A typology of practice narratives during the implementation of a preventive, community intervention trial

System Action Learning: Reorientating Practice for System Change in Preventive Health

It is now widely accepted that many of the problems we face in public health are complex, from chronic disease to COVID-19. To grapple with such complexity, researchers have turned to both complexity science and systems thinking to better understand the problems and their context. Less work, however, has focused on the nature of complex solutions, or intervention design, when tackling complex problems. This paper explores the nature of system intervention design through case illustrations of system action learning from a large systems level chronic disease prevention study in Australia. The research team worked with community partners in the design and implementation of a process of system action learning designed to reflect on existing initiatives and to reorient practice towards responses informed by system level insights and action. We were able to observe and document changes in the mental models and actions of practitioners and in doing so shine a light on what may be possible once we turn our attention to the nature and practice of system interventions.

Extending and adapting the concept of quality management for museums and cultural heritage attractions: A comparative study of southern European cultural heritage managers' perceptions

Quality in cultural heritage attractions is mainly approached from the visitors' satisfaction perspective, and the literature does not contain a clear definition of quality in the management of cultural heritage sites open to the public. The present study aims to reframe this trend. By way of theoretical contribution, we propose a definition of quality in cultural heritage attractions management based on dimensions such as the capacity of preserving the cultural assets, the ability to communicate effectively their significance, the quality of commodification for visitor use, and the ability to boost intercultural competence and promote intercultural dialogue. Based on the above, an empirical, qualitative study was conducted on the cultural heritage managers' current perceptions of quality. The results suggest that a profound asymmetry exists among practitioners' opinions and practices, and four types of cultural heritage managers were defined with regard to their perception of quality: Reactionary, Reticent, Pragmatic, Enthusiastic.

Will E-Monitoring of Policy and Program Implementation Stifle or Enhance Practice? How Would We Know?

Electronic or digital monitoring systems could promote the visibility of health promotion and disease prevention programs by providing new tools to support the collection, analysis, and reporting of data. In clinical settings however, the benefits of e-monitoring of service delivery remain contested. While there are some examples of e-monitoring systems improving patient outcomes, the smooth introduction into clinical practice has not occurred. Expected efficiencies have not been realized. The restructuring of team work has been problematic. Most particularly, knowledge from research has not advanced sufficiently because the meaning of e-monitoring has not been well theorized in the first place. As enthusiasm for e-monitoring in health promotion grows, it behooves us to ensure that health promotion practice learns from these insights. We outline the history of program monitoring in health promotion and the development of large-scale e-monitoring systems to track policy and program delivery. We interrogate how these technologies can be understood, noticing how they inevitably elevate some parts of practice over others. We suggest that progress in e-monitoring research and development could benefit from the insights and methods of improvement science (the science that underpins how practitioners attempt to solve problems and promote quality) as conceptually distinct from implementation science (the science of getting particular evidence-based programs into practice). To fully appreciate whether e-monitoring of program implementation will act as an aid or barrier to health promotion practice we canvass a wide range of theoretical perspectives. We illustrate how different theories draw attention to different aspects of the role of e-monitoring, and its impact on practice.

It's hard to play ball: A qualitative study of knowledge exchange and silo effects in public health

BACKGROUND

Partnerships in public health form an important component of commissioning and implementing services, in England and internationally. In this research, we examine the views of staff involved in a City-wide health improvement programme which ran from 2009 to 2013 in England. We examine the practicalities of partnership work in community settings, and we describe some of barriers faced when implementing a large, multi-organisation health improvement programme.

METHODS

Qualitative, semi-structured interviews were performed. Purposive sampling was used to identify potential participants in the programme: programme board of directors, programme and project managers and intervention managers. Interviews were conducted one-to-one. We conducted a thematic analysis using the 'one sheet of paper' technique. This involved analysing data deductively, moving from initial to axial coding, developing categories and then identifying emerging themes.

