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”

http://conferences.thehillgroup.com/UMich/complexity-disparities-populationhealth/agenda.html 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: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3134519/  


  • 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!


Image from: http://canute2.sealevelrise.info/slr/Story%20of%20Canute

  • 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: http://onlinelibrary.wiley.com/doi/10.1002/oby.20255/full

  • 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! http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3644212/pdf/nihms414057.pdf   


  • 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
e: tpettman@unimelb.edu.au


Highlights from a rookie researcher’s first conference.

A few weeks ago I attended the conference Progress 2013 (http://progress2013.org.au/). The first of its kind in Australia, it brought together progressive left thinkers with not-for profit organizations, unions, private industry and experts in the health and environment sector. Its aim was to talk about the issues that will define Australia’s not-for profits and social movements for the years to come. As a recent graduate, this was my first ever conference and a chance to understand how people from all over the workforce come together to share skills, nut out ideas and most importantly – network. This blog post will cover some of the major highlights from the conference and touch on some of the lessons I learnt, from the perspective of a budding young researcher.


Highlight no 1.
To begin, one of the major highlights for me was listening to rock star academic and expert on the social determinants of health, Richard Wilkinson (http://www.ted.com/talks/richard_wilkinson.html), speak about the importance of understanding how income inequality affects health and wellbeing. Wilkinson, author of ‘The Spirit level’ and co-founder of The Equality Trust (http://www.equalitytrust.org.uk), researches the problems of inequality in society and produces evidence-based arguments to support social movements for change. In particular, Wilkinson drew attention to the problem that health and wellbeing in high and middle income countries is worse for all when the gap between the rich and poor is greater. Data was collated to demonstrate that even in high income countries as measured by Gross Domestic Product (GDP), population levels of health and wellbeing are influenced by income inequality. Therefore, the average wellbeing of societies is not dependent on gross national income and the rhetoric of economic growth but rather the relation between each other within society itself. This trend also occurs in child health and wellbeing, mental health, drug abuse and obesity – proving the tangible effect that inequality has in society. Some factors Wilkinson attributed as the drivers of negative health in unequal societies include status anxiety, stress, mistrust and dominance caused by a competitive consumer based economy. Wilkinson therefore advocated for a more inclusive society where value is placed on the way we relate to one another and where possible to harness positive social relations, such as friendship. Although these insights seem somewhat intuitive, I was taken aback by how relevant it is to continue to produce evidence that highlights this problem. When considering health and wellbeing, Wilkinson makes us think about the less visible effects of how we relate to one another and re-establishes the importance of family, friendship and positive social interaction to maintaining a sustainable quality of life.


Highlight no 2.

Another highlight was the talk given by Anat Shenker-Osorio, a communications expert and researcher who authored the book ‘Don’t Buy It: The Trouble with Talking Nonsense about the Economy’. Her work looks at how people understand issues, such as the economy or climate change, through the words used to narrate them. Without getting too bogged down in detail, the gist of her research suggests that you can reliably persuade or change a person’s thinking about an issue depending on the words used to describe it. For example, immigration. A study was conducted to measure how people responded to immigrants depending on whether they were framed as either a burden or a resource. The findings showed that when immigrants were talked about in a positive framing, by expressing what they bring to society and not what they lack, people’s acceptance of immigrants were overall more favourable. Shenker-Osorio argues that by literally changing the words we use to speak about an issue, we can also influence how people think about it, having repercussions for politics and policy. Something to think about when writing the next report or talking at a conference about a sticky issue. Frame it positively and you will have people receive it much more favorably.

Highlight no 3.

Arguably one of the best parts of Progress 2013 however, was the chance to mingle with those I consider some of my professional role models. As I mentioned above, this was my first ever conference, so the task of introducing yourself to those you admire is quite daunting. However, after a few awkward first conversations I learnt the following things;

  1. Go with a plan. Since time is scarce at these events and the professionals you meet talk to so many different individuals every day, working out a plan of who you want to speak to and what you want to speak to them about prior to the meeting is essential. This way, you won’t get caught in a conversation about the weather and how good the muffins are, but instead get to use your limited time to your best advantage.
  2. Don’t be scared to introduce yourself. As daunted as you might be about shaking hands with someone you find just a huge bit intimidating because of their greatness, it never hurts to just introduce yourself and say you are a huge admirer of their work. A few times I saw rock star academics on their lonesome at the coffee table, probably because everyone was too in awe to say hi.
  3. When in doubt ask questions. When you have reached your small talk capacity and feel like the conversation is drying out, ask questions of them. People love to talk about themselves and asking them questions about themselves shows that a) you have a strong interest and b) that you are engaged in what they do.

