Case study research for better evaluations of complex interventions: rationale and challenges

Access to primary health care: perspectives of primary care physicians and community stakeholders

BACKGROUND

Action on the social determinants of health is important to strengthen primary health care and promote access among underserved populations. We report on findings from stakeholder consultations undertaken at one of the Canadian sites of the Innovative Models Promoting Access-to-Care Transformation (IMPACT) program, as part of the development of a best practice intervention to improve access to primary health care. The overarching objective of this qualitative study was to understand the processes, barriers, and facilitators to connect patients to health enabling community resources (HERs) to inform a patient navigation model situated in primary care.

METHODS

Focus groups and interviews were conducted with primary care physicians, and community health and social service providers to understand their experiences in supporting patients in reaching HERs. Current gaps in access to primary health care and the potential of patient navigation were also explored. We applied Levesque et al., (2013) access framework to code the data and four themes emerged: (1) Approachability and Ability to Perceive, (2) Acceptability and Ability to Seek, (3) Availability and Accommodation, and Ability to Reach, and (4) Appropriateness.

RESULTS

Determinants of access included patient and provider awareness of HERs, the nature of the patient-provider relationship, funding of HERs, integration of primary and community care services, and continuity of information. Participants' perspectives about the potential scope and role of a patient navigator provided valuable insight for the development of the Access to Resources in the Community (ARC) navigation model and how it could be embedded in a primary care setting.

CONCLUSION

Additional consultation with key stakeholders in the health region is needed to gain a broader understanding of the challenges in caring for primary care patients with social barriers and how to support them in accessing community-based primary health care to inform the design of the ARC intervention.

Implementing and evaluating integrated care models for non-communicable diseases in fragile and humanitarian settings

In this commentary, we advocate for the wider implementation of integrated care models for NCDs within humanitarian preparedness, response, and resilience efforts. Since experience and evidence on integrated NCD care in humanitarian settings is limited, we discuss potential benefits, key lessons learned from other settings, and lessons from the integration of other conditions that may be useful for stakeholders considering an integrated model of NCD care. We also introduce our ongoing project in North Lebanon as a case example currently undergoing parallel tracks of program implementation and process evaluation that aims to strengthen the evidence base on implementing an integrated NCD care model in a crisis setting.

Implementing a tobacco-free workplace program at a substance use treatment center: a case study

BACKGROUND

People with substance use disorders smoke cigarettes at much higher rates than the general population in the United States and are disproportionately affected by tobacco-related diseases. Many substance use treatment centers do not provide evidence-based tobacco cessation treatment or maintain comprehensive tobacco-free workplace policies. The goal of the current work is to identify barriers and facilitators to a successful and sustainable implementation of a tobacco-free workplace program, which includes a comprehensive tobacco-free policy and evidence-based cessation treatment services, in a substance use treatment center.

METHODS

This study is based on an ethnographic approach and uses a qualitative case study design. Data were collected via interviews with staff (n = 6) and clients (n = 16) at the substance use treatment center and site visits (n = 8). Data were analyzed using thematic analysis guided by the extended Normalization Process Theory designed to inform the implementation of innovations in healthcare practice.

RESULTS

Staff at the substance use treatment center supported the implementation of the program and shared a good understanding of the purpose of the intervention and its potential benefits. However, the study identified significant challenges faced by the center during implementation, including widespread tobacco use among clients, contributing to attitudes among staff that tobacco cessation was a low-priority problem due to a perceived lack of interest in quitting and inability to quit among their clients. We identified several factors that contributed to changing this attitude, including provision of tobacco training to staff, active leadership support, low number of staff members who smoked, and access to material resources, including nicotine replacement products. The implementation and active enforcement of a comprehensive tobacco-free workplace program contributed to a gradual change in attitudes and improved the provision of evidence-based tobacco cessation care at the substance use treatment center.

CONCLUSIONS

Substance use treatment centers can integrate tobacco cessation practices in their daily operations, despite multiple challenges they face due to the complex behavioral health and socioeconomic needs of their clients. With proper support, substance use treatment centers can provide much needed tobacco cessation care to their clients who are disproportionately affected by tobacco-related health conditions and systemic health inequities.

The Integrated Atlas of Dementia Care in the Australian Capital Territory: A Collective Case Study of Local Service Provision

Background

This study evaluates the dementia care system in a local area and aimed to include all specialised services designed to provide health and social services to people with dementia or age-related cognitive impairment, as well as general services with a high or very high proportion of clients with dementia.

Methods

The study used an internationally standardised service classification instrument called Description and Evaluation of Services and DirectoriEs for Long Term Care (DESDE-LTC) to identify and describe all services providing care to people with dementia in the Australian Capital Territory (ACT).

Results

A total of 47 service providers were eligible for inclusion. Basic information about the services was collected from their websites, and further information was obtained through interviews with the service providers. Of the 107 services offered by the 47 eligible providers, 27% (n = 29) were specialised services and 73% (n = 78) were general services. Most of the services were residential or outpatient, with a target population mostly of people aged 65 or older, and 50 years or older in the case of Aboriginal and Torres Strait Islander Australians. There were government supports available for most types of care through various programmes.

Conclusions

Dementia care in the ACT relies heavily on general services. More widespread use of standardised methods of service classification in dementia will facilitate comparison with other local areas, allow for monitoring of changes over time, permit comparison with services provided for other health conditions and support evidence-informed local planning.

Implementing the QUALI-DEC project in Argentina, Burkina Faso, Thailand and Viet Nam: a process delineation and theory-driven process evaluation protocol

The project 'Quality Decision-making by women and providers' (QUALI-DEC) combines four non-clinical interventions to promote informed decision-making surrounding mode of birth, improve women's birth experiences, and reduce caesarean sections among low-risk women. QUALI-DEC is currently being implemented in 32 healthcare facilities across Argentina, Burkina Faso, Thailand, and Viet Nam. In this paper, we detail implementation processes and the planned process evaluation, which aims to assess how and for whom QUALI-DEC worked, the mechanisms of change and their interactions with context and setting; adaptations to intervention and implementation strategies, feasibility of scaling-up, and cost-effectiveness of the intervention. We developed a project theory of change illustrating how QUALI-DEC might lead to impact. The theory of change, together with on the ground observations of implementation processes, guided the process evaluation strategy including what research questions and perspectives to prioritise. Main data sources will include: 1) regular monitoring visits in healthcare facilities, 2) quantitative process and output indicators, 3) a before and after cross-sectional survey among post-partum women, 4) qualitative interviews with all opinion leaders, and 5) qualitative interviews with postpartum women and health workers in two healthcare facilities per country, as part of a case study approach. We foresee that the QUALI-DEC process evaluation will generate valuable information that will improve interpretation of the effectiveness evaluation. At the policy level, we anticipate that important lessons and methodological insights will be drawn, with application to other settings and stakeholders looking to implement complex interventions aiming to improve maternal and newborn health and wellbeing.Trial registration: ISRCTN67214403.

