A Holistic Way to Understand the Determinants of Physical Activity in Urban New South Wales, Australia: A Codesigned Systems Mapping Project.

BACKGROUND: To meet the World Health Organization goal of reducing physical inactivity by 15% by 2030, a multisectoral system approach is urgently needed to promote physical activity (PA). We report the process of and findings from a codesigned systems mapping project to present determinants of PA in the context of urban New South Wales, Australia. METHODS: A participatory conceptual mapping workshop was held in May 2023 with 19 participants working in education, transportation, urban planning, community, health, and sport and recreation. Initial maps were developed and refined using online feedback from the participants. Interviews were conducted with 10 additional policymakers from relevant sectors to further refine the maps. RESULTS: Two systems maps were cocreated, identifying over 100 variables influencing PA and their interconnections. Five settings emerged from the adults' map-social and community, policy, built environment and transportation, health care, and workplace-and 4 for the young people's map-family, school, transportation, and community and environment. The maps share similarities, such as regarding potential drivers within the transportation, community, and built environment sectors; however, the young people's map has a specific focus on the school setting and the adults' map on workplace and health care settings. Interviews with policymakers provided further unique insights into understanding and intervening in the PA system. CONCLUSIONS: This codesigned participatory systems mapping process, supplemented by stakeholder interviews, provided a unique opportunity to bring together stakeholders across sectors to understand the complexity within the PA system and begin to identify leverage points for tackling physical inactivity in New South Wales.

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

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

Peanut hulls, an underutilized nutritious culinary ingredient: valorizing food waste for global food, health, and farm economies-a narrative review.

Peanut hulls (PHs) are an edible food waste that is an underutilized food source for human consumption. While edible and palatable, currently they are mainly diverted to livestock feed or building materials. Here, we describe existing literature supporting human food valorization of PHs, and propose methods to optimize recapturing nutrients (protein, fiber, phenols and other phytonutrients) lost by treating PHs as waste. Incorporated into common foods, PHs could be processed into functional ingredients to improve nutrient-density with anticipated corresponding positive health outcomes associated with increases in plant foods. Valorization of PHs addresses multiple priorities of the UN Sustainable Development Goals using a Food Systems Approach (FSA) including reducing food waste, increasing economic opportunities for farmers, and increasing the availability of healthy shelf-stable foodstuffs to address food security. Recent advances in sustainable food processing technologies can be utilized to safely incorporate PHs into human food streams. We propose future applications that could make meaningful impacts for food availability and the nutritional composition of common foods like bread and plant-based meat alternatives. While the limited literature on this topic spans several decades, no commercial operations currently exist to process PHs for human consumption, and most literature on the topic precedes the technological "green revolution." The approaches outlined in this review may help bolster commercialization of this underutilized and nutritious food potentially improving opportunities for multiple global stakeholders.

How can health systems approach reducing health inequalities? An in-depth qualitative case study in the UK.

BACKGROUND: Addressing socioeconomic inequalities in health and healthcare, and reducing avoidable hospital admissions requires integrated strategy and complex intervention across health systems. However, the understanding of how to create effective systems to reduce socio-economic inequalities in health and healthcare is limited. The aim was to explore and develop a system's level understanding of how local areas address health inequalities with a focus on avoidable emergency admissions. METHODS: In-depth case study using qualitative investigation (documentary analysis and key informant interviews) in an urban UK local authority. Interviewees were identified using snowball sampling. Documents were retrieved via key informants and web searches of relevant organisations. Interviews and documents were analysed independently based on a thematic analysis approach. RESULTS: Interviews (n = 14) with wide representation from local authority (n = 8), NHS (n = 5) and voluntary, community and social enterprise (VCSE) sector (n = 1) with 75 documents (including from NHS, local authority, VCSE) were included. Cross-referenced themes were understanding the local context, facilitators of how to tackle health inequalities: the assets, and emerging risks and concerns. Addressing health inequalities in avoidable admissions per se was not often explicitly linked by either the interviews or documents and is not yet embedded into practice. However, a strong coherent strategic integrated population health management plan with a system's approach to reducing health inequalities was evident as was collective action and involving people, with links to a "strong third sector". Challenges reported include structural barriers and threats, the analysis and accessibility of data as well as ongoing pressures on the health and care system. CONCLUSION: We provide an in-depth exploration of how a local area is working to address health and care inequalities. Key elements of this system's working include fostering strategic coherence, cross-agency working, and community-asset based approaches. Areas requiring action included data sharing challenges across organisations and analytical capacity to assist endeavours to reduce health and care inequalities. Other areas were around the resilience of the system including the recruitment and retention of the workforce. More action is required to embed reducing health inequalities in avoidable admissions explicitly in local areas with inaction risking widening the health gap.

