A randomised fractional factorial screening experiment to predict effective features of audit and feedback.

BACKGROUND: Audit and feedback aims to improve patient care by comparing healthcare performance against explicit standards. It is used to monitor and improve patient care, including through National Clinical Audit (NCA) programmes in the UK. Variability in effectiveness of audit and feedback is attributed to intervention design; separate randomised trials to address multiple questions about how to optimise effectiveness would be inefficient. We evaluated different feedback modifications to identify leading candidates for further "real-world" evaluation. METHODS: Using an online fractional factorial screening experiment, we randomised recipients of feedback from five UK NCAs to different combinations of six feedback modifications applied within an audit report excerpt: use effective comparators, provide multimodal feedback, recommend specific actions, provide optional detail, incorporate the patient voice, and minimise cognitive load. Outcomes, assessed immediately after exposure to the online modifications, included intention to enact audit standards (primary outcome, ranked on a scale of -3 to +3, tailored to the NCA), comprehension, user experience, and engagement. RESULTS: We randomised 1241 participants (clinicians, managers, and audit staff) between April and October 2019. Inappropriate repeated participant completion occurred; we conservatively excluded participant entries during the relevant period, leaving a primary analysis population of 638 (51.4%) participants. None of the six feedback modifications had an independent effect on intention across the five NCAs. We observed both synergistic and antagonistic effects across outcomes when modifications were combined; the specific NCA and whether recipients had a clinical role had dominant influences on outcome, and there was an antagonistic interaction between multimodal feedback and optional detail. Among clinical participants, predicted intention ranged from 1.22 (95% confidence interval 0.72, 1.72) for the least effective combination in which multimodal feedback, optional detail, and reduced cognitive load were applied within the audit report, up to 2.40 (95% CI 1.88, 2.93) for the most effective combination including multimodal feedback, specific actions, patient voice, and reduced cognitive load. CONCLUSION: Potentially important synergistic and antagonistic effects were identified across combinations of feedback modifications, audit programmes, and recipients, suggesting that feedback designers must explicitly consider how different features of feedback may interact to achieve (or undermine) the desired effects. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number: ISRCTN41584028.

The Human-Nature Relationship and Its Impact on Health: A Critical Review.

Within the past four decades, research has been increasingly drawn toward understanding whether there is a link between the changing human-nature relationship and its impact on people's health. However, to examine whether there is a link requires research of its breadth and underlying mechanisms from an interdisciplinary approach. This article begins by reviewing the debates concerning the human-nature relationship, which are then critiqued and redefined from an interdisciplinary perspective. The concept and chronological history of "health" is then explored, based on the World Health Organization's definition. Combining these concepts, the human-nature relationship and its impact on human's health are then explored through a developing conceptual model. It is argued that using an interdisciplinary perspective can facilitate a deeper understanding of the complexities involved for attaining optimal health at the human-environmental interface.

Patterns of contribution to citizen science biodiversity projects increase understanding of volunteers' recording behaviour.

The often opportunistic nature of biological recording via citizen science leads to taxonomic, spatial and temporal biases which add uncertainty to biodiversity estimates. However, such biases may also give valuable insight into volunteers' recording behaviour. Using Greater London as a case-study we examined the composition of three citizen science datasets - from Greenspace Information for Greater London CIC, iSpot and iRecord - with respect to recorder contribution and spatial and taxonomic biases, i.e. when, where and what volunteers record. We found most volunteers contributed few records and were active for just one day. Each dataset had its own taxonomic and spatial signature suggesting that volunteers' personal recording preferences may attract them towards particular schemes. There were also patterns across datasets: species' abundance and ease of identification were positively associated with number of records, as was plant height. We found clear hotspots of recording activity, the 10 most popular sites containing open water. We note that biases are accrued as part of the recording process (e.g. species' detectability) as well as from volunteer preferences. An increased understanding of volunteer behaviour gained from analysing the composition of records could thus enhance the fit between volunteers' interests and the needs of scientific projects.