‘The cent issue a il ext achive of hs journal is availabe on eral Isght at: srr emeralinsight.com2586-840X htm 352 ‘eee ee 8 Effectiveness of the intervention program for dengue hemorrhagic fever prevention among rural communities in Thailand A quasi-experimental study Suda Hanklang Faculty of Nursing, Vongchavalitkul University, Nakhon Ratchasima, Thailand Paul Ratanasiripong California State University, Long Beach, California, USA, and Suleegorn Sivasan Faculty of Nursing, Vongchavalitkul University, Nakhon Ratchasima, Thailand Abstract, Purpose — The purpose of this paper isto evaluate the effectiveness ofthe intervention program for dengue fever preveation azn peopl nul companies. Designimethodology/approsch ~ A quasvexperimental study was designed for two groups iBlerveation group recived Ienowiedge broadcast, campaign, model house contest ané group edcaton, The ¢ any the tal sare of health promoting hospitals. The primary expected ostoomes were changes in Knowledge, perceived susceptbilty, pesceived severity, perceived. benefit perceived baits and preventive’ action from bastline data, postinterveation and threesvonth followup, along with Eamparison between the two groups. The secondary expected outcomes were changes i house index (i) irom baseline to postantervention and threem "he eo groupe. Findings — From the total of 64 participants, 32 were randomly assigned tothe cots) group and 32 were Fandomly assigned to the intervention group, There wee significant differences in knowledge, perclved fuscepubiity, perceived severity, perceved beneit, perceived barriers, preventive action and HI ts the intervention group afer recesred the iveweek intervention program and at theeemionth follow-up 2003, Griginaltyivalue — Dengue hemwrhagie prevention program based on the Health Bali Model was fictive in lowering HL and improving knowledge, peesved stscetblty, perceived severity, perceived benefit, perceived buries and preventive acioh hong people in rwal cammniies. The intervention ‘rogram may be beneficial in primary care in sucha rural comm Commons Attribution (CC BY 40) licence. Anyone may reproduce, distribute, translate and « Gerivative works of ths article (or bots commercial and noncommercial purposes), subject to f attribution fo the orginal pablcaion and authors. The ful rms ‘reativecommons ogiicence/by/t Oegalcode “The authore declared no potential conflicts of interest with respect to the research, authorship andlor publication ofthis paper. The authors are grateful to Maharat Nakhon Ratchasima Hospital tnd Health Provineial Osfice for coordinating and supporting data collections, The authors thank all village bealth volunteers for assistance with data collecting and all staff at Sub-District Health Promoting HospitalIntroduction Dengue is a mosquite-borme disease found mainly in countries with tropical and subtropical climates. The global prevalence of dengue has grown dramatically in recent decades. Currently, about half of the world’s population is at risk of infection{1], Globally, one recent estimate indicates 390m dengue infections per year (95 percent credible interval of 284-528m), of which 96m (67—136m) manifest clinical symptoms{2}. An estimated 500,000 people with severe dengue require hospitalization each year and about 25 percent of those infected dies(I] Dengue fever is a disease caused by the dengue virus. The main cause of dengue virus infection in human is through bites from infected female mosquitoes (Aedes aegypti) Dengue virus is a carvier disease found in all age groups(3}, The symptoms of dengue fever include high fever, chils, fatigue, rash, nausea, vomiting, headache, sore throat and pain (muscle, back, joint and abdomen areas)[d] In severe cases, it can be life threatening due to serious bleeding and shock{4], The most effective intervention is to prevent mosquito bites(5} Thailand is still suffering from dengue fever nationwide and during all seasons. In 2017, Thailand has reported 52,049 dengue cases from all 77 provinces, including 62 deaths(6). The Ministry of Public Health has adopted a policy to control dengue hemorrhagic fever in the National Health Development Plan No, 11 (2012-2016) which targeted the reduction of dengue hemorrhagic fever rate to not more than 25 percent ‘of the median in the past five years and the reduction of morbidity rate to not more than 0.02 percent{7}. ‘The Northeastern region of Thailand has the largest land area. Nakhon Ratchasima province has the highest population in the Northeast region and the second highest population in the country, The incidence of dengue hemorrhagic fever in Nakhon Ratchasima in the past five years (2013-2017) were 269.29, 33.58, 27453, 62.45, 65.38 per 100,000 population, respectively. In 2017, the