Interventions In Complex Systems Research Articles

Equity and justice should underpin the discourse on tipping points

Abstract. Radical and quick transformations towards sustainability will be fundamental to achieving a more sustainable future. However, deliberate interventions to reconfigure systems will result in winners and losers, with the potential for greater or lesser equity and justice outcomes. Positive tipping points (PTPs) have been proposed as interventions in complex systems with the aim to (a) reduce the likelihood of negative Earth system tipping points and/or (b) increase the likelihood of achieving just social foundations. However, many narratives around PTPs often do not take into account the entire spectrum of impacts the proposed alternatives could have or still rely on narratives that maintain current unsustainable behaviours and marginalize many people (i.e. do not take “b” into account). One such example is the move from petrol-based to electric vehicles. An energy transition that remains based on natural resource inputs from the Global South must be unpacked with an equity and justice lens to understand the true cost of this transition. There are two arguments why a critical engagement with these and other similar proposals needs to be made. First, the idea of transitioning through a substitution (e.g. of fuel) while maintaining the system structure (e.g. of private vehicles) may not necessarily be conceived as the kind of radical transformation being called for by global scientific bodies like the Intergovernmental Panel on Climate Change (IPCC) and Intergovernmental Science-Policy Platform on Biodiversity and Ecosystem Services (IPBES). Second, and probably more importantly, the question of positive for whom, positive where, and positive how must be considered. In this paper, we unpack these narratives using a critical decolonial view from the south and outline their implications for the concept of tipping points.

Systemic Modeling of Care Pathways by Identifying Invariant Determinants: A Qualitative Study Protocol

Background: Care pathways are useful for optimizing patient or disease management. However, in practice, the implementation of this concept remains below its potential. Probably because it is a complex intervention in complex systems. In such cases, modeling is beneficial. Thus, facilitating the representation of care pathways can go through the formalization of a standardizable part. Indeed, certain structural elements of care pathways are systematically present, whatever the area of healthcare. The objective of the present study will be to identify and develop a list of these key factors, called “invariant determinants of care pathways”. Methods: This qualitative study will adopt a descriptive design. Semi-structured interviews will be conducted with different types of health experts: practitioners, academics, and institutional representatives. An interview guide was designed in 3 research sections: identifying the main key elements of the care pathway concept, defining the main determinants considered as pathway invariants, projecting the interviewee into a broader perspective of systemic pathway description. Once collected, data will be anonymized, transcribed and analyzed according to a thematic approach. The analysis report will follow the COREQ checklist. This research project has been validated by the ethics committee of Lyon (n°2022-05-19-003). Discussion: The results of our research will enable us to use a systems approach to gain a better understanding of the concept of care pathways and, in the longer term, to model these pathways. This study will make it possible to identify and characterize the invariant determinants of care pathways. However, although these factors are systematically present, their influence on the care pathway varies. Methods for calculating the power of impact will be used to assess this variability. Then, for a more exhaustive approach, specific factors known as variant determinants will be identified. Determining the invariant and variant determinants will enable each care pathway to be modelled.

Stakeholder engagement in agro-climate service planning

The impacts of weather, climate variability and climate change on agricultural production underline the increasing importance of actionable agro-climatic services. Transitioning from supply-driven provision of climate and agricultural information to demand-driven agro-climate services (ACS) at scale cannot be accomplished in a top-down manner but requires the engagement of diverse stakeholders in all phases of ACS development and implementation. This requires methods and tools to handle the diversity and dynamics of interactions between relevant stakeholders, including during the pre-financing stage of the ACS. We propose a transparent method to identify and engage stakeholders in the ACS planning phase and demonstrate this method as part of the socio-economic development planning process in Dien Bien, Vietnam. We find that considering stakeholder attributes such as availability, experience, gender, expertise, benefits and costs for each stakeholder, interest, influence, relevance, and attitude, combined with insights about the socio-economic development planning processes, is crucial for the engagement of stakeholders. We also find that facilitating collaborative interaction between ACS stakeholders is pivotal in supporting the planning of demand-driven ACS. Our methodology for engaging stakeholders is transferrable to designing and planning other interventions in complex systems.

