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From Ethnography to Randomized Controlled Trial: An Innovative Approach to Developing Complex Social Interventions Martin Webber
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Department of Social Policy and Social Work , University of York , York , United Kingdom Published online: 09 Jan 2014.
Click for updates To cite this article: Martin Webber (2014) From Ethnography to Randomized Controlled Trial: An Innovative Approach to Developing Complex Social Interventions, Journal of Evidence-Based Social Work, 11:1-2, 173-182, DOI: 10.1080/15433714.2013.847265 To link to this article: http://dx.doi.org/10.1080/15433714.2013.847265
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Journal of Evidence-Based Social Work, 11:173–182, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1543-3714 print/1543-3722 online DOI: 10.1080/15433714.2013.847265
From Ethnography to Randomized Controlled Trial: An Innovative Approach to Developing Complex Social Interventions Martin Webber Department of Social Policy and Social Work, University of York, York, United Kingdom
The evidence base for mental health social work is vastly under-developed in contrast to medicine and psychology. Without randomized controlled trial evidence of effectiveness, social work interventions are largely absent from UK clinical guidelines and are increasingly difficult to defend in multidisciplinary teams. This article will discuss an innovative and thorough approach to developing a social intervention which will be amenable to evaluation in a randomized controlled trial. Using ethnography to capture practice wisdom, underpinned by social capital theory with its own rich evidence base, the intervention will help people recovering from an episode of psychosis to connect, or reconnect, with other people. It is envisaged that by ensuring the intervention is grounded in the lived experience of workers and service users it will be more amenable to implementation in routine practice, and produce better outcomes. Keywords: Ethnography, social intervention, connecting people, social capital, social networks, mental health social work
INTRODUCTION Evidence-based practice (EBP) is a process of inquiry which helps practitioners to make the best possible decisions about interventions or services for people (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996; Sheldon & Chilvers, 2000). EBP takes practitioners on a journey from searching for available evidence to answer a practice question; through appraising the validity, impact, and applicability of relevant evidence; to integrating it with clinical expertise and the service user’s values and circumstances in making decisions. EBP suggests that practitioners should accord greater weight to evidence higher in the evidentiary hierarchy, such as systematic reviews or randomized controlled trials (RCTs), as these studies have greater internal validity. However, all forms of evidence should be considered if these are not available. EBP in social work appears to be healthy and growing in the United States (Thyer & Myers, 2011), though the social work profession in the United Kingdom is struggling to embed it in curricula and practice (Blewett, 2007; McCrystal & Wilson, 2009). This article presents independent research funded by the NIHR School for Social Care Research. The views expressed in this article are those of the authors and not necessarily those of the NIHR School for Social Care Research or the Department of Health, NIHR, or NHS. The author would like to gratefully acknowledge the time given by the participants in this study and would like to thank their agencies for providing access to their expertise. Address correspondence to Martin Webber, Department of Social Policy and Social Work, University of York, Heslington, York, YO10 5DD, UK. E-mail: [email protected]
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Recent surveys in the United States and the United Kingdom (e.g., Morago, 2010; Pope, Rollins, Chaumba, & Risler, 2011) have found that social workers are more positive about the ideas and principles of EBP, than actually implementing research findings in their practice. Pope et al.’s (2011) sample drawn predominantly from the United States appeared very knowledgeable about EBP, though only about two-thirds accessed practice guidelines or research online. Similarly, over 95% of Morago’s (2010) sample stated that good quality research findings should form the basis for making decisions in social work, but only 17% stated that their agency’s implementation of EBP was “good” or “excellent.” Taking social desirability and response bias into account, it is likely that these figures underestimate the true translation of social work research into practice. Respondents to Morago’s (2010) survey predominantly stated that lack of time, resources, information or training were the main barriers to implementing EBP. Thirty-eight percent stated that it was difficult to translate research into practice, whilst only 3% saw EBP as a deterministic approach which is not compatible with the complexity of social work practice. These findings suggest there is a willingness to engage with research findings if organizational constraints and implementation barriers are resolved. Similar findings emerged in Cooke et al.’s (2008) survey of social care workers in two U.K. local authorities. However, highlighting the poor implementation of research in practice, they found that less than 15% of their sample had access to research-based practice guidelines and of these only one-third reported using them in the three months prior to the survey. The limited adoption of EBP by social workers is most apparent when they are compared to colleagues from health disciplines in multi-disciplinary mental health teams. In a U.S. survey, Mullen and Bacon (2004) found that social workers were poorly informed about practice guidelines, infrequently read research papers, and viewed supervisors as the conduit for practice wisdom in contrast to psychologists and psychiatrists who appeared to have readily adopted EBP. In the United Kingdom, the social work contribution to the evidence base for mental health practice is meager, as it suffers from a combination of structural, economic, and academic constraints (McCrae, Murray, Huxley, & Evans, 2005). Consequently, mental health services rely upon evidence from psychiatry and psychology to inform policy. In the United Kingdom, the National Institute for Health and Care Excellence (NICE) develops guidelines for practitioners about evidence-based interventions for the treatment of particular disorders. Although meta-analysis of qualitative data has been used to inform NICE guidelines (Gould, 2010), they are predominantly composed of RCT evidence. NICE guidelines relating to the treatment of mental health problems contain very few social interventions because of the lack of RCT evidence of their effectiveness. For example, the NICE (2009a) guideline for depression mentions that befriending people with severe depression may support their recovery, as has been found in one RCT (Harris, Brown, & Robinson, 1999). Otherwise, it is largely dominated by pharmacological and psychological interventions. Similarly, the NICE (2009b) guideline for schizophrenia includes few social interventions. Family interventions, social skills training, and vocational rehabilitation are recommended as there is good evidence of their effectiveness, but they are included alongside psychological interventions as there is an insufficient quantity of evidence to justify their own separate section. Social work researchers seldom feature in the author lists of studies cited in these guidelines, with the research largely being led by psychologists or psychiatrists. Without an evidence base of its own, social work practice in U.K. mental health services is in danger of becoming marginalized to process-dominated and statutory roles, whilst health clinicians deliver interventions recommended by clinical guidelines. There is some evidence that this is happening already (Huxley et al., 2005). The “bureau-medicalization” of mental health care (Nathan & Webber, 2010), which prioritizes managerial care co-ordination and risk management in a medicalized intervention framework, further diminishes the ability of social workers to develop their own evidence base. As practitioners working in contexts with more bureaucracy are less likely to embrace EBP (Aarons, 2004), the problem for U.K. social workers is compounded.