Written by Hannah Morrice
Research Assistant, Jack Brockhoff Child Health & Wellbeing Program
The University of Melbourne
e: hannah.morrice@unimelb.edu.au

On the conference circuit – from Melbourne to Thailand and back again

In an academic work environment you could say that one of the ‘perks’ is representing your work, or collaborative work, at academic and topic-focused conferences (However in comparison to my days working in the private health industry, business travel in the University signals a more economically responsible mode, namely frequenting the back of the plane rather than the upper deck on long haul flights!). This year has been no exception for me, being fortunate to attend a range of conferences on topics of public health, health promotion, knowledge translation and exchange, and obesity prevention.

So we pack our bags, roll up our posters and prepare our presentation slides at the eleventh hour – but what for? What motivates researchers and practitioners to scramble to find funding so we can run laps of the conference circuit? What benefit does our research and its end-users gain from us attending these forums?

Recently I attended with colleagues what might be considered seminal conferences in public health research/practice/policy: The World conference on Health Promotion by the International Union for Health Promotion and Education (IUHPE) – in Pattaya, Thailand, followed by the Public Health Association of Australia annual conference – in Melbourne. We’ve also attended emerging conferences in our field of interest: The “FUSE 2nd Conference on Knowledge Exchange in Public Health: How to get practice into science” – in Noordwijkerhout, The Netherlands; and the “2nd Annual NHMRC research translation symposium: from Bench to Bourke” – in Sydney. Note the similar style of the long-winded titles on the last two conferences on knowledge translation… For people interested in communicating and doing ‘real world’ research, you’d think we’d have more succinct event titles!

Aside from enjoying a working week near a sandy beach or among fields of tulips, I believe that conference attendances (and active participation obviously) are a necessary perk if we want our research to be useful and utilised, and if we want to link our ideas to a broader national and international dialogue. At these conferences, I took away a few points about the issues being explored and debated, as well as some reflections on what we gain from attending, and thus what we offer as research practitioners. Here’s a wrap-up, fresh from my suitcase.

Salient issues that resonated for me as a conference participant:

  1. Social justice concerns are high on the agenda in public health and health promotion.
    All the policy, practice and research communities represented at theses conferences appear to be very dedicated to chipping away at the systemic barriers to attainment of good health. Good thing.
  2.  Public health and health promotion decision-makers, advocates and researchers need to better articulate what we do, and what good it does.
    What is public health and health promotion anyway? Sure, we all know that the sum of our parts is more than water sanitation and quit-smoking campaigns, but try explaining that to a new acquaintance at a backyard barbeque. And what are the benefits of investing Government dollars in preventive health? Can anyone tell me the economic return on investment of health promotion partnership meetings, or the productivity gains from banning junk-food ads in kids TV viewing hours? Either way, a strong theme that continued to emerge for me was the sheer lack of public outrage when public health research funds are cut, or when a health promotion unit is shut down.
  3. Working across sectors means singing from the same song-sheet.
    I often go to conferences realising that I’m preaching to the converted. It’s not a new concept that public health and health promotion decision-makers need to be working with other sectors like planning, transport and education – this message has continued to come through, but more focused on tweaking our agendas and language, to make it easier to work together. Finding processes to allow cross-sectoral work are getting more focus too – like embedding health impact assessments into local government’s power. We might be a long way away from that but in the meantime we can at least coordinate the message.
  4. We keep on with research to know that we are doing the right things, and doing things fairly.
    Not all of the conferences I went to had an ‘academic’ or scholarly focus, but thankfully, I walked away from each and every session knowing that the majority of attendees valued the role of research and evaluation, rigorous methods, or evidence-informed decision-making – all of this is achieved by furthering research and academic inquiry.
  5. It takes specific skills to advocate, and without advocacy, our concerns won’t be heard.
    Like me, you might not always feel comfortable with the term advocacy so let’s call it leadership, or whatever you like – either way, see points #2 and #3 above. We need to find smarter ways of communicating evidence and knowledge to influence decision-making.
  6. We all love a framework!
    I think every conference session I went to had a ‘framework’, ‘model’ or ‘tool’ which was ‘guiding’ or ‘underpinning’ or ‘informing’ their approach. Hopefully this is more than jargon, and actually means rigor and systematic ways of conceptualising and working – whether you’re in research, practice, or somewhere in between. So I think it’s a good thing, as long as we don’t get lost in translation!

