Life, complexity, and psychotherapy: A systemic perspective on the elusive construct of extra-therapeutic factors.

STUDY AIMS: Despite being mentioned in well-known models of psychotherapeutic change, the concept of extra-therapeutic factors seems to have left the scene across time, eaten away by the progressive refinement of the construct of common factors. Aim of the present study is to better understanding the historical evolution of the concept of extra-therapeutic factors and its importance for psychotherapy today. METHODS: This is a position paper based on a literature review on extra-therapeutic factors and psychotherapy outcome and process. DISCUSSION: There is growing evidence of the decisive role of clients' and therapists' characteristics, as well as of the importance of therapeutic alliances and relationships in promoting change. Within this context, the concept of extra-therapeutic factors still deserves proper attention, rather than being relegated to a residual and vanishing category. CONCLUSION: A renewed interest on extra-therapeutic factors could reinvigorate the debate over the relationship between psychotherapy and life contexts and conditions. In terms of complexity and systems thinking nothing, a priori, really falls outside the realm of psychotherapy and, in turn, psychotherapy is not a practice that could be abstracted from the context in which it is practiced or from clients' and therapists' lives.

Use of systems thinking and adapted group model building methods to understand patterns of technology use among older adults with type 1 diabetes: a preliminary process evaluation.

BACKGROUND: A growing number of older adults (ages 65+) live with Type 1 diabetes. Simultaneously, technologies such as continuous glucose monitoring (CGM) have become standard of care. There is thus a need to understand better the complex dynamics that promote use of CGM (and other care innovations) over time in this age group. Our aim was to adapt methods from systems thinking, specifically a participatory approach to system dynamics modeling called group model building (GMB), to model the complex experiences that may underlie different trajectories of CGM use among this population. Herein, we report on the feasibility, strengths, and limitations of this methodology. METHODS: We conducted a series of GMB workshops and validation interviews to collect data in the form of questionnaires, diagrams, and recordings of group discussion. Data were integrated into a conceptual diagram of the "system" of factors associated with uptake and use of CGM over time. We evaluate the feasibility of each aspect of the study, including the teaching of systems thinking to older adult participants. We collected participant feedback on positive aspects of their experiences and areas for improvement. RESULTS: We completed nine GMB workshops with older adults and their caregivers (N = 33). Each three-hour in-person workshop comprised: (1) questionnaires; (2) the GMB session, including both didactic components and structured activities; and (3) a brief focus group discussion. Within the GMB session, individual drawing activities proved to be the most challenging for participants, while group activities and discussion of relevant dynamics over time for illustrative (i.e., realistic but not real) patients yielded rich engagement and sufficient information for system diagramming. Study participants liked the opportunity to share experiences with peers, learning and enhancing their knowledge, peer support, age-specific discussions, the workshop pace and structure, and the systems thinking framework. Participants gave mixed feedback on the workshop duration. CONCLUSIONS: The study demonstrates preliminary feasibility, acceptability, and the value of GMB for engaging older adults about key determinants of complex health behaviors over time. To our knowledge, few studies have extended participatory systems science methods to older adult stakeholders. Future studies may utilize this methodology to inform novel approaches for supporting health across the lifespan.

Identifying Features of a System of Practice to Inform a Contemporary Competency Framework for Paramedics in Canada.

INTRODUCTION: Paramedic practice is highly variable, occurs in diverse contexts, and involves the assessment and management of a range of presentations of varying acuity across the lifespan. As a result, attempts to define paramedic practice have been challenging and incomplete. This has led to inaccurate or under-representations of practice that can ultimately affect education, assessment, and the delivery of care. In this study, we outline our efforts to better identify, explore, and represent professional practice when developing a national competency framework for paramedics in Canada. METHODS: We used a systems-thinking approach to identify the settings, contexts, features, and influences on paramedic practice in Canada. This approach makes use of the role and influence of system features at the microsystem, mesosystem, exosystem, macrosystem, supra-macrosystem, and chronosystem levels in ways that can provide new insights. We used methods such as rich pictures, diagramming, and systems mapping to explore relationships between these contexts and features. FINDINGS: When we examine the system of practice in paramedicine, multiple layers become evident and within them we start to see details of features that ought to be considered in any future competency development work. Our exploration of the system highlights that paramedic practice considers the person receiving care, caregivers, and paramedics. It involves collaboration within co-located and dispersed teams that are composed of other health and social care professionals, public safety personnel, and others. Practice is enacted across varying geographical, cultural, social, and technical contexts and is subject to multiple levels of policy, regulatory, and legislative influence. CONCLUSION: Using a systems-thinking approach, we developed a detailed systems map of paramedic practice in Canada. This map can be used to inform the initial stages of a more representative, comprehensive, and contemporary national competency framework for paramedics in Canada.

