Understanding a successful obesity prevention initiative in children under 5 from a systems perspective

Uncovering the key working mechanisms of a complex community-based obesity prevention programme in the Netherlands using ripple effects mapping

BACKGROUND

Much remains unknown about how complex community-based programmes can successfully achieve long-term impact. More insight is needed to understand the key mechanisms through which these programmes work. Therefore, we conducted an in-depth study in five communities that implemented the Healthy Youth, Healthy Future (JOGG) approach, a Dutch community-based obesity prevention programme. We aimed to identify perceived outcomes and long-term impacts among local stakeholders and explore potential causal pathways and working mechanisms.

METHODS

We used ripple effects mapping (REM), a qualitative participatory method to map outcomes and identify causal pathways, in five communities. We involved 26 stakeholders, professionals and policy-makers affiliated with the local JOGG approach, spread over eight REM sessions and conducted individual interviews with 24 additional stakeholders. To uncover working mechanisms, we compared outcomes and causal pathways across communities.

RESULTS

Over 5-9 years of implementation, participants perceived that JOGG had improved ownership of local stakeholders, health policies, intersectoral collaboration and social norms towards promoting healthy lifestyles. Causal pathways comprised small initial outcomes that created the preconditions to enable the achievement of long-term impact. Although exact JOGG actions varied widely between communities, we identified five common working mechanisms through which the JOGG approach contributed to causal pathways: (1) creating a positive connotation with JOGG, (2) mobilizing stakeholders to participate in the JOGG approach, (3) facilitating projects to promote knowledge and awareness among stakeholders while creating successful experiences with promoting healthy lifestyles, (4) connecting stakeholders, thereby stimulating intersectoral collaboration and (5) sharing stakeholder successes that promote healthy lifestyles, which gradually created a social norm of participation.

CONCLUSIONS

The JOGG approach seems to work through activating initial stakeholder participation and bolstering the process towards ownership, policy change, and intersectoral collaboration to promote healthy lifestyles. Key working mechanisms can inform further development of JOGG as well as other complex community-based prevention programmes.

Elusive boundaries: using an attribute framework to describe systems for population physical activity promotion

The cost of physical inactivity is alarming, and calls for whole-of-system approaches to population physical activity promotion (PPAP) are increasing. One innovative approach to PPAP is to use a framework of interdependent attributes and associated dimensions of effective systems for chronic disease prevention. Describing system boundaries can be an elusive task, and this article reports on using an attribute framework as a first step in describing and then assessing and strengthening a provincial system for PPAP in British Columbia, Canada. Interviews were conducted with provincial stakeholders to gather perspectives regarding attributes of the system. Following this, two workshops were facilitated to document important stories about the current system for PPAP and link story themes with attributes. Results from interviews and workshops were summarized into key findings and a set of descriptive statements. One hundred and twenty-one statements provide depth, breadth and scope to descriptions of the system through the lens of an adapted framework including four attributes: (i) implementation of desired actions, (ii) resources, (iii) leadership and (iv) collaborative capacity. The attribute framework was a useful tool to guide a whole-of-system approach and turn elusive boundaries into rich descriptors of a provincial system for PPAP. Immediate implications for our research are to translate descriptive statements into variables, then assess the system through group model building and identify leverage points from a causal loop diagram to strengthen the system. Future application of this approach in other contexts, settings and health promotion and disease prevention topics is recommended.

A systems framework for implementing healthy food retail in grocery settings

BACKGROUND

Food retailers can be reluctant to initiate healthy food retail activities in the face of a complex set of interrelated drivers that impact the retail environment. The Systems Thinking Approach for Retail Transformation (START) is a determinants framework created using qualitative systems modelling to guide healthy food retail interventions in community-based, health-promoting settings. We aimed to test the applicability of the START map to a suite of distinct healthy food marketing and promotion activities that formed an intervention in a grocery setting in regional Victoria, Australia.

METHODS

A secondary analysis was undertaken of 16 previously completed semi-structured interviews with independent grocery retailers and stakeholders. Interviews were deductively coded against the existing START framework, whilst allowing for new grocery-setting specific factors to be identified. New factors and relationships were used to build causal loop diagrams and extend the original START systems map using Vensim.

RESULTS

A version of the START map including aspects relevant to the grocery setting was developed ("START-G"). In both health-promoting and grocery settings, it was important for retailers to 'Get Started' with healthy food retail interventions that were supported by a proof-of-concept and 'Focus on the customer' response (with grocery-settings focused on monitoring sales data). New factors and relationships described perceived difficulties associated with disrupting a grocery-setting 'Supply-side status quo' that promotes less healthy food and beverage options. Yet, most grocery retailers discussed relationships that highlighted the potential for 'Healthy food as innovation' and 'Supporting cultural change through corporate social responsibility and leadership'.

