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Dynamics of intervention adoption, implementation, and maintenance inside organizations: The case of an obesity prevention initiative
... Several studies have used causal loop diagrams to explore the implementation or operation of a program or strategy [26][27][28][29][30]. Fredericks et al. [28] concluded that the development of a causal loop diagram provided insight into factors that affect variability in program implementation, highlighted competing goals within the system and identified critical feedback processes and unintended consequences. ...
... Brown et al. [30] described how creating the diagram with stakeholders deepened their understanding of their programs and led to the development of useful indicators for ongoing monitoring and evaluation. Despite its relatively limited application in this context, those who have utilised causal loop diagrams concluded that they gained practical insight into how the organisational dynamics of a project affected its success [26,27,29]. ...
... For analysis, SiREN is the bounded situation, factors outside of SiREN's control were not included. Taking a narrower focus supported a deeper exploration of SiREN and provided greater insight into how a model like SiREN may be implemented in another context [27]. The concept of perspectives acknowledges that each system stakeholder may hold a different view of reality. ...
Introduction
Public health policy and practice is strengthened by the application of quality evidence to decision making. However, there is limited understanding of how initiatives that support the generation and use of evidence in public health are operationalised. This study examines factors that support the internal functioning of a partnership, the Western Australian Sexual Health and Blood-borne Virus Applied Research and Evaluation Network (SiREN). SiREN aims to build research and evaluation capacity and increase evidence-informed decision making in a public health context.
Methods
This study was informed by systems concepts. It developed a causal loop diagram, a type of qualitative system model that illustrated the factors that influence the internal operation of SiREN. The causal loop diagram was developed through an iterative and participatory process with SiREN staff and management (n = 9) via in-depth semi-structured interviews (n = 4), workshops (n = 2), and meetings (n = 6).
Results
Findings identified critical factors that affected the functioning of SiREN. Central to SiREN’s ability to meet its aims was its capacity to adapt within a dynamic system. Adaptation was facilitated by the flow of knowledge between SiREN and system stakeholders and the expertise of the team. SiREN demonstrated credibility and capability, supporting development of new, and strengthening existing, partnerships. This improved SiREN’s ability to be awarded new funding and enhanced its sustainability and growth. SiREN actively balanced divergent stakeholder interests to increase sustainability.
Conclusion
The collaborative development of the diagram facilitated a shared understanding of SiREN. Adaptability was central to SiREN achieving its aims. Monitoring the ability of public health programs to adapt to the needs of the systems in which they work is important to evaluate effectiveness. The detailed analysis of the structure of SiREN and how this affects its operation provide practical insights for those interested in establishing a similar project.
... Across a wide range of research questions (Supplemental Table 2), studies implemented complex systems models for 3 primary purposes-descriptive (n = 4) ( (105), or procurement locations used by food assistance program participants (93). Seven studies used models for only mechanistic purposes, including ABM (n = 5) (41, 47, 71-73), hybrid (n = 1) (66), and SD (n = 1) (97). The mechanisms of interest ranged widely and depended on the specific research question [e.g., understanding the effects of neighborhood income segregation on healthy food access (72), understanding customer and producer features that make alternative food hubs sustainable (41)]. ...
... We assessed model quality by examining the rigor and inclusivity of methods across studies ( Table 3). All studies used empirical information to develop and parameterize models, with most (n = 53) (37-47, 61-91, 94-104) using datasets and/or prior literature (e.g., published estimates) and a few (n = 5) (41,92,93,97,105) collecting primary data either to augment other data sources or model alone. Few studies (n = 10) (61, 81, 84-87, 95, 96, 100, 103) reported consulting with experts during model development, and Koh et al. (69) conducted the only study that explicitly engaged stakeholders in the modeling process via a group model building approach. ...
... Twenty-four studies (47, 62, 68, 69, 71-74, 77-80, 82-86, 88, 89, 97, 98, 101, 102, 104) had a high degree of transparency; however, transparency criteria only examined presence and not extent, creating a potential ceiling effect for overall scores. Individually, the least common transparency criteria we identified across studies (n = 12 studies) (47,68,69,74,77,78,97,98,(101)(102)(103)(104) was providing a way for replication (e.g., public access to model code; see Supplemental Table 1). ...
Retail food environments (RFEs) are complex systems with important implications for population health. Studying the complexity within RFEs comes with challenges. Complex systems models are computational tools that can help. We performed a systematic scoping review of studies that used complex systems models to study RFEs for population health. We examined the purpose for using the model, RFE features represented, extent to which the complex systems approach was maximized, and quality and transparency of methods employed. The PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) guidelines were followed. Studies using agent-based modeling, system dynamics, discrete event simulations, networks, hybrid, or microsimulation models were identified from 7 multidisciplinary databases. Fifty-six studies met the inclusion criteria, including 23 microsimulation, 13 agent-based, 10 hybrid, 4 system dynamics, 4 network, and 2 discrete event simulation models. Most studies (n = 45) used models for experimental purposes and evaluated effects of simulated RFE policies and interventions. RFE characteristics simulated in models were diverse, and included the features (e.g., prices) customers encounter when shopping (n = 55), the settings (e.g., restaurants, supermarkets) where customers purchase food and beverages (n = 30), and the actors (e.g., store managers, suppliers) who make decisions that influence RFEs (n = 25). All models incorporated characteristics of complexity (e.g., feedbacks, conceptual representation of multiple levels), but these were captured to varying degrees across model types. The quality of methods was adequate overall; however, few studies engaged stakeholders (n = 10) or provided sufficient transparency to verify the model (n = 12). Complex systems models are increasingly utilized to study RFEs and their contributions to public health. Opportunities to advance the use of these approaches remain, and areas to improve future research are discussed. This comprehensive review provides the first marker of the utility of leveraging these approaches to address RFEs for population health.
... In terms of research aims found in the 23 articles, four themes emerged: 1) to examine the complexity of a public health topic and illustrate complex systems thinking [26][27][28][29][30][31][32][33][34]; 2) to discuss the complexity of a public health intervention [35][36][37][38][39][40]; 3) to describe study protocol and how CLDs were created [41][42][43][44]; and 4) to illustrate how CLDs can be used to monitor and track initiatives to improve population health or evaluate impact of interventions [45][46][47][48]. ...
... Health systems are complex adaptive systems; many interactions among parts produces system behaviour Following on this, feedback loops in complex systems were explicitly discussed in all articles to some extent. Jalali et al. [38] described these in terms of "causal chains of multiple variables in which changes in each variable could be traced back to its historical values." They go on to define the difference between reinforcing and balancing feedback loops. ...
... Some articles described this as providing "the opportunity to understand, test, and revise our understanding of how the different components in a system work together" [31] and "to study complex problems as the manifestation of dynamic interactions among their constituent parts" [36]. Furthermore, a few articles expanded the discussion to include such concepts as boundary judgement [38,43,47], that is, "establishing boundaries to the system is a fundamental starting point to efforts to change systems" [47]. ...
Objectives: Complex systems thinking methods are increasingly called for and used as analytical lenses in public health research. The use of qualitative system mapping and in particular, causal loop diagrams (CLDs) is described as one promising method or tool. To our knowledge there are no published literature reviews that synthesize public health research regarding how CLDs are created and used.
Methods: We conducted a scoping review to address this gap in the public health literature. Inclusion criteria included: 1) focused on public health research, 2) peer reviewed journal article, 3) described and/or created a CLD, and 4) published in English from January 2018 to March 2021. Twenty-three articles were selected from the search strategy.
Results: CLDs were described as a new tool and were based upon primary and secondary data, researcher driven and group processes, and numerous data analysis methods and frameworks. Intended uses of CLDs ranged from illustrating complexity to informing policy and practice.
Conclusion: From our learnings we propose nine recommendations for building knowledge and skill in creating and using CLDs for future public health research.
... To the authors' knowledge, only two examples of the application of CBPR, systems science, and implementation science exist in the current literature-both pertaining to childhood obesity in cities in the United States. The first example applied a combined approach toward the design and implementation of interventions to enhance healthy offerings at carry-out shops and corner stores in Baltimore, MD. 52 The authors utilized previously collected and published intervention data and newly collected qualitative data to create an underlying causal loop diagram and then developed a systems dynamics model to understand factors affecting adoption, implementation, and maintenance (AIM of the Reach, Effectiveness, Adoption, Implementation, Maintenance [RE-AIM] framework) 53 of the interventions. 52 The authors identified stakeholder (storeowner) motivation and early and continued communication between the interventionist and stakeholder to be the most critical elements for intervention success, and provide specific details on how these may be operationalized in the practice setting. ...
... The first example applied a combined approach toward the design and implementation of interventions to enhance healthy offerings at carry-out shops and corner stores in Baltimore, MD. 52 The authors utilized previously collected and published intervention data and newly collected qualitative data to create an underlying causal loop diagram and then developed a systems dynamics model to understand factors affecting adoption, implementation, and maintenance (AIM of the Reach, Effectiveness, Adoption, Implementation, Maintenance [RE-AIM] framework) 53 of the interventions. 52 The authors identified stakeholder (storeowner) motivation and early and continued communication between the interventionist and stakeholder to be the most critical elements for intervention success, and provide specific details on how these may be operationalized in the practice setting. 52 Moreover, the projects described represent a deep, trusted, and longstanding partnership in research between the academic institution and the community 54 -thus more meaningfully reflecting the priorities of the target population instead of merely being in the community setting. ...
... 52 The authors identified stakeholder (storeowner) motivation and early and continued communication between the interventionist and stakeholder to be the most critical elements for intervention success, and provide specific details on how these may be operationalized in the practice setting. 52 Moreover, the projects described represent a deep, trusted, and longstanding partnership in research between the academic institution and the community 54 -thus more meaningfully reflecting the priorities of the target population instead of merely being in the community setting. ...
Purpose: Dietary behaviors are key modifiable risk factors in averting cardiovascular disease (CVD), the leading cause of morbidity, mortality, and disability in the United States. Before investing in adoption and implementation, community-based organizations, public health practitioners, and policymakers—often working with limited resources—need to compare the population health impacts of different food policies and programs to determine priorities, build capacity, and maximize resources. Numerous reports, reviews, and policy briefs have synthesized across evidence-based policies and programs to make recommendations, but few have made a deep acknowledgment that dietary policies and programs are not implemented in a vacuum, and that “real-world” settings are complex, multifaceted and dynamic.
Methods: A narrative review was conducted of currently recommended evidence-based approaches to improving dietary behaviors, to describe and characterize applied and practical factors for consideration when adopting and implementing these dietary policies and programs across diverse settings.
Results: From the narrative review, six key considerations emerged to guide community-based organizations, public health practitioners, and policymakers on moving from the evidence base, toward implementation in local and community settings.
Conclusions: Considerations of “real-world” contextual factors are necessary and important when adopting and selecting evidence-based policies and programs to improve dietary behaviors and ultimately improve CVD outcomes. Promising approaches include those that apply community-partnered research and systems science to examine the equitable implementation of evidence-based dietary policies and programs.
... They include feedback loops which are circular relationships between variables that can reinforce or balance change. Causal loop diagrams can provide insight into factors that influence a program's effectiveness and the kinds of changes it can achieve (34,35). ...
... Causal loop diagrams can act as a complexity sensitive theory of change (49)(50)(51). Causal loop diagrams have been used in other studies seeking to understand public health programs including prevention marketing (51), policy adoption (52), peerbased programs (21) and obesity prevention (35). However, they have not been used to evaluate a research or evaluation capacity building program (33). ...
The capacity to engage in research, evaluation and evidence-informed decision-making supports effective public health policy and practice. Little is known about partnership-based approaches that aim to build capacity across a system or how to evaluate them. This study examines the impacts of a research and evaluation capacity building partnership called the Western Australian Sexual Health and Blood-borne Virus Applied Research and Evaluation Network (hereafter, SiREN). SiREN aims to strengthen capacity across a system of clinical and medical services and government and non-government organizations. These organizations are connected through their shared aim of preventing and managing sexually transmissible infections and blood-borne viruses. To examine SiREN, systems concepts and methods were used. Data were collected from SiREN organizational documents (n = 42), a survey tool (n = 104), in-depth interviews (n = 17), a workshop and three meetings with SiREN stakeholders and used to develop two causal loop diagrams. Findings show engagement with SiREN was influenced by a complex interplay of contextual (e.g., organizational capacity) and process (e.g., presence of trusting relationships) factors. SiREN contributed to system level changes, including increased resources for research and evaluation, the development of networks and partnerships that led to more efficient responses to emerging health issues, evidence sharing, and sustainable research and evaluation practice. The use of causal loop diagrams enabled the identification of key leverage points that SiREN can use for continuous improvement or evaluation. The focus on how contextual factors influenced SiREN's ability to create change provides valuable information for researchers, policymakers or practitioners seeking to develop a similar partnership.
... We also consider value creation through exogenous drivers outside of the model such as project complexity and uncertainty. These exogenous variables are outside (input) variables that affect but are not affected by the system (Jalali et al., 2017). Here, we not only take endogenous and exogenous perspectives but also quantify the feedback mechanisms. ...
