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Matheson A, Wehipeihana N, Gray R, Walton M, Uia T, Lindberg K, Shanthakumar M, Lopez MI, Reidy J, Firestone R, Ellison-Loschmann L. Building a systems-thinking community workforce to scale action on determinants of health in New Zealand. Health Place 2024; 87:103255. [PMID: 38710122 DOI: 10.1016/j.healthplace.2024.103255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 04/17/2024] [Accepted: 04/23/2024] [Indexed: 05/08/2024]
Abstract
This article describes findings from the evaluation of Healthy Families NZ (HFNZ), an equity-driven, place-based community health initiative. Implemented in nine diverse communities across New Zealand, HFNZ aims to strengthen the systems that can improve health and well-being. Findings highlight local needs and priorities including the social mechanisms important for reorienting health and policy systems towards place-based communities. Lessons encompass the importance of local lived experience in putting evidence into practice; the strength of acting with systems in mind; the need for relational, learning, intentional, and well-resourced community organisation; examples of how to foster place-based 'community-up' leadership; and how to enable responsiveness between communities and local and national policy systems. A reconceptualisation of scaling in the context of complexity and systems change is offered, which recognises that relationships and agency are key to making progress on the determinants of health.
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Affiliation(s)
- Anna Matheson
- School of Health, Te Herenga Waka - Victoria University of Wellington, Kelburn 6012, Wellington, New Zealand.
| | - Nan Wehipeihana
- Weaving Insights, PO Box 147, Levin 5540, Horowhenua, New Zealand
| | - Rebecca Gray
- School of Health, Te Herenga Waka - Victoria University of Wellington, Kelburn 6012, Wellington, New Zealand
| | - Mat Walton
- Institute of Environmental Science and Research Limited (ESR), Kenepuru Science Centre: 34 Kenepuru Drive, Kenepuru, Porirua 5022, PO Box 50348, Porirua 5240, New Zealand
| | - Tali Uia
- School of Health, Te Herenga Waka - Victoria University of Wellington, Kelburn 6012, Wellington, New Zealand
| | - Kirstin Lindberg
- Environmental Health Intelligence New Zealand, Massey University, Wallace Street, Mount Cook, Wellington 6021, New Zealand
| | - Mathu Shanthakumar
- Environmental Health Intelligence New Zealand, Massey University, Wallace Street, Mount Cook, Wellington 6021, New Zealand
| | - Maite Irurzun Lopez
- Health Services Research Centre, Te Herenga Waka, Victoria University of Wellington, Kelburn 6012, Wellington, New Zealand
| | - Johanna Reidy
- School of Health, Te Herenga Waka - Victoria University of Wellington, Kelburn 6012, Wellington, New Zealand
| | - Riz Firestone
- Centre for Hauora and Health, Massey University, Wallace Street, Mount Cook, Wellington 6021, New Zealand
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Koorts H, Ma J, Swain CTV, Rutter H, Salmon J, Bolton KA. Systems approaches to scaling up: a systematic review and narrative synthesis of evidence for physical activity and other behavioural non-communicable disease risk factors. Int J Behav Nutr Phys Act 2024; 21:32. [PMID: 38515118 PMCID: PMC10958859 DOI: 10.1186/s12966-024-01579-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 02/24/2024] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND Non-communicable diseases (NCDs) are the leading causes of death worldwide. Systems approaches have potential for creating sustainable outcomes at scale but have rarely been used to support scale up in physical activity/nutrition promotion or NCD prevention more generally. This review aimed to: (i) synthesise evidence on the use of systems approaches in scaling up interventions targeting four behavioural risk factors for NCDs; and (ii) to explore how systems approaches have been conceptualised and used in intervention implementation and scale up. METHOD Seven electronic databases were searched for studies published 2016-2021. Eligible studies targeted at least one of four NCD behavioural risk factors (physical inactivity, tobacco use, alcohol consumption, diet), or described evaluation of an intervention planned for or scaled up. Studies were categorised as having a (i) high, (ii) moderate, or (iii) no use of a systems approach. A narrative synthesis of how systems approaches had been operationalised in scale up, following PRISMA guidelines. RESULTS Twenty-one intervention studies were included. Only 19% (n = 4) of interventions explicitly used systems thinking to inform intervention design, implementation and scale up (targeting all four risk factors n = 2, diet n = 1, tobacco use n = 1). Five studies ('high use') planned and implemented scale up with an explicit focus on relations between system elements and used system changes to drive impact at scale. Seven studies ('moderate use') considered systems elements impacting scale-up processes or outcomes but did not require achieving system-level changes from the outset. Nine studies ('no use') were designed to work at multiple levels among multiple agencies in an intervention setting, but the complexity of the system and relations between system elements was not articulated. We synthesised reported barriers and facilitators to scaling up, and how studies within each group conceptualised and used systems approaches, and methods, frameworks and principles for scaling up. CONCLUSION In physical activity research, and NCD prevention more broadly, the use of systems approaches in scale up remains in its infancy. For researchers, practitioners and policymakers wishing to adopt systems approaches to intervention implementation at scale, guidance is needed on how to communicate and operationalise systems approaches in research and in practice. TRIAL REGISTRATION PROSPERO (CRD42021287265).
