Do complexity-informed health interventions work? A scoping review

Abstract

BackgroundThe lens of complexity theory is widely advocated to improve health care delivery. However, empirical evidence that this lens has been useful in designing health care remains elusive. This review assesses whether it is possible to reliably capture evidence for efficacy in results or process within interventions that were informed by complexity science and closely related conceptual frameworks.MethodsSystematic searches of scientific and grey literature were undertaken in late 2015/early 2016. Titles and abstracts were screened for interventions (A) delivered by the health services, (B) that explicitly stated that complexity science provided theoretical underpinning, and (C) also reported specific outcomes. Outcomes had to relate to changes in actual practice, service delivery or patient clinical indicators. Data extraction and detailed analysis was undertaken for studies in three developed countries: Canada, UK and USA. Data were extracted for intervention format, barriers encountered and quality aspects (thoroughness or possible biases) of evaluation and reporting.ResultsFrom 5067 initial finds in scientific literature and 171 items in grey literature, 22 interventions described in 29 articles were selected. Most interventions relied on facilitating collaboration to find solutions to specific or general problems. Many outcomes were very positive. However, some outcomes were measured only subjectively, one intervention was designed with complexity theory in mind but did not reiterate this in subsequent evaluation and other interventions were credited as compatible with complexity science but reported no relevant theoretical underpinning. Articles often omitted discussion on implementation barriers or unintended consequences, which suggests that complexity theory was not widely used in evaluation.ConclusionsIt is hard to establish cause and effect when attempting to leverage complex adaptive systems and perhaps even harder to reliably find evidence that confirms whether complexity-informed interventions are usually effective. While it is possible to show that interventions that are compatible with complexity science seem efficacious, it remains difficult to show that explicit planning with complexity in mind was particularly valuable. Recommendations are made to improve future evaluation reports, to establish a better evidence base about whether this conceptual framework is useful in intervention design and implementation.Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-016-0492-5) contains supplementary material, which is available to authorized users.

The development of implementation management instruments for a new complex stroke caregiver intervention based on systematic stakeholder and risk analyses

“…As of yet, only a few publications on complex interventions in health care have reported on their development phase , and the reported examples often lack essential information . A review by Brainhard and Hunter cited only three articles dealing with use of analysis methods to explore implementation barriers. We advocate early investment in exploring the complexity of the stakeholder landscape and potential implementation risks of a complex public health intervention, as this influences its implementation .…”

Advancing Complexity Theory as a Qualitative Research Methodology

“…The poststructural rejection of an objective ontology maintains openness to interaction between both explored and unexplored elements of a complex system and their continuously shifting nature (Cheek, 2000;Cilliers, 1998Cilliers, , 2011. This perspective is especially useful for this study considering the continuously changing inputs, relationships, outcomes, and consequences involved in IPV (Brainard & Hunter, 2016;Family Violence Death Review Committee, 2014;Gear et al, 2017). While complexity theory has also been usefully applied using a realist approach (Byrne, Callaghan, & Winter, 2013), we rejected the search for a "reality" for being at odds with a continuously transforming health care system which generates uncertainty, surprise, and multiple possibilities (Begun & Kaissi, 2010).…”

Implementation considerations in a Complex Adaptive System

“…Agents here refer to individuals who work and interact everyday with one another, and are the single most influential factors on the outcomes that the system produces. Agents can have their own relationships not defined by their job title or other status, and can have different beneficial or negative effects (such as being a bridge or a gate-keeper respectively (Brainard & Hunter, 2016).…”

“…Bridging agents allow for dialogue between groups that may or may not have much communication in the past (Brainard & Hunter, 2016). Relevant to eHealth implementation, in traditional medical models the IT department and the primary care providers had little reason to intermingle.…”

“…This is a result of the self-organizational nature of agents within a complex adaptive system. Self organization is another key attribute of complex adaptive systems (Alami et al, 2017;Brainard & Hunter, 2016). It is commonly defined as the agent-based movement or alignment with other agents of similar characteristics, whether characteristics defined by the hospital that the agents work in (such as nurses self-organizing with other nurses, or ICU staff self-organizing within the ICU) or other characteristics which are held by a broader population (religious affiliations, recreational interests, etc.).…”