... To fulfil the research aim, we integrated the existing feedback loops and causal relationships in the literature (Ford and Sterman, 1998;Lyneis and Ford, 2007;Pargar et al., 2019) and quantified these mechanisms into a detailed simulation model. Detailed explanation of quantification of the causal loop diagrams provides insights drawn from complex causal pathways with the aid of computational tools (Jalali et al., 2017). Quantitative model also allows us to quantify the relationship between variables and the outputs of interest to assess the plausibility of dynamic hypotheses. ...
The focus of this paper is on analyzing the value creation dynamics in the project implementation phase. By value creation, we mean the activities, processes, and strategies that the project team uses to increase benefits and/or reduce costs in the project. By synthesizing the literature on project management and system dynamics, we developed a simulation model with various structures underlying project dynamics. We considered four structures that influence project realized value: project team features, project characteristics, project controls and value creation processes, and project remedial actions due to ripple effects. The resulting model can systematically examine the interplay of value creation processes: work progression, rework, redesign and innovation, and rescheduling. We used the model to explain how the project team’s capability, motivation, and speed of making the best-for-project decisions ensure that the value creation goals are met. We simulate various scenarios that show the significance of the processes and their influencing structures on the realized value. The results present how endogenous and exogenous drivers of system behavior unfold over time and provide a richer understanding of the effect of various model structures such as project complexity and uncertainty on value creation.
... Researchers from Johns Hopkins Bloomberg School of Public Health worked with the carry-out vendors to design and implement the intervention, which included changes in menu items, raw material suppliers, marketing and presentation of stores, and pricing of items. We do not present the BHC here-it is thoroughly discussed in [34,35]. Our discussions and analyses in this article are based on Shape NC and HFEH and are consistent with the BHC case, increasing the generalizability of our findings. ...
... We suggest that these reinforcing mechanisms can create path dependencies in capability evolution trajectories (capabilities achieved due to the implemented interventions) across organizations, leading to heterogeneity in performance, even when the elements of the intervention are relatively well-known. Similar dynamic mechanisms were presented for the BHC case in [34]. The basic design, implementation, and maintenance of new organizational processes are shared in developing many health interventions. ...
In this study, we present case studies to explore the dynamics of implementation and maintenance of health interventions. We analyze how specific interventions are built and eroded, how the building and erosion mechanisms are interconnected, and why we can see significantly different erosion rates across otherwise similar organizations. We use multiple comparative obesity prevention case studies to provide empirical information on the mechanisms of interest, and use qualitative systems modeling to integrate our evolving understanding into an internally consistent and transparent theory of the phenomenon. Our preliminary results identify reinforcing feedback mechanisms, including design of organizational processes, motivation of stakeholders, and communication among stakeholders, which influence implementation and maintenance of intervention components. Over time, these feedback mechanisms may drive a wedge between otherwise similar organizations, leading to distinct configurations of implementation and maintenance processes.
... We focused on adoption given its significance in the integration and scale-up of interventions. Public health interventions rely not only on their efficacy but also on successful adoption [14]. ...
Background
School and Community-embedded reproductive health interventions have been implemented in developing countries, with evidence that they led to improved sexual and reproductive health among adolescents. However, this type of intervention is rarely evaluated for its potential adoption and use. This study evaluated the constraints and enablers of the adoption of a school and community-embedded intervention that used community engagement, capacity building, partnerships and collaborations to deliver sexual and reproductive health services to adolescents.
Methods
The intervention was implemented between 2019 and 2021 in six local government areas in Ebonyi State. The results on adoption presented here were collected four months into the mid-phase of the project, targeting adolescents, parents, adult family members, healthcare providers, local authorities, and community members. Sixteen in-depth interviews were conducted with policymakers, 14 with health service providers and 18 Focus Group Discussions (FGDs) with parents, community leaders and adolescents who were part of the implementation process. The coding reliability approach, a type of thematic data analysis was used, that involves early theme development and the identification of evidence for the themes.
Results
The adoption of school and community-embedded reproductive health intervention was strong among stakeholders at the early stages of the implementation process. Multi-stakeholder involvement and its multi-component approach made the intervention appealing, thereby enabling its adoption. However, at the later stage, the adoption was constrained by beliefs and norms about sexual and reproductive health (SRH) and the non-incentivisation of stakeholders who acted as advocates at the community level. The sustainability of the intervention may be threatened by the non-incentivisation of stakeholders and the irregular supply of materials and tools to facilitate SRH advocacy at the community level.
Conclusions
The inclusive community-embedded reproductive health intervention was adopted by stakeholders because of the enablers which include timely stakeholder engagement. However, for it to be sustainable, implementers must address the non-incentivising of community-level advocates which serve as constraints.
... CLDs serve as a starting point for quantitative modeling. In this work, SD is used to quantify the aggregate Vaccines 2024, 12, 24 6 of 27 relationship between model variables and outputs of interest to generate insights on plausible scenarios rather than make specific predictions [63]. By capturing interdependencies among variables, SD sheds light on the complexities, delays, and unintended consequences inherent in systems. ...
Health emergencies caused by epidemic-prone pathogens (EPPs) have increased exponentially in recent decades. Although vaccines have proven beneficial, they are unavailable for many pathogens. Furthermore, achieving timely and equitable access to vaccines against EPPs is not trivial. It requires decision-makers to capture numerous interrelated factors across temporal and spatial scales, with significant uncertainties, variability, delays, and feedback loops that give rise to dynamic and unexpected behavior. Therefore, despite progress in filling R&D gaps, the path to licensure and the long-term viability of vaccines against EPPs continues to be unclear. This paper presents a quantitative system dynamics modeling framework to evaluate the long-term sustainability of vaccine supply under different vaccination strategies. Data from both literature and 50 expert interviews are used to model the supply and demand of a prototypical Ebolavirus Zaire (EBOV) vaccine. Specifically, the case study evaluates dynamics associated with proactive vaccination ahead of an outbreak of similar magnitude as the 2018–2020 epidemic in North Kivu, Democratic Republic of the Congo. The scenarios presented demonstrate how uncertainties (e.g., duration of vaccine-induced protection) and design criteria (e.g., priority geographies and groups, target coverage, frequency of boosters) lead to important tradeoffs across policy aims, public health outcomes, and feasibility (e.g., technical, operational, financial). With sufficient context and data, the framework provides a foundation to apply the model to a broad range of additional geographies and priority pathogens. Furthermore, the ability to identify leverage points for long-term preparedness offers directions for further research.
... To date, systems approaches have been used to understand a variety of 'wicked problems' within public health, including adoption of new medical technologies [13,14], the effectiveness of health care systems [8,15], sustainability of public health interventions [16], substance use [17,18], the determining factors which influence sedentary behaviours [19,20] and levels of obesity [21][22][23][24], neonatal mortality [25], among others. Traditionally, research in public health has heavily relied on experimental designs, following a deductive process to test hypotheses. ...
Background
Increasingly, public health faces challenges requiring complex, multifaceted and multi-sectoral responses. This calls for systems-based approaches that facilitate the kind of collective and collaborative thinking and working required to address complexity. While the literature on systems thinking, system dynamics and the associated methodologies is extensive, there remains little clear guidance on how to plan, govern and implement participatory systems approaches within a co-creation process.
Methods
We used a three-step process to develop DISCOVER, a framework for implementing, and governing systems-based co-creation:Stage 1: We conducted a literature analysis of key texts to identify well-documented methods and phases for co-creation using a systems approach, as well as areas where gaps existed.
Stage 2: We looked for the most appropriate methods and approaches to fill the gaps in the knowledge production chain.
Stage 3: We developed the framework, identifying how the different tools and approaches fit together end-to-end, from sampling and recruiting participants all the way through to responding with an action plan.
Results
We devised DISCOVER to help guide researchers and stakeholders to collectively respond to complex social, health and wider problems. DISCOVER is a strategic research planning and governance framework that provides an actionable, systematic way to conceptualise complex problems and move from evidence to action, using systems approaches and co-creation. In this article, we introduce the eight-step framework and provide an illustrative case study showcasing its potential. The framework integrates complementary approaches and methods from social network analysis, systems thinking and co-creation literature. The eight steps are followed sequentially but can overlap.
Conclusions
DISCOVER increases rigour and transparency in system approaches to tackling complex issues going from planning to action. It is being piloted in environmental health research but may be suitable to address other complex challenges and could be incorporated into research proposals and protocols for future projects.
... 1. What are the effects of poor mental wellbeing on dietary, PA, and sleep behaviors that contribute to AdOWOB prevalence? 2. What are the effects of potential mental wellbeing intervention points in the system on the prevention and mitigation of current obesity trends? 2 | METHODS 2.1 | The SD modeling approach SD modeling has been increasingly employed in public health 42 and specifically in obesity prevention research, policy, and practice. [43][44][45][46][47] The development of a SD model is an iterative process that typically involves the following steps. 41,48 First, a problem is defined in terms of behavior over time of main performance indicators (e.g., obesity prevalence). ...
Both obesity and poor mental wellbeing have a high prevalence in European youth. Adolescents in six countries identified mental wellbeing factors as main drivers of youth obesity through systems mapping. This study sought to (1) explore the dynamics of the interplay between poor mental wellbeing, energy balance-related behaviors , and adolescent overweight and obesity prevalence and (2) test the effect of intervention point scenarios to reduce adolescent obesity. Drawing on the youth-generated systems maps and a literature synthesis, we built a simulation model that represents the links from major feedback pathways for poor mental wellbeing to changes in dietary, physical activity, and sleep behaviors. The model was calibrated using survey data from Norway, expert input, and literature and shows a good fit between simulated behavior and available statistical data. The simulations indicate that adolescent mental wellbeing is harmed by socio-cultural pressures and stressors, which trigger reinforcing feedback mechanisms related to emotional/binge eating, lack of motivation to engage in physical activity, and sleep difficulty. Targeting a combination of intervention points that support a 25% reduction of pressure on body image and psychosocial stress showed potentially favorable effects on mental wellbeing-doubling on average for boys and girls and decreasing obesity prevalence by over 4%.
... Here, there are no single root causes. With a few exceptions (e.g., Cohen, 2017;Jalali, Rahmandad, Bullock, Lee-Kwan, Gittelsohn, & Ammerman, 2019;Kochan, Nowicki, Sauser, & Randall, 2018;Mahamoud et al., 2013), the application of methods to analyze feedback loops in public health is a nascent phenomenon that requires further development (Carey, Malbon, Carey, Joyce, Crammond, & Carey, 2015;Chughtai & Blanchet, 2017). ...
The objective of this thought leadership article is to create a systems view of drug shortages based on the perceptions of practitioners and policymakers. We develop a comprehensive framework describing what stakeholders are currently doing when faced with drug shortages and show the outcomes of their actions. In a review of practitioner literature and public reports published from 2010 to 2020, we identify cause‐and‐effect relationships related to generic drug shortages in six high‐income European countries (Belgium, France, the Netherlands, Norway, Sweden, and the UK) in normal times. By combining and connecting data from these different sources, we develop a systems view of the current state. Though several of the associations covered in the systems view are well known, putting them all together and considering their interrelationships is what is offered by this research. Based on this systems view, we derive three basic solution archetypes for drug shortages: (1) let the market handle it; (2) search for alternatives; and (3) bend the rules. The interactions between these archetypes generate causal ambiguity making it harder to understand and solve the problem as the side effects of solutions can be missed. We show how the interaction of archetypes can compromise intended behavior or escalate unintended behavior. However, our systems view allows us to suggest higher‐level solution archetypes that overrule such side effects. The basic and higher‐order solution archetypes can provide baselines for research and support the development of future interventions.
... System dynamics models (SDMs) or compartmental models have been broadly used to capture the nonlinear dynamics of complex systems over time and integrate the time delays and feedback loops prevalent in disease transmission and progression as well as in public health [16]. SDMs have been widely applied in investigating contagious diseases [17,18] and non-communicable chronic diseases [19,20]. The applications of SDMs have been widely seen in the areas of health service improvement [21,22], impact assessments of policies and interventions [23][24][25][26], resource allocation [25], national health planning [27,28], and the determining the complexities of health-related socioeconomic systems [29,30]. ...
