Social Determinants of Health from a Feedback Perspective " - - PowerPoint PPT Presentation
Social Determinants of Health from a Feedback Perspective " Peter S. Hovmand, PhD, MSW ! Brown School of Social Work Washington University in St. Louis ! phovmand@wustl.edu ! CSAPH-CUSSP Speaker Series 2012-2013 ! Columbia University
Brown School of Social Work Washington University in St. Louis! phovmand@wustl.edu ! CSAPH-CUSSP Speaker Series 2012-2013! Columbia University Mailman School of Public Health! !
– System'dynamics'computer'modeling'and'simula3on'&' group'model'building' – Applica3on'areas'include'domes3c'violence,'mental'health,' child'welfare,'childhood'obesity,'cancer,'implementa3on' and'scale<up,'financial'inclusion,'environment,'K<12' educa3on,'and'child'and'maternal'health'
– System'dynamics,'group'model'building,'field'based'summer' and'winter'ins3tutes'for'graduate'students'and' professionals' – High'school'internships,'MSW/MPH'prac3cums,'and' doctoral'post<doctoral'training'
– Training'ins3tutes,'professional'development'workshops,' host'Systems'Thinking'in'Schools'Ins3tute'each'year,'hosted' Ins3tute'on'Systems'Science'and'Health'in'2012,'topic' specific'workshops'for'organiza3ons''
P.S.'Hovmand'April'2013' 2'
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From'Brennan'Ramirez,'L.'K.,'Baker,'E.'A.,'&'Metzler,'M.'(2008).'Promo3ng'health'equity:'a'resource'to'help'communi3es'address' social'determinants'of'health.'Atlanta,'GA:'U.S.'Department'of'Health'and'Human'Services,'Centers'for'Disease'Control'and' Preven3on.' P.S.'Hovmand'April'2013' 4'
Discrimina)on+is+a+not+sta)c,+one/)me+phenomenon+that+has+a+clearly+limited+ effect.+Discrimina)on+can+feed+on+discrimina)on+in+self/perpetua)ng+cycles+ ' ' ' ' ' '<'U.S.'Commission'on'Civil'Rights,'1981,'p.'12.' ' ' As+a+prior+ma;er,+however,+trea)ng+issues+of+sexual+equality+as+sameness+and+ difference+is+to+take+a+par)cular+approach.+This+is+approach+is+here+termed+the+ sameness/difference+approach+because+it+is+obsessed+with+the+sex+difference.+ ' ' ' ' ' '<'Catherine'MacKinnon,'1989,'p.'220.' ' ' '
' ' ' United'States'Commission'on'Civil'Rights.'(1981).'Affirma)ve+Ac)on+in+the+1980s:+Dismantling+the+Process+of+Discrimina)on.'(65).' MacKinnon,'C.+A.+(1989).+Sex+equality:+On+difference+and'dominance.'In'Toward'a'feminist'theory+of+the+state+(pp.'215<236).' Cambridge,'MA:'Harvard'University'Press.''
' '
P.S.'Hovmand'April'2013' 5'
Johnson<Laird,'P.'(1983).'Mental+models:+Towards+a+cogni)ve+science+of+language,+inference+and+consciousness.'Cambridge,' MA:'Harvard'University'Press.' P.S.'Hovmand'April'2013' 6'
P.S.'Hovmand'April'2013' 7'
Aggregate'sta3s3cs,' parameters,'and'distribu3ons' Mental'models' Feedback'structures'in'a' system' Qualita3ve'behavior'of'system'
Category'structures'
P.S.'Hovmand'April'2013' 8'
Women' Men' Medium'weekly' income' $657' $819'
New Women New Men Experienced Women Experienced Men + +
“We'try'to'recruit,'hire'and'promote'the' most'qualified'candidates,'and'don’t' make'decisions'based'on'gender.”' “Men'and'women'are'essen3ally'the' same.”'
