Government, governance, and place-based approaches: lessons from and for public policy.

BACKGROUND: Place-based approaches are increasingly applied to address the determinants of health, many of which are complex problems, to ultimately improve population health outcomes. Through public policy, government actions can affect the effectiveness of place-based approaches by influencing the conceptualisation, development, implementation, governance, and/or evaluation of place-based approaches. Despite the important role of public policy, there has been limited examination of public policy related to place-based approaches. We add to the limited knowledge base by analysing Australian national public policy, to explore: (1) the definitions, conceptualisations, and characteristics of place-based approaches in public policy; (2) the government's perception and communication of its role in place-based approaches; and (3) the extent to which government policy reflects the necessary conditions for successful place-based governance developed by Marsh and colleagues, namely localised context, embedded learning, and reciprocal accountability. METHODS: This research was underpinned by the Theory of Systems Change and methodologically informed by the READ approach to document analysis. Ritchie and Spencer's framework method was utilised to analyse the data. RESULTS: We identified and reviewed 67 policy documents. In terms of conceptualisation, common characteristics of place-based approaches related to collaboration, including community in decision-making, responsiveness to community needs, and suitability of place-based approaches to address complex problems and socio-economic determinants of health. Three roles of government were identified: funder, partner, and creator of a supportive policy environment. From the three criteria for successful place-based governance, localised context was the most dominant across the documents and reciprocal accountability the least. CONCLUSIONS: Based on our findings, we drew key implications for public policy and research. There was a disproportionate emphasis on the bottom-up approach across the documents, which presents the risk of diminishing government interest in place-based approaches, potentially burdening communities experiencing disadvantage beyond their capacities. Governments engaged in place-based approaches should work towards a more balanced hybrid approach to place-based approaches that maintain the central functions of government while allowing for successful place-based governance. This could be achieved by promoting consistency in conceptualisations of 'place-based', employing an active role in trust building, advancing the creation of a supportive policy environment, and embedding 'learning' across place-based approaches.

Scoping review of practice-focused resources to support the implementation of place-based approaches.

ISSUE ADDRESSED: There is increasing interest across public health research, policy, and practice in place-based approaches to improve health outcomes. Practice-focused resources, such as grey literature, courses and websites, are utilised by practitioners to support the implementation of place-based approaches. METHODS: A detailed search of two search engines: Google and DuckDuckGo to identify free practice-focused resources was conducted. RESULTS: Forty-one resources met inclusion criteria, including 26 publications, 13 web-based resources and two courses. They were mainly focused on collaboration, developed by not-for-profit organisations, focused on a broad target audience, and supported people living with disadvantage. The publications we reviewed generally: clearly stated important information, such as the author of the publication; used their own evaluations, professional experience and other grey literature as supporting evidence; included specific, practical implementation strategies; and were easy to read. CONCLUSIONS: Based on findings, we recommend that: (1) the development of resources to support evidence-informed practice and governance be prioritised; (2) resources clearly state their target audience and tailor communication to this audience; (3) resources draw on evidence from a range of sources; (4) resources continue to include practical implementation strategies supported by examples and (5) resource content be adaptable to different contexts (e.g., different settings and/or target populations). SO WHAT?: This is the first review of practice-focused resources to support the implementation of place-based approaches and the findings can be used to reduce duplication of efforts and inform future research, policy, and practice, particularly the refinement of existing resources and the development of future resources.

The C-CAP Process: A Comprehensive Approach to Community Resource Mapping.

