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The spirit of the intervention:reflections on social effectiveness inpublic health intervention researchMorten Hulvej Roda, Liselotte Ingholta, Betina Bang Sørensena &Tine Tjørnhøj-Thomsena

a Centre for Intervention Research in Health Promotion andDisease Prevention, National Institute of Public Health, Universityof Southern Denmark, Copenhagen, DenmarkPublished online: 01 Oct 2013.

To cite this article: Morten Hulvej Rod, Liselotte Ingholt, Betina Bang Sørensen & Tine Tjørnhøj-Thomsen (2014) The spirit of the intervention: reflections on social effectiveness in public healthintervention research, Critical Public Health, 24:3, 296-307, DOI: 10.1080/09581596.2013.841313

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The spirit of the intervention: reflections on social effectiveness inpublic health intervention research

Morten Hulvej Rod*, Liselotte Ingholt, Betina Bang Sørensen andTine Tjørnhøj-Thomsen

Centre for Intervention Research in Health Promotion and Disease Prevention, National Instituteof Public Health, University of Southern Denmark, Copenhagen, Denmark

(Received 8 November 2012; accepted 31 August 2013)

This paper suggests that public health intervention research would benefitfrom more thorough considerations of the social dynamics in which publichealth interventions are embedded. Rather than simply asking ‘What works?’,researchers should examine the social effectiveness of interventionprogrammes; i.e. (i) the creation of shared understandings among researchersand practitioners and (ii) the ways in which programmes reconfigure socialrelationships. Drawing on the theoretical work of philosopher Charles Taylorand sociologist Marcel Mauss, we suggest that the term ‘the spirit of the inter-vention’ may enable researchers to further articulate – and hence discuss – thesource of an intervention’s social effectiveness. The empirical impetus of thepaper lies in our experiences as an interdisciplinary team of researchers,trained in social science and public health and now working within interven-tion research. We describe our attempts at reconciling the methodologicalrequirements of an effect evaluation, modelled on the randomised clinical trial,with a process of intervention development grounded in ethnographic meth-ods. In particular, we discuss how we have grappled with the schism betweenfidelity and adaptation, which is a key methodological issue in interventionresearch. While public health intervention research tends to conceptualiseprogrammes as fixed and bounded entities, we argue that ‘the spirit of theintervention’ offers a conceptual starting point for reflections on programmesas on-going social processes. In order to capture and explore this dimensionof public health interventions, a great deal of potential lies in a furtherengagement between intervention research, ethnographic methods and socialtheory.

Keywords: intervention research; programme evaluation; fidelity; implementation;ethnography; social theory

Introduction

In public health intervention research, the randomised controlled trial (RCT) remainsthe paradigmatic gold standard method. Even if many intervention studies are conductedin quasi-experimental setups, and attempts have been made to promote the use ofso-called pragmatic trials (Roland and Torgerson 1998), the overarching purpose ofintervention research is to examine the causal efficacy of interventions. Simply put,most intervention research projects aim to answer the question ‘What works?’ in terms

*Corresponding author. Email: mhj@niph.dk

© 2013 Taylor & Francis

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of achieving certain public health outcomes. When it comes to the investigation of suchcausal questions, the RCT is, for sure, a powerful method.

This paper sets out to introduce and discuss a particular aspect of efficacy, namelythe social effectiveness of public health interventions. We would like to highlight theimportance of understanding public health interventions as social processes, and thusnot simply as effect-generating entities with fixed and circumscribed properties. In linewith anthropological and sociological research into the workings of clinical trials (see,e.g. Will and Moreira 2010), we suggest that public health interventions work throughcomplex social dynamics that condition and influence the research findings (cf. alsoBonell 2002; Oakley et al. 2006). Our argument is developed with reference toso-called complex interventions that attempt to change the course of human action(Cohn et al. 2013), but we consider the overall theoretical point of this paper to be ofrelevance to intervention research in general and beyond the field of public health.

In order to discuss the social dynamics involved in public health interventions, wedraw on classic insights from social theory, emphasizing the dialogical nature of socialaction (Taylor 1995) and the establishment of reciprocity through processes of exchange(Mauss [1923] 2002). Further, the argument is based on our experiences with an inter-disciplinary intervention research project, which aimed at developing and evaluating ahealth promotion programme in Danish vocational colleges, covering the education ofcarpenters, mechanics, hair dressers, IT consultants and many others. In our researchpractice, we have tried to reconcile the methodological requirements of a quasi-experi-mental effect evaluation, modelled on the RCT, with a process of interventiondevelopment grounded in ethnographic methods. One particularly important problemturned out to be the conceptual distinction between fidelity and adaptation.

