How health programs and health care services might promote positive social change. Then, consider how your health care services marketing plan may relate to positive social change in pr

Health promotion as a systems science and practicejep_1273 868..872

Cameron D. Norman PhD

Assistant Professor, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada

Keywords

complexity, health promotion, systems thinking, social networks, communities of practice, evaluation

Correspondence

Cameron D. Norman Dalla Lana School of Public Health University of Toronto 155 College Street Room 586 Toronto ON Canada M5T 3M7 E-mail: [email protected]

Accepted: for publication: 21 August 2009

doi:10.1111/j.1365-2753.2009.01273.x

Abstract Rationale Health promotion is where clinical practice and prevention science intersect to address complex or ‘wicked’ problems that have multiple sources and require a broad perspective to address. This means focusing on the social determinants of health and the complex individual, community and environmental interactions that influence health and wellbeing. Health promotion research and practice recognizes that social change is not linear and involves multiple communities of interest working together in a coordinated manner in order to address health problems. An approach that acknowledges this non-linear system of interaction in its data gathering, strategic planning, and program implementation is necessary to addressing this complexity in practice. Methods Concepts such as chaos theory, self-organization, social emergence can inform how health promotion is practiced at multiple levels. Evaluation approaches such as social network analysis, system dynamics modeling combined with social organizing strategies like communities of practice and unconferences provide opportunities to leverage social capital effectively to promote health in complex environments with diverse populations. Conclusion Health promotion’s focus on the multi-layered, complex interactions that create or limit health and wellbeing require knowledge and action that match this com- plexity. Approaches to engagement and evaluation that are based on systems theories and methodologies provide the means of addressing this complexity, while framing health promotion as a systems science and practice.

Clinical care is where the impact of past decisions meets present day reality, while health promotion deals primarily with the question of how people become sick (or keep well) and why some are healthier than others; both interact within clinical prac- tice. The role of complexity in clinical practice and evaluation has been examined by focusing on changing our understanding of the biomedical model [1], management of illness and the human body [2,3], the experience of being a patient [4], and even the meaning of health itself [5,6]. This paper focuses on the health promotion aspects of clinical practice by illustrating its fit with complexity science and demonstrating how health promo- tion constitutes a form of systems thinking and action about the causes and consequences of health and well-being.

Framing health promotion Health promotion is described as: ‘a comprehensive social and political process; it not only embraces actions directed at strength- ening the skills and capabilities of individuals, but also action directed towards changing social, environmental and economic conditions so as to alleviate their impact on public and individual

health. Health promotion is the process of enabling people to increase control over the determinants of health and thereby improve their health’ [7]. Health promotion encompasses a com- mitment to education, action and evaluation within a set of values that emphasize social justice and health equity, respect for diver- sity, and the social determinants of health, while focused at the level of the individual, organization, community or system. The broad-based strategies associated with health promotion enable individuals to fully participate in health decision making, includ- ing emphasizing health literacy. It is this emphasis on the ‘causes of the causes’ and its explicit value base that distinguishes health promotion from health education, although the two share much in common.

The shift towards ‘consumer’ health and self-care in the late 1960s and early 1970s inspired new conversations about what non-biological factors influenced health and well-being (c.f., [8,9]) and that informed development of new fields of practice and ways of working within clinical care. Health promotion’s beginnings as a field of practice are often traced back to a 1974 report issued by Marc Lalonde, the Canadian Minister of National Health and Welfare at the time, that encouraged consideration of a wider lens

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on health at the policy and programme level. The report, A new perspective on the health of Canadians, challenged the established perspective in the health system that tended to equate health with health care and took as its focus the biomedical human model. The ‘Lalonde report’ sought to expand the focus of health towards a more ecological approach that included: biology, lifestyle, envi- ronment and health care organization [10]. Four years later, the Alma Ata declaration [11] was put forth, which expanded the social-ecological focus further by arguing that primary care had to play a strong role in advancing prevention and social justice (i.e. influencing the social world where ill health is produced) not just treatment goals. The Ottawa Charter for Health Promotion [12] went further and explicitly emphasized the need to address the social determinants of health by laying out a series of prerequisites for health and processes that, if enacted throughout societies, would advance health for all. In 2005, the Bangkok Charter for Health Promotion in a Globalized World expanded the scope of the original Ottawa Charter’s values and principles and applied them to the interconnected, global realities experienced in the 21st century [13].