P.S.'Hovmand'April'2013' 9'
– “The'use'of'informal'maps'and'formal'models'with'computer' simula3on'to'uncover'and'understand'endogenous'sources'of'system' behavior”'[emphasis'added]'(Richardson,'2011,'p.'241)' '
– Endogenous'or'feedback'perspec3ve'
– Flow'or'rate'variables'represen3ng'ac3vity' » Using'computers'to'simulate'more'realis3c'mathema3cal'models' '
'
Richardson,'G.P.'(2011).'Reflec3ons'on'the'founda3ons'of'system'dynamics.'System+Dynamics+Review,+27(3),'219<243.' P.S.'Hovmand'April'2013' 10'
Average Wait Time for ER Emergency Room Caseload Persons Needing ER Services Admitting +
P.S.'Hovmand'April'2013' 11'
Glass Pouring water P.S.'Hovmand'April'2013' 12'
Glass Pouring water Pitcher
P.S.'Hovmand'April'2013' 13'
Glass Pouring water Pitcher Spilling water
P.S.'Hovmand'April'2013' 14'
Average Wait Time for ER Emergency Room Caseload Persons Needing ER Services Admitting +
Onset Demand to Capacity Ratio
+ B1
P.S.'Hovmand'April'2013' 15'
Average Wait Time for ER Emergency Room Caseload Persons Needing ER Services Admitting +
Persons with Services and Supports Discharing from ER with Supports Discharging without Supports
Onset Demand to Capacity Ratio
+ B1
P.S.'Hovmand'April'2013' 16'
Average Wait Time for ER Emergency Room Caseload Persons Needing ER Services Admitting +
Persons with Services and Supports Discharing from ER with Supports Discharging without Supports
Proportion of ER Patients Discharged wtih Supports Average Time to Discharge Onset Demand to Capacity Ratio
+
Desired Quality
+ B1 B2 R1
17'
Average Wait Time for ER Emergency Room Caseload Persons Needing ER Services Admitting +
Persons with Services and Supports Needing Services Discharing from ER with Supports Discharging without Supports
+ Fraction of Persons with Supports Needing Services + Proportion of ER Patients Discharged wtih Supports Average Time to Discharge <Average Time to Discharge>
Demand to Capacity Ratio
+
Desired Quality
+ B1 B2 R1
18'
Average Wait Time for ER Emergency Room Caseload Persons Needing ER Services Admitting +
Persons with Services and Supports Needing Services Discharing from ER with Supports Discharging without Supports
+ Fraction of Persons with Supports Needing Services + Proportion of ER Patients Discharged wtih Supports Average Time to Discharge <Average Time to Discharge>
Onset Demand to Capacity Ratio
+
Desired Quality
+ Effect of Caseload on Quality of Care B1 B2 R1
P.S.'Hovmand'April'2013' 19'
Average Wait Time for ER Emergency Room Caseload Persons with Needing ER Services Admitting +
Persons with Services and Supports Needing Services Discharing from ER with Supports Discharging without Supports Normal Wait Time
+ Fraction of Persons with Supports Needing Services + Proportion of ER Patients Discharged wtih Supports
Discharge <Average Time to Discharge>
Onset Demand to Capacity Ratio
+
Desired Quality
+ Effect of Caseload on Quality of Care B1 B2 R1
P.S.'Hovmand'April'2013' 20'
Proportion of ER Patients Discharged wtih Supports 1 0.75 0.5 0.25
1 1 1 1 1 1 1 1 1 1 1 1
0.20 0.40 0.60 0.80 1 Time (Year)
Dmnl Proportion of ER Patients Discharged wtih Supports : Baserun 1 1
P.S.'Hovmand'April'2013' 21'
Proportion of ER Patients Discharged wtih Supports 1 0.75 0.5 0.25
2 2 2 2 2 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1
0.20 0.40 0.60 0.80 1 Time (Year)
Dmnl Proportion of ER Patients Discharged wtih Supports : Shorten wait time 1 Proportion of ER Patients Discharged wtih Supports : Baserun 2 2 2
P.S.'Hovmand'April'2013' 22'
Proportion of ER Patients Discharged wtih Supports 2 1.5 1 0.5
3 3 3 3 3 3 3 3 3 3 3 2 2 2 2 2 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1
0.20 0.40 0.60 0.80 1 Time (Year)