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Social workers can potentially influence NICE guidelines, and regain control over their future within mental health services, by undertaking RCTs of social interventions which are of both high “inner” and “outer” quality (Shaw & Norton, 2008). Well-designed RCTs with strong inner scientific validity can be credible in the eyes of health colleagues and policy makers, and be suitable for inclusion in NICE guidelines. Social interventions with high outer science qualities will have currency with practitioners as they are informed by techniques, values and theories which resonate with them. Notwithstanding scepticism about the value of RCTs from U.K. social scientists and social workers (Oakley et al., 2003), it is possible that social interventions evaluated in RCTs with both high inner and outer quality may be easier to implement in practice (Mullen, Bledsoe, & Bellamy, 2008). Researchers aiming to evaluate the effectiveness of social interventions in an RCT with high inner validity need to develop intervention manuals which, to some extent, standardize practice. Manuals help to transfer intervention knowledge, provide consistency in the delivery of interventions, permit replication in different contexts, clarify intervention processes, and facilitate the measurement of fidelity (Fraser, Richman, Galinsky, & Day, 2009). However, manuals are criticized by practitioners for discounting practice experience and being too formulaic (Rosen & Proctor, 2003). For manuals to be successful and implemented faithfully, they need to incorporate practice wisdom and enable practitioners to make informed choices whilst working with a particular individual or group (Proctor & Rosen, 2003). This paper argues that ethnography of practice could inform the development of social interventions and facilitate the inclusion of practice wisdom into manuals. A rigorous process of intervention development, grounded in the reality of real-world practice, may improve the effect of the intervention when evaluated in an RCT, and facilitate its subsequent implementation into routine practice by practitioners (Medical Research Council, 2008). Figure 1 illustrates the importance of local, practice, and explanatory knowledge in the early stages of intervention development. This knowledge first identifies social problems for epidemiologists to explore and then helps to interpret their findings. Practice wisdom then informs theoretical models about the association between risk factors and outcomes and helps to identify potential interventions which may address the social problem. Using the example of the development of
FIGURE 1
Process of social intervention development. Adapted from Fraser (2003).
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an intervention to support people recovering from psychosis to connect with others (from the Connecting People Study), this paper argues that ethnography of health and social care practice can make the intervention relevant to local conditions; amenable to both practitioners and service users; reflect existing good practice; and produce good outcomes.
Epidemiological Context of Connecting People Study Social factors are prominent in the etiology (Morgan et al., 2008) and course (Albert et al., 2011) of psychosis. People with psychosis, or those who receive a diagnosis of schizophrenia, face social exclusion (Boardman, 2011), have restricted social networks (Catty, Goddard, White, & Burns, 2005), and limited access to social capital (Dutt & Webber, 2010). Further, an inverse relationship has been found between the incidence of schizophrenia in ethnic minority groups and the density of ethnic groups within neighborhoods (Boydell et al., 2001; Schofield, Ashworth, & Jones, 2011). Or, in other words, the risk of schizophrenia in Black ethnic groups is greatest for those living in areas with fewer people from the same ethnic group, possibly as a result of inequalities in access to social capital. Social capital is increasingly being recognized as important for health and well-being (Kawachi, Subramanian, & Kim, 2007), and it could contribute both to our understanding of the epidemiology of psychosis and assist in the development of new social interventions which may support an individual’s recovery. Defined by Lin and others (Lin, 2001; Lin & Erickson, 2008) as the resources that are embedded within social networks, social capital can lead to greater occupational prestige, income, and political influence when mobilized (Lin & Erickson, 2008). Social capital theory suggests that health gains can be accrued by investing in relationships which may promote positive health behaviors (Zambon et al., 2010); provide employment opportunities (Flap, 1999); mitigate health risks through the additive effect of network members’ resources; act as social credentials and directly intervene in health and social care; and reinforce an individual’s identification with a group and help to maintain subjective social status (Song, 2007), which may help to promote mental well-being. Some social care workers help people to build relationships and strengthen their connections with their local community (Huxley, Evans, Beresford, Davidson, & King, 2009), but this is afforded a low priority by many (McConkey & Collins, 2010). There is good evidence that positive and supportive social relationships are associated with well-being (Aked, Marks, Cordon, & Thompson, 2008; Bowling, 2011; Brugha et al., 2005; Webber, Huxley, & Harris, 2011), but there are no evidence-based interventions for health or social care practitioners to assist people with psychosis to connect with others.
