'Atawhai': a primary care provider-led response to family violence in Aotearoa New Zealand.

BACKGROUND: As a key determinant of ill-health, family violence is inadequately responded to within Aotearoa New Zealand health policy and practice. Without adequate system support, health professionals can often be unsure of what to do, or how to help. Developed in response to this system gap, 'Atawhai' aims to make it easier for primary care professionals to respond to family violence. METHODS: Underpinned by indigenous Maori customs, Atawhai combines complexity theory and participatory research methodologies to be responsive to the complexity involved in family violence. We worked with 14 primary care professionals across ten whakawhitiwhiti korero wananga (meetings for deliberate dialogue) to identify and develop primary care system pathways and tools for responding to family violence. This paper focuses on the development of Atawhai through wananga and observation methods. Methods used to capture change will be reported separately. FINDINGS: Atawhai is a relational response to family violence, focused on developing a network of trusted relationships between health and social care professionals to support safe responses to those accessing care. This study identified four key health system pathways to responsiveness and developed associated tools to support health care responsiveness to family violence. We found the quality of relationships, both among professionals and with those accessing care, coupled with critical reflection on the systems and structures that shape policy and practice are essential in generating change within primary care settings. CONCLUSIONS: Atawhai is a unique health care response to family violence evidenced on empirical knowledge of primary care professionals. Our theoretical lens calls attention to parts of the system often obscured by current health care responses to family violence. Atawhai presents an opportunity to develop a grassroots-informed, long-term response to family violence that evolves in response to needs.

Integrated System Responses for Families Impacted by Violence: A Scoping Review.

Introduction: Violence within families is a complex problem which significantly impacts health and wellbeing. Despite the ubiquitous call for integrated family violence service delivery, integrated approaches vary significantly and challenges to implementation remain. This scoping review explored how integrated approaches to family violence service delivery are conceptualised within international and Aotearoa New Zealand literature. Methods: Following a documented scoping review process identified from literature, dynamic interplay between system agents within integrated family violence service delivery were mapped with the assistance of a complexity theory lens. We analysed characteristics of included studies, agents involved, how they interacted and the methods and mechanisms of integration among them. Results: Seventy-two published reports were included. The most common interactions occurred between statutory agencies such as police and child protection. While health care service providers were included within 55 studies, their engagement was often peripheral. Qualitative analysis elucidated three broad pathways to service delivery impact underpinned by systems-centred, person-centred, or Indigenous-centred worldviews. Discussion and Conclusion: Integrated approaches to family violence service delivery are highly variable. Despite a strong assumption that integration leads to improved safety, health, and wellbeing for care-seekers, most studies did not include evidence of such impact. Consideration of how worldviews characterise service provision provides insight into why integration has proven challenging over time.

Complexity biomechanics: a case study of dragonfly wing design from constituting composite material to higher structural levels.

Presenting a novel framework for sustainable and regenerative design and development is a fundamental future need. Here we argue that a new framework, referred to as complexity biomechanics, which can be used for holistic analysis and understanding of natural mechanical systems, is key to fulfilling this need. We also present a roadmap for the design and development of intelligent and complex engineering materials, mechanisms, structures, systems, and processes capable of automatic adaptation and self-organization in response to ever-changing environments. We apply complexity biomechanics to elucidate how the different structural components of a complex biological system as dragonfly wings, from ultrastructure of the cuticle, the constituting bio-composite material of the wing, to higher structural levels, collaboratively contribute to the functionality of the entire wing system. This framework not only proposes a paradigm shift in understanding and drawing inspiration from natural systems but also holds potential applications in various domains, including materials science and engineering, biomechanics, biomimetics, bionics, and engineering biology.

Barriers and Opportunities for WHO "Best Buys" Non-communicable Disease Policy Adoption and Implementation From a Political Economy Perspective: A Complexity Systematic Review.

