An update from the Cochrane Public Health Group

Our work within Public Health Insight aims to generate evidence-informed solutions for decision makers. Public Health Insight incorporates the Cochrane Public Health Group (CPHG) and we thought it was time to provide an update on the work of CPHG and highlight the scope of our Cochrane reviews.

By way of background, in 2005 the World Health Organisation (WHO) convened the Commission on Social Determinants of Health to determine the available evidence globally on health inequities. The ultimate goal of the commission was to identify strategies to curb the increase in inequities.

The results suggested that inequities were not naturally occurring and could be avoidable by improving policy choices, i.e. acting on the social and structural determinants of population health.

In 2008, the Cochrane Public Health Group (CPHG) was registered as an editorial group with the international Cochrane Collaboration to address these challenges. Our mandate is to produce systematic reviews of interventions that seek to support decision-making involving the upstream determinants of health. Our group filled a crucial gap in the existing coverage of Cochrane review topics relevant to global population-level health evidence.

CPHG authors, guided by our editorial team, have utilised contemporary systematic review methods to identify not only whether interventions work, but the ability of these interventions to reduce inequities. Our reviews also seek to identify pointers to potential ineffectiveness or harm (including inequities) due to implementation or resource issues. We understand the need for decision-makers to have access to information about how to implement effective interventions in their own contexts. Review authors are also asked to highlight issues for low and middle income countries, often in the absence of good quality evidence in these countries.

The CPHG works with the Campbell and Cochrane Equity Methods Group to encourage authors to utilise the PROGRESS (Places of residence, race/ethnicity, occupation, gender, religion, socioeconomic status and social capital) tool for extracting data and reporting outcomes.

We currently have a wide range of reviews published or underway (see below). If you are interested in learning more visit our website and please join us on Twitter (@CochranePH), where you will be notified of exciting new reviews published and other news items of relevance to evidence-informed public health. If you are interested in being involved in any of the topics (for example, by commenting as a content expert) contact our Managing Editor (Jodie Doyle:


  • Later school start times for supporting the education, health and well-being of high school students
  • Interventions for enhancing the implementation of school-based policies or practices targeting risk factors for chronic disease
  • Interventions for enhancing the implementation of policies or practices supportive of healthy eating, physical activity, and obesity
  • prevention in child care settings
  • Education support services for improving school engagement and academic performance of children and adolescents with a chronic health condition

Employment & the Work Environment

  • Flexible working conditions and their effects on employee health and wellbeing
  • Workplace-based organisational interventions to prevent and control obesity by improving dietary intake and/or increasing physical activity

Food Supply/Access and Public Health Nutrition

  • Staple crops biofortified with increased micronutrient content for improving vitamin and mineral status in populations
  • Interventions for preventing undernutrition in children (0-5 years) living in slum environments Portion, package or tableware size for changing consumption of food, alcohol and tobacco
  • Policy level and environmental interventions for reducing the consumption of non-alcoholic sweet drinks among children
  • Interventions for preventing obesity in children
  • Interventions for preventing obesity in children: an overview of systematic reviews
  • Iodine fortification of foods and condiments, other than salt, for preventing iodine deficiency disorders
  • Nutritional labelling to promote healthier food purchasing and consumption
  • Fortification of condiments and seasonings with iron for preventing anaemia and improving health
  • Community-level interventions to improve food security in developed countries
  • Community-level interventions for improving access to food in low- and middle-income countries
  • Fortification of rice with vitamins and minerals for addressing micronutrient malnutritition
  • Fortification of staple foods with vitamin A for preventing vitamin A deficiency
  • Wheat flour fortification with iron for reducing anaemia and improving iron status in whole and at-risk populations
  • Fortification of maize flour with iron for preventing anaemia and iron deficiency in populations
  • Fortification of wheat and maize flour with folic acid for population health outcomes
  • Population-level interventions in government jurisdictions for dietary sodium reduction
  • Food fortification with calcium and vitamin D: impact on health outcomes
  • Fortification of staple foods with zinc for improving health outcomes in the general population
  • Food fortification with multiple micronutrients: impact on health outcomes

Housing and the Built Environment

  • Housing improvements for health and associated socio-economic outcomes
  • Built environment interventions for physical activity in adults and children
  • Interventions to improve water quality and supply, sanitation and hygiene practices, and their effects on the nutritional status of children
  • Slum upgrading strategies and their effects on health and social outcomes
  • Interventions to reduce ambient particulate matter air pollution and their effect on health

