System-level Changes Research Articles

Professional Coaching as a Continuing Professional Development Intervention to Address the Physician Distress Epidemic.

Physician distress and burnout are reaching epidemic proportions, threatening physicians' capacities to develop and maintain competencies in the face of the increasingly demanding and complex realities of medical practice in today's world. In this article, we suggest that coaching should be considered both a continuing professional development intervention as well as an integral part of a balanced and proactive solution to physician distress and burnout. Unlike other interventions, coaching is intended to help individuals gain clarity in their life, rather than to treat a mental health condition or to provide advice, support, guidance, or knowledge/skills. Certified coaches are trained to help individuals discover solutions to complex problems and facilitate decision-making about what is needed to build and maintain capacity and take action. Across many sectors, coaching has been shown to enhance performance and reduce vulnerability to distress and burnout, but it has yet to be systematically implemented in medicine. By empowering physicians to discover and implement solutions to challenges, regain control over their lives, and act according to their own values, coaching can position physicians to become leaders and advocates for system-level change, while simultaneously prioritizing their own well-being.

IMG-14. Cognitive deficits and altered functional network organization in pediatric brain tumor patients

INTRODUCTION: Survivors of pediatric brain tumors experience significant cognitive deficits from their diagnosis and treatment. Mechanisms of cognitive injury are poorly understood, and predictors of long-term outcome are lacking. Large-scale, distributed brain systems provide a window into brain organization and function that may yield insight into these mechanisms and outcomes. Recent evidence suggests that systems-level changes are related to cognitive performance across the lifespan. Here, we evaluated brain network architecture, cognitive performance, and brain-behavior relationships in pediatric brain tumor patients. METHODS: Forty-nine patients (ages 7-18y.o.) with any brain tumor diagnosis underwent resting state functional Magnetic Resonance Imaging (rsfMRI) during regularly scheduled clinical visits. All patients were tested with the NIH Toolbox Cognition Battery. One-hundred thirty-nine age- and sex-matched typically developing children were used as controls. All data were processed to minimize artifactual sources of variance. Functional brain networks were created for each patient via rsfMRI data from 300 regions of interest that sample the whole brain. Multilinear models were implemented to examine brain-behavior relationships, while accounting for demographic and clinical factors. RESULTS: Functional network organization was significantly altered in patients compared to controls (p<0.001). Network organization was more affected in patients who received whole-brain radiation therapy than those who did not (t=2.52, p<0.015). Patients demonstrated significant impairments in multiple domains of cognitive performance, e.g. attention (p<0.0001). Weak relationships were found between cognitive performance and network organization, none of which survived multiple comparison correction. CONCLUSIONS: Brain network architecture is significantly altered in pediatric brain tumor patients. Whole-brain radiation was related to the largest changes. Most network and cognitive changes were significant with large effect sizes, yet brain-behavior relationships were weak. Our results suggest that systems-level changes in brain organization may provide insight into long-term changes in brain function in pediatric brain tumor patients.

Prologue Cuaderno 157 Transition Design [Special Issue

Transition Design is an emerging, transdisciplinary area of research, study and practice aimed at addressing systemic (wicked) problems and thereby catalyzing societal transitions toward more sustainable, equitable and desirable long-term futures. It recognizes that such problems are always interconnected, and addressing them requires systems level change (that is, the reconfiguration of socio-technical-ecological systems). While this is a long-term endeavor, it requires incremental, systemic interventions in the present at multiple levels of scale. The necessity for systems level change is increasingly being recognized by practitioners, academics and activists, making Transition Design and other approaches to systems change ever more relevant. In various ways, all the papers in this volume explore how to bring this about, recognizing that it is a transdisciplinary, long term, place-based project that needs to engage marginalized and disenfranchised stakeholders, and weaves together theory and practice and academic and non-academic forms of knowledge.

