Scalability – not generalizability – of findings is what distinguishes truly valuable health systems research

Michele Battle-Fisher:

A lesson for policymakers searching for a one-size fits all solution…

Originally posted on Strengthening Health Systems:

It may be stating the obvious to say it, but health systems are context-specific. Every country’s system is a hotch-potch of features. Some created by deliberate decisions; some stop gap-turned-permanent solutions; and many organic arrangements that have grown to fill gaps, with interesting arrays of unintended effects.

These systems usually have similar goals – to deliver effective, impactful health care equitably and accessibly – but the ways those goals are achieved are necessarily idiosyncratic. More often than not, it is the approach to implementation that determines eventual outcomes, rather than the intervention itself.

For these reasons, research that focuses on finding the “right” way to organise a health system by comparing settings is intellectually interesting but not necessarily directly useful for policy or programme design. There are many lessons that can be learnt by looking at the experiences of countries with common features, but aiming for generalizable conclusions often means…

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My Social Networks and Health syllabus included in Complexity Explorer

http://www.complexityexplorer.org/home

The Complexity Explorer project, being developed by the Sante Fe Institute, has included my Social Networks and Health course syllabus in its depository of course syllabi that offer instruction on complex systems science. Though I have since worked on some revisions, this is the second organization that has highlighted my course. The syllabus was first selected for the KaiserEDU course depository (since taken offline). I am working on integrating my new forthcoming book more prominently in the new syllabus.

MBF

Michele Battle-Fisher is affliated with the Ronin Institute

Founded by Jon Wilkins, formerly associated with the Sante Fe Institute, the Ronin Institute is flipping and transforming the nature of academia. The Ronin Institute houses established researchers of various disciplines that reside mostly outside of academic institutions. I do not need to stress that there are a large number of could-be researchers who do not make it or do not care to be a part of the traditional university system. The popular code for what we do is ‘fractional’ research. Fractional or not, we are a group of strong researchers that kick butt and have bonded together to have a collective voice while adding to scientific knowledge.

http://ronininstitute.org/

michele.battle-fisher@ronininstitute.org

Some press about the Ronin Institute:

1. http://www.wired.com/2012/05/the-rise-of-fractional-scholarship-and-the-ronin-institute/

2. http://www.bostonglobe.com/ideas/2012/05/26/new-idea-for-unemployed-academics/UUZOGe1KNWvUXDl7Yae1IL/story.html- We ain’t wayward! We are Ronins!

3. http://p2pfoundation.net/Ronin_Institute_for_Independent_Scholarship

Well, my article in System Dynamics is finally in Early View!!! Reasoning dynamics of weight gain and loss

public and health professionals misconceptions System Dynamics Rev 2014

If you have the urge, here is the abstract, paper and citation. Pretty cool, HUH?

Abdel-Hamid T., Ankel F., Battle-Fisher M., Gibson B., Gonzalez-Parra G., Jalali M., Kaipainen K., Kalupahana N., Karanfil O., Marathe A., Martinson B., McKelvey K., Sarbadhikari S. N., Pintauro S., Poucheret P., Pronk N., Qian Y., Sazonov E., Oorschot K. V., Venkitasubramanian A. and Murphy P. (2014), Public and health professionals’ misconceptions about the dynamics of body weight gain/loss, Syst. Dyn. Rev., doi: 10.1002/sdr.1517

Abstract: Human body energy storage operates as a stock-and-flow system with inflow (food intake) and outflow (energy expenditure). In spite of the ubiquity of stock-and-flow structures, evidence suggests that human beings fail to understand stock accumulation and rates of change, a difficulty called the stock–flow failure. This study examines the influence of health care training and cultural background in overcoming stock–flow failure. A standardized protocol assessed lay people’s and health care professionals’ ability to apply stock-and-flow reasoning to infer the dynamics of weight gain/loss during the holiday season (621 subjects from seven countries). Our results indicate that both types of subjects exhibited systematic errors indicative of use of erroneous heuristics. Indeed 76% of lay subjects and 71% of health care professionals failed to understand the simple dynamic impact of energy intake and energy expenditure on body weight. Stock–flow failure was found across cultures and was not improved by professional health training. The problem of stock–flow failure as a transcultural global issue with education and policy implications is discussed.