Research into the outcomes of interventions is generally required to evaluatewhether or not programmes are delivered as intended because, as the argument goes,this is a necessary step in discerning ‘the true effect’ (Carroll et al. 2007, 31) of aprogramme. In other words, researchers need to ascertain if the programme isimplemented with fidelity (ibid.; Hasson 2010). On the other hand, some researchersargue that any programme will need some degree of adaptation to the local context ofits implementation and suggest that it is necessary to find the right balance betweenadaptation and fidelity (Backer 2001; Bartholomew et al. 2011; Blakely et al. 1987;Durlak and DuPre 2008).

Arguments in favour of fidelity tend to draw on a particular set of concepts, such asdose, adherence and active ingredient, which are modelled on the language used inRCTs. Arguments stressing the importance of adaptation often turn towards theories oforganizational change and innovation (e.g. Roger’s diffusion of innovation [1995, citedin Bartholomew et al. 2011]) and highlight concepts such as culture, context andcommunity (Backer 2001; Nielsen et al. 2006). Both sides agree, however, to theexistence of an inherent schism between fidelity and adaptation, and it appears to bethis simple differentiation that drives the entire debate and which may have caused it toend in a rather unproductive gridlock: Without fidelity, valid claims cannot be madeabout the effects of a programme and yet, without adaptation a programme cannot beput into practice. However, as Durlak and DuPre have argued, the debate concerningfidelity and adaptation might be ‘framed inappropriately in either-or terms’ (2008, 341).They suggest that researchers should aim to find ‘the right mix’ (ibid.) through carefulmeasurements of both dimensions during the implementation of programmes. Similararguments are made by Castro, Barrera, and Martinez (2004) and Dusenbury et al.(2003) who suggest that intervention developers need to integrate some degree of

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flexibility and opportunities for adaptation in their programmes even while maximizingfidelity. Our aim is, however, to take the conceptual discussion to a more fundamentallevel. The problem may not be solvable through more refined measurements or moredetailed implementation models, because it raises some serious questions concerningthe very epistemological basis for intervention research.

The traps of intervention research

Before we turn to the theoretical and epistemological issues, we would like to presentour own experiences as intervention researchers. As a research team, we are trained inpsychology, public health and anthropology, and presently we are engaged in the devel-opment and evaluation of an intervention set to reduce drop-out and drug use, whilepromoting well-being and social ties, among students in vocational training. We havedeveloped the intervention through ethnographic fieldwork at four vocational colleges,where we found that the students had few possibilities for developing social ties andfriendships. Further, we have worked from a basic set of theoretical assumptions thatemphasise the social practices and local institutional arrangements in which our targetgroup is embedded (see, e.g. Bourdieu 1990; Lave and Wenger 1991). This means thatour intervention does not directly address the behaviours of individual students, butattempts to change the physical and institutional environments which condition andshape the problems of drop-out and drug use.

Basically, the programme consists of a set of suggestions for teachers, counsellorsand managers that are meant to improve the ways in which they welcome new students,allow for greater integration of social and educational activities, and enhance the capaci-ties of teachers and counsellors for dealing with drug use problems among the students.

The suggestions have been printed in a blue brochure and distributed to theintervention schools. We have presented the programme at a number of meetings withteachers, counsellors and managers who agreed to implement the programme over thecourse of a year from October 2011 to October 2012. The effects of this interventionhave been tested in a quasi-experimental set-up, where questionnaire surveys of studentsin four intervention schools are to be compared with surveys of a matching group ofstudents in six control schools. As a complement to the effect evaluation, we haveconducted a process evaluation, based on ethnographic observations and interviews, inorder to see how our suggestions have been interpreted and put to practice (cf. Oakleyet al. 2006). Furthermore, we have developed a method for measuring the degree towhich the schools implement our intervention. This measure should, in the end, allowus to account for differential effects that depend on variations in the implementationfrom one school to another. However, the actual development of this measure turnedout to be an extremely difficult task that revealed the very epistemological problemsthat are discussed in this paper.