With each document a more complex picture of health and health promotion emerges, one that illustrates a greater sense of the interconnectedness of the issues that impact on human well- being. This complexity also reveals the ‘wicked problems’ associ- ated with promoting health and well-being when the causes of illness and ‘the causes of the causes’ cannot be reduced to their component parts [14]. Indeed, it could be argued on the basis of the complexity of these wicked problems alone that health promotion is a science and practice of complex adaptive systems, even if it is not explicitly stated as such. That is the position taken within this paper: health promotion is systems thinking in action and that the science of complexity and systems intervention ought to be a central tenet of health promotion activity given its history, values, methods and focus. Some attempts to frame health promotion in systems thinking terms have been made elsewhere [15]; however, for those unfamiliar with complexity science, some examples to illustrate this fit will be presented to make this case.

Sensitivity to initial conditions The dynamic, interconnected structure and processes that take place within complex systems make them highly sensitive to small changes, which can have far-reaching consequences that are both unpredictable and unintended. This concept is most easily demon- strated in how it is expressed in changes in weather patterns (c.f., [16]). Thus, the initial conditions play a critical role given the potential spin-off effects that can emerge with myriad changes that take place over the course of a lifetime. It is for this reason that health promotion strategies place emphasis on early childhood development and why the effects of poor health in children is often felt throughout the life course [17,18]. It is in early childhood that the effects of poverty, neglect, education and safety can shape social patterns for generations and why actions to enhance health equity and increase pathways to advantage are so central to health promotion.

Sensitivity to initial conditions can be seen in issues of health literacy, one of the areas where health promotion has great poten- tial to influence personal and population health [19–21]. Literacy in its various forms enables individuals to navigate through

complex systems and is highly dependent upon education, expo- sure to health concepts in practice and the opportunity to interact with a system in a manner that allows individuals to exercise control. These initial conditions of literacy development can have wide-ranging consequences on other areas of health and social functioning throughout the life course [20–27].

Sensitivity to initial conditions is a hallmark feature of chaos theory, a concept embedded within complexity science. Chaos theory suggests that systems thrive at the ‘edge of chaos’ where there is a blend of both structured and unstructured dynamics at play. This means developing programmes and policies that are neither highly restrictive in their parameter settings, nor too broadly focused. Chaotic systems are not about disorder and con- fusion; rather, they present a hidden order that is often reflected in deeper patterns than is apparent [28]. In health promotion practice, the manner by which these deeper patterns are attended to is through relationship building and paying attention to the settings and events that influence health as part of daily life; such as understanding the rhythmic patterns, ebbs and flows of a commu- nity including celebrations and daily rituals. This attention to pat- terns requires personal and community engagement [29].

Self-organization and social networks Health promotion is not only a discipline of its own (i.e. people can receive formal training in it and it is recognized as a health spe- cialty by organizations like the World Health Organization) but is also performed by clinicians, community health workers, teachers and non-professionals alike without formal training in this field. There are no overarching bodies that govern health promotion practice, and while there are efforts to promote best practices through national public health organizations [30], these practices are often recognized as highly contingent on context compared with best practice guidelines for clinical care. Health promotion activities may be coordinated, but are not centrally controlled, making it an ideal case study for emergence and self-organization.

Self-organized systems develop when there are opportunities to obtain feedback, initiate dialogue, leverage diversity and do so in a manner that is coordinated, rather than centralized. This coordi- nation can be achieved using face-to-face, online or hybrid models. Face-to-face models that are complexity-oriented include the Open Space technology [31], World Café approach [32] or the ‘Unconference’ [33,34]. All of these methods of face-to-face orga- nizing build on the interests of the participants to shape the agenda for the day and use a more flexible organizational structure to frame interaction opportunities. Sustained opportunities for ongoing collaboration and self-organization can lead to creation of communities of practice (CoP) or other social change movements.

Communities of practice are self-organized, voluntary, collec- tives of people and organizations who work towards common understanding on a focused issue or problem domain [35,36]. CoP’s contribute to evidence creation and knowledge exchange, cultivate partnerships, develop professional skills and serve as a dissemination vehicle for those with a common purpose [36]. The model has evolved over time, particularly within the health sector [37,38] in part because it is suited to fields that lack a hierarchical structure and centralized command like health promotion, public health or community organizing.

