This Research Topic includes high-quality Hypothesis and Theory articles published in every section of Frontiers in Health Services in 2022. The mission of the journal is to ultimately contribute to helping health systems improve both experiences and outcomes of patients and make health systems more efficient. Hypothesis and Theory articles aim to highlight a novel argument, interpretation, or model intended to introduce a new hypothesis or theory.  The articles in this collection may provide a new interpretation of recent data or findings in Health Services, or include an accurate presentation of previously posed hypotheses or theories. Hypotheses presented should be testable in the framework of current knowledge and the articles may include original data as well as personal insights and opinions.

University of Helsinki

Cheng Shiu University

University of Alberta

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Frontiers in Health Services

Implementation Science

Cost and Resource Allocation

Health Policy and Management

Mental Health Services

Hypothesis and Theory in Health Services: 2022

Health system transformation is a complex journey that often results in unintended consequences. Existing methods to drive health system transformation have intrinsic limitations which impede successful implementation in local contexts. The Health System Transformation Playbook is a design-, systems-, and complexity-thinking enabled methodology to systematically design, prioritize and test health system and services transformation actions, anchored on iterative story telling, model building and pathfinding processes that tackles the scale of socially and technologically complex adaptive systems through time. The Unified Care Model and its associated cascade of models are examples of ongoing application of Health System Transformation Playbook in a regional population health system in Singapore. Use of Health System Transformation Playbook enables stewards of health systems to gain a more systematic and coherent understanding of health systems and services planning and organization development, to accelerate transformation towards people-centered, integrated and value-driven health systems.

Health system transformation is a complex journey that often results in unintended consequences. Existing methods to drive health system transformation have intrinsic limitations which impede successful implementation in local contexts. The Health System Transformation Playbook is a design-, systems-, and complexity-thinking enabled methodology to systematically design, prioritize and test health system and services transformation actions, anchored on iterative story telling, model building and pathfinding processes that tackles the scale of socially and technologically complex adaptive systems through time. The Unified Care Model and its associated cascade of models are examples of ongoing application of Health System Transformation Playbook in a regional population health system in Singapore. Use of Health System Transformation Playbook enables stewards of health systems to gain a more systematic and coherent understanding of health systems and services planning and organization development, to accelerate transformation towards people-centered, integrated and value-driven health systems.

Health System Transformation Playbook and Unified Care Model: an integrated design, systems & complexity thinking approach to health system transformation

Reducing the “science-to-practice” gap has gained significant attention across multi-disciplinary settings, including school psychology and student wellbeing, trauma-informed practice, community and human services, and clinically focused health care. There has been increasing calls for complexity and contextualisation to be integrated within the implementation science literature. This includes the design and implementation of interventions spanning “systems” (whole-of-community capacity building initiatives), “programs” (e.g., evidence-based programs, clinical interventions) and “moment-to-moment” support or care. The latter includes responses and communication designed to deliver specific learning, growth or wellbeing outcomes, as personalised to an individual's presenting needs and context (e.g., trauma-informed practice). Collectively, this paper refers to these interventions as “wellbeing solutions”. While the implementation science literature offers a range of theories, models and approaches to reduce the science-to-practice gap in wellbeing solution design and implementation, they do not operationalise interventions into the “moment”, in a manner that honours both complexity and contextualisation. Furthermore, the literature's language and content is largely targeted towards scientific or professional audiences. This paper makes the argument that both best-practice science, and the frameworks that underpin their implementation, need to be “sticky”, practical and visible for both scientific and non-scientific knowledge users. In response to these points, this paper introduces “intentional practice” as a common language, approach and set of methods, founded upon non-scientific language, to guide the design, adaptation and implementation of both simple and complex wellbeing solutions. It offers a bridge between scientists and knowledge users in the translation, refinement and contextualisation of interventions designed to deliver clinical, wellbeing, growth, therapeutic and behavioural outcomes. A definitional, contextual and applied overview of intentional practice is provided, including its purported application across educational, wellbeing, cross-cultural, clinical, therapeutic, programmatic and community capacity building contexts.

