Systems Change Science

Introductory Paragraph

The primary purpose of this article is to demystify systems change science. Anyone working to change social norms is, by definition, aspiring to change a variety of systems which are resistant to innovative solutions. Anyone involved in working across the continuum of care or doing multi-sectoral work is, by definition, breaking down silos (See the SAFE Solution article titled, “Activate Your Community.”) Systems change science simply highlights the most effective ways to make those changes happen.

The secondary purpose of this article is to introduce the relationships between the themes covered in greater detail in the other articles in this collection of articles on system-building. For example, all of the articles of the Strategic Prevention Framework (SPF) incorporate data, whether it is in needs assessment, prioritization of implementation choices during planning, or in evaluating outcomes. Likewise, the process of advocacy (see “Advocate for Policy Change”) is dependent not only upon data but also on the effective communication of measurable outcomes (See “Build Education and Raise Awareness”).

Key Information

In keeping with the objective of demystifying systems change science, it may be useful to keep in mind the saying, “the whole is greater than the sum of the parts.” This comes from the systems approach, which is really just a way of thinking. It focuses on the big picture and on seeing the relationships between the component parts of the system. In a way it is bifocal vision — seeing both the forest and trees. It invites seeing patterns and underlying structures. Such a vantage point equips us to identify optimal courses of action to create change most effectively. For example, one motivated champion in a coalition may have more community impact than ten people who are members because of their departmental obligations, so finding three more comparable champions helps the coalition to leverage change more effectively than just focusing on growing the size of the coalition.

A systems approach also takes a deep view. It focuses on changing the source of conditions, rather than addressing symptoms. For example, in addressing recidivism or the "prison revolving door," a systems approach fosters tighter linkage between the judicial systems and numerous community systems. In another example, when county commissioners examine the amount of their annual budgets allocated to foster care, they are doing systems work when they seek root causes and fund programs which target substance use disorder within families. The prevention community has done a good job of promoting the need to balance “downstream” work with an “upstream” and proactive approach. Systems thinking goes further and looks at the groundwater. In many respects, a focus on protective factors creates a context for linking with allies working in related fields, such as substance use prevention, suicide prevention, and the prevention of gun violence or domestic violence (See the SAFE Solution article titled, “Apply a Multi-Sectoral Approach.” ) Likewise, the deep view of a systems approach encounters underlying values and worldviews that shape the landscape of the work we are doing around substance use.

One by-product of taking a systems-thinking approach is the ability to transcend binary-thinking which limits choices to only black or white. In the treatment world, medicated-assisted treatment (MAT) is an example of "finding the gray." Motivational interviewing is another therapeutic model which focuses on person-centered immediate goals which promote progress on client-centered terms, rather than measuring results only upon the long-term outcomes which a therapist might hold.

Examples of System-Building

Any form of multi-sectoral collaboration is inherently systems work. Building coalition membership with representation from stakeholders who represent different agencies requires acting on a broad view. Bringing together health promotion and law enforcement agencies is a complex systems task because they tend to work on opposite ends of the upstream/downstream continuum. Drug take-back are a useful mechanism for forging this type of collaboration. (See the SAFE Solution article titled, "Expand Prescription Drug Take-Back and Disposal Programs.) Likewise, fostering collaboration between the medical community and the faith community reveals the kind of language translation that is needed because one tends to speak of curing while the other operates in a healing modality. In a similar fashion, advances in chronic pain management as an alternative to prescription medication is fostering a multi-sectoral collaboration between doctors and alternative health practitioners. (See the SAFE Solution article titled, “Expand and Enhance Chronic Pain Prevention and Management.”) Community/Campus initiatives are also examples of systems work. Finally, whenever efforts bridge two or more of the five zones of the social-ecological model (individual, family, peer, school, community) they reflect a systems approach.

