Complexity Theory: An Overview with Potential Applications for the Social Sciences

Uncovering Complexities in Reducing Aggression, Conflict and Restrictive Practices in Acute Mental Healthcare Settings: An Overview of Reviews

Aggression, conflict and restrictive practices present complexities in acute mental health services, as do implementing service changes to reduce them. Existing published literature needs to offer more high-level guidance on the effectiveness of these service changes and their associated implementation factors. As a result, an overview of systematic reviews was undertaken to identify (i) nonpharmacological interventions to reduce conflict, aggression and restrictive practices in acute mental health settings, and (ii) their effects across different clinical outcomes. A parallel re-extraction from primary studies was then utilised (iii) to identify factors influencing successful intervention implementation. Of 124 articles sourced from nine databases and registries, four reviews were retained for the final analysis, using the direction of effect and tabular and narrative summaries. These reviews included programmes or interventions focused on inpatient adolescent, adult and older adult populations. They reported on alternative containment strategies, risk assessments, Safewards, sensory rooms and equipment, Six Core Strategy-based interventions and staff training. The overview found that a combination of interventions intended to improve relationships and reduce interpersonal conflict may help reduce aggression, conflict and restrictive practices. At the same time, stand-alone staff training and sensory rooms and equipment may have mixed effects. The quality of the evidence linking these interventions to reductions in aggression, conflict and restrictive practices is limited. Successful implementation hinges on multiple factors: intervention characteristics, preparation and planning, evaluation and monitoring, outcome interpretation, stakeholder involvement/investment, staff-related factors and contextual factors. Any implementation initiative may benefit from using pragmatic and complexity-informed research methodologies, including integrating meaningful involvement with service users, peer workers and culturally diverse groups.

Systems archetypes to investigate the unintended consequences of telehealth in rural Australia: A systems thinking approach to telehealth evaluation and policymaking

As an alternative model of delivery to standard care, telehealth offers a promising solution to health access issues faced by rural and remote communities in Australia and worldwide. However, research typically focuses on its expected benefits and pitfalls, with little to no consideration of its unintended consequences and factors influencing its better utilisation. Drawing on systems thinking and informed by complexity science, we propose using systems archetypes-systems thinking tools - as a magnifying lens to investigate potential telehealth unintended consequences or outcomes. We conceptualise telehealth implementation in rural and remote Australia as a sociotechnical system whereby the interactions between its various agents shape telehealth implementation and, in turn, are shaped by it. When introducing new policies or interventions to any system, these interactions often lead to outcomes other than those initially planned or intended. Although systems archetypes cannot necessarily predict these outcomes, they are valuable for helping anticipate unintended, unforeseen outcomes and facilitating discussions about them to mitigate their negative impact and maximise their benefits. Outcomes are not necessarily adverse; they can also be positive. So, investigating such outcomes will minimise their negative impact and maximise their benefit. Our method was to review existing research and a selection of complexity and systems informed frameworks. Then, we assessed systems archetypes. And how they can be utilised to investigate unintended consequences. A worked example of what an unintended consequence in the implementation of telehealth in rural and remote Australia is presented.

I and thou in dialogue: Becoming more relational in couple therapy

Couple therapists have the unique and challenging opportunity of helping people find deeper connection in their intimate relationships. These clinicians apply therapeutic models and interventions designed to help couples. However, many of these models are derived from theoretical, scientific, and sociocultural traditions that conceptualize human phenomena as individualistic and reductionistic, and the language in these theories may not match clients' experiences, which include deeply relational phenomena such as love and loss. We review how Western scientific and sociocultural traditions have shaped conceptualization of problems and clinical intervention in couple therapy. In contrast, we provide an alternative, strongly relational framework for couple therapy that draws upon philosophical perspectives asserting that relational, rather than individual, experience is fundamental in human interaction. These ideas provide relational language which can influence how couple therapy is viewed and enacted. Specifically, we discuss how a strongly relational approach changes how therapists understand and intervene with conflict, abuse, love, and deception. This relational framework can help couples in their own goals to become more unified. Implications for the therapeutic relationship, interventions, and scholarship are provided.

Using network analysis to identify leverage points based on causal loop diagrams leads to false inference

Network analysis is gaining momentum as an accepted practice to identify which factors in causal loop diagrams (CLDs)-mental models that graphically represent causal relationships between a system's factors-are most likely to shift system-level behaviour, known as leverage points. This application of network analysis, employed to quantitatively identify leverage points without having to use computational modelling approaches that translate CLDs into sets of mathematical equations, has however not been duly reflected upon. We evaluate whether using commonly applied network analysis metrics to identify leverage points is justified, focusing on betweenness- and closeness centrality. First, we assess whether the metrics identify the same leverage points based on CLDs that represent the same system but differ in inferred causal structure-finding that they provide unreliable results. Second, we consider conflicts between assumptions underlying the metrics and CLDs. We recognise six conflicts suggesting that the metrics are not equipped to take key information captured in CLDs into account. In conclusion, using betweenness- and closeness centrality to identify leverage points based on CLDs is at best premature and at worst incorrect-possibly causing erroneous identification of leverage points. This is problematic as, in current practice, the results can inform policy recommendations. Other quantitative or qualitative approaches that better correspond with the system dynamics perspective must be explored.