Latina Women’s Experiences With Health Facility Breastfeeding Care: Implications for Quality Improvement

ObjectivesLittle is known about how to promote high-quality, person-centered breastfeeding care for women of color. We sought to understand breastfeeding care experiences among Latina women to inform the co-design of quality improvement interventions.MethodsWe conducted in-depth interviews with 21 Latina women with low incomes in Connecticut about their breastfeeding care experiences during prenatal, birth, and postpartum visits and ways to improve care experiences. We conducted a thematic analysis and mapped results to the WHO quality of care framework for maternal and newborn health.ResultsMost women received little or no breastfeeding information during prenatal visits and reported that providers rushed visits. Yet, women wanted to learn about breastfeeding before birth and valued spending quality time with providers, particularly when they asked open-ended questions about breastfeeding that promoted discussion. Women emphasized that respectful breastfeeding care requires providers be attentive to their needs and preferences, especially during birth care. While most women appreciated birth care nurses who answered breastfeeding questions and responded to requests (e.g., for breast pumps), a few felt disrespected when nurses ignored requests for their infants to be brought to them and pressured women to formula feed against their wishes. Women reported that lactation consultants (LCs) offered encouragement, though LCs were often unavailable when needed. After discharge, some women felt discouraged because providers did not follow up to offer breastfeeding support. Among women who had negative experiences, many still strove to meet their breastfeeding goals; a few chose to not use postpartum and primary care services as result of negative experiences. At the provider level, women recommended that providers build relationships and trust with women by engaging in breastfeeding conversations. They also recommended systems level changes, including longer prenatal visits, continuity of breastfeeding care, culturally responsive providers who speak Spanish and look like them, provision of breastfeeding peer counselors, and timely access to LCs.ConclusionsMulti-level changes recommended by Latina women should be prioritized in efforts to improve breastfeeding care quality.Funding SourcesNIH/NHLBI K12HL138037; CDC U48DP006380-02-00.

1412-P: Preexisting Nonalcoholic Steatohepatitis Attenuates Improvement of Adipose Tissue OXPHOS Capacity after Weight-Loss Surgery

Impaired adipose tissue (AT) function closely associates with obesity, type 2 diabetes and nonalcoholic fatty liver disease (NAFLD) . Mitochondrial oxidative phosphorylation (OXPHOS) capacity of AT improves after weight loss surgery. However, it is not clear if the improvement is affected by the presence of NAFLD before surgery. We examined 52 severely obese people exhibiting no histological liver disease (OBE_CON) , simple steatosis (OBE_NAFL) or steatohepatitis (OBE_NASH) before (0 weeks) , 12 and 52 weeks after bariatric surgery. Whole-body insulin sensitivity was measured by hyperinsulinemic euglycemic clamps. OXPHOS capacity of subcutaneous AT was assessed by high-resolution respirometry. Transcript levels of TNFα in AT were quantified by RT-PCR. Before surgery, OBE_NASH presented with lower insulin sensitivity and higher HbA1c compared to OBE_CON and OBE_NAFL (all p&amp;lt;0.05) whereas OXPHOS capacity in AT was comparable between the groups. Maximum coupled respiration declined at week 12 by 17% from week 0 in OBE_CON only (p&amp;lt;0.05) . From 12 to 52 weeks, AT maximum coupled respiration markedly increased by 82 and 49% in OBE_CON and OBE_NAFL (both p&amp;lt;0.001) but only by 28% in OBE_NASH (p=0.05; maximum coupled OXPHOS at week 52: OBE_CON vs. OBE_NASH p&amp;lt;0.05) . The changes in AT maximum coupled respiration from 12 to 52 weeks correlated negatively with changes in AT TNFα levels in OBE_CON (β=-0.83, p&amp;lt;0.001) and negatively with changes in systemic C-reactive protein levels in OBE_NASH (β=-0.34, p&amp;lt;0.05) . Maximal noncoupled OXPHOS yielded similar changes and correlations. In conclusion, in severe obesity, weight loss-related improvements in AT OXPHOS capacity may be mediated to a great extent by reduced AT inflammation in people without liver disease; however, with pre-surgery manifestation of NASH and worsening of metabolic control, residual systemic subclinical inflammation may attenuate the improvement of AT OXPHOS capacity after bariatric surgery. Disclosure S.Kahl: None. G.Heilmann: None. I.Esposito: None. M.Schlensak: None. M.Roden: Advisory Panel; Eli Lilly and Company, Research Support; Boehringer Ingelheim International GmbH, Nutricia, Speaker's Bureau; Novo Nordisk. K.Strassburger: None. S.Gancheva: None. N.Saatmann: None. C.Granata: None. C.Herder: Research Support; Sanofi. K.Pafili: None. J.Puetzer-furmanczak: None. T.Sarabhai: None. Funding German Federal Ministry of Health; Ministry of Culture and Science of the State North Rhine-Westphalia;German Federal Ministry of Education and Research;European Funds for Regional Development (EFRE-0400191) ;EUREKA Eurostars-2 (E!113230DIA-PEP) ;German Science Foundation (CRC/SFB1116/2 B12; RTG/GRK 2576 vivid, Project 3) ;Schmutzler Stiftung