Is being liquid enough to innovate toward policy success?

Comparison of requirements of the liquid network to the mathematical requirements of Social Networks

Comparison of requirements of the liquid network to the mathematical requirements of Social Networks

Steven Johnson (2010), the popular author of “Where Good Ideas Come From- The Natural History of Innovation”, wrote that innovation is structure based. A cornerstone of Johnson’s (2010) book is this idea of an informal, liquid network in which ideas collide. Johnson (2010) visualized the liquid network as the Hogarth’s painting “Humours of an Election”. Ideas generate from informal meetings not that company annual retreat in Florida ac-cording to Johnson (2010). The closer the people’s ideas are in space and time, the better the chance for the ideas to collide with a few new (idea) bonds formed along the way. Johnson’s use of network would better be labeled as idea management rather than being complexity driven. But for policy to be able to account for the long-term implications of idea management, ethical deliberation drives the complexity of organization. The included table compares the offerings of the liquid network of Johnson (2010) to the social networks for idea management. Collision unfortunately lacks the formality and accountability afforded by the structural relationships of social networks. Broadening idea generation beyond a “bump” illustrates the immensity of the effect of the social and political reach of policy.
People connect within a social space. According to Alba and Kadushin (1976), the measure of proximity is concerned with pairs of individuals and how “distant” they are. Traditionally, proximity is all what diffusion of social commodities, often defined by information sharing, as a flow (Alba and Kadushin 1976). In a liquid network of Johnson’s conceptualization, ideas bump into each other due to the act of discourse as an event. First, there must be connections to other people and the environment supports the development of ties. Johnson concurs. There are the things colliding in a network which in Johnson’s (2010) case is the idea. Discourse turns that “private solid state to a (public) liquid network” (Johnson 2010). In what Johnson (2010) called the state of adapting exaptation, people can informally engage due to the “bump factor” of these chance meetings (Johnson 2010). To Johnson (2010), innovations linger in a “slow hunch” countering the eureka moment. The power of leverage points values the ability to find a small change that can make a huge impact. This is not the same as the epiphany. Systems that undulate slowly can be most frustrating to the urgency placed on having policies work.
The liquid network is mildly bound enough to be a network but not enough to strangle innovation with rigidness. Ideas are innovative because of the people that offer them with their skills and prestige. Some ideas are drowned out or flatly ignored. Connecting the ideas as a structure is often descriptive. Which idea (or person with the idea) was most connected? Which idea structurally demonstrated power in the network of ideas? Then this whole idea of playing with private ideas within a public space by basing it on the structure of the irrational agents is the more interesting, and fruitful question to pose.
Johnson (2010) proposed that platforms, or orchestrated spaces, may foster innovation. Within these platforms, liquid networks which do not restrict movement within an organization and their innovation ideas may be better supported to thrive. The ideas take on a fluid state without outside restriction. Does the event become more consequential than the interaction supported by the event? Networks are systems in which the nodes (the things that are connected) are connected by ties. When one is interested in reasons for why people affiliate over an idea, two mode networks could be employed (Borgatti and Everett 1997). The people would be agents (set 1 mode) while the IDEAS serve as a “series of events” (set 2 mode) that they are sharing. In a two-mode network, both the idea and agent indicates the elements of the network. The idea becomes an element to be weighted with the agents and chance meetings. So there is a tie be-tween the agent and the event. The tie formation could be due to “bump factor”:
1) to accept the chance meeting and
2) engage in the innovating chance meeting.
Both nodes engage in it since Johnson (2010) is basing adapting exaptation on engagement not its possibility. But a concern with approaching such two-mode networks, which mode takes the primary position? For instance, Johnson (2010) does not divorce the person from the idea and but for his paradigm the idea is element of focus. The idea is the primary node. The idea comes from the person (secondary node). The argument would also be made that if innovation is viewed as a dynamic, social experiment, the person as the primary mode may say more about why that idea even came to be in the first place. While the platform may be nature be useful in revisiting existing resources such as ideas in a liquid network, the problem often uncovered in policy is the lack of new ideas and continued reliance on existing ideas that may lead to attribution errors. To Johnson (2010), the ideas are used as bonding agents. Two-mode networks deal with the nature of affiliation. The idea is no longer just assumed but is now used as a means to investigate the structure in which ideas are embedded within the ties connecting the author of the idea (see Smith and Christakis 2008). The approach of Johnson (2010) had ideas brought “together” by its messengers as one frame. I do not believe that Johnson (2010) is marginalizing the person behind the idea of the liquid network. By stressing the network, the structure at two mode levels appears to capture the reality of how innovation in a liquid network more likely occurs.
To Johnson (2010) removing boundaries to the liquid network leads to chaos. This may be wise as any chaotic system does not return back to original state before the spiraling began. This chaos could hamper innovation by changing the new starting point and disrupting the momentum started in creating the innovative (see Feigenbaum 1983). As Johnson (2010) was intending avoiding chaos for a malleable liquid state, there is no history of events connected with a state of chaos. When things are chaotic, the past matters far less, only the energies running amok are important. What significance might this hold for developing innovation? Unlike chaotic systems, complexity is tied to its history of events upon which the system was built (see Buchanan 2000).
What is applicable to policymakers under liquid networks, according to Johnson, is less promising. In offering the example of Howard Dean’s Presidential Campaign “supernova”, Johnson (2010) admitted that “political leadership involves some elements (decision making and oratory) that aren’t best outsourced to a liquid network.” So how do policymakers innovate and think creatively under political stressors? Using Wasserman and Faust (1994) taxonomy, two-mode networks have three possible purposes under Johnson’s (2010) liquid networks:

