Writing Assignment #4 – ONE PAGE. Apply a Systems Thinking tool from the slide presentation, “Systems Tools for Complex Health Systems: A Guide to Creating Causal Loop Diagrams” to one of the high leverage problems of obesity, chronic disease or poverty listed in the video, “CDC on System Thinking in Public Health.”
Week Four: Writing Assignment. Systems Thinking Tool Application
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Systems Thinking Tool Application Review the following attached slides and follow the directions below: ·
– PDF Document (2.10 MB) (SEE ATTACTMENT) Writing Assignment #4 – ONE PAGE. Apply a Systems Thinking tool from the slide presentation, “Systems Tools for Complex Health Systems: A Guide to Creating Causal Loop Diagrams” to one of the high leverage problems of obesity, chronic disease or poverty listed in the video, “CDC on System Thinking in Public Health.” Example: Change versus consequences, Impact Pathway Analysis, System Archetypes, Rich Pictures, Inter-relationship diagraphs, systems maps (causal loop diagrams), Systems dynamic modeling, agent based modeling, network analysis, Scenario Development ***Students are expected to use evidence in their writing and to cite reference in APA 6th edition style. Systems thinking in public health Interrelation diagraph of obesity SAMPLE National University
This interrelation diagraph represents some of the most prominent issues that are linked to the rise of obesity. The two most frequently discussed causes of obesity are unhealthy diet and physical inactivity. As a healthy weight is maintained through a balance of energy intake and expenditure (as cited in Centers for Disease Control and Prevention [CDC], 2017) , excess energy intake due to lack of physical activity, high-caloric malnutritional diet, or a combination of both may contribute to weight gain and obesity. Physical inactivity among adults in modern day America may be attributed to modern lifestyle of increased office-style jobs and duties, increased sedentary recreational activities, and excessive workload. All of these factors may reduce heavy loads on the bodies but they also reduce energy expense in overall (Harvard Men’s Health Watch, 2012). In addition, unhealthy diet of high caloric food, caused by low socioeconomic status, and modern work schedule is also linked to obesity in America (Harvard Men’s Health Watch, 2012; Ogden, Lamb, Carroll, & Flegal, 2010). Other reasons such as smoking cessation, illnesses, or inadequate sleep can also be attributed to changes in the society and the modern lifestyle that requires individual to be more productive regardless of personal wellbeing. There are more factors that can directly and indirectly affect the obesity prevalence in the US but overall, it is a complex situation where multi-dimensional factors are interacting with each other and ultimate create this public health issue.
References Centers for Disease Control and Prevention. (2017, August 27). Adult obesity causes and consequences. Retrieved September 25, 2019, from Harvard Men’s Health Watch. (2012, February). Obesity in America: What’s driving the epidemic? Harvard Health Publishing. Retrieved from Ogden, C. L., Lamb, M. M., Carroll, M. D., & Flegal, K. M. (2010). Obesity and socioeconimic status in adults: United States, 2005-2008 (No. 50). Washington, D.C: U.S. Department of Health and Human Services.
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Rubric Name: Systems Thinking Tool
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This table lists criteria and criteria group names in the first column. The first row lists level names and includes scores if the rubric uses a numeric scoring method. You can give feedback on each criterion by tabbing to the add feedback buttons in the table.Criteria
Outstanding Achievement
Commendable Achievement
Marginal Achievement
Unsatisfactory
Failing
Criterion Score
Applies one of the systems thinking tools to Obesity, chronic Disease or Poverty
5.25 points
Appropriately applies one of the identified tools to a contemporary public health issue. Uses evidence in the writing.
4.6725 points
Appropriately applies one of the identified tools to a contemporary public health issue. Use of evidence in the writing is partially weak.
4.1475 points
Appropriately applies one of the identified tools to a contemporary public health issue. Use of evidence in the writing is somewhat weak.
3.6225 points
Appropriately applies one of the identified tools to a contemporary public health issue. Use of evidence in the writing is very weak.
3.0975 points
missing
Score of Applies one of the systems thinking tools to Obesity, chronic Disease or Poverty,/ 5.25
Reflection
6 points
Reflects on the positive impact and effectiveness of systems thinking in public health.
5.34 points
Partially reflects on the positive impact and effectiveness of systems thinking in public health.