Two-Year Results of a Five-Year Personalized Integrative Obesity Coaching Program (IBO) Based upon a Systems Health Perspective and an Evolutionary Longitudinal Study Approach.

This study presents the outcomes of a 5-year personalized integrative coaching program for adults with obesity (body mass index BMI ≥ 30 kg/m2), based upon a systems health perspective, during the first 2 years. This longitudinal study, which had an evolutionary design, included all adults who enrolled in the program. Health-related quality of life (HRQoL) was measured with the Short Form-36 (SF-36), and physical outcomes included weight, waist circumference, aerobic capacity, lipid profile, and HbA1c. Subsequently, participants completed questionnaires (e.g., the Symptom Checlist-90 (SCL-90) and the Checklist Individual Strength (CIS)). Seventy-nine adults with a mean BMI of 39.5 kg/m2 (SD 5.3) were included. Forty-four participants completed 2 years in the program. Compared to baseline, there were significant improvements in the SF-36 subscales 'physical functioning' (MD 9.9 points, 95% CI: 2.1-17.5, p = 0.013) and 'general health perceptions' (MD 9.3 points, 95% CI 2.9-15.7, p = 0.006). Furthermore, significant improvements in physical outcomes and psychosocial questionnaires (e.g., weight loss (MD 3.5 kg, 95% CI: 1.2-5.7, p = 0.003), waist circumference (MD 5.1 cm, 95% CI: 2.4-7.8, p < 0.001), and CIS fatigue (MD 6.8, 95% CI: 3.1-10.5, p = 0.001) were observed. This study highlights the importance of a systems health perspective supporting the development of a personalized integrative coaching program for adults with obesity in a 'real-world' setting.

Application of a Human Factors Systems Approach to Healthcare Control Centres for Managing Patient Flow: A Scoping Review.

Over the past decade, healthcare systems have started to establish control centres to manage patient flow, with a view to removing delays and increasing the quality of care. Such centres-here dubbed Healthcare Capacity Command/Coordination Centres (HCCCs)-are a challenge to design and operate. Broad-ranging surveys of HCCCs have been lacking, and design for their human users is only starting to be addressed. In this review we identified 73 papers describing different kinds of HCCCs, classifying them according to whether they describe virtual or physical control centres, the kinds of situations they handle, and the different levels of Rasmussen's [1] risk management framework that they integrate. Most of the papers (71%) describe physical HCCCs established as control centres, whereas 29% of the papers describe virtual HCCCs staffed by stakeholders in separate locations. Principal functions of the HCCCs described are categorised as business as usual (BAU) (48%), surge management (15%), emergency response (18%), and mass casualty management (19%). The organisation layers that the HCCCs incorporate are classified according to the risk management framework; HCCCs managing BAU involve lower levels of the framework, whereas HCCCs handling the more emergent functions involve all levels. Major challenges confronting HCCCs include the dissemination of information about healthcare system status, and the management of perspectives and goals from different parts of the healthcare system. HCCCs that take the form of physical control centres are just starting to be analysed using human factors principles that will make staff more effective and productive at managing patient flow.

Exploring the mechanisms underlying increased risk of depressive disorder in ethnic minority populations in Europe: A causal loop diagram.