Championing a move from sustainability to Planetary Health in nursing curriculum.

In this paper, we review the progress on developing sustainability-related content in the Bachelor of Nursing curriculum in Aotearoa New Zealand and engage with Planetary Health. Sustainability in nurse education is explored and the concept of sustainability-practising graduates is promoted. THE ISSUE: We have seen ambivalence towards sustainability persisting amongst nurse educators and students, and sustainability-related content discarded. Despite this, we continue to recognise that sustainability is closely related to climate change which is the greatest threat to planetary, human, and animal health and as such is an essential component of nurse education and practice. Never has there been a timelier reminder of nurses' responsibility to recognise we are ideally placed to contribute to, and help lead, the health response to climate change and champion sustainability. A SYSTEMS-THINKING APPROACH: This response includes a systems-thinking approach to understanding climate change and the impact on health, nursing's responsibility to address climate change, promote health, and respond to health needs. As we revise our current Bachelor of Nursing curriculum, it is timely to review how our sustainability content and thinking has progressed since our previous review in 2017. We are mindful of the need to continue championing this topic, ensuring it is situated at the forefront of nurse education. We propose that a gradual and purposeful shift towards a Planetary Health focus will help to counter the sustainability fatigue and ambivalence we have noted amongst our colleagues and students, ensuring our revised Bachelor of Nursing curriculum is future proofed.

Baby and Family-Centered Care in the Neonatal Intensive Care Unit: Changing Perspective.

The goal of baby and family-centered care in the neonatal intensive care unit (NICU) is to recognize the baby's needs exhibited through the baby's individual behavior and communication and support parent education, engagement, and interaction with the baby to build a nurturing relationship. Health care providers and caregivers must guide rather than control the role of the parents from birth through NICU care, transition to home, and continuing care at home. Parents are health care team members, primary caregivers, and shared decision-makers in caring for their babies.

Participatory co-learning for human-wildlife coexistence: Reflections on a novel program applying systems thinking, nonviolent communication, and learning-based approaches.

As wildlife habitats become increasingly fragmented, sharing landscapes with wildlife is becoming difficult and complex. Because stakeholders with diverging interests struggle to collaborate to manage human-wildlife interactions, new approaches are needed. Here we reflect on a novel participatory learning program we implemented with farmers in communal conservancies in the Zambezi region of Namibia. The 9 week program aimed to understand why human-wildlife conflict remained a challenge. We combined three theoretical framings in the program design-systems thinking, nonviolent communication, and learning based approaches. We summarize key outcomes of each session and reflect on the overall program. We found a synergistic effect of the three framings and concluded that our integrated program had been a useful collaborative learning tool to understand the human-wildlife governance system, identify interventions, empower communities, and build capacity for collaboration to improve human wellbeing and human-wildlife interactions. Drawing on our experience, we make suggestions for how the program could be adapted for similar or other environmental problems elsewhere.

Infant mortality in Ghana: investing in health care infrastructure and systems.

Child and infant mortality is a global problem. Almost half of deaths of children under age 5 years occur in the neonatal period, the first 28 days of life, with 2.4 million neonatal deaths globally in 2020. Sub-Saharan Africa has disproportionately high numbers of neonatal deaths. Ghana's neonatal mortality rate is 22.8 per 1000 live births and remains behind targets set by the United Nations Sustainable Development Goals. Quality antenatal care, postnatal monitoring, breastfeeding support, and postnatal family planning are important in preventing neonatal deaths. While Ghana has made progress in making care more financially accessible, it has not been matched with the improvements in the critical infrastructure required to ensure quality health care. The improvements have also not eliminated out-of-pocket costs for care, which have hindered progress in decreasing infant mortality. Policymakers should consider investments in health care infrastructure, including expanding public-private partnerships. Policies that improve workforce development programs, transportation infrastructure, and health insurance systems improvements are needed.

A consulting room with a view: Psychotherapy and the ecological context.