A system science perspective on burn-out: development of an expert-based causal loop diagram

Introduction

Burn-out leads to reduced worker well-being, long-term absenteeism, and high costs for employers and society. Determinants at different levels may affect burn-out in an interrelated and dynamic manner. The aim of the present study was to apply a broader systems perspective by exploring and visualizing the complex system of determinants at different levels (living conditions, working conditions, and societal developments) underlying the prevalence of burn-out in the Netherlands.

Methods

During three group model building (GMB) sessions with in total eight experts on workers' mental health, a causal loop diagram (CLD) was developed and relevant feedback loops were identified. For the selection of determinants to be included in the CLD a recently published overview of determinants on burn-out at different levels was used. Experts could also add factors that were not listed in the overview.

Results

The final CLD consists of 20 factors and depicts a central position of working conditions. Societal developments (e.g., access to mental health care, size of the working population, rougher social climate, etc.) were mostly located at the outside of the CLD and barely integrated in feedback loops. Several reinforcing feedback loops resulting in an increase of the prevalence of burn-out were identified in which the factors (very) high workload, imbalance between work and private life, and insufficient recovery time play an important role. Also, several balancing loops were found that visualize the crucial role of functional support from supervisors to prevent burn-out among workers.

Discussion

Applying a broader systems perspective, including determinants at different levels, offers new insights into dynamic feedback loops that contribute to the prevalence of burn-out. Supervisors, amongst others, have a considerable impact on the system underlying the high prevalence of burn-out and may therefore contribute to its prevention. Even though societal developments were less integrated in feedback loops, they might be considered drivers of existing feedback loops. The results from this study confirm that determinants at various levels underly the prevalence of burn-out. To be able to address the diversity of determinants underlying a high prevalence of burn-out, a complex system approach can be helpful.

A qualitative system model to describe the causes and drivers of frequent potentially avoidable presentations to the emergency department

Frequent potentially avoidable presentations to Emergency Departments (EDs) represent a complex problem, driven by multiple interdependent and interacting factors that change over time and influence one another. We sought to describe and map the drivers of frequent potentially avoidable presentations to a regional ED, servicing regional and rural areas, and identify possible solutions from the perspectives of key stakeholders. This study used a qualitative, community-based systems dynamics approach utilising Group Model Building (GMB). Data were collected from two 3-h online workshops embedded with small-group discussions and conducted with stakeholder groups operating within a regional health system. Stakeholders were guided through a series of participatory tasks to develop a causal loop diagram (CLD) using Systems Thinking in Community Knowledge Exchange software (n=29, workshop one), identify potential action points and generate a prioritised action list to intervene in the system (n=21, workshop two). Data were collected through note taking, real-time system mapping, and recording the workshops. Each action was considered against the Public Health 12 framework describing twelve leverage points to intervene in a system. A CLD illustrating the complex and interrelated factors that drive frequent potentially avoidable ED presentations was developed and classified into four categories: (1) access to services; (2) coordination; (3) patient needs; and (4) knowledge and skills. Nine action areas were identified, with many relating to care and service coordination. Most actions aligned with lower-level system impact actions. This study provides an in-depth understanding of influencing factors and potential solutions for frequent potentially avoidable ED presentations across a regional health system. The CLD demonstrates frequent potentially avoidable ED presentations are a complex problem and identified that a prevention response should engage with system- and individual-level solutions. Further work is needed to prioritise actions to support the implementation of higher-level system impacts.

Equilibrium in the governance of cross-sectoral policies: how does it translate into practice?

BACKGROUND

There is growing interest from health researchers in the governance of Health in All Policies (HiAP). Furthermore, the COVID-19 pandemic has re-ignited managers' interest in HiAP governance and in health prevention activities that involve actors from outside health ministries. Since the dynamics of these multi-actor, multi-sectoral policies are complex, the use of systems theory is a promising avenue toward understanding and improving HiAP governance. We focus on the concept of equilibrium within systems theory, especially as it points to the need to strike a balance between actors that goes beyond synergies or mimicry-a balance that is essential to HiAP governance.

