背景:正确的康复方式(HRW)旨在通过促进系统级获得文化上安全的康复服务来改善患有中风或创伤性脑损伤的澳大利亚原住民的健康状况。使用阶梯式楔形随机对照试验(RCT)设计(ACTRN12618000139279,2018年1月30日),在四家农村医院和四家城市医院引入了双管齐下的干预措施,包括1。员工的文化安全培训(CST)和2。培训/雇用土著脑损伤协调员(ABIC),以支持土著患者受伤后6个月。四分之三的招募患者生活在农村。主要结果指标是生活质量,次要结果包括功能测量,最低护理流程(MPC);接受服务的康复次数,改善医院体验。评估是在基线时进行的,受伤后12周和26周。在干预患者中,只有MPC和医院经验得到改善。我们报告了旨在支持结果解释和翻译的过程评估。
方法:使用混合方法,评估设计是由实施研究综合框架提供的。数据源包括分钟数、项目日志,调查,半结构化面试,和观察。四个评估问题为系统确定试验质量提供了基础。将来自不同来源的调查结果结合起来,以综合解决评估问题的新兴主题。分别考虑了三个组成部分:试验过程,CST和ABIC。
结果:复杂的HRW试验实施到令人满意的水平,尽管有挑战性的设定因素,特别是城乡系统动态。无法克服患者招募限制。阶梯式楔形设计对时间效应的脆弱性影响了招募和试验结果,由于COVID。尽管后续行动相对较多,包括农村/偏远地区,数据点减少。缺乏文化上适当的评估工具影响了评估数据的质量/完整性。ABIC的作用被认为是可行的,并且广受好评。CST涉及复杂的物流,但评价很高,尽管在线组件通常不完整。项目管理对员工做出了回应,患者和设置因素。
结论:尽管结果大多模棱两可,ABIC的作用在主流医院中是可行的,CST受到高度重视.学习将有助于为脑损伤后的原住民建立强大的全州文化安全康复模型,包括MPC,劳动力,培训和跟进。
BACKGROUND: Healing Right Way (HRW) aimed to improve health outcomes for Aboriginal Australians with stroke or traumatic brain injury by facilitating system-level access to culturally secure rehabilitation services. Using a stepped-wedge randomised controlled trial (RCT) design (ACTRN12618000139279, 30/01/2018), a two-pronged intervention was introduced in four rural and four urban hospitals, comprising 1.Cultural security training (CST) for staff and 2.Training/employment of Aboriginal Brain Injury Coordinators (ABIC) to support Aboriginal patients for 6-months post-injury. Three-quarters of recruited patients lived rurally. The main outcome measure was quality-of-life, with secondary outcomes including functional measures, minimum processes of care (MPC); number rehabilitation occasions of service received, and improved hospital experience. Assessments were undertaken at baseline, 12- and 26-weeks post-injury. Only MPCs and hospital experience were found to improve among intervention patients. We report on the process evaluation aiming to support interpretation and translation of results.
METHODS: Using mixed methods, the evaluation design was informed by the Consolidated Framework for Implementation Research. Data sources included minutes, project logs, surveys, semi-structured interviews, and observations. Four evaluation questions provided a basis for systematic determination of the quality of the trial. Findings from separate sources were combined to synthesise the emerging themes that addressed the evaluation questions. Three components were considered separately: the trial process, CST and ABIC.
RESULTS: The complex HRW trial was implemented to a satisfactory level despite challenging setting factors, particularly rural-urban system dynamics. Patient recruitment constraints could not be overcome. The vulnerability of stepped-wedge designs to time effects influenced recruitment and trial results, due to COVID. Despite relatively high follow-up, including to rural/remote areas, data points were reduced. The lack of culturally appropriate assessment tools influenced the quality/completeness of assessment data. The ABIC role was deemed feasible and well-received. The CST involved complex logistics, but rated highly although online components were often incomplete. Project management was responsive to staff, patients and setting factors.
CONCLUSIONS: Despite mostly equivocal results, the ABIC role was feasible within mainstream hospitals and the CST was highly valued. Learnings will help build robust state-wide models of culturally secure rehabilitation for Aboriginal people after brain injury, including MPC, workforce, training and follow-up.