BACKGROUND: The field of psychotherapy is witnessing a lively debate today. The literature on the efficacy of psychological interventions has grown exponentially, but the assumptions of the prevailing research paradigms have been criticised from many points of view. One of the main concerns is that of a too often simplistic conception of psychotherapy, viewed as a set of specific methods for the treatment of point-like problems or symptoms. LITERATURE REVIEW ON MENTAL HEALTH AND THE ECOLOGICAL CONTEXT: Instead, emerging perspectives are trying to promote a more complex view on psychotherapy, as a process based on the therapeutic potential of relationships, which takes place in relevant social and cultural contexts. Even the ecological context is taken in greater consideration, as growing evidence exists about the detrimental effects of ecological threats-such as climate change and other environmental challenges-on mental health. CONCLUSIONS: Psychotherapists and psychotherapy associations are now paying due attention to such issues, as well as to social justice and other dimensions that no longer can be thought of as mere elements of the scenario in which psychotherapy is practiced. Rather they are dimensions that exert a strong influence on psychological well-being, and thus must be properly acknowledged and assessed to connect clinical work with the communities and ecological contexts in which people live.

Where do we intervene to optimize sports systems? Leverage Points the way.

Sport and sports research are inherently complex systems. This appears to be somewhat at odds with the current research paradigm in sport in which interventions are aimed are fixing or solving singular broken components within the system. In any complex system, such as sport, there are places where we can intervene to change behaviour and, ideally, system outcomes. Meadows influential work describes 12 different points with which to intervene in complex systems (termed "Leverage Points"), which are ordered from shallow to deeper based on their potential effectiveness to influence transformational change. Whether research in sport is aimed at shallow or deeper Leverage Points is unknown. This study aimed to assess highly impactful research in sports science, sports nutrition/metabolism, sports medicine, sport and exercise psychology, sports management, motor control, sports biomechanics and sports policy/law through a Leverage Points lens. The 10 most highly cited original-research manuscripts from each journal representing these fields were analysed for the Leverage Point with which the intervention described in the manuscript was focused. The results indicate that highly impactful research in sports science, sports nutrition/metabolism, sports biomechanics and sports medicine is predominantly focused at the shallow end of the Leverage Points hierarchy. Conversely, the interventions drawn from journals representing sports management and sports policy/law were focused on the deeper end. Other journals analysed had a mixed profile. Explanations for these findings include the dual practitioner/academic needing to "think fast" to solve immediate questions in sports science/medicine/nutrition, limited engagement with "working slow" systems and method experts and differences in incremental vs. non-incremental research strategies.

The Source-to-Sea Landscape: A hybrid integrative territory management approach.

Whether fresh or salty, water is a unique resource, a continuum interlinked by the hydrological cycle. It forms a complex system connected to the landscape. When the landscape is altered, water flows and their benefits are impacted. Degraded land compromises water resources. The governance and management of landscape and water resources are handled in a fragmented manner and in separate contexts. The Source-to-Sea approach offers an integrative vision based on systems thinking that focuses its concerns on the interaction among parts, flows, and processes. It proposes a framework for the governance and management of freshwater and marine water but does not bring the landscape into the context of the approach. This research used an analytical-deductive method to explore the interactions and connections between the Source-to-sea approach, landscape concepts and approaches, and the guidelines of the European Landscape Convention. The main objective was to identify and assess the feasibility of integrating these elements. The integration resulted in a governance and management approach termed the S2S Landscape approach. It is grounded in systems thinking, practical learning, active participation, and adaptive governance and management, providing an integrated vision between landscape and water. The approach includes four essential steps (Comprehension, Involvement, Planning, and Execution and Monitoring) that address the complex connections that freshwater and marine water maintain in the landscape, considering physical, biological, socio-environmental, and economic aspects across all segments, from the land to the open sea. This S2S Landscape approach may be the path to address the challenges of governance and sustainable management of resources in an interconnected and constantly changing world.

A concept for international societally relevant microbiology education and microbiology knowledge promulgation in society.

