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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.

Map the System 2020: A judge’s reflection from Sharon Zivkovic

On 15-17 June 2020, the Skoll Centre’s Map the System competition held its Global Final virtually. Sharon Zivkovic shares her experience as a judge for this year’s competition and reflects on the importance of systems thinking for addressing the challenges we currently face.

As a social entrepreneur with a passion for systems change, it was an absolute honour to be a judge for the 2020 Global Finals of the Skoll Centre for Social Entrepreneurship’s Map the System Competition. Holding a global competition that focuses on understanding complex challenge at a time when the world is facing its most profound and pervasive complex challenge in a generation did not go without notice. The global Covid-19 pandemic clearly brought home the need to develop skills for understanding and addressing complex global challenges.

During the Map the System competition, participating teams developed and presented a holistic view of a complex challenge of their choice by applying systems thinking tools and concepts. They undertook research to understand the landscape for their challenge, and the existing efforts that were occurring to address the challenge. With a deep contextual understanding of their issue, teams were able to identify gaps and levers of change for their challenge. The diverse topics chosen by teams this year included: violence, women, and modern slavery in Papua New Guinea; the U.S opioid epidemic; and the youth suicide crisis in India.

As a judge, I had the opportunity to read through the written submissions and analyse the visual systems maps of finalists before the Global Finals pitch event. After each team’s pitch presentation, the judges asked questions of the team members. While I thoroughly enjoyed every aspect of the Map the System competition, it was the opportunity to hear the responses of finalists to the judges questions that gave me the most delight. Not only had the finalists gained a systemic understanding of the challenges that they had researched, but it was very apparent from their responses to questions that they had developed meaningful relationships with the stakeholders in their challenge landscape. The finalists were also passionate about using what they have learned during Map the System to take meaningful action on their challenge beyond the time frame of the competition.

At the closing of Map the System 2020, Peter Drobac, Director of the Skoll Centre for Social Entrepreneurship, stated that in the wake of the Covid-19 pandemic there was the opportunity for the global Map the System community to ‘Build Back Better’: to focus on building more resilient and more equitable and just systems. Peter’s comments resonated very strongly with me. In recent months I had become disheartened with messages from political leaders that suggested the direction the world needed to take in response to Covid-19 was to ‘bounce back‘, just ‘hibernate’ and ‘rebound’.  Personally, I was more in favour of the view expressed by David Suzuki, that the COVID-19 pandemic could be an opportunity for the world to reflect and change its direction

Reflecting on my experience – observing the significant systemic leadership skills that the finalists had developed during the Map the System 2020 process, and having spent time with an amazing global Map the System community of changemakers – I am confident that together we can ‘Build Back Better’. 

highlights from the Map the System 2020 global final judge panel discussion
Click the image to explore highlights from the judges panel discussion

Sharon Zivkovic is the Founder and CEO of Community Capacity Builders and Cofounder and Chief Innovation Officer at Wicked Lab. In partnership with government, Community Capacity Builders delivers a program for social entrepreneurs that takes a systems approach. Wicked Lab has developed an online Tool for Systemic Change that is underpinned by complex adaptive systems theory.  This software assists governments and communities to address wicked problems by mapping, strengthening and transitioning ecosystems of initiatives that address the underpinning causal factors of a specific wicked problem. Wicked Lab also delivers a project-based Complex Systems Leadership Program and a program that supports the development of Systemic Innovation Labs.

Mapping the System to address sexual assault in New Delhi

On Sunday, 9 June 2019, the Skoll Centre’s Map the System Competition held its Global Final in Oxford for another year. Making it to the final six teams out of 20 overall finalists, the University of Oxford team, No Means No, took 2nd place, winning £3,000 in cash prize money. But the money and the prestige of being in the top three winners only came 2nd to the incredible journey of learning and discovery this team of five Indian students, four of which were Oxford MBAs.

