Systems thinking for Aboriginal Health: Understanding the value and acceptability of group model building approaches

Co-designing restrictive practice elimination: A systems thinking approach with mental health service users and practitioners in rural/regional Australia

Elimination of restrictive practices (physical/mechanical restraint and seclusion) from adult acute mental health care services has been demanded internationally for many decades. This study aimed to: (1) Identify priority issues in the elimination of and use of alternative approaches to restrictive practices (seclusion and physical/mechanical restraint) in rural/regional acute adult mental healthcare services, as told by mental healthcare service users and practitioners, (2) identify the community-based, system-level feedback loops that enhance or reduce the use of restrictive practices and viable alternatives and, (3) identify potential action areas to improve system structures to increase regional mental healthcare services' ability to eliminate restrictive practices and use alternative approaches. Group model building (GMB) workshops were held with a small group (n = 9) of mental healthcare practitioners and service users with lived experience of restrictive practice use. This participatory approach enables exploration and visual mapping of local structures causing behaviour patterns of practitioner and service user concern over time - in this case, the barriers, and enablers to alternative approaches to restrictive practices in adult acute mental healthcare services within the Geelong-Barwon region. This is the first study that specifically applies GMB in the discussion of the elimination of restrictive practices in mental health in the non-metropolitan regional/rural context. Participants identified four key priorities in relation to eliminating restrictive practices: (1) self-advocacy, (2) continuity of care, (3) early intervention, and (4) safety for all. The study findings were distilled into a novel preliminary set of mental healthcare practitioner and service user action ideas.

Mapping pandemic responses in urban Indigenous Australia: Reflections on systems thinking and pandemic preparedness

OBJECTIVES

We investigate some of the strengths and challenges associated with Covid-19 responses in urban Indigenous communities in Brisbane, Australia. Our research reflects on the interconnected dynamics that impact health outcomes and mitigate or exacerbate the risk of Covid-19 spreading within urban Indigenous communities.

METHODS

Three systems thinking workshops were held in 2021 with Indigenous and non-Indigenous stakeholders (N15/workshop) from State and Federal services, along with Aboriginal Community Controlled Health Organisations. All worked in the urban Indigenous health sector. Stakeholders produced a Causal Loop Diagram (CLD) incorporating the critical feedbacks determining the dynamics influencing health outcomes. The aim of the research was to help stakeholders' build awareness of how the structure of the system influences health outcomes.

RESULTS

Stakeholders identified 6 key dynamics which have a negative or positive impact on mitigating risks of Covid-19 infection. By mapping these dynamics within a CLD, 7 intervention points were identified.

CONCLUSIONS

Systems thinking provides a useful tool in identifying the complexities associated with navigating health challenges, but further research is needed to develop frameworks that work in conjunction with Indigenous Australian methodologies.

IMPLICATIONS FOR PUBLIC HEALTH

Indigenous voices and communities must lie central to health responses/policies for Indigenous peoples. When systems thinking is done by or in collaboration with stakeholders it provides a visual language that can help design public health policy. What can be ascertained is that their effectiveness is predicated on systems thinking's integration with Indigenous methodologies that acknowledges Indigenous self-determination and challenges Eurocentric representations of health and Indigeneity.

Systems thinking in local government: intervention design and adaptation in a community-based study

BACKGROUND

Systems thinking approaches are increasingly being used by communities to address complex chronic disease. This paper reports on the VicHealth Local Government Partnership (VLGP) which sought to co-create improvements in the health and well-being of children and young people by working with local government in Victoria, Australia.

METHODS

The VLGP included a series of health promotion modules, aimed at creating policy, programme and practice changes across local government. One of these modules, Connecting the Dots - creating solutions for lasting change, aimed to build capacity for systems thinking in municipal public health and well-being planning across 13 councils. The approach was adapted and data were collected on the stimuli for, and results of, adaptation.

RESULTS

The council adapted the systems thinking approach to meet geographic characteristics, priority health issue/s and participant target group needs. Adaptions applied to workshop materials, training delivery, existing and new resources, and to align with other community-based approaches. Stimuli for adaptation included the COVID-19 pandemic, needs of children and young people, capacity of council to deliver the workshop series, and time available within the project or for the participant group.

CONCLUSIONS

Systems thinking was used and adapted by councils to improve the health and well-being of children and young people and increase the voices of children and young people in decision-making. Flexible delivery is critical to ensure communities can adapt the approach to meet local needs.

