Systems Thinking as a Framework for Analyzing Commercial Determinants of Health

Policy Points:

• Worldwide, more than 70% of all deaths are attributable to noncommunicable diseases (NCDs), nearly half of which are premature and apply to individuals of working age. Although such deaths are largely preventable, effective solutions continue to elude the public health community.
• One reason is the considerable influence of the “commercial determinants of health”: NCDs are the product of a system that includes powerful corporate actors, who are often involved in public health policymaking.
• This article shows how a complex systems perspective may be used to analyze the commercial determinants of NCDs, and it explains how this can help with (1) conceptualizing the problem of NCDs and (2) developing effective policy interventions.

Context

The high burden of noncommunicable diseases (NCDs) is politically salient and eminently preventable. However, effective solutions largely continue to elude the public health community. Two pressing issues heighten this challenge: the first is the public health community's narrow approach to addressing NCDs, and the second is the involvement of corporate actors in policymaking. While NCDs are often conceptualized in terms of individual‐level risk factors, we argue that they should be reframed as products of a complex system. This article explores the value of a systems approach to understanding NCDs as an emergent property of a complex system, with a focus on commercial actors.

Methods

Drawing on Donella Meadows's systems thinking framework, this article examines how a systems perspective may be used to analyze the commercial determinants of NCDs and, specifically, how unhealthy commodity industries influence public health policy.

Findings

Unhealthy commodity industries actively design and shape the NCD policy system, intervene at different levels of the system to gain agency over policy and politics, and legitimize their presence in public health policy decisions.

Conclusions

It should be possible to apply the principles of systems thinking to other complex public health issues, not just NCDs. Such an approach should be tested and refined for other complex public health challenges.     

Analyzing the Sendai Framework for Disaster Risk Reduction

<正>On 11 March 2011,a massive,shallow earthquake off the east coast of Japan demonstrated the remarkable successes which that country has achieved in earthquake engineering.Building collapses tended to be mainly older structures while comparatively few deaths resulted from the shaking(including from landslides),illustrating how decades of initiatives and efforts in disaster risk reduction can reduce vulnerability,ensuring that a hazard does not necessarily     

Conceptualizing the Mechanisms of Social Determinants of Health: A Heuristic Framework to Inform Future Directions for Mitigation

Policy Points

• A large body of scientific work examines the mechanisms through which social determinants of health (SDOH) shape health inequities. However, the nuances described in the literature are infrequently reflected in the applied frameworks that inform health policy and programming.
• We synthesize extant SDOH research into a heuristic framework that provides policymakers, practitioners, and researchers with a customizable template for conceptualizing and operationalizing key mechanisms that represent intervention opportunities for mitigating the impact of harmful SDOH.
• In light of scarce existing SDOH mitigation strategies, the framework addresses an important research-to-practice translation gap and missed opportunity for advancing health equity.

     

Psychological Symptoms and Social Functioning Following Repair of Obstetric Fistula in a Low-Income Setting

Objectives Obstetric fistula is a maternal injury that causes uncontrollable leaking of urine or stool, and most women who develop it live in poverty in low-income countries. Obstetric fistula is associated with high rates of stigma and psychological morbidity, but there is uncertainty about the impact of surgical treatment on psychological outcomes. The objective of this exploratory study was to examine changes in psychological symptoms following surgical fistula repair, discharge and reintegration home. Methods Women admitted for surgical repair of obstetric fistula were recruited from a Tanzanian hospital serving a rural catchment area. Psychological symptoms and social functioning were assessed prior to surgery. Approximately 3 months after discharge, a data collector visited the patients’ homes to repeat psychosocial measures and assess self-reported incontinence. Baseline to follow-up differences were measured with paired t tests controlling for multiple comparisons. Associations between psychological outcomes and leaking were assessed with t tests and Pearson correlations. Results Participants (N = 28) had been living with fistula for an average of 11 years. Baseline psychological distress was high, and decreased significantly at follow-up. Participants who self-reported continued incontinence at follow-up endorsed significantly higher PTSD and depression symptoms than those who reported being cured, and severity of leaking was associated with psychological distress. Conclusions Fistula patients experience improvements in mental health at 3 months after discharge, but these improvements are curtailed when women experience residual leaking. Given the rate of stress incontinence following surgery, it is important to prepare fistula patients for the possibility of incomplete cure and help them develop appropriate coping strategies.     

