Making sense in a complex landscape: how the Cynefin Framework from Complex Adaptive Systems Theory can inform health promotion practice.

Health promotion addresses issues from the simple (with well-known cause/effect links) to the highly complex (webs and loops of cause/effect with unpredictable, emergent properties). Yet there is no conceptual framework within its theory base to help identify approaches appropriate to the level of complexity. The default approach favours reductionism--the assumption that reducing a system to its parts will inform whole system behaviour. Such an approach can yield useful knowledge, yet is inadequate where issues have multiple interacting causes, such as social determinants of health. To address complex issues, there is a need for a conceptual framework that helps choose action that is appropriate to context. This paper presents the Cynefin Framework, informed by complexity science--the study of Complex Adaptive Systems (CAS). It introduces key CAS concepts and reviews the emergence and implications of 'complex' approaches within health promotion. It explains the framework and its use with examples from contemporary practice, and sets it within the context of related bodies of health promotion theory. The Cynefin Framework, especially when used as a sense-making tool, can help practitioners understand the complexity of issues, identify appropriate strategies and avoid the pitfalls of applying reductionist approaches to complex situations. The urgency to address critical issues such as climate change and the social determinants of health calls for us to engage with complexity science. The Cynefin Framework helps practitioners make the shift, and enables those already engaged in complex approaches to communicate the value and meaning of their work in a system that privileges reductionist approaches.

A reverse pathway? Actual and perceived skill proficiency and physical activity.

PURPOSE: Motor skills are considered a prerequisite to physical activity, yet the relationship may be reciprocal and perceived sports competence might mediate associations. METHODS: In 2006/2007, 215 adolescents completed motor skill proficiency (Get Skilled Get Active), perceived sport competence (Physical Self-Perception Profile) and physical activity assessments (Adolescent Physical Activity Recall Questionnaire) as part of the Physical Activity and Skills Study. Using AMOS (Version 7.0), reciprocal relationships were examined between motor skill (object control and locomotor) and moderate to vigorous physical activity (MVPA). Both models were then run in different versions to understand the role of perceived sports competence as a potential mediator. RESULTS: Mean age was 16.4 yr (SD=0.6), 51.6% (111/215) were females. A reciprocal relationship between object control and MVPA and a one-way relationship from MVPA to locomotor skill was found. When perceived sports competence was examined as a mediator, the best-fitting model versions explained 16% (R=0.16) MVPA variation, and 30% object control (R=0.30), and 12% locomotor skill variation (R=0.12) (reverse relationship). Perceived sports competence partially mediates the relationship between object control proficiency and physical activity for both directions and fully mediates the relationship between physical activity and locomotor skill; but only when locomotor skill is the outcome. CONCLUSIONS: If the relationship between object control skill and physical activity is viewed as a "positive feedback loop," skill development and increasing physical activity should simultaneously be targeted in physical activity interventions. Increasing perceived sport competence should also be an intervention focus.

Networked resilience in rural Australia--a role for health promotion in regional responses to climate change.

ISSUES ADDRESSED: This paper provides a model for how health promotion teams might establish and support regional collaborations of organisations in a broad response to climate change that enables emergence of multiple strategies tailored to regional needs. METHODS: Complex Adaptive Systems Theory (CAS) and Organisational Learning informed action to foster a Climate Change Collaboration that engaged in strategies to improve transport options, food security and energy sustainability. Social Network Analysis was used to evaluate the degree to which member organisations became networked, the evolution of key network qualities and the way the organisations were affiliated via their participation in emergent strategies. RESULTS: Between 2005 and 2009 a highly connected network of organisations emerged and rapidly evolved to collaborate for action on climate change. There were significant improvements in network density, centralisation, clustering and reciprocity. Member organisations collaborated on a broad range of strategies. CONCLUSIONS: Reducing regional impact of climate change is complex. It requires long-term collaboration between organisations that may not usually work together. Sustain Northern Rivers provides a successful model for achieving such collaboration.

Gender differences in motor skill proficiency from childhood to adolescence: a longitudinal study.

Students' proficiency in three object control and three locomotor skills were assessed in 2000 (M age = 10.06 years, SD = 0.63) in New South Wales, Australia and in 2006-07 (M age = 16.44 years, SD = 0.64). In 2006-07, 266 students, 138 girls (51.9%) and 128 boys (48.1%), had at least one skill reassessed. Boys were more object control proficient than girls. Childhood object control proficiency significantly predicted (p = .001) adolescent object control proficiency (r2 = .39), and, while gender was significant (p = .001), it did not affect the relationship between these variables (p = .53). Because childhood object control proficiency is predictive of subsequent object control proficiency, developing skills in childhood is important.