Utilizing Causal Loop Diagramming to Explore a Research and Evaluation Capacity Building Partnership.

The capacity to engage in research, evaluation and evidence-informed decision-making supports effective public health policy and practice. Little is known about partnership-based approaches that aim to build capacity across a system or how to evaluate them. This study examines the impacts of a research and evaluation capacity building partnership called the Western Australian Sexual Health and Blood-borne Virus Applied Research and Evaluation Network (hereafter, SiREN). SiREN aims to strengthen capacity across a system of clinical and medical services and government and non-government organizations. These organizations are connected through their shared aim of preventing and managing sexually transmissible infections and blood-borne viruses. To examine SiREN, systems concepts and methods were used. Data were collected from SiREN organizational documents (n = 42), a survey tool (n = 104), in-depth interviews (n = 17), a workshop and three meetings with SiREN stakeholders and used to develop two causal loop diagrams. Findings show engagement with SiREN was influenced by a complex interplay of contextual (e.g., organizational capacity) and process (e.g., presence of trusting relationships) factors. SiREN contributed to system level changes, including increased resources for research and evaluation, the development of networks and partnerships that led to more efficient responses to emerging health issues, evidence sharing, and sustainable research and evaluation practice. The use of causal loop diagrams enabled the identification of key leverage points that SiREN can use for continuous improvement or evaluation. The focus on how contextual factors influenced SiREN's ability to create change provides valuable information for researchers, policymakers or practitioners seeking to develop a similar partnership.

Changing Care: Applying the Transtheoretical Model of Change to Embed Equity, Diversity, and Inclusion in Long-Term Care Research in Canada

Healthcare policy reform is evident when considering the past, present and future of long-term care (LTC) in Canada. Some of the most pressing issues facing the LTC sector include the changing demographic composition in Canadian LTC homes, minimal consideration for the role of intersectionality in LTC data collection and analysis, and the expanding need to engage diverse participants and knowledge users. Using the Transtheoretical Model of Change (TTMC) as a framework, we consider opportunities to address intersectionality in LTC research. Engaging diverse knowledge users in LTC (e.g., unpaid caregivers, paid care staff), community (e.g., advocacy groups, service providers) and policy decision-makers (e.g., provincial government) is crucial. Empowering individuals to participate, modifying environments to support engagement, and facilitating ongoing partnerships with knowledge users are critical aspects of change efforts. Addressing structural barriers (e.g., accessibility, capacity, jurisdictional policies, and mandates) to research in LTC is also essential. The TTMC offers a framework for planning and enacting individual, organizational, and system-level changes for the future of LTC.