Mobilising context as complex and dynamic in evaluations of complex health interventions

BACKGROUND

The relationship between healthcare interventions and context is widely conceived as involving complex and dynamic interactions over time. However, evaluations of complex health interventions frequently fail to mobilise such complexity, reporting context and interventions as reified and demarcated categories. This raises questions about practices shaping knowledge about context, with implications for who and what we make visible in our research. Viewed through the lens of case study research, we draw on data collected for the Triple C study (focused on Case study, Context and Complex interventions), to critique these practices, and call for system-wide changes in how notions of context are operationalised in evaluations of complex health interventions.

METHODS

The Triple C study was funded by the Medical Research Council to develop case study guidance and reporting principles taking account of context and complexity. As part of this study, a one-day workshop with 58 participants and nine interviews were conducted with those involved in researching, evaluating, publishing, funding and developing policy and practice from case study research. Discussions focused on how to conceptualise and operationalise context within case study evaluations of complex health interventions. Analysis focused on different constructions and connections of context in relation to complex interventions and the wider social forces structuring participant's accounts.

RESULTS

We found knowledge-making practices about context shaped by epistemic and political forces, manifesting as: tensions between articulating complexity and clarity of description; ontological (in)coherence between conceptualisations of context and methods used; and reified versions of context being privileged when communicating with funders, journals, policymakers and publics.

CONCLUSION

We argue that evaluations of complex health interventions urgently requires wide-scale critical reflection on how context is mobilised - by funders, health services researchers, journal editors and policymakers. Connecting with how scholars approach complexity and context across disciplines provides opportunities for creatively expanding the field in which health evaluations are conducted, enabling a critical standpoint to long-established traditions and opening up possibilities for innovating the design of evaluations of complex health interventions.

Supported: Supporting, enabling, and sustaining homecare workers to deliver end-of-life care: A qualitative study protocol

BACKGROUND

Homecare workers provide essential care at home for people at end-of-life but are often poorly trained and supported.

AIM

To explore the experiences and needs of homecare workers and the views of homecare clients and carers, and other community-based health and social care staff about the homecare worker role, including identification of good practice.

METHODS

In this qualitative exploratory study, we will conduct 150 semi-structured interviews with homecare workers within three geographic English localities chosen for maximum socio-demographic variation. Eligible participants will be consenting adults providing care services (workers [n = 45], managers [n = 15] community practitioners [n = 30]), receiving care (clients thought to be in the last 6 months of life [n = 30], family carers [n = 15], or commissioners of homecare services supporting end-of-life care [n = 15]. Interviews may adopt a Pictor-guided or standard semi-structured approach according to their preference. Managers and commissioners can contribute to an online focus group if preferred. A range of recruitment strategies will be used, including through homecare agencies, local authorities, local NHS services, charities, voluntary sector groups and social media. Interviews and focus groups will be recorded, transcribed, anonymised, and analysed adopting a case-based approach for each geographic area within-case and then comparison across cases using reflexive thematic analysis. The design and analysis will be informed by Bronfenbrenner's Adapted Ecological Systems theory. This study is registered on the Research Registry (No.8613).

CONTRIBUTION

We will provide evidence on ways to improve the experiences and address the needs of homecare workers in relation to caring for people nearing end-of-life. It will offer insight into good practice around supporting homecare workers including responding to their training and development needs. Findings will inform subsequent stages of an evaluation-phase study of a training resource for homecare workers.

Evaluation of Digitalisation in Healthcare and the Quantification of the "Unmeasurable"

Evaluating healthcare digitalisation, where technology implementation and adoption transforms existing socio-organisational processes, presents various challenges for outcome assessments. Populations are diverse, interventions are complex and evolving over time, meaningful comparisons are difficult as outcomes vary between settings, and outcomes take a long time to materialise and stabilise. Digitalisation may also have unanticipated impacts. We here discuss the limitations of evaluating the digitalisation of healthcare, and describe how qualitative and quantitative approaches can complement each other to facilitate investment and implementation decisions. In doing so, we argue how existing approaches have focused on measuring what is easily measurable and elevating poorly chosen values to inform investment decisions. Limited attention has been paid to understanding processes that are not easily measured even though these can have significant implications for contextual transferability, sustainability and scale-up of interventions. We use what is commonly known as the McNamara Fallacy to structure our discussions. We conclude with recommendations on how we envisage the development of mixed methods approaches going forward in order to address shortcomings.

A complexity-informed in-depth case study into the sustainability and impact of a culture of health: The TR14ers community youth dance group

There are calls for researchers to study existing community assets and activities that appear to improve health and have achieved longevity. The TR14ers Community Dance Charity Limited is a community youth dance group that has been running since 2005 providing free weekly sessions for children and adolescents in an economically disadvantaged town in the UK. An in-depth case study employing qualitative, quantitative and participatory methods was undertaken with the TR14ers (current participants and those who have left, co-ordinators and families) over 6 months with the aim of understanding the sustainable processes and impact of the Group. The 12 complex systems' leverage points described by Meadows and the five domains of adolescent wellbeing developed by the United Nations H6+ Technical Working Group on Adolescent Health and Well-Being were used as frameworks to recognise the complexity of community assets like the TR14ers. The quantitative and qualitative data indicated that being part of the TR14ers contributed to multiple health and wellbeing outcomes. The positive experiences of being a TR14er led members to actively recruit others through word of mouth and public performances. Central to the TR14ers is a commitment to children's rights, which is communicated formally and informally throughout the membership informing how and what the Group does, leading to the structure and delivery of the Group evolving over time. Members sought to ensure the sustainability of the Group after they had left and were keen to mentor younger members to develop and become the leaders. Based on the insights from this case study we suggest that efforts to develop cultures of health, like the TR14ers, should focus on the core values of the activity or intervention that underpin what it does and how within the local context.

