Potential Leverage Research Articles

Transformation archetypes in global food systems

Food systems are primary drivers of human and environmental health, but the understanding of their diverse and dynamic co-transformation remains limited. We use a data-driven approach to disentangle different development pathways of national food systems (i.e. ‘transformation archetypes’) based on historical, intertwined trends of food system structure (agricultural inputs and outputs and food trade), and social and environmental outcomes (malnutrition, biosphere integrity, and greenhouse gases emissions) for 161 countries, from 1995 to 2015. We found that whilst agricultural total factor productivity has consistently increased globally, a closer analysis suggests a typology of three transformation archetypes across countries: rapidly expansionist, expansionist, and consolidative. Expansionist and rapidly expansionist archetypes increased in agricultural area, synthetic fertilizer use, and gross agricultural output, which was accompanied by malnutrition, environmental pressures, and lasting socioeconomic disadvantages. The lowest rates of change in key structure metrics were found in the consolidative archetype. Across all transformation archetypes, agricultural greenhouse gases emissions, synthetic fertilizer use, and ecological footprint of consumption increased faster than the expansion of agricultural area, and obesity levels increased more rapidly than undernourishment decreased. The persistence of these unsustainable trajectories occurred independently of improvements in productivity. Our results underscore the importance of quantifying the multiple human and environmental dimensions of food systems transformations and can serve as a starting point to identify potential leverage points for sustainability transformations. More attention is thus warranted to alternative development pathways able of delivering equitable benefits to both productivity and to human and environmental health.

Putting the BRI in Perspective: History, Hegemony and Geoeconomics

If successfully realised, the Belt and Road Initiative will be the most ambitious and expansive developmental project the world has ever seen. It is not, however, unprecedented. In the aftermath of the Second World War the United States developed what was then an equally unprecedented and ambitious initiative designed to simultaneously facilitate the (re)development of some of the world’s key economies and reinforce its own position as the leader of the western world. Both the American Marshall Plan and China’s BRI are important expressions of geoeconomic influence and power. This paper compares the two projects from the perspectives of ‘hegemonic transitions’ and ‘comparative hegemony’ in order to highlight some striking similarities and noteworthy differences, and gauge the prospects for the BRI and its possible scenarios. Comparatively speaking, the BRI does not have the same sort of compelling geopolitical imperatives and narrative that the emerging Cold War provided for American hegemonic leadership. The Chinese project also lacks the comprehensive global institutional architecture developed in the aftermath of the Second World War that facilitated American influence. Consequently, it may prove more difficult for China to utilise the BRI to translate potential geoeconomic leverage into the sort of hegemonic influence that the US enjoyed during the Cold War, despite its unparalleled ambitions.

Beyond Numbers: Determining the Socioeconomic and Livelihood Impacts of African Swine Fever and Its Control in the Philippines.

The impacts of African Swine Fever (ASF) have most frequently been described quantitatively though it is increasingly acknowledged these impacts extend well beyond numbers. During 2020, a multidisciplinary team of researchers developed a framework for Socioeconomic and Livelihood Impact Assessment (SELIA) of livestock diseases in smallholder communities. Two key innovations within this SELIA framework are the integration of sustainable livelihoods concepts to capture rich information beyond financial impacts, and the inclusion of stakeholders across the value chain, beyond farmers. This paper focuses on the findings from one of the first applications of the SELIA framework. In late 2020 the research team applied participatory tools from the SELIA Framework (8 focus group discussions, 14 key informant interviews, and 2 network mapping activities) to gather data to describe the impact of ASF in backyard pig-farming communities and value chains. This was undertaken across two locations in the Philippines, in turn highlighting potential leverage points for intervention. Owing to COVID-19 travel restrictions and risks, modifications to training and field activities were made. Findings from focus groups and interviews revealed the deep, emotional impacts of ASF and the associated control measures. Pigs were considered pets by many farmers and some women described them as being like their children. Animal health-workers (AHWs) also recognised the emotional toll on farmers and were sometimes strongly criticised by community members due to their involvement in depopulation campaigns. Misinformation early in the epidemic also led farmers to hide their animals from AHWs, and to dispose of them inappropriately. While the overall impact of ASF on society was negative, the impacts across different communities, scales of production and different value chain actors varied. The losses experienced by backyard farmers resulted in significant losses to linked value chain actors, such as input suppliers. This trial application of the SELIA framework revealed some complex and varied impacts of ASF. This included significant differences in livelihood and socio-economic impacts amongst different actors within value chains and also among different categories of actors (for example small, medium and large-scale traders). Repeated themes and triangulated findings suggest two leverage points for further consideration. Firstly, it is recommended a One Welfare approach to ASF control in the Philippines is explored. Emphasising careful communication between animal health-workers and farmers, and humane and sensitive pig depopulation practices. Secondly, consideration of ASF support programs tailored to sectoral and specific communities is recommended.

