Complexity and public health Recognising signs of complexity

1. Complexity and public healthRecognising signs of complexity Nigel Monaghan

2. Questions I am asking • Can we recognise signs of complexity? • Can we interpret these signs to provide clues on how complexity may be operating? (implications for possible action)

3. If we can recognise complexity • We can look for greater understanding of the interactions contributing to emerging phemonena (more holistic analysis) • We can look to implement (more holistic) new interventions – to take advantage of non-linear responses • We can “Expect the unexpected” D Adams Hitchhikers Guide to the Galaxy)

4. If we can recognise complexity • We can consider more holistic evaluations – (we may find answers to other intractable problems) • We can take an incremental action research approach (quality improvement method, trial and error) to see what does work here, i.e. action and reflection

5. Complexity is normally present • Interactions between agents • Interactions with the environment • Potential for agents to change environment and vice-versa • Despite this many things still appear to operate in a deterministic way • On other occasions they do not...

6. Signs of possible complexity Where we are operating? • Environment is complicated and uncontrolled • Lots of interactions between autonomous agents and environment What we are seeking to address? • Human behaviour is what we are seeking to change

7. Signs of possible complexity Evidence-base related warning signs • Small intervention effect • High number needed to treat • Moving from a controlled trial in a controlled environment to a low control environment • Extrapolating to a different environment/culture

8. Signs of possible complexity Outcomes • Non-linear phenomena • Unexpected phenomena • Using a one club approach is not working Predictability • Limits to prediction • Repeating events in same place leads to different results • Results from there do not transfer to here

9. If complexity is always there • Why don’t we just treat everything as complex? • Waste resources when simple approach will suffice • Reputation: sledgehammer to crack a nut Problem is currently we are often trying to use a nutcracker to break up concrete.

10. Can we... • Identify that complexity is operating? • Identify how it is operating? • Use than knowledge to focus our information gathering, analysis and intervention design? • Thereby improve our effectiveness?

11. Dynamics of Complexity • Confounders • Non-linearity/feedback loops • Environment/Culture • Co-evolution • Human Behaviour

12. Complexity Diagnosis - Confounders Interventions • High number needed to treat • Small benefit interventions • Series of trials demonstrating impacts ranging from negative to positive Outside the confines of a randomised controlled trial are confounding factors likely to be as important as an intervention?

13. Complexity Diagnosis – Non-linearity Outcomes • Non-linear phenomena • Problems which are resistant to change • No regression towards the mean • Huge change with small inputs • Unexpected phenomena Is non-linearity associated with positive feedback loops?

14. Complexity Diagnosis - Environment Predictability • Limits to prediction • Repeat events in same place = different results • Results from there do not transfer to here Are some of these demonstrating that the environment (or culture) and interactions with the environment (or within the culture) matter?

15. Complexity Diagnosis – Co-evolution Ecosystem factors • Co-evolution is occuring – i.e. a “Cold War” (e.g. Evolution of antibiotic resistance vs developing new antimicrobials) Are these signs that show that interaction between 2 or more factors are dominant?

16. Complexity Diagnosis – Human Behaviour To err is human/Irrationality • Human behaviour is what we are seeking to change Is this area particularly challenging? There is plenty of evidence that humans do respond to their environment, that they interact to influence each other and that (confounding) factors can influence human behaviour, feedback loops are most likely present too

17. Can we improve on this? • Your thoughts and contributions are welcomed