Leading collective action to address wicked problems

The alleviation of wicked problems requires collective action because these issues are characterized by significant uncertainty and complexity. This research extends prior work by examining how conveners' use robust action to navigate wicked problems' defining characteristics in the mobilization process. It provides a longitudinal study of a health care nonprofit attempting to engage other stakeholders in addressing the high costs and inadequate quality of health care in a region of the United States. Specifically, the convener sought to address this wicked problem by developing a health information exchange. The findings relate five robust action tactics through which the convener advanced collective action.     

养老服务的逻辑、实现方式与治理路径

养老服务是不同供给主体将不同内容、质量和价格的养老产品或项目,以不同的方式配送到不同需求老年群体的过程。不同供给主体基于责任驱动和利益驱动,为需求主体提供适应性养老服务,是养老服务的基本逻辑。养老服务的实现,是在特定地域、特定的社会关系网络中,通过优化配置养老服务资源,聚集整合养老服务资本,来保障有质量、有尊严的老年生活。鉴于养老服务供给的多元性和需求的复杂性,养老服务的治理则需要运用先进的合作治理与参与治理理念、选择科学的治理工具和现代化的治理技术,保障养老服务供给与需求的适应性匹配,进而保障养老服务实现方式的有序运行。     

Striking a Balance between Program-Specific and Portfolio-Level Evaluation: Lessons Learned from a Multi-Site Evaluation on the Texas-Mexico Border

Funders are increasingly making strategic investments across multiple grantees, aiming for their portfolio to improve targeted outcomes in a specific issue area. To this end, funders might use multi-site evaluation (MSE) approaches to examine the impact of their collective investments. However, it is important to recognize that each program—and its own program evaluation—must be tailored to its setting, population, and local context to best meet the needs of its target population. Therefore, multi-site evaluations need to account for this complexity. This paper describes the Sí Texas project, a large initiative of eight grantees implementing different integrated behavioral health models to improve physical and mental health outcomes along the Texas-Mexico border. With over 4,200 MSE study participants, the evaluation for Sí Texas used a partnership-centered approach to both enhance the evidence base and build local organizational capacity. This paper describes this approach, the process of tailoring evaluation practices to the grantees’ context, and the challenge of balancing consistency at the grantee-level for the portfolio multi-site evaluation. Successes, challenges, and lessons learned related to study design, data collection, grantee partnership, and capacity building are discussed.     

Development and application of a rubric to compare strategies for improving access to health care in rural communities in the United States

Rural areas are underserved in terms of the availability of and access to health care services. According to Healthy People 2020, access to health care continues to be the most frequently identified rural health priority in the United States.PurposeThe purpose was to develop an efficient approach for standardizing and prioritizing strategies to improve access to health care in rural areas across the United States. The rubric provides a quantitative metric of the effectiveness of each strategy in terms of impact and feasibility and allows community health departments and other access to care groups to compare strategies and facilitate discussion of various strategies’ ability to meet the needs of diverse communities.FrameworkThe Plan, Do, Check, Act (PDCA) cycle was used to create the rubric. The research team constructed a plan for creating a rubric to measure each strategy’s impact and feasibility. We checked the rubric by applying it to selected access to care improvement strategies evaluated by the Robert Wood Johnson Foundation (RWJF). Members of a rural community Access to Care Workgroup applied the rubric to several RWJF What Works for Health strategies. The final step was to compare the results of the application phase through facilitated conversations with the goal of determining which strategy or strategies would best meet the needs of the rural community.DiscussionA rubric is a valuable tool to facilitate assessment and discussion and for assisting community members in determining access to care priorities. After applying the rubric in a community setting, we identified two important tactics: 1) the rubric is best applied to strategies when they are summarized consistently and cohesively; and 2) it is important to involve community stakeholders early in the process of identifying strategies for evaluation. The next step is to apply the rubric to similar strategies in other rural communities to further validate the rubric’s effectiveness.     

