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Background: Online health services are a rapidly growing aspect of public health provision, including testing for sexually transmitted and other blood-borne infections (STBBI). Generally, healthcare providers, policymakers, and clients imbue online approaches with great positive potential (e.g., encouraging clients' agency; providing cost-effective services to more clients). However, the promise of online health services may vary across contexts and be perceived in negative or ambiguous ways (e.g., risks to 'gold standard' care provision; loss of provider control over an intervention; uncertainty related to budget implications). This study examines attitudes and perceptions regarding the development of a novel online STBBI testing service in Vancouver, Canada. We examine the perceptions about the intervention's potential by interviewing practitioners and planners who were engaged in the development and initial implementation of this testing service., Methods: We conducted in-depth interviews with 37 healthcare providers, administrators, policymakers, and community-based service providers engaged in the design and launch of the new online STBBI testing service. We also conducted observations during planning and implementation meetings for the new service. Thematic analysis techniques were employed to identify codes and broader discursive themes across the interview transcripts and observation notes., Results: Some study participants expressed concern that the potential popularity of the new testing service might increase demand on existing sexual health services or become fiscally unsustainable. However, most participants regarded the new service as having the potential to improve STBBI testing in several ways, including reducing waiting times, enhancing privacy and confidentiality, appealing to more tech-savvy sub-populations, optimizing the redistribution of demands on face-to-face service provision, and providing patient-centred technology to empower clients to seek testing., Conclusions: Participants perceived this online STBBI testing service to have the potential to improve sexual health care provision. But, they also anticipated actions-and-reactions, revealing a need to monitor ongoing implementation dynamics. They also identified the larger, potentially system-transforming dimension of the new technology, which enables new system drivers (consumers) and reduces the amount of control health care providers have over online STBBI testing compared to conventional in-person testing.

Background: The effectiveness of many interventions to promote health and prevent disease has been well established. The imperative has therefore shifted from amassing evidence about efficacy to scale-up to maximise population-level health gains. Electronic implementation monitoring, or 'e-monitoring', systems have been designed to assist and track the delivery of preventive policies and programs. However, there is little evidence on whether e-monitoring systems improve the dissemination, adoption, and ongoing delivery of evidence-based preventive programs. Also, given considerable difficulties with e-monitoring systems in the clinical sector, scholars have called for a more sophisticated re-examination of e-monitoring's role in enhancing implementation., Methods: In the state of New South Wales (NSW), Australia, the Population Health Information Management System (PHIMS) was created to support the dissemination of obesity prevention programs to 6000 childcare centres and elementary schools across all 15 local health districts. We have established a three-way university-policymaker-practice research partnership to investigate the impact of PHIMS on practice, how PHIMS is used, and how achievement of key performance indicators of program adoption may be associated with local contextual factors. Our methods encompass ethnographic observation, key informant interviews and participatory workshops for data interpretation at a state and local level. We use an on-line social network analysis of the collaborative relationships across local health district health promotion teams to explore the relationship between PHIMS use and the organisational structure of practice., Discussion: Insights will be sensitised by institutional theory, practice theory and complex adaptive system thinking, among other theories which make sense of socio-technical action. Our working hypothesis is that the science of getting evidence-based programs into practice rests on an in-depth understanding of the role they play in the on-going system of local relationships and multiple accountabilities. Data will be synthesised to produce a typology to characterise local context, PHIMS use and key performance indicator achievement (of program implementation) across the 15 local health districts. Results could be used to continuously align e-monitoring technologies within quality improvement processes to ensure that such technologies enhance practice and innovation. A partnership approach to knowledge production increases the likelihood that findings will be put into practice.

Background: Complexity has been linked to health interventions in two ways: first as a property of the intervention, and secondly as a property of the system into which the intervention is implemented. The former recognizes that interventions may consist of multiple components that act both independently and interdependently, making it difficult to identify the components or combinations of components (and their contexts) that are important mechanisms of change. The latter recognizes that interventions are implemented in complex adaptive systems comprised of intelligent agents who modify their behaviour (including any actions required to implement the intervention) in an effort to improve outcomes relative to their own perspective and objectives. Although an intervention may be intended to take a particular form, its implementation and impact within the system may deviate from its original intentions as a result of adaptation. Complexity highlights the challenge in developing interventions as effective health solutions. The UK Medical Research Council provides guidelines on the development and evaluation of complex interventions. While mathematical modelling is included in the guidelines, there is potential for mathematical modeling to play a greater role., Discussion: The dynamic non-linear nature of complex adaptive systems makes mathematical modelling crucial. However, the tendency is for models of interventions to limit focus on the ecology of the system - the 'real-time' operation of the system and impacts of the intervention. These models are deficient by not modelling the way the system reacts to the intervention via agent adaptation. Complex intervention modelling needs to capture the consequences of adaptation through the inclusion of an evolutionary dynamic to describe the long-term emergent outcomes that result as agents respond to the ecological changes introduced by intervention in an effort to produce better outcomes for themselves. Mathematical approaches such as those found in economics in evolutionary game theory and mechanism design can inform the design and evaluation of health interventions. As an illustration, the introduction of a central screening clinic is modeled as an example of a health services delivery intervention. Complexity necessitates a greater role for mathematical models, especially those that capture the dynamics of human actions and interactions.