INTRODUCTION: Place-based systems change approaches are gaining popularity to address the complex problems associated with locational disadvantage. An important stage of place-based systems change involves understanding the context that surrounds (re)produces a target problem. Community resource mapping can be used to establish the context and identify the strengths of a community that might be leveraged through systems change efforts. Approaches to community resource mapping draw on a range of philosophical assumptions and methodological frameworks. However, comprehensive, practical guidance for researchers and practitioners to conduct community resource mapping is scarce. METHOD: Drawing on the learnings from a literature review, scoping workshops, and reflective practice sessions, we developed a flexible, methodologically robust process called the Contextualize, Collect, Analyze, and Present (C-CAP) process: a four-phase approach to preparing for, conducting, and reporting on community resource mapping. The C-CAP process was co-developed by researchers and practitioners and was tested and refined in two different communities. RESULTS: The C-CAP process provides robust guidance for conducting and reporting on a community resource mapping project. The C-CAP process can be applied by public health practitioners and researchers and adapted for use across different communities, problems, and target groups. We encourage others guided by differing theoretical perspectives to apply C-CAP and share the learnings. CONCLUSION: Application of the C-CAP process has the potential to improve the comparability and comprehensiveness of findings from community resource mapping projects and avoids duplication of effort by reducing the need to design new processes for each new community resource mapping activity.

System Action Learning: Reorientating Practice for System Change in Preventive Health.

It is now widely accepted that many of the problems we face in public health are complex, from chronic disease to COVID-19. To grapple with such complexity, researchers have turned to both complexity science and systems thinking to better understand the problems and their context. Less work, however, has focused on the nature of complex solutions, or intervention design, when tackling complex problems. This paper explores the nature of system intervention design through case illustrations of system action learning from a large systems level chronic disease prevention study in Australia. The research team worked with community partners in the design and implementation of a process of system action learning designed to reflect on existing initiatives and to reorient practice towards responses informed by system level insights and action. We were able to observe and document changes in the mental models and actions of practitioners and in doing so shine a light on what may be possible once we turn our attention to the nature and practice of system interventions.

Understanding Prevention Networks in a Local Government Area: Insights From a Social Network Analysis Among Western Australian Nutrition, Physical Activity, and Obesity Prevention Programs.

This study aimed to use systems thinking tools to understand network relationships to inform discussions, policy, and practice to improve nutrition, physical activity, and overweight/obesity prevention activities in a Western Australian local government area. An audit of nutrition, physical activity, and obesity prevention activities was conducted, and identified organizations were invited to participate in an organizational network survey. Social network analysis (SNA) determined the extent to which organizations shared information, knowledge, and resources; engaged in joint program planning; applied for and shared funding; and identified operational barriers and contributors. SNA data were mapped and analyzed using UCINET 6 and Netdraw software. Five organizations within the network were identified as core; the remainder were periphery. The strongest networks were sharing information, and the weakest was funding. The connections were centralized to one organization, enabling them to readily influence other organizations and network operations. Remaining organizations indicated limited partnership across the networks. Strengthened collaborations and partnerships are essential to health promotion, as they extend reach and organizational capabilities. This study provides a process for undertaking network analysis, identifying leverage points to facilitate communication and information sharing, and reorienting of collaborations and partnerships to consolidate scarce resources and act strategically within a bounded area. There is a need for stronger relationships between organizations and a reorientation of partnerships to facilitate resource sharing within the local government area, to improve nutrition, physical activity, and obesity prevention practices. SNA can assist in understanding organizational prevention networks within a bounded area to support future planning of practices and policy.

Leadership for systems change: Researcher practices for enhancing research impact in the prevention of chronic disease.

Introduction: Strengthening systems for chronic disease prevention is essential. Leadership for systems change is an important key to strengthening systems. Leadership in prevention research for supporting systems change remains a relatively abstract concept and there is limited empirical information about the leadership practices of prevention research teams when viewed through a complexity lens. In this paper we examine and describe some systems leadership practices for creating change through prevention research, as identified in a series of six case studies. Methods: A qualitative approach incorporating semi-structured interviews, participant observation, and document review was used to facilitate an in-depth investigation of the research topic. Results: Several researcher practices for enhancing research impact in the prevention of chronic disease were distilled from the data pertaining to how they sought to create change. These included persuasive communication, compassion and deep listening, reflective practice, and embedding themselves within the systems they sought to change. Discussion: The findings provide insights that may assist prevention researchers and other practitioners dedicated to creating change in chronic disease prevention.