While system-building may seem complex at first, it becomes much simpler when we see how much we are already engaged in working across multiple systems. However, simple is not necessarily easy. One area of doing the hard work is in the community-wide norm change associated with stigma reduction (See the SAFE Solution article titled, “Reduce Stigma.”) Another example is work done to address social determinants of health. One cannot work very long in prevention, treatment, or recovery without encountering the “negative synergy” often caused by multiple concurrent barriers in transportation, housing, and employment systems (See the SAFE Solution article titled, “Apply a Health Equity Lens.”) Four more detailed examples are provided below, with specific action pathways:

• Harm Reduction. Any inroads that are made either in the realm of multiple recovery pathways or in harm reduction are proof of at least some degree of success in navigating through a systems approach. The distribution and training of how to use Naloxone continues to be an effective way to reverse opioid overdose and save lives. Other programs, like needle/syringe exchanges, reduce the risk of infection and prevent the spread of other diseases. Resistance to these programs is reduced when they are paired with providing information about treatment options and other available support in the community.
  • What training on Naloxone administration is available in the area?
  • How is this service being marketed to ensure organizations across the health system know it is available? What are the most effective ways to expand distribution of Naloxone and add other harm reduction measures?
  • Are there ways to improve linkages to care?
  • What can the coalition do to reach more people, especially in areas with the highest rates of overdose, to expand harm reduction efforts?

• Recovery Supports. Housing, education, childcare, job training, and job placement assistance are just some of the recovery support services needed to help people in early recovery. Without these supports, many people can become frustrated or hopeless - increasing their chances of relapse. Communities with strong supports for people newer to recovery have seen positive results.
  • What types of recovery support services exist in the region?
  • Who are the key organizations working on one or more recovery supports?
  • Are area employers engaged? What about area workforce development entities?
  • Who can help expand these efforts as part of the coalition?

• Peer Support Networks. Peer Support Specialists and Recovery Coaches can play a vital role across numerous systems change initiatives. Working together with police, health services, treatment providers, and recovery support networks, they often provide an initial link to care for someone seeking help after an overdose or just wanting help. In many instances, they continue to work with people for longer periods of time - helping them find and get through treatment, as well as to provide support in meeting needs to maintain recovery.
  • How are peers being utilized in the area?
  • Is there room to expand current efforts and add more peer support through additional training and funding?
  • If more peer specialists and coaches could be added in the region, who is needed to help make that a reality?

• Collaboration with the Criminal Justice System. It is generally recognized that, in contrast to long-term incarceration, a person suffering from SUD can be helped to a far greater degree through various diversion and treatment programs which can lead to a life in recovery. This is tremendously beneficial, both socially and economically.
  • What options are there for those in the criminal justice system in terms of diversion, drug court, treatment while incarcerated, and treatment/support services for those leaving incarceration?
  • Are there areas that need to be added or improved?
  • Given what programs currently exist, what improvements could be made within the state and local criminal justice systems in terms of additional or expanded programs to help those with SUD find treatment - either through diversion programs or treatment for those incarcerated?
  • Are key figures who are part of the system willing to participate in a coalition?

Methods

System science uses a variety of tools to concurrently promote wide-scale, deep, and long-term change. One method for educating coalitions and the broader community on the need for such change is the iceberg model. It is commonly understood that the largest part of an iceberg is below the surface level. By correlating surface conditions to the “visible” symptoms, or the the events which most programs are oriented, it becomes obvious that we are not addressing deeper causes of the symptoms. Systems science encourages “going below the surface of the iceberg” to detect patterns. This relates to root causes, and is presented as the diagnosis of “what” is really happening. Going even deeper, the iceberg model approach asks “why?” and gently unravels our personal, agency, and broader social complicity in perpetuating the surface events.

One set of systems science tools that link to the prevention science methodology of communication campaigns or norm change fall under the umbrella of paradigm shifting. This is sometimes referred to as worldview work, because it identifies the values that both create the “why’s” in the iceberg model and help to keep them in place. Understanding different forms of values held by stakeholders is foundational to finding common ground across the community. This informs the systems change approach to building strategic partnerships.

Feedback loops reinforce both positive and negative results. The first, while beneficial can also lead to only continuing to do the same thing since that is working and to limiting other opportunities for innovation. It can also lead to expanding some agencies or programs and concentrating success, rather than fostering diverse efforts. Negative feedback loops lead to unintended consequences, such as rebounds or rewarding dysfunctional strategies.

The Theory of Change Model and the Collective Impact Model are examples of methods designed to change longstanding patterns and to foster the potential of innovative pathways to desired outcomes. Such approaches identify optimal leverage points and work at multiple scales

Relevant Research

• David Peter Stroh. Extensive work has been done in systems research in the physical and biological sciences, but less in the social sciences, especially focused on social systems associated with SUD. In contrast, Stroh has published a book, “Systems Thinking for Social Change: A Practical Guide for Solving Complex Problems, Avoiding Unintended Consequences, and Achieving Lasting Results.” This builds upon years of trainings in systems thinking in which he provided to fellows in the CDC Environmental HealthLeadership Institute. The text offers an introduction to systems thinking, a series of case studies, and tools for facilitating systemic collaboration.

