Complex adaptive systems: a new approach for understanding health practices

Health literacy, governance and systems leadership contribute to the implementation of the One Health approach: a virtuous circle

One Health is an important approach to addressing health threats and promoting health through interdisciplinary health, policy, legislation and leadership research to achieve better human and animal health and better outcomes for the planet. The Covid-19 pandemic has triggered an urgent awareness of the need to develop innovative integrative solutions to address root causes of such threats to health, which requires collaboration across disciplines and amongst different sectors and communities. We explore how achieving the Quadripartite Organizations' One Health Joint Plan of Action can be supported by the concepts of 'One Health literacy' and 'One Health governance' and promote both academic and policy dialogue. We show how One Health literacy and One Health governance influence and reinforce each other, while an interdisciplinary systems leadership approach acts as a catalyst and mechanism for understanding and enacting change. Based on our understanding of how these elements influence the implementation of the One Health approach, we describe a model for considering how external triggering events such as the Covid-19 pandemic may prompt a virtuous circle whereby exposure to and exploration of One Health issues may lead to improved One Health literacy and to better governance. We close with recommendations to international organisations, national governments and to leaders in policy, research and practice to enhance their influence on society, the planetary environment, health and well-being.

Multimodal neuroimaging correlates of physical-cognitive covariation in Chilean adolescents. The Cogni-Action Project

Health-related behaviours have been related to brain structural features. In developing settings, such as Latin America, high social inequality has been inversely associated with several health-related behaviours affecting brain development. Understanding the relationship between health behaviours and brain structure in such settings is particularly important during adolescence when critical habits are acquired and ingrained. In this cross-sectional study, we carry out a multimodal analysis identifying a brain region associated with health-related behaviours (i.e., adiposity, fitness, sleep problems and others) and cognitive/academic performance, independent of socioeconomic status in a large sample of Chilean adolescents. Our findings suggest that the relationship between health behaviours and cognitive/academic performance involves a particular brain phenotype that could play a mediator role. These findings fill a significant gap in the literature, which has largely focused on developed countries and raise the possibility of promoting healthy behaviours in adolescence as a means to influence brain structure and thereby cognitive/academic achievement, independently of socioeconomic factors. By highlighting the potential impact on brain structure and cognitive/academic achievement, policymakers could design interventions that are more effective in reducing health disparities in developing countries.

Informal health sector and routine immunization: making the case for harnessing the potentials of patent medicine vendors for the big catch-up to reduce zero-dose children in sub-Saharan Africa

The COVID-19 pandemic caused a surge in the number of unimmunized and under-immunized children in Africa. The majority of unimmunized (or zero-dose) children live in hard-to-reach rural areas, urban slums, and communities affected by conflict where health facilities are usually unavailable or difficult to access. In these settings, people mostly rely on the informal health sector for essential health services. Therefore, to reduce zero-dose children, it is critical to expand immunization services beyond health facilities to the informal health sector to meet the immunization needs of children in underserved places. In this perspective article, we propose a framework for the expansion of immunization services through the informal health sector as one of the pillars for the big catch-up plan to improve coverage and equity. In African countries like Nigeria, Ethiopia, Tanzania, and the Democratic Republic of Congo, patent medicine vendors serve as an important informal health sector provider group, and thus, they can be engaged to provide immunization services. A hub-and-spoke model can be used to integrate patent medicine vendors into the immunization system. A hub-and-spoke model is a framework for organization design where services that are provided by a central facility (hub) are complimented by secondary sites (spokes) to optimize access to care. Systems thinking approach should guide the design, implementation, and evaluation of this model.

Attractor landscapes: a unifying conceptual model for understanding behaviour change across scales of observation

Models and theories in behaviour change science are not in short supply, but they almost exclusively pertain to a particular facet of behaviour, such as automaticity or reasoned action, or to a single scale of observation such as individuals or communities. We present a highly generalisable conceptual model which is widely used in complex systems research from biology to physics, in an accessible form to behavioural scientists. The proposed model of attractor landscapes can be used to understand human behaviour change on different levels, from individuals to dyads, groups and societies. We use the model as a tool to present neglected ideas in contemporary behaviour change science, such as hysteresis and nonlinearity. The model of attractor landscapes can deepen understanding of well-known features of behaviour change (research), including short-livedness of intervention effects, problematicity of focusing on behavioural initiation while neglecting behavioural maintenance, continuum and stage models of behaviour change understood within a single accommodating framework, and the concept of resilience. We also demonstrate potential methods of analysis and outline avenues for future research.