INTERVENTION MODELING Intervention modeling is the process of identifying potential approaches to address social problems. It includes identifying how risk factors may interact to exacerbate social problems, understanding how local conditions may impact upon outcomes, and surfacing implicit knowledge of practitioners working in the field. Practice wisdom is required to inform interventions to ensure that they are acceptable to the practitioners who implement them and to those they are intended to benefit. Careful modeling is required to ensure that complex interventions fit with and reflect the complexities of the practice environments in which they will be used (Medical Research Council, 2008; Rowlands, Sims, & Kerry, 2005). Intervention models which understand practice contexts can connect intervention theory to social work practice, thus potentially facilitating the translation of new interventions into routine use. In the emerging theoretical and empirical field of social
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capital there is a lack of explicit or documented practice wisdom on how it may inform social interventions with people with psychosis. The Connecting People Study aims to harvest practice wisdom to inform social intervention development. In particular, the Connecting People Study aims to understand how social care workers help people (referred to here as “service users”) recovering from psychosis to generate and mobilize social capital, even if they do not frame their interventions in these terms. Reflecting processes implicit within social capital theory (Lin, 2001; Lin & Erickson, 2008), the study aims to understand how workers develop effective working relationships with service users; encourage users to develop secure attachments with them; create new opportunities for social engagement; discuss users’ concerns about creating and maintaining social relationships; discuss with users about developing social relationships with resourceful people, (and their understanding of “resourcefulness” in this context); advise users on when to mobilize their social capital and provide opportunities for them to discuss this process with them; reflect with service users on the outcomes of mobilized social capital; use “soft” and “instinctive” intervention skills such as empathy, flexibility, and creativity to underpin their interventions.
To meet these aims the Connecting People Study is using a combinative ethnography (Baszanger & Dodier, 1997) of social care practice in contexts where workers have the opportunity to enhance service users’ access to social capital. A combinative ethnography requires simultaneous field work in a number of different settings. This method allows exploration of existing practice more comprehensively, and with less potential for bias, than using only semi-structured interviews, for example. Workers’ interview responses are triangulated with the perspectives of service users and the researcher’s observations of their practice to minimise bias caused by socially desirable responses. To achieve rich data on a range of social capital enhancement activities, social capital practice with people recovering from psychosis in a variety of settings is being investigated. Practice in statutory community mental health services is being studied. In this setting, practice within two early-intervention psychosis teams and a specialist social-inclusion team supporting the recovery of people with psychosis is being observed. These teams employ a variety of health and social care workers, though the focus is particularly on the work of support, time, and recovery workers, occupational therapists and social workers. Floating support workers are also being observed, and other social care workers employed by a voluntary sector agency providing housing and other support services to people with psychosis and other needs across London. Finally, people with mental health problems in two small innovative third sector projects are being investigated. Smaller projects, more embedded in their local neighborhoods than larger statutory or voluntary sector agencies, may be more effective at helping people to foster connections in their local community. Sample selection is guided by social capital theory (Lin, 2001). Workers are recruited and users who appeared to be engaged in social capital enhancement and mobilization, initially on the advice of workers and managers within participating agencies, and subsequently by the researcher as familiarization with the agencies grew. A diversity of workers according to gender, age, ethnicity, professional background, and levels of experience is purposively selected until achieving data saturation in each practice area. Similarly, a diverse sample of service users according to gender, age, and ethnicity is being recruited to explore their experiences and perspectives on social capital practice. Although the study is ongoing at the time of writing, data has been collected from over 120 workers and service users to date.
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Ethnographic field work is being conducted in two phases using a sequential iteration method by which the researcher spends time within different teams, sites, and settings in distinct phases of the data collection process. The researcher is conducting semi-structured interviews, unstructured interviews, non-participant observation, and informal discussions with participants to explore their social capital enhancement and mobilization practice. Observations are seeking to reveal the instinctive and intuitive practice of expert practitioners, which is rarely articulated but integral to effective social interventions. Interviews with workers allow them to reflect on their practice and data collection with service users allows them to express their thoughts about their workers’ practice. This process allows a “thick description” of social capital practice to be obtained. The second phase of the ethnography helps to confirm findings from the first phase and to ensure that data saturation is achieved through further observations of social care practice. Field work processes are being repeated in each setting with different workers and service users to help refine the emerging intervention model. Following each phase, focus groups are being held with workers and service users to help check the validity of the data being collecting; to explore possible assumptions made during the analysis; to refine emerging intervention models; and to give feedback on results of the ethnography to participants. INTERVENTION DESIGN The social intervention which is emerging from the Connecting People Study is likely to prompt a transmogrification of social capital theory. Although the study is ongoing, it is apparent that social care practice does not routinely draw upon a social capital paradigm and that social capital enhancement is not a primary objective of social care or social work. Applied social capital theory will need to achieve synergy between engaging with wider social structures, which constrain opportunities for accessing social capital and enhancing individual capacity for building relationships. This requires, on one hand, workers identifying opportunities for social engagement and supporting people to resolve psycho-social or inter-personal difficulties which militate against social connectivity. On the other hand, it requires workers to challenge social structures which discriminate against people with mental health problems. This reflects thinking on social integration (Ware, Hopper, Tugenberg, Dickey, & Fisher, 2008), but it also needs to consider relationship insecurity as a barrier to accessing social capital (Webber et al., 2011). The social capital intervention, which has the working title of the Connecting People Intervention, will be articulated in the form of an intervention manual to permit replication, fidelity measurement, and evaluation. This will articulate the underlying theory of change; the aims and objectives of the intervention; and the intervention components and processes, including training that should be delivered to workers and the organizational support for the intervention. The intervention manual will be refined using the Delphi consultation method (Linstone & Turoff, 1975) to ensure that it is feasible in practice and is faithful to social capital theory. The Delphi will involve a wide reference group of up to 30 participants comprising service users, practitioners, international social work, and social capital experts to achieve consensus from a diverse range of perspectives. Participants will be asked to provide ratings on the fidelity of the intervention to social capital theory; adequacy, clarity, and comprehensiveness of the intervention guidelines; and feasibility and acceptability of interventions in practice. They will also be invited to provide some brief qualitative responses to these items to inform the refinement of the intervention. The Delphi will comprise two stages to allow for the iterative development of the manual and for participants to re-evaluate their opinions in the light of the average ratings of the group. Manuals for social interventions are the subject of considerable debate, particularly due to concerns about their ability to effectively articulate the complexity of practice, incorporate practice wisdom and encourage the use of intuition (Fraser et al., 2009). The roots of the Connecting