prevalence of dengue hemorrhagic fever in Nakhon Ratchasima were 1,716 cases with the morbidity rate of 65:38 per 100,000 population and two cases of death by dengue hemorrhagic fever, giving the mortality rate of 0.08 per 100,000 population(6}. The model forecasting of dengue hemorrhagic fever in 2017 showed that Nakhon Ratchasima was the high-risk area to monitor the disease(8] It is believed that the outbreak of dengue hemorrhagic fever is mainly from mosquitoes and by the general nature of mosquitoes, like laying eggs in containers of water inside and outside the house. This is due to the behaviors of local rural people. Some behaviors that may not be appropriate include disorganized house, inadequate lighting management. hanging dirty clothes in the house, not covering water storage container and leaving wet waste with water, As a result, mosquito breeding becomes widespread®] Dengue morbidity can be reduced by applying effective communication that can achieve behavioral outcomes that augment prevention programs{10] At present, the main method to control or prevent the transmission of dengue virus isto combat vector mosquitoes through preventing mosquitoes from accessing egg-laying habitats by environmental management and modification, active monitoring and surveillance of vectors to determine the effectiveness of control interventions, 10] ‘The Health belief model (HBM), developed from the theory of social psychology. describes the behavior of individuals{11], The HEM believes that people who change their behavior must perceive their susceptibility, perceived severity, perceived benefits of modifying health behaviors and perceived fewer barriers of preventive behaviors, cues to action, modifying factors and health motivation{11, 12), Therefore, from HBM constructs, the researcher expected to apply the theory of HEM to use in the prevention of dengue disease because theory says individuals will eek ways to follow the recommendations for prevention and rehabilitation as long as the disease prevention practice is more positive Effectiveness of the intervention program, 353354 Figure 1 ‘Thecretcalfmewore athe iy than the difficulty(11), By following these theory instructions, a person aust feel fear for the disease or feel threatened. In addition, a person must feel to have an ability for disease prevention(13) Previous studies in Thailand have adopted the HBM to modify dengue prevention behaviors and received good results(14, 15}, Therefore, this research is based on the HBM as a theoretical framework for the prevention measures and for designing intervention activities, It is necessary to encourage people in the community to receive knowledge about the disease, promote risk perception and benefits of disease prevention so that people can find solutions to reduce the barriers to disease prevention then take action to prevent dengue fever. The dengue hemorrhagic disease prevention in the community must be supported by the community and apply the campaign for community awareness of the dengue problem, Previous studies have focused mainly on source reduction of water containers in a household and vector controlf16-18], These studies earlier did not investigate the combination of vector control activities, and the behavior changing based on the HBM for dengue fever prevention, For this study, the researchers are interested in examining the effects of the dengue hemorrhagic fever prevention intervention program in rural communities. The data from this study will lead to health promotion planning for dengue hemorrhagic prevention in rural communities, The focus is on promoting knowledge in disease prevention, raising awareness of risk and severity of disease, encouraging the benefits of disease prevention and reducing barriers to disease prevention. The main objective of the community intervention program is for eradicating dengue hemorrhagic fever which is a major public health problem in Thailand. Research objective ‘The purpose of this study is to examine the effectiveness of the intervention program for dengue hemorrhagic fever prevention among rural communities in Thailand based on the theory of HBM (Figure 2). Study design This is a quasiexperimental study that examined the effect of dengue hemorrhagic fever ‘prevention intervention in rural communities. Participants were randomly divided into two sue emu Dee re (Keowee of gue beonag fe teva cteapeit mae eg gl fees i ‘Sitostoet nde fH veosot (U0) Providing the knowledge of dengue 00 Reser ‘Shona teh €23)Pasna ty comnany (2.3) Perocived benefits of protection (24 Pesved bats to proton (6) Comore fr safety donee ose Bean men eanpistemertacs (2) Grp eduction (4) House idee (ithe percentage ofsroups as explained below. The experimental group received a five-week intervention Effectiveness contol group contined fe as Usa. Variables Were measured before the of the atte the five wek intervention, and at thtee-month followup intervention rogram Sample size Progr: The sample size was calculated by the following formula(29} 355 yy _ WeawZa)* x08 _20.98-+084? x BAI? _ 5p a 38)" ° amples percentile vakte (100-(a2) percent under the normal curve set at 005=195 (Wwortaled); 0=020, Z.