How to enable healthier and more sustainable food practices in collective meal contexts: A scoping review

Collective meal contexts such as restaurants, cafeterias and canteens can help accelerate transitions to healthier and more sustainable diets. However, evidence from intervention studies on these contexts lacks integration. This scoping review aimed to map determinants of dietary change in collective meal contexts across multiple settings, interventions, target groups, and target behaviors. The review provided two main outcomes: (i) identifying intervention components to promote dietary change in collective meal contexts, based on the existing body of evidence; and (ii) classifying and integrating these intervention components into an overarching framework of behavior change (i.e., COM-B system). The review encompassed twenty-eight databases via two indexing services and extracted information from 232 primary sources (27,458 records selected for title and abstract screening, 574 articles selected for full-text screening). We identified a total of 653 intervention activities, which were classified into intervention components and grouped under three broad themes, namely contextual and environmental changes, social influence, and knowledge and behavioral regulation. Multi-component interventions tended to report overall positive outcomes. The review proposes several directions for future research, including: (i) moving toward more theory-based interventions in collective meal contexts; (ii) providing more detailed information about intervention settings, implementation, target groups, activities, and materials; and (iii) improving the use of open science practices in the field. Furthermore, the review offers a free, original, open-access list and synthesis of 277 intervention studies in collective meal contexts, which can help intervention planners and evaluators optimize their efforts to promote healthier and more sustainable food practices in these contexts.

Implementing a cirrhosis order set in a tertiary healthcare system: a theory-informed formative evaluation

BACKGROUND

Standardized order sets are a means of increasing adherence to clinical practice guidelines and improving the quality of patient care. Implementation of novel quality improvement initiatives like order sets can be challenging. Before the COVID-19 pandemic, we conducted a formative evaluation to understand healthcare providers' perspectives on implementing clinical changes and the individual, collective and organizational contextual factors that might impact implementation at eight hospital sites in Alberta, Canada.

METHODS

We utilized concepts from the Consolidated Framework for Implementation Research (CFIR) and Normalisation Process Theory (NPT) to understand the context, past implementation experiences, and perceptions of the cirrhosis order set. Eight focus groups were held with healthcare professionals caring for patients with cirrhosis. Data were coded deductively using relevant constructs of NPT and CFIR. A total of 54 healthcare professionals, including physicians, nurses, nurse practitioners, social workers and pharmacists and a physiotherapist, participated in the focus groups.

RESULTS

Key findings revealed that participants recognized the value of the cirrhosis order set and its potential to improve the quality of care. Participants highlighted potential implementation challenges, including multiple competing quality improvement initiatives, feelings of burnout, lack of communication between healthcare provider groups, and a lack of dedicated resources to support implementation.

CONCLUSIONS

Implementing a complex improvement initiative across clinician groups and acute care sites presents challenges. This work yielded insights into the significant influence of past implementation of similar interventions and highlighted the importance of communication between clinician groups and resources to support implementation. However, by using multiple theoretical lenses to illuminate what and how contextual and social processes will influence uptake, we can better anticipate challenges during the implementation process.

Yoga and pain: A mind-body complex system

Introduction

The human body's response to pain is indicative of a complex adaptive system. Therapeutic yoga potentially represents a similar complex adaptive system that could interact with the pain response system with unique benefits.

Objectives

To determine the viability of yoga as a therapy for pain and whether pain responses and/or yoga practice should be considered complex adaptive systems.

Methods

Examination through 3 different approaches, including a narrative overview of the evidence on pain responses, yoga, and complex system, followed by a network analysis of associated keywords, followed by a mapping of the functional components of complex systems, pain response, and yoga.

Results

The narrative overview provided extensive evidence of the unique efficacy of yoga as a pain therapy, as well as articulating the relevance of applying complex systems perspectives to pain and yoga interventions. The network analysis demonstrated patterns connecting pain and yoga, while complex systems topics were the most extensively connected to the studies as a whole.

