A realist review of interventions and strategies to promote evidence-informed healthcare: a focus on change agency

Background
Change agency in its various forms is one intervention aimed at improving the effectiveness of the uptake of evidence. Facilitators, knowledge brokers and opinion leaders are examples of change agency strategies used to promote knowledge utilization. This review adopts a realist approach and addresses the following question: What change agency characteristics work, for whom do they work, in what circumstances and why?

Methods
The literature reviewed spanned the period 1997-2007. Change agency was operationalized as roles that are aimed at effecting successful change in individuals and organizations. A theoretical framework, developed through stakeholder consultation formed the basis for a search for relevant literature. Team members, working in sub groups, independently themed the data and developed chains of inference to form a series of hypotheses regarding change agency and the role of change agency in knowledge use.

Results
24, 478 electronic references were initially returned from search strategies. Preliminary screening of the article titles reduced the list of potentially relevant papers to 196. A review of full document versions of potentially relevant papers resulted in a final list of 52 papers. The findings add to the knowledge of change agency as they raise issues pertaining to how change agents’ function, how individual change agent characteristics effect evidence-informed health care, the influence of interaction between the change agent and the setting and the overall effect of change agency on knowledge utilization. Particular issues are raised such as how accessibility of the change agent, their cultural compatibility and their attitude mediate overall effectiveness. Findings also indicate the importance of promoting reflection on practice and role modeling. The findings of this study are limited by the complexity and diversity of the change agency literature, poor indexing of literature and a lack of theory-driven approaches.

Conclusion
This is the first realist review of change agency. Though effectiveness evidence is weak, change agent roles are evolving, as is the literature, which requires more detailed description of interventions, outcomes measures, the context, intensity, and levels at which interventions are implemented in order to understand how change agent interventions effect evidence-informed health care.

Geolocator studies on Ruddy Turnstones Arenaria interpres and Greater Sandplovers Charadrius leschenaultii in the East Asian-Australasia Flyway reveal widely different migration strategies

In 2010, following successful trials with geolocators on Ruddy Turnstones in 2009, a total of 105 units, of four different models, were deployed at five locations on Ruddy Turnstones and Greater Sandplovers. Geolocator retrieval rates were 44% on Ruddy Turnstone and 27% on Greater Sandplover. Complete (59%) and partial (15%) technical failure rates on geolocators were high and were mostly the result of wear and saltwater corrosion. All 30 units from the Swiss Ornithological Institute failed. Only half of the Mk10 and Mk12 units from the British Antarctic Survey produced full migration histories. The northward migration of Ruddy Turnstones was on a narrow path with many birds completing an initial non-stop flight of 7,600 km to Taiwan. Later, most made a stopover in the Yellow Sea. Median migration duration was 39.5 days and average migration speed of the first major leg of the journey (assuming the birds followed the great circle route between stopovers) was 63.4 kph. Southward migration paths showed a much wider spread, ranging from Mongolia to the central Pacific. The latter involved the same bird that had been tracked along this route the previous year. It has now been logged on similar 27,000 km round trips in two successive years. The median duration of southward migration (78 days) was nearly twice that of northward migration and data on average migration speed for just two migration legs indicated that it might be lower, 30 and 40 kph being the values recorded. Greater Sandplovers were only tracked on northward migration but seemed to follow a similar migration strategy with a large initial non-stop flight followed by shorter flights and more regular stopovers. Plans are outlined for further analyses and future deployments of geolocators.

Expanding a successful community-based obesity prevention approach into new communities : challenges and achievements

OBJECTIVE: A previously successful community-based obesity prevention intervention with a focus on school settings was expanded into new communities with varying contexts. In order to understand the complexities involved in implementing health promotion activities in schools, this study examined experiences of school staff and project officers including barriers, contextual factors and achievements. METHODS: School environment assessments were conducted in schools across four Victorian communities with school staff (n=1-5 staff plus a trained researcher per group in 9 primary and 8 secondary schools) 12-18 months post-intervention. Process reports from project officers were also reviewed and analysed (n=4). RESULTS: School staff commonly reported time pressures as a barrier to implementation and project officers working within schools reported competing priorities and limited health promotion experience of staff; lack of stakeholder engagement; low participation in some activities and insufficient implementation time. Contextual factors included community socioeconomic status, student ethnicity and living rurally. Achievements included student and staff enjoyment from programme activities, staff capacity building, partnerships, embedding activities into existing infrastructure and programmes, and having consistent health-related messages repeated through a variety of strategies. CONCLUSIONS: Community-based interventions with a focus on school settings need to consider system level, organisational and contextual (i.e. socioeconomic, ethnicity, family and town characteristics) factors when expanding previously effective strategies into new communities. Implementation benefits may have added whole of school benefits in addition to child health. Focussing on overcoming the challenges experienced in this complex initiative is required for future interventions.