Equity, technological innovation and sustainable behaviour in a low-carbon future.

The world must ambitiously curtail greenhouse gas emissions to achieve climate stability. The literature often supposes that a low-carbon future will depend on a mix of technological innovation-improving the performance of new technologies and systems-as well as more sustainable behaviours such as travelling less or reducing waste. To what extent are low-carbon technologies, and their associated behaviours, currently equitable, and what are potential policy and research implications moving forward? In this Review, we examine how four innovations in technology and behaviour-improved cookstoves and heating, battery electric vehicles, household solar panels and food-sharing-create complications and force trade-offs on different equity dimensions. We draw from these cases to discuss a typology of inequity cutting across demographic (for example, gender, race and class), spatial (for example, urban and rural divides), interspecies (for example, human and non-human) and temporal (for example, future generations) vulnerabilities. Ultimately, the risk of inequity abounds in decarbonization pathways. Moreover, low-carbon innovations are not automatically just, equitable or even green. We show how such technologies and behaviours can both introduce new inequalities and reaffirm existing ones. We then discuss potential policy insights and leverage points to make future interventions more equitable and propose an integrated research agenda to supplement these policy efforts.

Using systems thinking to investigate the sustainability of digital fabrication projects in the humanitarian and development sector

Recently, designers have started using digital fabrication to create new solutions to meet global challenges. However, many technology projects in the humanitarian and development sector have been criticised for failing to deliver sustainable solutions. This study responds to these concerns by investigating the sustainability of digital fabrication projects in the humanitarian and development sector. A systems approach is used to synthesise knowledge from 14 digital fabrication projects in healthcare, education and water and sanitation. Causal loop diagrams are created to investigate the relationships between the drivers and barriers to sustainability. Several systems archetypes are also identified revealing potential leverage points for driving more sustainable solutions. The paper contextualises these findings by drawing on theories from participatory development and cosmopolitan localism. It concludes that digital fabrication presents an opportunity for more local and participatory design; however, sustainability is being undermined by a tendency to seek short-term solutions.

Lifestyles and cities of the future – Rome and Montreal: comparing two realities

This article presents the results of an international research project carried out in Italy and Canada, conducted by architects, landscape architects, sociologists and medical doctors. The study originated in the conviction that health and well-being are crucial objectives integrated within the notion of a sustainable city. For this reason, the configuration of urban space plays a decisive role in defining lifestyles and can contribute to improving the welfare of citizens. Many of today’s diseases are caused by a sedentary lifestyle; it is essential, therefore, to centre prevention on the promotion of physical well-being encouraging an active lifestyle, which can be achieved by changing the urban structure. With the aim of bringing about sustainable and healthy lifestyles, streets are in vogue. Streets are meeting and experimental places, theatres of everyday life and settings for cultural events. They provide crucial urban space for people and, in the context of urban studies, offer intellectual research nourishment to reflect on this fundamental element of the structure of the city. The research project presented here is aimed at encouraging active lifestyles, walkability and the use of public transport by facilitating accessibility to four sites in Rome and Montreal, and by exploring the potential leveraging of existing infrastructures and services. The research-based design proposals start with the idea of redeveloping the system of public spaces, beginning with the increase of bicycle and pedestrian routes in relation to schools, commerce, sports facilities and archaeological heritage. The goal is to build feasible, safe, recognisable and attractive routes and well-equipped public spaces in order to discourage the use of private vehicles, especially for short trips. The projects presented here are based on a systemic vision and make use of existing, but often abandoned or undervalued, spaces and resources.