Oxford MBA 2018-19, Prerna Choudhury and teammate and Duke University Sandford School of Public Policy alumna, Tanmayata Bansal, tell us how they mapped the system of gender-based violence in New Delhi, India.

In early January, we came together as a team with a common thread that is unfortunately part of the lived narrative of most Indian women—we all had either been victims of sexual assault or known someone close to us who had. In 2012, the brutal gang rape and death of 23-year-old Jyoti Singh brought the city of New Delhi to the forefront. Seven years later, Jyoti’s parents, who have now turned activists feel that change has not occurred and that justice in India has failed Jyoti and women like her.

Not only were we frustrated by the lack of progress made to address the problem in our country, but we were also passionate about wanting to be a part of the change. Map the System offered a public platform for us to break the societal taboo we had dealt with our whole lives, using the lens of systems thinking, which was particularly relevant to a problem as complex as ours that involved a diverse range of stakeholders and was multi-faceted in its contributing causes and solutions.

We conducted extensive primary and secondary research to help us map stakeholders and develop a narrative illustrating the interplay between these stakeholders. This ongoing interplay contributes to perpetuating sexual assault against women in New Delhi. We read news articles, op-eds, reports, and academic literature to help us understand the history and quantify the extent of the issue. We identified 20 distinct stakeholders that were either experiencing, contributing to, or trying to prevent the problem.

The second phase included primary research which included 31 interviews across our stakeholder spectrum. We started by reaching out to our internal network and gradually progressed to sending out cold emails. We received an overwhelming response to our cold emails, which further strengthened our belief that the issue needs to be discussed on a visible platform.

These interviews further tied to our secondary research and gave us nuanced perspectives on the issue. The process also contributed to our final systems map which underwent multiple iterations – from a linear process map, to a rather convoluted and more accurate depiction of the problem and aspects related to it.

So what were our findings? We’ve outlined and synthesized our research and findings:

Solutions

Widespread change can only be achieved if the city of New Delhi implements a concerted city-level strategy that targets solutions in education, policy, law, technology, and infrastructure:

  • Education: All our interviewees advocated for education as key to fostering long-term change in mindset. Solutions targeting education taking the longest to make an impact but yield the highest probability of bringing about a paradigm shift.
  • Policy: Implementation and enforcement of policies takes time and is key to success.
  • Law: A comprehensive legal structure already exists in India to deal with crimes of sexual assault. Reform should focus on expedition, reduction of errors, and placing the victim at the center of the case.
  • Technology: Use of mobile phone apps and SOS emergency lines have provided women with an avenue to report sexual harassment. Social media campaigns have also enabled stigma reduction.
  • Infrastructure: Physical infrastructure such as lighting, or social infrastructure such as networks help reduce the incidence of sexual assault.
Tanmayata Bansal wit her team mates at the Global Final of the Map the System
Tanmayata Bansal presenting with her teammates at the Global Final of the Map the System competition on Sunday, 9 June.

Gaps & Levers of Change

  • A lack of prioritization and implementation can be addressed by prioritizing gender equality as part of the national agenda through policy changes such as reducing investigation times or portraying women in empowered roles in Bollywood movies.
  • A lack of sensitivity and support is mitigated through the creation of a safe and reliable place for women to fight against assault, achieved through repeated gender sensitization trainings and the building of strong social networks and cohesion among female professionals.
  • Shortfalls in staffing and representation are countered by increasing the agency and representation of women across sectors.
  • A lack of knowledge, awareness and accessibility can be addressed by increasing educators’ awareness of the importance of developing emotional intelligence in students.

Systems Map

Our systems map was divided into three parts:

  • A system that promotes gender equality: A map tracing the way in which gender inequality is deeply entrenched in Indian society and promoted from birth.
  • A system that normalizes sexual assault: A map analyzing the ways society, the political and legal system engage in victim blaming and shaming and enable the attacker through his ability to exercise control through power and bribery.
  • The mental models and underlying structures that support the system such as a deeply entrenched patriarchy, an outdated and rigid educational system, caste system, religious and cultural traditions, weak institutional support, and social stigma.

