Eleanor Malbon

Systems science and systems thinking for public health: a systematic review of the field

Objectives This paper reports on findings from a systematic review designed to investigate the state of systems science research in public health. The objectives were to: (1) explore how systems methodologies are being applied within public health and (2) identify fruitful areas of activity. Design A systematic review was conducted from existing literature that draws on or uses systems science (in its various forms) and relates to key public health areas of action and concern, including tobacco, alcohol, obesity and the social determinants of health. Data analysis 117 articles were included in the review. An inductive qualitative content analysis was used for data extraction. The following were systematically extracted from the articles: approach, methodology, transparency, strengths and weaknesses. These were then organised according to theme (ie, commonalities between studies within each category), in order to provide an overview of the state of the field as a whole. The assessment of data quality was intrinsic to the goals of the review itself, and therefore, was carried out as part of the analysis. Results 4 categories of research were identified from the review, ranging from editorial and commentary pieces to complex system dynamic modelling. Our analysis of each of these categories of research highlighted areas of potential for systems science to strengthen public health efforts, while also revealing a number of limitations in the dynamic systems modelling being carried out in public health. Conclusions There is a great deal of interest in how the application of systems concepts and approach might aid public health. Our analysis suggests that soft systems modelling techniques are likely to be the most useful addition to public health, and align well with current debate around knowledge transfer and policy. However, the full range of systems methodologies is yet to be engaged with by public health researchers.

Using systems science to understand the determinants of inequities in healthy eating

Introduction Systems thinking has emerged in recent years as a promising approach to understanding and acting on the prevention and amelioration of non-communicable disease. However, the evidence on inequities in non-communicable diseases and their risks factors, particularly diet, has not been examined from a systems perspective. We report on an approach to developing a system oriented policy actor perspective on the multiple causes of inequities in healthy eating. Methods Collaborative conceptual modelling workshops were held in 2015 with an expert group of representatives from government, non-government health organisations and academia in Australia. The expert group built a systems model using a system dynamics theoretical perspective. The model developed from individual mind maps to pair blended maps, before being finalised as a causal loop diagram. Results The work of the expert stakeholders generated a comprehensive causal loop diagram of the determinants of inequity in healthy eating (the HE2 Diagram). This complex dynamic system has seven sub-systems: (1) food supply and environment; (2) transport; (3) housing and the built environment; (4) employment; (5) social protection; (6) health literacy; and (7) food preferences. Discussion The HE2 causal loop diagram illustrates the complexity of determinants of inequities in healthy eating. This approach, both the process of construction and the final visualisation, can provide the basis for planning the prevention and amelioration of inequities in healthy eating that engages with multiple levels of causes and existing policies and programs.

Can the sociology of social problems help us to understand and manage ‘lifestyle drift’?

Lifestyle drift is increasingly seen as a barrier to broad action on the social determinants of health. The term is currently used in the population health literature to describe how broad policy initiatives for tackling inequalities in health that start off with social determinants (upstream) approach drift downstream to largely individual lifestyle factors, as well as the general trend of investing a the individual level. Lifestyle drift occurs despite the on-going efforts of public health advocates, such as anti-obesity campaigners, to draw attention to the social factors which shape health behavior and outcomes. In this article, we explore whether the sociology of social problems can help understand lifestyle drift in the context of obesity. Specifically, we apply Jamrozik and Nocellas residualist conversion model to the problem of obesity in order to explore whether such an approach can provide greater insight into the processes that underpin lifestyle drift and inform our attempts to mitigate it.

Preventing Dysfunction and Improving Policy Advice: The Role of Intra‐Departmental Boundary Spanners

It is well established in the public management literature that boundary spanners – people or groups that work across departments or sectors – are critical to the success of whole of government and joined-up working. In studying recent unprecedented change to central government agencies in the Australian context, our research identified that intra-departmental boundary spanners also play a critical role in the functioning of government departments, particularly during restructuring. Although most contemporary literature in public management concentrates on boundaries across formal organisational entities (departments, agencies, sectors), boundaries also exist within departments. Our research has found that without dedicated intra-departmental boundary spanners, significant role confusion and dysfunctional practices arise. In turn, this has serious implications for the quality of policy advice given to Cabinet. Further research needs to be undertaken into both the role of intra-departmental boundary spanners and how to nurture and manage the practice of intra-departmental boundary spanners. This is especially the case if changes in Australia represent a fundamental shift more broadly in the way central government agencies operate.