=084; 4=7;—z;, mean difference of preventive practice score for dengue fever prevention from previous studied 4] =2.38, o= standard deviation of mean difference of preventive practice score for dengue fever prevention from previously studied l4]=3.41 ‘The sample size needed for this study was 32 for each group, Participant inclusion criteria include: atleast 20 years old; Thai nationality; both male and female; has lived inthe community for more than six months, able to answer questions, no problem speaking, listening and communicating; no training on educational program for dengue hemorrhagic fever prevention in the previous six months; willing to participate in this study; and able to sign the informed consent form. ‘The criteria for exchiding participants from this step are: participants who have ficulties communicating in Thaf, and participants who are not available at the time of data collection (Figure 2} Participants Two districts were randomly selected irom Nakhon Ratchasima province. Then, two sub-distriets from two districts were randomly chosen. Further, two villages were randomly selected from the two sub-distrits to be part of the study. To prevent the contamination of data, the entire village was randomly assigned as either experimental group or control group. Individual household from each village is randomly selected to be inchuded in the study. They were excluded if they had lived in the community less than six months, had Symptoms or illnesses that limit activity, of had partiipated in any education program for dengue prevention during the prior six months Data collection Participants were randomly divided into two groups (intervention group, n = 33; control group, n=33). The intervention group was assigned to a five-week program The control group received the usual health education érom public health personnel Evaluations by questionnaire were measured three times for both groups. The questionnaire consisted of 52 questions that took approximately 45min for respondents to complete. Written consent forms were obtained irom participants prior to data collection This study was approved by the Committee of Human Ethical Research, Makarat Hospital, Nakhon Ratchasima, Research instrument Part 1: demographic information included seven items on gender, age, marital status, highest education, occupation, income and information obtained from the community356 Figure 2 Flow dagram ofthe stacy Eseates n= 28) 1 Sesto { hocene stnsed arent an 38) Sanit 3) [eats ewig Teste lonap ge rsros)n= Disorientation gh esos in Dicartned etrenan ove reer) n=O) Doan 38) {Exled ton aes gh eso n= evra ve rents f=) Part 2: knowledge about dengue hemorrhagic fever included 20 items that assessed participant's knowledge af the causes of dengue fever, signs and symptoms, treatment aad prevention. The score of 1 point was given for each correct answer and 0 point for each ‘wrong answer, Part 3: perception of dengue hemorrhagic fever prevention included 20 items which derived from four main constructs of HBM: perceived susceptibility, perceived severity, perceived benefits, and perceived barriers to prevention. Perception measurement utilized a three-point Likert scale that inchided disagree (1), neither agree nor disagree (2) and agree 3) Part 4: dengue fever prevention practices were measured using five items derived from. principle for dengue hemorrhagic fever prevention practices from the Department of Disease Control, Ministry of Public Health, Thailand|20), Intervention Participants in the control group did not receive any interventions. Participants jn the experimental group were enrolled in the intervention program based on the HBM theory. The HBM has four constructs representing the perceived threat and net benefits: perceived susceptibility, perceived severity, perceived benefits and perceived barries[12). The specific intervention program included four main activities based on HBM theory.Activity 1: providing knowledge of dengue hemorrhagic fever Implementation timeframe: Weeks 1-5, “The objective of tis activity was to provide the knowledge of dengue hemorrhagic fever through the daily community broadcast. The messages were based on HBM constructs as described below: (1) Raise the perceived susceptibility: “dengue is @ problem in com ‘eroup.” 