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Drivers of sustainability transformations: leverage points, contexts and conjunctures.

ABSTRACT: While increasing hopes are being attached to deliberate societal transformative change to achieve the targets of the 2030 Agenda and the Paris Agreement, questions remain about whether and whereby such profound systemic change can be governed. This paper analyses how transformative changes are intended to be encouraged and achieved, where and when. The paper explores critical drivers and how they relate to leverage points at different places in the societal systems. The paper builds on a comprehensive sense-making analysis of scholarly literature, policy documents, including countries' contributions to the Paris Agreement and national reviews of progress towards the UN Sustainable Development Goals, international news media and lay focus group discussions on five continents. There are great variations in how drivers were made sense of in the data. The many ongoing interacting transformations across societies involve different social, cultural, and political contexts, while the implementation of the 2030 Agenda also contains goal conflicts and unavoidable trade-offs. The paper highlights four categories of drivers as particularly important to consider in view of international transformation efforts: technological innovations, political economy redistribution, new narratives, and transformative learning. Four features are important for bringing clarity on how deliberate transformations can be encouraged: (1) the function of drivers in enabling and restricting transformations of societal systems characterised by detailed or dynamic complexity, (2) cultural and geographical contexts of transformations, (3) where in the systems the drivers are intended to intervene, and (4) the role of critical junctions in time, where transformative trajectories can branch out.

Supplementary information

The online version contains supplementary material available at 10.1007/s11625-021-00957-4.

SUBMITTER: Linner BO

PROVIDER: S-EPMC8075710 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundCurrent local food environments encourage poor diets, posing a significant threat to public and planetary health. Acknowledging and addressing its inherent complexity is vital to making meaningful improvements to the food environment. Using a participatory approach with local stakeholders, this study aims to gain insight into the factors and mechanisms underlying the local food environment and to identify leverage points and system-based actions to foster healthy and sustainable local food environments.MethodsA systems-thinking approach was used in a Dutch municipality in 2022. Two group model building (GMB) workshops were held with community stakeholders (e.g. local policymakers, retailers and residents). During the first workshop (June 2022), factors and mechanisms influencing the local food environment were identified and visualized through a causal loop diagram (CLD). During the second workshop, leverage points and system-based actions to improve food environments were identified by the stakeholders. Four months after (October 2022), an action-implementation meeting was organized to stimulate the implementation of selected actions. Progress was monitored through brief telephone interviews 6 and 12 months after the second workshop.ResultsThe CLD visualises the factors and mechanisms influencing the local food environment from the point of view of the community stakeholders. The CLD consists of 46 factors shaping the local food environment, which were categorized into four identified subsystems: societal factors, individual, socio-economic factors, commercial factors and political factors. Eight leverage points were identified within the CLD, for example, 'lobby from food industry', 'governmental food policies' and 'e-commerce and platform economy'. Stakeholders formulated 20 actions targeting the identified leverage points. During the action-implementation meeting, long-term plans were created for five actions. After 1 year, only one participant (policy advisory role) remained actively engaged in three of these actions.ConclusionsThis study yields insight into the numerous factors and mechanisms underlying the local food environment and identified system-based actions as perceived by local stakeholders to improve this food environment locally. The CLD offers stakeholders valuable insights on employing a systems approach when enhancing food environments. More research is necessary, especially into the long-term processes and effects of implementing system-oriented actions to improve local food environments.

Project description:BackgroundBenzodiazepines and benzodiazepine-receptor agonists (BDZRAs, often known as "Z-drugs") are commonly used in older adults despite well-documented harms.ObjectiveTo evaluate patterns of benzodiazepine and BDZRA use in Israel, focusing on potential leverage points where quality improvement initiatives might effectively curtail new use or the transition from intermittent to chronic use.Design and participantsWe used national electronic medical data to assess a 10% random sample of adults receiving care in Clalit Health Services, which serves half of Israel's population. The sample included 267,221 adults, of whom 56,808 (21%) were age 65 and older.Main measuresMedication use from 2013 to 2015 was ascertained using pharmacy dispensing data.ResultsIn 2014, 7% of adults age 21-64 and 32% of adults age 65 and older received at least one benzodiazepine/BDZRA, including 49% of adults age 85 and older (P < 0.001). The majority of older users (59%) were long-term users of the drugs, and 21% of older adults who were short-term users in 2014 transitioned to medium- or long-term use in 2015. Older Arab Israelis were much less likely to receive benzodiazepine/BDZRAs than older Jewish Israelis (adjusted OR 0.28, 95% 0.25-0.31), but within each community there was no major variation in prescribing rates across clinics. Depression diagnosis was associated with particularly high rates of benzodiazepine/BDZRA use: 17% of older adults with depression received a benzodiazepine/BDZRA but no antidepressant, and 42% received both. Recent hospitalization increased the risk of new benzodiazepine/BDZRA use (adjusted OR 1.41, 95% CI 1.01-1.96), but the absolute risk increase was only 3%.ConclusionsBenzodiazepines/BDZRAs are used at exceptionally high rates by older Israeli adults, especially the oldest old. Important leverage points for quality improvement efforts include curtailing the transition from short-term to long-term use, reducing use in older adults with depression, and identifying reasons that explain large differences in benzodiazepine/BDZRA prescribing between different ethnic groups.