Examining health sector stakeholder perceptions on the efficiency of county health systems in Kenya.

Efficiency gains is a potential strategy to expand Kenya's fiscal space for health. We explored health sector stakeholders' understanding of efficiency and their perceptions of the factors that influence the efficiency of county health systems in Kenya. We conducted a qualitative cross-sectional study and collected data using three focus group discussions during a stakeholder engagement workshop. Workshop participants included health sector stakeholders from the national ministry of health and 10 (out 47) county health departments, and non-state actors in Kenya. A total of 25 health sector stakeholders participated. We analysed data using a thematic approach. Health sector stakeholders indicated the need for the outputs and outcomes of a health system to be aligned to community health needs. They felt that both hardware aspects of the system (such as the financial resources, infrastructure, human resources for health) and software aspects of the system (such as health sector policies, public finance management systems, actor relationships) should be considered as inputs in the analysis of county health system efficiency. They also felt that while traditional indicators of health system performance such as intervention coverage or outcomes for infectious diseases, and reproductive, maternal, neonatal and child health are still relevant, emerging epidemiological trends such as an increase in the burden of non-communicable diseases should also be considered. The stakeholders identified public finance management, human resources for health, political interests, corruption, management capacity, and poor coordination as factors that influence the efficiency of county health systems. An in-depth examination of the factors that influence the efficiency of county health systems could illuminate potential policy levers for generating efficiency gains. Mixed methods approaches could facilitate the study of both hardware and software factors that are considered inputs, outputs or factors that influence health system efficiency. County health system efficiency in Kenya could be enhanced by improving the timeliness of financial flows to counties and health facilities, giving health facilities financial autonomy, improving the number, skill mix, and motivation of healthcare staff, managing political interests, enhancing anticorruption strategies, strengthening management capacity and coordination in the health sector.

Leveraging Sub-national Collaboration and Influence for Improving Animal Health Surveillance and Response: A Stakeholder Mapping in Tanzania.

Animal health surveillance plays a vital role in ensuring public health, animal welfare, and sustainable food production by monitoring disease trends, early detecting (new) hazards, facilitating disease control and infection, and providing data for risk analysis. Good stakeholder collaboration across the sector can lead to better communication, better science and decision-making and more effective surveillance and response. An understanding of relevant stakeholders, their interests and their power can facilitate such collaboration. While information on key stakeholders in animal health surveillance is available at the national level in Tanzania, it is missing at the subnational level. The study aimed to explore the existing stakeholders' collaborations and influences at the subnational level through stakeholder mapping and to determine potential leverage points for improving the national animal health surveillance system. A qualitative design was used, involving consultative workshops with government animal health practitioners in Sumbawanga, Sikonge and Kilombero districts of Tanzania from December 2020 to January 2021. Data were collected using an adapted USAID stakeholder collaboration mapping tool with the following steps: (i) Define the objective (ii) Identify all stakeholders (iii) Take stock of the current relationships (iv) Determine resource-based influence (v) Determine non-resource based influence and (vi) Review and revise the collaboration map. Forty-five stakeholders were identified in all three districts and grouped into four categories: private sector and non-government organizations (n = 16), government (n = 16), community (n = 9) and political leaders (n = 4). Animal health practitioners had a stronger relationship with community stakeholders as compared to other categories. The results also showed that most of the stakeholders have non-resource-based influence compared to resource-based influence. The private sector and non-government organizations have a relatively higher number of resource-based influential stakeholders, while political leaders have more non-resource-based influence. The mapping exercise demonstrated that the system could benefit from community mobilization and sensitization, resource mobilization and expanding the horizon of surveillance data sources. Some of the leverage points include integration of surveillance activities into animal health services, clear operational processes, constant engagement, coordination and incentivization of stakeholders. The diversity in the identified stakeholders across the districts suggests that collaborations are contextual and socially constructed.

