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Map the System: Using Systems Science to Advance Health Equity in Tobacco Control

On 15-17 June 2020, the Skoll Centre’s Map the System Competition held its Global Final virtually. The team from The University of North Carolina at Chapel Hill competed against 30 other finalists from institutions around the world at the event, coming in third place in the competition. Team members Meghan O’Leary, Paige Logan, Sarah Mills, Shelley Golden and Kristen Hassmiller Lich tell us how they mapped the system to explore inequities in tobacco control.

Smoking rates have declined considerably over the last five decades in the United States. However, this progress has not been shared equally. Many lower-income and racial/ethnic minority populations are more likely to smoke than their counterparts and disproportionately shoulder the burden of tobacco-related disease.

We created a team focused on understanding socioeconomic and racial/ethnic disparities in smoking from a systems perspective. Members of our team represent the fields of health behavior, health policy, and systems science. Building on these backgrounds, we developed a model that captures the multilevel factors affecting smoking. Processes of marginalization and segregation, as well as employment and housing factors that may produce financial strain, are included as key contributors to smoking in our model. By documenting these structural reasons for smoking disparities and lived experiences of people of color and lower-income groups, we hope our model can help to effectively engage communities and relevant stakeholders and to design tobacco control policies and programs capable of reducing smoking in priority populations.

Developing our model

Our model of smoking is informed by tobacco control literature and interviews with key stakeholders. We consulted prior research to identify factors associated with smoking. This included a close review of 12 prior smoking models – none of which addressed the specific factors contributing to higher smoking rates in priority populations. We turned to fundamental cause and social stress theories to identify these root causes of smoking among racial/ethnic minorities and lower-income groups.

We shared a model draft with nine stakeholders, who provided insightful feedback about our model, allowing us to consider new factors that should be included and challenging us to carefully consider the relationships between variables. They provided the perspectives of smokers, mental health professionals, health equity advocates, and community-based organizations.

Our Smoking Model

  • Green = individual-level factors associated with smoking
  • Blue = environmental-level factors associated with smoking
  • Red = root causes of smoking among racial/ethnic minority and low-income populations
  • + indicates the variables move in the same direction (e.g., as stress increases, tobacco use increases)
  • – indicates the variables move in the opposite direction (e.g., as access to cessation services increases, tobacco use decreases)

Policy Implications

We applied our model to tobacco control policies designed to improve equity in tobacco control, revealing how the policies are intended to address disparities, as well as their potential unintended effects that may sustain or worsen disparities. For example, smoke-free public housing aims to lower smoking among public housing residents by creating more smoke-free homes and reducing pro-smoking norms. Yet, violation of this policy may result in financial strain and/or housing instability, increasing stress and reducing feelings of controls, which can lead to increased smoking. The figures below illustrate these intended and unintended effects.

Text Box: Smoke-free Air Policy
Figure 1. Expected Impacts of the Smoke-free Air Policy

Reinforcing loops in the model are indicated with an ‘R’ and represent relationships that will continue to grow, or reinforce, over time.

Figure 2. Unintended Impacts of the Smoke-free Air Policy

We identified two other disparities-focused policies with potential unintended consequences per our model:

  • A menthol ban intends to reduce smoking among those who prefer menthol cigarettes. However, targeted marketing of other tobacco products is still possible through segregation and discrimination.
  • Minimum price laws (MPLs) enact the largest price increases on the least expensive tobacco products. While expected to reduce smoking by raising prices, this policy may unintentionally increase financial strain and stress and reduce feelings of control.

Our Recommendations

1. Use a health equity lens

Tobacco control efforts often focus on reducing smoking at the population level, but to ensure equitable outcomes, attention to priority populations is needed. Being intentional and focusing on how systemic racism and other structural factors permeate the model pathways and contribute to smoking disparities is critical. Future tobacco control efforts must acknowledge and address these lived experiences of communities.