EXECUTIVE SUMMARY: Microbes are all pervasive in their distribution and influence on the functioning and well-being of humans, life in general and the planet. Microbially-based technologies contribute hugely to the supply of important goods and services we depend upon, such as the provision of food, medicines and clean water. They also offer mechanisms and strategies to mitigate and solve a wide range of problems and crises facing humanity at all levels, including those encapsulated in the sustainable development goals (SDGs) formulated by the United Nations. For example, microbial technologies can contribute in multiple ways to decarbonisation and hence confronting global warming, provide sanitation and clean water to the billions of people lacking them, improve soil fertility and hence food production and develop vaccines and other medicines to reduce and in some cases eliminate deadly infections. They are the foundation of biotechnology, an increasingly important and growing business sector and source of employment, and the centre of the bioeconomy, Green Deal, etc. But, because microbes are largely invisible, they are not familiar to most people, so opportunities they offer to effectively prevent and solve problems are often missed by decision-makers, with the negative consequences this entrains. To correct this lack of vital knowledge, the International Microbiology Literacy Initiative-the IMiLI-is recruiting from the global microbiology community and making freely available, teaching resources for a curriculum in societally relevant microbiology that can be used at all levels of learning. Its goal is the development of a society that is literate in relevant microbiology and, as a consequence, able to take full advantage of the potential of microbes and minimise the consequences of their negative activities. In addition to teaching about microbes, almost every lesson discusses the influence they have on sustainability and the SDGs and their ability to solve pressing problems of societal inequalities. The curriculum thus teaches about sustainability, societal needs and global citizenship. The lessons also reveal the impacts microbes and their activities have on our daily lives at the personal, family, community, national and global levels and their relevance for decisions at all levels. And, because effective, evidence-based decisions require not only relevant information but also critical and systems thinking, the resources also teach about these key generic aspects of deliberation. The IMiLI teaching resources are learner-centric, not academic microbiology-centric and deal with the microbiology of everyday issues. These span topics as diverse as owning and caring for a companion animal, the vast range of everyday foods that are produced via microbial processes, impressive geological formations created by microbes, childhood illnesses and how they are managed and how to reduce waste and pollution. They also leverage the exceptional excitement of exploration and discovery that typifies much progress in microbiology to capture the interest, inspire and motivate educators and learners alike. The IMiLI is establishing Regional Centres to translate the teaching resources into regional languages and adapt them to regional cultures, and to promote their use and assist educators employing them. Two of these are now operational. The Regional Centres constitute the interface between resource creators and educators-learners. As such, they will collect and analyse feedback from the end-users and transmit this to the resource creators so that teaching materials can be improved and refined, and new resources added in response to demand: educators and learners will thereby be directly involved in evolution of the teaching resources. The interactions between educators-learners and resource creators mediated by the Regional Centres will establish dynamic and synergistic relationships-a global societally relevant microbiology education ecosystem-in which creators also become learners, teaching resources are optimised and all players/stakeholders are empowered and their motivation increased. The IMiLI concept thus embraces the principle of teaching societally relevant microbiology embedded in the wider context of societal, biosphere and planetary needs, inequalities, the range of crises that confront us and the need for improved decisioning, which should ultimately lead to better citizenship and a humanity that is more sustainable and resilient. ABSTRACT: The biosphere of planet Earth is a microbial world: a vast reactor of countless microbially driven chemical transformations and energy transfers that push and pull many planetary geochemical processes, including the cycling of the elements of life, mitigate or amplify climate change (e.g., Nature Reviews Microbiology, 2019, 17, 569) and impact the well-being and activities of all organisms, including humans. Microbes are both our ancestors and creators of the planetary chemistry that allowed us to evolve (e.g., Life's engines: How microbes made earth habitable, 2023). To understand how the biosphere functions, how humans can influence its development and live more sustainably with the other organisms sharing it, we need to understand the microbes. In a recent editorial (Environmental Microbiology, 2019, 21, 1513), we advocated for improved microbiology literacy in society. Our concept of microbiology literacy is not based on knowledge of the academic subject of microbiology, with its multitude of component topics, plus the growing number of additional topics from other disciplines that become vitally important elements of current microbiology. Rather it is focused on microbial activities that impact us-individuals/communities/nations/the human world-and the biosphere and that are key to reaching informed decisions on a multitude of issues that regularly confront us, ranging from personal issues to crises of global importance. In other words, it is knowledge and understanding essential for adulthood and the transition to it, knowledge and understanding that must be acquired early in life in school. The 2019 Editorial marked the launch of the International Microbiology Literacy Initiative, the IMiLI. HERE, WE PRESENT: our concept of how microbiology literacy may be achieved and the rationale underpinning it; the type of teaching resources being created to realise the concept and the framing of microbial activities treated in these resources in the context of sustainability, societal needs and responsibilities and decision-making; and the key role of Regional Centres that will translate the teaching resources into local languages, adapt them according to local cultural needs, interface with regional educators and develop and serve as hubs of microbiology literacy education networks. The topics featuring in teaching resources are learner-centric and have been selected for their inherent relevance, interest and ability to excite and engage. Importantly, the resources coherently integrate and emphasise the overarching issues of sustainability, stewardship and critical thinking and the pervasive interdependencies of processes. More broadly, the concept emphasises how the multifarious applications of microbial activities can be leveraged to promote human/animal, plant, environmental and planetary health, improve social equity, alleviate humanitarian deficits and causes of conflicts among peoples and increase understanding between peoples (Microbial Biotechnology, 2023, 16(6), 1091-1111). Importantly, although the primary target of the freely available (CC BY-NC 4.0) IMiLI teaching resources is schoolchildren and their educators, they and the teaching philosophy are intended for all ages, abilities and cultural spectra of learners worldwide: in university education, lifelong learning, curiosity-driven, web-based knowledge acquisition and public outreach. The IMiLI teaching resources aim to promote development of a global microbiology education ecosystem that democratises microbiology knowledge.

