No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Systems Thinking for Knowledge Integration: New Models for Policy-Research Collaboration
Abstract
Systems thinking is attracting great interest in public health as a conceptual orientation to solving complex challenges around health care renewal in developed countries. Our approach is based on the tenet that effective systems thinking relies on the development of a trans-disciplinary knowledge base integrating traditional complex adaptive systems theory with community development, social ecology, social networks, and public health theory and practice (Best et al. 2003).
... Research on the knowledge-to-action (KTA) process has been concerned with conceptualising and mapping the research-policy-practice cycle from a theoretical and applied perspective. This literature has been particularly focused on public sector performance and one aim has been to identify factors that influence the implementation of evidence-based policy and practice (Nutley et al, 2007;Mitton et al, 2007;Best et al, 2008;Wandersman et al, 2008;Ward et al, 2009;Lane and Flagg, 2010). KTA scholarship has been influenced by different disciplinary perspectives, including knowledge and change management, institutional and organisational learning, the diffusion of innovations, social psychology and research utilisation. ...
... KTA scholarship has been influenced by different disciplinary perspectives, including knowledge and change management, institutional and organisational learning, the diffusion of innovations, social psychology and research utilisation. One recent development that has gained attention is systems thinking (see Espejo, 1994;Schön and Rein, 1994;Senge, 2006;Flood, 2010). 2 For example, Best et al argue, in reference to public health sector reform, that the field needs more holistic frameworks that capture the dynamic and contingent ways in which research-based knowledge informs policy and practice (Best et al, 2008(Best et al, , 2009Best and Holmes, 2010). Drawing on systems thinking, Best and Holmes (2010) argue that KTA is shaped, embedded and organised through structures that mediate how agents (ie, policy makers and practitioners) interact and adopt evidence. ...
... They also suggest that agents are tied together by an interdependent system that requires activation of its various constituent parts so they are linked together in ways that mutually support one another (see also Greenhalgh et al, 2004). This model of systems thinking has been advocated across a range of social and health policy sectors (Chapman, 2004;Best et al, 2008;Zimmerman et al, 2001). ...
The processes for moving research-based knowledge to the domains of action in social policy and professional practice are complex. Several disciplinary research traditions have illuminated several key aspects of these processes.A more holistic approach, drawing on systems thinking, has also been outlined and advocated by recent contributors to this debate.This paper seeks to draw on these foundations to sketch a more integrated approach to nine organisational variables that influence the successful implementation of a 'knowledge-to-action' framework for evidence-based policy and practice.
... Technology transfer is less subjective and more focused (24,26). Further, technology transfer is more reliant on pilot tests and experimentation, while knowledge transfer involves more trial and error (24,26,27). Both activities require proper identification of external sources and appropriate integration into processes (24,26). ...
... Gilbert and Cordey-Hayes provided a five-stage model that includes knowledge transfer phases that progress from knowledge acquisition to assimilation of knowledge into the organization (28). Ultimately, organizations seek knowledge integration such that knowledge is assimilated into business practices and policies and informs decisions (27,29). This paper focuses on the knowledge transfer phase. ...
... Models for the integration or assimilation of research knowledge have evolved from linear models, in which knowledge is transferred from a source to a recipient, to relationship models, which recognize that knowledge comes from multiple sources and must be adapted to conditions (27,29). More recently, the use of systems modeling has emerged as a more appropriate way to consider the existence of various actors, perspectives, priorities, organizational structures, and processes involved in knowledge transfer (27,29). ...
Research units in state government transportation agencies exist within traditionally hierarchical, or mechanistic, organizations. They manage and conduct research studies and ensure the successful transfer of knowledge through both inter- and intraorganizational relationships and through knowledge transfer activities. These activities may entail the transfer of knowledge at the local, state, federal or international level. Improving knowledge transfer ultimately improves organizational performance. Use of Burns and Stalkers' dualism - mechanistic versus organic management systems - to describe government organizations aids in the recognition of the current condition and in the identification of the characteristics of an environment that will be more conducive to efficient knowledge transfer. This information will help decision makers within these organizations to select the appropriate organizational structure, or processes, to enhance knowledge transfer. The increasing amount of information and growing organizational complexity require a systems thinking approach to identifying opportunities for improvement within these organizations. This paper describes how systems thinking can aid in exploring knowledge transfer within organic and mechanistic state government organizations and offers contributions to the body of knowledge concerning government entities and intentional knowledge transfer.
... Best practices participatory SD modeling uses a group model building (GMB) approach to stakeholder engagement (Martinez-Moyano & Richardson, 2013;Richardson & Andersen, 1995). GMB is a multi-stepped, iterative series of stakeholder group "systems thinking" workshops (Best, Trochim, Haggerty, Moor & Norman, 2008;Palma & Lounsbury, 2017). These workshops often incorporate co-occurring activities that include problem identification, system conceptualization, model formulation, deliberative feedback, evaluation, and in some cases model simulation (Hovmand, 2014;Martinez-Moyano & Richardson, 2013). ...
... System dynamics modeling has been used as a tool to bring stakeholders together to examine complex problems at the community level, from environmental concerns (Arquitt & Johnstone, 2004;Stave, 2010;Van den Belt, 2004), to urban and rural development (Hoard et al., 2005;Richardson, 2011), to public health problems (Gillen et al., 2014;Hirsch, Homer, Evans & Zielinski, 2010;Hovmand & Ford, 2009;Lounsbury, Hirsch, Vega & Schwartz, 2014), including HIV and AIDS (Batchelder et al., 2015;Lounsbury et al., 2015;Martin et al., 2015). The unique mechanism by which SD modeling supports community solutions to tackle systemic problems is through the engagement of stakeholders in a "systems thinking" process (Best et al., 2008;Trochim, Cabrera, Milstein, Gallagher & Leischow, 2006). Through this process, stakeholders most directly engaged in the system are facilitated and capacitated both to hear and to share divergent perspectives and come to consensus through the group model building process (Hovmand et al., 2012;Rouwette, Vennix & van Mullekom, 2002). ...
Highlights
Participatory system dynamics modeling helps improve the HIV service system to reduce the epidemic.
We engaged local stakeholders to critique their HIV service system using system dynamics modeling.
Participants showed enhanced communication and consensus about systems understanding and solutions.
... Knowledge-to-action models often ignore experiential learning, tacit knowledge, and how exchanges between individuals incorporate teaching and learning simultaneously, including the various literacy skills that actors within the system need to fully engage in modern information-driven health systems, including use of ICT for health [23]. Such challenges suggest a need to examine the entire system, not just the components within it in isolation [10,24] if workable solutions are to be proposed. ...
... Ongoing waves of data collection with feedback consistent with a developmental evaluation [70,[72][73][74] or an actionresearch approach [75][76][77] provide ongoing information about the performance of the system. Providing evaluation data to participants in a form that is clear and easy to interpret both serves to validate the knowledge development process and is a form of network guidance/reinforcement in its own right [29]. 5 Integration: Knowledge integration occurs when what has been learned has been integrated into normal practice [24,78,79]. This integration involves taking the innovation and using it to create new ways of working, policies and strategies, and having such innovations sustain themselves over time. ...