Conclusion

All three approaches support considering yoga a complex adaptive system that exhibits unique benefits as a pain management system. These findings have implications for treating chronic, pervasive pain with behavioral medicine as a systemic intervention. Approaching yoga as complex system suggests the need for research of mind-body topics that focuses on long-term systemic changes rather than short-term isolated effects.

A National Study of Patient Safety Culture and Patient Safety Goal in Chinese Hospitals

OBJECTIVES

This study aimed to measure the patient safety culture and the current practice of patient safety goals in China.

METHODS

This cross-sectional survey was conducted between November 2020 and November 2021. The 12-dimensions Hospital Survey on Patient Safety Culture questionnaire and the 14-items Survey on the Current Practice of Patient Safety Goal questionnaire were electronically distributed to 8164 healthcare providers across 26 provinces in China. Data were analyzed using descriptive statistics, correlation analysis, and multivariate linear regression.

RESULTS

A total of 8164 surveys were received, of which 7765 were valid and analyzed. The average positive response rate for the Hospital Survey on Patient Safety Culture survey was 69.68% (43.41%-91.54%). The percentage of positive responses in 5 dimensions (organizational learning, teamwork within units, feedback about error, management support for safety, and teamwork across units) was above the control limits, and 3 (nonpunitive response to error, staffing, and frequency of event reporting) were below the control limits. The average positive response rate for the Survey on the Current Practice of Patient Safety Goal survey was 96.11%. Patient safety culture was positively related to the current practice of patient safety goals ( r = 0.34, P < 0.001).

CONCLUSIONS

Our study concludes that although healthcare providers in China feel positively toward patient safety culture and practicably toward patient safety goals, considerable work is still needed to promote a patient safety movement.

Implementation and Practice Barriers of Family-Centered Care Encountered by Neonatal Nurses

BACKGROUND

Approximately 7 out of every 100 births in the United States result in admission to the neonatal intensive care unit (NICU), which contributes to a delay in initial physical contact between the parents and their newborn. While family-centered care (FCC) increases opportunities for parent-infant connection, implementation barriers persist in clinical practice. Research has yet to examine whether organizational and nursing factors of empowerment and compassion fatigue (CF) in the NICU are associated with FCC practice.

PURPOSE

The aim of this study was to determine the relationship between empowerment, CF, and FCC practices among NICU nurses.

METHODS

This quantitative portion of a mixed-methods study used a cross-sectional, descriptive correlational design. Bedside NICU nurses with at least 6-month experience were recruited to complete an anonymous online survey using established, valid, and reliable instruments.

RESULTS

Except for organizations with Magnet status, there were no significant differences in FCC practice within individual and institutional characteristics. Hierarchical linear regression model indicated nurse empowerment was a strong predictor of FCC practice (β= 0.31, R2 = 0.35, P < .001). There was only a weak, inverse association between CF and FCC practices ( r =-0.199, P < .001).

IMPLICATION FOR RESEARCH AND PRACTICE

Further qualitative research will integrate these findings to understand the process by which neonatal nurses engage in FCC practices in the context of NICU setting. Future studies should examine facilitators and barriers of FCC practice in the NICU. Strategies (eg, policies and trainings) to increase nurse empowerment and support for FCC implementation should be developed and evaluated.

Healthcare professionals' experiences and attitudes to care coordination across health sectors: an interview study

Background

The number of older people is increasing, resulting in more people endure chronic diseases, multimorbidities and complex care needs. Insufficient care coordination across healthcare sectors has negative consequences for health outcomes, costs and patient evaluation. Despite introducing initiatives to solve coordination challenges within healthcare, the need remains for more consistent solutions. In particular, improved care coordination would benefit older adults characterised by complex care needs, high use of healthcare resources and multiple care providers.

Aims and objectives

To identify and analyse healthcare professionals’ perspectives and approaches to care coordination across sectors when older people are acutely hospitalised.

Design

Qualitative interview study.

