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Chapter 5. Actors in PHIR

p. 93-118


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1As seen in Chapter 1, a population health intervention is not simply a list of activities to be implemented. It is clearly much more complex than that, and the roles played by contexts and actors are key to the success of a population health intervention (Craig et al., 2018), as particularly underscored in the realistic approach described above. The proponents of this approach even argue that, if an intervention is effective, it is not just because the activities were well implemented, but rather, and above all, because the (social) actors decided it was possible. They explain that it is people, through their decisions, intentions, and reasoning, who make a population health intervention work (or not) (Pérez et al., 2021; Robert & Ridde, 2014). We will not address the methodological and epistemological issues of this worldview in this chapter (Pawson, 2013), but it is useful for showing to what extent the actors are at the heart of population health interventions (Gilson, 2012). Like health systems, population health interventions are clearly social phenomena in which the role of individuals is central (Whyle & Olivier, 2020). It is thus essential to understand these different categories of actors and, in the context of PHIR, the various roles they can play.

The categorisation of PHIR actors

2This book is not a reflection by sociologists or political scientists (Crozier & Friedberg, 1977; Lipsky, 2010) on the social actors at the heart of PHIR. Our primary aim is to equip those involved in this subject matter so that they can better understand it. However, the ability to understand the stakeholders in an intervention, and to categorise, analyse, and engage in dialogue with them, is also an essential competency in evaluation and population health (Stevahn et al., 2005). Indeed:

“…failure to attend to the interests, needs, concerns, powers, priorities, and perspectives of stakeholders represents a serious flaw in thinking or action that too often and too predictably leads to poor performance, outright failure, or even disaster.” (Bryson et al., 2011).

3While this know-how must be applied throughout a PHIR process (Bryson et al., 2011), it will be especially essential at the start, particularly during the pre-evaluation phase (evaluability assessment) (Beaudry & Gauthier, 1992; Soura et al., 2019). Thus, it is useful, both for this chapter and for PHIR practice, to show how different people can propose different approaches for categorising actors. Each person, depending on their circumstances, objectives, and skills, can select the most appropriate methodological approaches for this stakeholder analysis exercise (Brugha & Varvasovszky, 2000; Hurteau et al., 2012). Bryson and colleagues (2011) propose some very useful tools. Moreover, this list is not intended to be exhaustive (as in Chapter 1), but simply to shed light on the possibilities based on a few disciplinary approaches (see Table 6).

Table 6. Examples of PHIR stakeholder groups across three disciplines.

Evaluation

Public policies

Anthropology

Legitimising
Implementers
Beneficiaries

Managers
Agents
Individuals concerned

Strategic Groups

4In the field of evaluation, and particularly with regard to the decision-making involved, some have proposed that there are three groups of people. The first are the doers, i.e. those implementing the intervention. The second are the recipients, i.e. those who should benefit from the actions and for whom they have normally been intended. Finally, the third group consists of legitimators, i.e. those who will ultimately formalise the decisions (Monnier & Spenlehauer, 1992). In the field of policy research, Kingdon (1995) and Lemieux (2002) have proposed dividing actors into four groups according to their position with respect to the government and their expertise in the subject matter. Thus, they propose that there are officials (in government but not specialists), agents (in government and specialists), interested parties (outside government and specialists), and individuals (outside government and non-specialists). These are all groups within which social actors can be placed, with the understanding, of course, that these categories are permeable and that people are mobile. In the context of health system reforms, Rocher (2004) proposes a slightly different set of actors. He thus suggests the existence of reform designers, then promoters, and then modellers, who will be responsible for transforming the ideas into action plans. Next, he describes the existence of couriers and intermediaries who disseminate the reform’s ideas to frontline actors in particular (Lipsky, 2010), much like the dissemination entrepreneurs in a health intervention in Mali analysed by Gautier and colleagues (2019). Finally, Rocher (2004) proposes the presence of reform operators, who will implement it, and of opponents, who will use their energy and position to counter and resist the reform. This sociological perspective is in line with the classical thinking of political scientists and the role of power in the analysis of interventions (Béland, 2010). Indeed, we know very well that “it is through the exercise of power that [population health interventions] are, or are not, implemented” (Lemieux, 2002). Reich and Campos (2020) recently suggested a method for analysing the actors in health reforms based on their position with regard to the proposed changes and their power (or influence) over them. In particular, this approach groups actors according to whether they support, oppose, or are neutral about the reform, as well as their level of potential influence. Interest, position, and power are classic dimensions of stakeholder analysis in a health intervention (Balane et al., 2020). Based on a review of the scientific literature, consultation with experts, and a group consensus exercise, Balane and colleagues (2020) propose that stakeholder analysis should study the actors concerned along four dimensions that could have an effect on the intervention: knowledge (its scope), interests (and motivations), power (political, financial, technical, leadership), and position (support, opposition, neutrality). Finally, the last example is from the field of development anthropology, where Bierschenk and Olivier de Sardan (1994) have proposed, after a German sociologist (Evers), labile groups of actors that they call strategic groups. These groups are starting points for empirical analyses, especially around conflicts and controversies (somewhat similar to actor-network theory), without necessarily becoming the final groups.

5This overview of possible approaches for identifying and analysing stakeholders in a health intervention will be useful in the remainder of this chapter to describe the actors involved in PHIR. First, we will present these stakeholder groups and analyse where they fit within PHIR. Then we will focus on the importance of frontline actors and the challenges of working in partnership, which is an essential and integral process in PHIR.

