Revisiting context: Implications for population health intervention research

Size: px

Start display at page:

Download "Revisiting context: Implications for population health intervention research"

Mark Booth
3 years ago
Views:

Who were the health experts who designed the Classic RCT?
Where is Nancy Edwards employed?
What did the researchers find was a major problem with context?

1 Revisiting context: Implications for population health intervention research Nancy Edwards, RN, PhD CHSRF/CIHR Nursing Chair Professor, School of Nursing and Department of Epidemiology and Community Medicine University of Ottawa Scientific Director, CIHR Institute of Population and Public Health

2 Outline Acknowledgements Dimensions of context Implications for knowledge synthesis and intervention research

3 Acknowledgements Colleagues who participated in the invitational symposium on Multiple Interventions and Context (2007) (Funded by CHSRF/CIHR Chair award and PHAC) Multiple interventions communities of practice group Kathryn Clinton (co-author of working paper on context prepared for PHAC) Community Health Research Unit (Funded by Ontario Ministry of Health and Long-term Care)

4 Dimensions of Context

5 Recognizing context Researcher s Context: Disciplinary roots and traditions Methodological and theoretical familiarity Prevailing values and priorities (historical and contemporary) Why do you study what you do in the way you do it?

6 Disciplinary Treatment of Context (Edwards & Clinton, PHAC Context Background Paper, 2008) harness context as a critical element of intervention strategies (e.g., organizational psychology, political science) acknowledge influence of context with focus on proximal contexts (e.g., behavioural and child psychology) treat context as a confounder or nuisance variable (e.g., epidemiology)

7 Approaching context: The epidemiological tradition Burden of illness emphasis on proximal determinants SES gradient Intervention research control contamination and co-interventions describe study setting Scaling-up and sustainability external generalizability Knowledge synthesis focus on active ingredients, intervention fidelity

8 Tackling Health Inequities Through Public Health Practice: A Handbook for Action (2006) Epidemiology s theoretical paradigms, driven by the biomedical sciences and often choosing not to question the values that shape its perspectives, have downplayed the historical conditions and social context that make populations vulnerable, including ecology, class, and racism (p. 21)

9 Determinants of Health Source: Dahlgren and Whitehead (1991)

10 Socioecological Framework A distal determinant does not mean an unimportant determinant (Krieger, AJPH, 2008) Determinants are nested and inter-relationships are dynamic Inequities cannot be understood in isolation of their policy and political contexts Data on health gradients have the potential to obscure the structures of disadvantage. (NACCO, p. 21)

11 Classic RCT Designed by research and community health experts Pre-packaged with stipulated markers of fidelity Serious time constraints for implementation with consequent focus on proximal determinants

12 Vexing Results from Well-Designed Multiple Intervention Studies Lack of community engagement in all project phases (including design) Short time frame for implementation Constraints of standardized interventions A focus on attribution constrains design of intervention protocols Focus on behaviour change rather than systems change (e.g. policy) Failures to attend to and leverage dynamic contexts

13 Implementation Context (Greenhalgh, Robert & Bate, 2004) Inner program context - proximal Outer program context - distal

14 Inner Program Context Program parameters Funding requirements and constraints Capacity to deliver intervention Competing priorities among those responsible for program implementation Leadership and champions Organizational mandates and change processes Results-based management, accountability

15 Outer Program Context Community readiness Community leadership Social structures and disparities Existing infrastructure (built environment, legislation) Buy-in, strengths and working relationships among partner organizations Policy directions, policy windows Political ideologies

16 Interventions are products of their context (Pawson, 2006) Contextual layers: individual capacities of key actors interpersonal relationships supporting the intervention institutional setting wider infrastructure system Interventions are continually affected by the interaction of these different layers (p. 31).

17 What produces change? It is not programs that make things change, it is people, embedded in their context who, when exposed to programs, do something to activate given mechanisms, and change (Pawson & Tilley, 1997)

18 An intimate knowledge of context and dominant forms of knowledge The Long Exile by Melanie McGrath Forced relocation of Inuit People in 1953 All manner of people were consulted about what to do with the Inuit except the Inuit people themselves. But the culture of the Inuit and their way of living was finely-tuned to the terrain.. In order to hunt on the land, you have to know the land and the Inuit did not know the land where they were relocated.

