Open Access Highly Accessed Research article

Developing social capital in implementing a complex intervention: a process evaluation of the early implementation of a suicide prevention intervention in four European countries

Fiona M Harris1*, Margaret Maxwell1, Rory C O’Connor2, James Coyne3, Ella Arensman4, András Székely5, Ricardo Gusmão6, Claire Coffey4, Susana Costa6, Zoltan Cserháti5, Nicole Koburger7, Chantal van Audenhove8, David McDaid9, Julia Maloney10, Peeter Värnik11 and Ulrich Hegerl7

Author Affiliations

1 Nursing, Midwifery and Allied Health Professions Research Unit, Iris Murdoch Building, University of Stirling, FK9 4LA, Stirling, UK

2 Suicidal Behaviour Research Laboratory, School of Natural Sciences, University of Stirling, FK9 4LA, Stirling, UK

3 Department of Psychiatry, University of Pennsylvania School of Medicine, 3535 Market Street, 6th Floor, 19104, Philadelphia, PA, USA

4 National Suicide Research Foundation, 1 Perrott Avenue, College Road, Cork, Ireland

5 Institute of Behavioural Sciences, Semmelweis University Budapest, Nagyvárad tér 4, 1089, Budapest, Hungary

6 CEDOC, Departamento de Saúde Mental, Faculdade de Ciências Médicas da Universidade Nova de Lisboa, 1169-056, Lisbon, Portugal

7 Klinik und Poliklinik für Psychiatrie und Psychotherapie, Universitätsklinikum Leipzig AöR, Semmelweisstraße 10, 04103, Leipzig, Germany

8 LUCAS, Katholieke Universiteit Leuven, Kapucijnenvoer 39 - bus 5310, 3000, Leuven, Belgium

9 Personal Social Services Research Unit, London School of Economics and Political Science, Houghton Street, WC2A 2AE, London, UK

10 Klinik und Poliklinik für Psychiatrie, Psychosomatik und Psychotherapie der Universität Würzburg, Füchsleinstraße 15, 97080, Würzburg, Germany

11 Estonian-Swedish Mental Health and Suicidology Institute, Õie 39, 11615, Tallinn, Estonia

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BMC Public Health 2013, 13:158  doi:10.1186/1471-2458-13-158

Published: 20 February 2013



Variation in the implementation of complex multilevel interventions can impact on their delivery and outcomes. Few suicide prevention interventions, especially multilevel interventions, have included evaluation of both the process of implementation as well as outcomes. Such evaluation is essential for the replication of interventions, for interpreting and understanding outcomes, and for improving implementation science. This paper reports on a process evaluation of the early implementation stage of an optimised suicide prevention programme (OSPI-Europe) implemented in four European countries.


The process analysis was conducted within the framework of a realist evaluation methodology, and involved case studies of the process of implementation in four European countries. Datasets include: repeated questionnaires to track progress of implementation including delivery of individual activities and their intensity; serial interviews and focus groups with stakeholder groups; and detailed observations at OSPI implementation team meetings.


Analysis of local contexts in each of the four countries revealed that the advisory group was a key mechanism that had a substantial impact on the ease of implementation of OSPI interventions, particularly on their ability to recruit to training interventions. However, simply recruiting representatives of key organisations into an advisory group is not sufficient to achieve impact on the delivery of interventions. In order to maximise the potential of high level ‘gatekeepers’, it is necessary to first transform them into OSPI stakeholders. Motivations for OSPI participation as a stakeholder included: personal affinity with the shared goals and target groups within OSPI; the complementary and participatory nature of OSPI that adds value to pre-existing suicide prevention initiatives; and reciprocal reward for participants through access to the extended network capacity that organisations could accrue for themselves and their organisations from participation in OSPI.


Exploring the role of advisory groups and the meaning of participation for these participants revealed some key areas for best practice in implementation: careful planning of the composition of the advisory group to access target groups; the importance of establishing common goals; the importance of acknowledging and complementing existing experience and activity; and facilitating an equivalence of benefit from network participation.

Complex interventions; Process evaluation; Suicide prevention; Realist evaluation; Social capital; Advisory groups