Methods

Semi-structured, individual interviews with 13 healthcare professionals across health sectors and professions were conducted. The strategy for the qualitative analysis was inspired by Kirsti Malterud and labelled ‘systematic text condensation’. This strategy is a descriptive and explorative method for thematic cross-case analysis of qualitative data.

Results

Four themes/categories emerged from the analysis; “Organisational factors”, “Approaches to care”, “Communication and knowledge”, and “Relations”.

Conclusion

Different organisational cultures can discourage intersectoral care coordination. Approaches to care vary at all levels across health sectors and professions. Organisational, leadership and professional identity affect the working cultures and must be considered in the future recruitment and socialisation of healthcare staff. Our research suggests that combinations of healthcare standardisations and flexible, adaptive solutions are required to improve intersectoral care coordination.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03200-6.

The future of burn care from a complexity science perspective

Healthcare is undergoing a profound technological and digital transformation and has become increasingly complex. It is important for burns professionals and researchers to adapt to these developments which may require new ways of thinking and subsequent new strategies. As Einstein has put it: 'We must learn to see the world anew'. The relatively new scientific discipline "Complexity science" can give more direction to this and is the metaphorical open door that should not go unnoticed in view of the burn care of the future. Complexity sciences studies 'why the whole is more than the sum of the parts'. It studies how multiple separate components interact with each other and their environment and how these interactions lead to 'behavior of the system'. Biological systems are always part of smaller and larger systems and exhibit the behavior of adaptivity, hence the name complex adaptive systems. From the perspective of complexity science, a severe burn injury is an extreme disruption of the 'human body system'. But this disruption also applies to the systems at the organ and cellular level. All these systems follow principles of complex systems. Awareness of the scaling process at multilevel helps to understand and manage the complex situation when dealing with severe burn cases. The aim of this paper is to create awareness of the concept of complexity and to demonstrate the value and possibilities of complexity science methods and tools for the future of burn care through examples from preclinical, clinical, and organizational perspective in burn care.

Striving for autonomy in everyday diabetes self-management-qualitative exploration via grounded theory approach

OBJECTIVES

The rapid worldwide increase in the incidence of diabetes significantly influences the lives of individuals, families and communities. Diabetes self-management requires personal autonomy and the presence of a supportive social environment. These attributes can considerably ameliorate the outcomes of the chronic condition. However, little is known about individual variations in overcoming the illness-related challenges and in the achievement of autonomy in daily activities. This paper seeks to bridge this knowledge gap.

DESIGN

This qualitative study used the grounded theory approach. Semi-structured interviews were conducted, and the data collection and data analysis probed participant experiences of autonomy through the self-management of their daily socio-physical environments.

SETTING

Participants were recruited from the outpatient ward of a university clinic in Hungary.

PARTICIPANTS

The study was conducted with 26 adult patients with type 2 diabetes mellitus (15 females and 11 males aged between 26 and 80 years; M=62.6 years; SD=13.1). The inclusion criteria were: T2D diagnosis at least 1 year before the beginning of the study; prescribed insulin injection therapy; aged over 18 years; native Hungarian speaker and not diagnosed with dementia or any form of cognitive impairment.

RESULTS

The study established three principal aspects of the active construction of personal autonomy in diabetes self-management: coping strategies vis-à-vis threats posed by the symptoms and the treatment of the disease; autonomous ways of creating protective space and time and relationship processes that support everyday experiences of self-directedness.

CONCLUSIONS

The results of this study confirm the validity of the self-determination theory in diabetes self-management. They also imply that pathways towards constructing everyday experiences of self-directedness in participants lead through self-acceptance, supporting family relationships and a doctor-patient relationship characterised by partnership. The tentative empirical model of pathways towards patients' experience of self-directedness can serve as a framework for future research, patient-centred clinical practice, and education.

