Interdisciplinarity and systems science to improve population health: a view from the NIH Office of Behavioral and Social Sciences Research

Using system dynamics modeling approach to strengthen health systems to combat cancer: a systematic literature review

AIM

Dynamic cancer control is a current health system priority, yet methods for achieving it are lacking. This study aims to review the application of system dynamics modeling (SDM) on cancer control and evaluate the research quality.

METHODS

Articles were searched in PubMed, Web of Science, and Scopus from the inception of the study to 15 November 2023. Inclusion criteria were English original studies focusing on cancer control with SDM methodology, including prevention, early detection, diagnosis and treatment, and palliative care. Exclusion criteria were non-original research, and studies lacking SDM focus. Analysis involved categorization of studies and extraction of relevant data to answer the research question, ensuring a comprehensive synthesis of the field. Quality assessment was used to evaluate the SDM for cancer control.

RESULTS

Sixteen studies were included in this systematic review predominantly from the United States (7, 43.75%), with a focus on breast cancer research (5, 31.25%). Studies were categorized by WHO cancer control modules, and some studies may contribute to multiple modules. The results showed that included studies comprised two focused on prevention (1.25%), ten on early detection (62.50%), six on diagnosis and treatment (37.50%), with none addressing palliative care. Seven studies presented a complete SDM process, among which nine developed causal loop diagrams for conceptual models, ten utilized stock-flow charts to develop computational models, and thirteen conducted simulations.

LIMITATIONS

This review's macrofocus on SDM in cancer control missed detailed methodological analysis. The limited number of studies and lack of stage-specific intervention comparisons limit comprehensiveness. Detailed analysis of SDM construction was also not conducted, potentially overlooking nuances in cancer control strategies.

CONCLUSION

SDM in cancer control is underutilized, focusing mainly on early detection and treatment. Inconsistencies suggest a need for standardized SDM approaches. Future research should expand SDM's application and integrate it into cancer control strategies.

Training Future Physician-Scientists in Social Sciences and Humanities

MD/PhD programs have traditionally prioritized the biomedical sciences, training physician-scientists skilled at advancing medical knowledge. Yet, with health disparities increasingly traced to social determinants of health (SDOH), a broader approach-one that integrates "non-traditional" fields such as the social sciences and humanities (SSH)-is essential. Significant challenges persist at three levels: (1) at the structural and systemic levels, where funding mechanisms like the NIH's Medical Scientist Training Program (MSTP) prioritize biomedical fields, limiting support for SSH fields; (2) at the institutional level, where curricula and resources remain narrowly aligned with biomedical timelines, leaving SSH trainees without adequate support; and (3) at the individual level, where the demands of SSH research often clash with the broader structure of MD/PhD programs, creating unique hurdles. Addressing these barriers requires coordinated reforms, including expanding MSTP programs' eligibility to include SSH fields and partnering with funding agencies and foundations to establish dedicated SSH funding. Medical schools could further support these students by developing cross-departmental SSH-integrated tracks with dedicated mentorship from SSH departments. Additionally, SSH-specific mentorship and community-building initiatives could reduce isolation and nurture a shared identity among SSH trainees. Bridging these gaps is paramount to making MD/PhD training for SSH students more inclusive and effective.

The CAMPUS Study: A Systems Approach to Alcohol-Involved Sexual Violence on College Campuses

OBJECTIVE

Developing a better mechanistic and multilevel understanding of sexual violence on college campuses can help us evaluate and implement existing interventions, as well as develop new ones. We brought together scientists, practitioners, and college students to collaboratively characterize the systems surrounding alcohol-involved sexual violence on college campuses. Using collaborative model-building, they created models that highlight interconnected and multilevel influences and consequences of sexual violence.

METHOD

Collaborative model-building activities involved two collaborator groups (12 students and 8 practitioners) and a core modeling team (7 scientists). Each collaborator group met for four 2-hour sessions to develop systems models of alcohol use and sexual violence on college campuses. The core modeling team facilitated each session and worked between sessions to ensure the successful development of the model. Specific activities included identifying and prioritizing the causes and consequences of alcohol-involved sexual violence, characterizing the causal relationships between these factors, and developing and modifying causal loop diagrams to illustrate these relationships.

RESULTS

Both students and practitioners identified key causes and consequences, including both individual-level (e.g., drinking to intoxication) and campus-level (e.g., institutional support for survivors) constructs. Both groups identified the causal relationships between these variables and identified salient, modifiable mechanisms for reducing alcohol-involved sexual violence.

CONCLUSIONS

The collaborative model-building process successfully included diverse collaborator voices, integrating influential factors across multiple social-ecological levels. This iterative and capability-building approach can bridge intensive modeling efforts with the implementation and development of more effective sexual violence interventions.

Trends and Gaps in Digital Precision Hypertension Management: Scoping Review

BACKGROUND

Hypertension (HTN) is the leading cause of cardiovascular disease morbidity and mortality worldwide. Despite effective treatments, most people with HTN do not have their blood pressure under control. Precision health strategies emphasizing predictive, preventive, and personalized care through digital tools offer notable opportunities to optimize the management of HTN.

OBJECTIVE

This scoping review aimed to fill a research gap in understanding the current state of precision health research using digital tools for the management of HTN in adults.

METHODS

This study used a scoping review framework to systematically search for articles in 5 databases published between 2013 and 2023. The included articles were thematically analyzed based on their precision health focus: personalized interventions, prediction models, and phenotyping. Data were extracted and summarized for study and sample characteristics, precision health focus, digital health technology, disciplines involved, and characteristics of personalized interventions.

RESULTS

After screening 883 articles, 46 were included; most studies had a precision health focus on personalized digital interventions (34/46, 74%), followed by prediction models (8/46, 17%) and phenotyping (4/46, 9%). Most studies (38/46, 82%) were conducted in or used data from North America or Europe, and 63% (29/46) of the studies came exclusively from the medical and health sciences, with 33% (15/46) of studies involving 2 or more disciplines. The most commonly used digital technologies were mobile phones (33/46, 72%), blood pressure monitors (18/46, 39%), and machine learning algorithms (11/46, 24%). In total, 45% (21/46) of the studies either did not report race or ethnicity data (14/46, 30%) or partially reported this information (7/46, 15%). For personalized intervention studies, nearly half (14/30, 47%) used 2 or less types of data for personalization, with only 7% (2/30) of the studies using social determinants of health data and no studies using physical environment or digital literacy data. Personalization characteristics of studies varied, with 43% (13/30) of studies using fully automated personalization approaches, 33% (10/30) using human-driven personalization, and 23% (7/30) using a hybrid approach.

CONCLUSIONS

This scoping review provides a comprehensive mapping of the literature on the current trends and gaps in digital precision health research for the management of HTN in adults. Personalized digital interventions were the primary focus of most studies; however, the review highlighted the need for more precise definitions of personalization and the integration of more diverse data sources to improve the tailoring of interventions and promotion of health equity. In addition, there were significant gaps in the reporting of race and ethnicity data of participants, underuse of wearable devices for passive data collection, and the need for greater interdisciplinary collaboration to advance precision health research in digital HTN management.

TRIAL REGISTRATION

OSF Registries osf.io/yuzf8; https://osf.io/yuzf8.

Understanding the obesity dynamics by socioeconomic status in Colombian and Mexican cities using a system dynamics model

Purpose

This paper aims to enrich understanding of the obesity transition among socioeconomic status (SES) strata by gender and age in cities of Colombia and Mexico. The study uses harmonized data from the Salud Urbana en América Latina (SALURBAL) study.