The informal way to success or failure? Findings from a comparative case study on video consultation training and implementation in two Danish hospitals

BACKGROUND

This study evaluated an attempt to implement video consultations through a novel education intervention in telehealth training and implementation in two middle-sized hospitals in Denmark. Three units tested the education intervention along with a regional decision to strengthen multidisciplinary and cross-sectoral collaboration through technology to improve service delivery by making the process more coherent and saving time and resources. This study aims to identify what contextual factors enable workplace learning, skills acquisition, and utilization of new digital skills to use and routinize video consultations in workplace practice.

METHODS

This qualitative case study draws on the principles of the realist evaluation framework using cross-case comparisons to test and refine program theories by exploring the complex and dynamic interaction among context, mechanism, and outcome. The methods in this study include participant observations, document analysis, semi-structured individual interviews, and focus groups. We performed an interpretive cross-case analysis, which explored the context-mechanism-outcome relationship using the guiding question, "What works, for whom, under what circumstances, and why?".

RESULTS

Two broad mechanisms appeared to enable skills acquisition and routinization of video consultations: informal workplace learning and adjusting video consultations to professional judgment. The three units had different approaches to the implementation and training and, as such, had different outcomes. First, the skills acquired in the units differed; therefore, how and with whom they used video consultations varied. Second, video consultation use was more likely to be adjusted to workflows if unit managers were responsive to staff's professional judgments regarding patients, as was evident in all three units.

CONCLUSION

Our study shows that a formal training course alone is insufficient to provide healthcare professionals with the skills needed to use video consultations in workplace practice. Informal workplace learning with support on the spot and continuous follow-up seems to equip healthcare professionals with the skills to use video consultations. Video consultations are more likely to be used confidently if novel workflows are adjusted to health care professionals' knowledge, skills, and judgment and their concerns regarding patient soundness.

Implementation of a multicomponent family support intervention in adult intensive care units: study protocol for an embedded mixed-methods multiple case study (FICUS implementation study)

BACKGROUND

The implementation of complex interventions is considered challenging, particularly in multi-site clinical trials and dynamic clinical settings. This study protocol is part of the family intensive care units (FICUS) hybrid effectiveness-implementation study. It aims to understand the integration of a multicomponent family support intervention in the real-world context of adult intensive care units (ICUs). Specifically, the study will assess implementation processes and outcomes of the study intervention, including fidelity, and will enable explanation of the clinical effectiveness outcomes of the trial.

METHODS AND ANALYSIS

This mixed-methods multiple case study is guided by two implementation theories, the Normalisation Process Theory and the Consolidated Framework for Implementation Research. Participants are key clinical partners and healthcare professionals of eight ICUs allocated to the intervention group of the FICUS trial in the German-speaking part of Switzerland. Data will be collected at four timepoints over the 18-month active implementation and delivery phase using qualitative (small group interviews, observation, focus group interviews) and quantitative data collection methods (surveys, logs). Descriptive statistics and parametric and non-parametric tests will be used according to data distribution to analyse within and between cluster differences, similarities and factors associated with fidelity and the level of integration over time. Qualitative data will be analysed using a pragmatic rapid analysis approach and content analysis.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Cantonal Ethics Committee of Zurich BASEC ID 2021-02300 (8 February 2022). Study findings will provide insights into implementation and its contribution to intervention outcomes, enabling understanding of the usefulness of applied implementation strategies and highlighting main barriers that need to be addressed for scaling the intervention to other healthcare contexts. Findings will be disseminated in peer-reviewed journals and conferences.

PROTOCOL REGISTRATION NUMBER

Open science framework (OSF) https://osf.io/8t2ud Registered on 21 December 2022.

Exploring the contribution of case study research to the evidence base for occupational therapy: a scoping review

BACKGROUND

Case study research is generating interest to evaluate complex interventions. However, it is not clear how this is being utilized by occupational therapists or how feasible it is to contribute to the evidence base. This scoping review explores case study research within occupational therapy in terms of how it is defined, the methodological characteristics adopted, such as data collection and analysis, and the range of practice contexts in which it is applied. We consider the viability of case study research for contributing to our evidence base.

METHODS

Opinion, text and empirical studies within an occupational therapy practice context were included. A three-step extensive search following Joanna Briggs Institute methodology was conducted in June 2020 and updated in July 2021 across ten databases, websites, peer-reviewed and grey literature from 2016 onwards. Study selection was completed by two independent reviewers. A data extraction table was developed and piloted and data charted to align with research questions. Data extraction was completed by one reviewer and a 10% sample cross checked by another.

RESULTS

Eighty-eight studies were included in the review consisting of (n = 84) empirical case study and (n = 4) non-empirical papers. Case study research has been conducted globally, with a range of populations across different settings. The majority were conducted in a community setting (n = 48/84; 57%) with populations experiencing neurodevelopmental disorder (n = 32/84; 38%), stroke (n = 14/84;17%) and non-diagnosis specific (n = 13/84; 15%). Methodologies adopted quantitative (n = 42/84; 50%), mixed methods (n = 22/84; 26%) and qualitative designs (n = 20/84; 24%). However, identifying the methodology and 'case' was a challenge due to methodological inconsistencies.

CONCLUSIONS

Case study research is useful when large-scale inquiry is not appropriate; for cases of complexity, early intervention efficacy, theory testing or when small participant numbers are available. It appears a viable methodology to contribute to the evidence base for occupation and health as it has been used to evaluate interventions across a breadth of occupational therapy practice contexts. Viability could be enhanced through consistent conduct and reporting to allow pooling of case data. A conceptual model and description of case study research in occupational therapy is proposed to support this.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework 10.17605/OSF.IO/PCFJ6.

Analyzing the value of IONM as a complex intervention: The gap between published evidence and clinical practice

OBJECTIVE

Intraoperative neurophysiological monitoring (IONM) was investigated as a complex intervention (CI) as defined by the United Kingdom Medical Research Council (MRC) in published studies to identify challenges and solutions in estimating IONM's effects on postoperative outcomes.

METHODS

A scoping review to April 2022 of the influence of setting on what was implemented as IONM and how it influenced postoperative outcomes was performed for studies that compared IONM to no IONM cohorts. IONM complexity was assessed with the iCAT_SR tool. Causal graphs were used to represent this complexity.

