A simple guide to chaos and complexity

Effective communication of public health guidance to emergency department clinicians in the setting of emerging incidents: a qualitative study and framework

BACKGROUND

Evidence to inform communication between emergency department clinicians and public health agencies is limited. In the context of diverse, emerging public health incidents, communication is urgent, as emergency department clinicians must implement recommendations to protect themselves and the public. The objectives of this study were to: explore current practices, barriers and facilitators at the local level for communicating public health guidance to emergency department clinicians in emerging public health incidents; and develop a framework that promotes effective communication of public health guidance to clinicians during emerging incidents.

METHODS

A qualitative study was conducted using semi-structured interviews with 26 key informants from emergency departments and public health agencies in Ontario, Canada. Data were analyzed inductively and the analytic approach was guided by concepts of complexity theory.

RESULTS

Emergent themes corresponded to challenges and strategies for effective communication of public health guidance. Important challenges related to the coordination of communication across institutions and jurisdictions, and differences in work environments across sectors. Strategies for effective communication were identified as the development of partnerships and collaboration, attention to specific methods of communication used, and the importance of roles and relationship-building prior to an emerging public health incident. Following descriptive analysis, a framework was developed that consists of the following elements: 1) Anticipate; 2) Invest in building relationships and networks; 3) Establish liaison roles and redundancy; 4) Active communication; 5) Consider and respond to the target audience; 6) Leverage networks for coordination; and 7) Acknowledge and address uncertainty. The qualities inherent in local relationships cut across framework elements.

CONCLUSIONS

This research indicates that relationships are central to effective communication between public health agencies and emergency department clinicians at the local level. Our framework which is grounded in qualitative evidence focuses on strategies to promote effective communication in the emerging public health incident setting and may be useful in informing practice.

Multidimensional Complexity of Cancer. Simple Solutions Are Needed

Cancer is a complex system. Tumor complexity is determined not only by genetic and epigenetic heterogeneity, but also by a huge number of interactions between cancer and normal cells. The heterogeneity and complexity of a tumor causes failure of molecular targeting therapy as a tool for fighting cancer. This review considers the concepts of malignant tumors as organisms that have common characteristics despite all heterogeneity. This leads to the idea that one of the most promising strategies for fighting cancer is the use of the patient's immune system.

PIPELINEs: Creating Comparable Clinical Knowledge Efficiently by Linking Trial Platforms

Adaptive, seamless, multisponsor, multitherapy clinical trial designs executed as large scale platforms, could create superior evidence more efficiently than single-sponsor, single-drug trials. These trial PIPELINEs also could diminish barriers to trial participation, increase the representation of real-world populations, and create systematic evidence development for learning throughout a therapeutic life cycle, to continually refine its use. Comparable evidence could arise from multiarm design, shared comparator arms, and standardized endpoints-aiding sponsors in demonstrating the distinct value of their innovative medicines; facilitating providers and patients in selecting the most appropriate treatments; assisting regulators in efficacy and safety determinations; helping payers make coverage and reimbursement decisions; and spurring scientists with translational insights. Reduced trial times and costs could enable more indications, reduced development cycle times, and improved system financial sustainability. Challenges to overcome range from statistical to operational to collaborative governance and data exchange.

Consequences of removing cheap, super-strength beer and cider: a qualitative study of a UK local alcohol availability intervention

OBJECTIVES

Increasingly, English local authorities have encouraged the implementation of an intervention called 'Reducing the Strength' (RtS) whereby off-licences voluntarily stop selling inexpensive 'super-strength' (≥6.5% alcohol by volume (ABV)) beers and ciders. We conceptualised RtS as an event within a complex system in order to identify pathways by which the intervention may lead to intended and unintended consequences.

DESIGN

A qualitative study including a focus group and semistructured interviews.

SETTING

An inner-London local authority characterised by a high degree of residential mobility, high levels of social inequality and a large homeless population. Intervention piloted in three areas known for street drinking with a high alcohol outlet density.

PARTICIPANTS

Alcohol service professionals, homeless hostel employees, street-based services managers and hostel dwelling homeless alcohol consumers (n=30).

RESULTS

Participants describe a range of potential substitution behaviours to circumvent alcohol availability restrictions including consuming different drinks, finding alternative shops, using drugs or committing crimes to purchase more expensive drinks. Service providers suggested the intervention delivered in this local authority missed opportunities to encourage engagement between the council, alcohol services, homeless hostels and off-licence stores. Some participants believed small-scale interventions such as RtS may facilitate new forms of engagement between public and private sector interests and contribute to long-term cultural changes around drinking, although they may also entrench the view that 'problem drinking' only occurs in certain population groups.

CONCLUSIONS

RtS may have limited individual-level health impacts if the target populations remain willing and able to consume alternative means of intoxication as a substitute for super-strength products. However, RtS may also lead to wider system changes not directly related to the consumption of super-strengths and their assumed harms.

Global Health, Geographical Contingency, and Contingent Geographies

Health geography has emerged from under the "shadow of the medical" to become one of the most vibrant of all the subdisciplines. Yet, this success has also meant that health research has become increasingly siloed within this subdisciplinary domain. As this article explores, this represents a potential lost opportunity with regard to the study of global health, which has instead come to be dominated by anthropology and political science. Chief among the former's concerns are exploring the gap between the programmatic intentions of global health and the unintended or unanticipated consequences of their deployment. This article asserts that recent work on contingency within geography offers significant conceptual potential for examining this gap. It therefore uses the example of alcohol taxation in Botswana, an emergent global health target and tool, to explore how geographical contingency and the emergent, contingent geographies that result might help counter the prevailing tendency for geography to be side-stepped within critical studies of global health. At the very least, then, this intervention aims to encourage reflection by geographers on how to make explicit the all-too-often implicit links between their research and global health debates located outside the discipline.

A systematic literature review of the key challenges for developing the structure of public health economic models

OBJECTIVES

To identify the key methodological challenges for public health economic modelling and set an agenda for future research.

