Health Systems and Population Studies Division, icddr,b, Dhaka, Bangladesh; Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Sunway, Malaysia.
Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Sunway, Malaysia; International Institute for Global Health, United Nations University, Kuala Lumpur, Malaysia.
Soc Sci Med. 2022 May;301:114959. doi: 10.1016/j.socscimed.2022.114959. Epub 2022 Apr 4.
There is a significant challenge in global health and development research that pivots on the difficulties of delivering (cost-)effective treatments or interventions that are scalable andtransferable across settings. That is, how does one deliver "true effects", proven treatments, into new settings? This is often addressed in pragmatic trials or implementation research in which one makes adjustments to the delivery of the treatment to ensure that it works here and there. In this critical analytical review, we argue that the approach mis-characterises the cause-effect relationship and fails to recognise the local, highly contextual nature of what it means to say an intervention "works". We use an ongoing randomised controlled trial (RCT)-an informal settlement redevelopment intervention in Indonesia and Fiji to reduce human exposure to pathogenic faecal contamination-as a vehicle for exploring the ideas and implications of identifying interventions that work in global health and development. We describe the highly contextualised features of the research and the challenges these would pose in attempts to generalise the results. In other words, we detail that which is frequently elided from most RCTs. As our critical lens, we us the work of American philosopher, Nancy Cartwright, who argued that research produces dappled regions of causal insights-lacunae against a backdrop of causal ignorance. Rather than learn about a relationship between a treatment and an outcome, we learn that in the right sort of context, a treatment reliably produces a particular outcome. Moving a treatment from here to there becomes, therefore, something of an engineering exercise to ensure the right factors (or "shields") are in place so the cause-effect is manifest. As a consequence, one cannot assume that comparative effectiveness or cost-effectiveness would be maintained.
在全球健康和发展研究中存在一个重大挑战，其核心问题是如何提供具有成本效益、可扩展且可在不同环境中转化的治疗方法或干预措施。也就是说，如何将“真正的效果”，即已证明有效的治疗方法，应用于新环境？这通常在实用临床试验或实施研究中得到解决，即对治疗方法的实施进行调整，以确保其在新环境中有效。在本批判性分析评论中，我们认为这种方法错误地描述了因果关系，并且未能认识到干预措施“有效”的含义在当地的高度情境性。我们使用正在进行的随机对照试验（RCT）——印度尼西亚和斐济的非正规住区重新开发干预措施，以减少人类接触致病粪便污染——作为探索确定在全球健康和发展中有效的干预措施的想法和影响的工具。我们描述了研究的高度情境特征，以及这些特征在尝试推广结果时会带来的挑战。换句话说，我们详细说明了在大多数 RCT 中经常被省略的内容。作为我们的批判性视角，我们引用了美国哲学家南希·卡特赖特的著作，她认为研究产生了因果洞察力的斑驳区域——在因果无知的背景下存在的空白。我们不是了解治疗方法与结果之间的关系，而是了解在正确的环境中，治疗方法可靠地产生特定的结果。因此，将治疗方法从一个地方转移到另一个地方，就成为了确保正确因素（或“盾牌”）到位以表现因果关系的工程学任务。因此，不能假设比较有效性或成本效益会得到维持。