RESULTS

IONM implementation depended on the surgical procedure, institution and/or surgeon. "How" IONM influenced neurologic outcomes was attributed to surgeon or institutional experience with the surgical procedure, surgeon or institutional experience with IONM, co-interventions in addition to IONM, models of IONM service delivery and individual characteristics of the IONM provider. Indirect effects of IONM mediated by extent of tumor resection, surgical approach, changes in operative procedure, shorter operative time, and duration of aneurysm clipping were also described. There were no quantitative estimates of the relative contribution of these indirect effects to total IONM effects on outcomes.

CONCLUSIONS

IONM is a complex intervention whose evaluation is more challenging than that of a simple intervention. Its implementation and largely indirect effects depend on specific settings that are usefully represented in causal graphs.

SIGNIFICANCE

IONM evaluation as a complex intervention aided by causal graphs and multivariable analysis could provide a valuable framework for future study design and assessments of IONM effectiveness in different settings.

Assessing safe and personalised maternity and neonatal care through a pandemic: a case study of outcomes and experiences in two trusts in England using the ASPIRE COVID-19 framework

BACKGROUND

The COVID-19 pandemic has resulted in profound and far-reaching impacts on maternal and newborn care and outcomes. As part of the ASPIRE COVID-19 project, we describe processes and outcome measures relating to safe and personalised maternity care in England which we map against a pre-developed ASPIRE framework to establish the potential impact of the COVID-19 pandemic for two UK trusts.

METHODS

We undertook a mixed-methods system-wide case study using quantitative routinely collected data and qualitative data from two Trusts and their service users from 2019 to 2021 (start and completion dates varied by available data). We mapped findings to our prior ASPIRE conceptual framework that explains pathways for the impact of COVID-19 on safe and personalised care.

RESULTS

The ASPIRE framework enabled us to develop a comprehensive, systems-level understanding of the impact of the pandemic on service delivery, user experience and staff wellbeing, and place it within the context of pre-existing challenges. Maternity services experienced some impacts on core service coverage, though not on Trust level clinical health outcomes (with the possible exception of readmissions in one Trust). Both users and staff found some pandemic-driven changes challenging such as remote or reduced antenatal and community postnatal contacts, and restrictions on companionship. Other key changes included an increased need for mental health support, changes in the availability and uptake of home birth services and changes in induction procedures. Many emergency adaptations persisted at the end of data collection. Differences between the trusts indicate complex change pathways. Staff reported some removal of bureaucracy, which allowed greater flexibility. During the first wave of COVID-19 staffing numbers increased, resolving some pre-pandemic shortages: however, by October 2021 they declined markedly. Trying to maintain the quality and availability of services had marked negative consequences for personnel. Timely routine clinical and staffing data were not always available and personalised care and user and staff experiences were poorly captured.

CONCLUSIONS

The COVID-19 crisis magnified pre-pandemic problems and in particular, poor staffing levels. Maintaining services took a significant toll on staff wellbeing. There is some evidence that these pressures are continuing. There was marked variation in Trust responses. Lack of accessible and timely data at Trust and national levels hampered rapid insights. The ASPIRE COVID-19 framework could be useful for modelling the impact of future crises on routine care.

TRIPLE C reporting principles for case study evaluations of the role of context in complex interventions

BACKGROUND

Guidance and reporting principles such as CONSORT (for randomised trials) and PRISMA (for systematic reviews) have greatly improved the reporting, discoverability, transparency and consistency of published research. We sought to develop similar guidance for case study evaluations undertaken to explore the influence of context on the processes and outcomes of complex interventions.

METHODS

A range of experts were recruited to an online Delphi panel, sampling for maximum diversity in disciplines (e.g. public health, health services research, organisational studies), settings (e.g. country), and sectors (e.g. academic, policy, third sector). To inform panel deliberations, we prepared background materials based on: [a] a systematic meta-narrative review of empirical and methodological literatures on case study, context and complex interventions; [b] the collective experience of a network of health systems and public health researchers; and [c] the established RAMESES II standards (which cover one kind of case study). We developed a list of topics and issues based on these sources and encouraged panel members to provide free text comments. Their feedback informed development of a set of items in the form of questions for potential inclusion in the reporting principles. We circulated these by email, asking panel members to rank each potential item twice (for relevance and validity) on a 7-point Likert scale. This sequence was repeated twice.

RESULTS

We recruited 51 panel members from 50 organisations across 12 countries, who brought experience of a range of case study research methods and applications. 26 completed all three Delphi rounds, reaching over 80% consensus on 16 items covering title, abstract, definitions of terms, philosophical assumptions, research question(s), rationale, how context and complexity relates to the intervention, ethical approval, empirical methods, findings, use of theory, generalisability and transferability, researcher perspective and influence, conclusions and recommendations, and funding and conflicts of interest.

CONCLUSION

The 'Triple C' (Case study, Context, Complex interventions) reporting principles recognise that case studies are undertaken in different ways for different purposes and based on different philosophical assumptions. They are designed to be enabling rather than prescriptive, and to make case study evaluation reporting on context and complex health interventions more comprehensive, accessible and useable.

Uptake of Mpox vaccination among transgender people and gay, bisexual and other men who have sex with men among sexually-transmitted infection clinic clients in Vancouver, British Columbia

OBJECTIVES

As the primary public health strategy for controlling the 2022 Mpox outbreak, it is critical to evaluate the impact of Mpox vaccination campaigns for transgender people and gay, bisexual and other men who have sex with men (T/GBM). We measured vaccine uptake and associated factors among T/GBM clients of an urban STI clinic in British Columbia (BC).

METHODS

We conducted a cross-sectional online survey between August 8-22, 2022 of clients who had attended the STI clinic, 5-7 weeks following the first-dose Mpox vaccination campaign in BC. We drew on a systematic review of factors associated with vaccine uptake to develop survey questions, and measured vaccine uptake among vaccine-eligible T/GBM.

RESULTS

Overall, 51% of T/GBM had received the first dose of the vaccine. The sample (331 participants) was majority White and university educated, identified as a man and gay, 10% had trans experience, and 68% met eligibility criteria for vaccination. Among vaccine-eligible participants identifying as T/GBM, 66% had been vaccinated; being unvaccinated was more common among participants identifying as bisexual or heteroflexible/mostly straight, and who spent less time with other T/GBM. Eligible yet unvaccinated participants had lower perceived susceptibility, and reported fewer cues to action (e.g., fewer saw information promoting the vaccine), and increased constraints to vaccine access; vaccine barriers related to accessing clinics and privacy were common. The majority (85%) of those eligible and unvaccinated at time of survey were willing to receive the vaccine.

