Pathways for Strengthening Lived Experience Leadership for Transformative Systems Change: Reflections on Research and Collective Change Strategies.

INTRODUCTION: The Activating Lived Experience Leadership (ALEL) project was a South Australian participatory action research project that aimed to improve the ways lived experience is recognised, valued and integrated across mental health and social sector systems. ALEL was completed during 2019-2021, where it engaged 182 participants in generating community action and research knowledge. OBJECTIVE: Our paper discusses the project's processes of building a collective partnership among lived experience leaders and other leaders from within the sector, so that the actions and strategies identified through research could be implemented by systems-level impact. We describe the collaborative process and key learnings that resulted in eight key action areas for transformative systems change in South Australia. METHODS: The project invited a diverse range of self-identified lived experience and other leaders to be involved in a PAR process featuring formal qualitative research (focus groups, surveys and interviews) as well as community development activities (leaders' summit meetings, consultations, training and community of practice meetings). These processes were used to help us describe the purpose, achievements and potential of lived experience leadership. Project priorities and systems-level analysis was also undertaken with lived experience sector leaders and project advisors across two leaders' summit meetings, integrating research outcomes with sector planning to define high-level actions and a vision for transformational change. RESULTS: Participatory action research as informed by systems change and collective impact strategies assisted the project to generate detailed findings about the experiences and complexities of lived experience leadership, and collective responses of how systems could better support, be accountable to and leverage lived experience perspectives, experience and peer-work approaches. CONCLUSION: Systems change to define, value and embed lived experience leadership benefits from collective efforts in both formal research and sector development activities. These can be used to generate foundational understandings and guidance for working together in genuine ways for transforming mental health and social sector systems, experience and outcomes. PUBLIC CONTRIBUTION: Members of lived experience communities codesigned the project, and contributed to project governance and the development of all findings and project reports.

Development and testing of the capacity of organisations for system practices scale.

BACKGROUND: Systems change approaches are increasingly adopted in public health to address complex problems. It is important that measures of systems change be developed so that the effects of systems change on health outcomes can be evaluated. Organisational practices are potential levers for systems change. However, robust measures of organisational capacity to engage in these practices are lacking. Informed by the Theory of Systems Change, we developed and tested the Capacity of Organisations for System Practices (COSP) scale. The COSP scale comprises four inter-related system practices within organisations-adaptation, alignment, collaboration and evidence-driven action and learning. METHODS: We applied a three-stage process: (1) Item generation; (2) Scale pre-testing; and (3) Structural analyses. Item response theory tests and semantic review, together with factor analytic techniques, were applied to refine the item set and determine the scale structure. RESULTS: An initial pool of 97 items was generated and pre-tested with six content experts and four target audience representatives. Modifications resulted in 60 items. In total, 126 participants provided data for the structural analysis. A second-order hierarchical four-factor model fit the data better than the more basic correlated factor model (Δχ2 = 1.758, p = .415). The fit indices for the final 31-item model were acceptable (RMSEA = .084, TLI = .819). CONCLUSIONS: The COSP scale is ready for further testing to ensure construct validity, stability and utility. SO WHAT?: Once validated, the Capacity of Organisations for System Practices (COSP) scale has the potential to advance the theory and practice of systems change approaches.

Integrated behavioral health implementation and chronic disease management inequities: an exploratory study of statewide data.

BACKGROUND: People with diabetes, vascular disease, and asthma often struggle to maintain stability in their chronic health conditions, particularly those in rural areas, living in poverty, or racially or ethnically minoritized populations. These groups can experience inequities in healthcare, where one group of people has fewer or lower-quality resources than others. Integrating behavioral healthcare services into primary care holds promise in helping the primary care team better manage patients' conditions, but it involves changing the way care is delivered in a clinic in multiple ways. Some clinics are more successful than others in fully integrating behavioral health models as shown by previous research conducted by our team identifying four patterns of implementation: Low, Structural, Partial, and Strong. Little is known about how this variation in integration may be related to chronic disease management and if IBH could be a strategy to reduce healthcare inequities. This study explores potential relationships between IBH implementation variation and chronic disease management in the context of healthcare inequities. METHODS: Building on a previously published latent class analysis of 102 primary care clinics in Minnesota, we used multiple regression to establish relationships between IBH latent class and healthcare inequities in chronic disease management, and then structural equation modeling to examine how IBH latent class may moderate those healthcare inequities. RESULTS: Contrary to our hypotheses, and demonstrating the complexity of the research question, clinics with better chronic disease management were more likely to be Low IBH rather than any other level of integration. Strong and Structural IBH clinics demonstrated better chronic disease management as race in the clinic's location became more White. CONCLUSIONS: IBH may result in improved care, though it may not be sufficient to resolve healthcare inequities; it appears that IBH may be more effective when fewer social determinants of health are present. Clinics with Low IBH may not be motivated to engage in this practice change for chronic disease management and may need to be provided other reasons to do so. Larger systemic and policy changes are likely required that specifically target the mechanisms of healthcare inequities.

