Complex Public Health Interventions Research Articles

What methods and challenges for taking account of context when transferring complex interventions?

Abstract For complex public health interventions to be effective their implementation needs to adapt to the situation of those implementing and those receiving the intervention. While context matter for intervention implementation and effect, we still insist on learning from cross-country comparison of implementation. Next methodological challenges include how to increase learning from implementation of complex public health interventions from various context. The interventions presented in this workshop all aims to improve quality of reproductive health care for immigrants, however with different focus: contraceptive care in Sweden, group based antenatal care in France, and management of pregnancy complications in Denmark. What does these interventions have in common and are there cross cutting themes that help us to identify the larger challenges of reproductive health care for immigrant women in Europe? Issues shared across the interventions relate to improved interactional dynamics between women and the health care system, and theory around a woman-centered approach and cultural competence of health care providers and systems might enlighten shared learnings across the different interventions and context. Could the mechanisms of change be understood using theoretical underpinnings that allow us to better generalize the finding across context? What adaption would for example be needed, if the Swedish contraceptive intervention should work in a different European setting? Should we distinguish between adaption of function and form, where the latter might be less important for intervention fidelity? These issues will shortly be introduced during this presentation using insights from the three intervention presentations and thereafter we will open up for discussion with the audience.

Optimizing a stroke caregiver support programme in practice with Participatory Action Research

Abstract Family caregivers (FCG) play a key role in the day-to-day care of stroke survivors. Most FCG support programmes are complex public health interventions. Often, they are designed top-down without key stakeholder participation. Hence, when implementing these programmes in real world settings, they may experience “teething problems”. Optimization in practice and actively engaging its stakeholders to accurately fit the programme to the needs in practice may enhance the programmés chance of success. The Participatory Action Research (PAR) strategy was chosen for the optimization of a German primary prevention programme for stroke FCGs. Immediately after the development of the preliminary support concept (5 Conceptual Building Blocks - CBB), conducted top-down by the academic research team, iterative PAR-cycles (observe - reflect - plan - act) were applied. Together with the stakeholders (service providers and FCG), three steps were taken: (1) verifying and fitting the preliminary CBBs, (2) detecting, developing, verifying and fitting new blocks, and (3) prioritizing all blocks. For data collection a multi-methodological design was chosen. Through PAR, a matured FCG support concept was obtained, containing eight CBBs. The five preliminary CBBs: ‘Content’, ‘Human resources’, ‘Personalized approach’, ‘Timing’, and ‘Setting’, were optimized and prioritized as core blocks, providing the base for individual caregiver support. Three new CBBs: ‘Network building’, ‘Communication’, and ‘Social safety-net’ were assigned as facilitating blocks, interlinking and securing the programme within the existing support system. PAR was found to be essential for both systematically detecting conceptual weaknesses of the preliminary concept and adjusting its components to the needs of the key stakeholders, before full-scale implementation. Involvement of stakeholders, with high levels of participation, will enhance the acceptance of the matured concept and its feasibility in practice.

Healthy Habits, Happy Homes Scotland (4HS) feasibility study: Translation of a home-based early childhood obesity prevention intervention evaluated using RE-AIM framework

ObjectiveHealthy Habits, Happy Homes (4H) is a home-based, pre-school childhood obesity prevention intervention which demonstrated efficacy in North America which we translated to Scotland (4HS) by considering contextual factors and adapting study design. RE-AIM Framework was used to assess 1) extent to which development of 4HS intervention (including recruitment) was participatory and inclusive; 2) feasibility of translating a complex public health intervention from one setting to another; 3) extent to which translation was pragmatic and 4) fidelity of intervention to the principles of Motivational Interviewing (MI). Study designFeasibility testing, process evaluation and measurements of intervention fidelity were undertaken to evaluate the translation of 4H to an economically deprived area of Scotland (4HS). Methods4HS study processes; participatory approach, recruitment methods, level of pragmatism were evaluated using the RE-AIM framework. Qualitative and quantitative measures identified key implementation features and functioning of 4HS intervention. Fidelity MI principles was determined through coding of audiotapes using Motivation Interviewing Treatment Integrity (MITI) code. ResultsKey facilitators for positive impact with families, included: inclusive recruitment methods, appropriate channels of communication and correspondence (Reach) with n ​= ​126 enquiries and n ​= ​26 (21%) families recruited. Positive links with local parents and community workers integral to the research process at n ​= ​9 meetings (Effectiveness). 61.5% of families lived in the most deprived data zone in Scotland, 23% were one parent families, thus awareness and consideration of local contextual factors (Adoption) and locally relevant materials were important. 4HS was feasible to deliver, pragmatic in nature and intervention demonstrated good fidelity to MI (Implementation). ConclusionTranslation of 4H from North America to Scotland was successful. Future studies should consider implementation of 4HS approach within routine practice within the UK (practice based evidence) or through thoughtful evaluation in a future trial (evidence based practice).