BACKGROUND: Multiple ethnic minority populations in Europe show high risk of major depressive disorder (MDD), with ethnic discrimination and low socioeconomic position (SEP) as established risk factors. How this risk is shaped by the interactions between these, and other social factors, remains to be elucidated. We aimed to develop a causal-loop diagram (CLD) to gain a better understanding of how factors at the intersection of ethnic discrimination and SEP dynamically interact to drive MDD risk. METHODS: We iteratively mapped the interactions and feedback loops between factors at the intersection of ethnic discrimination and SEP, drawing input from (i) a series of two interviews with a range of MDD domain experts, (ii) an existing CLD mapping the onset of MDD across psychological, biological, and social dimensions at the level of the individual, and (iii) other relevant literature. RESULTS: Through tracing the feedback loops in the resulting CLD, we identified ten driving mechanisms for MDD onset in ethnic minorities (two related to ethnic discrimination, SEP, social network and support, and acculturation, as well as one relating to the living environment and self-stigma towards MDD); and four factors that modulate these mechanisms (recent migration, religious affiliation, neighborhood social environment, and public stigma towards MDD). The intersecting nature of ethnic discrimination and SEP, combined with the reinforcing dynamics of the identified driving mechanisms across time- and spatial scales, underscores the excess exposure to circumstances that increase MDD risk in ethnic minorities. CONCLUSIONS: While this CLD requires validation through future studies, the intersecting and reinforcing nature of the identified driving mechanisms highlights that tackling the high risk of MDD in ethnic minorities may require intervening at multiple targets, from the individual (e.g., psychological interventions targeting negative beliefs or reducing stress) to the societal level (e.g., addressing labor market discrimination).

Process evaluation of implementation of the early stages of a whole systems approach to obesity in a small Island.

BACKGROUND: The small Atlantic island of St Helena is a United Kingdom Overseas Territory (UKOT) with a high prevalence of childhood obesity (over a quarter of 4-5 and 10-11 year olds) and, anecdotally, adulthood obesity and its associated health detriments. St Helena have taken a whole systems approach to obesity (WSAO) to address the issue. A WSAO recognises the factors that impact obesity as a complex system and requires a 'health in all policies' approach. UK academic and public health technical support was provided to the local St Helena delivery team. This process evaluation sought to explore the early stages of the WSAO implementation and implications for the transferability of the approach to other small island developing states and UKOT. METHODS: Data was collected via eight semi-structured interviews, paper based and online surveys, and document analysis. Thematic analysis was used to analyse the data. RESULTS: The analysis identified three factors which aided the first phase of WSAO implementation: (1) senior leaders support for the approach; (2) the academic support provided to establish and develop the approach; and (3) effective adaptation of UK Government resources to suit the local context. Key challenges of early implementation included: maintaining and broadening stakeholder engagement; limited local workforce capacity and baseline knowledge related to obesity and systems thinking; and limited capacity for support from the UK-based academic team due to contract terms and COVID-19 restrictions. CONCLUSIONS: Early stages of implementation of a WSAO in a UKOT can be successful when using UK's resources as a guide and adapting them to a small island context. All participants recommended other small islands adopt this approach. Continued senior support, dedicated leadership, and comprehensive community engagement is needed to progress implementation and provide the foundation for long-term impact. Small island developing states considering adopting a WSAO should consider political will, senior level buy-in and support, funding, and local workforce knowledge and capacity to enable the best chances of successful and sustainable implementation.

The Healthy Start scheme in England "is a lifeline for families but many are missing out": a rapid qualitative analysis.