When developing the intervention we learned that each school – not to mention thevarious educational branches at each school – had its own way of organizing, managingand practising its work. In order to embrace these differences, and in line with our owntheoretical assumptions about the problems the intervention was to address, we phrasedour suggestions in the blue brochure in fairly general terms and we deliberately adoptedan attitude of flexibility and open-endedness. However, when our research teamgathered over two days set aside specifically with the aim of developing a measure forimplementation, we found out that we needed to adopt a more rigorous attitude to ourown suggestions. We found that the best way to create this measure was by assessing,

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via a questionnaire survey among the involved teachers, the extent to which theycarried out the specific tasks described in the brochure. This would provide the basisfor a measure of the ‘dose’ which, in accordance with the recommendations of the liter-ature on implementation fidelity (e.g. Carroll et al. 2007), we complemented with ameasure of the ‘quality’ of the implementation as assessed by the teachers themselves.

During the process evaluation, ethnographic observations of the implementationhave documented that the suggestions in blue brochure may be incorporated into theeveryday practices at the schools in manifold ways. For example, our programmeincluded a suggestion that, at the beginning of each term, the teachers should facilitatea simple round of introduction among the new students, and in our dose questionnairewe included a question asking the teachers whether or not this actually happened. Ourobservations indicated, however, that such rounds of introduction could be more or lesssuccessful in creating a welcoming and inclusive atmosphere. This depended heavily onthe attitudes of the teachers, their (body) language and the energy they put into theactivity which, of course, again depended upon the specific situational conditions andthe particularities of the groups of students. We tried to include this aspect in ourquality measure by asking, in a rather general manner, if the teachers thought that theyhad appropriately welcomed the students. Still, something seemed to be missing fromthat measure that was clearly captured in the ethnography while not lending itself easilyto quantification.

The need to develop a method for measuring the dose and quality of theintervention delivery led us into a fidelity trap: It was not our original intention that thespecific activities mentioned in the blue brochure were to be implemented andinterpreted in a literal manner. Rather, we wanted to test if, as a whole, the suggestionscould contribute to the creation of stronger ties amongst the students as well as betweenteachers and students. Somewhat paradoxically, however, the need for measuringimplementation fidelity led us to circumvent our original intentions with theprogramme. The implementation measure transformed the brochure into something tobe read like a manual, even though it was written with a different purpose in mind.

While our creation of a measure of implementation led us into a fidelity trap, we alsoencountered something that is best described as an adaptation trap. One element in ourprogramme had an even more open-ended character than the rest of the suggestions: Ateach of the participating colleges we formed a working group of teachers, managers andcounsellors with the purpose of discussing how they might enhance their capacities fordealing with drug use problems among the students. In our initial ethnography we foundthat most schools had adopted fairly strict zero-tolerance substance use policies and ruleswhich were not, however, mirrored in the everyday practices of teachers and counsellors(Sørensen, Ingholt, and Frank 2012). Hence, we wanted to see if the existing rules andpolicies could be supplemented with more practice-oriented guidelines that would enablethe teachers to identify drug use problems and to do something about these problemsthat, unlike the zero-tolerance policy of expulsion, would not conflict with the overarch-ing aim of getting the students to complete their education.

We considered this a chance to experiment with methods known from so-calleddevelopmental evaluation (Patton 2011), which aims to generate new solutions througha process where the evaluator actively facilitates, analyses and shapes the programmedevelopment in collaboration with practitioners. Thus, the first author of this paper(MHR) participated in the working groups and to some extent facilitated their work.Having been trained in social anthropology, MHR entered into the combined role offacilitator, developer and evaluator with the attitude of an ethnographic fieldworker:

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Attuned to listening and learning from the participants in the working groups, but alsoprovoking and stimulating discussions by presenting preliminary analyses of theirpractices (Patton 2011).

Two types of problems occurred in this process and got us caught in the adaptationtrap:

First, the built-in possibilities for adaptation did not prove as productive as we hadexpected. Some participants in the groups openly wondered why MHR did not presentready-made solutions. One participant quickly withdrew from his group, because he hadexpected to attend a course rather than a discussion group. Others asked MHR to bringa proper contribution to the table. Even though many participants said that they werehappy to engage in this type of discussion, which they claimed was both useful andrelevant, it became apparent that our commitment to adaptability came with a risk ofappearing unfocussed and non-contributive.

