It’s more complicated than that

Abstract

In this commentary the findings from a systematic review that concluded there is no compelling evidence to suggest that implementing complicated, multi-faceted interventions is more effective than simple, single component interventions to changing healthcare professional’s behaviour are considered through the lens of Harvey and Kitson’s editorial. Whilst an appealing conclusion, it is one that hides a myriad of complexities. These include issues concerning how best to tailor interventions and how best to evaluate such efforts. These are complex issues that do not have simple solutions.

Finding ways to successfully bridge the gap between research and practice has taken up a lot of resource and energy. Therefore, any signal that this task might be made simpler would be music to many people’s ears! I suspect however, as the authors of this editorial indicate, it is more complicated than that (1).

The authors raise some interesting questions in the context of the findings of a review of reviews, which concludes that we may be wasting valuable resources on designing and developing multi-faceted strategies to overcome implementation challenges when single, more straight forward ones may be just as effective and cheaper (2). Inspired by the author’s own work in developing the Promoting Action on Research Implementation in Health Services framework (PARIHS) (3–5) and by drawing on relevant theory from outside of healthcare – they point out that the answer to many of the questions about whether multi-faceted or single interventions are more likely to work will be: ‘it depends’.

First, it is worth reflecting on the review which prompted their response (2).

This review was conducted in a systematic and robust way, including the use of carefully applied inclusion criteria and by undertaking methodologically sound analyses and synthesis. However, the results of any review are always going to be dependent on the characteristics of the evidence that feeds it. What we do not know from the evidence presented (because this is a review of reviews and it was not one of the authors’ questions), is the process by which decisions were made about which interventions to use and why, within the individual studies included in the reviews. Therefore, we do not know whether there was something about the way in which interventions were designed and delivered that may have contributed to the results of the studies that eventually made their way into a systematic review. Additionally at each stage of a review, study findings get aggregated such that detail is lost and findings become general. The point here is that decisions about how to design and implement an intervention are going to be critical to the outcome of implementation efforts and these are missing. Furthermore, it has been suggested that often an assessment of barriers and enablers leads to the design and implementation of multi-faceted interventions being the next logical step (2). But, is that necessarily the case? This is the nub of Harvey and Kitson’s argument – an assessment of  the situation in the planning of implementation will likely surface some simple challenges that require simple solutions, but also potentially more complex challenges that inevitably require more involved and yes, more multi-faceted, approaches (1).

The critical issue then is ensuring an appropriate assessment in the planning stages of implementation followed by appropriately designed interventions tailored or particularised to that assessment. Whilst findings from a systematic review indicate that interventions that are prospectively tailored have the potential to change professional practice (6), the evidence base falls short on detail about how to tailor interventions to people, context and evidence. Applying boundary theory (7), the authors offer one theoretical lens through which deliberate and a more tailored approach could be managed. This is why theory is important and has a critical role to play in plugging these sorts of evidence gaps and offering fresh insights into persistent challenges. Other frameworks that might prove useful in making an assessment of ‘what needs to be done’ and have been used frequently used within a healthcare context include PARIHS itself (3–5), the Knowledge to Action Cycle (8) and the consolidated framework (9). As such, the ‘transfer-translate-transformation solution’ proposed by Harvey and Kitson (1) might be prefaced by ‘assess-particularise-design’.

The authors also suggest one mechanism – facilitation – through which these processes might be managed and enabled. Embedded as a core element of the PARIHS framework, facilitation offers opportunities, but also challenges. Facilitation is in itself a complex intervention in that it is usually enacted by a person who engages in activities and processes with individuals, groups and organisations in a flexible way (10). As such, there is a potent mix of mechanisms of action at play in facilitation, i.e. it is in itself a multi-faceted implementation strategy. This complexity raises some important issues about the evaluation of implementation strategies such as facilitation. Arguably approaches to evaluation require development and greater attention to issues of theory and more sophisticated methods that better unpack interactions and complexities. Being able to tap into the active ingredients of an intervention like facilitation requires attention to detail about the who, why, what and how of intervention design and delivery. Further, evaluation approaches need to be able to accommodate the likely ‘learning effects’ that come from implementing a complex intervention that aims to improve practice and/or service delivery in the reality of the practice context (11).

Knowledge translation is complex but there might be simple solutions to some implementation challenges. A ‘kitchen sink’ approach to intervention implementation where a number of different approaches are thrown together in the hope that something works, is unlikely to be helpful and will be a potential waste of resource. What is critical is to ensure the right solution is chosen to target a particular challenge or set of challenges. Harvey and Kitson offer us some insights into how this might be achieved and as such they helpfully remind us that we should not be implementing strategies that are more complicated than they need to be. A challenge to us all however is in better crafting and articulating our approaches to intervention development, design, implementation and evaluation. We may then be able to undertake systematic reviews that enable the development of conclusions that provide clearer answers to whether we should rely on single or multi-faceted approaches, in what circumstances, how and to what effect. However, this will also require us to reflect more judiciously on our approach to evidence review. If we want to gain a deeper, context relevant understanding of how interventions are implemented and how they work (or not), it is unlikely that a review of reviews will give us those answers. More context sensitive approaches such as realist reviews and meta-ethnographies although more challenging to conduct, might be more fruitful and provide more useful evidence of what works, in what contexts.

Ethical issues

Not applicable.

Competing interests

The author of this commentary and the authors of the editorial have worked together in the past.

Author’s contribution

JRM is the single author of the manuscript.

Citation: Rycroft-Malone J. It’s more complicated than that: Comment on "Translating evidence into healthcare policy and practice: single versus multi-faceted implementation strategies – is there a simple answer to a complex question?" Int J Health Policy Manag. 2015;4(7):481–482. doi:10.15171/ijhpm.2015.67