Complex problems require strategies to engage diverse perspectives in a focused, flexible manner, yet few options exist that fit with the current health care and public health system constraints. The Complex Network Electronic Knowledge Translation Research model (CoNEKTR) brings together complexity science, design thinking, social learning theories, systems thinking and eHealth technologies together to support a sustained engagement strategy for social innovation support and enhancing knowledge integration.
The CoNEKTR model adapts elements of other face-to-face social organizing methods and combines it with social media and electronic networking tools to create a strategy for idea generation, refinement and social action. Drawing on complexity science, a series of networking and dialogue-enhancing activities are employed to bring diverse groups together, facilitate dialogue and create networks of networks.
Ten steps and five core processes informed by complexity science have been developed through this model. Concepts such as emergence, attractors and feedback play an important role in facilitating networking among participants in the model.
Using a constrained, focused approach informed by complexity science and using information technology, the CoNEKTR model holds promise as a means to enhance system capacity for knowledge generation, learning and action while working within the limitations faced by busy health professionals.
... Although a recent review identified factors facilitating a HPS approach at a school-level [13], there is limited synthesized knowledge on the broader elements that facilitate a HPS approach at a school system-level. Systems-thinking offers a theoretical lens that recognizes interrelationships and interactions across stakeholders that are tied together by organizational structures, processes and contexts but require stronger linkages to promote behaviour change within and across systems [14][15][16]. This perspective is appropriate for interventions within the education system considering the interdependency of a range of system-level elements [17] (e.g., government ministries may develop HPS standards and offer professional development for groups of schools). ...
... Systems-thinking offers a theoretical lens that recognizes interrelationships and interactions across stakeholders that are tied together by organizational structures, processes and contexts but require stronger linkages to promote behaviour change within and across systems [14][15][16]. This perspective is appropriate for interventions within the education system considering the interdependency of a range of system-level elements [17] (e.g., government ministries may develop HPS standards and offer professional development for groups of schools). ...
Health promoting schools (HPS) is recognized globally as a multifaceted approach that can support health behaviours. There is increasing clarity around factors that influence HPS at a school level but limited synthesized knowledge on the broader system-level elements that may impact local implementation barriers and support uptake of a HPS approach. This study comprised a scoping review to identify, summarise and disseminate the range of research to support the uptake of a HPS approach across school systems. Two reviewers screened and extracted data according to inclusion/exclusion criteria. Relevant studies were identified using a multi-phased approach including searching electronic bibliographic databases of peer reviewed literature, hand-searching reference lists and article recommendations from experts. In total, 41 articles met the inclusion criteria for the review, representing studies across nine international school systems. Overall, studies described policies that provided high-level direction and resources within school jurisdictions to support implementation of a HPS approach. Various multifaceted organizational and professional interventions were identified, including strategies to enable and restructure school environments through education, training, modelling and incentives. A systematic realist review of the literature may be warranted to identify the types of intervention that work best for whom, in what circumstance to create healthier schools and students.
... Vol needed to bring about that activation for the purposes of KTA. 8,9 While the need for systems approaches to KTA is acknowledged, and concepts are gaining clarity, practical strategies to design and implement systems approaches to KTA are very limited. 8,10,11 The purpose of the environmental scan reported in this paper was to begin to show some practical strategies that may usefully guide the design, implementation and impact of KTA initiatives to solve complex problems. ...
Solving complex problems such as preventing chronic diseases introduces unique challenges for the creation and application of knowledge, or knowledge to action (KTA). KTA approaches that apply principles of systems thinking are thought to hold promise, but practical strategies for their application are not well understood. In this paper we report the results of a scan of systems approaches to KTA with a goal to identify how to optimize their implementation and impact.
A 5-person advisory group purposefully selected 9 initiatives to achieve diversity on issues addressed and organizational forms. Information on each case was gathered from documents and through telephone interviews with primary contacts within each organization. Following verification of case descriptions, an inductive analysis was conducted within and across cases.
The cases revealed 5 guidelines for moving from conceiving KTA systems to implementing them: 1) establish and nurture relationships, 2) co-produce and curate knowledge, 3) create feedback loops, 4) frame as systems interventions rather than projects, and 5) consider variations across time and place.
Results from the environmental scan are a modest start to translating systems concepts for KTA into practice. Use of the strategies revealed in the scan may improve KTA for solving complex public health problems. The strategies themselves will benefit from the development of a science that aims to understand adaptation and ongoing learning from policy and practice interventions, strengthens enduring relationships, and fills system gaps in addition to evidence gaps. Systems approaches to KTA will also benefit from robust evaluations.
... Such methods for measuring and evaluating various types of knowledge and levels of knowledge use in PHIR provide the policy, practice and research communities with the rich, detailed and highly practical understanding of social interventions that is useful when planning and implementing population health interventions. Integrating many sources of knowledge reinforces the tenets of the relationship and systems models of KT that are naturally embedded within PHIR because they provide models for linking the various sources of knowledge encompassed by PHIR (Best et al, 2008b;Best and Holmes, 2010). These models acknowledge that local context and various sources of knowledge must be taken into account in designing and adapting population health intervention strategies. ...
Population and public health research has been shifting from describing factors that shape health to an interrogation of the processes and outcomes underpinning policy and programme interventions. This shift has given rise to acknowledging population health intervention research (PHIR)
as a distinct field of study in Canada. Given that PHIR aims to maximise the use of evidence to inform interventions, a discussion paper was written and a workshop was held, with 24 participants working across policy, practice and research, to identify distinct features of PHIR that create
opportunities and challenges for knowledge translation (KT). Building on the discussion paper and activities at the workshop, workshop participants surfaced five features of PHIR that need specific consideration to facilitate progress on understanding and capitalising on the relationships
between KT and PHIR. Implications for stakeholders interested in maximising the use of evidence to inform strategies for chronic disease prevention are also provided.
... Second, the central role of organizational culture and structure reinforces our initial proposition that facilitation and support of lifestyle medicine requires planned and coordinated change at the practitioner, practice setting, and organizational levels. 32 Finally, the Alliance project resulted in what we believe is the first conceptual framework that can be used to strengthen relationships among primary care researchers and practitioners, to enhance the capacity for knowledge uptake among practitioners, and to accelerate the flow of research evidence regarding lifestyle interventions into the primary care setting to ultimately reduce the cancer burden within the United States. ...
Effective dissemination, implementation, and adoption of research-tested lifestyle risk factor interventions within primary care are critical to reduce cancer morbidity and mortality. The objective of this study is to identify short- and long-term action steps within primary care research and practice to bridge the discovery-to-delivery gap in cancer prevention and control. Experts in primary care research and practice from the United States and Canada participated in this qualitative project. Concept mapping was used to synthesize expert input on actions to improve research-practice integration in cancer prevention and control. Results were used to facilitate an action-planning meeting among primary care researchers and practitioners. Five areas were identified as critical to improving the integration of research and practice in cancer prevention and control: (1) stakeholder collaborations, (2) organizational culture and structure, (3) learning infrastructure, (4) incentives and funding, and (5) data and accountability systems. Addressing the discovery-to-delivery gap in primary care requires collaboration among researchers and practitioners throughout the knowledge production cycle. The model developed in this project can be used to stimulate actions at the individual, organizational, and systems level to reduce the burden of cancer related to lifestyle risk factors.