METHODS

An iterative literature search identified papers describing methodological challenges for developing the structure of public health economic models. Additional multidisciplinary literature searches helped expand upon important ideas raised within the review.

RESULTS

Fifteen articles were identified within the formal literature search, highlighting three key challenges: inclusion of non-healthcare costs and outcomes; inclusion of equity; and modelling complex systems and multi-component interventions. Based upon these and multidisciplinary searches about dynamic complexity, the social determinants of health, and models of human behaviour, six areas for future research were specified.

CONCLUSIONS

Future research should focus on: the use of systems approaches within health economic modelling; approaches to assist the systematic consideration of the social determinants of health; methods for incorporating models of behaviour and social interactions; consideration of equity; and methodology to help modellers develop valid, credible and transparent public health economic model structures.

EQUIP Healthcare: An overview of a multi-component intervention to enhance equity-oriented care in primary health care settings

Background

The primary health care (PHC) sector is increasingly relevant as a site for population health interventions, particularly in relation to marginalized groups, where the greatest gains in health status can be achieved. The purpose of this paper is to provide an overview of an innovative multi-component, organizational-level intervention designed to enhance the capacity of PHC clinics to provide equity-oriented care, particularly for marginalized populations. The intervention, known as EQUIP, is being implemented in Canada in four diverse PHC clinics serving populations who are impacted by structural inequities. These PHC clinics serve as case studies for the implementation and evaluation of the EQUIP intervention. We discuss the evidence and theory that provide the basis for the intervention, describe the intervention components, and discuss the methods used to evaluate the implementation and impact of the intervention in diverse contexts.

Design and methods

Research and theory related to equity-oriented care, and complexity theory, are central to the design of the EQUIP intervention. The intervention aims to enhance capacity for equity-oriented care at the staff level, and at the organizational level (i.e., policy and operations) and is novel in its dual focus on:

Staff education: using standardized educational models and integration strategies to enhance staff knowledge, attitudes and practices related to equity-oriented care in general, and cultural safety, and trauma- and violence-informed care in particular, and;

Organizational integration and tailoring: using a participatory approach, practice facilitation, and catalyst grants to foster shifts in organizational structures, practices and policies to enhance the capacity to deliver equity-oriented care, improve processes of care, and shift key client outcomes.

Using a mixed methods, multiple case-study design, we are examining the impact of the intervention in enhancing staff knowledge, attitudes and practices; improving processes of care; shifting organizational policies and structures; and improving selected client outcomes.

Discussion

The multiple case study design provides an ideal opportunity to study the contextual factors shaping the implementation, uptake and impact of our tailored intervention within diverse PHC settings. The EQUIP intervention illustrates the complexities involved in enhancing the PHC sector's capacity to provide equity-oriented care in real world clinical contexts.

How to Measure Costs and Benefits of eHealth Interventions: An Overview of Methods and Frameworks

Information on the costs and benefits of eHealth interventions is needed, not only to document value for money and to support decision making in the field, but also to form the basis for developing business models and to facilitate payment systems to support large-scale services. In the absence of solid evidence of its effects, key decision makers may doubt the effectiveness, which, in turn, limits investment in, and the long-term integration of, eHealth services. However, it is not realistic to conduct economic evaluations of all eHealth applications and services in all situations, so we need to be able to generalize from those we do conduct. This implies that we have to select the most appropriate methodology and data collection strategy in order to increase the transferability across evaluations. This paper aims to contribute to the understanding of how to apply economic evaluation methodology in the eHealth field. It provides a brief overview of basic health economics principles and frameworks and discusses some methodological issues and challenges in conducting cost-effectiveness analysis of eHealth interventions. Issues regarding the identification, measurement, and valuation of costs and benefits are outlined. Furthermore, this work describes the established techniques of combining costs and benefits, presents the decision rules for identifying the preferred option, and outlines approaches to data collection strategies. Issues related to transferability and complexity are also discussed.

Climate change, biodiversity, ticks and tick-borne diseases: The butterfly effect

We have killed wild animals for obtaining food and decimated forests for many reasons. Nowadays, we are burning fossil fuels as never before and even exploring petroleum in deep waters. The impact of these activities on our planet is now visible to the naked eye and the debate on climate change is warming up in scientific meetings and becoming a priority on the agenda of both scientists and policy decision makers. On the occasion of the Impact of Environmental Changes on Infectious Diseases (IECID) meeting, held in the 2015 in Sitges, Spain, I was invited to give a keynote talk on climate change, biodiversity, ticks and tick-borne diseases. The aim of the present article is to logically extend my rationale presented on the occasion of the IECID meeting. This article is not intended to be an exhaustive review, but an essay on climate change, biodiversity, ticks and tick-borne diseases. It may be anticipated that warmer winters and extended autumn and spring seasons will continue to drive the expansion of the distribution of some tick species (e.g., Ixodes ricinus) to northern latitudes and to higher altitudes. Nonetheless, further studies are advocated to improve our understanding of the complex interactions between landscape, climate, host communities (biodiversity), tick demography, pathogen diversity, human demography, human behaviour, economics, and politics, also considering all ecological processes (e.g., trophic cascades) and other possible interacting effects (e.g., mutual effects of increased greenhouse gas emissions and increased deforestation rates). The multitude of variables and interacting factors involved, and their complexity and dynamism, make tick-borne transmission systems beyond (current) human comprehension. That is, perhaps, the main reason for our inability to precisely predict new epidemics of vector-borne diseases in general.

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Human development affects the environment and the climate.

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Environmental and climate changes impacts on biodiversity.

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Environmental and climate changes alter tick population dynamics.

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Biodiversity loss affects tick-borne pathogen transmission.