CONCLUSION

In this sample of STI clinic clients, vaccine uptake among eligible T/GBM was high in the initial weeks following a Mpox vaccination campaign. However, uptake was patterned on social gradients with lower uptake among T/GBM who may be less effectively engaged by available promotion channels. We recommend early, intentional and diverse engagement of T/GBM populations in Mpox and other targeted vaccination programs.

Case study research and causal inference

Case study methodology is widely used in health research, but has had a marginal role in evaluative studies, given it is often assumed that case studies offer little for making causal inferences. We undertook a narrative review of examples of case study research from public health and health services evaluations, with a focus on interventions addressing health inequalities. We identified five types of contribution these case studies made to evidence for causal relationships. These contributions relate to: (1) evidence about system actors' own theories of causality; (2) demonstrative examples of causal relationships; (3) evidence about causal mechanisms; (4) evidence about the conditions under which causal mechanisms operate; and (5) inference about causality in complex systems. Case studies can and do contribute to understanding causal relationships. More transparency in the reporting of case studies would enhance their discoverability, and aid the development of a robust and pluralistic evidence base for public health and health services interventions. To strengthen the contribution that case studies make to that evidence base, researchers could: draw on wider methods from the political and social sciences, in particular on methods for robust analysis; carefully consider what population their case is a case 'of'; and explicate the rationale used for making causal inferences.

Developing an implementation research logic model: using a multiple case study design to establish a worked exemplar

Background

Implementation science frameworks explore, interpret, and evaluate different components of the implementation process. By using a program logic approach, implementation frameworks with different purposes can be combined to detail complex interactions. The Implementation Research Logic Model (IRLM) facilitates the development of causal pathways and mechanisms that enable implementation. Critical elements of the IRLM vary across different study designs, and its applicability to synthesizing findings across settings is also under-explored. The dual purpose of this study is to develop an IRLM from an implementation research study that used case study methodology and to demonstrate the utility of the IRLM to synthesize findings across case sites.

Method

The method used in the exemplar project and the alignment of the IRLM to case study methodology are described. Cases were purposely selected using replication logic and represent organizations that have embedded exercise in routine care for people with cancer or mental illness. Four data sources were selected: semi-structured interviews with purposely selected staff, organizational document review, observations, and a survey using the Program Sustainability Assessment Tool (PSAT). Framework analysis was used, and an IRLM was produced at each case site. Similar elements within the individual IRLM were identified, extracted, and re-produced to synthesize findings across sites and represent the generalized, cross-case findings.

Results

The IRLM was embedded within multiple stages of the study, including data collection, analysis, and reporting transparency. Between 33-44 determinants and 36-44 implementation strategies were identified at sites that informed individual IRLMs. An example of generalized findings describing “intervention adaptability” demonstrated similarities in determinant detail and mechanisms of implementation strategies across sites. However, different strategies were applied to address similar determinants. Dependent and bi-directional relationships operated along the causal pathway that influenced implementation outcomes.

Conclusions

Case study methods help address implementation research priorities, including developing causal pathways and mechanisms. Embedding the IRLM within the case study approach provided structure and added to the transparency and replicability of the study. Identifying the similar elements across sites helped synthesize findings and give a general explanation of the implementation process. Detailing the methods provides an example for replication that can build generalizable knowledge in implementation research.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00337-8.

Exploring common dialectical tensions constraining collaborative communication required for post-2020 conservation

Contemporary conservation requires improved collaboration characterized by greater recognition and incorporation of multiple and diverse actors. Effective communication is central to this endeavour. However, the expression of concerns, perspectives, and the exchange of knowledge between actors and across multiple scales (i.e., collaborative communication), must navigate inevitable competing systems of meaning and motivation (i.e., dialectical tensions). Yet, a lack of understanding of how to improve collaborative communication within conservation interventions persists within the literature. Consequently, this paper reviews relevant literature to propose a framework that identifies common sources of dialectical tensions in collaborative conservation interventions that if managed effectively can improve required collaborative communication. The framework is then revised based on interviews conducted with 277 respondents in three African coastal-marine collaborative conservation interventions. Findings reinforce the effect of continued marginalization of certain actors' 'voices' within governance processes. More specifically, enabling collaborative communication requires managing several identified institutional-, agenda-, cultural-, and perception-based tensions. In particular, tensions emerging from formal-informal institutional interactions; gender-based exclusion; conflicting livelihood-ecological and economic-environmental agendas, and project-funder objectives; between indigenous/local-scientific knowledge and values; and perceived necessary-acceptable change. Furthermore, specific local-scale tensions identified included those associated with local-customary institutions; democratic-meritocratically elected local representatives; and exclusion based on cultural diversity. Consequently, these tensions require the 'co-creation' of communicative strategies amongst all actors to promote greater social equity that better aligns with local priorities to achieve 'positive' post-2020 ecological and social outcomes. Findings should be relevant to diverse conservation actors, and many others working within multi-stakeholder environmental interventions.

Novel device for assisted vaginal birth: using integrated qualitative case study methodology to optimise Odon Device use within a feasibility study in a maternity unit in the Southwest of England

OBJECTIVE

When novel devices are used 'in human' for the first time, their optimal use is uncertain because clinicians only have experience from preclinical studies. This study aimed to investigate factors that might optimise use of the Odon Device for assisted vaginal birth.

DESIGN

We undertook qualitative case studies within the ASSIST Study, a feasibility study of the Odon Device. Each 'case' was defined as one use of the device and included at least one of the following: observation of the attempted assisted birth, and an interview with the obstetrician, midwife or woman. Data collection and thematic analysis ran iteratively and in parallel.

SETTING

Tertiary referral National Health Service maternity unit in the Southwest of England.

PARTICIPANTS

Women requiring a clinically indicated assisted vaginal birth.

INTERVENTION

The Odon Device, an innovative device for assisted vaginal birth.

PRIMARY AND SECONDARY OUTCOME MEASURES

Determining the optimal device technique, device design and defining clinical parameters for use.

RESULTS

Thirty-nine cases involving an attempted Odon-assisted birth were included in this study, of which 19 resulted in a successful birth with the device. Factors that improved use included optimisation of device technique, device design and clinical parameters for use. Technique adaptations included: applying the device during, rather than between, contractions; having a flexible approach to the application angle; and deflating the air cuff sooner than originally proposed. Three design modifications were proposed involving the deflation button and sleeve. Although use of the device was found to be appropriate in all fetal positions, it was considered contraindicated when the fetal station was at the ischial spines.