"And Then He Got into the Wrong Group": A Qualitative Study Exploring the Effects of Randomization in Recruitment to a Randomized Controlled Trial.

Background: Randomized controlled trials (RCTs) are regarded as the most internally valid means of estimating the effectiveness of complex public health interventions, but the recruitment of participants can be difficult. The aim of this study was to explore factors that may have affected the recruitment of employees with musculoskeletal disorders (MSDs) to a multicenter worksite health promotion program from the perspective of recruiting case managers. Methods: Factors in recruitment to the RCT were explored using three focus group discussions with case managers. Data were processed using MAXQDA and analyzed with a combination of content and sequence analysis. Results: Findings showed that randomization is a major challenge for recruitment. Case managers adapted their communication with, and approaches to possible participants because of the randomization design and employed coping strategies to compensate for allocation into the control arm of the study. Perceptions of the superiority of the intervention group over the control group, perceptions of the (mis)match of participants to one of the groups, as well as the understanding of the necessity of randomization for effectiveness evaluations, further affected recruitment. Perceived expectations of possible participants and their (emotional) reactions to the randomization allocation also complicated recruitment. Conclusion: We were able to gain insight into the challenges of randomization for the recruitment of participants to a multicenter RCT. This study assisted the development of strategies to overcome barriers in the ongoing implementation process of the trial (i.e., the adaption of best practice information sheets and newsletters). There remains a need to develop effective interventions to help those recruiting to trials.

Social enterprises' impact on older people's health and wellbeing: exploring Scottish experiences.

The global aging demographic is putting pressure on state-delivered health and social care services. As the austerity agenda in the UK cuts state-funded service provision for older people despite increasing demand, social enterprise has become a politically and economically attractive model for the sustainable delivery of some public services. Yet little is known about the impact of social enterprise on the health and wellbeing of older people. In this paper we address this gap in understanding and consider social enterprise activities as complex public health-promoting interventions. Our study aimed to understand what impact social enterprise activities had on the health and wellbeing of participants aged over 50, and also how that impact was created. To achieve this, we conducted qualitative semi-structured interviews with a sample (n = 43) of staff, volunteers, clients and carers aged over 50 who were involved in activities delivered by three social enterprises. Using a thematic analysis to explore manifest and latent themes, two antecedents of subjective younger age emerged explaining how benefit was created, namely downward social comparison and identity. The social enterprise activities we studied benefited participants' health and wellbeing, impacting positively on participants' sense of purpose, social support, connectedness and inclusion. These health and wellbeing benefits can be considered as outcomes of complex public health interventions for older people, and we relate these outcomes to beneficial conditions within the intermediary social determinants of health. We conclude by discussing the future impact of social enterprise activities and current UK policy on the structural determinants of health.

The development of implementation management instruments for a new complex stroke caregiver intervention based on systematic stakeholder and risk analyses.

Stakeholders are important contributors in the implementation of a complex public health intervention. During the development phase of an implementation, alongside careful design of its components and investing in the exploration of the dynamic multi-stakeholder stroke rehabilitation setting, it is essential to assess possible implementation risks. Systematic stakeholder and risk analyses can guide the exploration process and enable teams involved in complex interventions to develop context-tailored implementation management instruments. To develop instruments that facilitate the implementation of the complex stroke caregiver intervention project in the real-life support system. Systematic stakeholder and risk analyses were conducted composing five activities. Project stakeholders were identified, classified and assessed using a top-down approach, while implementation risks were identified and assessed by applying a bottom-up approach. Data were collected through interviews and focus groups. Based on the knowledge provided by the stakeholders, two context-tailored implementation management instruments were designed with a top-down approach: (1) a comprehensive 'stakeholder-risk atlas' providing individual stakeholder information, such as role, access, contribution, power and interest, expectations, perceived risks and specific engagement activities and (2) an overall 'project implementation strategy' concentrating on communication, transparency, network building and professionalism. Complex interventions will benefit from early and comprehensive stakeholder and risk analyses. The early involvement of stakeholders, with their insightful knowledge, enables the research team to develop context-tailored implementation management instruments. Instruments will support the team during implementation and may impact positively on the outcome of the intervention. Knowledge can be obtained by combining top-down and bottom-up working approaches.