CONCLUSIONS

Several differences were found when implementing healthy food retail in grocery compared to health promotion settings. The START-G map offers preliminary guidance for identifying and addressing commercial interests in grocery settings that currently promote less healthy foods and beverages, including by starting to address business outcomes and supplier relationships.

Measuring Shifts in Mental Models in the Prevention of Childhood Obesity in Rural Australia

Group model building is a participatory workshop technique used in system dynamics for developing community consensus to address complex problems by consensus building on individual assumptions. This study examines changes in individual mental models of the complex problem of childhood obesity following participation in group model building (GMB), as part of a larger community-based system dynamics project. Data are drawn from GMB participants across six community sites in the Whole of Systems Trial of Prevention Strategies for Childhood Obesity (WHO STOPS) in rural and regional Victoria, Australia. Each community participated in two GMB sessions resulting in a causal loop diagram (CLD) of drivers of childhood obesity for each community. Presurvey and postsurvey captured participants' perspectives before and after (n = 25) participation in both GMB sessions and a blend of inductive and deductive qualitative content analysis was used to code individual responses. Three calculations were used to determine the number of responses, whether responses were a result of persuasion from others, and comparison of responses to those found in the CLD. Our study found participant mental models shifted during the course of the GMB sessions, with some responses persuaded by others and 75% of new insights identified in CLDs created by communities. The GMB process created a platform for participants to share ideas and learn from each other. In addition, participants listed new insights about childhood obesity in their community through developing CLDs.

The use of participatory systems mapping as a research method in the context of non-communicable diseases and risk factors: a scoping review

CONTEXT

Participatory systems mapping is increasingly used to gain insight into the complex systems surrounding non-communicable diseases (NCDs) and their risk factors.

OBJECTIVES

To identify and synthesize studies that used participatory systems mapping in the context of non-communicable diseases.

DESIGN

Scoping review.

ELIGIBILITY CRITERIA

Peer-reviewed studies published between 2000 and 2022.

STUDY SELECTION

Studies that focused on NCDs and/or related risk factors, and included participants at any stage of their system's mapping process, were included.

CATEGORIES FOR ANALYSIS

The main categories for analysis were: (1) problem definition and goal-setting, (2) participant involvement, (3) structure of the mapping process, (4) validation of the systems map, and (5) evaluation of the mapping process.

RESULTS

We identified 57 studies that used participatory systems mapping for a variety of purposes, including to inform or evaluate policies or interventions and to identify potential leverage points within a system. The number of participants ranged from 6 to 590. While policymakers and professionals were the stakeholder groups most often included, some studies described significant added value from including marginalized communities. There was a general lack of formal evaluation in most studies. However, reported benefits related mostly to individual and group learning, whereas limitations described included a lack of concrete actions following from systems mapping exercises.

CONCLUSIONS

Based on the findings of this review, we argue that research using participatory systems mapping would benefit from considering three different but intertwined actions: explicitly considering how different participants and the power imbalances between them may influence the participatory process, considering how the results from a systems mapping exercise may effectively inform policy or translate into action, and including and reporting on evaluation and outcomes of the process, wherever possible.

An Analysis of Key Actor Networks for Scale-Up Strategies for Childhood Obesity Prevention and the Care of Children with Obesity in Brazil

Background

Effective scale-up of multisectoral strategies aimed to prevent and treat childhood obesity has been a challenge in Brazil, the largest country in Latin America. Implementation Science methods, such as Net-Map, can identify key actors and opinion leaders (OLs) to advance the implementation and promote sustainability.

Objectives

This study aimed to analyze power relations between key actors and OLs who influence the scale-up of Brazilian strategies for childhood obesity at the federal and state/municipal (local) levels.

Methods

A mixed method study, applying the Net-Map method, collected data through virtual workshops with federal and local level stakeholders. The Net-Map included key actors mapping, power mapping, and identification of OLs. Four domains of power were analyzed: command, funding, technical assistance, and dissemination. Network cohesion and centrality measures were calculated. A qualitative analysis was conducted to qualify power relations according to ∗ gears for a successful scale-up (i.e., coordination, goals, and monitoring; advocacy; political will; legislation and policy; funding and resources; training; program delivery; communication; and research and technical cooperation).