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People Intervention in the ethnography of practice will help it to incorporate practice wisdom. Practitioners and service users are fully involved in its development to help ensure its relevance and applicability in practice. However, this provides no guarantee that it will actually work in practice. Although manualized interventions have been developed for complex interventions which involve social networks, and been found to be effective (e.g., Social Behavior and Network Therapy [SBNT]; Copello, Orford, Hodgson, & Tober, 2009), the Connecting People Intervention must not lose sight of the ethnography from which it is derived to ensure that the manual will be readily adopted by practitioners. DISCUSSION The synergy of using ethnography within the context of existing theory is a novel approach to developing complex interventions in social work and social care. This method allows embedding apparent good practice within the intervention, accounting for different practice contexts, and ensuring its feasibility in practice, thus hopefully facilitating its eventual smooth implementation. However, the Connecting People Intervention will first be piloted in a small number of agencies to provide some data on its likely effectiveness and cost-effectiveness. It will also be adapted for use with adults with learning disabilities and older adults with mental health problems, a process which has been successfully achieved with other social interventions (e.g., SBNT [Copello, Williamson, Orford, & Day, 2006]). Data from the pilot study will help to refine the intervention and prepare it for evaluation in a RCT. Critics (and many defenders) of EBP argue that more than evidence alone is required to inform practice decisions in social work, such as the values of service users and the professional judgment of practitioners. For example, Nevo and Slonim-Nevo (2011) suggest that as evidence has such a limited role to play in social work practice the phrase “evidence-informed practice” (EIP) more accurately depicts its function. EBP or EIP requires practitioners to use their judgement about the applicability of RCT evidence, or that derived from any other study design, to the unique circumstances of the individual they are working with. If future RCT evidence about the Connecting People Intervention shows it to be effective at enhancing individuals’ social connections and well-being, practitioners are still required to decide whether or not it should be used with any particular individual with whom they are working. The extent to which practice wisdom is incorporated in the design of the intervention may influence practitioners’ decisions about its implementation. For example, if they consider the intervention to accord with their values and that of the individual they are working with, and if they consider it able to accommodate the unique circumstances of their service user, they are perhaps more likely to use it in routine practice. Fraser et al. (2009) suggested that evidence-based social interventions should be congruent with the cultural context in which they are being used to facilitate their full implementation. As the Connecting People Intervention was developed using ethnography, the cultural context of social care and social work in the United Kingdom is embedded within it which should allow a smooth translation into practice. However, some local adaptation may still be required. To ensure that intervention fidelity will not be compromised, some local adaptation by individual agencies will be permitted and written into the intervention manual. Further, as the intervention development process was explicit and theory-based, it could be replicated in other countries so that the Connecting People Intervention could be adapted for cross-cultural use. Starting from the propositions of social capital theory (Lin, 2001), researchers could replicate our ethnography to investigate practitioners’ work in different contexts and adapt the intervention accordingly. A limitation of this approach may be the prohibitive cost of ethnographic studies to develop the intervention in different countries or cultural contexts. However, mixed findings from replication studies of evidence-based interventions in different countries highlight the importance of appropri-
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ate adaptation to facilitate their effective implementation in different cultural and practice contexts (Fraser, Guo, Ellis, Thompson, Wike, & Li, 2011). For example, assertive community treatment (ACT) for people with severe mental health problems has been positively evaluated in the United States (Marshall & Lockwood, 1998), but the model has not produced equivalent effects in the United Kingdom (Killaspy et al., 2006, 2009). This is likely to be because community mental health teams in the United Kingdom (the control condition in RCTs for ACT and now considered the evidence-based intervention of choice in the United Kingdom [Burns, 2010]) are just as effective at reducing hospitalization as ACT. An early understanding of the factors underpinning this may have prompted an early adaptation of ACT to UK conditions, which may have improved its relative effectiveness. The successful translation of the Connecting People Intervention into practice will require the full support of employers as well as practitioners. The intervention requires agencies to be fully embedded within their local communities and to fully utilize local community networks. Through the ethnography, a rich understanding has been gained of organizational climate and culture which that enables the necessary conditions for the successful implementation of the intervention to be described. However, this may require organizational transformation for some agencies which prove a barrier to effective implementation (Fraser et al., 2011). The effectiveness of the Connecting People Intervention is not yet known, which is perhaps the most important limitation of this paper. If it is subsequently found to be ineffective, its thorough and explicit development process could be replicated elsewhere to redevelop the intervention in cultural contexts where it may have more impact. The ethnographic data on which it is built could also be reviewed to explore potential reasons for its failure to improve outcomes and appropriate amendments made to the intervention. Alternatively, if the Connecting People Intervention is found to be effective, there will be a rich understanding of the practice context from which it is derived that, in turn, may assist its implementation. CONCLUSION Guidelines on developing and evaluating complex interventions highlight the importance of identifying appropriate underlying theory and of modelling processes and outcomes (Medical Research Council, 2008). This is rarely achieved in the development of social interventions, which are usually pragmatic solutions to practical problems. This article has introduced an innovative and thorough approach to developing a social intervention which both incorporates practice wisdom and will be amenable to evaluation in an RCT. The Connecting People Intervention is being developed by viewing current practice through the lens of social capital theory to produce a theory and evidence-informed model of how workers can support people to enhance their access to, and use of, social capital. This model considers social care practice within its context to understand the potential constraints or opportunities for a social capital intervention strategy within a variety of settings. Although the Connecting People Intervention is as yet untested, future evaluation studies are planned with the ambition of enhancing the evidence base for practice in this field. Whether or not it can be effectively translated into practice will also be the subject of further research, but it is anticipated that the practice wisdom incorporated within the Connecting People Intervention will assist practitioners to adopt it in routine practice. REFERENCES Aarons, G. A. (2004). Mental health provider attitudes toward adoption of evidence based practice: The evidence-based practice attitude scale (EBPAS). Mental Health Services Research, 6(2), 61–74.