Older adults' perceptions of current and future hearing healthcare services in Australia, England, US and Canada.

A high prevalence of hearing loss in older adults contrasts with a small proportion of people who seek help. Emerging developments in hearing healthcare (HHC) could reduce costs but may not increase access. This study evaluated older adults' perceptions of current and future HHC services in Australia, England, US and Canada to explore potential levers and system improvements. Semi-structured focus groups (n = 47) were conducted, and data were analysed using a directed content analysis. Participants were adults 60 years and older with a) no hearing problems; b) hearing problems and hearing aid use; and c) hearing problems and no hearing aid use. Perceived barriers, facilitators and preferences were largely consistent across countries, with stigma and trust in HHC being the barriers most often discussed. Although cost and access were consistently deemed important, there may be limited change in help-seeking and HHC uptake unless the key barriers of trust and stigma are addressed. When seeking to undertake transformative change to healthcare it is important to engage recipients of care to understand existing barriers and coproduce a user-centered solution.

Factors Associated with HIV Drug Resistance in Dar es Salaam, Tanzania: Analysis of a Complex Adaptive System.

HIV drug resistance (HIVDR) is a complex problem with multiple interconnected and context dependent causes. Although the factors influencing HIVDR are known and well-studied, HIVDR remains a threat to the effectiveness of antiretroviral therapy. To understand the complexity of HIVDR, a comprehensive, systems approach is needed. Therefore, a local systems map was developed integrating all reported factors influencing HIVDR in the Dar es Salaam Urban Cohort Study area in Tanzania. The map was designed based on semi-structured interviews and workshops with people living with HIV and local actors who encounter people living with HIV during their daily activities. We visualized the feedback loops driving HIVDR, compared the local map with a systems map for Sub-Saharan Africa, previously constructed from interviews with international HIVDR experts, and suggest potential interventions to prevent HIVDR. We found several interconnected balancing and reinforcing feedback loops related to poverty, stigmatization, status disclosure, self-esteem, knowledge about HIVDR and healthcare system workload, among others, and identified three potential leverage points. Insights from this local systems map were complementary to the insights from the Sub-Saharan systems map showing that both viewpoints are needed to fully understand the system. This study provides a strong baseline for quantitative modelling, and for the identification of context-dependent, complexity-informed leverage points.

Investigating the Socio-Economic and Livelihoods Impacts of African Swine Fever in Timor-Leste: An Application of Spatial Group Model Building.

Small-scale pig farming is highly important to the economic and social status of households in Timor-Leste. The presence of an African Swine Fever (ASF) outbreak in Timor-Leste was confirmed in 2019, a major concern given that around 70% of agricultural households practice pig farming. This research used a virtual spatial group model building process to construct a concept model to better understand the main feedback loops that determine the socio-economic and livelihood impacts of the ASF outbreak. After discussing the interaction of reinforcing and balancing feedback loops in the concept model, potential leverage points for intervention are suggested that could reduce the impacts of ASF within socio-economic spheres. These include building trust between small-scale farmers and veterinary technicians, strengthening government veterinary services, and the provision of credit conditional on biosecurity investments to help restock the industry. This conceptual model serves as a starting point for further research and the future development of a quantitative system dynamics (SD) model which would allow ex-ante scenario-testing of various policy and technical mitigation strategies of ASF outbreaks in Timor-Leste and beyond. Lessons learned from the blended offline/online approach to training and workshop facilitation are also explored in the paper.

