Wicked problems and a 'wicked' solution.

BACKGROUND: 'Wicked' is the term used to describe some of the most challenging and complex issues of our time, many of which threaten human health. Climate change, biodiversity loss, persisting poverty, the advancing obesity epidemic, and food insecurity are all examples of such wicked problems. However there is a strong body of evidence describing the solutions for addressing many of these problems. Given that much is known about how many of these problems could be addressed - and given the risks of not acting - what will it take to create the 'tipping point' needed for effective action? MAIN BODY: A recent (2015) court ruling in The Hague held that the Dutch government's stance on climate change was illegal, ordering them to cut greenhouse gas emissions by at least 25% within 5 years (by 2020), relative to 1990 levels. The case was filed on behalf of 886 Dutch citizens, suing the government for violating human rights and climate changes treaties by failing to take adequate action to prevent the harmful impacts of climate change. This judicial ruling has the potential to provide a way forward, inspiring other civil movements and creating a template from which to address other wicked problems. CONCLUSION: This judicial strategy to address the need to lower greenhouse gas emissions in the Netherlands is not a magic bullet, and requires a particular legal and institutional setting. However it has the potential to be a game-changer - providing an example of a strategy for achieving domestic regulatory change that is likely to be replicable in some countries elsewhere, and providing an example of a particularly 'wicked' (in the positive, street-slang sense of the word) strategy to address seemingly intractable and wicked problems

Value and effectiveness of National Immunization Technical Advisory Groups in low- and middle-income countries : A qualitative study of global and national perspectives

© The Author(s) 2019. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.The Global Vaccine Action Plan proposes that every country establish or have access to a National Immunization Technical Advisory Group (NITAG) by 2020. The NITAG role is to produce evidence-informed recommendations that incorporate local context, to guide national immunization policies and practice. This study aimed to explore the value and effectiveness of NITAGs in low- and middle-income countries (LMICs), identifying areas in which NITAGs may require further support to improve their functionality and potential barriers to global investment. A multi-methods study design was used, comprising 134 semi-structured interviews and 82 literature review sources that included 38 countries. Interviews were conducted with 53 global/regional and 81 country-level participants able to provide insight into NITAG effectiveness, including NITAG members, national immunization programme staff, and global agency representatives (e.g. the World Health Organisation, the Bill and Melinda Gates Foundation, Gavi the Vaccine Alliance). The review, including published and unpublished sources on NITAGs in LMICs, was conducted to supplement and corroborate interview findings. Data were analysed thematically. NITAGs were described as valuable in promoting evidence-informed vaccination decision-making, with NITAG involvement enhancing national immunization programme strength and sustainability. Challenges to NITAG effectiveness included: (1) unreliable funding; (2) insufficient diversity of member expertise; (3) inadequate conflicts of interest management procedures; (4) insufficient capacity to access and use evidence; (5) lack of transparency; and (6) limited integration with national decision-making processes that reduced the recognition and incorporation of NITAG recommendations. LMIC NITAGs have developed significantly in the past decade. Well-functioning NITAGs were trusted national resources that enhanced country ownership of immunization provision. However, many LMIC NITAGs require additional technical and funding support to strengthen quality and effectiveness, while maintaining impartiality and ensuring sufficient integration with national decision-making processes. Barriers to sustainable global support need to be addressed for LMIC NITAGs to both continue and develop further.Peer reviewedFinal Published versio

Trade and investment liberalization and Asia's noncommunicable disease epidemic: a synthesis of data and existing literature.

