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Dr. Ric Rosenkranz & Chelsey Schlechter recently applied RE-AIM to a review of recent literature to assess external validity components of child dietary interventions featuring parents as change agents, and examined the contribution of parent involvement to the effectiveness of dietary interventions (Schlechter et al., 2016). They were nice enough to provide the following for folks to think about as they consider applying RE-AIM to a synthesis of a body of literature.
Applying RE-AIM to the evaluation of published efficacy or effectiveness studies can pose several challenges. In general, these challenges tend to arise from lack of sufficient information within the published work, or from having a mix of information that may be difficult to classify. For us, these challenges included:
1) Reporting of RE-AIM elements. Much of the literature that we reviewed focused on Effectiveness, but details were scant or missing for Reach, Adoption, Implementation, and Maintenance. Consistent with many other review papers that have focused on RE-AIM, it was difficult to reach firm conclusions because the authors did not report sufficient detail of these indices of external validity.
2) How to classify the parent’s role within the RE-AIM framework. During data extraction, we compiled two sets of RE-AIM categories: one for the parent and one for the child. As we began to compose the manuscript, we decided to define parents as the agents of change. This decision led to classification of parents as ‘Adopters’ within the home setting. Based on Lichstein’s Implementation model (delivery, receipt, enactment), we re-organized the information that we had originally coded. Our measure of Implementation became receipt (e.g., did the parent complete the homework that the child brought home?) and Effectiveness became enactment (e.g., did the parent provide more fruits and vegetables during meal time?). During the peer review process, reviewers did not agree with those designations. Therefore, we needed to bolster our reasoning and our argument that parents were the leaders within the home setting, and therefore suitable targets for Adoption.
3). How to deal with parent-child dyads. Some of the studies we reviewed focused on parent-child dyads as the unit of analysis and target of intervention. Therefore, we struggled to decide how to treat such dyads, eventually deciding that children were the population for Reach metrics, and parents were analyzed for Adoption metrics. In such cases, however, Reach and Adoption numbers were identical.
4). How to describe the Effectiveness of direct vs indirect intervention strategies. From an earlier systematic review on our topic, Hingle et al (2010) concluded that direct strategies were more effective than indirect strategies. We followed Hingle and colleague’s (2010) definition of direct and indirect strategies, as well as their ratings for Effectiveness (positive, mixed, no change). Unfortunately, we were missing so much information on receipt and enactment of the parent strategy, we were unable to draw a similar conclusion to the previous review. We dealt with this issue by graphically depicting our conceptual model of how interventions featuring parents as change agents should work, and where gaps may occur.
Findings and lessons learned: Our attempts to extract data relevant to external validity helped us to understand not only the content of the review with a new perspective, it reinforced the crucial need to plan data collection efforts and report results relevant to Reach, Adoption, Implementation, and Maintenance. We found that the reporting of Implementation and other external validity information from child dietary interventions featuring parents as change agents was lacking. Also, a limited number of studies exist that were designed to test whether or not parent involvement in child dietary interventions increased Effectiveness, compared to a non-parent control. To improve the translation of research into practice, researchers must increasingly emphasize external validity during the planning and reporting of interventions.
By Richard Rosenkranz and Chelsey Schlechter
Hingle, M. D., O’Connor, T. M., Dave, J. M., & Baranowski, T. (2010). Parental involvement in interventions to improve child dietary intake: a systematic review. Preventive Medicine, 51(2), 103-111.
Lichstein, K. L., Riedel, B. W., & Grieve, R. (1994). Fair tests of clinical trials: A treatment implementation model. Advances in Behaviour Research and Therapy, 16(1), 1-29.
Schlechter, C. R., Rosenkranz, R. R., Guagliano, J. M., & Dzewaltowski, D. A. (2016). A systematic review of children’s dietary interventions with parents as change agents: application of the RE-AIM framework. Preventive Medicine, 91, 233-243.
Please send comments and suggestions or your own RE-AIM related work for inclusion on the site to Paul Estabrooks.