... • take into account the large number of elements that interact in nonlinear and dynamic ways (Sterman, 2006); • understand context, reflecting the history of the system, and the fact that hindsight does not lead to foresight, because the external conditions and systems constantly change (Snowden and Boone, 2007); • look beyond individual cause-and-effect relationships, but rather embark on a continuous learning process and discover emerging patterns as a foundation for more effective KTA strategies (Best et al, 2008b); • realise that the people in the system shape the system and are influenced by the system. They make decisions based on past patterns of success and failure, rather than clear, logical rules (Osborn et al, 2002;Snowden and Boone, 2007); • provide the right kinds of evidence in easily usable forms; support innovation and change with training and technical assistance; and integrate new knowledge into the delivery system (Wandersman et al, 2008). ...
The way we think about how research, policy and practice inform and interact with each other shapes our efforts to improve health and social outcomes. In this paper we describe linear, relationship and systems models with regard to how they approach bridging evidence and policy/practice, or turning knowledge into action. We contribute to the knowledge to action (KTA) systems thinking discussion by highlighting four interconnected aspects of this model we believe merit exploration: evidence and knowledge, leadership, networks and communications. We conclude with the challenge of developing measurement methods for systems research to better understand the KTA process.
Research units in state government transportation agencies exist within traditionally hierarchical, or mechanistic, organizations. They manage and conduct research studies and ensure the successful transfer of knowledge through both inter- and intraorganizational relationships and through knowledge transfer activities. These activities may entail the transfer of knowledge at the local, state, federal or international level. Improving knowledge transfer ultimately improves organizational performance. Use of Burns and Stalkers' dualism—mechanistic versus organic management systems—to describe government organizations aids in the recognition of the current condition and in the identification of the characteristics of an environment that will be more conducive to efficient knowledge transfer. This information will help decision makers within these organizations to select the appropriate organizational structure, or processes, to enhance knowledge transfer. The increasing amount of information and growing organizational complexity require a systems thinking approach to identifying opportunities for improvement within these organizations. This paper describes how systems thinking can aid in exploring knowledge transfer within organic and mechanistic state government organizations and offers contributions to the body of knowledge concerning government entities and intentional knowledge transfer.
Purpose
Within intellectual disability care organizations (IDCOs), it is vital that professionals share and apply knowledge to improve the quality of care for their service users. Given that chief executive officers (CEOs) play a pivotal role in enabling these processes, this paper aims to investigate both the underlying motives and strategies behind CEOs’ organizational knowledge leadership and their contribution to improving these knowledge processes.
Design/methodology/approach
In this exploratory qualitative study, 11 CEOs from IDCOs in the Netherlands who are actively involved in knowledge management within their organizations were interviewed. An inductive thematic analysis was conducted.
Findings
CEOs’ motives for stimulating knowledge processes among professionals in IDCOs arise from the internal (e.g. the CEOs themselves) and external (e.g. policy) contexts. This study also identified four strategies adopted by CEOs to stimulate sharing and application of knowledge: providing organizational conditions for effective knowledge processes; focused attention on talent development; acknowledgment and deployment of knowledge holders; and knowledge-driven participation in collaborative partnerships. These strategies are used in combination and have been shown to reinforce one another.
Practical implications
An overview of strategies for stimulating knowledge processes is now available.
Originality/value
The results display the leadership of CEOs in knowledge strategies. Insights into their perceptions and values are provided while elaborating on their motives to take this role.
Complex problems require strategies that leverage the knowledge of diverse actors working in a coordinated manner in order to address them in a manner that is appropriate to the context. Such strategies require building relationships among groups that enable them to network in ways that have the intensity of face-to-face meetings, but also extend over time. The Complexity, Networks, EHealth, & Knowledge Translation Research (CoNEKTR) model draws upon established methods of face-to-face social engagement and supported with information technology and proscribes an approach to issue exploration, idea generation and collective action that leverages social networks for health innovation. The model combines aspects of communities of practice, online communities, systems and complexity science, and theories of knowledge translation, exchange and integration. The process and steps of implementing the model are described using a case study applied to food systems and health. Implications for health research and knowledge translation are discussed.
Introduction
La résolution de problèmes complexes du type de la prévention des maladies chroniques présente des défis particuliers pour la création et le transfert de connaissances, soit le passage de la connaissance à l’action (PCA). Les approches axées sur le PCA respectant les principes de la pensée systémique sont jugées prometteuses, mais les stratégies pour les mettre en place ne sont pas bien comprises. Dans cet article, nous présentons les résultats d’une analyse de plusieurs approches systémiques axées sur le PCA dans le but de déterminer comment optimiser leur mise en oeuvre et leur efficacité.
Méthodologie
Un groupe consultatif de cinq personnes a choisi neuf initiatives représentant une diversité d’enjeux et de formes organisationnelles. Pour chaque cas, l’information a été recueillie à partir de documents et par l’entremise d’entrevues téléphoniques avec des personnes-ressources de chaque organisation. Après la vérification des descriptions de cas, une analyse inductive a été effectuée à la fois pour chaque cas et entre les cas.
Résultats
Ces cas ont révélé cinq lignes directrices permettant de passer de la conception de systèmes de PCA à leur mise en oeuvre : 1) établir et entretenir des relations, 2) coproduire et organiser les connaissances, 3) créer des boucles de rétroaction, 4) les encadrer comme des interventions systémiques plutôt que comme des projets et 5) envisager des variations dans le temps et selon les lieux.
Conclusion
Les résultats de cette analyse contextuelle constituent un départ modeste pour transformer en résultats concrets les concepts systémiques de PCA. L’utilisation des stratégies mises au jour pourrait améliorer le PCA pour la résolution de problèmes complexes en matière de santé publique. Les stratégies elles-mêmes pourront bénéficier de l’évolution d’une science visant à comprendre l’adaptation et l’apprentissage constant des politiques et des interventions pratiques, ce qui renforcera les relations durables et comblera les lacunes des systèmes, et pas simplement celles des données probantes. Les approches systémiques de PCA tireront également des bénéfices d’évaluations rigoureuses.
Global health care and promotion in the twenty-first century faces challenges posed by aging populations, mass migration, environmental threats, and the rise of new types of infectious diseases; issues that are interconnected, dynamic in nature, and without precedent. These are commonly calledwicked problems: ones that are complex, ill formulated, “joined-up”, confusing, and require multi-party collaboration to address [1]. Wicked or complex problems are resistant to the linear and simple solutions sets that are often employed in health systems that typically come with a push towards models of best practice and evidence-based medicine [2, 3]. While these solution sets demonstrate utility in certain areas pertaining to healthcare, they typically fail when applied to health promotion and population health [4] which commonly deal with multi-causal, contextually bound, and dynamic problems. It is for this type of problem space that complexity science and systems thinking are most appropriate [5]. In terms of action, it is often the place frequented by designers [6].
