing type 1 error. Power gains attenuated when ICC was high and sample size was low. Type 1 error was lower comparable between adaptive and non-adaptive designs. Adaptive designs are feasible for cRCTs with few clusters. They are not as feasible when the ICC is high due to increased risk of incorrect adaptive interim decisions.

To explore adult medical oncology outpatients' understanding of and preferences for the format of health risk information. Two surveys, one assessing sociodemographic characteristics and a second survey examining perceptions of risk information. Of the 361 (74%) consenting patients, 210 completed at least one question on risk communication. 17% to 65% of patients understood numeric risk information, depending on the format of the information. More than 50% of people interpreted a \"very good\" chance of remission as greater than 80%, greater than 90% or 100%. The most preferred format of information was in both words and numbers (38% to 43%) followed by words alone (28% to 30%). Numeric risk information is understood by 17% to 65% of respondents, depending on the format. Interpretation of verbal risk information is highly variable, posing a risk of misunderstanding. Provision of information in both words and numbers may assist in aiding comprehension.

Healthcare initiatives have a larger impact if effective initiatives are spread (brought from one site to the next) or scaled (infrastructure developed to underpin and support widespread implementation), while sustaining initial benefits. Unfortunately, many initiatives, including digital health initiatives, remain confined to the pilot stage. Of those initiatives that do progress, little is known about how to plan for the equitable spread and scale of effective initiatives. There are many structural \"models\" of spread and scale, defined here as conceptual representations of how initiatives are organised and delivered across multiple settings (i.e., hub-and-spoke model), yet little is known about these models. Primary Objective: To identify and describe structural models for spreading and scaling digital health initiatives. Secondary Objectives: 1. To describe the associated factors, strengths, limitations, and necessary preconditions associated with each model. 2. To describe the barriers and facilitators experienced when applying each model. 3. To explore whether and how each model prioritized equitable delivery of care. 4. To determine which pre-established types of scale (horizontal, vertical, diversification, and spontaneous) are associated with each model. A scoping review will be conducted following Joanna Briggs Institute (JBI) methodology and reported in accordance with PRISMA-ScR guidelines. The search strategy includes peer-reviewed databases for health and business, alongside grey literature sources. Eligibility criteria follow the Population-Concept-Context framework, focusing on digital health initiatives delivered in healthcare settings. The review will produce a comprehensive overview of structural models for spreading and scaling digital health initiatives, including model names, descriptions, strengths, limitations, preconditions, associated barriers and facilitators of applying each model, relationships between models and established types of scale, and equity considerations. This novel review aims to inform practical planning of how to bring digital health initiatives to new settings and populations, to support more equitable access to these initiatives.

Background Optimisation is the iterative process to improve a health intervention or implementation strategy within resource constraints. This review aimed to identify which study designs are being used to evaluate the optimisation of health interventions and implementation strategies, and whether they differ by optimisation target. This review identifies possible strategies to improve future optimisation trials. Methods A scoping review of the Medline, EMBASE, CINAHL, and ProQuest Nursing and Allied Health Source databases was undertaken. The International Clinical Trials Registry Platform and the Australian New Zealand Clinical Trials Registry were also searched for relevant trials. Data were extracted by one reviewer for 64% of studies, and by two reviewers for 36% of studies. Data extracted included research designs, optimisation target and constraints, and whether an optimisation framework and criteria for optimisation success was used. The frequency of optimisation constraints was tabulated by experimental design and optimisation target. Results 183 studies aimed to optimise an intervention ( n  = 142) or implementation strategy ( n  = 39) or both ( n  = 2). Factorial designs were the most common design used to evaluate optimisation of an intervention (41%), whereas pre-post designs were the most common for implementation strategies (46%). Optimisation success was defined in 11% of trials and 24% of trials used a framework for optimisation. Conclusions This review characterises the design features of trials aiming to optimise health interventions or implementation strategies. There is a need for the use of frameworks to guide trial design and for a clear definition of optimisation success. It is recommended to consider using alternate methods that may overcome common impediments and align better with optimisation, such as adaptive designs and Bayesian statistics.

Background Effective evidence-based physical activity and nutrition interventions to prevent overweight and obesity and support healthy child development need to be sustained within Early Childhood Education and Care (ECEC) services. Despite this, little is known about factors that influence sustainability of these programs in ECEC settings. Therefore, the aim of this study was to describe the factors related to sustainability of physical activity and nutrition interventions in ECEC settings and examine their association with ECEC service characteristics. Methods A cross-sectional study was undertaken with a nationally representative sample of 473 Australian ECEC services. Factors related to the sustainability of ECEC-based physical activity and nutrition interventions were assessed using the validated Integrated Measure of PRogram Element SuStainability in Childcare Settings (IMPRESS-C), measuring Outer Contextual Factors, Inner Contextual Factors, Processes and Characteristics of the Intervention domains for interventions that supervisors reported as currently implementing. Participants responded using a 5-point Likert scale, with responses ranging from 1 (completely disagree) to 5 (completely agree). Domain scores were calculated for each service by averaging item responses. Linear regression models between ECEC service characteristics and the IMPRESS-C domains were undertaken. Results Data from 473 Australian childcare services nationally found that the domains: Processes ( x ¯ =3.78, SD = 0.64), consisting of partnership/engagement and training/support/supervision; and Outer Contextual Factors ( x ¯ =3.93, SD = 0.63), including policy and legislation, and socio-political context had the lowest mean scores indicating they may likely be barriers to sustainability. Linear regression analyses revealed no statistically significant associations between examined factors and ECEC service characteristics. There was a statistically significant association between the number of years services delivered their interventions and the Characteristics of the Intervention domain ( p  = 0.035) suggesting that this domain may influence sustainability of programs. Conclusions This study suggests that factors related to the Processes and Outer Contextual Factors domains had the lowest scores and as such, strategies to support the sustainability of physical activity and nutrition interventions implemented in ECEC settings may need to consider how to best address these factors.