• The World Health Organization promotes systems thinking as a way to mitigate negative behaviors, anticipate positive synergies, and create system-ready policies.

• The University of NC Center for the Business of Health examined optimal strategies for the use of opioid settlement funds. They provide the results of a literature review on five strategies most likely to be used by NC communities — recovery support, Naloxone distribution, post-overdose response, evidence-based addiction treatment, and criminal justice diversion programs.

Impactful Federal, State, and Local Policies

• The National Prevention Strategy (NPS) was developed as a result of the Affordable Care Act of 2010 (ACA). The National Prevention Council which authored the NPS is in itself an example of a systems approach, as it involved the efforts of seventeen different federal agencies. The Strategy explicitly places the responsibility for health and safety to the linking of community services with the empowerment of people and the elimination of disparities. It not only promotes the integration of SUD and mental health services, it does so by focusing on the relationship of both to diet, exercise, tobacco-free living, reproductive health, and injury and violence prevention. One example resulting from ACA and the NPS is the mandate for local hospitals to regularly work with the health departments in their county to collaboratively generate their needs assessments.

• SAMHSA is inherently defined as a systems agency by including both substance abuse and mental health in its name. SAMHSA has also been instrumental in advancing ROSC (Recovery-Oriented Systems of Care). See the SAFE Solutions article titled "Create Recovery-Ready Communities" for more information on ROSC. In addition to promoting the five data-driven phases of the Strategic Prevention Framework, two key concepts inform and are embedded within all five phases:
  • Sustainability. This is a system-building strategic posture, because it requires a long temporal view. However, SAMHSA promotes sustainability as more than just an approach to financing coalition efforts. It also intends for coalitions to develop and sustain their human capital.
  • Cultural Competency. Any projects funded through SAMHSA are required to meet certain inclusivity requirements, such as provision of resources in multiple languages. However cultural competency also extends much further into addressing health equity in building the capacity of a diverse coalition and ensuring all populations within a community are served. This creates a foundation for taking on the systems-level change required to address social determinants of health. (See SAFE Solutions article titled, "Apply a Health Equity Lens.")

• HHS 5-Point Plan. HHS developed a comprehensive strategy to improve access to prevention, treatment, and recovery support services. The strategy aims to support individuals to achieve long-term recovery and to prevent the health, social, and economic consequences associated with opioid misuse and addiction:
  • Better Addiction Prevention, Treatment, and Recovery Services. This involves working across the continuum of care. It has evolved to explicitly include harm reduction.
  • Better Data strengthens public health reporting to improve the timeliness and specificity of data and to inform a real-time public health response.
  • Better Pain Management advances the practice of pain management to enable access to high-quality, evidence-based pain care which reduces the burden of pain for individuals, families, and society while reducing the inappropriate use of opioids.
  • Better Targeting of Overdose Reversing Drugs. This has a particular focus on high-risk populations. Increasing the availability and distribution of overdose-reversing medications ensures broader provision of these drugs to people most likely to experience or respond to an overdose.
  • Better Research. Supporting cutting-edge research advances our understanding of pain, overdose and addiction. This leads to the development of new treatment and identifies effective public health interventions to reduce opioid-related health harms.

• The National Action Plan for Adverse Drug Event Prevention (ADE Action Plan) identifies common, preventable, and measurable adverse drug events and aligns the efforts of federal health agencies to reduce patient harms from these ADEs nationwide.

Available Tools and Resources

• SAMHSA. One example of systems work from a multi-sectoral approach is fostering collaboration between coalitions and the faith community. SAMHSA provides the “Faith and Community Engagement” website which notes that over 800 faith-based community partners have been among its grantees. The website offers information on grant funding and provides resources for community leaders.

• The US Department of Health and Human Services hosts an online Partnership Center for Faith-based and Neighborhood Partnerships. This site includes the “Opioid Epidemic Practical Toolkit: Helping Faith and Community Leaders Bring Hope and Healing to Our Communities.”