19 People s Republic of China Beijing Yunnan Maternal & Child Health Project, Yunnan Province, China

20 Yunnan Maternal and Child Health Project Purpose: To improve the quality of village life and promote the development of productivity and social prosperity in poor ethnic minority counties in Yunnan Province Participatory training for grassroots workers Essential MCH equipment Strengthen MCH referral mechanisms Participatory monitoring and evaluation

21 Threats to Project Sustainability (Edwards & Roelofs, CJPH, 2006) Uneven support for the training innovation across system levels Work unit leaders expressed doubt about the utility and appropriateness of participatory approaches for village health workers Supervisory approaches mirrored the authoritative and didactic approaches to training that were standard practice Significant national reforms increased work demands and threatened job security

22 Context (Edwards & Clinton, 2008) Knowledge of context is deeply intimate Multi-level Dynamic rather than static Pervasive - relevant context is not defined by scope of program Contemporary and historical

23 Knowledge Synthesis Techniques and Policy Pathways The Public Health Regime (Asathan & Halliday, Millbank Quarterly, 2006) Public health regime specific legislative, social, political and economic structures that have an impact on public health & the appropriateness and effectiveness of interventions adopted Decontextualized systematic reviews Some interventions work for certain conditions and in certain contexts but not in others conditionally successful (Pawson & Tilley, 1997)

24 Systematic reviews synthesis tools (Armstrong, Waters et al., 2008; Edwards & Clinton, 2008) RCTs generally strip away context Analysis of context cannot exceed descriptions of context provided in primary research papers Settings - most common description of context in systematic reviews (from analysis of >25 Cochrane reviews)

25 An Illustration Environmental hazards and falls prevention (Edwards & Benjamin) Review of >60 international studies examining relationship between environmental hazards and falls among elderly No studies included any reference to the policy context of building codes

26 Implications for methods Knowledge synthesis Intervention research

27 Addressing Context: Additional Requirements for Structured Abstracts? What was the contextual readiness for the intervention and how was this assessed? What were the contextual eligibility criteria that guided sample selection? What were the dynamic features of context and how were these monitored and/or leveraged during the implementation period?

28 Intervention Research: Mixed Methods Paradigmatic and philosophical tensions Mixed research designs Mixed data collection methods But a weak link mixed methods analysis and interpretation

29 Looking back and looking forward: Intervention research Emphasis to date: Fidelity of intervention Standardized protocols Control co-intervention, reduce contamination Attribution what active ingredient(s) yield a particular effect? Future emphasis: Responsive to community & to participants (contextual fit) Adaptation of intervention to dynamic context and to feedback processes (contextual adaptation) Longer-term spin-offs, scaling-up, sustainability (contextual uptake)

30 Expand our lexicon of intervention studies Questions of attribution: Efficacy Effectiveness Efficiency Questions of adaptation: Contextual fit Contextual adaptation Contextual uptake

31 What can be learned about context? MIP trial +ve MIP trial ve Pop health changes +ve Pop health changes -ve

32 Discrepant Findings: Opportunities to understand context +ve pop health program, -ve MIP trial Temporal and dynamic contextual fit Leveraging context (context an active ingredient) Synergistic action with long-term investment -ve pop health program, +ve MIP trial Barriers to scaling-up (community readiness, infrastructure & policy support) Need for cultural or contextual adaptation as intervention is scaled up

33 Context Queries Intervention design: How would those who intimately know the context(s) advise us to adapt the intervention? What elements of the intervention can or should be adapted for a dynamic context? Evaluation: What is the interface between the inner and the outer context and the intervention? How has context shaped the intervention? How was the intervention adapted to the context?

34 Context Queries Is the intervention and/or the context the active ingredient? What assumptions are we making about the context for intervention implementation? What contextual conditions are necessary for: Authentic community engagement Program implementation Sustainability Scaling-up

35 Take home messages Enhance examination of context (historical, contemporary, structural) in study of population health interventions Generate substantive propositions regarding contextual influences on population health interventions Query context as part of knowledge synthesis techniques (context impact assessment)

SCO Health Service and the Institute on Health of the Elderly. Post Graduate Nursing Research Fellowship in Gerontology

SCO Health Service and the Institute on Health of the Elderly Post Graduate Nursing Research Fellowship in Gerontology August 2002 1. Introduction Advanced nursing practice (ANP) is a term that describes

Revisiting context: Implications for population health intervention research

Who were the health experts who designed the Classic RCT?

Where is Nancy Edwards employed?

What did the researchers find was a major problem with context?