BACKGROUND: Trade and investment liberalization (trade liberalization) can promote or harm health. Undoubtedly it has contributed, although unevenly, to Asia's social and economic development over recent decades with resultant gains in life expectancy and living standards. In the absence of public health protections, however, it is also a significant upstream driver of non-communicable diseases (NCDs) including cardiovascular disease, cancer and diabetes through facilitating increased consumption of the 'risk commodities' tobacco, alcohol and ultra-processed foods, and by constraining access to NCD medicines. In this paper we describe the NCD burden in Asian countries, trends in risk commodity consumption and the processes by which trade liberalization has occurred in the region and contributed to these trends. We further establish pressing questions for future research on strengthening regulatory capacity to address trade liberalization impacts on risk commodity consumption and health. METHODS: A semi-structured search of scholarly databases, institutional websites and internet sources for academic and grey literature. Data for descriptive statistics were sourced from Euromonitor International, the World Bank, the World Health Organization, and the World Trade Organization. RESULTS: Consumption of tobacco, alcohol and ultra-processed foods was prevalent in the region and increasing in many countries. We find that trade liberalization can facilitate increased trade in goods, services and investments in ways that can promote risk commodity consumption, as well as constrain the available resources and capacities of governments to enact policies and programmes to mitigate such consumption. Intellectual property provisions of trade agreements may also constrain access to NCD medicines. Successive layers of the evolving global and regional trade regimes including structural adjustment, multilateral trade agreements, and preferential trade agreements have enabled transnational corporations that manufacture, market and distribute risk commodities to increasingly penetrate and promote consumption in Asian markets. CONCLUSIONS: Trade liberalization is a significant driver of the NCD epidemic in Asia. Increased participation in trade agreements requires countries to strengthen regulatory capacity to ensure adequate protections for public health. How best to achieve this through multilateral, regional and unilateral actions is a pressing question for ongoing research

Understanding the Drivers of Food Choice to Improve Population Nutrition: An Application of Economics to Public Health

There is much to learn about what shapes people’s food choices, particularly in countries with a high burden of malnutrition. Whilst public health  policymakers and practitioners in many countries seek to address malnutrition, including through for example in Malawi with improving national  food production via large-scale agricultural input subsidy programmes, there are significant gaps in the understanding of people’s food choices and  trade-offs including in the context of such policy interventions. Considerable insight into research of the drivers of food choices and trade-offs can  be gained from both the conceptual perspectives and applied methodological techniques that are offered by the discipline of economics. Here, we  describe our current research, an example of the use of conceptualisations and methods from economics to explore drivers of food choice to  improve population  nutrition in the context of Malawi’s FISP

Age at quitting smoking as a predictor of risk of cardiovascular disease incidence independent of smoking status, time since quitting and pack-years

BACKGROUND Risk prediction for CVD events has been shown to vary according to current smoking status, pack-years smoked over a lifetime, time since quitting and age at quitting. The latter two are closely and inversely related. It is not known whether the age at which one quits smoking is an additional important predictor of CVD events. The aim of this study was to determine whether the risk of CVD events varied according to age at quitting after taking into account current smoking status, lifetime pack-years smoked and time since quitting. FINDINGS We used the Cox proportional hazards model to evaluate the risk of developing a first CVD event for a cohort of participants in the Framingham Offspring Heart Study who attended the fourth examination between ages 30 and 74 years and were free of CVD. Those who quit before the median age of 37 years had a risk of CVD incidence similar to those who were never smokers. The incorporation of age at quitting in the smoking variable resulted in better prediction than the model which had a simple current smoker/non-smoker measure and the one that incorporated both time since quitting and pack-years. These models demonstrated good discrimination, calibration and global fit. The risk among those quitting more than 5 years prior to the baseline exam and those whose age at quitting was prior to 44 years was similar to the risk among never smokers. However, the risk among those quitting less than 5 years prior to the baseline exam and those who continued to smoke until 44 years of age (or beyond) was two and a half times higher than that of never smokers. CONCLUSIONS Age at quitting improves the prediction of risk of CVD incidence even after other smoking measures are taken into account. The clinical benefit of adding age at quitting to the model with other smoking measures may be greater than the associated costs. Thus, age at quitting should be considered in addition to smoking status, time since quitting and pack-years when counselling individuals about their cardiovascular risk.This research was supported by an NHMRC health services research grant (no. 465130), an NHMRC/NHF PhD scholarship and a Vichealth Fellowship