Implementation of new technologies designed to improve cervical cancer screening and completion of care in low-resource settings: a case study from the Proyecto Precancer.

BACKGROUND: This case study details the experience of the Proyecto Precancer in applying the Integrative Systems Praxis for Implementation Research (INSPIRE) methodology to guide the co-development, planning, implementation, adoption, and sustainment of new technologies and screening practices in a cervical cancer screening and management (CCSM) program in the Peruvian Amazon. We briefly describe the theoretical grounding of the INSPIRE framework, the phases of the INSPIRE process, the activities within each phase, and the RE-AIM outcomes used to evaluate program outcomes. METHODS: Proyecto Precancer iteratively engaged over 90 stakeholders in the Micro Red Iquitos Sur (MRIS) health network in the Amazonian region of Loreto, Perú, through the INSPIRE phases. INSPIRE is an integrative research methodology grounded in systems thinking, participatory action research, and implementation science frameworks such as the Consolidated Framework for Implementation Research. An interrupted time-series design with a mixed-methods RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) evaluation framework was used to examine the adoption of human papillomavirus (HPV) testing (including self-sampling), with direct treatment after visual inspection with portable thermal ablation, at the primary level. RESULTS: This approach, blending participatory action research, implementation science, and systems-thinking, led to rapid adoption and successful implementation of the new cervical cancer screening and management program within 6 months, using an HPV-based screen-and-treat strategy across 17 health facilities in one of the largest public health networks of the Peruvian Amazon. Monitoring and evaluation data revealed that, within 6 months, the MRIS had surpassed their monthly screening goals, tripling their original screening rate, with approximately 70% of HPV-positive women reaching a completion of care endpoint, compared with around 30% prior to the new CCSM strategy. CONCLUSIONS: Proyecto Precancer facilitated the adoption and sustainment of HPV testing with subsequent treatment of HPV-positive women (after visual inspection) using portable thermal ablation at the primary level. This was accompanied by the de-implementation of existing visual inspection-based screening strategies and colposcopy for routine precancer triage at the hospital level. This case study highlights how implementation science approaches were used to guide the sustained adoption of a new screen-and-treat strategy in the Peruvian Amazon, while facilitating de-implementation of older screening practices.

A qualitative study to explore experiences of anti-racism teaching in medical residency programs across the United States and subsequent creation of the SPOC (Support - Pipeline - Outcomes - Community) Model to guide future curricula design.