The Challenge of Cardiovascular Diseases and Diabetes to Public Health: A Study Based on Qualitative Systemic Approach

The most common modeling approaches to understanding incidence, prevalence and control of chronic diseases in populations, such as statistical regression models, are limited when it comes to dealing with the complexity of those problems. Those complex adaptive systems have characteristics such as emerging properties, self-organization and feedbacks, which structure the system stability and resistance to changes. Recently, system science approaches have been proposed to deal with the range, complexity, and multifactor nature of those public health problems. In this paper we applied a multilevel systemic approach to create an integrated, coherent, and increasingly precise conceptual framework, capable of aggregating different partial or specialized studies, based on the challenges of the Longitudinal Study of Adult Health - ELSA-Brasil. The failure to control blood pressure found in several of the study's subjects was discussed, based on the proposed model, analyzing different loops, time lags, and feedback that influence this outcome in a population with high educational level, with reasonably good health services access. We were able to identify the internal circularities and cycles that generate the system's resistance to change. We believe that this study can contribute to propose some new possibilities of the research agenda and to the discussion of integrated actions in the field of public health.

Taxonomy for complexity theory in the context of maternity care

BACKGROUND

The linear focus of 'normal science' is unable to adequately take account of the complex interactions that direct health care systems. There is a turn towards complexity theory as a more appropriate framework for understanding system behaviour. However, a comprehensive taxonomy for complexity theory in the context of health care is lacking.

OBJECTIVE

This paper aims to build a taxonomy based on the key complexity theory components that have been used in publications on complexity theory and health care, and to explore their explanatory power for health care system behaviour, specifically for maternity care.

METHOD

A search strategy was devised in PubMed and 31 papers were identified as relevant for the taxonomy.

FINDINGS

The final taxonomy for complexity theory included and defined 11 components. The use of waterbirth and the impact of the Term Breech trial showed that each of the components of our taxonomy has utility in helping to understand how these techniques became widely adopted. It is not just the components themselves that characterise a complex system but also the dynamics between them.

Is uncertainty in complex disease epidemiology resolvable?

The imposed limitations on what we can know about nature have been long recognized. Yet in the field of epidemiology a futile search for lifestyle-related risk factors for common chronic diseases continues unabated. This has led to the production of a growing body of evidence about potential lifestyle risk factors that tend to be marginal, contradictory, irreproducible, or hard to interpret. While epidemiologists are calling for a more refined methodology, I argue that our limitation in studying complex diseases is insurmountable. This is because the study of lifestyle-related small risks requires accurate measurement of multiple behaviors-exposures over a long period of time. It is also because in complex systems such as population's health, the effect of rich interactions between its parts cannot be predicted based on traditional causal models of epidemiology. Within complex systems, understanding the interactions between system components can be more important than the contribution of each to disease risk.

Revisiting Chaos Theorem to Understand the Nature of miRNAs in Response to Drugs of Abuse

Just like Matryoshka dolls, biological systems follow a hierarchical order that is based on dynamic bidirectional communication among its components. In addition to the convoluted inter-relationships, the complexity of each component spans several folds. Therefore, it becomes rather challenging to investigate phenotypes resulting from these networks as it requires the integration of reductionistic and holistic approaches. One dynamic system is the transcriptome which comprises a variety of RNA species. Some, like microRNAs, have recently received a lot of attention. miRNAs are very pleiotropic and have been considered as therapeutic and diagnostic candidates in the biomedical fields. In this review, we survey miRNA profiles in response to drugs of abuse (DA) using 118 studies. After providing a summary of miRNAs related to substance use disorders (SUD), general patterns of miRNA signatures are compared among studies for single or multiple drugs of abuse. Then, current challenges and drawbacks in the field are discussed. Finally, we provide support for considering miRNAs as a chaotic system in normal versus disrupted states particularly in SUD and propose an integrative approach for studying and analyzing miRNA data.

Lessons from complex interventions to improve health

Complexity-resulting from interactions among many component parts-is a property of both the intervention and the context (or system) into which it is placed. Complexity increases the unpredictability of effects. Complexity invites new approaches to logic modeling, definitions of integrity and means of standardization, and evaluation. New metaphors and terminology are needed to capture the recognition that knowledge generation comes from the hands of practitioners/implementers as much as it comes from those usually playing the role of intervention researcher. Failure to acknowledge this may blind us to the very mechanisms we seek to understand. Researchers in clinical settings are documenting health improvement gains made as a consequence of complex systems thinking. Improvement science in clinical settings has much to offer researchers in population health.

Medicine is not science: guessing the future, predicting the past

RATIONALE, AIMS AND OBJECTIVES

Irregularity limits human ability to know, understand and predict. A better understanding of irregularity may improve the reliability of knowledge.

METHOD

Irregularity and its consequences for knowledge are considered.

RESULTS

Reliable predictive empirical knowledge of the physical world has always been obtained by observation of regularities, without needing science or theory. Prediction from observational knowledge can remain reliable despite some theories based on it proving false. A naïve theory of irregularity is outlined. Reducing irregularity and/or increasing regularity can increase the reliability of knowledge. Beyond long experience and specialization, improvements include implementing supporting knowledge systems of libraries of appropriately classified prior cases and clinical histories and education about expertise, intuition and professional judgement.

CONCLUSIONS

A consequence of irregularity and complexity is that classical reductionist science cannot provide reliable predictions of the behaviour of complex systems found in nature, including of the human body. Expertise, expert judgement and their exercise appear overarching. Diagnosis involves predicting the past will recur in the current patient applying expertise and intuition from knowledge and experience of previous cases and probabilistic medical theory. Treatment decisions are an educated guess about the future (prognosis). Benefits of the improvements suggested here are likely in fields where paucity of feedback for practitioners limits development of reliable expert diagnostic intuition. Further analysis, definition and classification of irregularity is appropriate. Observing and recording irregularities are initial steps in developing irregularity theory to improve the reliability and extent of knowledge, albeit some forms of irregularity present inherent difficulties.