Income Distribution and Financial Interventions

  • Welfare to work interventions and their effects on the health and wellbeing of lone parents and their children
  • In-work tax credits for families and their impact on health status in adults
  • Unconditional cash transfers for assistance in humanitarian disasters: effect on use of health services and health outcomes in low and middle income countries
  • Unconditional cash transfers for reducing poverty and vulnerabilities: effect on use of health services and health outcomes in low and middle income countries
  • Livestock development programs: effects on indicators of livelihood and health status for families in low and middle income countries

Natural Environment

  • Interventions for reducing adverse health effects of high temperature and heatwaves
  • Participation in environmental enhancement and conservation activities for health and well-being in adults
  • Participation in outdoor education programs in natural environments and children’s health

Public Safety

  • Interventions for preventing abuse in the elderly

Social Networks/Support

  • Social cohesion and community building interventions in local communities for improving health and quality of life
  • Interventions for promoting reintegration and reducing harmful behaviour and lifestyles in street-connected children and young people
  • Community coalition-driven interventions to reduce health disparities among racial and ethnic minority populations
  • Individual-, family-, and school-level interventions for preventing multiple risk behaviours in individuals aged 8 to 25 years
  • Population-level intervention for preventing multiple risk behaviours in 8 to 25 year olds

Systems for Health

  • Interventions implemented through sporting organisations for increasing participation in sport
  • Policy interventions implemented through sporting organisations for promoting healthy behaviour change
  • Interventions for enhancing the implementation of school-based policies or practices targeting risk factors for chronic disease
  • Interventions for enhancing the implementation of policies or practices supportive of healthy eating, physical activity, and obesity prevention in childcare services
  • Portion, package or tableware size for changing consumption of food, alcohol and tobacco
  • Collaboration between local health and local government agencies for health improvement
  • Service brokerage for improving health outcomes in ex-prisoners (previously entitled, Population level interventions for improving health outcomes in ex-prisoners)
  • Community-based, population level interventions for promoting child oral health
  • Knowledge translation strategies for facilitating evidence-informed public health decision making among managers and policymakers
  • Interventions for improving the use of the oral healthcare services by adults

Transport, Active Transport and Physical Activity

  • Legislative and engineering interventions for preventing road traffic injuries and fatalities among vulnerable road users (nonmotorised road users and motorised two-wheel road users) in low and middle income countries
  • Community wide interventions for increasing physical activity
  • Environmental and behavioural interventions for reducing sedentary behaviour in community dwelling older adults
  • Public health interventions for increasing physical activity in adults, adolescents and children: an overview of systematic reviews
  • Workplace based organisational interventions to prevent and control obesity by improving dietary intake and/or increasing physical activity
  • Interventions for enhancing the implementation of policies or practices supportive of healthy eating, physical activity, and obesity prevention in child care settings
  • Built environment interventions for physical activity in adults and children
  • Incentive-based interventions to increase physical activity
  • Interventions for preventing obesity in children
  • Interventions for preventing obesity in children: an overview of systematic reviews

Unraveling quality of life measures within interventions: A focus on children with cerebral palsy

Earlier this year, members of the Jack Brockhoff Child and Wellbeing Program were invited to join the Centre for Research Excellence in Cerebral Palsy (CRE-CP), which was recently awarded by the National Health Medical Research Council (NHMRC) to the Murdoch Childrens Research Institute (MCRI). The aim of this Centre is to substantially improve the assessment and care of young people with cerebral palsy in Australia. Working together with a number of leading clinicians and researchers, we will undertake a range of projects to improve the outcomes for children including trials of various medical, allied health and surgical interventions and how these interventions impact on their quality of life. More information can be found out about the centre, which is led by Professor Dinah Reddihough here: 

To start this wonderful work off, I will hold a seminar at the MCRI to introduce the construct of quality of life and how this can be measured and implemented within clinical interventions in order to better understand their impact beyond functional change to outcomes valued by families and children.

Measures of quality of life (QoL) can provide a broad indication of children’s well-being across several life domains such as physical health and social and emotional well-being. This seminar will introduce the concept of quality of life and provide an overview of QoL measures for children with cerebral palsy. Given the increased number of available measures it can be hard to decide on the most appropriate measure to use. A number of criteria will be discussed that can guide clinical researchers and clinicians in their decision-making. The seminar will also focus on the inclusion of QoL outcome measures in randomised controlled trials. There are a spectrum of issues that need to be considered in order to draw helpful conclusions about the impact of interventions on children’s quality of life for clinicians, researchers and families.

