title: Implementation, context and complexity.
abstract: Context is a problem in research on health behaviour change, knowledge translation, practice implementation and health improvement. This is because many intervention and evaluation designs seek to eliminate contextual confounders, when these represent the normal conditions into which interventions must be integrated if they are to be workable in practice.
  
  
  
  We present an ecological model of the ways that participants in implementation and health improvement processes interact with contexts. The paper addresses the problem of context as it affects processes of implementation, scaling up and diffusion of interventions. We extend our earlier work to develop Normalisation Process Theory and show how these processes involve interactions between mechanisms of resource mobilisation, collective action and negotiations with context. These mechanisms are adaptive. They contribute to self-organisation in complex adaptive systems.
  
  
  
  Implementation includes the translational efforts that take healthcare interventions beyond the closed systems of evaluation studies into the open systems of 'real world' contexts. The outcome of these processes depends on interactions and negotiations between their participants and contexts. In these negotiations, the plasticity of intervention components, the degree of participants' discretion over resource mobilisation and actors' contributions, and the elasticity of contexts, all play important parts. Understanding these processes in terms of feedback loops, adaptive mechanisms and the practical compromises that stem from them enables us to see the mechanisms specified by NPT as core elements of self-organisation in complex systems.
authors.affiliation: Faculty of Health Sciences, University of Southampton, Building 67 (Nightingale), University Road, Highfield, Southampton, SO17 1BJ, UK. c.r.may@soton.ac.uk.|University Hospital Southampton NHS Foundation Trust, Southampton, UK. c.r.may@soton.ac.uk.|NIHR CLAHRC Wessex, University of Southampton, Southampton, UK. c.r.may@soton.ac.uk.
authors.forename: Carl R
authors.initials: CR
authors.lastname: May
authors.affiliation: University Hospital Southampton NHS Foundation Trust, Southampton, UK.|NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK.
authors.forename: Mark
authors.initials: M
authors.lastname: Johnson
authors.affiliation: Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK.
authors.forename: Tracy
authors.initials: T
authors.lastname: Finch
mesh_terms: D003695:Delivery of Health Care / Q000379:methods*; D006801:Humans; D057170:Translational Research, Biomedical / Q000379:methods*