BACKGROUND: Racism contributes to health disparities and is a serious threat to public health. Teaching physicians about racism, how to address it in medical practice, and developing high quality and sustainable curricula are essential to combating racism. OBJECTIVE: This study aimed to (1) describe the experience of racism and anti-racism teaching in residency programs, and elicit recommendations from key informants, and (2) use these data and formative research to develop recommendations for other residencies creating, implementing, and evaluating anti-racism curricula in their own programs. METHODS: From May to July 2023, 20 faculty and residents were recruited via convenience sampling for key informant interviews conducted via Microsoft Teams. Interviews were audio recorded, transcribed, and coded. An initial list of themes was developed using theoretical frameworks, and then refined using a grounded-theory approach. A brief online optional anonymous demographic survey was sent to participants in August of 2023.  RESULTS: Eighty percent (20/25) of participants approached were interviewed. Seventy-five percent (15/20) answered a brief optional demographic survey. Seven themes emerged: (1) Racism in medicine is ubiquitous; (2) Anti-racism teaching in medicine varies widely; (3) Sustainability strategies should be multifaceted and include recruitment, resource allocation, and outcome measures; (4) Resources are widely available and accessible if one knows where to look; (5) Outcomes and metrics of success should include resident- faculty-, patient- community-, and system-focused outcomes; (6) Curricular strategies should be multilayered, longitudinal, and woven into the curriculum; and (7) Self-reflection and discomfort are necessary parts of the process.  CONCLUSIONS: This study is one of the first to qualitatively examine perspectives of key stakeholders invested in anti-racism teaching for residents. The Support - Pipeline - Outcomes - Community (SPOC) Model, that was developed using information collected during this study, can be used in the future as a guide for others working to design and implement sustainable and high quality anti-racism curricula for residents.

Fit-for-purpose-The bottom-up redesign of the nursing home system: The Australian Aged Care System.

Nursing homes struggle to meet the needs of their residents as they become older and frailer, live with more complex co-morbidity, and are impacted by memory impairment and dementia. Moreover, the nursing home system is overwhelmed with significantly constraining organisational and regulatory demands that stand in the way of achieving resident-focused outcomes. These issues are compounded by the perceptions of poor working environments, poor remuneration, and poor satisfaction amongst staff. The system is beyond the state of 'reform' and requires a fundamental redesign based on first organisational systems understandings: a clearly defined purpose and goal, shared values, and system-wide agreed "simple (or operating) rules". A 'fit-for-purpose' future requires a complex adaptive nursing home system characterised by seamless 'bottom-up and top-down' information flows to ensure that the necessary 'work that needs to be done' is done, and a governance structure that focuses on quality improvement and holds the system accountable for the quality of care that is provided.

From urban ecology to urban enquiry: How to build cumulative and context-sensitive understandings.

This paper positions urban ecology as increasingly conversant with multiple perspectives and methods for understanding the functions and qualities of diverse cities and urban situations. Despite progress in the field, we need clear pathways for positioning, connecting and synthesising specific knowledge and to make it speak to more systemic questions about cities and the life within them. These pathways need to be able to make use of diverse sources of information to better account for the diverse relations between people, other species and the ecological, social, cultural, economic, technical and increasingly digital structures that they are embedded in. Grounded in a description of the systemic knowledge needed, we propose five complementary and often connected approaches for building cumulative systemic understandings, and a framework for connecting and combining different methods and evidence. The approaches and the framework help position urban ecology and other fields of study as entry points to further advance interdisciplinary synthesis and open up new fields of research.

A review of implementation and evaluation frameworks for public health interventions to inform co-creation: a Health CASCADE study.

BACKGROUND: By including the needs and perspectives of relevant stakeholders, co-creation is seen as a promising approach for tackling complex public health problems. However, recommendations and guidance on how to plan and implement co-creation are lacking. By identifying and analysing existing implementation and evaluation frameworks for public health, this study aims to offer key recommendations for professional stakeholders and researchers wanting to adopt a co-creation approach to public health interventions. METHODS: Firstly, PubMed and CINAHL databases were screened for articles introducing original implementation and evaluation frameworks for public health interventions. Backwards snowballing techniques were applied to the included papers. Secondly, identified frameworks were classified and relevant data extracted, including steps and constructs present in the frameworks. Lastly, recommendations were derived by conducting thematic analysis on the included frameworks. RESULTS: Thirty frameworks were identified and data related to their nature and scope extracted. The frameworks' prominent steps and constructs were also retrieved. Recommendations related to implementation and evaluation in the context of co-creation were included. CONCLUSION: When engaging in co-creation, we recommend including implementation considerations from an early stage and suggest adopting a systems thinking as a way to explore multiple levels of influence, contextual settings and systems from an early planning stage. We highlight the importance of partnering with stakeholders and suggest applying an evaluation design that is iterative and cyclical, which pays particular attention to the experience of the engaged co-creators.

Sex Workers in Canada Face Unequal Access to Healthcare: A Systems Thinking Approach.

