Analysing the role of complexity in explaining the fortunes of technology programmes: empirical application of the NASSS framework
Open accessAbstract
BACKGROUND: Failures and partial successes are common in technology-supported innovation programmes in health and social care. Complexity theory can help explain why. Phenomena may be simple (straightforward, predictable, few components), complicated (multiple interacting components or issues) or complex (dynamic, unpredictable, not easily disaggregated into constituent components). The recently published NASSS framework applies this taxonomy to explain Non-adoption or Abandonment of technology by individuals and difficulties achieving Scale-up, Spread and Sustainability. This paper reports the first empirical application of the NASSS framework. METHODS: Six technology-supported programmes were studied using ethnography and action research for up to 3 years across 20 health and care organisations and 10 national-level bodies. They comprised video outpatient consultations, GPS tracking technology for cognitive impairment, pendant alarm services, remote biomarker monitoring for heart failure, care organising software and integrated case management via data warehousing. Data were collected at three levels: micro (individual technology users), meso (organisational processes and systems) and macro (national policy and wider context). Data analysis and synthesis were guided by socio-technical theories and organised around the seven NASSS domains: (1) the condition or illness, (2) the technology, (3) the value proposition, (4) the adopter system (professional staff, patients and lay carers), (5) the organisation(s), (6) the wider (institutional and societal) system and (7) interaction and mutual adaptation among all these domains over time. RESULTS: The study generated more than 400 h of ethnographic observation, 165 semi-structured interviews and 200 documents. The six case studies raised multiple challenges across all seven domains. Complexity was a common feature of all programmes. In particular, individuals' health and care needs were often complex and hence unpredictable and 'off algorithm'. Programmes in which multiple domains were complicated proved difficult, slow and expensive to implement. Those in which multiple domains were complex did not become mainstreamed (or, if mainstreamed, did not deliver key intended outputs). CONCLUSION: The NASSS framework helped explain the successes, failures and changing fortunes of this diverse sample of technology-supported programmes. Since failure is often linked to complexity across multiple NASSS domains, further research should systematically address ways to reduce complexity and/or manage programme implementation to take account of it.
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The NASSS framework was developed in the United Kingdom, and several included studies were part of the initial empirical testing and refinement of the NASSS domains.
“However, it is noteworthy that the NASSS framework was developed in the United Kingdom, and several included studies were part of the initial empirical testing and refinement of the NASSS domains [25].”
From The NASSS (Non-Adoption, Abandonment, Scale-Up, Spread and Sustainability) framework use over time: A scoping review (2025) · cites this paper as [25]
The intricate nature of the implementation under examination in the included studies could be explained by the framework's underlying assumption that, in complex situations, the NASSS domains interact with one another and are interdependent.
“This observation may indicate the intricate nature of the implementation under examination in the included studies, which could be explained by the framework’s underlying assumption that, in complex situations, the NASSS domains interact with one another and are interdependent [25].”
From The NASSS (Non-Adoption, Abandonment, Scale-Up, Spread and Sustainability) framework use over time: A scoping review (2025) · cites this paper as [25]
When interdependencies among the NASSS domains exist, it often leads to the inability to address a singular issue without inadvertently giving rise to new challenges in other domains.
“In other words, when interdependencies among the domains exist, it often leads to the inability to address a singular issue without inadvertently giving rise to new challenges in other domains of the NASSS [25].”
From The NASSS (Non-Adoption, Abandonment, Scale-Up, Spread and Sustainability) framework use over time: A scoping review (2025) · cites this paper as [25]
The NASSS framework has been widely used across a range of settings for evaluating and explaining the fortunes of various kinds of health technology projects and draws on complexity theory.
“The NASSS framework has been widely used across a range of settings for evaluating and explaining the fortunes of various kinds of health technology projects [see for example (18–20)] and draws on complexity theory (21).”
From Planning and Evaluating Remote Consultation Services: A New Conceptual Framework Incorporating Complexity and Practical Ethics (2021) · cites this paper as [18]
The few detailed real-world studies suggest that efforts to implement remote consultation services even without an ongoing pandemic are logistically complex, resource-intensive and often stymied by technical and regulatory challenges.
“The few detailed real-world studies in the literature suggest that efforts to implement remote consultation services even without an ongoing pandemic are logistically complex, resource-intensive and often stymied by technical and regulatory challenges (18, 26, 27, 115, 117, 118)”
From Planning and Evaluating Remote Consultation Services: A New Conceptual Framework Incorporating Complexity and Practical Ethics (2021) · cites this paper as [18]
Difficulties and challenges in IAT research can be related to the individual technology users (micro level), the organizational processes and systems (meso level), and the national policy context (macro level).
“From an overall perspective, difficulties and challenges in IAT research can be related to the individual technology users (micro level), the organizational processes and systems (meso level), and the national policy context (macro level) [50].”
From Acceptance and use of innovative assistive technologies among people with cognitive impairment and their caregivers: a systematic review (2019) · cites this paper as [50]
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- Authors
- Greenhalgh, T., Wherton, J., Papoutsi, C., Lynch, J., Hughes, G., A’Court, C., Hinder, S., Procter, R., & Shaw, S.
- Affiliations
- University of Oxford (GB)
- RAFT (GB)
- University of Warwick (GB)
- Corresponding author
- Greenhalgh, Trisha
- Venue
- BMC Medicine
- Published
- 2018-05-14
- Volume
- 16
- Issue
- 1
- Pages
- 66-66
- ISSN
- 1741-7015 (ISSN-L)
- PMC
- PMC5950199
- OpenAlex
- W2804955212
- Cited by
- 232
- References
- 59
- Citations by year
- 2026: 20 · 2025: 28 · 2024: 38 · 2023: 36 · 2022: 21 · 2021: 35 · 2020: 37 · 2019: 13 · 2018: 4
- FWCI
- 50.62
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- BMC Medicine (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, other-oa)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Warwick Research Archive Portal (University of Warwick) (acceptedVersion)
- University of Hertfordshire Research Archive (University of Hertfordshire) (submittedVersion, cc-by)
- University of Hertfordshire Research Archive (University of Hertfordshire) (submittedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
- Funders
- Wellcome Trust (WT104830MA)
- Health Services and Delivery Research Programme (13/59/26)
- Programme Development Grants (RP-DG-1213-10003)
- National Institute for Health Research (NIHR- BRC-1215-20008)
- Topics
- Social Sciences › Sociology and Political Science › Information Systems Theories and Implementation
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Technology and Human Factors in Education and Health
- Keywords
- NASSS framework, complexity theory, technology adoption, health and social care, implementation failure, socio-technical systems, heart failure, integrated case management, data warehousing
- MeSH terms
- Humans, Technology Assessment, Biomedical
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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