4.74 points
Somewhat reflects on the positive impact and effectiveness of systems thinking in public health.
4.14 points
Marginally reflects on the positive impact and effectiveness of systems thinking in public health.
3.54 points
missing
Score of Reflection,/ 6
Referencing
0.75 points
Citations and references are in proper APA format. Ample sources are cited. All claims are supported with a professional reference.
0.6675 points
Citations and references are in proper APA format. Ample sources are cited. Some claims leave the reader looking for a reference.
0.5925 points
Citations and references are in proper APA format. Ample sources are cited. Many claims leave the reader looking for a reference.
0.5175 points
Citations and references are limited, missing or incorrect.
0.4425 points
missing
Score of Referencing,/ 0.75
Writing organization and style
3 points
The paper is well organized both overall and at the paragraph level. Sentences are smooth and carefully crafted. There are virtually no errors in punctuation, spelling, grammar or usage.
2.67 points
The paper is well organized, but the paragraphs structure may sometimes be disjointed. The paper may have a few awkward passages and a few errors in punctuation, spelling, grammar and usage.
2.37 points
The paper is basically well organized, though individual paragraphs may be disjointed or misplaced. The writing is competent, but often wordy, overly general, imprecise or trite.
2.07 points
The paper is poorly organized. Some sentences may be so confused that their meaning does not clearly emerge. Words may be imprecise, incorrect, trite or vague.
1.77 points
The paper lacks clarity. The language or sentence structure is so muddled as to be unclear in several spots. Errors in punctuation, spelling, grammar and usage are highly distracting
Score of Writing organization and style,/ 3
SYSTEMS TOOLS FOR
COMPLEX HEALTH
SYSTEMS:
A GUIDE TO CREATING
CAUSAL LOOP DIAGRAMS
1. An introduction to Systems Thinking
2. Developing a Rich Picture
3. Creating Interrelationship
Digraphs
4. Surfacing Causal Loop Diagrams
5. Applying Systems Thinking Tools
Five sessions
Session One 2
SESSION ONE
INTRODUCTION TO
SYSTEMS THINKING
1. An introduction to Systems Thinking
2. Developing a Rich Picture
3. Creating Interrelationship Digraphs
4. Surfacing Causal Loop Diagrams
5. Applying Systems Thinking Tools
Five sessions
Session One 4
• The complexity of health systems
• Thinking about “systems
”
•
What is systems thinking?
• How can systems thinking help us address health
system challenges?
• Introducing systems thinking
tools
Session outline
Session One 5
• The complexity of health systems
• Thinking about “systems”
• What is systems thinking?
• How can systems thinking help us address health
system challenges?
• Introducing systems thinking tools
Session One 6
Session outline
• What is our current reality?
• How has this changed over time?
Working in health systems…
Session One 7
Current reality for health
systems
“practitioners”
Prior context
• Discipline-based expertise
(e.g., epidemiology)
• Disease-focused initiatives
• Disease-focused teams
and
units
• Donors/agencies working in
parallel
• Donor-driven programs
Current context
• Focus on Health
system
strengthening
• Inter- and multi-disciplinary
teamwork
• Collaborative partnerships
and joint planning
• Complex flows of funding,
information and
communication channels
• Increased use of technology
• Country-owned sustainable
national health strategies
Session One 8
Events and
Symptoms
Patterns
Systems
and Structure
Crises
Tasks
Trends
Reward
Systems
Unwritten Rules
Political
dynamics
Hargreaves M, 2010
What is happening now?
How do patterns play out
over time and space?
What are the drivers
and deep structures?
How are they related?
Session One 9
How do we understand our
reality?
Events and
Symptoms
Patterns
Systems
and Structure
Crises
Tasks
Trends
Reward
Systems
Unwritten Rules
Political dynamics
Session One 10
Hargreaves M, 2010
Fire-fighting
Anticipating
Designing
How do we respond to our
reality?
• The complexity of health systems
• Thinking about “systems”
• What is systems thinking?
• How can systems thinking help us address health
system challenges?
• Introducing systems thinking tools
Session outline
Session One 11
Elements of a system
Components/
Variables
Inter-
connections
Function
Session One 12
• System: an assembly of components connected
together in an organized way
– Components are affected by being in the system and are
changed if they leave it
• Assembly of components does something
– Assembly has been identified by someone as being
of interest
What is a system?