Download our map here

Image of group photo of team No Means No
From left to right: Tanmayata Bansal, Prerna Choudhury, Sahl Abdus Salam, Neha Sethi and Mridula Vasudevamurthy

Map the System empowered us to speak about a topic that was deeply personal to all of us. Ever since the competition, we noticed programs and campaigns happening in the city of New Delhi increasing awareness on the issue. Most notably, a leading radio station has started a campaign to make Delhi safe, especially at night by creating a sense of responsibility among its residents and urging them to be more vocal and actionable if they witness sexual harassment. We look forward to collaborating with such efforts and disseminate our findings and report among our stakeholders and organizations to take our efforts forward.

Authors: Prerna Choudhury Oxford MBA 2018-19 & Tanmayata Bansal Masters in Public Policy Analysis at Duke University.

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Accelerating Systems Change: Making Possibility Real

Each year the Skoll Centre invites a small number of Oxford students to the annual Skoll World Forum on Social Entrepreneurship. Each year they share their unique perspectives of the sessions and events that unfold during this magical time in Oxford.

It’s hard to deny that social issues are becoming ever more global, complex, and interdependent—‘systems change’ embraces this.  As Peter Drobac (Director of the Skoll Centre for Social Entrepreneurship) explained in the Skoll World Forum’s Opening Plenary: ‘social entrepreneurs treat the system, not the symptom’. 

Expanding on this, the panel moderated by Sally Osberg (Past President and CEO, Skoll Foundation) explored the theme ‘Accelerating Systems Change: Making Possibility Real’.

For those of us still confused about what systems change actually means, Marc Freedman (CEO and Founder of Encore.org) probably nailed it, responding with a laugh: ‘I didn’t realise I was working on systems change before arriving at the Forum’.  Freedman’s organisation addresses the societal shift—more people over 60 than under 18 now than ever before—as a systems problem.  He describes that ‘the needs and the assets of the young and old fit together like the pieces of a jig-saw puzzle’. 

Social entrepreneurship may not try and complete the whole puzzle, but it fits some key pieces together with a view of what the puzzle or system itself may look like.

This systems approach, however, doesn’t come without risks.  As social entrepreneurs and philanthropists engage with problems where government was once the only actor struggling to achieve change, at least one risk is clear.  How do independent actors engage in systems change without being accountable to, or representative of, the people? 

Safeena Hussain (Founder and Executive Director, Educate Girls Foundation) noted with reference to development impact bonds, ‘these are sharp tools’, ‘ceramic knives’ even.  Their design and use can lead to unintended and potentially cutting consequences.  Becoming divorced from ideas of social justice and equity in the sole pursuit of easily measurable objectives is one of them.  As Hussain continued, ‘who decides what is important?’

Olivia Leland (Founder and CEO, Co-Impact) commented that the key, for philanthropy at least, is to listen.  To work with all other participants in the system to ensure that these developing tools of social intervention have only positive impact.

But social entrepreneurship can also create accountability as Ma Jun (Director, Institute of Public and Environmental Affairs) exemplifies. 

China’s economic advancement over the past forty years has come at a cost to the environment in particular (and the environment’s effect on health).  Identifying a piece of the puzzle, Ma Jun developed a way of substituting China’s limited ability to enforce environmental regulations with disruptive transparency.  The Institute of Public and Environmental Affairs believes that although ‘transparency seems subordinate to regulation, it is of greater importance’. 

Sourcing and reporting pollution data from almost 1 million factories Ma Jun’s Institute has engaged with thousands of factories and changed behaviour through replacing regulatory enforcement with shame and blame. 

Most excitingly, this approach is globally (and cheaply) transferable.  Data monitoring (even in real time) and transparent reporting of pollution is low cost and can be expanded across the world with ease.  As manufacturing shifts from China to less regulated countries with more limited enforcement capacity, protecting health and the environment through disruptive transparency can follow.  This solution, even if inadvertent, can apply across a global system to prevent continued environmental damage.

