Guideline evaluation and implementation mechanisms in school health services (GuideMe): protocol for a hybrid randomized factorial trial.

BACKGROUND: Norwegian school health services received a national best-practice guideline in 2017. To promote healthy life skills and identify adolescents needing support, the guideline includes strong recommendations for individual consultations with all 8th graders and increased collaboration with schools. To help implement the recommendations, a blended implementation strategy (SchoolHealth) was co-created with school nurses, students, and stakeholders. SchoolHealth consists of three implementation elements: Digital dialog and administration tool (audit and feedback +), Dialog support (external consultation), and Collaboration materials (targeted dissemination). This hybrid study will test the main and combined effects of the elements on guideline fidelity and effectiveness. METHODS: The GuideMe study is a factorial cluster randomized controlled trial examining SchoolHealth's effectiveness on guideline fidelity and guideline effectiveness goals. Forty Norwegian secondary schools will be randomized to eight different combinations of the elements in SchoolHealth. Participants will include school nurses and school personnel from these schools, and 8th grade students (n = 1200). Primary outcomes are school nurses' fidelity to the guidelines and student's ability to cope with their life (i.e., health literacy, positive health behaviors and self-efficacy). Quantitative methods will be used to test effects and mechanisms, while mixed- and qualitative methods will be used to explore mechanisms, experiences, and other phenomena in depth. Participants will complete digital questionnaires at the start and end of the schoolyear, and after the consultation during the schoolyear. The study will run in two waves, each lasting for one school year. The multifactorial design allows testing of interactions and main effects due to equal distribution of all factors within each main effect. Sustainment and scale-up of optimized SchoolHealth elements using national infrastructure are simultaneously prepared. DISCUSSION: The study will investigate possible effects of the implementation elements in isolation and in combination, and hypothesized implementation mechanisms. In-depth study of user experiences will inform improvements to elements in SchoolHealth. The results will yield causal knowledge about implementation strategies and the mechanisms through which they assert effects. Mixed-methods will provide insights into how and when the elements work. Optimizing guideline implementation elements can support adolescents in a crucial life phase. TRAIL REGISTRATION: ISRCTN24173836. Registration date 8 August 2022.

Study protocol of a factorial trial ECHO: optimizing a group-based school intervention for children with emotional problems.

BACKGROUND: Youth mental health problems are a major public health concern. Anxiety and depression are among the most common psychological difficulties. The aim of this study is to evaluate an optimized version of a promising indicated group intervention for emotional problems. The program (EMOTION Coping Kids Managing Anxiety and Depression) targets school children 8-12 years with anxious and depressive symptoms and examines three factors. Factor 1 compares the standard EMOTION intervention delivered in 16 group-based sessions (Group), versus a partially-digital EMOTION intervention (DIGGI) delivered as eight group sessions and eight digital sessions. Both versions use virtual reality technology (VR) to improve behavioral experiments. Factor 2 compares parent participation in a 5-session parent group (high involvement) versus sharing information with parents via a brochure (low involvement). Factor 3 compares the use of a measurement and feedback system (MFS) designed to help group leaders tailor the intervention using feedback from children with no MFS. METHODS: Using a cluster-randomized factorial design, 40 schools across Norway will be randomized to eight different experimental conditions based on three, two-level factors. To assess internalizing symptoms in children, children and their parents will be given self-report questionnaires pre-, post-, and one year after intervention. Parents also report on demographics, user satisfaction, personal symptoms and perception of family related factors. Teachers report on child symptoms and school functioning. Group leaders and the head of the municipal services report on implementation issues. The primary outcomes are changes in depressive and anxious symptoms. Some secondary outcomes are changes in self-esteem, quality of life, and user satisfaction. Questions regarding the consequences of the COVID-19 pandemic are included. Treatment fidelity is based on checklists from group leaders, and on user data from the participating children. DISCUSSION: This study is a collaboration between three regional centers for child and adolescent mental health in Norway. It will provide knowledge about: (1) the effect of school-based preventive interventions on anxiety and depression in children; (2) the effect of feedback informed health systems, (3) the effect and cost of digital health interventions for children, and (4) the effect of parental involvement.

When recognition memory is independent of hippocampal function.