Toward a Public Health Approach to Farmer Suicide Prevention: The Potential Power of Systems Change.

OBJECTIVE: Suicide among farmers has, over the past 20 years, garnered attention from scholars around the world. The purpose of this paper is twofold. First, this paper will present a framework for considering farmer suicide that builds upon the Interpersonal-Psychological Theory of Suicidal Behavior and extends our current explanations of suicide to include a multilevel, multifactorial focus on individual, interpersonal, community and systemic factors at the root of stressors contributing to suicide among farmers. Secondly, a blueprint for farmer suicide prevention, leveraging the Water of Systems Change Model, is proposed. METHOD: In the spirit of conveying multi-layered influence on farmer suicide while highlighting relevant levels for prevention a parsimonious, prevention-based model of farmer suicide is presented. RESULTS: The Water of Systems Change (WSC) model incorporates research to bring attention to the community, organizational, and societal conditions that keep a problem, such as farmer suicide, from being eradicated. CONCLUSION: Suicide is a societal issue that requires a multi-level response. Farmer suicide is a particular concern, as farmers provide for and support all of us. It is incumbent upon public health and the community-at-large to improve our policies, systems, and contexts to create an environment in which farmers are also provided for and supported.

Volunteer programs, empowerment, and life satisfaction in Jordan: mapping local knowledge and systems change to inform public policy and science diplomacy.

Introduction: Volunteering in the community is thought to provide unique benefits to people who experience limited engagement in society. In the global South, volunteer programs are often framed as empowering women and benefiting the poor, without empirical evidence or systematic investigation of what this means from a local perspective. For this reason, it is critical to represent stakeholder knowledge, understand how change happens systemically, and reduce cultural bias in scientific inquiry and public policy. As such, efforts to respect diverse narratives and problem-solving approaches are key to science diplomacy - they help us understand cultural relevance, program efficacy, and for whom a program is considered transformative. Methods and results: This study shows how Syrian refugee and Jordanian women, living in resource-poor families, articulated (i) concepts of empowerment and life satisfaction and (ii) the benefits of engaging in community-based volunteering programs. Through engaging in a participatory methodology known as Fuzzy Cognitive Mapping, women generated visual representations of these constructs and cause-and-effect reasoning. They identified several dimensions of empowerment (e.g., cultural, financial, and psychological empowerment) and several meanings of life satisfaction (e.g. adaptation, acceptance, and contentment). They also mapped connections between variables, identifying those that might catalyze change. We were specifically interested in evaluating understandings of We Love Reading, a program that trains volunteers to become changemakers in their local community. In simulations, we modelled how employment, education, money, and volunteering would drive system change, with notable results on cultural empowerment. Discussion: Through visual maps and scenarios of change, the study demonstrates a participatory approach to localizing knowledge and evaluating programs. This is key to improving scientific enquiry and public policy.

ReThinking clinical reasoning: A paradigm shift.

Numerous studies have demonstrated that our healthcare systems and medical education programs are fundamentally flawed. In North America and Europe, most systems were built upon values and structures that have historically benefitted middle and upper class males of European descent in the global north. As a result, there continue to be systemic biases that are pervasive throughout our healthcare systems and medical education programs. This has led to inequities in health outcomes and clinical reasoning practices which marginalize several communities. These biases are perpetuated as we continue to lead medical education research and practice with traditional values and views of evidence. To address these issues, we proposed a 'flipped' conference in which three interdisciplinary writing teams, comprised of both junior and senior academics, clinicians, and researchers, were invited to rethink the foundations of clinical reasoning. In the months leading up to the conference, each writing team explored a specific topic related to clinical reasoning and racial equity. The papers, presented during the virtual conference are now available in this issue of the Journal for the Evaluation of Clinical Practice. In addition, 6 more publications were added to this special topic to showcase new evidence and theory that builds on the recommendations in the three core papers.