Mr Freedman spoke for many of us – we didn’t realise we were working on systems change until now.

About the author

Christian Habla

Christian Habla is currently undertaking the Master of Public Policy (MPP) at Oxford to pursue his interests in people, complex societal problems and the systems they exist in. Upon completing the MPP, Christian intends to apply his studies and his professional experiences – advising and investigating major global companies and governments as a lawyer, and co-founding youth suicide prevention initiatives in community building, investments, education and strategic advocacy – to social impact.

Photo credit: Skoll Foundation

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Skoll Centre launches Impact Lab programme

The Skoll Centre for Social Entrepreneurship this year launches the “Impact Lab”, a one year co-curricular programme designed to enable Oxford MBA students to take a leading role in tackling the complex and pressing social and environmental challenges of our world.

The programme cultivates the knowledge, tools and personal leadership qualities needed to drive ambitious and systemic change across sectoral and organisational boundaries. Weekly workshop sessions and in-depth bootcamps with leading practitioners and thought leaders cover topics such as systems thinking, human centred design, impact measurement and impact investing. In tandem with this, through action learning and access to executive coaches, Impact Lab participants are supported in deepening their self-awareness, developing character, and understanding their own impact leadership journeys. The programme concludes with an opportunity for Lab members to create and deliver a personal talk on their own journey, how they have changed and the impact they wish to have on the world.

Building on our successful pilot “Skoll Academy” in 2017, the Impact Lab launched on October 6 this year with an inaugural cohort of 38 fantastic MBA students selected through an application process. Lab participants include students from a range of backgrounds, including:

  • Julie Greene, a social entrepreneur who ran bakeries across East Africa providing vocational training, employment and wellness services to women;
  • Sergio Navarro, a former VP at Goldman Sachs, doctor and founder of a health-tech company using augmented reality to deliver rehabilitation therapy;
  • Kudzai Chigiji director of a Pan-African advisory and infrastructure development company, currently operating in education and healthcare across East, West and Southern Africa;
  • Mridhula Sridharan, an investment strategist who has advised high net worth individuals, corporates and foundations across India and enabled investments to be directed into development initiatives.

The ethos of the Lab cultivates peer-led and peer-to-peer activities, and students are actively engaged in shaping the evolution of the Lab across the Oxford year.

In light of the United Nations Sustainable Development Goals, the ambitious targets in the Paris Climate Agreement and the multiple social and environmental challenges facing our world, now more than ever, we need leaders who can understand these interconnected and complex issues, design and execute effective interventions, and lead teams, organisations and movements.

For more information or if you would like to collaborate, feel free to contact us. Many of the Impact Lab presenters are also running public sessions as part of the Skoll Centre Speaker Series. More information can be found on the Saïd Business School events listing.

By Shruthi Vijaykumar, Skoll Centre Associate

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Vanilla, blockchain and the circular economy – one year on the Oxford MBA

Skoll Scholar and circular economy entrepreneur, Nikhil Dugal, highlights the best part of his year at Oxford on the MBA programme. 

The Oxford MBA is quite a unique experience in the world of business education. The extent to which our class discussions and interests differ from other business schools is apparent when I travel to London to meet friends enrolled in other MBAs.

Over the course of the past year, the MBA has helped me keep pace with many issues of recent development, including emerging technologies, climate change mitigation and the circular economy, all while keeping one foot firmly in the business world.

Sustainable Vanilla

Another opportunity to undertake learning was the entrepreneurship project (EP) in Trinity term. In addition to encouraging novel business ideas, Oxford Saïd also invites external collaborators to come pitch live projects to the MBAs for the EP. This offers individuals in Oxford the opportunity to work with MBAs on their project for a semester, while the students get the opportunity to work on a live project and contribute to real-world impact.