Intensive care nurses' experiences with the new electronic medication administration record.

AIM: To explore the experiences of Registered Nurses who administered medications to patients using the electronic medication administration record (eMAR) in Electronic Record for Intensive Care (eRIC) at one adult intensive care unit (ICU) in NSW, Australia. DESIGN: The study research design used a qualitative descriptive exploratory approach that took place in two stages. METHODS: Five participants attended one focus group followed by the observation of each participant as medications were administered to their assigned patient using the eMAR in eRIC. RESULTS: From the data, three themes and one subtheme were identified. Themes included forcing nurses to work outside legal boundaries; patient safety; with a subtheme titled experiencing computer fatigue; and taking time away from the patient. To practise safely, nurses were required to implement workaround practices when using the new eMAR in ICU. Nurses also were concerned that the eMAR in eRIC took time away from the patient at the bedside and 'added more screen time' to their day.

Initiatives and partnerships in an Australian metropolitan obesity prevention system: a social network analysis.

BACKGROUND: Limited resources make prevention of complex population-level issues such as obesity increasingly challenging. Collaboration and partnerships between organisations operating in the same system can assist, however, there is a paucity of research into how relationships function at a local level. The aim of this study was to audit initiatives, explore networks, and identify potential opportunities for improving the obesity prevention system in a Health Service area of Western Australia (WA). METHODS: A mixed-methods study was undertaken in a metropolitan Health Service in Perth, WA in 2019-20. Structured face-to-face interviews (n = 51) were conducted with organisations engaged in obesity prevention, to identify prevention initiatives and their characteristics using a Systems Inventory tool. The Research Team identified the 30 most active organisations during the Systems Inventory, and an online Organisational Network Survey was administered to explore: relationships across six domains; partnership duration; frequency of interaction with other organisations; barriers to implementation; and key contributions to obesity prevention. Descriptive statistics were used to summarise barriers, contributions and Systems Inventory data. Organisational Network Survey data were analysed using social network analysis through UCINET 6 for Windows and Netdraw software. Whole network and cohesion scores were calculated: average degree; density; diameter; and degree centralization. Core-periphery analysis was conducted to identify densely connected core and sparsely connected periphery organisations. RESULTS: The Systems Inventory identified 189 unique prevention initiatives, mostly focusing on individual-level behaviour change. Fifty four percent (n = 15) of the Organisational Network Survey respondent organisations and most core organisations (67%, n = 8) were government. The information and knowledge sharing network had a density of 45% indicating a high level of information and knowledge exchange between organisations. The lowest densities were found within the receiving (3.3%), providing (5.5%) and sharing (5.6%) funding networks, suggesting that these formal relationships were the least established. CONCLUSION: Applying a systems thinking lens to local obesity prevention revealed that initiatives conducted focused on individual-level behaviour change and that collaboration and communication between organisations focused on information sharing. Capturing the extent and nature of initiatives and the way partnerships operate to improve obesity prevention can help to identify opportunities to strengthen the networks.

Mergers may enhance the legitimacy of community health organisations in neoliberal environments.

