Caveats in Attending to Context Early On
While we have posited that interventions should be designed with the end in mind, there are a few caveats. Designing an intervention for existing contexts and stakeholder values may in fact shortchange innovation by confining intervention development to fit current inadequate or ineffective practice realities. Take for example, Hospital at Home—while it draws upon prevailing resources (physicians, nurses, existing medical treatments, best practices and protocols), it was designed as a different mechanism than prevailing hospital models for delivering acute medical care. At the time of its development, hospitals sought revenue through encouraging hospitalizations and greater lengths of stay and thus the approach threatened the culture and value context of hospitals. Hospital at Home also illustrates how the broader sociohistorical and political contexts (see Chapter 1, Figure 1.2) influence implementation potential. When it was initially shown to be an effective alternative to hospitalizing vulnerable older adults, it was not viewed favorably by stakeholders. With changes in U.S. health care and policy, the model now is a better fit and health care organizations seek to adopt it.
Similar to the Hospital at Home program, it may be that, with policy and contextual changes, GBGB will be able to be adopted more easily in the future in senior centers. If GBGB was designed for delivery in existing mental health systems, it would not have had the same positive impact on the population it targeted, older African Americans, or have the potential to address health disparities that continue to persist in existing mental health delivery approaches. Nevertheless, an understanding of its current implementation challenges helps to frame the evidence needed for policy change. It may be that GBGB will not be adopted at this point in time, but its evaluation demonstrates the feasibility of addressing depressive symptoms in a practice and cost-efficient manner. With policy change, the implementation potential of GBGB may be more feasible, similar to Hospital at Home.
Thus, timing, policy, and societal fit are equally important contextual factors to understand and consider. Some interventions may be designed for current contexts whereas others need to be designed in such a way as to push for change in contexts.