Complex Systems Approaches to Understand Drivers of Mental Health and Inform Mental Health Policy: A Systematic Review

Scaling Interventions to Manage Chronic Disease: Innovative Methods at the Intersection of Health Policy Research and Implementation Science

Policy implementation is a key component of scaling effective chronic disease prevention and management interventions. Policy can support scale-up by mandating or incentivizing intervention adoption, but enacting a policy is only the first step. Fully implementing a policy designed to facilitate implementation of health interventions often requires a range of accompanying implementation structures, like health IT systems, and implementation strategies, like training. Decision makers need to know what policies can support intervention adoption and how to implement those policies, but to date research on policy implementation is limited and innovative methodological approaches are needed. In December 2021, the Johns Hopkins ALACRITY Center for Health and Longevity in Mental Illness and the Johns Hopkins Center for Mental Health and Addiction Policy convened a forum of research experts to discuss approaches for studying policy implementation. In this report, we summarize the ideas that came out of the forum. First, we describe a motivating example focused on an Affordable Care Act Medicaid health home waiver policy used by some US states to support scale-up of an evidence-based integrated care model shown in clinical trials to improve cardiovascular care for people with serious mental illness. Second, we define key policy implementation components including structures, strategies, and outcomes. Third, we provide an overview of descriptive, predictive and associational, and causal approaches that can be used to study policy implementation. We conclude with discussion of priorities for methodological innovations in policy implementation research, with three key areas identified by forum experts: effect modification methods for making causal inferences about how policies' effects on outcomes vary based on implementation structures/strategies; causal mediation approaches for studying policy implementation mechanisms; and characterizing uncertainty in systems science models. We conclude with discussion of overarching methods considerations for studying policy implementation, including measurement of policy implementation, strategies for studying the role of context in policy implementation, and the importance of considering when establishing causality is the goal of policy implementation research.

Systems Thinking and Complexity Science Methods and the Policy Process in Non-communicable Disease Prevention: A Systematic Scoping Review

BACKGROUND

Given the complex determinants of non-communicable diseases (NCDs), and the dynamic policy landscape, researchers and policymakers are exploring the use of systems thinking and complexity science (STCS) in developing effective policies. The aim of this review is to systematically identify and analyse existing applications of STCS-informed methods in NCD prevention policy.

METHODS

Systematic scoping review: We searched academic databases (Medline, Scopus, Web of Science, EMBASE) for all publications indexed by 13 October 2020, screening titles, abstracts and full texts and extracting data according to published guidelines. We summarised key data from each study, mapping applications of methods informed by STCS to policy process domains. We conducted a thematic analysis to identify advantages, limitations, barriers and facilitators to using STCS.

RESULTS

4681 papers were screened and 112 papers were included in this review. The most common policy areas were tobacco control, obesity prevention and physical activity promotion. Methods applied included system dynamics modelling, agent-based modelling and concept mapping. Advantages included supporting evidence-informed decision-making; modelling complex systems and addressing multi-sectoral problems. Limitations included the abstraction of reality by STCS methods, despite aims of encompassing greater complexity. Challenges included resource-intensiveness; lack of stakeholder trust in models; and results that were too complex to be comprehensible to stakeholders. Ensuring stakeholder ownership and presenting findings in a user-friendly way facilitated STCS use.

CONCLUSION

This review maps the proliferating applications of STCS methods in NCD prevention policy. STCS methods have the potential to generate tailored and dynamic evidence, adding robustness to evidence-informed policymaking, but must be accessible to policy stakeholders and have strong stakeholder ownership to build consensus and change stakeholder perspectives. Evaluations of whether, and under what circumstances, STCS methods lead to more effective policies compared to conventional methods are lacking, and would enable more targeted and constructive use of these methods.