Dmnl Proportion of ER Patients Discharged wtih Supports : Increase capacity 1 Proportion of ER Patients Discharged wtih Supports : Shorten wait time 2 Proportion of ER Patients Discharged wtih Supports : Baserun 3 3
P.S.'Hovmand'April'2013' 23'
Proportion of ER Patients Discharged wtih Supports 2 1.5 1 0.5
4 4 4 4 4 4 4 4 3 3 3 3 3 3 3 3 3 2 2 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1
0.20 0.40 0.60 0.80 1 Time (Year)
Dmnl Proportion of ER Patients Discharged wtih Supports : Increase capacity2 1 Proportion of ER Patients Discharged wtih Supports : Increase capacity 2 Proportion of ER Patients Discharged wtih Supports : Shorten wait time 3 Proportion of ER Patients Discharged wtih Supports : Baserun 4 4
P.S.'Hovmand'April'2013' 24'
Average Wait Time for ER Emergency Room Caseload Persons with Needing ER Services Admitting +
Persons with Services and Supports Needing Services Discharing from ER with Supports Discharging without Supports Normal Wait Time
+ Fraction of Persons with Supports Needing Services + Proportion of ER Patients Discharged wtih Supports
Discharge <Average Time to Discharge>
Onset Demand to Capacity Ratio
+
Desired Quality
+ Effect of Caseload on Quality of Care B1 B2 R1
P.S.'Hovmand'April'2013' 25'
Average Wait Time for ER Emergency Room Caseload Persons with Needing ER Services Admitting +
Persons with Services and Supports Needing Services Discharing from ER with Supports Discharging without Supports Normal Wait Time
+ Fraction of Persons with Supports Needing Services + Proportion of ER Patients Discharged wtih Supports
Discharge <Average Time to Discharge>
Onset Demand to Capacity Ratio
+
Desired Quality
+ Effect of Caseload on Quality of Care B1 B2 R1
What'about' people'who' don’t'seek' services?' W h e r e ' i s ' r e c
e r y ' i n ' t h i s ' m
e l ? ! ' There'are'no' constraints'on' social'supports?' Where'is' s3gma?' Where'are'the' factors'that' influence'effec3ve' discharges?' People'accumulate' injuries'from'cycling' through'the' system.'Where’s' that?'
P.S.'Hovmand'April'2013' 26'
Increased'morbidity'and' mortality'of'persons'with'SMI' Implicit'and'explicit'policies'for' managing'bed'occupancy,' discharging'pa3ents,'etc.'' Feedback'system'genera3ng' trends' Decreasing'trend'in'ED' discharges'with'adequate' supports' Medical'model''versus'' recovery'model'
P.S.'Hovmand'April'2013' 27'
Adapted'from'Forrester,'J.'W.'(1980).'Informa3on'sources'for'modeling'the'na3onal'economy.'Journal+of+the+American+ Sta)s)cal+Associa)on,+75(371),'555<566.'
Direct'observa3on,' group'model'building,'' focus'groups,'and'key' informant'interviews' Literature'reviews,' reports,'case'studies' Experiments,' administra3ve'data,' surveys'
P.S.'Hovmand'April'2013' 28'
their'percep3ons'of'a'problem'and'explore'such'ques3ons'as:'what' exactly'is'the'problem'we'face?'How'did'the'problema3c'situa3on'
tackled?”'(Vennix'1996,'p.'3)'
involve'a'rela3vely'large'client'group'in'the'business'of'model' formula3on,'not'just'conceptualiza3on”'(Richardson'and'Andersen,'1995,' p.'1)'
Vennix,'J.'(1996).'Group+model+building.'New'York:'John'Wiley'&'Sons.' Richardson,'G.'P.,'&'Andersen,'D.'F.'(1995).'Teamwork'in<group'model'building,'from'hgp://www.albany.edu/~gpr/ Teamwork.pdf' P.S.'Hovmand'April'2013' 29'
– Problem'conceptualiza3on' – Formula3on' – Policy'analysis' – Implementa3on'
– Sharing'of'insights' – Developing'consensus' – Design'for'implementa3on' – “Dignity'of'risk”'
Ulaanbaatar,'Mongolia' Staff'from'Save'the'Children'UK'develop'a'model'of'the'impact'of' condi3onal'cash'transfer'program'on'households'living'in'poverty' and'children’s'schooling'to'design'an'evalua3on'study'and' household'survey.'' P.S.'Hovmand'April'2013' 30'
– Is'the'general'issue'or'problem'defined'by'par3cipants'in'the'system'
– Will'the'group'process'be'structured'with'a'detailed'agenda'or' unstructured'an'improvised?'