PURPOSE: Comprehensive primary health care (PHC) models are seldom implemented in high income countries, in part due to their contested legitimacy in neoliberal policy environments. This article explores how merging affected the perceived legitimacy of independent community health organisations in Victoria, Australia, in providing comprehensive PHC services. DESIGN/METHODOLOGY/APPROACH: A longitudinal follow-up study (2-3 years post-merger) of two amalgamations among independent community health organisations from the state of Victoria, Australia, was conducted. This article explores the perceived effects of merging on (1) the pragmatic, normative and cognitive legitimacy of studied organisations and (2) the collective legitimacy of these organisations in Victoria's health care system. Data were collected through 19 semi-structured interviews with key informants and subjected to template and thematic analyses. FINDINGS: Merging enabled individual organisations to gain greater overall legitimacy as regional providers of comprehensive PHC services and thus retain some capacity to operationalise a social model of health. Normative legitimacy was most enhanced by merging, through acquisition of a large organisational size and adoption of business practices favoured by neoliberal norms. However, mergers may have destabilised the already contested cognitive legitimacy of community health services as a group of organisations and as a comprehensible state-wide platform of service delivery. PRACTICAL IMPLICATIONS: Over-reliance on individual organisational behaviour to maintain the legitimacy of comprehensive PHC as a model of organising health and social care could lead to inequities in access to such models across communities. ORIGINALITY/VALUE: This study shows that organisations can manage their perceived legitimacy in order to ensure the survival of their preferred model of service delivery.

The International Classification of Health Interventions: an 'epistemic hub' for use in public health.

The current lack of a common basis for collecting data on population-level prevention and health promotion interventions causes public health to be relatively invisible within broader health systems, making it vulnerable to funding cuts when there is pressure to reduce spending. Further, the inconsistent use of terms for describing interventions hinders knowledge translation and building an evidence base for public health practice and policy. The International Classification of Health Interventions (ICHI), being developed by the World Health Organization, is a standard statistical classification for interventions across the full scope of health systems. ICHI has potential to meet the need for a common language and structure for describing and capturing information about prevention and health promotion interventions. We report on a developmental appraisal conducted to examine the strengths and limitations of ICHI for coding interventions delivered for public health purposes. Our findings highlight classification challenges in relation to: consistently identifying separate components within multi-component interventions; operationalizing the ICHI concept of intervention target when there are intermediary targets as well as an ultimate target; coding an intervention component that involves more than one ICHI target or action; and standardising what is being counted. We propose that, alongside its purpose as a statistical classification, ICHI can play a valuable role as an 'epistemic hub', to be used flexibly by public health actors to meet a range of information needs, and as a basis for improved communication and exchange.

Core and peripheral organisations in prevention: Insights from social network analysis.

ISSUE: Formal (eg funded) community-level organisational collaborations are becoming more common in prevention. Rapid methods to assess organisational relationships could allow us to consider the significance of any pre-existing relationship patterns in communities that might impact on collaboration effectiveness. Insights may identify new options for practice. METHODS: We used social network analysis to study organisations engaged in prevention but not (yet) part of a formal purposive collaboration. Within a single community, we identified organisations providing programs in chronic disease prevention. We used whole network analysis methods to describe the extent to which organisations were aware, had contact, coordinated activity and/or collaborated more intensively. We also identified the contribution made to prevention locally. Results were compared with key informant interviews. RESULTS: There was an identifiable network structure, with more relationships across the network than one would expect by chance. The network had a core-periphery structure, meaning that, in terms of the relationships we measured, there were highly connected organisations who were strongly interlinked with each other (the core), alongside less connected organisations that were linked to the core but not to each other (the periphery). Core organisations were significantly more likely to have expertise in prevention and to have prevention staff. CONCLUSIONS: To our knowledge, it is new to identify inherent or "pre-existing" core-periphery structures in interorganisational health promotion. Yet, core-periphery structures are common in many social settings. They advantage entities in the core and are prone to further entrenchment. SO WHAT?: Our results map and quantify intuitive understandings about organisational "key players", thus enabling practitioners/organisations to critically reflect on what their role should be when it comes to activating communities ie to embed, or attempt to counterbalance, pre-existing power structures.

A system dynamic perspective of stop-start prevention interventions in Australia.

