Bridges and Mechanisms: Integrating Systems Science Thinking into Implementation Research

The sustainability of health interventions implemented in Africa: an updated systematic review on evidence and future research perspectives

BACKGROUND

Sustaining evidence-based interventions in resource-limited settings is critical to optimizing gains in health outcomes. In 2015, we published a review of the sustainability of health interventions in African countries, highlighting gaps in the measurement and conceptualization of sustainability in the region. This review updates and expands upon the original review to account for developments in the past decade and recommendations for promoting sustainability.

METHODS

First, we searched five databases (PubMed, SCOPUS, Web of Science, Global Health, and Cumulated Index to Nursing and Allied Health Literature (CINAHL)) for studies published between 2015 and 2022. We repeated the search in 2023 and 2024. The review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Studies were included if they reported on the sustainability of health interventions implemented in African countries. Study findings were summarized using descriptive statistics and narrative synthesis, and sustainability strategies were categorized based on the Expert Recommendations for Implementing Change (ERIC) strategies.

RESULTS

Thirty-four publications with 22 distinct interventions were included in the review. Twelve African countries were represented in this review, with Nigeria (n = 6) having the most representation of available studies examining sustainability. Compared to the 2016 review, a similar proportion of studies clearly defined sustainability (52% in the current review versus 51% in the 2015 review). Eight unique strategies to foster sustainability emerged, namely: a) multi-sectorial partnership and developing stakeholder relationships, b) tailoring strategies to enhance program fit and integration, c) active stakeholder engagement and collaboration, d) capacity building through training, e) accessing new funding, f) adaptation, g) co-creation of intervention and implementation strategies and h) providing infrastructural support. The most prevalent facilitators of sustainability were related to micro-level factors (e.g., intervention fit and community engagement). In contrast, salient barriers were related to structural-level factors (e.g., limited financial resources).

CONCLUSIONS

This review highlights some progress in the published reports on the sustainability of evidence-based intervention in Africa. The review emphasizes the importance of innovation in strategies to foster funding determinants for sustainable interventions. In addition, it underscores the need for developing contextually relevant sustainability frameworks that emphasize these salient determinants of sustainability in the region.

Next Steps in Efforts to Address the Obesity Epidemic

Obesity prevalence continues to rise globally at alarming rates, with adverse health and economic implications. In this state-of-the-art review, we provide an analysis of selected evidence about the current knowledge in the obesity literature, including a synthesis of current challenges in obesity and its determinants. In addition, we review past and current efforts to combat the obesity epidemic, highlighting both successful efforts and areas for further development. Last, we offer insights into the next steps to address the obesity epidemic and advance the field of obesity through both research and practice by (a) adopting a systems perspective, (b) fostering cross-sector and community collaborations, (c) advancing health equity, (d) narrowing the research-to-practice and research-to-policy gaps with multidisciplinary approaches, and (e) embracing complementary approaches for concurrent obesity prevention and treatment.

A co-designed conceptual model for implementing falls prevention programmes for community-dwelling older adults in Singapore: a systems thinking approach

INTRODUCTION

Implementing falls prevention programmes in the community presents numerous challenges. We sought to understand the dynamics between the determinants influencing implementation to develop a common conceptual model describing the complexities of implementing falls prevention programmes in Singapore.

METHODS

A full-day group model building workshop with a series of structured activities was organised with 31 multidisciplinary stakeholders. Stakeholders who attended include healthcare professionals of different specialities (i.e. geriatrics, rehabilitation medicine, physiotherapy, nursing), community-based voluntary welfare organisations, researchers and policymakers.

RESULTS

A causal loop diagram was developed to illustrate the determinants influencing implementation of community-based fall prevention programmes. It revealed factors driving key implementation and service outcomes in supply and demand of such programmes. Determinants of these outcomes were synthesised into four themes: (i) structural factors affecting the management and resource allocation for community-based falls prevention programmes, (ii) participation in programmes affected by older adults' willingness and ability to participate, (iii) perceived value as a composite of costs and benefits, and (iv) social support and exercise self-efficacy motivating long-term adherence. Furthermore, in our analysis of feedback relationships, two organisational behaviours were identified: unsustainable growth due to resource constraints (Limits to Growth) and tensions between executing symptomatic or fundamental solutions (Eroding Goals). Stakeholders also explored strategies for effective implementation.