Methods

A population-level system dynamics model was developed using 2010 and 2015 data from Colombia and 2012 and 2016 data from Mexico (national health surveys). The model simulates the prevalence of different BMI categories (i.e., not overweight, overweight, obese) stratified by gender, age, and SES, in the SALURBAL cities (aggregated to the country level) of Colombia and Mexico from 2010 to 2050. Sample sizes for Colombia in 2010 and Mexico in 2012 were 7420 and 5785 children (<5 years), 21601 and 14413 children and adolescents (5-17 years), and 46597 and 20464 adults (18-64 years), respectively. Sample sizes for Colombia in 2015 and Mexico in 2016 were 4450 and 907 children, 12468 and 2350 children and adolescents, and 90430 and 3413 adults, respectively.

Results

For men in Colombia and Mexico, the burden of obesity is projected to increase among lower SES adults over time. Colombian women show similar patterns observed in men but the burden of obesity was already greater in the lower SES groups as early as 2012. In Mexican women, the burden of obesity in 2012 is higher in the lower SES population; however, the prevalence of obesity is projected to increase at a faster rate in the higher SES population. Patterns for children aged 0-14 years differed by gender and country.

Conclusions

The model suggests that the prevalence of obesity among SES strata by age and gender in SALURBAL cities of Colombia and Mexico are likely to change over time, and predicts their possible evolution through the different stages of the obesity transition.

Artificial intelligence significantly facilitates development in the mental health of college students: a bibliometric analysis

Objective

College students are currently grappling with severe mental health challenges, and research on artificial intelligence (AI) related to college students mental health, as a crucial catalyst for promoting psychological well-being, is rapidly advancing. Employing bibliometric methods, this study aim to analyze and discuss the research on AI in college student mental health.

Methods

Publications pertaining to AI and college student mental health were retrieved from the Web of Science core database. The distribution of publications were analyzed to gage the predominant productivity. Data on countries, authors, journal, and keywords were analyzed using VOSViewer, exploring collaboration patterns, disciplinary composition, research hotspots and trends.

Results

Spanning 2003 to 2023, the study encompassed 1722 publications, revealing notable insights: (1) a gradual rise in annual publications, reaching its zenith in 2022; (2) Journal of Affective Disorders and Psychiatry Research emerged were the most productive and influential sources in this field, with significant contributions from China, the United States, and their affiliated higher education institutions; (3) the primary mental health issues were depression and anxiety, with machine learning and AI having the widest range of applications; (4) an imperative for enhanced international and interdisciplinary collaboration; (5) research hotspots exploring factors influencing college student mental health and AI applications.

Conclusion

This study provides a succinct yet comprehensive overview of this field, facilitating a nuanced understanding of prospective applications of AI in college student mental health. Professionals can leverage this research to discern the advantages, risks, and potential impacts of AI in this critical field.

Systems mapping of multilevel factors contributing to dental caries in adolescents

Dental caries is a prevalent chronic disease among adolescents. Caries activity increases significantly during adolescence due to an increase in susceptible tooth surfaces, immature permanent tooth enamel, independence in pursuing self-care, and a tendency toward poor diet and oral hygiene. Dental caries in permanent teeth is more prevalent among adolescents in low-income families and racial/ethnic minority groups, and these disparities in adolescent dental caries experience have persisted for decades. Several conceptual and data-driven models have proposed unidirectional mechanisms that contribute to the extant disparities in adolescent dental caries experience. Our objective, using a literature review, is to provide an overview of risk factors contributing to adolescent dental caries. Specifically, we map the interactive relationships of multilevel factors that influence dental caries among adolescents. Such interactive multilevel relationships more closely reflect the complex nature of dental caries experience among the adolescent population. The methods that we use are two-fold: (1) a literature review using PubMed and Cochrane databases to find contributing factors; and (2) the system dynamics approach for mapping feedback mechanisms underlying adolescent dental caries through causal loop diagramming. The results of this study, based on the review of 138 articles, identified individual, family and community-level factors and their interactions contributing to dental caries experience in adolescents. Our results also provide hypotheses about the mechanisms underlying persistence of dental caries among adolescents.

Conclusions

Our findings may contribute to a deeper understanding of the multilevel and interconnected factors that shape the persistence of dental caries experience among adolescents.

Research trend of epigenetics and depression: adolescents' research needs to strengthen

Objective

With its high prevalence, depression's pathogenesis remains unclear. Recent attention has turned to the interplay between depression and epigenetic modifications. However, quantitative bibliometric analyses are lacking. This study aims to visually analyze depression epigenetics trends, utilizing bibliometric tools, while comprehensively reviewing its epigenetic mechanisms.

Methods

Utilizing the Web of Science core dataset, we collected depression and epigenetics-related studies. Employing VOSViewer software, we visualized data on authors, countries, journals, and keywords. A ranking table highlighted field leaders.

Results

Analysis encompassed 3,469 depression epigenetics studies published from January 2002 to June 2023. Key findings include: (1) Gradual publication growth, peaking in 2021; (2) The United States and its research institutions leading contributions; (3) Need for enhanced collaborations, spanning international and interdisciplinary efforts; (4) Keyword clustering revealed five main themes-early-life stress, microRNA, genetics, DNA methylation, and histone acetylation-highlighting research hotspots; (5) Limited focus on adolescent depression epigenetics, warranting increased attention.

Conclusion

Taken together, this study revealed trends and hotspots in depression epigenetics research, underscoring global collaboration, interdisciplinary fusion, and multi-omics data's importance. It discussed in detail the potential of epigenetic mechanisms in depression diagnosis and treatment, advocating increased focus on adolescent research in this field. Insights aid researchers in shaping their investigative paths toward understanding depression's epigenetic mechanisms and antidepressant interventions.

Bibliometric analysis of global research on psychological well-being, subjective burden, and psychosocial support of family caregivers of cancer patients

This study delves into the realm of informal cancer caregivers. Through a meticulous bibliometric analysis, the study sheds light on the burgeoning interest in this field, with a significant focus on the psychological well-being, subjective burden, and psychosocial support for caregivers. A significant portion of the retrieved articles (n = 1366) was published after 2017 and primarily disseminated through a select number of journals. Notably, the study reveals a substantial gap in randomized controlled trials addressing interventions tailored to family caregivers, indicating a critical need for more high-quality trials to guide effective support strategies. Despite the increasing recognition of caregivers' significance, limited research collaboration was observed, emphasizing the importance of fostering collaborative efforts to address cultural differences and expand the scope of research on cancer caregivers globally. The findings underscore the urgent call for comprehensive interventions and collaborative endeavors to optimize the well-being of family caregivers.

ECRIN - CESSDA strategies for cross metadata mappings in selected areas between life sciences and social sciences and humanities

Background

The recent COVID-19 (Corona Virus Disease 2019) pandemic dramatically underlined the multi-faceted nature of health research, requiring input from basic biological sciences, pharmaceutical technologies, clinical research), social sciences and public health and social engineering. Systems that could work across different disciplines would therefore seem to be a useful idea to explore. In this study we investigated whether metadata schemas and vocabularies used for discovering scientific studies and resources in the social sciences and in clinical research are similar enough to allow information from different source disciplines to be easily retrieved and presented together.

Methods

As a first step a literature search was performed, exemplarily identifying studies and resources, in which data from social sciences have been usefully employed or integrated with that from clinical research and clinical trials. In a second step a comparison of metadata schemas and related resource catalogues in ECRIN (European Clinical Research Infrastructure Network) and CESSDA (Consortium of European Social Science Data Archives) was performed. The focus was on discovery metadata, here defined as the metadata elements used to identify and locate scientific resources.

