Development and evaluation of system dynamics methods to engage with policy makers on the prevention and control of diabetes in a middle income region

Lead Research Organisation: University of the West Indies
Department Name: Caribbean Institute for Health Research

Abstract

Diabetes is a serious and growing problem globally. Evidence suggests diabetes disproportionately affects people in low- and middle-income countries, where 80% of people with diabetes live, both in terms of numbers of people affected as well as outcomes and deaths. Diabetes affects between 10 and 20% of the adult population in the Caribbean region with deaths due to diabetes estimated to be 35% higher than in the neighbouring United States. Not only are prevalence and mortality a large burden but also rates of complications such as lower-limb amputation are also high. Much of the high burden of diabetes can be attributed to major risk factors such as physical inactivity and obesity. Health systems with limited resources in these developing countries are struggling to meet the growing epidemic.
There is a strong political will in the region to tackle diabetes and other non-communicable diseases (NCDs). In 2007, the Heads of Government of the Caribbean Community put forth the Port of Spain Declaration (POSD) on NCDs, definitively challenging the high burden of these diseases in the region and pledging action through policies to strengthen prevention and treatment. This laid the groundwork for a global political movement to recognise NCDs on the public health agenda culminating in the United Nations High Level (UNHLM) meeting on NCDs in September 2011. Both the POSD and UNHLM strongly emphasise the importance of policy measures for reducing NCD risk factors and put forth policies and targets.

However, evidence on how to achieve a reduction in overweight/obesity and physical inactivity and subsequently reducing NCDs at the population level is scarce, particularly in developing countries. While the risk factors and determinants of NCDs like diabetes are well studied and established, research has not been able to conclusively demonstrate real-world interventions that can reduce their popburden or change the course of the epidemic.

Systems science, which combines multiple factors and complex interrelationships, may offer a solution to evaluating and testing policies for diabetes reduction. It does this by explicitly taking into account system behaviour that is non-linear and complex, with feedback loops and time delays. Within systems science, system dynamics modelling is a methodology incorporating input from experts and stakeholders and combining that with quantitative research evidence to produce a map of a system with the ability to simulate outcomes by changing parameters. The approach has been used effectively in a wide variety of fields including engineering, agriculture, energy planning, business dynamics, and health including diabetes. However, few models have been developed for use in middle-income countries.

This study will be the first to explicitly develop a model for diabetes in developing countries, drawing from work successfully conducted by the Centers for Disease Control in the United States and their model for diabetes. The study will apply the rigorous qualitative methods required by interviewing stakeholders, experts and policy makers in the region as well as gathering evidence from research published on risk factors, outcomes, and health system performance for diabetes in the Caribbean. The study will use the developed model to engage stakeholders and policy makers in time for the on going evaluation of the POSD as a tool for effective policy planning. It will also evaluate the utility of this method in the region in engaging policy makers to think in terms of systems and with long time horizons. The results of this development study will be used to build a larger model incorporating economics and costs, which can then be adapted and used in other low- and middle-income countries.

Technical Summary

The study will target English speaking middle-income countries in the Caribbean Community (CARICOM) who participated in the Heads of Government Port of Spain Declaration on NCDs (POSD). An on-going data analysis on mortality, morbidity and risk factor trends across the 20 CARICOM member states is underway, alongside detailed new data collection to define current policy responses to NCDs. This work will be used to inform which countries have sufficient data and strong stakeholder contacts for the development of a system dynamics model. Jamaica will be included as well as two other countries.

The study will use mixed methods, gathering primary data through qualitative methods and secondary quantitative data. These data will then be applied to the design and implementation of a system dynamics model for policy evaluation.

The qualitative phase will use in-depth semi-structured interviews with stakeholders identified through work with the on going POSD evaluation. The data will then be used to develop the first draft of a conceptual model using the Centers for Disease Control diabetes model as a basis.

A quantitative data collection phase will collect evidence on diabetes prevalence, risk factors, determinants, outcomes, and health system response for the countries of interest. This review will provide the necessary information to quantify the relationships described by the conceptual model. Following the initial data collection phase, a model building workshop including all relevant stakeholders and investigators will work intensively to further refine the conceptual model until a consensus is reached. The final conceptual model will then be tested and validated.

The final phase will involve a series of simulations evaluating policies for the prevention and management of diabetes. The results will be used engage policy makers and to evaluate the utility of the system dynamics methodology in adoption of policy.

Planned Impact

The impact of the work can be divided into three time periods: immediate benefits to policy makers and other stakeholders who participate in the system dynamics model development and use; mid-term benefits to other policy makers in the Caribbean as the findings from the modelling process are disseminated regionally; and finally, long-term benefits as the work from this development grant is used in a larger study and adapted elsewhere.