BACKGROUND: Improving the adoption and implementation of policies to curb non-communicable diseases (NCDs) is a major challenge for better global health. The adoption and implementation of such policies remain deficient in various contexts, with limited insights into the facilitating and inhibiting factors. These policies have traditionally been treated as technical solutions, neglecting the critical influence of political economy dynamics. Moreover, the complex nature of these interventions is often not adequately incorporated into evidence for policy-makers. This study aims to systematically review and evaluate the factors affecting NCD policy adoption and implementation. METHODS: We conducted a complex systematic review of articles discussing the adoption and implementation of World Health Organization's (WHO's) "best buys" NCD policies. We identified political economy factors and constructed a causal loop diagram (CLD) program theory to elucidate the interplay between factors influencing NCD policy adoption and implementation. A total of 157 papers met the inclusion criteria. RESULTS: Our CLD highlights a central feedback loop encompassing three vital variables: (1) the ability to define, (re)shape, and pass appropriate policy into law; (2) the ability to implement the policy (linked to the enforceability of the policy and to addressing NCD local burden); and (3) ability to monitor progress, evaluate and correct the course. Insufficient context-specific data impedes the formulation and enactment of suitable policies, particularly in areas facing multiple disease burdens. Multisectoral collaboration plays a pivotal role in both policy adoption and implementation. Effective monitoring and accountability systems significantly impact policy implementation. The commercial determinants of health (CDoH) serve as a major barrier to defining, adopting, and implementing tobacco, alcohol, and diet-related policies. CONCLUSION: To advance global efforts, we recommend focusing on the development of robust accountability, monitoring, and evaluation systems, ensuring transparency in private sector engagement, supporting context-specific data collection, and effectively managing the CDoH. A system thinking approach can enhance the implementation of complex public health interventions.

Unravelling the asymmetric effects of procurement practices on firm performance: A complexity theory approach to complementing fsQCA with NCA.

Current economic upheavals and supply chain uncertainty have threatened the profitability and sustainability of business organisations. Procurement has proved to be one of the strategies for enhancing firm performance without necessarily increasing revenue with its attendant increase in costs. However, rather than investigating the complex asymmetric relationship between procurement practices and firm performance (which this study advocates), past research engaged in a symmetric evaluation of the relationship between the phenomena. Accordingly, this study, using complexity theory, employs fsQCA and NCA on a sample of 150 respondents from private universities in Ghana to (a) identify different combinations of procurement practices, namely procurement planning, supplier partnership, contract management, and compliance, that lead to firm performance and (b) explore the necessity of these procurement practices (in kind and degree) for firm performance. Whereas the findings from fsQCA reveal three distinct combinations of procurement practices for high firm performance and further suggest that none of the procurement practices was necessary for firm performance, the NCA results suggest that two out of the four procurement practices investigated are necessary for firm performance and hence must be present in the causal recipes produced by fsQCA to guarantee that they lead to firm performance. The study offers pathways to firm performance through procurement practices and demonstrates how to complement fsQCA with NCA to ensure that causal recipes produced by fsQCA can produce the outcome.

Slack Is Needed to Solve the Shortage of Nurses.

Healthcare systems are facing a shortage of nurses. This article identifies some of the major causes of this and the issues that need to be solved. We take a perspective derived from queuing theory: the patient-nurse relationship is characterized by a scarcity of time and resources, requiring comprehensive coordination at all levels. For coordination, we take an information-theoretic perspective. Using both perspectives, we analyze the nature of healthcare services and show that ensuring slack, meaning a less than exhaustive use of human resources, is a sine qua non to having a good, functioning healthcare system. We analyze what coordination efforts are needed to manage relatively simple office hours, wards, and home care. Next, we address the level of care where providers cannot themselves prevent the complexity of organization that possibly damages care tasks and job quality. A lack of job quality may result in nurses leaving the profession. Job quality, in this context, depends on the ability of nurses to coordinate their activities. This requires slack resources. The availability of slack that is efficient depends on a stable inflow and retention rate of nurses. The healthcare system as a whole should ensure that the required nurse workforce will be able to coordinate and execute their tasks. Above that, workforce policies need more stability.

Using Systems Thinking and Complexity Theory to understand and improve Emergency Medicine: Lessons from COVID-19 in a safety net health system.