Beyond interviews and focus groups: a framework for integrating innovative qualitative methods into randomised controlled trials of complex public health interventions

BackgroundRandomised controlled trials (RCTs) are widely used for establishing evidence of the effectiveness of interventions, yet public health interventions are often complex, posing specific challenges for RCTs. Although there is increasing recognition that qualitative methods can and should be integrated into RCTs, few frameworks and practical guidance highlight which qualitative methods should be integrated and for what purposes. As a result, qualitative methods are often poorly or haphazardly integrated into existing trials, and researchers rely heavily on interviews and focus group discussions. To improve current practice, we propose a framework for innovative qualitative research methods that can help address the challenges of RCTs for complex public health interventions.MethodsWe used a stepped approach to develop a practical framework for researchers. This consisted of (1) a systematic review of the innovative qualitative methods mentioned in the health literature, (2) in-depth interviews with 23 academics from different methodological backgrounds working on RCTs of public health interventions in 11 different countries, and (3) a framework development and group consensus-building process.ResultsThe findings are presented in accordance with the CONSORT (Consolidated Standards of Reporting Trials) Statement categories for ease of use. We identify the main challenges of RCTs for public health interventions alongside each of the CONSORT categories, and potential innovative qualitative methods that overcome each challenge are listed as part of a Framework for the Integration of Innovative Qualitative Methods into RCTs of Complex Health Interventions. Innovative qualitative methods described in the interviews include rapid ethnographic appraisals, document analysis, diary methods, interactive voice responses and short message service, community mapping, spiral walks, pair interviews and visual participatory analysis.ConclusionsThe findings of this study point to the usefulness of observational and participatory methods for trials of complex public health interventions, offering a novel contribution to the broader literature about the need for mixed methods approaches. Integrating a diverse toolkit of qualitative methods can enable appropriate adjustments to the intervention or process (or both) of data collection during RCTs, which in turn can create more sustainable and effective interventions. However, such integration will require a cultural shift towards the adoption of method-neutral research approaches, transdisciplinary collaborations, and publishing regimes.

To what extent can the activities of the South Australian Health in All Policies initiative be linked to population health outcomes using a program theory-based evaluation?

BackgroundThis paper reports on a five-year study using a theory-based program logic evaluation, and supporting survey and interview data to examine the extent to which the activites of the South Australian Health in All Policies initiative can be linked to population health outcomes.MethodsMixed-methods data were collected between 2012 and 2016 in South Australia (144 semi-structured key informant interviews; two electronic surveys of public servants in 2013 (n = 435) and 2015 (n = 483); analysis of state government policy documents; and construction of a program logic model to shape assessment of the feasibility of attribution to population health outcomes).ResultsMultiple actions on social determinants of health in a range of state government sectors were reported and most could be linked through a program logic model to making some contribution to future population health outcomes. Context strongly influences implementation; not all initiatives will be successful and experimentation is vital. Successful initiatives included HiAP influencing the urban planning department to be more concerned with the health impacts of planning decisions, and encouraging the environment department to be concerned with the health impacts of its work.ConclusionsThe theory-based program logic suggests that SA HiAP facilitated improved population health through working with multiple government departments. Public servants came to appreciate how their sectors impact on health. Program logic is a mechanism to evaluate complex public health interventions in a way that takes account of political and economic contexts. SA HiAP was mainly successful in avoiding lifestyle drift in strategy. The initiative encouraged a range of state government departments to tackle conditions of daily living. The broader underpinning factors dictating the distribution of power, money and resources were not addressed by HiAP. This reflects HiAP’s use of a consensus model which was driven by (rather than drove) state priorities and sought ‘win-win’ strategies.

Health Technology Assessment of Public Health Interventions Published 2012 to 2016: An Analysis of Characteristics and Comparison of Methods.

