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The Lancet Commission report on COVID-19 recently described a 'staggering' death toll (approaching 7 million at the time of writing) (1) and declared the pandemic response 'a massive global failure [...]

To authenticate to the full-text of this article, please visit this link: http://dx.doi.org/10.1111/j.1468-0009.2010.00610.x Byline: TRISHA GREENHALGH (1) Author Affiliation: (1)Barts and the London School of Medicine and Dentistry, University of London Article note: Address correspondence to: Trisha Greenhalgh, Healthcare Innovation and Policy Unit, Centre for Health Sciences, Barts and The London School of Medicine and Dentistry, Abernethy Building, 2 Newark Street, London E1 2AT (email: p.greenhalgh@qmul.ac.uk).

To authenticate to the full-text of this article, please visit this link: http://dx.doi.org/10.1111/j.1467-9566.2010.01243.x Byline: Christine Chan (1), Toity Deave (2), Trisha Greenhalgh (3) Keywords: obesity; modernity; urbanisation; ethnography; healthy cities Abstract: Abstract Childhood obesity is particularly prevalent in areas that have seen rapid economic growth, urbanisation, cultural transition, and commodification of food systems. Structuration theory may illuminate the interaction between population and individual-level causes of obesity. We conducted in-depth ethnographies of six overweight/obese and four non-overweight preschool children in Hong Kong, each followed for 12-18 months. Analysis was informed by Stones' strong structuration theory. Risk factors played out differently for different children as social structures were enacted at the level of family and preschool. The network of caregiving roles and relationships around the overweight/obese child was typically weak and disjointed, and the primary caregiver appeared confused by mixed messages about what is normal, expected and legitimate behaviour. In particular, external social structures created pressure to shift childcare routines from the logic of nurturing to the logic of consumption. Our findings suggest that threats to what Giddens called ontological security in the primary caregiver may underpin the poor parenting, family stress and weak mealtime routines that mediate the relationship between an obesogenic environment and the development of obesity in a particular child. This preliminary study offers a potentially transferable approach for studying emerging epidemics of diseases of modernity in transition societies. Author Affiliation: (1)Department of Early Childhood Education, The Hong Kong Institute of Education, Tai Po, New Territories, Hong Kong (2)Centre for Child and Adolescent Health, University of the West of England, Bristol (3)Centre for Health Sciences, Barts and The London School of Medicine and Dentistry, Queen Mary University of London Article note: Address for correspondence: Trisha Greenhalgh, Centre for Health Sciences, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 2 Newark Street, London E1 2AT, e-mail: p.greenhalgh@qmul.ac.uk

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.socscimed.2009.12.034 Byline: Trisha Greenhalgh (a), Rob Stones (b) Abstract: The UK National Health Service is grappling with various large and controversial IT programmes. We sought to develop a sharper theoretical perspective on the question 'What happens - at macro-, meso- and micro-level - when government tries to modernise a health service with the help of big IT?' Using examples from data fragments at the micro-level of clinical work, we considered how structuration theory and actor-network theory (ANT) might be combined to inform empirical investigation. argued that social structures and human agency are recursively linked and co-evolve. ANT studies the relationships that link people and technologies in dynamic networks. It considers how discourses become inscribed in data structures and decision models of software, making certain network relations irreversible. strong structuration theory (SST) is a refinement of Giddens' work, systematically concerned with empirical research. It views human agents as linked in dynamic networks of position-practices. A quadripartite approcach considers [a] external social structures (conditions for action); [b] internal social structures (agents' capabilities and what they 'know' about the social world); [c] active agency and actions and [d] outcomes as they feed back on the position-practice network. In contrast to early structuration theory and ANT, SST insists on disciplined conceptual methodology and linking this with empirical evidence. In this paper, we adapt SST for the study of technology programmes, integrating elements from material interactionism and ANT. We argue, for example, that the position-practice network can be a socio-technical one in which technologies in conjunction with humans can be studied as 'actants'. Human agents, with their complex socio-cultural frames, are required to instantiate technology in social practices. Structurally relevant properties inscribed and embedded in technological artefacts constrain and enable human agency. The fortunes of healthcare IT programmes might be studied in terms of the interplay between these factors. Author Affiliation: (a) University College London, London, United Kingdom (b) University of Essex, Essex, United Kingdom