RATIONALE: COVID-19 has fundamentally changed the practice of Emergency Medicine (EM). Care delivery on the front lines has historically depended upon ostensibly reliable input-output models for staffing, supplies, policies, and therapies. Challenged by the complexity of healthcare during the pandemic, the fallibility of these reductionist models was quickly revealed. Providers and systems quickly had to reconceptualize their dependence on the wider, complex system in which healthcare operates and find adaptive solutions to rapid changes. AIMS/METHOD: This papers seeks to review and describe how Systems Thinking and Complexity Theory (ST/CT)-concepts, principles, and tools that can be used to understand and impact our constantly evolving health system-can be applied to better understand and enact change in complex settings such as during COVID-19. Some of these ST/CT are described through the real world example of the Alameda Health System Vaccine Taskforce. RESULTS: ST/CT concepts such as Unintended Consequences, Interrelationships, Emergent Behavior, Feedback Loops, and Path Dependence can help EM providers and planners understand the context in which their system operates. Key principles such as Collaboration, Iterative Learning, and Transformational Leadership can help these actors respond to current and future challenges. The integration of these concepts and principles into the Learning Health System offers a model for tying these key concepts and principles together into an adaptive, cross-sectoral organizational approach. CONCLUSION: By integrating ST/CT into the practice of EM, we can not only improve our ability to care for patients but also our capacity to understand and strengthen our wider systems of care.

Monochorionic twin pregnancy from the perspective of the theory of complexity. / El embarazo gemelar monocorial desde la perspectiva de la teoría de la complejidad.

In practice, it is very common to associate monochorionic (MC) twin pregnancies with complex or complicated pregnancies, using both terms interchangeably. However, these are not synonyms; dynamism is the protagonist in complex systems, but not in complicated ones. In order to understand a MC pregnancy as a complex system, it is necessary to first look into its main characteristics. The placenta is one of the main sources of problems. Then, the MC pregnancy has to be analyzed from the perspective of complexity, identifying the system characteristics and its complications as emergent properties.

En la práctica, es muy frecuente asociar las gestaciones gemelares monocoriales (MC) con embarazos complejos o complicados, utilizando ambos términos en forma intercambiable. Sin embargo, no lo son; el dinamismo es protagonista en los sistemas complejos, pero no en los complicados. Para entender a la embarazada con una gestación MC como un sistema complejo, primero se desarrollarán las características principales de los embarazos MC; su placenta es una de las principales responsables de los problemas. Luego se analizará el embarazo MC desde la complejidad, identificando las características del sistema y sus complicaciones como propiedades emergentes.

Application of the evolutionary theory of behavior dynamics to severe challenging behavior.

The evolutionary theory of behavior dynamics (ETBD) is a genetic algorithm that applies the Darwinian principles of evolutionary biology to model how behavior changes dynamically via selection by contingencies of reinforcement. The ETBD is a complexity theory where low-level rules of selection, reproduction, and mutation operate iteratively to animate "artificial organisms" that generate emergent outcomes. Numerous studies have demonstrated the ETBD can accurately model behavior of live animals in the laboratory, and it has been applied recently to model automatically maintained self-injury. The purpose of the current series of studies was to further extend the application of the ETBD to model additional functional classes of challenging behavior and clinical procedures. Outcomes obtained with artificial organisms generally corresponded well with outcomes observed with clinical cases sourced from consecutive controlled case series studies. Conceptual and methodological considerations on the application of the ETBD to model challenging behavior are discussed.

The lecturer-tutor in undergraduate medical education; navigating complexity as "a recruiter, a timetabler, an administrator, a counsellor".

