Knowledge generated from practice shows how to bring about system change for better health

Professor Penny Hawe and her team have conducted a behind-the-scenes ethnography of the way practitioners scale-up obesity prevention policies and practices to every school and early childhood centre in NSW.¹

The team behind the Prevention Centre project, Policy and program implementation and the role of context in explaining prevention, has been observing the use of bespoke software, known as PHIMS (Population Health Information Management System). The software assists program delivery and helps track implementation target achievement, like whether sites adopt healthier food nutrition and physical activity practices.² Already, NSW Health has reported some outstanding results.  

On a macro scale, dynamic simulation models show us how to sequence and/or combine different types of solutions to address problems, like reducing alcohol related harm³ or diabetes.⁴

“But we can also learn about systems science from micro contexts. We can learn from the close-up and indepth study of how practitioners implement programs, that is, in how they bring about change within ‘the system’ itself. We can look for patterns in their actions. Understanding these patterns could yield benefits more efficiently. It could also help us monitor and facilitate change more easily,” said Professor Hawe.

The research team is made up of four university-based researchers working with seven research policy partners in NSW Health. The team has revealed new insights into complex processes of implementation and why they matter.

Multisolving

The project team observed how some practitioners ‘multisolve’ problems,⁵ working out ways to tackle multiple issues with the same investment of energy. Practitioners do this by thinking about short and long-term gains and with a view to reaching different groups.⁶

The researchers also observed that while practitioners use PHIMS, extra recording systems have also grown up around it. These serve six main functions, two being to track relationship-building with local stakeholders and the work done for related (or possibly future) purposes.⁷

“Observing what people do in practice, in a free-form way, makes no assumptions about what they should be doing” said Professor Hawe.

“It allows us to see what type of knowledge is needed, kept, and passed around the team. We see how much effort goes into achieving an obesity target in a school. Butwe also see how this can lay the groundwork for servicing other needs like, say, mental health.⁸ If we were just looking at what was recorded in PHIMS, we’d miss the wider change processes being orchestrated simultaneously,” said Professor Hawe. 

Illuminating the multiple roles and pathways

The research has illuminated the wider role educational materials such as electronic newsletters and leaflets play in program scale-up. These materials do more than simply transfer information, they also encourage local innovation and creativity.⁹

“If programs are transferred more by regeneration, or recrafting, rather than faithful duplication,¹⁰ then this creativity is vital for creating local ownership and sustainability, especially when a program becomes routine.

“You see, the essence of complexity is that there are multiple pathways to a goal and multiple logic models underpinning a change process,”¹¹ said Professor Hawe.

“This study has allowed us to seek out those multiple logics. They could more fully explain NSW Health’s overall success with obesity prevention,” said Professor Hawe.

Globally, scholars have argued that complex problems are clustered or interlinked.¹²

“We’re just saying that when you watch change-agents at a practice-level they constantly engage with the notion of problem clustering. So, we need to think about how we can more easily capture the gains they make,” said Professor Hawe.

Creative thinking tools

The team used creative tools at the beginning of the project to imagine what the findings might be and to rehearse responses to different hypothetical scenarios.¹³

“This sensitised us to what people found most interesting and why. It also made us see that nothing could be too alarming, if the overall commitment is to learning and improvement,” Professor Hawe said.

On the other side of COVID we hope there will be time for the team to reflect further on all the higher order learnings that are coming from the project. But we are really excited by what we see already.” 

References

1. Conte K, Groen S, Loblay V, Green A, Innes-Hughes C, Mitchell J, Milat A, Persson L, Thackway S, Williams M, Hawe P. Dynamics behind the scale up of evidence-based obesity prevention: Protocol for a multi-site case study of an electronic implementation monitoring system in health promotion practice. Implement Sci. 2017;12:146.
2. Innes-Hughes C, Rissel C, Thomas M, Wolfenden L. Reflections on the NSW Healthy Children Initiative: A comprehensive, state-delivered childhood obesity prevention initiative. Public Health Res Prac. 2019;29(1):e2911908. doi: 10.17061/phrp2911908
3. Atkinson JA, Prodan A, Livingston M, Knowles D, O’Donnell, Room R, Indig D, Page A, McDonnell G, Wiggers J. Impacts of licensed premises trading hour policies on alcohol-related harms. J Addict. 2018;113(7):1244-1251. doi: 10.1111/add.14178
4. Freebairn L, Atkinson J, Osgood N, Kelly P, McDonnell J, Rychetnik L. Turning conceptual systems maps into dynamic simulation models: An Australian case study for diabetes in pregnancy. PLoS One. 27 June 2019 .
5. Sawin E. The magic of ’multisolving’: Six principles and practices to unlock cross-sectoral collaboration. Stanford Social Innovation Review  [Internet]. 2018 Jul 16. Available from: https://ssir.org/articles/entry/the_magic_of_multisolving
6. Groen S, Loblay V, Conte KP, Green A, Innes-Hughes C, Milat A, Thackway S, Persson L, Williams M, Mitchell J, Hawe P. Key performance indicators for program scale-up and divergent practice styles: A study from NSW, Australia. Health Promot Int. 2020:daaa001. doi: 10.1093/heapro/daaa001. [Epub ahead of print.]
7. Conte KP, Shahid A, Grøn S, Loblay V, Green A, Innes-Hughes C, Milat A, Persson L, Williams M, Thackway S, Mitchell J, Hawe P. Capturing implementation knowledge: applying focused ethnography to study how implementers generate and manage knowledge in the scale-up of obesity prevention programs. Implement Sci. 2019;14:91.
8. Conte K,* Marks L,* Loblay V, Groen S, Green A, Innes-Hughes C, Milat A, Persson L, Mitchell J, Thackway S, Williams M, Hawe P. Can an electronic monitoring system capture implementation of health promotion programs? A focussed ethnographic exploration of the story behind program monitoring data. BMC Public Health . 2020;20:917. *Equal first author. doi: 10.1186/s12889-020-08644-2
9. Loblay V, Conte K, Groen S, Green A, Innes-Hughes C, Persson L, Williams M, Hawe P. New roles for ‘old’ tools: Unpacking the role of promotional and informational resources in scaled-up preventive interventions. (Submitted for publication.)
10. Hawe P. Lessons from complex interventions to promote health. Annu  Rev Public Health. 2015;36:307–323.
11. Horton T, Illingworth J, Warburton W. 2018. The spread challenge. How to support the successful uptake of innovations and improvements in health care. The  Health Foundation. London. ISBN: 978-1-911615-18-7.
12. Singer M, Bulled N, Ostrach B, Mendenhall E. Syndemics and biosocial conception of health. Lancet . 2017;389:941–950.
13. Hawe P, Conte KP, Groen S, Loblay V, Green A, Mitchell J, Innes-Hughes C, Milat A, Thackway S, Persson L, Williams M. Mock abstracts with mock findings: a device to catalyse production, interpretation and use of knowledge outputs in a university policy-practice-research partnership. Evid  Policy. 2019 Oct 09.