CONCLUSIONS

Case study methodology facilitated the acquisition of rapid insights into device function in clinical practice, providing key insights regarding use, design and key clinical parameters for success. This methodology should be considered whenever innovative devices are introduced into clinical practice.

TRIAL REGISTRATION NUMBER

ISRCTN10203171.

Effectiveness of personal recovery facilitators in adults with schizophrenia and other psychoses: A systematic review of reviews and narrative synthesis

This review aimed to examine the evidence base for the use of personal recovery facilitators [non-psychopharmacological approaches] for adults with a diagnosis of schizophrenia and other psychoses. A systematic review (umbrella review) was conducted of reviews published in English between January 2010 and February 2022, which examined the effectiveness of personal recovery facilitators to support aspects of personal recovery as defined by the CHIME framework (connectedness, hope and optimism, identity, meaning and purpose, and empowerment). Twenty-one systematic reviews on thirteen different types of personal recovery facilitators [PRFs] were included in this umbrella review. Only one review sought to directly measure personal recovery processes according to the CHIME framework. Outcome measures mostly aligned with the processes of hope (21 reviews) and connectedness (19 reviews). Those related to empowerment (2 reviews), identity (5 reviews) and meaning and purpose (1 review) were less frequently the focus of PRFs. Yoga and music therapy showed the most promise as PRFs. Vocational treatments and integrated supported employment show good potential as personal recovery facilitators. However, together with narrative photovoice, art making and exhibition, they require further robust research to fully examine their impact. Personal recovery is only beginning to be considered as an intended outcome of interventions for persons with schizophrenia and other psychoses. This may be due in part to the continued predominance of the biomedical model approach to recovery within statutory services. Future evaluations of PRFs should include outcome measures that directly assess personal recovery according to the CHIME framework or other measures developed in consultation with recipients of these approaches. Review registration number and date: PROSPERO 2020 CRD42020215471: 10/11/20.

Conceptualizing Context and Intervention as a System in Implementation Science: Learning From Complexity Theory Comment on "Stakeholder Perspectives of Attributes and Features of Context Relevant to Knowledge Translation in Health Settings: A Multi-country Analysis"

In implementation science, implementation has been widely theorized and assessed. Context, on the other hand, usually played a minor role in the field and was usually conceptualized in a rather positivist way. Despite some promising efforts, there is a strong need to continue building theory on context and operationalizing the concept in implementation practice. I argue for the benefit of integrating complexity theory into our understanding of context in order to further our thinking about context and intervention as a system. This should be reflected by the way in which we build theory as well as apply this theory by employing methods that adequately account for complexity in systems.

Using participatory action research to pilot a model of service user and caregiver involvement in mental health system strengthening in Ethiopian primary healthcare: a case study

Background

Little is known about actual involvement or how to achieve service user and caregiver in mental health systems strengthening in low-and middle-income countries. This study describes the processes and explores involvement experiences of participants in a pilot study of a new model of service user involvement in mental health system strengthening in a rural district in southern Ethiopia.

Methods

We applied a case study design using participatory action research (PAR). The PAR process comprised of three stages, each with iterative activities of plan, act, observe and reflect. Two stakeholder groups, a Research Advisory Group (RAG) and Research Participant Group (RPG), were established and collaborated in the PAR process. Data collection involved process documentation of meetings and activities: attendances, workshop minutes, discussion outputs, reflective notes, participatory observation of sessions, and in-depth interviews with 12 RPG members. We analyzed the process data descriptively. Thematic analysis was used for qualitative data. Triangulation and synthesis of findings was carried out to develop the case study.

Results

The stakeholder groups identified their top research priorities, developed an intervention and action plan and made a public presentation of preliminary findings. Key mechanisms used for inclusive participation included capacity building and bringing together diverse stakeholders, anchoring the study in established strong community involvement structures, and making use of participatory strategies and activities during the PAR process. Four themes were developed about experiences of involvement in PAR: (i) expectations and motivation, (ii) experiences of the dynamics of the PAR process, (iii) perceived impacts of involvement in the PAR process, and (iv) implementation challenges and future directions.

Conclusions

This case study demonstrated the feasibility and acceptability of implementing a complex model of service-user involvement in mental health system strengthening in a resource constrained setting. More needs to be done to embed service-user involvement into routines of the primary healthcare system, alongside sustained support and strengthening multi-stakeholder collaboration at multiple levels.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13033-022-00545-8.

Integrated enhanced cognitive behavioural (I-CBTE) therapy significantly improves effectiveness of inpatient treatment of anorexia nervosa in real life settings

BACKGROUND

Inpatient treatment of anorexia nervosa can be lifesaving but is associated with high rates of relapse and poor outcomes. To address this, the Oxford service has adapted the enhanced cognitive behavioural treatment (CBTE) model, first developed for inpatients in Italy to a UK national health service (NHS) setting. In this study, we compared the outcomes from treatment as usual (TAU), integrated CBTE (I-CBTE), and alternative treatment models in routine UK clinical practice.

METHODS

This is a longitudinal cohort study, using routinely collected data between 2017 and 2020 involving all adults with anorexia nervosa admitted to specialist units from a large geographical area in England covering a total population of 3.5 million. We compared TAU with (1) I-CBTE (13 weeks inpatient CBTE, restoration to a healthy weight, combined with 7 weeks day treatment followed by 20 weeks of outpatient CBTE; (2) standalone inpatient CBTE (due to insufficient resources since the pandemic; and (3) 6-8 weeks admission with partial weight restoration as crisis management. Primary outcome measures (min. 1 year after discharge from hospital) were defined as: (1) good outcome: Body Mass Index (BMI) > 19.5 and no abnormal eating or compensatory behaviours; (2) poor outcome: BMI < 19.5 and/or ongoing eating disorder behaviours; (3) readmission; or (4) deceased. Secondary outcomes were BMI on discharge, and length of stay.

RESULTS

212 patients were admitted to 15 specialist units in the UK depending on bed availability. The mean age was 28.9 (18-60) years, mean admission BMI was 14.1 (10-18.3), 80% were voluntary. At minimum 1-year follow up after discharge, 70% of patients receiving I-CBTE and 29% standalone inpatient CBTE maintained good outcomes, in contrast with < 5% TAU and crisis management admission. Readmission rates of I-CBTE were 14.3% vs ~ 50% (χ² < 0.0001) in the other groups. The main predictors of good outcome were reaching healthy BMI by discharge, I-CBTE and voluntary status. Age, psychiatric comorbidity and length of stay did not predict outcomes. BMI on discharge and length of stay were significantly better in the CBTE groups than in TAU.