Reduction in staff smoking rates in North Coast Area Health Service, NSW, following the introduction of a smoke-free workplace policy.

AIM: To evaluate changes in staff smoking rates following the implementation of Smoke Free Health Care, an innovative, change-management process that introduced a smoke-free workplace policy in the North Coast Area Health Service of NSW. METHODS: Survey questionnaires were sent to all staff before and after the introduction of the policy. Return rates were 17.3% (690/3988) in 1999 and 25.4% (2012/7921) in 2007. Chi-square tests and multivariate logistic regression analysis were used to determine differences. RESULTS: Staff smoking rates decreased significantly from 22.3% to 11.8% (p<0.0001). Smoking rates in 1999 were not significantly different to the state population's (22.3% and 24.1%, p=0.3), but were significantly different in 2007 (11.8% and 20.1%, p<0.0001). Over a quarter (27.6%) of staff who smoked when implementation began quit smoking; more than twice the rate before implementation (12%, p<0.0001). CONCLUSION: These changes in staff smoking rates indicate the effectiveness of a comprehensive change-management approach to implementing smoke-free workplace policy.

Young driver education programs that build resilience have potential to reduce road crashes.

OBJECTIVE: The research aimed to explore associations between participation in 2 education programs for school-based learner drivers and subsequent road traffic offenses and crashes among a large cohort of newly licensed drivers. METHODS: DRIVE is a prospective cohort study of 20822 first-year drivers aged 17 to 24 in New South Wales (NSW), Australia. Participants completed a detailed questionnaire and consented to data linkage in 2003-2004. Questionnaire items included year of participation in 2 specific education programs: a 1-day workshop-only program focusing on driving risks ("driver-focused") and a whole-of-community program also including a 1-day workshop but also longer term follow-up activities and a broader focus on reducing risk-taking and building resilience ("resilience-focused"). Survey data were subsequently linked to police-reported crash and offense data for 1996-2005. Poisson regression models that adjusted for multiple confounders were created to explore offenses and crashes as a driver (dichotomized as 0 vs >or=1) after program participation. RESULTS: Offenses did not differ between groups; however, whereas the driver-focused program was not associated with reduced crash risk, the resilience-focused program was associated with a 44% reduced relative risk for crash (0.56 [95% confidence interval: 0.34-0.93]). CONCLUSIONS: The large effect size observed and complementary findings from a comparable randomized, controlled trial in the United States suggest programs that focus more generally on reducing risks and building resilience have the potential to reduce crashes. A large, representative, randomized, controlled trial is urgently needed to confirm road safety benefits and ensure evidence-based spending and practitioner recommendations in this field.

Promoting a team ball game (Lifeball) to older people: who does this game attract and who continues?

ISSUE ADDRESSED: To describe the demographic and health-related characteristics (physical activity, self-reported health status, quality of life and falls history) of older people who enrol in a team-based game, Lifeball, and examine associations between continuation and participant characteristics. Reasons for stopping, participants' perceptions of the game and changes in health-related characteristics over 12 months were examined. METHODS: Telephone surveys were conducted with a cohort of Lifeball players at: baseline, soon after commencing playing and 12 months later. RESULTS: At baseline, participants were aged 40 to 96 years (mean 67). Most were female (84%), in good to excellent health (86%) and reported being sufficiently (>150 minutes per week) physically active (69%). Almost half (43%) were still playing 12 months later (continuers). Continuers were more likely to perceive Lifeball had helped them to: feel fitter and healthier (91%); improve their social life (73%); and be more active (53%). No significant changes in continuers' physical activity, self-reported health status and quality of life measures were reported. The main reason for stopping playing was illness/injury unrelated to Lifeball. CONCLUSIONS: Lifeball mainly appealed to healthy, active older people.

Six year follow-up of students who participated in a school-based physical activity intervention: a longitudinal cohort study.

