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Complex Interventions May 16th 2011
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Complex Interventions May 16th 2011



Presentation at a joint seminar day for occupational therapy, physiotherapy and nursing at Umeå University, Sweden. ...

Presentation at a joint seminar day for occupational therapy, physiotherapy and nursing at Umeå University, Sweden.

(Credits to professor David Richards, University of Exeter, for his enthusiasm and inspiration at the Summer Schools of the European Academy of Nursing.)



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Complex Interventions May 16th 2011 Complex Interventions May 16th 2011 Presentation Transcript

  • Complex
    Anders Ringnér
    R.N., PhD Student
  • Background and history
    First MRC paper
    from 2000
    Updated in 2008
    (937 citations)
    (200 citations)
  • Examples
    Rehabilitation units for stroke patients
    Self-study to decrease disturbing behaviour among people with learning disabilities
    Community prevention of heart disease
    Group psychotherapy
    Patient education
    A clinical drug trial
  • Where is the complexityin a complex intervention?
    Takes place in a naturalistic setting
    possible outcomes
    levels of the health care system
    Heterogeneous population
    Almost always needs tailoring
  • Differences
  • The MRC model
  • Development
    Identifying the evidence base
    Identifying/developing theory
    Modelling process and outcomes
  • Modelling– an example
    Intervention points and behaviour change techniques
    Casual model
    Measures for evaluation
    Past behaviour
    Physical ActivityQuestionnaire
    • Information about disease risk and preventive behaviour
    • Identifying salient beliefs towards behaviour change
    • Reinforcing positive beliefs
    • Problem solving in relation to negative beliefs
    Attitude towards behaviour
    Subjective norm
    Perceived behaviour control
    Theory of Planned BehaviourQuestionnaire
    Theory of Planned BehaviourQuestionnaire
    • Setting achievable goals
    Behaviour intention
    • Action planning (prompts)
    • Self-monitoring
    • Self-reinforcement
    • Goal review
    • Building new habits
    • Preparing for and dealing with setbacks
    Physical ActivityQuestionnaire
    Specific behaviours to increase physical activity
  • The interventionprotocol
    Strict fidelity is probably inappropriate. Strive for tailoring!
    Should be possible to replicate
    Should be published
  • Feasibility/piloting
    Testing procedures
    Estimating recruitment/retention
    Determining sample size
  • Evaluation
    Assessing effectiveness
    Understanding change process
    Assessing cost-effectiveness
  • Choosing theoptimal design
    Don’t just go for the most common design in your field!
    Always consider randomisation!
    Always consider experimental designs!
    Usual treatment rather than placebo
  • Measuring outcomes
    A step away from “primary outcome”
    What variation is there in outcomes...
    Between individuals
    Between sites
    Over time
    And what causes the variation?
  • Whatever happenswithin the black box?

  • Evaluation of complex interventions requires use of qualitative and quantitativeevidence”
    MRC guidelines, 2000
  • Implementation
    Surveillance and follow-up
    Long term follow-up
  • Conclusion:why would we need this?
    Evidence-based practice
    Complexity is no reason for not evaluating
    Focus on practical effectiveness
    Implementation in practice is emphasized
  • The MRC guidance
    Short executive summary
    All steps described
    Lots of questions to ask yourself
    14 case studies
    161 references
  • References