Comprehensive application of a systems approach to obesity prevention: a scoping review of empirical evidence

A systems approach to obesity prevention is increasingly urged. However, confusion exists on what a systems approach entails in practice, and the empirical evidence on this new approach is unclear. This scoping review aimed to identify and synthesise studies/programmes that have comprehensively applied a systems approach to obesity prevention in intervention development, delivery/implementation, and evaluation. By searching international databases and grey literature, only three studies (10 publications) met inclusion criteria, which might be explained partially by suboptimal reporting. No conclusion on the effectiveness of this approach can be drawn yet due to the limited evidence base. We identified common features shared by the included studies, such as measuring ongoing changes, in addition to endpoint outcomes, and supporting capacity building. Some facilitators and barriers to applying a comprehensive systems approach in practice were identified. More well-designed and reported studies are needed, especially from low- and middle-income countries.

Participatory systems science for enhancing health and wellbeing in the Indian Ocean territories

Objectives

Co-creation of diabetes and obesity prevention with remote communities allows local contextual factors to be included in the design, delivery, and evaluation of disease prevention efforts. The Indian Ocean Territories (IOT) comprise the Christmas (CI) and Cocos Keeling Islands (CKI) and are remote Australian external territories located northwest of the mainland. We present results of a co-design process conducted with residents of IOT using realist inquiry and system mapping.

Methods

Interviews with 33 community members (17 CI, 14 CKI, 2 off Islands) on causes and outcomes of diabetes (2020/21) comprising community representatives, health services staff, dietitians, school principals and government administrators. Interviews were used to create causal loop diagrams representing the causes of diabetes in the IOT. These diagrams were used in a participatory process to identify existing actions to address diabetes, identify areas where more effort would be valuable in preventing diabetes, and to described and prioritize actions based on feasibility and likely impact.

Findings

Interviews identified 31 separate variables categorized into four themes (structural, food, knowledge, physical activity). Using causa loop diagrams, community members developed 32 intervention ideas that included strengthening healthy behaviors like physical activity, improving access to healthy and culturally appropriate foods, and overcoming the significant cost and availability limitations imposed by remoteness and freight costs. Interventions included relatively unique Island issues (e.g., freight costs, limited delivery timing), barriers to healthy food (e.g., limited fresh food availability), physical activity (e.g., transient workforce) and knowledge (e.g., multiple cultural backgrounds and language barriers, intergenerational knowledge).

The Application of Systems Thinking to the Prevention and Control of Sexually Transmissible Infections among Adolescents and Adults: A Scoping Review

Systems thinking is a mechanism for making sense of complex systems that challenge linear explanations of cause-and-effect. While the prevention and control of sexually transmissible infections (STIs) has been identified as an area that may benefit from systems-level analyses, no review on the subject currently exists. The aim of this study is to conduct a scoping review to identify literature in which systems thinking has been applied to the prevention and control of STIs among adolescent and adult populations. Joanna Briggs Institute guidelines for the conduct of scoping reviews were followed. Five databases were searched for English-language studies published after 2011. A total of n = 6102 studies were screened against inclusion criteria and n = 70 were included in the review. The majority of studies (n = 34) were conducted in African nations. Few studies focused on priority sub-populations, and 93% were focused on HIV (n = 65). The most commonly applied systems thinking method was system dynamics modelling (n = 28). The review highlights areas for future research, including the need for more STI systems thinking studies focused on: (1) migrant and Indigenous populations; (2) conditions such as syphilis; and (3) innovations such as pre-exposure prophylaxis and at-home testing for HIV. The need for conceptual clarity around 'systems thinking' is also highlighted.

When primary healthcare meets queerstory: community-based system dynamics influencing regional/rural LGBTQ + people's access to quality primary healthcare in Australia

BACKGROUND

Lesbian, gay, bisexual, transgender, Queer, and people of any other minority sexuality or gender identity (LGBTQ + or "Queer") are often marginalised from accessing quality primary healthcare (PHC) in their local community. This is largely due to Queerphobic, cis-heteronormative/sexist systems pathologising Queer life and identities. The study aims were to: (1) identify key priorities for increasing Queer people's access to quality PHC as told by Queer people themselves, (2) identify the feedback loops that reduce or support Queer people's access to quality PHC in non-metropolitan, regional/rural communities, and (3) identify potential action areas to improve system structures to increase Queer people's access to quality PHC.

METHODS

Group Model Building (GMB) workshops were held with a small group (n = 8) of LGBTQ + people in regional Victoria with lived experience of using PHC services. This participatory approach permits exploration and visual mapping of local structures causing behaviour patterns of community concern over time - in this case, Queer people's ability to access quality PHC in the Geelong-Barwon region. This is the first study that specially applies GMB in Queer PHC in the non-metropolitan regional/rural context.