Food Storage on the Appalachian Trail: A Theory of Planned Behavior Approach to Understanding Backpacker Bear Canister Use

Improper food storage fuels human-bear conflicts in parks and protected areas around the globe. Bear-resistant food storage canisters provide an extremely effective solution for reducing food-related human-bear conflicts, especially for overnight visitors in backcountry settings. However, the success of this intervention depends on recreationists’ willingness to use and comply with such food storage methods. This study used internet-based surveys to identify Appalachian Trail backpackers’ attitudes, norms, perceived behavioral control, and intentions regarding the use of bear canisters through an application of the Theory of Planned Behavior. Results indicate attitudes and subjective norms provide potential leverage points for messaging under voluntary conditions; messaging incorporating attitudes, subjective norms, and perceived behavioral control may help influence food storage behavior under required conditions. Specific recommendations for effective, theory-based interpretation strategies aimed at reducing human-black bear conflicts on the Appalachian Trail are provided.

Older people's experiences of dignity and support with eating during hospital stays: analytical framework, policies and outcomes

AbstractThere is growing recognition of the importance of dignity and support with eating as markers of high-quality and older-person-centred hospital services. We use data on these markers from the national Adult Inpatient Survey for England to build up statistical evidence on older people's experiences. We find that poor and inconsistent experiences of being treated with dignity and respect, and of receiving support with eating, affect a substantial proportion of inpatients across the vast majority of acute hospital trusts. There has been remarkably little change over time, although small improvements provide some grounds for optimism relating to policy developments in the period following the Francis Inquiry. Amongst people over 65, the prevalence of inconsistent and poor experiences of dignity and support with eating was higher amongst the ‘oldest of the old’ (inpatients aged over 80), individuals who experience a long-standing limiting illness or disability, and women. The highest rates of prevalence were observed amongst disabled women over 80. Perceptions of inadequate nursing quantity and quality, and lack of choice of food, stand out from logistic regression analysis as having consistent, large associations with lack of support with eating. These factors provide potential policy levers since they are within the control of hospitals to a certain extent. In drawing lessons from our analysis for inspection, regulation and monitoring, we highlight the importance of inequalities analysis – including systematic disaggregation and separate identification of at risk sub-groups (e.g. older disabled women) – rather than relying on a ‘population average approach’.

Social aspect of forestry land use balance in Ukraine

The purpose of the article is to identify the social component of forestry land use for decision-making at the national level to ensure the balanced use of forestlands both at the regional level and at the level of state forest enterprises. Theoretical and methodological bases of the research are based on the analysis of a set of social, economic and ecological indicators of reporting of forestry enterprises as indicators of the state of use of forest lands in the context of balanced development. Several aspects of the activity of the state forest enterprises in the period 2016-2020 by regions and climatic zones were studied in detail, and the scope of forest certification in Ukraine was assessed for a better ecological understanding of social processes in forestry in the country. A positive relationship with a significant correlation rate (r = 0.9078) is proved between the capital investments in forestry production and employment in the forest sector. In addition, fluctuations of the capital investments correlate with the staff qualification (r = 0.816). Assessment results for the level of technical provision of forestry enterprises point to the relationships between the level of technical provision and labour productivity (r = 0.7515) and the level of staff qualification (r = 0.7494). The strength of the relationship between labour productivity and labour remuneration varies over the regions of Ukraine with the correlation rate ranging between 0.7222 and 0.9852. We discuss key asymmetries, interactions and conflicts based on natural and regional specifics of forestry land use. Based on the results of the assessment of the relationships and dynamics of selected indicators, the present study substantiates the necessity to take into account both national and stakeholders’ interests in view of the social aspects of forestry land use with a focus on balance. Regional imbalance in income and labour productivity, insufficient training of employees, insufficient government funding and certification of forests, no practice of carbon units accounting at the regional and local levels, illegal felling are proven to be the restraining factors of the social balance of forestry land use. The results obtained in the study could help to identify potential levers of influence to ensure the balance of forestry land use and a better understanding of the social balance of forestry activities of enterprises.