2) Raise the perceived severity: “it is alittle one but itis the one that can kill you.” nity for all age Raise the perceived benelits: “take care of the house environment, then the safe environment will protect your family from dengue hemorrhagic fever (1) Reduce the perceived barriers: ust few minutes for easy clean-up can reduce many risks from dengue Activity 2: dengue hemorrhagic fever campaign Implementation timeframe: Week 2. "The emphasis is on individuals to receive information through campaign activities: (0), The individuals who took part in the campaign consisted of the head ofthe village, assistant head of the village, vlage health volunteer, adults in the village and students in the village. Mosquito mascot and cartoons were also part of the campaign parade 2) Poster boards were used during campaign parade to raise awareness of dengue hemorthagic fever such as principle for dengue hemorthagic fever prevention practices fom the Department of Disease Cantsol20] and mosquito life eye @) Campaign announcements about practices to eradicate larvae using temephos or abate sand and using mosquito repel #)_ Distribution of leaflet and messages on dengue hemorrhagic fever, such as signs and ‘symptoms of dengue hemorrhagic fever. (6) All participants in the parade campaign went to all the houses in the village to identify mosquito breeding sites. If an open water container was found, the participants removed all the water étom it, Activity 3: a contest for safety dengue house Implementation timeframe: Weeks 3-1 and announcement of the winner during Week 5. ‘The objective ofthis activity was to find a model house that is safe from dengue and to encourage villagers to see the importance of environmental management and create good examples for their neighbors: (1) Defined the attributes of the house that is safe from dengue on the basis of the hygienic and clean house assessment from the Department of Disease Control, ‘Thailand|20] then selected major topics in the assessment, An award-winning house thas to show the important features ofall attributes. @) Assigned the committee to evaluate the houses that participate in community Contest. The committee consisted of seven representatives of the community, Effectiveness of the intervention program, 357358 including the village head (one), the assistant village heads (two) and village health ‘volunteers (four) (Public announcement the rules of the contest. ecruit people in the community tothe contest and to inform valuation process, (©) The announcement of the award for the winner and the second place during the ‘group activity atthe village hal (©) The winners received a large catifcate to display at the front oftheir houses to be examples to neighbors and motivate them to be safe from dengue. Activity 4: group education Implementation timeframe: Week 5, “The objective ofthis activity was to provide knowledge about dengue hemorrhagic fever. Activity was set in the comunity hall with the following activities: (2) knowledge exhibition about dengue, mosquito's repellent and methods for exadicating mosquitos; and (@) stage play and role play that reflected the susceptibility for risks, the dengue severity, the benefits of prevention, and reduction in barriers to prevent dengue hemorthagic fever. Validity and reliability of research instruments The intervention program and research instrument were adapted from the literature review based on the HBM theory and were reviewed by experts inthe field, Content validity: a panel of three experts evaluated the content validity of the intervention program and research instrument. For content validity testing, CVI was analyzed and found to be 029. Reliabilty: the questionnaire was tested for reliability with 30 people with similar characteristics to the samples, For internal consistency reliability testing, Cronbach's a coefficient was analyzed. All scales had good levels of internal consistency of more than 0.70, Data analyses Statistical Packet for the Social Sciences 23.0 was used for data analyses. Descriptive statistics were calculated to describe demographic characteristics and other backgrounds of the participants. To compare the data between the two groups, /-test and 7” test were used, Two-way repeated measures ANOVA was used to analyze the difference in the total scores of six scales for dengue hemorrhagic fever prevention between the two groups actoss times of measure. The 7 test was used for analyzing the difference in the number of house index GD between the two groups, Results A total of 64 of the initial 66 participants completed the study questionnaires at three timeframes, Thus, data analyses were performed using 64 subjects, At baseline, there were no significant differences in general characteristics between the intervention