Time-limited prevention initiatives are frequently used to address complex and persisting public health issues, such as non-communicable diseases. This often creates issues in terms of achieving sustainable change. In this study, we use a system dynamic perspective to explore the effects of stop-start funding over system behaviour in two community-based initiatives designed to prevent chronic diseases and obesity. We conducted a qualitative exploratory study using complexity theory as an analytical lens of two Healthy Together Communities (HTCs) initiatives in Victoria, Australia. Data were generated from 20 semi-structured interviews with health promotion practitioners and managers, from community health and local government organizations. Template analysis based on properties of complex systems informed the inductive identification of system behaviour narratives across the stop-start life-course of HTCs. A central narrative of system behaviour emerged around relationships. Within it, we identified pre-existing contextual conditions and intervention design elements that influenced non-linearity of system self-organization and adaptation, and emergence of outcomes. Examples include cynicism, personal relationships and trust, and history of collaboration. Feedback loops operated between HTCs and these conditions, in a way that could influence long-term system behaviour. Taking a dynamic life-course view of system behaviour helps understand the pre-existing contextual factors, design and implementation influences, and feedback loops which shape the long-term legacy of short-lived interventions aimed at solving complex issues. In turn, greater awareness of such interactions can inform better design and implementation of community-based interventions.

Together stronger: boundary work within an Australian systems-based prevention initiative.

Complexity and systems science are increasingly used to devise interventions to address health and social problems. Boundaries are important in systems thinking, as they bring attention to the power dynamics that guide decision-making around the framing of a situation, and how it is subsequently tackled. Using complexity theory as an analytical frame, this qualitative exploratory study examined boundary interactions between local government and community health organizations during the operationalization of a systems-based initiative to prevent obesity and chronic diseases (Healthy Together Communities-HTCs) in Victoria, Australia. Across two HTC sites, data was generated through semi-structured interviews with 20 key informants, in mid-2015. Template analysis based on properties of complex systems was applied to the data. The dynamics of boundary work are explored using three case illustrations: alignment, boundary spanning and boundary permeability. Alignment was both a process and an outcome of boundary work, and occurred at strategic, operational and individual levels. Boundary spanning was an important mechanism to develop a unified collaborative approach, and ensure that mainstream initiatives reached disadvantaged groups. Finally, some boundaries exhibited different levels of permeability for local government and community health organizations. This influenced how each organization could contribute to HTC interventions in unique, yet complementary ways. The study of boundary work offers potential for understanding the mechanisms that contribute to the nonlinear behaviour of complex systems. The complementarity of partnering organizations, and boundary dynamics should be considered when designing and operationalizing multilevel, complex systems-informed prevention initiatives.

Exploring network structure and the role of key stakeholders to understand the obesity prevention system in an Australian metropolitan health service: study protocol.

INTRODUCTION: Little progress has been made to address the increasing obesity prevalence over the past few decades, and there is growing concern about the far-reaching consequences for health and well-being related to obesity on a global scale. Systems thinking is emerging as a suitable approach for obesity prevention, as it allows health researchers, practitioners and policy-makers to systematically synthesise existing data, expose gaps, inform priority setting and identify leverage points in the system. The aim of this study is to trial a systems thinking approach to better understand the local obesity prevention system, and identify gaps and viable opportunities for health promotion activities to strengthen obesity prevention efforts in an Australian metropolitan health service. METHODS AND ANALYSIS: A mixed methods design will be undertaken in a metropolitan health service area in Perth, Western Australia in 2019-2020. A systems inventory audit will be used to identify physical activity, nutrition and overweight/obesity prevention activities taking place in the study area. An organisational network survey will be administered, and a social network analysis undertaken to examine relationships between organisations in the network. The relationships and interactions will compare the level and type of interactions each organisation has within the network. Parameters including density, centrality and betweenness will be computed using UCINET and Netdraw. ETHICS AND DISSEMINATION: Ethics approval has been obtained from the Curtin University Human Research Ethics Committee (approval number HRE2017-0862). Results will be reviewed with members of the advisory group, submitted to relevant journals and presented at relevant conferences to health promotion practitioners and policy-makers. The area health service, as co-producers of the research, will use findings to inform policy and strategy across the study area.