RESULTS

Fifteen interviews were completed. Three themes were identified. The first theme reflects how poor communication approaches hindered the ability of partnerships to deliver their aims and objectives in a range of ways and for a range of reasons. Our second theme reflects how a lack of appropriate knowledge exchange hindered decision-making, affected trust and contributed to protectionist approaches to working. This lack of shared, and communicated, understanding of what type of knowledge is most appropriate and in which circumstance made meaningful knowledge exchange challenging for decision-making and partnership-working in the City-wide health improvement programme. Theme three demonstrates how perceptions about silos in partnership-working could be problematic, but silos themselves were at times beneficial to partnerships. This revealed a mismatch between rhetoric and a realistic understanding of what components of the programme were functional and which were more hindrance than help.

DISCUSSION

There were high expectations placed on the concept of what partnership work was, or how it should be done. We found our themes to be interdependent, and reflective of the 'dynamic fluid process' discussed within the knowledge mobilisation literature. We contend that reframing normal and embedded processes of silos and silo-working already in use might ease resistance to some knowledge exchange processes and contribute to better long-term functioning of public health partnerships.

Comparison communities in a cluster randomised trial innovate in response to 'being controlled'

We conducted qualitative interviews among primary health care teams and community agencies in eight communities in Victoria, Australia which had (1) agreed to be part of a universal primary care and community development intervention to reduce post natal depression and promote maternal health; and (2) were randomised to the comparison arm. The purpose was to document their experience with and interpretation of the trial. Although 'control' in a controlled trial refers to the control of confounding of the trial result by factors other than allocation to the intervention, participants interpreted 'control' to mean restrictions on what they were allowed to do during the trial period. They had agreed not to use the Edinburgh Post Natal Depression Scale or the SF 36 in clinical practice and not to implement any of the elements of the intervention. We found that no elements of the intervention were implemented. However, the extension of the trial from three to five years made the trial agreement a strain. The imposition of trial conditions also encouraged a degree of lateral thinking and innovation in service delivery (quality improvement). This may have potentially contributed to the null trial results. The observations invite interrogation of intervention theory and consequent rethinking of the way contamination in a cluster trial is defined.

Lessons from complex interventions to improve health

Complexity-resulting from interactions among many component parts-is a property of both the intervention and the context (or system) into which it is placed. Complexity increases the unpredictability of effects. Complexity invites new approaches to logic modeling, definitions of integrity and means of standardization, and evaluation. New metaphors and terminology are needed to capture the recognition that knowledge generation comes from the hands of practitioners/implementers as much as it comes from those usually playing the role of intervention researcher. Failure to acknowledge this may blind us to the very mechanisms we seek to understand. Researchers in clinical settings are documenting health improvement gains made as a consequence of complex systems thinking. Improvement science in clinical settings has much to offer researchers in population health.

The adaptive nature of implementation practice: case study of a school-based nutrition education intervention

OBJECTIVE

To describe how and why nutritionists implement and strategize particular program operations across school contexts.

DESIGN

Instrumental case study with empirical propositions from Actor-Network Theory (ANT). Data derived from interviews with interventionists and observations of their practices.

SETTING

Seven primary schools from disadvantaged Montreal neighborhoods.

PARTICIPANTS

Six nutritionists implementing the nutrition intervention in grades 4 and 5. From 133 nutrition workshops held in 2005/06, 31 workshops were observed with audio-recordings.

INTERVENTION(S)

Little Cooks--Parental Networks aims to promote healthy eating behaviors through engagement in food preparation and promotion of nutrition knowledge.

PHENOMENON OF INTEREST

The program-context interface where interventionists' practices form interactively within a given social context.

ANALYSIS

Coding inspired by ANT. Interview analysis involved construction of collective implementation strategies. Observations and audio-recordings were used to qualify and quantify nutritionists' practices against variations in implementation.

RESULTS

Nutritionists privileged intervention strategies according to particularities of the setting. Some such variation was accounted for by school-level social conditions, individual preferences and nutritionists' past experiences.

CONCLUSIONS AND IMPLICATIONS

Implementation practices are strategic and aim to engage educational actors to achieve intervention goals. These results challenge implementation frameworks centered on purely technical considerations that exclude the social and interpretive nature of practice.