Hippocampal damage has been thought to result in broad memory impairment. Recent studies in humans, however, have raised the possibility that recognition memory for faces might be spared. In five experiments we investigated face recognition in patients with hippocampal lesions (H) or large medial temporal lobe (MTL) lesions, including patients where neurohistological information was available. Recognition of novel faces was unequivocally intact in H patients but only at a short retention interval. Recognition memory for words, buildings, inverted faces, and famous faces was impaired. For MTL patients, recognition memory was impaired for all materials and across all retention intervals. These results indicate that structures other than the hippocampus, perhaps the perirhinal cortex, can support face recognition memory in H patients under some conditions. The fact that the faces were novel when recognition memory was intact does not fully account for our findings. We propose that the role of the hippocampus in recognition memory is related to how recognition decisions are accomplished. In typical recognition tasks, participants proceed by forming an association between a study item and the study list, and the recognition decision is later made based on whether participants believe the item was on the study list. We suggest that face recognition is an exception to this principle and that, at short retention intervals, participants can make their recognition decisions without making explicit reference to the study list. Important features of faces that might make face recognition exceptional are that they are processed holistically and are difficult to verbally label.

Effects of an internet support system to assist cancer patients in reducing symptom distress: a randomized controlled trial.

BACKGROUND: Cancer patients experience many physical and psychosocial problems for which they need support. WebChoice is an Internet-based, interactive health communication application that allows cancer patients to monitor their symptoms and problems, provides individually tailored information and self-management support, e-communication with expert cancer nurses, and an e-forum for group discussion with other patients. OBJECTIVE: The objective of this study was to examine the effects of WebChoice on symptom distress (primary outcome), depression, self-efficacy, health-related quality of life, and social support (secondary outcomes). METHODS: In this 1-year repeated-measures randomized controlled trial, 325 breast and prostate cancer patients were randomized into 1 experimental group with access to WebChoice and 1 control group who received URLs of publicly available cancer Web sites. RESULTS: Group differences on symptom distress were significant only for the global symptom distress index on the Memorial Symptom Assessment Scale (slope estimate, -0.052 [95% confidence interval, -0.101 to -0.004]; t = 4.42; P = .037). There were no significant group differences on secondary outcomes. Additional analyses showed significant within-group improvements in depression in the experimental group only. In the control group, self-efficacy and health-related quality of life deteriorated significantly over time. CONCLUSION: This randomized controlled trial is one of the first to evaluate effects of an interactive health communication application to support cancer patients in illness management on symptoms. Although only 1 hypothesis was partially supported, the combined results show a clear trend toward better scores in the intervention group on most outcome measures. IMPLICATIONS FOR PRACTICE: If findings can be supported with additional research, WebChoice may become an important tool to support nursing care that can equip cancer patients to better manage their illness.

Visual working memory capacity and the medial temporal lobe.

Patients with medial temporal lobe (MTL) damage are sometimes impaired at remembering visual information across delays as short as a few seconds. Such impairments could reflect either impaired visual working memory capacity or impaired long-term memory (because attention has been diverted or because working memory capacity has been exceeded). Using a standard change-detection task, we asked whether visual working memory capacity is intact or impaired after MTL damage. Five patients with hippocampal lesions and one patient with large MTL lesions saw an array of 1, 2, 3, 4, or 6 colored squares, followed after 3, 4, or 8 s by a second array where one of the colored squares was cued. The task was to decide whether the cued square had the same color as the corresponding square in the first array or a different color. At the 1 s delay typically used to assess working memory capacity, patients performed as well as controls at all array sizes. At the longer delays, patients performed as well as controls at small array sizes, thought to be within the capacity limit, and worse than controls at large array sizes, thought to exceed the capacity limit. The findings suggest that visual working memory capacity in humans is intact after damage to the MTL structures and that damage to these structures impairs performance only when visual working memory is insufficient to support performance.

Working memory, long-term memory, and medial temporal lobe function.