group and control group. However, there was a significant difference in gender (see Table DyEffectiveness Intervention gop n= 32) Coto group (»=32) 2 Demographic data Nunber Percent Number Percent ort _pevalue of the ‘Gnd intervention Male 2 63 cry 0.005 program Female a ss 5 Age ear) gnean:t SD) conn 118t Liss os 359 Mania status Since 1 a1 o 00 0003 Mortiea B no as Widowed 7 no a1 Diver i 3 a1 Tight education Primary sca 2 a3 ms 206 0518 Dh schal 4 25 3 °4 igh 2 33 Q 90 xcpation Famer a eas mo ws Tracer 3 3 4s ied 2 a3 3 94 Official 0 00 1 31 co Rie Fosse work 3 o4 ‘ 25. evan Other 4 ns 0 00 seneral characterise Income sse2s0.2 627882 02s.26sa588 oxo ommy age eteeentn Note: *p<005 ‘bate ‘Table Il showed HI decreased in both groups at the end of the intervention program and revealed a significant difference between groups for both the post-intervention and the follow-up. Comparison of the groups before starting intervention revealed no significant difference in the scores of knowledge, perceived susceptibility, perceived severity, perceived benefits perceived barriers and preventive action (see Table I. ‘The intervention group had increases in the scores of knowledge, perceived susceptibility, perceived severity, perceived benefits, perceived barriers and preventive action aiter mtervention. Only preventive action showed the interaction between group and time (F=11.19, p-value < 0.001) (Table IV), Discussion A quasiexperimental study was designed to assess the effectiveness of the intervention program based on HBM to prevent dengue hemorrhagic fever Intervention group (v=32)—_Contol group (x= 32) use idee Measuring tine Found arvae(n) Found larvae (o) ih (percentage of houses infested it Preinterventon 2 3750 uw 0058 larvae andlor pupae Pestintervention ° ° 0 1185 Betiveeninlervetion Followssp 6 ° 2 14769 ‘snd conta groups360 ‘Table HL. Comparison of study ‘arabes between rope at aselne Results demonstrated that this intervention program significantly increased the knowledge, perceived susceptibility, perceived severity, perceived benefits, perceived barriers and preventive action. This finding supported the assumption that applying the HBM to the intervention in rural communities can promote the preventive actions and may be beneficial in the primary care of people with a high risk of dengue hemorrhagic fever The intervention program was created to meet the HBM theory because protective behavior is related to the knowledge, perceived susceptibility, perceived severity, perceived benefits and perceived barriers. Although education campaigns have increased people's awareness of dengue, it remains unclear to what extent this knowledge js put into practice, and to what extent this practice actually reduces mosquito ‘populations. In this study, the intervention encouraged the practice of participants in many ways. The knowledge was provided via daily broadcast to the community, dengue campaign and group education atthe village hall Cues-to-action was implemented via the contest for a model house for safety from dengue, which was in line with an earlier research suggestion(13] that there is a greater likelihood of positive outcomes for preventive actions when the participants are supported and encouraged by the good ‘model in the community. ‘After the intervention program, the total scores on the six scales for dengue hemorrhagic {ever prevention were significantly higher in the intervention group than those inthe control group. These results support the effectiveness of the intervention program direct However, in the follow-up phase, some scores were decreased; this may be because the community engagement tends to be insufficient, Thus, the approach toward enkancing community involvement is important. ‘The results of this study showed that the HI for the intervention group deczeased for ‘both postintervention and follow-up. The effectiveness ofthe program on preventive action is consistent with the earlier studied that showed the direct link between knowledge of dengue preventive measures and container protection practice{21] In order to decrease the brooding site of mosquitoes, itis necessary for people in the community to change the behaviors for the dengue hemorrhagic fever prevention, Conclusions Dengue hemorrhagic fever is pervasive among rural communities, In the present study, We conducted a quasiexperimental study to investigate the effectiveness of the intervention program. The effects were measured by the knowledge, perceived susceptibility, perceived severity, perceived benefits, perceived barriers and preventive action. After participation in the intervention program, the five scales showed a significant increase; therefore, the intervention program may be beneficial in primary care