METHOD

We mobilized two sources of data to understand how the concept of equilibrium applies to HiAP governance. First, we reviewed the literature on existing frameworks for collaborative governance, both in general and for HiAP specifically, in order to extract equilibrium-related elements. Second, we conducted an in-depth case study over three years of an HiAP implemented in Quebec, Canada.

RESULTS

In total, we identified 12 equilibrium-related elements relevant to HiAP governance and related to knowledge, actors, learning, mindsets, sustainability, principles, coordination, funding and roles. The equilibria were both operational and conceptual in nature.

CONCLUSIONS

We conclude that policy makers and policy implementers could benefit from mobilizing these 12 equilibrium-related elements to enhance HiAP governance. Evaluators of HiAP may also want to consider and integrate them into their governance assessments.

Application of the evolutionary theory of behavior dynamics to severe challenging behavior

The evolutionary theory of behavior dynamics (ETBD) is a genetic algorithm that applies the Darwinian principles of evolutionary biology to model how behavior changes dynamically via selection by contingencies of reinforcement. The ETBD is a complexity theory where low-level rules of selection, reproduction, and mutation operate iteratively to animate "artificial organisms" that generate emergent outcomes. Numerous studies have demonstrated the ETBD can accurately model behavior of live animals in the laboratory, and it has been applied recently to model automatically maintained self-injury. The purpose of the current series of studies was to further extend the application of the ETBD to model additional functional classes of challenging behavior and clinical procedures. Outcomes obtained with artificial organisms generally corresponded well with outcomes observed with clinical cases sourced from consecutive controlled case series studies. Conceptual and methodological considerations on the application of the ETBD to model challenging behavior are discussed.

The lecturer-tutor in undergraduate medical education; navigating complexity as "a recruiter, a timetabler, an administrator, a counsellor"

BACKGROUND

Tutors play an important role in the delivery of effective undergraduate medical education (UGME). These roles commonly involve competing clinical, educational and research commitments. We sought to obtain a rich description of these posts from doctors working in them.

METHODS

We used a pragmatist, sequential explanatory mixed-methods design with a sampling frame of clinical lecturer/tutors in 5 Irish medical schools. Purposive sampling was used for recruitment. Quantitative data collected from a validated online questionnaire were used to inform a semi-structured interview question guide. Thematic analysis was conducted independently by each of the study researchers, using a coding frame derived in part from the findings of the online questionnaire. Quantitative and qualitative mixing occurred during data collection, analysis and reporting.

RESULTS

34 tutors completed the online survey with 7 volunteers for interview. Most respondents took the job to gain experience in either educational practice (79.4%) or in research (61.8%). Major themes to emerge were the diverse interactions with students, balancing multiple professional commitments, a high degree of role-autonomy, mis-perception of role by non-tutor colleagues, challenges around work-life balance and unpredictable work demands. Using a complexity theory lens, the tutor role was defined by its relational interactions with numerous stakeholders, all in the context of an environment that changed regularly and in an unpredictable manner.

CONCLUSIONS

The undergraduate tutor works in a demanding role balancing educational and non-educational commitments with suboptimal senior guidance and feedback. The role is notable for its position within a complex adaptive system. An understanding of the system's interactions recognises the non-linearity of the role. Using a complex systems lens, we propose improvements to undergraduate education centred around the tutor.

Applying complexity theory perspective to knowledge management in the innovation context

Purpose

Interdependence on the global economy and rapid technological changes raised the degree of uncertainty and complexity, leading to innovation challenges. Innovation depends on knowledge, and the solution might rest on how sound firms manage it, particularly in emerging markets such as India. The purpose of this paper is to examine how firms implement knowledge management (KM) in highly innovation-oriented firms (biotechnology and pharmaceuticals) and the factors affecting its implementation by examining knowledge interactions between individuals.

Design/methodology/approach

This study consists of a systematic literature review, a case study with embedded units and the use of grounded theory to analyse the data. The factors emerging from the results were examined from an individual and organisational lens. Next, complexity theory (CT) was used to understand the impact of these factors in KM by facilitating its incorporation as a system.

Findings

The findings of this paper suggest that constant technology adoption increases human-to-technology interaction, higher circulation of existing knowledge and more controlled environments, discouraging individuals from learning or sharing knowledge. From a system perspective, results of this paper suggest that firms self-organise around technology, indicating that innovation decreases as knowledge creation and sharing tend to reduce with lesser social interactions. This study shows the usefulness of using CT in analysing KM for innovation. The performance of the system is analysed based on its constituents and interactions.

Originality/value

This study contributes to advancing CT in KM in the context of innovation in highly knowledge-intensive firms, as few studies were found in the literature.