Results

A close view at the metadata schemas of CESSDA and ECRIN and the basic discovery metadata as well as a crosswalk between ECRIN and CESSDA metadata schemas have shown that there is considerable resemblance between them.

Conclusions

The resemblance could serve as a promising starting point to implement a common search mechanism for ECRIN and CESSDA metadata. In the paper four different options for how to proceed with implementation issues are presented.

System dynamics modeling for cancer prevention and control: A systematic review

Cancer prevention and control requires consideration of complex interactions between multilevel factors. System dynamics modeling, which consists of diagramming and simulation approaches for understanding and managing such complexity, is being increasingly applied to cancer prevention and control, but the breadth, characteristics, and quality of these studies is not known. We searched PubMed, Scopus, APA PsycInfo, and eight peer-reviewed journals to identify cancer-related studies that used system dynamics modeling. A dual review process was used to determine eligibility. Included studies were assessed using quality criteria adapted from prior literature and mapped onto the cancer control continuum. Characteristics of studies and models were abstracted and qualitatively synthesized. 32 studies met our inclusion criteria. A mix of simulation and diagramming approaches were used to address diverse topics, including chemotherapy treatments (16%), interventions to reduce tobacco or e-cigarettes use (16%), and cancer risk from environmental contamination (13%). Models spanned all focus areas of the cancer control continuum, with treatment (44%), prevention (34%), and detection (31%) being the most common. The quality assessment of studies was low, particularly for simulation approaches. Diagramming-only studies more often used participatory approaches. Involvement of participants, description of model development processes, and proper calibration and validation of models showed the greatest room for improvement. System dynamics modeling can illustrate complex interactions and help identify potential interventions across the cancer control continuum. Prior efforts have been hampered by a lack of rigor and transparency regarding model development and testing. Supportive infrastructure for increasing awareness, accessibility, and further development of best practices of system dynamics for multidisciplinary cancer research is needed.

Enhancing healthcare at home for older people in rural and regional Australia: A protocol for co-creation to design and implement system change

BACKGROUND

World-wide, health service providers are moving towards innovative models of clinical home-based care services as a key strategy to improve equity of access and quality of care. To optimise existing and new clinical home-based care programs, evidence informed approaches are needed that consider the complexity of the health care system across different contexts.

METHODS

We present a protocol for working with health services and their partners to perform rapid identification, prioritisation, and co-design of content-appropriate strategies to optimise the delivery of healthcare at home for older people in rural and regional areas. The protocol combines Systems Thinking and Implementation Science using a Consensus Mapping and Co-design (CMC) process delivered over five workshops.

DISCUSSION

The protocol will be implemented with rural and regional healthcare providers to identify digital and non-digital solutions that have the potential to inform models of service delivery, improve patient experience, and optimise health outcomes. The combination of system and implementation science is a unique approach for optimising healthcare at home for older populations, especially in the rural context where need is high. This is the first protocol to integrate the use of systems and implementation science into one process and articulating these methods will help with replicating this in future practice. Results of the design phase will translate into practice through standard health service planning methods to enhance implementation and sustainability. The delivery of the protocol will include building capacity of health service workers to embed the design, implementation, and evaluation approach into normal practice. This protocol forms part of the DELIVER (Delivering Enhanced heaLthcare at home through optImising Virtual tools for oldEr people in Rural and regional Australia) Project. Funded by Australia's Medical Research Future Fund, DELIVER involves a collaboration with public health services of Western Victoria, Australia.

Combining systems thinking approaches and implementation science constructs within community-based prevention: a systematic review

BACKGROUND

Systems science offers methods for designing population health interventions while implementation science provides specific guidance for successful implementation. Integrating systems and implementation science may strengthen implementation and enhance and sustain systemic change to achieve system-level outcomes. Little is known about the extent to which these two approaches have been integrated to date. This review aimed to identify and synthesise the peer-reviewed literature that has reported the combined use of systems thinking approaches and implementation science constructs (within the same study), to deliver population health interventions.

METHODS

A systematic literature search of peer-reviewed original research was conducted across six databases from 2009 to 2021. Journal manuscripts were included if they: (1) reported on a population health study conducted in a community, (2) reported the use of a systems method in the design of the intervention, and (3) used an implementation science theory, framework or model in the delivery of the intervention. Data extracted related to the specific systems methods and definitions and implementation science constructs used. The Mixed Methods Appraisal Tool (MMAT) was used to assess study quality.

RESULTS

Of the 9086 manuscripts returned, 320 manuscripts were included for full-text review. Of these, 17 manuscripts that reported on 14 studies were included in the final extraction. The most frequently reported systems methods were a 'whole of community systems approach' (n = 4/14) and 'community-based system dynamics' (n = 2/14). Nineteen different implementation science theories, frameworks and models were used for intervention delivery, with RE-AIM being the only framework used in more than one study.

CONCLUSION

There are few published peer-reviewed studies using systems thinking and implementation science for designing and delivering population health interventions. An exploration of synergies is worthwhile to operationalise alignment and improve implementation of systems thinking approaches. Review protocol registration PROSPERO CRD42021250419.

A Systematic Review of Systems Science Approaches to Understand and Address Domestic and Gender-Based Violence

Purpose

We aimed to synthesize insights from systems science approaches applied to domestic and gender-based violence.

Methods

We conducted a systematic review of systems science studies (systems thinking, group model-building, agent-based modeling [ABM], system dynamics [SD] modeling, social network analysis [SNA], and network analysis [NA]) applied to domestic or gender-based violence, including victimization, perpetration, prevention, and community responses. We used blinded review to identify papers meeting our inclusion criteria (i.e., peer-reviewed journal article or published book chapter that described a systems science approach to domestic or gender-based violence, broadly defined) and assessed the quality and transparency of each study.

Results

Our search yielded 1,841 studies, and 74 studies met our inclusion criteria (45 SNA, 12 NA, 8 ABM, and 3 SD). Although research aims varied across study types, the included studies highlighted social network influences on risks for domestic violence, clustering of risk factors and violence experiences, and potential targets for intervention. We assessed the quality of the included studies as moderate, though only a minority adhered to best practices in model development and dissemination, including stakeholder engagement and sharing of model code.

Conclusions

Systems science approaches for the study of domestic and gender-based violence have shed light on the complex processes that characterize domestic violence and its broader context. Future research in this area should include greater dialogue between different types of systems science approaches, consideration of peer and family influences in the same models, and expanded use of best practices, including continued engagement of community stakeholders.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10896-023-00578-8.

Using systems science to advance health equity in tobacco control: a causal loop diagram of smoking

OBJECTIVES

Develop and use a causal loop diagram (CLD) of smoking among racial/ethnic minority and lower-income groups to anticipate the intended and unintended effects of tobacco control policies.

METHODS

We developed a CLD to elucidate connections between individual, environmental and structural causes of racial/ethnic and socioeconomic disparities in smoking. The CLD was informed by a review of conceptual and empirical models of smoking, fundamental cause and social stress theories and 19 qualitative interviews with tobacco control stakeholders. The CLD was then used to examine the potential impacts of three tobacco control policies.

