Rhodes Tim, Closson Elizabeth F, Paparini Sara, Guise Andy, Strathdee Steffanie
Centre for Research on Drugs and Health Behaviour, London School of Hygiene and Tropical Medicine, London, UK; National Centre for Social Research on Health, University of New South Wales, Sydney, Australia.
Centre for Research on Drugs and Health Behaviour, London School of Hygiene and Tropical Medicine, London, UK.
Int J Drug Policy. 2016 Apr;30:17-26. doi: 10.1016/j.drugpo.2016.01.002. Epub 2016 Feb 1.
In this commentary, we take the recent introduction of methadone treatment in response to emerging problems of HIV linked to heroin addiction in Kenya as a case for reflecting on the social science of implementation science. We offer a framework of 'evidence-making intervention' which we hold as distinct from mainstream 'evidence-based intervention' approaches. Whilst accepting that interventions are shaped in their contexts, evidence-based intervention approaches tend to imagine a stable intervention object with universal effect potential. By contrast, an evidence-making intervention approach investigates how an intervention, and the knowledge which constitutes it, is made locally, through its processes of implementation. Drawing on qualitative research generated in Kenya prior to (2012-2013) and during (2014-2015) the implementation of methadone treatment, we explore the making of 'methadone promise' as a case of evidence-making intervention. We show how enactments of methadone promise make multiple methadones, through which a binary is negotiated between the narratives of methadone as hope for addiction recovery and methadone as hope for HIV prevention. Addiction recovery narratives predominate, despite methadone's incorporation into policy via its globally supported HIV prevention evidence-base. Key practices in the making of methadone promise in Kenya include its medicalization, and renaming, as 'medically assisted treatment' - or simply 'MAT' - which distance it from prior constitutions elsewhere as a drug of substitution, and the visualisation of its effects wherein unhealthy people can be seen and shown to have become well. We also show how actors seek to protect the story of methadone promise from counter narratives, including through mass media projects. We conclude that there is no single biomedical object of methadone intervening on a single biological body across contexts, and no single universe of evidence. By giving weight to local rather than outside expert knowledge, and by tracing how the meaning of intervention is made locally through its implementation, we can make visible the multiple enactments of an intervention and how these shape local ecologies of care, including in ways beyond those foreseen by an intervention's evidencing elsewhere.
在本评论中，我们以肯尼亚近期引入美沙酮治疗来应对与海洛因成瘾相关的新出现的艾滋病毒问题为例，反思实施科学的社会科学。我们提供了一个“证据制造干预”框架，我们认为它与主流的“循证干预”方法不同。虽然承认干预是在其背景中形成的，但循证干预方法往往设想一个具有普遍潜在效果的稳定干预对象。相比之下，证据制造干预方法研究一种干预及其构成知识是如何通过其实施过程在当地形成的。借鉴在肯尼亚美沙酮治疗实施之前（2012 - 2013年）和期间（2014 - 2015年）产生的定性研究，我们探讨“美沙酮承诺”的形成，作为证据制造干预的一个案例。我们展示了美沙酮承诺的制定如何产生多种美沙酮，通过这些美沙酮，在美沙酮作为成瘾康复希望的叙述与美沙酮作为艾滋病毒预防希望的叙述之间进行了二元协商。尽管美沙酮通过其全球支持的艾滋病毒预防证据基础被纳入政策，但成瘾康复叙述占主导地位。肯尼亚美沙酮承诺制定中的关键做法包括将其医学化并重新命名为“药物辅助治疗”——或简称为“MAT”——这使其与其他地方先前作为替代药物的构成有所不同，以及对其效果的可视化，即可以看到不健康的人变得健康。我们还展示了行动者如何寻求保护美沙酮承诺的故事免受反叙事影响，包括通过大众媒体项目。我们得出结论，不存在跨越不同背景作用于单一生物体的单一生物医学美沙酮对象，也不存在单一的证据领域。通过重视当地而非外部专家知识，并通过追踪干预的意义如何通过其实施在当地形成，我们可以看到干预的多种表现形式以及它们如何塑造当地的护理生态，包括以干预在其他地方的证据所未预见的方式塑造。