Project description:BACKGROUND:Clinical trials are one of the most challenging and meaningful designs in medical research. One essential step before starting a clinical trial is screening, that is, to identify patients who fulfill the inclusion criteria and do not fulfill the exclusion criteria. The screening step for clinical trials might be supported by modern information technology (IT). OBJECTIVE:This explorative study aimed (1) to obtain insights into which tools for feasibility estimations and patient screening are actually used in clinical routine and (2) to determine which method and type of IT support could benefit clinical staff. METHODS:Semistandardized interviews were conducted in 5 wards (cardiology, gynecology, gastroenterology, nephrology, and palliative care) in a German university hospital. Of the 5 interviewees, 4 were directly involved in patient screening. Three of them were clinicians, 1 was a study nurse, and 1 was a research assistant. RESULTS:The existing state of study feasibility estimation and the screening procedure were dominated by human communication and estimations from memory, although there were many possibilities for IT support. Success mostly depended on the experience and personal motivation of the clinical staff. Electronic support has been used but with little importance so far. Searches in ward-specific patient registers (databases) and searches in clinical information systems were reported. Furthermore, free-text searches in medical reports were mentioned. For potential future applications, a preference for either proactive or passive systems was not expressed. Most of the interviewees saw the potential for the improvement of the actual systems, but they were also largely satisfied with the outcomes of the current approach. Most of the interviewees were interested in learning more about the various ways in which IT could support and relieve them in their clinical routine. CONCLUSIONS:Overall, IT support currently plays a minor role in the screening step for clinical trials. The lack of IT usage and the estimations made from memory reported by all the participants might constrain cognitive resources, which might distract from clinical routine. We conclude that electronic support for the screening step for clinical trials is still a challenge and that education of the staff about the possibilities for electronic support in clinical trials is necessary.

Project description:OBJECTIVES:To generate system insights on patient and provider levers and strategies that must be activated to improve hospital-based smoking cessation treatment. DESIGN:Mixed methods study including a series of in-depth group model building sessions, which informed the design of an online survey completed by healthcare providers and a structured interview protocol administered at the bedside to patients who smoke. SETTING:Large, tertiary care hospital in the Midwestern United States. PARTICIPANTS:Group model building: 28 healthcare providers and 22 previously-hospitalised patients; Online survey: 308 healthcare providers; Bedside interviews: 205 hospitalised patients. PRIMARY AND SECONDARY OUTCOME MEASURES:Hypothesis-generating, participatory qualitative methods informed the examination of the following quantitative outcomes: patient interest versus provider perception of patient interest in smoking cessation and treatment; patient-reported receipt versus provider-reported offering of inpatient smoking cessation interventions; and priority ratings of importance and feasibility of strategies to improve treatment. RESULTS:System insights included patients frequently leaving the floor to smoke, which created major workflow disruption. Leverage points included interventions to reduce withdrawal symptoms, and action ideas included nurse-driven protocols for timely administration of nicotine replacement therapy. Quantitative data corroborated system insights; for instance, 80% of providers reported that patients frequently leave the floor to smoke, leading to safety risks, missed assessments and inefficient use of staff time. Patients reported significantly lower rates of receiving any smoking cessation interventions, compared with provider reports (mean difference=17.4%-33.7%, p<0.001). Although 92% of providers cited patient interest as a key barrier, only 4% of patients indicated no interest in quitting or reducing smoking. CONCLUSIONS:Engaging hospital providers and patients in participatory approaches to develop an implementation strategy revealed discrepant perceptions of patient interest and frequency of hospital-based treatment for smoking. These findings spurred adoption of standardised point-of-care treatment for cigarette smoking, which remains highly prevalent yet undertreated among hospitalised patients.

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Drivers of sustainability transformations: leverage points, contexts and conjunctures.

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