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Developing and evaluating complex interventionsEvaluating complex interventions is complicated. The Medical Research Council's evaluation framework (2000) brought welcome clarity to the task. Now the council has updated its guidanceComplex interventions are widely used in the health service, in public health practice, and in areas of social policy that have important health consequences, such as education, transport, and housing. They present various problems for evaluators, in addition to the practical and methodological difficulties that any successful evaluation must overcome. In 2000, the Medical Research Council (MRC) published a framework1 to help researchers and research funders to recognise and adopt appropriate methods. The framework has been highly influential,nike shox deliver feminino, and the accompanying BMJ paper is widely cited.2 However, much valuable experience has since accumulated of both conventional and more innovative methods. In this article we summarise the issues that prompted the revision and the key messages of the new guidance.Summary pointsThe Medical Research Council guidance for the evaluation of complex interventions has been revised and updatedThe process of developing and evaluating a complex intervention has several phases, although they may not follow a linear sequenceExperimental designs are preferred to observational designs in most circumstances, but are not always practicableUnderstanding processes is important but does not replace evaluation of outcomesComplex interventions may work best if tailored to local circumstances rather than being completely standardisedReports of studies should include a detailed description of the intervention to enable replication, evidence synthesis,ver nike shox, and wider implementationRevisiting the 2000 MRC frameworkAs experience of evaluating complex interventions has accumulated since the 2000 framework was published, interest in the methodology has also grown. Several recent papers have identified limitations in the framework,tenis nike shox deliver w, recommending,nike shox lancamento, for example, greater attention to early phase piloting and development work,3 a less linear model of evaluation process,4 integration of process and outcome evaluation,nike shox rosa,5 recognition that complex interventions may work best if they are tailored to local contexts rather than completely standardised,nike air mex,6 and greater use of the insights provided by the theory of complex adaptive systems.7A workshop held by the MRC Population Health Sciences Research Network to consider whether and how the framework should be updated likewise recommended the inclusion of a model of the evaluation process less closely to tied to the phases of drug development; more guidance on how to approach the development,tenis nyke, reporting, and implementation of complex interventions; and greater attention to the contexts in which interventions take place. It further recommended consideration of alternatives to randomised trials, and of highly complex or non health sector interventions to which biomedical methods may not be applicable, and more evidence and examples to back up and illustrate the recommendations. The new guidance addresses these issues in depth, and here we set out the key messages.What are complex interventions?Complex interventions are usually described as interventions that contain several interacting components, but they have other characteristics that evaluators should take into account (box 1). There is no sharp boundary between simple and complex interventions. Few interventions are truly simple,nike air max azul e branco, but the number of components and range of effects may vary widely. Some highly complex interventions, such as the Sure Start intervention to support families with young children in deprived communities,8 may comprise a set of individually complex interventions.Box 1 What makes an intervention complex?Number of interacting components within the experimental and control interventionsNumber and difficulty of behaviours required by those delivering or receiving the interventionNumber of groups or organisational levels targeted by the interventionNumber and variability of outcomesDegree of flexibility or tailoring of the intervention permittedHow these characteristics are dealt with will depend on the aims of the evaluation. A key question in evaluating complex interventions is whether they are effective in everyday practice (box 2).9 It is therefore important to understand the whole range of effects and how they vary, for example, among recipients or between sites. A second key question in evaluating complex interventions is how the intervention works: what are the active ingredients and how are they exerting their effect? Answers to this kind of question are needed to design more effective interventions and apply them appropriately across group and setting.10Box 2 Developing and evaluating complex studiesA good theoretical understanding is needed of how the intervention causes change,nike air max preto e laranja, so that weak links in the causal chain can be identified and strengthenedLack of effect may reflect implementation failure (or teething problems) rather than genuine ineffectiveness; a thorough process evaluation is needed to identify implementation problemsVariability in individual level outcomes may reflect higher level processes; sample sizes may need to be larger to take account of the extra variability and cluster randomised designs consideredA single primary outcome may not make best use of the data; a range of measures will be needed and unintended consequences picked up where possibleEnsuring strict standardisation may be inappropriate; the intervention may work better if a specified degree of adaptation to local settings is allowed for in the protocolDevelopment, evaluation, and implementation The 2000 framework characterised the process of development through to implementation of a complex intervention in terms of the phases of drug development. Although it is useful to think in terms of phases,nike air max 1 brasil, in practice these may not follow a linear or even a cyclical sequence (figure).4View larger version:In a new windowDownload as PowerPoint SlideFig 1 Key elements of the development and evaluation processBest practice is to develop interventions systematically, using the best available evidence and appropriate theory, then to test them using a carefully phased approach, starting with a series of pilot studies targeted at each of the key uncertainties in the design, and moving on to an exploratory and then a definitive evaluation. The results should be disseminated as widely and persuasively as possible, with further research to assist and monitor the process of implementation.In practice, evaluation takes place in a wide range of settings that constrain researchers' choice of interventions to evaluate and their choice of evaluation methods. Ideas for complex interventions emerge from various sources, which may greatly affect how much leeway the researcher has to modify the intervention, to influence the way it is implemented, or to adopt an ideal evaluation design.8 Evaluation may take place alongside large scale implementation, rather than starting beforehand. Strong evidence may be ignored or weak evidence taken up, depending on its political acceptability or fit with other ideas about what works.11Researchers need to consider carefully the trade off between the importance of the intervention and the value of the evidence that can be gathered given these constraints. In an evaluation of the health impact of a social intervention, such as a programme of housing improvement,tenis nike branco, the researcher may have no say in what the intervention consists of and little influence over how or when the programme is implemented, limiting the scope to undertake development work or to determine allocation. Experimental methods are becoming more widely accepted as methods to evaluate policy,12 but there may be political or ethical objections to using them to assess health effects, especially if the intervention provides important non health benefits.13 Given the cost of such interventions, evaluation should still be considered the best available methods, even if they are not optimal in terms of internal validity,promocao de tenis, may yield useful results.14相关的主题文章:
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Later on the primary school
Zhou Runfa in the entertainment circle is a "civilian king", can often be found on the web in a certain film together with Fage, youth representatives concluded that "in the subway, bus stations, markets and Fage encounter level absolute reached five stars". Zhou Runfa in the program also shows the reason: when young family was poor, he was little more than a dozen workers went out to play. While the movie is playing a job, money earn much, there will be many red are not very concerned about. So, even become a circle, he still loves free subway, buses, visiting the farms.
but the two storey building was bought private
reporter to verify: Sanjiang building is located in Lanxi on the road to peace, was the first high-rise in Lanxi city. Listen to local people say, this building was built in the 90's of the last century,nike air max trainers, became the unfinished building. 2005 before the developers took over, for the transformation of the building and put into use. Also some people said that, the clock has been for many years has not passed, now just for show.yesterday, the netizen micro-blog question: Sanjiang building has been the (Zhejiang) Lanxi city landmark building, the roof tower of the clock was the first bell in Lanxi, many Lanxi people take it as a symbol of the city of Lanxi. But in the past few days, the clock tower erected scaffolding outside, heard not to repair the clock tower, but the two storey building was bought private, after the transformation will be used for other purposes, the clock will be removed. More strange is, in the design drawings of buildings,mulberry london, couldn't find the traces. Don't ever as a Lanxi landmark tower, is actually illegal buildings?
Built nearly 20 years
yesterday afternoon, the reporters came to the peace road, Lanxi City,cheap air max, the clock far can see Sanjiang building roof.
first floor room on the ground, with the shovel, bucket in construction, cement,tracolla louis vuitton, mortar and brick floor. The two floor room, three walls of each opened a new window. Near the LAN that surface, the scaffolding outside the building, wall brick seems to be newly built,borse louis vuitton outlet, here was cut.
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according to the owner of the design, the clock tower after the transformation, the huge clock will be four windows replaced the renovation renderings, this had been removed pointer clock
The lift only
4 years ago,nike tn outlet, the two layer of the tower was sold to private
Sanjiang building, private to the clock tower four years ago, is now being converted to
two layer tower is in the decoration,scarpe hogan donna, filled with cement mortar
Lanxi Sanjiang landmark building tower is illegal buildings?
Zhejiang Lanxi city landmark building was unfinished building two layer tower has no property in
reporter survey: this building was unfinished building,black nike air max, two storey tower there is no property
in Sanjiang building 20 layer, a company,borse louis vuitton, a company staff told reporters, from 20 layer to the layer, all his boss bought.
even so,hogan milano, because far can see, this two story tower building roof in Sanjiang, Lanxi landmark status is no doubt.
originally, this two storey four facades have a clock. However, yesterday, close to the surface of Lanjiang River bell had been removed,mulberry outlet shops, the clock hour hand and the minute hand of the rest have not see.
two workers sat outside the rest,hogan online, they say, is on the 20 floor of the boss asked them to decoration. "Urban management to work, not to let, the transformation of the." The workers said that.
Sanjiang building to the 22 floor, the reporter had to climb the stairs up to the bell tower where the floor. The tower house is divided into two layers, each layer inside the larger space, an area of about seventy or eighty square meters.
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