Denna rapport redovisar hur Landstinget i Östergötland, under medverkan av representanter för Institutionen för medicin och hälsa (IMH) vid Linköpings universitet, under åren 2010 till 2012 utvecklade och prövade ett program där forskningsbaserad kunskap sammanställdes och presenterades vid dialogmöten bland kliniska enheter i landstinget. Avsikten var att anpassa ett program som prövats i provinsen Alberta i Kanada, ” The Alberta Ambassador Program”, till svenska förhållanden. Den styrgrupp som under Metodrådet ansvarade för programmet genomförde 2012 sammanlagt 14 dialogmöten vid sjukhuskliniker och vårdcentraler i Östergötland.
Rapportens syfte är att med hjälp av ett ramverk för ”knowledge brokering” - en form för kunskapsöverföring i hälso- och sjukvård - analysera utvecklingen och genomförandet av programmet för ordnat införande av metoder (”Östgötamodellen”) och jämföra med den kanadensiska modellen samt diskutera eventuella skillnader och likheter mellan modellerna.
Complex health problems such as chronic disease or pandemics require knowledge that transcends disciplinary boundaries to generate solutions. Such transdisciplinary discovery requires researchers to work and collaborate across boundaries, combining elements of basic and applied science. At the same time, calls for more interdisciplinary health science acknowledge that there are few metrics to evaluate the products associated with these new ways of working. The Research on Academic Research (RoAR) initiative was established to evaluate the process of discovery and impact of collaboration that emerged through the Life Sciences Institute (LSI) at the University of British Columbia, a state-of-the-art facility designed to support researchers—self-organized around specific health problems rather than disciplines. A logic model depicting the factors influencing such collaboration is presented along with a multimethod evaluation plan to assist understanding of the discovery process in this new environment and develop new metrics for assessing collaborative impact.
This paper aims to describe methods and models designed to build a comprehensive, integrative framework to guide the research to policy and practice cycle in health care.
Current models of science are summarised, identifying specific challenges they create for knowledge to action (KTA). Alternative models for KTA are outlined to illustrate how researchers and decision makers can work together to fit the KTA model to specific problems and contexts. The Canadian experience with the evolving paradigm shift is described, along with recent initiatives to develop platforms and tools that support the new thinking. Recent projects to develop and refine methods for embedded research are described. The paper concludes with a summary of lessons learned and recommendations that will move the KTA field towards an integrated science.
Conceptual models for KTA are advancing, benefiting from advances in team science, development of logic models that address the realities of complex adaptive systems, and new methods to more rapidly deliver knowledge syntheses more useful to decision and policy makers.
KTA is more likely when co-produced by researchers, practitioners, and policy makers. Closer collaboration requires shifts in thinking about the ways we work, capacity development, and greater learning from practice.
More powerful ways of thinking about the complexities of knowledge to action are provided, along with examples of tools and priorities drawn from systems thinking.
Objective
The primary purposes of this review were to identify key social-environmental influences on the physical-activity behavior of women and to propose an organizing framework of these influences in the social environment.
Data Sources
Computerized searches of MEDLINE, Science Direct, and CINAHL were conducted to identify relevant research.
Study Inclusion and Exclusion Criteria
Studies were included if they used a sample of adult women or included gender-specific analysis, identified or measured some aspect of the social environment in relation to physical activity, and were published in English within the last two decades.
Data Extraction
Characteristics of study design, sample population, and identified social-environmental variables were extracted.
Data Synthesis
Through an iterative review of the data by several researchers, common influences and themes were identified and organized into a social environment framework, which included the following components: social support/social networks, life transitions/multiple roles, and cultural standards/gender role expectations.
Results
Women are exposed to societal messages that indicate physical activity is not a priority and may be inappropriate; they may also lack the social support necessary to adopt and maintain physical activity.
Conclusions
This review reveals the complex range of factors in the social environment that influence women, and it provides support for the importance of the social environment on physical-activity behavior in women. A social-environmental framework related to Bronfenbrenner's social ecological model is proposed along with recommended strategies to apply in interventions targeting women.
The formation of partnerships with the public, non‐profit and commercial sectors is becoming an increasingly common way for leisure service departments in local government to fulfil their mandate under conditions of economic restraint, political pressures and increased demand for services. However, these departments often lack the capacity to successfully manage the number and complexity of partnerships initiated. While under‐managed partnerships have been identified as a significant problem in the literature, little attention has been devoted to understanding the organizational dynamics that underpin them. Interviews with leisure service managers and staff in ten Canadian cities were conducted, revealing a lack of guidelines, insufficient training, poor coordination and a number of other problems contributing to under‐managed partnerships. This warrants further research and attention because it can lead to unsuccessful partnerships and negative consequences for all partners involved.
This is the first in a series of four articlesAcross all disciplines, at all levels, and throughout the world, health care is becoming more complex. Just 30 years ago the typical general practitioner in the United Kingdom practised from privately owned premises with a minimum of support staff, subscribed to a single journal, phoned up a specialist whenever he or she needed advice, and did around an hour's paperwork per week. The specialist worked in a hospital, focused explicitly on a particular system of the body, was undisputed leader of his or her “firm,” and generally left administration to the administrators. These individuals often worked long hours, but most of their problems could be described in biomedical terms and tackled using the knowledge and skills they had acquired at medical school.You used to go to the doctor when you felt ill, to find out what was wrong with you and get some medicine that would make you better. These days you are as likely to be there because the doctor (or the nurse, the care coordinator, or even the computer) has sent for you. Your treatment will now be dictated by the evidence—but this may well be imprecise, equivocal, or conflicting. Your declared values and preferences may be used, formally or informally, in a shared management decision about your illness. The solution to your problem is unlikely to come in a bottle and may well involve a multidisciplinary team.Not so long ago public health was the science of controlling infectious diseases by identifying the “cause” (an alien organism) and taking steps to remove or contain it. Today's epidemics have fuzzier boundaries (one is even known as “syndrome X”1): they are the result of the interplay of genetic predisposition, environmental context, and lifestyle choices.The experience of …
Over the past thirty-five years complexity theory has become a broad ranging subject that is appreciated in a variety of ways, illustrated more or less in the books by Anderson, has become the ultimate interdisciplinary science, focusing its modeling activities on how microstate events, whether particles, molecules, genes, neurons, human agents, or firms, self-organize into emergent aggregate structure. Clearly, the mission of this and subsequent issues of Emergence is to systematically build up a base of high quality scientific activity aimed at supporting complexity applications to management and organization science— thereby thwarting faddish tendencies. In this founding issue I suggest a bottom-up focus on organizational microstates and the adoption of the "semantic conception" of scientific theory. The union of these two hallmarks of current science and philosophy, along with computational modeling, may prevent complexity theory from becoming just another fad.