BACKGROUND: The purpose of this paper was to evaluate the long-term impact of a childhood motor skill intervention on adolescent motor skills and physical activity. METHODS: In 2006, we undertook a follow-up of motor skill proficiency (catch, kick, throw, vertical jump, side gallop) and physical activity in adolescents who had participated in a one-year primary school intervention Move It Groove It (MIGI) in 2000. Logistic regression models were analysed for each skill to determine whether the probability of children in the intervention group achieving mastery or near mastery was either maintained or had increased in subsequent years, relative to controls. In these models the main predictor variable was intervention status, with adjustment for gender, grade, and skill level in 2000. A general linear model, controlling for gender and grade, examined whether former intervention students spent more time in moderate-to-vigorous physical activity at follow-up than control students. RESULTS: Half (52%, n = 481) of the 928 MIGI participants were located in 28 schools, with 276 (57%) assessed. 52% were female, 58% in Grade 10, 40% in Grade 11 and 54% were former intervention students. At follow-up, intervention students had improved their catch ability relative to controls and were five times more likely to be able to catch: ORcatch = 5.51, CI (1.95 - 15.55), but had lost their advantage in the throw and kick: ORthrow = .43, CI (.23 - .82), ORkick = .39, CI (.20 - .78). For the other skills, intervention students appeared to maintain their advantage: ORjump = 1.14, CI (.56 - 2.34), ORgallop = 1.24, CI (.55 - 2.79). Intervention students were no more active at follow-up. CONCLUSION: Six years after the 12-month MIGI intervention, whilst intervention students had increased their advantage relative to controls in one skill, and appeared to maintain their advantage in two, they lost their advantage in two skills and were no more active than controls at follow up. More longitudinal research is needed to explore whether gains in motor skill proficiency in children can be sustained and to determine the intervention characteristics that translate to subsequent physical activity.

Childhood motor skill proficiency as a predictor of adolescent physical activity.

PURPOSE: Cross-sectional evidence has demonstrated the importance of motor skill proficiency to physical activity participation, but it is unknown whether skill proficiency predicts subsequent physical activity. METHODS: In 2000, children's proficiency in object control (kick, catch, throw) and locomotor (hop, side gallop, vertical jump) skills were assessed in a school intervention. In 2006/07, the physical activity of former participants was assessed using the Australian Physical Activity Recall Questionnaire. Linear regressions examined relationships between the reported time adolescents spent participating in moderate-to-vigorous or organized physical activity and their childhood skill proficiency, controlling for gender and school grade. A logistic regression examined the probability of participating in vigorous activity. RESULTS: Of 481 original participants located, 297 (62%) consented and 276 (57%) were surveyed. All were in secondary school with females comprising 52% (144). Adolescent time in moderate-to-vigorous and organized activity was positively associated with childhood object control proficiency. Respective models accounted for 12.7% (p = .001), and 18.2% of the variation (p = .003). Object control proficient children became adolescents with a 10% to 20% higher chance of vigorous activity participation. CONCLUSIONS: Object control proficient children were more likely to become active adolescents. Motor skill development should be a key strategy in childhood interventions aiming to promote long-term physical activity.

Older people playing ball: What is the risk of falling and injury?

Increasing physical activity amongst seniors is important for public health, yet guidance is needed to minimise injury risks. To describe the incidence of falls/injuries in a walking team ball game (Lifeball) designed for seniors, a prospective cohort study was undertaken amongst community dwelling Lifeball participants in Australia. Players completed a telephone survey soon after commencing Lifeball (2004) and 12 months later (2005). Attendance and incident records were audited for the period. Subjects joined a Lifeball group with opportunity to play at least once per week. Baseline was completed by 284 players aged between 40 and 96 years (mean 67 years), with most (83.8%, 238/284) female. Of 263 followed up, the average attendances was 25, with 19.3% attending on fewer than 4 occasions and 14.3% attending 52 or more times. Most (93.9%) reported no injuries requiring medical attention. However, 16 (6.1%) had injuries requiring medical attention and their 27 injuries represent an injury rate of 3.3 per 1000hours of participation. Twenty participants (7.6%) had a Lifeball fall equating to a fall rate of 2.8 per 1000hours of participation. Falls in Lifeball were not associated with measured predictors (age, gender, falls history, perceived falls risk or hours played). Incident records showed a trip/stumble involving rushing, walking backwards, or overextending (all against rules) as common falling causes. Lifeball is not 'risk free' however due to a lack of comparative data it is difficult to compare injury rate to relevant activities. Prevention of injury should concentrate on enforcing safety rules.

Does childhood motor skill proficiency predict adolescent fitness?