Professor Rob Carter will also introduce QoL measurement from a health economics perspective, serving as a teaser to a upcoming seminar that will be held on December 3rd at MCRI. Professor Rob Carter is Head of Deakin Health Economics and a CI on the CRE-CP.

For anyone who has is curious about quality of life and how to measure it, and interventions that would benefit from including QoL measures, please do come along!

Seminar details:
Unraveling quality of life measures within interventions: A focus on children with Cerebral Palsy

When: Wednesday 1st October
Time: 3-4pm, followed by afternoon tea
Where: Walford Room:Murdoch Childrens Research Institute



Written by Dr Kim-Michelle Gilson
Post doctoral Research Fellow, Jack Brockhoff Child Health & Wellbeing Program

Introducing Public Health Insight!

This week we are really excited to introduce Public Health Insight.

Over the last 13 years our Public Health Evidence and Knowledge Translation team has been involved in a significant number of knowledge translation, implementation science and evidence related research initiatives with a range of stakeholders. However, what we probably have the greatest profile in is the international leadership of the Cochrane Public Health Group. This group is based within the Melbourne School of Population and Global Health and linked closely to the Australasian Cochrane Centre at Monash University.

Given the breadth of our work, we have recognized that we need to create a profile that better communicates our skills and expertise including collaborating and leading on evidence and knowledge translation related research, training, consultancies and evidence reviews. With the support of VicHealth, we have invested in a wide consultation process with stakeholders to identify ways in which we could strengthen our profile and brand.


Our new name, brand and profile is now Public Health Insight. Further information on the group and our work program can be found on our new website:

Our new brand better reflects our range of activities and services. It also reflects the philosophy and strategic goals of what we have done, and what we are keen to continue to evolve – making our services and activities clearer. As Public Health Insight, our vision remains the same: evidence informed decisions leading to better and more equitable public health. It is the way we strive to achieve this that defines us: inclusive research for healthier decisions.

Our key research services will continue to be:

  • Public Health Evidence reviews
  • Managing and editing Cochrane reviews
  • Knowledge Translation research and action
  • Training
  • Consultancy

Public Health Insight will incorporate the CPHG and maintain its strong links with the Jack Brockhoff Child Health and Wellbeing Program at the University of Melbourne, and with the Cochrane Collaboration. We are really excited to embark on this new chapter and we encourage any researchers working in this area to get in touch, as we would welcome opportunities to explore new research questions.

Follow on Twitter: @PH_Insight and @CochranePH

Also visit the Cochrane Public Health Website to learn more about our Cochrane reviews.

Grant Success!

Dr Rebecca Armstrong and Dr Tahna Pettman and our new Public Health Insight team have just had some great news: their National Cancer Institute R21 grant has been funded!

It is a cross-country comparison of evidence-based practice in cancer prevention, focusing on state government decision-makers. They have a validated tool (not dissimilar to KT4LG survey) which they will implement across state government health departments in USA (Washington University in St Louis, Missouri), Brazil (Pontifícia Universidade Católica do Paraná, Parana), China (Hong Kong Polytechnic University, Hong Kong and Tongii University School of Medicine, Shanghai) and Australia – so a mix of middle and high income countries.
Ross Brownson, Rebecca Armstrong, Tahna Pettman, Rodrigo Reis, Katherine Stamatakis, Pauline Sung, Zhaoxin Wang. A cross-country comparison of evidence-based prevention of cancer. National Institutes of Health and National Cancer Institute (R21 grant in response to PAR 13-054).

Please join me in congratulating them both – their partnership with Ross is a long and strong one, and what a great welcome back from maternity leave for Rebecca and a wonderful outcome from Tahna’s participation in the NIH TIDIRH – training in Dissemination and Implementation research in health that she attended (the only Australian) – at the Office of Behavioral and Social Sciences Research, NIH, USA in 2012

This dovetails nicely with a new WHO grant to the Nossal Institute that we are leading in collaboration with Public Health Evidence South Asia (our CPHG South Asia satellite) at University of Manipal, which focusses on NCD’s and Disability – prevention, management and rehabilitation, and Tahna’s invited presentation to present within the World Cancer Congress in December on Implementing and evaluating a National Knowledge Translation and Exchange platform for NCD prevention,

If anyone would like more information, please do contact Rebecca and Tahna directly – and

Prof Elizabeth Waters
Jack Brockhoff Chair of Child Public Health

Guest Blog: Challenges for health promotion practice in the digital age

Working in health promotion is tough. With so many skilled practitioners, job hunting is competitive and job security is increasingly hard to find. Have you seen a permanent health promotion job advertised lately?