• SAFE Project offers “Bridging Prevention Recovery (BPR): A Community Approach to Systems Change” which is an evidence-based program model designed for substance use disorder prevention and recovery professionals. It is offered in-person and virtually, guides community leaders through an action-oriented model to systemically integrate prevention and recovery systems to strengthen programs and improve outcomes. BPR is a 3.5 day training program that culminates with 6 technical assistance sessions tailored to each community’s unique set of needs to support implementation and sustainability of joint prevention and recovery community projects. Certification as a trainer is also available.

• The Recovery Ecosystem Index Mapping Tool was developed by NORC at the University of Chicago, East Tennessee State University, and the Fletcher Group, Inc. to better understand the strength of recovery ecosystems in communities nationwide. This tool helps users assess important elements of the recovery ecosystem in their communities and leverage data to inform community efforts to support individuals in recovery. The online geo-spatial search engine allows users to evaluate availability of treatment services, recovery residences, harm reduction organizations, employment opportunities, and prevention organizations which are critical features of a recovery ecosystem.

• The University of Kansas through its Center for Community Health and Development offers the “Community Tool Box” which includes 16 different online toolkits Toolkits help a community to get a quick start on key activities in community work.

• The Search Institute has surveyed over 6 million youth in their acquisition of specific developmental assets which have been shown to both reduce risky behavior and enhance positive youth development. The Search Institute developed a set of 40 assets (20 internal skills and 20 inter-personal supports) which can be fostered in an “it takes an asset village” approach.

• The Annie E. Casey Foundation provides a document on their website titled, “Developing A Theory Of Change: Practical Theory of Change (TOC) Guidance, Templates and Examples.” TOC helps funders and leaders of a social change effort clearly articulate their objectives, discuss equity considerations, define roles of decision-making authority and enable useful measurement and learning.

• The Tamarack Institute provides an online course on the community impact model which is a widely used approach to forming cross-sector coalitions.

• The Center for Appreciative Inquiry offers trainings, workshops, and consulting projects in an asset-based approach to organizational and social engagement that utilizes questions and dialogue to help participants uncover existing strengths, advantages, or opportunities in their communities, organizations, or teams.

• The School of System Change offers a variety of fee-based courses and workshop for in-depth exploration of systems change science.

• Video Introduction. Hans-Georg Moeller, a philosophy professor at the University of Macau offers a YouTube video which (at timestamp 7:08) provides accessible examples of social systems theory by comparing “Dreamland,” Sam Quinones book on the opioid crisis to the portrayal of various social systems in the TV series “The Wire” and the film “Don’t look Up.” He uses each of the three cases to show how scientific/medical systems interact with legal, economic and political systems — all without centralized control.

• Reference Text. Patrick Hoverstadt has authored “The Grammar Of Systems: From Order To Chaos And Back.” This text is divided into two parts. The first part provides methods for thinking like a systems thinker. The second part provides 33 different principles of systems change, each supported with applied examples.

• System Conveners. The text “Systems Convening: A Crucial Form Of Leadership For The 21st Century” is authored by Etienne & Beverly Wenger-Trayner. It provides a series of profiles of people who are “working on sustainable change, across challenging silos, in complex social landscapes, amid changing circumstances.” This shifts emphasis form what systems thinking is to the people skills needed to make it succeed.

• Society for Organizational Learning (SOL) is an international source for leaders in business and government and non-profit agencies. SOL was founded by Peter Senge, a senior lecturer at MIT and author of the landmark text, “The Fifth Discipline: The Art & Practice of the Learning Organization.” System thinking is the fifth discipline pioneered by Senge in complement to such commonly practiced disciplines as personal mastery, mental models, shared vision, and team learning.

Promising Practices

• Maryland. The Maryland Collaborative to Reduce College Drinking and Related Problems has a mixed membership of public and private schools and community colleges and has grown to a representation of 19 of the state’s 42 campuses. It has a voluntary membership model which includes a requirement of annual board participation on the part of campus presidents. The Collaborative has two faculty co-directors and three staff members.

• North Carolina. The Campus & Community Coalition (CCC) serves as an example of the kind of work accomplished through the collaboration of the University of NC and the surrounding community in Chapel Hill. In 2014, the launch of CCC was provided through joint funding for the Coalition's full-time coordinator by UNC, the Town of Chapel Hill, the Orange County Health Department, and the Orange County Board of the Alcohol Beverage Commission.