Use of qualitative systems mapping and causal loop diagrams to understand food environments, diet and obesity: a scoping review protocol

INTRODUCTION

Food systems can shape dietary behaviour and obesity outcomes in complex ways. Qualitative systems mapping using causal loop diagrams (CLDs) can depict how people understand the complex dynamics, inter-relationships and feedback characteristic of food systems in ways that can support policy planning and action. To date, there has been no attempt to review this literature. The objectives of this review are to scope the extent and nature of studies using qualitative systems mapping to facilitate the development of CLDs by stakeholders to understand food environments, including settings and populations represented, key findings and the methodological processes employed. It also seeks to identify gaps in knowledge and implications for policy and practice.

METHODS AND ANALYSIS

This protocol describes a scoping review guided by the Joanna Briggs Institute manual, the framework by Khalil and colleagues and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist reporting guidelines. A search strategy was iteratively developed with two academic librarians and the research team. This strategy will be used to search six databases, including Ovid MEDLINE, Embase, EmCare, Web of Science, Scopus and ProQuest Central. Identified citations will be screened by two independent reviewers; first, by title and abstract, and then full-text articles to identify papers eligible for inclusion. The reference lists of included studies and relevant systematic reviews will be searched to identify other papers eligible for inclusion. Two reviewers will extract information from all included studies and summarise the findings descriptively and numerically.

ETHICS AND DISSEMINATION

The scoping review will provide an overview of how CLDs developed by stakeholders have been elicited to understand food environments, diet and obesity, the insights gained and how the CLDs have been used. It will also highlight gaps in knowledge and implications for policy and practice. The review will be disseminated through publication in an academic journal and conference presentations.

Theory of brain complexity and marital behaviors: The application of complexity science and neuroscience to explain the complexities of marital behaviors

The extant theories on the quality and stability of marital relationships have some difficulties in explaining some of the complexities of marital behaviors. The present article is an initial attempt to explain the complexities of marital behaviors based on the science of complexity and neuroscience. This article proposes a new theoretical framework relying on this simple argument that marital behaviors, as one of the most complex human behaviors, are the product of one's brain's complex adaptive system (CAS). Hence, to understand the complexities of marital behaviors, a movement toward familiarity with the brain's CAS involved in marital behaviors needs to be started. The article presents the theory of brain complexity and marital behaviors (BCM) and outlines its assumptions, concepts, and propositions. Then, BCM is compared with the extant theories on happy and stable marriage, and finally, it was concluded by discussing the testability and the potential application of the theory. This article might inspire interdisciplinary studies of marital relationships, complex systems, and neuroscience and may have considerable practical implications.

Tingbjerg Changing Diabetes: experiencing and navigating complexity in a community-based health promotion initiative in a disadvantaged neighbourhood in Copenhagen, Denmark

As a response to the complexity of reducing health inequity there has been a rise in community-based health promotion interventions adhering to the principles of complexity thinking. Such interventions often work with adaptive practice and constitute themselves in complex webs of collaborations between multiple stakeholders. However, few efforts have been made to articulate how complexity can be navigated and addressed by stakeholders in practice. This study explores how partners experience and navigate complexity in the partnership behind Tingbjerg Changing Diabetes (TCD), a community-based intervention addressing health and social development in the disadvantaged neighborhood of Tingbjerg in urban Copenhagen. The study provides important insights on the role of context and how it contributes complexity in community-based health promotion.The study is based on 18 months of ethnographic fieldwork in the local community including participant observations and 9 in-depth interviews with key partner representatives. Findings show that complexity in TCD can be characterized by unpredictability in actions and outcomes, undefined purpose and direction, and differing organizational logics. Factors that support partners' navigation in complexity include connectivity, embracing a flexible intervention framework, autonomy, and quick responsiveness. The study showcases the interdependency between the intervention and the context of the disadvantaged neighborhood of Tingbjerg and encourages stakeholders and researchers to embrace the messiness of complexity, and to pay attention to ways through which messiness and unpredictability can be handled.

Using Network and Complexity Theories to Understand the Functionality of Referral Systems for Surgical Patients in Resource-Limited Settings, the Case of Malawi

BACKGROUND

A functionally effective referral system that links district level hospitals (DLHs) with referral hospitals (RHs) facilitates surgical patients getting timely access to specialist surgical expertise not available locally. Most published studies from low- and middle-income countries (LMICs) have examined only selected aspects of such referral systems, which are often fragmented. Inadequate understanding of their functionality leads to missed opportunities for improvements. This research aimed to investigate the functionality of the referral system for surgical patients in Malawi, a low-income country.

METHODS

This study, conducted in 2017-2019, integrated principles from two theories. We used network theory to explore interprofessional relationships between DLHs and RHs at referral network, member (hospital) and community levels; and used principles from complex adaptive systems (CAS) theory to unpack the mechanisms of network dynamics. The study employed mixed-methods, specifically surveys (n=22 DLHs), interviews with clinicians (n=20), and a database of incoming referrals at two sentinel RHs over a six-month period.