Health promoters need to be skilled at working with multiple stakeholders, keep up to date with best practice, and continually chip away to improve policy and environments. It can take decades to see population health changes. Of course there are lots of rewards, from seeing communities thrive, achieving positive and meaningful engagement and making huge differences to the world that negate the need for ‘miracle cures’ and expensive treatments that consume government health budgets.

The challenges and rewards of working in health promotion have not really changed over time. But as we move more and more into a digital age, what are the emerging challenges for health promotion practice?

As a reader of the Research Connect blog, there’s a good chance you are a researcher rather than practitioner. If so, as you read on keep in mind what role you think researchers can play to generate the evidence that supports practitioners in relation to the outlined issues.

I believe the challenges for health promotion practitioners in the digital age are as follows:

Professional development and competencies. Understanding how to apply social media to health promotion practice can require a new set of skills. When it comes to use in health promotion, social media expertise is often borrowed from, or outsourced to disciplines such as communications, public relations or marketing rather than from practitioners themselves. Whilst the current health promotion competencies touch upon technology, they do not incorporate the seismic shift in communication that web 2.0 technologies and social media have introduced.

Comparison paralysis. When you consider that Coca-Cola has more likes on Facebook than Harry Potter, Justin Bieber and Lady Gaga, and that there is a tweet a second made directly to McDonalds, it’s easy for health promotion programs to get sucked into believing that they need to compete with the private sector. It is unrealistic to think that small scale health promotion programs can compete with the resources of the private sector. That said, health promotion programs should choose social media strategies that are consistent with their populations/target groups and in line with their overall program objectives.

Finding evidence. Social media platforms and their nuances change frequently, much faster than traditional research cycles. How are practitioners meant to know how and what they should be doing health promotion work using social media if evidence can’t keep up? The answer may lie in social media! It’s really important that practitioners who are using social media work together to share their experiences, lessons and findings. The Australian Health Promotion Association in several jurisdictions offer online groups via LinkedIn or Facebook which create a great opportunity for professionals to exchange advice and ask questions.

Lure of social media as a tool for behaviour change. One of my key messages is that social media is another tool in a health promotion practitioner’s toolbox. Remember, a tool is just that and it should not be a case of ‘the tail wagging the dog’. With shareables, images and quotes being popular content on social media, it’s tempting to piggy-back on this trend and use social media purely as an intervention tool for behaviour change and promotion of social marketing messages. It’s important to think about how social media could be used for broader health promotion objectives, including creating new cultural norms. Organisations like GetUp and Obesity Policy Coalition are experts at this. Similarly there are some fantastic examples of promoting positive mental health and reducing mental illness stigma on social media.

Despite these new challenges, health promoters are a resilient and resourceful lot. With the support of research institutes and knowledge brokers, I am confident that there will be a growing baseline of technology literacy and competency in the health promotion workforce.

Given the range of challenges, how do you think researchers can generate evidence and support practitioners? Share your thoughts in the comments below.


Written by Kristy Schirmer

Kristy Schirmer worked as health promotion practitioner for more than a decade prior to starting Zockmelon, a consultancy that focuses on health promotion and social media strategy.

Subscribe to Zockmelon’s blogs and e-newsletter to keep up to date on social media, apps and health promotion. Sign up here.

Hidden agendas – do researchers and participants bring bias to studies?

The recent publication of our research on child health in same-sex families has gained a little media attention this week following my piece in the Conversation. I have had some wonderful feedback from members of the community who feel that this research provides valuable insights into the many diverse ways in which same-sex attracted people are raising children. But in the background the usual group of critics have set about trying to undermine our work.

One issue that has been raised is that of bias. There are many types of bias that can have an impact on research and this is one key area that academics like myself make every effort to account for. In clinical sciences the randomised control trial is the gold standard for eliminating bias, but in many population studies this is not always an achievable methodology. You can’t take a group of children, for example, and randomly allocate them to being raised by same-sex attracted parents or heterosexual parents. When bias cannot be completely omitted it is important to acknowledge its potential influence and this is something authors will highlight when considering the limitations of their work.

