Analysing data from a cluster randomized trial (cRCT) in primary care: a case study

Health technology assessment often requires the evaluation of interventions which are implemented at the level of the health service organization unit (e.g. GP practice) for clusters of individuals. In a cluster randomized controlled trial (cRCT), clusters of patients are randomized; not each patient individually.

The majority of statistical analyses, in individually RCT, assume that the outcomes on different patients are independent. In cRCTs there is doubt about the validity of this assumption as the outcomes of patients, in the same cluster, may be correlated. Hence, the analysis of data from cRCTs presents a number of difficulties. The aim of this paper is to describe the statistical methods of adjusting for clustering, in the context of cRCTs.

There are essentially four approaches to analysing cRCTs: 1. Cluster-level analysis using aggregate summary data.

2. Regression analysis with robust standard errors.

3. Random-effects/cluster-specific approach.

4. Marginal/population-averaged approach.

This paper will compare and contrast the four approaches, using example data, with binary and continuous outcomes, from a cRCT designed to evaluate the effectiveness of training Health Visitors in psychological approaches to identify post-natal depressive symptoms and support post-natal women compared with usual care. The PoNDER Trial randomized 101 clusters (GP practices) and collected data on 2659 new mothers with an 18-month follow-up.     

(Unintended) Consequences of initiating an alcohol sales policy at college football stadiums: A case study

University officials are increasingly considering selling alcoholic beverages at campus football stadiums. To inform this decision, we report on offenses occurring at a campus football stadium and surrounding community on game day weekends between 2009 and 2013. Campus police log data for 35 home football weekends were examined, accounting for 1,940 distinct incidents. There was a general upward trend in crime incidents. On average, 330 total crime incidents occurred when alcohol was not sold (2009–2011) compared to 475 annually when alcohol was sold (2012–2013). Liquor law violations and alcohol consumption by a minor were the two most frequently cited offenses. Liquor law violations (317) was highest after alcohol sales initiated. Police incidents were markedly higher when playing a traditional football rival at home. College administrators, health officials, athletic departments, and local law enforcement must work together to weigh the potential benefit of enhanced financial profit against the risk of increased alcohol-related crime.     

Seeing the Invisible Children and Young People Affected by Disability

This paper presents a brief review of literature relating to children in families with a disabled member, including the 'young carers' and disability studies literature, and relevant works from the social psychology and sociology of childhood. Key themes identified in the literature are then illustrated by findings from two exploratory research studies that sought to explore the experiences and service needs of children in families with a disabled member, within two Scottish areas. The authors suggest that, although young people affected by disability in the family, including young carers, face significant problems, particularly in socially disadvantaged areas, there are other issues that need to be addressed. Alternative conceptual frameworks are proposed, which challenge the dominance of the young carers research paradigm.     

Organizational Form as a Mechanism to Involve Staff,Public and Users in Public Services: A Study of the Governance of NHS Foundation Trusts

In addition to introducing markets and market‐like structures into public services, New Labour wished to promote the involvement of users and the public in decision‐making in other ways than as individual consumers. One way was to involve the public in the governance of organizations. This could be done by removing public services from state control, and transferring them to mutual ownership; or by increasing public involvement in the governance of public bodies. NHS foundation trusts (FTs) were presented as mutuals. Our study shows FTs are not mutuals, as they continue to be owned by the state. Moreover, staff of FTs were generally not engaging with the new governance structures. In general, there was mixed experience of the new structures enabling governors to increase accountability of the hospitals to the public. On the other hand, having a membership did enhance the legitimacy of FTs, as opposed to other NHS organizations. The findings of the study are of current interest as the coalition government is continuing with the policy of FTs, and also encouraging mutuals and other forms of public involvement.     

Company spokesperson vs. customer testimonial: Investigating quoted spokesperson credibility and impact in business-to-business communication

Through the framework of source credibility, this study examines the impact of quoting a company executive versus a customer testimonial in a business communication context. A 2 (spokesperson) × 7 (media channel) full factorial experiment (N = 514) showed partial support for enhanced perceived credibility of information conveyed by a customer testimonial compared to a company spokesperson in independent and controlled media channels online. When evaluated through a measure of media credibility, a customer spokesperson rates higher than a company spokesperson. In addition, a product is viewed more positively by an audience receiving information quoting a customer spokesperson rather than a company spokesperson. An audience with low business expertise considers both types of spokespersons as more trustworthy than a high-expertise audience; however, a customer is considered more trustworthy than a company spokesperson. The study provides public relations professionals with insight in determining the use of spokespersons when communicating to businesspeople.     

Midwifery care: A perinatal mental health case scenario

The establishment of the National Perinatal Depression Initiative (NPDI, 2008–2013) has brought a focus across Australia for the need to identify women at risk of perinatal mental health disorders, suggesting that routine screening by relevant health professionals may aid earlier detection, better care and improved outcomes. Midwives are frequently the primary point of contact in the perinatal period and thus ideally placed to identify, interpret and manage complex situations, including screening for perinatal mental health disorders.This paper offers strategies that could be implemented into daily midwifery practice in order to achieve the goals consistent with the National Perinatal Depression Initiative. A case study (Jen) and discussion, guided by recommendations from the Australian Nursing and Midwifery Competency standards and beyondblue Clinical Practice Guidelines, are used to demonstrate how midwifery care can be provided.In accordance with her legal obligations, the midwife should act within her scope of practice to undertake a series of psychosocial and medical assessments in order to best determine how midwifery care and support can be of benefit to Jen, her infant and her family. Suggestions described include administration of validated screening questionnaires, clinical interview, physical assessment, discussion with partner, awareness of the mother–infant interactions and questioning around baby's sleep and feeding. Based on evaluation of the information gained from a bio-psycho-social assessment, suggestions are made as to the midwifery care options that could be applied.