BACKGROUND: Healthy Start (HS) is a government scheme in England, Wales and Northern Ireland that offers a financial payment card and free vitamins to families experiencing low income. Pregnant women and families with children < 4 years can use the HS card to buy fruit, vegetables, cow's milk, infant formula and pulses. HS was fully digitalised in March 2022. While digitalisation has improved the user experience for many families, in the context of the cost-of-living crisis and increasing dietary inequalities, it is important to understand why HS is not reaching more families. This study aimed to (i) assess the perceptions and experiences of HS from stakeholders across the system including those who promote, implement and are eligible for HS, and (ii) identify recommendations to improve the scheme's effectiveness and uptake. METHODS: The study design was a post-implementation rapid qualitative evaluation using stakeholder interviews. Data were collected between January and June 2023 via semi-structured interviews (50% online; 50% in person) with 112 stakeholders, including parents (n = 59), non-government organisations (n = 13), retailers (n = 11) and health and community professionals (n = 29) at national and local levels. Findings were confirmed by a sub-sample of participants. RESULTS: Six core themes cut across stakeholders' perceptions and experiences, and stakeholders collectively outlined seven recommendations they felt could be acted upon to maximise uptake and efficiency of HS, with actions at both national and local levels. A novel finding from this study is that raising awareness about HS alone is unlikely to result automatically or universally in higher uptake rate. Recommendations include: continuing to provide this scheme that is universally valued; the need for many families to be provided with a helping hand to successfully complete the application; reframing of the scheme as a child's right to food and development to ensure inclusivity; improved leadership, coordination and accountability at both national and local levels. CONCLUSIONS: HS provides benefits for child development and family wellbeing. The study's recommendations should be actioned by national and local governments to enable all families eligible for the scheme to benefit from this nutritional safety net.

Urban densification in the Netherlands and its impact on mental health: An expert-based causal loop diagram.

Urban densification is a key strategy to accommodate rapid urban population growth, but emerging evidence suggests serious risks of urban densification for individuals' mental health. To better understand the complex pathways from urban densification to mental health, we integrated interdisciplinary expert knowledge in a causal loop diagram via group model building techniques. Six subsystems were identified: five subsystems describing mechanisms on how changes in the urban system caused by urban densification may impact mental health, and one showing how changes in mental health may alter urban densification. The new insights can help to develop resilient, healthier cities for all.

Road Traffic Injuries in South Africa: A Complex Global Health Crisis.

1.3 million people die each year as a result of Road traffic crashes. Road Traffic Injuries are a global health crisis with 90% of global deaths affecting LMICs. Sustainable Development Goal 3.6 focuses on reducing road injury and death. The global plan is based on the Safe Systems approach. In South Africa, the burden of crashes on the health system and society is particularly high with a population death rate of 20.7 per 100 000 population. Understanding local context and culture is critical. Rurality, distorted urban planning, higher travel exposure and alcohol usage disproportionately impact racial and ethnic minorities. Pedestrian safety is a key priority. There is a critical need for the global health community to take an active role in advocacy in order to achieve SDG 3.6 by 2030.

A Social Network Analysis of a Multi-sector Service System for Intimate Partner Violence in a Large US City.

About one in four women in the US report having experienced some form of intimate partner violence (IPV) during their lifetime and an estimated 15.5 million children live in families in which IPV occurred in the past year. Families of young children with IPV experiences often face complex needs and require well-coordinated efforts among service providers across social and health sectors. One promising partnership aims to support pregnant and parenting IPV survivors through coordination between IPV agencies and community-based maternal and early childhood home visiting programs. This study used social network analysis (SNA) to understand the interconnectedness of the system of IPV prevention and intervention for families with young children in a large US city. The SNA included 43 agencies serving this population across various service domains spanning IPV, legal, maternal and child health, and public benefit programs. An SNA survey collected data on four forms of collaboration between agencies, including formal administrative relationship, referral reciprocity, case consultation, and shared activities in community committees/organizing bodies. Density and centrality were the primary outcomes of interest. A community detection analysis was performed as a secondary analysis. The overall level of interconnectedness between the 43 responding agencies was low. Making referrals to each other was the most common form of collaboration, with a network density of 30%. IPV agencies had the highest average number of connections in the networks. There was a high level of variation in external collaborations among home visiting agencies, with several home visiting agencies having very few connections in the community but one home visiting program endorsing collaborative relationships with upwards of 38 partner agencies in the network. In serving families at risk for IPV, home visiting agencies were most likely to have referral relationships with mental health provider agencies and substance use disorder service agencies. A community detection analysis identified distinct communities within the network and demonstrated that certain agency types were more connected to one another while others were typically siloed within the network. Notably, the IPV and home visiting communities infrequently overlapped. Sensitivity analyses showed that survey participants' knowledge of their agencies' external collaborations varied by their work roles and agencies overall had low levels of consensus about their connectedness to one another. We identified a heterogeneous service system available to families of young children at-risk for or experiencing IPV. Overall inter-agency connectedness was low, with many siloed agencies and a lack of shared knowledge of community resources. Understanding current collaborations, silos, and centrality of agencies is an effective public health tool for allocating scarce resources across diverse service sectors to efficiently improve the system serving families experiencing IPV.