Physiological complexity of acute traumatic brain injury in patients treated with a brain oxygen protocol: utility of symbolic regression in predictive modeling of a dynamical system

Predictive modeling of emergent behavior, inherent to complex physiological systems, requires the analysis of large complex clinical data streams currently being generated in the intensive care unit. Brain tissue oxygen protocols have yielded outcome benefits in traumatic brain injury (TBI), but the critical physiological thresholds for low brain oxygen have not been established for a dynamical patho-physiological system. High frequency, multi-modal clinical data sets from 29 patients with severe TBI who underwent multi-modality neuro-clinical care monitoring and treatment with a brain oxygen protocol were analyzed. The inter-relationship between acute physiological parameters was determined using symbolic regression (SR) as the computational framework. The mean patient age was 44.4±15 with a mean admission GCS of 6.6±3.9. Sixty-three percent sustained motor vehicle accidents and the most common pathology was intra-cerebral hemorrhage (50%). Hospital discharge mortality was 21%, poor outcome occurred in 24% of patients, and good outcome occurred in 56% of patients. Criticality for low brain oxygen was intracranial pressure (ICP) ≥22.8 mm Hg, for mortality at ICP≥37.1 mm Hg. The upper therapeutic threshold for cerebral perfusion pressure (CPP) was 75 mm Hg. Eubaric hyperoxia significantly impacted partial pressure of oxygen in brain tissue (PbtO2) at all ICP levels. Optimal brain temperature (Tbr) was 34-35°C, with an adverse effect when Tbr≥38°C. Survivors clustered at [Formula: see text] Hg vs. non-survivors [Formula: see text] 18 mm Hg. There were two mortality clusters for ICP: High ICP/low PbtO2 and low ICP/low PbtO2. Survivors maintained PbtO2 at all ranges of mean arterial pressure in contrast to non-survivors. The final SR equation for cerebral oxygenation is: [Formula: see text]. The SR-model of acute TBI advances new physiological thresholds or boundary conditions for acute TBI management: PbtO2≥25 mmHg; ICP≤22 mmHg; CPP≈60-75 mmHg; and Tbr≈34-37°C. SR is congruous with the emerging field of complexity science in the modeling of dynamical physiological systems, especially during pathophysiological states. The SR model of TBI is generalizable to known physical laws. This increase in entropy reduces uncertainty and improves predictive capacity. SR is an appropriate computational framework to enable future smart monitoring devices.

Complexity and indeterminism of evidence-based public health: an analytical framework

Improving the evidence in public health is an important goal for the health promotion community. With better evidence, health professionals can make better decisions to achieve effectiveness in their interventions. The relative failure of such evidence in public health is well-known, and it is due to several factors. Briefly, from an epistemological point of view, it is not easy to develop evidence-based public health because public health interventions are highly complex and indeterminate. This paper proposes an analytical explanation of the complexity and indeterminacy of public health interventions in terms of 12 points. Public health interventions are considered as a causal chain constituted by three elements (intervention, risk factor, and disease) and two levels of evaluation (risk factor and disease). Public health interventions thus differ from clinical interventions, which comprise two causal elements and one level of evaluation. From the two levels of evaluation, we suggest a classification of evidence into four typologies: evidence of both relations; evidence of the second (disease) but not of the first (risk factor) relation; evidence of the first but not of the second relation; and no evidence of either relation. In addition, a grading of indeterminacy of public health interventions is introduced. This theoretical point of view could be useful for public health professionals to better define and classify the public health interventions before acting.

Applying complexity theory: a review to inform evaluation design

Complexity theory has increasingly been discussed and applied within evaluation literature over the past decade. This article reviews the discussion and use of complexity theory within academic journal literature. The aim is to identify the issues to be considered when applying complexity theory to evaluation. Reviewing 46 articles, two groups of themes are identified. The first group considers implications of applying complexity theory concepts for defining evaluation purpose, scope and units of analysis. The second group of themes consider methodology and method. Results provide a starting point for a configuration of an evaluation approach consistent with complexity theory, whilst also identifying a number of design considerations to be resolved within evaluation planning.

Changing our lens: seeing the chaos of professional practice as complexity

AIM

The purpose of this evidence-based management practice project was to analyse dimensions of the Getting my Work Done issue, the only one of seven issues of highest concern for which 907 nurse interviewees were unable to identify effective strategies, formulate a 'best management practice', integrate the practice into clinical settings and evaluate results. METHOD/PROCESS: The evidence-based management practice process was used to identify the major impediment to Getting Work Done-assignment to multiple patients with simultaneous complex needs. Best management practice consisted of class presentation of a clinical-management problem scenario to 144 residents in nine Magnet hospitals, a private action commitment, class discussion and terminal action commitments.

RESULTS

Responses indicated that this 'best management practice' was effective in helping newly licensed registered nurses manage and handle multiple patients with simultaneous complex needs. A major avenue of resolution was perception of professional practice responsibilities as a series of complex, interrelated, adaptive systems. CONCLUSIONS/IMPLICATIONS FOR NURSING MANAGEMENT: Perception and use of the principles of complexity science assists newly licensed registered nurses in mastering management dilemmas that inhibit professional practice. In many participating hospitals, plans are underway to expand this best practice to include input and perception exchange among experienced nurses, managers and physicians.

Reviewing the ketamine model for schizophrenia

The observation that antagonists of the N-methyl-D-aspartate receptor (NMDAR), such as phencyclidine (PCP) and ketamine, transiently induce symptoms of acute schizophrenia had led to a paradigm shift from dopaminergic to glutamatergic dysfunction in pharmacological models of schizophrenia. The glutamate hypothesis can explain negative and cognitive symptoms of schizophrenia better than the dopamine hypothesis, and has the potential to explain dopamine dysfunction itself. The pharmacological and psychomimetic effects of ketamine, which is safer for human subjects than phencyclidine, are herein reviewed. Ketamine binds to a variety of receptors, but principally acts at the NMDAR, and convergent genetic and molecular evidence point to NMDAR hypofunction in schizophrenia. Furthermore, NMDAR hypofunction can explain connectional and oscillatory abnormalities in schizophrenia in terms of both weakened excitation of inhibitory γ-aminobutyric acidergic (GABAergic) interneurons that synchronize cortical networks and disinhibition of principal cells. Individuals with prenatal NMDAR aberrations might experience the onset of schizophrenia towards the completion of synaptic pruning in adolescence, when network connectivity drops below a critical value. We conclude that ketamine challenge is useful for studying the positive, negative, and cognitive symptoms, dopaminergic and GABAergic dysfunction, age of onset, functional dysconnectivity, and abnormal cortical oscillations observed in acute schizophrenia.