RESULTS

The CLD includes 24 constructs encompassing individual (eg, risk perceptions), environmental (eg, marketing) and structural (eg, systemic racism) factors associated with smoking. Evaluations of tobacco control policies using the CLD identified potential unintended consequences that may maintain smoking disparities. For example, the intent of a smoke-free policy for public housing is to reduce smoking among residents. Our CLD suggests that the policy may reduce smoking among residents by reducing smoking among family/friends, which subsequently reduces pro-smoking norms and perceptions of tobacco use as low risk. On the other hand, some residents who smoke may violate the policy. Policy violations may result in financial strain and/or housing instability, which increases stress and reduces feelings of control, thus having the unintended consequence of increasing smoking.

CONCLUSIONS

The CLD may be used to support stakeholder engagement in action planning and to identify non-traditional partners and approaches for tobacco control.

Discounting Health Grades for Disparity: The 2021 Wisconsin Population Health and Equity Report Card

We describe updates to the University of Wisconsin Population Health Institute's methodology for a state health report card, first described in Preventing Chronic Disease in 2010, and the considerations that were weighed in making those updates. These methods have been used since 2006 to issue a periodic report entitled Health of Wisconsin Report Card. The report highlights Wisconsin's standing among other states and serves as an example for others seeking to measure and improve their population's health. For 2021, we revisited our approach with an increased emphasis on disparities and health equity, which required many choices about data, analysis, and reporting methods. In this article, we outline the decisions, rationale, and implications of several choices we made in assessing Wisconsin's health by answering several questions, among them: Who is the intended audience and which measures of length (eg, mortality rate, years of potential life lost) and quality of life (eg, self-reported health, quality-adjusted life years) are most relevant to them? Which subgroups should we report disparities about, and which metric is most easily understood? Should disparities be summarized with overall health or reported separately? Although these decisions are applicable to 1 state, the rationale for our choices could be applied to other states, communities, and nations. Consideration of the purpose, audience, and context for health and equity policy making is important in developing report cards and other tools that can improve the health of all people and places.

The Role of Primary Care in Improving Population Health

Policy Points Systems based on primary care have better population health, health equity, and health care quality, and lower health care expenditure. Primary care can be a boundary-spanning force to integrate and personalize the many factors from which population health emerges. Equitably advancing population health requires understanding and supporting the complexly interacting mechanisms by which primary care influences health, equity, and health costs.

Systems science approaches to cardiovascular disease prevention and management in the era of COVID-19: A Humpty-Dumpty dilemma?

The coronavirus disease 2019 (COVID-19) pandemic necessitated the implementation and prioritizing of strict public health strategies to mitigate COVID-19 transmission and infection over all else. As we enter a 'recovery' phase in which the impact of the virus recedes (but does not relent), we ask, "How do we develop a game plan that considers prevention over management of public health threats of a more chronic nature, including cardiovascular disease?" We frame this choice point as a "Humpty-Dumpty" moment for public health with enduring and potentially irreversible consequences. Citing clear examples of other public health successes and failures, we outline in detail how sustaining cardiovascular population health under complex post-pandemic conditions will necessitate decision-making to be informed with a systems science approach, in which interventions, goals, outcomes and features of complex systems are carefully aligned.

Type 2 Diabetes as a Socioecological Disease: Can Youth Poets of Color Become Messengers of Truth and Catalysts for Change?

BACKGROUND

Efforts to confront the type 2 diabetes (T2D) epidemic have been stymied by an absence of effective communication on policy fronts. Whether art can be harnessed to reframe the T2D discourse from an individual, biomedical problem to a multilevel, communal and social problem is not known.

METHOD

We explored whether spoken word workshops enable young artists of color to convey a critical consciousness about T2D. The Bigger Picture fosters creation and dissemination of art to shift from the narrow biomedical model toward a comprehensive socioecological model (SEM). Workshops offer (1) public health content, (2) writing exercises, and (3) feedback on drafts. Based on Freire and Boal's participatory pedagogy, workshops encourage youth to tap into their lived experiences when creating poetry. We analyzed changes in public health literary and activation among participants and mapped poems onto the SEM to assess whether their poetry conveyed the multilevel perspective critical to public health literacy.

RESULTS

Participants reported significant increases in personal relevance of T2D prevention, T2D discussions with peers, concern about corporations' targeted marketing, and interest in community organizing to confront the epidemic. Across stanzas, nearly all poems (95%) featured >three of five SEM levels (systemic forces, sectors of influence, societal norms, behavioral settings, individual factors); three-quarters (78%) featured >four levels.

CONCLUSIONS

Engaging youth poets of color to develop artistic content to combat T2D can increase their public health literary and social activation and foster compelling art that communicates how complex, multilevel forces interact to generate disease and disease disparities.

Developing a dynamic simulation model to support the nationwide implementation of whole genome sequencing in lung cancer

BACKGROUND

This study shows how dynamic simulation modeling can be applied in the context of the nationwide implementation of Whole Genome Sequencing (WGS) for non-small cell lung cancer (NSCLC) to inform organizational decisions regarding the use of complex and disruptive health technologies and how these decisions affect their potential value.

METHODS

Using the case of the nationwide implementation of WGS into clinical practice in lung cancer in the Dutch healthcare system, we developed a simulation model to show that including service delivery features across the diagnostic pathway can provide essential insight into the affordability and accessibility of care at the systems level. The model was implemented as a hybrid Agent-Based Model and Discrete-Event Simulation model in AnyLogic and included 78 hospital agents, 7 molecular tumor board agents, 1 WGS facility agent, and 5313 patient agents each year in simulation time.

RESULTS

The model included patient and provider heterogeneity, including referral patterns, capacity constraints, and diagnostic workflows. Patient preference and adoption by healthcare professionals were also modeled. The model was used to analyze a scenario in which only academic hospitals have implemented WGS. To prevent delays in the diagnostic pathway, the capacity to sequence at least 1600 biopsies yearly should be present. There is a two-fold increase in mean diagnostic pathway duration between no patients referred or all patients referred for further diagnostics.

CONCLUSIONS

The systems model can complement conventional health economic evaluations to investigate how the organization of the workflow can influence the actual use and impact of WGS. Insufficient capacity to provide WGS and referral patterns can substantially impact the duration of the diagnostic pathway and thus should be considered in the implementation of WGS.

Mapping the complex causal mechanisms of drinking and driving behaviors among adolescents and young adults

BACKGROUND

The proportion of motor vehicle crash fatalities involving alcohol-impaired drivers declined substantially between 1982 and 1997, but progress stopped after 1997. The systemic complexity of alcohol-impaired driving contributes to the persistence of this problem. This study aims to identify and map key feedback mechanisms that affect alcohol-impaired driving among adolescents and young adults in the U.S.

METHODS

We apply the system dynamics approach to the problem of alcohol-impaired driving and bring a feedback perspective for understanding drivers and inhibitors of the problem. The causal loop diagram (i.e., map of dynamic hypotheses about the structure of the system producing observed behaviors over time) developed in this study is based on the output of two group model building sessions conducted with multidisciplinary subject-matter experts bolstered with extensive literature review.

RESULTS

The causal loop diagram depicts diverse influences on youth impaired driving including parents, peers, policies, law enforcement, and the alcohol industry. Embedded in these feedback loops are the physical flow of youth between the categories of abstainers, drinkers who do not drive after drinking, and drinkers who drive after drinking. We identify key inertial factors, discuss how delay and feedback processes affect observed behaviors over time, and suggest strategies to reduce youth impaired driving.

CONCLUSION

This review presents the first causal loop diagram of alcohol-impaired driving among adolescents and it is a vital first step toward quantitative simulation modeling of the problem. Through continued research, this model could provide a powerful tool for understanding the systemic complexity of impaired driving among adolescents, and identifying effective prevention practices and policies to reduce youth impaired driving.