When researching child health in same-sex families the first problem is identifying, and then recruiting, such families. In Australia there is only one way that this can be achieved: through convenience sampling. Overseas, attempts have been made to draw representative samples from population surveys. While perhaps removing the volunteer nature of the sample these studies do suffer from small sample sizes, as the same-sex parent population within any population sample will be very small. This strategy is not an option in Australia where there are no population datasets that capture parent sexual orientation. Thus the volunteer sample is the only option. This is where the first criticisms of our study have been leveled.

It is argued that only parents with a vested interest in promoting positive health outcomes will volunteer. While this cannot be discounted as a possibility there is no evidence to suggest that this is the case. The underlying aim of the study was to characterise health and wellbeing and to understand the influence of stigma on child health in this context. As any parent will tell you what is paramount is ensuring that your children have the best health opportunities available. To intentionally corrupt research so that it cannot identify where problems may lie is doing yourself, and your children, a disservice. Only by providing an accurate picture of your child’s health will you know what can be done if there are issues. And in a context where stigma might be having a negative impact this is important to identify.

Further to this is the fact that significantly positive outcomes were only identified on a handful of scales. Overall 29 different measures of health and wellbeing were included in our study. Almost all showed no difference to the general population. Only 3 measures showed a significant difference, albeit a positive one for same-sex families. If same-sex attracted parents were systematically working to ensure an outcome that shows their children in the best light would there not be a more consistent skewing across all the scales? What is more likely is that there truly is something within same-sex families that shows a benefit on those three measures.

While the criticism has touched on the methodology, the limitations of which are clearly outlined in the published paper, there has also been an unfortunate focus on more personal aspects of the research. Some groups have highlighted the fact that I, the lead author on the paper, am a gay man raising children, suggesting that this is a conflict of interest and introduces inappropriate bias.

Family photo

The research team for this study is based within the Jack Brockhoff Child Health and Wellbeing Program at the University of Melbourne. This Program is led by Professor Elizabeth Waters, an internationally renowned child health researcher who leads work on many aspects of child health including obesity, oral health, disability and disaster recovery, to name a few. She is also a heterosexual parent and second author on the paper. The rest of the research team bring a range of research experiences and family backgrounds. But is there any relevance to their personal situations? All published papers go through a rigorous peer review process that is blind to such things, assessing work on its methodological merits alone. To suggest that my family situation is of relevance implies that no heterosexual researcher can produce unbiased work on heterosexual families. Or that any non-Caucasian researcher would be able to objectively conduct research on racial discrimination and child health.

Increasingly, across all areas of research, there is a move towards the publication of protocols. This establishes the theoretical underpinnings and methodological basis of studies and allows a continued process of transparency to be engaged from the outset. Our recently published findings on same-sex families took this approach and a protocol was published in the early phases of the project. By being up front and transparent at all times about the research we are allowing the work to be continually interrogated.

Research on same-sex families always draws critics. There is a small but vocal minority who do not accept family forms that fall outside the traditional mother-father construct. It is interesting to note that at the same time as criticising methodologies such as ours these same groups would baulk at including questions around sexual orientation on national surveys such as the Census. It is up to the scientific community to consider the merits of our work and place it in its appropriate context in terms of future health interventions and policy work.

It will never be possible to exclude bias completely from all research. But in the mean time it is up to us, the researchers, to maintain objectivity, be open about limitations, and be true to the evidence that our work provides.

Dr Simon R Crouch
Lead Investigator, the Australian Study of Child Health in Same-Sex Families (ACHESS)

Parent-reported measures of child health and wellbeing in same-sex parent families: a cross-sectional survey

Kids from same-sex families fare as well as peers – or better


You may know that Sunday 15 June to Saturday 21 June 2014 is Refugee Week. Held annually in Australia to coincide with World Refugee Day on the 20th June, Refugee Week is Australia’s peak annual activity to raise awareness about issues affecting refugees and celebrate the positive contributions made by refugees to Australian society.

The Refugee Council of Australia (RCA) has chosen ‘Restoring Hope’ as the theme for this year’s Refugee Week to remind us that ‘while a refugee’s journey begins with danger, it also begins with hope. Refugees flee their homelands not only because they fear persecution, but also because they have hope: they hope to find freedom from persecution, and safety and security for themselves and their families; they hope to be given a chance to start a new life and recover from past trauma’.

