Together stronger: boundary work within an Australian systems-based prevention initiative

Abstract

Complexity and systems science are increasingly used to devise interventions to address health and social problems. Boundaries are important in systems thinking, as they bring attention to the power dynamics that guide decision-making around the framing of a situation, and how it is subsequently tackled. Using complexity theory as an analytical frame, this qualitative exploratory study examined boundary interactions between local government and community health organizations during the operationalization of a systems-based initiative to prevent obesity and chronic diseases (Healthy Together Communities—HTCs) in Victoria, Australia. Across two HTC sites, data was generated through semi-structured interviews with 20 key informants, in mid-2015. Template analysis based on properties of complex systems was applied to the data. The dynamics of boundary work are explored using three case illustrations: alignment, boundary spanning and boundary permeability. Alignment was both a process and an outcome of boundary work, and occurred at strategic, operational and individual levels. Boundary spanning was an important mechanism to develop a unified collaborative approach, and ensure that mainstream initiatives reached disadvantaged groups. Finally, some boundaries exhibited different levels of permeability for local government and community health organizations. This influenced how each organization could contribute to HTC interventions in unique, yet complementary ways. The study of boundary work offers potential for understanding the mechanisms that contribute to the nonlinear behaviour of complex systems. The complementarity of partnering organizations, and boundary dynamics should be considered when designing and operationalizing multilevel, complex systems-informed prevention initiatives.

Building a Prevention System: Infrastructure to Strengthen Health Promotion Outcomes

“…Previous research on adopting systems approaches has examined the micro-level of community-based practice in HTC [5,[41][42][43] and other papers explore various aspects of HTV [14,16,35,41,43,44]. This paper is the first to appreciate the macro-level architecture of system design, examining how the HTV prevention system was constructed and its strengths and limitations.…”

“…Within Australia, the Victorian Government identified the need for a new prevention system, as the existing one, known as Integrated Health Promotion (IHP), was ineffective [34]. It was located in community health services and was criticized for delivering fragmented and short-term projects [16,35]. IHP was to be deliberately disrupted by Healthy Together Victoria (HTV), a large-scale intervention that adopted systems thinking to reduce obesity and preventable chronic disease from 2012 to 2016 [36].…”

“…IHP was to be deliberately disrupted by Healthy Together Victoria (HTV), a large-scale intervention that adopted systems thinking to reduce obesity and preventable chronic disease from 2012 to 2016 [36]. HTV aimed to improve the effectiveness of health promotion in the state of Victoria [16]. The theory of change was a complex whole of system approach that required the activation of communitylevel organisations via multifaceted interventions to improve physical inactivity, poor diet, smoking and harmful alcohol use [29,37].…”

“…From the outset community health were marginalized, initially perceived as unimportant for the delivery of community-based prevention. However, in practice, they were drawn into the work of the HTC locally, contributing a community development approach, important connections and health promotion expertise [16]. With the benefit of hindsight, an interesting consideration is whether to have included community health services within the HTV prevention system boundary, rather than designing them outside of it.…”

“…There is limited research about the use of systems sciences pertaining to the macro environment in public health [14,15]. This paper uniquely describes the establishment of Healthy Together Victoria's (HTV) infrastructure for a systems approach to prevention [16].…”