OBJECTIVES: Despite Canada's universal health system, sex workers across the country face an alarmingly high number of barriers when they seek to healthcare services. This has resulted in unmet healthcare needs and substantially poorer health outcomes than the general Canadian population. The objective of this study was to use a systems thinking approach to gain an in-depth understanding of the barriers sex workers face and how access could be improved. METHODS: The analysis was conducted using a systems thinking methodology, which incorporates systems tools and inquiry processes. The methodology comprised 2 domains of inquiry: (1) Problem Landscape, (2) Solutions Landscape. Systems tools and methods, such as causal loop diagrams, iceberg diagram, and systems mapping, investigated the problem landscape for understanding the interconnected nature of the issue, alongside review of both published and gray literature. An environmental scan explored the current solutions landscape. These methods connected through systemic inquiry processes, including ongoing review and application of diverse perspectives, boundary judgments, interrelationships; enabled gaps and levers of change to be determined. RESULTS: The main barriers sex workers face are stigma, criminalization, accessibility, and cost of healthcare. The stigma of sex work stems from otherization, paternalism, and moralistic, faith-based beliefs. The barriers unique to sex work are stigma and criminalization; both of which surface as avoidance, dislike, and/or fear of medical professionals. Five gaps each with a lever of change to improve access were identified: (1) Stigma - Collectivization and external collaboration, (2) Criminal status of sex work - Decriminalization, (3) Lack of adequate education - Improved healthcare professional training and anti-discriminatory health policies, (4) Lack of support - Increased community-based healthcare services, (5) Cost of healthcare - Universal coverage of "secondary" healthcare components. CONCLUSION: Through reducing the stigma surrounding sex work, making changes that improve the healthcare services that sex workers receive, and collaboration between involved parties, sex workers can be prevented from falling through the cracks of the Canadian healthcare system; lessening the health inequities sex workers face and improving their health outcomes.

The common drivers of children and young people's health and wellbeing across 13 local government areas: a systems view.

BACKGROUND: System dynamics approaches, including group model building (GMB) and causal loop diagrams (CLDs), can be used to document complex public health problems from a community perspective. This paper aims to apply Social Network Analysis (SNA) methods to combine multiple CLDs created by local communities into a summary CLD, to identify common drivers of the health and wellbeing of children and young people. METHODS: Thirteen community CLDs regarding children and young people health and wellbeing were merged into one diagram involving three steps: (1) combining variable names; (2) CLD merging, where multiple CLDs were combined into one CLD with a set of unique variables and connections; (3) paring, where the Decision-Making Trial and Evaluation Laboratory (DEMATEL) method was used to generate a cut-point to reduce the number of variables and connections and to rank the overall importance of each variable in the merged CLD. RESULTS: Combining variable names resulted in 290 variables across the 13 CLDS. A total of 1,042 causal links were identified in the merged CLD. The DEMATEL analysis of the merged CLD identified 23 common variables with a net importance between 1.0 and 4.5 R + C values and 57 causal links. The variables with the highest net importance were 'mental health' and 'social connection & support' classified as high net receivers of influence within the system. CONCLUSIONS: Combining large CLDs into a simple diagram represents a generalisable model of the drivers of complex health problems.

Informal health sector and routine immunization: making the case for harnessing the potentials of patent medicine vendors for the big catch-up to reduce zero-dose children in sub-Saharan Africa.

The COVID-19 pandemic caused a surge in the number of unimmunized and under-immunized children in Africa. The majority of unimmunized (or zero-dose) children live in hard-to-reach rural areas, urban slums, and communities affected by conflict where health facilities are usually unavailable or difficult to access. In these settings, people mostly rely on the informal health sector for essential health services. Therefore, to reduce zero-dose children, it is critical to expand immunization services beyond health facilities to the informal health sector to meet the immunization needs of children in underserved places. In this perspective article, we propose a framework for the expansion of immunization services through the informal health sector as one of the pillars for the big catch-up plan to improve coverage and equity. In African countries like Nigeria, Ethiopia, Tanzania, and the Democratic Republic of Congo, patent medicine vendors serve as an important informal health sector provider group, and thus, they can be engaged to provide immunization services. A hub-and-spoke model can be used to integrate patent medicine vendors into the immunization system. A hub-and-spoke model is a framework for organization design where services that are provided by a central facility (hub) are complimented by secondary sites (spokes) to optimize access to care. Systems thinking approach should guide the design, implementation, and evaluation of this model.