BACKGROUND: Tutors play an important role in the delivery of effective undergraduate medical education (UGME). These roles commonly involve competing clinical, educational and research commitments. We sought to obtain a rich description of these posts from doctors working in them. METHODS: We used a pragmatist, sequential explanatory mixed-methods design with a sampling frame of clinical lecturer/tutors in 5 Irish medical schools. Purposive sampling was used for recruitment. Quantitative data collected from a validated online questionnaire were used to inform a semi-structured interview question guide. Thematic analysis was conducted independently by each of the study researchers, using a coding frame derived in part from the findings of the online questionnaire. Quantitative and qualitative mixing occurred during data collection, analysis and reporting. RESULTS: 34 tutors completed the online survey with 7 volunteers for interview. Most respondents took the job to gain experience in either educational practice (79.4%) or in research (61.8%). Major themes to emerge were the diverse interactions with students, balancing multiple professional commitments, a high degree of role-autonomy, mis-perception of role by non-tutor colleagues, challenges around work-life balance and unpredictable work demands. Using a complexity theory lens, the tutor role was defined by its relational interactions with numerous stakeholders, all in the context of an environment that changed regularly and in an unpredictable manner. CONCLUSIONS: The undergraduate tutor works in a demanding role balancing educational and non-educational commitments with suboptimal senior guidance and feedback. The role is notable for its position within a complex adaptive system. An understanding of the system's interactions recognises the non-linearity of the role. Using a complex systems lens, we propose improvements to undergraduate education centred around the tutor.

Examining the nexus between medical education and complexity: a systematic review to inform practice and research.

BACKGROUND: Medical education is a multifarious endeavour integrating a range of pedagogies and philosophies. Complexity as a science or theory ('complexity') signals a move away from a reductionist paradigm to one which appreciates that interactions in multi-component systems, such as healthcare systems, can result in adaptive and emergent outcomes. This examination of the nexus between medical education and complexity theory aims to discover ways that complexity theory can inform medical education and medical education research. METHODS: A structured literature review was conducted to examine the nexus between medical education and complexity; 5 databases were searched using relevant terms. Papers were included if they engaged fully with complexity as a science or theory and were significantly focused on medical education. All types of papers were included, including conceptual papers (e.g. opinion and theoretical discussions), case studies, program evaluations and empirical research. A narrative and thematic synthesis was undertaken to create a deep understanding of the use of complexity in medical education. RESULTS: Eighty-three papers were included; the majority were conceptual papers. The context and theoretical underpinnings of complexity as a relevant theory for medical education were identified. Bibliographic and temporal observations were noted regarding the entry of complexity into medical education. Complexity was relied upon as a theoretical framework for empirical studies covering a variety of elements within medical education including: knowledge and learning theories; curricular, program and faculty development; program evaluation and medical education research; assessment and admissions; professionalism and leadership; and learning for systems, about systems and in systems. DISCUSSION: There is a call for greater use of theory by medical educators. Complexity within medical education is established, although not widespread. Individualistic cultures of medicine and comfort with reductionist epistemologies challenges its introduction. However, complexity was found to be a useful theory across a range of areas by a limited number of authors and is increasingly used by medical educators and medical education researchers. This review has further conceptualized how complexity is being used to support medical education and medical education research. CONCLUSION: This literature review can assist in understanding how complexity can be useful in medical educationalists' practice.

Using a complexity science approach to evaluate the effectiveness of just-in-time adaptive interventions: A meta-analysis.

Objective: Just-in-time adaptive interventions (JITAIs), which allow individuals to receive the right amount of tailored support at the right time and place, hold enormous potential for promoting behavior change. However, research on JITAIs' implementation and evaluation is still in its early stages, and more empirical evidence is needed. This meta-analysis took a complexity science approach to evaluate the effectiveness of JITAIs that promote healthy behaviors and assess whether key design principles can increase JITAIs' impacts. Methods: We searched five databases for English-language papers. Study eligibility required that interventions objectively measured health outcomes, had a control condition or pre-post-test design, and were conducted in the real-world setting. We included randomized and non-randomized trials. Data extraction encompassed interventions' features, methodologies, theoretical foundations, and delivery modes. RoB 2 and ROBINS-I were used to assess risk of bias. Results: The final analysis included 21 effect sizes with 592 participants. All included studies used pre- and post-test design. A three-level random meta-analytic model revealed a medium effect of JITAIs on objective behavior change (g = 0.77 (95% confidence interval (CI); 0.32 to 1.22), p < 0.001). The summary effect was robust to bias. Moderator analysis indicated that design principles, such as theoretical foundations, targeted behaviors, and passive or active assessments, did not moderate JITAIs' effects. Passive assessments were more likely than a combination of passive and active assessments to relate to higher intervention retention rates. Conclusions: This review demonstrated some evidence for the efficacy of JITAIs. However, high-quality randomized trials and data on non-adherence are needed.

