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Development of an evidence-based complex intervention for community rehabilitation of patients with hip fracture using realist review, survey and focus groups
  1. Jessica Louise Roberts1,
  2. Nafees Ud Din1,
  3. Michelle Williams1,
  4. Claire A Hawkes2,
  5. Joanna M Charles1,
  6. Zoe Hoare1,
  7. Val Morrison3,
  8. Swapna Alexander4,
  9. Andrew Lemmey5,
  10. Catherine Sackley6,
  11. Phillipa Logan7,
  12. Clare Wilkinson1,
  13. Jo Rycroft-Malone1,
  14. Nefyn H Williams1,4
  1. 1 School of Healthcare Sciences, Bangor University, Bangor, Gwynedd, UK
  2. 2 Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
  3. 3 School of Psychology, Bangor University, Bangor, Gwynedd, UK
  4. 4 Betsi Cadwaladr University Health Board, Bangor, Gwynedd, UK
  5. 5 School of Sports, Health and Exercise Science, Bangor University, Bangor, Gwynedd, UK
  6. 6 Division of Health and Social Care Research, King’s College, London, UK
  7. 7 School of Medicine, University of Nottingham, Nottingham, UK
  1. Correspondence to Dr Jessica Louise Roberts; j.l.roberts{at}


Objectives To develop an evidence and theory-based complex intervention for improving outcomes in elderly patients following hip fracture.

Design Complex-intervention development (Medical Research Council (MRC) framework phase I) using realist literature review, surveys and focus groups of patients and rehabilitation teams.

Setting North Wales.

Participants Surveys of therapy managers (n=13), community and hospital-based physiotherapists (n=129) and occupational therapists (n=68) throughout the UK. Focus groups with patients (n=13), their carers (n=4) and members of the multidisciplinary rehabilitation teams in North Wales (n=13).

Results The realist review provided understanding of how rehabilitation interventions work in the real-world context and three programme theories were developed: improving patient engagement by tailoring the intervention to individual needs; reducing fear of falling and improving self-efficacy to exercise and perform activities of daily living; and coordination of rehabilitation delivery. The survey provided context about usual rehabilitation practice; focus groups provided data on the experience, acceptability and feasibility of rehabilitation interventions. An intervention to enhance usual rehabilitation was developed to target these theory areas comprising: a physical component consisting of six additional therapy sessions; and a psychological component consisting of a workbook to enhance self-efficacy and a patient-held goal-setting diary for self-monitoring.

Conclusions A realist approach may have advantages in the development of evidence-based interventions and can be used in conjunction with other established methods to contribute to the development of potentially more effective interventions. A rehabilitation intervention was developed which can be tested in a future randomised controlled trial (MRC framework phases II and III).

Trial registration number ISRCTN22464643, Pre-results.

  • hip
  • realist review
  • survey
  • focus groups
  • intervention development
  • rehabilitation medicine

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  • Contributors NHW: Chief investigator (CI) responsible for study design, conduct and analysis, led intervention development, led writing of manuscript and is the guarantor; JLR: conducted focus group analysis and contributed to survey analysis, led writing of manuscript, development of intervention materials; NUD: conducted realist review, contributed to writing of manuscript; MW: conducted survey analysis, contributed to writing of manuscript; CAH: trial management, input to study and survey design, oversight of intervention development, conducted focus groups and survey, initial focus group analysis; JMC: assisted with realist review; ZH: input to study design, design of survey and initial survey analysis; VM: Co-investigator (Co-I) responsible for study design, provided health psychology expertise and methodological oversight; SA: Co-I, consultant orthogeriatrician, provided orthogeriatric expertise and input on intervention design; AL: Co-I responsible for study design, provided methodological oversight; CS and PL: Co-I contributing to methodology and study design, provided physiotherapy and rehabilitation expertise and input on intervention design; CW: Co-I contributing to study design and methodology; JRM: Co-I providing realist review expertise and methodological input. All authors were involved in writing and reviewing of the manuscript and decisions on final content.

  • Funding This research was funded by the Health Technology Assessment (HTA) programme of the National Institute for Health Research (NIHR) (HTA reference 11/33/03). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HTA programme, NIHR, the National Health Service, or the Department of Health.

  • Competing interests None declared.

  • Ethics approval NHS North Wales Research Ethics Committee (West Ref 12/WA/0355).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The data sets generated and analysed during the current study are available from the corresponding author on reasonable request.

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