Making sense in a complex landscape: how the Cynefin Framework from Complex Adaptive Systems Theory can inform health promotion practice.

Health promotion addresses issues from the simple (with well-known cause/effect links) to the highly complex (webs and loops of cause/effect with unpredictable, emergent properties). Yet there is no conceptual framework within its theory base to help identify approaches appropriate to the level of complexity. The default approach favours reductionism--the assumption that reducing a system to its parts will inform whole system behaviour. Such an approach can yield useful knowledge, yet is inadequate where issues have multiple interacting causes, such as social determinants of health. To address complex issues, there is a need for a conceptual framework that helps choose action that is appropriate to context. This paper presents the Cynefin Framework, informed by complexity science--the study of Complex Adaptive Systems (CAS). It introduces key CAS concepts and reviews the emergence and implications of 'complex' approaches within health promotion. It explains the framework and its use with examples from contemporary practice, and sets it within the context of related bodies of health promotion theory. The Cynefin Framework, especially when used as a sense-making tool, can help practitioners understand the complexity of issues, identify appropriate strategies and avoid the pitfalls of applying reductionist approaches to complex situations. The urgency to address critical issues such as climate change and the social determinants of health calls for us to engage with complexity science. The Cynefin Framework helps practitioners make the shift, and enables those already engaged in complex approaches to communicate the value and meaning of their work in a system that privileges reductionist approaches.

Networked resilience in rural Australia--a role for health promotion in regional responses to climate change.

ISSUES ADDRESSED: This paper provides a model for how health promotion teams might establish and support regional collaborations of organisations in a broad response to climate change that enables emergence of multiple strategies tailored to regional needs. METHODS: Complex Adaptive Systems Theory (CAS) and Organisational Learning informed action to foster a Climate Change Collaboration that engaged in strategies to improve transport options, food security and energy sustainability. Social Network Analysis was used to evaluate the degree to which member organisations became networked, the evolution of key network qualities and the way the organisations were affiliated via their participation in emergent strategies. RESULTS: Between 2005 and 2009 a highly connected network of organisations emerged and rapidly evolved to collaborate for action on climate change. There were significant improvements in network density, centralisation, clustering and reciprocity. Member organisations collaborated on a broad range of strategies. CONCLUSIONS: Reducing regional impact of climate change is complex. It requires long-term collaboration between organisations that may not usually work together. Sustain Northern Rivers provides a successful model for achieving such collaboration.

The population approach to falls injury prevention in older people: findings of a two community trial.

BACKGROUND: There is a sound rationale for the population-based approach to falls injury prevention but there is currently insufficient evidence to advise governments and communities on how they can use population-based strategies to achieve desired reductions in the burden of falls-related injury. The aim of the study was to quantify the effectiveness of a streamlined (and thus potentially sustainable and cost-effective), population-based, multi-factorial falls injury prevention program for people over 60 years of age. METHODS: Population-based falls-prevention interventions were conducted at two geographically-defined and separate Australian sites: Wide Bay, Queensland, and Northern Rivers, NSW. Changes in the prevalence of key risk factors and changes in rates of injury outcomes within each community were compared before and after program implementation and changes in rates of injury outcomes in each community were also compared with the rates in their respective States. RESULTS: The interventions in neither community substantially decreased the rate of falls-related injury among people aged 60 years or older, although there was some evidence of reductions in occurrence of multiple falls reported by women. In addition, there was some indication of improvements in fall-related risk factors, but the magnitudes were generally modest. CONCLUSIONS: The evidence suggests that low intensity population-based falls prevention programs may not be as effective as those that are intensively implemented.

Tooty Fruity Vegie in Preschools: an obesity prevention intervention in preschools targeting children's movement skills and eating behaviours.