(1) The affiliation is the tie of the person/ideas (node) to the informal chance meetings (event).
(2) The “bump factor” (if it supports interaction) may make interaction, therefore innovation, more likely.
(3) In order to framing the adapting exaptation realistically, the measurement of homophily is required.
The two mode network is difficult to interpret, let alone analyze. But how ever said that policymaking was easy? People tend to clique around policy issues, perhaps based on the process of idea generation or even bunch out due to personal access due to co-location. Two modes capture this bunching up as cliques that overlap, perhaps by party affiliation or side of a legislative issue. But the point of this methods tale is not the complicated analysis but that that coming together to work policy out that on the surface can be deceivingly simplistic. This is a great example of how the mental model of a liquid network does not apply neatly to policymaking but still has a place in the discussion. Unlike the informal liquid network, the innovation required by policy must translate into proper strictures under governance. The chaos of a liquid network must be operationally linked to the structural nature of complexity. But this fact does not mean that networks, whether liquid or mathematically understood, are not useful in discerning policy. While the informal ideas that are eventually brought to the policy table may utilize adapting exaptation, the policymaking process strips away the lacquer of casualness.

References

Alba R, Kadushin C (1976) The intersection of social circles- a new measure of social prox-imity in networks. Socio Meth Res 5(1): 77-101
Borgatti S, Everett M (1997) Network analysis of 2-mode data. Soc Network 19: 243-269
Buchanan M (2000) Ubiquity- The Science of History…Or Why the World is Simplier Than We Think. Weidenfeld & Nichols, London
Feigenbaum M J (1983) Universal behavior in nonlinear systems. Physica 7: 16-39
Johnson S (2010) Where Good Ideas Come from. Riverhead-Penguin, New York
Smith K, Christakis N (2008). Social Networks and Health. Annual Review of Sociology 34: 405-429