RESULTS

Obstacles to referral system functionality in Malawi included weaknesses in formal coordination structures, notably: unclear scope of practice of district surgical teams; lack of referral protocols; lack of referral communication standards; and misaligned organisational practices. Deficiencies in informal relationships included mistrust and uncollaborative operating environments, undermining coordination between DLHs and RHs. Poor system functionality adversely impacted the quality, efficiency and safety of patient referral-related care. Respondents identified aspects of the district-RH relationships, which could be leveraged to build more collaborative and productive inter-professional relationships in the future.

CONCLUSION

Multi-level interventions are needed to address failures at both ends of the referral pathway. This study captured new insights into longstanding problems in referral systems in resource-limited settings, contributing to a better understanding of how to build more functional systems to optimise the continuum and quality of surgical care for rural populations in similar settings.

Self-Organization of Interprofessional Staff to Improve Mobility of Hospitalized Patients with STRIDE: a Complexity Science-Informed Qualitative Study

BACKGROUND

Inpatient mobility programs can help older adults maintain function during hospitalization. Changing hospital practice can be complex and require engagement of various staff levels and disciplines; however, we know little about how interprofessional teams organize around implementing such interventions. Complexity science can inform approaches to understanding and improving multidisciplinary collaboration to implement clinical programs.

OBJECTIVE

To examine, through a complexity science lens, how clinical staff's understanding about roles in promoting inpatient mobility evolved during implementation of the STRIDE (assiSTed eaRly mobIlity for hospitalizeD older vEterans) hospital mobility program.

DESIGN

Qualitative study using semi-structured interviews.

PARTICIPANTS

Ninety-two clinical staff at eight Veterans Affairs hospitals.

INTERVENTIONS

STRIDE is a supervised walking program for hospitalized older adults designed to maintain patients' mobility and function.

APPROACH

We interviewed key staff involved in inpatient mobility efforts at each STRIDE site in pre- and post-implementation periods. Interviews elicited staff's perception of complexity-science aspects of inpatient mobility teams (e.g., roles over time, team composition). We analyzed data using complexity science-informed qualitative content analysis.

KEY RESULTS

We identified three key themes related to patterns of self-organization: (1) individuals outside of the "core" STRIDE team voluntarily assumed roles as STRIDE advocates, (2) leader-champions adapted their engagement level to match local implementation team needs during implementation, and (3) continued leadership support and physical therapy involvement were key factors for sustainment.

CONCLUSIONS

Staff self-organized around implementation of a new clinical program in ways that were responsive to changing program and contextual needs. These findings demonstrate the importance of effective self-organization for clinical program implementation. Researchers and practitioners implementing clinical programs should allow for, and encourage, flexibility in staff roles in planning for implementation of a new clinical program, encourage the development of advocates, and engage leaders in program planning and sustainment efforts.

Untangling the complexity generating material delivery “schedule instability”: insights from automotive OEMs

Purpose

Changes frequently made to material delivery schedules (MDSs) accumulate upstream in the supply chain (SC), causing a bullwhip effect. This article seeks to elucidate how dynamic complexity generates MDS instability at OEMs in the automotive industry.

Design/methodology/approach

An exploratory multiple-case study methodology involved in-depth semistructured interviews with informants at three automotive original equipment manufacturers (OEMs).

Findings

Dynamic complexity destabilizes MDSs primarily via internal horizontal interactions between product and process complexities and demand and SC complexities. A network of complexity interactions causes and moderates such instability through complexity absorption and generation and complexity importation and exportation.

Research limitations/implications

The multiple-case study contributes to empirical knowledge about the dynamics of MDS instability. Deductive research to validate the identified relationships remains for Future research.

Practical implications

In revealing antecedents of complexity’s effect on MDS instability, the findings imply the need to develop strategies, programs, and policies dedicated to improving capacity scalability, supplier flexibility, and the flexibility of material order fulfillment.

Originality/value

Building on complexity literature, the authors operationalize complexity transfer and develop a framework for analyzing dynamic complexity in SCs, focusing on complexity interactions. The identification and categorization of interactions provide a granular view of the dynamic complexity that generates MDS instability. The identified and proposed importance of readiness of the SC to absorb complexity challenges the literature focus on external factors for explaining complexity outcomes. The results can be used to operationalize such dynamic interactions by introducing new variables and networks of relationships. Moreover, the work showcases how a complexity perspective could be used to discern the root causes of a complex phenomenon driven by non-linear relationships.