2. Consider the intended and unintended consequences of tobacco control policies and programs

Well-intentioned efforts to lower smoking in priority populations can have unintentional and even counteractive effects. Consideration of these adverse outcomes upfront, as well as ongoing evaluation of policies and programs, can help to identify, react to, and address these unwanted effects.

3. Engage diverse types of stakeholders in tobacco control efforts

Additional voices are needed to represent the needs and perspectives of priority populations. We recommend engaging smokers, retailers, housing officials, law enforcement, social service agencies, mental health practitioners, and community-based organizations. Partnering with local communities can help to identify other relevant stakeholders.

Next Steps

Map the System provided a platform to present our model of smoking and receive feedback from other systems thinkers working on similarly complex issues. We value the information learned and are committed to continuing this work. We are currently conducting additional stakeholder interviews. We hope to build confidence in our model by testing some of the relationships between variables through future studies, and use our model to facilitate collaborative discussions about tobacco control in diverse populations.

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A Tale of Two Viruses

Dr. Diana Esther Wangari is a current 2019-20 Skoll Scholar and Oxford MBA. She is the co-founder of last mile health venture, Checkups Medical Centre in Kenya where she dedicates her work to treating those who need it most. Read more about Diana’s experience as a health professional during two viruses.

It started when I was in the queue at immigration. This was at Brussels Airport. The elegant lady looked at me, almost apologetically, then whispered to her partner. He turned and looked, decidedly less friendly, pulled her towards him and they moved forward.

They didn’t have to tell me what they were thinking. I was the only African in this queue, and it was at the height of the 2014 Ebola crisis in West Africa: they had no way of knowing what country I had come from.

And by then, global news headlines had already proclaimed the ultimate horror: a man infected with Ebola had travelled all the way to the USA, without his deadly infection being detected.

Worse still, he had interacted with various members of his friends and family – over and above his fellow passengers on the flights to the US, and the airline crew – before the truth had emerged that he had Ebola. Total panic had ensued in America, and demands were made for all flights to the US from West Africa (if not all of Africa) to be suspended immediately.

I knew they were looking at me and thinking just one thing…Ebola.

It was a time of global hysteria over this terrifying disease, and thus not really the best time for an African to be flying to Europe or North America.

So why was I there? At that airport? In that immigration queue?

I had travelled from Nairobi, Kenya to Brussels, Belgium.

My final destination was the Institute of Tropical Medicine (ITM) Antwerp, the very institution where Ebola had been discovered by Dr. Peter Piot back in 1976.

You could argue that this feeling of being dehumanised – of being seen essentially as a potential carrier of a deadly and highly contagious virus – was all in my head. But I was to have an even more disturbing encounter in the train on my way from Brussels to Antwerp.

On the train where I was seated next to the window, a child came and sat next to me only for the mother to promptly grab her hand and swiftly move with her to a distant couch. The gentleman seated opposite, noticing my facial reaction, leaned in and started speaking in French.

Now while I do know some French, it certainly didn’t prepare me for the verbal onslaught of incomprehensible French that poured forth, and so I stared at the gentleman and said, “En anglais s’il vous plait.”

“Aha, so you are not from a Francophone country,” said the gentleman, “I was simply apologizing on behalf of the lady as it is ignorance and now, I see that you are not from West Africa.”

In the conversation that followed, I explained to the kind gentleman that I was actually from Kenya. And that despite there being no cases of Ebola in Kenya, the impact of the Ebola outbreak on sectors of our economy would be notable.

Our parliament had officially decreed that Kenya Airways, our national carrier, suspend all its flights to West Africa for fear that one of the many transit passengers from West Africa would bring the dreaded disease to Kenya.

The Kenya Airways management argued in vain that they were taking precautions against any such possibility; that there were even European airlines still flying to the West African nations affected; and that flights from West Africa to Dubai or China, via the Nairobi hub, were a key profit centre for Kenya Airways.