Session One 13
The central concept “system” embodies the
idea of a set of elements connected together
which form a whole, this showing properties
which are properties of the whole, rather
than properties of its component parts.
(Checkland, 1981)
What is a system?
“
”
Session One 14
• A system is more than the sum of its parts.
• How a system behaves and performs is determined
by its components, the relationships amongst these
components and resultant structure of the system.
• System behavior reveals itself as a series of events
over time.
Thinking about systems
Session One 15
Distinguish between systems based on:
• degree of certainty about the link between cause and
effect amongst variables in the system
and
• degree of agreement as to the best course of action
in a situation in order to produce a consistent
outcome
Thinking about systems
Session One 16
http://www.replacementcarkeys.net/
Thinking about systems
Mills A, 2010
High
High
Low
Low
Degree of certainty
D
e
g
re
e
o
f
a
g
re
e
m
e
n
t
Complex
systems
Random
systems
Simple
systems
Session One 17
• Simple (puzzle)
•
Complicated (problem)
• Complex (mess)
General types of systems
Session One 18
Following a recipe
• The recipe is essential
• Recipes are tested to assure
replicability of later efforts
• No particular expertise required;
knowing how to cook increases
success
• Recipe notes the quantity and
nature of “parts” needed
• Recipes produce standard
products
• Certainty of same results every
time
Simple (puzzle) systems
Freedman, 2008.
Session One 19
Sending a rocket to the moon
• Formulae are critical and necessary
• Sending one rocket increases
assurance that next will be ok
• High level of expertise in many
specialized fields + coordination
• Separate into parts and then
coordinate
• Rockets similar in critical ways
• High degree of certainty of outcome
Complicated (problem)
systems
Freedman, 2008.
Session One 20
Raising a Child
• Formulae have only a limited application
• Raising one child gives no assurance of success with the next
• Expertise can help but is not sufficient – relationships are key
• Can’t separate parts from the whole
• Every child is unique
• Uncertainty of outcome remains
Complex (mess) systems
Freedman, 2008.
Session One 21
• Collaborating with partners?
• Implementing a supply chain system?
• Strengthening adherence to anti- retrovirals?
Simple, complicated or
complex?
Session One 22
A complex adaptive system is a collection of
individual actors with freedom to act in
ways that are often not predictable, and
whose actions are interconnected, so that
one agent’s actions changes the context for
other agents
(Plesk 2001)
What is a Complex Adaptive
System?
“
”
Session One 23
Observance of health systems – including findings from
failed interventions – tells us that a health system is a
complex adaptive system
BUT
Methods for addressing health system problems are
designed as though the health system is merely
complicated
Health systems are complex
systems
Session One 24
• The complexity of health systems
• Thinking about “systems”
• What is systems thinking?
• How can systems thinking help us address health
system challenges?
• Introducing systems thinking tools
Session outline
Session One 25
Systems thinking is a discipline for seeing
wholes, recognizing patterns and
interrelationships, and learning how to
structure those interrelationships in more
effective, efficient ways.
(Senge & Lannon-Kim 1991)
What is systems thinking?
“
”
Session One 26
It is a way of thinking in approaching problems
and in designing solutions that appreciates the
very nature of complex [adaptive] systems as:
– dynamic, constantly changing,
– governed by history and by feedback,
– where the role and influence of stakeholders
and context is critical, and
– where new policies and actions (of different
stakeholders) often generate
counterintuitive and unpredictable effects,
sometimes long after policies have been
implemented – policy resistance.
What is systems thinking?
“
”
(Adam 2012)
Session One 27
It is a way of thinking in approaching problems and in
designing solutions that …
…allows the identification of solutions that
simultaneously address different problem areas and
leverage improvement throughout the system.
What is systems thinking?
Allen W, 2013
Session One 28
Events and
Symptoms
Patterns
Systems
and Structure
Crises
Tasks
Trends
Reward
Systems
Unwritten Rules
Political dynamics
Systems Thinking moves from
this….
Hargreaves M, 2010
What is happening now?
How do patterns play out
over time and space?
What are the drivers
and deep structures?
How are they related?
Session One 29
Events and
Symptoms
Patterns
Systems
and Structure
Crises
Tasks
Trends
… to making sense of the
dynamics
Hargreaves M, 2010
What is happening now?