Effective strategies for weight loss in post-partum women: a systematic review and meta-analysis

Post-partum weight loss is critical to preventing and managing obesity in women, but the results from lifestyle interventions are variable and the components associated with successful outcomes are not yet clearly identified. This study aimed to identify lifestyle intervention strategies associated with weight loss in post-partum women. MEDLINE, EMBASE, PubMed, CINAHL and four other databases were searched for lifestyle intervention studies (diet or exercise or both) in post-partum women (within 12 months of delivery) published up to July 2014. The primary outcome was weight loss. Subgroup analyses were conducted for self-monitoring, individual or group setting, intervention duration, intervention types, the use of technology as a support, and home- or centre-based interventions. From 12,673 studies, 46 studies were included in systematic review and 32 randomized controlled trials were eligible for meta-analysis (1,892 women, age 24-36 years). Studies with self-monitoring had significantly greater weight lost than those without (-4.61 kg [-7.08, -2.15] vs. -1.34 kg [-1.66, -1.02], P = 0.01 for subgroup differences). Diet and physical activity when combined were significantly more effective on weight loss compared with physical activity alone (-3.24 kg [-4.59, -1.90] vs. -1.63 kg [-2.16, -1.10], P < 0.001 for subgroup differences). Lifestyle interventions that use self-monitoring and take a combined diet-and-exercise approach have significantly greater weight loss in post-partum women.

Business strateBusiness strategies under conditions of uncertainty: The rise of mutual life insurers in colonial Australiagies under conditions of uncertainty

The early development of Australian life insurance was marked by the failure of stock companies to successfully establish a market presence. Mutual insurers emerged in the mid-nineteenth century in response to this gap in supply. The underlying rationale behind their establishment differed but the business model adopted proved remarkably successful. Mutual life insurers dominated the market for life insurance for nearly a century. This chapter investigates mutualism as a business strategy that addressed particular problems associated with doing business in a small and underdeveloped economy. Business and social networks were important facilitators of new business. In addition, most mutual life insurers had a social/philanthropic charter and they were able to utilize this to build business. An outcome of this mix was the emergence of a particular type of entrepreneurship that fostered innovative product development and cemented the role of mutual insurers as market leaders.. The Variety, Choice, Governance, and Regulation of Organizational Forms 2.

Drought survival strategies, dispersal potential and persistence of invertebrate species in an intermittent stream landscape

Intermittent stream systems create a mosaic of aquatic habitat that changes through time, potentially challenging freshwater invertebrate dispersal. Invertebrates inhabiting these mosaics may show stronger dispersal capacity than those in perennial stream systems. To relate different combinations of dispersal and drought survival strategies to species persistence, we compared the distribution and dispersal potential of six invertebrate species across all streams in a montane landscape where drying is becoming increasingly frequent and prolonged. Invertebrates were collected from seventeen streams in the Victoria Range, Grampians National Park, Victoria, Australia. The species analysed were as follows: the caddisflies Lectrides varians Moseley (Leptoceridae) and Agapetus sp. (Glossosomatidae); the mayflies Nousia AV1 and Koorrnonga AV3 (Leptophlebiidae); the water penny beetle Sclerocyphon sp. (Psephenidae); and a freshwater crayfish Geocharax sp. nov. 1 (Parastacidae). These species were widespread in the streams and varied in their dispersal and drought survival strategies. The distribution of each species across the Victoria Range, their drought responses and within-stream habitat associations were determined. Hypotheses of the dispersal capacity and population structure for each species were developed and compared to four models of gene flow: Death Valley Model (DVM), Stream Hierarchy Model (SHM), Headwater Model (HM) or panmixia (PAN). Molecular genetic methods were then used to infer population structure and dispersal capacity for each species. The large caddisfly Lectrides resisted drought through aestivation and was panmictic (PAN) indicating strong dispersal capacity. Conversely, the small caddisfly Agapetus relied on perennially flowing reaches and gene flow was limited to short distances among stream headwaters, resembling the HM. Both mayflies depended on perennial surface water during drying and showed evidence of gene flow among streams: Koorrnonga mainly dispersed along stream channels within catchments, resembling the SHM, whereas Nousia appeared to disperse across land by adult flight. Sclerocyphon relied on perennial water to survive drying and showed an unusual pattern of genetic structure that indicated limited dispersal but did not resemble any of the models. Geocharax survived drought through aestivation or residence in perennial pools, and high levels of genetic structure indicated limited dispersal among streams, resembling the DVM. Despite good knowledge of species' drought survival strategies, the population structure of four species differed from predictions. Dispersal capacity varied strongly among species; most species were poor dispersers and only one species showed panmixia. Therefore, intermittent stream species may not necessarily be better dispersers than those in perennial streams. Species showing strong drought resistance strategies differed in dispersal capacity. Knowledge of life-history characteristics, distribution and refuge use does not necessarily enable successful prediction of invertebrate dispersal pathways or population structure. Dispersal among intermittent streams may be restricted to relatively short distances (km) for most invertebrate species. Thus, frequent drought refuges (perennial water) that provide strong connectivity to subpopulations through stream flow (hydrological dispersal), or continuous terrestrial vegetation (flight dispersal), will be critical to maintain genetic diversity, adaptability and population persistence.