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.)

2. Complex interventions Anders Ringnér R.N., PhD Student

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

4. 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

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

6. Differences

7. The MRC model

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

10. Identifying salient beliefs towards behaviour change

11. Reinforcing positive beliefs

13. Self-monitoring

14. Self-reinforcement

15. Goal review

16. Building new habits

17. Preparing for and dealing with setbacksPhysical ActivityQuestionnaire Specific behaviours to increase physical activity

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

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

20. Evaluation Assessing effectiveness Understanding change process Assessing cost-effectiveness

21. 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

22. 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?

23. Whatever happenswithin the black box?

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

25. Implementation Dissemination Surveillance and follow-up Long term follow-up

26. 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

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

28. References http://bit.ly/kva9vp