RESULTS

Key community identified PHC priorities were: (a) providers' level of Queer Literacy, (b) the responsibility of Queer Advocacy (at individual, systemic, and collective levels), (c) support from safe Queer Spaces, (d) strength from a Queer Presence, and (e) power from Intersectional Queer Life. These priorities interconnected, creating system-level feedback loops reinforcing barriers and enablers to Queer people's access to quality PHC in the Geelong-Barwon region; with potential action areas identified.

CONCLUSIONS

Improving Queer people's access to quality PHC in the Geelong-Barwon region requires embedding principles of Queer Literacy, Queer Advocacy, Queer Space, Queer Presence, and Intersectional Queer Life within practices and service systems. The study findings were distilled into a novel, preliminary set of Queer Equity Principles. These need to be taken back to regional Queer communities for further co-design and planning for translation across PHC practices and systems, with potential applicability in other areas of the healthcare spectrum.

Success of community-based system dynamics in prevention interventions: A systematic review of the literature

Systems thinking approaches are increasingly being used to help communities understand and develop responses to preventing complex health problems. Less is known about how success is characterized and what influences success in these approaches. We present a systematic review of how concepts of success are understood and evaluated in the peer reviewed literature of studies using systems thinking in community prevention. We searched five databases for peer-reviewed literature published between 2000 and 2022, with search terms related to systems thinking, prevention and community. Studies were included if they; reported using community-based systems thinking to prevent a public health problem; described the engagement and empowerment of community members to address a public health issue; and, were published in English. Thirty-four articles were identified from 10 countries. Twenty-one aimed to prevent a chronic disease (e.g., obesity) and 16 measured success using specific tools, 10 of which used semi-structured interviews or surveys. Measures of success included implementation processes, cultural appropriateness, the number or type of actions implemented, effectiveness of community action, and changes in individual thinking or mental models, population health outcomes, data collected, or systems level measures. Implementation factors influencing success included the capacity to engage participants, composition and experience of facilitators, strength of coordination teams, allocation of resources, adaptation to participant feedback, use of multiple systems approaches, workshop process providing time and methods to allow new insights, flexible delivery, and diversity of perspectives. Findings from each of the articles indicated that approaches increased a range of outcomes including community action, strategic thinking, future planning and evaluation, community buy-in, community voice, contribution and leadership, in addition to developing shared visions and goals and creating new, ongoing collaborations, among many others. Measures of success varied, suggesting more empirical reporting of proposed outcomes of system science in communities would be valuable. While the measurement of success in the use of systems thinking in community-based prevention efforts is limited, there are helpful examples we can look to for future measurement of success.

A Comprehensive Review of Optimal Approaches to Co-Design in Health with First Nations Australians

BACKGROUND

Australia's social, structural, and political context, together with the continuing impact of colonisation, perpetuates health care and outcome disparities for First Nations Australians. A new approach led by First Nations Australians is required to address these disparities. Co-design is emerging as a valued method for First Nations Australian communities to drive change in health policy and practice to better meet their needs and priorities. However, it is critical that co-design processes and outcomes are culturally safe and effective. Aims: This project aimed to identify the current evidence around optimal approaches to co-design in health with First Nations Australians.

METHODS

First Nations Australian co-led team conducted a comprehensive review to identify peer-reviewed and grey literature reporting the application of co-design in health-related areas by and with First Nations Australians. A First Nations Co-Design Working Group (FNCDWG) was established to guide this work and team.A Collaborative Yarning Methodology (CYM) was used to conduct a thematic analysis of the included literature.

RESULTS

After full-text screening, 99 studies were included. Thematic analysis elicited the following six key themes, which included 28 practical sub-themes, relevant to co-design in health with First Nations Australians: First Nations Australians leadership; Culturally grounded approach; Respect; Benefit to First Nations communities; Inclusive partnerships; and Evidence-based decision making.

CONCLUSION

The findings of this review provide a valuable snapshot of the existing evidence to be used as a starting point to guide appropriate and effective applications of co-design in health with First Nations Australians.

Student reflections on an interdisciplinary pandemics course utilising systems thinking

ISSUE ADDRESSED

The complexity and uncertainty of the COVID-19 pandemic highlights the need to change training of public health professionals in higher education by shifting from siloed specialisations to interdisciplinary collaboration. At the end of 2020 and 2021, public health professionals collaboratively designed and delivered, a week-long intensive course-Public Health in Pandemics. The aim of this research study was to understand whether the use of systems thinking in the design and delivery of the course enabled students to grasp the interdisciplinary nature of contemporary health promotion and public health practice.

RESEARCH METHODS

Two focus group interviews (n = 5 and 3/47) and a course opinion survey (n = 11/47) were utilised to gather information from students regarding experiences and perceptions of course design and delivery, and to determine if students felt better able to understand the complex nature of pandemics and pandemic responses.