PURPOSE: To determine whether childhood fundamental motor skill proficiency predicts subsequent adolescent cardiorespiratory fitness. METHODS: In 2000, children's proficiency in a battery of skills was assessed as part of an elementary school-based intervention. Participants were followed up during 2006/2007 as part of the Physical Activity and Skills Study, and cardiorespiratory fitness was measured using the Multistage Fitness Test. Linear regression was used to examine the relationship between childhood fundamental motor skill proficiency and adolescent cardiorespiratory fitness controlling for gender. Composite object control (kick, catch, throw) and locomotor skill (hop, side gallop, vertical jump) were constructed for analysis. A separate linear regression examined the ability of the sprint run to predict cardiorespiratory fitness. RESULTS: Of the 928 original intervention participants, 481 were in 28 schools, 276 (57%) of whom were assessed. Two hundred and forty-four students (88.4%) completed the fitness test. One hundred and twenty-seven were females (52.1%), 60.1% of whom were in grade 10 and 39.0% were in grade 11. As children, almost all 244 completed each motor assessments, except for the sprint run (n = 154, 55.8%). The mean composite skill score in 2000 was 17.7 (SD 5.1). In 2006/2007, the mean number of laps on the Multistage Fitness Test was 50.5 (SD 24.4). Object control proficiency in childhood, adjusting for gender (P = 0.000), was associated with adolescent cardiorespiratory fitness (P = 0.012), accounting for 26% of fitness variation. CONCLUSION: Children with good object control skills are more likely to become fit adolescents. Fundamental motor skill development in childhood may be an important component of interventions aiming to promote long-term fitness.

Perceived sports competence mediates the relationship between childhood motor skill proficiency and adolescent physical activity and fitness: a longitudinal assessment.

BACKGROUND: The purpose of this paper was to investigate whether perceived sports competence mediates the relationship between childhood motor skill proficiency and subsequent adolescent physical activity and fitness. METHODS: In 2000, children's motor skill proficiency was assessed as part of a school-based physical activity intervention. In 2006/07, participants were followed up as part of the Physical Activity and Skills Study and completed assessments for perceived sports competence (Physical Self-Perception Profile), physical activity (Adolescent Physical Activity Recall Questionnaire) and cardiorespiratory fitness (Multistage Fitness Test). Structural equation modelling techniques were used to determine whether perceived sports competence mediated between childhood object control skill proficiency (composite score of kick, catch and overhand throw), and subsequent adolescent self-reported time in moderate-to-vigorous physical activity and cardiorespiratory fitness. RESULTS: Of 928 original intervention participants, 481 were located in 28 schools and 276 (57%) were assessed with at least one follow-up measure. Slightly more than half were female (52.4%) with a mean age of 16.4 years (range 14.2 to 18.3 yrs). Relevant assessments were completed by 250 (90.6%) students for the Physical Activity Model and 227 (82.3%) for the Fitness Model. Both hypothesised mediation models had a good fit to the observed data, with the Physical Activity Model accounting for 18% (R2 = 0.18) of physical activity variance and the Fitness Model accounting for 30% (R2 = 0.30) of fitness variance. Sex did not act as a moderator in either model. CONCLUSION: Developing a high perceived sports competence through object control skill development in childhood is important for both boys and girls in determining adolescent physical activity participation and fitness. Our findings highlight the need for interventions to target and improve the perceived sports competence of youth.

Multimedia campaign on a shoestring: promoting 'Stay Active - Stay Independent' among seniors.

ISSUE ADDRESSED: This paper describes a multimedia campaign implemented in rural New South Wales on a budget smaller than that typical of many published campaigns. The 'To Be Young at Heart - Stay Active Stay Independent' (SASI) campaign was one arm of a multi-strategic program to reduce falls among seniors by promoting physical activity. METHODS: This 18-month campaign used social marketing techniques. Central to this campaign was strong formative research, significant use of corporate, community and media partnerships and a detailed, strategic distribution plan. Campaign reach was evaluated by a community intercept survey. RESULTS: A variety of high-quality information, education and communication (IEC) resources were developed. Overall, the campaign cost was calculated at USD 191,000. The actual cost of USD 42,000 (excluding staff time) was used to generate almost double this amount in sponsorship (USD 82,000). In the mid-campaign reach survey, 36% recognised the campaign and attributed this to television (58%), newspaper (33%), poster (13%) and bus-back advertising (8%). Of these respondents, 21% reported seeking information about physical activity, 33% reported increased intention to be more active, and 22% reported becoming more active as a result of the campaign. CONCLUSIONS: It is possible to develop and deliver a well-designed, multi-media campaign on a limited budget by using sound formative research and engaging community and corporate partners to generate sponsorship. An effective distribution strategy is crucial and may require additional partnerships at State or national level.

Smoke free health care: an organisational change to increase effective intervention for tobacco.

