shifting the paradigm for chronic disease prevention: from simple solutions to system approaches...
TRANSCRIPT
Shifting the Paradigm for Chronic Disease Prevention:
from simple solutions to system approaches
Professor, Biomedical Physiology and Kinesiology, Simon Fraser University
Executive Director, The CAPTURE Project@DTFinegood
Oxford Health Alliance Meeting April 14-15, 2011
Take Home Messages
• Chronic disease prevention is complex (not simple or even complicated).
• Accepting complexity does not mean we should give up, but we must turn to solutions appropriate for complex problems.
• Interactions between: levels, capacity & complexity, competition & cooperation, and networks are places to look for solutions.
Obesity System Map
http://kim.foresight.gov.uk/Obesity/Obesity.html
O
ITY
PREVALE
INDIVIDUAL
EnergyExpenditure
POPULATION
%
OBESE
OR
UNDERWT
Food intake :
Nutrient density
FACTORSINTERNATIONAL
Development
Globalizationof
markets
SchoolFood &Activity
WORK/SCHOOL/
HOME
Infections
Labour
Worksite Food & Activity
LeisureActivity/Facilities
Agriculture/Gardens/Local markets
COMMUNITYLOCALITY
Health Care
System
PublicSafety
PublicTransport
Manufactured/Imported Food
Sanitation
NATIONAL/REGIONAL
Food & Nutrition
Urbanization
Education
Health
Social Security
Transport
Family &Home
Nationalperspective
Media &CultureMedia
programs& advertising
Source: see Kumanyika Ann Rev Pub Health 2001; 22:293-308
“Causal Web”
Causality and Complex Systems
“….causality can only be meaningfully defined for systems with linear interactions
among their variables.”
Wagner. Biology and Philosophy 14: 83–101, 1999.From flickr.com by nerovivo
Characteristics of Systems
Simple or Complicated Systems Complex Systems
Homogeneous Heterogeneous
Linear Nonlinear
Deterministic Stochastic
Static Dynamic
Independent Interdependent
No feedback Feedback
Not adaptive or self-organizing Adaptive and self organizingNo connection between levels or subsystems Emergence
Common Responses to Complex Problems
• Retreat
• Despair
• Believe the problem is beyond hope
• Assign blame, figure out who is responsible
• Simple solutions
• Galvanize our collective efforts and invest significant resources
Bar-Yam, Y. Making Things Work, 2004.
Places to Look for Solutions to Complex Problems
• In the interaction between levels
• In the relationship between an individual’s (or organization’s) capacity to deal with the complexity of it’s tasks
• In the interdependence between competition and cooperation
• By influencing emergence
Levels Relevant to Obesity & Chronic Disease
• International
• National
• Regional / Municipal
• Worksites / Schools
• Home / Family
• Individuals
• Organ / Metabolic Systems
• Proteins
• Genes
• UN Summit on NCDs
• Implementation of FCTC
• CIH Sites
• Romp and Chomp
• Angawadi workers
• Health Education
• Metformin
Scale: Relationship between the macro and the micro
From flickr.com by maliasFrom flickr.com by Ethan Hein
Coherence vs Alignment
From flickr.com by mister.crowleyFrom flickr.com by shadowfall
Places to Intervene in a complex system 1. The power to transcend paradigms2. The paradigm that the system arises out of3. The goal of the system4. The power to add, change, evolve, or self-organize system
structure5. The rules of the system 6. The structure of information flow 7. The gain around driving positive feedback loops8. The strength of negative feedback loops9. The length of delays10. The structure of material stocks and flows 11. The size of buffers and other stabilizing stocks12. Constants, parameters, numbers
Effec
tiven
ess
Diffi
culty
D. Meadows. Thinking in Systems, A Primer, Chelsea Green, 2009.
One Approach to Scale: Intervention Level Framework
Effec
tiven
ess
Diffi
culty
Level Definition
Paradigm Deepest held beliefs
Goals What trying to achieve
Structure Information flows, connectivity, trust
Feedback & delays
Self-regulation, reinforcement & adaptation
Structural elements
Subsystems, actors, operating parameters
Finegood, DT. The Complex System Science of Obesity. In: The SocialScience of Obesity, Ed. J Cawley. Oxford University Press, 2011
Intervention Levels: Research & EvaluationEff
ectiv
enes
s
Diffi
culty
Level From
Paradigm Reductionism, accountability
Goals Attribution
Structure Disconnected
Feedback & delays Indirect; glacial
Structural elements Mismatched; many gaps
Intervention Levels: Research & EvaluationEff
ectiv
enes
s
Diffi
culty
Level From To
Paradigm Reductionism, accountability Learning
Goals Attribution Adaptation
Structure Disconnected Interdependent
Feedback & delays Indirect; glacial Continuous
Structural elements Mismatched; many gaps Coherent
Intervention Levels: Obesity & NCDsEff
ectiv
enes
s
Diffi
culty
Level From To
Paradigm Simple solutions, reductionist approach
Accepting complexity, integrative approaches
GoalsIncreased physical activity; healthier dietary habits; healthier food supply
Increased physical activity; healthier dietary habits; healthier food supply
Structure
Silos between research & evaluation; government, private sector, NGO’s, academia.