– Will'the'exercises'be'scripted'or'unscripted?'
– Is'the'goal'to'develop'a'qualita3ve'(non<simula3on)'model'or' quan3ta3ve'(simula3on)'model?'
– Will'an'ini3al'model'be'used'(e.g.,'seed'structure,'concept'model,' backbone'structure)'or'will'the'project'start'with'a'“blank'slate”?'
Vennix,'J.'(1996).'Group+model+building.'New'York:'John'Wiley'&'Sons.' P.S.'Hovmand'April'2013' 31'
– Is'the'general'issue'or'problem'defined'by'par3cipants'in'the'system'
– Will'the'group'process'be'structured'with'a'detailed'agenda'or' unstructured'an'improvised?'
– Will'the'exercises'be'scripted'or'unscripted?'
– Is'the'goal'to'develop'a'qualita3ve'(non<simula3on)'model'or' quan3ta3ve'(simula3on)'model?'
– Will'an'ini3al'model'be'used'(e.g.,'seed'structure,'concept'model,' backbone'structure)'or'will'the'project'start'with'a'“blank'slate”?'
P.S.'Hovmand'April'2013' 32' Vennix,'J.'(1996).'Group+model+building.'New'York:'John'Wiley'&'Sons.'
distort'scien3fic'results'and'dominant'poli3cal'narra3ves'by:'
– Pursuing'strong'objec3vity'(Harding,'1991),'cri3cal'pedagogy'and'as'using'computer'models'and' simula3ons'as'genera3ve'tools'for'developing'and'tes3ng'hypotheses'(Black,'1962)'about'the' nature'of'social'rela3ons'
– Teaching'and'organizing'(Horton'and'Freire,'1990)'with'models'through'through'cri3cal'pedagogy' (Freire,'2007)'to'enact'a'new'“language'game”'(Wiggenstein,'1958)'
2009):'
– Using'models'as'genera3ve'metaphors'(Schön,'1979)'and'finding'and'effec3vely'using'visual' elements'of'system'dynamics'as'“boundary'objects”'(Black'and'Andersen,'2012;'Lane,'2000)'
Black,'L.'J.,'&'Andersen,'D.'F.'(2012).'Using'visual'representa3ons'as'boundary'objects'to'resolve'conflict'in'collabora3ve' model<building'applica3ons.'Systems+Research+and+Behavioral+Science,+29,'194<208;'Harding,'S.'(1991).'Whose+science?+Whose+ knowledge:+Thinking+from+women's+lives.'Ithaca,'NY:'Cornell'University'Press;'Horton,'M.,'&'Freire,'P.'(1990).'We+make+this+ road+by+walking:+conversa)ons+on+educa)on+and+social+change.'Philadelphia:'Temple'University'Press;'Freire,'P.'(2007).' Pedagogy+of+the+oppressed.'New'York,'NY:'Con3nuum;'Lane,'D.'C.'(2000).'Diagramming'conven3ons'in'system'dynamics.'The+ Journal+of+the+Opera)onal+Research+Society,+51(2),'241<245;'Vergan3,'R.'(2009).'Design/driven+innova)on:+changing+the+rules+of+ compe))on+by+radically+innova)ng+what+things+mean.'Boston,'MA:'Harvard'Business'Press;'Schön,'D.'(1979).'Genera3ve' metaphor:'A'perspec3ve'on'problem<seyng'in'social'policy.'In'A.'Ortony'(Ed.),'Metaphor+and+society'(pp.'254<283).'New'York;' and,'Wenger,'E.'(1999).'Communi)es+of+prac)ce:+learning,+meaning,+and+iden)ty+(learning+in+doing:+social,+cogni)ve+and+ computa)onal+perspec)ves).'Cambridge,'UK:'Cambridge'University'Press.' P.S.'Hovmand'April'2013' 33'
Phase' Ac6vi6es' Problem'discovery'
background,'purpose,'audience,'scope,'and'resources' needed' Core'modeling' team'planning'
Group'model' building'with' par6cipants'
elicita3on,'model'formula3on,'tes3ng,'policy'analysis,' transfer'of'ownership'