The actors in PHIR

6The definition of PHIR proposed in Chapter 1 shows the breadth of its complexity and, by extension, the wide range of people involved and concerned. Without prejudging their importance or precedence, and keeping in mind the porosity of these six groups and the mobility of people, we consider the main stakeholders in PHIR to be as shown in Figure 10.

Figure 10. Seven groups of PHIR actors.

Image 10000000000002C20000027DD2CD7747F0CAD0D8.png

Implementers

7These are the people who implement population health intervention activities. They are sometimes involved in upstream design of the intervention, and occasionally in evaluation and research processes, but their main responsibilities are organisation and implementation. Their level of involvement may vary depending on their expertise and skills, and to different degrees of intensity depending to the needs of the intervention and its resources. They may be based at all levels of the organisations responsible for the intervention (from local to national) and may be associated with more closely connected institutions and partners (NGO, associations, etc.).

Researchers

8These individuals are mobilised not only to help design the intervention in relation to the current state of knowledge, but also to produce knowledge on population health intervention. Most often they work independently of the intervention, but sometimes they may be hired as consultants and experts to evaluate it. In most cases, the researchers work in teams, usually interdisciplinary in order to bring a diverse perspective on the intervention. These teams will be able to provide others with the methods, conceptual frameworks, and theories that are needed to understand the actions undertaken, based on the questions raised about the intervention. Unlike in clinical research, where there are many support staff positions (database managers, engineers, research associates, etc.), this is not yet sufficiently the case in PHIR.

Decision-makers

9While this is a loaded term, and undoubtedly overused, since it is rare that a single person takes a decision alone, here we refer to those in charge of organisations, who will (usually) decide on actions to meet a population health need. In a democratic system, decision-makers are accountable to the public and therefore to the people who will benefit from the interventions being evaluated. They will strive to obtain the necessary human and material resources to make the intervention feasible and to implement it. These are also the people who should be able to receive the results of research on the intervention so that they can understand it better and make decisions about its adaptation, sustainability (or termination), and dissemination. Although it is still rare, intermediate actors (Ridde et al., 2013) can operate at the interface between decision-makers and stakeholders to promote the use of research data. This point will be covered more specifically in Chapter 6.

Population

10Whether they are patients, beneficiaries of an intervention, or simply living in the area where it is implemented, the population as a whole is broadly affected by PHIR. As we have noted, the boundaries between these groups are fluid, and those benefiting from the action may also be subject experts or hold positions of responsibility in governing bodies. However, these people are more rarely involved upstream in the intervention’s development and later in its evaluation and any research on it.

Funders

11These people can sometimes be mistaken for decision-makers, but often the organisations that fund PHIR are less present in executive bodies or governing authorities. Sometimes this funding is provided specifically for the intervention, sometimes for research only, and very rarely for PHIR as a whole. These funding bodies are also found at all levels and ranges of government, from the very local to the international.

Leaders of scholarly societies and journals, and expert bodies that produce recommendations

12PHIR contributes to the construction of population health knowledge while also promoting the use of evidence to define and implement interventions. Thus, it is essential that PHIR results be shared with scholarly societies and scientific journals. These two institutions have real normative power over how knowledge derived from PHIR can be shared (in the form of syntheses, opinions, and scientific papers) and how the scientificness of this type of approach, which is still underdeveloped in the health field, is perceived in this area.

Interest groups

13A final category of actors consists of multiple interest groups, which are known to be capable of introducing conflicts of interest (see Chapter 6) into the processes of using research results. The potential impacts of these actors, which are still seldom taken into account in PHIR, unlike in clinical research, can be readily understood by observing the commercial determinants of health (de Lacy-Vawdon & Livingstone, 2020).

Stakeholder analysis at three key junctures of PHIR

14In this section, our aim is to show how these multiple actors play an essential role in the different stages and processes of PHIR. These actors’ positions and power plays will obviously depend greatly on the context, the timing of their mobilisation, and their interaction history. However, for this chapter, we propose a general analysis that illustrates the substance of the various possibilities and situations, to serve as a source of inspiration for readers involved in PHIR.

15Obviously, the seven categories of actors proposed above could be expanded ad infinitum, as could the issues around which it would be useful to organise our reflection. However, we believe the important elements for reflection are the roles and challenges encountered by these categories of actors at different junctures not only in the intervention itself (emergence, implementation, evaluation) but also in the research (design, implementation, knowledge transfer), the two being clearly intertwined, as noted in the definition of PHIR proposed in Chapter 1. It is thus impossible to represent in two dimensions these seven categories of actors, each with this triadic perspective, and with the dual intertwining of intervention and research at the heart of PHIR (7×3×2!). So, to make the reflection more readable, these processes have been grouped into three key junctures of PHIR (Figure 11), to be understood as often concurrent sub-processes (as in Kingdon’s [1995] stream theory) and not as linear steps: design, implementation, and knowledge transfer (Ridde & Dagenais, 2019), as spelled out particularly in Chapter 3.

Figure 11. Three key junctures of PHIR.

Image 100000000000031200000270952921FE94F1F2FF.png

Design of the PHIR project

16The design of the PHIR project is a crucial juncture for building a partnership (see below) among all the actors involved in understanding the problem driving the solution that will be attempted through a population health intervention. Thus, the actors need to define the content of both the intervention itself and the associated research and knowledge transfer processes (see Table 7).