Advancing socioecological mental health promotion intervention: A mixed methods exploration of Phase 1 Agenda Gap findings

Introduction

Protecting and promoting the mental health of youth under 30 years of age is a priority, globally. Yet investment in mental health promotion, which seeks to strengthen the determinants of positive mental health and wellbeing, remains limited relative to prevention, treatment, and recovery. The aim of this paper is to contribute empirical evidence to guide innovation in youth mental health promotion, detailing the early outcomes of Agenda Gap, an intervention centering youth-led policy advocacy to influence positive mental health for individuals, families, communities and society.

Methods

Leveraging a convergent mixed methods design, this study draws on data from n = 18 youth (ages 15 to 17) in British Columbia, Canada, who contributed to pre- and post-intervention surveys and post-intervention qualitative interviews following their participation in Agenda Gap from 2020-2021. These data are supplemented by qualitative interviews with n = 4 policy and other adult allies. Quantitative and qualitative data were analyzed in parallel, using descriptive statistics and reflexive thematic analysis, and then merged for interpretation.

Results

Quantitative findings suggest Agenda Gap contributes to improvements in mental health promotion literacy as well as several core positive mental health constructs, such as peer and adult attachment and critical consciousness. However, these findings also point to the need for further scale development, as many of the available measures lack sensitivity to change and are unable to distinguish between higher and lower levels of the underlying construct. Qualitative findings provided nuanced insights into the shifts that resulted from Agenda Gap at the individual, family, and community level, including reconceptualization of mental health, expanded social awareness and agency, and increased capacity for influencing systems change to promote positive mental health and wellbeing.

Discussion

Together, these findings illustrate the promise and utility of mental health promotion for generating positive mental health impacts across socioecological domains. Using Agenda Gap as an exemplar, this study underscores that mental health promotion programming can contribute to gains in positive mental health for individual intervention participants whilst also enhancing collective capacity to advance mental health and equity, particularly through policy advocacy and responsive action on the social and structural determinants of mental health.

Discrete-Event Simulation Modeling in Healthcare: A Comprehensive Review

Discrete-event simulation (DES) is a stochastic modeling approach widely used to address dynamic and complex systems, such as healthcare. In this review, academic databases were systematically searched to identify 231 papers focused on DES modeling in healthcare. These studies were sorted by year, approach, healthcare setting, outcome, provenance, and software use. Among the surveys, conceptual/theoretical studies, reviews, and case studies, it was found that almost two-thirds of the theoretical articles discuss models that include DES along with other analytical techniques, such as optimization and lean/six sigma, and one-third of the applications were carried out in more than one healthcare setting, with emergency departments being the most popular. Moreover, half of the applications seek to improve time- and efficiency-related metrics, and one-third of all papers use hybrid models. Finally, the most popular DES software is Arena and Simul8. Overall, there is an increasing trend towards using DES in healthcare to address issues at an operational level, yet less than 10% of DES applications present actual implementations following the modeling stage. Thus, future research should focus on the implementation of the models to assess their impact on healthcare processes, patients, and, possibly, their clinical value. Other areas are DES studies that emphasize their methodological formulation, as well as the development of frameworks for hybrid models.

Impactos do avanço da pandemia de COVID-19 na saúde mental de profissionais de saúde

O estudou verificou a associação e influência entre variáveis sociodemográficas, laborais, impactos da pandemia (desesperança, contaminação, óbito na família), traços de personalidade e de saúde mental em profissionais de saúde brasileiros em dois tempos distintos da pandemia de Covid-19. Foram incluídos 155 profissionais que responderam questionário online. Foi utilizado o modelo de redes para a análise dos dados. Os sintomas de depressão, ansiedade e estresse foram os mais influentes no modelo testado e apresentaram associações com a desesperança nos dois tempos. No tempo 1, o estigma foi uma das variáveis mais influentes. No tempo 2, o estigma e a ansiedade reduziram sua influência, enquanto o estresse e a desesperança tornaram-se mais influentes. Os alvos das intervenções para os profissionais de saúde podem ser diferenciados no início e no avanço do contexto pandêmico, mas cabe contínua focalização do estresse e da desesperança.

