ultiple disciplines for complex challenges – way markers for the practice of public health in the 2020s

This paper seeks to think through a style and approach to Public Health Practice that works through complex challenges in a multi-disciplinary environment. It covers some principles and waymarkers and sets out aspects of a project for further elucidation.

McManus, J. Multiple disciplines for complex challenges – way markers for the practice of public health in the 2020s. Paper presented at Making a difference: mixing methods and crossing disciplines conference: Centre for Health, Activity and Wellbeing Research, Cardiff Metropolitan University : 26th June 2024; Cardiff.

1. Multiple disciplines for complex challenges way markers for the practice of public health in the 2020s CAWR Annual Conference, June 26th 2024 Jim McManus National Director of Health and Wellbeing Public Health Wales

2. The TLDR version of this talk… 2

3. The landscape for our practice Davies et al (2014) For debate: a new wave in public health improvement - The Lancet 3

4. But while we can describe the problem in ever more complex ways…where’s the change? 4

5. So why do we sometimes struggle to move from description to impact? Four challenges to practice 5 Some elements across this Hyper-modernist quantitative RCTs only epistemology Postmodernist there can be no meta-narrative epistemology The advantages of metamodern critical realism?

6. Public Health as Style Some key pillars for public health in facing complex challenges 6

7. This should not surprise us – the need to think in 3D – or complexify The forms of knowledge at our disposal Public Health traditional core subjects Social and Behavioural Sciences Implementation Sciences Leadership 7 Layer of Society at which action can be taken ( Dettels 1999) Legislative and Environmental Level Social Level Domestic Unit Level Individual Level Time

8. How do we overcome these? Time to re-focus what we mean by Public Health Practice Some waymarkers for public health as inclusive style of practice.. 8

9. Waymarkers for Public Health as Style 01 03 05 02 04 Part of complexifying a problem. Synthesising and articulating becomes a key skill set. Three Dimensional Thinking This is never a finished product because neither problems nor knowledge stays still Clear principles of what we mean by PH Practice Principles & Values A leadership style which works for this new environment PH Leadership Style Open-ness to whichever disciplines can contribute Disciplinary Open-ness Always “on the journey”

10. Disciplnary Open-ness Public Health from its inception has maintained an outlook 1 characterised by being curious about, respectful and inclusive of other disciplines that can add value to public health practice and applications We need to maintain this. Today this entails some key principles for practice: 10 See citations slide at end for references to the hermeneutical openness of public health

11. If… Public health is the art and science of the organised efforts of society to improve and protect the health of a population Then is it a TEAM SPORT and there is room for all the talents Means we need to rethink what we mean by knowledge and evidence 11 Improving People's Health – National Strategy | BSPHN

12. That means we need to challenge some exclusivist practices… 12

13. Principles for a new public health approach Hoekstra, R., Vazire , S. Aspiring to greater intellectual humility in science.  Nat Hum Behav  5, 1602–1607 (2021). https://doi.org/10.1038/s41562-021-01203-8 Naumova, E.N. Intellectual humility in public health training, research, and practice.  J Public Health Pol  44, 1–5 (2023). https://doi.org/10.1057/s41271-022-00389-z

14. The need to think in 3D as part of “complexifying” a problem The forms of knowledge at our disposal Public Health traditional core subjects Social and Behavioural Sciences Implementation Sciences Leadership 14 Layer of Society at which action can be taken ( eg Dettels 1999) Legislative and Environmental Level Social Level Domestic Unit Level Individual Level (psychological and biological) Time

15. 15 Complexifying the scope of Prevention   Some examples of the range of preventive activity underway: The Scope of Prevention Behavioural Determinants Psychosocial Determinants Early Detection and intervention Wider Determinants Treatment and Care How structural factors like income, employment, housing educational attainment, physical environment influence health and wellbeing How mental wellbeing, experience of chronic stress, violence, abuse or trauma and social and emotional development in early childhood provide a foundation for healthy people How smoking, diet, alcohol and drug use, physical activity increase risk of disease How well we identify disease at an early point through screening and self awareness, actively manage key clinical risks such as high blood pressure and obesity Equitable access to treatment and care; rehabilitation and recovery Examples of work Building a Healthier Wales Shaping Healthy Places Examples of work HAPUS Whole School Mental Health Examples of work Quit Smoking Exercise Referral Diabetes Prevention Examples of work Tackling Diabetes Together Prevention Based Health and Care Exercise Refrerral Examples of work Prevention Based Health and Care Healthcare Public Health Framework Tackling Diabetes Together

16. Values in public health? Whose? Where from?

17. Leadership - What is your role? Or will it change from project to project? 17 Each of these models have downsides and upsides. Advisors rarely change whole organisations Understanding and valuing your expertise is important but read Goodall on humility and leadership Leadership here is hard work, so some thoughts