Table 7. Actors’ roles and challenges in PHIR design.

Roles

Challenges

Implementers

Explain the determinants of the problem
Propose appropriate solutions
Mobilise local actors
Take evidence into account
Explain data availability
Participate in adapting data collection tools
Seek funding

Steering discussions and actions
Hiding conflicts and history
Breaking with routines
Understanding evaluation and scientific issues
Bringing on researchers late
Focusing on efficiency

Population

Explain the problem and its determinants
Participate in selecting actions
Participate in producing and validating the intervention theory

Overall perception of the problem
Representation of diversity
Position of experts

Research team

Produce the intervention theory
Clarify evaluation issues
Propose appropriate methods
Answer operational questions and produce scientific knowledge
Seek funding

Understanding the intervention logic
Understanding local contexts
Operational vs. scientific duality
Adapting to partners
Sharing methodological decision-making
Organising an interdisciplinary team

Decision-makers and funders

Identify needs for action
Provide funding
Participate in the choice of instruments
Clarify issues and decision-making processes

Being willing to get involved
Being open to complexity
Using evidence as a source of decision-making

Interest groups

Promote the interests of their members

Influencing the perception of problems and therefore of solutions

17The implementers normally have a thorough understanding of the context and of population needs with regard to the problem being addressed. As such, their role will be, among other things, to explain the determinants of the problem and propose actions to be implemented. For this, they can call on research teams to better understand the state of knowledge on the subject in question and on the interventions to be implemented. To facilitate the evaluation processes and, in particular, the methodological choices, they must be able to explain the availability of data and the questions they have about the intervention (Bamberger & Rugh, 2012). Implementers can also play a key role in mobilising local actors and adapting solutions to contexts, which they often know much better than all the other stakeholders. In particular, they can support the search for funding, but they can also be involved in adapting the tools proposed by the researchers. The challenges are related to their intimate knowledge of the contexts, which allows them to steer the discussions and actions beyond the interests of the population and to ignore pre-existing power issues and prior conflicts that outsiders may not necessarily understand rapidly or readily. Also, implementers may have a tendency to decide on the content of actions without first considering the scientific or theoretical underpinnings and then simply follow their routines. They may also begin thinking about collaborating with a research team on PHIR only after the intervention has been in place for a long time, such that it is impossible or difficult to obtain comparative data. These individuals may also tend to be more interested in analysing the effectiveness of their interventions than in understanding the processes that led (or not) to the achievement of their objectives. This challenge is compounded by their tendency to overlook or minimise the costs of the evaluative dimensions of PHIR and by their lack of availability or expertise to collaborate with researchers.

18Populations will be the primary targets of the intervention and, as users or patients, must be able to be involved at a very early stage in understanding the problem (and its determinants) and the solutions to remedy it. This involvement can be direct, by participating in discussions and workshops to formulate the intervention, or indirect, when the research team conducts a data collection process to gather their perceptions. Whenever possible, a way must be found to involve them in the production and validation of the intervention theory; there are many participatory methods for doing this. Issues related to representativeness and diversity (Ridde et al., 2021) also pose a major challenge. While there may sometimes be neighbourhood representatives or leaders of patient associations, this is not the case for all problems, and this raises the question of the representativeness of the people being included the processes (Saillant, 2004). Moreover, these people sometimes have a limited view of the problem being addressed, being focused on their local context and unaware of the state of scientific knowledge. Conversely, it may happen that the population representatives are also experts in the field being addressed (e.g. a retired doctor or scientist), which poses a different challenge in terms of their ability to consider more experiential knowledge.

19In a PHIR process, research teams have the role, among other things, of supporting the clarification of the intervention theory based on the expertise of the implementers and others involved, as well as on their own scientific knowledge (and available literature) about how the problem could be tackled. Thus, they are able to enrich the intervention theory with elements that actors on the ground sometimes overlook or are not fully aware of. They also need to make explicit the evaluation issues raised by questions of interest to other stakeholders. In particular, the research teams have to explain not only what is methodologically practicable, but also what is feasible from a budgetary standpoint, while being involved in the search for funding. They have to propose methods adapted to the context and needs, and not necessarily those with which they are most familiar. For the researchers, the challenges will be to understand the local context, the intervention, and its causal logic. They must be willing to organise an interdisciplinary team to address questions and share their power to leave room for open discussion of epistemological, disciplinary, and methodological issues. The teams need to engage less in basic research and more in mobilising rigorous but useful practical research methods to understand an intervention (and thus respond to implementers’ questions), while pursuing their own research agendas to develop scientific knowledge. Research teams are thus challenged to wear two hats, or deal with two sides of the same coin: on the one hand, to mobilise methods to answer relatively operational questions, and on the other, to develop the state of knowledge and contribute to building up the field. Finding funding will be a significant challenge, as PHIR is not yet the norm in the scientific world and in the usual calls for tender (see Box 15).

Box 15. Designing a PHIR studyagainst the dengue vector in Burkina Faso

In Burkina Faso, as elsewhere in West Africa, malaria is one of the most common diseases against which interventions are implemented. Thus, other vector-borne diseases are overlooked, such as dengue fever, even though its vector (Aedes aegypti) is widespread. A PHIR study was therefore planned in the country’s capital to assess the effectiveness of a community-based dengue intervention that involved acting on its vector presence. To decide on the content of the intervention to be deployed, the team used four sources of information: 1) a systematic review of the state of scientific knowledge; 2) conceptual models to guide the choice of intervention theory; 3) an analysis of the local context and a quantitative and qualitative study of the population’s preferences with regard to a few promising activities; and 4) an analysis of potential actions according to stakeholders (Ouédraogo et al., 2019). The evaluation showed that the intervention was effective (Ouédraogo et al., 2018).