Second, and somewhat paradoxically given the intended flexibility of the workinggroup set-up, we experienced some difficulties in keeping the discussions going in theright direction. For instance, MHR came at odds with his methodological opennesswhen, in one group, the participants wished to introduce a fairly rigorous regime ofdrug testing. MHR knew of scientific studies indicating that this would be a potentiallycounter-productive strategy and informed the participants of these studies. Nonetheless,it proved difficult to take on the role of a drug intervention expert in the midst of aprocess where that particular role had been toned down in order to create opennesstowards the inputs of the research participants.

The happenings in the working groups may reflect some problems that are specificto developmental evaluation in so far as the open-endedness of this type of evaluationcontrasts starkly with the rigour expected by RCT designs. Nonetheless, we wouldargue that the adaptation trap is a more general phenomenon that intervention research-ers may encounter in any evaluation where the boundaries for adaptability are not easilyestablished.

One way of interpreting our encounters with these two traps of intervention researchwould be to dismiss our efforts as an example of a poorly designed project. We should,of course, have had the required measures in place at an earlier stage. We should haveanticipated the need for more elaborate descriptions of the programme activities in orderto enable proper measurements of fidelity. We should have specified some corecomponents, the central effective ingredients, of our intervention before we startedtesting it. Why did we not produce a manual in the first place, instead of a simple bluebrochure? A straightforward answer to that question would turn to the arguments infavour of adaption and the theoretical framework of the intervention itself: It is hardlypossible to make a generic script that would fit the highly varied practices and socialdynamics in vocational colleges. However, the above account of our experiences canalso be taken to indicate that the distinction between fidelity and adaptation is problem-atic, because even the greatest scope for adaptability does not preclude the necessity ofsome sorts of fidelity – and vice versa. In order to get a further grasp of this problem,we now turn to philosopher Charles Taylor (1995) whose view on the characteristics ofhuman action has some profound implications for intervention research.

Implementation as dialogical action

A manual can be viewed as a set of rules and explanations to be followed by thepersons implementing a programme. In our case, such a manual would have had to

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explain the particular acts, words and attitudes to be adopted by teachers carrying outthe programme activities. As Taylor points out, however, any explanation that is meantto guide human behaviour will have to leave potential issues unresolved (1995, 166).Following a rule, he maintains, is a social practice that cannot be reduced to a singleagent – ‘the monological subject’ – following particular instructions articulated inlanguage. Taylor criticizes, thus, an intellectualist view of human action that leaves outany notion of the body and the other. The body is important, he argues, because humanpractices are guided by an embodied understanding that is usually taken for granted,and which remains largely unarticulated. Indeed, one might speculate that oncearticulated (and thus stabilised) such an understanding will lose its effectiveness due tothe situational contingencies in which any action is embedded:

Human situations arise in infinite variations … Just being able to formulate rules will notbe enough. The person of real practical wisdom is less marked by the ability to formulaterules than by knowing how to act in each particular situation. There is a crucial ‘phroneticgap’ between the formula and its enactment. (Taylor 1995, 177)

This point is particularly relevant to intervention research because any programme,whether manualised or not, will require that those implementing it know how to act ineach particular situation. Even the most concise and elaborate manual would not be ableto pre-empt the endless possibilities that arise in the course of implementation. This ispart of the explanation why the fidelity/adaptation distinction is flawed: To follow a rulewith fidelity does not run counter to situational adjustment or, as phrased by Taylor,‘Express rules can only function in our lives along with an inarticulate sense encodedin the body’ (1995, 180).

We have already mentioned the example with the rounds of introduction which weremeant to create a welcoming atmosphere, but which did not always succeed in doingso. The solution to this problem is hardly to create an even more detailed manualspecifying particular elements and acts that need to be included. Following Taylor’sargument, the question remains how to change the inarticulate and hence much moresubtle understandings that shape the socially contingent acts of welcoming new studentsin specific situations.