CONCLUSIONS

A conceptual model describing the dynamics of implementing community-based fall prevention programmes was developed. This informed the formulation of a National Falls Prevention Framework, a priority action step for the effective implementation of these programmes in Singapore.

Considerations for using participatory systems modeling as a tool for implementation mapping in chronic disease prevention

Effective chronic disease prevention requires a systems approach to the design, implementation, and refinement of interventions that account for the complexity and interdependence of factors influencing health outcomes. This paper proposes the Participatory Implementation Systems Mapping (PISM) process, which combines participatory systems modeling with implementation strategy development to enhance intervention design and implementation planning. PISM leverages the collaborative efforts of researchers and community partners to analyze complex health systems, identify key determinants, and develop tailored interventions and strategies that are both adaptive and contextually relevant. The phases of the PISM process include strategize, innovate, operationalize, and assess. We describe and demonstrate how each phase contributes to the overall goal of effective and sustainable intervention implementation. We also address the challenges of data availability, model complexity, and resource constraints. We offer solutions such as innovative data collection methods and participatory model development to enhance the robustness and applicability of systems models. Through a case study on the development of a chronic disease prevention intervention, the paper illustrates the practical application of PISM and highlights its potential to guide epidemiologists and implementation scientists in developing interventions that are responsive to the complexities of real-world health systems. The conclusion calls for further research to refine participatory systems modeling techniques, overcome existing challenges in data availability, and expand the use of PISM in diverse public health contexts.

Leveraging group model building to operationalize implementation strategies across implementation phases: an exemplar related to child maltreatment intervention selection

BACKGROUND

Implementation strategies can help support the adoption and implementation of health interventions that are appropriate for a local context and acceptable to decision makers and community members. Implementation strategies should be designed to handle the complexity of the multi-level, dynamic contexts in which interventions are implemented. Systems science theories and methods explicitly attend to complexity and can be valuable for specifying implementation strategies. Group Model Building (GMB) combines research partner engagement strategies with systems science to support researchers' and partners' learning about complex problems and to identify solutions through consensus. This paper specifies how GMB can operationalize implementation strategies - methods for supporting evidence implementation in real-world practice - and describes how GMB can aid in selecting and tailoring both health interventions and implementation strategies. A case study in child maltreatment prevention planning is provided to illustrate how GMB was used to specify the "actions" - strategy activities - for three implementation strategies (conduct local consensus discussions; build a coalition; model and simulate change) during the earliest implementation phases, with the goal of supporting intervention selection decisions. Examples are provided of generalizable research products that can be produced concurrently through GMB, in addition to contextually-driven implementation support.

METHODS

Participants (n = 8) were engaged over four sessions using tailored GMB activities. Participants generated a qualitative system dynamics model that described their theory of change for how to prevent child maltreatment in their communities. This theory of change reflected a dynamic understanding of the interconnected determinants of child maltreatment.

RESULTS

GMB was acceptable to participants and resulted in products that could be used for implementation planning (e.g., to model and simulate change) and future research. GMB fostered trust and idea sharing between participants.

CONCLUSION

GMB can facilitate learning about which outcomes are (or are not) impacted by interventions, which resources and approaches are required for quality implementation (e.g., implementation strategies), and tradeoffs in outcomes and resources between interventions. GMB also provides a structured, effective process to generate a shared implementation vision amongst participants. Lessons learned include methods for developing trust with and between participants, and the need for researchers to tailor GMB actions for participant and project needs.