Using complex systems mapping to build a strategic public health response to mental health in England

Purpose

This paper aims to use systems mapping as a tool to develop an organisation-wide approach to public mental health to inform strategic direction within a national public health agency.

Design/methodology/approach

Two workshops were facilitated with internal staff from a wide range of public health policy teams working in small groups to produce paper-based maps. These were collated and refined by the project team and digitised.

Findings

The approach engaged a range of teams in forming a shared understanding and producing a complex system map of the influences on population mental health and well-being, where current policy initiatives were addressing them and what the gaps and priorities were. Participants valued the approach which led to further study and organisational commitment to the whole system working as part of national public mental health strategy.

Research limitations/implications

The approach was limited to internal stakeholders and wider engagement with other sectors and community members would help further the application of complex system approaches to public mental health.

Originality/value

It was a valuable process for developing a whole-organisation approach and stimulating thinking and practice in complex system approaches. The paper provides a practical example of how to apply systems mapping and its benefits for organising public mental health practice.

Systems thinking and complexity science methods and the policy process in non-communicable disease prevention: a systematic scoping review protocol

INTRODUCTION

Given the complex causal origins of many non-communicable diseases (NCDs), and the complex landscapes in which policies designed to tackle them are made and unfold, the need for systems thinking and complexity science (STCS) in developing effective policy solutions has been emphasised. While numerous methods informed by STCS have been applied to the policy process in NCD prevention, these applications have not been systematically catalogued. The aim of this scoping review is to identify existing applications of methods informed by STCS to the policy process for NCD prevention, documenting which domains of the policy process they have been applied to.

METHODS AND ANALYSIS

A systematic scoping review methodology will be used.

IDENTIFICATION

We will search Medline, SCOPUS, Embase and Web of Science using search terms combining STCS, NCD prevention and the policy process. All records published in English will be eligible for inclusion, regardless of study design.

SELECTION

We will screen titles and abstracts and extract data according to published guidelines for scoping reviews. In order to determine the quality of the included studies, we will use the approach developed by Dixon-Woods et al, excluding studies identified as fatally flawed, and determining the credibility and contribution of included studies.

SYNTHESIS

We will identify relevant studies, summarising key data from each study and mapping applications of methods informed by STCS to different parts of the policy process. Review findings will provide a useful reference for policy-makers, outlining which domains of the policy process different methods have been applied to.

ETHICS AND DISSEMINATION

Formal ethical approval is not required, as the study does not involve primary data collection. The findings of this study will be disseminated through a peer-reviewed publication, presentations and summaries for key stakeholders.

Scaling up evidence-based treatments in youth behavioral healthcare: Social work licensing influences on task-shifting opportunities

Youth behavioral healthcare workforce shortages have inhibited the scale-up of evidence-based treatments to address longstanding unmet needs andinequitable service coverage. Task-shifting is a strategy that could bolster workforce shortages. Legal and regulatory barriers, such as scope of practice licensing regulations, have hampered the use of task-shifting. Social workers make up the majority of the behavioral healthcare workforce in the U.S. and most social workers provide services to children and families. As such, social workers would play a pivotal role in any scale-up effort. In this guest editorial, we discuss the importance of social work licensing and use a case example to illustrate the unintended consequences that certain licensing regulations have on scaling-up evidence-based treatments via task-shifting. We conclude with recommendations on how social workers could be involved in taskshifting efforts to scale-up evidence-based treatments.

Leveraging Complex Systems Science to Advance Sexual and Gender Minority Youth Health Research and Equity

Over the past two decades, sexual and gender minority (SGM) youth health inequities have remained the same or widened, highlighting the need for new approaches to foster health equity. Complex systems science (CSS) techniques must be added to our armamentarium because of the following: CSS techniques can model cyclical feedback loops inherent in the relationships between SGM youth health outcomes and their multilevel causes, thereby enhancing the integration of real-world complexity in scientific models; and CSS can simulate multiple hypothetical interventions, thereby identifying future interventions with great potential impact. We describe four promising CSS techniques for advancing SGM youth health equity.