ISSUE ADDRESSED: This paper outlines the implementation strategies and evaluation methods of the Tooty Fruity Vegie (TFV) in Preschools program in NSW Australia which addressed diet, movement skills and overweight indicators. METHODS: The TFV program was a one-year intervention conducted during 2006 and 2007 in 18 preschools (matched with 13 control preschools). The study had a quasi-experimental design with pre- and postintervention evaluation of nutrition and physical activity variables as well as anthropometric measures. Details of the program's methodological aspects such as the recruitment process, intervention strategies and evaluation instruments are described.

Multimedia campaign on a shoestring: promoting 'Stay Active - Stay Independent' among seniors.

ISSUE ADDRESSED: This paper describes a multimedia campaign implemented in rural New South Wales on a budget smaller than that typical of many published campaigns. The 'To Be Young at Heart - Stay Active Stay Independent' (SASI) campaign was one arm of a multi-strategic program to reduce falls among seniors by promoting physical activity. METHODS: This 18-month campaign used social marketing techniques. Central to this campaign was strong formative research, significant use of corporate, community and media partnerships and a detailed, strategic distribution plan. Campaign reach was evaluated by a community intercept survey. RESULTS: A variety of high-quality information, education and communication (IEC) resources were developed. Overall, the campaign cost was calculated at USD 191,000. The actual cost of USD 42,000 (excluding staff time) was used to generate almost double this amount in sponsorship (USD 82,000). In the mid-campaign reach survey, 36% recognised the campaign and attributed this to television (58%), newspaper (33%), poster (13%) and bus-back advertising (8%). Of these respondents, 21% reported seeking information about physical activity, 33% reported increased intention to be more active, and 22% reported becoming more active as a result of the campaign. CONCLUSIONS: It is possible to develop and deliver a well-designed, multi-media campaign on a limited budget by using sound formative research and engaging community and corporate partners to generate sponsorship. An effective distribution strategy is crucial and may require additional partnerships at State or national level.

Global Principles, Regional Action: Guiding Ecohealth Practice in Oceania.

In Oceania, a region challenged by rapid urbanisation and climate change, integrative frameworks are required to enable effective actions on health and sustainability. The Ecohealth approach provides a framework for practice that acknowledges human health is intrinsically linked to ecosystem health. This research communication reports on a study involving interviews with twenty-seven leading health and sustainability thinkers from Oceania and across the globe. In examining their ideas for action, the report presents the study findings in relation to the guiding principles of Ecohealth: systems thinking, transdisciplinarity, participation, sustainability, equity and knowledge-to-action. Implications for Ecohealth practitioners working in Oceania are considered.

Falls prevention in rural general practice: what stands the test of time and where to from here?

OBJECTIVE: General practitioner recall of the 1992-96 'Stay on Your Feet' (SOYF) program and its influence on practice were surveyed five years post-intervention to gauge sustainability of the SOYF General Practice (GP) component. METHODS: A survey assessed which SOYF components were still in existence, current practice related to falls prevention, and interest in professional development. All general practitioners (GPs) situated within the boundaries of a rural Area Health Service were mailed a survey in late 2001. RESULTS: Response rate was 66.5% (139/209). Of 117 GPs in practice at the time of SOYF, 80.2% reported having heard of SOYF and 74.4% of those felt it had influenced practice. Half (50.9%) still had a copy of the SOYF GP resource and of those, 58.6% used it at least 'occasionally'. Three-quarters of GPs surveyed (75.2%) checked medications 'most/almost all' of the time with patients over 60 years; 46.7% assessed falls risk factors; 41.3% gave advice; and 22.6% referred to allied health practitioners. GPs indicated a strong interest in falls prevention-related professional development. There was no significant association between use of the SOYF resource package and any of the current falls prevention practices (all chi2 > 0.05). CONCLUSIONS AND IMPLICATIONS: There was high recall of SOYF and a general belief that it influenced practice. There was little indication that use of the resource had any lasting influence on GPs' practices. In future, careful thought needs to go into designing a program that has potential to affect long-term change in GPs' falls prevention practice.

