Applying Systems Thinking Approaches to Address Preventive Health Factors through Public Parks and Recreation Agencies

Within the United States parks and recreation agencies (P&R) manage public facilities, spaces, lands, and recreation programs. Public health (PH) evidence has increasingly pointed to local public P&R agencies as critical for promoting preventive health. Programs and strategies are available, but most P&R agencies have limited resources and lack local knowledge on which to base actions. However, the research base is growing. The global research question has shifted from asking IF P&R agencies can positively affect PH factors, to HOW they can best do so with limited resources.This research adapted a systems theory approach to how local public P&R agencies are addressing health factors. Methods included a literature review along with iterative exploration through a three-stage Delphi panel study with 17 P&R agency Expert Panelists in the U.S and Canada. Panelists were identified through a waterfall selection process. Each had at least three years of senior administration experience with interest in addressing PH factors.The study explored which preventive factors appear to be most modifiable by P&R. Results indicated increased physical activity, improved nutrition, enhanced safety or perception of safety, increased social and parental engagement, improved transportation and access to locations (especially nature), and cessation or reduced overconsumption of tobacco and alcohol. However, the priority of factors varies by community, and the continuing challenge is determining the priority of the factors for agencies and their partners to address. Community-specific data are not typically readily available to P&R agencies. Programs, strategies, internal methods, policies, and documents utilized by agencies were collected. Thirty-one related national initiatives (programs) were identified and ranked by the panelists.Key common strategies for P&R were identified. Results indicated a need to focus strategies on leadership and adequate funding to create a strong organizational culture of systematic assessment for addressing PH through allocation of P&R staff and financial resources. Systems thinking analysis and strategies can improve outcomes for cultural ethics of inclusion and equity, equitable access to assets and programs, collaboration with other partners, utilization of crime prevention and environmental design strategies, increased health promotions and education, and centralized tracking and evaluation of feasible measures.Implications for research include needs for additional validation and dissemination of research, evidence-based tools, and proven methods. There continues to be a strong need to help address gaps in knowledge transfer between research and practice realms. Management implications suggest methods for practice to enhance systems-thinking approaches for better preventive health outcomes through P&R in communities.

Safety, efficacy and delivery of isometric resistance training as an adjunct therapy for blood pressure control: a modified Delphi study

Uncontrolled hypertension remains the major risk factor for cardiovascular disease. Isometric resistance training (IRT) has been shown to be a useful nonpharmacological therapy for reducing blood pressure (BP); however, some exercise physiologists and other health professionals are uncertain of the efficacy and safety of IRT. Experts’ consensus was sought in light of the current variability of IRT use as an adjunct treatment for hypertension. An expert consensus-building analysis (Delphi study) was conducted on items relevant to the safety, efficacy and delivery of IRT. The study consisted of 3 phases: (1) identification of items and expert participants for inclusion; (2) a two-round modified Delphi exercise involving expert panelists to build consensus; and (3) a study team consensus meeting for a final item review. A list of 50 items was generated, and 42 international experts were invited to join the Delphi panel. Thirteen and 10 experts completed Delphi Rounds 1 and 2, respectively, reaching consensus on 26 items in Round 1 and 10 items in Round 2. The study team consensus meeting conducted a final item review and considered the remaining 14 items for the content list. A final list of 43 items regarding IRT reached expert consensus: 7/10 items on safety, 11/11 items on efficacy, 10/12 items on programming, 8/10 items on delivery, and 7/7 on the mechanism of action. This study highlights that while experts reached a consensus that IRT is efficacious as an antihypertensive therapy, some still have safety concerns, and there is also ongoing conjecture regarding optimal delivery.

Development of strategies to support home-based exercise adherence after stroke: a Delphi consensus

ObjectiveTo develop a set of strategies to enhance adherence to home-based exercises after stroke, and an overarching framework to classify these strategies.MethodWe conducted a four-round Delphi consensus (two online surveys, followed by a focus group then a consensus round). The Delphi panel consisted of 13 experts from physiotherapy, occupational therapy, clinical psychology, behaviour science and community medicine. The experts were from India, Australia and UK.ResultsIn round 1, a 10-item survey using open-ended questions was emailed to panel members and 75 strategies were generated. Of these, 25 strategies were included in round 2 for further consideration. A total of 64 strategies were finally included in the subsequent rounds. In round 3, the strategies were categorised into nine domains—(1) patient education on stroke and recovery, (2) method of exercise prescription, (3) feedback and supervision, (4) cognitive remediation, (5) involvement of family members, (6) involvement of society, (7) promoting self-efficacy, (8) motivational strategies and (9) reminder strategies. The consensus from 12 experts (93%) led to the development of the framework in round 4.ConclusionWe developed a framework of comprehensive strategies to assist clinicians in supporting exercise adherence among stroke survivors. It provides practical methods that can be deployed in both research and clinical practices. Future studies should explore stakeholders’ experiences and the cost-effectiveness of implementing these strategies.

