school-based health interventions, the reductionist approach of intervention design, implementation and evaluation has limited the progression of knowledge within this field. Intervention components are often viewed as ‘add-ons’ whereby they are designed in isolation from context and therefore conducted on a school, not integrated into the school system. Interventions are often under-theorised and researchers regularly neglect to theorise how interventions will engage with and adapt to differing systems (Hawe, 2015; Moore et al., 2015a). This has perhaps, to some extent, been perpetuated by a tendency for researchers to select off-the-shelf theories, which often focus only on individual level processes, even where the aim is to achieve change at organisational levels. In a recent review of effects of school- based interventions on health inequalities for example, the minority of studies which cited a theoretical framework almost exclusively drew on theories from health psychology (Moore et al., 2015b).
While much attention is often paid to intervention “theories of change”, in terms of how actions are anticipated to impact student health, if implemented as intended (Moore et al., 2015a), there is typically little attention to system level theories of change in school health research (Moore et al., 2015b). Thus, interventions utilising such theoretical standpoints in their design, are unlikely to have a significant effect on school system functioning as the process of achieving system change is under-
27 theorised and, subsequently, student outcomes. In fact, alongside inadequate
methods and involvement of communities, impotent theory has been identified as a potential reason for the current problem of elicitation of negligible or no effects within public health interventions (Zaza, Briss & Harris, 2005). This demonstrates the need for research targeting school health improvement to focus on system-level change.
Models such as the Theory of Planned behaviour (TPB) (Ajzen, 1985) have been widely used in school health interventions, despite their individualistic focus. This has been reinforced by the MRC guidance for developing and evaluating complex interventions, which advises that a behavioural scientist should be involved in implementation studies (Craig et al., 2008). Glanz and Bishop (2010) reviewed the role of behaviour change theories in both the development and implementation of public health interventions finding that the TPB, the Social Cognitive Theory, the Transtheoretical Model, the Health Belief Model and the PRECEDE/PROCEED model were the most frequently employed theories, highlighting the neglect of system-level constraints within intervention design (Grimshaw et al., 2014). This suggests a need to identify theories that address structure and agency issues and their potential utility in understanding school contexts and implementation processes.
2.5.1 Structure and agency-based theory
Social network theories
Social networks among humans are one way of measuring both structure and agency, and are characterised by cliques of similar individuals (Newman & Park, 2003). While the formation of cliques may be problematic when these represent clusters of insular, homogenous groups with limited communication between them, cliques can serve a functional purpose where sufficient brokerage exists between them, for example when they are connected through weak ties (Granovetter, 1973). Brokers are defined as actors who inhabit a bridging position within a network which allows them to send and receive information or other resources between otherwise
28 Structural Hole theory describes alters, or the individual members nominated as part of a network (Burt, 1984), playing a brokerage role to fill structural holes between cliques, where distinct information is held (Burt, 1992). Individuals in brokerage roles may be more likely to have their ideas listened to and actioned (Burt, 2004a). Burt (2004a) posits that brokerage can facilitate the development of social capital and good ideas through allowing individuals in brokerage positions to experience alternative views and behaviour.
Whilst the above social network theories provide insight into relational contexts between actors, they do not tend to provide a full insight into the structures and contexts within which these interactions occur. One example of the use of social network analysis in health research comes from Provan and Millward (1995) who used a cross-sectional design to compare the effectiveness, density and centrality of inter-organisational systems of mental health primary care in the US. A mixture of quantitative and qualitative methods demonstrated that system effectiveness varied according to network structure and context (Provan & Milward, 1995). Furthermore, this may help to theorise the interactive relationship between structure and agency, which will be elaborated upon within the next section.
Diffusion of Innovations
Diffusion can be defined as the process by which an innovation or new idea spreads via certain communication channels over time and among members of a social system (Rogers, 1995). The theory can be used to help explain arrival at the
consequences of the adoption of an intervention (Rogers, 1995). Change agents can also be influential in the diffusion process by securing the adoption of a new idea or trying to slow the process of diffusion and prevent adoption of innovations with undesirable effects. However, investigations of Diffusion of Innovations (DOI) often rely on recall and do not address the effect on socioeconomic inequalities within a social system (Greenhalgh, Robert, Macfarlane, Bate & Kyriakidou, 2004; Haider & Kreps, 2004). Moreover, DOI Theory has been criticised for oversimplifying a complex reality, emphasising individual choice of agents over and above system- level determinants (Greenhalgh et al., 2004). Therefore, there would be a need to utilise other theories in combination in order to understand the role of context in system level change.
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Normalisation Process Theory
Normalisation process Theory (NPT) has been used as a framework to facilitate the successful implementation and integration of an intervention into a setting (McEvoy et al., 2014). In effect, NPT posits that an intervention becomes normalised within that setting through a social process of collective action (May, 2013a; May & Finch, 2009). The four main components of NPT, which have interactive relationships with each other and the intervention context, are coherence (sense-making), cognitive participation (engagement), collective action (work to enable the intervention to happen) and reflexive monitoring (formal and informal appraisal of costs and benefits of intervention). An example of NPT’s use in implementation research comes from a qualitative study focusing on the implementation of e-health initiatives in healthcare (Murray et al., 2011). The authors found this theory to be useful for studying implementation and findings showed that perceptions of implementers, such as their views on the initiative’s impact on professional-patient interactions and its fit with organisational goals, were associated with normalisation (Murray et al., 2011).
This theory takes into account the wider system to a greater extent than DOI Theory, through collective action and reflexive monitoring and the acknowledgement of interactive relationships between the four main components and context. However, it still focuses upon the implementation of individual intervention components, rather than how the intervention functions as a whole and interacts with context to create emergent outcomes. The next section will elaborate further on theories that, to varying degrees, take system structure into account.
Implementation Theory
Although Implementation Theory (IT) is relatively new and has not been employed within published studies of implementation, it has been theorised by May (2013b) who combined NPT with other relevant constructs from psychological and
sociological theories to outline the processes of implementation. These processes are social mechanisms developed through emergent expressions of agency and dynamic elements of context, which are contextualised within social systems (May, 2013b). Processes of implementation are understood through the interactions between
30 agency, components of interventions and contextual factors. The four constructs of the IT include capability, capacity, potential and contribution (see Figure 1).
Capability of agents to implement and embed processes depends on the workability and integration of an intervention within a social system. Capacity relates to the social and structural resources within a system and includes social norms, social roles, material resources and cognitive resources of agents. If contributions carry forward in time and space and are sustained, they could potentially be normalised into every day practice (May, 2013b).
Despite having built upon DOI and NPT and creating a positive move towards acknowledging the role of both system structure and agency in interventions, IT still focuses upon the individualistic and simplistic language of intervention components (May, 2013b). Moreover, due to the relative youth of this theory, there are very few concrete examples of its operationalisation within studies of implementation. One study focusing on the implementation of a coordinated healthy lifestyle intervention in primary care employed IT (May, 2013a). They found this theory to be a useful tool for comprehensively studying and identifying barriers and facilitators to implementation. They also discovered that in practice the constructs of capacity, capability and potentional led to contribution, as outlined within the theoretical
CONTRIBUTION