The Future of School Health Education in the United States: An Ontology.

BACKGROUND: As summarized in this article, the widespread implementation of modern school health education (SHE) could become one of the most effective means available to improve the well-being of people in the United States and in other nations. However, the development and evolution of SHE largely remains unorganized, underdeveloped, and neglected by health and education agencies, policymakers, and the public. METHODS: Essential to the development of any scientific discipline, scientists today use the word ontology to refer to efforts to organize knowledge in particular domains. A useful working definition of a scientific ontology is an explicit, formal specification of a shared conceptualization-a systematic set of shared terms and an explication of their interrelationships. Nine interdependent questions are outlined to help guide the development of an initial, broad, and actionable scientific ontology for SHE. RESULTS: Whether and how we respond to these questions arguably will determine the future of SHE research, policy, practice, and equity in the United States. CONCLUSIONS: An initial ontology might help conceptualize, inform, and facilitate more systematic and strategic local, state, national, and international deliberations and actions to improve SHE.

Measuring and improving the timeliness of vancomycin therapeutic drug monitoring and potential patient safety impacts.

Background: Timely vancomycin therapeutic drug monitoring (TDM) enables prompt dose adjustments and safe treatment. Local incidents prompted an investigation into the reasons for prolonged reporting times. Objectives: To investigate the variation in reporting times of vancomycin concentrations between hospitals with and without on-site TDM processing, and patient safety implications. Methods: Vancomycin concentration results for Hospital 1 (off-site monitoring), Hospitals 2 and 3 (both on-site monitoring) from June to December 2021 were retrospectively analysed. Retrospective data collection was repeated for Hospital 1 three months post on-site TDM commencement for comparison. Vancomycin clinical incidents at Hospital 1 were reviewed to identify examples of when delays in reporting of results potentially contributed towards adverse patient outcomes. Results: Hospital 1 had a median reporting time of 11.13 h compared with Hospital 2 and Hospital T3 (1.73 h and 1.70 h respectively). Following the commencement of on-site TDM at Hospital 1, the reporting time reduced to 1.33 h (p < 0.001). Several incidents at Hospital 1 during the period of off-site monitoring involved delays to TDM results. Conclusions: Off-site processing of TDM introduced significant delays in reporting of vancomycin concentrations, which was significantly improved by transitioning to onsite availability of testing. This study also highlights the impact of accurate problem identification in improving patient safety.

A matter of (good) faith? Understanding the interplay of power and the moral agency of managers in healthcare service reconfiguration.

Previous studies of service reconfiguration in healthcare have explored the influence of power on processes and outcomes. However, in these accounts the moral agency of managers is often underemphasised. This paper draws on the theoretical tools provided by the sociology of morality to help deepen understanding of the interaction between power and moral agency in service reconfiguration in healthcare. It presents results from a qualitative study of a pan-organisational service reconfiguration in the NHS in England, involving nineteen in-depth interviews with those leading the change and the analysis of twelve programme documents. We combine concepts of the moral background and epistemic governance to interpret participants' conviction that the service change was 'the right thing to do'. The paper shows how epistemic work carried out by service change regulations shaped the moral background within which participants worked. This, in turn, channelled their moral agency - specifically their commitment to patient care - in a way that also reflected central priorities. The paper adds to sociological understandings of service reconfiguration through considering the interaction of structure, agency and power, while also developing the concept of the moral background to show how power relations can influence moral beliefs.

Impact of Wellness Policy Review, Wellness Council Activity, and Student Health Objectives on Overall School Wellness Climate.