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From Ethnography to Randomized Controlled Trial: An Innovative Approach to Developing Complex Social Interventions Martin Webber
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Department of Social Policy and Social Work , University of York , York , United Kingdom Published online: 09 Jan 2014.
Click for updates To cite this article: Martin Webber (2014) From Ethnography to Randomized Controlled Trial: An Innovative Approach to Developing Complex Social Interventions, Journal of Evidence-Based Social Work, 11:1-2, 173-182, DOI: 10.1080/15433714.2013.847265 To link to this article: http://dx.doi.org/10.1080/15433714.2013.847265
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Journal of Evidence-Based Social Work, 11:173–182, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1543-3714 print/1543-3722 online DOI: 10.1080/15433714.2013.847265
From Ethnography to Randomized Controlled Trial: An Innovative Approach to Developing Complex Social Interventions Martin Webber Department of Social Policy and Social Work, University of York, York, United Kingdom
The evidence base for mental health social work is vastly under-developed in contrast to medicine and psychology. Without randomized controlled trial evidence of effectiveness, social work interventions are largely absent from UK clinical guidelines and are increasingly difficult to defend in multidisciplinary teams. This article will discuss an innovative and thorough approach to developing a social intervention which will be amenable to evaluation in a randomized controlled trial. Using ethnography to capture practice wisdom, underpinned by social capital theory with its own rich evidence base, the intervention will help people recovering from an episode of psychosis to connect, or reconnect, with other people. It is envisaged that by ensuring the intervention is grounded in the lived experience of workers and service users it will be more amenable to implementation in routine practice, and produce better outcomes. Keywords: Ethnography, social intervention, connecting people, social capital, social networks, mental health social work
INTRODUCTION Evidence-based practice (EBP) is a process of inquiry which helps practitioners to make the best possible decisions about interventions or services for people (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996; Sheldon & Chilvers, 2000). EBP takes practitioners on a journey from searching for available evidence to answer a practice question; through appraising the validity, impact, and applicability of relevant evidence; to integrating it with clinical expertise and the service user’s values and circumstances in making decisions. EBP suggests that practitioners should accord greater weight to evidence higher in the evidentiary hierarchy, such as systematic reviews or randomized controlled trials (RCTs), as these studies have greater internal validity. However, all forms of evidence should be considered if these are not available. EBP in social work appears to be healthy and growing in the United States (Thyer & Myers, 2011), though the social work profession in the United Kingdom is struggling to embed it in curricula and practice (Blewett, 2007; McCrystal & Wilson, 2009). This article presents independent research funded by the NIHR School for Social Care Research. The views expressed in this article are those of the authors and not necessarily those of the NIHR School for Social Care Research or the Department of Health, NIHR, or NHS. The author would like to gratefully acknowledge the time given by the participants in this study and would like to thank their agencies for providing access to their expertise. Address correspondence to Martin Webber, Department of Social Policy and Social Work, University of York, Heslington, York, YO10 5DD, UK. E-mail: [email protected]
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Recent surveys in the United States and the United Kingdom (e.g., Morago, 2010; Pope, Rollins, Chaumba, & Risler, 2011) have found that social workers are more positive about the ideas and principles of EBP, than actually implementing research findings in their practice. Pope et al.’s (2011) sample drawn predominantly from the United States appeared very knowledgeable about EBP, though only about two-thirds accessed practice guidelines or research online. Similarly, over 95% of Morago’s (2010) sample stated that good quality research findings should form the basis for making decisions in social work, but only 17% stated that their agency’s implementation of EBP was “good” or “excellent.” Taking social desirability and response bias into account, it is likely that these figures underestimate the true translation of social work research into practice. Respondents to Morago’s (2010) survey predominantly stated that lack of time, resources, information or training were the main barriers to implementing EBP. Thirty-eight percent stated that it was difficult to translate research into practice, whilst only 3% saw EBP as a deterministic approach which is not compatible with the complexity of social work practice. These findings suggest there is a willingness to engage with research findings if organizational constraints and implementation barriers are resolved. Similar findings emerged in Cooke et al.’s (2008) survey of social care workers in two U.K. local authorities. However, highlighting the poor implementation of research in practice, they found that less than 15% of their sample had access to research-based practice guidelines and of these only one-third reported using them in the three months prior to the survey. The limited adoption of EBP by social workers is most apparent when they are compared to colleagues from health disciplines in multi-disciplinary mental health teams. In a U.S. survey, Mullen and Bacon (2004) found that social workers were poorly informed about practice guidelines, infrequently read research papers, and viewed supervisors as the conduit for practice wisdom in contrast to psychologists and psychiatrists who appeared to have readily adopted EBP. In the United Kingdom, the social work contribution to the evidence base for mental health practice is meager, as it suffers from a combination of structural, economic, and academic constraints (McCrae, Murray, Huxley, & Evans, 2005). Consequently, mental health services rely upon evidence from psychiatry and psychology to inform policy. In the United Kingdom, the National Institute for Health and Care Excellence (NICE) develops guidelines for practitioners about evidence-based interventions for the treatment of particular disorders. Although meta-analysis of qualitative data has been used to inform NICE guidelines (Gould, 2010), they are predominantly composed of RCT evidence. NICE guidelines relating to the treatment of mental health problems contain very few social interventions because of the lack of RCT evidence of their effectiveness. For example, the NICE (2009a) guideline for depression mentions that befriending people with severe depression may support their recovery, as has been found in one RCT (Harris, Brown, & Robinson, 1999). Otherwise, it is largely dominated by pharmacological and psychological interventions. Similarly, the NICE (2009b) guideline for schizophrenia includes few social interventions. Family interventions, social skills training, and vocational rehabilitation are recommended as there is good evidence of their effectiveness, but they are included alongside psychological interventions as there is an insufficient quantity of evidence to justify their own separate section. Social work researchers seldom feature in the author lists of studies cited in these guidelines, with the research largely being led by psychologists or psychiatrists. Without an evidence base of its own, social work practice in U.K. mental health services is in danger of becoming marginalized to process-dominated and statutory roles, whilst health clinicians deliver interventions recommended by clinical guidelines. There is some evidence that this is happening already (Huxley et al., 2005). The “bureau-medicalization” of mental health care (Nathan & Webber, 2010), which prioritizes managerial care co-ordination and risk management in a medicalized intervention framework, further diminishes the ability of social workers to develop their own evidence base. As practitioners working in contexts with more bureaucracy are less likely to embrace EBP (Aarons, 2004), the problem for U.K. social workers is compounded.