My team used the opportunity to work with an agro-ecologist from Oxford who is working on preventing deforestation in Indonesia by encouraging local farmers to grow Vanilla in the rainforests. Vanilla is the second-most expensive cash crop in the world. However, only 1% of the world’s supply comes from natural sources, while the majority comes from synthetic vanilla manufactured from petrochemicals. Natural vanilla grows as an orchid and can be planted in degraded rainforests to help restore the natural ecosystem in a polyculture system. Establishing a larger market for forest-grown organic Vanilla from Indonesia can help restore degraded rainforests and provide smallholder farmers a more lucrative alternative to engaging in unsustainable palm oil farming. We spent a semester working on their business models, financial projections and market entry strategy. Meanwhile, they have started a pilot in Kalimantan and planted 18000 saplings on 500 hectares of land leased from the government. Moving forward, their team will be using our research and projections to scale the project, raise funding and enter the market.

Nikhil debating at the Responsible Business Forum.

Nikhil debating at the Responsible Business Forum.

Circular Economy

Before joining Oxford Saïd, I was working on a circular business in India, making eco-friendly infrastructure for development sector organizations. The circular economy elective in Trinity term gave me the opportunity to interact with a diverse set of stakeholders working to establish the circular economy in the UK. This included entrepreneurs from companies such as Toast Ale and Elvis & Kresse, investors such as LWARB and Circularity Capital as well as practitioners from the Ellen MacArthur Foundation. This gave us a broader view of how the ecosystem works in the UK and provided opportunities to network with people working on the front-lines of the problem.

Blockchain for Impact

Over the course of  ‘Strategy and Innovation’, we were given the chance to apply concepts learned in class to an emerging field. I took the opportunity to research the use of blockchain technology for sustainable supply chain tracking. After learning more about this topic for my final coursework, I was given the opportunity to interact with two practitioners working on applying the technology on the ground and hear their perspective on it as well. Hugh Locke, the president and co-founder of the Smallholder Farmers Alliance in Haiti visited to speak at the Responsible Business Forum 2018. Their partnership with Timberland is using blockchain technology, built from the ground up with beneficiaries in mind, to help source sustainably grown cotton and revive the Haitian Cotton Industry. At the same forum, we were also visited by David Davies, the founder of AgUnity, which is using blockchain to increase the transparency of financial transactions in farmer cooperatives and increase farmer’s trust in the institution.  During Trinity Term, our Tech for Impact class hosted one of the founders of Alice, which is using blockchain technology to undertake social impact tracking to help create a new type of cryptocurrency based social impact bonds. At Saïd Business School, what I’ve appreciated about the learning style is the ability to balance both theory and practice.

Nikhil and his peers in traditional Oxford exam attire.

Nikhil and his study group on the MBA.

Systems Change

The issues social entrepreneurs work on are extremely complex and involve many stakeholders with diver interests. Tackling complex problems like climate change can seem overwhelming because of the complexity of the problem itself. Systems change constitutes studying how systems work, identifying stakeholders that are part of a system, understanding their preferences and identifying inflection points in the system where an intervention can lead to a significant impact. At the Skoll World Forum, I had the opportunity to also meet system entrepreneurs who are working in the field of systems change, in organizations such as Participatory Cities and Forum for the Future.

Moving forward, I will be spending the summer researching systems change and meeting practitioners to undertake landscaping research with the Skoll Centre for Social Entrepreneurship.

This past year has given me the opportunity to step back, reconsider the impact of my work, and inform my opinion by giving me a broad exposure to topics that are interrelated to my work. Although the year has gone by unbelievably fast, it has also reformed my perception of the world. There are an uncountable number of people of all ages and professions, who are working to help realize the world of the future. It’s a world that includes autonomous electric vehicles, distributed ledger technology and a global shift towards renewable energy.

The opportunity for me to be at the center of this transition has been made possible with a Skoll Scholarship and it will continue to shape my thinking as I transition out of Oxford, back into the world.