Delineating and Analyzing Locality-Level Determinants of Cholera,Haiti

Centre Department, Haiti, was the origin of a major cholera epidemic during 2010–2019. Although no fine-scale spatial delineation is officially available, we aimed to analyze determinants of cholera at the local level and identify priority localities in need of interventions. After estimating the likely boundaries of 1,730 localities by using Voronoi polygons, we mapped 5,322 suspected cholera cases reported during January 2015–September 2016 by locality alongside environmental and socioeconomic variables. A hierarchical clustering on principal components highlighted 2 classes with high cholera risk: localities close to rivers and unimproved water sources (standardized incidence ratio 1.71, 95% CI 1.02–2.87; p = 0.04) and urban localities with markets (standardized incidence ratio 1.69, 95% CI 1.25–2.29; p = 0.0006). Our analyses helped identify and characterize areas where efforts should be focused to reduce vulnerability to cholera and other waterborne diseases; these methods could be used in other contexts.     

Systems Science and Obesity Policy: A Novel Framework for Analyzing and Rethinking Population-Level Planning

Objectives. We demonstrate the use of a systems-based framework to assess solutions to complex health problems such as obesity.Methods. We coded 12 documents published between 2004 and 2013 aimed at influencing obesity planning for complex systems design (9 reports from US and Canadian governmental or health authorities, 1 Cochrane review, and 2 Institute of Medicine reports). We sorted data using the intervention-level framework (ILF), a novel solutions-oriented approach to complex problems. An in-depth comparison of 3 documents provides further insight into complexity and systems design in obesity policy.Results. The majority of strategies focused mainly on changing the determinants of energy imbalance (food intake and physical activity). ILF analysis brings to the surface actions aimed at higher levels of system function and points to a need for more innovative policy design.Conclusions. Although many policymakers acknowledge obesity as a complex problem, many strategies stem from the paradigm of individual choice and are limited in scope. The ILF provides a template to encourage natural systems thinking and more strategic policy design grounded in complexity science.Obesity is widely recognized as a complex problem emerging from a system composed of many diverse, interacting variables.1–3 Several factors make the obesity system difficult to shift, including but not limited to the presence of feedback loops and delays; an abundance of nonlinear, overlapping interdependencies; and the heterogeneity of individuals and organizations.1,4 Policymakers and planners have responded to the obesity epidemic by producing a large number of frameworks, strategies, and action plans. Although past efforts have been criticized for emphasizing individual lifestyle change as the solution,5,6 recent efforts have embraced socioecological models of intervention, emphasizing the obesogenic environment and its impact on individual weight gain.3,7 The many options available to policymakers have the potential to result in what Lang and Rayner6^(p166) termed a “policy cacophony” of noise drowning out effort.Efforts to shift the systems that support the emergence of chronic disease and obesity are starting to benefit from a focused effort to apply systems science,8 as has been done with other pressing public health issues such as tobacco.9 Obesity, tied up with difficult ideological and political questions regarding responsibility and stigma,10–13 is a particularly wicked social problem for which reductionist science may be less helpful. Systems science can complement socioecological models of health promotion by examining not just the causes of obesity but also interactions across its contributing subsystems.14 The UK government’s Foresight program contributed to the perception of obesity as a complex problem with the development of an obesity system map highlighting the diversity of factors involved in subsystems such as food production and consumption, individual physical activity and the physical activity environment, social and individual psychology, and physiology.4 The heuristic value of the Foresight map in demonstrating the complexity of obesity and the interdependencies between the system’s variables is an example of a systems science tool that may help to advance the conversation about what actions need to be taken.Although the Foresight map helps to focus dialogue on the complex nature of obesity, it does not immediately lead to discussion of solutions appropriate for this complex problem. We recently developed a systems science framework that may be a useful and accessible means of operationalizing systems thinking toward solutions. The intervention-level framework (ILF) was adapted from Donella Meadows’15 list of 12 places to intervene in complex systems. Meadows, a pioneering environmental scientist, spent decades analyzing the complexities of economic growth and environmental sustainability, and she grew frustrated with the unintended consequences that resulted when simple solutions were applied to complex problems. We collapsed the original 12 points of intervention into 5 more mutually exclusive levels that retain all of the original ideas but allow for the sorting of content in a reproducible fashion. These levels account for system operation at the levels of paradigm, goals, system structure, feedback and delays, and structural elements. To date, the ILF has been used in framework analyses of content concerning actions to improve food systems, wherein it was useful in elucidating points of conflict and convergence to make them more healthy, green, fair, and affordable.16In this article, we explore the application of the ILF to the obesity system by analyzing recent strategies and reports aimed at influencing policy and planning. Our interest was in developing a deeper, more integrated understanding of how best to act in addressing the complex problem of obesity. Using a systems lens, we sought to advance our understanding of the various system levels and the specific interventions required to support large-scale change. We also sought to further the application of systems-based frameworks in the analysis of complex health problems in a manner accessible to public health practitioners and policymakers lacking expertise in systems science methodologies.     