Facilitating cancer systems epidemiology research

Systems epidemiology offers a more comprehensive and holistic approach to studies of cancer in populations by considering high dimensionality measures from multiple domains, assessing the inter-relationships among risk factors, and considering changes over time. These approaches offer a framework to account for the complexity of cancer and contribute to a broader understanding of the disease. Therefore, NCI sponsored a workshop in February 2019 to facilitate discussion about the opportunities and challenges of the application of systems epidemiology approaches for cancer research. Eight key themes emerged from the discussion: transdisciplinary collaboration and a problem-based approach; methods and modeling considerations; interpretation, validation, and evaluation of models; data needs and opportunities; sharing of data and models; enhanced training practices; dissemination of systems models; and building a systems epidemiology community. This manuscript summarizes these themes, highlights opportunities for cancer systems epidemiology research, outlines ways to foster this research area, and introduces a collection of papers, "Cancer System Epidemiology Insights and Future Opportunities" that highlight findings based on systems epidemiology approaches.

Families navigating community resources: understanding and supporting Nunavimmiut families

In a project aiming to develop community-led resources for families in northern Quebec, Canada, members (Inuit and non-Inuit) of the project decided to meet with Inuit parents to hear their experiences and needs, and to better understand how family dynamics might be related to ways of using resources within communities. In this article, we present secondary analyses of interviews conducted in 2015 with 14 parents living in a community of Nunavik, northern Quebec, accompanied by participatory analysis sessions. A dual data analysis strategy was adopted. Non-Inuit researchers and research assistants with significant lived experience in Nunavik explored what they learned from the stories that Inuit parents shared with them through the interviews and through informal exchanges. Inuit partners then discussed the large themes identified by the research team to guide non-Inuit researchers in their analysis. The aim was to better inform non-Inuit service providers and people whose mandate it is to support community mobilisation in relation to the heterogeneous realities of Inuit families, and the ways in which they can be of support to families based on their specific realities and needs.

Epidemic modeling as a means to reimagine health education and policy post-COVID

Purpose

As illustrated by coronavirus disease 2019 (COVID-19), epidemic models are powerful health policy tools critical for disease prevention and control, i.e. if they are fit for purpose. How do people ensure this is the case and where does health education fit in?

Design/methodology/approach

This research takes a multidisciplinary approach combining qualitative secondary and primary data from a literature review, interviews and surveys. The former spans academic literature, grey literature and course curriculum, while the latter two involve discussions with various modeling stakeholders (educators, academics, students, modeling experts and policymakers) both within and outside the field of epidemiology.

Findings

More established approaches (compartmental models) appear to be favored over emerging techniques, like agent-based models. This study delves into how formal and informal education opportunities may be driving this preference. Drawing from other fields, the authors consider how this can be addressed.

Practical implications

This study offers concrete recommendations (course design routed in active learning pedagogies) as to how health education and, by extension, policy can be reimagined post-COVID to make better use of the full range of epidemic modeling methods available.

Originality/value

There is a lack of research exploring how these methods are taught and how this instruction influences which methods are employed. To fill this gap, this research uniquely engages with modeling stakeholders and bridges disciplinary silos to build complimentary knowledge.

Planning for suicide prevention in Thai refugee camps: Using community-based system dynamics modeling

Suicide and associated behaviors represent a significant health disparity among refugees and displaced persons. Despite this burden, evidence for prevention programing in these populations is limited. This study aimed to inform the selection and implementation of suicide prevention strategies in refugee camps in Northwestern, Thailand - camps that had experienced recent spikes in suicides and suicide attempts at the time of the study. We leveraged Community Based System Dynamics modeling through a series of four workshops with key local stakeholders and suicide prevention experts, to build a qualitative systems model that accounts for complexities and is aimed at assisting local partners with selecting the most promising strategies for implementation and evaluation. The process expanded local understanding of the causes and consequences of suicide and resulted in selection of priority interventions aimed at reducing suicide in this context. Our research illustrates the application of a novel methodology that aims to account for the complexities of suicide prevention in the context of displacement and helps to optimize local suicide prevention efforts.

Evolving Science to Inform Emerging Concussion Practices

Purpose This article describes two concussion models built on the current state of science that help illustrate the complicated interactions among the multiple factors that drive concussion symptoms. Consideration of these models remind practitioners, including speech-language pathologists, to attend to factors that increase the risk of patients developing prolonged symptoms, as well as attend to symptoms that result from various interactions and may differentially respond to specific treatments. In particular, the models encourage personalized or precision medicine and the implementation of targeted, coordinated therapies.

Noncontact Knee Ligament Injury Prevention Screening in Netball: A Clinical Commentary with Clinical Practice Suggestions for Community-Level Players

Netball is a predominantly female team court-sport which is played worldwide. Netball is becoming more popular in the United States following its countrywide introduction to schools and community centers. A unique characteristic of netball is the footwork rule which restricts players to a one-step landing after catching the ball. Most netball landings are single-leg landings resulting in high vertical ground reaction forces and high skeletal tissue forces. Thus, high-risk landing events that have the biomechanical potential for injury occur frequently. Noncontact knee ligament injuries are common following a knee abduction collapse when landing. Because the consequences of noncontact knee ligament injury are profound, strategies are needed to mitigate the burden of such injury for players, teams, and society. The purpose of this clinical commentary is to demonstrate how theoretical principles, different types of research, and different levels of evidence underpin a rational clinical reasoning process for developing noncontact knee ligament injury prevention screening procedures in netball. The theoretical principles that are discussed in this commentary include injury control, the sequence of prevention, principles of screening in injury prevention, the multifactorial model of injury etiology, complex systems theory, and systems science. The different types of research that are reviewed include descriptive and analytic-observational studies. The different levels of evidence that are discussed include prospective studies, cross-sectional studies, and clinicians' own kinesiological modelling. Subsequently, an integrated approach to the evidence-informed development of noncontact knee ligament injury prevention screening procedures is presented. Clinical practice suggestions include a selection of evidence-informed screening tests that are quickly and easily implemented with netball players in local communities. The need for repeated screening at strategic timepoints across a season/year is explained. Sports physical therapists will find this commentary useful as an example for how to undertake clinical reasoning processes that justify the content of screening procedures contributing to noncontact knee ligament injury prevention in community-level netball.

LEVEL OF EVIDENCE

5.

Applying systems thinking to knowledge mobilisation in public health

CONTEXT

Knowledge mobilisation (KM) is a vital strategy in efforts to improve public health policy and practice. Linear models describing knowledge transfer and translation have moved towards multi-directional and complexity-attuned approaches where knowledge is produced and becomes meaningful through social processes. There are calls for systems approaches to KM but little guidance on how this can be operationalised. This paper describes the contribution that systems thinking can make to KM and provides guidance about how to put it into action.

METHODS

We apply a model of systems thinking (which focuses on leveraging change in complex systems) to eight KM practices empirically identified by others. We describe how these models interact and draw out some key learnings for applying systems thinking practically to KM in public health policy and practice. Examples of empirical studies, tools and targeted strategies are provided.

FINDINGS

Systems thinking can enhance and fundamentally transform KM. It upholds a pluralistic view of knowledge as informed by multiple parts of the system and reconstituted through use. Mobilisation is conceived as a situated, non-prescriptive and potentially destabilising practice, no longer conceptualised as a discrete piece of work within wider efforts to strengthen public health but as integral to and in continual dialogue with those efforts. A systems approach to KM relies on contextual understanding, collaborative practices, addressing power imbalances and adaptive learning that responds to changing interactions between mobilisation activities and context.