Compound urban crises

The crises that cities face-such as climate change, pandemics, economic downturn, and racism-are tightly interlinked and cannot be addressed in isolation. This paper addresses compound urban crises as a unique type of problem, in which discrete solutions that tackle each crisis independently are insufficient. Few scholarly debates address compound urban crises and there is, to date, a lack of interdisciplinary insights to inform urban governance responses. Combining ideas from complex adaptive systems and critical urban studies, we develop a set of boundary concepts (unsettlement, unevenness, and unbounding) to understand the complexities of compound urban crises from an interdisciplinary perspective. We employ these concepts to set a research agenda on compound urban crises, highlighting multiple interconnections between urban politics and global dynamics. We conclude by suggesting how these entry points provide a theoretical anchor to develop practical insights to inform and reform urban governance.

Advanced Practice Registered Nurse Transition to Practice in the Long-Term Care Setting: An Ethnography

Advanced practice registered nurses are successful in improving quality outcomes and filling provider care gaps in long-term care. However, little is known about the nurse’s transition to practice in this setting. A 12-month ethnography was conducted via participant-observation with nine advanced practice registered nurses in five long-term care facilities to understand practice environment influence on the nurses’ transition and on the reciprocal influence of the nurse on the practice environment. Transition was fraught with uncertainty as documented by five themes: where’s my authority, institutional acceptance, personal role fulfillment, provider relationships, and individual versus organizational care. These findings suggest that transition in this setting is complex, characterized by insecurity whether the individual is new to advanced practice or experienced. Transition in long-term care could be strengthened by formal programs that include clinical practice, reconceived mentorship for advanced practice registered nurses, and education designed to improve comfort and expertise with indirect care.

Confronting complexity and supporting transformation through health systems mapping: a case study

INTRODUCTION

Health systems are a complex web of interacting and interconnected parts; introducing an intervention, or the allocation of resources, in one sector can have effects across other sectors and impact the entire system. A prerequisite for effective health system reorganisation or transformation is a broad and common understanding of the current system amongst stakeholders and innovators. Chronic obstructive pulmonary disease (COPD) and heart failure (HF) are common chronic diseases with high health care costs that require an integrated health system to effectively treat.

STUDY DESCRIPTION

This case study documents the first phase of system transformation at a regional level in Ontario, Canada. In this first phase, visual representations of the health system in its current state were developed using a collaborative co-creation approach, and a focus on COPD and HF. Multiple methods were used including focus groups, open-ended questionnaires, and document review, to develop a series of graphical and visual representations; a health care ecosystem map.

RESULTS

The ecosystem map identified key sectoral components, inter-component interactions, and care requirements for patients with COPD and HF and inventoried current programs and services available to deliver this care. Main findings identified that independent system-wide navigation for this vulnerable patient group is limited, primary care is central to the accessibility of nearly half of the identified care elements, and resources are not equitably distributed. The health care ecosystem mapping helped to identify care gaps and illustrates the need to resource the primary care provider and the patient with system navigation resources and interdisciplinary team care.

CONCLUSION

The co-created health care ecosystem map brought a collective understanding of the health care system as it applies to COPD and HF. The map provides a blueprint that can be adapted to other disease states and health systems. Future transformation will build on this foundational work, continuing the robust interdisciplinary co-creation strategies, exploring predictive health system modelling and identifying areas for integration.

Understanding the impact of exposure to adverse socioeconomic conditions on chronic stress from a complexity science perspective

BACKGROUND

Chronic stress increases chronic disease risk and may underlie the association between exposure to adverse socioeconomic conditions and adverse health outcomes. The relationship between exposure to such conditions and chronic stress is complex due to feedback loops between stressor exposure and psychological processes, encompassing different temporal (acute stress response to repeated exposure over the life course) and spatial (biological/psychological/social) scales. We examined the mechanisms underlying the relationship between exposure to adverse socioeconomic conditions and chronic stress from a complexity science perspective, focusing on amplifying feedback loops across different scales.

METHODS

We developed a causal loop diagram (CLD) to interpret available evidence from this perspective. The CLD was drafted by an interdisciplinary group of researchers. Evidence from literature was used to confirm/contest the variables and causal links included in the conceptual framework and refine their conceptualisation. Our findings were evaluated by eight independent researchers.

RESULTS

Adverse socioeconomic conditions imply an accumulation of stressors and increase the likelihood of exposure to uncontrollable childhood and life course stressors. Repetition of such stressors may activate mechanisms that can affect coping resources and coping strategies and stimulate appraisal of subsequent stressors as uncontrollable. We identified five feedback loops describing these mechanisms: (1) progressive deterioration of access to coping resources because of repeated insolvability of stressors; (2) perception of stressors as uncontrollable due to learned helplessness; (3) tax on cognitive bandwidth caused by stress; (4) stimulation of problem avoidance to provide relief from the stress response and free up cognitive bandwidth; and (5) susceptibility to appraising stimuli as stressors against a background of stress.