The aim of this study was to provide an overview of the methodological characteristics and compare the assessment methods applied in health technology assessments (HTAs) of public health interventions (PHIs). We defined a PHI as a population-based intervention on health promotion or for primary prevention of chronic or nonchronic diseases. HTAs on PHIs were identified by systematically searching the Web pages of members of international HTA networks. We included only full HTA reports published between 2012 and 2016. Two reviewers extracted data on the methods used to assess effectiveness/safety, as well as on economic, social, cultural, ethical, and legal aspects using a-priori standardized tables. We included ten HTAs provided by four different organizations. Of these, all reports assessed the effectiveness of the interventions and conducted economic evaluations, seven investigated social/cultural aspects, and four each considered legal and ethical aspects, respectively. Some reports addressed applicability, context/setting, and intervention fidelity issues in different ways. We found that most HTAs adapted their methods to some extent, for example, by including nonrandomized studies, expanding the search strategy, involving stakeholders, or applying a framework to guide the HTA process. Our analysis provides a comprehensive overview of methods applied in HTAs on public health interventions. We found that a heterogeneous set of approaches is used to deal with the challenges of evaluating complex public health interventions.

Development of guidance for feasibility studies to decide whether and how to proceed to full-scale evaluation of complex public health interventions: a systematic review

BackgroundThe importance of feasibility studies (also referred to as exploratory or pilot studies) for optimising complex public health interventions and evaluation designs before evaluating effectiveness is widely acknowledged. In a systematic review of guidance on feasibility studies, we found that guidance is lacking or inconsistent on many aspects of their purpose, design, and conduct, and that it is lacking on the evidence needed to inform decisions about when to proceed to an effectiveness study. This work, building on that review, aimed to develop guidance for researchers, peer reviewers, and funders. MethodsThe systematic review was followed by a three-round web-based, Delphi exercise. We identified novel approaches to intervention optimisation and study designs from beyond public health through a scoping review and qualitative interviews with 15 experts in intervention design and evaluation. We discussed key aspects of the draft guidance with evaluation design specialists, funders, and journal editors in a consensus workshop (n=30), and we revised the guidance accordingly. The review is registered with PROSPERO, number CRD42016047843. FindingsOur systematic review had identified 25 unique sets of guidance. The Delphi identified consensus on many aspects of feasibility study methodology, but disagreement on others, including terminology, how feasibility study data can inform decisions about sample size, how progression criteria should be set, and how progression decisions should be made. A number of study designs typically used in clinical studies (eg, n of 1), digital health (eg, A–B testing), and engineering (eg, fractional factorial designs) have the potential to be applied more widely in feasibility studies of complex public health interventions—for example, to optimise interventions or to explore variation in intervention effects. InterpretationThe guidance will help researchers to develop and conduct feasibility studies, and take appropriate decisions on progression to an effectiveness study. It will provide peer reviewers and research funders with objective criteria against which to assess bids and publications. Study limitations include a lower response from less experienced researchers than from more experienced research methodologists in the Delphi exercise. The systematic review of guidance covered seven health-related bibliographic databases but might have missed guidance from other areas of social intervention research. FundingMedical Research Council (MRC)/National Institute of Health Research (NIHR) Methodology Research Panel (MR/N015843/1).

To what extent are complex public health interventions transferable across contexts?

To what extent are complex public health interventions transferable across contexts?

To what extent are complex public health interventions transferable across contexts?

To what extent are complex public health interventions transferable across contexts?

Examining diffusion to understand the how of SASA!, a violence against women and HIV prevention intervention in Uganda

BackgroundA growing number of complex public health interventions combine mass media with community-based “change agents” and/or mobilisation efforts acting at multiple levels. While impact evaluations are important, there is a paucity of research into the more nuanced roles intervention and social network factors may play in achieving intervention outcomes, making it difficult to understand how different aspects of the intervention worked (or did not). This study applied aspects of diffusion of innovations theory to explore how SASA!, a community mobilisation approach for preventing HIV and violence against women, diffused within intervention communities and the factors that influenced the uptake of new ideas and behaviours around intimate partner relationships and violence.MethodsThis paper is based on a qualitative study of couples living in SASA communities and secondary analysis of endline quantitative data collected as part of a cluster randomised control trial designed to evaluate the impact of the SASA! intervention. The primary trial was conducted in eight communities in Kampala, Uganda between 2007 and 2012. The secondary analysis of follow up survey data used multivariate logistic regression to examine associations between intervention exposure and interpersonal communication, and relationship change (n = 928). The qualitative study used in-depth interviews (n = 20) and framework analysis methods to explore the intervention attributes that facilitated engagement with the intervention and uptake of new ideas and behaviours in intimate relationships.ResultsWe found communication materials and mid media channels generated awareness and knowledge, while the concurrent influence from interpersonal communication with community-based change agents and social network members more frequently facilitated changes in behaviour. The results indicate combining community mobilisation components, programme content that reflects peoples’ lives and direct support through local change agents can facilitate diffusion and powerful collective change processes in communities.ConclusionsThis study makes clear the value of applying diffusion of innovations theory to illuminate how complex public health intervention evaluations effect change. It also contributes to our knowledge of partner violence prevention in a low-income, urban East African context.Trial registrationClinicalTrials.gov #NCT00790959. Registered 13th November 2008.