Reducing the &#x201c;science-to-practice&#x201d; gap has gained significant attention across multi-disciplinary settings, including school psychology and student wellbeing, trauma-informed practice, community and human services, and clinically focused health care. There has been increasing calls for complexity and contextualisation to be integrated within the implementation science literature. This includes the design and implementation of interventions spanning &#x201c;systems&#x201d; (whole-of-community capacity building initiatives), &#x201c;programs&#x201d; (e.g., evidence-based programs, clinical interventions) and &#x201c;moment-to-moment&#x201d; support or care. The latter includes responses and communication designed to deliver specific learning, growth or wellbeing outcomes, as personalised to an individual&apos;s presenting needs and context (e.g., trauma-informed practice). Collectively, this paper refers to these interventions as &#x201c;wellbeing solutions&#x201d;. While the implementation science literature offers a range of theories, models and approaches to reduce the science-to-practice gap in wellbeing solution design and implementation, they do not operationalise interventions into the &#x201c;moment&#x201d;, in a manner that honours both complexity and contextualisation. Furthermore, the literature&apos;s language and content is largely targeted towards scientific or professional audiences. This paper makes the argument that both best-practice science, and the frameworks that underpin their implementation, need to be &#x201c;sticky&#x201d;, practical and visible for both scientific and non-scientific knowledge users. In response to these points, this paper introduces &#x201c;intentional practice&#x201d; as a common language, approach and set of methods, founded upon non-scientific language, to guide the design, adaptation and implementation of both simple and complex wellbeing solutions. It offers a bridge between scientists and knowledge users in the translation, refinement and contextualisation of interventions designed to deliver clinical, wellbeing, growth, therapeutic and behavioural outcomes. A definitional, contextual and applied overview of intentional practice is provided, including its purported application across educational, wellbeing, cross-cultural, clinical, therapeutic, programmatic and community capacity building contexts.

Intentional practice: a common language, approach and set of methods to design, adapt and implement contextualised wellbeing solutions

Context in implementation science includes not only characteristics of a setting in which an intervention will be delivered, but also social systems (e.g., interrelationships). Context is dynamic and interacts with both, the intervention and its implementation. Therefore, contextual analysis is recognized as an indispensable part of implementation science methodology: it provides the foundation for successful and sustainable implementation projects. Yet, driven by the prevailing post-positivist understanding of context, contextual analysis typically focuses on individual characteristics of context i.e., contextual dynamics and interactions go unnoticed. Conducting contextual analysis from a constructivist perspective promotes a multilayered approach, building a more comprehensive understanding of context, and thus facilitating successful implementation. In this article, we highlight the limitations of prevailing perspectives on context and approaches to contextual analysis. We then describe how contextual analysis can be enriched by working from a constructivist perspective. We finish with a discussion of the methodological and practical implications the proposed changes would entail. Emerging literature attempts to address both the concept of context and methods for contextual analysis. Various theories, models and frameworks consider context, however, many of these are reductionistic and do not acknowledge the dynamic nature of context or interactions within it. To complement recent conceptualizations of context, we suggest consider the following five constructivist concepts: 1) social space; 2) social place; 3) agency; 4) sensation; and 5) embodiment. We demonstrate the value of these concepts using COVID-19 vaccination uptake as an example and integrate the concepts in the Context and Implementation of Complex Interventions (CICI) framework—an implementation science framework that pays ample attention to context. To study context from a constructivist perspective, we also suggest additional considerations in view of methodologies for data collection and analysis, e.g., rapid ethnographic methods. A constructivist perspective contributes to a stronger conceptualization of contextual analysis. Considering the five constructivist concepts helps to overcome contextual analysis' current shortcomings, while revealing complex dynamics that usually go unnoticed. Thus, more comprehensive understanding of context can be developed to inform subsequent phases of an implementation project, thereby maximizing an intervention's uptake and sustainability.

Context in implementation science includes not only characteristics of a setting in which an intervention will be delivered, but also social systems (e.g., interrelationships). Context is dynamic and interacts with both, the intervention and its implementation. Therefore, contextual analysis is recognized as an indispensable part of implementation science methodology: it provides the foundation for successful and sustainable implementation projects. Yet, driven by the prevailing post-positivist understanding of context, contextual analysis typically focuses on individual characteristics of context i.e., contextual dynamics and interactions go unnoticed. Conducting contextual analysis from a constructivist perspective promotes a multilayered approach, building a more comprehensive understanding of context, and thus facilitating successful implementation. In this article, we highlight the limitations of prevailing perspectives on context and approaches to contextual analysis. We then describe how contextual analysis can be enriched by working from a constructivist perspective. We finish with a discussion of the methodological and practical implications the proposed changes would entail. Emerging literature attempts to address both the concept of context and methods for contextual analysis. Various theories, models and frameworks consider context, however, many of these are reductionistic and do not acknowledge the dynamic nature of context or interactions within it. To complement recent conceptualizations of context, we suggest consider the following five constructivist concepts: 1) social space; 2) social place; 3) agency; 4) sensation; and 5) embodiment. We demonstrate the value of these concepts using COVID-19 vaccination uptake as an example and integrate the concepts in the Context and Implementation of Complex Interventions (CICI) framework—an implementation science framework that pays ample attention to context. To study context from a constructivist perspective, we also suggest additional considerations in view of methodologies for data collection and analysis, e.g., rapid ethnographic methods. A constructivist perspective contributes to a stronger conceptualization of contextual analysis. Considering the five constructivist concepts helps to overcome contextual analysis' current shortcomings, while revealing complex dynamics that usually go unnoticed. Thus, more comprehensive understanding of context can be developed to inform subsequent phases of an implementation project, thereby maximizing an intervention's uptake and sustainability.