What I think we gain and can offer from active participation at conferences:

  1. Disseminating research and practice.
    This is an obvious benefit, and the one most often used by conference organisers to lure you into spending $900 of your precious budget to be out of the office for two days, subjected to death-by-powerpoint, and forced to catch up on all your emails late at night after the welcome reception. But in order to ‘keep it real’ and stay connected to the broader health and wellbeing dialogue, attendance and active participation at conferences are actually an efficient way to communicate your work. Ok, so I might not feel that way when I’m standing next to my poster watching conference delegates walk straight past, making a bee-line for the coffee stand without an interest in my glossy artwork and data. But if you’re proactive to network, interact, present and tweet, it really is an chance to build the profile of your/your team’s work, and get others to know who you are and what you do.
  2. Networking and engagement.
    By signing up for conferences, we open ourselves to public scrutiny of our work, and let’s not forget those awkward moments of introducing yourself to that esteemed Professor or Policy-maker who has no idea who you are. But this is almost always a positive outcome. We meet new people with similar passions, discuss different contexts and ways of working, and maybe even score a new collaboration, friend, or new LinkedIn connection. The use of social media is really growing at public health conferences, engaging both participants and those who couldn’t attend in person. I’ve come away from every conference with lots of new follows and followers, which also boosts engagement of the research group and links in our other collaborators.
  3. Broadened thinking, new perspectives.
    Sitting in an early morning plenary deciding what to tweet really makes you think about what you think about the topic. In my early days at conferences I probably didn’t reflect much, and was more focused on staying awake and when the next coffee break was. But as a more experienced practitioner, I find that I am continually thinking, appraising, analysing and reflecting on what’s being said. I ask more questions, and use the breaks to chat (to anyone who’ll listen) about the perspectives emerging at the conference.
  4. Confidence.
    After meeting such a range of different people from different contexts, doing different jobs and working in different ways – you realise that you’re all doing good stuff and sharing the goal to promote public health. It’s a nice confidence boost to have your work verified in an international or national context, and helps you feel like you’re on the right track.
  5.  A break from routine.
    I work in an office, and I can’t say I get regular tea-breaks with cake and tropical fruit, nor am I offered a selection of mini-baguettes for lunch. Conferences are good for this. But I do think it is good to get away from the desk and reflect on your practice within a broader context. I always enjoy catching up with colleagues old and new, who are equally as nerdy and equally keen to get out of the office for a few days. Another emerging trend at conferences which is a very welcome break in a workday routine is tea-break flash-mob dances. Enough said.


Disasters impacting communities all over the world.

At the international conference on The Demography of Disasters, I was overwhelmed with the amount of deaths resulting from overseas disasters that killed hundreds of thousands of people. It struck me that the 2009 Victorian bushfires seem on such a small scale compared to this. As I have been working on a project for three years now (looking at the medium to long term impacts from the 2009 Victorian bushfires), I feel that I have some understanding of the huge impact it has, and continues to have, on many people and communities. Therefore I can only imagine the impact on these other countries when such loss has occurred. Especially as these countries are at high risk of future disasters and are usually under resourced to prepare, respond and recover from these. This is a massive challenge for recovery and resilience work within these areas. But imagine if we had that many people die within Victoria? How come there is such a large difference in the death toll between these countries and our own? Is it that these countries are highly populated, even in their rural areas? Or is it because we have greater resources and preparedness mechanisms in place to prevent such large scale impacts?

Over the two days, it was emphasised that disaster recovery efforts need to be tailored to the particular area in which they occur. This is due to variability of culture and traditions, which can both assist and hinder the resilience process. Change in anyone’s life is difficult, especially after a disaster, therefore attempting to restore traditions is important but the difficulty within these countries is that at times it’s more dangerous to restore these traditions than change. The cultural relevance within Victorian communities differs greatly from these countries, which further complicates the applicability of these learnings in different contexts.

Throughout the conference there were many different presentations, exploring the impact on communities after a disaster. However, many of the areas being presented were at constant high risk of disasters. Recovery planning needs to occur after a disaster along with planning for the possibility of another disaster, as they are at high threat of one occurring within their lifetime. This threat needs to be accounted for in regards to resilience and future preparedness.


Trees recovering from the Victorian 2009 bushfires.

Some of the presenters completed studies in Asian countries – however, some of the limitations of their studies included not knowing or understanding the local context and how their research findings fit into this. To overcome this many of these researchers collaborate with others within the country or the particular rural area in which the research is being completed. For our study: Beyond Bushfires: Community, Resilience and Recovery (www.beyondbushfires.org.au) we have also taken on this approach. We have many stakeholders from local areas within the participating communities which include residents, local government, NGO’s. As part of the research process we are taking back our initial findings to our community partners and asking them for assistance in interpreting these in terms of what they mean locally. This knowledge adds another level of understanding and allows for non-fire related impacts to be accounted for.

There is a shift in the social environment being just as important as the physical environment in the countries that were presented. However, as this is a major focus of our study – hopefully we can add some interesting evidence to this literature. So stay tuned to not only to this blog but the emerging findings that the Beyond Bushfires team has to report later this year.

If you would like to keep updated with the project to join the Beyond Bushfires email list please send an email to: info-beyondbushfires@unimelb.edu.au