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Social workers can potentially influence NICE guidelines, and regain control over their future within mental health services, by undertaking RCTs of social interventions which are of both high “inner” and “outer” quality (Shaw & Norton, 2008). Well-designed RCTs with strong inner scientific validity can be credible in the eyes of health colleagues and policy makers, and be suitable for inclusion in NICE guidelines. Social interventions with high outer science qualities will have currency with practitioners as they are informed by techniques, values and theories which resonate with them. Notwithstanding scepticism about the value of RCTs from U.K. social scientists and social workers (Oakley et al., 2003), it is possible that social interventions evaluated in RCTs with both high inner and outer quality may be easier to implement in practice (Mullen, Bledsoe, & Bellamy, 2008). Researchers aiming to evaluate the effectiveness of social interventions in an RCT with high inner validity need to develop intervention manuals which, to some extent, standardize practice. Manuals help to transfer intervention knowledge, provide consistency in the delivery of interventions, permit replication in different contexts, clarify intervention processes, and facilitate the measurement of fidelity (Fraser, Richman, Galinsky, & Day, 2009). However, manuals are criticized by practitioners for discounting practice experience and being too formulaic (Rosen & Proctor, 2003). For manuals to be successful and implemented faithfully, they need to incorporate practice wisdom and enable practitioners to make informed choices whilst working with a particular individual or group (Proctor & Rosen, 2003). This paper argues that ethnography of practice could inform the development of social interventions and facilitate the inclusion of practice wisdom into manuals. A rigorous process of intervention development, grounded in the reality of real-world practice, may improve the effect of the intervention when evaluated in an RCT, and facilitate its subsequent implementation into routine practice by practitioners (Medical Research Council, 2008). Figure 1 illustrates the importance of local, practice, and explanatory knowledge in the early stages of intervention development. This knowledge first identifies social problems for epidemiologists to explore and then helps to interpret their findings. Practice wisdom then informs theoretical models about the association between risk factors and outcomes and helps to identify potential interventions which may address the social problem. Using the example of the development of
FIGURE 1
Process of social intervention development. Adapted from Fraser (2003).
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an intervention to support people recovering from psychosis to connect with others (from the Connecting People Study), this paper argues that ethnography of health and social care practice can make the intervention relevant to local conditions; amenable to both practitioners and service users; reflect existing good practice; and produce good outcomes.
Epidemiological Context of Connecting People Study Social factors are prominent in the etiology (Morgan et al., 2008) and course (Albert et al., 2011) of psychosis. People with psychosis, or those who receive a diagnosis of schizophrenia, face social exclusion (Boardman, 2011), have restricted social networks (Catty, Goddard, White, & Burns, 2005), and limited access to social capital (Dutt & Webber, 2010). Further, an inverse relationship has been found between the incidence of schizophrenia in ethnic minority groups and the density of ethnic groups within neighborhoods (Boydell et al., 2001; Schofield, Ashworth, & Jones, 2011). Or, in other words, the risk of schizophrenia in Black ethnic groups is greatest for those living in areas with fewer people from the same ethnic group, possibly as a result of inequalities in access to social capital. Social capital is increasingly being recognized as important for health and well-being (Kawachi, Subramanian, & Kim, 2007), and it could contribute both to our understanding of the epidemiology of psychosis and assist in the development of new social interventions which may support an individual’s recovery. Defined by Lin and others (Lin, 2001; Lin & Erickson, 2008) as the resources that are embedded within social networks, social capital can lead to greater occupational prestige, income, and political influence when mobilized (Lin & Erickson, 2008). Social capital theory suggests that health gains can be accrued by investing in relationships which may promote positive health behaviors (Zambon et al., 2010); provide employment opportunities (Flap, 1999); mitigate health risks through the additive effect of network members’ resources; act as social credentials and directly intervene in health and social care; and reinforce an individual’s identification with a group and help to maintain subjective social status (Song, 2007), which may help to promote mental well-being. Some social care workers help people to build relationships and strengthen their connections with their local community (Huxley, Evans, Beresford, Davidson, & King, 2009), but this is afforded a low priority by many (McConkey & Collins, 2010). There is good evidence that positive and supportive social relationships are associated with well-being (Aked, Marks, Cordon, & Thompson, 2008; Bowling, 2011; Brugha et al., 2005; Webber, Huxley, & Harris, 2011), but there are no evidence-based interventions for health or social care practitioners to assist people with psychosis to connect with others.