Increased coherence and connectivity; increased trust for cross-sectoral collaboration
Intervention Levels: Obesity & NCDsEff
ectiv
enes
s
Diffi
culty
Level From To
Feedback & delays
Long loops and delays, eg in research funding, data to users, government action
More balancing (as opposed to reinforcing feedback loops)
Structural elements
Health education, social marketing, multiple food labeling schemes, high cost of healthy food, no access to treatment, etc.
Quality daily PE, decreased marketing, simplified labeling, walkable neighborhoods, affordable healthy food, accessible treatment options, etc.
Distribution of Effort/Investments?
0
10
20
30
40
50
60
Paradigm Goals Feedback& Delays
StructuralElements
Structure
Distribution of Effort/Investments?
0
10
20
30
40
50
60
Paradigm Goals Feedback& Delays
StructuralElements
Structure
Places to Look for Solutions to Complex Problems
• In the interaction between levels
• In the relationship between an individual’s (or organization’s) capacity to deal with the complexity of it’s tasks
• In the interdependence between competition and cooperation
• By influencing emergence
Matching Capacity and Complexity
Bar-Yam, Y. Complexity Rising, www.necsi.org
Complexity of Environment
Complexity ofOrganism orOrganization
(Capacity)
Fail
Survive
Food Labeling Environment
By jovike
Food & Nutrition Information Sources
23
27
41
46
50
51
52
65
66
76
77
A dietitian
Fitness/ weightloss programs
Government materials
The Internet or the Web
Health association materials
A famiy physician or other health professional
Food company materials or advertisements
Radio/TV programs
Friends/relatives/colleagues
Magazines, newspapers, and books
Food product labels
Q.16 People can get information about food and nutrition from a number of different sources. Please tell me from which of the following sources you personally got information on food and nutrition in the past year.
Base: Total Canadians, n=2014
Mindless eating decreases the complexity of food consumption
The average person makes around 250 decisions about food every day:
– Breakfast or no breakfast?
– Pop-tart or bagel? – Part of it or all of
it?– Kitchen or car?– Fun food or better
for you food?
Trust as a System Variable
• Trust is a way of dealing with complexity in an increasingly complex society.
• High trust societies are able to form wide-reaching and successful cooperative partnerships.
• Low trust societies tend to be economic disaster areas and can be terrible places to live.
Soloman, R.C. & Flores, F. (2001). Building trust in business, politics, relationships, and life. New York: Oxford University Press.
Building Trust to Address Obesity and Chronic Disease Prevention
Lessons Learned Through Building Trust Initiative
• Within sector (private sector, NGO, government, academia) is more difficult to build than between sector trust
• Regulation is needed when competition is undesirable; Regulation levels the playing field
• Trust building to address obesity needs a safe space
http://www.youtube.com/watch?v=sZh8jAqeLAU
Places to Look for Solutions to Complex Problems
• In the interaction between levels
• In the relationship between an individual’s (or organization’s) capacity to deal with the complexity of it’s tasks
• In the interdependence between competition and cooperation
• By influencing emergence
Cooperation and Competition
From flicker.com by LodewijkB
Cooperation and Competition
Bar-Yam, Y. COMPLEX SYSTEMS AND SPORTS: Complex Systems insights to building effective teams
Foresight
Prevention is a cross government issue – like climate change
Foresight Programme, B. Butland, unpublished observations
ActNowBC: Promising Practices
• Leadership
• Increasing collaborative action among government sectors with diverse strategies and mechanisms– An incentive fund of $15 million supported pilot
health promotion projects by ministries other than the Ministry of Health
• The involvement of civil society organizations
http://www.phac-aspc.gc.ca/publicat/2009/ActNowBC/pdf/anbc-eng.pdf
Places to Look for Solutions to Complex Problems
• In the interaction between levels
• In the relationship between an individual’s (or organization’s) capacity to deal with the complexity of it’s tasks
• In the interdependence between competition and cooperation
• By influencing emergence
Life Cycle of Emergence• Stage 1 – Networks:
– self-organized
– for finding like-minded others
– based on self-interest
– have fluid membership
• Stage 2 – Communities of Practice: – also self-organized
– used to share knowledge, support one another, and to intentionally create new knowledge
– people commit to be there for each other, to serve the needs of others
– good ideas move rapidly amongst members.
M Wheatley and D Frieze ©2006, USING EMERGENCE TO TAKE SOCIAL INNOVATIONS TO SCALE
Life Cycle of Emergence
• Stage 3 – Systems of Influence: – can’t be predicted; sudden appearance of a system that has real
power and influence.
– pioneering efforts that hovered at the periphery suddenly become the norm.
– their approaches and methods are quickly adopted
– policy and funding debates now include the perspectives and experiences of these pioneers.
– critics who said it could never be done suddenly become chief supporters
M Wheatley and D Frieze ©2006, USING EMERGENCE TO TAKE SOCIAL INNOVATIONS TO SCALE
Influencing Emergence
• Emergence only happens through connections
• “Act locally, connect regionally, learn globally.”
M Wheatley and D Frieze ©2006, USING EMERGENCE TO TAKE SOCIAL INNOVATIONS TO SCALE
Diffusion of Innovation
Greenhalgh, T. et al. The Milbank Quarterly, 82 (4): 581, 2004
Take Home Messages
• Chronic disease prevention is complex (not simple or even complicated).
• Accepting complexity does not mean we should give up, but we must turn to solutions appropriate for complex problems.
• Interactions between: levels, capacity & complexity, competition & cooperation, and networks are places to look for solutions.