The threshold of the new millennium offers an opportunity to celebrate remarkable past achievements and to reflect on promising new directions for the field of public health. Despite historic achievements, much will always remain to be done (this is the intrinsic nature of public health). While every epoch has its own distinct health challenges, those confronting us today are unlike those plaguing public health a century ago. The perspectives and methods developed during the infectious and chronic disease eras have limited utility in the face of newly emerging challenges to public health. In this paper, we take stock of the state of public health in the United States by (1) describing limitations of conventional US public health, (2) identifying different social philosophies and conceptions of health that produce divergent approaches to public health, (3) discussing institutional resistance to change and the subordination of public health to the authority of medicine, (4) urging a move from risk factorology to multilevel explanations that offer different types of intervention, (5) noting the rise of the new "right state" with its laissez-faire attitude and antipathy toward public interventions, (6) arguing for a more ecumenical approach to research methods, and (7) challenging the myth of a value-free public health.
Medical scientists and public health policy makers are increasingly concerned that the scientific discoveries of the past generation are failing to be translated efficiently into tangible human benefit. This concern has generated several initiatives, including the Clinical Research Roundtable at the Institute of Medicine, which first convened in June 2000. Representatives from a diverse group of stakeholders in the nation's clinical research enterprise have collaborated to address the issues it faces. The context of clinical research is increasingly encumbered by high costs, slow results, lack of funding, regulatory burdens, fragmented infrastructure, incompatible databases, and a shortage of qualified investigators and willing participants. These factors have contributed to 2 major obstacles, or translational blocks: impeding the translation of basic science discoveries into clinical studies and of clinical studies into medical practice and health decision making in systems of care. Considering data from across the entire health care system, it has become clear that these 2 translational blocks can be removed only by the collaborative efforts of multiple system stakeholders. The goal of this article is to articulate the 4 central challenges facing clinical research at present--public participation, information systems, workforce training, and funding; to make recommendations about how they might be addressed by particular stakeholders; and to invite a broader, participatory dialogue with a view to improving the overall performance of the US clinical research enterprise.
Introduction
Although there is general agreement about the complex interplay among individual-, family-, organizational-, and community-level factors as they influence health outcomes, there is still a gap between health promotion research and practice. The authors suggest that a disjuncture exists between the multiple theories and models of health promotion and the practitioner's need for a more unified set of guidelines for comprehensive planning of programs. Therefore, we put forward in this paper an idea toward closing the gap between research and practice, a case for developing an overarching framework—with several health promotion models that could integrate existing theories—and applying it to comprehensive health promotion strategy.
An Integrative Framework
We outline a theoretical foundation for future health promotion research and practice that integrates four models: the social ecology; the Life Course Health Development; the Predisposing, Reinforcing, and Enabling Constructs in Educational/Environmental Diagnosis and Evaluation–Policy, Regulatory and Organizational Constructs in Educational and Environmental Development; and the community partnering models. The first three models are well developed and complementary. There is little consensus on the latter model, community partnering. However, we suggest that such a model is a vital part of an overall framework, and we present an approach to reconciling theoretical tensions among researchers and practitioners involved in community health promotion.
Integrating the Models: The Need for Systems Theory and Thinking
Systems theory has been relatively ignored both by the health promotion field and, more generally, by the health services. We make a case for greater use of systems theory in the development of an overall framework, both to improve integration and to incorporate key concepts from the diverse systems literatures of other disciplines.
Vision for Healthy Communities
(1) Researchers and practitioners understand the complex interplay among individual-, family-, organizational-, and community-level factors as they influence population health; (2) health promotion researchers and practitioners collaborate effectively with others in the community to create integrated strategies that work as a system to address a wide array of health-related factors; (3) The Healthy People Objectives for the Nation includes balanced indicators to reflect health promotion realities and research-measures effects on all levels; (4) the gap between community health promotion “best practices” guidelines and the way things work in the everyday world of health promotion practice has been substantially closed.
Conclusions and Recommendations
We suggest critical next steps toward closing the gap between health promotion research and practice: investing in networks that promote, support, and sustain ongoing dialogue and sharing of experience; finding common ground in an approach to community partnering; and gaining consensus on the proposed integrating framework.
When we launched the Journal of Translational Medicine a few months ago, we were interested primarily in exploring scientific consideration of this discipline. However, as editors of JTM, we have been contacted almost daily to discuss the problems faced by scientists and clinicians around the world who are challenging the traditional boundaries of science and medicine. Through these conversations, we have learned that translational medicine is in fact "lost in translation," inspiring much angst, many promises and some Federal appropriations. However, little has been done to substantively promote this important field. Authoritative reviews on the subject are available to the interested reader 1234567. In this article, we will address JTM's "constituency" to report what we've learned about the obstacles to translational medicine from the myriad of phone conversations and e-mail interactions.
This article summarizes an extensive literature review addressing the question, How can we spread and sustain innovations in health service delivery and organization? It considers both content (defining and measuring the diffusion of innovation in organizations) and process (reviewing the literature in a systematic and reproducible way). This article discusses (1) a parsimonious and evidence-based model for considering the diffusion of innovations in health service organizations, (2) clear knowledge gaps where further research should be focused, and (3) a robust and transferable methodology for systematically reviewing health service policy and management. Both the model and the method should be tested more widely in a range of contexts.
With this review, the authors sought to determine what strategies have been evaluated (including the outcomes assessed) to disseminate cancer control interventions that promote the uptake of behavior change. Five topic areas along the cancer care continuum (smoking cessation, healthy diet, mammography, cervical cancer screening, and control of cancer pain) were selected to be representative. A systematic review was conducted of primary studies evaluating dissemination of a cancer control intervention. Thirty-one studies were identified that evaluated dissemination strategies in the 5 topic areas. No strong evidence currently exists to recommend any one dissemination strategy as effective in promoting the uptake of cancer control interventions. The authors conclude that there is a strong need for more research into dissemination of cancer control interventions. Future research should consider methodological issues such as the most appropriate study design and outcomes to be evaluated.
One of the greatest challenges facing health promotion and disease prevention is translating research findings into evidence-based public health and clinical practices that are actively disseminated and widely adopted. Despite the tremendous strides made in developing effective disease prevention and control programs, there has been little study of effective dissemination of evidence-based programs to and adoption by community, public health, and clinical practice settings. This special section provides a venue in which to highlight exemplary dissemination research efforts while also identifying limitations in research to date and framing important future research questions. This issue establishes a resource for investigators interested in dissemination research, with relevance to health psychology. In this sense, it can serve as a benchmark by which to examine subsequent progress. The 6 articles reflect the state of the science in dissemination research for the promotion and adoption of health behavior change interventions.
Awareness of and support for systems thinking and modeling in the public health field are growing, yet there are many practical challenges to implementation. We sought to identify and describe these challenges from the perspectives of practicing public health professionals.
A systems-based methodology, concept mapping, was used in a study of 133 participants from 2 systems-based public health initiatives (the Initiative for the Study and Implementation of Systems and the Syndemics Prevention Network). This method identified 100 key challenges to implementation of systems thinking and modeling in public health work.
The project resulted in a map identifying 8 categories of challenges and the dynamic interactions among them.