INTERVENTION MODELING Intervention modeling is the process of identifying potential approaches to address social problems. It includes identifying how risk factors may interact to exacerbate social problems, understanding how local conditions may impact upon outcomes, and surfacing implicit knowledge of practitioners working in the field. Practice wisdom is required to inform interventions to ensure that they are acceptable to the practitioners who implement them and to those they are intended to benefit. Careful modeling is required to ensure that complex interventions fit with and reflect the complexities of the practice environments in which they will be used (Medical Research Council, 2008; Rowlands, Sims, & Kerry, 2005). Intervention models which understand practice contexts can connect intervention theory to social work practice, thus potentially facilitating the translation of new interventions into routine use. In the emerging theoretical and empirical field of social
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capital there is a lack of explicit or documented practice wisdom on how it may inform social interventions with people with psychosis. The Connecting People Study aims to harvest practice wisdom to inform social intervention development. In particular, the Connecting People Study aims to understand how social care workers help people (referred to here as “service users”) recovering from psychosis to generate and mobilize social capital, even if they do not frame their interventions in these terms. Reflecting processes implicit within social capital theory (Lin, 2001; Lin & Erickson, 2008), the study aims to understand how workers develop effective working relationships with service users; encourage users to develop secure attachments with them; create new opportunities for social engagement; discuss users’ concerns about creating and maintaining social relationships; discuss with users about developing social relationships with resourceful people, (and their understanding of “resourcefulness” in this context); advise users on when to mobilize their social capital and provide opportunities for them to discuss this process with them; reflect with service users on the outcomes of mobilized social capital; use “soft” and “instinctive” intervention skills such as empathy, flexibility, and creativity to underpin their interventions.
To meet these aims the Connecting People Study is using a combinative ethnography (Baszanger & Dodier, 1997) of social care practice in contexts where workers have the opportunity to enhance service users’ access to social capital. A combinative ethnography requires simultaneous field work in a number of different settings. This method allows exploration of existing practice more comprehensively, and with less potential for bias, than using only semi-structured interviews, for example. Workers’ interview responses are triangulated with the perspectives of service users and the researcher’s observations of their practice to minimise bias caused by socially desirable responses. To achieve rich data on a range of social capital enhancement activities, social capital practice with people recovering from psychosis in a variety of settings is being investigated. Practice in statutory community mental health services is being studied. In this setting, practice within two early-intervention psychosis teams and a specialist social-inclusion team supporting the recovery of people with psychosis is being observed. These teams employ a variety of health and social care workers, though the focus is particularly on the work of support, time, and recovery workers, occupational therapists and social workers. Floating support workers are also being observed, and other social care workers employed by a voluntary sector agency providing housing and other support services to people with psychosis and other needs across London. Finally, people with mental health problems in two small innovative third sector projects are being investigated. Smaller projects, more embedded in their local neighborhoods than larger statutory or voluntary sector agencies, may be more effective at helping people to foster connections in their local community. Sample selection is guided by social capital theory (Lin, 2001). Workers are recruited and users who appeared to be engaged in social capital enhancement and mobilization, initially on the advice of workers and managers within participating agencies, and subsequently by the researcher as familiarization with the agencies grew. A diversity of workers according to gender, age, ethnicity, professional background, and levels of experience is purposively selected until achieving data saturation in each practice area. Similarly, a diverse sample of service users according to gender, age, and ethnicity is being recruited to explore their experiences and perspectives on social capital practice. Although the study is ongoing at the time of writing, data has been collected from over 120 workers and service users to date.
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Ethnographic field work is being conducted in two phases using a sequential iteration method by which the researcher spends time within different teams, sites, and settings in distinct phases of the data collection process. The researcher is conducting semi-structured interviews, unstructured interviews, non-participant observation, and informal discussions with participants to explore their social capital enhancement and mobilization practice. Observations are seeking to reveal the instinctive and intuitive practice of expert practitioners, which is rarely articulated but integral to effective social interventions. Interviews with workers allow them to reflect on their practice and data collection with service users allows them to express their thoughts about their workers’ practice. This process allows a “thick description” of social capital practice to be obtained. The second phase of the ethnography helps to confirm findings from the first phase and to ensure that data saturation is achieved through further observations of social care practice. Field work processes are being repeated in each setting with different workers and service users to help refine the emerging intervention model. Following each phase, focus groups are being held with workers and service users to help check the validity of the data being collecting; to explore possible assumptions made during the analysis; to refine emerging intervention models; and to give feedback on results of the ethnography to participants. INTERVENTION DESIGN The social intervention which is emerging from the Connecting People Study is likely to prompt a transmogrification of social capital theory. Although the study is ongoing, it is apparent that social care practice does not routinely draw upon a social capital paradigm and that social capital enhancement is not a primary objective of social care or social work. Applied social capital theory will need to achieve synergy between engaging with wider social structures, which constrain opportunities for accessing social capital and enhancing individual capacity for building relationships. This requires, on one hand, workers identifying opportunities for social engagement and supporting people to resolve psycho-social or inter-personal difficulties which militate against social connectivity. On the other hand, it requires workers to challenge social structures which discriminate against people with mental health problems. This reflects thinking on social integration (Ware, Hopper, Tugenberg, Dickey, & Fisher, 2008), but it also needs to consider relationship insecurity as a barrier to accessing social capital (Webber et al., 2011). The social capital intervention, which has the working title of the Connecting People Intervention, will be articulated in the form of an intervention manual to permit replication, fidelity measurement, and evaluation. This will articulate the underlying theory of change; the aims and objectives of the intervention; and the intervention components and processes, including training that should be delivered to workers and the organizational support for the intervention. The intervention manual will be refined using the Delphi consultation method (Linstone & Turoff, 1975) to ensure that it is feasible in practice and is faithful to social capital theory. The Delphi will involve a wide reference group of up to 30 participants comprising service users, practitioners, international social work, and social capital experts to achieve consensus from a diverse range of perspectives. Participants will be asked to provide ratings on the fidelity of the intervention to social capital theory; adequacy, clarity, and comprehensiveness of the intervention guidelines; and feasibility and acceptability of interventions in practice. They will also be invited to provide some brief qualitative responses to these items to inform the refinement of the intervention. The Delphi will comprise two stages to allow for the iterative development of the manual and for participants to re-evaluate their opinions in the light of the average ratings of the group. Manuals for social interventions are the subject of considerable debate, particularly due to concerns about their ability to effectively articulate the complexity of practice, incorporate practice wisdom and encourage the use of intuition (Fraser et al., 2009). The roots of the Connecting