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Unlike hierarchical systems, self-organized, decentralized systems like public health and health promotion require models of leadership that are congruent with complexity [39,40]. This lead- ership model requires greater attention to cultivating relationships within the system over methods of exercising control [41]. It also means attending to unclear boundaries, dynamic flows of informa- tion, diverse actors and non-linear change directives that are resis- tant to being ‘managed’ – all elements that are antithetical to traditional leadership models [42,43]. In its place, models of dis- tributed leadership based on collaboration, a shared vision and flexibility in both timing and approach are those most likely to succeed in building health-promoting organizations and healthy individuals [44].

Leveraging social capital through networks Social networks are vehicles for enhancing social capital by pro- viding a means to bridge diversity, facilitate both inclusion and exclusion, and fundamentally enable the means to ‘do more’ through collective action. Network theories include those based on homophily (sameness), structural holes (strategic connections) and collective action that each explores ways in which social networks leverage diversity to enhance communication [45]. Connectedness enables responses and reactions to new information faster, while promoting greater opportunities to learn within communities and organizations [46].

Promoting connectedness through social networks is also a way to leverage social capital through strengthening and extending both formal and informal networks. This boundary spanning quality of social networks is a means of promoting social cohesion through exposing and connecting the diversity within a community [47], to both positive and negative effects [48]. When combined with behavioural assessments of knowledge, attitudes, behaviour and activity, this method can enable evaluators to understand how interaction patterns change over time and provide those within that system with meaningful feedback in which to make strategic plan- ning decisions [38]. From an evaluation standpoint, social network analysis can be useful in supporting health promotion and public health [49], particularly in the area of evaluation of partnerships and collaborations [38,50–52], and the influence of peer groups on health behaviour [53–56].

Developing models or simulations based on systems informa- tion is one method of capturing some of the complex social and biological conditions that influence health and well-being [5]. System dynamics modelling is another relevant method that aims to explain or anticipate potential outcomes of a policy decision, outline the consequences and feedback loops embedded in system activities, or provide guidance on specific points within a system to intervene [57–60]. The method is predicated on the observation that complex behaviours within social and organizational systems emerge from accumulations (material, psychological states, bio- logical processes) and through balancing and reinforcing feedback loops that result from these build-ups [59]. Development of these models may include qualitative and quantitative data (e.g. stake- holder interviews, administrative records), expert opinion and feedback from the potential end users (e.g. policy leaders, com- munity members). Within health promotion, systems dynamic models have been used to illustrate: the value of ‘upstream’ invest-

ments of chronic disease prevention [61]; complex influences on tobacco use and control [62]; understanding the impact of community-level change initiatives [58]; and as an evaluation method to assess programme implementation and outcomes [63].

Conclusion Complexity science is a vehicle for change as much as it is one for explaining how change may occur [64]. It is important to note that clinical practice is a system in its own right and that this system is embedded within organizations, communities and a larger social sphere and that many of its practices are entrenched within a specific culture [65]. Thus, to initiate change in established systems, it is important to recognize the embedded nature of indi- viduals and groups within organizations and develop change strat- egies based on such relationships [28,44,46,66]. Some of the ways to do this include: 1 Optimize the diversity within and across organizations [67]. Provide avenues for cross-talk between people in different posi- tions, with different histories, and a variety of skill sets. 2 Facilitate self-organizing structures to emerge within existing organizations by relaxing strict controls that limit creativity and social mixing [68]. 3 Promote knowledge exchange across these networks through methods like unconferences and explore ways to develop organiz- ing models like CoP that leverage diversity, while enhancing con- nectedness [38,46]. 4 Enable this dialogue to continue through the use of accessible information and communication technologies [69,70]. 5 Build reflection into clinical practice to help identify the con- nections between various parts of the system to generate new knowledge and to reveal potential links between this new infor- mation and the structures and processes used to transform this knowledge into health value [71,72]. 6 Support the development of literacies that assist individuals and organizations in realizing the opportunities available within the complexity of the system [21,23].

Change requires paying attention to the individuals and com- munities that are the focus of clinical practice and recognizing how health care and promotion are embedded within those communi- ties. Systems thinking for health promotion involves both up- and downstream thinking and seeing the ‘big picture’, but it also involves recognizing that small changes can make a big difference. Adopting a perspective that embraces a complex view of health and health promotion is the first step. With a few advocates, embedded within the communities of interest, yet connected and coordinated across boundaries, substantial systems change for the health and well-being of all can be achieved.

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