Penelope Hawe

Complex interventions: how “out of control” can a randomised controlled trial be?

Complex interventions are more than the sum of their parts, and interventions need to be better theorised to reflect this nnMany people think that standardisation and randomised controlled trials go hand in hand. Having an intervention look the same as possible in different places is thought to be paramount. But this may be why some community interventions have had weak effects. We propose a radical departure from the way large scale interventions are typically conceptualised. This could liberate interventions to be responsive to local context and potentially more effective while still allowing meaningful evaluation in controlled designs. The key lies in looking past the simple elements of a system to embrace complex system functions and processes.nnThe suitability of cluster randomised trials for evaluating interventions directed at whole communities or organisations remains vexed.1 It need not be.2 Some health promotion advocates (including the WHO European working group on health promotion evaluation) believe randomised controlled trials are inappropriate because of the perceived requirement for interventions in different sites to be standardised or look the same.1 3 4 They have abandoned randomised trials because they think context level adaptation, which is essential for interventions to work, is precluded by trial designs. An example of context level adaptation might be adjusting educational materials to suit various local learning styles and literacy levels.nnLead thinkers in complex interventions, such as the UKs Medical Research Council, also think that trials of complex interventions must “consistently provide as close to the same intervention as possible” by “standardising the content and delivery of the intervention.”5 By contrast, however, they do not see this as a reason to reject randomised controlled trials.nnThese divergent views have led to problems on two fronts. Firstly, the field of health promotion is being turned away from randomised …

Multiplying Health Gains: the critical role of capacity-building within health promotion programs

Health outcomes in populations are the product of three factors: (1) the size of effect of the intervention; (2) the reach or penetration of an intervention into a population and (3) the sustainability of the effect. The last factor is crucial. In recent years, many health promotion workers have moved the focus of their efforts away from the immediate population group or environment of interest towards making other health workers and other organisations responsible for, and more capable of, conducting health promotion programs, maintaining those programs and initiating others. Capacity-building by health promotion workers to enhance the capacity of the system to prolong and multiply health effects thus represents a value added dimension to the health outcomes offered by any particular health promotion program. The value of this activity will become apparent in the long term, with methods to detect multiple types of health outcomes. But in the short term its value will be difficult to assess unless we devise specific measures to detect it. At present the term capacity-building is conceptualised and assessed in different ways in the health promotion literature. Development of reliable indicators of capacity-building which could be used both in program planning and in program evaluation will need to take this into account. Such work will provide health-decision makers with information about program potential at the conclusion of the funding period, which could be factored into resource allocation decisions, in addition to the usual information about a programs impact on health outcomes. By program potential, we mean ability to reap greater and wider health gains.

A glossary of terms for navigating the field of social network analysis

Social network analysis is the study of social structure. This glossary introduces basic concepts in social network analysis. It is designed to help researchers to be more discriminating in their thinking and choice of methods.

A simple guide to chaos and complexity

The concepts of complexity and chaos are being invoked with increasing frequency in the health sciences literature. However, the concepts underpinning these concepts are foreign to many health scientists and there is some looseness in how they have been translated from their origins in mathematics and physics, which is leading to confusion and error in their application. Nonetheless, used carefully, “complexity science” has the potential to invigorate many areas of health science and may lead to important practical outcomes; but if it is to do so, we need the discipline that comes from a proper and responsible usage of its concepts. Hopefully, this glossary will go some way towards achieving that objective.

The Privileging of Communitarian Ideas: Citation Practices and the Translation of Social Capital Into Public Health Research

The growing use of social science constructs in public health invites reflection on how public health researchers translate, that is, appropriate and reshape, constructs from the social sciences. To assess how 1 recently popular construct has been translated into public health research, we conducted a citation network and content analysis of public health articles on the topic of social capital. The analyses document empirically how public health researchers have privileged communitarian definitions of social capital and marginalized network definitions in their citation practices. Such practices limit the way public health researchers measure social capitals effects on health. The application of social science constructs requires that public health scholars be sensitive to how their own citation habits shape research and knowledge.

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.

Lost in translation: a genealogy of the “social capital” concept in public health

Study objective: To examine the genealogy of the social capital concept in public health, with attention to the epistemological concerns and academic practices that shaped the way in which this concept was translated into public health. Design: A citation-network path analysis of the public health literature on social capital was used to generate a genealogy of the social capital concept in public health. The analysis identifies the intellectual sources, influential texts, and developments in the conceptualisation of social capital in public health. Participants: The population of 227 texts (articles, books, reports) was selected in two phases. Phase 1 texts were articles in the PubMed database with “social capital” in their title published before 2003 (nu200a=u200a65). Phase 2 texts are those texts cited more than once by phase 1 articles (nu200a=u200a165). Main results: The analysis shows how the scholarship of Robert Putnam has been absorbed into public health research, how three seminal texts appearing in 1996 and 1997 helped shape the communitarian form that the social capital concept has assumed in public health, and how both were influenced by the epistemological context of social epidemiology at the time. Conclusions: Originally viewed in public health research as an ecological level, psychosocial mechanism that might mediate the income inequality-health pathway, the dominance of the communitarian approach to social capital has given disproportionate attention to normative and associational properties of places. Network approaches to social capital were lost in this translation. Recovering them is key to a full translation and conceptualisation of social capital in public health.

The need for a complex systems model of evidence for public health

This work was funded by a grant from The Health Foundation (London, UK) that supported HR, KG, and NS. HR was also supported by the UK National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) North Thames at Barts Health NHS Trust. LM is supported by the UK Medical Research Council ( MC_UU_12017/14 ) and the Chief Scientist Office ( SPHSU14 ). MW is funded in part by the UK NIHR as Director of its Public Health Research Programme.

Are preferences over health states complete

Most applied work in health economics accepts, if only implicitly, the axiom of completeness. Preferences over health states or health services are assumed to be well formed. They are effectively data waiting to be collected. An alternative perspective suggests that values are initially incomplete and are constructed rather than just revealed in the process of answering choice-related questions such as willingness to pay or standard gambles. What might appear as measurement error may, therefore, be a more deliberate process of reflection and deliberation. This paper reports on a study that assessed the completeness of health preferences. The results show a mixed pattern. For most of the sample, values were stable over repeat administration, suggesting completeness. However, one-third of participants deliberately changed their answers and suggested that the interview process had forced them to think about their values more deeply. While it is premature to draw conclusions from this small sample, the suggestion is that completeness cannot be taken for granted.

Focus group composition: a comparison between natural and constructed groups

Objective: To provide insight into the effects of focus group composition.