COVID-19 scenarios were run using an epidemiological mathematical model (system dynamics model) and counterfactual analysis to simulate the impacts of different control and containment measures on cumulative infections and deaths in Bangladesh and Pakistan. The simulations were based on national-level data concerning vaccination level, hospital capacity, and other factors, from the World Health Organization, the World Bank, and the Our World in Data web portal. These data were added to cumulative infections and death data from government agencies covering the period from 18 March 2020 to 28 February 2022. Baseline curves for Pakistan and Bangladesh were obtained using piecewise fitting with a consideration of different events against the reported data and allowing for less than 5% random errors in cumulative infections and deaths. The results indicate that Bangladesh could have achieved more reductions in each key outcome measure by shifting its initial lockdown at least five days backward, while Pakistan would have needed to extend its lockdown to achieve comparable improvements. Bangladesh’s second lockdown appears to have been better timed than Pakistan’s. There were potential benefits from starting the third lockdown two weeks earlier for Bangladesh and from combining this with the fourth lockdown or canceling the fourth lockdown altogether. Adding a two-week lockdown at the beginning of the upward slope of the second wave could have led to a more than 40 percent reduction in cumulative infections and a 35 percent reduction in cumulative deaths for both countries. However, Bangladesh’s reductions were more sensitive to the duration of the lockdown. Pakistan’s response was more constrained by medical resources, while Bangladesh’s outcomes were more sensitive to both vaccination timing and capacities. More benefits were lost when combining multiple scenarios for Bangladesh compared to the same combinations in Pakistan. Clearly, cumulative infections and deaths could have been highly impacted by adjusting the control and containment measures in both national settings. However, COVID-19 outcomes were more sensitive to adjustment interventions for the Bangladesh context. Disaggregated analyses, using a wider range of factors, may reveal several sub-national dynamics. Nonetheless, the current research demonstrates the relevance of lockdown timing adjustments and discrete adjustments to several other control and containment measures.
... Although initial findings regarding WSAs are promising, a cautionary approach is advised as descriptions of what constitute a WSA and outcomes reported in some studies were limited. Furthermore, long-term evaluation of WSAs is lacking in the available literature and it remains unclear how WSA are implemented and how the interactions between the stakeholders, processes, and other elements driving the implementation process affect WSA success, an area where System Dynamics Modelling (SDM) can provide important insights [3]. To address some shortcomings of existing evidence regarding WSAs, Public Heath England (2019) [4] provided a six-phase framework, referred to as the 'Leeds Beckett Model' regarding how to apply a WSA to diet and healthy weight. ...
Obesity is a global epidemic affecting all age groups, populations and income levels across continents. The causes of obesity are complex and are routed in health behaviours, environmental factors, government policy and the cultural and built environment. Consequently, a Whole System Approach (WSA) which considers the many causes of obesity and shifts the focus away from individuals as points of intervention and puts an emphasis on understanding and improving the system in which people live in is required. This protocol describes a programme of research that will: critically evaluate the evidence for WSAs; assess longitudinally the implementation of a WSA to diet and healthy weight to explore the range of levers (drivers) and opportunities to influence relevant partnerships and interventions to target obesity in East Scotland. The programme consists of four workstreams within a mixed methods framework: 1) Systematic review of reviews of WSAs to diet and healthy weight; 2) Longitudinal qualitative process evaluation of implementing two WSAs in Scotland; 3) Quantitative and Qualitative momentary analysis evaluation of a WSA; and 4) the application of System Dynamics Modelling (SDM) methodology to two council areas in Scotland. A Public Involvement in Research group (PIRg) have informed each stage of the research process. The research programme’s breadth and its novel nature, mean that it will provide valuable findings for the increasing numbers who commission, deliver, support and evaluate WSAs to diet and healthy weight nationally and internationally.
... The ideas were further refined prior to publication, but in the conclusion of the article, they are described as tentative, creating an invitation for further development [16]. System dynamics simulation modelling has been used as an implementation science tool in healthcare and health promotion [17], demonstrating its usefulness in adopting a systems approach to implementation science. However, given the cost and time required for simulation, there is a need to fast-track insights generated from simulation into community-based implementation. ...
Background
Systems science approaches have demonstrated effectiveness in identifying underlying drivers of complex problems and facilitating the emergence of potential interventions that are locally tailored, feasible, sustainable and evidence informed. Despite the potential usefulness of system dynamics simulation modelling and other systems science modelling techniques in guiding implementation, time and cost constraints have limited its ability to provide strong guidance on how to implement complex interventions in communities. Guidance is required to ensure systems interventions lead to impactful systems solutions, implemented utilising strategies from the intersecting fields of systems science and implementation science. To provide cost-effective guidance on how and where to implement in systems, we offer a translation of the ‘Meadows 12 places to act in a system’ (Meadows 12) into language useful for public health.
Methods
This translation of Meadows 12 was informed by our experience in working with 31 communities across two complex large scale randomised control trials and one large whole of community case study. These research projects utilised systems science and implementation science to co-create childhood obesity prevention interventions. The team undertaking this translation comprised research academics, implementation specialists and practitioners, practice-based researchers and a systems dynamicist. Our translation of each of the Meadows 12 levels to act in the system maintains the fidelity and nuance of the 12 distinct levels. We provide examples of each level of the Public Health 12 framework (PH12) drawn from 31 communities. All research was conducted in Victoria, Australia between 2016 and 2020.
Results
PH12 provides a framework to guide both research and practice in real world contexts to implement targeted system level interventions. PH12 can be used with existing implementation science theory to identify relevant strategies for implementation of these interventions to impact the system at each of the leverage points.
Conclusion
To date little guidance for public health practitioners and researchers exists regarding how to implement systems change in community-led public health interventions. PH12 enables operationalisation Meadows 12 systems theory into public health interventions. PH12 can help research and practice determine where leverage can be applied in the system to optimise public health systems level interventions and identify gaps in existing efforts.
Trial registration
WHO STOPS: ANZCTR: 12616000980437 . RESPOND: ANZCTR: 12618001986268p .
... Outputs of the simulation were predictions of the total weight reduced [174]. The issue of effective obesity prevention was studied by Jalali et al. [175]. The research was focused on the study of dynamics that regulate the adoption, implementation, and maintenance of intervention programs. ...
System dynamics, as a methodology for analyzing and understanding various types of systems, has been applied in research for several decades. We undertook a review to identify the latest application domains and map the realm of system dynamics. The systematic review was conducted according to the PRISMA methodology. We analyzed and categorized 212 articles and found that the vast majority of studies belong to the fields of business administration, health, and environmental research. Altogether, 20 groups of modeling and simulation topics can be recognized. System dynamics is occasionally supported by other modeling methodologies such as the agent-based modeling approach. There are issues related to published studies mostly associated with testing of validity and reasonability of models, leading to the development of predictions that are not grounded in verified models. This study contributes to the development of system dynamics as a methodology that can offer new ideas, highlight limitations, or provide analogies for further research in various research disciplines.
... The BS and obesity have serious industrial implications. Data on the prevalence of these conditions are widely available for developed countries; therefore, these nations have been able to take corrective actions to prevent and manage the incidence of obesity and the BS in the workplace (Jalali et al., 2019). However, in developing countries such as Mexico, the scientific community still needs to explore the occurrence of these conditions, their relationship, and the implications of such relationships for the industrial sector. ...
Burnout syndrome (BS) and obesity are two growing conditions that affect employees’ health and company productivity. Recently, several studies have pointed to a possible relationship between both phenomena. However, such a relationship has not been clearly defined. This research analyzes the relationship between BS dimensions and body mass index (BMI), the latter being treated as a moderator variable among obese senior and middle managers in the Mexican maquiladora industry through a structural equation model. A total of 361 senior and middle managers (124 of them classified as obese under the World Health Organization’s criteria) completed both the Maslach Burnout Inventory-General Survey [with emotional exhaustion (EE), cynicism, and professional efficacy (PE) as subscale dimensions] and a sociodemographic questionnaire (which included BMI). The results showed a statistically significant relationship between EE and PE (P < 0.001; β = -0.320), with BMI acting as a moderator variable. The results showed that when BMI increases as a moderator variable, the strength of the relationship between EE and PE also changes. For example, although PE had a negative value of 0.14 before the moderator effect, the value increased up to 0.32 when the BMI was factored into the relationship. Therefore, maquiladora industries are being advised to increase their investments on the identification and prevention of employees’ EE and obesity. Such interventions would promote a better quality of life and could prevent economic losses resulting from poor employee performance.
... There is a large body of literature on quantitative methods for complex systems approaches and some examples of such methods being applied to the study of policies and interventions that may affect population health [28][29][30][31][32][33]. Many of these approaches build simulation models that estimate and predict the impact of interventions on outcomes of interest [34]. ...
Background
Public health evaluation methods have been criticized for being overly reductionist and failing to generate suitable evidence for public health decision-making. A “complex systems approach” has been advocated to account for real world complexity. Qualitative methods may be well suited to understanding change in complex social environments, but guidance on applying a complex systems approach to inform qualitative research remains limited and underdeveloped. This systematic review aims to analyze published examples of process evaluations that utilize qualitative methods that involve a complex systems perspective and proposes a framework for qualitative complex system process evaluations.
Methods and findings
We conducted a systematic search to identify complex system process evaluations that involve qualitative methods by searching electronic databases from January 1, 2014–September 30, 2019 (Scopus, MEDLINE, Web of Science), citation searching, and expert consultations. Process evaluations were included if they self-identified as taking a systems- or complexity-oriented approach, integrated qualitative methods, reported empirical findings, and evaluated public health interventions. Two reviewers independently assessed each study to identify concepts associated with the systems thinking and complexity science traditions. Twenty-one unique studies were identified evaluating a wide range of public health interventions in, for example, urban planning, sexual health, violence prevention, substance use, and community transformation. Evaluations were conducted in settings such as schools, workplaces, and neighborhoods in 13 different countries (9 high-income and 4 middle-income). All reported some utilization of complex systems concepts in the analysis of qualitative data. In 14 evaluations, the consideration of complex systems influenced intervention design, evaluation planning, or fieldwork. The identified studies used systems concepts to depict and describe a system at one point in time. Only 4 evaluations explicitly utilized a range of complexity concepts to assess changes within the system resulting from, or co-occurring with, intervention implementation over time. Limitations to our approach are including only English-language papers, reliance on study authors reporting their utilization of complex systems concepts, and subjective judgment from the reviewers relating to which concepts featured in each study.
Conclusion
This study found no consensus on what bringing a complex systems perspective to public health process evaluations with qualitative methods looks like in practice and that many studies of this nature describe static systems at a single time point. We suggest future studies use a 2-phase framework for qualitative process evaluations that seek to assess changes over time from a complex systems perspective. The first phase involves producing a description of the system and identifying hypotheses about how the system may change in response to the intervention. The second phase involves following the pathway of emergent findings in an adaptive evaluation approach.
... In fact, no one simulation model for opioids can answer all research questions. In other areas of research, such as obesity [21,22] and infectious diseases (e.g. HIV/AIDS) [23][24][25], a stream of systems science research helped intervention and policy development. ...
Abstract The opioid epidemic in the United States has had a devastating impact on millions of people as well as on their families and communities. The increased prevalence of opioid misuse, use disorder and overdose in recent years has highlighted the need for improved public health approaches for reducing the tremendous harms of this illness. In this paper, we explain and call for the need for more systems science approaches, which can uncover the complexities of the opioid crisis, and help evaluate, analyse and forecast the effectiveness of ongoing and new policy interventions. Similar to how a stream of systems science research helped policy development in infectious diseases and obesity, more systems science research is needed in opioids.
... First, few studies have focused on managerial issues of healthcare delivery. In general, SD has contributed extensively to management and organizational science literature; however, fewer SD studies have contributed to understanding specific managerial problems of healthcare providers or organizational challenges of implementation of health interventions (Jalali et al. [2019] is an exception). Future studies can adapt previous SD models developed for improving organizational processes for use in healthcare management. ...
This article reports the first systematic literature review of system dynamics (SD) applications in health and medicine published between 1960 and 2018. We categorize SD contributions into three groups—disease‐related modeling, organizational modeling, and regional health modeling—and explore major trends and approaches. We then focus on disease‐related modeling and discuss (1) common structures underlying models of infectious and noninfectious diseases, (2) major findings and modeling insights, and (3) avenues for future modeling efforts. While application areas cover a wide range of contexts, a considerable level of quality variation is observable, particularly in regards to model documentation, use of data, and model validation. While these shortcomings are not specific to SD modeling—and other schools of modeling often suffer from similar problems—we invite the community to address the issues both as authors and reviewers. Our study provides a reference document for several exemplary SD models, which is especially useful for early career modelers.
© 2020 System Dynamics Society
... For instance, maintaining the quality of nonprofit medical services is particularly challenging for e-hospitals constructed by for-profit companies. Therefore, establishing a government supervision mechanism [69] and increasing communication among stakeholders may play a key role in assuring the quality of adoption [70]. In addition, evaluation efforts should incorporate robust measures to document the outcomes of e-hospitals and establish a pathway for quick resolution of reported issues. ...
Background: As an innovative approach to providing web-based health care services from physical hospitals to patients at a distance, e-hospitals (ie, extended care hospitals through the internet) have been extensively developed in China. This closed health care delivery chain was developed by combining e-hospitals with physical hospitals; treatment begins with web-based consultation and registration, and then, patients are diagnosed and treated in a physical hospital. This approach is promising in its ability to improve accessibility, efficiency, and quality of health care. However, there is limited research on end users’ acceptance of e-hospitals and the effectiveness of strategies aimed to prompt the adoption of e-hospitals in China.
Objective: This study aimed to provide insights regarding the adoption of e-hospitals by investigating patients’ willingness to use e-hospitals and analyzing the barriers and facilitators to the adoption of this technology.