Competency framework on simulation model-based decision-making for Master of Public Health students

Abstract Background Simulation models support decision-making by helping public health practitioners evaluate the potential effects of interventions in complex systems and their ultimate health impacts. However, many public health professionals remain unfamiliar with constructing simulation models and how best to use their outputs for decision-making due to a lack of training. This study developed a competency framework on simulation model-supported decision-making targeting Master of Public Health students. Methods The study was conducted in three phases: a literature review, a two-stage online Delphi survey, and an online consensus workshop. A draft competency framework was developed based on 28 peer-reviewed publications. A two-stage online Delphi survey involving experts in simulation modelling, health policy, and public health education was conducted to validate the domains and competencies in the framework. Finally, an online consensus workshop was held to evaluate the competency framework and discuss its implementation in education. Results The literature-based draft framework included twenty competencies related to project planning, stakeholder engagement, problem definition, evidence identification, participatory system mapping, model calibration, and the interpretation and dissemination of model results. The Delphi surveys included four and twelve European experts each and identified additional competencies in assessing uncertainty and generalisability. The online consensus workshop included six experts and recommended expertise and profile differentiation to enhance the framework's utility for public health training. Conclusions The competency framework developed in this study is critical to including simulation model-supported decision-making in public health training. Developing self-assessment tools will refine the competency framework through expertise and profile differentiation and support developing appropriate educational interventions. Key messages • Public health professionals need training in simulation model-supported decision-making to evaluate the health impact of various interventions more effectively. • The developed competency framework is critical to including simulation model-supported decision-making in public health training but needs expertise and profile differentiation for implementation.

Value and roles of qualitative methods in natural experimental evaluations

Abstract Background For natural experimental evaluations that estimate effect sizes of population health interventions, qualitative evidence contributes multiple benefits. Incorporating qualitative methods strengthens natural experimental evaluations, particularly when studying interventions in complex systems, and contributes to minimising evaluation design weaknesses. Methods Guidance was developed from three international workshops and an online consultation with researchers, journal editors and end users of natural experimental evaluations. The project team comprised researchers with expertise in natural experimental evaluations. The project included an oversight group and an advisory group of independent experts, including researchers, a journal editor, and scientific and public health advisors on central and local government. Results The guidance recommends that most evaluations of natural experiments will require the inclusion of qualitative evidence. Qualitative methods are valuable when describing the natural experiment intervention, the system and context it exists within, and theories of change. Qualitative work can help appropriately define exposed and unexposed groups, investigate causal mechanisms, facilitate meaningful selection of outcomes, and understand stakeholder perspectives on the intervention and its effects. Conclusions Gaining an understanding of the value and application of qualitative evidence will help producers and users of natural experimental evaluations conduct and identify robust evaluations. To fully benefit the evaluation, qualitative methods should be integrated throughout.

Optimization of Care Pathways Through Technological, Clinical, Organizational and Social Innovations: A Qualitative Study.

Numerous calls at national and international level are leading some countries to seek to redesign the provision of healthcare and services. Care pathways have the potential to improve outcomes by providing a mechanism to coordinate care and reduce fragmentation and ultimately costs. However, their implementation still shows variable results, resulting in them being considered as complex interventions in complex systems. By mobilizing an emerging approach combining action research and grounded theory methodology, we conducted a pilot project on care pathways. We used a strongly inductive process, to mobilize comparison and continuous theoretical sampling to produce theories. Forty-two interviews were conducted, and participant observations were made throughout the project, including 60 participant observations at meetings, workshops and field observations. The investigators kept logbooks and recorded field notes. Thematic analysis was used with an inductive approach. The present model explains the factors that positively or negatively influence the implementation of innovations in care pathways. The model represents interactions between facilitating factors, favourable conditions for the emergence of innovation adoption, implementation process enablers and challenges or barriers including those related specifically to the local context. What seems to be totally new is the embodiment of the mobilizing shared objective of active patient-partner participation in decision-making, data collection and analysis and solution building. This allows, in our opinion, to transcend professional perspectives for the benefit of patient-oriented results. Finally, the pilot project has created expectations in terms of spread and scaling. Future research on care pathway implementation should go further in the evaluation of the multifactorial impacts and develop a methodological framework of care pathway implementation, as the only existing proposition seems limited. Furthermore, from a social science perspective, it would be interesting to analyse the modes of social valuation of the different actors to understand what allows the transformation of collective action.

