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BackgroundMore research on sustainment of interventions is needed, especially return on investment (ROI) studies to determine cost-benefit trade-offs for effort required to sustain and how much is gained when effective programs are sustained. The ROSE sustainment (ROSES) study uses a sequential multiple assignment randomized (SMART) design to evaluate the effectiveness and cost-effectiveness of a stepwise approach to sustainment of the ROSE postpartum depression prevention program in 90 outpatient clinics providing prenatal care to pregnant women on public assistance. Postpartum depression (PPD) is common and can have lasting consequences. Outpatient clinics offering prenatal care are an opportune place to provide PPD prevention because most women visit while pregnant. The ROSE (Reach Out, Stay Strong, Essentials for mothers of newborns) program is a group educational intervention to prevent PPD, delivered during pregnancy. ROSE has been found to reduce cases of PPD in community prenatal settings serving low-income pregnant women.MethodsAll 90 prenatal clinics will receive enhanced implementation as usual (EIAU; initial training + tools for sustainment). At the first time at which a clinic is determined to be at risk for failure to sustain (i.e., at 3, 6, 9, 12, and 15 months), that clinic will be randomized to receive either (1) no additional implementation support (i.e., EIAU only), or (2) low-intensity coaching and feedback (LICF). If clinics receiving LICF are still at risk at subsequent assessments, they will be randomized to either (1) EIAU + LICF only, or (2) high-intensity coaching and feedback (HICF). Additional follow-up interviews will occur at 18, 24, and 30 months, but no implementation intervention will occur after 18 months. Outcomes include (1) percent sustainment of core program elements at each time point, (2) health impact (PPD rates over time at each clinic) and reach, and (3) ROI (costs and cost-effectiveness) of each sustainment step. Hypothesized mechanisms include sustainment of capacity to deliver core elements and engagement/ownership.DiscussionThis study is the first randomized trial evaluating the ROI of a stepped approach to sustainment, a critical unanswered question in implementation science. It will also advance knowledge of implementation mechanisms and clinical care for an at-risk population.Trial registrationClinicaltrials.gov, NCT03267563. Registered June 14, 2018.

While a good user interface is often defined as one which is immediately intuitive to use, this assumption can be dangerously applied. Designers of web pages know that if they don't get a user's interest in a few seconds, then the user will exit the site and navigate elsewhere. The gaming enthusiasts will reject a game if they cannot learn to play it in a few minutes. These types of applications require different design attributes than an application that will be used for hours by a trained employee or specialist. Many user experience design techniques involve obtaining feedback on low fidelity prototypes or think out loud protocols which emphasize the need that a user interface be immediately intuitive to use. User interface designers feel the pressure of the gaming culture to value immediate intuitivism or preference as the primary measure for design goodness. However, our study shows that the ability to learn how to use a display for some applications may be more important, especially if the less intuitive display reduces errors after minimal training times. Our study also suggests there may be a unique tendency of gamers to be less risk adverse in using a system, taking action without carefully measuring the risks. This has a tremendous influence on the design of high consequence systems where a user must perform critical tasks with high accuracy for personnel safety and task success.

Operability is a driving requirement for next generation space launch vehicles. Launch site ground operations include numerous operator tasks to prepare the vehicle for launch or to perform preflight maintenance. Ensuring that components requiring operator interaction at the launch site are designed for optimal human use is a high priority for operability. To promote operability, a Design Quality Evaluation Survey based on Universal Design framework was developed to support Human Factors Engineering (HFE) evaluation for NASA's launch vehicles. Universal Design per se is not a priority for launch vehicle processing however; applying principles of Universal Design will increase the probability of an error free and efficient design which promotes operability.The Design Quality Evaluation Survey incorporates and tailors the seven Universal Design Principles and adds new measures for Safety and Efficiency. Adapting an approach proven to measure Universal Design Performance in Product, each principle is associated with multiple performance measures which are rated with the degree to which the statement is true. The Design Quality Evaluation Survey was employed for several launch vehicle ground processing worksite analyses. The tool was found to be most useful for comparative judgments as opposed to an assessment of a single design option. It provided a useful piece of additional data when assessing possible operator interfaces or worksites for operability.

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