P.S.'Hovmand'April'2013' 34'
Ini3al'group'of' interested'par3es'
Adapted'from,'Straus,'D.'(2002).'How+to+make+collabora)on+work.'San'Francisco,'CA:'Berreg<Koehler'Publishers.'' P.S.'Hovmand'April'2013' 35'
Ques6on' How'is'this'answered' What'is'the'problem?'Is'the' problem'dynamic?' Drawing'a'reference'mode'with'the'desired'and'feared' behavior'over'3me'over'a'defined'period'of'3me' What'kind'of'problem'is'it?'' Primary'diagnosis'as'a'learning,'coordina3on,'analysis,'or' restructuring'problem' Does'the'system'involve' feedback'mechanisms?' Drawing'a'diagram'of'the'system'that'involves'one'or'more' feedback'loops' What'kinds'of'insights'would' help'solve'the'problem?'' Iden3fying'the'types'of'model'based'insights'such'as' visualizing'the'system'or'iden3fying'leverage'points'that'will' help'solve'the'problem' What'is'the'purpose'of'the' model?' Write'a'model'project'descrip3on'that'defines'the'problem,' explains'why'it'is'dynamic'and'involves'feedback,'and'clearly' states'the'purpose'in'terms'of'the'type'of'insights'that'will' help'solve'the'problem.' What'would'be'the'added' value?'' Iden3fying'how'the'approach'being'considered'would'offer' something'above'exis3ng'tools'
P.S.'Hovmand'April'2013' 36'
Ini3al'group'of' interested'par3es' Core'modeling' team'
Adapted'from,'Straus,'D.'(2002).'How+to+make+collabora)on+work.'San'Francisco,'CA:'Berreg<Koehler'Publishers.'' P.S.'Hovmand'April'2013' 37'
1. Introduc3on'of'team'members,'review'of'modeling'project'descrip3on,' and'introduc3on'to'group'model'building,'system'dynamics'(always'face' to'face)' 2. Developing'a'process'map'(Strauss,'2002)'to'iden3fy'stakeholder'groups' and'sequence/structure'of'GMB'sessions' 3. Developing'detailed'agenda'for'each'GMB'type'of'GMB'session' consis3ng'of'a'sequence'of'alterna3ng'divergent'and'convergent'GMB' scripts' 4. Crea3ng'a'facilita3on'manual'by'adap3ng,'tailoring,'and'crea3ng'new' GMB'scripts'for'each'small'group'exercise'(Hovmand'et'al.,'2012)' 5. Reviewing'facilita3on'manual'and'training'agenda'
Adapted'from,'Straus,'D.'(2002).'How+to+make+collabora)on+work.'San'Francisco,'CA:'Berreg<Koehler'Publishers.'' Hovmand,'P.'S.,'Andersen,'D.'F.,'Rouwege,'E.,'Richardson,'G.'P.,'Rux,'K.,'&'Calhoun,'A.'(2012).'Group'model'building'"scripts"' as'a'collabora3ve'tool.'Systems+Research+and+Behavioral+Science,+29,'179<193.'' P.S.'Hovmand'April'2013' 38'
Ini3al'group'of' interested'par3es' Core'modeling' team' Par3cipants'in' GMB'sessions' phase'I'
Adapted'from,'Straus,'D.'(2002).'How+to+make+collabora)on+work.'San'Francisco,'CA:'Berreg<Koehler'Publishers.'' P.S.'Hovmand'April'2013' 39'
Ini3al'group'of' interested'par3es' Core'modeling' team' Par3cipants'in' GMB'sessions' phase'I' Par3cipants'in' GMB'sessions' phases'II,'III,'…'
Adapted'from,'Straus,'D.'(2002).'How+to+make+collabora)on+work.'San'Francisco,'CA:'Berreg<Koehler'Publishers.'' P.S.'Hovmand'April'2013' 40'
Ini3al'group'of' interested'par3es' Core'modeling' team' Par3cipants'in' GMB'sessions' phase'I' Par3cipants'in' GMB'sessions' phases'II,'III,'…' Community' feedback' session'