To authenticate to the full-text of this article, please visit this link: http://dx.doi.org/10.1111/j.1468-0009.2009.00578.x Byline: TRISHA GREENHALGH (1), HENRY W.W. POTTS (1), GEOFF WONG (1), PIPPA BARK (1), DEBORAH SWINGLEHURST (1) Keywords: Systematic review; electronic patient records; innovation Abstract: Context: The extensive research literature on electronic patient records (EPRs) presents challenges to systematic reviewers because it covers multiple research traditions with different underlying philosophical assumptions and methodological approaches. Methods: Using the meta-narrative method and searching beyond the Medline-indexed literature, this review used 'conflicting' findings to address higher-order questions about how researchers had differently conceptualized and studied the EPR and its implementation. Findings: Twenty-four previous systematic reviews and ninety-four further primary studies were considered. Key tensions in the literature centered on (1) the EPR ('container' or 'itinerary'); (2) the EPR user ('information-processer' or 'member of socio-technical network'); (3) organizational context ('the setting within which the EPR is implemented' or 'the EPR-in-use'); (4) clinical work ('decision making' or 'situated practice'); (5) the process of change ('the logic of determinism' or 'the logic of opposition'); (6) implementation success ('objectively defined' or 'socially negotiated'); and (7) complexity and scale ('the bigger the better' or 'small is beautiful'). Conclusions: The findings suggest that EPR use will always require human input to recontextualize knowledge; that even though secondary work (audit, research, billing) may be made more efficient by the EPR, primary clinical work may be made less efficient; that paper may offer a unique degree of ecological flexibility; and that smaller EPR systems may sometimes be more efficient and effective than larger ones. We suggest an agenda for further research. Author Affiliation: (1)University College London Article note: Address correspondence to: Trisha Greenhalgh, University College London, 206 Holborn Union Building, Highgate Hill, London N19 5LW, England (email: p.greenhalgh@ucl.ac.uk).

To authenticate to the full-text of this article, please visit this link: http://dx.doi.org/10.1111/j.1468-0009.2009.00562.x Byline: TRISHA GREENHALGH (1), CHARLOTTE HUMPHREY (1), JANE HUGHES (1), FRASER MACFARLANE (1), CERI BUTLER (1), RAY PAWSON (1) Keywords: Modernization; change; transformation; realist evaluation Abstract: Context: Large-scale, whole-systems interventions in health care require imaginative approaches to evaluation that go beyond assessing progress against predefined goals and milestones. This project evaluated a major change effort in inner London, funded by a charitable donation of approximately $21 million, which spanned four large health care organizations, covered three services (stroke, kidney, and sexual health), and sought to 'modernize' these services with a view to making health care more efficient, effective, and patient centered. Methods: This organizational case study draws on the principles of realist evaluation, a largely qualitative approach that is centrally concerned with testing and refining program theories by exploring the complex and dynamic interaction among context, mechanism, and outcome. This approach used multiple data sources and methods in a pragmatic and reflexive manner to build a picture of the case and follow its fortunes over the three-year study period. The methods included ethnographic observation, semistructured interviews, and scrutiny of documents and other contemporaneous materials. As well as providing ongoing formative feedback to the change teams in specific areas of activity, we undertook a more abstract, interpretive analysis, which explored the context-mechanism-outcome relationship using the guiding question 'what works, for whom, under what circumstances?' Findings: In this example of large-scale service transformation, numerous projects and subprojects emerged, fed into one another, and evolved over time. Six broad mechanisms appeared to be driving the efforts of change agents: integrating services across providers, finding and using evidence, involving service users in the modernization effort, supporting self-care, developing the workforce, and extending the range of services. Within each of these mechanisms, different teams chose widely differing approaches and met with differing success. The realist analysis of the fortunes of different subprojects identified aspects of context and mechanism that accounted for observed outcomes (both intended and unintended). Conclusions: This study was one of the first applications of realist evaluation to a large-scale change effort in health care. Even when an ambitious change program shifts from its original goals and meets unforeseen challenges (indeed, precisely because the program morphs and adapts over time), realist evaluation can draw useful lessons about how particular preconditions make particular outcomes more likely, even though it cannot produce predictive guidance or a simple recipe for success. Noting recent calls by others for the greater use of realist evaluation in health care, this article considers some of the challenges and limitations of this method in the light of this experience and suggests that its use will require some fundamental changes in the worldview of some health services researchers. Author Affiliation: (1)University College London; King's College London; University of Surrey; University of Leeds Article note: Address correspondence to: Trisha Greenhalgh, 206 Holborn Union Building, Highgate Hill, London N19 5LW, United Kingdom (email: p.greenhalgh@pcps.ucl.ac.uk).