Understanding dynamic complexity in context—Enriching contextual analysis in implementation science from a constructivist perspective

This paper posits that a clinician's own anxious reaction to delivering specific evidence-based interventions (EBIs) should be better accounted for within implementation science frameworks. A key next step for implementation science is to delineate the causal processes most likely to influence successful implementation of evidence-based interventions (EBIs). This is critical for being able to develop tailored implementation strategies that specifically target mechanisms by which implementation succeeds or fails. First, we review the literature on specific EBIs that may act as negatively valenced stimuli for clinicians, leading to a process of clinician maladaptive anxious avoidance that can negatively impact EBI delivery. In the following sections, we argue that there are certain EBIs that can cause emotional distress or discomfort in a clinician, related to either: (1) a clinicians' fear of the real or predicted short-term distress the EBI can cause patients, or (2) fears that the clinician will inadvertently cause the patient harm and/or face liability. This distress experienced by the clinician can perpetuate a cycle of maladaptive anxious avoidance by the clinician, contributing to lack of or suboptimal EBI implementation. We illustrate how this cycle of maladaptive anxious avoidance can influence implementation by providing several examples from leading EBIs in the psychosocial literature. To conclude, we discuss how leveraging decades of treatment literature aimed at mitigating maladaptive anxious avoidance can inform the design of more tailored and effective implementation strategies for EBIs that are negatively valenced.

This paper posits that a clinician&apos;s own anxious reaction to delivering specific evidence-based interventions (EBIs) should be better accounted for within implementation science frameworks. A key next step for implementation science is to delineate the causal processes most likely to influence successful implementation of evidence-based interventions (EBIs). This is critical for being able to develop tailored implementation strategies that specifically target mechanisms by which implementation succeeds or fails. First, we review the literature on specific EBIs that may act as negatively valenced stimuli for clinicians, leading to a process of clinician maladaptive anxious avoidance that can negatively impact EBI delivery. In the following sections, we argue that there are certain EBIs that can cause emotional distress or discomfort in a clinician, related to either: (1) a clinicians&apos; fear of the real or predicted short-term distress the EBI can cause patients, or (2) fears that the clinician will inadvertently cause the patient harm and/or face liability. This distress experienced by the clinician can perpetuate a cycle of maladaptive anxious avoidance by the clinician, contributing to lack of or suboptimal EBI implementation. We illustrate how this cycle of maladaptive anxious avoidance can influence implementation by providing several examples from leading EBIs in the psychosocial literature. To conclude, we discuss how leveraging decades of treatment literature aimed at mitigating maladaptive anxious avoidance can inform the design of more tailored and effective implementation strategies for EBIs that are negatively valenced.

Clinician Maladaptive Anxious Avoidance in the Context of Implementation of Evidence-Based Interventions: A Commentary

This article aims to answer how a commissioning body can steer health services based on value in an environment where the commissioner is responsible for the health services of a population with varying health service needs. In this design science study, we constructed a value-based steering model consisting of three parts: (1) the principles of steering; (2) the steering process; and (3) Value Steering Canvas, a concrete tool for steering. The study is based on Finland, a tax-funded healthcare system, where healthcare is a public service. The results can be applied in any system where there is a commissioner and a service provider, whether they are two separate organizations or not. We conclude that steering can be done based on value. The commissioning body can start using value-based steering without changes in legislation or in the present service system. Further research is needed to test the model in practice.

This article aims to answer how a commissioning body can steer health services based on value in an environment where the commissioner is responsible for the health services of a population with varying health service needs. In this design science study, we constructed a value-based steering model consisting of three parts: (1) the principles of steering; (2) the steering process; and (3) Value Steering Canvas, a concrete tool for steering. The study is based on Finland, a tax-funded healthcare system, where healthcare is a public service. The results can be applied in any system where there is a commissioner and a service provider, whether they are two separate organizations or not. We conclude that steering can be done based on value. The commissioning body can start using value-based steering without changes in legislation or in the present service system. Further research is needed to test the model in practice.