CONCLUSIONS

Taking a complexity science perspective reveals that exposure to adverse socioeconomic conditions implies recurrent stressor exposure which impacts chronic stress via amplifying feedback loops that together could be conceptualised as one vicious cycle. This means that in order for individual-level psychological interventions to be effective, the context of exposure to adverse socioeconomic conditions also needs to be addressed.

Developing a Conceptual Model for Sustainable water Resource Management and Agricultural Development: the Case of the Breede River Catchment Area, South Africa

The complex relationship that exists between water resources and agricultural production has been increasing constantly globally. Several factors are interacting to influence the management of water resources making the system complex and dynamic. To increase the understanding of these complex and dynamic systems, relevant tools are needed to identify the causal relationships that exist between the drivers and their influences on the system. Participatory modelling based on the system dynamics approach provides a simplistic and visualisation tool that can improve the understanding of the functioning of a complex and dynamic system. A multi-stage participatory approach was used in this study involving relevant stakeholders in the development of an integrated conceptual system dynamic model using causal loop diagrams. This approach was used because it captures the thought process and mental model of relevant stakeholders in the development of the model, making it a valuable tool for policy and decision making at government and individual levels. The integrated model built in this study used causal loop diagrams to address problems of water management and agricultural sustainability in the Breede River Catchment. The model shows major causal-relationships and feedback loops that determine the functioning of the overall system. The model demonstrates the usefulness of the participatory approach in solving problems related to water management and agricultural development in the catchment.

What theories underpin performance-based financing? A scoping review

PURPOSE

The study aims to explore the theoretical bases justifying the use of performance-based financing (PBF) in the health sector in low- and middle-income countries (LMICs).

DESIGN/METHODOLOGY/APPROACH

The authors conducted a scoping review of the literature on PBF so as to identify the theories utilized to underpin it and analyzed its theoretical justifications.

FINDINGS

Sixty-four studies met the inclusion criteria. Economic theories were predominant, with the principal-agent theory being the most commonly-used theory, explicitly referred to by two-thirds of included studies. Psychological theories were also common, with a wide array of motivation theories. Other disciplines in the form of management or organizational science, political and social science and systems approaches also contributed. However, some of the theories referred to contradicted each other. Many of the studies included only casually alluded to one or more theories, and very few used these theories to justify or support PBF. No theory emerged as a dominant, consistent and credible justification of PBF, perhaps except for the principal-agent theory, which was often inappropriately applied in the included studies, and when it included additional assumptions reflecting the contexts of the health sector in LMICs, might actually warn against adopting PBF.

PRACTICAL IMPLICATIONS

Overall, this review has not been able to identify a comprehensive, credible, consistent, theoretical justification for using PBF rather than alternative approaches to health system reforms and healthcare providers' motivation in LMICs.

ORIGINALITY/VALUE

The theoretical justifications of PBF in the health sector in LMICs are under-documented. This review is the first of this kind and should encourage further debate and theoretical exploration of the justifications of PBF.

Towards Understanding and Sustaining Natural Resource Systems through the Systems Perspective: A Systematic Evaluation

A bibliometric and network analysis was performed to explore global research publication trends and to investigate relevant policy recommendations in the field of sustainability of natural resources, system dynamics, and systems thinking, to solve water resources issues and enhance water resource management. Overall, 1674 academic research articles data were generated from the Web of Science and Scopus databases, from 1981 to 2019. The findings of this study revealed that system dynamics and systems thinking research has significantly increased over the last decade (from 40 to 250 articles). Countries such as the USA (20%), China (18%), the United Kingdom (5%), Canada, Iran, Australia, and India (4% each) have the most publications and strongest collaborative networks. Sterman (2000) and Forrester (1961) had the most co-cited research while Zhang X had the highest citations, respectively. Results also showed that system theory which includes systems thinking and system dynamics were the most used keywords. The Journal of Cleaner Production was found to have published the highest number of systems thinking and system dynamics related studies, perhaps due to scope relevance. Despite the exponential rise in natural resource sustainability research globally, the result of this study shows that developing countries especially in Africa have low numbers of research publications in the field. Thus, the result of this study serves as a signal for policymakers to increase attention on research publications that could enhance natural resource sustainability, particularly in less developed countries in Africa where the application of systems thinking to natural resource management is limited.

Highways to Ageing - Linking life course SEP to multivariate trajectories of health outcomes in older adults

OBJECTIVES

Ageing is a temporal, multi-faceted process subject to interacting factors. In this study, we used life course and multidimensional approaches to elucidate the association between socioeconomic forces across a lifetime and the developmental origins in health and disease of the Mexican elderly.