This article summarises the findings from a large qualitative study in east London. In a series of focus groups involving 147 people, the team explored the perceptions of the Bangladeshi [...]

Health research is fundamental to the development of improved health and healthcare. Despite its importance, and the role of policy in guiding the kind of research that gets addressed, there are very few empirical studies of health research policy. This paper redresses this, exploring the means by which one area of health research policy is shaped, enabled and constrained. We ask: what are the historical, social and political origins of research policy in primary care in England? What are the key discourses that have dominated debate; and what are the tensions between discourses and the implications this raises for practitioners and policymakers? To answer these questions we employed a Foucauldian approach to discourse analysis to explicitly recognise the historical, social and ideological origins of policy texts; and the role of power and knowledge in policy development. We adapted Parker's framework for distinguishing discourses as a means of selecting and analysing 29 key policy documents; 16 narrative interviews with historical and contemporary policy stakeholders; and additional contextual documents. Our analysis involved detailed deconstruction and linking across texts to reveal prevailing storylines, ideologies, power relations, and tensions. Findings show how powerful policy discourses shaped by historical and social forces influence the type of research undertaken, by whom and how. For instance, recent policy has been shaped by discourse associated with the knowledge-based economy that emphasises microscopic 'discovery', exploitation of information and the contribution of highly technological activities to 'UK plc' and has re-positioned primary care research as a strategic resource and 'population laboratory' for clinical research. Such insights challenge apolitical accounts of health research and reveal how health research serves particular interests. Keywords: Health research policy; Primary care; Knowledge-based economy; UK; Discourse analysis

To purchase or authenticate to the full-text of this article, please visit this link: http://dx.doi.org/10.1111/j.1467-9566.2007.01047.x Byline: Trisha Greenhalgh (1), Christopher Voisey (1), Nadia Robb (1) Keywords: minority ethnic groups; interpreting; translation; organisational routines; identity; primary healthcare Abstract: Abstract UK general practices operate in an environment of high linguistic diversity, because of recent large-scale immigration and of the NHS's commitment to provide a professional interpreter to any patient if needed. Much activity in general practice is co-ordinated and patterned into organisational routines (defined as repeated patterns of interdependent actions, involving multiple actors, bound by rules and customs) that tend to be stable and to persist. If we want to understand how general practices are responding to pressures to develop new routines, such as interpreted consultations, we need to understand how existing organisational routines change. This will then help us to address a second question, which is how the interpreted consultation itself is being enacted and changing as it becomes routinised (or not) in everyday general practice. In seeking answers to these two questions, we undertook a qualitative study of narratives of interpreted primary care consultations in three London boroughs with large minority ethnic populations. In 69 individual interviews and two focus groups, we sought accounts of interpreted consultations from service users, professional interpreters, family member interpreters, general practitioners, practice nurses, receptionists, and practice managers. We asked participants to tell us both positive and negative stories of their experiences. We analysed these data by searching for instances of concepts relating to the organisational routine, the meaning of the interpreted consultation to the practice, and the sociology of medical work. Our findings identified a number of general properties of the interpreted consultation as an organisational routine, including the wide variation in the form of adoption, the stability of the routine, the adaptability of the routine, and the strength of the routine. Our second key finding was that this variation could be partly explained by characteristics of the practice as an organisation, especially whether it was traditional (small, family-run, 'personal' identity, typically multilingual, loose division of labour, relatively insular) or contemporary (large, bureaucratic, 'efficient' identity, typically monolingual, clear division of labour, richly networked). We conclude that there is a fruitful research agenda to be explored that links the organisational dimension of interpreting services with studies of clinical care and outcomes. Author Affiliation: (1)Department of Primary Care and Population Sciences, University College London Article note: Address for correspondence: Trisha Greenhalgh, Department of Primary Care and Population Sciences, University College London, 417 Holborn Union Building, Highgate Hill, London N19 5LW, e-mail: p.greenhalgh@pcps.ucl.ac.uk