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Affiliation(s)
- Harriet Koorts
- School of Exercise and Nutrition Sciences, Deakin University, Institute for Physical Activity and Nutrition (IPAN), 221 Burwood Highway, Burwood Geelong, VIC, 3125, Australia.
| | - Jiani Ma
- School of Exercise and Nutrition Sciences, Deakin University, Institute for Physical Activity and Nutrition (IPAN), 221 Burwood Highway, Burwood Geelong, VIC, 3125, Australia
| | - Christopher T V Swain
- Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Australia
- Department of Physiotherapy, Faculty of Medicine Dentistry and Health Sciences, Melbourne School of Health Sciences, University of Melbourne, Melbourne, Australia
| | - Harry Rutter
- Department of Social and Policy Sciences, University of Bath, Claverton Down, Bath, UK
| | - Jo Salmon
- School of Exercise and Nutrition Sciences, Deakin University, Institute for Physical Activity and Nutrition (IPAN), 221 Burwood Highway, Burwood Geelong, VIC, 3125, Australia
| | - Kristy A Bolton
- School of Exercise and Nutrition Sciences, Deakin University, Institute for Physical Activity and Nutrition (IPAN), 221 Burwood Highway, Burwood Geelong, VIC, 3125, Australia
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Sharma KM, Jones PB, Cumming J, Middleton L. Key elements and contextual factors that influence successful implementation of large-system transformation initiatives in the New Zealand health system: a realist evaluation. BMC Health Serv Res 2024; 24:54. [PMID: 38200522 PMCID: PMC10782523 DOI: 10.1186/s12913-023-10497-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 12/19/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Despite three decades of policy initiatives to improve integration of health care, delivery of health care in New Zealand remains fragmented, and health inequities persist for Māori and other high priority populations. An evidence base is needed to increase the chances of success with implementation of large-system transformation (LST) initiatives in a complex adaptive system. METHODS This research aimed to identify key elements that support implementation of LST initiatives, and to investigate contextual factors that influence these initiatives. The realist logic of enquiry, nested within the macro framing of complex adaptive systems, formed the overall methodology for this research and involved five phases: theory gleaning from a local LST initiative, literature review, interviews, workshop, and online survey. NVivo software programme was used for thematic analysis of the interview, workshop, and the survey data. We identified key elements and explained variations in success (outcomes) by identifying mechanisms triggered by various contexts in which LST initiatives are implemented. RESULTS The research found that a set of 10 key elements need to be present in the New Zealand health system to increase chances of success with implementation of LST initiatives. These are: (i) an alliancing way of working; (ii) a commitment to te Tiriti o Waitangi; (iii) an understanding of equity; (iv) clinical leadership and involvement; (v) involved people, whānau, and community; (vi) intelligent commissioning; (vii) continuous improvement; (viii) integrated health information; (ix) analytic capability; and (x) dedicated resources and time. The research identified five contextual factors that influenced implementation of LST initiatives: a history of working together, distributed leadership from funders, the maturity of Alliances, capacity and capability for improvement, and a continuous improvement culture. The research found that the key mechanism of trust is built and nurtured over time through sharing of power by senior health leaders by practising distributed leadership, which then creates a positive history of working together and increases the maturity of Alliances. DISCUSSION Two authors (KMS and PBJ) led the development and implementation of the local LST initiative. This prior knowledge and experience provided a unique perspective to the research but also created a conflict of interest and introduced potential bias, these were managed through a wide range of data collection methods and informed consent from participants. The evidence-base for successful implementation of LST initiatives produced in this research contains knowledge and experience of senior system leaders who are often in charge of leading these initiatives. This evidence base enables decision makers to make sense of complex processes involved in the successful implementation of LST initiatives. CONCLUSIONS Use of informal trust-based networks provided a critical platform for successful implementation of LST initiatives in the New Zealand health system. Maturity of these networks relies on building and sustaining high-trust relationships among the network members. The role of local and central agencies and the government is to provide the policy settings and conditions in which trust-based networks can flourish. OTHER This study was approved by the Victoria University of Wellington Human Ethics Committee (Ethics Approval Number 27,356). The research was supported by the Victoria University of Wellington research grant (222,809) and from the University of Auckland Department of Medicine research fund (H10779).