Challenges, opportunities, and prospects of adopting and using smart digital technologies in learning environments: An iterative review.

The adoption of smart digital technologies in the education system has grown exponentially over the years, creating new possibilities to improve teaching and enhance learning. Against this backdrop, the 'brick-and-mortar' education approach survives on life support, with digital technologies promoting ubiquitous teaching and learning. Through complexity theory, this study uses an iterative review research approach comprising of nine steps to frame the study of smart digital education. The complexity theory lens provides an appropriate framework to reason about the complexities that surface due to interactions of the elements of smart digital technologies in the education system. The complementary strength of the adopted methodological approach led to multiple discourses on technology-enabled and technology-enhanced learning environments. In particular, four broad themes emerged, which demonstrated the prevalence of various technologies and how they interact as a means of making sense of the emerging digitally-enabled education environment. Through these themes, this paper highlights digitalisation affordances (which include multimodality, a/synchronicity, and new forms of engagement), discusses the key challenges and complexities of digitally enabled education, and advances the discourse on how digitalisation can support and promote inclusivity amidst historic challenges. Finally, it discusses how the advancement of technologies provides a new paradigm of learning, revolutionises knowledge construction, and extends and enriches the 'brick-and-mortar' learning environment to enhance the educational experience. As a future research agenda, this paper recommends comprehensive end-to-end programmes and innovative ways to conceptualise and execute digitally-enabled education that provides equity-oriented opportunities for cognitive development.

Developing an agent-based model to minimize spreading of malicious information in dynamic social networks.

This research introduces a systematic and multidisciplinary agent-based model to interpret and simplify the dynamic actions of the users and communities in an evolutionary online (offline) social network. The organizational cybernetics approach is used to control/monitor the malicious information spread between communities. The stochastic one-median problem minimizes the agent response time and eliminates the information spread across the online (offline) environment. The performance of these methods was measured against a Twitter network related to an armed protest demonstration against the COVID-19 lockdown in Michigan state in May 2020. The proposed model demonstrated the dynamicity of the network, enhanced the agent level performance, minimized the malicious information spread, and measured the response to the second stochastic information spread in the network.

Creating and Studying the Behavior of Artificial Organisms Animated by an Evolutionary Theory of Behavior Dynamics.

The evolutionary theory of behavior dynamics (ETBD) is a complexity theory, which means that it is stated in the form of simple low-level rules, the repeated operation of which generates high-level outcomes that can be compared to data. The low-level rules of the theory implement Darwinian processes of selection, reproduction, and mutation. This tutorial is an introduction to the ETBD for a general audience, and illustrates how the theory is used to animate artificial organisms that can behave continuously in any experimental environment. Extensive research has shown that the theory generates behavior in artificial organisms that is indistinguishable in qualitative and quantitative detail from the behavior of live organisms in a wide variety of experimental environments. An overview and summary of this supporting evidence is provided. The theory may be understood to be computationally equivalent to the biological nervous system, which means that the algorithmic operation of the theory and the material operation of the nervous system give the same answers. The applied relevance of the theory is also discussed, including the creation of artificial organisms with various forms of psychopathology that can be used to study clinical problems and their treatment. Finally, possible future directions are discussed, such as the extension of the theory to behavior in a two-dimensional grid world.

Climate change and government policy: Fresh insights from complexity theory.