in such a rural community Variables ezvention group X SD) Contzol group F Knowledge 1528 223 ust gs) ox Perceived susceptity 1328 (119 1316 014) 0433 Perceived seventy 1216 (125) 9564 Peteived benefit 1347 (105 030 Perceived barrie 14.09 (093) Preventive action 441 078) O78 Note: n=64000) srtt ao00>) 9899 ves ier at $288 BOEPERGES g 55 Peal SB 2 ESE a oad Spoon pe aang ero eco (eaco) 2x (a0) TE 0) FFE sug passag (S50) 0ceT SRO GEST Geo 980 asta) zet soar crDoorr cone sugag pasameg (eoeter Us Hest we Gio sro (e100) sav io) ese oyna Suias posrg (e50) seer sin ‘osyo) ovo 100 «zor (SoU iret ones yadooms passing (se 6st 09 wea art ta9>) ze 60) zzt some spatnonsy wea mo aA yx dno ma, nog362 References 1, World Heath Organization [WHO] Dengue and severe dent D1). (update 2017 Apr: ce 2018 Mar 24}. 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The elect of health edsaton program for prevention and contra of, dengue emer fever infamy coe leaders, Maangpha Sbtiste, Aranyaprathel Dis, Srakaeo Prosnce. PRR) 2015, 100) 6581 16, Phuanukoonnon $, Mueler J Bryan JL. Btetveness of dengue contol practices in household vate containers in Nortbeast Thane, TM eI, 205; 108) 75.68 17, Chaooiatana A, Chanruang S, PotbaledP. A comparison of dengue hemorrhagic fever contol interventions in northeaser Thailand. Southeast Asian J Top Med Public Healt, 2008, 35) erat 18, Ballenger Browning KK Elder JP Multimode] Andes aegyt mosqito reduction interventions and denge ever prevention TM & IH. 2008, 1402 154281 19, Polit DE, Hungler BP, Nursing Research: Principles and methods. Sof, Philadephia, OA Lappinot 198720, Department af Disease Control, Ministry of Public Health, Thailand. Manual for guiding cognizant of diseases and healt hazards for the pubic people. The Bureau of Risk Communication and Behavioral Health Development. Ist ed The Agricultural Federative Coaperation of Thailand Limite, Bangkok, 2013: 20-25, 21, Koentaadt CIM, Tuiten W, Sihiprasasna R Kijchalao U, Jones JW, Scot TW. Dengue knowledge and practies and their impact on Aedes aegypti populations in Kamphaeng Phe, Thailand. An J ‘Trop. Med. Hyg. 2006, 744) 692.700, Corresponding author Suda Hanklang can be contacted at: en101_987654@hotmailcom For instructions on bow to order reprints of this article please visi our webs ‘www.emeraldgrouppublishing comflicensing/reprints htm Or contact us fr further details: permissions @emeraldinsight.com Effectiveness of the intervention program, 363The Joanna Briggs Institute Critical Appraisal tools for use in JBI Systematic Reviews. Checklist for Quasi-Experimental Studies (non-randomized experimental studies) http://joannabriggs.org/research/critical-appraisal-tools.html www.joannabriggs.org> JBI Critical Appraisal Checklist for Quasi-Experimental Studies (non-randomized experimental studies) Reviewer. _Date__ Author Year _Record Number. Yes No Unclear Not applicable 1, sit clear in the study what is the ‘cause’ and what is the ‘effect’ (ie, there is no confusion about which variable comes first)? oO 2. Were the participants included in any comparisons similar? 3, Were the participants included in any comparisons receiving similar treatment/care, other than the exposure or intervention of interest? 4, Was there a control group? 5. Were there multiple measurements of the outcome both pre ‘and post the intervention/exposure? 6. Was follow up complete and if not, were differences between groups in terms of their follow up adequately described and analyzed? 7. Were the outcomes of participants included in any comparisons ‘measured in the same way? 8. Were outcomes measured in a reliable way? OOo0dcOdUvOdUmdondlmUmcde hc Oo00dUdmUCUODWUOUUODUcUODlUco lm OoOoddcvUuodmUmUDUcUlUmce lo OocU0ndoUdmUODUcUOUUDODULcUDlhUmO 9, Was appropriate statistical analysis used? Overall appraisal include LC] txctude C1 seek further info C1 Comments (Including reason for exclusion) © Joanna Briggs Institute 2017 Critical Appraisal Checklist | 3 for Quasi-Experimental StudiessS- Explanation for the critical appraisal tool for Quasi-Experimental Studies (experimental studies without random allocation) How to cite: Tufanaru C, Munn 2, Aromataris E, Campbell J, Hopp L. Chapter 3: Systematic reviews of effectiveness. In: Aromataris E, Munn Z (Editors). Joanna Briggs Institute Reviewer's Manual. The Joanna Briggs Institute, 2017. Available from https://reviewersmanual.joannabriges.or Critical Appraisal Tool for Quasi-Experimental Studies {experimental studies without random allocation) Answers: Yes, No, Unclear or Not Applicable 1, Isit clear in the study what is the ‘cause’ and what is the ‘effect’ (i.e. there is no confusion about which variable comes first)? ‘Ambiguity with regards to the temporal relationship of variables constitutes a threat to the internal validity of a study exploring causal relationships. The ‘cause’ (the independent variable, thattis, the treatment or intervention of interest) should occur in time before the explored ‘effect’ (the dependent variable, which is the effect or outcome of interest). Check if it is clear which variable is manipulated as a potential cause. Check if itis clear which variable is measured as the effect of the potential cause. Is it clear that the ‘cause’ was manipulated before the occurrence of the ‘effect’? 