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Affiliation(s)
- Kanchan M Sharma
- Te Tai Ōhanga- The Treasury, 1 The Terrace, 6011, Wellington, New Zealand.
| | - Peter B Jones
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, 34 Princes Street, Auckland CBD, 1010, Auckland, New Zealand
| | - Jacqueline Cumming
- Health Services Research Centre, Faculty of Health, Victoria University of Wellington, Kelburn Parade, 6012, Kelburn, Wellington, New Zealand
| | - Lesley Middleton
- Faculty of Health, Victoria University of Wellington, Kelburn Parade, 6012, Kelburn, Wellington, New Zealand
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Whelan J, Fraser P, Bolton KA, Love P, Strugnell C, Boelsen-Robinson T, Blake MR, Martin E, Allender S, Bell C. Combining systems thinking approaches and implementation science constructs within community-based prevention: a systematic review. Health Res Policy Syst 2023; 21:85. [PMID: 37641151 PMCID: PMC10463953 DOI: 10.1186/s12961-023-01023-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 06/22/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Systems science offers methods for designing population health interventions while implementation science provides specific guidance for successful implementation. Integrating systems and implementation science may strengthen implementation and enhance and sustain systemic change to achieve system-level outcomes. Little is known about the extent to which these two approaches have been integrated to date. This review aimed to identify and synthesise the peer-reviewed literature that has reported the combined use of systems thinking approaches and implementation science constructs (within the same study), to deliver population health interventions. METHODS A systematic literature search of peer-reviewed original research was conducted across six databases from 2009 to 2021. Journal manuscripts were included if they: (1) reported on a population health study conducted in a community, (2) reported the use of a systems method in the design of the intervention, and (3) used an implementation science theory, framework or model in the delivery of the intervention. Data extracted related to the specific systems methods and definitions and implementation science constructs used. The Mixed Methods Appraisal Tool (MMAT) was used to assess study quality. RESULTS Of the 9086 manuscripts returned, 320 manuscripts were included for full-text review. Of these, 17 manuscripts that reported on 14 studies were included in the final extraction. The most frequently reported systems methods were a 'whole of community systems approach' (n = 4/14) and 'community-based system dynamics' (n = 2/14). Nineteen different implementation science theories, frameworks and models were used for intervention delivery, with RE-AIM being the only framework used in more than one study. CONCLUSION There are few published peer-reviewed studies using systems thinking and implementation science for designing and delivering population health interventions. An exploration of synergies is worthwhile to operationalise alignment and improve implementation of systems thinking approaches. Review protocol registration PROSPERO CRD42021250419.
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Affiliation(s)
- Jillian Whelan
- School of Medicine, Deakin University, Geelong, Australia.
- Institute for Health Transformation, Geelong, Australia.
- Global Centre for Preventive Health and Nutrition, Geelong, Australia.
| | - Penny Fraser
- School of Health and Social Development, Deakin University, Geelong, Australia
- Institute for Health Transformation, Geelong, Australia
- Global Centre for Preventive Health and Nutrition, Geelong, Australia
| | - Kristy A Bolton
- School of Exercise and Nutrition Sciences, Deakin University, Geelong, Australia
- Institute for Health Transformation, Geelong, Australia
- Institute for Physical Activity and Nutrition, Geelong, Australia
| | - Penelope Love
- School of Exercise and Nutrition Sciences, Deakin University, Geelong, Australia
- Institute for Physical Activity and Nutrition, Geelong, Australia
| | - Claudia Strugnell
- School of Health and Social Development, Deakin University, Geelong, Australia
- Global Centre for Preventive Health and Nutrition, Geelong, Australia
- Institute for Physical Activity and Nutrition, Geelong, Australia
| | - Tara Boelsen-Robinson
- School of Health and Social Development, Deakin University, Geelong, Australia
- Institute for Health Transformation, Geelong, Australia
- Global Centre for Preventive Health and Nutrition, Geelong, Australia
| | - Miranda R Blake
- School of Health and Social Development, Deakin University, Geelong, Australia
- Institute for Health Transformation, Geelong, Australia
- Global Centre for Preventive Health and Nutrition, Geelong, Australia
| | - Erik Martin
- School of Medicine, Deakin University, Geelong, Australia
| | - Steven Allender
- School of Health and Social Development, Deakin University, Geelong, Australia
- Institute for Health Transformation, Geelong, Australia
- Global Centre for Preventive Health and Nutrition, Geelong, Australia
| | - Colin Bell
- School of Medicine, Deakin University, Geelong, Australia
- Institute for Health Transformation, Geelong, Australia
- Global Centre for Preventive Health and Nutrition, Geelong, Australia
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Nau T, Bauman A, Smith BJ, Bellew W. A scoping review of systems approaches for increasing physical activity in populations. Health Res Policy Syst 2022; 20:104. [PMID: 36175916 PMCID: PMC9524093 DOI: 10.1186/s12961-022-00906-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 09/02/2022] [Indexed: 11/27/2022] Open
