Advancing the application of systems thinking in health: understanding the growing complexity governing immunization services in Kerala, India

Health Research Policy and Systems

Taghreed Adam²  Ligia Paina¹  V Raman Kutty³  Joe Varghese⁴ 

[1] Department of International Health, Johns Hopkins University School of Public Health, Baltimore, USA;Alliance for Health Policy and Systems Research, World Health Organization, Geneva, Switzerland;Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Science and Technology, Thiruvananthapuram, India;Centre for Chronic Disease Control and Governance Hub, Public Health Foundation of India, Delhi NCR, Plot No. 47, Sector 44, Gurgaon 122002, India

关键词: Vensim;    Trust;    Systems thinking;    Kerala;    India;    Immunization;    Governance;    Complex adaptive systems;    Causal loop diagram;   

Others  :  1177328
DOI  :  10.1186/1478-4505-12-47

 received in 2014-01-26, accepted in 2014-07-30,  发布年份 2014

【 摘 要 】

Background

Governing immunization services in a way that achieves and maintains desired population coverage levels is complex as it involves interactions of multiple actors and contexts. In one of the Indian states, Kerala, after routine immunization had reached high coverage in the late 1990s, it started to decline in some of the districts. This paper describes an application of complex adaptive systems theory and methods to understand and explain the phenomena underlying unexpected changes in vaccination coverage.

Methods

We used qualitative methods to explore the factors underlying changes in vaccination coverage in two districts in Kerala, one with high and one with low coverage. Content analysis was guided by features inherent to complex adaptive systems such as phase transitions, feedback, path dependence, and self-organization. Causal loop diagrams were developed to depict the interactions among actors and critical events that influenced the changes in vaccination coverage.

Results

We identified various complex adaptive system phenomena that influenced the change in vaccination coverage levels in the two districts. Phase transition describes how initial acceptability to vaccination is replaced by a resistance in northern Kerala, which involved new actors; actors attempting to regain acceptability and others who countered it created several feedback loops. We also describe how the authorities have responded to declining immunization coverage and its impact on vaccine acceptability in the context of certain highly connected actors playing disproportionate influence over household vaccination decisions.

Theoretical exposition of our findings reveals the important role of trust in health workers and institutions that shape the interactions of actors leading to complex adaptive system phenomena.

Conclusions

As illustrated in this study, a complex adaptive system lens helps to uncover the ‘real’ drivers for change. This approach assists researchers and decision makers to systematically explore the driving forces and factors in each setting and develop appropriate and timely strategies to address them. The study calls for greater consideration of dynamics of vaccine acceptability while formulating immunization policies and program strategies. The analytical approaches adopted in this study are not only applicable to immunization or Kerala but to all complex interventions, health systems problems, and contexts.