Adaptive Policies for Reducing Inequalities in the Social Determinants of Health

Inequalities in the social determinants of health (SDH), which drive avoidable health disparities between different individuals or groups, is a major concern for a number of international organisations, including the World Health Organization (WHO). Despite this, the pathways to changing inequalities in the SDH remain elusive. The methodologies and concepts within system science are now viewed as important domains of knowledge, ideas and skills for tackling issues of inequality, which are increasingly understood as emergent properties of complex systems. In this paper, we introduce and expand the concept of adaptive policies to reduce inequalities in the distribution of the SDH. The concept of adaptive policy for health equity was developed through reviewing the literature on learning and adaptive policies. Using a series of illustrative examples from education and poverty alleviation, which have their basis in real world policies, we demonstrate how an adaptive policy approach is more suited to the management of the emergent properties of inequalities in the SDH than traditional policy approaches. This is because they are better placed to handle future uncertainties. Our intention is that these examples are illustrative, rather than prescriptive, and serve to create a conversation regarding appropriate adaptive policies for progressing policy action on the SDH.

Redressing or entrenching social and health inequities through policy implementation? Examining personalised budgets through the Australian National Disability Insurance Scheme

BackgroundIncreasing attention is being given to political agenda setting for the social determinants of health. While designing policies that can improve the social determinants of health is critical, so too is ensuring these policies are appropriately administered and implemented. Many policies have the potential to entrench or even expand inequities during implementation. At present little attention has been given to this in the social determinants of health literature.There is an international trend in the personalisation of funding for care services, from the National Health Service in the England to the Brukerstyrt Personlig Assistanse in Norway. Part of this trend is the Australian National Disability Insurance Scheme (NDIS). The NDIS has the potential to secure gains in health for hundreds of thousands of Australians living with a disability. However, policies are only as good as their implementation.MethodsAs part of a longitudinal study on the implementation of the Australian NDIS, we conducted a systematic document search of policy documents pertaining to the Scheme on the websites of government departments with auspice over the design and implementation of the scheme with the aim of examining issues of equity.Results and discussionScheme architects have argued that the NDIS has the potential to replace a piecemeal and fragmented set of state-determined services with an empowering model of user choice and control. However, without careful attention to both existing inequities and, diversity and difference across populations (e.g. different disability types and different localities), market based approaches such as the NDIS have the serious potential to entrench or even widen inequities.ConclusionsThe research concluded that ‘personalisation’ approaches can widen inequities and inequalities unless careful consideration is given at both policy design and implementation stages.

What can policymakers learn from feminist strategies to combine contextualised evidence with advocacy

We give a short overview of feminist perspectives on the use of evidence in policy making, covering both empirical and conceptual work. We present the case of the Conflict Tactics Scale, a measure of interpersonal violence that is both widely used and heavily criticised in work on violence between intimate partners. We examine this case to illustrate the way that feminist advocacy and research organisations use gender informed theory to counter positivist narratives about intimate partner violence. In doing so, we show that the evidence-based policy approach, even when considered as principle or ideal, frames the policy-making process as “objective”, and in doing so ignores the gendered contexts in which knowledge is produced, used and translated into policy and implementation. By examining feminist approaches to this case study, we can learn from feminist advocate researchers the importance of context, normative arguments and the politicisation of evidence in policymaking and implementation.

The personalisation agenda: the case of the Australian National Disability Insurance Scheme

ABSTRACT As part of the international trend towards personalisation, in 2013 Australia launched a major disability scheme aiming to give participants greater choice and control over services. The scheme aims to cover a wide diversity of disabilities, services and significant geographical area – resulting in a highly complex system of local overlapping markets. At four years into implementation a range of challenges have emerged. In this paper we firstly describe the Australian National Disability Insurance Scheme, then explore a range of implementation challenges it currently faces as a large-scale personalisation scheme. Based on these experiences we pose a range of questions for similar schemes internationally.

Boundary Challenges and the Work of Boundary Spanners

In sketching out a vision for the future public service, Dickinson and Sullivan (2014) argued that we were at the frontier of significant change. These changes, they suggested, would pose challenges to the way in which we think about what the public service workforce does and how it goes about doing it. A key part of the discussion of the future public service workforce is the centrality of cross-boundary working. This chapter explains the imperatives for crossing boundaries. It identifies the characteristic and skill requirements of the workforce required to cross boundaries. It argues that the persistent need to work across boundaries highlights the necessity of supporting boundary spanners and boundary spanning activity. It then outlines the key aspects of the supportive architecture required to support boundary spanning skill development.

Strange magic: what can the emergence of ‘magic concepts’ tell us about policy implementation?

Abstract Pollitt and Hupe have identified the emergence of “magic concepts” in public administration and policy. These concepts are seductive but do not solve – and often render invisible – important policy challenges. In highlighting the role of magic concepts, Pollitt and Hupe demonstrate the importance of linguistic battles within the bureaucracies. In this paper we examine the emergence of magic concepts in the context of the Australian National Disability Insurance Scheme. We analyze semi-structured interviews with policymakers to elucidate their use of magic concepts – for example, the new NDIS regulatory body – for addressing implementation challenges in the NDIS. This paper examines implementation of the NDIS through the application of Pollit and Hupe’s “magic concepts” to a context-specific case. We argue that paying attention to where magic concepts emerge is critical – they can alert us to areas that require further inquiry and where problems are emerging in governance, practice, and policy implementation.