Implementation by public health professionals of the 8 simple rules we derived from the clusters in the map identified here will help to address challenges and improve the organization of systems that protect the public's health.
Today's problems often arise as unintended consequences of yesterday's solutions. Business and public policy settings suffer from policy resistance, the tendency for well-intentioned interventions to be defeated by the response of the system to the intervention itself. Just as an airline uses flight simulators to help pilots learn, system dynamics enables us to create management flight simulators to avoid policy resistance and design more effective policies. System dynamics is also a process for working with high-level teams designed to improve the chances for implemented results. This article discusses how system dynamics can be used effectively to design high-leverage policies for sustainable improvement and introduces the next three articles in this issue discussing the application of system dynamics to a variety of critical issues facing business leaders today.
This is the classic work upon which modern-day game theory is based. What began more than sixty years ago as a modest proposal that a mathematician and an economist write a short paper together blossomed, in 1944, when Princeton University Press published Theory of Games and Economic Behavior. In it, John von Neumann and Oskar Morgenstern conceived a groundbreaking mathematical theory of economic and social organization, based on a theory of games of strategy. Not only would this revolutionize economics, but the entirely new field of scientific inquiry it yielded--game theory--has since been widely used to analyze a host of real-world phenomena from arms races to optimal policy choices of presidential candidates, from vaccination policy to major league baseball salary negotiations. And it is today established throughout both the social sciences and a wide range of other sciences. This sixtieth anniversary edition includes not only the original text but also an introduction by Harold Kuhn, an afterword by Ariel Rubinstein, and reviews and articles on the book that appeared at the time of its original publication in the New York Times, tthe American Economic Review, and a variety of other publications. Together, these writings provide readers a matchless opportunity to more fully appreciate a work whose influence will yet resound for generations to come.
Objectives To assess the impact of prompting physicians on health maintenance, answer questions regarding the mode of delivery, and identify opportunities and limitations of this information intervention. Methods Systematic electronic and manual searches (January 1, 1966, to December 31, 1996) were conducted to identify clinical trial reports on prompting clinicians. Three eligibility criteria were applied: (1) randomized controlled clinical trial, (2) clinician prompt, alert, or reminder in the study group and no similar intervention in the control group, and (3) measurement of the intervention effect on the frequency of preventive care procedures. Data were abstracted by independent reviewers using a standardized abstraction form, and quality of methodology was scored. A series of meta-analyses on triggering clinical actions was performed using the random-effects method. The statistical analyses included 33 eligible studies, which involved 1547 clinicians and 54,693 patients. Results Overall, prompting can significantly increase preventive care performance by 13.1% (95% confidence interval [CI], 10.5%-15.6%). However, the effect ranges from 5.8% (95% CI, 1.5%-10.1%) for Papanicolaou smear to 18.3% (95% CI, 11.6%-25.1%) for influenza vaccination. The effect is not cumulative, and the length of intervention period did not show correlation with effect size ( R = −0.015, P = .47). Academic affiliation, ratio of residents, and technique of delivery did not have a significant impact on the clinical effect of prompting. Conclusions Dependable performance improvement in preventive care can be accomplished through prompting physicians. Vigorous application of this simple and effective information intervention could save thousands of lives annually. Health care organizations could effectively use prompts, alerts, or reminders to provide information to clinicians when patient care decisions are made.
Today's problems often arise as unintended consequences of yesterday's solutions. Business and public policy settings suffer from policy resistance, the tendency for well-intentioned interventions to be defeated by the response of the system to the intervention itself. Just as an airline uses flight simulators to help pilots learn, system dynamics enables us to create management flight simulators to avoid policy resistance and design more effective policies. System dynamics is also a process for working with high-level teams designed to improve the chances for implemented results. This article discusses how system dynamics can be used effectively to design high-leverage policies for sustainable improvement and introduces the next three articles in this issue discussing the application of system dynamics to a variety of critical issues facing business leaders today.
Medical scientists and public health policy makers are increasingly
concerned that the scientific discoveries of the past generation are failing
to be translated efficiently into tangible human benefit. This concern has
generated several initiatives, including the Clinical Research Roundtable
at the Institute of Medicine, which first convened in June 2000. Representatives
from a diverse group of stakeholders in the nation's clinical research enterprise
have collaborated to address the issues it faces. The context of clinical
research is increasingly encumbered by high costs, slow results, lack of funding,
regulatory burdens, fragmented infrastructure, incompatible databases, and
a shortage of qualified investigators and willing participants. These factors
have contributed to 2 major obstacles, or translational blocks: impeding the
translation of basic science discoveries into clinical studies and of clinical
studies into medical practice and health decision making in systems of care.
Considering data from across the entire health care system, it has become
clear that these 2 translational blocks can be removed only by the collaborative
efforts of multiple system stakeholders. The goal of this article is to articulate
the 4 central challenges facing clinical research at present—public
participation, information systems, workforce training, and funding; to make
recommendations about how they might be addressed by particular stakeholders;
and to invite a broader, participatory dialogue with a view to improving the
overall performance of the US clinical research enterprise.
Scitation is the online home of leading journals and conference proceedings from AIP Publishing and AIP Member Societies
In this provocative article, the author sets out a personal list of "problems" that must be solved if the field of system dynamics is "… to advance beyond a craft, to approach the rigors of a science." The problems include issues in the enhancement of technical and interpretive aspects of modeling, and in the advancement and propogation of good practice. These identified problems are characterised as those that are, through their difficulty, deserving of continuing attention, and at the same time are those that threaten the field if not resolved. The article carefully ends with an epilogue inviting response, rather than a conclusion.
BACKGROUND. Increasing recognition of the failure to translate research findings into practice has led to greater awareness of the importance of using active dissemination and implementation strategies. Although there is a growing body of research evidence about the effectiveness of different strategies, this is not easily accessible to policy makers and professionals. OBJECTIVES. To identify, appraise, and synthesize systematic reviews of professional educational or quality assurance interventions to improve quality of care. RESEARCH DESIGN. An overview was made of systematic reviews of professional behavior change interventions published between 1966 and 1998. RESULTS. Forty-one reviews were identified covering a wide range of interventions and behaviors. In general, passive approaches are generally ineffective and unlikely to result in behavior change. Most other interventions are effective under some circumstances; none are effective under all circumstances. Promising approaches include educational outreach (for prescribing), and reminders. Multifaceted interventions targeting different barriers to change are more likely to be effective than single interventions. CONCLUSIONS. Although the current evidence base is incomplete, it provides valuable insights into the likely effectiveness of different interventions. Future quality improvement or educational activities should be informed by the findings of systematic reviews of professional behavior change interventions.