Public health and social measures during health emergencies such as the COVID-19 pandemic: an initial logic model to conceptualise and classify measures

Abstract Issue/problem In the context of the COVID-19 pandemic, public health and social measures (PHSM) are being implemented worldwide, but in very different ways. This is also due to a lacking common understanding of PHSM so far. As a result, there are limited insights regarding their components, implementation and effectiveness as well as impacts beyond health of PHSM. Description of the problem The project contributes to the WHO PHSM initiative. A logic model is being developed that offers a shared language and understanding of how PHSM are intended to achieve transmission-related outcomes, but also that non-intended consequences need to be considered. The overall approach is informed by a system-based logic model template and a staged approach to logic modeling. The development process is making use of (i) existing COVID PHSM taxonomies and related literature, (ii) existing theoretical frameworks related to complex interventions in complex systems, (iii) consultations with WHO staff and the according PHSM steering group, and (v) iterative brainstorming within the working group. Results The initial logic model is rooted in a complexity perspective which recognises that (i) all measures have both intended and unintended consequences for health and society and (ii) all elements within the logic model are interconnected and interact with each other. All PHSM operate through two basic mechanisms: reducing contacts and making contacts safer. Taken together, these two mechanisms work to reduce transmission-relevant contacts. Any specific PHSM is defined by a combination of the measure itself, the population and/or setting targeted and the mode of enactment. The central hub of the logic model connects and integrates all elements. The initial logic model was applied to school and travel measures as examples. Main messages The PHSM logic model is a conceptual basis to facilitate research on PHSM, monitoring and evaluation of PHSM, and evidence-informed decision-making.

System Complexity in Influenza Infection and Vaccination: Effects upon Excess Winter Mortality.

Unexpected outcomes are usually associated with interventions in complex systems. Excess winter mortality (EWM) is a measure of the net effect of all competing forces operating each winter, including influenza(s) and non-influenza pathogens. In this study over 2400 data points from 97 countries are used to look at the net effect of influenza vaccination rates in the elderly aged 65+ against excess winter mortality (EWM) each year from the winter of 1980/81 through to 2019/20. The observed international net effect of influenza vaccination ranges from a 7.8% reduction in EWM estimated at 100% elderly vaccination for the winter of 1989/90 down to a 9.3% increase in EWM for the winter of 2018/19. The average was only a 0.3% reduction in EWM for a 100% vaccinated elderly population. Such outcomes do not contradict the known protective effect of influenza vaccination against influenza mortality per se—they merely indicate that multiple complex interactions lie behind the observed net effect against all-causes (including all pathogen causes) of winter mortality. This range from net benefit to net disbenefit is proposed to arise from system complexity which includes environmental conditions (weather, solar cycles), the antigenic distance between constantly emerging circulating influenza clades and the influenza vaccine makeup, vaccination timing, pathogen interference, and human immune diversity (including individual history of host-virus, host-antigen interactions and immunosenescence) all interacting to give the observed outcomes each year. We propose that a narrow focus on influenza vaccine effectiveness misses the far wider complexity of winter mortality. Influenza vaccines may need to be formulated in different ways, and perhaps administered over a shorter timeframe to avoid the unanticipated adverse net outcomes seen in around 40% of years.

Strengthening Management, Community Engagement, and Sustainability of the Subnational Response to Accelerate Malaria Elimination in Namibia.

ABSTRACT.Leadership and management skills are critical for health programs to deliver high-quality interventions in complex systems. In malaria-eliminating countries, national and subnational health teams are reorienting strategies to address focal transmission while preventing new cases and adapting to decentralization and declines in external financing. A capacity-strengthening program in two regions in Namibia helped malaria program implementers identify and address key operational, political, and financial challenges. The program focused on developing skills and techniques in problem-solving and teamwork, engaging decision-makers, and using financial evidence to prioritize domestic resources for malaria through participatory approaches. Results of the program included an observed 40% increase in malaria case reporting, 32% increase in reporting and tracing of imported malaria cases, 10% increase in malaria case management, integration of malaria activities into local operational plans, and an increase in subnational resources for malaria teams. To promote program sustainability beyond the implementation period, key program aspects were institutionalized into existing health system structures, program staff were trained in change leadership, and participants integrated the skills and approaches into their professional roles. A capacity-strengthening program with joint focus on leadership, management, and advocacy has potential for application to other health issues and geographies.