Citizens’ Jury and Elder Care: Public Participation and Deliberation in Long-Term Care Policy in Thailand

Health care policies for the elderly are complex, multidimensional, and contextually circumscribed. While engagement of health experts, economists, health care administrators, and political leaders is generally viewed as instrumental to the success and sustainability of eldercare programs, the elders themselves are often viewed as passive recipients of care and not included in the policy processes. Experiences and expectations from users’ perspectives can be invaluable information for policy formulation and systems design. This paper examines a participatory policy process using a “citizens’ jury” to promote public engagement in eldercare policy. The process was initiated by the National Health Commission Office in Thailand to explore how a citizens’ jury as a model for civic deliberation can be utilized to provide sophisticated policy recommendations on long-term care policies for the elderly. The objectives of this paper are to (1) examine how public participation in health policy can be actualized through the citizens’ jury as an operational model, (2) understand the strengths and weaknesses of the ways the idea was implemented, and (3) provide recommendations for further use of the model. Details of how a citizens’ jury was deployed are discussed, with recommendations for further use provided at the end.     

Is There a Woodwork Effect? Addressing a 200-Year Debate on the Impacts of Expanding Community-Based Services

In U.S. social welfare history, many have suggested that if benefits were too attractive, consumers would come out of the woodwork to take advantage of the opportunity. Clinical trials have provided evidence of the woodwork effect’s existence, suggesting caution when expanding home- and community-based services (HCBS). However, it is unclear whether these studies are best suited to assess whether a system-level effect occurs. Using state and federal data tracking Ohio’s long-term services and support (LTSS) system from 1995 to 2015, this paper examines changes in the utilization rates and expenditures of Medicaid LTSS to explore whether a woodwork effect occurred as Ohio moved to improve its LTSS system balance (80% Nursing Home [NH], 20% HCBS) to (49% Nursing Home [NH], 51% HCBS). After accounting for population growth of individuals older than 60 and those with two or more impairments in activities of daily living, there was no change in utilization rates of older people with severe disability (1995: 491 per 1000 population, 2015: 495 per 1000 population) or overall LTSS expenditures (1997: $2.7 million [in 2013 dollars], 2013: $2.9 million). Our results suggest that states can make significant strides in HCBS expansion without increasing the overall long-term services utilization rate.     

Global Convergence: Aging and Long-Term Care Policy Challenges in the Developing World

Aging around the world poses a global challenge in eldercare. This challenge is particularly felt in low- and middle-income countries (LMICs), where population aging outpaces the development of aged care policies and services. This Perspective highlights the phenomenon of global convergence in several unsettling trends and challenges shared across LMICs. These include the weakening of informal family care systems for the elderly, growing need for formal long-term care of the frail and disabled who can no longer be adequately supported by family members, and mounting pressures for policy responses to tackle these societal challenges. It is argued that policymakers should take a proactive stance. That is, when family care for the elderly falls short and family caregivers are increasingly under strain, the government should step in and step up support to fill in the gap by developing appropriate policies and a continuum of long-term care services that are accessible and affordable for the majority of older people in need. Three general principles are then suggested with regard to long-term care provision, financing, and quality assurance, which transcend national borders and can be used to guide long-term care policymaking across LMICs.     

‘We create our own small world’: daily realities of mothers of disabled children in a South African urban settlement

Parents of disabled children face many challenges. Understanding their experiences and acknowledging contextual influences is vital in developing intervention strategies that fit their daily realities. However, studies of parents from a resource-poor context are particularly scarce. This ethnographic study with 30 mothers from a South African township (15 semi-structured interviews and 24 participatory group sessions) unearths how mothers care on their own, in an isolated manner. The complexity of low living standards, being poorly supported by care structures and networks, believing in being the best carer, distrusting others due to a violent context, and resigning towards life shape and are shaped by this solitary care responsibility. For disability inclusive development to be successful, programmes should support mothers by sharing the care responsibility taking into account the isolated nature of mothers’ lives and the impact of poverty. This can provide room for these mothers to increase the well-being of themselves and their children.     

Journey towards independent living: resilience processes of women leaving residential care in South Africa

Among the many youth transitioning to young adulthood, a group that has been found to be particularly vulnerable is young people transitioning out of care, particularly residential care. Research on this population of youth has burgeoned over the past few decades, but in South Africa it remains limited. This article focuses on the resilience processes that facilitate better transitions of young women out of care and towards independent living. It replicates the research design of a previous study with young men, with the aim of determining to what extent the resilience process of young women are similar to those of men. A sample of nine women was purposively selected, interviewed in-depth and data analysed using grounded theory methods. The findings indicate that the same resilience process found among male care-leavers are evident also in the narratives of female care-leavers, confirming the findings of the previous study. However, these processes had a slightly stronger relational focus among women than was seen among men. The authors conclude that similar resilience-building programmes can be implemented to prepare both males and females for leaving care.