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 Mailman School of Public Health ! !

Social'System'Design'Lab' Research( • – 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' Teaching( • – 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' Professional(development( • – 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'

Overview' • Social'determinants'“Iceberg”' • Moving'from'thinking'about'specific'events'and'distribu3ons' to'underlying'structure,'mental'models,'and'paradigms' • Introduce'system'dynamics' • Example'on'access'to'ED'for'persons'with'SMI' • Challenge'of'iden3fying'models'related'to'social' determinants' • Par3cipatory'group'model'building'as'a'method' to'overcome'those'difficul3es' • Two'examples'of'where'the'approach'made'a'difference' • What’s'next' P.S.'Hovmand'April'2013' 3'

Health & Behaviors Community Assets Social Determinants 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' '

Challenge'to'understanding' dynamically'complex'systems' Percep6on' Reality' Mental'Model' Ac6on' 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'

“Iceberg”'of'social'determinants' Events' Behavior' Pagerns' System' Structure' Mental'Models' Worldview'or'paradigm' P.S.'Hovmand'April'2013' 7'

Social'determinants'understood'as' differences'in…' Aggregate'sta3s3cs,' Events' parameters,'and'distribu3ons' Qualita3ve'behavior'of'system' Behavior' over'3me' Pagerns' System' Feedback'structures'in'a' system' Structure' Mental'models' Mental'Models' Category'structures' Worldview'or'paradigm' P.S.'Hovmand'April'2013' 8'

Women' Men' Example'of'gender' Medium'weekly' $657' $819' income' differences'in'income' Events' Behavior' + Pagerns' Experienced New Men Men System' Experienced New Women Women Structure' + “We'try'to'recruit,'hire'and'promote'the' most'qualified'candidates,'and'don’t' make'decisions'based'on'gender.”' Mental'Models' “Men'and'women'are'essen3ally'the' Worldview'or'paradigm' same.”' P.S.'Hovmand'April'2013' 9'

System'Dynamics' • Field'invented'by'Jay'W.'Forrester'at'MIT'in'1958' • System'dynamics:' – “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)' ' • Founda3ons'of'system'dynamics:' – Endogenous'or'feedback'perspec3ve' • Stock'or'level'(state)'variables'represen3ng'accumula3ons' – 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'

Onset Emergency Persons Needing Room Caseload ER Services Admitting + - Average Wait Time for ER P.S.'Hovmand'April'2013' 11'

Glass'is'an'example'of'accumula3ons'called'“stocks”' with'water'pouring'in'a'“flow”' ' Pouring water =' Glass P.S.'Hovmand'April'2013' 12'

Glass'is'an'example'of'accumula3ons'called'“stocks”' with'water'pouring'in'a'“flow”' ' Pitcher Pouring water =' Glass P.S.'Hovmand'April'2013' 13'

Glass'is'an'example'of'accumula3ons'called'“stocks”' with'water'pouring'in'a'“flow”' ' Pitcher Pouring water =' Glass Spilling water P.S.'Hovmand'April'2013' 14'

Onset Emergency Persons Needing Room Caseload ER Services Admitting ED Capacity + B1 - + - Average Wait Time for ER Demand to Capacity Ratio + P.S.'Hovmand'April'2013' 15'

Persons with Services and Supports Discharing from ER with Supports + Onset Emergency Persons Needing Room Caseload ER Services Admitting ED Capacity + B1 - + - Average Wait Time for ER Demand to Capacity Ratio + - Discharging without Supports P.S.'Hovmand'April'2013' 16'

Persons with Services and Supports Discharing from ER with Supports + Onset Emergency Persons Needing R1 Room Caseload ER Services Admitting ED Capacity + B1 - + + - Desired Quality Average Wait of Care Time for ER Demand to Capacity Ratio + + - - B2 Discharging Proportion of ER Patients without Supports Discharged wtih Supports - Average Time to Discharge P.S.'Hovmand'April'2013' 17'

<Average Time to Persons with Discharge> Services and Supports - + Fraction of Needing Discharing from ER Persons with Services with Supports Supports Needing + Services + Onset Emergency Persons Needing R1 Room Caseload ER Services Admitting ED Capacity + B1 - + + - Desired Quality Average Wait of Care Time for ER Demand to Capacity Ratio + + - - B2 Discharging Proportion of ER Patients without Supports Discharged wtih Supports - Average Time to Discharge P.S.'Hovmand'April'2013' 18'

What’s+wrong+with+this+model?+ <Average Time to Persons with Discharge> Services and Supports - + Fraction of Needing Discharing from ER Persons with Services with Supports Supports Needing + Services + Onset Emergency Persons Needing R1 Room Caseload ER Services Admitting ED Capacity + B1 - + + - Desired Quality Average Wait of Care Time for ER Demand to Capacity Ratio + + - Effect of Caseload - on ER Wait Time B2 Discharging Proportion of ER Patients without Supports Discharged wtih Supports - Effect of Caseload on Average Time to Quality of Care Discharge P.S.'Hovmand'April'2013' 19'

<Average Time to Persons with Discharge> Services and Supports - + Fraction of Needing Discharing from ER Persons with Services with Supports Supports Needing + Services + Onset Persons with Emergency R1 Needing ER Room Caseload Services Admitting ED Capacity + B1 - + + - Desired Quality Normal Average Wait of Care Wait Time Time for ER Demand to Capacity Ratio + + - Effect of Caseload on ER Wait Time - Proportion of ER Patients Discharged wtih Supports Discharging B2 without Supports - Effect of Caseload on Average Time to Quality of Care Discharge P.S.'Hovmand'April'2013' 20'

Proportion of ER Patients Discharged wtih Supports 1 0.75 Dmnl 0.5 1 1 0.25 1 1 1 1 1 1 1 1 1 0 1 0 0.20 0.40 0.60 0.80 1 Time (Year) 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 Dmnl 0.5 2 2 0.25 1 1 2 2 1 2 1 2 1 2 1 2 2 1 2 1 2 0 1 1 1 2 1 0 0.20 0.40 0.60 0.80 1 Time (Year) 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 Dmnl 1 1 0.5 1 1 3 1 1 2 3 1 3 2 1 1 3 2 1 3 1 2 3 1 2 3 1 0 2 3 2 3 3 2 3 2 2 2 2 0 0.20 0.40 0.60 0.80 1 Time (Year) 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'