20Decision-makers and funders should have the role of reporting on the needs driving the PHIR and of participating as much as possible in its initial design, which is known to be a factor conducive to its sustainability and to the eventual use of results (see below) (Seppey et al., 2021). They need to make the decision-making processes around the PHIR project very explicit so that all stakeholders take these into account in their subsequent involvement. Of course, it is also expected (we can dream) that decision-makers will take into account the latest evidence in defining the content of the interventions they wish to see tested by the PHIR project. One challenge is that they must accept that policy issues are not the only ones to be considered when formulating interventions and that they must provide the financial resources for PHIR. Their responsiveness and openness to complexity (which politics seeks to simplify) are other challenges to consider in interactions with them (Box 16).

Box 16. Funders involved in formulating an intervention for evidence-based advocacy

Malnutrition is a major issue in Burkina Faso, particularly in the north of the country. In this context, access to care is known to be an essential determinant of children’s nutrition, particularly since its modelling by Unicef in the 2000s. However, in West Africa, accessing the health system requires fee-for-service for everyone, including the poorest, for whom nutrition is a challenge. Governments have never wanted to become involved in user fee exemption processes. Thus, in the mid-2000s, the European Union’s Humanitarian Aid Commission (Echo) launched into funding interventions that would eliminate user fees for children under 5 years of age to show that this improvement in use of care would have an impact on malnutrition. Besides funding NGO interventions, which is its mandate, Echo funded more than 1.2 million Euros of research and knowledge brokering activities over eight years to gather scientific evidence on this approach in order to support its advocacy for policy change, something which this organisation had never done before. Ten years later, the user fee exemption strategy became a state-funded national policy (Ridde & Yaméogo, 2018).

21Finally, interest groups often of a private nature but not exclusively, may try to influence research agendas. Examples of this can be seen in the definitions of strategic research designs in certain very specific fields (nutrition, occupational health, cancer, etc.), where many groups would like to influence how the problem is approached and understood, and subsequently studied. As states increasingly embark on setting national research priorities (sometimes regional, but not often enough), this can carry risks for how the problem is understood (with solutions viewed through the lens of the interventions studied) if these groups are able to be present directly or to influence indirectly. Examples of this are economic interest groups (commercial determinants of health, influence on alcohol control strategies, etc.), community interest groups (patient associations), and ideological interest groups (faith-based, sexual health strategies, etc.). The social construction of a problem is a classic approach in public policy research (Cobb & Coughlin, 1998), and there is no reason why it should not be applied in the field of PHIR.

Implementation of a PHIR project

22Organising a PHIR project involves not only implementing the intervention to benefit the population, but also conducting research activities to better understand it and the strategies conducive to results use (see Table 8).

Table 8. Actors’ roles and challenges in PHIR implementation.

Roles

Challenges

Implementers

Implement and adapt the intervention plan
Inform about contextual developments and (new) actions
Facilitate access to the field and collaborate with researchers
Interact with decision-makers

Adhering too closely to the plan
Distorting the data or orienting the research
Instrumentalising the intervention

Populations

Participate in the implementation
Be involved in the choice of instruments and activities

Ensuring availability
Managing a variety of skills and competencies
Supporting mobility
Managing power issues and ensuring diversity

Research team

Use appropriate methods
Produce valid, useful, and timely knowledge
Manage data in ways that are transparent and accessible to everyone
Build capacity among partners

Working in interdisciplinarity and with mixed methods
Sharing symbolic academic power
Engaging in an approach still not highly valued by universities
Adopting a reflexive approach

Decision-makers and funders

Monitor the process regularly
Participate in decision-making
Facilitate access to the field
Adapt the ethical issues

Orienting the process in other directions
Taking over the intervention politically

23In this process, implementers have the role of ensuring the difficult balance between fidelity to the implementation plan, which is often overlooked by researchers using experimental approaches (Pérez et al., 2018), and continuous adaptation to the context, needs, and reactions of frontline actors and populations (see below). They must inform the research teams and decision-makers of such developments or, at the very least, must organise to keep track of them so that the evaluation does not study an intervention that does not exist (or exists only on paper) or that has fundamentally changed (which may, or may not, be a good thing), the notorious type 3 error (Ridde & Haddad, 2013). The arrival of new interventions or the occurrence of significant disruptive events must be promptly explained by the implementers so that the evaluators can factor these into evaluation processes, or decision-makers into their thinking. Implementers must be able to facilitate the research teams’ access to and understanding of the field in order to strengthen the quality of the methods they deploy. In the data collection process, the implementers must be committed to provide accurate responses and not to distort reality in order to instrumentalise the intervention, among other things. Nevertheless, PHIR makes no judgements about individuals or personal competencies, but rather about interventions as a whole, which obviously poses a challenge of understanding for implementers involved in actions associated with their positions and salaries.