Developing Complexity-Informed COVID-19 Responses to Optimize Community Well-Being: A Systems Thinking Approach

Despite a range of federal and state interventions to slow the spread of COVID-19, the US has seen millions of infections and hundreds of thousands of deaths. Top-down mandates have been ineffective because the community spread of the pandemic has been influenced by complex local dynamics that have evolved over time. Systems thinking approaches, specifically causal loop diagrams, and leverage points, are important techniques for representing complexity at the local level and identifying responsive systems change opportunities. This commentary presents a causal loop diagram highlighting the progressive effects of prolonged state-level COVID-19 mandates at the community level. We also identify potential system leverage points that address these effects and present an imagined future state causal loop diagram in which these solutions are implemented. Our future system demonstrates the importance of collaborations to enable community-driven, bottom-up approaches to public health crises, such as the COVID-19 pandemic, that are adaptive and responsive to local needs.

Impact of the COVID-19 Pandemic on Urological Care Delivery in the United States.

We examined changes in urological care delivery due to COVID-19 in the U.S. based on patient, practice, and local/regional demographic and pandemic response features. We analyzed real-world data from the American Urological Association Quality (AQUA) Registry collected from electronic health record systems. Data represented 157 outpatient urological practices and 3,165 providers across 48 U.S. states and territories, including 3,297,721 unique patients, 12,488,831 total outpatient visits and 2,194,456 procedures. The primary outcome measure was the number of outpatient visits and procedures performed (inpatient or outpatient) per practice per week, measured from January 2019 to February 2021. We found large (>50%) declines in outpatient visits from March 2020 to April 2020 across patient demographic groups and states, regardless of timing of state stay-at-home orders. Nonurgent outpatient visits decreased more across various nonurgent procedures (49%-59%) than for procedures performed for potentially urgent diagnoses (38%-52%); surgical procedures for nonurgent conditions also decreased more (43%-79%) than those for potentially urgent conditions (43%-53%). African American patients had similar decreases in outpatient visits compared with Asians and Caucasians, but also slower recoveries back to baseline. Medicare-insured patients had the steepest declines (55%), while those on Medicaid and government insurance had the lowest percentage of recovery to baseline (73% and 69%, respectively). This study provides real-world evidence on the decline in urological care across demographic groups and practice settings, and demonstrates a differential impact on the utilization of urological health services by demographics and procedure type.

Elementary teachers’ reflections on their use of digital instructional resources in four educational contexts: Belgium, Finland, Sweden, and U.S.

We examine teachers’ reflections on incorporating digital instructional resources (DIRs) into their mathematics teaching. We analyze qualitative interviews with 39 elementary school teachers from four educational contexts: Belgium, Finland, Sweden, and the U.S., using a framework proposed by Pepin et al. (Int J Math Educ 46: 645-661, 2017) to consider opportunities for DIRs to shift elements of teaching and learning in potentially transformative ways. Teachers described three major domains of teaching practice where they used DIRs: (a) class instruction, (b) student practice, and (c) professional participation. We found that teachers readily used DIRs during class instruction and to support student practice, guided by their existing instructional goals, which were shaped in part by education structures in the context. Few teachers incorporated DIRs in ways that transformed typical learning spaces. We also found that DIRs impacted several aspects of teachers’ professional practices, including professional learning and collaboration. In particular, participation in social media and resource sharing altered the nature of and ways teachers participated in their own professional learning. We assert that efforts to use DIRs to stimulate change need to begin with an understanding of teachers’ current practices and use our findings to identify three potential levers that might support movement toward change.

Using Qualitative System Dynamics Analysis to Promote Inclusive Livestock Value Chains: A Case Study of the South African Broiler Value Chain.