BACKGROUND: The whole school, whole community, whole child (WSCC) model suggests wellness councils, ongoing review of wellness policy, and a plan for evaluating set objectives are some of the key features needed to support school wellness infrastructure. This study explored the relationship between implementation of these infrastructure features and overall school wellness environment assessment scores among a sampling of Pennsylvania schools. METHODS: The Healthy Champions program provides Pennsylvania schools an opportunity to self-assess their wellness environments across several school wellness topics. Staff enrolled their school in the program by completing a self-report electronic assessment. Enrollment data from the 2020/2021 program year were analyzed using the Kruskal-Wallis test and linear fixed model to identify the impact of varied implementation levels across 3 wellness infrastructure activities. Interactions between these variables and overall assessment score were also analyzed. RESULTS: Of the 645 Pennsylvania schools enrolled and analyzed, we observed higher mean wellness environment assessment scores (∆ 0.74 95% CI 0.40-1.07; p < 0.001) among schools that reported some frequency of all 3 wellness infrastructure activities, compared to schools that reported no frequency for the activities. IMPLICATIONS: Schools with existing policies and practices related to the 3 wellness infrastructure activities should consider the degree of implementation to best support overall wellness in their school setting. Additional research to explore implementation barriers and supports is needed. CONCLUSIONS: Analyses indicated that overall wellness environment assessment scores are impacted by implementation thresholds for wellness council meeting frequency, revision of wellness policy, and review of student health promotion objectives.

Alliance-building for equity and justice: An inter-organizational perspective.

Cultivating alliances between specific sectors or fields with unrealized synergies is a promising strategy for systems change. Social network analysis is a useful tool for assessing whether such alliances build relationships between these previously disparate organizations. Two waves of valued network data were collected from the members (N = 25) of a justice system reform coalition composed of two types of community-based organizations: those involved in restorative justice practice and those involved in grassroots community organizing. Social network homophily analyses were employed to characterize the impact of alliance participation on relationships over time across three domains: working together, doing impactful work together, and sharing a philosophy about justice system reform. Results indicate marked increases in the prevalence of relationships between restorative justice and community organizing organizations across all domains, with the greatest increases occurring in perceptions of shared philosophy. Network structures at each time point differed by relational domain and organization type. Findings suggest that the alliance strengthened relationships between restorative justice and community organizing organizations, particularly in perceptions of shared philosophy, but that the magnitude of these changes varied depending on pre-existing interorganizational relationships and organization type. Findings challenge the idea that close working relationships between diverse members is critical to coalition effectiveness, pointing instead to the value of ambidextrous networks and alignment in members' philosophy and vision.

Exploring Whether the Electronic Optimization of Routine Health Assessments Can Increase Testing for Sexually Transmitted Infections and Provider Acceptability at an Aboriginal Community Controlled Health Service: Mixed Methods Evaluation.

BACKGROUND: In the context of a syphilis outbreak in neighboring states, a multifaceted systems change to increase testing for sexually transmitted infections (STIs) among young Aboriginal people aged 15 to 29 years was implemented at an Aboriginal Community Controlled Health Service (ACCHS) in New South Wales, Australia. The components included electronic medical record prompts and automated pathology test sets to increase STI testing in annual routine health assessments, the credentialing of nurses and Aboriginal health practitioners to conduct STI tests independently, pathology request forms presigned by a physician, and improved data reporting. OBJECTIVE: We aimed to determine whether the systems change increased the integration of STI testing into routine health assessments by clinicians between April 2019 and March 2020, the inclusion of syphilis tests in STI testing, and STI testing uptake overall. We also explored the understandings of factors contributing to the acceptability and normalization of the systems change among staff. METHODS: We used a mixed methods design to evaluate the effectiveness and acceptability of the systems change implemented in 2019. We calculated the annual proportion of health assessments that included tests for chlamydia, gonorrhea, and syphilis, as well as an internal control (blood glucose level). We conducted an interrupted time series analysis of quarterly proportions 24 months before and 12 months after the systems change and in-depth semistructured interviews with ACCHS staff using normalization process theory. RESULTS: Among 2461 patients, the annual proportion of health assessments that included any STI test increased from 16% (38/237) in the first year of the study period to 42.9% (94/219) after the implementation of the systems change. There was an immediate and large increase when the systems change occurred (coefficient=0.22; P=.003) with no decline for 12 months thereafter. The increase was greater for male individuals, with no change for the internal control. Qualitative data indicated that nurse- and Aboriginal health practitioner-led testing and presigned pathology forms proved more difficult to normalize than electronic prompts and shortcuts. The interviews identified that staff understood the modifications to have encouraged cultural change around the role of sexual health care in routine practice. CONCLUSIONS: This study provides evidence for the first time that optimizing health assessments electronically is an effective and acceptable strategy to increase and sustain clinician integration and the completeness of STI testing among young Aboriginal people attending an ACCHS. Future strategies should focus on increasing the uptake of health assessments and promote whole-of-service engagement and accountability.