A Human Rights-Based Approach to Farmworker Health: An Overarching Framework to Address the Social Determinants of Health

Migrant and seasonal workers have a right to the highest attainable standard of health. Unfortunately, these farmworkers face a multitude of challenges. They are employed in one of the most dangerous industries and face serious occupational health risks, while positioned at the bottom of the social hierarchy. They often lack formal education and training, English language proficiency, legal status, access to information, and equitable opportunities to health and healthcare. This article will explore the international human rights conventions that support farmworkers’ right to health and healthcare in the United States. International human rights may provide a valuable legal framework that could be used to advocate on behalf of farmworkers and address the social determinants of health. Therefore, a Human Rights-Based Approach to Farmworker health will be presented along with recommendations for how to advance health and access to healthcare among this population. Fostering the health and well-being of migrant and seasonal farmworkers is critical to advancing equity, social justice, and maintaining the workforce required to meet production needs and safeguard the economic competitiveness of the industry.     

An Episode-Based Framework for Analyzing Health Care Expenditures: An Application of Reward Renewal Models

Objective. To illustrate an episode-based framework for analyzing health care expenditures based on reward renewal models, a stochastic process used in engineering for describing processes that cycle on and off with "rewards" (or costs) occurring at the end of each cycle.
Data Sources/Study Setting. Data used in the illustration were collected as part of an evaluation of a national initiative to improve mental health services for children and youth. Participants were enrolled in a longitudinal study at a demonstration site and in a comparison community between 1997 and 1999. The illustration involves analyses of mental health expenditures at the two sites and of the dynamics of service use behind those expenditures.
Data Collection/Extraction Methods. Services data were derived from management information systems as well as patient records at inpatient facilities in the two communities. These data cover services received between 1997 and 2003. The analysis focuses on the year following study entry.
Principal Findings. Between-site differences in expenditures reflect complex between-site differences in the timing of service use. In particular, children at the demonstration stayed in treatment longer but were less likely to return for treatment later. In contrast, children at the comparison site experienced substantially less continuity of care. Costs per day of treatment within an episode were comparable at the two sites.
Conclusions. Reward renewal models offer a promising means for integrating research on service episodes and the dynamics of service use with that on health care expenditures.     