How do patterns play out
over time and space?
What are the drivers
and deep structures?
How are they related?
Session One 30
• The complexity of health systems
• Thinking about “systems”
• What is systems thinking?
• How can systems thinking help us
address health system challenges?
• Introducing systems thinking tools
Session outline
Session One 31
Applying systems thinking to health system helps to:
• anticipate synergies
• mitigate negative emergent behaviours, policy resistance
and unintended consequences
when
• designing changes in the health system
• evaluating these interventions
Health systems are complex
systems
Session One 32
Practitioners need to:
• SEE differently
• THINK differently
• ACT differently
How can “Systems Thinking” help
to understand health systems?
Session One 33
SEE
differently
Session One 34
From
• Understanding individual health
systems building blocks
To
• Understanding the
relationships
amongst building blocks
Expanding our vision of health
systems
World Health Organization. 2007 Session One 35
From:
• Patients
Towards people:
• who are consumers, taxpayers, citizens and co-
producers of health
and
• who interact with each other and their environment in
complex, adaptive ways
Expanding our vision of health
systems
Session One 36
From
• a sole focus on health outcomes
Towards
• emergent properties that serve to strengthen the health
system including:
• Equity
• Trust
• Responsiveness
• Social and fair financing protection
• Efficiency
Expanding our vision of health
systems
Session One 37
From
• technical interventions
Towards
• understanding implementation within an enabling
environment
Expanding our vision of health
systems
Session One 38
THINK
differently
Session One 39
We cannot solve our
problems with the
same thinking we used
when we created
them.
(Albert Einstein)
Think differently
“
”
Session One 40
Systems thinking is an ordered, methodological
approach to understanding problem situations and
identifying solutions to these problems.
It takes into account both the “forest and the trees”
through a process of synthesis, analysis and inquiry.
Think differently
Edson R, 2008
Session One 41
Without Systems Thinking…
We risk doing the wrong things with greater and
greater efficiency rather than establishing what is the
right thing to be doing.
“It is better to do the right
thing imperfectly than to keep
doing the wrong thing better
and better.”
(Russell Ackoff, 1995)
Session One 42
Think differently
Without Systems Thinking…
We are at risk of committing a Type III Error – the
right answer for the wrong question
(Schwartz 1999)
Think differently
In other words we have the perfect solution for
a problem that has not been adequately
understood
Session One 43
ACT
differently
Session One 44
We need new ways of thinking and of working
in order to accommodate the complexity of
the challenges in and urgent need for health
system innovation and change.
(Herbert and Best, 2011)
Act differently
”
Adam T, 2012 Session One 45
“
Accept that systems thinking is about dealing
with the inevitable lack of
comprehensiveness, and is not the means to
achieve comprehensiveness
Act differently
Midgley G, 2007
“
”
(Midgley & Richardson, 2007)
Session One 46
We need systems thinking tools that will assist us to:
• Challenge assumptions
• Make sense of the complexity
• Model a situation over time
• Identify appropriate leverage points for intervention
• Mitigate policy resistance
• Enable collaboration and sharing
Act differently
Session One 47
Systems thinking tools enable three functions:
Synthesis: putting together, assessing the system as a whole in
its environment/context e.g., Rich Picture,
Interrelationship Digraph
Analysis: (combined with synthesis) – understanding the detail
and how the components fit together within a context e.g.
Systems Map, Causal Loop Diagrams
Inquiry: developing robust interventions through a systemic
investigation e.g. Systems Dynamic Modeling, Scenario Planning
Act differently
Session One 48
Synthesis
• Understand Whole
System Context
• Determine Boundaries
Analysis
• Understand System
Itself within Context
• Surface & Challenge
Assumptions
Inquiry
• Identify Leverage
Points
• Develop
Interventions through
Systemic
Investigation
Systems thinking tools
Session One 49
• The complexity of health systems
• Thinking about “systems”
• What is systems thinking?
• How can systems thinking help us address health
system challenges?