24In terms of the population, patients and participants in PHIR interventions should be able to decide on their involvement in implementation. Their role in this process should not be seen as solely one of passive reception, but rather of participation and even co-construction (of instruments and activities) when relevant and necessary (Daigneault & Jacob, 2012). They must be able to be stakeholders not only in the intervention but also in the evaluation and thus in all the processes of the PHIR project (Ridde, 2006). Obviously, beyond the challenges related to availability for such participation, it must be understood as an option and not an obligation. It is also essential to ensure that people have the means (technical, human, financial) and time (availability and mobility) to participate. If they do not, it is the role of the other PHIR actors to make this possible (Box 17). This can take the form of participatory forums (see below) or capacity-building activities, for example. Power issues can sometimes be exacerbated when participants from the population are included in the PHIR arena, where implementers, decision-makers, and researchers can often have imposing and destabilising symbolic capital if they are not careful. This issue is even more important when it comes to taking into account diversity issues in PHIR to ensure that all members of society are present and involved (Ridde et al., 2021).

Box 17. Involving vulnerable populationsin action research

In the previous box, we explained how access to healthcare in Africa was constrained by a significant financial barrier. This barrier is insurmountable for the poorest, whom public policies in West Africa refer to as the indigents. In Burkina Faso and Mali, we undertook several action-research projects to find operational solutions to their access to healthcare. The main challenge that we have not yet been able to overcome is how to involve them in the whole process. In fact, these people live most often in conditions of extreme material and social deprivation and are entirely on the margins of local societies. The conditions for involving them in defining interventions have always been a subject of debate among the actors involved in various action-research projects: ethical issues, the challenge of stigmatisation, issues of power, etc. (Yaogo et al., 2012). Conscious of these issues, the action-research teams decided not to organise a collective gathering of these people to obtain their views, but rather to meet with them individually and to take time to have conversations with them in supportive conditions where they could express their needs. The analysis of their statements, lifestyles, and difficulties around using healthcare thus complemented the contextual analyses and the scientific literature review to define the content of the interventions to be carried out with the implementers (Bonnet et al., 2019; Kadio et al., 2020).

25Research teams should ensure that they are able to mobilise within a limited time frame and close to the time of the intervention. The long-time frame of research is not that of PHIR. Methodological rigour must compete with the relatively short time expected by the other PHIR colleagues and the constantly changing contexts (see Chapter 1). The role of the research teams is to serve the evaluation questions about the intervention and not to impose a particular method that the researchers prefer. The principle is to collect the data needed to answer the evaluation questions without engaging in a lengthy and costly wide-ranging collection of data for which there will subsequently be no known use (see Chapter 4). Obviously, this doesn’t mean not developing, whenever possible and when the intervention allows it, knowledge that is more theoretical, more academic, or less evaluative and pragmatic. The challenge for research teams is to maintain a balance between these two facets of the same endeavour specific to PHIR. Data management, both in terms of parsimony and transparency, is a central role for research teams (which need support staff), and all PHIR stakeholders should have access. The rationale for these methods and the use of the data must be explained to everyone, without presuming (and prejudging) anyone’s inability to understand them. It is also a matter of sharing power and, to the extent possible, throughout the PHIR, helping to build capacity for evaluation among the implementers, and even among decision-makers and population representatives. The challenge for these teams is to be willing to work in an interdisciplinary manner, as PHIR is fundamentally a venture in which several disciplines must work together harmoniously and in full complementarity (Pluye, 2019). Thus, teamwork, using complementary mixed methods and different disciplinary approaches (Pluye, 2019) and being respectful of each other, is an essential challenge in PHIR, as well as being a reflexive approach for moving processes forward (Box 18).

Box 18. When epistemological agreement among researchers is impossible

In France, a PHIR programme on social inequalities in health was launched. The project was original in that it brought together researchers who had not yet collaborated but who had, on paper, very complementary skills that would be useful a priori for understanding the complex subject of interventions aimed at reducing inequalities. They knew each other from a distance, through meetings, conferences, and reading each other’s articles. They were a medical epidemiologist, a sociologist, and three researchers in public health and health promotion. The latter advocated using a research design inspired by realistic evaluation (see Chapter 3), still very new in France and not yet well understood by the others. The debates were endless, as the epistemological divide was great, even irreconcilable. During the tense meetings, the students in attendance were baffled, and while they did not dare say anything, they sent each other SMS messages expressing surprise at the virulence of the arguments. The debates became heated in particular around the definition of the concept of “mechanism” (Lacouture et al., 2015), which is at the heart of the realistic approach and is widely debated in the field of sociology, and even anthropology (Olivier de Sardan, 2021). In the end, the programme concluded with no collaboration being possible, and each group putting forward its own ideas (Breton et al., 2017).

26However, when researchers act as consultants paid from the same funder’s intervention budget, links and conflicts of interest can arise in the PHIR process. While not all links of interest turn into conflicts of interest, it is essential that they be made public, as (almost) all clinical research teams now do. Finally, the vagaries of the intervention itself, as well as those related to mobilising the actors, make PHIR fundamentally dynamic. This can be advantageous, but it also requires researchers to find a balance between rigour and often predetermined methods, on the one hand, and the need for adjustments in knowledge production, on the other (Box 19). Thus, both the research questions and the investigative methods can evolve over the course of the PHIR project (Box 20), similar to a flexible research design (Robson, 2011).