Methods: We used a pretested self-administered questionnaire and performed a cross-sectional analysis in 1032 patients across three hierarchical hospitals in West China from June to August 2019. Patients’ sociodemographic characteristics, medical history, current disease status, proficiency with electronic devices, previous experience with web-based health services, willingness to use e-hospitals, and perceived facilitators and barriers were surveyed. Multiple significance tests were employed to examine disparities across four age groups, as well as those between patients who were willing to use e-hospitals and those who were not. Multivariate logistic regression was also performed to identify the potential predictors of willingness to use e-hospitals.
Results: Overall, it was found that 65.6% (677/1032) of participants were willing to use e-hospitals. The significant predictors of willingness to use e-hospitals were employment status (P=.02), living with children (P<.001), education level (P=.046), information technology skills (P<.001), and prior experience with web-based health care services (P<.001), whereas age, income, medical insurance, and familiarity with e-hospitals were not predictors. Additionally, the prominent facilitators of e-hospitals were convenience (641/677, 94.7%) and accessibility to skilled medical experts (489/677, 72.2%). The most frequently perceived barrier varied among age groups; seniors most often reported their inability to operate technological devices as a barrier (144/166, 86.7%), whereas young participants most often reported that they avoided e-hospital services because they were accustomed to face-to-face consultation (39/52, 75%).
Conclusions: We identified the variables, facilitators, and barriers that play essential roles in the adoption of e-hospitals. Based on our findings, we suggest that efforts to increase the adoption of e-hospitals should focus on making target populations accustomed to web-based health care services while maximizing ease of use and providing assistance for technological inquiries.
... For instance, maintaining the quality of nonprofit medical services is particularly challenging for e-hospitals constructed by for-profit companies. Therefore, establishing a government supervision mechanism [69] and increasing communication among stakeholders may play a key role in assuring the quality of adoption [70]. In addition, evaluation efforts should incorporate robust measures to document the outcomes of e-hospitals and establish a pathway for quick resolution of reported issues. ...
Background
As an innovative approach to providing web-based health care services from physical hospitals to patients at a distance, e-hospitals (ie, extended care hospitals through the internet) have been extensively developed in China. This closed health care delivery chain was developed by combining e-hospitals with physical hospitals; treatment begins with web-based consultation and registration, and then, patients are diagnosed and treated in a physical hospital. This approach is promising in its ability to improve accessibility, efficiency, and quality of health care. However, there is limited research on end users’ acceptance of e-hospitals and the effectiveness of strategies aimed to prompt the adoption of e-hospitals in China.
Objective
This study aimed to provide insights regarding the adoption of e-hospitals by investigating patients’ willingness to use e-hospitals and analyzing the barriers and facilitators to the adoption of this technology.
Methods
We used a pretested self-administered questionnaire and performed a cross-sectional analysis in 1032 patients across three hierarchical hospitals in West China from June to August 2019. Patients’ sociodemographic characteristics, medical history, current disease status, proficiency with electronic devices, previous experience with web-based health services, willingness to use e-hospitals, and perceived facilitators and barriers were surveyed. Multiple significance tests were employed to examine disparities across four age groups, as well as those between patients who were willing to use e-hospitals and those who were not. Multivariate logistic regression was also performed to identify the potential predictors of willingness to use e-hospitals.
ResultsOverall, it was found that 65.6% (677/1032) of participants were willing to use e-hospitals. The significant predictors of willingness to use e-hospitals were employment status (P=.02), living with children (P
... This qualitative method is widely used in the public health domain (e.g., see [114][115][116] ) and incorporates positive and negative feedback loops to illustrate the different causal aspects of the problem that perpetuate, reinforce, and balance the system. Stock and flow diagrams and system archetypes are quantitative models which capture the movement and behavior of the elements within the system (e.g., see [117][118][119][120] for applications in public health and health policy). See 121 for more information about systems science tools used in public health. ...
The prevalence of opioid use and misuse has provoked a staggering number of deaths over the past two and a half decades. Much attention has focused on individual risks according to various characteristics and experiences. However, broader social and contextual domains are also essential contributors to the opioid crisis such as interpersonal relationships and the conditions of the community and society that people live in. Despite efforts to tackle the issue, the rates of opioid misuse and non-fatal and fatal overdose remain high. Many call for a broad public health approach, but articulation of what such a strategy could entail has not been fully realised. In order to improve the awareness surrounding opioid misuse, we developed a social-ecological framework that helps conceptualise the multivariable risk factors of opioid misuse and facilitates reviewing them in individual, interpersonal, communal and societal levels. Our framework illustrates the multi-layer complexity of the opioid crisis that more completely captures the crisis as a multidimensional issue requiring a broader and integrated approach to prevention and treatment.
... The SD is a methodology for understanding and evaluating the nonlinear behavior of complex problems and feedback loops over time [20]. This methodology was used in analyzing various public health issues such as depression, obesity, infant mortality, diabetes, and post-traumatic stress disorder to provide insights to policymakers in understanding the problem and providing solutions [21][22][23][24][25][26][27]. ...
Preterm birth rate (PBR) stands out as a major public health concern in the U.S. However, effective policies for mitigating the problem is largely unknown. The complexities of the problem raise critical questions: Why is PBR increasing despite the massive investment for reducing it? What policies can decrease it? To address these questions, we develop a causal loop diagram to investigate mechanisms underlying high preterm rate in a community. Our boundary is broad and includes medical and education systems, as well as living conditions such as crime rate and housing price. Then, we built a simulation model and divided the population into two groups based on their chance of delivering a preterm baby. We calibrated the model using the historical data of a case study, Cuyahoga Ohio, from 1995 to 2017. Prior studies mostly applied reductionist approaches to determine factors associated with high preterm rate at the individual level. Our simulation model examines the reciprocal influences of multiple factors and investigates the effect of different resource allocation scenarios on the PBR. Results show that, in the case of Cuyahoga county with one of the highest rates of PBR in the U.S., estimated preterm birth rates will not be lower than the rates of 1995 during the next five years.
The cost of physical inactivity is alarming, and calls for whole-of-system approaches to population physical activity promotion (PPAP) are increasing. One innovative approach to PPAP is to use a framework of interdependent attributes and associated dimensions of effective systems for chronic disease prevention. Describing system boundaries can be an elusive task, and this article reports on using an attribute framework as a first step in describing and then assessing and strengthening a provincial system for PPAP in British Columbia, Canada. Interviews were conducted with provincial stakeholders to gather perspectives regarding attributes of the system. Following this, two workshops were facilitated to document important stories about the current system for PPAP and link story themes with attributes. Results from interviews and workshops were summarized into key findings and a set of descriptive statements. One hundred and twenty-one statements provide depth, breadth and scope to descriptions of the system through the lens of an adapted framework including four attributes: (i) implementation of desired actions, (ii) resources, (iii) leadership and (iv) collaborative capacity. The attribute framework was a useful tool to guide a whole-of-system approach and turn elusive boundaries into rich descriptors of a provincial system for PPAP. Immediate implications for our research are to translate descriptive statements into variables, then assess the system through group model building and identify leverage points from a causal loop diagram to strengthen the system. Future application of this approach in other contexts, settings and health promotion and disease prevention topics is recommended.
Tackling the Root Causes Upstream of Unhealth Urban Development” is a trans‐disciplinary research project seeking to map and understand urban development decision‐making, visualise stakeholder mental models and codevelop improvement interventions. The project's primary data was gathered through 123 semistructured interviews. This article applies, compares, and discusses four variations on a method for constructing causal loop diagrams to illuminate mental models and collective decision‐making, based on manual and semiautomated processes applied to individual interview transcripts and datasets collected by thematic analysis. It concludes that while semiautomated approaches offer some time saving over manual approaches when applied to large data sets, care is required in interpreting and including peripheral contextual variables at the boundaries of the thematic analysis. Decisions regarding automation depend on the purpose of the modelling. Finally, the article recommends future applications record quantitative descriptors characterising the process of constructing CLDs from large qualitative data sets. © 2023 The Authors. System Dynamics Review published by John Wiley & Sons Ltd on behalf of System Dynamics Society.
The rapid spread of COVID-19 in Ethiopia was attributed to joint effects of multiple factors such as low adherence to face mask-wearing, failure to comply with social distancing measures, many people attending religious worship activities and holiday events, extensive protests, country election rallies during the pandemic, and the war between the federal government and Tigray Region. This study built a system dynamics model to capture COVID-19 characteristics, major social events, stringencies of containment measures, and vaccination dynamics. This system dynamics model served as a framework for understanding the issues and gaps in the containment measures against COVID-19 in the past period (16 scenarios) and the spread dynamics of the infectious disease over the next year under a combination of different interventions (264 scenarios). In the counterfactual analysis, we found that keeping high mask-wearing adherence since the outbreak of COVID-19 in Ethiopia could have significantly reduced the infection under the condition of low vaccination level or unavailability of the vaccine supply. Reducing or canceling major social events could achieve a better outcome than imposing constraints on people’s routine life activities. The trend analysis found that increasing mask-wearing adherence and enforcing more stringent social distancing were two major measures that can significantly reduce possible infections. Higher mask-wearing adherence had more significant impacts than enforcing social distancing measures in our settings. As the vaccination rate increases, reduced efficacy could cause more infections than shortened immunological periods. Offsetting effects of multiple interventions (strengthening one or more interventions while loosening others) could be applied when the levels or stringencies of one or more interventions need to be adjusted for catering to particular needs (e.g., less stringent social distancing measures to reboot the economy or cushion insufficient resources in some areas).
Intestinal campylobacteriosis, caused by Campylobacter ingestion, is the most reported zoonosis in the EU; it is societally costly and can lead to more severe sequelae. To reduce Campylobacter infections, biosecurity measures at both farms and slaughterhouses are warranted. However, the potential improvements achieved by these interventions have not been quantified. We used a systems science approach to develop a simulation model, synthesizing information from interviews with stakeholders in the Dutch broiler production industry and the current literature. The model includes both farms and slaughterhouses in a “system of systems,” helping to clarify the complexity of interrelated components of these systems and analyse the impact of various interventions. Insects, transportation crates, farm personnel, and catchers were identified as potential Campylobacter sources and modelled as elements of feedback loops. Insect control, farm hygiene, visitor control, thinning, and transportation control interventions were analysed. The model was shown to accurately describe the seasonality of Campylobacter, which supports its validity. Model simulation revealed that insect control interventions had the strongest impacts, followed by combined farm hygiene and visitor control, and combined thinning and transportation control. Insect control interventions alone reduced the peak percentage of contaminated chickens from 51% to 26% and the peak percentage of highly contaminated (>1000 CFU/g) neck samples of chicken carcasses from 13% to 8%. Implementing all interventions concurrently reduced the peak percentages of contaminated chickens to 5% and highly contaminated chicken neck samples to 2%. These results suggest that multiple biosecurity measures must be implemented to reduce Campylobacter contamination.
Change is ubiquitous in the study of organizations. Organizational change is characterized by multiple perspectives, both conceptually and methodologically. Computational modeling efforts are not the exception. In this work, we aim to provide an analysis of computational modeling approaches to organizational change. For that, we first review published works that directly connect to developing knowledge in organizational change from a computational lens. Second, we offer an account of unexplored topics in computational organizational change. Last, we highlight the potentialities of computer simulation models based on agent interactions in regard to how they could contribute to the understanding of central issues in this organizational research subfield.
A imagem corporal é um constructo amplamente estudado e pesquisas nessa área têm aumentado nos últimos anos, entretanto adolescentes com deficiência visual ainda carecem de investigação. Esta revisão sistemática tem por objetivo investigar trabalhos que buscam evidências científicas sobre aspectos da imagem corporal de adolescentes com deficiência visual. Realizou-se uma busca sistemática de artigos em quatro bases de dados, Scopus, PsycInfo, PubMed e Web of Science. O recrutamento dos estudos, sem restrição temporal, foi concluído em 8 de junho de 2019. Foram incluídos 32 artigos, os quais se classificaram em quatro categorias: (1) aspectos psicossociais do corpo, (2) conceito corporal, (3) atividade física/saúde (4) instrumentos de avaliação da imagem corporal e insatisfação corporal. A maioria dos estudos inseridos nesta revisão demonstraram, mediante evidências científicas, que há implicações negativas sobre a imagem corporal de adolescentes com deficiência visual, Alguns achados, contudo, baseiam-se nas limitações da deficiência, valorizando o déficit orgânico. Fazem-se necessários estudos que busquem uma abordagem biopsicossocial na formação da imagem corporal positiva nesta população.
Background
Food retailers in community settings are gatekeepers to the crucial food systems changes needed to improve population nutrition. Evidence-based models of change are needed to enable shifts in these complex retail environments. Systems thinking offers unique insights by capturing potential unintended consequences and multiple pathways to success. This study sought to create a systems map for retailers, public health practitioners and other stakeholders seeking to implement healthy food retail policies. It aimed to identify (i) points of intervention through which community-based organisations can shift to healthier food provision, and (ii) key feedback loops that could drive potential unintended consequences of such policies in a complex system.