Adapted'from,'Straus,'D.'(2002).'How+to+make+collabora)on+work.'San'Francisco,'CA:'Berreg<Koehler'Publishers.'' P.S.'Hovmand'April'2013' 41'
Healthy eating Exercise NHL survival Access to medical care Obesity Health of Immune system + + NHL treatment Fatigue from treatment
+ Discrimination +
packaged food + Effectiveness of chemotherapy Compliance
attainment
+ + Expected survival + + + +
incidence + + +
Mental health issues
health insurance, crime, stress, trauma, homelessness, drug abuse, access, social norms, HIV/AIDS status, access to healthy food, access to mental health services, access to transportation, informal care giving, smoking)
support + + + + <Family support> <Family support> +
policy + + Health Literacy + + + +
TREC@WUSTL'Project'4—Role'of'Social'Determinants'in'the'Links'between'Obesity'and'Cancer' 'Preliminary'Synthesis'of'Models'from'Group'Model'Building'Sessions''
(Last'revised,'December'20,'2012)' P.S.'Hovmand'April'2013' 42'
Healthy eating Exercise NHL survival Access to medical care Obesity Health of Immune system + + NHL treatment Fatigue from treatment
+ Discrimination +
packaged food + Effectiveness of chemotherapy Compliance
attainment
+ + Expected survival + + + +
incidence + + +
Mental health issues
health insurance, crime, stress, trauma, homelessness, drug abuse, access, social norms, HIV/AIDS status, access to healthy food, access to mental health services, access to transportation, informal care giving, smoking)
support + + + + <Family support> <Family support> +
policy + + Health Literacy + + + +
TREC@WUSTL'Project'4—Role'of'Social'Determinants'in'the'Links'between'Obesity'and'Cancer' 'Preliminary'Synthesis'of'Models'from'Group'Model'Building'Sessions''
(Last'revised,'December'20,'2012)'
What'are'most'influen3al' across'the'lifespan,' endogenous'feedback' effects'or'pervasive' exogenous'variables?'
P.S.'Hovmand'April'2013' 43'
Boyapalle,'India' Rural'villagers'work'with'Founda3on'for'Ecology'Security'(FES)'staff'and'researchers'to' develop'a'model'of'the'pressures'they'face'to'collect'fuelwood.'
P.S.'Hovmand'April'2013' 44'
P.S.'Hovmand'April'2013' 45'
Ques6on' Answer' What'is'the'problem?'Is'the' problem'dynamic?' Drawing'a'reference'mode'with'the'desired'and'feared' behavior'over'3me'over'a'defined'period'of'3me' What'kind'of'problem'is'it?'' Primary'diagnosis'as'a'learning,'coordina3on,'analysis,'
Does'the'system'involve' feedback'mechanisms?' Drawing'a'diagram'of'the'system'that'involves'one'or' more'feedback'loops' What'kinds'of'insights' would'help'solve'the' problem?'' Iden3fying'the'types'of'model'based'insights'such'as' visualizing'the'system'or'iden3fying'leverage'points'that' will'help'solve'the'problem' What'is'the'purpose'of'the' model?' Write'a'model'project'descrip3on'that'defines'the' problem,'explains'why'it'is'dynamic'and'involves' feedback,'and'clearly'states'the'purpose'in'terms'of'the' type'of'insights'that'will'help'solve'the'problem.'
P.S.'Hovmand'April'2013' 46'