The RCA also makes the point that the theme calls attention to the role of countries that offer protection to refugees and provide them with an opportunity to rebuild their lives and restore hope for a future free from fear, persecution, violence and insecurity. Despite fluctuating (and recently, increasingly harsh) policies of deterrence towards asylum seekers who arrive in Australia by boat, our government also offers permanent settlement to between 13,000 and 14,000 refugees annually through the UNHCR (United Nations High Commissioner for Refugees) resettlement program. While permanent settlement offers opportunities for a new life, it is also accompanied by significant challenges. Refugees settling in Australia come from diverse backgrounds but face a common need to deal with experiences of loss, family disruption, long periods in refugee camps or seeking asylum and the trauma that forced them to flee their homes. Following resettlement, they must negotiate a new language and culture, unfamiliar health, education and welfare systems and are also likely to experience social isolation, poverty and discrimination. Over 40% of people settling in Australia from refugee backgrounds are under the age of 18 and some of these face additional obstacles associated with disrupted – or even non-existent – formal education, prior to arrival.

We know that despite these challenges, most refugee settlers go on to become successful and productive members of Australian society. We also know that providing appropriate support, particularly in the early stages of settlement, can be crucial to enable this to happen. I, along with others in the Jack Brockhoff Child Health and Wellbeing Program are engaged in a number of projects where we work in partnership with others across the University and with community organisations to investigate and promote conditions that support refugee-background children and families to overcome barriers to social inclusion, participation and wellbeing.

Completed projects include evaluations we have conducted of programs such as Ucan2 – which assists young people transitioning from language schools and centres into mainstream education settings – and the Foundation House School Support Program – which supports schools to provide an inclusive environment for refugee-background children and families. We have also explored barriers for refugee-background parents in accessing Maternal and Child Health Services and investigated ways to support driver education for refugees settling in regional Victoria.

Current projects include an exploration of the experiences of refugee-background parents and young children who attend supported playgroups run by Save the Children Australia, and a new project focused on sports participation as a means to promoting social inclusion and wellbeing for refugee-background children. We are also about to begin a project looking at ways the University of Melbourne can provide enhanced opportunities and support to tertiary students from refugee-backgrounds.

Underpinning all of these projects is the understanding that improving support for those new to Australia can make all the difference when it comes to them being able to create the new life that they hope for. Some of the remarkable stories of Australians from diverse backgrounds who first came here as refugees with hope for a better future have been collected by Melbourne University’s Researchers for Asylum seekers. You can read some of those stories celebrating their lives and contributions here.

Written by Dr Karen Block
Research Fellow, Jack Brockhoff Child Health & Wellbeing Program
The University of Melbourne

World Refugee Day

Restoring Hope

Resettlement program


School Support Program

Maternal and Child Health

Driver education

Refugee-background parents and young children


A non-specific sex

I have previously written about the unfortunate way in which boys and girls are pigeonholed based purely on their biology. But this gendered stereotyping and heteronormative worldview go far beyond the choices parents make when buying toys. It permeates all aspects of our society impacting on health programs, health policy and ultimately the ability of all individuals who do not fit within the binary construct of ‘male’ and ‘female’ to lead healthy and fulfilling lives. This week has seen a significant advancement when it comes to determining sex however. The NSW High Court has ruled that “non-specific” is now a legally allowed option on official records. The court found that there were no legal grounds that required a person to be identified as either a man or a woman, and perhaps this will now be recognised a little more in the wider society. Ironically, it was suggested by the court that the only place where a legal definition of ‘man’ or ‘woman’ may be required is in the Federal Marriage Act – perhaps it is time for this Act to be changed so that the gender binary is not used as an impediment when it comes to love and the legal security of all families. For Norrie, the person at the centre of the case, it was a matter of equality. And for the same-sex parent families with which we work equality is all they seek.


Norrie Photo: Dalla Kilponen

Writing in The Conversation Prof Marian Pitts examines this legal decision further, highlighting the frustration and distress that results when people feel that their sex and gender identity are not being recognised. Over a number of years now there has been much progress made in the understanding that gender is not necessarily so black and white. Just earlier this year the popular social media site Facebook changed its settings to recognise over 50 different options for gender. Many people will not notice such a change, but for those people that it does affect such recognition sends a powerful message of acceptance.