Methods
Semi-structured interviews (n = 26) were conducted, from 2015 to 2018, across four community food retail settings where healthy food retail policies had been implemented in Victoria, Australia. Interviews were coded by identifying causal relationships and their direction between factors. Vensim software was used to merge interview results and then reduce the map to the strongest and most frequent factors and relationships. Illustrative implementation stories and points of intervention were identified.
Findings
The resulting map is titled the Systems Thinking Approach for Retail Transformation (START) map. Five prominent implementation stories incorporating 17 factors highlighted that: 1) retailer resistance to change is strongest in the beginning but decreases with the demonstration of favourable initiative outcomes; 2) successive changes tend to be increasingly complex, and therefore harder for retailers to implement; 3) organisational resourcing can be influenced through multiple pathways; 4) customer acceptability of healthy changes and retailers' willingness to engage in changes influence each other; and 5) challenges in accessing healthy supply options make retailers more resistant to implementing healthy changes.
Conclusions
The application of systems thinking to the challenge of unhealthy food retail creates novel and practical insights for retailers and health promotion practitioners into what actions are most likely to promote healthy changes in complex retail environments.
Introduction
Applying a complex systems perspective to public health evaluation may increase the relevance and strength of evidence to improve health and reduce health inequalities. In this review of methods, we aimed to: (i) classify and describe different complex systems methods in evaluation applied to public health; and (ii) examine the kinds of evaluative evidence generated by these different methods.
Methods
We adapted critical review methods to identify evaluations of public health interventions that used systems methods. We conducted expert consultation, searched electronic databases (Scopus, MEDLINE, Web of Science), and followed citations of relevant systematic reviews. Evaluations were included if they self-identified as using systems- or complexity-informed methods and if they evaluated existing or hypothetical public health interventions. Case studies were selected to illustrate different types of complex systems evaluation.
Findings
Seventy-four unique studies met our inclusion criteria. A framework was developed to map the included studies onto different stages of the evaluation process, which parallels the planning, delivery, assessment, and further delivery phases of the interventions they seek to inform; these stages include: 1) theorising; 2) prediction (simulation); 3) process evaluation; 4) impact evaluation; and 5) further prediction (simulation). Within this framework, we broadly categorised methodological approaches as mapping, modelling, network analysis and ‘system framing’ (the application of a complex systems perspective to a range of study designs). Studies frequently applied more than one type of systems method.
Conclusions
A range of complex systems methods can be utilised, adapted, or combined to produce different types of evaluative evidence. Further methodological innovation in systems evaluation may generate stronger evidence to improve health and reduce health inequalities in our complex world.
Background. Whole-of-community interventions have been recommended and show promise for preventing obesity; however, research to understand the mechanisms underlying their success or failure is lacking. Complex systems approaches may be useful to address this gap. Purpose. To describe the evolution and utilization of qualitative and quantitative complex systems methods to understand and model whole-of-community obesity prevention interventions. Approach. We illustrate the retrospective qualitative development of a systems map representing community change dynamic within the Shape Up Somerville (SUS) intervention. We then describe how this systems map, and complementary work of other successful obesity prevention interventions (Romp & Chomp intervention), informed the COMPACT (childhood obesity modeling for prevention and community transformation) study. COMPACT’s design aligns complex systems science principles and community-engaged research to better understand stakeholders’ leadership roles in whole-of-community interventions. We provide an overview of the complex systems tools used in COMPACT: agent-based modeling, group model building, and social network analysis and describe how whole-of-community intervention stakeholders (“agents”) use their social networks to diffuse knowledge about and engagement with childhood obesity prevention efforts, laying the groundwork for community readiness for sustainable change. Conclusion. Complex systems approaches appear feasible and useful to study whole-of-community obesity prevention interventions and provide novel insights that expand on those gained from traditional approaches. Use of multiple methods, both qualitative and quantitative, from the complex systems toolkit working together can be important to success.
Early childhood is a critical period for instilling healthy habits to prevent overweight and obesity. This paper describes the development of an educational intervention for the promotion of healthy eating and physical activity among two-to-four-year-old children in public child care centers (CCCs) in Mexico City. Following the Intervention Mapping (IM) protocol, we developed the Bright Futures multidisciplinary intervention. First, a formative research process to identify the personal and environmental determinants of childhood overweight and obesity, behavioral outcomes and performance objectives was conducted. Then, a matrix of change objectives by intersecting the performance objectives with the determinants was integrated. Bright Futures lasted six months and included 24 weekly sessions, each composed of five phases: warm-up, theory, active movements, relaxation, and hydration. Ad hoc interactive teaching materials focused on recreational activities, and formulated plans for the adoption, implementation and process/impact evaluation of the intervention was developed. IM successfully guided the design of a theory-driven and evidence-based intervention for children in CCCs within a socio-ecological and participatory planning framework. This is one of the first studies in Mexico to use IM in the context of CCCs.
We developed a simulation game to study the effectiveness of decision-makers in overcoming two complexities in building cybersecurity capabilities: potential delays in capability development; and uncertainties in predicting cyber incidents. Analyzing 1479 simulation runs, we compared the performances of a group of experienced professionals with those of an inexperienced control group. Experienced subjects did not understand the mechanisms of delays any better than inexperienced subjects; however, experienced subjects were better able to learn the need for proactive decision-making through an iterative process. Both groups exhibited similar errors when dealing with the uncertainty of cyber incidents. Our findings highlight the importance of training for decision-makers with a focus on systems thinking skills, and lay the groundwork for future research on uncovering mental biases about the complexities of cybersecurity.
The systemic interactions among depressive symptoms, rumination, and stress are important to understanding depression but have not yet been quantified. In this article, we present a system dynamics simulation model of depression that captures the reciprocal relationships among stressors, rumination, and depression. Building on the response styles theory, this model formalizes three interdependent mechanisms: 1) Rumination contributes to ‘keeping stressors alive’; 2) Rumination has a direct impact on depressive symptoms; and 3) Both ‘stressors kept alive’ and current depressive symptoms contribute to rumination. The strength of these mechanisms is estimated using data from 661 adolescents (353 girls and 308 boys) from two middle schools (grades 6-8). These estimates indicate that rumination contributes to depression by keeping stressors ‘alive’—and the individual activated—even after the stressor has ended. This mechanism is stronger among girls than boys, increasing their vulnerability to a rumination reinforcing loop. Different profiles of depression emerge over time depending on initial levels of depressive symptoms, rumination, and stressors as well as the occurrence rate for stressors; levels of rumination and occurrence of stressors are stronger contributors to long-term depression. Our systems model is a steppingstone towards a more comprehensive understanding of depression in which reinforcing feedback mechanisms play a significant role. Future research is needed to expand this simulation model to incorporate other drivers of depression and provide a more holistic tool for studying depression.
A wide range of modeling methods have been used to inform health policies. In this chapter, we describe three models for understanding the complexities of post-traumatic stress disorder (PTSD), a major mental disorder. The models are: (1) a qualitative model describing the social and psychological complexities of PTSD treatment; (2) a system dynamics model of a population of PTSD patients in the military and the Department of Veterans Affairs (VA); and (3) a Monte Carlo simulation model of PTSD prevalence and clinical demand over time among the OEF/OIF population. These models have two characteristics in common. First, they take systems approaches. In all models, we set a large boundary and look at the whole system, incorporating both military personnel and veterans. Second, the models are informed by a wide range of qualitative and quantitative data. Model I is rooted in qualitative data, and models II and III are calibrated to several data sources. These models are used to analyze the effects of different policy alternatives, such as more screening, more resiliency, and better recruitment procedures, on PTSD prevalence. They also provide analysis of healthcare costs in the military and the VA for each policy. Overall, the developed models offer examples of modeling techniques that incorporate a wide range of data sources and inform policy makers in developing programs for mitigating PTSD, a major premise of policy informatics.
In this study, we present case studies to explore the dynamics of implementation and maintenance of health interventions. We analyze how specific interventions are built and eroded, how the building and erosion mechanisms are interconnected, and why we can see significantly different erosion rates across otherwise similar organizations. We use multiple comparative obesity prevention case studies to provide empirical information on the mechanisms of interest, and use qualitative systems modeling to integrate our evolving understanding into an internally consistent and transparent theory of the phenomenon. Our preliminary results identify reinforcing feedback mechanisms, including design of organizational processes, motivation of stakeholders, and communication among stakeholders, which influence implementation and maintenance of intervention components. Over time, these feedback mechanisms may drive a wedge between otherwise similar organizations, leading to distinct configurations of implementation and maintenance processes.
Post-traumatic stress disorder (PTSD) stands out as a major mental illness; however, little is known about effective policies for mitigating the problem. The importance and complexity of PTSD raise critical questions: What are the trends in the population of PTSD patients among military personnel and veterans in the postwar era? What policies can help mitigate PTSD? To address these questions, we developed a system dynamics simulation model of the population of military personnel and veterans affected by PTSD. The model includes both military personnel and veterans in a “system of systems.” This is a novel aspect of our model, since many policies implemented at the military level will potentially influence (and may have side effects on) veterans and the Department of Veterans Affairs. The model is first validated by replicating the historical data on PTSD prevalence among military personnel and veterans from 2000 to 2014 (datasets from the Department of Defense, the Institute of Medicine, the Department of Veterans Affairs, and other sources). The model is then used for health policy analysis. Our results show that, in an optimistic scenario based on the status quo of deployment to intense/combat zones, estimated PTSD prevalence among veterans will be at least 10% during the next decade. The model postulates that during wars, resiliency-related policies are the most effective for decreasing PTSD. In a postwar period, current health policy interventions (e.g., screening and treatment) have marginal effects on mitigating the problem of PTSD, that is, the current screening and treatment policies must be revolutionized to have any noticeable effect. Furthermore, the simulation results show that it takes a long time, on the order of 40 years, to mitigate the psychiatric consequences of a war. Policy and financial implications of the findings are discussed.
To better understand the factors that support or inhibit internally focused change, we conducted an inductive 's attempt to improve two of its core study of one firm business processes. Our data suggest that the critical determinants of success in efforts to learn and improve are the interactions between managers' attributions about the cause of poor organizational performance and the physical structure of the workplace, particularly delays between investing in improvement and recognizing the rewards. Building on this observation, we propose a dynamic model capturing the mutual evolution of those attributions, managers' and workers' actions, and the production technology. We use the model to show how managers' beliefs about those who work for them, workers' beliefs about those who manage them, and the physical structure of the environment can coevolve to yield an organization characterized by conflict, mistrust, and control structures that prevent useful change of any type.
Quantifying human weight and height dynamics due to growth, aging, and energy balance can inform clinical practice and policy analysis. This paper presents the first mechanism-based model spanning full individual life and capturing changes in body weight, composition and height. Integrating previous empirical and modeling findings and validated against several additional empirical studies, the model replicates key trends in human growth including A) Changes in energy requirements from birth to old ages. B) Short and long-term dynamics of body weight and composition. C) Stunted growth with chronic malnutrition and potential for catch up growth. From obesity policy analysis to treating malnutrition and tracking growth trajectories, the model can address diverse policy questions. For example I find that even without further rise in obesity, the gap between healthy and actual Body Mass Indexes (BMIs) has embedded, for different population groups, a surplus of 14%-24% in energy intake which will be a source of significant inertia in obesity trends. In another analysis, energy deficit percentage needed to reduce BMI by one unit is found to be relatively constant across ages. Accompanying documented and freely available simulation model facilitates diverse applications customized to different sub-populations.
In the US, obesity has been recognized as a major public health challenge for over two decades. A large number of obesity interventions, from upstream (policy) to downstream (individual level), have been put forward to curb the obesity trend; however, not all those interventions have been successful. Overall effectiveness of obesity interventions relies not only on the average efficacy of a generic intervention, but also on the successful Adoption, Implementation, and Maintenance (AIM) of that intervention. In this study, we aim to understand how effectiveness of organizational level obesity interventions depends on dynamics of AIM. We focus on an obesity intervention, implemented in food carry-outs in low-income urban areas of Baltimore city, which aims to improve dietary behavior for adults through better food access and point of purchase prompts. Building on data from interviews and literature, we first develop a contextualized map of causal relationships integral to dynamics of AIM, and then quantify those mechanisms using a system dynamics simulation model. The objective is to enhance our understanding of organizational dynamics that impact the effectiveness of chronic disease preventive interventions. We show how as a result of several reinforcing loops that span stakeholder motivation, communications, and implementation quality and costs, little changes in the process of AIM can make the difference between success and failure.
Background
The RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework is a reliable tool for the translation of research to practice. This framework has been widely applied to assess the impact of individual interventions. However, RE-AIM has rarely been used to evaluate implementation interventions, especially from multi-sector partnerships. The primary purpose of this paper is to operationalize the RE-AIM approach to evaluate large, multi-sector partnerships. SCI Action Canada, a community-university partnership aimed to promote physical activity among adults with spinal cord injury, is used as an example. A secondary purpose is to provide initial data from SCI Action Canada by using this conceptualization of RE-AIM.
Methods
Each RE-AIM element is operationalized for multi-sector partnerships. Specific to SCI Action Canada, seven reach calculations, four adoption rates, four effectiveness outcomes, one implementation, one organizational maintenance, and two individual maintenance outcomes are defined. The specific numerators based on SCI Action Canada activities are also listed for each of these calculations.