CONCLUSION

Systems thinking offers valuable perspectives, tools and strategies to better understand complex problems in their settings and for strengthening KM practice. We make four suggestions for further developing empirical evidence and debate about how systems thinking can enhance our capacity to mobilise knowledge for solving complex problems - (1) be specific about what is meant by 'systems thinking', (2) describe counterfactual KM scenarios so the added value of systems thinking is clearer, (3) widen conceptualisations of impact when evaluating KM, and (4) use methods that can track how and where knowledge is mobilised in complex systems.

Using Social Network Analysis to Strengthen Organizational Relationships to Better Serve Expectant and Parenting Young People

Introduction

Expectant and parenting young people (young parents) need a range of supports but may have difficulty accessing existing resources. An optimally connected network of organizations can help young parents navigate access to available services. Community organizations participating in the Pathways to Success (Pathways) initiative sought to strengthen their network of support for young parents through social network analysis (SNA) undertaken within an action research framework.

Method

Evaluators and community partners utilized a survey and analysis tool to map and describe the local network of service providers offering resources to young parents. Respondents were asked to characterize their relationship with all other organizations in the network. Following survey analysis, all participants were invited to discuss and interpret the results and plan the next actions to improve the network on behalf of young parents.

Results

Scores described the diversity of organizations in the network, density of connections across the community, degree to which the network was centralized or decentralized, which organizations were central or outliers, frequency of contact, levels of collaboration, and levels of trust. Findings were interpreted with survey participants and used by Pathways staff for action planning to improve their network.

Discussion

SNA clarified complex relationships and set service providers on a path toward optimizing their network. The usefulness of SNA to impact and improve a network approach to supporting young parents is discussed, including lessons learned from this project.

Creating Systems-Level Change to Better Support Expectant and Parenting Young People: A Case Study

INTRODUCTION

Expectant and parenting young people (young parents) require diverse services to support their health, educational success, and family functioning. Rarely can the needs of young parents be met by a single school or service provider. This case study examines how one large school district funded through the pathways to success initiative was able to facilitate systems change to increase young parents' access to and use of supportive services.

METHODS

Data sources include a needs and resources assessment, quarterly reports documenting grantee effort, sustainability plans, social network analysis, and capstone interviews. All data sources were systematically reviewed to identify the existing context prior to the start of the initiative, the changes that resulted from the initiative, and efforts that could potentially be maintained beyond the grant period.

RESULTS

The community context prior to Pathways implementation was one of disconnected services and missed opportunities. The full-time program coordinator hired by the district focused on systems-level change and facilitated connections between organizations. This greater connectivity contributed to increased collaboration with the goal of producing lasting benefits for young parents.

DISCUSSION

Promoting sustainable connections and collaboration at the systems level can help dismantle barriers to service access and benefit young parents.

Predicting mortality from 57 economic, behavioral, social, and psychological factors

In our prospective study using nationally representative data from 13,611 adults in the US Health and Retirement Study, we used traditional and machine-learning statistical approaches to reveal the most important factors across the behavioral and social sciences that predict mortality in older adults. In the study, we found that top predictors of mortality spanned all investigated domains, opening up opportunities for future hypothesis generation in observational and clinical studies and the identification of potential new targets for screening and policy.

Behavioral and social scientists have identified many nonbiological predictors of mortality. An important limitation of much of this research, however, is that risk factors are not studied in comparison with one another or from across different fields of research. It therefore remains unclear which factors should be prioritized for interventions and policy to reduce mortality risk. In the current investigation, we compare 57 factors within a multidisciplinary framework. These include (i) adverse socioeconomic and psychosocial experiences during childhood and (ii) socioeconomic conditions, (iii) health behaviors, (iv) social connections, (v) psychological characteristics, and (vi) adverse experiences during adulthood. The current prospective cohort investigation with 13,611 adults from 52 to 104 y of age (mean age 69.3 y) from the nationally representative Health and Retirement Study used weighted traditional (i.e., multivariate Cox regressions) and machine-learning (i.e., lasso, random forest analysis) statistical approaches to identify the leading predictors of mortality over 6 y of follow-up time. We demonstrate that, in addition to the well-established behavioral risk factors of smoking, alcohol abuse, and lack of physical activity, economic (e.g., recent financial difficulties, unemployment history), social (e.g., childhood adversity, divorce history), and psychological (e.g., negative affectivity) factors were also among the strongest predictors of mortality among older American adults. The strength of these predictors should be used to guide future transdisciplinary investigations and intervention studies across the fields of epidemiology, psychology, sociology, economics, and medicine to understand how changes in these factors alter individual mortality risk.

Mental Health and Well-Being of University Students: A Bibliometric Mapping of the Literature

The purpose of this study is to map the literature on mental health and well-being of university students using metadata extracted from 5,561 journal articles indexed in the Web of Science database for the period 1975-2020. More specifically, this study uses bibliometric procedures to describe and visually represent the available literature on mental health and well-being in university students in terms of the growth trajectory, productivity, social structure, intellectual structure, and conceptual structure of the field over 45 years. Key findings of the study are that research on mental health and well-being in university students: (a) has experienced a steady growth over the last decades, especially since 2010; (b) is disseminated in a wide range of journals, mainly in the fields of psychology, psychiatry, and education research; (c) is published by scholars with diverse geographical background, although more than half of the publications are produced in the United States; (d) lies on a fragmented research community composed by multiple research groups with little interactions between them; (e) is relatively interdisciplinary and emerges from the convergence of research conducted in the behavioral and biomedical sciences; (f) tends to emphasize pathogenic approaches to mental health (i.e., mental illness); and (g) has mainly addressed seven research topics over the last 45 years: positive mental health, mental disorders, substance abuse, counseling, stigma, stress, and mental health measurement. The findings are discussed, and the implications for the future development of the field are highlighted.

The Diffusion of Discrete Event Simulation Approaches in Health Care Management in the Past Four Decades: A Comprehensive Review

This study systematically examines the diffusion of the discrete event simulation (DES) approach in health services and health care management by examining relevant factors such as research areas, channels with the objective of promoting the application of DES in the health field. We examined 483 journal papers referencing this approach that were published in 230 journals during 1981 to 2014. The application of DES has extended from health service operational research evaluation to the assessment of interventions in diverse health arenas. The increase in the number of adopters (paper authors) of DES and the increase in number of related channels (journals publishing DES-related articles) are highly correlated, which suggests an increase of DES-related publications in health research. The same conclusion is reached, that is, an increased diffusion of DES in health research, when we focus on the temporal trends of the channels and adopters. The applications of DES in health research cover 22 major areas based on our categorization. The expansion in the health areas also suggests to a certain extent the rapid diffusion of DES in health research.

Estimating the population impact of hypothetical breastfeeding interventions in a low-income population in Los Angeles County: An agent-based model

BACKGROUND

Breastfeeding has clear benefits. Yet, breastfeeding practices fall short of recommendations in low-income populations including participants of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). To promote breastfeeding, it is important to understand breastfeeding-related behaviors such as initiation and maintenance within the context of a complex societal system. For individual women, making choices about infant feeding (whether to breastfeed or formula-feed a newborn, or when to stop breastfeeding) is a dynamic process involving interactions with health professionals, family, peers and workplaces. Integrating behavioral change theories with systems science tools such as agent-based modeling can help illuminate patterns of breastfeeding behaviors, identify key factors affecting breastfeeding behaviors within this complex dynamic system, and estimate the population impact of hypothetical interventions.