CONCLUSIONS

Our main finding is that in a real-life setting, I-CBTE has superior short- and minimum 1 year outcomes as compared with alternative inpatient treatment models. Dissemination of I-CBTE across the care pathway has the potential to transform outcomes of inpatient treatment for this high-risk patient population and reduce personal and societal costs.

Implementing and evaluating online advance care planning training in UK nursing homes during COVID-19: findings from the Necessary Discussions multi-site case study project

BACKGROUND

Advance care planning in nursing homes is important to ensure the wishes and preferences of residents are recorded, especially during the COVID-19 pandemic. However, care staff and family members frequently report feeling unprepared for these conversations. More resources are needed to support them with these necessary discussions. This research aimed to develop, implement and evaluate a website intervention for care staff and family members to provide training and information about advance care planning during COVID-19.

METHODS

The research was a primarily qualitative case study design, comprising multiple UK nursing home cases. Data collection included semi-structured interviews with care staff and family members which were coded and analysed thematically. A narrative synthesis was produced for each case, culminating in a thematic cross-case analysis of the total findings. Theoretical propositions were refined throughout the research.

RESULTS

Eight nursing homes took part in the study, involving 35 care staff and 19 family members. Findings were reported according to the RE-AIM framework which identified the reach, effectiveness, adoption, implementation and maintenance of the intervention. Themes included: website content that was well received; suggestions for improvement; implementation barriers and facilitators; examples of organisational and personal impact.

CONCLUSIONS

Four theoretical propositions relating to advance care planning in nursing homes are presented, relating to: training and information needs, accessibility, context, and encouraging conversations. Implications for practice and training include an awareness of diverse learning styles, re-enforcing the right to be involved in advance care planning and encouraging opportunities for facilitated discussion.

TRIAL REGISTRATION

ISRCTN registry (ID 18003630 ) on 19.05.21.

PERFECTED enhanced recovery pathway (PERFECT-ER) versus standard acute hospital care for people after hip fracture surgery who have cognitive impairment: a feasibility cluster randomised controlled trial

OBJECTIVES

Assess feasibility of a cluster randomised controlled trial (RCT) to measure clinical and cost-effectiveness of an enhanced recovery pathway for people with hip fracture and cognitive impairment (CI).

DESIGN

Feasibility trial undertaken between 2016 and 2018.

SETTING

Eleven acute hospitals from three UK regions.

PARTICIPANTS

284 participants (208 female:69 male).

INCLUSION CRITERIA

aged >60 years, confirmed proximal hip fracture requiring surgical fixation and CI; preoperative AMTS ≤8 in England or a 4AT score ≥1 in Scotland; minimum of 5 days on study ward; a 'suitable informant' able to provide proxy measures, recruited within 7 days of hip fracture surgery.

EXCLUSION CRITERIA

no hip surgery; not expected to survive beyond 4 weeks; already enrolled in a clinical trial.

INTERVENTION

PERFECT-ER, an enhanced recovery pathway with 15 quality targets supported by a checklist and manual, a service improvement lead a process lead and implemented using a plan-do-study-act model.

PRIMARY AND SECONDARY OUTCOME MEASURES

Feasibility outcomes: recruitment and attrition, intervention acceptability, completion of participant reported outcome measures, preliminary estimates of potential effectiveness using mortality, EQ-5D-5L, economic and clinical outcome scores.

RESULTS

282 participants were consented and recruited (132, intervention) from a target of 400. Mean recruitment rates were the same in intervention and control sites, (range: 1.2 and 2.7 participants/month). Retention was 230 (86%) at 1 month and 54%(144) at 6 months. At 3 months a relatively small effect (one quarter of an SD) was observed on health-related quality of life of the patient measured with EQ-5D-5L proxy in the intervention group.

CONCLUSION

This trial design was feasible with modifications to recruitment. Mechanisms for delivering consistency in the PERFECT-ER intervention and participant retention need to be addressed. However, an RCT may be a suboptimal research design to evaluate this intervention due to the complexity of caring for people with CI after hip fracture.

TRIAL REGISTRATION NUMBER

ISRCTN99336264.

Case study research: Building the occupational therapy evidence base one case at a time

BACKGROUND

There is growing recognition in healthcare that evidence from randomised controlled trials may not be appropriate to answer the full spectrum of practice-based questions and a more pluralistic approach is needed.

AIM

To consider the use of case study research in contributing to the occupational therapy evidence base.

MATERIAL AND METHODS

A critical discussion of the current state of evidence-based practice in occupational therapy and exploration of a viable approach to case study research is used.

RESULTS

Case study research can capture the context and complexity of occupational therapy practice. Cases can then be pooled to make a substantial contribution to the evidence base.

CONCLUSIONS

Occupational therapists should consider the use of case study research to produce practice related, meaningful research. Journal editorial boards need to be mindful of the value of high-quality case study research when considering publication priorities in occupational therapy literature.

SIGNIFICANCE

Highlights a changing landscape in the literature about how best to conduct research in health and social care, particularly for complex interventions and describes a pragmatic approach to case study research for occupational therapy.

Evaluating complex interventions in context: systematic, meta-narrative review of case study approaches

BACKGROUND

There is a growing need for methods that acknowledge and successfully capture the dynamic interaction between context and implementation of complex interventions. Case study research has the potential to provide such understanding, enabling in-depth investigation of the particularities of phenomena. However, there is limited guidance on how and when to best use different case study research approaches when evaluating complex interventions. This study aimed to review and synthesise the literature on case study research across relevant disciplines, and determine relevance to the study of contextual influences on complex interventions in health systems and public health research.

METHODS

Systematic meta-narrative review of the literature comprising (i) a scoping review of seminal texts (n = 60) on case study methodology and on context, complexity and interventions, (ii) detailed review of empirical literature on case study, context and complex interventions (n = 71), and (iii) identifying and reviewing 'hybrid papers' (n = 8) focused on the merits and challenges of case study in the evaluation of complex interventions.