A prospective evaluation of first people's health promotion program design in the goulburn-murray rivers region.

BACKGROUND: Aboriginal Community Controlled Organisations (ACCOs) provide community-focussed and culturally safe services for First Peoples in Australia, including crisis intervention and health promotion activities, in a holistic manner. The ecological model of health promotion goes some way towards describing the complexity of such health programs. The aims of this project were to: 1) identify the aims and purpose of existing health promotion programs conducted by an alliance of ACCOs in northern Victoria, Australia; and 2) evaluate the extent to which these programs are consistent with an ecological model of health promotion, addressing both individual and environmental determinants of health. METHODS: The project arose from a long history of collaborative research. Three ACCOs and a university formed the Health Promotion Alliance to evaluate their health promotion programs. Local community members were trained in, and contributed to developing culturally sensitive methods for, data collection. Information on the aims and design of 88 health promotion activities making up 12 different programs across the ACCOs was systematically and prospectively collected. RESULTS: There was a wide range of activities addressing environmental and social determinants of health, as well as physical activity, nutrition and weight loss. The design of the great majority of activities had a minimal Western influence and were designed within a local Aboriginal cultural framework. The most common focus of the activities was social connectedness (76 %). Physical activity was represented in two thirds of the activities, and nutrition, weight loss and culture were each a focus of about half of the activities. A modified coding procedure designed to assess the ecological nature of these programs showed that they recruited from multiple settings; targeted a range of individual, social and environmental determinants; and used numerous and innovative strategies to achieve change. CONCLUSION: First Peoples' health promotion in the Goulburn-Murray Rivers region encompasses a broad range of social, cultural, lifestyle and community development activities, including reclaiming and strengthening cultural identity and social connectedness as a response to colonisation.

Strengths and limitations of a tool for monitoring and evaluating First Peoples' health promotion from an ecological perspective.

BACKGROUND: An ecological approach to health and health promotion targets individuals and the environmental determinants of their health as a means of more effectively influencing health outcomes. The approach has potential value as a means to more accurately capture the holistic nature of Australian First Peoples' health programs and the way in which they seek to influence environmental, including social, determinants of health. METHODS: We report several case studies of applying an ecological approach to health program evaluation using a tool developed for application to mainstream public health programs in North America - Richard's ecological coding procedure. RESULTS: We find the ecological approach in general, and the Richard procedure specifically, to have potential for broader use as an approach to reporting and evaluation of health promotion programs. However, our experience applying this tool in academic and community-based program evaluation contexts, conducted in collaboration with First Peoples of Australia, suggests that it would benefit from cultural adaptations that would bring the ecological coding procedure in greater alignment with the worldviews of First Peoples and better identify the aims and strategies of local health promotion programs. CONCLUSIONS: Establishing the cultural validity of the ecological coding procedure is necessary to adequately capture the underlying program activities of community-based health promotion programs designed to benefit First Peoples, and its collaborative implementation with First Peoples supports a human rights approach to health program evaluation.

Comparison communities in a cluster randomised trial innovate in response to 'being controlled'.

We conducted qualitative interviews among primary health care teams and community agencies in eight communities in Victoria, Australia which had (1) agreed to be part of a universal primary care and community development intervention to reduce post natal depression and promote maternal health; and (2) were randomised to the comparison arm. The purpose was to document their experience with and interpretation of the trial. Although 'control' in a controlled trial refers to the control of confounding of the trial result by factors other than allocation to the intervention, participants interpreted 'control' to mean restrictions on what they were allowed to do during the trial period. They had agreed not to use the Edinburgh Post Natal Depression Scale or the SF 36 in clinical practice and not to implement any of the elements of the intervention. We found that no elements of the intervention were implemented. However, the extension of the trial from three to five years made the trial agreement a strain. The imposition of trial conditions also encouraged a degree of lateral thinking and innovation in service delivery (quality improvement). This may have potentially contributed to the null trial results. The observations invite interrogation of intervention theory and consequent rethinking of the way contamination in a cluster trial is defined.