Results
The results are derived from SCI Action Canada activities. SCI Action Canada’s reach ranged from 3% (end-user direct national reach) to 37% (total regional reach). Adoption rates were 15% (provincial level adoption) to 76% (regional level adoption). Implementation and organizational maintenance rates were 92% and 100%, respectively.
Conclusions
We have operationalized the RE-AIM framework for larger multi-sectoral partnerships and demonstrated its applicability to such partnerships with SCI Action Canada. Future partnerships could use RE-AIM to assess their public health impact.
Reproducibility of research is critical for the healthy growth and accumulation of reliable knowledge, and simulation-based research is no exception. However, studies show many simulation-based studies in the social sciences are not reproducible. Better standards for documenting simulation models and reporting results are needed to enhance the reproducibility of simulation-based research in the social sciences. We provide an initial set of Reporting Guidelines for Simulation-based Research (RGSR) in the social sciences, with a focus on common scenarios in system dynamics research. We discuss these guidelines separately for reporting models, reporting simulation experiments, and reporting optimization results. The guidelines are further divided into minimum and preferred requirements, distinguishing between factors that are indispensable for reproduction of research and those that enhance transparency. We also provide a few guidelines for improved visualization of research to reduce the costs of reproduction. Suggestions for enhancing the adoption of these guidelines are discussed at the end.
Dynamic modeling and simulation are systems science tools that examine behaviors and outcomes resulting from interactions among multiple system components over time. Although there are excellent examples of their application, they have not been adopted as mainstream tools in population health planning and policymaking. Impediments to their use include the legacy and ease of use of statistical approaches that produce estimates with confidence intervals, the difficulty of multidisciplinary collaboration for modeling and simulation, systems scientists' inability to communicate effectively the added value of the tools, and low funding for population health systems science. Proposed remedies include aggregation of diverse data sets, systems science training for public health and other health professionals, changing research incentives toward collaboration, and increased funding for population health systems science projects. (Am J Public Health. Published online ahead of print May 15, 2014: e1-e6. doi:10.2105/AJPH.2014.301873).
Objectives:
We present a system dynamics model that quantifies the energy imbalance gap responsible for the US adult obesity epidemic among gender and racial subpopulations.
Methods:
We divided the adult population into gender-race/ethnicity subpopulations and body mass index (BMI) classes. We defined transition rates between classes as a function of metabolic dynamics of individuals within each class. We estimated energy intake in each BMI class within the past 4 decades as a multiplication of the equilibrium energy intake of individuals in that class. Through calibration, we estimated the energy gap multiplier for each gender-race-BMI group by matching simulated BMI distributions for each subpopulation against national data with maximum likelihood estimation.
Results:
No subpopulation showed a negative or zero energy gap, suggesting that the obesity epidemic continues to worsen, albeit at a slower rate. In the past decade the epidemic has slowed for non-Hispanic Whites, is starting to slow for non-Hispanic Blacks, but continues to accelerate among Mexican Americans.
Conclusions:
The differential energy balance gap across subpopulations and over time suggests that interventions should be tailored to subpopulations' needs.
This paper presents a system dynamics policy model of nutritional food market transformation, tracing over-time interactions between the nutritional quality of supply, consumer food choice, population health, and governmental policy. Applied to the Canadian context and with body mass index as the primary outcome, we examine policy portfolios for obesity prevention, including (1) industry self-regulation efforts, (2) health- and nutrition-sensitive governmental policy, and (3) efforts to foster health- and nutrition-sensitive innovation. This work provides novel theoretical and practical insights on drivers of nutritional market transformations, highlighting the importance of integrative policy portfolios to simultaneously shift food demand and supply for successful and self-sustaining nutrition and health sensitivity. We discuss model extensions for deeper and more comprehensive linkages of nutritional food market transformation with supply, demand, and policy in agrifood and health/health care. These aim toward system design and policy that can proactively, and with greater impact, scale, and resilience, address single as well as double malnutrition in varying country settings.
Despite growth in implementation research, limited scientific attention has focused on understanding and improving sustainability of health interventions. Models of sustainability have been evolving to reflect challenges in the fit between intervention and context.
We examine the development of concepts of sustainability, and respond to two frequent assumptions ---'voltage drop,' whereby interventions are expected to yield lower benefits as they move from efficacy to effectiveness to implementation and sustainability, and 'program drift,' whereby deviation from manualized protocols is assumed to decrease benefit. We posit that these assumptions limit opportunities to improve care, and instead argue for understanding the changing context of healthcare to continuously refine and improve interventions as they are sustained. Sustainability has evolved from being considered as the endgame of a translational research process to a suggested 'adaptation phase' that integrates and institutionalizes interventions within local organizational and cultural contexts. These recent approaches locate sustainability in the implementation phase of knowledge transfer, but still do not address intervention improvement as a central theme. We propose a Dynamic Sustainability Framework that involves: continued learning and problem solving, ongoing adaptation of interventions with a primary focus on fit between interventions and multi-level contexts, and expectations for ongoing improvement as opposed to diminishing outcomes over time.
A Dynamic Sustainability Framework provides a foundation for research, policy and practice that supports development and testing of falsifiable hypotheses and continued learning to advance the implementation, transportability and impact of health services research.
The Dutch multidisciplinary sciatica guideline recommends that the team of professionals involved in sciatica care and the patient together decide on surgical or prolonged conservative treatment (shared decision making [SDM]). Despite this recommendation, SDM is not yet integrated in sciatica care. Existing literature concerning barriers and facilitators to SDM implementation mainly focuses on one discipline only, whereas multidisciplinary care may involve other barriers and facilitators, or make these more complex for both professionals and patients. Therefore, this qualitative study aims to identify barriers and facilitators perceived by patients and professionals for SDM implementation in multidisciplinary sciatica care.
We conducted 40 semi-structured interviews with professionals involved in sciatica care (general practitioners, physical therapists, neurologists, neurosurgeons, and orthopedic surgeons) and three focus groups among patients (six to eight per group). The interviews and focus groups were audiotaped and transcribed in full. Reported barriers and facilitators were classified according to the framework of Grol and Wensing. The software package Atlas.ti 7.0 was used for analysis.
Professionals reported 53 barriers and 5 facilitators, and patients 35 barriers and 18 facilitators for SDM in sciatica care. Professionals perceived most barriers at the level of the organizational context, and facilitators at the level of the individual professional. Patients reported most barriers and facilitators at the level of the individual professional. Several barriers and facilitators correspond with barriers and facilitators found in the literature (e.g., lack of time, motivation) but also new barriers and facilitators were identified. Many of these new barriers mentioned by both professionals and patients were related to the multidisciplinary setting, such as lack of visibility, lack of trust in expertise of other disciplines, and lack of communication between disciplines.
This study identified barriers and facilitators for SDM in the multidisciplinary sciatica setting, by both professionals and patients. It is clear that more barriers than facilitators are perceived for implementation of SDM in sciatica care. Newly identified barriers and facilitators are related to the multidisciplinary care setting. Therefore, an effective implementation strategy of SDM in a multidisciplinary setting such as in sciatica care should focus on these barriers and facilitators.
Prepared food sources, including fast food restaurants and carry-outs, are common in low-income urban areas. These establishments provide foods high in calories, sugar, fat, and sodium. The aims of the study were to (1) describe the development and implementation of a carry-out intervention to provide and promote healthy food choices in prepared food sources, and (2) to assess its feasibility through a process evaluation.
To promote healthy eating in this setting, a culturally appropriate intervention was developed based on formative research from direct observation, interviews and focus groups. We implemented a 7-month feasibility trial in 8 carry-outs (4 intervention and 4 comparison) in low-income neighborhoods in Baltimore, MD. The trial included three phases: 1) Improving menu boards and labeling to promote healthier items; 2) Promoting healthy sides and beverages and introducing new items; and 3) Introducing affordable healthier combo meals and improving food preparation methods. A process evaluation was conducted to assess intervention reach, dose received, and fidelity using sales receipts, carry-out visit observations, and an intervention exposure assessment.
On average, Baltimore Healthy Carry-outs (BHC) increased customer reach at intervention carry-outs; purchases increased by 36.8% at the end of the study compared to baseline. Additionally, menu boards and labels were seen by 100.0% and 84.2% of individuals (n = 101), respectively, at study completion compared to baseline. Customers reported purchasing specific foods due to the presence of a photo on the menu board (65.3%) or menu labeling (42.6%), suggesting moderate to high dose received. Promoted entree availability and revised menu and poster presence all demonstrated high fidelity and feasibility.
The results suggest that BHC is a culturally acceptable intervention. The program was also immediately adopted by the Baltimore City Food Policy Initiative as a city-wide intervention in its public markets.
Background
In the United States, as in many other parts of the world, the prevalence of overweight/obesity is at epidemic proportions in the adult population and even higher among Veterans. To address the high prevalence of overweight/obesity among Veterans, the MOVE!® weight management program was disseminated nationally to Veteran Affairs (VA) medical centers. The objective of this paper is two-fold: to describe factors that explain the wide variation in implementation of MOVE!; and to illustrate, step-by-step, how to apply a theory-based framework using qualitative data.
Methods
Five VA facilities were selected to maximize variation in implementation effectiveness and geographic location. Twenty-four key stakeholders were interviewed about their experiences in implementing MOVE!. The Consolidated Framework for Implementation Research (CFIR) was used to guide collection and analysis of qualitative data. Constructs that most strongly influence implementation effectiveness were identified through a cross-case comparison of ratings.
Results
Of the 31 CFIR constructs assessed, ten constructs strongly distinguished between facilities with low versus high program implementation effectiveness. The majority (six) were related to the inner setting: networks and communications; tension for change; relative priority; goals and feedback; learning climate; and leadership engagement. One construct each, from intervention characteristics (relative advantage) and outer setting (patient needs and resources), plus two from process (executing and reflecting) also strongly distinguished between high and low implementation. Two additional constructs weakly distinguished, 16 were mixed, three constructs had insufficient data to assess, and one was not applicable. Detailed descriptions of how each distinguishing construct manifested in study facilities and a table of recommendations is provided.
Conclusions
This paper presents an approach for using the CFIR to code and rate qualitative data in a way that will facilitate comparisons across studies. An online Wiki resource (http://www.wiki.cfirwiki.net) is available, in addition to the information presented here, that contains much of the published information about the CFIR and its constructs and sub-constructs. We hope that the described approach and open access to the CFIR will generate wide use and encourage dialogue and continued refinement of both the framework and approaches for applying it.
Background
Childhood obesity is a ‘wicked’ public health problem that is best tackled by an integrated approach, which is enabled by integrated public health policies. The development and implementation of such policies have in practice proven to be difficult, however, and studying why this is the case requires a tool that may assist local policy-makers and those assisting them. A comprehensive framework that can help to identify options for improvement and to systematically develop solutions may be used to support local policy-makers.
Discussion
We propose the ‘Behavior Change Ball’ as a tool to study the development and implementation of integrated public health policies within local government. Based on the tenets of the ‘Behavior Change Wheel’ by Michie and colleagues (2011), the proposed conceptual framework distinguishes organizational behaviors of local policy-makers at the strategic, tactical and operational levels, as well as the determinants (motivation, capability, opportunity) required for these behaviors, and interventions and policy categories that can influence them. To illustrate the difficulty of achieving sustained integrated approaches, we use the metaphor of a ball in our framework: the mountainous landscapes surrounding the ball reflect the system’s resistance to change (by making it difficult for the ball to roll). We apply this framework to the problem of childhood obesity prevention. The added value provided by the framework lies in its comprehensiveness, theoretical basis, diagnostic and heuristic nature and face validity.
Summary
Since integrated public health policies have not been widely developed and implemented in practice, organizational behaviors relevant to the development of these policies remain to be investigated. A conceptual framework that can assist in systematically studying the policy process may facilitate this. Our Behavior Change Ball adds significant value to existing public health policy frameworks by incorporating multiple theoretical perspectives, specifying a set of organizational behaviors and linking the analysis of these behaviors to interventions and policies. We would encourage examination by others of our framework as a tool to explain and guide the development of integrated policies for the prevention of wicked public health problems.
Background
Public health programs can only deliver benefits if they are able to sustain activities over time. There is a broad literature on program sustainability in public health, but it is fragmented and there is a lack of consensus on core constructs. The purpose of this paper is to present a new conceptual framework for program sustainability in public health.
Methods
This developmental study uses a comprehensive literature review, input from an expert panel, and the results of concept-mapping to identify the core domains of a conceptual framework for public health program capacity for sustainability. The concept-mapping process included three types of participants (scientists, funders, and practitioners) from several public health areas (e.g., tobacco control, heart disease and stroke, physical activity and nutrition, and injury prevention).
Results
The literature review identified 85 relevant studies focusing on program sustainability in public health. Most of the papers described empirical studies of prevention-oriented programs aimed at the community level. The concept-mapping process identified nine core domains that affect a program’s capacity for sustainability: Political Support, Funding Stability, Partnerships, Organizational Capacity, Program Evaluation, Program Adaptation, Communications, Public Health Impacts, and Strategic Planning. Concept-mapping participants further identified 93 items across these domains that have strong face validity—89% of the individual items composing the framework had specific support in the sustainability literature.