Meta-Analysis of Complex Interventions.

Meta-analysis is a prominent method for estimating the effects of public health interventions, yet these interventions are often complex in ways that pose challenges to using conventional meta-analytic methods. This article discusses meta-analytic techniques that can be used in research syntheses on the effects of complex public health interventions. We first introduce the use of complexity frameworks to conceptualize public health interventions. We then present a menu of meta-analytic procedures for addressing various sources of complexity when answering questions about the effects of public health interventions in research syntheses. We conclude with a review of important practices and key resources for conducting meta-analyses on complex interventions, as well as future directions for research synthesis more generally. Overall, we argue that it is possible to conduct meaningful quantitative syntheses of research on the effects of public health interventions, though these meta-analyses may require the use of advanced techniques to properly consider and attend to issues of complexity.

Pragmatic pilot cluster randomised control trial of a school-based peer-led anti-smoking intervention for 13-14 year olds in Malaysia

PurposeThe purpose of this paper is to report the process evaluation of a pilot randomised control trial of an anti-smoking intervention for Malaysian 13-14-year olds, conducted in 2011/2012. It was hypothesised that trained peer supporters would promote non-smoking among classmates through informal conversations.Design/methodology/approachSmoking-related baseline and follow-up questionnaires were administered, seven months apart, to Form 1 students (n=2,118) attending eight schools across two districts in Sabah (Kota Kinabalu; Keningau). Concealed stratified randomisation assigned two schools per district to the control and intervention arms. Control schools received usual care. Intervention schools received usual care and the peer supporter intervention. Peer supporters completed smoking-related knowledge and attitudes questionnaires before and after peer supporter training and peer supporter training evaluation questionnaires. They also discussed the peer supporter training and role in focus groups immediately following training (n=4) and three months later (n=3), and additionally, recorded post-training anti-smoking activity in diaries.FindingsThe pilot trial found that student recruitment was high (baseline students matched at follow-up n=1,681 (79 per cent of class-registered students). More boys (n=38) than girls (n=35) attended peer supporter training. Post-training, most peer supporters had improved smoking-related knowledge (n=55; 75 per cent) and attitudes (n=57; 78 per cent) and returned diaries (n=49; 67 per cent). Some focus group boys reported they were reluctant peer supporters and/or found resisting smoking difficult.Practical implicationsFuture trials would benefit from outlined modifications to peer supporter selection, recruitment and training and additionally, assessments of context and intervention acceptability and reach.Originality/valueTrials of complex public health interventions are scarce in economically developing countries.

Why is it difficult to evaluate the effectiveness and cost-effectiveness of complex public health interventions in the community? A health economics perspective.

Health economics is an evolving field. This article considers operationalising the complexities of interventions, evaluation processes and outcomes as well as why, despite various limitations in appraising effectiveness and cost-effectiveness in health economics, continuous improvement in the field remains the way forward.

Concerted action by multidisciplinary stakeholders: The development phase of a complex public health intervention in regards to adolescent self-harm

Self-harm has a strong prevalence within adolescent populations in Europe, and a potent relationship with suicide. In the UK, adolescent self-harm hospital admissions are rising each year. These statistics reflect the “tip of the iceberg”, with the majority of incidents hidden from public health networks. This invisibility creates barriers to: epidemiological information; the planning and evaluation of evidence-based support; health management within the complexity of adolescent self-harming behaviours to ensure recovery and healthy adolescent trajectories. It is also a serious health risk for this population group, and accidental death from self-harm is one of the common causes of injury-related adolescent death.Within the aforementioned context, this paper describes a UK county-wide complex public health intervention (2013 to 2015) in regards to adolescent self-harm, with concerted action by key stakeholders in health, child welfare, education and social science due to concerns about the increasing self-harm rate within the adolescent population group. As self-harm is a complex behaviour, and the evidence-base for effective interventions is sparse, the development of protective factors within education, health and social care environments were targeted. A synergy of theoretical models from neuroscience and social science informed the intervention's logic model. The intervention's development phase utilised the Medical Research Council's guidance on complex interventions to improve public health, which this paper will exposit.Disclosure of interestThe author has not supplied his/her declaration of competing interest.

