title: Exploring synergistic interactions and catalysts in complex interventions: longitudinal, mixed methods case studies of an optimised multi-level suicide prevention intervention in four european countries (Ospi-Europe).
abstract: BACKGROUND
  The Medical Research Council (MRC) Framework for complex interventions highlights the need to explore interactions between components of complex interventions, but this has not yet been fully explored within complex, non-pharmacological interventions. This paper draws on the process evaluation data of a suicide prevention programme implemented in four European countries to illustrate the synergistic interactions between intervention levels in a complex programme, and to present our method for exploring these.
  
  
  METHODS
  A realist evaluation approach informed the process evaluation, which drew on mixed methods, longitudinal case studies. Data collection consisted of 47 semi-structured interviews, 12 focus groups, one workshop, fieldnoted observations of six programme meetings and 20 questionnaires (delivered at six month intervals to each of the four intervention sites). Analysis drew on the framework approach, facilitated by the use of QSR NVivo (v10). Our qualitative approach to exploring synergistic interactions (QuaSIC) also developed a matrix of hypothesised synergies that were explored within one workshop and two waves of data collection.
  
  
  RESULTS
  All four implementation countries provided examples of synergistic interactions that added value beyond the sum of individual intervention levels or components in isolation. For instance, the launch ceremony of the public health campaign (a level 3 intervention) in Ireland had an impact on the community-based professional training, increasing uptake and visibility of training for journalists in particular. In turn, this led to increased media reporting of OSPI activities (monitored as part of the public health campaign) and also led to wider dissemination of editorial guidelines for responsible reporting of suicidal acts. Analysis of the total process evaluation dataset also revealed the new phenomenon of the OSPI programme acting as a catalyst for externally generated (and funded) activity that shared the goals of suicide prevention.
  
  
  CONCLUSIONS
  The QuaSIC approach enabled us to develop and refine our definition of synergistic interactions and add the innovative concept of catalytic effects. This represents a novel approach to the evaluation of complex interventions. By exploring synergies and catalytic interactions related to a complex intervention or programme, we reveal the added value to planned activities and how they might be maximised.
authors.affiliation: Nursing, Midwifery & Allied Health Professions Research Unit, University of Stirling, Unit 13, University of Stirling Innovation Park, Stirling, FK9 4NF, UK. fiona.harris@stir.ac.uk.
authors.forename: Fiona M
authors.initials: FM
authors.lastname: Harris
authors.affiliation: Nursing, Midwifery & Allied Health Professions Research Unit, University of Stirling, Unit 13, University of Stirling Innovation Park, Stirling, FK9 4NF, UK.
authors.forename: Margaret
authors.initials: M
authors.lastname: Maxwell
authors.affiliation: Institute of Health & Well-being, University of Glasgow, Glasgow, UK.
authors.forename: Rory
authors.initials: R
authors.lastname: O'Connor
authors.affiliation: Faculty of Medical Sciences, University of Groningen, Groningen, The Netherlands.
authors.forename: James C
authors.initials: JC
authors.lastname: Coyne
authors.affiliation: National Suicide Research Foundation, University College Cork, Cork, Ireland.
authors.forename: Ella
authors.initials: E
authors.lastname: Arensman
authors.affiliation: National Suicide Research Foundation, University College Cork, Cork, Ireland.
authors.forename: Claire
authors.initials: C
authors.lastname: Coffey
authors.affiliation: Department of Psychiatry and Psychotherapy, University of Leipzig, Leipzig, Germany.
authors.forename: Nicole
authors.initials: N
authors.lastname: Koburger
authors.affiliation: CEDOC, Faculdade e Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal.
authors.forename: Ricardo
authors.initials: R
authors.lastname: Gusmão
authors.affiliation: CEDOC, Faculdade e Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal.
authors.forename: Susana
authors.initials: S
authors.lastname: Costa
authors.affiliation: Institute of Behavioural Sciences, Semmelweis University Budapest, Budapest, Hungary.
authors.forename: András
authors.initials: A
authors.lastname: Székely
authors.affiliation: Institute of Behavioural Sciences, Semmelweis University Budapest, Budapest, Hungary.
authors.forename: Zoltan
authors.initials: Z
authors.lastname: Cserhati
authors.affiliation: Personal Social Services Research Unit, London School of Economics and Political Science, London, UK.
authors.forename: David
authors.initials: D
authors.lastname: McDaid
authors.affiliation: LUCAS, KU Leuven, Leuven, Belgium.
authors.forename: Chantal
authors.initials: C
authors.lastname: van Audenhove
authors.affiliation: Department of Psychiatry and Psychotherapy, University of Leipzig, Leipzig, Germany.
authors.forename: Ulrich
authors.initials: U
authors.lastname: Hegerl
mesh_terms: D005060:Europe; D006293:Health Promotion / Q000458:organization & administration*; D006801:Humans; D007407:Interviews as Topic; D008137:Longitudinal Studies; D012107:Research Design; D011795:Surveys and Questionnaires; D000092864:Suicide Prevention
keywords: Complex interventions; Longitudinal study; Process evaluation; Programme as catalyst; Suicide prevention; Synergistic interactions