Invitation to Participate in the 58th Meeting of the International Society for the Systems Sciences late July- early August 2014

The George Washington University, Washington, DC.
July 27 – August 1, 2014

Theme: Learning Across Boundaries: Exploring the Variety of
Systemic Theory and Practice

CALL FOR PAPERS
The International Society for the Systems Sciences (ISSS) was founded in 1956 as a section of the AAAS, to “encourage the development of theoretical systems which are applicable to more than one of the traditional departments of knowledge”. There are now many thousands of systems thinkers, complexity scientists and cyberneticians worldwide. As more and more new application areas, practices, systems methodologies, theories and philosophies are developed, the number of research communities continues to increase. Fragmentation is the inevitable result of the proliferation of new systems ideas in response to new issues and contexts. While this might, at first, appear to be a negative consequence of our success, it brings with it an enormous opportunity: mutual learning from each other to enhance systems, cybernetic and complexity theories and practices in all our diverse domains. It is this opportunity that provides the focus for our 2014 conference.
This conference will reach out to all the diverse systems communities and provide a forum for mutual learning across their boundaries.
This year we will innovate in three ways:

* Not centrally determining all the conference streams. While the ISSS ‘special integration groups’ (SIGs) will each have their own stream (as in previous years), we also encourage anyone with an interest not already represented by the SIGs to put forward their own ideas for streams.

* Inviting thought leaders from as many research communities as possible.

* Designing hour-long boundary-spanning workshops where a single theory or practice, developed in a given research community, will be presented.
This conference represents a tremendously exciting learning opportunity, and we warmly welcome your participation, whether you are a long-standing member of the ISSS or have never heard of us before. We particularly welcome systems, cybernetics and complexity researchers who have knowledge of a particular domain of theory, methodology or practice, and want to expand their understanding of what else might be available. We invite abstracts and papers in all areas of systemic thinking and practice, and details of possible SIG streams and Exploratory groups are listed on the ISSS website.
This year, the American Society for Cybernetics (ASC) meeting “Living in Cybernetics” will also be held at GWU in the week following the ISSS meeting (3-9th August). There will be a discount for those attending both conferences, and details are on each society’s conference web pages.
Note that the conference fee includes free membership of the ISSS for a year, including electronic access to our journal, Systems Research and Behavioral Science.
Important dates:
May 31, 2014 End of Early Discount Rate on ISSS conference
May 31, 2014 Deadline for Workshop Proposals
June 30, 2014 Last date for Abstracts to be included in the Conference Programme. Full Papers may be submitted at any point, but people must first submit an abstract for review. See website for further details on publications, and all conference information is available at http://www.isss.org/world or by emailing: enquiryisss@gmail.com<mailto:enquiryisss@gmail.com

Building on What We’ve Started- Disney World, Gorillas and Oval Pegs in Square Policy Holes