2. Were the participants included in any comparisons similar? The differences between participants included in compared groups constitute a threat to the internal validity of a study exploring causal relationships. If there are differences between participants included in compared groups there is a risk of selection bias. If there are differences between participants included in the compared groups maybe the ‘effect’ cannot be attributed to the potential ‘cause’, as maybe it is plausible that the ‘effect’ may be explained by the differences between participants, that is, by selection bias. Check the characteristics reported for participants. Are the participants from the compared groups similar with regards to the characteristics that may explain the effect even in the absence of the ‘cause’, for example, age, severity of the disease, stage of the disease, co-existing conditions and so on? [NOTE: In one single group pre-test/post-test studies where the patients are the same (the same one group) in any pre-post comparisons, the answer to this question should be ‘yes.] 3. Were the participants included in any comparisons receiving similar treatment/care, other n of interest? than the exposure or interven In order to attribute the ‘effect’ to the ‘cause’ (the exposure or intervention of interest), assuming that there is no selection bias, there should be no other difference between the groups in terms of treatments or care received, other than the manipulated ‘cause’ (the intervention of © Joanna Briggs Institute 2017 Critical Appraisal Checklist | 4 for Quasi-Experimental Studies> interest). If there are other exposures or treatments occurring in the same time with the ‘cause’, other than the intervention of interest, then potentially the ‘effect’ cannot be attributed to the intervention of interest, as it is plausible that the ‘effect’ may be explained by other exposures or treatments, other than the intervention of interest, occurring in the same time with the intervention of interest. Check the reported exposures or interventions received by the compared groups. Are there other exposures or treatments occurring in the same time with the intervention of interest? Is it plausible that the ‘effect’ may be explained by other exposures or treatments occurring in the same time with the intervention of interest? 4, Was there a control group? Control groups offer the conditions to explore what would have happened with groups exposed to other different treatments, other than to the potential ‘cause’ (the intervention of interest). The comparison of the treated group (the group exposed to the examined ‘cause’, that is, the group receiving the intervention of interest) with such other groups strengthens the examination of the causal plausibility. The validity of causal inferences is strengthened in studies with at least one independent control group compared to studies without an independent control group. Check if there are independent, separate groups, used as control groups in the study. (Note: The control group should be an independent, separate control group, not the pre-test group ina single group pre-test post-test design.] 5. Were there multiple measurements of the outcome both pre and post the intervention/exposure? In order to show that there is a change in the outcome (the ‘effect’) as a result of the intervention/treatment (the ‘cause’) it is necessary to compare the results of measurement before and after the intervention/treatment. If there is no measurement before the treatment and only measurement after the treatment is available it is not known if there is a change after the treatment compared to before the treatment. If multiple measurements are collected before the intervention/treatment is implemented then it is possible to explore the plausibility of alternative explanations other than the proposed ‘cause’ (the intervention of interest) for the observed ‘effect’, such as the naturally occurring changes in the absence of the ‘cause’, and changes of high (or low) scores towards less extreme values even in the absence of the ‘cause’ (sometimes called regression to the mean). If multiple measurements are collected after the intervention/treatment is implemented it is