Box 19. Obsessive and academic researchers

The research community is a broad constellation of very different people. However, when it comes to engaging in PHIR, research teams must be able to adapt to needs and find a compromise between scientific rigour and timely sharing of results. For instance, despite being well aware of these issues, two researchers had never really been able to resolve this matter, even after having been involved in PHIR many times. They were physicians trained in epidemiology or health economics who had always been obsessed with the accuracy of their analyses. They always pushed for experimental research designs that were impossible to fund, and in their statistical analyses of the effects of interventions, they always sought to validate them over months or even years. Some of their analyses were still unpublished after 10 years, a doctoral thesis in epidemiology never completed. They had many times refused to publish preliminary results for stakeholders until these were published in a scientific journal, even though it is well known that this often takes several years. This attitude is not unique to quantitative scientists, as a medical anthropologist recently refused to write a policy brief on his results until his article was published by a scholarly journal, which only happened a year later, even though he chose a journal with a 40% acceptance rate.

 

Box 20. From effectivenessto acceptability

In Nouvelle-Aquitaine (France), a PHIR project was undertaken to evaluate in a pilot study the transferability (effectiveness in another setting) of an alcohol consumption harm reduction (HR) strategy in different settings that provide treatment and support to patients (addiction treatment centres, shelters, associations, etc.).
A mixed evaluation protocol was designed to assess not only the effect of the strategy on alcohol consumption, addiction, and indicators for quality of life and recovery (quantitative study), but also the adaptations made to the HR strategy in each treatment and support setting (qualitative survey). However, as time went by and the HR strategy was implemented, ultimately the professionals did not offer it to patients as much as other strategies. It was also poorly accepted by patients, even though it had been very successful in the initial setting in which it was developed. The team therefore reoriented its research questions by no longer focusing on the conditions for its effectiveness in other settings (i.e. transferability) but rather, on the conditions for its adoption or non-adoption (feasibility, acceptability, etc).

27Decision-makers and funders should be able to monitor the intervention’s implementation on a regular basis and be involved in deciding on changes in the PHIR project content over time. For this, occasions for discussion need to be organised (see below). Depending on the context, they can also facilitate access to the field, especially for research teams, and ensure that sufficient resources are deployed. The challenges here relate to the risk that they might seek to orient interventions less towards problems relevant to the population and more towards political or organisational issues. Decision-makers must also be attentive to the ethical standards of PHIR, which cannot duplicate those of health research, often biomedical; rather, the standards must be adapted to the needs of the people concerned by the interventions, especially in a context of vulnerability (Ridde et al., 2016). The challenge, however, is that most ethics committees and their members are very often clinicians or ethicists with little knowledge of the specific ethical issues of PHIR (Hamelin et al., 2018, 2020; Yaogo et al., 2012). Thus, their advice or recommendations can sometimes introduce significant biases into the intervention’s acceptability to the individuals involved.

Knowledge transfer and PHIR

28PHIR is fundamentally concerned with the use of its results, its social function as described in Chapter 1, more than with simply disseminating knowledge in scholarly journals (see above). Thus, at the heart of PHIR is the question of knowledge transfer, an established term that in no way prejudices the interactive and multidirectional nature of the knowledge and strategies (Dagenais et al., 2013). This will be discussed in detail in Chapter 6.

29Implementers must be able not only to take into account the state of knowledge when developing their intervention, as noted above, but also to make their needs in this respect explicit in order to obtain the support of research teams or knowledge brokers (Ridde et al., 2013) who will have an intermediary role (see Chapter 6). They should participate actively in all knowledge transfer strategies resulting from their intervention because, while decision-makers are often the primary recipients of these processes, implementers also have everything to gain from reinforcing their actions. They must be able to facilitate these processes and identify the needs and issues of decision-makers and those who are intended to benefit from those processes, in order to support their adaptation to make them as effective as possible. The challenges are related to the need for availability on their part, as well as for funding for these knowledge transfer activities, which implementers often forget to plan for in their intervention budgets. They often tend to be wary of research teams, especially when the latter display superiority behaviours that leave little room for knowledge exchange. This challenge must be overcome if collaboration is to be successful. Implementers sometimes also tend to think they have no role to play in research activities or in influencing of decision-makers, yet their involvement is essential and their investment in this area can be very helpful. Some want to maintain a considerable distance from decision-makers and funders for fear of political co-optation and the instrumentalisation of their interventions in local settings.

30Populations are rarely involved in knowledge transfer activities and often relegated to being in the audience at scientific outreach or results dissemination sessions. Yet patient-experts and other people mobilised in their communities can be key to the success of these strategies (Langer et al., 2016). It is therefore essential to involve them from the beginning in planning knowledge transfer activities and subsequently in all the processes. They can have an important role in influencing decision-makers in their local settings, as populations are also the ones who vote and have close connections with elected officials. The challenges associated with their involvement in knowledge transfer are numerous, having to do with their availability, their expertise in the subject matter, the means and resources to get involved, their willingness to influence decision-makers, and their concern for the wider public, over and above their own interests.