浅谈下段直肠癌术后吻合口漏的防治

目的探讨大肠癌术后吻合口漏的原因及治疗方法。方法对我院近五年来收治的216例直肠癌的临床资料进行回顾性分析。结果216例手术患者中共发生吻合口漏12例,发生率为5.6%。28例手术后行直肠内引流,均一期愈合。结论行肠腔内引流以降低肠腔内压是减少吻合口漏的一种方法。吻合口漏的处理是通畅引流,促进漏口自行愈合,手术是最后的治疗措施。     

子宫腔会阴瘘1例

子宫腔会阴瘘是各种原因引起子宫穿孔后感染而引起的会阴瘘道。子宫穿孔是人流、诊刮、引产后清宫、取环、放环等一系列宫腔手术比较容易发生的手术失误,一旦发生,后果严重,合并内出血、感染、内脏损伤时,如不及时处理,可危及生命。宜宾市矿山急救医院收治子宫腔会阴瘘1例,     

A Framework for the Next Generation of Risk Science

Objectives: In 2011, the U.S. Environmental Protection Agency initiated the NexGen project to develop a new paradigm for the next generation of risk science.Methods: The NexGen framework was built on three cornerstones: the availability of new data on toxicity pathways made possible by fundamental advances in basic biology and toxicological science, the incorporation of a population health perspective that recognizes that most adverse health outcomes involve multiple determinants, and a renewed focus on new risk assessment methodologies designed to better inform risk management decision making.Results: The NexGen framework has three phases. Phase I (objectives) focuses on problem formulation and scoping, taking into account the risk context and the range of available risk management decision-making options. Phase II (risk assessment) seeks to identify critical toxicity pathway perturbations using new toxicity testing tools and technologies, and to better characterize risks and uncertainties using advanced risk assessment methodologies. Phase III (risk management) involves the development of evidence-based population health risk management strategies of a regulatory, economic, advisory, community-based, or technological nature, using sound principles of risk management decision making.Conclusions: Analysis of a series of case study prototypes indicated that many aspects of the NexGen framework are already beginning to be adopted in practice.Citation: Krewski D, Westphal M, Andersen ME, Paoli GM, Chiu WA, Al-Zoughool M, Croteau MC, Burgoon LD, Cote I. 2014. A framework for the next generation of risk science. Environ Health Perspect 122:796–805; http://dx.doi.org/10.1289/ehp.1307260     

新一代风险科学的框架(待续)

[目的] 2011年,美国环境保护署启动了NexGen项目,为下一代的风险科学建立了新的模式. [方法]NexGen框架建立于三个基石之上:由于基础生物学和毒理学的重要进展,人们获得了有关毒性通路的新数据;从人群健康角度来看,大多数的不良健康结局均涉及数种影响因素;重新关注新型风险评估方法,以期更好地为风险管理决策提供信息. [结果] NexGen框架分为三个阶段:第一阶段(目标)重点关注问题的提出和范围,将风险背景和风险管理决策可选方案纳入考虑范畴;第二阶段(风险评估)旨在运用新的毒性检测工具和技术确定关键的毒理学通路的扰动,以及采用先进的风险评估方法去更好地描述风险及其不确定性;第三阶段(风险管理)包括采用合理的风险管理决策原则,发展符合法律规范、经济效益、合理建议、以社区为基础或高技术含量的循证人群健康风险管理策略. [结论]对一系列案例研究原型的分析表明,实践中已开始采用NexGen框架的诸多方面.     

新一代风险科学的框架(续完)

5.2.5 暴露评估 目前,人类暴露评估主要基于人类环境中环境因素的测量水平(美国EPA,2010);某些情况下,内部剂量测量值也可能通过生物监测(Hays 和Aylward,2008)或药代动力学模型(Barton等,2007)获取.在NexGen方法中,暴露评估将更侧重通过先进的生物监测技术(NRC,2012)结合新高通量方法,获得大量环境因素暴露指标(Jones等,2012),从而直接测量人类关键的毒性通路扰动.