Developing a Set of Standardized Core Principles and Methods Across Multiple Training and Technical Assistance Centers

Despite a growing body of research demonstrating the value of using evidence-based programs and practices (EBPPs) to address health and education issues, the gap between research evidence and practice in education and human services continues to be a vexing problem. Technical assistance (TA) is widely accepted as a key strategy to support evidence-based programs and practices (EBPP) uptake and implementation. However, little is known about how TA practices are used in TA delivery. Moreover, little attention has been paid to building the capacity of TA providers and assessing the fidelity of the implementation of TA practices. The case example presented in this article describes one organization's efforts to develop common language and definitions of TA services, core principles, and methods, and to standardize the delivery of TA by enhancing the capacity and retention of TA providers. We conclude with recommendations about how like organizations can employ similar efforts to improve the quality and consistency of TA delivery, thereby establishing a foundation for building a strong evidence base.

Advancing and strengthening the study of social networks in community-level dissemination and implementation research: A narrative review

The dissemination and implementation (D&I) of evidence at the community level is critical to improve health and advance health equity. Social networks are considered essential to D&I efforts, but there lacks clarity regarding how best to study and leverage networks. We examined networks in community-level D&I frameworks to characterize the range of network actors, activities, and change approaches. We conducted a narrative review of 66 frameworks. Among frameworks that explicitly addressed networks - that is, elaborated on network characteristics, structure, and/or activities - we extracted and synthesized network concepts using descriptive statistics and narrative summaries. A total of 24 (36%) frameworks explicitly addressed networks. Commonly included actors were implementers, adopters/decision-makers, innovation developers, implementation support professionals, and innovation recipients. Network activities included the exchange of resources, knowledge, trust, and norms. Most network-explicit frameworks characterized ties within and across organizations and considered element(s) of network structure - for example, size, centrality, and density. The most common network change strategy was identifying individuals to champion D&I efforts. We discuss opportunities to expand network inquiry in D&I science, including understanding networks as implementation determinants, leveraging network change approaches as implementation strategies, and exploring network change as an implementation outcome.

Vision and Goals as the New Editor-in-Chief of Global Pediatric Health

As the newly appointed Editor-in-Chief (EIC) of Global Pediatric Health (GPH), it is both an honor and a privilege to lead this prestigious journal, building upon the strong foundation established by my predecessor, Dr. Aishat Akere. Under her leadership and that of her predecessors, GPH has grown into a globally recognized platform for clinical studies, case studies, public health research, and health services delivery practices focused on the pediatric population. Dr. Akere's tenure was marked by significant achievements, including the expansion of the Editorial Board, which strengthened the journal's editorial team and expanded its global reach. My appointment comes at a time when the landscape of academic publishing is rapidly evolving, particularly with the rise in the number of online journals. Despite these changes, GPH continues to stand out, receiving over 230 submissions and more than 350 000 downloads in the year 2023 alone. These numbers reflect not only the journal's relevance but also the trust that researchers and clinicians worldwide place in GPH as a reliable source of high-quality pediatric health research. As I step into this role, my vision is to further elevate the journal's standing and impact by focusing on several key goals that align with the needs of our authors, the global community, and the field of pediatric health at large.

Leveraging systems science and design thinking to advance implementation science: moving toward a solution-oriented paradigm

Many public health challenges are characterized by complexity that reflects the dynamic systems in which they occur. Such systems involve multiple interdependent factors, actors, and sectors that influence health, and are a primary driver of challenges of insufficient implementation, sustainment, and scale of evidence-based public health interventions. Implementation science frameworks have been developed to help embed evidence-based interventions in diverse settings and identify key factors that facilitate or hinder implementation. These frameworks are largely static in that they do not explain the nature and dynamics of interrelationships among the identified determinants, nor how those determinants might change over time. Furthermore, most implementation science frameworks are top-down, deterministic, and linear, leaving critical gaps in understanding of both how to intervene on determinants of successful implementation and how to scale evidence-based solutions. Design thinking and systems science offer methods for transforming this problem-oriented paradigm into one that is solution-oriented. This article describes these two approaches and how they can be integrated into implementation science strategies to promote implementation, sustainment, and scaling of public health innovation, ultimately resulting in transformative systems changes that improve population health.