It is an issue that a large proportion of the population would give little thought to. In fact something as simple as the difference between gender and biological sex passes most people by. It is quite possible to be biologically male yet identify as female when it comes to gender. Even when biology and primary gender identity match it might not be as straightforward as it seems; say a person of female biological sex who identifies as female in terms of their gender identity but also acknowledges typically male characteristics. In a heterosexual world this person might be considered as a tomboy, but if we complicate things further and add in sexual orientation then she might be described as a butch lesbian.

Prof Pitts begins her discussion questioning whether it is necessary for institutions to ask people to identify their sex as male or female. Working with children in many family contexts the Jack Brockhoff Child Health and Wellbeing Program often collects data on both gender and biological sex. An understanding of the social determinants of health tells us that there are many factors that contribute to overall wellbeing, and gender identity and biological sex, as well as sexual orientation and a myriad of other characteristics, are all important factors. If we do not collect these data in our ongoing epidemiological work then we are not in a position to identify areas of need as we seek to enable a healthy and fulfilling life for all. The challenge is to collect information in an inclusive manner, ensuring that everyone has the opportunity to identify in a way that most fits their innate being. As such the Jack Brockhoff Child Health and Wellbeing Program continues to examine the research it conducts in a way that is both inclusive and empowering.

As we recognise the significance of the NSW ruling we should all reflect on our own roles and ask if we are constraining ourselves to an outdated binary construct. Let’s celebrate difference. Let’s celebrate that non-specific sex.

By Dr Simon R Crouch

Lead Investigator, The Australian Study of Child Health in Same-Sex Families

What’s complexity got to do with health? It’s complex…

Still defrosting from my visit to Washington DC, I’ve reflected on the conference that I’ve just attended in complexity, inequalities and health. Sound complex? Well, here’s a simple summary that’s not as snow-covered as I have been over the past few days. But why waste your coffee time reading this article? Well, this might give you some insights about the perspectives and methods emerging from leading researchers working in complex systems, health and inequalities, as well as the investments in the area from the main health policy agency in the US.

  • “Complex Systems, Health Disparities & Population Health: Building bridges” This conference was organised by the USA’s Network on Inequalities, Complexity and Health (NICH) and hosted by the National Institutes of Health (NIH) on campus in Bethesda, Maryland, USA. Not much tweeting throughout the two days, but I did start a hashtag that was picked up: #NICHconference


  • The socio-ecological model of health lives on

As with most quality public health conferences, we saw the socio-ecological model in the opening comments. And one of the authors of papers about the socio-ecological model was present! It is a crucial framework by which we think, talk, measure, and report – important to communicate the individual, interpersonal, organisational, community and social policy impacts upon health of populations globally. It shows the complexity of health determinants, simply.

  • Complex systems theory challenges our thinking about how health is constructed

To begin we heard the nuts and bolts of complex systems science as it applies to health, and a message that the “find it, fix it” approach to public health isn’t working. If traditional approaches were effective, we wouldn’t have epidemics of non-communicable disease and unfair health inequalities.  Unbalanced investment exists in most contexts – for example in the USA they know that 40% of health problems are socially determined, 50% behavioural and only 10% due to health care. However, only 3% is spent on societal and individual-level prevention strategies (complex solutions), whilst 97% is spent on health care (simple solutions).

  • Complex systems science reorients our thinking about how to act to improve health

We can always interrogate the ‘why’ of health issues and inequalities. A person smokes because it’s socially acceptable, affordable, possible to do where they live, work/learn and play, and because cigarettes are available– actively marketed by for-profit companies. Food supply was given as another example. The production, marketing, acquisition, distribution, retail, purchasing and consumption of food is dynamic and depends on many factors such as market forces, housing, economics and built environment. Consider that the majority of countries in the world have McDonalds in urban areas; and, that the majority of countries have 50% of their population housed in urban areas.  What influences do these factors have on healthy food supply and access? Then how does that affect health and lifespan? As you can see, it’s complex. Check out this paper by Sandro Galea for more:  


  • Everything should be made as simple as possible, but not simpler

One speaker articulated that using simple interventions to address complex health issues is likely to fail. It’s a bit like King Canute ‘ordering back the tide’ – with health interventions and measurements, we can’t simply push against how things go naturally in a system, we need to identify multiple points and levers for interventions at different socio-ecological levels. Similarly, intervention research in this area can’t continue to be ‘linear’ and use averages for estimating effects –we need to capture heterogeneity. It’s tempting and logical to believe that if the parts get better (e.g. risk factors) then the whole will get better (e.g. populations), but change is contextually dependent. The response to multiple interventions will be very different than the totality of responses to each intervention separately. In other words, the whole is greater than the sum of its parts!