18. Styles of Leadership required for this Source: Wiggins and Smallwood (2018) reproduced by permission Wiggins, L and Smallwood, J. (2018) ‘An OD Approach to leadership development: questions and consequences.’ Journal of Management Development . Emerald Publications Vol. 37 No. 8, pp. 613-623.  https://doi.org/10.1108/JMD-12-2016-0306

19. A “consulting approach” to practice not the style criticized my Mazzucato et al 19 A schema of domains of knowledge needed in consulting approach, reflecting on Wiggins et al Benefits of a consulting approach – clarity, responsibility Attitude and disposition – Humility and appreciation not “the expert” Source: Constable and McManus (forthcoming) in Brady, Ed Palgrave Handbook of Consulting in Health Psychology

20. Phase 1 – Case for change Phase 2 – Establishing System Conditions Phase 3 – System Delivery Getting system leadership working We are here Assess System Capabilities System Design Frameworks Implementation Planning Pathways Shifts in investment, funding and cost flows Quality Performance Metrics

21. The Authorising Environment Public Sector agencies require authority to deliver – formal and informal But too often we exclude local communities or do not factor them in What formal authorising environment do you need? What informal authorising environment do you need? Stacey – “Complex Social Processes” 21 Idealised Actual – multiple, conflicting, unclear Source: Andrews et al, 2017 Managing your authorizing environment | Building State Capability: Evidence, Analysis, Action | Oxford Academic (oup.com)

22. Australian Public Service Commission Guide – Understand your authorising environment 22 Understand your authorising environment | Australian Public Service Commission (apsc.gov.au)

23. Improvements in Population Health and Wellbeing Outcomes Data on morbidity and mortality Horizon scanning – estimating impact of future threats Trends in health and wellbeing outcomes Modelling Burden of disease – relative contributions of key risks to outcomes Prevalence of determinants at population and sub population level Information about behaviours Evidence base on aetiology and opportunities for prevention, early intervention Insight into influences on behaviours Research evidence on effective action Research evidence on effective methodologies Process evaluation Theory of Change or Logic Models Pilot or developmental studies Evidence base for change e.g. implementation science Data on behaviours or behavioural components Participation, engagement and action Reach Outcomes Adoption A Public Health Process Approach Principles of this approach: complexity, multi-disciplinarity, parity of esteem, inquiry/humility, systems wide, co-production

24. Waymarkers for Public Health as Style 01 03 05 02 04 Part of complexifying a problem. Synthesising and articulating becomes a key skill set. Three Dimensional Thinking This is never a finished product because neither problems nor knowledge stays still Clear principles of what we mean by PH Practice Principles & Values A leadership style which works for this new environment PH Leadership Style Open-ness to whichever disciplines can contribute Disciplinary Open-ness Always “on the journey”

25. The so what… (a recap) 25

26. Heelan , P. A., & Schulkin , J. (1998). Hermeneutical Philosophy and Pragmatism: A Philosophy of Science.  Synthese ,  115 (3), 269–302. http://www.jstor.org/stable/20118058 Hovey, R. B., Vigouroux , M., Noushi , N., Pavate , V., & Amja , K. (2022). Applied Philosophical Hermeneutic Research: the unmethod .  International Journal of Qualitative Methods ,  21 .  https://doi.org/10.1177/16094069221101237 Islam, Z. (2017) ‘Ontology of public health in university curriculum: Exploring basic elements of an interdisciplinary field of knowledge’, Journal of Educational Issues , 3(1), p. 170. doi:10.5296/jei.v3i1.10478 . McCaffrey, G., Wilson, E., Jonatansdottir , S., Zimmer, L., Zimmer, P., Graham, I., Snadden , D., & MacLeod, M. (2022). But is It Hermeneutic Enough?: Reading for Methodological Salience in a Scoping Review of Hermeneutics and Implementation Science.  International Journal of Qualitative Methods ,  21 .  https://doi.org/10.1177/16094069211070408 Porter D. Health, civilization, and the state : a history of public health from ancient to modern times. London ; New York: Routledge; 1999. Rosen G, Fee E, Pascal James Imperato , Morman ET. A history of public health . Baltimore: Johns Hopkins University, Cop; 2015. Tulchinsky TH, Varavikova EA. A History of Public Health. The New Public Health . 2014:1–42. doi : 10.1016/B978-0-12-415766-8.00001-X. Epub 2014 Oct 10. PMCID: PMC7170188. Winslow, Charles-Edward Amory (1920). "The Untilled Field of Public Health". Modern Medicine . 2 (1306): 183–191. Bibcode:1920Sci....51...23W. doi:10.1126/science.51.1306.23. Some reading on values and principles Public Health from its inception has maintained an outlook characterised by being curious about, respectful and inclusive of other disciplines that can add value to public health practice and applications. This hermeneutical permeability has been key to the discipline’s success and is well documented in both classical and modern works on the history and philosophy of public health practice.

27. Diolch ! Thank You! Gweithio gyda'n gilydd i greu Cymru iachach Working together for a healthier Wales [email protected]