Governments worldwide are increasingly concerned about ensuring a balance between economic and environmental well being. Global economies, particularly developing ones, emphasize the importance of achieving escofriendly growth to maintain the levels of the ecological footprint while achieving higher economic growth. The ecological footprint is a comprehensive indicator of environmental degradation. It is used to assess the state of the environment because it reflects the impact of all human activities on nature. This study contributes to the literature by offering a novel analytical approach for solving complex interactions of ecological footprint antecedents, advancing the theoretical reasoning behind how government policy combines to explain the ecological footprint from some G7 countries (France, Italy, Japan, United Kingdom, and Germany) from 1996 to 2020. To establish a composite score of environmental footprint, we used complexity theory as well as fuzzy set qualitative comparative analysis (fsQCA) and necessary condition analysis (NCA). Our analysis revealed that low expenditures on environmental protection and waste management, low taxes on transport, and high energy use are sufficient conditions to be included in the causal configurations for a high ecological footprint. Additionally, the sufficient solution, which has the highest coverage score that produces a low ecological footprint relies on high expenditure on environmental protection and high taxes on transportation. In this framework, Japan, Italy, and France have more effective government policies in terms of reducing the ecological footprint.

Complexities of contemporary urban planning in local government in the City of Polokwane, Limpopo province.

Urbanisation is characterised by the high consumption of nonrenewable resources and being resource-intensive in meeting the energy demands of the growing urban population. The growth compels the efficient management of urbanisation to mitigate climate change. The inability to effectively plan and manage urbanisation will result in high consumption of nonrenewable resources, greenhouse gas (GHG) emissions and pollution, which contribute to the intensification of climate change. Complexity theory as a theoretical framework asserts that the management of urbanisation is both complex and nonlinear. This means that the management of urbanisation cannot be done by reducing the system into individual components. The study adopted both qualitative and quantitative approaches to research. The data were collected from the four areas around the City of Polokwane and officials from the Polokwane Local Municipality. The finding of the study is that the City of Polokwane is still facing multiple challenges such as traffic congestion, lack of community participation, illegal dumping of wastes and a decline in green spaces. Furthermore, the Polokwane Local Municipality has made inroads towards reducing traffic congestion through the implementation of Bus Rapid Transit (BRT) (Leeto la Polokwane). It can be concluded that urbanisation in the City of Polokwane is not effectively planned and managed to address climate change. Contribution: This article recommends that the Polokwane Local Municipality should implement a solar system plant and generate gas from the increasing level of waste in the City of Polokwane. Furthermore, the Polokwane Local Municipality should transition from operating street lights, office lights and traffic lights with electricity towards the use of solar systems.

How to not revert to type: Complexity-informed learnings from the pandemic response for health system reform and universal access to integrated care.

This article is part of the Research Topic 'Health Systems Recovery in the Context of COVID-19 and Protracted Conflict'. Background: COVID-19 has highlighted existing health inequalities and health system deficiencies both in Ireland and internationally; however, understanding of the critical opportunities for health system change that have arisen during the pandemic is still emerging and largely descriptive. This research is situated in the Irish health reform context of Sláintecare, the reform programme which aims to deliver universal healthcare by strengthening public health, primary and community healthcare functions as well as tackling system and societal health inequities. Aims and objectives: This study set out to advance understanding of how and to what extent COVID-19 has highlighted opportunities for change that enabled better access to universal, integrated care in Ireland, with a view to informing universal health system reform and implementation. Methods: The study, which is qualitative, was underpinned by a co-production approach with Irish health system leadership. Semi-structured interviews were conducted with sixteen health system professionals (including managers and frontline workers) from a range of responses to explore their experiences and interpretations of social processes of change that enabled (or hindered) better access to universal integrated care during the pandemic. A complexity-informed approach was mobilized to theorize the processes that impacted on access to universal, integrated care in Ireland in the COVID-19 context. Findings: A range of circumstances, strategies and mechanisms that created favorable system conditions in which new integrated care trajectories emerged during the crisis. Three key learnings from the pandemic response are presented: (1) nurturing whole-system thinking through a clear, common goal and shared information base; (2) harnessing, sharing and supporting innovation; and (3) prioritizing trust and relationship-building in a social, human-centered health system. Policy and practice implications for health reform are discussed.