But the parliamentarians would have none of it. One MP even declared that the next flight from West Africa landing in Nairobi, would find him – along with his supporters – lying on the runway to prevent it from landing “if that is what it would take to secure the lives of innocent Kenyans, threatened by Ebola”.

But I digress. Bruno (for that was his name) told me of his dream to go on Safari in Kenya and was considering going to the Maasai Mara to witness the annual wildebeest migration, famously, “The eighth wonder of the world”.

I was smiling and laughing by the time I got off the train.  But that night – my first night at ITM – I cried. I just could not help it.

However, that nasty experience of being an African traveling in Europe at the time of Ebola was quickly forgotten as I settled into ITM, as every day I got to interact with scientists who were travelling regularly to Liberia at the very heart of the outbreak: the kind of courageous and dedicated biomedical researchers that the world has learned to think of as heroes, since the COVID-19 pandemic descended on us all.

airplane window showing the wing of the plane in blue skies

And speaking of COVID-19, six years after the incident at Brussels Airport, I found myself in another queue. This time at the Jomo Kenyatta International Airport in Nairobi.

After completing the re-entry formalities, getting into the Uber, I noticed the undue speed with which the driver picked up my bags and flung them into the boot.

And then, once I was seated in the back of his car, ever so casually, he asked, “Where are you flying in from, my sister?”

“London,” I answered.

And I could hear the “Oh” and then a moment of silence, before he continued in a rather accusing tone of voice, “Kenya just confirmed its first case of “corona” yesterday. It was a lady coming from London as well.”

I got the impression that he felt I should have volunteered that piece of information about having flown in from London before I got into his cab; given him the opportunity to decline to drive me home.

An uneasy silence followed.

“Are you worried?” I asked despite the fact that I was in the back seat with ample space between. He quickly shook his head but did not say anything.

We drove in silence. But it was unnerving to see the occasional glances he threw back – taking his eyes away from the road for a second or two – as if he was checking for some indication that he was at risk: that a fine mist of coronavirus might be floating towards him, brought back from a contaminated London, to infect innocent people in Nairobi.

On arrival, I volunteered to take out my own bags. The driver seemed relieved.

Thanks to that great Kenyan innovation, the ubiquitous Mpesa mobile phone money transfer system, I was able to pay him without having to hand over to him, what he would no doubt have considered to be “corona”-infected cash.

There was a time when I would have been very tempted to scream at him that I refused to be treated like a leper in my own country.

But I had seen much more of the world over the past six years. I understood fear. I just paid him and thanked him. I even gave him a tip.

And that night, I did not cry.

For you see, I had learnt over the course of time, life is not black and white. I was now an MBA student at Oxford University’s Saïd Business School and I had the sinking feeling that our MBA experience, just like the rest of the world, was not going to be the same. It has been two months and I was right.

Perhaps the hardest part was being torn between answering the call to aid my country as a health professional and continuing down the path I had already embarked on at Oxford. And some days, I do find myself volunteering in the hospital because the little we can do, we must do.

And as we continue with our classes online and I think back to the classmates, the faculty, the friends and the family I made, I know it has not been easy.

I will tell you what Bruno told me as we left the train that autumn evening at Antwerpen-Central, “Take care of yourself my dear. Don’t forget to smile. It shall pass”.

This too shall pass.

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How to understand public healthcare challenges

The Skoll Centre’s Apprenticing with a Problem awards support individuals to engage in experiential learning and deep immersion around the challenges that they seek to tackle.

Oxford MBA alumna, Melissa McCoy, is a 2016-17 awardee whose apprenticeship took her to South Africa to learn about the real challenges faced in the healthcare system, from those who experience it first-hand.

About two years ago, I started trying to solve South African public healthcare challenges before setting foot in the country. For my Oxford MSc Computer Science thesis project, I built a low bandwidth-optimised online telehealth platform and a machine-learning based triage tool for South African patients to solve issues of doctor scarcity and misdistribution. While this sounds logical, I jumped into creating a solution before truly understanding the problem space.

