1.

2.
Complex<br />interventions<br />Anders Ringnér<br />R.N., PhD Student<br />

3.
Background and history<br />First MRC paper<br />from 2000<br />Updated in 2008<br />(937 citations)<br />(200 citations)<br />

4.
Examples<br />Rehabilitation units for stroke patients<br />Self-study to decrease disturbing behaviour among people with learning disabilities<br />Community prevention of heart disease<br />Group psychotherapy<br />Patient education<br />A clinical drug trial<br />

5.
Where is the complexityin a complex intervention?<br />Takes place in a naturalistic setting<br />Several...<br />components<br />behaviours<br />possible outcomes<br />levels of the health care system<br />Heterogeneous population<br />Almost always needs tailoring<br />

6.
Differences<br />

7.
The MRC model<br />

8.
Development<br />Identifying the evidence base<br />Identifying/developing theory<br />Modelling process and outcomes<br />

9.
Modelling– an example<br />Intervention points and behaviour change techniques<br />Casual model<br />Measures for evaluation<br />Past behaviour<br />Physical ActivityQuestionnaire<br /><ul><li>Information about disease risk and preventive behaviour

10.
Identifying salient beliefs towards behaviour change

11.
Reinforcing positive beliefs

12.
Problem solving in relation to negative beliefs</li></ul>Attitude towards behaviour<br />Subjective norm<br />Perceived behaviour control<br />Theory of Planned BehaviourQuestionnaire<br />Theory of Planned BehaviourQuestionnaire<br /><ul><li>Setting achievable goals</li></ul>Behaviour intention<br /><ul><li>Action planning (prompts)

13.
Self-monitoring

14.
Self-reinforcement

15.
Goal review

16.
Building new habits

17.
Preparing for and dealing with setbacks</li></ul>Physical ActivityQuestionnaire<br />Specific behaviours to increase physical activity<br />

18.
The interventionprotocol<br />Strict fidelity is probably inappropriate. Strive for tailoring!<br />Should be possible to replicate<br />Should be published<br />

19.
Feasibility/piloting<br />Testing procedures<br />Estimating recruitment/retention<br />Determining sample size<br />

20.
Evaluation<br />Assessing effectiveness<br />Understanding change process<br />Assessing cost-effectiveness<br />

21.
Choosing theoptimal design<br />Don’t just go for the most common design in your field!<br />Always consider randomisation!<br />Always consider experimental designs!<br />Usual treatment rather than placebo<br />

22.
Measuring outcomes<br />A step away from “primary outcome”<br />What variation is there in outcomes...<br />Between individuals<br />Between sites<br />Over time<br />And what causes the variation?<br />

23.
Whatever happenswithin the black box?<br />

24.
”<br />Evaluation of complex interventions requires use of qualitative and quantitativeevidence”<br />MRC guidelines, 2000<br />

25.
Implementation<br />Dissemination<br />Surveillance and follow-up<br />Long term follow-up<br />

26.
Conclusion:why would we need this?<br />Evidence-based practice<br />Complexity is no reason for not evaluating<br />Focus on practical effectiveness<br />Implementation in practice is emphasized<br />

27.
The MRC guidance<br />Short executive summary<br />All steps described<br />Lots of questions to ask yourself<br />14 case studies<br />161 references<br />

28.
References<br />http://bit.ly/kva9vp<br />