Validity of an Instrument to Detect Cheating Confirmed by the Elicited Emotional Reactions

Cheating forms part of a complex emotional and cognitive process. However, although a relatively mundane phenomenon, instruments to evaluate cheating and its effects socially are scarce. This paper presents a five-stage approach aimed at providing validity to an instrument designed to assess cheating — specifically, its detection, and emotional reactions towards it once detected. An instrument was designed after (1) reviewing the relevant literature on cheating, in order to (2) design a bank of stimuli, (3) formulate a Delphi panel to judge the most coherent and pertinent ones, and (4) perform three pilot studies to adjust the final version of the instrument. Results from Stages 1 to 4 show that content validity was achieved for the Instrument for Detecting Cheating and its Emotional Reactions (INDETRAE, in Spanish: Instrumento para la Detección de Trampa y sus Reacciones Emocionales). Stimuli were grouped into five categories of 18 different scenarios, for a total of 90 vignettes: meaning, the INDETRAE is a 5-category, vignette-based questionnaire consisting of contrasting social cost-benefit scenarios, where the cheating situation affects an undefined, a first or a third person, and also a neutral category with no cheating. In Stage 5, several chi-squared tests (p < 0.0005) revealed significant differences between categories, proving that the instrument can indeed be used to detect cheating and to identify differentiated emotional reactions – for example, anger when there was detriment to a third person as opposed to neutral situations, or glad when there was a case of cheating which benefited the first person. The last stage counts as the first approximation to support construct validity of the INDETRAE. The most important contribution of this work consists in developing an instrument to detect cheating, confirmed by the resulting emotional reactions, which therefore demonstrate its validity.

Implantation of corporate social responsibility measures in the horticulture in Mexico and Spain

This work presents the results of a survey, following the Delphi methodology, to experts from the horticultural sector of Mexico and Spain. Interactions with experts have made it possible to identify relevant aspects where the level of consensus is high about the proliferation of Corporate Social Responsibility (CSR) initiatives in the export sector of both countries, standing out: the horticultural sector's leadership in the implementation of standards, which responds to the demand for destination supermarkets in the US and Europe, which despite their particularities, have similar dynamics. Not implementing is considered a risk factor; the implementations are positive actions, which enhance the reputation of companies. Agricultural companies that have a lack of business culture, ignorance, and high administrative burden limit their development, especially among smaller production companies. The greatest progress has been made in the area of labor and environmental practices, areas where consumer concern is growing. Despite CRS initiatives are not providing an immediate benefit to companies, strategic spending is valued. The research is completed with a SWOT analysis (Weaknesses, Threats, Strengths and Opportunities), providing a valuable ranking of great interest for the design of competitive improvements. Highlights Corporate Social Responsibility (CRS) measures in the horticultural activity are driven mainly for the Supermarkets Chains. There are other factors to implement it: gain competitive advantage, improve the reputation of the sector, stay in the market. The Delphi Method is a useful instrument to identify advantages, limitations, and barriers to adopt food safety and Social Responsibility Standards in the global value chain in the agricultural sector. The horticultural activity is adopting several CRS standards in order to stay in the market such as: GRASP, FAIR TRADE, SEDEX, SA 8000. The Delphi Panel considers that the CRS standards and measures implemented improve the labor, environmental and human rights in the horticultural activity in Mexico and Spain.

Improving the understanding of how patients with non-dystrophic myotonia are selected for myotonia treatment with mexiletine (NaMuscla): outcomes of treatment impact using a European Delphi panel