"This is the classic work upon which modern-day game theory is based. What began more than sixty years ago as a modest proposal that a mathematician and an economist write a short paper together blossomed, in 1944, when Princeton University Press published Theory of Games and Economic Behavior. In it, John von Neumann and Oskar Morgenstern conceived a groundbreaking mathematical theory of economic and social organization, based on a theory of games of strategy. Not only would this revolutionize economics, but the entirely new field of scientific inquiry it yielded--game theory--has since been widely used to analyze a host of real-world phenomena from arms races to optimal policy choices of presidential candidates, from vaccination policy to major league baseball salary negotiations. And it is today established throughout both the social sciences and a wide range of other sciences. This sixtieth anniversary edition includes not only the original text but also an introduction by Harold Kuhn, an afterword by Ariel Rubinstein, and reviews and articles on the book that appeared at the time of its original publication in the New York Times, tthe American Economic Review, and a variety of other publications. Together, these writings provide readers a matchless opportunity to more fully appreciate a work whose influence will yet resound for generations to come.
Scitation is the online home of leading journals and conference proceedings from AIP Publishing and AIP Member Societies
A major scientific revolution has begun, a new paradigm that rivals
Darwin's theory in importance. At its heart is the discovery of the
order that lies deep within the most complex of systems, from the origin
of life, to the workings of giant corporations, to the rise and fall of
great civilizations. And more than anyone else, this revolution is the
work of one man, Stuart Kauffman, a MacArthur Fellow and visionary
pioneer of the new science of complexity. Now, in At Home in the
Universe , Kauffman brilliantly weaves together the excitement of
intellectual discovery and a fertile mix of insights to give the general
reader a fascinating look at this new science--and at the forces for
order that lie at the edge of chaos.We all know of instances of
spontaneous order in nature--an oil droplet in water forms a sphere,
snowflakes have a six-fold symmetry. What we are only now discovering,
Kauffman says, is that the range of spontaneous order is enormously
greater than we had supposed. Indeed, self-organization is a great
undiscovered principle of nature. But how does this spontaneous order
arise? Kauffman contends that complexity itself triggers
self-organization, or what he calls "order for free," that if enough
different molecules pass a certain threshold of complexity, they begin
to self-organize into a new entity--a living cell. Kauffman uses the
analogy of a thousand buttons on a rug--join two buttons randomly with
thread, then another two, and so on. At first, you have isolated pairs;
later, small clusters; but suddenly at around the 500th repetition, a
remarkable transformation occurs--much like the phase transition when
water abruptly turns to ice--and the buttons link up in one giant
network. Likewise, life may have originated when the mix of different
molecules in the primordial soup passed a certain level of complexity
and self-organized into living entities (if so, then life is not a
highly improbable chance event, but almost inevitable). Kauffman uses
the basic insight of "order for free" to illuminate a staggering range
of phenomena. We see how a single-celled embryo can grow to a highly
complex organism with over two hundred different cell types. We learn
how the science of complexity extends Darwin's theory of evolution by
natural selection: that self-organization, selection, and chance are the
engines of the biosphere. And we gain insights into biotechnology, the
stunning magic of the new frontier of genetic engineering--generating
trillions of novel molecules to find new drugs, vaccines, enzymes,
biosensors, and more. Indeed, Kauffman shows that ecosystems, economic
systems, and even cultural systems may all evolve according to similar
general laws, that tissues and terra cotta evolve in similar ways. And
finally, there is a profoundly spiritual element to Kauffman's thought.
If, as he argues, life were bound to arise, not as an incalculably
improbable accident, but as an expected fulfillment of the natural
order, then we truly are at home in the universe. Kauffman's earlier
volume, The Origins of Order , written for specialists, received lavish
praise. Stephen Jay Gould called it "a landmark and a classic." And
Nobel Laureate Philip Anderson wrote that "there are few people in this
world who ever ask the right questions of science, and they are the ones
who affect its future most profoundly. Stuart Kauffman is one of these."
In At Home in the Universe , this visionary thinker takes you along as
he explores new insights into the nature of life.
381 p., ref. bib. : 2 p.1/2 In a rented convent in Santa Fe, a revolution has been brewing. The activists are not anarchists, but rather Nobel Laureates in physics and economics such as Murray Gell-Mann and Kenneth Arrow, and pony-tailed graduate students, mathematicians, and computer scientists down from Los Alamos. They've formed an iconoclastic think tank called the Santa Fe Institute, and their radical idea is to create a new science called complexity. These mavericks from academe share a deep impatience with the kind of linear, reductionist thinking that has dominated science since the time of Newton. Instead, they are gathering novel ideas about interconnectedness, coevolution, chaos, structure, and order―and they're forging them into an entirely new, unified way of thinking about nature, human social behavior, life, and the universe itself. They want to know how a primordial soup of simple molecules managed to turn itself into the first living cell-and what the origin of life some four billion years ago can tell us about the process of technological innovation today. They want to know why ancient ecosystems often remained stable for millions of years, only to vanish in a geological instant―and what such events have to do with the sudden collapse of Soviet communism in the late 1980s. They want to know why the economy can behave in unpredictable ways that economists can't explain-and how the random process of Darwinian natural selection managed to produce such wonderfully intricate structures as the eye and the kidney. Above all, they want to know how the universe manages to bring forth complex structures such as galaxies, stars, planets, bacteria, plants, animals, and brains. There are common threads in all of these queries, and these Santa Fe scientists seek to understand them. Complexity is their story: the messy, funny, human story of how science really happens. Here is the tale of Brian Arthur, the Belfast-born economist who stubbornly pushed his theories of economic change in the face of hostile orthodoxy. Here, too, are the stories of Stuart Kauffman, the physician-turned-theorist whose most passionate desire has been to find the principles of evolutionary order and organization that Darwin never knew about; John Holland, the affable computer scientist who developed profoundly original theories of evolution and learning as he labored in obscurity for thirty years; Chris Langton, the one-time hippie whose close brush with death in a hang-glider accident inspired him to create the new field of artificial life; and Santa Fe Institute founder George Cowan, who worked a lifetime in the Los Alamos bomb laboratory, until-at age sixty―three―he set out to start a scientific revolution. Most of all, however, Complexity is the story of how these scientists and their colleagues have tried to forge what they like to call "the sciences of the twenty-first century.".
This work gives, for the first time, a complete overview of the field of Systems and Cybernetics, as it developed from its beginnings more than 40 years ago up to date. It covers at the same time very general and well known basic concepts and much more information on the subject, until now scattered among hundreds of papers presented in international or national meetings, most of them completely out of reach of the majority of scholars. While redacted in English, it contains also a considerable store of valuable information gathered from sources in various other languages e.g. Dutch, French, German, Italian, Russian, Spanish, etc. The work contains nearly: 3,000 entries in alphabetical order A considerable quantity of verbatim quotes from hundreds of authors More than 1,200 specific references General information about Systems and Cybernetic Societies in the world Principal journals in the field
To assess the impact of prompting physicians on health maintenance, answer questions regarding the mode of delivery, and identify opportunities and limitations of this information intervention.
Systematic electronic and manual searches (January 1, 1966, to December 31, 1996) were conducted to identify clinical trial reports on prompting clinicians. Three eligibility criteria were applied: (1) randomized controlled clinical trial, (2) clinician prompt, alert, or reminder in the study group and no similar intervention in the control group, and (3) measurement of the intervention effect on the frequency of preventive care procedures. Data were abstracted by independent reviewers using a standardized abstraction form, and quality of methodology was scored. A series of meta-analyses on triggering clinical actions was performed using the random-effects method. The statistical analyses included 33 eligible studies, which involved 1547 clinicians and 54 693 patients.