Situational contingencies occur because, more often than not, human action is‘dialogical’ rather than ‘monological’. Taylor uses the image of two people sawing witha two-handed saw to illustrate that certain acts require a shared sense of rhythm andflow (ibid., 172) and he defines dialogical action as follows:

An action is dialogical, in the sense I’m using it here, when it is effected by an integrated,nonindividual agent. This means that for those involved in it, its identity as this kind ofaction essentially depends on the agency being shared. These actions are constituted assuch by a shared understanding among those who make up the common agent. (ibid.,172)

Our contention is that the social effectiveness of public health interventions dependsupon dialogical action and, thus, that some shared understanding – a common sense ofrhythm and flow – is required among those involved. Our suggestions in the bluebrochure could only be effective if we succeeded in creating a shared understandingwith teachers and counsellors about the overall direction of the programme. The bluebrochure was, in itself, an intervention in social relationships that was meant toeffectuate this integration of agency.

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This is why our questionnaire survey among the teachers missed something. It wasdesigned to capture the dose of the intervention actually delivered, and it did so byenumerating the number of programme activities according to the contents of thebrochure. However, the questionnaire was incapable of capturing the extent to whichwe succeeded in creating a shared understanding of these activities with the practitio-ners. As Taylor puts it, ‘Rules aren’t self-interpreting; without a sense of what they’reabout, and an affinity to their spirit, they remain dead letters or become a travesty inpractice’ (ibid. 179).

Attempts at measuring fidelity vis-à-vis adaptation place the agency in implementa-tion processes squarely with practitioners. The causal effects of the intervention aretaken, then, to spring from the acts of these ‘monological subjects’ who, in the best ofcases, act in accordance with a manualised set of prescriptive rules. This view isseriously challenged by Taylor’s suggestion that human action may be seen as theoutcome of a dialogical process that presupposes a shared understanding among theinvolved actors.

As Taylor points out, human action is guided by unarticulated and embodiedunderstandings rather than express rules and prerogatives. This represents a challenge tointervention researchers who seek to change behaviours and practices – not only amongthose belonging to the target group, but importantly also among the practitioners whoare supposed to implement a programme. In order for such programmes to work, it isessential that practitioners are able to fill out the ‘“phronetic gap” between the formulaand its enactment’ (op.cit.) as they encounter new and unforeseen situations of imple-mentation. In this respect, the creation of a shared understanding between researchersand practitioners is likely to be more important (and effective) than the strict adherenceto particular manualised activities (see Montoya and Kent (2011) for a relateddiscussion which draws on the ideas of participatory action research).

Implementation as a process of exchange

A prime example of dialogical action is to be found in processes of gift exchangewhich have been famously examined and theorised in Mauss’ work on exchange andreciprocity in Polynesia (2002). One of Mauss’ central points concerning the exchangeof gifts has universal applicability: Processes of exchange involve a threefold obliga-tion: An obligation to give, an obligation to receive, and an obligation to reciprocate.What matters in the present discussion is the insight that exchange is a fundamentalhuman practice that creates and sustains (and when disrupted suspends) social relations.

Our experiences with the working groups illustrate how intervention research worksthrough the establishment of a reciprocal relationship between researchers and practitio-ners. The direct face-to-face and quasi-ethnographic interaction in the groups may beatypical to public health intervention research which tends to favour quantitative and,arguably, more detached methods. However, conducting a questionnaire survey amongteachers is equally dependent on reciprocal relations. Indeed, the survey represents amedium for transforming something that belongs to the teachers (i.e. knowledge abouttheir actions) into something of use to us as researchers (i.e. a measure of theimplementation).

The working groups, the questionnaire survey – and implementation processes ingeneral – may, thus, be understood as processes of exchange. More specifically, theproblems arising in the working groups can be interpreted as matters of failed reciproc-ity: The first problem, which concerned the contribution of MHR, is clearly an example

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of a researcher not delivering what is expected by the practitioners. The second problemexemplifies the opposite situation; the practitioners reciprocate the researcher’sintervention in an unexpected manner that does not conform to the expectations of theresearchers. In both cases, the particularities of these exchange practices reworked therelations between researchers and practitioners, and the examples highlight the ways inwhich the control over implementation processes is not placed squarely with singularactors. The implementation – and the research itself – is conditioned by the on-goingreconfiguration of social relations.