The tooty fruity vegie project: changing knowledge and attitudes about fruits and vegetables.

OBJECTIVES: The Tooty Fruity Vegie (TFV) project was a multi-strategic, school-based intervention aimed at preventing the large decline in fruit and vegetable intake that typically starts during primary school. METHODS: During 1999 and 2000, TFV was implemented in 10 volunteer primary schools across the Northern Rivers region of New South Wales. Surveys were conducted, in late 2000, with children, parents, teachers and principals across nine intervention and three matched control schools. Intervention schools' management teams also completed strategy implementation indexes indicating how often, how well and with how many people each major strategy was implemented. RESULTS: Completed surveys from 613 parents (59%), 392 older children (65%), 50 teachers (81%) and all 10 intervention principals and school management teams showed the project was well implemented, achieved high reach and was very positively received. The project enhanced the quality, diversity and frequency of classroom fruit and vegetable-promoting activities, substantially increasing children's involvement and enjoyment levels. It significantly improved children's fruit and vegetable knowledge, attitudes, access and preparation skills; parents' knowledge and involvement in fruit and vegetable-promoting activities in schools and beyond; and teachers' perceived support for doing fruit and vegetable promotions. CONCLUSION: Despite some methodological limitations, which may limit confidence in our findings, survey results across all target groups consistently indicated that primary schools can be supported to establish, implement and sustain highly acceptable and effective fruit and vegetable-promoting programs.

Substance use disorders in an Australian community survey.

A community survey of the common mental disorders in a geographically defined treatment service area was used to explore the socio-demographic correlates and service utilization of people with alcohol and drug use disorders living in the area. These data represent the most comprehensive data on substance use disorders in a defined geographic region in Australia. Alcohol and drug use disorders were most likely to be found in the young, with those aged 18-34 years being three times more likely to have an alcohol use disorder than those aged 55 years and over. A third (33%) of those people with an alcohol use disorder and 42% of those with a drug use disorder had consulted a health professional in the past 12 months for their substance use disorder.

Incidence and outcomes of mental disorders in a regional population: the Northern Rivers Mental Health Study.

OBJECTIVES: To estimate the incidence of mental disorders in a cohort of previously symptom-free individuals who are representatives of a regional Australian population. To map changing patterns of diagnosis and comorbidity within the cohort over a 2 year period. METHOD: Two year follow-up of a community-based cohort drawn from a telephone screening of 9191 randomly selected adults. Subjects were administered a comprehensive face-to-face interview which included the Composite International Diagnostic Interview. A total of 1407 subjects were interviewed at baseline, and 968 subjects were reinterviewed (a 68.8% follow-up rate). RESULTS: There was considerable change in disorder status over the study period, and analysis of the Composite International Diagnostic Interview scoring suggests that these changes reflected real changes in symptomatology. Of subjects interviewed at both baseline and follow-up, 638 were classified as disorder-free at their entry to the study. After 2 years, 98 of these met criteria for a mental disorder during the preceding 12 months. After adjusting for sampling and gender, the 12 month incidence of any mental disorder among subjects who had been disorder-free 2 years previously was 9.95 per hundred person-years at risk. At baseline, a further 330 subjects met ICD-10 criteria for a mental disorder during the previous 12 months. Two years later, 167 of these subjects (50.6%) were disorder-free, and 163 still met the criteria for a mental disorder, although there had often been considerable change in their diagnosis. Subjects with a mental disorder at the commencement of the study were significantly more likely than those without a disorder to have a positive diagnosis 2 years later (p < 0.001). The number of diagnoses at baseline was a strong predictor of the number of diagnoses at follow-up (p < 0.001), and each additional comorbid diagnosis at baseline also increased the probability of a persisting disorder at follow-up (p < 0.001). CONCLUSIONS: Over a 2 year period, the majority of subjects with a mental disorder will become disorder-free, while a significant number of previously disorder-free individuals will develop a positive diagnosis. Health services need to be designed to meet this labile demand.