Methodological Challenges

of Structural Intervention

Design challenges

Amy Knowlton
Johns Hopkins Bloomberg School of Public Health
Pre-Summit Learning Institute, June 2, 2010
 Structural intervention
• Definition: intervention beyond the
individual

• Addresses common factors, or drivers

– HIV prevention
– HIV care & treatment
– Psychosocial support

• More powerful & sustainable than individual-

level intervention
 Questions

• What are we intervening in?

• What are critical components of the

intervention (independent variables)?

• What are we trying to affect? (outcomes)

• How do we measure these things?

 Conceptualization of structural
intervention
• It‟s not just about “serving” people

• Building, leveraging, & linking systems

– Physical space

– Social relationships

– Political, economic, legal and social policies

 Structural model
Macro: power, policies, laws, & economic factors

Physical Social
Resources space interconnectedness

Agency

Norms

Access
 Defining the problem
• Individual level
– Frequent flyers in EMS, EDs

• Systems
– EMS (service “abusers”)
• Choice of ED or jail
– Healthcare (public vs. private interests)
• Perverse incentives of hospitals
– Drug tx
• Not “ready”, motivated to come
– Emergency preparedness
• Huge funding stream
• Ignore vulnerable populations
 Systems problem
• Service system fragmentation

• Lack of linkage impedes appropriately

addressing needs of their shared client
population

• Client-centered services delivery

– Public health approach
Proposed structural intervention

• EMS approach to identify people at risk,

link to appropriate services

• EMS screening, brief intervention &

referral to drug abuse treatment (SBIRT)
Client Provider factors Client
factors Perceived need
Knowledge
motivation
Perceived burden
Enabling
factors

Client-provider Client treatment

Pre-
disposing interactions use
factors Enrollment
Organizational Retention
factor
Service demand,
time; Work control,
satisfaction
Treatment services
Availability, Accessibility,
Affordability,
Acceptability
 Window of opportunity
• Evidence-based, supportive leadership

• New technologies
– Electronic databases (EPRs)
– Centralized tx slot locator & intake system

• Organizational “champion”

• New funding streams for outpatient tx

• Buprenorphine
– Increases tx options, tx acceptability
– Nested within primary health care system
– Baltimore has model bupe program
 Social relationships

• Which social connections to develop,

alter?
– Client-provider
– Provider-provider
– Prosocial peers
Social norms (outcomes or mediators)

• Social norms can be conceptualized as existing on different level of

analyses
– There are norms among partners, networks, neighborhoods,
communities, and societal norms
– Norms are attributes of individuals and groups

• Norms can be considered social motivators for risk reduction and

influencing perceptions of risk
• They are the rules for social interactions and the outcomes of group
interactions
• Norms vary on homogeneity, strength, salience, and flexibility
• Important for sustainability
 Access (outcomes)

– Primary prevention materials

• syringes, condoms, HIV testing
– Indirect prevention materials
• Drug, mental health, and HIV medical treatment
– Economic resources
• Employment, food, education
 Agency (outcomes)
• Structural factors can facilitate or
impede agency
– Lack of partner choice due to incarceration
and employment opportunities in the inner-
cities may reduce agency to choose safer
partners.
– Programs that reduce youth from dropping out
of school may enhance agency.
• Conceptual tool for analyzing,
implementing, and evaluating
structural approaches to HIV
prevention
 Systems approach
• Input/output: For structural approaches inputs are
often material resources and social policies.
– We can also consider information, HIV related norms, and
behaviors.
• Transient: system is disturbed after an initial setting of
conditions.
– Lack of housing exposes social systems of networks and daily
routines to constant disturbances.
• Couplings: two systems can couple to form one.
– Lack of housing may lead to greater integration of drug
economy and exchanging sex for money
• Feedback: if A changes B, B may also change A: If A
changes B, B may also change A
– A group receiving an HIV test from a health center can provide
money, information, or a head count necessary to maintain a
service, justify to the state.
 Systems approach
• Independence within a whole (no immediate effects
of one part on another).
• Size: there are “very large systems” such as societies;
such systems can by definition be specified only
incompletely.
– Risk groups, are involved in many systems and the
categorization of risk group is a very incomplete system.
• Random coupling: e.g., connecting wires of a system
at random to see what happens.
– Without housing individuals have a higher likelihood of
interacting with high risk partners.
• Richness of connection. Overlapping systems,
networks and settings within larger social structures.
This system factor may militate against or amplify
change.
 Systems approach
• Localized properties: in parts that are not well
coupled, a part may have properties that have
relatively no effect on the other parts of the system.
– Homeless are often in highly impoverished inner-city areas
that are often bereft of social services and economic
opportunities.

• Self-locking properties: a property that develops

becomes inaccessible to other factors that would
undevelop it.
– Homelessness may lead to disconnection from resources at a
network level and other levels.
 Systems approach
• Properties that breed: the existence of a property in
one part of the system at one point of time increases
the probability of that property existing in other parts at
a later time.
– Homelessness may social disorganization, which may lead to
material resources flowing out of certain neighborhoods and
greater levels of homelessness in those neighborhoods.
• Amplification loops: may maximize interventions
„impact.
• Systems approach provides an opportunity to examine
the methods of increasing sustainability of
interventions and emphasizes that terminating
behaviors is different from introducing and sustaining
new behaviors.
 Systems approach
• Loose and tightly coupled relationships:
– Poverty and HIV are loosely linked, whereas syringe
availability and needle sharing may be more tightly coupled.

• Systems theory may help to understand and predict

unintended consequences of structural interventions
– Loans with high interest rates may lead to sex exchange.
– Group empowerment interventions may lead to formation of
high risk groups.
– There can also be positive unintended outcomes, e.g.,
Treatment of HIV may lead to reduction in stigma.
The End