Conclusions
The sustainability framework presented here suggests that a number of selected factors may be related to a program’s ability to sustain its activities and benefits over time. These factors have been discussed in the literature, but this framework synthesizes and combines the factors and suggests how they may be interrelated with one another. The framework presents domains for public health decision makers to consider when developing and implementing prevention and intervention programs. The sustainability framework will be useful for public health decision makers, program managers, program evaluators, and dissemination and implementation researchers.
This paper examines the nature of the core capabilities of a firm, focusing in particular on their interaction with new product and process development projects. Two new concepts about core capabilities are explored here. First, while core capabilities are traditionally treated as clusters of distinct technical systems, skills, and managerial systems, these dimensions of capabilities are deeply rooted in values, which constitute an often overlooked but critical fourth dimension. Second, traditional core capabilities have a down side that inhibits innovation, here called core rigidities. Managers of new product and process development projects thus face a paradox: how to take advantage of core capabilities without being hampered by their dysfunctional flip side. Such projects play an important role in emerging strategies by highlighting the need for change and leading the way. Twenty case studies of new product and process development projects in five firms provide illustrative data.
Obesity and other diet-related chronic disease affect low-income ethnic minority populations at high rates. Formative research was used to develop a food store–based intervention for low-income African Americans in Baltimore City. A combination of qualitative and quantitative methods were used, including in-depth interviews with food store owners (n = 19) and low-income residents (n = 17), food source assessment (n = 11 census tracts), a consumer survey (n = 50), and direct observations (n = 6). Healthy food options were poorly available in low-income census tracts, with no fresh fruits and vegetables sold in 6 census tracts. Local consumers purchase less healthy options and prepare foods in ways that add fat. Corner stores are a common food source, but store owners expressed reservations about stocking healthier food options, citing low consumer demand for healthier products. Residents were unhappy with the limited range of healthy food options available but tended to see obesity as the result of poor personal and parental choices. Neighborhood food stores have the potential to provide healthy food choices, reinforce health messages, increase the population reached by nutritional interventions, and work with local residents to facilitate healthier dietary choices.
To understand vendor perspectives regarding changes made in 2009 to the Special Supplemental Nutrition Program for Women, Infant, and Children (WIC) food package.
Fifty-two in-depth, qualitative interviews with owners or managers of small stores in 8 urban areas across 7 states conducted 6-12 months after the changes.
Store owners experienced implementation challenges, but felt the changes increased the number of customers, sales, and profits.
This research provides vendor perspectives on the 2009 WIC policy changes and may enhance policy implementation directed at increasing healthy food availability, particularly in urban communities.
Objective:
The present study assessed the impact of the 2009 food packages mandated by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) on perceived sales, product selection and stocking habits of small, WIC-authorized food stores.
Design:
A cross-sectional study involving in-depth interviews with store managers/owners.
Setting:
Small, WIC-authorized food stores in eight major cities in the USA.
Subjects:
Fifty-two store managers/owners who had at least 1 year of experience in the store prior to study participation.
Results:
The WIC-approved food products (fresh, canned and frozen fruits; fresh, canned and frozen vegetables; wholegrain/whole-wheat bread; white corn/whole-wheat tortillas; brown rice; lower-fat milk (<2 %)) were acquired in multiple ways, although acquisition generally occurred 1-2 times/week. Factors such as customer requests (87 %), refrigerator/freezer availability (65 %) and profitability (71 %) were rated as very important when making stocking decisions. Most managers/owners perceived increases in sales of new WIC-approved foods including those considered most profitable (wholegrain/whole-wheat bread (89 %), lower-fat milk (89 %), white corn/whole wheat tortillas (54 %)), but perceived no changes in sales of processed fruits and vegetables. Supply mechanisms and frequency of supply acquisition were only moderately associated with perceived sales increases.
Conclusions:
Regardless of type or frequency of supply acquisition, perceived increases in sales provided some evidence for the potential sustainability of these WIC policy efforts and translation of this policy-based strategy to other health promotion efforts aimed at improving healthy food access in underserved communities.
Many delivery-system interventions are fundamentally about change in social systems (both planned and unplanned). This systems perspective raises a number of methodological challenges for studying the effects of delivery-system change--particularly for answering questions related to whether the change will work under different conditions and how the change is integrated (or not) into the operating context of the delivery system.
The purpose of this paper is to describe the methodological and measurement challenges posed by five key issues in delivery-system research: (1) modeling intervention context; (2) measuring readiness for change; (3) assessing intervention fidelity and sustainability; (4) assessing complex, multicomponent interventions; and (5) incorporating time in delivery-system models to discuss recommendations for addressing these issues. For each issue, we provide recommendations for how research may be designed and implemented to overcome these challenges.
We suggest that a more refined understanding of the mechanisms underlying delivery-system interventions (treatment theory) and the ways in which outcomes for different classes of individuals change over time are fundamental starting points for capturing the heterogeneity in samples of individuals exposed to delivery-system interventions. To support the research recommendations outlined in this paper and to advance understanding of the "why" and "how" questions of delivery-system change and their effects, funding agencies should consider supporting studies with larger organizational sample sizes; longer duration; and nontraditional, mixed-methods designs.A version of this paper was prepared under contract with the Agency for Healthcare Research and Quality (AHRQ), US Department of Health and Human Services for presentation and discussion at a meeting on "The Challenge and Promise of Delivery System Research," held in Sterling, VA, on February 16-17, 2011. The opinions in the paper are those of the author and do not represent the views or recommendations of AHRQ or the US Department of Health and Human Services.1.
We examine how delays between actions and their consequent payoffs affect the process of organizational adaptation. Formal conceptions of organizational learning typically include the assumption that payoffs immediately follow their antecedent actions, making the search for better strategies relatively straightforward. However, previous actions influence current organizational performance through their effects on organizational resources and capabilities. These resources and capabilities cannot be modified instantly, so delays--from actions to changes in resources and capabilities to altered organizational performance--are inevitable. Our computational experiments show that delays increase learning complexity and performance heterogeneity through two mechanisms. First, complexity of state-space and, therefore, of learning grows exponentially with delay length. Second, the time required to experience the benefits of long-term strategies means the intermediate steps of those strategies are initially undervalued, prompting premature abandonment of potentially fruitful regions of the strategy space. We find that these mechanisms often cause organizations to converge to suboptimal, routine-like cycles of actions, based on organizations' continually updated cognitive maps of how actions influence payoffs. Furthermore, the evolution of these cognitive maps exhibits path dependence, leading to heterogeneity across organizations. Implications for overcoming temporal complexity and the impact of initial cognitive maps are discussed.
e investigate the conditions under which managerial cognition affects the timing of incumbent entry into a radical new technological market. We address this question using a longitudinal study of communications technology firms entering the fiber-optics product market. Using a hazard rate model, we investigate the relevance of cognition based on the direction of CEO attention. We find that attention toward the emerging technology and the affected industry is associated with faster entry, and attention to existing technologies is associated with slower progress. Second, we assess the extent to which the effect of cognition is dependent upon the levels of relevant organizational factors and find that CEO attention to the emerging technology may amplify the effects of industry orientation. Managerial cognition is important in understanding organizational outcomes, and considering both the direction of cognition and its interaction with organizational factors provides a more nuanced view of entry behavior. These results contribute to the literatures on incumbent response to technical change and new product development by suggesting that context-specific managerial cognition has a separate and important influence on the degree and direction of strategic renewal. We argue that managerial cognition is therefore a dynamic managerial capability that can shape adaptation by established firms.
This paper investigates the mechanisms through which organizations develop dynamic capabilities, defined as routinized activities directed to the development and adaptation of operating routines. It addresses the role of (1) experience accumulation, (2) knowledge articulation, and (3) knowledge codification processes in the evolution of dynamic, as well as operational, routines. The argument is made that dynamic capabilities are shaped by the coevolution of these learning mechanisms. At any point in time, firms adopt a mix of learning behaviors constituted by a semiautomatic accumulation of experience and by deliberate investments in knowledge articulation and codification activities. The relative effectiveness of these capability-building mechanisms is analyzed here as contingent upon selected features of the task to be learned, such as its frequency, homogeneity, and degree of causal ambiguity. Testable hypotheses about these effects are derived. Somewhat counterintuitive implications of the analysis include the relatively superior effectiveness of highly deliberate learning processes such as knowledge codification at lower levels of frequency and homogeneity of the organizational task, in contrast with common managerial practice.
The food environment is associated with obesity risk and diet-related chronic diseases. Despite extensive research conducted on retail food stores, little is known about prepared food sources(PFSs). We conducted an observational assessment of all PFSs(N = 92) in low-income neighborhoods in Baltimore. The most common PFSs were carry-outs, which had the lowest availability of healthy food choices. Only a small proportion of these carry-outs offered healthy sides, whole wheat bread, or entrée salads (21.4%, 7.1%, and 33.9%, respectively). These findings suggest that carry-out-specific interventions are necessary to increase healthy food availability in low-income urban neighborhoods.
An unresolved issue in the field of implementation research is how to conceptualize and evaluate successful implementation. This paper advances the concept of "implementation outcomes" distinct from service system and clinical treatment outcomes. This paper proposes a heuristic, working "taxonomy" of eight conceptually distinct implementation outcomes-acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability-along with their nominal definitions. We propose a two-pronged agenda for research on implementation outcomes. Conceptualizing and measuring implementation outcomes will advance understanding of implementation processes, enhance efficiency in implementation research, and pave the way for studies of the comparative effectiveness of implementation strategies.
Based on substantial formative research, the authors developed and implemented a year-long corner store-based program in East Baltimore focusing on Korean American (KA) stores. To understand acceptability of the intervention by storeowners, the authors examined the motivating factors for program participation, barriers to program implementation, perceived effectiveness of intervention materials, and perceptions about the program. Data collection methods included in-depth interviews with seven corner store owners, field notes by interventionists, and a follow-up survey. Stores varied considerably in terms of owners' perceptions about the program, supportive atmosphere, and acceptability of intervention strategies. The storeowners who showed strong or moderate support for the program were more likely to sustain the stocking of promoted foods such as cooking spray and baked or low-fat chips after the program was completed as compared to less supportive stores. The level of support and active participation of storeowners can greatly influence the success of corner store-based nutrition interventions.
Universal Health Coverage (UHC) is one of the targets for the United Nations Sustainable Development Goal 3. The impetus for UHC has led to an increased demand for time-sensitive tools to enhance our knowledge of how health systems function and to evaluate impact of system interventions. We define the field of “health system modeling” (HSM) as an area of research where dynamic mathematical models can be designed in order to describe, predict, and quantitatively capture the functioning of health systems. HSM can be used to explore the dynamic relationships among different system components, including organizational design, financing and other resources (such as investments in resources and supply chain management systems) – what we call “inputs” – on access, coverage, and quality of care – what we call “outputs”, toward improved health system “outcomes”, namely increased levels and fairer distributions of population health and financial risk protection. We undertook a systematic review to identify the existing approaches used in HSM. We identified “systems thinking” – a conceptual and qualitative description of the critical interactions within a health system – as an important underlying precursor to HSM, and collated a critical collection of such articles. We then reviewed and categorized articles from two schools of thoughts: “system dynamics” (SD)” and “susceptible-infected-recovered-plus” (SIR+). SD emphasizes the notion of accumulations of stocks in the system, inflows and outflows, and causal feedback structure to predict intended and unintended consequences of policy interventions. The SIR + models link a typical disease transmission model with another that captures certain aspects of the system that impact the outcomes of the main model. These existing methods provide critical insights in informing the design of HSM, and provide a departure point to extend this research agenda. We highlight the opportunity to advance modeling methods to further understand the dynamics between health system inputs and outputs.
This paper examines the nature of the core capabilities of a firm, focusing in particular on their interaction with new product and process development projects. Two new concepts about core capabilities are explored here. First, while core capabilities are traditionally treated as clusters of distinct technical systems, skills, and managerial systems, these dimensions of capabilities are deeply rooted in values, which constitute an often overlooked but critical fourth dimension. Second, traditional core capabilities have a down side that inhibits innovation, here called core rigidities. Managers of new product and process development projects thus face a paradox: how to take advantage of core capabilities without being hampered by their dysfunctional flip side. Such projects play an important role in emerging strategies by highlighting the need for change and leading the way. Twenty case studies of new product and process development projects in five firms provide illustrative data.
Understanding sources of sustained competitive advantage has become a major area of research in strategic management. Building on the assumptions that strategic resources are heterogeneously distributed across firms and that these differences are stable over time, this article examines the link between firm resources and sustained competitive advantage. Four empirical indicators of the potential of firm resources to generate sustained competitive advantage-value, rareness, imitability, and substitutability are discussed. The model is applied by analyzing the potential of several firm resources for generating sustained competitive advantages. The article concludes by examining implications of this firm resource model of sustained competitive advantage for other business disciplines.