Sustainable collaboration on complex problems: a "who" not a "what" challenge.

Despite decades of collective efforts and millions of dollars of cross-sector investment, collaborations created to address wicked problems-complex issues that span industries and sectors whose root causes are unclear-have had mixed success. The wicked problems terrain is tribal and competitive. It is contested by proponents of competing collective change and innovation tools and methodologies, advocates of different leadership approaches and, in recent years, big business champions who claim private enterprise is the most effective driver of solutions. This perspective article argues that while all these elements deserve attention, the primary focus of many collaborations reflects a Western scientific bias toward "what" and "how" questions-governance, processes, activities, metrics and outcomes-at the expense of the "who" component: the human relationships, or relational infrastructure, required to build and sustain effective collective efforts. This is crucial given the grueling realities of complex multi-year initiatives. This article explores the tension between this bias and the need to develop robust relational networks through skilful collective leadership, as reflected in numerous First Nations knowledge practices. We discuss leadership as a both an individual and a collective capability and highlight the need for better understanding of its significant role in anchoring, shaping and guiding effective system-based efforts that achieve positive impact.

Commentary: The challenges and promises of competitively employing autistic adults in the United States.

Current United States statistics suggest that autistic individuals will experience high unemployment and underemployment rates throughout their lives. Furthermore, despite the passage of federal legislation to employ young autistic adults in competitive integrated settings, where they work alongside non-disabled workers and earn at least minimum wage, most individuals receiving state services still are placed in day programs or sheltered workshops. Since meaningful employment is the most important determinant of life satisfaction, this failure is a critical societal problem, exerting increasing pressure for systems change. But the news is not all bad. Private sector companies have increased their hiring of disabled workers, producing a growing base of expertise in the recruitment, on-boarding, training, and management of autistic employees. This has led to a growing recognition that autistic individuals can be ideal workers. Autism researchers have advanced the field by investigating these private industry programs as well as conducting efficacy trials of interventions and services that help autistic individuals in the workplace. However, gaps in knowledge persist stemming from the heterogeneity of autistic workers, limited knowledge about those not receiving state services, and a system of federal services that is fragmented, poorly coordinated, difficult to navigate, and over-taxed. Autism researchers can continue to improve outcomes of autistic workers through investigations of the fit between autistic workers, their preferences, and the characteristics of available jobs, and through effectiveness trails of promising employment interventions and services that promote systems change that help break down the barriers to better integration of existing state services and resources in the United States.

Expanding Community Engagement and Equitable Access Through All-Abilities Community Gardens.

Community gardens accessible to people of all abilities provide affordable fresh produce for people with disabilities (PwD) who frequently experience food inequity and related health risks. The objective of this project was to enable 9 community gardens in southern New Jersey to welcome PwD and encourage their use through inclusive designs and practices. Postprogram surveys and a half-day group collaboration session demonstrated the desire of PwD to engage in inclusive gardens, the potential for increased social connections and produce consumption among PwD, and the challenge of limited resources in maintaining community gardens.

What makes community-based, multilevel physical activity promotion last? A systematic review with narrative synthesis on factors for sustainable implementation.

AIM: To follow the need for more research and strategies to enhance the knowledge of sustainable implementation, we examined cases of community-based, multilevel physical activity-related health promotion after initial funding has ceased and aimed to identify factors that influence their sustainable implementation. METHODS: Five scientific databases (PubMed; Scopus; Ebsco Host with CINAHL, PsychInfo, and Sportdiscus; ProQuest and Web of Science) were systematically searched for relevant literature in December 2021. Three reviewers performed a title/abstract screening and independently screened the full texts of the remaining papers, followed by a quality assessment. A narrative synthesis method, including qualitative text analysis, was used to synthesise retrieved articles. As starting point, the framework of Schell et al. containing nine domains for sustainability capacity was used and new emerging themes were inductively added. RESULTS: The search revealed 270 potentially eligible articles out of 27,652 hits. After the systematic review process, 14 studies were included. In the synthesis, 14 factors influencing the sustainablity of community-based, multilevel physical activity-related health promotion were identified of which six are new factors compared to Schell et al. In particular, our findings bring forth a novel understanding of the importance of the factors 'Participation and Partnerships', 'Empowerment and Capacity Building' and 'Community Support'. A dynamic interplay and high connectedness between factors were visible. CONCLUSION: The identified factors can help establish a better understanding of sustainability processes within whole-system approaches intervening on multiple levels in the community with the aim of systems change. They are relevant for practitioners, researchers and policy makers alike. Future research should more closely examine based on further theoretical elaboration how an interplay between the factors can promote sustainability and which interdependencies are of particular importance in facilitating sustainable and equitable change.