The Skoll Centre’s Global Challenge competition, which resulted in an Apprenticing with a Problem grant, was a huge blessing. It gave me the resources and thought space to understand South African healthcare challenges from several angles and ensure I was tackling the problems in the right way.

The resulting research that my team and I completed focused on visiting 15 healthcare facilities, spanning several characteristic types:

  1. Primary, secondary, and tertiary levels of healthcare
  2. Gauteng, Western Cape, North West, and Mpumalanga provinces
  3. Remote rural, rural, and urban geographies.

The research also focused on speaking with four types of stakeholders (doctors, nurses, facility managers, ICT professionals) that represent the various healthcare system perspectives.

While our findings around the problem space were extremely valuable (and are fully detailed in our report), we also took away some surprising insights:

  1. Willingness to embrace change: Contrary to our initial beliefs, people in the public healthcare system in South Africa do not enjoy the status quo. They are cognisant of the challenges and inefficiencies in the system. They also believe that while there is a lot that rests on the powers that be, there is a lot that they can do themselves to bring about change. Our visits were viewed with optimism and most facilities were hopeful and confident that our suggestions would be beneficial for them. A system that is not cynical and is open to feedback is bound to see progress in due course of time. The positive attitude of practitioners and the administration alike towards embracing technological improvements was a huge motivational factor for us.
  2. Bottom-up, Organic Tech Solutions: While many facilities lacked digital infrastructure to allow for referrals and sharing information, healthcare facilities & professionals devised their own ways to facilitate these processes. Doctors had created WhatsApp groups to discuss difficult patient cases. Nurses had equally formed networks among themselves and would send SMS messages to each other to communicate bed occupancy and information about referred patients.
  3. Learning from field interviews is hard: We came into the research with several pre-conceived ideas around the core problems and the appropriate solutions to solve them. We wanted to validate if our hypotheses were correct without biasing interviewees in the process. In Rob Fitzpatrick’s book, The Mom Test (which we referenced often), he summarises the challenges of this process well: ‘Trying to learn from field conversations is like excavating a delicate archaeological site. While each blow with your shovel gets you closer to the truth, you’re liable to smash it into a million little pieces if you use too blunt an instrument. I see a lot of teams using a bulldozer and crate of dynamite for their excavation. They use heavy-handed questions like “do you think it’s a good idea” and shatter their prize. At the other end of the spectrum, some founders are using a toothbrush to unearth a city, flinching away from digging deep and finding out whether anything of value is actually buried down there.’ We botched at least a dozen conversations with stakeholder, by either introducing our concept of interest too early or never bringing it up and getting their true thoughts. This was a skill we gradually improved upon with every interaction.

Overall, the exploration was invaluable and one-of-a-kind. It set the stage for how our company, ConnectMed, planned to work with the South African public healthcare system, as well as how we now think about engaging the Kenyan system.

Melissa recently completed her MSc Computer Science and MBA at University of Oxford on a Rhodes Scholarship and is now working on a Africa-focused digital health venture, ConnectMed, in South Africa and Kenya. She previously worked in the Americas and Africa as an engineer, entrepreneur, and consultant.

Follow @melissa_mccoy

Download Melissa’s Apprenticing with a Problem report.

Read more about Apprenticing with a Problem on the Skoll Centre website.

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Who wants to be sexy, anyway? How ignoring the boring bits of global health costs lives

Global Health: Getting from Innovation to Implementation panel

Forging Common Ground – Series of Oxford Student Insights to the Skoll World Forum 2017.

Oxford DPhil candidate in Philosophy, Michael Plant, gives his perspective on the  Skoll World Forum session “Global Health: Getting from Innovation to Implementation”.