Livestock value chains globally are increasingly dualistic, with integrated market-leaders co-existing with comparatively disadvantaged small producers who, nevertheless, support rural livelihoods and food access, and can also contribute to more resilient supply chains. The South African broiler value chain provides a highly illustrative case study. The purpose of this study is to identify potential leverage points for policy intervention to support small and emerging producers in the South African broiler value chain, and to discuss the strengths and limitations of system dynamics approaches to promote inclusive food value chains. This study develops a causal loop diagram (CLD) based on semi-structured stakeholder interviews and policy documents. The main challenges, key variables and causal relationships between them are systematically identified. Variables are coded, generalised and graphically represented, and entry points for intervention and their links to existing policies are mapped. The challenges faced by smallholders in the context of our study can be characterised, using a CLD, as a set of interlinked and reinforcing dynamics which perpetuate existing disadvantages and reinforce duality in the value chain. Key policy entry points have been identified that could be targeted by a coordinated policy package, including: Direct support for infrastructure investment and input access through grants, subsidies or other policies; credit and liquidity provision for day-to-day expenses; creation of aggregation mechanisms for both inputs and outputs; regulations or initiatives that directly target the relationship of farmers with the commercial segment to improve access to day-old-chicks and, finally, training in business and technical skills. Although most of these interventions have been addressed at some point, implementation has been fragmented, failing to fully consider their complementary nature, thus undermining effectiveness. Existing approaches to consensus building and stakeholder participation in system dynamics research can present challenges when it comes to engaging with complex policy processes and issues of conflict of interest that are relevant in the context of smallholder promotion and equitable food systems, but there are promising avenues for addressing. Despite some methodological challenges, we find that there is considerable scope for system dynamics approaches to inform policy for smallholder promotion, even in contexts characterised by complex policy processes.

A Scoping Review of Breastfeeding in Active Duty U.S. Military Women

Active duty (AD) women in the U.S. military experience challenges during childbearing owing to unique occupational demands. The purpose of this article is to report the findings from a scoping review on pregnancy, childbirth, and the postpartum period that are specific to breastfeeding among servicewomen. A secondary aim is to identify leverage points that would promote breastfeeding in this population. We developed a PRISMA-ScR protocol to identify publications from 2000 to 2018 regarding pregnancy, childbirth, and the postpartum period in AD women. Among articles pertaining to the postpartum period, we recognized those specific to breastfeeding for separate analysis. Using the social ecological model for military women's health (SEM-MWH) to synthesize our results, we identified actionable leverage points in the military setting for positive change. Research articles specific to breastfeeding (n=8) included descriptive, cross-sectional, and qualitative studies. Non-research articles (n=7) were either an integrative review, nonsystematic review, or commentary. Thirty-four leverage points were identified throughout the social ecological system of military women, including support for lactation in the workplace, employment of lactation consultants, occupational hazards assessment, personnel policies that delay the separation of women and their infants, and research to fill gaps in knowledge about breastfeeding while on AD. The greatest number of leverage points are in the SEM-MWH mesosystem and exosystem. There are multiple potential leverage points throughout the SEM-MWH to generate positive changes in the social ecological system of military women. These changes could serve to enhance the breastfeeding experiences of AD women.

EXPLORING SYSTEMIC FORCES THAT INFLUENCE SUSTAINABLE DESIGN TRANSITIONS

AbstractIn this research some systemic forces to sustainable design are described and mapped out, along with key areas, dimensions and stakeholders. These results are visualized in a causal loop diagram (CLD), which was the outcome of a group model building approach supported by a literature review. Within the proposed system model, represented by the system-level variables and their relationships within the CLD, some potential leverage points that can help make product design better contribute to sustainability are identified and described. These can be found in the balancing and reinforcing feedback loops of the CLD as well as the mapping to societal dimensions of sustainability transitions and stakeholder groups. Among the stakeholder groups, business managers, scientific researchers and engineering designers can be tied to the design community. Future research is proposed to build on these initial results to deepen the knowledge about the systemic drivers and barriers and leverage the contribution of design practice to sustainable development.