Early studies of memory-impaired patients with medial temporal lobe (MTL) damage led to the view that the hippocampus and related MTL structures are involved in the formation of long-term memory and that immediate memory and working memory are independent of these structures. This traditional idea has recently been revisited. Impaired performance in patients with MTL lesions on tasks with short retention intervals, or no retention interval, and neuroimaging findings with similar tasks have been interpreted to mean that the MTL is sometimes needed for working memory and possibly even for visual perception itself. We present a reappraisal of this interpretation. Our main conclusion is that, if the material to be learned exceeds working memory capacity, if the material is difficult to rehearse, or if attention is diverted, performance depends on long-term memory even when the retention interval is brief. This fundamental notion is better captured by the terms subspan memory and supraspan memory than by the terms short-term memory and long-term memory. We propose methods for determining when performance on short-delay tasks must depend on long-term (supraspan) memory and suggest that MTL lesions impair performance only when immediate memory and working memory are insufficient to support performance. In neuroimaging studies, MTL activity during encoding is influenced by the memory load and correlates positively with long-term retention of the material that was presented. The most parsimonious and consistent interpretation of all the data is that subspan memoranda are supported by immediate memory and working memory and are independent of the MTL.

Medial temporal lobe function and recognition memory: a novel approach to separating the contribution of recollection and familiarity.

Human neuroimaging studies of recognition memory have often been interpreted to mean that the hippocampus supports recollection but not familiarity. This interpretation is complicated by the fact that recollection-based decisions are typically associated with stronger memories than familiarity-based decisions. Some studies of source memory controlled for this difference in memory strength and found that hippocampal activity during learning predicted subsequent item memory strength while recollection-based memory (performance on source memory questions) was held at chance. This result suggests that the hippocampus is important for familiarity. However, a difficulty with this approach is that when source memory is assessed by asking specific, task-relevant source memory questions, participants who fail to answer the prescribed questions might nevertheless have available other (task-irrelevant) source information. Accordingly, successful item memory could still be associated with recollection. The present study used a novel method to assess item memory and source memory. Instead of responding to specific source questions, participants rated their source memory strength based on any information about the learning episode that was available to them. When subsequent source memory strength was held constant at the lowest possible level, we identified regions bilaterally in hippocampus, as well as in perirhinal cortex, where activity during learning increased as subsequent item memory increased in strength. In addition, activity in cortical regions (including prefrontal cortex) was related to source memory success independently of item memory strength. These findings suggest that activity in the hippocampus is related to the encoding of familiarity-based item memory, independent of subsequent recollection-based success.

The role of the hippocampus in retaining relational information across short delays: the importance of memory load.

Patients with hippocampal damage are sometimes impaired at remembering information across delays as short as a few seconds. How are these impairments to be understood? One possibility is that retention of some kinds of information is critically dependent on the hippocampus, regardless of the retention interval and regardless of whether the task depends on working memory or long-term memory. Alternatively, retention may be dependent on the hippocampus only when the task involves a memory load large enough to exceed working memory capacity. To explore these possibilities, we assessed the performance of patients with hippocampal lesions on two tasks requiring retention of the same object-in-scene information across a brief delay. The tasks placed different demands on memory. In one task, which used a continuous recognition format, participants needed to try to hold up to nine scenes in mind, even when no scene intervened between the study scene and the corresponding test scene. Patients were impaired in this condition. In a second task, using a conventional study-test format, participants needed to hold in mind only one scene at a time for either 3 or 14 sec. With this procedure, patients performed as well as controls after a 3-sec delay but were impaired after a 14-sec delay. We suggest that retention of object-in-scene information is dependent on the hippocampus only when working memory is insufficient to support performance (because memory load is high or the retention interval is long). In these circumstances performance depends, at least in part, on long-term memory.

Memory, visual discrimination performance, and the human hippocampus.

We evaluated recent proposals that the hippocampus supports certain kinds of visual discrimination performance, for example, when spatial processing is required and the stimuli have a high degree of feature overlap. Patients with circumscribed hippocampal lesions tried to discriminate between images of similar faces or images of similar scenes. In one condition, elements of the stimulus display repeated from trial to trial, and in another condition every trial was unique. In the repeated condition for both faces and scenes, controls gradually improved their performance across testing. In the trial-unique condition, no improvement occurred. The patients were impaired for both faces and scenes in the repeated condition where controls could benefit from learning. However, the patients were fully intact in the trial-unique condition. The results suggest that previous reports of impaired discrimination performance after medial temporal lobe damage may reflect impaired learning rather than impaired visual perception. The findings support the fundamental idea that memory is a distinct cerebral function separable from other perceptual and cognitive abilities.