People have difficulties inferring the behavior of a stock variable from its inflows and outflows. Our goal is to offer low-cost interventions to help overcome this difficulty. We hypothesize that the failure to understand accumulation relates to the cognitive mode of thinking: if people use their System 2 mode of thinking (analytical thinking), they are more likely to answer stock–flow questions correctly. We conduct an experiment with 400 participants and test effects of two interventions. The study replicates previously observed stock–flow failure and uncovers several variables that can influence subjects' response to the department store task. One particular finding is that having participants answer an analytical question right before the department store task marginally increases their chances of answering stock–flow questions correctly. Copyright © 2015 System Dynamics Society
Today's managers face a paradox. On the one hand, the number of tools, techniques, and technologies available to improve operational performance is growing rapidly. On the other hand, despite dramatic success in a few companies, most efforts to use them fail to produce significant results. To understand and resolve this paradox, this article investigates the difficulties organizations face in implementing processes and techniques such as lean production, TQM, computer-aided design and development tools, stage-gate product development processes, and improved customer service systems. The inability of most organizations to reap the full benefit of these innovations has little to do with the specific technique. Instead, the problem has its roots in how the introduction of a new improvement effort interacts with the physical, economic, social, and psychological structures in which implementation takes place. This article presents a framework to understand how these failures arise and illustrates strategies for overcoming the pathological behaviors through case studies of successful improvement.
Purpose:
To investigate how a pilot environmental intervention changed food sales patterns in carryout restaurants.
Design:
Quasi-experimental.
Setting:
Low-income neighborhoods of Baltimore, Maryland.
Subjects:
Seven carryouts (three intervention, four comparison).
Intervention:
Phase 1, menu board revision and healthy menu labeling; phase 2, increase of healthy sides and beverages; and phase 3, promotion of cheaper and healthier combination meals.
Measures:
Weekly handwritten menu orders collected to assess changes in the proportion of units sold and revenue of healthy items (entrée, sides and beverages, and combined).
Analysis:
Logistic and Poisson regression models with generalized estimating equations.
Results:
In the intervention group, odds for healthy entrée units and odds for healthy side and beverage units sold significantly increased in phases 2 and 3; odds for healthy entrée revenue significantly increased in phase 1 (odds ratio [OR] 1.16, 95% confidence interval [CI] 1.08-1.26), phase 2 (OR 1.32, 95% CI 1.25-1.41), and phase 3 (OR 1.39, 95% CI 1.14-1.70); and odds for healthy side and beverage revenues increased significantly in phase 2 (OR 1.62, 95% CI 1.33-1.97) and phase 3 (OR 2.73, 95% CI 2.15-3.47) compared to baseline. Total revenue in the intervention group was significantly higher in all phases than in the comparison group (p < .05).
Conclusion:
Environmental intervention changes such as menu revision, menu labeling, improved healthy food selection, and competitive pricing can increase availability and sales of healthy items in carryouts.
Human body energy storage operates as a stock-and-flow system with inflow (food intake) and outflow (energy expenditure). In spite of the ubiquity of stock-and-flow structures, evidence suggests that human beings fail to understand stock accumulation and rates of change, a difficulty called the stock–flow failure. This study examines the influence of health care training and cultural background in overcoming stock–flow failure. A standardized protocol assessed lay people's and health care professionals’ ability to apply stock-and-flow reasoning to infer the dynamics of weight gain/loss during the holiday season (621 subjects from seven countries). Our results indicate that both types of subjects exhibited systematic errors indicative of use of erroneous heuristics. Indeed 76% of lay subjects and 71% of health care professionals failed to understand the simple dynamic impact of energy intake and energy expenditure on body weight. Stock–flow failure was found across cultures and was not improved by professional health training. The problem of stock–flow failure as a transcultural global issue with education and policy implications is discussed.
This 4th edition of the text introducing the Precede-Proceed model provides extensive links (via www.lgreen.net) to the research and theory on which it has built since previous editions. A 5th edition is in progress, featuring new published applications of the model in community, school, and healthcare settings.
This paper elucidates the underlying economics of the resource-based view of competitive advantage and integrates existing perspectives into a parsimonious model of resources and firm performance. The essence of this model is that four conditions underlie sustained competitive advantage, all of which must be met. These include superior resources (heterogeneity within an industry), ex post limits to competition, imperfect resource mobility, and ex ante limits to competition. In the concluding section, applications of the model for both single business strategy and corporate strategy are discussed.
Getting an innovation adopted is difficult; a common problem is increasing the rate of its diffusion. Diffusion is the communication of an innovation through certain channels over time among members of a social system. It is a communication whose messages are concerned with new ideas; it is a process where participants create and share information to achieve a mutual understanding. Initial chapters of the book discuss the history of diffusion research, some major criticisms of diffusion research, and the meta-research procedures used in the book. This text is the third edition of this well-respected work. The first edition was published in 1962, and the fifth edition in 2003. The book's theoretical framework relies on the concepts of information and uncertainty. Uncertainty is the degree to which alternatives are perceived with respect to an event and the relative probabilities of these alternatives; uncertainty implies a lack of predictability and motivates an individual to seek information. A technological innovation embodies information, thus reducing uncertainty. Information affects uncertainty in a situation where a choice exists among alternatives; information about a technological innovation can be software information or innovation-evaluation information. An innovation is an idea, practice, or object that is perceived as new by an individual or an other unit of adoption; innovation presents an individual or organization with a new alternative(s) or new means of solving problems. Whether new alternatives are superior is not precisely known by problem solvers. Thus people seek new information. Information about new ideas is exchanged through a process of convergence involving interpersonal networks. Thus, diffusion of innovations is a social process that communicates perceived information about a new idea; it produces an alteration in the structure and function of a social system, producing social consequences. Diffusion has four elements: (1) an innovation that is perceived as new, (2) communication channels, (3) time, and (4) a social system (members jointly solving to accomplish a common goal). Diffusion systems can be centralized or decentralized. The innovation-development process has five steps passing from recognition of a need, through R&D, commercialization, diffusions and adoption, to consequences. Time enters the diffusion process in three ways: (1) innovation-decision process, (2) innovativeness, and (3) rate of the innovation's adoption. The innovation-decision process is an information-seeking and information-processing activity that motivates an individual to reduce uncertainty about the (dis)advantages of the innovation. There are five steps in the process: (1) knowledge for an adoption/rejection/implementation decision; (2) persuasion to form an attitude, (3) decision, (4) implementation, and (5) confirmation (reinforcement or rejection). Innovations can also be re-invented (changed or modified) by the user. The innovation-decision period is the time required to pass through the innovation-decision process. Rates of adoption of an innovation depend on (and can be predicted by) how its characteristics are perceived in terms of relative advantage, compatibility, complexity, trialability, and observability. The diffusion effect is the increasing, cumulative pressure from interpersonal networks to adopt (or reject) an innovation. Overadoption is an innovation's adoption when experts suggest its rejection. Diffusion networks convey innovation-evaluation information to decrease uncertainty about an idea's use. The heart of the diffusion process is the modeling and imitation by potential adopters of their network partners who have adopted already. Change agents influence innovation decisions in a direction deemed desirable. Opinion leadership is the degree individuals influence others' attitudes
This paper reviews the literature on organizational learning. Organizational learning is viewed as routine-based, history-dependent, and target-oriented. Organizations are seen as learning by encoding inferences from history into routines that guide behavior. Within this perspective on organizational learning, topics covered include how organizations learn from direct experience, how organizations learn from the experience of others, and how organizations develop conceptual frameworks or paradigms for interpreting that experience. The section on organizational memory discusses how organizations encode, store, and retrieve the lessons of history despite the turnover of personnel and the passage of time. Organizational learning is further complicated by the ecological structure of the simultaneously adapting behavior of other organizations, and by an endogenously changing environment. The final section discusses the limitations as well as the possibilities of organizational learning as a form of intelligence.
This paper documents the long-run stock price performance of firms with effective Total Quality Management (TQM) programs. The winning of quality awards is used as a proxy for effective TQM implementation. We compare stock price performance of award winners against various matched control groups for a five-year implementation period and a five-year postimplementation period. During the implementation period there is no difference in the stock price performance, but during the postimplementation period award winners significantly outperform firms in the various control groups. Depending on the control group used, the mean outperformance ranges from 38% to 46%. Our results clearly indicate that effective implementation of TQM principles and philosophies leads to significant wealth creation. Furthermore, our results should alleviate many of the concerns regarding the value of quality award systems. Overall, these systems are valuable in terms of recognizing TQM firms and promoting awareness of TQM.
Given incomplete factor markets, appropriate time paths of flow variables must be chosen to build required stocks of assets. That is, critical resources are accumulated rather than acquired in "strategic factor markets" (Barney [Barney, J. 1986. Strategic factor markets: Expectations, luck, and business strategy. Management Sci. (October) 1231--1241.]). Sustainability of a firm's asset position hinges on how easily assets can be substituted or imitated. Imitability is linked to the characteristics of the asset accumulation process: time compression diseconomies, asset mass efficiencies, inter-connectedness, asset erosion and causal ambiguity.
Background and purpose. Despite the widely acknowledged public health burden and years of individually based intervention approaches, physical inactivity remains a growing concern among industrialized nations. Interventions aimed at changing individual dispositions that increase physical activity generally result in small changes in behavior that dissipate within weeks. Correlational research testing theories and models focusing on these same individual dispositions explain, at best, 20–40% of the variance in physical activity. As a result, recent calls have been made for consideration of broader, multilevel, ecological approaches to physical activity promotion. The purpose of this article is to define a comprehensive model for understanding physical activity and consider future directions for research.Methods. Relevant literature is reviewed within each of the areas being discussed.Results and conclusions. Ecological models incorporate both intra- and extra-individual influences that may impact on individual physical activity. However, the role of extra-individual factors has not been clearly defined in current ecological models of physical activity. We present the theoretical background of ecological models of health behavior, and define an ecological model for physical activity promotion. This model portrays physical activity behavior as being influenced by interplay between environmental settings and biological and psychological factors. Further testing of this and existing ecological models of physical activity is recommended.
Diet-related chronic diseases are at epidemic levels in low-income ethnic minority populations. The purpose of this study is to decrease risk for obesity in children by modifying the food environment and conducting point-of-purchase promotions that will lead to changes in psychosocial factors and behaviors associated with healthier food choices among low-income communities with a preponderance of Native Hawaiians and Pacific Islanders. We implemented an intervention trial over a 9-11-month period in five food stores in two low-income multiethnic communities in Hawaii, targeting both children and their adult caregivers. The Healthy Foods Hawaii (HFH) intervention consisted of an environmental component to increase store stocking of nutritious foods, point-of-purchase promotions, interactive sessions, and involved local producers and distributors. We evaluated the impact of the program on 116 child-caregiver dyads, sampled from two intervention and two comparison areas before and after intervention implementation. Program impacts were evaluated using multivariable linear regression. The HFH program had a significant impact on caregiver knowledge and the perception that healthy foods are convenient. Intervention children significantly increased their Healthy Eating Index (HEI) score for servings of grains, their total consumption of water, and showed an average 8.5 point (out of 90 total, eliminating the 10 points for variety, giving a 9.4% increase) increase in overall HEI score. A food store intervention was effective in improving healthy food knowledge and perception that healthy foods are convenient among caregivers, and increased the consumption of several targeted healthy foods by their children. Greater intensity, sustained food system change, and further targeting for children are needed to show greater and sustained change in food-related behaviors in low-income Native Hawaiian and Pacific Islander communities.
Increasing evidence suggests that public health and health-promotion interventions that are based on social and behavioral science theories are more effective than those lacking a theoretical base. This article provides an overview of the state of the science of theory use for designing and conducting health-promotion interventions. Influential contemporary perspectives stress the multiple determinants and multiple levels of determinants of health and health behavior. We describe key types of theory and selected often-used theories and their key concepts, including the health belief model, the transtheoretical model, social cognitive theory, and the ecological model. This summary is followed by a review of the evidence about patterns and effects of theory use in health behavior intervention research. Examples of applied theories in three large public health programs illustrate the feasibility, utility, and challenges of using theory-based interventions. This review concludes by identifying cross-cutting themes and important future directions for bridging the divides between theory, practice, and research.
Despite documented benefits, the processes described in the new product development literature often prove difficult to follow in practice. A principal source of such difficulties is the phenomenon of fire fighting the unplanned allocation of resources to fix problems discovered late in a product's development cycle. While it has been widely criticized, fire fighting is a common occurrence in many product development organizations. To understand both its existence and persistence, in this article I develop a formal model of fire fighting in a multi-project development environment. The major contributions of this analysis are to suggest that: (1) fire fighting can be a self-reinforcing phenomenon; and (2) multi-project development systems are far more susceptible to this dynamic than is currently appreciated. These insights suggest that many of the current methods for aggregate resource and product portfolio planning, while necessary, are not sufficient to prevent fire fighting and the consequent low performance. MIT Center for Innovation in Product Development under NSF Cooperative Agreement Number EEC-9529140, the Harley-Davidson Motor Company and the Ford Motor Company