31Research teams must be able to understand, from the outset of the PHIR project, the importance of knowledge transfer activities and that their knowledge production is first and foremost at the service of the intervention, which takes precedence over their academic career. Their role is to uncover evidence that is useful for the intervention and accessible to all. Their involvement in the PHIR project must not end once the research is completed; rather, they need to remain active throughout the knowledge transfer processes. Their responsibility is also to share valid results as widely as possible and with the scientific community in a reasonable time frame to facilitate their use, particularly by decision-makers and in interventions. The challenge for researchers is to adapt their terminology, avoid jargon, and make their methods and knowledge accessible without wielding their symbolic power, which creates needless distance between them and other PHIR stakeholders (Box 21). Sometimes researchers move from one project to another without taking the time to finalise their reports or analyses, publishing the results a long time later, which is a significant challenge in PHIR, whose results need to be readily usable. It is also sometimes difficult for research teams to understand the decision-making arenas, to be willing to engage in them, and to understand that decision-makers must contend with multiple influences beyond just the evidence from the intervention (Cairney, 2016). Moreover, academic systems do not yet sufficiently value researchers’ involvement in these knowledge transfer processes, thus creating little incentive, among some researchers, to engage in these time-consuming activities that do little for their careers (Ridde, 2009).

Box 21. Researchers’ jargon and its effects on stakeholders

During a malaria control PHIR project, the team decided to organise many knowledge transfer activities. For this, several training courses were first provided to researchers and stakeholders, as we knew that the former sometimes had difficulty adapting their methods and terminology for the latter. This involved improving the quality and readability of the slideshows used by researchers at stakeholder workshops and writing policy briefs that were accessible to as many people as possible while providing operational recommendations. On this occasion, we witnessed the sheer arrogance of certain academics, who thought they knew everything better than the others and who were unable to speak clearly and simply. The socialisation of some of these academics had made them internalise the use of jargon, which was impossible for some stakeholders in the field to understand, but which was indispensable to the academics’ status and power games. They refused to adapt their language and their form of writing or presentation, such that the messages were ultimately poorly understood by stakeholders who were too benumbed, intimidated, or simply dubious to dare to ask questions and better understand what was being presented to them about their intervention (Mc Sween-Cadieux et al., 2017).

32Decision-makers and funders need to assign particular importance to knowledge transfer, especially in the funding they provide for the PHIR project. Too often, these issues are overlooked, and it is only at the end of the intervention that the question of how to make the PHIR results useful comes up, just as, too often, people think about sustainability only when an action is ending (Pluye et al., 2000). They also need to be able to focus on the results, become involved in knowledge transfer processes, and be available to reflect on how they can use the PHIR results in their decision-making. Thus, they need to take this into account and inform the other PHIR partners, including the research teams, of the times and places they think would be appropriate for the results to be presented. They also need to interact with those involved in this sharing to ensure the evidence is understandable and presented in a factual and convincing manner. Their involvement in interpreting the results can be a positive factor in subsequent decision-making, insofar as the intrinsic quality of the study (internal validity, essentially the responsibility of the research team) and the ability to extrapolate the results to other settings (external validity) are under their responsibility. The challenges are obviously political in nature, in terms of how decision-makers use the results, their capacity to do so, and whether they can take the results into account without picking and choosing what suits them. Their desire to share decision-making and involvement with other PHIR stakeholders must be galvanised. For decision-makers and funders, issues related to their availability and their training (i.e. literacy) in research methods and knowledge transfer can pose challenges to their involvement and understanding of PHIR.

33Furthermore, those in charge of scholarly societies and journals are less concerned with the design and implementation of interventions than with knowledge transfer. They have an important role to play in making PHIR more prominent. Indeed, especially in the health field, for an interdisciplinary and applied PHIR project to exist and be taken seriously, it must contend with numerous challenges. The health field, and in particular the health of French-speaking populations (Ridde et al., 2021), is still not very open to these issues because it is dominated by a biomedical and Pasteurian approach, which clashes with the logics and approaches of PHIR complexity, as the Covid-19 pandemic crisis has clearly shown again (Paul et al., 2020). Scholarly societies need to make more room for discussion and training in PHIR, whose core competencies are becoming increasingly standardised (Riley et al., 2015). Scientific journals need to assign more value and space to PHIR, both to disseminate results and to provide reflexive analyses of these processes (Alexander et al., 2020) and the challenges involved in creating an effective partnership of multiple actors around an intervention. In particular, one group of researchers has called for more space to be allotted to presenting backgrounds in scientific journals, as these elements are critical to understanding PHIR evidence (Craig et al., 2018). Finally, as discussed earlier, links and conflicts of interest should be a constant concern of scholarly journals, so that the readers of PHIR scientific articles can understand the circumstances, and especially the financial circumstances, surrounding collaboration between researchers and implementers.

Table 9. Actors’ roles and challenges in knowledge transfer.

Roles

Challenges

Implementers

Use science for the intervention
Make their knowledge transfer needs explicit
Participate actively and facilitate knowledge transfer activities
Identify relevant decision-makers and decisional arenas

Being available
Securing knowledge transfer funding
Distrust of research and knowledge transfer
Distance from decision-makers

Population

Be involved from the beginning
Participate in interpreting results
Influence decision-makers

Being available
Scientific literacy
Corporatism/communitarianism
Selection of results

Research team

Assign importance to knowledge transfer
Produce knowledge in a reasonable time frame
Make knowledge accessible
Participate in the knowledge transfer process

Understanding decision-making processes
Wanting to get involved beyond scientific aspects
Pursuing academic recognition

Decision-makers and funders

Be interested in knowledge transfer and be available
Participate in interpreting results
Secure funding for knowledge transfer
Reflect on possible use of the results
Inform others about decision-making issues
Open up decision-making arenas
Interact with knowledge transfer leaders

Political will to use the results
Distortion and selection of results
Scientific literacy
Decision-making time frame
Politicisation of results

The importance of frontline Actors

34Those familiar with public policy literature will not be surprised to read about the importance, which we wish to underscore, of frontline actors, whom Lipsky (2010) called street level workers. In his view, these are the real decision-makers of interventions, more than those responsible upstream for formulating or funding actions. These frontline workers, poised at the interface between those who will (should) benefit from the intervention and those who have decided it should be organised, are at the heart of its potential effectiveness. The support provided to them and their involvement in the organisation are often predictors of success and factors in the quality of implementation (Meyers et al., 2012).