possible to explore the changes of the ‘effect’ in time in each group and to compare these changes across the groups. Check if measurements were collected before the intervention of interest was implemented. Were there multiple pre-test measurements? Check if measurements were collected after the intervention of interest was implemented. Were there multiple post-test measurements? © Joanna Briggs Institute 2017 Critical Appraisal Checklist | 5 for Quasi-Experimental Studies> 6. Was follow up complete and if not, were differences between groups in terms of their follow up adequately described and analyzed? If there are differences with regards to the loss to follow up between the compared groups these differences represent a threat to the internal validity of a study exploring causal effects as these differences may provide a plausible alternative explanation for the observed ‘effect’ even in the absence of the ‘cause’ (the treatment or exposure of interest). Check if there were differences with regards to the loss to follow up between the compared groups. If follow up was incomplete (that is, there is incomplete information on all participants), examine the reported details about the strategies used in order to address incomplete follow up, such as descriptions of loss to follow up (absolute numbers; proportions; reasons for loss to follow up; patterns of loss to follow up) and impact analyses (the analyses of the impact of loss to follow up on results). Was there a description of the incomplete follow up (number of participants and the specific reasons for loss to follow up)? If there are differences between groups with regards to the loss to follow up, was there an analysis of patterns of loss to follow up? If there are differences between the groups with regards to the loss to follow up, was there an analysis of the impact of the loss to follow up on the results? 7. Were the outcomes of participants included in any comparisons measured in the same way? If the outcome (the ‘effect’) is not measured in the same way in the compared groups there is a threat to the internal validity of a study exploring a causal relationship as the differences in ‘outcome measurements may be confused with an effect of the treatment or intervention of interest (the ‘cause’). Check if the outcomes were measured in the same way. Same instrument or scale used? Same measurement timing? Same measurement procedures and instructions? 8, Were outcomes measured in a reliable way? Unreliability of outcome measurements is one threat that weakens the validity of inferences about the statistical relationship between the ‘cause’ and the ‘effect’ estimated in a study exploring causal effects. Unreliability of outcome measurements is one of different plausible explanations for errors of statistical inference with regards to the existence and the magnitude of the effect determined by the treatment (‘cause’). Check the details about the reliability of measurement such as the number of raters, training of raters, the intra-rater reliability, and the inter-raters reliability within the study (not to external sources). This question is about the reliability of the measurement performed in the study, it is not about the validity of the measurement instruments/scales used in the study. (Note: Two other important threats that weaken the validity of inferences about the statistical relationship between the ‘cause’ and the ‘effect’ ore low statistical power and the violation of the assumptions of statistical tests. These other threats are not explored within Question 8, these are explored within Question 9.] © Joanna Briggs Institute 2017 Critical Appraisal Checklist | 6 for Quasi-Experimental Studies> 9. Was appropriate statistical analysis used? Inappropriate statistical analysis may cause errors of statistical inference with regards to the existence and the magnitude of the effect determined by the treatment (‘cause’). Low statistical power and the violation of the assumptions of statistical tests are two important threats that weakens the validity of inferences about the st ‘effect’. Check the following aspec ical relationship between the ‘cause’ and the if the assumptions of statistical tests were respected; if appropriate statistical power analysis was performed; if appropriate effect sizes were used; if appropriate statistical procedures or methods were used given the number and type of dependent and independent variables, the number of study groups, the nature of the relationship between the groups (independent or dependent groups), and the objectives of statistical analysis (association between variables; prediction; survival analysis etc.) © Joanna Briggs Institute 2017 Critical Appraisal Checklist | 7 for Quasi-Experimental Studies