Interesting trio of articles testing the applicability of a complex adaptive systems approach to school-based interventions.
1. Keshavarz N, Nutbeam D, Rowling L, Khavarpour F. Schools as social complex adaptive systems: A new way to understand the challenges of introducing the health promoting schools concept. Social Science & Medicine. [doi: DOI: 10.1016/j.socscimed.2010.01.034]. 2010;70(10):1467-74.
2. Keshavarz N, Nutbeam D, Rowling L. Social complex adaptive systems. A response to Haggis. Social Science & Medicine. [doi: DOI: 10.1016/j.socscimed.2010.01.023]. 2010;70(10):1478-9.
3. Haggis T. Approaching complexity: A commentary on Keshavarz, Nutbeam, Rowling and Khavarpour. Social Science & Medicine. [doi: DOI: 10.1016/j.socscimed.2010.01.022]. 2010;70(10):1475-7.
The article by Keshavarz on schools as complex adaptive system (CAS), is an excellent approach to understanding the concept of complexity theory and CAS. Although this theory has been studied in detail in natural and artificial CAS, this is one of the first attempts to study it in a social system. They emphasize the importance of tools to understand the complexity of the system and the explanatory framework applied in understanding the changes occurring in such inherently adaptive systems.
ReplyDeleteThe commentary of Haggis on this paper underlines the concepts "ontology and epistemology" in understanding complexity theory and CAS and challenges in its application. However this is a good starting point to understand CAS in health promotion at lower (school) level which can help in understanding more complex systems at State and national level.
Maybe I missed it, but I did not see anything in this paper on how the "health promoting schools program" was implemented, other than that it was funded and organized by the local health services.
ReplyDeleteThis paper takes a SCAS viewpoint, describes components of this conceptual framework, and points out many or the schools characteristics that correspond to components of SCAS and their impact on the implementation of the health promoting schools program. Just as CAS describes a complex system with interlocking components and a variety of adaptive processes that values examining a forest with "fuzzy boundaries" --- I wonder if examining an intervention such as this health promoting schools program with only one conceptual framework is sufficient. If that was clear as mud, I will explain myself:
As I was reading this article, I thought to myself (with a Business Processes / Organizational Change / Community Based Health Intervention cap on) --- WHAT ARE THEY DOING?!?!? There are (pre-implementation) critical success factors that did not seem to be addressed in this program. Just off the top of my head:
(1) Executive support - the program was not considered compulsory by the Department of Education. The Department of Education is the CEO in this case. For any implementation to succeed it is mandatory that there is executive support AND, additionally, a high level "champion". The champion is someone who can be on the ground cheering on the operational level activities and making sure that the implementation team has the resources required. There also needs to be the support of "thought leaders" in the form of constant communication with the operational folks. These are respected members of the organization that are not executive level, but one of the "people" --- usually called "end users" in business, but in this case it would be parents, teachers, and principles. So, the president of the PTA, for example. This will enhance end-user "buy-in". The next topic ...
(2) End-user buy-in is important to avoid sabotage. Teachers reacted by saying that health education was not a priority for them so they pushed it aside. Information about the program did not flow as well as other types of information. You might argue that it is true the school has other more important agendas. But when you are introducing something new, that is the time (at conception) when it needs to be given the highest priority, if you want success. Reading and numeracy will always be important, but if the organization ever wants to make health education a component of their mission, then when they first introduce the program, it has to be a priority with adequate resources devoted to it. Later when they are done with implementation and onto simple maintenance a new equilibrium between competing interests will emerge. So, back to end-users. If you do not involve them in the process, get their acceptance of the new implementation, focus their attention on how it will benefit them, and solicit continual feedback --- then they may just thwart efforts of change.
(3) Integrated processes / information. This program seem siloed in its approach to communicating information and processes. The schools did not talk to each other; the local health departments did not seem to be communicating with the Department of Education (which should have been the first place they talked to --- and continued to talk to).
ReplyDelete(4) Small victories. I don't know that this program had a well defined plan or if they did, whether it was communicated to everyone. But often, small goals leading to small victories leading to a nice, small celebration and then moving on to the next goal, helps achieve a big final goal. It seemed like, whatever the plan was it was a "Big Bang" implementation.
(5) Culture of change. The article expressed a very agile culture of change; however, it also seemed very reactionary and thus, perhaps, an overwhelmed system unable to strategically adapt and foresee threats or opportunities.
(6) Was there an evaluation plan? A list of goals? Key performance indicators to monitor those small successes? Was there some sort of tracking mechanism - a dashboard, balanced scorecard?
(7) The article did mention diversity within and among schools, a scenario which would benefit from population specific targeted interventions. This is more time and resource consuming; but would you want the same hypertension intervention for a black southern baptist church in rural Georgia as for a Mormon church in Arizona?
Okay, so what I want to know is:
If the intervention is lacking in basic implementation structures and processes does that affect what and how we learn about the SCAS nature of what we are studying? Or should we study SCAS in relation to an intervention at all. Or if we do, should we examine the system before and after the implementation?
I guess I am a little confused.