METHODS

An agent-based model (ABM) was developed to investigate the influences of multiple levels of factors affecting breastfeeding behaviors among WIC participants. Health behavioral change theories were applied and stakeholder input obtained to improve the model, particularly during the conceptual design and model specification steps. The model was then used to identify critical points for intervention and assess the effects of five common interventions (improving knowledge through education, implementing Baby-Friendly Hospital Initiative practices, providing postpartum breastfeeding counselling, strengthening partner support, and fostering supportive workplace environments.).

RESULTS

The ABM developed in this study produced outcomes (i.e., breastfeeding rates) that were concordant with empirical data. Increasing the coverage of the five selected interventions produced various levels of improvement in breastfeeding practices in the target population. Specifically, improving breastfeeding knowledge had a positive impact on women's intent to breastfeed, while increasing the availability of the Baby-Friendly Hospital Initiative improved breastfeeding initiation rates. However, neither of these two interventions showed a significant impact on breastfeeding maintenance, which was supported by postpartum breastfeeding counseling, partner support and a supportive workplace environment. These three intervention strategies each improved breastfeeding rates at 6 months from 55.6% to 57.1%, 59.5% and 59.3%, respectively. Increasing the coverage of multiple interventions simultaneously had a synergistic effect on breastfeeding maintenance with their effects being greater than the cumulative effects of increasing the coverage of these interventions individually.

CONCLUSION

The ABM we developed was helpful for understanding the dynamic process of decision-making regarding infant feeding modalities in a low-income population, and for evaluating the aggregated population-level impact of breastfeeding promotion interventions.

Introduction to the Theme Issue on Dynamics of Health Behavior: Revisiting Systems Science for Population Health

Systems science can help public health professionals to better understand the complex dynamics between factors affecting health behaviors and outcomes and to identify intervention opportunities. Despite their demonstrated utility in addressing health topics such influenza, tobacco control, and obesity, the associated methods continue to be underutilized by researchers and practitioners addressing health behaviors. This article discusses the growth of systems science methods (e.g., system dynamics, social network analysis, and agent-based modeling) in health research, provides a frame for the articles included in this themed issue, and closes with recommendations for enhancing the future of systems science and health behavior research. We argue that integrating systems sciences methods into health behavior research and practice is essential for improved population health and look forward to supporting the evolution of the field.

Building a systems thinking prevention workforce

ISSUE ADDRESSED

Healthy Together Victoria (HTV) was a large-scale intervention that adopted a systems approach to prevention. It established the capability of an inexperienced workforce by cultivating their understanding of systems theories, tools and practice. This paper explores how this capacity was developed and what helped and hindered the process.

METHODS

This qualitative research included 31 primary semi-structured interviews that focused on participants' understanding of systems thinking. Deductive thematic analysis was undertaken. A workforce development framework informed the coding that was used to create a causal loop diagram.

RESULTS

The findings display the multiple influencers on capacity-building. Practice change was enabled with training-although it lacked coordination and participation was limited. Yet, the systems approach was strengthened with governance arrangements, policies, funding, team support and leadership that empowered practitioners to trial systems methods. Capacity-building was hindered by HTV's unspecified theory that made it harder for novice practitioners to grasp. Funding cuts due to political changes reduced the initiative's duration and prompted resignations, causing the newfound experience to exit the workforce.

CONCLUSION

Capacity-building for systems practice requires a holistic approach of simultaneous, complimentary actions that address the individual and environmental influences of workforce development, especially the drivers of organisational culture that facilitate new practice. SO WHAT?: Effective training methods should specifically teach skills and knowledge that help practitioners to implement systems thinking. The workforce development requirements of other contributors also need to be considered, in addition to the policies, opportunities and resources that embed practice change.

Developing a Systems Mindset in Community-Based Prevention

Background. A systems mindset is the ability to see problems in their wider context and in terms of their underlying structure. This research describes how a systems mindset was understood and applied by prevention practitioners in a large-scale community-based initiative that employed a systems thinking approach. Method. This qualitative research included 31 primary semistructured interviews. Deductive thematic analysis was based on Braun and Clarke's analysis framework and was guided by Senge and Scharmer's knowledge-creating system. Results. The practitioners had been introduced to systems theory and were aware of complex problems and the need for equally sophisticated solutions. Their knowledge was not in-depth, although this may be adequate, as a theoretical overview seemed to be sufficient to support practice. A range of tools was available to practitioners to guide their systems mindset; however, none were preferred. Practitioners' awareness of the tools varied, as did their feelings toward them as some found them helpful and others did not. A narrower focus on tools could have benefited those who had not yet grasped systems theory. The use of projects within a systems approach confused some practitioners, yet others saw them as platforms to leverage change from. Implications for practice. With a systems mindset practitioners are able to develop systemic solutions to difficult problems. To do this, they require an overview of complex adaptive systems theory, an applied understanding of systems tools, and an experiential learning opportunity to shift their knowledge into practical know-how.

A systemic approach to achieving population-level impact in injury and violence prevention

The contemporary public health model for injury and violence prevention is a four-step process, which has been difficult to fully actualize in real-world contexts. This difficulty results from challenges in bridging science to practice and developing and applying population-level approaches. Prevention programmes and policies are embedded within and impacted by a range of system-level factors, which must be considered and actively managed when addressing complex public health challenges involving multiple sectors and stakeholders. To address these concerns, a systemic approach to population-level injury and violence prevention is being developed and explored by the Division of Analysis, Research, and Practice Integration in the National Center for Injury Prevention and Control at the Centers for Disease Control and Prevention. This article makes the case for and provides a high-level overview of this systemic approach, its various components, and how it is being applied in one governmental unit.

Translating systems thinking into practice for community action on childhood obesity

We report on the first 18 months of two communities' efforts using methods inspired by community-based participatory system dynamics for the development, implementation, and evaluation of whole of community efforts to improve the health of children. We apply Foster-Fishman's theoretical framework for characterizing systems change to describe the initiatives. Bounding the system began with defining leaders more broadly than standard health interventions to be those who had the ability to change environments to improve health, including food retailers, government, and business, and using high-quality childhood monitoring data to define the problem. Widespread access to junk food, barriers to physical activity, and efforts to promote health predominantly through programmatic approaches were identified as potential root causes. System interactions existed in the form of relationships between stakeholder groups and organizations. The approach described built new relationships and strengthened existing relationships. Willingness in taking risks, changing existing practice, and redesigning health promotion work to have a community development focus, were levers for change. This approach has resulted in hundreds of community-led actions focused on changing norms and environments. Insights from this approach may be useful to support other communities in translating systems theory into systems practice. Further empirical research is recommended to explore the observations in this paper.

Notes From the Field: Creating a Typology of Childhood Obesity Intervention Strategies

Classification systems can be useful for evaluating and communicating the impact of interventions. We describe how a typology was created to inform the development of a community intervention dose index (CIDI) intended to measure the strength of impacts attributed to multiple childhood obesity intervention strategies implemented in a large, diverse urban jurisdiction in the United States during 2000-2016. The categorization system was constructed via a three-stage process: (Stage 1) identify relevant constructs for categorizing intervention strategies; (Stage 2) review peer-reviewed literature and program requests for proposals to identify and integrate common attributes of intervention strategies based on Stage 1 constructs; and (Stage 3) vet the results from prior stages to develop a final version of the typology, slated for research application and for use in program improvement. The final system grouped strategies into four macrolevel and five microlevel categories. Macrolevel strategies included government/public institutional policies, infrastructure investments, and business practices. Microlevel strategies included group education, counseling, health communication and social marketing, home visitation, and screening and referral. Grouping intervention strategies in a purposeful, classified manner facilitated communications among researchers and practitioners during the gathering and quantifying of intervention data for the CIDI project and may be used to guide scarce public health resource allocation decisions.

