Academic journal article Contemporary Nurse : a Journal for the Australian Nursing Profession

Evaluating a Complex Intervention: A Process Evaluation of a Psycho-Education Program for Lung Cancer Patients Receiving Palliative Radiotherapy

Academic journal article Contemporary Nurse : a Journal for the Australian Nursing Profession

Evaluating a Complex Intervention: A Process Evaluation of a Psycho-Education Program for Lung Cancer Patients Receiving Palliative Radiotherapy

Article excerpt

INTRODUCTION

Psycho-educational interventions (PEIs) are considered to be complex interventions since they are made up of several components and involve the active participation of patients and interveners (Campbell et al., 2000). It is not easy to define 'active ingredients' of such interventions as they are built up from the nature of the intervention (for example dose and frequency), and the specification of delivering the intervention (for example type of intervener and their required skill). Complex interventions, even with random assignment, can violate the assumptions of traditional randomized controlled trial (RCT), as there may be variations in the delivery of the dose and participation level of the patient in the clinical environment that may threaten the integrity of the intervention. Integrity is the degree to which the intervention is carried out as planned (Campbell et al., 2000). Hodges et al. (2010) advocate all aspects of a psychological intervention need to be delineated adequately in order to assess and enhance intervention integrity.

One problem with evaluating and implementing a complex intervention is that the integrity of intervention delivery is likely to influence the extent to what it is meant to achieve. Arguably, it is fairly easy to standardize delivery of a drug. But quality of interventions, particularly psychosocial approaches, depending on the work of interveners may be much affected by other factors, such as their training, and quality of associated written materials. There is growing evidence that variation in mode of delivery results in very different outcomes. Two school-based interventions designed to increase fruit and vegetable intake (Resnicow et al., 1998) and physical activity (Saunders, Ward, Felton, Dowda, & Pate, 2006) reported a direct correlation between intervention integrity and trial outcomes.

Consequently it is argued the simple RCT paradigm needs to be replaced with a more flexible pragmatic design that mirrors the complexity of intervention delivery (Campbell et al., 2000). A pragmatic design allows interveners to treat patients slightly differently according to their needs and recognize patients play an active part in the outcome of an intervention, without sacrificing the quality and essential elements of an intervention (Richardson, 2000). In this type of design contextual factors, such as patients' attention or the way treatment is given, are optimized and evaluated in order to ensure the approach closely mirrors clinical practice (Richardson, 2000). To achieve this, and ensure integrity of the intervention, process evaluation is advocated by many researchers (Billings, 2000; Chan, 2009) as a particularly useful approach to examine the process of complex interventions against the planned criteria of a quality intervention.

Process evaluation involves investigation of how an intervention was delivered. Lack of intervention integrity can occur when specific activities provided to patients deviate from those originally planned; and when patients are exposed to partial or different components of the intervention and at different levels of strength according to individual patient needs or changes in the intervener's performance (Chan, 2009). Therefore, process evaluation may include different aspects of patient, intervener and intervention (e.g., dose and frequency) variables. Variability in responses to an intervention can be explained in light of these variables (Chan, 2009; Richardson, 2000; Sidani & Braden, 1998). For instance, poor patient compliance to the full intervention package may explain why an intervention fails to achieve the intended outcome.

The main study

A PEI combining multiple cognitive, psychological and behavioral ingredients was developed to manage breathlessness, fatigue and anxiety for Hong Kong Chinese patients with advanced lung cancer undergoing palliative radiotherapy (RT; Chan, Richardson, & Richardson, 2011). …

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