Exploring why quality circles work in primary health care: a realist review protocol

BACKGROUND

Quality circles (QCs) are commonly used in primary health care in Europe to consider and improve standard practice over time. They represent a complex social intervention that occurs within the fast-changing system of primary health care. Numerous controlled trials, reviews, and studies have shown small but unpredictable positive effect sizes on behavior change. Although QCs seem to be effective, stakeholders have difficulty understanding how the results are achieved and in generalizing the results with confidence. They also lack understanding of the active components of QCs which result in changes in the behavior of health care professionals. This protocol for a realist synthesis will examine how configurations of components and the contextual features of QCs influence their performance.

METHODS/DESIGN

Stakeholder interviews and a scoping search revealed the processes of QCs and helped to describe their core components and underlying theories. After clarifying their historical and geographical distribution, a purposive and systematic search was developed to identify relevant papers to answer the research questions, which are: understanding why, how, and when QCs work, over what time frame, and in what circumstances. After selecting and abstracting appropriate data, configurations of contexts and mechanisms which influence the outcome of QCs within each study will be identified. Studies will be grouped by similar propositional statements in order to identify patterns and validation from stakeholders sought. Finally, theories will be explored in order to explain these patterns and to help stakeholders maintain and improve QC performance.

DISCUSSION

Analyzing context-mechanism-outcome (CMO) patterns will reveal how QCs work and how contextual factors interact to influence their outcome. The aim is to investigate unique configurations that enable them to improve the performance of health care professionals. Using a standardized reporting system, this realist review will allow the research questions to be answered to the satisfaction of key stakeholders and enable on-going critical examination and dissemination of the findings.

STUDY REGISTRATION

PROSPERO registration number: CRD42013004826.

Reducing health inequities: the contribution of core public health services in BC

BACKGROUND

Within Canada, many public health leaders have long identified the importance of improving the health of all Canadians especially those who face social and economic disadvantages. Future improvements in population health will be achieved by promoting health equity through action on the social determinants of health. Many Canadian documents, endorsed by government and public health leaders, describe commitments to improving overall health and promoting health equity. Public health has an important role to play in strengthening action on the social determinants and promoting health equity. Currently, public health services in British Columbia are being reorganized and there is a unique opportunity to study the application of an equity lens in public health and the contribution of public health to reducing health inequities. Where applicable, we have chosen mental health promotion, prevention of mental disorders and harms of substance use as exemplars within which to examine specific application of an equity lens.

METHODS/DESIGN

This research protocol is informed by three theoretical perspectives: complex adaptive systems, critical social justice, and intersectionality. In this program of research, there are four inter-related research projects with an emphasis on both integrated and end of grant knowledge translation. Within an overarching collaborative and participatory approach to research, we use a multiple comparative case study research design and are incorporating multiple methods such as discourse analysis, situational analysis, social network analysis, concept mapping and grounded theory.

DISCUSSION

An important aim of this work is to help ensure a strong public health system that supports public health providers to have the knowledge, skills, tools and resources to undertake the promotion of health equity. This research will contribute to increasing the effectiveness and contributions of public health in reducing unfair and inequitable differences in health among population groups. As a collaborative effort between public health practitioners/decision makers and university researchers, this research will provide important understanding and insights about the implementation of the changes in public health with a specific focus on health equity, the promotion of mental health and the prevention of harms of substance use.

Nurse leaders' experiences of implementing regulatory changes in sexual health nursing practice in British Columbia, Canada

Most research about regulatory policy change concerning expanded nursing activities has emphasized advanced practice roles and acute care settings. This study is a contribution to the small pool of research concerned with regulatory policy implementation for nurses undertaking expanded nursing practice activities in a public health context. Using the regulatory changes in certified nursing practice in one Canadian province as our starting point, we investigated the experiences of nurse leaders in implementing this change. Using a qualitative interpretive descriptive approach informed by tenets of complexity theory, we examined the experiences of 16 nurse leaders as situated within the larger public health care system in which nurses practice. Two interrelated themes, (a) preparing for certification and (b) the certification process, were identified to illustrate how competing and contrasting demands between health care and regulatory organizations created substantial barriers to policy change. Implications for health service delivery and future research are discussed.

Healthcare improvement as planned system change or complex responsive processes? a longitudinal case study in general practice

BACKGROUND

Interest in how to implement evidence-based practices into routine health care has never been greater. Primary care faces challenges in managing the increasing burden of chronic disease in an ageing population. Reliable prescriptions for translating knowledge into practice, however, remain elusive, despite intense research and publication activity. This study seeks to explore this dilemma in general practice by challenging the current way of thinking about healthcare improvement and asking what can be learned by looking at change through a complexity lens.

METHODS

This paper reports the local level of an embedded case study of organisational change for better chronic illness care over more than a decade. We used interviews, document review and direct observation to explore how improved chronic illness care developed in one practice. This formed a critical case to compare, using pattern matching logic, to the common prescription for local implementation of best evidence and a rival explanation drawn from complexity sciences interpreted through modern sociology and psychology.