Social policies are, more often than not, framed with the traditionalist rationalization of human intentionality. Be that as it may, policy tenders the protocols that are then acted up-on publically to bring social impact. Of course, a well-intended health policy must take into account on courses of action as well as funding priorities and constraints. I argue that socially based complexity puts into question the probability of purely rational public action. Social elements activated or retarded in a public policy can shift burden from one part of a healthcare system to another. In its most simple explanation, increased positive screening for disease within the safety net can lead to the probable increased usage of acute care treatment for individuals requiring more complicated care. While some level of desired social and health satisfaction may be experienced in the short term by shifting policy priorities, it is also probable that no tangible value is achieved toward to the overarching desire to elicit system wide impact. Will the positive changes last? I purport that living an illness with a public further complicates policy issues of keeping anything that is personally health related purely private.
According to network theory, naming a network is powerful. According to Trotter (1999), the existence of a boundary is defined by the rules of exit and entry. However, complex systems call for more intricate examinations of such boundaries. Unnamed groups are often identified by the observer and the boundaries are often most not agreed upon by the group members (Kadushin 2012). How might this idea work for special interests groups in making cohesion? According to Kadushin (2012), “a collectivity is structurally cohesive to the extent that the social relations of its members hold it together.” Further there are two mechanisms that support and disrupt this happy state of togetherness. First, if a “disruptive force” acts upon the group, will the network survive? Second, complexity is bound also to the health of its network. Like a game of Ker Plunk, disruption in a complex system occurs when one or more people are removed from the group (Kadushin 2012). The cohesion may or may not be able to survive. Then the process of community starts all over again with new set of actors and new structural relationships.
I do not recall an ICD code for attending family barbeques or activating one’s “social network” for staying healthy. Health care is not directly rewarded for healthy patients’ visits to Disneyland and the strength of the social support ties that keep patients well. More often than not, healthy patients demand less utilization of an already expensive and taxed health care system. Patients have social networks of confidantes of differing yields and compositions, but each member by association has the ability to persuade and dissuade if they wish. Often this network is an 800-pound gorilla in the examining room. This gorilla is a relative that has diabetes and complains of diabetic neuropathy while carefully sectioning the pecan pie with a surgeon’s precision. The sorority sister is a helpful “gorilla” that caresses your hand as you await medical results.
Failure is picking up a socially expected square peg after the innovative oval one fails to fit a conventional hole. If you really “need” the oval to work (and the world is not yet with the program), check out the board again. If there is no oval hole, darn it and chuck that board. Find a reamer and create your own or perhaps ask for a refund with no return shipping. Failure is the incessant attempt to satisfy others by hiding that socially acceptable square peg behind your back and asking for a few more days (in dog years) to work it out. Whittling that square peg with that dull pocket knife into a misshapen imposter of an oval peg serves no god. That imposter peg is not flush to the side of the hole. It is surrounded by slight flashes of open space. That open space created around the non-flush peg should extract with a slight tug. Trust me, that tug will be less taxing than the linear process that got that wrong peg there in the first place. Policy has little tolerance for misshapen pegs that bring with them unintended effects. Use a policy that works until it does not or admit that it never worked at all. Then make it work without the attribution errors gumming up the machinery. What works may not be the most apparent or popular choice.
At its simplest denominator, a citizen is by principle afforded the right of being included in a group’s decisions. But there is a special place for those who serve as policy experts. Sure, we could discuss until we are blue in the face how much a weight a vote in a representative democracy really holds. When I think of my job of being a citizen of any group, I am accountable in some manner to the group if I am not gerrymandered out of the process. Not unlike the idiom “we are in this together”, this cannot be truer in terms of health burden. The solidarity means that all of us have culpability in the collectives’ improving health. But each of our investment in this solidarity differs in our (re)actions, invocations and values. This knowledge should, in theory, affect the role that each of us plays in bettering health out-comes. But can and will citizenship overcome the medical reality that years of collective neglect have brought? How do we get people to give a darn and become a card-carrying Norma Rae? Those in policy hold a special role that should not be understated. A policy has the power to guide and mold the direction of societal movements or evade an unfortunate set-back. We are accountable but that job responsibility came with the rocky terrain. Necessary insights are gained from this systems approach. What is called for is the acknowledgement of the ligand and substrate nature of the two. In that regard, often a slanted pairwise comparison of objectivity to systems demonstrates the bias toward linearity. It is time for systems thinking to no longer be relegated to the kids’ table, peering around the corner and straining and wishing to bring its expertise to policy discussions. 

References
Kadushin C (2012) Understanding Social Networks. Oxford, New York
Trotter R (1999) Friends, Relatives and Relevant Others: Conducting Ethnographic Network Studies. In: Schensul J, LeCompte, M, Trotter R, Cromley E, Singer M (eds.) Mapping social networks, spatial data and hidden populations. AltaMira Press. Lanham, MD