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.

Reduction in staff smoking rates in North Coast Area Health Service, NSW, following the introduction of a smoke-free workplace policy.

AIM: To evaluate changes in staff smoking rates following the implementation of Smoke Free Health Care, an innovative, change-management process that introduced a smoke-free workplace policy in the North Coast Area Health Service of NSW. METHODS: Survey questionnaires were sent to all staff before and after the introduction of the policy. Return rates were 17.3% (690/3988) in 1999 and 25.4% (2012/7921) in 2007. Chi-square tests and multivariate logistic regression analysis were used to determine differences. RESULTS: Staff smoking rates decreased significantly from 22.3% to 11.8% (p<0.0001). Smoking rates in 1999 were not significantly different to the state population's (22.3% and 24.1%, p=0.3), but were significantly different in 2007 (11.8% and 20.1%, p<0.0001). Over a quarter (27.6%) of staff who smoked when implementation began quit smoking; more than twice the rate before implementation (12%, p<0.0001). CONCLUSION: These changes in staff smoking rates indicate the effectiveness of a comprehensive change-management approach to implementing smoke-free workplace policy.

Smoke free health care: an organisational change to increase effective intervention for tobacco.

In 1999, the NSW Health Smoke Free Workplace Policy directed that grounds of health sites would become smoke free, in addition to the existing policy requiring smoke-free buildings. This was one of the first attempts by any health service to exclude tobacco entirely from health sites. This task required the adoption of evidence-based management of tobacco dependence and changing the culture of smoking in the health service. There were many barriers to implementation.

The Mull Hypothesis: is cannabis use contributing to high tobacco use prevalence among young North Coast males?

Men aged 25-34 years, in North Coast NSW, have higher documented smoking rates than elsewhere in the state. The present paper explores potential causes of elevated smoking rates in this population and proposes that tobacco dependence resulting from 'mulling' (mixing) cannabis with tobacco may be contributing.