If, as we argue here, the implementation of interventions depends upon the successfulformation and maintenance of reciprocal relations, it is certainly worth considering, asdid Mauss, how such processes are kept flowing. Mauss asked, ‘What power resides inthe object given that causes its recipient to pay it back?’ (2002, 4). This question makesus look for the features of the exchanged objects that renders them socially effective. Ifpeople give, receive, and reciprocate it is not due to a rule or a theoretical principle (cf.Taylor 1995); rather people partake in these practices, or abstain from doing so, ifcompelled by the object and the specific circumstances of the exchange. As Taylor pointsout, ‘What on paper is a set of dictated exchanges under certainty, on the ground is livedin suspense and uncertainty’ (ibid., 177). This aspect of exchange processes is certainlyfelt by intervention researchers: Are the questionnaires returned? In time? Are we askingtoo much of our practitioner collaborators? Will they pass along the intervention to thetarget group? These are all pertinent questions that arise from the uncertainties involvedin processes of exchange. Unless the exchange is kept flowing, the intervention as wellas the research are bound to fail.

In the case of our project, the intervention was exchanged in a process involvingresearchers, school managers, teachers and students. Through this process the interven-tion, as an object of exchange, assumed numerous material and discursive forms: Theblue brochure was widely circulated to and within the schools in return for theirgranting us the possibility of carrying out research. Our PowerPoint presentations atmeetings with school managers and teachers were accompanied by elaborate verbalexplanations. Through changes in their daily practices the teachers passed on theintervention to the students, while their answers to the implementation questionnairesrepresented yet another way of giving something back to us as researchers.

This general cycle of reciprocity is, of course, an idealised picture. Each link in theexchange is forged (or fails to be forged) in specific situations of social interaction.Obviously, the teachers are involved in an institutional hierarchy, and their implementa-tion of a programme is influenced by their relations with the school management,colleagues and students. Nevertheless, the successful implementation of an interventiondepends on its being exchanged in a manner where something keeps flowing even ifthe material and discursive forms of the programme vary: Blue brochures, PowerPointpresentations, and verbal explanations are exchanged for the changed practices of teach-ers, answers to questionnaires and ultimately for effect measures concerning theexpected behavioural outcomes among students. This something that needs to be keptflowing may be conceptualised as the spirit of the intervention.

Mauss explains a fundamental principle in Polynesian gift exchange which concernsthe spirit of a gift: ‘What imposes obligation in the present received and exchanged, isthe fact that the thing received is not inactive. Even when it has been abandoned by thegiver, it still possesses something of him’ (Mauss 2002, 15). It is this spirit of the giftwhich makes it socially effective. It is a force contained in the actual thing given that,at least in principle, ensures that the exchange is kept flowing. Otherwise, explained a

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Maori informant to one of Mauss’ colleagues, ‘serious harm might befall me, evendeath’ (ibid., 14). In intervention research the consequences are, of course, less dire ifthe exchange fails. Nevertheless, the concept of the spirit enables us to discuss andscrutinise those aspects of an intervention programme which render it capable ofreconfiguring social relations among the involved actors and, thus, of achieving itssocial effectiveness.

Conclusion

Intervention researchers tend to view programmes as entities that work in and of them-selves. The fidelity/adaptation debate illustrates this focus on the programme contentwhich is understood in terms of predefined and preferably well-described activities fromwhich the causal effects are supposed to spring. Nonetheless, the above discussion hasrevealed that an intervention may assume numerous forms in the course of social inter-action and that the relationship between these forms may not be adequately captured bythe fidelity/adaptation distinction. As mentioned, our own intervention adopted multipleforms: brochures, presentations and explanations were translated into varied sociallycontingent practices.

In this article, we have introduced the notion of social effectiveness in an attempt togain a better understanding of the social processes in which public health programmesare embedded. We have applied some basic insights from social theory (represented byTaylor and Mauss) that highlight the importance of social relations, situational contin-gencies and reciprocity in intervention research. In that respect, the article draws oninsights from ‘the sociology of standardization’ (Timmermans and Epstein 2010) whichanalyses the workings of standards in particular social domains (e.g. manuals andprotocols in evidence-based practice). We wish to bring such insights into public healthintervention research by pointing out that even standardised interventions depend uponshared understandings (which are often unarticulated and embodied) and the reconfigu-ration of social relationships (through processes of exchange). Our own experiencestestify to the problems that may occur if one overlooks these dimensions of interventionresearch.

Mauss uses the term ‘spirit’ in a very particular sense: He uses the concept in adiscussion of the social effectiveness of gift-giving and ‘the spirit’ denominates thedimension of a gift that keeps the exchange flowing. His basic point is that gift-givingis not simply an activity through which certain material goods are exchanged, but it isessentially a process that serves to confirm, transform and, in some cases, deny socialrelations. Taylor also uses the term ‘spirit’ (1995, 179), but in a slightly differentunderstanding: To Taylor, the spirit designates the unarticulated dimension of rules andverbalised explanations – ‘what they’re about’ (ibid.) – without which it is impossibleto respond to situational contingencies.