RESULTS

We identified four broad (and to some extent overlapping) research traditions, all using case study in a slightly different way and with different goals: 1) developing and testing complex interventions in healthcare; 2) analysing change in organisations; 3) undertaking realist evaluations; 4) studying complex change naturalistically. Each tradition conceptualised context differently-respectively as the backdrop to, or factors impacting on, the intervention; sets of interacting conditions and relationships; circumstances triggering intervention mechanisms; and socially structured practices. Overall, these traditions drew on a small number of case study methodologists and disciplines. Few studies problematised the nature and boundaries of 'the case' and 'context' or considered the implications of such conceptualisations for methods and knowledge production.

CONCLUSIONS

Case study research on complex interventions in healthcare draws on a number of different research traditions, each with different epistemological and methodological preferences. The approach used and consequences for knowledge produced often remains implicit. This has implications for how researchers, practitioners and decision makers understand, implement and evaluate complex interventions in different settings. Deeper engagement with case study research as a methodology is strongly recommended.

Effectiveness of a Psychosocial Care Quality Improvement Strategy to Address Quality of Life in Patients With Cancer: The HuCare2 Stepped-Wedge Cluster Randomized Trial

IMPORTANCE

Many patients with cancer who would benefit from psychosocial care do not receive it. Implementation strategies may favor the integration of psychosocial care into practice and improve patient outcomes.

OBJECTIVE

To evaluate the effectiveness of the Humanization in Cancer Care (HuCare) Quality Improvement Strategy vs standard care as improvement of at least 1 of 2 domains (emotional or social function) of patient health-related quality of life at baseline and 3 months. A key secondary aim included investigation of the long-term effect.

DESIGN, SETTING, AND PARTICIPANTS

HuCare2 was a multicenter, incomplete, stepped-wedge cluster randomized clinical trial, conducted from May 30, 2016, to August 28, 2019, in three 5-center clusters of cancer centers representative of hospital size and geographic location in Italy. The study was divided into 5 equally spaced epochs. Implementation sequence was defined by a blinded statistician; the nature of the intervention precluded blinding for clinical staff. Participants included consecutive adult outpatients with newly diagnosed cancer of any type and stage starting medical cancer treatment.

INTERVENTIONS

The HuCare Quality Improvement Strategy comprised (1) clinician communication training, (2) on-site visits for context analysis and problem-solving, and (3) implementation of 6 evidence-based recommendations.

MAIN OUTCOMES AND MEASURES

The primary outcome was the difference between the means of changes of individual scores in emotional or social functions of health-related quality of life detected at baseline and 3-month follow-up (within each group) and during the postintervention epoch compared with control periods (between groups). Long-term effect of the intervention (at 12 months) was assessed as a secondary outcome. Intention-to-treat analysis was used.

RESULTS

A total of 762 patients (475 [62.3%] women) were enrolled (400 HuCare Quality Improvement Strategy and 362 usual care); mean (SD) age was 61.4 (13.1) years. The HuCare Quality Improvement Strategy significantly improved emotional function during treatment (odds ratio [OR], 1.13; 95% CI, 1.04-1.22; P = .008) but not social function (OR, 0.99; 95% CI, 0.89-1.09; P = .80). Effect on emotional function persisted at 12 months (OR, 1.05; 95% CI, 1.00-1.10; P = .04).

CONCLUSIONS AND RELEVANCE

In this trial, the HuCare Quality Improvement Strategy significantly improved the emotional function aspect of health-related quality of life during cancer treatment and at 12 months, indicating a change in clinician behavior and in ward organization. These findings support the need for strategies to introduce psychosocial care; however, more research is needed on factors that may maximize the effects.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03008993.

The use of Qualitative Comparative Analysis (QCA) to address causality in complex systems: a systematic review of research on public health interventions

Background

Qualitative Comparative Analysis (QCA) is a method for identifying the configurations of conditions that lead to specific outcomes. Given its potential for providing evidence of causality in complex systems, QCA is increasingly used in evaluative research to examine the uptake or impacts of public health interventions. We map this emerging field, assessing the strengths and weaknesses of QCA approaches identified in published studies, and identify implications for future research and reporting.

Methods

PubMed, Scopus and Web of Science were systematically searched for peer-reviewed studies published in English up to December 2019 that had used QCA methods to identify the conditions associated with the uptake and/or effectiveness of interventions for public health. Data relating to the interventions studied (settings/level of intervention/populations), methods (type of QCA, case level, source of data, other methods used) and reported strengths and weaknesses of QCA were extracted and synthesised narratively.

Results

The search identified 1384 papers, of which 27 (describing 26 studies) met the inclusion criteria. Interventions evaluated ranged across: nutrition/obesity (n = 8); physical activity (n = 4); health inequalities (n = 3); mental health (n = 2); community engagement (n = 3); chronic condition management (n = 3); vaccine adoption or implementation (n = 2); programme implementation (n = 3); breastfeeding (n = 2), and general population health (n = 1). The majority of studies (n = 24) were of interventions solely or predominantly in high income countries. Key strengths reported were that QCA provides a method for addressing causal complexity; and that it provides a systematic approach for understanding the mechanisms at work in implementation across contexts. Weaknesses reported related to data availability limitations, especially on ineffective interventions. The majority of papers demonstrated good knowledge of cases, and justification of case selection, but other criteria of methodological quality were less comprehensively met.

Conclusion

QCA is a promising approach for addressing the role of context in complex interventions, and for identifying causal configurations of conditions that predict implementation and/or outcomes when there is sufficiently detailed understanding of a series of comparable cases. As the use of QCA in evaluative health research increases, there may be a need to develop advice for public health researchers and journals on minimum criteria for quality and reporting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10926-2.

We Need to Talk About Complexity in Health Research: Findings From a Focused Ethnography

There is increasing focus on complexity-informed approaches across health disciplines. This attention takes several forms, but commonly involves framing research topics as "complex" to justify use of particular methods (e.g., qualitative). Little emphasis is placed on how divergent and convergent ways of knowing complexity become negotiated within academic communities. Drawing on findings from a focused ethnography of an international workshop, we illustrate how health researchers employ "boundary-ordering devices" to navigate different meanings ascribed to complexity while they attempt to sustain interdisciplinary communication and collaboration. These include (a) surfacing (but not resolving) tensions between philosophical grounding of knowledge claims and need for practical purchase, (b) employing techniques of representation and abstraction, and (c) drawing on the fluid, ongoing accomplishment of complexity for different audiences and purposes. Our findings have implications for progressing complexity-informed health research, particularly with respect to qualitative approaches.