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People Intervention in the ethnography of practice will help it to incorporate practice wisdom. Practitioners and service users are fully involved in its development to help ensure its relevance and applicability in practice. However, this provides no guarantee that it will actually work in practice. Although manualized interventions have been developed for complex interventions which involve social networks, and been found to be effective (e.g., Social Behavior and Network Therapy [SBNT]; Copello, Orford, Hodgson, & Tober, 2009), the Connecting People Intervention must not lose sight of the ethnography from which it is derived to ensure that the manual will be readily adopted by practitioners. DISCUSSION The synergy of using ethnography within the context of existing theory is a novel approach to developing complex interventions in social work and social care. This method allows embedding apparent good practice within the intervention, accounting for different practice contexts, and ensuring its feasibility in practice, thus hopefully facilitating its eventual smooth implementation. However, the Connecting People Intervention will first be piloted in a small number of agencies to provide some data on its likely effectiveness and cost-effectiveness. It will also be adapted for use with adults with learning disabilities and older adults with mental health problems, a process which has been successfully achieved with other social interventions (e.g., SBNT [Copello, Williamson, Orford, & Day, 2006]). Data from the pilot study will help to refine the intervention and prepare it for evaluation in a RCT. Critics (and many defenders) of EBP argue that more than evidence alone is required to inform practice decisions in social work, such as the values of service users and the professional judgment of practitioners. For example, Nevo and Slonim-Nevo (2011) suggest that as evidence has such a limited role to play in social work practice the phrase “evidence-informed practice” (EIP) more accurately depicts its function. EBP or EIP requires practitioners to use their judgement about the applicability of RCT evidence, or that derived from any other study design, to the unique circumstances of the individual they are working with. If future RCT evidence about the Connecting People Intervention shows it to be effective at enhancing individuals’ social connections and well-being, practitioners are still required to decide whether or not it should be used with any particular individual with whom they are working. The extent to which practice wisdom is incorporated in the design of the intervention may influence practitioners’ decisions about its implementation. For example, if they consider the intervention to accord with their values and that of the individual they are working with, and if they consider it able to accommodate the unique circumstances of their service user, they are perhaps more likely to use it in routine practice. Fraser et al. (2009) suggested that evidence-based social interventions should be congruent with the cultural context in which they are being used to facilitate their full implementation. As the Connecting People Intervention was developed using ethnography, the cultural context of social care and social work in the United Kingdom is embedded within it which should allow a smooth translation into practice. However, some local adaptation may still be required. To ensure that intervention fidelity will not be compromised, some local adaptation by individual agencies will be permitted and written into the intervention manual. Further, as the intervention development process was explicit and theory-based, it could be replicated in other countries so that the Connecting People Intervention could be adapted for cross-cultural use. Starting from the propositions of social capital theory (Lin, 2001), researchers could replicate our ethnography to investigate practitioners’ work in different contexts and adapt the intervention accordingly. A limitation of this approach may be the prohibitive cost of ethnographic studies to develop the intervention in different countries or cultural contexts. However, mixed findings from replication studies of evidence-based interventions in different countries highlight the importance of appropri-
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ate adaptation to facilitate their effective implementation in different cultural and practice contexts (Fraser, Guo, Ellis, Thompson, Wike, & Li, 2011). For example, assertive community treatment (ACT) for people with severe mental health problems has been positively evaluated in the United States (Marshall & Lockwood, 1998), but the model has not produced equivalent effects in the United Kingdom (Killaspy et al., 2006, 2009). This is likely to be because community mental health teams in the United Kingdom (the control condition in RCTs for ACT and now considered the evidence-based intervention of choice in the United Kingdom [Burns, 2010]) are just as effective at reducing hospitalization as ACT. An early understanding of the factors underpinning this may have prompted an early adaptation of ACT to UK conditions, which may have improved its relative effectiveness. The successful translation of the Connecting People Intervention into practice will require the full support of employers as well as practitioners. The intervention requires agencies to be fully embedded within their local communities and to fully utilize local community networks. Through the ethnography, a rich understanding has been gained of organizational climate and culture which that enables the necessary conditions for the successful implementation of the intervention to be described. However, this may require organizational transformation for some agencies which prove a barrier to effective implementation (Fraser et al., 2011). The effectiveness of the Connecting People Intervention is not yet known, which is perhaps the most important limitation of this paper. If it is subsequently found to be ineffective, its thorough and explicit development process could be replicated elsewhere to redevelop the intervention in cultural contexts where it may have more impact. The ethnographic data on which it is built could also be reviewed to explore potential reasons for its failure to improve outcomes and appropriate amendments made to the intervention. Alternatively, if the Connecting People Intervention is found to be effective, there will be a rich understanding of the practice context from which it is derived that, in turn, may assist its implementation. CONCLUSION Guidelines on developing and evaluating complex interventions highlight the importance of identifying appropriate underlying theory and of modelling processes and outcomes (Medical Research Council, 2008). This is rarely achieved in the development of social interventions, which are usually pragmatic solutions to practical problems. This article has introduced an innovative and thorough approach to developing a social intervention which both incorporates practice wisdom and will be amenable to evaluation in an RCT. The Connecting People Intervention is being developed by viewing current practice through the lens of social capital theory to produce a theory and evidence-informed model of how workers can support people to enhance their access to, and use of, social capital. This model considers social care practice within its context to understand the potential constraints or opportunities for a social capital intervention strategy within a variety of settings. Although the Connecting People Intervention is as yet untested, future evaluation studies are planned with the ambition of enhancing the evidence base for practice in this field. Whether or not it can be effectively translated into practice will also be the subject of further research, but it is anticipated that the practice wisdom incorporated within the Connecting People Intervention will assist practitioners to adopt it in routine practice. REFERENCES Aarons, G. A. (2004). Mental health provider attitudes toward adoption of evidence based practice: The evidence-based practice attitude scale (EBPAS). Mental Health Services Research, 6(2), 61–74.
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