Abstract
Introduction The past decade has increasingly seen systems approaches as a featured theme in public health studies and policy documents. This trend is evident in the area of physical activity, which is a significant global health risk factor that is addressed in WHO’s Global Action Plan on Physical Activity. We undertook a comprehensive scoping review to characterize the application of systems approaches to physical activity, to develop a typology of the objectives, themes and methods of research papers that purported to apply systems thinking to this issue. Methods We searched electronic databases (PubMed, Web of Science, Scopus and PsycINFO) for studies published during the period 2010–2021 that explicitly applied systems approaches or methods to investigate and/or address population physical activity. A framework using systems-based methodological approaches was adapted to classify physical activity studies according to their predominant approach, covering basic descriptive, complex analytical and advanced forms of practice. We selected case studies from retained studies to depict the current “state of the art”. Results We included 155 articles in our narrative account. Literature reporting the application of systems approaches to physical activity is skewed towards basic methods and frameworks, with most attention devoted to conceptual framing and predictive modelling. There are few well-described examples of physical activity interventions which have been planned, implemented and evaluated using a systems perspective. There is some evidence of “retrofitted” complex system framing to describe programmes and interventions which were not designed as such. Discussion We propose a classification of systems-based approaches to physical activity promotion together with an explanation of the strategies encompassed. The classification is designed to stimulate debate amongst policy-makers, practitioners and researchers to inform the further implementation and evaluation of systems approaches to physical activity. Conclusion The use of systems approaches within the field of physical activity is at an early stage of development, with a preponderance of descriptive approaches and a dearth of more complex analyses. We need to see movement towards a more sophisticated research agenda spanning the development, implementation and evaluation of systems-level interventions. Supplementary Information The online version contains supplementary material available at 10.1186/s12961-022-00906-2.
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Affiliation(s)
- Tracy Nau
- Prevention Research Collaboration, Charles Perkins Centre, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia. .,The Australian Prevention Partnership Centre, Sydney, NSW, Australia.
| | - Adrian Bauman
- Prevention Research Collaboration, Charles Perkins Centre, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,The Australian Prevention Partnership Centre, Sydney, NSW, Australia
| | - Ben J Smith
- Prevention Research Collaboration, Charles Perkins Centre, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,The Australian Prevention Partnership Centre, Sydney, NSW, Australia
| | - William Bellew
- Prevention Research Collaboration, Charles Perkins Centre, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,The Australian Prevention Partnership Centre, Sydney, NSW, Australia
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Measuring capacity to use evidence-based interventions in community-based organizations: A comprehensive, scoping review. J Clin Transl Sci 2022; 6:e92. [PMID: 36003212 PMCID: PMC9389281 DOI: 10.1017/cts.2022.426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/30/2022] [Accepted: 07/06/2022] [Indexed: 11/14/2022] Open
Abstract
Introduction: Community-based organizations (CBOs) are well-positioned to incorporate research evidence, local expertise, and contextual factors to address health inequities. However, insufficient capacity limits use of evidence-based interventions (EBIs) in these settings. Capacity-building implementation strategies are popular, but a lack of standard models and validated measures hinders progress in the field. To advance the literature, we conducted a comprehensive scoping review. Methods: With a reference librarian, we executed a comprehensive search strategy of PubMed/Medline, Web of Science Core Collection, and EBSCO Global Health. We included articles that addressed implementation science, capacity-building, and CBOs. Of 5527 articles, 99 met our inclusion criteria, and we extracted data using a double-coding process Results: Of the 99 articles, 47% defined capacity explicitly, 31% defined it indirectly, and 21% did not define it. Common concepts in definitions were skills, knowledge/expertise, and resources. Of the 57 articles with quantitative analysis, 48 (82%) measured capacity, and 11 (23%) offered psychometric data for the capacity measures. Of the 99 studies, 40% focused exclusively on populations experiencing inequities and 22% included those populations to some extent. The bulk of the studies came from high-income countries. Conclusions: Implementation scientists should 1) be explicit about models and definitions of capacity and strategies for building capacity, 2) specify expected multi-level implementation outcomes, 3) develop and use validated measures for quantitative work, and 4) integrate equity considerations into the conceptualization and measurement of capacity-building efforts. With these refinements, we can ensure that the necessary supports reach CBO practitioners and critical partners for addressing health inequities.