Preventing opioid use among justice-involved youth as they transition to adulthood: leveraging safe adults (LeSA)

BackgroundJuvenile justice (JJ) youth are at high risk of opioid and other substance use (SU), dysfunctional family/social relationships, and complex trauma. The purpose of the Leveraging Safe Adults (LeSA) Project is to examine the effectiveness of Trust-Based Relational Intervention® (TBRI®; leveraging family systems by providing emotional and instrumental guidance, support, and role modeling) in preventing opioid and other SU among youth after release from secure residential facilities.MethodsAn effectiveness-implementation Hybrid Type 1 design is used to test the effectiveness of TBRI for preventing non-medical use of opioids among JJ-youth (delayed-start at the site level; a randomized controlled trial at participant level) and to gain insight into facility-level barriers to TBRI implementation as part of JJ re-entry protocols. Recruitment includes two samples (effectiveness: 360 youth/caregiver dyads; implementation: 203 JJ staff) from nine sites in two states over 3 years. Participant eligibility includes 15 to 18-year-olds disposed to community supervision and receiving care in a secure JJ facility, without active suicide risk, and with one caregiver willing to participate. Effectiveness data come from (1) youth and caregiver self-report on background, SU, psychosocial functioning, and youth-caregiver relationships (Months 0, 3, 6, 12, and 18), youth monthly post-release check-ins, and caregiver report on youth psychological/behavioral symptoms, and (2) JJ facility records (e.g., recidivism, treatment utilization). Fidelity assessment includes post-session checklists and measures of TBRI strategy use. Collected four times over four years, implementation data include (1) JJ staff self-report on facility and staff characteristics, use of trauma-informed care and TBRI strategies, and (2) focus groups (line staff, leadership separately) on use of trauma-informed strategies, uptake of new interventions, and penetration, sustainment, and expansion of TBRI practices.DiscussionThe LeSA study is testing TBRI as a means to empower caregivers to help prevent opioid use and other SU among JJ-youth. TBRI’s multiple components offer an opportunity for caregivers to supplement and extend gains during residential care. If effective and implemented successfully, the LeSA protocol will help expand the application of TBRI with a wider audience and provide guidance for implementing multi-component interventions in complex systems spanning multiple contexts.Trial registrationClinicalTrials.govNCT04678960; registered November 11, 2020; https://clinicaltrials.gov/ct2/show/NCT04678960.

Reflexive Rejection: Confessions of our first encounters with SenseMaker®, an emerging research methodology for STEM education

Point of view (25-50 words):
 We are four female educational practitioners who engage in varying degrees and forms of teaching, research, and evaluation. And, we have been educated in legacy research methods. We are curious about new approaches to conceptualizing, inquiring into, and doing science, technology, engineering and math (‘STEM’) education that have the potential to disrupt systemic social, economic, and ecological abuse and exploitation.
 
 Value of submission (25-50 words): This autoethnographic analysis of our individual narratives serves as a cautionary tale and emotional sign-posts for those seeking to explore emerging research methodologies, particularly those that are suited for complex, dynamic social systems, such as “engineering education”: expect cognitive and/or emotional dissonance. By definition, alternative approaches to research will occur as new and possibly foreign to those trained in traditional research approaches. Such a reflexive rejection happens unconsciously and undermines the goal of learning--discovery.
 
 
 Abstract
 It is becoming increasingly common to hear engineering education described as a complex system (National Science Foundation, 2018). Such a perspective shifts the focus of analysis from the parts to the whole – from individual elements to the relationships between the elements. Most engineering education researchers, however, are trained in atomistic or reductionist models of inquiry (Borrego, 2007; Laszlo, 1996; Robbins, 2007), which begs the question – how prepared are engineering education researchers to conduct research on, and productively intervene in, complex systems? As four educational practitioners who have previously embraced complex systems thinking, both in our teaching and in our research, we considered ourselves well prepared to explore a new, participatory research methodology, called SenseMaker, which is explicitly designed to understand characterize and facilitate interventions in complex systems. And yet, all four of us independently and reflexively rejected this methodology upon our first encounter with it. In this study, we used collaborative autoethnographic techniques to examine what it is about our shared cultures, experiences, and training as engineering education researchers and practitioners that led us to react in this way. We reflect on how methodologies founded on complex systems theory, like SenseMaker, often sit outside the boundaries of what we are used to and may initially occur to us as “foreign,” or even “wrong.” Further, we explore how our reflexive responses were connected to embodied cognition, that is, a recognition that “[one’s] body, beyond the brain “play[s] a significant causal… role in cognitive processing” (Stanford Encyclopedia of Philosophy, 2011). We offer some suggestions for developing an awareness of both reflexive rejection responses and how to recognize and use our embodied cognition. These perspectives are important for researchers who seek new ways to understand and work with complex, dynamic social systems.