Taking the concept into intervention research, we propose that the term ‘the spirit ofthe intervention’ may be used as an entry point for discussing the dimensions of anintervention that make it socially effective. In so doing, we wish to point to therelevance of both Taylor’s and Mauss’ theoretical contributions:

(i) An intervention can only be socially effective if it succeeds in creating ashared understanding between researchers and practitioners that enable theintervention to become implemented under ever-shifting social circumstances.The shared-ness of this understanding does not necessarily imply a complete

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convergence of perspectives. Shared understandings are not the same asidentical understandings. Nonetheless, Taylor reminds us that human action isnot carried out by singular agents and that certain acts are best understood asthe outcome of dialogical processes and situational contingencies. We wouldargue that this point applies well to implementation processes.

(ii) As Mauss’ analysis of gift-giving shows, processes of exchange reconfiguresocial relations. Likewise, any intervention is bound to reconfigure socialrelationships in a particular manner. Like a gift in ancient Polynesia, theintervention generates and transforms social relations among those involvedin the process of exchange. Whether or not intervention researchers reflectupon and discuss this aspect of their work it is bound to influence andcondition their conclusions.

As the story of our encounters with the traps of intervention research indicates, theresearch process depends upon the establishment of reciprocal relations betweenresearchers and practitioners and it requires on-going efforts to keep the exchangeflowing. In our project, we have found it useful to think of the programme as a set ofprinciples that may be applied in the daily practices of teachers and other members ofstaff at the school. The implementation of the programme becomes a matter of changingthe implicit understandings of the professional practices in the schools, while itbecomes less important whether or not the schools carry out the specific activitiesdescribed in the brochure. Further, we consider it part of our role as interventionresearchers to not only trace the effects of the programme – and examine the processesof implementation – but also to actively influence the implementation through on-goingdialogue with the staff and students in the school. In this respect, the study clearlybreaks with the ambition to study the direct and socially uncontaminated effects of aprogramme, which is normally associated with an RCT.

Importantly, the spirit is not a fixed property, but is best seen as an emergentoutcome of the intervention that requires on-going research attention. If one imaginesthat the spirit of an intervention can be articulated, once and for all, by interventiondevelopers and then communicated to practitioners for them to implement in theirpractices, one is bound to end up exactly in the fidelity/adaptation gridlock where thispaper started. The problem concerning the limits of rules and explanations, as laid outby Taylor, would apply equally to an explanation of the spirit. Thus, increased reflexiv-ity is required throughout the research project in order to question and discuss theon-going transformations of the programme during the social process of implementa-tion. Such transformations cannot be adequately described in terms of fidelity andadaptation. It is a matter of the intervention assuming different forms in the course ofsocial interaction, rather than a prescribed set of activities being adapted to shiftingcircumstances.

In order to capture and discuss this dimension of public health interventions, a greatdeal of potential lies in a further engagement between intervention research, ethno-graphic methods and social theory. Ethnographic observations and the long-standingtradition for reflecting on the relations between subject and object in ethnographicresearch (see, e.g. Hastrup 2005) offer the possibility for documenting the various trans-formations of the programme in the interaction between researchers and the other actorsinvolved in intervention research.

By drawing attention to the social effectiveness of interventions, we wish to proposethat intervention researchers pay more attention to the social relations in which they are

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embedded – and with which they interfere. This requires that intervention researchposes a broader set of questions than simply ‘What works?’ Specifically, it seemspertinent to understand how programmes – and intervention research projects – serve tocreate, maintain, transform (or perhaps suspend) social relations. This is ultimately aquestion that relates to the distribution of power and agency among the research partici-pants which we have not been able to discuss here. In this paper we have concentratedon the relations between researchers and practitioners, but it is equally important toconsider the implications of programmes for the relations between practitioners andthose belonging to the ‘target group’. The basic point remains the same: If interventionsfail in being socially effective they are most unlikely to work at all.

Acknowledgements

The authors thank Simon Cohn for stimulating discussions and helpful comments to anearlier version of the article. The study was funded by TrygFonden and The DanishCancer Society.

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