Murradambirra Dhangaang (make food secure): Aboriginal community and stakeholder perspectives on food insecurity in urban and regional Australia

BackgroundIt is widely acknowledged that the invasion by colonial powers of the Australian continent had profound and detrimental impacts on Aboriginal Communities, including food security. Policies of successive governments since European arrival have since further exacerbated the situation, with food insecurity now affecting 20–25% of Aboriginal and Torres Strait Islander people. Food insecurity contributes to long-term impacts on health, in particular diet-sensitive chronic diseases. This study aimed to describe Aboriginal community and stakeholder perspectives on food insecurity to get a better understanding of the key contributing factors and recommendations for potential strategies to address this issue in Aboriginal communities in urban and regional Australia.MethodsSemi-structured interviews were conducted with 44 participants who were purposively selected. This included Aboriginal people in two communities and both Aboriginal and non-Aboriginal stakeholders from local food relief agencies, food suppliers, schools, and government in an urban and regional location in NSW. A conceptual framework was developed from literature on food security, and sensitizing concepts of availability, affordability, accessibility and acceptability or the lack thereof of healthy food were used to elicit responses from the participants. Interview transcripts were analysed thematically.ResultsAll participants felt strongly that food insecurity was a major problem experienced in their local Aboriginal communities. Five core areas impacting on food security were identified: trapped in financial disadvantage; gaps in the local food system; limitations of non-Aboriginal food relief services; on-going impacts of colonization; and maintaining family, cultural and community commitments and responsibilities. Participants suggested a number of actions that could help ease food insecurity and emphasized that Aboriginal values and culture must be strongly embedded in potential programs.ConclusionsThis study found Aboriginal families in urban and regional Australia are experiencing food insecurity on a regular basis, which is impacted by a range of socio-economic, environmental, systemic and cultural factors, as reported by the participants. Study findings highlight the need to address system level changes in the food environment and acknowledge Aboriginal history, culture and food preferences when considering the development of programs to alleviate food insecurity among Aboriginal people.

Macrophage Migration Inhibitory Factor (MIF) Makes Complex Contributions to Pain-Related Hyperactivity of Nociceptors after Spinal Cord Injury.

Neuropathic pain is a major, inadequately treated challenge for people with spinal cord injury (SCI). While SCI pain mechanisms are often assumed to be in the CNS, rodent studies have revealed mechanistic contributions from primary nociceptors. These neurons become chronically hyperexcitable after SCI, generating ongoing electrical activity that promotes ongoing pain. A major question is whether extrinsic chemical signals help to drive ongoing electrical activity after SCI. People living with SCI exhibit acute and chronic elevation of circulating levels of macrophage migration inhibitory factor (MIF), a cytokine implicated in preclinical pain models. Probable nociceptors isolated from male rats and exposed to an MIF concentration reported in human plasma (1 ng/ml) showed hyperactivity similar to that induced by SCI, although, surprisingly, a 10-fold higher concentration failed to increase excitability. Conditioned behavioral aversion to a chamber associated with peripheral MIF injection suggested that MIF stimulates affective pain. A MIF inhibitor, Iso-1, reversed SCI-induced hyperexcitability. Unlike chronic SCI-induced hyperexcitability, acute MIF-induced hyperexcitability was only partially abrogated by inhibiting ERK signaling. Unexpectedly, MIF concentrations that induced hyperactivity in nociceptors from naive animals, after SCI induced a long-lasting conversion from a highly excitable nonaccommodating type to a rapidly accommodating, hypoexcitable type, possibly as a homeostatic response to prolonged depolarization. Treatment with conditioned medium from cultures of DRG cells obtained after SCI was sufficient to induce MIF-dependent hyperactivity in neurons from naive rats. Thus, changes in systemic and DRG levels of MIF may help to maintain SCI-induced nociceptor hyperactivity that persistently promotes pain.SIGNIFICANCE STATEMENT Chronic neuropathic pain is a major challenge for people with spinal cord injury (SCI). Pain can drastically impair quality of life, and produces substantial economic and social burdens. Available treatments, including opioids, remain inadequate. This study shows that the cytokine macrophage migration inhibitory factor (MIF) can induce pain-like behavior and plays an important role in driving persistent ongoing electrical activity in injury-detecting sensory neurons (nociceptors) in a rat SCI model. The results indicate that SCI produces an increase in MIF release within sensory ganglia. Low MIF levels potently excite nociceptors, but higher levels trigger a long-lasting hypoexcitable state. These findings suggest that therapeutic targeting of MIF in neuropathic pain states may reduce pain and sensory dysfunction by curbing nociceptor hyperactivity.