Overall, prompting can significantly increase preventive care performance by 13.1% (95% confidence interval [CI], 10.5%-15.6%). However, the effect ranges from 5.8% (95% CI, 1.5%-10.1%) for Papanicolaou smear to 18.3% (95% CI, 11.6%-25.1%) for influenza vaccination. The effect is not cumulative, and the length of intervention period did not show correlation with effect size (R = -0.015, P = .47). Academic affiliation, ratio of residents, and technique of delivery did not have a significant impact on the clinical effect of prompting.
Dependable performance improvement in preventive care can be accomplished through prompting physicians. Vigorous application of this simple and effective information intervention could save thousands of lives annually. Health care organizations could effectively use prompts, alerts, or reminders to provide information to clinicians when patient care decisions are made.
vidence-based decision making be- came a touchstone of health care in the 1990s. The idea of better informing practice with research findings has spread from medi- cine to management and policy decisions. The expectation is that those allocating funding and those designing and running health serv- ices, as well as those delivering care to pa- tients, use the most up-to-date findings from health services and medical research to inform their decisions. Unfortunately, the rhetoric has so far largely exceeded the reality. Saul Feldman re- cently compared researchers and practitio- ners to "strangers in the night, dimly aware of each other's presence…Research findings have had only a negligible effect on managed men- tal health care." 1
This report, released by the Division of Health Promotion and Disease Prevention within the Institute of Medicine at the National Academy of Sciences, asserts that behavioral and social interventions such as health promotion and disease prevention offer great promise to reduce disease morbidity and mortality in the United States, but as yet their potential has not been recognized or tapped by the federal government. Two overarching recommendations are the need to address generic social and behavioral determinants of health rather than the clinical causes of disease and death, and the need to intervene at multiple levels of influence including the individual, interpersonal, institutional, community, and policy levels. Seven recommendations for intervention strategies, nine recommendations for research, and three recommendations for funding are offered.
International comparisons can provide clues to understanding some of the important policy-related determinants of health, including those related to the provision of health care services. An earlier study indicated that the strength of the primary care infrastructure of a health services system might be related to overall costs of health services. The purpose of the current research was to determine the robustness of the findings in the light of the passage of 5-10 years, the addition of two more countries, and the findings of other research on the possible importance of other determinants of country health levels.
Thirteen industrialized countries, all with populations of at least 5 million, were characterized by the relative strength of their primary care infrastructure, the degree of national income inequality, and a major manifestation of a behavioral determinant of health that is amenable to policy intervention (smoking), using international data sets and national informants. Health system and primary care practice characteristics were judged according to pre-set criteria. Major indicators of health were used as dependent variables, as were health care costs.
The stronger the primary care, the lower the costs. Countries with very weak primary care infrastructures have poorer performance on major aspects of health. Although countries that are intermediate in the strength of their primary care generally have levels of health at least as good as those with high levels of primary care, this is not the case in early life, when the impact of strong primary care is greatest. A subset of characteristics (equitable distribution of resources, publicly accountable universal financial coverage, low cost sharing, comprehensive services, and family-oriented services) distinguishes countries with overall good health from those with poor health at all ages. Neither income inequality nor smoking status accurately identified those countries with either consistently high or consistently poor performance on the health indicators. Interpretation: A certain level of health care expenditures may be required to achieve overall good health levels, even in the presence of strong primary care infrastructures. Very low costs may interfere with achievement of good health, particularly at older ages, although very high levels of costs may signal excessive and potentially health-compromising care. Five policy-relevant characteristics appear to be related to better population health levels. There is no consistent relationship between income inequality, smoking, and health levels as measured by various indicators of health in different age groups.
To assess the contribution of primary care systems to a variety of health outcomes in 18 wealthy Organization for Economic Cooperation and Development (OECD) countries over three decades.
Data were primarily derived from OECD Health Data 2001 and from published literature. The unit of analysis is each of 18 wealthy OECD countries from 1970 to 1998 (total n = 504).
Pooled, cross-sectional, time-series analysis of secondary data using fixed effects regression.
Secondary analysis of public-use datasets. Primary care system characteristics were assessed using a common set of indicators derived from secondary datasets, published literature, technical documents, and consultation with in-country experts.
The strength of a country's primary care system was negatively associated with (a) all-cause mortality, (b) all-cause premature mortality, and (c) cause-specific premature mortality from asthma and bronchitis, emphysema and pneumonia, cardiovascular disease, and heart disease (p<0.05 in fixed effects, multivariate regression analyses). This relationship was significant, albeit reduced in magnitude, even while controlling for macro-level (GDP per capita, total physicians per one thousand population, percent of elderly) and micro-level (average number of ambulatory care visits, per capita income, alcohol and tobacco consumption) determinants of population health.
(1) Strong primary care system and practice characteristics such as geographic regulation, longitudinality, coordination, and community orientation were associated with improved population health. (2) Despite health reform efforts, few OECD countries have improved essential features of their primary care systems as assessed by the scale used here. (3) The proposed scale can also be used to monitor health reform efforts intended to improve primary care.
The clinical research infrastructure of the United States is currently at a critical crossroads. To leverage the enormous biomedical research gains made in the past century efficiently, a drastic need exists to reengineer this system into a coordinated, safe, and more efficient and effective enterprise. To accomplish this task, clinical research must be transformed from its current state as a cottage industry to an enterprise-wide health care pipeline whose function is to bring the novel research from both government and private entities to the US public. We propose the establishment of a unique public-private partnership termed the National Clinical Research Enterprise (NCRE). Its agenda should consist of informed public participation, supportive information technologies, a skilled workforce, and adequate funding in clinical research. Devoting only 0.25% of the budgets from all health care stakeholders to support the NCRE would permit adequate funding to build the infrastructure required to address these problems in an enterprise fashion. All participants in the US health care delivery system must come together to focus on system-wide improvements that will benefit the public.
Concept mapping is a type of structured conceptualization which can be used by groups to develop a conceptual framework which can guide evaluation or planning. In the typical case, six steps are involved: (1) Preparation (including selection of participants and development of focus for the conceptualization); (2) the Generation of statements; (3) the Structuring of statements; (4) the Representation of Statements in the form of a concept map (using multidimensional scaling and cluster analysis); (5) the Interpretation of maps; and, (6) the Utilization of maps. Concept mapping: encourages the group to stay on task; results relatively quickly in an interpretable conceptual framework; expresses this framework entirely in the language of the participants; yields a graphic or pictorial product which simultaneously shows all major ideas and their interrelationships; and often improves group or organizational cohesiveness and morale. This paper describes each step in the process, considers major methodological issues and problems, and discusses computer programs which can be used to accomplish the process.
The web of life: a new synthesis of mind and matter
- F Capra
Capra, F., The web of life: a new synthesis of mind and matter (London: Flamingo, 1997).