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  • When it’s all ‘too complex’, or when there’s no ‘real’ data?

Try simulating or modelling data! There are often times when observed health issues are ‘too hard’ to disentangle from the modifiers and contextual factors. Modelling epidemiological associations between factor X (e.g. fast food) and factor Y (e.g. heart disease) may not reveal the nuances of what produced the issue in the first place – the causes of the causes.  The same goes for evaluating multifaceted interventions across the many socio-ecological levels – it’s hard to measure each and every factor that might have had an impact upon the observed outcomes, and then to attribute causation. Thus, we are often without empirical data that integrates the diversity of elements in a system, so it’s hard to prove what determinants to target. Also, limited quality evidence exists on processes and effectiveness of complex interventions, so we’re often ‘working in the gaps’.  Synthetic estimates can be produced by building simulation models, guided by existing data, evidence and theory. Models can control experimental conditions in a complex system, which is obviously impossible to do in ‘real world’ observational studies. Also, and rather compellingly, we heard that standard statistical approaches can’t examine feedback and adaptive mechanisms between environments and individuals/agents – whereas computational modelling can. This recent paper by Amy Auchincloss et al provides a recent example, with links between neighbourhood resources and obesity under study:

  • Methods for research of complex systems, health determinants and impacts

The main methods presented in the presentations and posters included system dynamics, social network analysis (SNA), agent based modelling (ABM), and discrete event modelling. These methods, having emerged from complex systems science, are being applied to public health research. The methods were described as tools to help us make sense of the interactions within complex systems, and the impacts that interventions might have on health and inequalities.  For a primer, see the take-home messages from Nathan Osgood below, refer to a recent paper by Doug Luke and Katherine Stamatakis – these sources will be eminently better than my interpretation would be!   


  • What are some of the applications for simulation and modelling research?

For the most part, the presentations and posters highlighted a series of examples of modelling research studies that explored a range of factors related to health inequalities at the individual, institutional and neighbourhood level. Mostly, this provided case studies for how inequalities are produced, but some focused on estimating potential effects of interventions.

  • Examples of data simulation/modelling studies

At the individual and community level, an ABM explored differential effects of alcohol outlet density restrictions and policing upon alcohol-related violence and homicide among white Americans and African-Americans. A simulation study explored potential effects of upstream policy on Healthy eating and Physical activity, finding proof of concept that it may be more effective to target neighbourhood factors, not race, in reducing disparities in some contexts. At the population level, a case study from New Zealand was described, conducted when the earthquakes in 2011 interrupted the annual census, and modelled data was used to predict ongoing trends in primary health care access among Maori and Pacific Islander populations.

  • Progress and pitfalls for complex systems methods in public health

Collectively, from this conference it seems that certain systems science methods may tell us more about the nuanced factors causing health inequalities. It may also help reveal leverage points and suggest how to tailor interventions. But as with all research, challenges and limitations remain with these methods. These studies require interdisciplinary teams to ensure sufficient expertise in epidemiology, mathematics, computer programming, geography, public health and urban planning. Working together is essential –from observational research to computational modelling, the first step is a doozy!

Another challenge highlighted was that ultimately, we need to be able to link the models to ‘real’ data, to ensure their validity. Involvement of community stakeholders and decision-makers in the process was discussed only briefly, but this would appear to be a key step in verifying models. Community physician and systems scientist Kurt Stange described a great example of a participatory process of community stakeholder involvement in model planning and development. This may be a good point for us to start, to ensure that we ‘keep it real’.


  • Closing thoughts from a complexity novice

From a KTE perspective, I would think that external validity would be a key challenge for the application of this research, which may be difficult to reconcile. The conference left me pondering how do we use the evidence generated for decision-making? How can we be sure that modelled data reflects what’s in the ‘real world’? A discussion on using these models to guide policy was led by Complex dynamics researcher Ross Hammond, and NIH program director Stephen Marcus, which began to raise these questions. I would imagine, as for research evidence generated through ‘traditional’ methods, that a similar approach to knowledge translation and exchange would be required for evidence generated through modelling.

So after that, a penny for your thoughts? Leave a comment if you’re using/exploring these methods!


Written by Dr Tahna Pettman

Research fellow: Public Health Evidence and Knolwedge translation
Evaluation fellow: CO-OPS collaboration

The Jack Brockhoff Child Health & Wellbeing Program.
The University of Melbourne