Background Non-dystrophic myotonias (NDMs) comprise muscle chloride and sodium channelopathies due to genetic defects of the CLCN1- and SCN4A-channels. No licensed antimyotonic treatment has been available until approval of mexiletine (NaMuscla®) for adult patients by the EMA in December 2018. This Delphi panel aimed to understand how outcomes of the pivotal phase III Mexiletine study (MYOMEX) translate to real world practice and investigate health resource use, quality of life and the natural history of NDM to support economic modelling and facilitate patient access. Methods Nine clinical experts in treating NDM took part in a two-round Delphi panel. Their knowledge of NDM and previous use of mexiletine as an off-label treatment prior to NaMuscla’s approval ensured they could provide both qualitative context and quantitative estimates to support economic modelling comparing mexiletine (NaMuscla) to best supportive care. Consensus in four key areas was sought: healthcare resource utilization (HRU), treatment with mexiletine (NaMuscla), patient quality of life (QoL), and the natural history of disease. Concept questions were also asked, considering perceptions on the feasibility of mapping the validated Individualized Neuromuscular Quality of Life (INQoL) instrument to the generic EQ-5D™, and the potential impact on caregiver QoL. Results Consensus was achieved for key questions including the average long-term dosage of mexiletine (NaMuscla) in practice, the criteria for eligibility of myotonia treatment, the clinical importance of QoL outcomes in MYOMEX, the higher proportion of patients with increased QoL, and the reduction in the need for mental health resources for patients receiving mexiletine (NaMuscla). While consensus was not achieved for other questions, the results demonstrated that most experts felt mexiletine (NaMuscla) reduced the need for HRU and was expected to improve QoL. The QoL mapping exercise suggested that it is feasible to map domains of INQoL to EQ-5D. Points of interest for future research were identified, including that mexiletine (NaMuscla) may slow the annual decrease in QoL of patients over their lifetime, and a significant negative impact on QoL for some caregivers. Conclusions This project successfully provided data from an informed group of clinical experts, complementing the currently available clinical trial data for mexiletine (NaMuscla) to support patient access decisions.

Evidence-based recommendations for economic evaluations in spine surgery: study protocol for a Delphi consensus

IntroductionConsidering the rising global healthcare expenses, economic evaluations are more important than ever. Even though the number of studies regarding costs and cost-effectiveness is increasing, the quality of these studies remains relatively low. This is mainly caused by abundant heterogeneity in methods used for determining, calculating and reporting cost data, despite current general guidelines for the conduct of economic evaluations. Disease-specific recommendations for the conduct of economic evaluations in the field of spine surgery, as complement to existing general guidelines, will ameliorate overall research quality, comparability and interpretability and thus, the overall quality. We aim to provide expert-based recommendations for the design, conduct, and reporting of economic evaluations in spine surgery.Methods and analysisA modified Delphi study will be conducted to formulate expert-based recommendations. The following steps will be taken:(1) The conduct of a systematic review to identify relevant publications and identify relevant authors. Formation of an expert group and a Delphi-panel. (2) Drafting of statements based on articles included in the systematic literature review. Validation of drafted statements by the expert group. Step 2 can be repeated up to three times, statements can be discarded and adjusted in these rounds. Statements with more than 75% agreement will be accepted as consensus statements. (3) Validation of statements by the Delphi-panel. (4) Final recommendations.Ethics and disseminationThe underlying work is based on existing literature and published data and does not include participation of patients, and thus does not require ethical review approval. The final recommendations are intended for (clinical) researchers in the field of cost-effectiveness in spine surgery. The Delphi method ensures that the final output reflects the opinions of international participants and gives insight in the adherence level to the recommendations. The aim is to reach uniformity in design, conduct and reporting of these studies, as is currently lacking. This will provide a solid basis to determine cost-effectiveness of spine surgeries and consequently aid to limit the rising healthcare costs. The findings of this study and the final recommendations will be disseminated in conferences and seminars and will be published in an international peer-reviewed journal.

Stakeholders perspectives of barriers and facilitators of childhood obesity prevention policies in Iran: A Delphi method study

Background The prevalence of obesity among children and adolescents is one of the most important health challenges of the present century. Many factors affect the prevention policies related to this health problem and make their implementation difficult. This study examined perceived barriers and facilitators of childhood obesity prevention policies by stakeholders. Methods A qualitative descriptive research design based on Delphi method was conducted. In addition, semi-structured one-to-one interviews were conducted with childhood obesity prevention policy stakeholders (n=39) and initial identification of barriers and facilitators in this area. Interviews were digitally recorded, transcribed verbatim, and finally analyzed, followed by using thematic analysis. Subsequently, two-round Delphi panel was done by sending e-mails to stakeholders (21 stakeholders participated in the first round and 15 stakeholders in the second round) for the final selection of barriers and facilitators of obesity prevention policies among children and adolescents in Iran. Results The identified barriers and facilitators were divided into three levels: individual, executive, and structural. Barriers and facilitators of the structural level showed a high score and priority regarding obesity prevention policies among children and adolescents. Conclusion The existence of significant barriers at all three levels and especially at the structural level were among the concerns of stakeholders.