Didactic program in dietetics (DPD) students' experiences with pandemic learning and expectations for their future education: a descriptive study through a systems lens.

BACKGROUND: The systems approach has been used to evaluate higher education and explores inputs, transformation process, and outputs of a system that is also influenced by environmental factors such as COVID-19. The COVID-19 pandemic shifted many college students to different learning modes, changing their university experience. This study evaluated dietetics students' education experiences and characteristics in the latter period (spring 2022) of the COVID-19 pandemic using the systems approach. METHODS: Researchers developed and distributed an electronic survey to all 215 US-based Didactic Program in Dietetics (DPD) directors during March to May 2022 to forward to their students. Researchers calculated descriptive statistics for variables related to inputs, transformation process, and outputs in the systems approach. RESULTS: Respondents (n = 341) represented 51 DPDs in 31 states in the United States. Overall, DPD students (88.5%) were mostly or very satisfied with their choice of majoring in dietetics. Most (84.0%) planned to earn the RDN credential. Nearly half (46.9%) of DPD students were somewhat or extremely concerned about their readiness to continue their dietetics education path due to the pandemic-related learning conditions. Most students (43.6%) reported dissatisfaction with asynchronous remote instruction in laboratory courses. DPD students' GPAs remained consistent within the range of 3.75-4.0 from Fall 2019 (43.2%) to Spring 2022 (44.5%). The most important expectations of professors moving forward were to communicate effectively (97.3%), employ cultural humility (93.8%), eliminate discrimination in the classroom (93.6%), provide lecture slides (89.7%), and be flexible and accommodating (88.7%). CONCLUSIONS: DPD students emerged from COVID-19 with new perspectives and expectations for their university learning experience. Future research should explore the perspectives of DI directors, preceptors, and employers of COVID-19 era DPD graduates.

Effects of digital transformation on firm performance: The role of IT capabilities and digital orientation.

Organisations undertake profound changes to fit in a rapidly evolving digital setting. However, although the IT capabilities of the organisational members play a critical role in this, the mechanism driving IT capabilities towards enhanced firm performance is not fully understood. A theoretical model to analyse the role of digital orientation and digital transformation in this relationship is introduced and tested on a set of 246 firms through the Partial Least Squares-Structural Equation Modeling method (PLS-SEM). This research contributes to the literature by introducing the social aspect to the study of technology management, delving also into the antecedents of digital transformation. Results confirm a positive effect of IT capabilities on firm performance through the development of a digital orientation and the digital transformation of the organisation.

Investigating Resilience Through Intrinsic Capacity Networks in Older Adults.

BACKGROUND: The network approach may provide a framework for understanding intrinsic capacity (IC) as a system's underlying functioning. The system's resilience to resist functional decline may arise from the interrelationships among system components, that is, body functions or capacities. We applied network analysis to investigate whether the interplay between different intrinsic capacities differs according to age and self-rated health (SRH) in older adults. METHODS: The study sample consisted of a population-based cohort of community-dwelling older adults aged 75, 80, and 85 years (men n = 356 and women n = 469). We quantified 5 IC domains: vitality, locomotion, cognition, psychology, and sensory, using performance-based measurements and questionnaires, and estimated IC networks for 2 age (75 vs 80 and 85 years) and SRH (higher vs lower) groups separately for sexes. Differences in global network properties (eg, density, overall connectivity) and centrality indices were compared between the groups. RESULTS: Intrinsic capacity network density (ie, the number of edges) was higher in the 80- and 85-year-olds compared to the 75-year-olds, and in the worse compared to the better SRH group in both sexes. However, the differences in edge weights and global strength of the networks were statistically nonsignificant. Walking speed was the most central node in the estimated networks. CONCLUSIONS: With increasing age and health decline, the IC network seems to become denser, which may indicate a loss of system resilience. Walking is a more complex activity than the others requiring the functioning of many subsystems, which may explain why it connects multiple domains in the IC network.

