Advancing the application of systems thinking in health:analysing the contextual and social network factors influencing the use of sustainability indicators in a health system - a comparative study in Nepal and Somaliland

BACKGROUND: Health systems strengthening is becoming a key component of development agendas for low-income countries worldwide. Systems thinking emphasizes the role of diverse stakeholders in designing solutions to system problems, including sustainability. The objective of this paper is to compare the definition and use of sustainability indicators developed through the Sustainability Analysis Process in two rehabilitation sectors, one in Nepal and one in Somaliland, and analyse the contextual factors (including the characteristics of system stakeholder networks) influencing the use of sustainability data. METHODS: Using the Sustainability Analysis Process, participants collectively clarified the boundaries of their respective systems, defined sustainability, and identified sustainability indicators. Baseline indicator data was gathered, where possible, and then researched again 2 years later. As part of the exercise, system stakeholder networks were mapped at baseline and at the 2-year follow-up. We compared stakeholder networks and interrelationships with baseline and 2-year progress toward self-defined sustainability goals. Using in-depth interviews and observations, additional contextual factors affecting the use of sustainability data were identified. RESULTS: Differences in the selection of sustainability indicators selected by local stakeholders from Nepal and Somaliland reflected differences in the governance and structure of the present rehabilitation system. At 2 years, differences in the structure of social networks were more marked. In Nepal, the system stakeholder network had become more dense and decentralized. Financial support by an international organization facilitated advancement toward self-identified sustainability goals. In Somaliland, the small, centralised stakeholder network suffered a critical rupture between the system's two main information brokers due to competing priorities and withdrawal of international support to one of these. Progress toward self-defined sustainability was nil. CONCLUSIONS: The structure of the rehabilitation system stakeholder network characteristics in Nepal and Somaliland evolved over time and helped understand the changing nature of relationships between actors and their capacity to work as a system rather than a sum of actors. Creating consensus on a common vision of sustainability requires additional system-level interventions such as identification of and support to stakeholders who promote systems thinking above individual interests

Learning cooking skills at different ages: a cross-sectional study

Background Cooking skills are increasingly included in strategies to prevent and reduce chronic diet-related diseases and obesity. While cooking interventions target all age groups (Child, Teen and Adult), the optimal age for learning these skills on: 1) skills retention, 2) cooking practices, 3) cooking attitudes, 4) diet quality and 5) health is unknown. Similarly, although the source of learning cooking skills has been previously studied, the differences in learning from these different sources has not been considered. This research investigated the associations of the age and source of learning with the aforementioned five factors. Methods A nationally representative (Northern/Republic of Ireland) cross-sectional survey was undertaken with 1049 adults aged between 20–60 years. The survey included both measures developed and tested by the researchers as well as validated measures of cooking (e.g. chopping) and food skills (e.g. budgeting), cooking practices (e.g. food safety), cooking attitudes, diet quality and health. Respondents also stated when they learnt the majority of their skills and their sources of learning. The data was analysed using ANOVAs with post-hoc analysis and Chi2 crosstabs with a significance level of 0.05. Results Results showed that child (<12 years) and/or teen (13–18 years) learners had significantly greater numbers of, and confidence in, their cooking and food skills, cooking practices, cooking attitudes, diet quality (with the exception of fibre intake where adult learners were higher) and health. Mother was the primary source of learning and those who learnt only from this source had significantly better outcomes on 12 of the 23 measures. Conclusions This research highlights the importance of learning cooking skills at an early age for skill retention, confidence, cooking practices, cooking attitude and diet quality. Mother remained the primary source of learning, however, as there is a reported deskilling of domestic cooks, mothers may no longer have the ability to teach cooking skills to the next generation. A focus on alternative sources including practical cooking skills education starting at an early age is required. This study also highlights the need for further longitudinal research on the impact of age and source of learning on cooking skills