Phosphoproteomics Unravel HBV Triggered Rewiring of Host Phosphosignaling Events.

Hepatitis B virus (HBV) infection persists as a major global health problem despite the availability of HBV vaccines for disease prevention. However, vaccination rates remains low in some regions of the world, driving the need for novel strategies to minimise infections and prevent disease progression. Thus, understanding of perturbed molecular signaling events during early phases of HBV infection is required. Phosphosignaling is known to be involved in the HBV infection processes, yet systems-level changes in phosphosignaling pathways in the host during infection remain unclear. To this end, we performed phosphoproteome profiling on HBV-infected HepG2-NTCP cells. Our results showed that HBV infection drastically altered the host phosphoproteome and its associated proteins, including kinases. Computational analysis of this phosphoproteome revealed dysregulation of the pathways involved in immune responses, cell cycle processes, and RNA processing during HBV infection. Kinase Substrate Enrichment Analysis (KSEA) identified the dysregulated activities of important kinases, including those from CMGC (CDK, MAPK, GSK, and CLK), AGC (protein kinase A, G, and C), and TK (Tyrosine Kinase) families. Of note, the inhibition of CLKs significantly reduced HBV infection in HepG2-NTCP cells. In all, our study unravelled the aberrated phosphosignaling pathways and the associated kinases, presenting potential entry points for developing novel therapeutic strategies for HBV treatment.

Urban and Rural Patients Perspectives on Late Diagnosis of Breast Cancer in Tanzania: A Qualitative Study

PURPOSE In Tanzania, women are diagnosed at an advanced stages of breast cancer. The aim of this study is to identify reasons for this finding from the patient perspective. METHODS Semi-structured in-depth interviews were conducted in inpatient and outpatient settings in the Kilimanjaro Cancer Care Center. Thematic coding via grounded theory technique was done by two independent reviewers. RESULTS Ten 10 patients (five rural and five urban) participated in the study. The average ages was 48. Seven (70.0%) were Christian. Eight (80.0%) patients had primary education, six (60.0%) were married, and eight (80.0%) were not employed. Two women (20.0%) had stage 2, four women (40.0%) had stage 3, and 4 (40.0%) had stage 4. The most common reasons reported by patients for advanced stage breast cancer at time of diagnosis are initially seeking care from traditional healers (n = 6, 60.0%), lack of breast cancer sign and symptoms knowledge (n = 8, 80.0%), misconceptions about breast cancer treatment especially mastectomy (n = 5, 50.0%), distrust of conventional medicine (n = 4, 40.0, seeking support from the religious leaders (n = 6, 60.0%). Furthermore, we found that, almost all (n = 9, 90.0%) of the patients express their concern regarding financial challenges to access care and treatment for cancer. For example (n = 3, 30.0%) said payment for cancer treatment is too costly and six patients (60.0%) stated that lack of money for transportation. CONCLUSION Lack of adequate breast cancer knowledge and awareness, patient provider relationships, and access to care are the most common mentioned reasons for advanced disease at time of diagnose among breast cancer patients. Engagement with the community through cultural sensitive public health campaigns and interventions must be designed to alleviate the misconceptions and knowledge gap in these communities. System level change is needed to improve access to care.

Honoring Nurses Where They Need It.

System-level changes must address issues such as staffing and burnout.

COVID-19 pandemic unmasking cardiovascular risk factors and non-communicable diseases among migrant workers: a cross-sectional study in Singapore

ObjectivesThis study aims to report the prevalence of cardiovascular risk factors (CVRFs) and other non-communicable diseases among migrant workers in Singapore admitted for COVID-19 infection, to highlight disease burden and...

The Association of the Childhood Opportunity Index on Pediatric Readmissions and Emergency Department Revisits.