Conceptualising interventions to enhance spread in complex systems: a multisite comprehensive medication review case study

BackgroundAdvancing the description and conceptualisation of interventions in complex systems is necessary to support spread, evaluation, attribution and reproducibility. Improvement teams can provide unique insight into how interventions are operationalised...

The political economy of state responses to infectious disease.

How can public policy best deal with infectious disease? In answering this question, scholarship on the optimal control of infectious disease adopts the model of a benevolent social planner who maximizes social welfare. This approach, which treats the social health planner as a unitary “public health brain” standing outside of society, removes the policymaking process from economic analysis. This paper opens the black box of the social health planner by extending the tools of economics to the policymaking process itself. We explore the nature of the economic problem facing policymakers and the epistemic constraints they face in trying to solve that problem. Additionally, we analyze the incentives facing policymakers in their efforts to address infectious diseases and consider how they affect the design and implementation of public health policy. Finally, we consider how unanticipated system effects emerge due to interventions in complex systems, and how these effects can undermine well‐intentioned efforts to improve human welfare. We illustrate the various dynamics of the political economy of state responses to infectious disease by drawing on a range of examples from the COVID‐19 pandemic.

The Political Economy of State Responses to Infectious Disease

How can public policy best deal with infectious disease? In answering this question, scholarship on the optimal control of infectious disease adopts the model of a benevolent social planner who maximizes social welfare. This approach, which treats the social health planner as a unitary “public health brain” standing outside of society, removes the policymaking process from economic analysis. This paper opens the black box of the social health planner by extending the tools of economics to the policymaking process itself. We explore the nature of the economic problem facing policymakers and the epistemic constraints they face in trying to solve that problem. Additionally, we analyze the incentives facing policymakers in their efforts to address infectious diseases and consider how they affect the design and implementation of public health policy. Finally, we consider how unanticipated system effects emerge due to interventions in complex systems, and how these effects can undermine well-intentioned efforts to improve human welfare. We illustrate the various dynamics of the political economy of state responses to infectious disease by drawing on a range of examples from the COVID-19 pandemic.

More harm than good? Building a framework to identify adverse effects of public health interventions

Abstract Background While the importance of adverse events of medical interventions is widely recognized, adverse effects of public health interventions remain a neglected topic. This project aims to develop a framework to guide researchers and decision-makers to systematically reflect on and identify potential adverse effects of public health interventions. Methods We conducted a mixed-method systematic review of theoretical and conceptual publications on adverse events of public health interventions to develop a preliminary framework employing best-fit framework synthesis. We used the WHO-INTEGRATE framework as a starting point for the synthesis, a multidimensional evidence-to-decision framework developed for complex interventions in complex systems. Results The framework includes two interlinked parts: The first maps domains in which potential adverse events might arise. Drawing on the WHO-INTEGRATE framework, these domains include aspects related to health, but also domains related to societal, economic, and environmental implications. The second part maps general mechanisms through which public health interventions can lead to adverse effects (e.g. reactive behaviour change, increase of labelling and stigmatization, and exposure to environmental risk-factors). Conclusions The framework will be advanced in the second phase of the project through empirical studies of harmful effects in public health interventions, which we will identify through an overview of systematic reviews. Adverse effects of public health interventions are currently not sufficiently considered in research and practice. Taking them into account is essential for informed decision-making and establishing appropriate countermeasures. Our framework could be a valuable asset for researchers and policy makers in developing, implementing and evaluating public health interventions. Key messages Awareness of the adverse effects of public health interventions is essential for informed decision-making and establishing countermeasures. This framework supports researchers and decision-makers in systematically reflecting on and identifying adverse events when developing, piloting, implementing or evaluating public health interventions.