A review of programs that targeted environmental determinants of Aboriginal and Torres Strait Islander health.

OBJECTIVE: Effective interventions to improve population and individual health require environmental change as well as strategies that target individual behaviours and clinical factors. This is the basis of implementing an ecological approach to health programs and health promotion. For Aboriginal People and Torres Strait Islanders, colonisation has made the physical and social environment particularly detrimental for health. METHODS AND RESULTS: We conducted a literature review to identify Aboriginal health interventions that targeted environmental determinants of health, identifying 21 different health programs. Program activities that targeted environmental determinants of health included: Caring for Country; changes to food supply and/or policy; infrastructure for physical activity; housing construction and maintenance; anti-smoking policies; increased workforce capacity; continuous quality improvement of clinical systems; petrol substitution; and income management. Targets were categorised according to Miller's Living Systems Theory. Researchers using an Indigenous community based perspective more often identified interpersonal and community-level targets than were identified using a Western academic perspective. CONCLUSIONS: Although there are relatively few papers describing interventions that target environmental determinants of health, many of these addressed such determinants at multiple levels, consistent to some degree with an ecological approach. Interpretation of program targets sometimes differed between academic and community-based perspectives, and was limited by the type of data reported in the journal articles, highlighting the need for local Indigenous knowledge for accurate program evaluation. IMPLICATIONS: While an ecological approach to Indigenous health is increasingly evident in the health research literature, the design and evaluation of such programs requires a wide breadth of expertise, including local Indigenous knowledge.

Fair and just or just fair? Examining models of government--not-for-profit engagement under the Australian Social Inclusion Agenda.

This paper explores the interrelationship between two contemporary policy debates: one focused on the social determinants of health and the other on social (inclusion) policy within contemporary welfare regimes. In both debates, academics and policy makers alike are grappling with the balance between universal and targeted policy initiatives and the role of local 'delivery' organizations in promoting health and social equality. In this paper, we discuss these debates in the context of a recent social policy initiative in Australia: the Social Inclusion Agenda. We examine two proposed models of engagement between the government and the not-for-profit welfare sector for the delivery of social services. We conclude that the two models of engagement currently under consideration by the Australian government have substantially different outcomes for the health of disadvantaged communities and the creation of a more socially inclusive Australia.

A typology of practice narratives during the implementation of a preventive, community intervention trial.

BACKGROUND: Traditional methods of process evaluation encompass what components were delivered, but rarely uncover how practitioners position themselves and act relative to an intervention being tested. This could be crucial for expanding our understanding of implementation and its contribution to intervention effectiveness. METHODS: We undertook a narrative analysis of in-depth, unstructured field diaries kept by nine community development practitioners for two years. The practitioners were responsible for implementing a multi-component, preventive, community-level intervention for mothers of new babies in eight communities, as part of a cluster randomised community intervention trial. We constructed a narrative typology of approaches to practice, drawing on the phenomenology of Alfred Schutz and Max Weber's Ideal Type theory. RESULTS: Five types of practice emerged, from a highly 'technology-based' type that was faithful to intervention specifications, through to a 'romantic' type that held relationships to be central to daily operations, with intact relationships being the final arbiter of intervention success. The five types also differed in terms of how others involved in the intervention were characterized, the narrative form (e.g., tragedy, satire) and where and how transformative change in communities was best created. This meant that different types traded-off or managed the priorities of the intervention differently, according to the deeply held values of their type. CONCLUSIONS: The data set constructed for this analysis is unique. It revealed that practitioners not only exercise their agency within interventions, they do so systematically, that is, according to a pattern. The typology is the first of its kind and, if verified through replication, may have value for anticipating intervention dynamics and explaining implementation variation in community interventions.