Immediate benefits
These will accrue to the policy makers and stakeholders who take part in the model building workshop and suggest policy scenarios for testing in the developed simulation model. A major benefit of participating in the model building workshop will be from collectively thinking about the systems that are driving obesity, physical inactivity and access to effective diabetes care. This process of itself is expect to provide 'policy insights' i.e. to suggest new ways of addressing these problems. One specific example that will help in thinking through the potential effectiveness of different policies in their settings is using the simulation model to examine the feasibility of achieving the relevant WHO global monitoring framework targets for NCDs.

Study participants will also be actively involved in an evaluation of the system dynamics methodology and its application to the prevention and management of diabetes. Their feedback and input will benefit the development of the broader model, into which, in studies made possible by this development grant, costing of the policy interventions will be included. Their feedback will also enable refinement of the actual process of engaging with policy makers/stakeholders in other settings - from in-depth interviews to inform the model structure, to how to run the model building workshop and interact on the results of model simulations.

Those working directly with the stakeholders may also learn directly from their colleagues who participated in the study, disseminating knowledge and expertise into the wider diabetes community.

Mid-term benefits
The findings from the model development and simulations will be distributed through the wider public health community in the Caribbean Community (CARICOM) countries through the Port of Spain Declaration Evaluation currently underway. The regional community will then be able to incorporate findings and learning from this study into the development of policies for diabetes and other non-communicable diseases. The policy makers in this sphere, comprising members of the Caribbean Public Health Agency, the Pan American Health Organization and the Healthy Caribbean Coalition, will be exposed to systems thinking and its applications. The interest generated from disseminating these results may result in the adaptation and use of the model in other countries in the region.

The wider diabetes community in the Caribbean region is expected to benefit from the evidence-based policies and informed interventions adopted from the POSD Evaluation using this development grant. The hope is that the model will help to inform policy makers into effective combinations of policies that will ultimately reduce the burden of diabetes.

Longer-term benefits
One of the outputs from this study will be a manual on the adaptation and implementation of the model in other settings. This manual will serve to open the possibility of using system dynamics in decision making for public health in other low and middle-income countries. In addition, findings from applications in other parts of the world may benefit in further refining and improving the Caribbean model in the future.
 
Description Group modelling building with multiple stakeholders (including farmers, processors, retailers, importers, government) in Jamaica to map the food system and inform coordinated, multi-sectoral, policy interventions aimed at improving population nutrition.
Geographic Reach National 
Policy Influence Type Participation in a national consultation
 
Description Group modelling building with multiple stakeholders (including farmers, processors, retailers, importers, government) in St Kitts & Nevis and to map the food system and inform coordinated, multi-sectoral, policy interventions aimed at improving population nutrition.
Geographic Reach National 
Policy Influence Type Participation in a national consultation
 
Description Informing policy on the prevention of diabetes and other non-communicable diseases in the Caribbean
Geographic Reach North America 
Policy Influence Type Participation in a advisory committee
 
Description IDRC: Food, Environment and Health
Amount £201,000,000 (JMD)
Organisation International Development Research Centre 
Sector Public
Country Canada
Start 04/2018 
End 03/2022
 
Title System dynamics simulation model for trends in diabetes in the Caribbean 
Description Computer simulation model designed to help appraise the potential impact in the Caribbean on diabetes incidence, prevalence and mortality of different policy options aimed at improving diet and physical activity. 
Type Of Material Computer model/algorithm 
Year Produced 2017 
Provided To Others? No  
Impact The model is still in development and will be made available to others once it is further developed and evaluated. 
 
Description Collaboration on system dynamics modelling methods with Professor Etienne Rouwette, Nijmegen School of Management, Radboud University, Netherlands 
Organisation Radboud University Nijmegen
Country Netherlands 
Sector Academic/University 
PI Contribution The link with Professor Rowette was established through Dr James Woodcock, co-investigator on this award.
Collaborator Contribution Professor Rouwette is internationally recognised for his contribution to using system dynamics modelling to assist with understanding complex problems and making informed policy decisions, in both the public and business sectors. He is currently the president of the System Dynamics Society, the main academic body for professionals working in this field. Professor Rouwette is a member of the project steering committee, participating in the monthly meetings and providing invaluable guidance on aspects of the project, including the design and running the group model building workshop (referred to in the section on engagement) and in building the quantitative simulation model.
Impact The project is a multi-disciplinary project. Professor Rouwette has a background in psychology, business management and system dynamics modelling. Other skills on the project include the epidemiology and prevention of non-communicable diseases, systematic review methodology, bio-statistics, and qualitative research methods.
Start Year 2016
 