MAJOR FINDINGS

Students provided positive feedback on the course and believed that the course design and delivery assisted in understanding the complex nature of health problems and the ways in which health promotion and public health practitioners need to work across sectors with diverse disciplines for pandemic responses.

CONCLUSIONS

The use of an integrated interdisciplinary approach to course design and delivery enabled students used systems thinking to understand the complexity in preparing for and responding to a pandemic. This approach may have utility in preparing an agile, iterative and adaptive health promotion and public health workforce more capable of facing the challenges and complexity in public health.

Community Co-Design of Regional Actions for Children's Nutritional Health Combining Indigenous Knowledge and Systems Thinking

Children's nutrition is highly influenced by community-level deprivation and socioeconomic inequalities and the health outcomes associated, such as childhood obesity, continue to widen. Systems Thinking using community-based system dynamics (CBSD) approaches can build community capacity, develop new knowledge and increase commitments to health improvement at the community level. We applied the formal structure and resources of a Group Model Building (GMB) approach, embedded within an Indigenous worldview to engage a high deprivation, high Indigenous population regional community in New Zealand to improve children's nutrition. Three GMB workshops were held and the youth and adult participants created two systems map of the drivers and feedback loops of poor nutrition in the community. Māori Indigenous knowledge (mātauranga) and approaches (tikanga) were prioritized to ensure cultural safety of participants and to encourage identification of interventions that take into account social and cultural environmental factors. While the adult-constructed map focused more on the influence of societal factors such as cost of housing, financial literacy in communities, and social security, the youth-constructed map placed more emphasis on individual-environment factors such as the influence of marketing by the fast-food industry and mental wellbeing. Ten prioritized community-proposed interventions such as increasing cultural connections in schools, are presented with the feasibility and likely impact for change of each intervention rated by community leaders. The combination of community-based system dynamics methods of group model building and a mātauranga Māori worldview is a novel Indigenous systems approach that engages participants and highlights cultural and family issues in the systems maps, acknowledging the ongoing impact of historical colonization in our communities.

Whose Health in Whose City? A Systems Thinking Approach to Support and Evaluate Plans, Policies, and Strategies for Lasting Urban Health

An increasing interest has been present in scientific literature and policy making for the links between urban environments and health, as also learnt from the COVID-19 pandemic. Collaboration between urban planning and public health is therefore critical for enhancing the capabilities of a city to promote the well-being of its people. However, what leverage potential for urban health can be found in existing plans, policies, and strategies that address urban health? Starting from the relationship between urban systems and health issues, the purpose of this contribution is to broaden the systemic knowledge of urban systems and health so as to try to figure out the impact potential of local urban governance on public health. Considering the systemic nature of health issues, as defined by the World Health Organisation, this is done through a systems thinking epistemological approach. Urban health proposals are studied and assessed in four European cities (Copenhagen, London, Berlin, and Vienna). Current criticalities are found, starting from the guiding goal of such proposals, yet a systemic approach is suggested aimed at supporting and evaluating lasting and healthy urban planning and management strategies.

Combining Cognitive Mapping and indigenous knowledge to improve food environments in regional New Zealand

Issue addressed

Hawke's Bay has one of the highest rates of childhood obesity in New Zealand. While several initiatives exist aiming to decrease obesity through physical activity, there are few nutritional interventions. This study adopted a systems science and mātauranga Māori approach to identify and target underlying drivers of rising childhood obesity and engage the community to improve the food environment.

Methods

Cognitive mapping interviews (CM) with local stakeholders (school principals, Iwi and district health board representatives, education managers and local councillors) were conducted. The aim was to map participants’ mental models of the causes of rising childhood obesity and to identify key principles for engaging with the local community in a meaningful, impactful and culturally appropriate way for future action.

Results

Eleven interviews were conducted face‐to‐face and cognitive maps were constructed. Follow‐up interviews were carried out online, due to COVID restrictions, to present the maps and for interviewees to make any adjustments. Four composite themes emerged through centrality and cluster analysis of the resulting cognitive maps: the importance of building in mātauranga Māori (Māori knowledge and ways of being), the “hauora” of children, working with the community and integrating existing initiatives. Two contextual factors are also considered: the growing need for food security in our communities and the opportunity to start interventions in the school setting.

Conclusion

Cognitive mapping can produce useful insights in the early stages of community engagement. The six “pou” (pillars) underscore the importance of incorporating indigenous knowledge when embarking on public health interventions, particularly around obesity and in regional communities.

So what?

When designing a public health initiative with a community with a high indigenous population, indigenous knowledge should be promoted to focus on holistic health, working with the community and creating opportunities for cohesion. These founding principles will be used to structure future community actions to improve children's food environments in regional New Zealand.