Behavioral Sciences in the Optimization of Pharmacological and Non-Pharmacological Therapy for Type 2 Diabetes

Type 2 diabetes mellitus is one of the main chronic diseases worldwide, with a significant impact on public health. Behavioral changes are an important step in disease prevention and management, so the way in which individuals adapt their lifestyle to new circumstances will undoubtedly be a predictor of the success of the treatments instituted, contributing to a reduction in the morbidity and mortality that may be associated with them. It is essential to prepare and educate all diabetic patients on the importance of changing behavioral patterns in relation to the disease, with health professionals assuming an extremely important role in this area, both from a pharmacological and non-pharmacological point of view, and also ensuring the monitoring of the progress of these measures. Diabetes is a chronic disease that requires a high self-management capacity on the part of patients in order to achieve success in treating the disease, and non-adherence to therapy or non-compliance with the previously defined plan, together with an erratic lifestyle, will contribute to failure in controlling the disease. The lower adherence to pharmacological and non-pharmacological treatment in diabetes is mainly correlated to socio-economic aspects, lower health literacy, the side effects associated with the use of antidiabetic therapy or even the concomitant use of several drugs. This article consists of a narrative review that aims to synthesize the findings published in the literature, retrieved by searching databases, manuals, previously published scientific articles and official texts, following the methodology of the Scale for Assessment of Narrative Review Articles (SANRA). We aim to address the importance of behavioral sciences in the treatment of diabetes, in order to assess behavior factors and barriers for behavior changes that have an impact on the therapeutic and non-therapeutic optimization in patients with type 2 diabetes mellitus control.

Imagining maternity care as a complex adaptive system: understanding health system constraints to the promotion of respectful maternity care

Evidence of the health system challenges to promoting respectful maternity care (RMC) is limited in Ethiopia and globally. This study investigated the health system constraints to RMC in three Southern Ethiopian hospitals. We conducted a qualitative study (7 focus group discussions (FGDs) with providers of RMC and 12 in-depth interviews with focal persons and managers) before and after the implementation of an RMC intervention. We positioned childbirth services within the health system and applied complex adaptive system theory to analyse the opportunities and constraints to the promotion of RMC. Both system “hardware” and “software” factors influencing the promotion of RMC were identified, and their interaction was complex. The “hardware” factors included bed availability, infrastructure and supplies, financing, and health workforce. “Software” factors encompassed service providers’ mindset, staff motivation, and awareness of RMC. Interactions between these factors included privacy breaches for women when birth companions were admitted in labour rooms. Delayed reimbursement following the introduction of fee-exemption for maternity services resulted in depleted revenues, supply shortages, and ultimately disrespectful behaviour among providers. Other financial constraints, including the insufficient and delayed release of funds, also led to complex interactions with the motivation of staff and the availability of workforce and supplies, resulting in poor adherence to RMC guidance. Interventions aimed at improving only behavioural components fall short of mitigating the mistreatment of women. System-wide interventions are required to address the complex interactions that constraint RMC.

Studying Behaviour Change Mechanisms under Complexity

Understanding the mechanisms underlying the effects of behaviour change interventions is vital for accumulating valid scientific evidence, and useful to informing practice and policy-making across multiple domains. Traditional approaches to such evaluations have applied study designs and statistical models, which implicitly assume that change is linear, constant and caused by independent influences on behaviour (such as behaviour change techniques). This article illustrates limitations of these standard tools, and considers the benefits of adopting a complex adaptive systems approach to behaviour change research. It (1) outlines the complexity of behaviours and behaviour change interventions; (2) introduces readers to some key features of complex systems and how these relate to human behaviour change; and (3) provides suggestions for how researchers can better account for implications of complexity in analysing change mechanisms. We focus on three common features of complex systems (i.e., interconnectedness, non-ergodicity and non-linearity), and introduce Recurrence Analysis, a method for non-linear time series analysis which is able to quantify complex dynamics. The supplemental website provides exemplifying code and data for practical analysis applications. The complex adaptive systems approach can complement traditional investigations by opening up novel avenues for understanding and theorising about the dynamics of behaviour change.