METHODS

Data stemmed from the Mexican Health and Ageing Study, constituting a sample of older adults (N= 5169, ≥50 years). With retrospective information on early, intermediary and contemporaneous socioeconomic indicators, life course typologies of socioeconomic position were identified using Latent Class Analysis. Based on prospective data of functional mobility, number of chronic conditions and self-rated health, multivariate trajectories of health outcomes were uncovered with Group Based Trajectory Model. Links between the extracted SEP and multivariate health latent constructs were explored with multinomial logistic regression.

RESULTS

Life course SEP classes were heterogeneous, yet a large proportion of subjects was characterized by persistent socioeconomic adversity throughout life. The health outcomes' patterns of co-evolution were diverse too, shedding light on the nature of their developmental links, while revealing variable synchronicity in their temporal decline. A graded association was observed between the life course SEP classes and ageing trajectories.

CONCLUSION

The results primarily backed the cumulative advantage/disadvantage life course framework, while finding some indication for age as a leveller hypothesis. Variability in patterns of dynamic co-action among the health outcomes depicts ageing as a naturally variable process of interconnected changes. Life course evidence for the ways socio-economic forces are differentially linked to distinct developmental profiles of ageing is provided.

The complex information needs of disadvantaged young first-time mothers: insights into multiplicity of needs

Purpose

The purpose of this paper is to holistically explore the information needs of socioeconomically disadvantaged young first-time mothers and associated issues of complexity.

Design/methodology/approach

This paper used survey and semi-structured field interviews with 39 young mothers (aged 15–23) from UK areas of multiple deprivations.

Findings

Participants reported multiple and complex needs spanning interrelated topics of parenting, poverty and personal development. In the majority of instances, participants were either unsure of their ability to meet their needs or needed help with needs, and several described situations of considerable anxiety and stress. Multiplicity is identified and conceptualised as an important factor contributing to complexity, including three component elements: simultaneous occurrence of needs (concurrency), relationships between needs (interconnectivity) and evolving needs (fluidity). In various combinations, these elements influenced a mother's actions and/or ability to selectively attend to needs, with multiple needs often competing for attention, and compounding issues of cognitive load and affect.

Research limitations/implications

This study draws attention to multiplicity of needs as an understudied topic within human information behaviour and calls for further research into how people recognise and attend to complex needs and influencing factors.

Practical implications

This study raises important questions regarding how we approach complexity of information needs in our design and delivery of information systems and services.

Originality/value

Evidences disadvantaged young mothers to have more extensive and complex information needs than previously understood, and identifies and conceptualised multiplicity as an important factor contributing to the complexity of information needs during major life transitions such as motherhood.

Understanding the Athena SWAN award scheme for gender equality as a complex social intervention in a complex system: analysis of Silver award action plans in a comparative European perspective

Background

Given the complex mix of structural, cultural and institutional factors that produce barriers for women in science, an equally complex intervention is required to understand and address them. The Athena SWAN Award Scheme for Gender Equality has become a widespread means to address barriers for women’s advancement and leadership in the United Kingdom, Ireland, Australia, the United States of America and Canada, while the European Commission is exploring the introduction of a similar award scheme across Europe.

Methods

This study analyses the design and implementation of 16 departmental Athena SWAN Silver Action Plans in Medical Sciences at one of the world’s leading universities in Oxford, United Kingdom. Data pertaining to the design and implementation of gender equality interventions were extracted from the action plans, analysed thematically, coded using categories from the 2015 Athena SWAN Charter Awards Handbook and synthesised against a typology of gender equality interventions in the European Research Area. The results were further analysed against the complexity research literature framework, where research organisations are perceived as dynamic systems that adapt, interact and co-evolve with other systems.

Results

Athena SWAN is a complex contextually embedded system of action planning within the context of universities. It depends on a multitude of contextual variables that relate in complex, non-linear ways and dynamically adapt to constantly moving targets and new emergent conditions. Athena SWAN Silver Action Plans conform to the key considerations of complexity – (1) multiple actions and areas of intervention with a focus on the complex system being embedded in local dynamics, (2) the non-linearity of interventions and the constantly emerging conditions, and (3) impact in terms of contribution to change, improved conditions to foster change and the increased probability that change can occur.

Conclusions

To enact effective sustainable structural and cultural change for gender equality, it is necessary to acknowledge and operationalise complexity as a frame of reference. Athena SWAN is the single most comprehensive and systemic gender equality scheme in Europe. It can be further strengthened by promoting the integration of sex and gender analysis in research and education. Gender equality policies in the wider European Research Area can benefit from exploring Athena SWAN’s contextually embedded systemic approach to dynamic action planning and inclusive focus on all genders and categories of staff and students.