Implementation, context and complexity
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Implementation, context and complexity Carl R. May1,2,3*, Mark Johnson2,4 and Tracy Finch5
Abstract Background: Context is a problem in research on health behaviour change, knowledge translation, practice implementation and health improvement. This is because many intervention and evaluation designs seek to eliminate contextual confounders, when these represent the normal conditions into which interventions must be integrated if they are to be workable in practice. Discussion: We present an ecological model of the ways that participants in implementation and health improvement processes interact with contexts. The paper addresses the problem of context as it affects processes of implementation, scaling up and diffusion of interventions. We extend our earlier work to develop Normalisation Process Theory and show how these processes involve interactions between mechanisms of resource mobilisation, collective action and negotiations with context. These mechanisms are adaptive. They contribute to self-organisation in complex adaptive systems. Conclusion: Implementation includes the translational efforts that take healthcare interventions beyond the closed systems of evaluation studies into the open systems of ‘real world’ contexts. The outcome of these processes depends on interactions and negotiations between their participants and contexts. In these negotiations, the plasticity of intervention components, the degree of participants’ discretion over resource mobilisation and actors’ contributions, and the elasticity of contexts, all play important parts. Understanding these processes in terms of feedback loops, adaptive mechanisms and the practical compromises that stem from them enables us to see the mechanisms specified by NPT as core elements of self-organisation in complex systems.
Background Context is a problem for implementation science. Researchers in the field have sought to identify, characterise and explain the mechanisms implicated in individual behaviour change and collective action for many years. They have sought to develop theoretical models and empirical research instruments, as well as practical toolkits that foster the implementation of innovations in practice. Against this background, context is an important practical problem for complex intervention and implementation trials. These are driven by a model of research that aims to show the operation of causal mechanisms, eliminate confounders and measure outcomes. The conceptual division between an intervention and its environment that is an inevitable consequence of trial design means that contexts are often framed as
* Correspondence: [email protected] 1 Faculty of Health Sciences, University of Southampton, Building 67 (Nightingale), University Road, Highfield, Southampton SO17 1BJ, UK 2 University Hospital Southampton NHS Foundation Trust, Southampton, UK Full list of author information is available at the end of the article
sources of obduracy and interference with the smooth delivery of the trial. Attempts to understa
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