Human-Centered Design Lessons for Implementation Science: Improving the Implementation of a Patient-Centered Care Intervention.

Evidence-based HIV interventions often fail to reach anticipated impact due to insufficient utilization in real-world health systems. Human-centered design (HCD) represents a novel approach in tailoring innovations to fit end-users, narrowing the gap between efficacious interventions and impact at scale. We combined a narrative literature review of HCD in HIV programs with our experience using HCD to redesign an intervention promoting patient-centered care (PCC) practices among health care workers (HCW) in Zambia. We summarize the use and results of HCD in the global HIV response and share case study insights to advance conceptualization of HCD applications. The literature review identified 13 articles (representing 7 studies) on the use of HCD in HIV. All studies featured HCD hallmarks including empathy development, user-driven inquiry, ideation, and iterative refinement. HCD was applied to mHealth design, a management intervention and pre-exposure prophylaxis delivery. Our HCD application addressed a behavioral service delivery target: changing HCW patient-centered beliefs, attitudes, and practices. Through in-depth developer-user interaction, our HCD approach revealed specific HCW support for and resistance to PCC, suggesting intervention revisions to improve feasibility and acceptability and PCC considerations that could inform implementation in transferable settings. As both a research and implementation tool, HCD has potential to improve effective implementation of the HIV response, particularly for product development; new intervention introduction; and complex system interventions. Further research on HCD application strengths and limitations is needed. Those promoting PCC may improve implementation success by seeking out resonance and anticipating the challenges our HCD process identified.

Formative Evaluation and Complex Health Improvement Initiatives: A Learning System to Improve Theory, Implementation, Support, and Evaluation

Sustainable community health improvement often requires the implementation of complex interventions in complex systems. Drawing from the Four Keys to Success frame (theory, implementation, support, and evaluation), this article describes how we used a formative evaluation approach to foster a learning system capable of monitoring and addressing emerging community needs within the Spreading Community Accelerators Through Learning and Evaluation (SCALE) initiative—a national capacity-building effort to support 24 community coalitions’ progress toward a Culture of Health. The formative evaluation approach resulted in critical advancements to the theory, implementation, and nature of supports provided in SCALE. These improvements enabled the SCALE evaluation team to shift from the initial focus on program implementation issues to a greater emphasis on downstream factors (community-level outcomes). The ability of formative evaluation to grapple with the emerging challenges of implementing complex interventions in complex systems makes it particularly valuable for community health improvement initiatives.

Care pathways are complex interventions in complex systems: New European Pathway Association framework

Care pathway implementation is characterised by a dual complexity. A care pathway itself represents a complex intervention with multiple interacting and interdependent intervention components and outcomes. The organisations in which care pathways are being implemented represent complex systems that need to be directed at change through an in-depth understanding of their external and internal context in which they are functioning in. This study sets out a new evidence-based and pragmatic framework that unpacks how intervention mechanisms, intervention fidelity and care context are converge and represent interacting processes that determine success or failure of the care pathway. We recommend researchers looking to increase the effectiveness of care pathway implementation and accelerate improvement of desired outcomes to adopt this framework from inception to implementation of the intervention.

Complex health interventions in complex systems: improving the process and methods for evidence-informed health decisions

The 2030 Agenda for Sustainable Development calls for real transformation, recognising that health goes beyond survival to include human rights, equity and the empowerment of vulnerable populations, including women and...

The Actor-Based Change Framework: A Pragmatic Approach to Developing Program Theory for Interventions in Complex Systems

Despite a wide body of literature on the importance of program theory and the need to tackle complexity to improve international development programming, the use of program theory to underpin interventions aimed at facilitating change in complex systems remains a challenge for many program practitioners. The actor-based change framework offers a pragmatic approach to address these challenges, integrating concepts and frameworks drawn from complexity science and behavioral change literature to develop robust program theory for complex interventions. This article presents the conceptual framework for the approach and describes how it has been applied in practice on an evaluation of a security and justice program in Nepal. It concludes with a discussion of the strengths and weaknesses of the approach in practice and how it can be applied more widely to improve program theory for interventions in complex systems.