Reutilization following discharge is costly to families and the health care system. Singular measures of the social determinants of health (SDOH) have been shown to impact utilization; however, the SDOH are multifactorial. The Childhood Opportunity Index (COI) is a validated approach for comprehensive estimation of the SDOH. Using the COI, we aimed to describe the association between SDOH and 30-day revisit rates. This retrospective study included children 0 to 17 years within 48 children's hospitals using the Pediatric Health Information System from 1/1/2019 to 12/31/2019. The main exposure was a child's ZIP code level COI. The primary outcome was unplanned readmissions and emergency department (ED) revisits within 30 days of discharge. Primary outcomes were summarized by COI category and compared using chi-square or Kruskal-Wallis tests. Adjusted analysis used generalized linear mixed effects models with adjustments for demographics, clinical characteristics, and hospital clustering. Of 728,997 hospitalizations meeting inclusion criteria, 30-day unplanned returns occurred for 96,007 children (13.2%). After adjustment, the patterns of returns were significantly associated with COI. For example, 30-day returns occurred for 19.1% (95% confidence interval [CI]: 18.2, 20.0) of children living within very low opportunity areas, with a gradient-like decrease as opportunity increased (15.5%, 95% CI: 14.5, 16.5 for very high). The relative decrease in utilization as COI increased was more pronounced for ED revisits. Children living in low opportunity areas had greater 30-day readmissions and ED revisits. Our results suggest that a broader approach, including policy and system-level change, is needed to effectively reduce readmissions and ED revisits.

Sustainability-oriented innovations in smart cities: A systematic review and emerging themes

The purpose of the paper is to clarify the relationship between sustainability-oriented innovations (SOI) and smart city development based on the systematic review of existing literature in the field. As an outcome of the review process, 159 articles were carefully selected for the in-depth analysis of the inter-linked concepts of smart city and sustainability-oriented innovations. The results show a growing trend of research papers in this field, especially in the last five years. The findings show the significance of a systemic multi-dimensional view of innovations for the smart sustainable development of cities. We have identified four main perspectives through which the scholars discourse the SOI dimensions in the smart city context: technology perspective, organizational perspective, social innovation perspective with citizen engagement, as well as system-level changes with innovation ecosystems. Second, we have recognized various focused themes under each main perspective. The various types of innovations also have impacts on different components of smart cities. Although the technological innovation perspectives dominate, and governance aspects are also paid attention to in recent studies, the increasing amount of research outputs also report on the developments of other components and perspectives, such as new human-centric approaches like citizen engagement.

Metrics to describe changes in the power system need for demand response resources

Grid decarbonization efforts can benefit significantly from demand response (DR) resources. However, system-level changes that affect the net-load such as increased variable renewable energy (VRE) generation and widespread deployment of energy efficiency (EE) also affect the type, magnitude and timing of DR required to support the grid. In this study, we use publicly available system-level data to define seven metrics to assess how these changes affect system-level shed and shift DR needs. Specifically, there are four metrics for grid conditions when DR has the highest system value and three metrics for DR program design that were developed by considering the magnitude and temporal distribution of net-load. We also develop three stylized load shape profiles illustrating EE measure impacts and one high VRE generation profile to demonstrate the application of these metrics. The results confirm the robustness of the metrics to identify complex interactions between demand-side and supply-side resources that can affect the DR need. Widespread application of our metrics can help system planners and operators be cognizant of such interactions and identify the DR need for the system in a way that can be most valuable.

Post-Pandemic Telehealth Policy for Primary Care: An Equity Perspective.

National telehealth policy thus far has focused on broadening access to service, specialties, and originating sites. Yet telehealth policy can further equity by providing system-level change needed to reduce structural determinants that hamper telehealth access in historically marginalized, low income, and limited English-speaking populations. The authors propose policy solutions for states and CMS to help address these structural determinants of telehealth care. A telehealth "ecosystem" grounded in the following core components would ensure equitable access to care: use of technology inclusive of economically marginalized patients, access to the technology and broadband for completing virtual visits, and concrete support for patients as they develop their digital and telehealth skills.

Well-Being Intervention in General Surgery: Multicenter Study of Program Director and Resident Perspectives.