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Firestone R, Matheson A, Firestone J, Schleser M, Yee E, Tuisano H, Kaholokula K, Ellison-Loschmann L. Developing principles of social change as a result of a Pasifika Youth Empowerment Program: A qualitative study. Health Promot J Austr 2020; 32 Suppl 2:197-205. [PMID: 32755045 PMCID: PMC8596690 DOI: 10.1002/hpja.395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 06/07/2020] [Accepted: 07/29/2020] [Indexed: 11/11/2022] Open
Abstract
ISSUE Empowerment is a concept over-used in health promotion, yet it is an important process that can used in developing the capacity and capability of young people for creating social change to improve healthier lives. METHODS The Youth Empowerment Program (YEP), a pilot study aimed at empowering 15 youth (18-24 years) to lead healthier lives. We present secondary outcomes of the original YEP study, using focus groups and mobile-mentary approaches to capture the impact of the YEP through the youths' understanding of the program. Thematic analyses to examine the pragmatic usefulness of the empowerment program. RESULTS We identified three major themes: (aa) Knowledge: education and awareness of healthy living and understanding of the wider social health issues, compound the health complexities of obesity; (b) Youth as catalysts for change: the youth viewed themselves as agents of social change; and (c) Transformation: the youth recognised themselves as catalysts for change that can positively transform communities into action. CONCLUSION This study contributes new insights and depth of understanding about how the empowerment program can strengthen the process of individual capacity in an effort to mobilise social change for the betterment of the whole community, particularly among indigenous Pasifika population groups. SO WHAT?: Developing empowerment principles will enable others to consider "how apply" empowerment more practically when working with young people and not use it flippantly with no real action-oriented outcome.
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Affiliation(s)
- Ridvan Firestone
- Centre for Public Health Research, Massey University, Wellington, New Zealand
| | - Anna Matheson
- School of Health, Faculty of Health, Victoria University of Wellington, Wellington, New Zealand
| | - Justice Firestone
- Centre for Public Health Research, Massey University, Wellington, New Zealand
| | - Max Schleser
- Department of Film and Animation, School of Arts, Social Sciences and Humanities, Faculty of Health, Arts and Design, Swinburne University of Technology, Melbourne, Australia
| | - Emily Yee
- Centre for Public Health Research, Massey University, Wellington, New Zealand
| | - Hana Tuisano
- Centre for Public Health Research, Massey University, Wellington, New Zealand
| | - Keawe'aimoku Kaholokula
- Department of Native Hawaiian Health, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI, USA
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Matheson A. Health Inequality as a Large-Scale Outcome of Complex Social Systems: Lessons for Action on the Sustainable Development Goals. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E2684. [PMID: 32295177 PMCID: PMC7215954 DOI: 10.3390/ijerph17082684] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 03/30/2020] [Accepted: 04/09/2020] [Indexed: 11/26/2022]
Abstract
Action on the Sustainable Development Goals (SDGs) needs to become real and impactful, taking a "whole systems" perspective on levers for systems change. This article reviews what we have learned over the past century about the large-scale outcome of health inequality, and what we know about the behaviour of complex social systems. This combined knowledge provides lessons on the nature of inequality and what effective action on our big goals, like the SDGs, might look like. It argues that economic theories and positivist social theories which have dominated the last 150 years have largely excluded the nature of human connections to each other, and the environment. This exclusion of intimacy has legitimatised arguments that only value-free economic processes matter for macro human systems, and only abstract measurement constitutes valuable social science. Theories of complex systems provide an alternative perspective. One where health inequality is viewed as emergent, and causes are systemic and compounding. Action therefore needs to be intensely local, with power relationships key to transformation. This requires conscious and difficult intervention on the intolerable accumulation of resources; improved reciprocity between social groups; and reversal of system flows, which at present ebb away from the local and those already disadvantaged.
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Affiliation(s)
- Anna Matheson
- School of Health, Te Herenga Waka, Victoria University of Wellington, Wellington 6140, New Zealand;
- Te Pūnaha Matatini, Centre for Complex Systems, Auckland 1142, New Zealand
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