Few Primary Care Physicians Lead Hospitals, Despite Their Immense Value: Systems Change and Delivery System Evolution Can Reverse This Trend.

Primary care physicians (PCPs) inherently offer a tremendous range of skills that would serve them well as chief executive officers in hospitals. Despite their immense value, very few serve in these top posts for a variety of reasons. Making changes in how we train, mentor, and support PCPs throughout their careers can reverse this trend.

The C-CAP Process: A Comprehensive Approach to Community Resource Mapping.

INTRODUCTION: Place-based systems change approaches are gaining popularity to address the complex problems associated with locational disadvantage. An important stage of place-based systems change involves understanding the context that surrounds (re)produces a target problem. Community resource mapping can be used to establish the context and identify the strengths of a community that might be leveraged through systems change efforts. Approaches to community resource mapping draw on a range of philosophical assumptions and methodological frameworks. However, comprehensive, practical guidance for researchers and practitioners to conduct community resource mapping is scarce. METHOD: Drawing on the learnings from a literature review, scoping workshops, and reflective practice sessions, we developed a flexible, methodologically robust process called the Contextualize, Collect, Analyze, and Present (C-CAP) process: a four-phase approach to preparing for, conducting, and reporting on community resource mapping. The C-CAP process was co-developed by researchers and practitioners and was tested and refined in two different communities. RESULTS: The C-CAP process provides robust guidance for conducting and reporting on a community resource mapping project. The C-CAP process can be applied by public health practitioners and researchers and adapted for use across different communities, problems, and target groups. We encourage others guided by differing theoretical perspectives to apply C-CAP and share the learnings. CONCLUSION: Application of the C-CAP process has the potential to improve the comparability and comprehensiveness of findings from community resource mapping projects and avoids duplication of effort by reducing the need to design new processes for each new community resource mapping activity.

Finding our own ways of working together: reflections on implementing and facilitating a multidisciplinary and equity-oriented model of Group Pregnancy Care for women of refugee background.

OBJECTIVE: This paper explores professional staff experiences of implementing and facilitating a multidisciplinary equity-oriented model of Group Pregnancy Care for women of refugee background. This model was the first of its kind in Australia and one of the first worldwide. DESIGN AND SETTING: This exploratory descriptive qualitative study reports the process evaluation findings from the formative evaluation of Group Pregnancy Care for women of refugee background. Data were collected in Melbourne, Australia between January and March 2021 via semi-structured interviews, and analysed using reflexive thematic analysis. PARTICIPANTS: Purposive sampling was used to recruit twenty-three professional staff involved in the implementation, facilitation, or oversight of Group Pregnancy Care. FINDINGS: This paper reports five themes: knowledge sharing, bicultural family mentors - the critical link, finding our own ways of working together, power dynamics at the intersection of community and clinical knowledge, and system capacity for change. KEY CONCLUSIONS: The bicultural family mentor role contributes to the cultural safety of the group, and increases the confidence and competence of professional staff through cultural bridging. Multidisciplinary cross-sector teams that collaborate well can provide cohesive care. It is possible for hospital and community-based services to establish cross-sector equity-oriented partnerships. However, there are challenges sustaining partnerships in the absence of explicit funding to support collaboration, and in context of organisational and professional inflexibility. IMPLICATIONS FOR PRACTICE: Investing in change is necessary to achieve health equity. Creating explicit funding pathways for the bicultural family mentor workforce, multidisciplinary collaboration, and cross-sector partnerships would strengthen service capacity to provide equity-oriented care. Working towards health equity also requires a commitment to continuing professional development for professional staff and organisations to increase knowledge and capacity.