RESULTS

The practice changed continuously over more than a decade to deliver better chronic illness care in line with research findings and policy initiatives--re-designing care processes, developing community linkages, supporting patient self-management, using guidelines and clinical information systems, and integrating nurses into the practice team. None of these improvements was designed and implemented according to an explicit plan in response to a documented gap in chronic disease care. The process that led to high quality chronic illness care exhibited clear complexity elements of co-evolution, non-linearity, self-organisation, emergence and edge of chaos dynamics in a network of agents and relationships where a stable yet evolving way of organizing emerged from local level communicative interaction, power relating and values based choices.

CONCLUSIONS

The current discourse of implementation science as planned system change did not match organisational reality in this critical case of improvement in general practice. Complexity concepts translated in human terms as complex responsive processes of relating fit the pattern of change more accurately. They do not provide just another fashionable blueprint for change but inform how researchers, policymakers and providers participate in improving healthcare.

Designing a theory-informed, contextually appropriate intervention strategy to improve delivery of paediatric services in Kenyan hospitals

BACKGROUND

District hospital services in Kenya and many low-income countries should deliver proven, effective interventions that could substantially reduce child and newborn mortality. However such services are often of poor quality. Researchers have therefore been challenged to identify intervention strategies that go beyond addressing knowledge, skill, or resource inadequacies to support health systems to deliver better services at scale. An effort to develop a system-oriented intervention tailored to local needs and context and drawing on theory is described.

METHODS

An intervention was designed to improve district hospital services for children based on four main strategies: a reflective process to distill root causes for the observed problems with service delivery; developing a set of possible intervention approaches to address these problems; a search of literature for theory that provided the most appropriate basis for intervention design; and repeatedly moving backwards and forwards between identified causes, proposed interventions, identified theory, and knowledge of the existing context to develop an overarching intervention that seemed feasible and likely to be acceptable and potentially sustainable.

RESULTS AND DISCUSSION

In addition to human and resource constraints key problems included failures of relevant professionals to take responsibility for or ownership of the challenge of pediatric service delivery; inadequately prepared, poorly supported leaders of service units (mid-level managers) who are often professionally and geographically isolated and an almost complete lack of useful information for routinely monitoring or understanding service delivery practice or outcomes. A system-oriented intervention recognizing the pivotal role of leaders of service units but addressing the outer and inner setting of hospitals was designed to help shape and support an appropriate role for these professionals. It aims to foster a sense of ownership while providing the necessary understanding, knowledge, and skills for mid-level managers to work effectively with senior managers and frontline staff to improve services. The intervention will include development of an information system, feedback mechanisms, and discussion fora that promote positive change. The vehicle for such an intervention is a collaborative network partnering government and national professional associations. This case is presented to promote discussion on approaches to developing context appropriate interventions particularly in international health.

Thinking through health capacity development for Fragile States

The purpose of this paper is to consider capacity development for healthcare in Fragile States and its roles, for example, in securing civil and political stability, as well as improved health, within the various contexts prevailing in fragile settings across the world. As a precursor to this, however, it is important to understand how, in rapidly changing environments, the role and contribution of different donors will have an impact in different ways. This paper sets out to interpret these issues, and what becomes apparent is the need to develop an understanding of the value base of donors, which we demonstrate through the development of a value-based framework. This highlights the separate motivations and choices made by donors, but what is apparent is that all remain within the positivist perspective perhaps for reasons of accountability and transparency. However, the emergence of new interpretations drawing on systems thinking, and followed by complexity theory more recently, in understanding contexts, suggests that the favouring of any one of these perspective can be counterproductive, without a consideration of the contexts in which they occur. In seeking an explanation of these environmental contexts, which also address the perspectives in use, we suggest the use of wider multi-ontology sense-making framework such as Cynefin. Through this approach, analytical insights can be given into the interpretation, decision and intervention processes available in these different and often changing environments, thus enabling greater coherence between donor values and recipient contexts.

Fair and just or just fair? Examining models of government--not-for-profit engagement under the Australian Social Inclusion Agenda

This paper explores the interrelationship between two contemporary policy debates: one focused on the social determinants of health and the other on social (inclusion) policy within contemporary welfare regimes. In both debates, academics and policy makers alike are grappling with the balance between universal and targeted policy initiatives and the role of local 'delivery' organizations in promoting health and social equality. In this paper, we discuss these debates in the context of a recent social policy initiative in Australia: the Social Inclusion Agenda. We examine two proposed models of engagement between the government and the not-for-profit welfare sector for the delivery of social services. We conclude that the two models of engagement currently under consideration by the Australian government have substantially different outcomes for the health of disadvantaged communities and the creation of a more socially inclusive Australia.

Heavy tailed distributions of effect sizes in systematic reviews of complex interventions

BACKGROUND

Systematic reviews of complex interventions commonly find heterogeneity of effect sizes among similar interventions which cannot be explained. Commentators have suggested that complex interventions should be viewed as interventions in complex systems. We hypothesised that if this is the case, the distribution of effect sizes from complex interventions should be heavy tailed, as in other complex systems. Thus, apparent heterogeneity may be a feature of the complex systems in which such interventions operate.

METHODOLOGY/PRINCIPAL FINDINGS

We specified three levels of complexity and identified systematic reviews which reported effect sizes of healthcare interventions at two of these levels (interventions to change professional practice and personal interventions to help smoking cessation). These were compared with each other and with simulated data representing the lowest level of complexity. Effect size data were rescaled across reviews at each level using log-normal parameters and pooled. Distributions were plotted and fitted against the inverse power law (Pareto) and stretched exponential (Weibull) distributions, heavy tailed distributions which are commonly reported in the literature, using maximum likelihood fitting. The dataset included 155 studies of interventions to change practice and 98 studies of helping smoking cessation. Both distributions showed a heavy tailed distribution which fitted best to the inverse power law for practice interventions (exponent = 3.9, loglikelihood = -35.3) and to the stretched exponential for smoking cessation (loglikelihood = -75.2). Bootstrap sensitivity analysis to adjust for possible publication bias against weak results did not diminish the goodness of fit.