【 授权许可】

   
2014 Varghese et al.; licensee BioMed Central Ltd.

【 图 表 】

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【 参考文献 】

• [1]Ministry of Health and Family Welfare: National Vaccine Policy. New Delhi: Government of India; 2011.
• [2]Sharma S: Immunization Coverage in India. Institute of Economic Growth: University of Delhi; 2007.
• [3]Datar A, Mukherji A, Sood N: Health infrastructure and immunization coverage in rural India. Indian J Med Res 2007, 125:31.
• [4]Banerji D: Crash of the immunization program: consequences of a totalitarian approach. Int J Health Serv Plan Adm Eval 1990, 20:501-510.
• [5]Streefland PH, Chowdhury AMR, Ramos-Jimenez P: Quality of vaccination services and social demand for vaccinations in Africa and Asia. Bull World Health Organ 1999, 77:722-730.
• [6]Sen A: Health in development. Bull World Health Organ 1999, 77:619-623.
• [7]International Institute for Population Sciences (IIPS): District Level Household and Facility Survey (DLHS-3), 2007-08. Mumbai: IIPS; 2010.
• [8]Naha AL: Vaccine-Preventable Diseases on the Rise in Malappuram. The Hindu; 2013.
• [9]Chitharanjan S: Concern over Resurgence of Vaccine-Preventable Diseases. The Times of India; 2013.
• [10]Need for Effective use of Immunisation Schemes. [http://www.hindu.com/2008/05/18/stories/2008051850720200.htm webcite]
• [11]Plsek PE, Greenhalgh T: Complexity science: the challenge of complexity in health care. BMJ 2001, 323:625-628.
• [12]Paina L, Peters DH: Understanding pathways for scaling up health services through the lens of complex adaptive systems. Health Policy Plan 2012, 27:365-373.
• [13]Sterman JD: Learning from evidence in a complex world. Am J Public Health 2006, 96:505-514.
• [14]Varghese J, Raman Kutty V, Ramanathan M: The interactions of ethical notions and moral values of immediate stakeholders of immunisation services in two Indian states: a qualitative study. BMJ Open 2013, 3:e001905.
• [15]Elo S, Kyngäs H: The qualitative content analysis process. J Adv Nurs 2008, 62:107-115.
• [16]Forrester JW: Industrial Dynamics. Hoboken, NJ: Wiley; 1961.
• [17]Sterman JD: Business Dynamics: Systems Thinking and Modeling for a Complex World. Ney York, NY: McGraw Hill; 2000.
• [18]International Institute for Population Studies: Reproductive and Child Health Project Rapid Household Survey (Phase I & II). Mumbai: IIPS; 1999.
• [19]Nair VM: Polio eradication–global initiative; strategy challenged in Kerala, India. J Public Health Med 2002, 24:207-210.
• [20]Pulse Polio Drive Needs a Booster Shot. The Hindu. [http://www.thehindu.com/todays-paper/tp-national/tp-kerala/pulse-polio-drive-needs-a-booster-shot/article1779221.ece webcite]
• [21]Pulse Polio Covers 80 Per Cent of Target in Malappuram. The Hindu. [http://www.thehindu.com/todays-paper/tp-national/tp-kerala/pulse-polio-covers-80-per-cent-of-target-in-malappuram/article1779625.ece webcite]
• [22]Gilson L: Trust in health care: theoretical perspectives and research needs. J Health Organ Manag 2006, 20:359-375.
• [23]Thiede M: Information and access to health care: is there a role for trust? Soc Sci Med 2005, 61:1452-1462.
• [24]Hall MA, Dugan E, Zheng B, Mishra AK: Trust in physicians and medical institutions: what is it, can it be measured, and does it matter? Milbank Q 2001, 79:613-639.
• [25]Pattison S: Ethical debate: vaccination against mumps, measles, and rubella: is there a case for deepening the debate? Dealing with uncertainty. BMJ 2001, 323:840.
• [26]Renne E: Perspectives on polio and immunization in Northern Nigeria. Soc Sci Med 1982 2006, 63:1857-1869.
• [27]Giddens A: The Consequences of Modernity. Stanford, CA: Stanford University Press; 1990.
• [28]Gilson L, Palmer N, Schneider H: Trust and health worker performance: exploring a conceptual framework using South African evidence. Soc Sci Med 2005, 61:1418-1429.
• [29]Russell S: Treatment-seeking behaviour in urban Sri Lanka: trusting the state, trusting private providers. Soc Sci Med 1982 2005, 61:1396-1407.
• [30]Justice J: The bureaucratic context of international health: a social scientist’s view. Soc Sci Med 1987, 25:1301-1306.
• [31]Banerji D: Hidden menace in the universal child immunisation programme. J Indian Med Assoc 1986, 84:229-232.
• [32]Chaturvedi S, Dasgupta R, Adhish V, Ganguly KK, Rai S, Sushant L, Arora NK: Deconstructing social resistance to pulse polio campaign in two North Indian districts. Indian Pediatr 2009, 46(11):963-974.