• Introducing (a few) systems thinking
tools
Session Outline
Session One 50
• Rich Pictures
• Inter-relationship diagraphs
• Systems maps (causal loop diagrams)
• Systems dynamic modeling
• Agent based modeling
• Network analysis
• Scenario development
Useful systems thinking tools
Session One 51
Create and use our own causal loop diagrams
What we will do
To end up here…
Session One 52
• Define the boundaries of our system – seek to
understand the big picture
• Identify the elements/variables in our system
• Understand how these variables might change over
time
• Surface and test our assumptions (consider how our
mental models affect our understanding of the
current reality)
To do all of the above we develop a RICH PICTURE
We need to first
Session One 53
Session One 54
Rich picture
• Explore how these elements/variables relate to one
another
• Resist coming to a quick conclusion and once again
surface and test our assumptions
• Identify the major drivers and outcomes in our
system
To do this we develop an INTERRELATIONSHIP
DIGRAPH
Then we will
Session One 55
Interrelationship Digraph
Prioritization of
(Maternal) Health in
Domestic Policy
Amount of International
FundingGovernment Financial
Resources
Level of Corruption
Presence of Conflict
Level of Infrastructure
Level of Function of
Referral System
Time Until Effective
Care (Third Delay)
Availability of Medical
Equipment, Supplies &
DrugsSize of Health
Workforce
Quality of Health
Services
Session One 56
… do we surface a CAUSAL LOOP DIAGRAM
• Informed by our Rich Picture, Interrelationship
Digraphs
• Considering both short and long-term consequences
• Understanding the system structure to identify
possible leverage actions
And only then…
Session One 57
• Understand the system structure giving rise to the
system behavior
• Find where unintended consequences (policy
resistance) emerge
• Explore consequences of proposed action
• Recognize impact of time delays when exploring
relationships
• Identify possible leverage
points for actions
We use this causal loop
diagram to:
Session One 58
All models are wrong, some are useful
Always remembering that
“ ”
(Attributed to George Box)
Session One 59
• Hargreaves M, Parsons B, and Moore M. “Evaluating Complex Systems Initiatives.” Professional
development workshop presented for the National Institutes of Health Evaluation Set-Aside Program,
Evaluation Office, Division of Program Coordination, Planning and Strategic Initiatives, Bethesda, MD,
February 25–26, 2010.
• Checkland P. (1981). Systems Thinking Systems Practice. Chichester: John Wiley.
• Mills A. Complexity science. An Introduction (and invitation) for actuaries. Society of Actuaries. 2010.
• Freedman, ODI presentation, Exploring the science and remains. complexity of aid policy and practice,
London, July 2008.
• Plsek P, Greenhalgh T. Complexity science. The challenge of complexity in health care. BMJ. 2001;323:625–8.
• Senge P, Lannon-Kim C. The Systems Thinker Newsletter. 1991; 2(5).
• Adam T, de Savigny D. Systems thinking for strengthening health systems in LMICs: need for a paradigm
shift Health Policy and Planning 2012;27:iv1–iv3
• Allen W. sparksforchange. Complicated or complex – knowing the difference is important. March 3, 2013.
http://learningforsustainability.net/sparksforchange/complicated-or-complex-knowing-the-difference-is-
important-for-the-management-of-adaptive-systems/
• World Health Organization. Everybody’s Business: Strengthening health systems to improve health
outcomes—WHO’s Framework for Action. Geneva: WHO, 2007, page 3.
• Edson R. Systems Thinking. Applied. A Primer. 2008. Accessed December 2014
http://www.anser.org/docs/systems_thinking_applied
• Midgley G, Richardson KA (ed.) Systems Thinking for Community Involvement in Policy Analysis Systems
thinking for community involvement in policy analysis E:CO Issue Vol. 9 Nos. 1-2 2007 pp. 167-183
• Foresight – Tackling obesities: future choices
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/296290/obesity-map-full-hi-
res
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Session One 60
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http://www.anser.org/docs/systems_thinking_applied
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https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/296290/obesity-map-full-hi-res
This work was coordinated by the Alliance for Health Policy and Systems Research,
the World Health Organization, with the aid of a grant from the
International Development Research Centre, Ottawa, Canada.
Thank you
Presentation developed by Helen de Pinho MBBCh, MBA, FCPH
assisted by Anna M. Larsen BS, MPH
Averting Maternal Death and Disability Program (AMDD)
Heilbrunn Department of Population and Family Health
Mailman School of Public Health
Columbia University
February 2015
February 2015
Session One 61