Background: Whole school, ethos-changing interventions reduce risk behaviours in middle adolescence, more than curriculum-based approaches. Effects on older ages are not known. We set out to replicate one of these interventions, Australia's Gatehouse Project, in a rural Canadian high school., Methods: A guided, whole school change process sought to make students feel more safe, connected, and valued by: changes in teaching practices, orientation processes, professional development of staff, recognition and reward mechanisms, elevating student voice, and strategies to involve greater proactivity and participation. We conducted risk behaviour surveys in grades 10 to 12 before the intervention and 2 years afterwards, and social network analyses with the staff. Changes in health and health risk behaviours were assessed using chi-square. Interactions between the intervention and gender and between the intervention and school engagement were assessed using interaction terms in logistic regression models. Changes in the density of relationships among staff were tested with methods analogous to paired t-tests., Results: Like Gatehouse, there was no statistically significant reduction in depressive symptoms or bullying, though the trend was in that direction. Among girls, there was a statistically significant decrease in low school engagement (45% relative reduction), and decreases in drinking (46% relative reduction), unprotected sex (61% relative reduction) and poor health (relative reduction of 73%). The reduction in drinking matched the national trend. Reductions in unprotected sex and poor health went against the national trend. We found no statistically significant changes for boys. The effects coincided with statistically significant increases in the densities of staff networks, indicating that part of the mechanism may be through relationships at school., Conclusions: A non-specific, risk protective intervention in the social environment of the school had a significant impact on a cluster of risk behaviours for girls. Results were remarkably like reports from similar school environment interventions elsewhere, albeit with different behaviours being affected. It may be that this type of intervention activates change processes that interact highly with context, impacting different risks differently, according to the prevalence, salience and distribution of the risk and the interconnectivity of relationships between staff and students. This requires further exploration.

Background: Low levels of physical activity and increased participation in sedentary leisure-time activities are two important obesity-risk behaviors that impact the health of today's youth. Friend's health behaviors have been shown to influence individual health behaviors; however, current evidence on the specific role of friendship networks in relation to levels of physical activity and sedentary behavior is limited. The purpose of this review was to summarize evidence on friendship networks and both physical activity and sedentary behavior among children and adolescents., Method: After a search of seven scientific databases and reference scans, a total of thirteen articles were eligible for inclusion. All assessed the association between friendship networks and physical activity, while three also assessed sedentary behavior., Results: Overall, higher levels of physical activity among friends are associated with higher levels of physical activity of the individual. Longitudinal studies reveal that an individual's level of physical activity changes to reflect his/her friends' higher level of physical activity. Boys tend to be influenced by their friendship network to a greater extent than girls. There is mixed evidence surrounding a friend's sedentary behavior and individual sedentary behavior., Conclusion: Friends' physical activity level appears to have a significant influence on individual's physical activity level. Evidence surrounding sedentary behavior is limited and mixed. Results from this review could inform effective public health interventions that harness the influence of friends to increase physical activity levels among children and adolescents.

Background: We study geographic variation within one community in the City of Calgary using a more fine-grained geographic unit than the Census tract, the Census Dissemination Area (DA). While most Riverside residents consider their neighbourhood to be a fairly cohesive community, we explore the effect of socio-economic variation between these small geographic areas on individuals' self-reported health, net of individual level determinants., Methods: We merge data from the 2001 Census for Riverside, Calgary with a 2004 random telephone survey of Riverside residents. Our data are unique in that we have information on individuals from every DA wholly contained in the Riverside community. These data enable us to conduct multinomial logistic regression analyses of self-reported health using both individual-level and DA-level variables as predictors., Results: We find significant variation in measures of DA socio-economic status within the Riverside community. We find that individual self-reported health is affected by variation in an index of DA-level socio-economic disadvantage, controlling for individual variation in gender, age, and socio-economic status. We investigate each aspect of the DA index of disadvantage separately, and find that average education and the percent of households that are headed by a lone parent are most important., Conclusions: These findings demonstrate that, even within a cohesive community, contextual effects on health can be located at a smaller geographic level than the Census tract. Research on the effects of local area socio-economic disadvantage on health that combines administrative and survey data enables researchers to develop more comprehensive measures of social and material deprivation. Our findings suggest that both social and material deprivation affect health at the local level.

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.