Effectiveness of reminders to sustain practice change among direct care providers in residential care facilities: a cluster randomized controlled trial

Abstract

Background: The study purpose was to compare the effectiveness of monthly or quarterly peer reminder knowledge translation interventions, with monthly or quarterly paper-based reminders, to sustain a mobility innovation, the sit-to-stand activity.

Method: A cluster RCT using a stratified 2 × 2 factorial design was conducted in 24 Canadian residential care facilities with 416 residents and 54 peer reminder care aides. The 1-year intervention included two intensities of reminders (high: socially based peer reminders delivered by volunteer care aides to other care aides; low: paper-based reminders posted in residents' rooms), at two frequencies (monthly; every 3 months). Intervention fidelity was assessed using questionnaires and observations. Monthly sustainability rate of the sit-to-stand activity was calculated as the percentage of opportunities that residents successfully completed the activity in 30 days. Residents' sustainability rates were analyzed using a linear mixed model that mirrored the clustered repeated-measures factorial trial design. The model included a random intercept to account for clustering within sites. An unstructured covariance structure characterized the interdependence of repeated measures over time.

Results: Twenty-four sites were randomized. One site was excluded because of falsifying data, leaving 23 sites and 349 residents for intention-to-treat analysis. Paper reminders were implemented with high fidelity across all arms (91.5% per protocol), while the peer reminders were implemented with moderate fidelity in the monthly group (81.0% per protocol) and poor fidelity in the quarterly group (51.7% per protocol). At month 1, mean sustainability ranged from 40.7 to 47.2 per 100 opportunities, across the four intervention arms (p = 0.43). Mean rate of sustainability in the high intensity, high frequency group diverged after randomization, yielding statistically significant differences among the groups at 4 months which persisted for the remainder of the trial. After 12 months, the mean sustainability in the high intensity, high frequency group was approximately twice that of the other three groups combined (64.1 versus 37.8 per 100 opportunities, p < 0.001).

Conclusions: A monthly peer reminder intervention was more effective than a quarterly peer reminder intervention, a monthly paper-based reminder intervention, and a quarterly paper-based reminder intervention, in supporting care aides to sustain a mobility innovation in residential care facilities over 1 year.

Trial registration: ClinicalTrials.gov , NCT01746459. Registered 11 December 2012: https://ichgcp.net/clinical-trials-registry/NCT01746459 .

Keywords: Cluster randomized controlled trial; Reminders; Sit-to-stand activity; Sustainability.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1

Screening, randomization, and follow-up

Fig. 2

Mean rate of sustainability by month of study and intervention group. High intensity, high frequency (), high intensity, low frequency (); low intensity, high frequency (); low intensity, low frequency (). The mean rates of adoption were estimated from a linear mixed model that included eight factors, a random intercept, and an unstructured covariance structure. The mean rate of sustainability in the combined high intensity, high frequency group diverged shortly after randomization, yielding a statistically significant difference among the groups as early as 4 months. At the end of 12 months, the mean rate of adoption in the high intensity, high frequency group was approximately twice as high than in the other three groups combined (64.1 versus 37.8 per 100 opportunities, p < 0.001), which were not significantly different from each other (p = 0.34), and their rates of sustainability remained relatively constant over the duration of the trial