The eSexual Health Clinic system for management, prevention, and control of sexually transmitted infections: exploratory studies in people testing for Chlamydia trachomatis

Self-directed and internet-based care are key elements of eHealth agendas. We developed a complex online clinical and public health intervention, the eSexual Health Clinic (eSHC), in which patients with genital chlamydia are diagnosed and medically managed via an automated online clinical consultation, leading to antibiotic collection from a pharmacy. Partner notification, health promotion, and capture of surveillance data are integral aspects of the eSHC. We aimed to assess the safety and feasibility of the eSHC as an alternative to routine care in non-randomised, exploratory proof-of-concept studies. Participants were untreated patients with chlamydia from genitourinary medicine clinics, untreated patients with chlamydia from six areas in England in the National Chlamydia Screening Programme's (NCSP) online postal testing service, or patients without chlamydia tested in the same six NCSP areas. All participants were aged 16 years or older. The primary outcome was the proportion of patients with chlamydia who consented to the online chlamydia pathway who then received appropriate clinical management either exclusively through online treatment or via a combination of online management and face-to-face care. We captured adverse treatment outcomes. Between July 21, 2014, and March 13, 2015, 2340 people used the eSHC. Of 197 eligible patients from genitourinary medicine clinics, 161 accessed results online. Of the 116 who consented to be included in the study, 112 (97%, 95% CI 91-99) received treatment, and 74 of those were treated exclusively online. Of the 146 eligible NCSP patients, 134 accessed their results online, and 105 consented to be included. 93 (89%, 95% CI 81-94) received treatment, and 60 were treated exclusively online. In both groups, median time to collection of treatment was within 1 day of receiving their diagnosis. 1776 (89%) of 1936 NCSP patients without chlamydia accessed results online. No adverse events were recorded. The eSHC is safe and feasible for management of patients with chlamydia, with preliminary evidence of similar treatment outcomes to those in traditional services. This innovative model could help to address growing clinical and public health needs. A definitive trial is needed to assess the efficacy, cost-effectiveness, and public health impact of this intervention. UK Clinical Research Collaboration.

Scaling up complex interventions: insights from a realist synthesis.

Preventing chronic diseases, such as cancer, cardiovascular disease and diabetes, requires complex interventions, involving multi-component and multi-level efforts that are tailored to the contexts in which they are delivered. Despite an increasing number of complex interventions in public health, many fail to be ‘scaled up’. This study aimed to increase understanding of how and under what conditions complex public health interventions may be scaled up to benefit more people and populations.A realist synthesis was conducted and discussed at an in-person workshop involving practitioners responsible for scaling up activities. Realist approaches view causality through the linkages between changes in contexts (C) that activate mechanisms (M), leading to specific outcomes (O) (CMO configurations). To focus this review, three cases of complex interventions that had been successfully scaled up were included: Vibrant Communities, Youth Build USA and Pathways to Education. A search strategy of published and grey literature related to each case was developed, involving searches of relevant databases and nominations from experts. Data extracted from included documents were classified according to CMO configurations within strategic themes. Findings were compared and contrasted with guidance from diffusion theory, and interpreted with knowledge users to identify practical implications and potential directions for future research.Four core mechanisms were identified, namely awareness, commitment, confidence and trust. These mechanisms were activated within two broad scaling up strategies, those of renewing and regenerating, and documenting success. Within each strategy, specific actions to change contexts included building partnerships, conducting evaluations, engaging political support and adapting funding models. These modified contexts triggered the identified mechanisms, leading to a range of scaling up outcomes, such as commitment of new communities, changes in relevant legislation, or agreements with new funding partners.This synthesis applies and advances theory, realist methods and the practice of scaling up complex interventions. Practitioners may benefit from a number of coordinated efforts, including conducting or commissioning evaluations at strategic moments, mobilising local and political support through relevant partnerships, and promoting ongoing knowledge exchange in peer learning networks. Action research studies guided by these findings, and studies on knowledge translation for realist syntheses are promising future directions.Electronic supplementary materialThe online version of this article (doi:10.1186/s12961-016-0158-4) contains supplementary material, which is available to authorized users.

5.E. Workshop: Complex public health interventions to increase Health Enhancing Physical Activity (HEPA)

5.E. Workshop: Complex public health interventions to increase Health Enhancing Physical Activity (HEPA)