35Yet researchers and population health actors still pay too little attention to the role of these people, unlike political scientists, sociologists, or anthropologists, for whom interventions can only be understood “from the bottom up” (Olivier de Sardan, 2021), a term obviously not used pejoratively (Erasmus, 2014). Evaluators are familiar with the concept of intervention fidelity, since it is known that what is stated in the project documents is very rarely actually implemented on the ground. A society cannot be changed by decree, said Crozier (1979), any more than interventions can be organised with logical frameworks (Giovalucchi & Olivier de Sardan, 2009). Intervention fidelity and adaptation are therefore the two sides of the coin of effective implementation of actions (Pérez et al., 2016). However, these coins are in the wallets of the frontline actors who will, in the end, decide whether they want the intervention to be available and useful for the people involved. In Burkina Faso, for example, research has shown that while regulations to ensure free access to healthcare for the poorest had existed for a very long time, frontline nurses knew little about them and applied them even less (Ridde et al., 2018). Despite this – and many will argue that this is a truism or simply common sense – we still see many interventions formulated with no involvement of those who will have to implement them afterwards, not to mention any involvement of those who should benefit from them or suffer the consequences, as was seen in the Covid-19 crisis. Similarly, there are still many research teams deciding on their own, without stakeholders, which evaluation questions they will seek to answer using their sophisticated methods. Without necessarily falling within the realm of action-research processes (see Chapter 1), where all decisions are taken by and for the persons concerned (Reason & Bradbury, 2001; Sylvestre et al., 2019), PHIR must give prominence to frontline actors, in addition to the fundamental importance of those targeted by the intervention. Clearly, PHIR involves mobilising multiple actors and thus depends on the organisation of partnerships, posing immense challenges for which researchers are rarely trained.

Conclusion: Partnership challenges

36Embarking on a PHIR project requires a wide range of actors, as we have seen. Players must be brought together from multiple scientific disciplines, with intersectoral expertise in the fields of intervention and population mobilisation. Among scientists, the challenges of interdisciplinary collaboration are known but rarely addressed (Resweber, 2011), notably with regard to training in population health (Ridde et al., 2021). For interventions, the issues related to intersectoral work have been understood for a long time, particularly in the field of health promotion (Corbin, 2017) and when working with communities (Boutilier et al., 2000). Obviously, issues of power in partnership processes cannot be ignored. Partnership is understood as “a space for interaction among different and socially unequal actors who defend a vision of reality that depends on their identity, their social position, and their history” (Bilodeau et al., 2003). These issues concern almost all PHIR situations. Thus, differences give rise to power issues related to the disciplines of research teams (social sciences versus basic sciences), to the status of individuals (permanent versus trainees and casual contract staff; academics versus association staff), or to the genders and social origins of the individuals involved, etc. The list of differences that trigger power issues is infinite.

37Thus, we believe it is important to understand how partnerships work to ensure that PHIR is not only ethical and respectful of diversity, but also effective in addressing the questions being posed. Angèle Bilodeau’s advice in this regard is particularly useful (Bilodeau et al., 2003; 2011). She and her team proposed a tool for diagnosing the partnership environment (already in place or to be set up) which can then be helpful in supporting a collaborative endeavour, in our case PHIR. The tool proposes a three-dimensional approach, not necessarily linear (Box 22).

Box 22. Developing partnership

Better understand the actors involved and those who should form the partnership:
- Explore all important aspects of the situation to be changed
- Identify the actors already engaged and solicited
- Examine all views and perspectives
- Mobilise strategic and critical actors

Seek to resolve controversies:
- Define a provisional shared PHIR plan
- Use controversy mapping to focus debates on specific disagreements
- Identify potential changing or shifting of actors to resolve controversies

Propose new solutions:
- Adapt and innovate

Source: Bilodeau et al. (2003; 2011).

38In a partnership, the quality of a PHIR implementation could be summarised into three factors, following Bilodeau and colleagues (2003): sufficiently dynamic participation by all members, attention paid to equalising power relations, and pooling of knowledge.

39Thus, given that power issues, as mentioned, are at the heart of these processes, it is important to find ways to establish as balanced a relationship as possible among the stakeholders involved. It is not a matter of creating constraints, but rather of creating a supportive environment where everyone would be able to use their assets and expertise (which everyone has!) for the community, which is being mobilised here for PHIR. It is therefore essential to recognise that everyone has strengths, but also responsibilities. One challenge, says Angèle Bilodeau, is to maintain this attention to issues of power and competencies constant throughout the PHIR project. It is important for people to have ways of working together even if they have different logics. This issue must be addressed as early as possible in a PHIR project, not only when it is being developed, but throughout the stages of its implementation. Forums for discussion and sharing at all stages can be used to support these reflections (Bilodeau et al., 2006). This can be particularly relevant, for instance, with respect to the perennial conflicts between researchers when it comes to deciding on signatories and their place in the scientific productions resulting from a PHIR project (Ridde et al., 2016).

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