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.socscimed.2006.03.033 Byline: Trisha Greenhalgh, Nadia Robb, Graham Scambler Keywords: Healthcare consultations; Interpreting; Translation; Primary health care; Health literacy; Habermas; UK Abstract: We report a qualitative study of accounts of interpreted consultations in UK primary care. The study sought to explore how three Habermasian tensions between (a) system and lifeworld, (b) communicative and strategic action, and (c) interpersonal and macropolitical spheres played out in the triadic consultation between clinician, interpreter and patient. In a total of 69 individual interviews and two focus groups, we collected narratives from service users (through interpreters or bilingual researchers), interpreters and doctors and other staff in general practice. We recorded, transcribed and analysed these, taking the story as the main unit of analysis. Our data suggest that the preconditions for communicative action are rarely met in the interpreted consultation. The interpreter's presence makes a dyadic interaction into a triad, adding considerable complexity to the social situation and generating operational and technical challenges. Lack of trust, intense pressure of time, mismatch of agendas (biomedical versus lifeworld), firm expectations of a specific outcome (e.g. referral, prescription) and profound power imbalances all promote strategic action (i.e. speech that seeks consciously or unconsciously to manipulate an outcome) rather than communicative action (i.e. sincere efforts to achieve understanding, and reach consensus) by all parties. In consultations interpreted by family members (an option traditionally seen as 'second best' by policy makers), the social situation is very different. Family members are generally trusted, share the lifeworld agenda, and shift the power balance in the patient's favour. The interpreter occupies multiple social roles, including translator, interpersonal mediator, system mediator, educator, advocate, and link worker. The essence of professionalism in interpreting is shifting judiciously between these potentially conflicting roles. We discuss the implications of our findings for communication with limited English speakers in healthcare consultations and for realizing contemporary policy goals such as concordance, shared decision-making, empowerment, and choice. Author Affiliation: University College London, London, UK

Producing literature reviews of complex evidence for policymaking questions is a challenging methodological area. There are several established and emerging approaches to such reviews, but unanswered questions remain, especially around how to begin to make sense of large data sets drawn from heterogeneous sources. Drawing on Kuhn's notion of scientific paradigms, we developed a new method--meta-narrative review--for sorting and interpreting the 1024 sources identified in our exploratory searches. We took as our initial unit of analysis the unfolding 'storyline' of a research tradition over time. We mapped these storylines by using both electronic and manual tracking to trace the influence of seminal theoretical and empirical work on subsequent research within a tradition. We then drew variously on the different storylines to build up a rich picture of our field of study. We identified 13 key meta-narratives from literatures as disparate as rural sociology, clinical epidemiology, marketing and organisational studies. Researchers in different traditions had conceptualised, explained and investigated diffusion of innovations differently and had used different criteria for judging the quality of empirical work. Moreover, they told very different over-arching stories of the progress of their research. Within each tradition, accounts of research depicted human characters emplotted in a story of (in the early stages) pioneering endeavour and (later) systematic puzzle-solving, variously embellished with scientific dramas, surprises and 'twists in the plot'. By first separating out, and then drawing together, these different metanarratives, we produced a synthesis that embraced the many complexities and ambiguities of 'diffusion of innovations' in an organisational setting. We were able to make sense of seemingly contradictory data by systematically exposing and exploring tensions between research paradigms as set out in their over-arching storylines. In some traditions, scientific revolutions were identifiable in which breakaway researchers had abandoned the prevailing paradigm and introduced a new set of concepts, theories and empirical methods. We concluded that meta-narrative review adds value to the synthesis of heterogeneous bodies of literature, in which different groups of scientists have conceptualised and investigated the 'same' problem in different ways and produced seemingly contradictory findings. Its contribution to the mixed economy of methods for the systematic review of complex evidence should be explored further. Keywords: Systematic review; Narrative; Meta-narrative; Diffusion of innovations

This article summarizes an extensive literature review addressing the question, How can we spread and sustain innovations in health service delivery and organization? It considers both content (defining and measuring the diffusion of innovation in organizations) and process (reviewing the literature in a systematic and reproducible way). This article discusses (1) a parsimonious and evidence-based model for considering the diffusion of innovations in health service organizations, (2) clear knowledge gaps where further research should be focused, and (3) a robust and transferable methodology for systematically reviewing health service policy and management. Both the model and the method should be tested more widely in a range of contexts.