CONCLUSIONS/SIGNIFICANCE

The distribution of effect sizes from complex interventions includes heavy tails as typically seen in both theoretical and empirical complex systems. This is in keeping with the idea of complex interventions as interventions in complex systems.

The current status of diabetes professional educational standards and competencies in the UK--a position statement from the Diabetes UK Healthcare Professional Education Competency Framework Task and Finish Group

Diabetes is a significant health concern, both in the UK and globally. Management can be complex, often requiring high levels of knowledge and skills in order to provide high-quality and safe care. The provision of good, safe, quality care lies within the foundations of healthcare education, continuing professional development and evidence-based practice, which are inseparable and part of a continuum during the career of any health professional. Sound education provides the launch pad for effective clinical management and positive patient experiences. This position paper reviews and discusses work undertaken by a Working Group under the auspices of Diabetes UK with the remit of considering all health professional educational issues for people delivering care to people with diabetes. This work has scoped the availability of education for those within the healthcare system who may directly or indirectly encounter people with diabetes and reviews alignment to existing competency frameworks within the UK's National Health Service.

Making sense in a complex landscape: how the Cynefin Framework from Complex Adaptive Systems Theory can inform health promotion practice

Health promotion addresses issues from the simple (with well-known cause/effect links) to the highly complex (webs and loops of cause/effect with unpredictable, emergent properties). Yet there is no conceptual framework within its theory base to help identify approaches appropriate to the level of complexity. The default approach favours reductionism--the assumption that reducing a system to its parts will inform whole system behaviour. Such an approach can yield useful knowledge, yet is inadequate where issues have multiple interacting causes, such as social determinants of health. To address complex issues, there is a need for a conceptual framework that helps choose action that is appropriate to context. This paper presents the Cynefin Framework, informed by complexity science--the study of Complex Adaptive Systems (CAS). It introduces key CAS concepts and reviews the emergence and implications of 'complex' approaches within health promotion. It explains the framework and its use with examples from contemporary practice, and sets it within the context of related bodies of health promotion theory. The Cynefin Framework, especially when used as a sense-making tool, can help practitioners understand the complexity of issues, identify appropriate strategies and avoid the pitfalls of applying reductionist approaches to complex situations. The urgency to address critical issues such as climate change and the social determinants of health calls for us to engage with complexity science. The Cynefin Framework helps practitioners make the shift, and enables those already engaged in complex approaches to communicate the value and meaning of their work in a system that privileges reductionist approaches.

Characterization of early partial seizure onset: frequency, complexity and entropy

OBJECTIVE

A clear classification of partial seizures onset features is not yet established. Complexity and entropy have been very widely used to describe dynamical systems, but a systematic evaluation of these measures to characterize partial seizures has never been performed.

METHODS

Eighteen different measures including power in frequency bands up to 300 Hz, Gabor atom density (GAD), Higuchi fractal dimension (HFD), Lempel-Ziv complexity, Shannon entropy, sample entropy, and permutation entropy, were selected to test sensitivity to partial seizure onset. Intracranial recordings from 45 patients with mesial temporal, neocortical temporal and neocortical extratemporal seizure foci were included (331 partial seizures).

RESULTS

GAD, Lempel-Ziv complexity, HFD, high frequency activity, and sample entropy were the most reliable measures to assess early seizure onset.

CONCLUSIONS

Increases in complexity and occurrence of high-frequency components appear to be commonly associated with early stages of partial seizure evolution from all regions. The type of measure (frequency-based, complexity or entropy) does not predict the efficiency of the method to detect seizure onset.

SIGNIFICANCE

Differences between measures such as GAD and HFD highlight the multimodal nature of partial seizure onsets. Improved methods for early seizure detection may be achieved from a better understanding of these underlying dynamics.

Understanding pathways for scaling up health services through the lens of complex adaptive systems

Despite increased prominence and funding of global health initiatives, efforts to scale up health services in developing countries are falling short of the expectations of the Millennium Development Goals. Arguing that the dominant assumptions for scaling up are inadequate, we propose that interpreting change in health systems through the lens of complex adaptive systems (CAS) provides better models of pathways for scaling up. Based on an understanding of CAS behaviours, we describe how phenomena such as path dependence, feedback loops, scale-free networks, emergent behaviour and phase transitions can uncover relevant lessons for the design and implementation of health policy and programmes in the context of scaling up health services. The implications include paying more attention to local context, incentives and institutions, as well as anticipating certain types of unintended consequences that can undermine scaling up efforts, and developing and implementing programmes that engage key actors through transparent use of data for ongoing problem-solving and adaptation. We propose that future efforts to scale up should adapt and apply the models and methodologies which have been used in other fields that study CAS, yet are underused in public health. This can help policy makers, planners, implementers and researchers to explore different and innovative approaches for reaching populations in need with effective, equitable and efficient health services. The old assumptions have led to disappointed expectations about how to scale up health services, and offer little insight on how to scale up effective interventions in the future. The alternative perspectives offered by CAS may better reflect the complex and changing nature of health systems, and create new opportunities for understanding and scaling up health services.

A multifaceted intervention to implement guidelines and improve admission paediatric care in Kenyan district hospitals: a cluster randomised trial

BACKGROUND

In developing countries referral of severely ill children from primary care to district hospitals is common, but hospital care is often of poor quality. However, strategies to change multiple paediatric care practices in rural hospitals have rarely been evaluated.