Physician well-being is critical for optimal care, but rates of psychological distress among surgical trainees are rising. Although numerous efforts have been made, the perceived efficacy of well-being interventions is not well understood. This qualitative thematic study included online questionnaires to Program Directors (PDs) and residents at 16 ACGME-accredited General Surgery residency programs. PDs reported active well-being interventions for surgical residents or those under consideration at their institutions. Residents shared perspectives of available well-being interventions through open-ended responses. Conventional content analysis was used to analyze responses. Fifteen PDs, or their proxies (94% response rate), responded. Responses revealed that a majority of available well-being interventions are focused on changing the individual experience rather than the underlying workplace. PD decision-making around well-being interventions is often not based on objective data. Three hundred residents (34% response rate) responded. Of available interventions, those that increase control (eg advanced and flexible scheduling), increase support (eg mentorship), and decrease demand (eg work hour limits) were consistently identified as beneficial, but interventions perceived to increase demand (eg held during unprotected time) were consistently identified as not beneficial. Group social activities, cognitive skills training, and well-being committees were variably seen as beneficial (increasing support) or not (increasing demand). Our findings underscore the prevalence of individual-based well-being interventions and the paucity of system-level changes. This may explain, in part, the persistence of distress among residents despite abundant effort, highlighting the imperative for system-level transformation.

A participatory approach to tracking system transformation in clusters and innovation ecosystems—Evolving practice in Sweden’s Vinnväxt programme

Abstract For decades, cluster initiatives and funding programmes have been used as instruments of industrial and innovation policy—addressing system failures by strengthening linkages among actors, fostering innovation, and developing more effective innovation systems. More recently, a growing segment of these initiatives are also focused on driving system-level transformation and contributing to broader societal benefits. This segment is characterized by larger-scale and longer-term strategic efforts involving a variety of stakeholders across different parts of society, aimed at contributing to addressing societal challenges. These characteristics are shared with the emerging frame of transformative innovation policy, which highlights the importance of embedded practices of learning and reflexivity to enable continuous monitoring of progress and inform and adapt the direction of systemic change processes—requiring new approaches to governance and evaluation. Despite deep experience with implementing cluster programmes and other systemic innovation policy instruments, practitioners still struggle with monitoring and evaluation. Current approaches focus on evidencing strengthened innovation (and economic effects) on the level of firms and research actors, and fail to capture contributions on the level of the broader system. This article presents an evolving approach for tracking system transformation in clusters and collaborative innovation initiatives. Through an interactive, co-development process with initiatives in the Swedish Vinnväxt programme, this research proposes a definition and set of system effect categories for cluster initiatives. It tests a participatory approach for tracking their contribution to system-level change over time, providing an initial case on which to build and apply in other transformative innovation programmes.

Tackling Ethnic Health Disparities Through Community Health Worker Programs: A Scoping Review on Their Utilization During the COVID-19 Outbreak.

The coronavirus disease (COVID-19) outbreak has magnified existing health inequities linked to social determinants of health, with racial and ethnic minorities being disproportionately affected by the pandemic. A proposed strategy to address these inequities is based on the implementation of community health worker (CHW) programs able to bridge the gaps between marginalized communities and the formal health care systems. A scoping review was conducted through searching 4 databases: PubMed, Scopus, Web of Science, and Science Direct. Inclusion criteria focused on studies defining any kind of adopted CHW intervention to address inequities related to racial/ethnic groups during the COVID-19 crisis, published from December 31, 2019, to October 31, 2021. Narrative synthesis was undertaken to summarize the findings. In total, 23 studies met the inclusion out of the 107 search results. Data converged on the relevant potential of CHWs on engaging with community leaders, addressing social determinants of health, and issues related to structural racism, promoting culturally tailored health information, and encouraging institutions to policy change in favor of people left behind. Although vulnerability of racial and ethnic minorities was already present before the COVID-19 outbreak, the pandemic has represented a wakeup call to address it more efficiently. In recent years, CHWs have increasingly been acknowledged as valuable members of the health care workforce. As health disparities may increase after our multicultural societies begin to recover from COVID-19, CHWs may play a crucial role in addressing system-level changes to have broad and lasting effects on health outcomes.