This is the first of a series of articles covering the CEIPS Seminar Series, monthly seminars that showcase systems approaches and complex public health interventions. This article originally appeared on the CEIPS blog and has been reproduced here with permission. It is written by Rebecca Zosel, public health practitioner, advocate and consultant, who tweets from @rzosel.

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Rebecca Zosel writes:

CEIPS launched their new seminar series with a bang on 17 March 2015, attracting a large crowd to the inaugural seminar by Dr Denise Goodwin: Is it possible to take a systems approach in obesity prevention? Findings from the Healthy Towns program in England.

The multidisciplinary crowd of policy makers, practitioners and researchers who gathered to hear Dr Goodwin speak were not disappointed. From her unique vantage point as part of the team evaluating the Healthy Towns program, Denise shared insights from the UK relevant to local obesity prevention efforts, the use of systems approaches to prevention, and Victoria’s own prevention initiative Healthy Together Victoria.

Healthy Towns program

The English context in which the Healthy Towns program was borne parallels our own: a treatment-oriented health care system facing pressure from rising demands and untenable costs. The program itself also has similarities to Healthy Together Victoria; both prevention initiatives are underpinned by a systems approach with concentrated, community-level effort in certain areas.

A number of events in the UK led to the establishment of Healthy Towns, including a call to develop a comprehensive strategy to tackle obesity (Health Select Committee of the House of Commons, 2004), release of the Foresight report ‘Tackling obesities: Future Choices’,  and a cross-government obesity strategy ‘Healthy Weight, Healthy Lives’.  All of these advocated the need for systemic change at multiple levels and multiple sectors across the life-span.

Healthy Towns was conceived as a way to take a systems approach to tackling the obesogenic environment. With £30 million funding, nine towns across England were involved in developing, implementing and evaluating programs to tackle the environmental determinants of diet and physical activity.

Dr Denise Goodwin presented the findings of the Healthy Towns process evaluation, a qualitative stakeholder interview study (n=72). The evaluation generated some interesting insights which seem to indicate a failure in the execution of a systems approach, rather than a failure of a systems approach per se.

The takeout messages from Denise’s presentation:

  1. We need to develop a shared understanding of systems approaches.

The lack of shared understanding of systems approaches in the Healthy Towns program was evident in the towns’ reliance on more ‘traditional’, risk-factor based approaches to program delivery. Misunderstanding was compounded by vague government tender documents and the provision of guidance on linear, structured, hierarchical ‘delivery chain’ approaches that are completely at odds with a systems approach.

Systems science has been used in fields such as engineering, organisational learning & economics for some time, yet is relatively new to public health. There are different interpretations about systems approaches including views that it is no different from existing public health practice. It is critical that we find a way to describe systems thinking that resonates with policy makers, researchers and practitioners alike. This will help all of us working in public health to buy into systems thinking, and sell it to decision makers and funders.

  1. 2.       Systems approaches can be hard to implement; tools and guidance are required.

There was a clear disconnect between what was theorised as a systems approach and how it was translated into practice in the Healthy Towns program. It was also clear that a wide range of barriers and enablers impacted on the towns’ ability to implement a systems approach. Although a systems approach has a strong theoretical basis, it requires a clear set of tools and guidance to implement, alongside a commitment to build workforce capacity and develop systems thinkers and leaders.

  1. 3.       The innovation: evidence paradox – Is it ever really safe to fail?

The Healthy Towns program was conceived as a formative, learning program, set up to generate evidence on environmental approaches to prevention. The expectation to innovate and build the evidence base resulted in some tensions related to the use of accountability frameworks (i.e. reporting requirements, pre-identified outcomes). The accountability framework did not fit with a systems approach, as it suggested that specific outcomes are the consequence of specific processes and inputs, ignoring the unpredictability of systems change, its non-linearity and the likelihood of unintended outcomes.

“The government on the one hand they were saying ‘Look, be very creative, be very exploratory, be very developmental, let’s learn lessons from all of this’, yeah that was one of their angles which was great, we were very much in favour of that. However, on the other side the same people were saying ‘Look we want it all tied down in great detail, you know in the old style in terms of inputs, processes, outputs and stuff’ and that didn’t really match up too well.” Program Manager

Pressure to produce certain outcomes (in too short a timeframe) acted as a disincentive to exploring innovative new strategies, where the benefits might be greater but the risk of failure is quite high. In effect, the accountability framework perpetuated conservative practices, and was at odds with the program’s imperative to innovate.

In our economically stringent climate characterised by change, competition and complexity, public health is grappling to balance best practice (evidence-based) and innovation (evidence-generating). One participant mooted a 70:30 split. There is no magic formula, however it is clear that the world is changing and public health needs to respond. We must continue to do what we know works, whilst developing truly innovative approaches to prevention. In order to do this, we need to be comfortable with failure and have accountability frameworks in place to reflect this

  1. 4.       A comprehensive and sustained approach to tackling obesity is required.

Those of us working in public health know all too well that change is best achieved using a comprehensive multi-pronged approach, and it is heartening to see this evident in initiatives such as Healthy Together Victoria. Public health also needs sustained effort and investment.

The Healthy Towns program was funded for a period of two years and five months, which was seen by local stakeholders as too short and reflective of ‘quick fix’ political expectations; those at the national level thought it long enough. We know from experience in tobacco control and skin cancer prevention that achieving sustained population level change requires a comprehensive and sustained approach. This is particularly pertinent to note at a time when Australian politics are volatile and prevention continues to be afforded a low priority and experience fluctuating commitment, as demonstrated by the recent termination of the National Partnership Agreement on Preventive Health.

Finally, obesity has been a national health priority area since 2008 which begs the question: where is Australia’s national obesity prevention strategy?

 Healthy Towns program reading

  • Goodwin et al. How can planning add value to obesity prevention programmes? Planning and planners in the Healthy Towns programme in England (2014) Health & Place 30 120-126
  • Sautkina et al. Lost in translation? Theory, policy and practice in systems-based environmental approaches to obesity prevention in the Healthy Towns programme in England (2014) Health & Place 29 60-66
  • Goodwin et al. The role and status of evidence and innovation in the Healthy Towns programme in England: qualitative stakeholder interview study (2013) JECH 67 106-112
  • Ogilvie et al. An evaluability assessment framework for complex public health interventions: five questions for researchers, funders and policymakers (2011) The Millbank Quarterly 86 206-215.

CEIPS Seminar Series

Recent seminar:

  • 27 April – Using health promotion practice recordings to improve practice, Dr Stephen McKenzie

Upcoming seminars:

  • 26 May – GoWell: The challenges of evaluating regeneration as a population health intervention, Dr Lyndal Bond
  • 23 June – Grappling with the issue of quality in systems science, Dr Therese Riley.

For further information on the CEIPS Seminar Series please contact Dr Liza Hopkins at [email protected] or 03 9667 1320.

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