Unraveling determinants of integrated farming systems adoption for sustainable livelihood and dietary diversity.

Introduction: Over the years, smallholder farmers have faced more vulnerability to risk and uncertainty in India due to their dependence on cereal crops. One way to reduce this risk is through diversified agriculture, integrating different practices for efficient resource utilization, and adopting a farming systems approach. An integrated farming system (IFS) is one such technique that provides year-round income from different components of enterprises. However, the decision to adopt IFS may be determined by several characteristics of farmers, which needs to be delineated through impact analysis to harness the benefits of a systems approach. Methods: This study analyzes the economic effects of integrated farming systems and assesses their determinants, as well as the dietary diversity patterns of farmers in two states of southern India, i.e., Kerala and Tamil Nadu. A multistage sampling technique was used to obtain cross-sectional data from 367 farmers randomly chosen from one district in Kerala and two districts in Tamil Nadu. The participants have Crop + Horticulture + Animal husbandry (45.45%) as their major system, whereas non-participants have Crop + Animal husbandry (44.35%) as their predominant system. Coarsened exact matching and logit regression methods were used to evaluate the economic impacts of IFS and its influencing factors. Results: The findings of the study indicate that age, education, livestock holding, access to credit, and plantation area have a positive and significant effect on participation by farmers in the program. The matching results show that adoption of IFS resulted in a significant economic impact, generating an additional gross income of Rs. 36,165 ha-1 and a net income of Rs. 35,852 ha-1 and improving the dietary diversity of farm households by 8.6% as compared to non-adopters. Discussion: This study suggests that IFS is a promising approach for improving farmers' livelihoods, economic gains, and nutritional security. Therefore, the integrated farming systems models need to be upscaled through the convergence of government schemes in other regions of India to support smallholder farmers' farming.

Correlations between Trunk Control and Balance in Children with Bilateral Spastic Cerebral Palsy.

Impairments of postural responses are a salient feature of children with cerebral palsy (CP). While the systems approach describes balance in seven components, the relationship between trunk control and balance in children with CP has not been previously examined with all seven of these components. In this study, we aimed to identify correlations between trunk control and all seven systems approach balance components in children with bilateral spastic CP. Our participants were 30 children (M age = 11.83, SD = 2.32 years) with CP having a Gross Motor Function Classification System level ranging from I to III. We assessed trunk control with the Trunk Control Measurement Scale, including static and dynamic balance (selective voluntary control and reaching). Balance in standing was assessed using Kids-Mini-BESTest involving four domains: anticipatory, reactive, sensory orientation and stability in gait. We used Spearman's rank correlations to correlate trunk control and balance, and we obtained a moderate correlation between the trunk control measurement scale and the Kids-Mini-BESTest in children with both bilateral spastic CP (rs = .618, p < .001) and spastic diplegic CP (rs = .52, p = .02). Analysis of the correlations between separate domains of the Kids-Mini-BESTest and the trunk control measurement scale subscales revealed moderate correlations between the static sitting balance subscale and all four domains of the Kids-Mini-BESTest. The dynamic selective motor control subscale of the trunk control measurement scale moderately correlated with the anticipatory domain of the Kids-Mini-BESTest. The dynamic reaching subscale also correlated moderately with anticipatory and stability in gait domains. This correlation was statistically significant in the 13 to 17-year-old age group and was strong among females, whereas the correlation was moderate in males. Trunk control was moderately associated with balance considering all the systems theory components of balance in children with bilateral spastic cerebral palsy.