Feeling Valued and Adding Value: A Participatory Action Research Project on Co-creating Practices of Social Inclusion in Kindergartens and Communities

Background: Contemporary public health problems connect to the social determinants of health, with a growing recognition of social inclusion as imperative to sustainable development. In this quest for social inclusion, early childhood and families are of particular interest. Although co-creation is suggested as viable path to support well-being, less is known how social inclusion might be co-created in practice. The aim of this study was to explore how Participatory Action Research (PAR) can be a tool for transformative practices in a local community, pointing to kindergartens as meeting places for recognizing social inclusion as a common value in early childhood. Methods: A qualitative PAR study was embedded in a Norwegian municipality as an integrated part of their local public health work. The study involved a wide range of participants and stakeholders in three kindergartens and the wider community. Together, we explored potentials for co-creating social inclusion to achieve well-being through cycles of transformative actions and reflections. Reflexive thematic analysis was applied to generate patterns and themes in the data. Results: The participants formulated and took on ownership to an inclusive agenda through the PAR-process. Acts of inclusion was framed by an intersection between political aims of achieving health and well-being for all and public value co-creation unfolding at the level of the place, in the context of the Norwegian welfare regime. To feel valued and adding value was seen as important aspects for social inclusion. Four themes were generated from analysis; (1) Co-creating a shared vision of inclusive communities, (2) Becoming aware and empowered through caring, sharing and collaboration, (3) Places and spaces of inclusiveness in kindergartens and beyond, and (4) Valuing and practicing inclusion, and signs of transformative change. Conclusions: Through the PAR process, parents, kindergartens employees, community members and policy makers appear to have opened a creative toolbox for inclusive and transformational change through formulating and co-creating inclusion and well-being as public values. The results suggest that local actors might support adaptive social systems to taking on relational responsibility for inclusive processes and outcomes in the pursuit of well-being for all.

Agile Innovation to transform healthcare: innovating in complex adaptive systems is an everyday process, not a light bulb event

Innovation is essential to transform healthcare delivery systems, but in complex adaptive systems innovation is more than ‘light bulb events’ of inspired creativity. To achieve true innovation, organisations must adopt a disciplined, customer-centred process. We developed the process of Agile Innovation as an approach any complex adaptive organisation can adopt to achieve rapid, systematic, customer-centred development and testing of innovative interventions. Agile Innovation incorporates insights from design thinking, Agile project management, and complexity and behavioural sciences. It was refined through experiments in diverse healthcare organisations. The eight steps of Agile Innovation are: (1) confirm demand; (2) study the problem; (3) scan for solutions; (4) plan for evaluation and termination; (5) ideate and select; (6) run innovation development sprints; (7) validate solutions; and (8) package for launch. In addition to describing each of these steps, we discuss examples of and challenges to using Agile Innovation. We contend that once Agile Innovation is mastered, healthcare delivery organisations can habituate it as the go-to approach to projects, thus incorporating innovation into how things are done, rather than treating innovation as a light bulb event.

Applying a complex adaptive systems approach to the evaluation of a school-based intervention for intimate partner violence prevention in Mexico

Despite calls for evaluation practice to take a complex systems approach, there are few examples of how to incorporate complexity into real-life evaluations. This article presents the case for using a complex systems approach to evaluate a school-based intimate partner violence-prevention intervention. We conducted a post hoc analysis of qualitative evaluation data to examine the intervention as a potential system disruptor. We analysed data in relation to complexity concepts particularly relevant to schools: 'diverse and dynamic agents', 'interaction', 'unpredictability', 'emergence' and 'context dependency'. The data-two focus groups with facilitators and 33 repeat interviews with 14-17-year-old students-came from an evaluation of a comprehensive sexuality education intervention in Mexico City, which serves as a case study for this analysis. The findings demonstrate an application of complex adaptive systems concepts to qualitative evaluation data. We provide examples of how this approach can shed light on the ways in which interpersonal interactions, group dynamics, the core messages of the course and context influenced the implementation and outcomes of this intervention. This gender-transformative intervention appeared to disrupt pervasive gender norms and reshape beliefs about how to engage in relationships. An intervention comprises multiple dynamic and interacting elements, all of which are unlikely to be consistent across implementation settings. Applying complexity concepts to our analysis added value by helping reframe implementation-related data to focus on how the 'social' aspects of complexity influenced the intervention. Without examining both individual and group processes, evaluations may miss key insights about how the intervention generates change, for whom, and how it interacts with its context. A social complex adaptive systems approach is well-suited to the evaluation of gender-transformative interventions and can help identify how such interventions disrupt the complex social systems in which they are implemented to address intractable societal problems.