METHODS AND FINDINGS

This cluster randomized trial was conducted in eight rural Kenyan district hospitals, four of which were randomly assigned to a full intervention aimed at improving quality of clinical care (evidence-based guidelines, training, job aides, local facilitation, supervision, and face-to-face feedback; n  =  4) and the remaining four to control intervention (guidelines, didactic training, job aides, and written feedback; n  =  4). Prespecified structure, process, and outcome indicators were measured at baseline and during three and five 6-monthly surveys in control and intervention hospitals, respectively. Primary outcomes were process of care measures, assessed at 18 months postbaseline. In both groups performance improved from baseline. Completion of admission assessment tasks was higher in intervention sites at 18 months (mean  =  0.94 versus 0.65, adjusted difference 0.54 [95% confidence interval 0.05-0.29]). Uptake of guideline recommended therapeutic practices was also higher within intervention hospitals: adoption of once daily gentamicin (89.2% versus 74.4%; 17.1% [8.04%-26.1%]); loading dose quinine (91.9% versus 66.7%, 26.3% [-3.66% to 56.3%]); and adequate prescriptions of intravenous fluids for severe dehydration (67.2% versus 40.6%; 29.9% [10.9%-48.9%]). The proportion of children receiving inappropriate doses of drugs in intervention hospitals was lower (quinine dose >40 mg/kg/day; 1.0% versus 7.5%; -6.5% [-12.9% to 0.20%]), and inadequate gentamicin dose (2.2% versus 9.0%; -6.8% [-11.9% to -1.6%]).

CONCLUSIONS

Specific efforts are needed to improve hospital care in developing countries. A full, multifaceted intervention was associated with greater changes in practice spanning multiple, high mortality conditions in rural Kenyan hospitals than a partial intervention, providing one model for bridging the evidence to practice gap and improving admission care in similar settings.

Complejidad: una introducción

Las ciencias de la complejidad aparecen en el siglo XX como una forma de entender muchos fenómenos que se perciben caóticos, predecibles y complejos desde la forma del pensamiento clásico y que todavía perduran en nuestra forma de explicar el mundo. Su objeto es estudiar los sistemas adaptativos complejos que son sensibles a las condiciones iniciales e impredecibles a futuro. Algunas de las características del pensamiento complejo son la mirada sistémica, la autopoiesis, la autorganización, las propiedades emergentes, la interconectividad, la impredecibilidad de los sistemas, el pensamiento analógico, la complementariedad de los fenómenos, entre otros. Los sistemas vivos responden a una lógica compleja, y en ese sentido, nuestra visión de las poblaciones humanas y de los pacientes, y la forma como intentamos resolver los problemas y enfermedades humanas deberían estar abiertas a las posibilidades que emergen de esta forma de entender el mundo y que requerimos para iluminar nuestro entorno.

Viewpoint: Economic evaluation of package of care interventions employing clinical guidelines

Increasingly attention is shifting towards delivering essential packages of care, often based on clinical practice guidelines, as a means to improve maternal, child and newborn survival in low-income settings. Cost effectiveness analysis (CEA), allied to the evaluation of less complex intervention, has become an increasingly important tool for priority setting. Arguably such analyses should be extended to inform decisions around the deployment of more complex interventions. In the discussion, we illustrate some of the challenges facing the extension of CEA to this area. We suggest that there are both practical and methodological challenges to overcome when conducting economic evaluation for packages of care interventions that incorporate clinical guidelines. Some might be overcome by developing specific guidance on approaches, for example clarity in identifying relevant costs. Some require consensus on methods. The greatest challenge, however, lies in how to incorporate, as measures of effectiveness, process measures of service quality. Questions on which measures to use, how multiple measures might be combined, how improvements in one area might be compared with those in another and what value is associated with improvement in health worker practices are yet to be answered.

Trans-biopolitics: Complexity in interspecies relations

This article introduces the concept of trans-biopolitics to account for complexity in the intermingling of animal and human bodies, with particular attention to diseases capable of crossing the species divide from animals to humans. While zoonotic diseases never disappeared, they had re-emerged as pressing concerns by the 21st century. The concept of trans-biopolitics takes into account the power relations inherent in human and nonhuman lives in contemporary global, industrial, and technological formations. More specifically, trans-biopolitics revolves around practices determining whose lives are possible or legitimate to prolong, whose bodies are sacrificed in order to preserve the vitality of other bodies, and whose bodies are sustained yet ultimately rendered insignificant. To illustrate, we examine connections between bovine spongiform encephalopathy and feline spongiform encephalopathy, to show how certain bodies (humans, livestock) are taken into consideration in terms of health and food regulations, whereas other bodies (pets) remain at the periphery. Acknowledging human—animal relations in contemporary technological and global contexts challenges us to rethink ways in which the politics of health continues to evolve.

Fractals for physicians

There is increasing interest in the study of fractals in medicine. In this review, we provide an overview of fractals, of techniques available to describe fractals in physiological data, and we propose some reasons why a physician might benefit from an understanding of fractals and fractal analysis, with an emphasis on paediatric respiratory medicine where possible. Among these reasons are the ubiquity of fractal organisation in nature and in the body, and how changes in this organisation over the lifespan provide insight into development and senescence. Fractal properties have also been shown to be altered in disease and even to predict the risk of worsening of disease. Finally, implications of a fractal organisation include robustness to errors during development, ability to adapt to surroundings, and the restoration of such organisation as targets for intervention and treatment.

When policy meets the personal: general practice nurses in Australia

OBJECTIVE

A significant focus of current health policy in Australia is to expand both the number and role of general practice nurses. Multiple new payment incentives have been instituted to encourage the use of practice nurses. This study explored the way these policies have framed their work.

METHODS

Multimethod research using observation, workspace photographs and interviews with nurses, doctors and managers collected through rapid appraisal in 25 practices in two states, followed by case studies of the role of nurses in seven practices over one year.

RESULTS

Many respondents reported unanticipated benefits in general practice functioning and teamwork as a result of employing a nurse, though this had not been a policy aim. Within funding constraints, nurses created new roles and manipulated old roles to fit their personal understanding of patient care. Policy initiatives targeting practice nurses are often based around tasks and system issues, rather than the personal creation of care and quality that patients require and nurses seek. Incentives in this study were targeted at both the uptake of nurses and specific nursing activities.

CONCLUSION

Policy development and funding structures would benefit from better understanding of nurses as agents of connectivity (rather than simply as performers of tasks) as well as the nature of teamwork in practices.