Public transit and depression among older adults: using agent-based models to examine plausible impacts of a free bus policy

BACKGROUND

Daily transport is associated with mental health. A free bus policy (FBP) may be effective in promoting the use of public transit in older adults and be associated with reductions in depressive symptoms.

METHODS

We developed an agent-based model and grounded it using empirical data from England to examine the impact of an FBP on public transit use and depression among older adults. We also used the model to explore whether the impact of the FBP bus use and depression is modified by the type of income segregation or by simultaneous efforts to improve attitudes towards the bus, to reduce waiting times or to increase the cost of driving via parking fees or fuel price.

RESULTS

Our model suggests that improving attitudes towards the bus (eg, campaigns that promote bus use) could enhance the effect of the FBP, especially for those in proximity to public transit. Reducing wait times could also significantly magnify FPB impacts, especially in those who live in proximity to public transit. Contrary to expectation, neither fuel costs nor parking fees significantly enhanced the impact of the FBP. The impact of improving attitudes towards the bus and increasing bus frequency was more pronounced in the lower-income groups in an income segregation scenario in which destination and public transit are denser in the city centre.

CONCLUSION

Our results suggest that the beneficial mental health effects of an FBP for older adults can be magnified when combined with initiatives that reduce bus waiting times and increased spatial access to transit.

The SIPHER Consortium: Introducing the new UK hub for systems science in public health and health economic research

The conditions in which we are born, grow, live, work and age are key drivers of health and inequalities in life chances. To maximise health and wellbeing across the whole population, we need well-coordinated action across government sectors, in areas including economic, education, welfare, labour market and housing policy. Current research struggles to offer effective decision support on the cross-sector strategic alignment of policies, and to generate evidence that gives budget holders the confidence to change the way major investment decisions are made. This open letter introduces a new research initiative in this space. The SIPHER ( Systems Science in Public Health and Health Economics Research) Consortium brings together a multi-disciplinary group of scientists from across six universities, three government partners at local, regional and national level, and ten practice partner organisations. The Consortium’s vision is a shift from health policy to healthy public policy, where the wellbeing impacts of policies are a core consideration across government sectors. Researchers and policy makers will jointly tackle fundamental questions about: a) the complex causal relationships between upstream policies and wellbeing, economic and equality outcomes; b) the multi-sectoral appraisal of costs and benefits of alternative investment options; c) public values and preferences for different outcomes, and how necessary trade-offs can be negotiated; and d) creating the conditions for intelligence-led adaptive policy design that maximises progress against economic, social and health goals. Whilst our methods will be adaptable across policy topics and jurisdictions, we will initially focus on four policy areas: Inclusive Economic Growth, Adverse Childhood Experiences, Mental Wellbeing and Housing.

Depression and alcohol misuse among older adults: exploring mechanisms and policy impacts using agent-based modelling

PURPOSE

To: (1) explore how multi-level factors impact the longitudinal prevalence of depression and alcohol misuse among urban older adults (≥ 65 years), and (2) simulate the impact of alcohol taxation policies and targeted interventions that increase social connectedness among excessive drinkers, socially isolated and depressed older adults; both alone and in combination.

METHODS

An agent-based model was developed to explore the temporal co-evolution of depression and alcohol misuse prevalence among older adults nested in a spatial network. The model was based on Los Angeles and calibrated longitudinally using data from the Multi-Ethnic Study of Atherosclerosis.

RESULTS

Interventions with a social component targeting depressed and socially isolated older adults appeared more effective in curbing depression prevalence than those focused on excessive drinkers. Targeting had similar impacts on alcohol misuse, though the effects were marginal compared to those on depression. Alcohol taxation alone had little impact on either depression or alcohol misuse trajectories.

CONCLUSIONS

Interventions that improve social connectedness may reduce the prevalence of depression among older adults. Targeting considerations could play an important role in determining the success of such efforts.