Description Collaboration with Dr Alafia Samuels, Director of the Chronic Disease Research Centre, University of the West Indies 
Organisation University of West Indies
Country Jamaica 
Sector Academic/University 
PI Contribution The link with the Director of the Chronic Disease Research Centre (CDRC) was made by me. The project concerns informing policy for the prevention of type 2 diabetes in the Caribbean. This is something of direct interest to CDRC, which is regularly asked to advise the Chief Medical Officers and the Ministers of Health of the Caribbean Community (CARICOM).
Collaborator Contribution Dr Samuels has a long history of advising, and excellent contacts with, health policy makers in CARICOM. Her collaboration has greatly facilitated engagement with policy makers in the three project countries: Belize, Jamaica and St Vincent & the Grenadines.
Impact The project is a multi-disciplinary project. Dr Samuels has a background in public health with a particular interest in guiding and evaluating public policy interventions for the prevention and control of chronic non-communicable diseases. Other skills on the project include simulation modelling, systematic review methodology, bio-statistics, and qualitative research methods.
Start Year 2016
 
Description American Public Health Association Annual Meeting; November 2017 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Professor Nigel Unwin was senior author on "Systems Science for Caribbean Health: The development of a system dynamics model for guiding policy on diabetes in the Caribbean" at the American Public Health Association Annual Meeting. The session discussed various trends and themes in the field of global health, as it relates to different areas of global health practice. He discussed challenges and best practices from different settings around the world.
Year(s) Of Engagement Activity 2017
URL https://apha.confex.com/apha/2017/meetingapp.cgi/Paper/380677
 
Description Engagement with Caribbean stakeholders on systems driving diabetes incidence and outcomes 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Policymakers/politicians
Results and Impact The activity was designed to meet two broad aims.

The first aim was to understand from the perspectives of policy makers the factors, and their interrelationships, driving increasing diabetes incidence and poor diabetes outcomes in the Caribbean. This was achieved through undertaking in-depth semi structured interviews with stakeholders in Belize, Jamaica and St Vincent and the Grenadines, followed by a two day model building workshop (held in Kingston, Jamaica, December 2016). Participants in the model building workshop worked together to agree systems maps (causal loop diagrams) of the factors and their interrelationships driving changes in diet, physical activity, obesity and access to effective health care. These causal loop diagrams provide the basis for developing a quantitative simulation model, which is currently in progress.

The second aim of this engagement process was to encourage participants at the workshop to think of in terms of systems driving the increasing risk of type 2 diabetes, and the implications of this for policies aimed at diabetes prevention and control. Feedback received after the workshop indicated that participants found the approach enlightening, helping to challenge their mental models on the appropriateness and potential effectiveness of different types of intervention. We will evaluate further, after stakeholders have had some experience with the simulation model that is currently being developed, how useful to policy decision making they find this systems approach to considering diabetes prevention and control.
Year(s) Of Engagement Activity 2016
 
Description Presentation at 62nd Annual Health Research Conference of the Caribbean Public Health Agency 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Professor Nigel Unwin was senior author on the presentation "Systems science for Caribbean health: the development of a model for guiding policy on diabetes in the Caribbean." which was presented at annual health research conference of the Caribbean Public Health Agency, which is the main health research conference for the Caribbean. Submissions for presentation are peer reviewed, and the abstract is published in the West Indian Med J 2017; 66 (Suppl. 1): 38-58.
Year(s) Of Engagement Activity 2017
URL https://www.mona.uwi.edu/fms/wimj/supplements
 
Description Presentation on current activities and future plans for Global Public Health Research 
Form Of Engagement Activity Participation in an open day or visit at my research institution
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact The presentation was designed to communicate our current research agenda for Global Public Health to the whole of the MRC Epidemiology Unit.
Year(s) Of Engagement Activity 2017
 
Description Society for Social Medicine, 61st Annual Scientific Meeting, University of Manchester 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Professor Nigel Unwin was senior author on "Systems science for caribbean health: the development of a system dynamics model for guiding policy on diabetes in a resource limited setting", which was presented at the Society for Social Medicine, 61st Annual Scientific Meeting, University of Manchester.
Year(s) Of Engagement Activity 2017
URL http://jech.bmj.com/content/71/Suppl_1/A36.2
 
Description The University of the West Indies, Cave Hill Campus, Annual PhD Symposium 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Postgraduate students
Results and Impact To present an update on the development of the work and to seek feedback.
Year(s) Of Engagement Activity 2018