title: Immediate versus sustained effects: interrupted time series analysis of a tailored intervention.
abstract: BACKGROUND
  Detailed intervention descriptions and robust evaluations that test intervention impact--and explore reasons for impact--are an essential part of progressing implementation science. Time series designs enable the impact and sustainability of intervention effects to be tested. When combined with time series designs, qualitative methods can provide insight into intervention effectiveness and help identify areas for improvement for future interventions. This paper describes the development, delivery, and evaluation of a tailored intervention designed to increase primary health care professionals' adoption of a national recommendation that women with mild to moderate postnatal depression (PND) are referred for psychological therapy as a first stage treatment.
  
  
  METHODS
  Three factors influencing referral for psychological treatment were targeted using three related intervention components: a tailored educational meeting, a tailored educational leaflet, and changes to an electronic system data template used by health professionals during consultations for PND. Evaluation comprised time series analysis of monthly audit data on percentage referral rates and monthly first prescription rates for anti-depressants. Interviews were conducted with a sample of health professionals to explore their perceptions of the intervention components and to identify possible factors influencing intervention effectiveness.
  
  
  RESULTS
  The intervention was associated with a significant, immediate, positive effect upon percentage referral rates for psychological treatments. This effect was not sustained over the ten month follow-on period. Monthly rates of anti-depressant prescriptions remained consistently high after the intervention. Qualitative interview findings suggest key messages received from the intervention concerned what appropriate antidepressant prescribing is, suggesting this to underlie the lack of impact upon prescribing rates. However, an understanding that psychological treatment can have long-term benefits was also cited. Barriers to referral identified before intervention were cited again after the intervention, suggesting the intervention had not successfully tackled the barriers targeted.
  
  
  CONCLUSIONS
  A time series design allowed the initial and sustained impact of our intervention to be tested. Combined with qualitative interviews, this provided insight into intervention effectiveness. Future research should test factors influencing intervention sustainability, and promote adoption of the targeted behavior and dis-adoption of competing behaviors where appropriate.
authors.forename: Andria
authors.initials: A
authors.lastname: Hanbury
authors.affiliation: Department of Health Sciences, University of York, Heslington, York YO10 5DD, UK. katherine.farley@york.ac.uk.
authors.forename: Katherine
authors.initials: K
authors.lastname: Farley
authors.forename: Carl
authors.initials: C
authors.lastname: Thompson
authors.forename: Paul M
authors.initials: PM
authors.lastname: Wilson
authors.forename: Duncan
authors.initials: D
authors.lastname: Chambers
authors.forename: Heather
authors.initials: H
authors.lastname: Holmes
mesh_terms: D019052:Depression, Postpartum / Q000188:drug therapy; D004059:Diffusion of Innovation; D005260:Female; D058005:General Practitioners; D006801:Humans; D007318:Inservice Training / Q000379:methods; D009722:Nurse Practitioners; D011320:Primary Health Care; D015397:Program Evaluation / Q000379:methods*; D036301:Qualitative Research; D012017:Referral and Consultation; D013997:Time Factors