Modelling the impact of menthol sales restrictions and retailer density reduction policies: insights from tobacco town Minnesota

Introduction

Tobacco control policies focused on the retail environment have the potential to reduce tobacco use and tobacco-related health disparities through increasing direct and indirect costs. Recently, national and subnational governments have begun to restrict the sale of menthol products and reduce tobacco retailer density.

Methods

We developed an agent-based model to project the impact of menthol cigarette sales restrictions and retailer density reduction policies for six types of communities and three priority populations. During each simulated day, agents smoke cigarettes, travel in the community and make purchase decisions—whether, where and which product type to purchase—based on a combination of their own properties and the current retail environment.

Results

Of the policies tested, restricting all cigarette sales or menthol cigarette sales to tobacco specialty shops may have the largest effect on the total (direct and indirect) costs of purchasing cigarettes. Coupling one of these policies with one that establishes a minimum distance between tobacco retailers may enhance the impact. Combining these policies could also make the costs of acquiring cigarettes more equal across communities and populations.

Discussion

Our simulations revealed the importance of context, for example, lower income communities in urban areas begin with higher retailer density and may need stronger policies to show impact, as well as the need to focus on differential effects for priority populations, for example, combinations of policies may equalise the average distance travelled to purchase. Adapting and combining policies could enhance the sustainability of policy effects and reduce tobacco use.

The SMART Framework: Integration of Citizen Science, Community-Based Participatory Research, and Systems Science for Population Health Science in the Digital Age

Citizen science enables citizens to actively contribute to all aspects of the research process, from conceptualization and data collection, to knowledge translation and evaluation. Citizen science is gradually emerging as a pertinent approach in population health research. Given that citizen science has intrinsic links with community-based research, where participatory action drives the research agenda, these two approaches could be integrated to address complex population health issues. Community-based participatory research has a strong record of application across multiple disciplines and sectors to address health inequities. Citizen science can use the structure of community-based participatory research to take local approaches of problem solving to a global scale, because citizen science emerged through individual environmental activism that is not limited by geography. This synergy has significant implications for population health research if combined with systems science, which can offer theoretical and methodological strength to citizen science and community-based participatory research. Systems science applies a holistic perspective to understand the complex mechanisms underlying causal relationships within and between systems, as it goes beyond linear relationships by utilizing big data–driven advanced computational models. However, to truly integrate citizen science, community-based participatory research, and systems science, it is time to realize the power of ubiquitous digital tools, such as smartphones, for connecting us all and providing big data. Smartphones have the potential to not only create equity by providing a voice to disenfranchised citizens but smartphone-based apps also have the reach and power to source big data to inform policies. An imminent challenge in legitimizing citizen science is minimizing bias, which can be achieved by standardizing methods and enhancing data quality—a rigorous process that requires researchers to collaborate with citizen scientists utilizing the principles of community-based participatory research action. This study advances SMART, an evidence-based framework that integrates citizen science, community-based participatory research, and systems science through ubiquitous tools by addressing core challenges such as citizen engagement, data management, and internet inequity to legitimize this integration.

How Biomedical HIV Prevention Trials Incorporate Behavioral and Social Sciences Research: A Typology of Approaches

In the field of biomedical HIV prevention, researchers have meaningfully incorporated behavioral and social sciences research (BSSR) into numerous clinical trials, though the timing and degree of integration have been highly variable. The literature offers few frameworks that systematically characterize these collaborations. To fill this gap, we developed a typology of BSSR approaches within biomedical HIV prevention research. Focusing on trials that had safety and/or efficacy endpoints, we identified five approaches for combining BSSR and clinical research: formative, embedded, parallel, explanatory, and implications. We describe each approach and provide illustrative examples. By offering a shared vocabulary for distinguishing the timing and design of collaborative BSSR and clinical research, this typology can facilitate greater transparency in collaborators’ expectations and responsibilities, and help collaborators address challenges likely to be associated with such interdisciplinary research.

Network Modeling of PrEP Uptake on Referral Networks and Health Venue Utilization Among Young Men Who Have Sex with Men

The objective of this study is to identify individual-level factors and health venue utilization patterns associated with uptake of pre-exposure prophylaxis (PrEP) and to evaluate whether PrEP uptake behavior is further diffused among young men who have sex with men (YMSM) through health venue referral networks. A sample of 543 HIV-seronegative YMSM aged 16-29 were recruited in 2014-2016 in Chicago, IL, and Houston, TX. Stochastic social network models were estimated to model PrEP uptake. PrEP uptake was associated with more utilization of health venues in Houston and higher levels of sexual risk behavior in Chicago. In Houston, both Hispanic and Black YMSM compared to White YMSM were less likely to take PrEP. No evidence was found to support the spread of PrEP uptake via referral networks, which highlights the need for more effective PrEP referral network systems to scale up PrEP implementation among at-risk YMSM.

Application of System Dynamics to Inform a Model of Adolescent SBIRT Implementation in Primary Care Settings

System dynamics (SD) modeling is used to compare and contrast strategies for effective implementation of an evidence-based adolescent behavioral health treatment in primary care settings. With qualitative and quantitative data from an on-going cluster-randomized trial in 7 federally qualified health center sites, two implementation conditions were compared: generalist vs. specialist. In the generalist approach, the primary care provider (PCP) delivered brief intervention (BI) for substance misuse (n = 4 clinics). In the specialist approach, BIs were delivered by behavioral health counselors (BHCs) (n = 3 clinics). The resultant SD model compared 'basecase' dynamics to strategic approaches to deploying continuous technical assistance (TA) and performance feedback reporting (PFR). The basecase effectively represented the SBIRT intervention, which reflected actual monthly volume of adolescent primary care visits (N = 9639), screenings (N = 5937), positive screenings (N = 246), and brief interventions (BIs; N = 50) over the 20-month implementation period. Insights gained suggest that implementation outcomes are sensitive to frequency of PFR, with bimonthly events generating the most rapid and sustained screening results. Simulated trends indicated that availability of the BHC directly impacts success of the specialist model. Similarly, understanding PCPs' perception of severity of need for intervention is key to outcomes in either condition.

Policy and Science for Global Health Security: Shaping the Course of International Health

The global burden of infectious diseases and the increased attention to natural, accidental, and deliberate biological threats has resulted in significant investment in infectious disease research. Translating the results of these studies to inform prevention, detection, and response efforts often can be challenging, especially if prior relationships and communications have not been established with decision-makers. Whatever scientific information is shared with decision-makers before, during, and after public health emergencies is highly dependent on the individuals or organizations who are communicating with policy-makers. This article briefly describes the landscape of stakeholders involved in information-sharing before and during emergencies. We identify critical gaps in translation of scientific expertise and results, and biosafety and biosecurity measures to public health policy and practice with a focus on One Health and zoonotic diseases. Finally, we conclude by exploring ways of improving communication and funding, both of which help to address the identified gaps. By leveraging existing scientific information (from both the natural and social sciences) in the public health decision-making process, large-scale outbreaks may be averted even in low-income countries.