Well-being in psychologists

Practising psychologists across a range of disciplines are known to frequently work with individuals who have complex emotional difficulties. Excessive job demands and lack of resources are known to impact on the well-being of these professionals (Hannigan, Edwards, & Burnard, 2004) with consequences for the individual, clients, and organisations at a wider level. This thesis examines some of the factors which can affect wellbeing in psychologists. Section 1 presents the findings from a systematic literature review including 22 papers that looked at the experience of burnout in practising psychologists (e.g., clinical, counselling, and school psychologists). Psychologist burnout was within the moderate to high range in at least half of the studies examined. Variables including gender, practice setting and level of experience were related to burnout, as were several psychosocial variables. Methodological quality of studies varied hugely and compared to other professions, the literature on burnout for psychologists was generally lacking. Relevance to clinical practice and implications for future research are discussed. Section 2 comprises the quantitative research study, which explored whether job demands predicted psychological well-being in clinical psychologists, and whether the quality of the supervisory relationship was capable of moderating that relationship. A total of 194 clinical psychologists participated in the online study consisting of a questionnaire gathering demographic information and information on job characteristics, and five standardised self-report measures including a measure of job demands, a measure of the supervisory relationship, and three measures of psychological well-being. Job demands significantly predicted psychological well-being, but that relationship was not moderated by the strength of the supervisory relationship. A discussion of the findings, including possible reasons for the lack of moderation, are presented, along with suggestions for further research. Section three presents a critical appraisal of the research. It discusses the findings of the literature review and research study, as well as a critique of the methodology. Reflections on the research process are given and implications for clinical practice are discussed

Achieving universal health coverage in small island states: could importing health services provide a solution?

BACKGROUND: Universal health coverage (UHC) is difficult to achieve in settings short of medicines, health workers and health facilities. These characteristics define the majority of the small island developing states (SIDS), where population size negates the benefits of economies of scale. One option to alleviate this constraint is to import health services, rather than focus on domestic production. This paper provides empirical analysis of the potential impact of this option. METHODS: Analysis was based on publicly accessible data for 14 SIDS, covering health-related travel and health indicators for the period 2003-2013, together with in-depth review of medical travel schemes for the two highest importing SIDS-the Maldives and Tuvalu. FINDINGS: Medical travel from SIDS is accelerating. The SIDS studied generally lacked health infrastructure and technologies, and the majority of them had lower than the recommended number of physicians in a country, which limits their capacity for achieving UHC. Tuvalu and the Maldives were the highest importers of healthcare and notably have public schemes that facilitate medical travel and help lower the out-of-pocket expenditure on medical travel. Although different in approach, design and performance, the medical travel schemes in Tuvalu and the Maldives are both examples of measures used to increase access to health services that cannot feasibly be provided in SIDS. INTERPRETATION: Our findings suggest that importing health services (through schemes to facilitate medical travel) is a potential mechanism to help achieve universal healthcare for SIDS but requires due diligence over cost, equity and quality control

A Systems Thinking Approach to Inform Coherent Policy Action for NCD Prevention; Comment on “How Neoliberalism Is Shaping the Supply of Unhealthy Commodities and What This Means for NCD Prevention”

Lencucha and Thow tackle the enormous public health challenge of developing non-communicable disease (NCD) policy coherence within a world structured and ruled by neoliberalism. Their work compliments scholarship on other causal mechanisms, including the commercial determinants of health, that have contributed to creating the risk commodity environment and barriers to NCD prevention policy coherence. However, there remain significant gaps in the understanding of how these causal mechanisms interact within a whole system. As such, public health researchers’ suggestions for how to effectively prevent NCDs through addressing the risk commodity environment tend to remain fragmented, incomplete and piecemeal. We suggest this is, in part, because conventional policy analysis methods tend to be reductionist, considering causal mechanisms in relative isolation and conceptualizing them as linear chains of cause and effect. This commentary discusses how a systems thinking approach offers methods that could help with better understanding the risk commodity environment problem, identifying a more comprehensive set of effective solutions across sectors and its utility more broadly for gaining insight into how to ensure recommended solutions are translated into policy, including though transformation at the paradigmatic level