In 1999, the NSW Health Smoke Free Workplace Policy directed that grounds of health sites would become smoke free, in addition to the existing policy requiring smoke-free buildings. This was one of the first attempts by any health service to exclude tobacco entirely from health sites. This task required the adoption of evidence-based management of tobacco dependence and changing the culture of smoking in the health service. There were many barriers to implementation.

The Mull Hypothesis: is cannabis use contributing to high tobacco use prevalence among young North Coast males?

Men aged 25-34 years, in North Coast NSW, have higher documented smoking rates than elsewhere in the state. The present paper explores potential causes of elevated smoking rates in this population and proposes that tobacco dependence resulting from 'mulling' (mixing) cannabis with tobacco may be contributing.

Older persons' perception of risk of falling: implications for fall-prevention campaigns.

OBJECTIVES: We examined older people's attitudes about falls and implications for the design of fall-prevention awareness campaigns. METHODS: We assessed data from (1) computer-assisted telephone surveys conducted in 2002 with Australians 60 years and older in Northern Rivers, New South Wales (site of a previous fall-prevention program; n=1601), and Wide Bay, Queensland (comparison community; n=1601), and (2) 8 focus groups (n=73). RESULTS: Participants from the previous intervention site were less likely than were comparison participants to agree that falls are not preventable (odds ratio [OR]=0.76; 95% confidence interval [CI]=0.65, 0.90) and more likely to rate the prevention of falls a high priority (OR=1.31; 95% CI=1.09, 1.57). There was no difference between the groups for self-perceived risk of falls; more than 60% rated their risk as low. Those with a low perceived risk were more likely to be men, younger, partnered, and privately insured, and to report better health and no history of falls. Focus group data indicated that older people preferred messages that emphasized health and independence rather than falls. CONCLUSIONS: Although older people accepted traditional fall-prevention messages, most viewed them as not personally relevant. Messages that promote health and independence may be more effective.

Is it worth the RRISK? Evaluation of the RRISK (Reduce Risk Increase Student Knowledge) program for adolescents in rural Australia.

PURPOSE: This study evaluates the effectiveness of an intervention targeting adolescent risk-taking associated with drug and alcohol use, driving, and celebrating. METHODS: Pre- and post written surveys were administered in 21 intervention and 19 comparison schools in Northern New South Wales during March 2003 and 2004. The instrument covered knowledge and attitudes associated with self-reported potentially harmful and protective behaviors. Analysis was by multi-level regression. RESULTS: There were 2705 baseline and 1996 follow-up respondents. Adolescents in the intervention area who attended the Reduce Risk Increase Student Knowledge (RRISK) seminar demonstrated some significant improvements in knowledge, attitudes and behavior compared with those who did not attend, and some significant improvements in knowledge compared with students in comparison schools. CONCLUSIONS: A well-designed one-day seminar that builds on existing curricula, can achieve some significant medium-term benefits in knowledge attitudes and behaviors.

Heavy episodic drinking and sensation seeking in adolescents as predictors of harmful driving and celebrating behaviors: implications for prevention.

OBJECTIVES: Effectiveness of strategies to counter injurious risk-taking in adolescents depends on the degree to which behaviors are modifiable or intrinsic to a sensation-seeking personality. Alcohol consumption is often targeted because it is seen as a modifiable determinant. This study sought to clarify the relative importance of engagement in heavy episodic drinking (HED) independently of sensation-seeking tendency (SS), as a predictor of potentially harmful (and protective) behaviors. METHODS: A written survey was administered to students aged 15-17 years in 40 high schools in New South Wales (NSW), Australia to measure HED, SS, and harmful and protective behaviors associated with drug and alcohol use, driving, and celebrating. RESULTS: Of 2705 respondents, 60% reported HED, 36% failed to wear a seatbelt, 23% rode with an alcohol-impaired driver, 23% rode with a drug-impaired driver and 9% had been alcohol impaired while driving. Two-thirds (65%) had engaged in harmful behaviors and 99% had engaged in protective behaviors while celebrating. SS, gender, income, and age were significant predictors of HED. HED and SS were significant, independent predictors of every harmful or protective behavior. HED had the greatest effect on harmful celebrating behaviors, riding with an alcohol-impaired acquaintance, and riding with a drug-impaired driver. HED had a stronger effect than SS, for alcohol-impaired driving, riding with an alcohol-impaired acquaintance, riding with a drug-impaired driver, and harmful celebrating behaviors. CONCLUSIONS: The vast majority of adolescents who are low to average sensation seekers may benefit from population-based prevention strategies emphasizing that decisions leading to harmful outcomes are more likely if they engage in HED.