Intact working memory for relational information after medial temporal lobe damage.

Working memory has traditionally been viewed as independent of the hippocampus and related medial temporal lobe structures. Yet memory-impaired patients with medial temporal lobe damage are sometimes impaired at remembering relational information (e.g., an object and its location) across delays as short as a few seconds. This observation has raised the possibility that medial temporal lobe structures are sometimes critical for maintaining relational information, regardless of whether the task depends on working or long-term memory. An alternative possibility is that these structures are critical for maintaining relational information only when the task exceeds working memory capacity and depends instead on long-term memory. To test these ideas, we drew on a method used previously in a classic study of digit span in patient HM that distinguished immediate memory from long-term memory. In two experiments, we assessed the ability of four patients with medial temporal lobe lesions to maintain varying numbers of object-location associations across a 1 s retention interval. In both experiments, the patients exhibited a similar pattern of performance. They performed similarly to controls when only a small number of object-location associations needed to be maintained, and they exhibited an abrupt discontinuity in performance with larger set sizes. This pattern of results supports the idea that maintenance of relational information in working memory is intact after damage to the hippocampus and related medial temporal lobe structures and that damage to these structures impairs performance only when the task depends on long-term memory.

Recognition without awareness: an elusive phenomenon.

Two recent studies described conditions under which recognition memory performance appeared to be driven by nondeclarative memory. Specifically, participants successfully discriminated old images from highly similar new images even when no conscious memory for the images could be retrieved. Paradoxically, recognition performance was better when images were studied with divided attention than when images were studied with full attention. Furthermore, recognition performance was better when decisions were rated as guesses than when decisions were associated with low or high confidence. In three experiments, we adopted the paradigm used in the earlier studies in an attempt to repeat this intriguing work. Our attempts were unsuccessful. In all experiments, recognition was better when images were studied with full attention than when images were studied with divided attention. Recognition was also better when participants indicated high or low confidence in their decision than when they indicated that their decision was a guess. Thus, our results conformed to what typically has been reported in studies of recognition memory, and we were unable to demonstrate recognition without awareness. We encourage others to explore this paradigm, and to try to identify conditions under which the phenomenon might be demonstrated.

Recognition memory and the hippocampus: A test of the hippocampal contribution to recollection and familiarity.

It has been suggested that the hippocampus selectively supports recollection and that adjacent cortex in the medial temporal lobe can support familiarity. Alternatively, it has been suggested that the hippocampus supports both recollection and familiarity. We tested these suggestions by assessing the performance of patients with hippocampal lesions on recognition memory tests that differ in the extent to which recollection and familiarity contribute to the recognition decision. When targets and foils are highly similar, prior evidence suggests that, on a forced-choice test in which targets are presented together with highly similar, corresponding foils (the FC-C format), performance is supported primarily by familiarity. By contrast, when targets are presented together with foils that are similar to other targets (the FC-NC format) or when memory is tested in a yes/no (Y/N) format, performance is based much more strongly on recollection. Accordingly, a finding that hippocampal damage impaired both Y/N recognition and FC-NC recognition but spared FC-C recognition would suggest that the hippocampus selectively supports recollection. We administered Y/N, FC-C, and FC-NC tests to five memory-impaired patients with circumscribed hippocampal lesions and 14 controls. The patients were impaired on all three types of recognition test, and there was no indication that the patients were disproportionately benefited or disproportionately impaired on any test. This pattern of performance suggests that the hippocampus supports both recollection and familiarity.

Designing tailored Internet support to assist cancer patients in illness management.

This paper describes the development and a preliminary usage analysis of a novel Internet-based support system that assists cancer patients in symptom monitoring and disease management. The system, called WebChoice, allows patients to monitor symptoms over time, and provides access to evidence-based self-management options tailored to their reported symptoms as well as a communication area where patients can ask questions to a clinical nurse specialist and exchange experiences with other cancer patients. A currently ongoing randomized clinical trial evaluates effects of WebChoice on patient outcomes. This paper describes essential features of WebChoice, steps we used to design it as user-friendly as possible; and preliminary findings on patients use.