As you start the marathon, crowds cheer you on. They’re with you for the first mile. And the second mile. Now you’re at the 15th mile. You hit the wall. You need support to keep you going –  a glass of water, a single cheer – but no one’s there. Who wants to watch the middle of a long race? You know they’ll be crowds to cheer you across the line, but that seems very far away.

This, argued Barbara Bush, founder of Global Health Corps, is an uncomfortably apt analogy for the problems facing global health as it tries to move from innovation to implementation. People get excited about the start: creating a new vaccine. And people can get excited about the end: making sure that vaccine travels the last mile and gets to the child who needs it.

Yet, in the long distance between those two, cheerleaders are thin on the ground. It’s very hard to get people interested in improving health systems, scaling up interventions and finding better ways to distribute medicines around the world.

Why? Systems simply aren’t sexy, unsexy things get ignored, and so millions of people die or suffer from health conditions we already have the technology to solve.

Hence the question Barbara posed to the three experts on her discussion panel: if we want to improve the ‘unsexy middle’ of global health, what should we do?

Steve Davis, CEO of PATH, argued healthcare innovators should be designing with scale in mind and the road to scale is mostly clearly through health ministers, rather than patients or funders. For instance, there’s little point creating a new drug so expensive developing countries can’t afford it.

Yap Boum of MSF added progress is often slow because locals aren’t invited to be part of the innovation process. How much better could NGOs be if they had locals on their boards who understood the country?

Surgeon and public health researcher Atul Gawande agreed going from ‘zero to one’ – inventing something – was valued much more by funders than taking discoveries and bringing them into the existing systems. At least in part, this is because discoveries feel much more tangible. He suggested a way around this is for funders to focus on scaling an innovation by one order of magnitude at a time, seeing each as a serious and independent goal. Pioneering a new procedure in one clinic should be thought of as a victory. Getting that procedure from 1 to 10 clinics is different second achievement requiring different methods, getting it from 10 clinics to 100 a third, and so on.

As panel discussion moved to questions, the audience wanted to understand why there wasn’t more collaboration between all the different organisations. If so much of global health is just a co-ordination problem, why haven’t we solved it yet?

The problem, it seems, is people having priorities. If, as Atul shrewdly noted, the US can’t even agree on whether to provide subsistence healthcare in their own country, how could we reasonably expect NGOs, governments and donors to all be effectively pulling in the same direction on global health? He suggested we need a unified metric, or yardstick, to compare different potential health priorities and reveal the top priorities.

Two things struck me from the conversation today. The first was: if we’re worried we’re overlooking things because they’re not sexy, what else are we ignoring?

As someone who’s interested in how best to increase happiness – or put another way, how best to reduce misery – I had hoped mental illness would have been a bigger part of the discussion. Research suggests mental pain can, and often does, have a bigger effect on self-reported happiness scores than physical pain does. What’s more the way standard health metrics, such as ‘QALYs’ (Quality-Adjusted Life Years), are constructed fails to adequately capture the badness of mental illness (see Dolan and Metcalfe 2012). Perhaps due to the stigma, measurement issues, or the complexity of treating them, mental illness is the marathon almost no one is even watching.

Second, if we need to agree on a single metric so we can prioritise resources in global health, it seems obvious to me the right metric is happiness. I take it we don’t value health just for its own sake, but because it helps us live longer and enjoy our lives more. Not all health conditions make people unhappy and, where there’s a choice between reducing unhappiness or ill-heath, we should target misery. Whilst some may worry happiness is too ‘fluffy’, the evidence suggests ‘subjective well-being’, as it’s often called, can be reliable measured. The OECD now recommends countries collect data on it.

Neither improving healthcare systems or mental health care are particularly sexy, which is why they’ve been overlooked. However, as Steve Davis said at the close to the session: our outrage at avoidable deaths and suffering should drive us to do better.

Michael Plant is a DPhil Candidate in Philosophy, CEO and Co-Founder of Hippo. Read more from Michael at www.plantinghappiness.co.uk.

Follow Michael: @michaeldplant