Results

A total of 121 federal key actors and 63 local key actors were identified across networks, of which 62 and 28 were identified as OLs, respectively. Whereas the command domain of power had the highest number of key actors, the funding domain had the least. The health sector executive branch emerged as an OL across all domains of power.

Conclusions

Barriers that threatened successful scale-up include the lack of coordination between domains of power, missing leadership within key actors, and lack of mechanisms to manage conflict of interest. Governance strategies to enhance multisectoral coordination and communication are needed to effectively scale-up and sustain childhood obesity strategies in Brazil.

Leverage point themes within Dutch municipalities' healthy weight approaches: A qualitative study from a systems perspective

INTRODUCTION

Despite all efforts of national and local approaches, obesity rates continue to rise worldwide. It is increasingly recognized that the complexity of obesity should be further addressed by incorporating a systems perspective when implementing approaches. Such an approach has four interconnected system levels: events, structures, goals, and beliefs, in which small changes ('leverage points') can lead to substantial changes in the functioning of the entire system. The current research examined the functioning of five Dutch municipalities' healthy weight approaches (HWAs) and the leverage point themes that can be identified in their system.

METHODS

Thirty-four semi-structured interviews were conducted with various stakeholders about the HWA, including policy advisors, care professionals, practice professionals, and citizens. An inductive thematic analysis was performed.

RESULTS

Three main themes were identified: 1) HWA organization structure, 2) collaboration between professionals, and 3) citizen participation. Across all system levels, we identified leverage point themes. The upper-levels events and structures occurred the most and were explained by underlying goals and beliefs. Leverage point themes regarding "HWA organization structure" were municipal processes, such as perceived impact; diversity of themes, activities, and tasks; network; and communication strategies, such as messages about the HWA. Leverage point themes regarding "collaboration between professionals" were linking pins, indicating central players within the network; motivation and commitment including support base; and stimulating one another to work on the HWA by spurring other professionals into action. Lastly, leverage point themes under "citizen participation" included reaching the target group, e.g., look for entry points; and citizens' motivation, including customization.

DISCUSSION

This paper provides unique insights into HWAs' leverage point themes that can lead to substantial changes in how the entire system functions and makes suggestions about underlying leverage points to help stakeholders improve their HWA. Future research could focus on studying leverage points within leverage point themes.

Development of the Systems Thinking for Health Actions framework: a literature review and a case study

BACKGROUND

Systems thinking is an approach that views systems with a holistic lens, focusing on how components of systems are interconnected. Specifically, the application of systems thinking has proven to be beneficial when applied to health systems. Although there is plenty of theory surrounding systems thinking, there is a gap between the theoretical use of systems thinking and its actual application to tackle health challenges. This study aimed to create a framework to expose systems thinking characteristics in the design and implementation of actions to improve health.

METHODS

A systematised literature review was conducted and a Taxonomy of Systems Thinking Objectives was adapted to develop the new 'Systems Thinking for Health Actions' (STHA) framework. The applicability of the framework was tested using the COVID-19 response in Pakistan as a case study.

RESULTS

The framework identifies six key characteristics of systems thinking: (1) recognising and understanding interconnections and system structure, (2) identifying and understanding feedback, (3) identifying leverage points, (4) understanding dynamic behaviour, (5) using mental models to suggest possible solutions to a problem and (6) creating simulation models to test policies. The STHA framework proved beneficial in identifying systems thinking characteristics in the COVID-19 national health response in Pakistan.

CONCLUSION

The proposed framework can provide support for those aiming to applying systems thinking while developing and implementing health actions. We also envision this framework as a retrospective tool that can help assess if systems thinking was applied in health actions.

Intersection between health, health literacy and local government: a mixed methods approach to identifying ways to better connect people to place-based primary health care in western Australia

BACKGROUND

The aim of this year-long mixed methods research was to examine the intersection between health, health literacy and local government to identify ways to better connect people to place-based primary health care (PHC).

METHODS

Four local government areas located within the Perth metropolitan geographic area provided the setting for the current research. Researchers were co-located into the four local governments over a 10-month period to engage with community stakeholders and services. Two methodologies were used to achieve the objective: eight group model building (GMB) workshops were conducted with N = 148 participants to create causal loop diagrams of the barriers and enablers to people being healthy and well in each of the LGAs and develop potential action ideas from these. Surveys were used to collect health service use and health literacy, as measured using a validated Health Literacy Questionnaire (HLQ), across the four LGAs (N = 409, approximately 100 respondents/area).

RESULTS

The causal loop diagram themes common across LGAs included: (1) mental health; (2) access to services; (3) health system capacity; (4) economics; and (5) physical wellbeing. Health literacy was relatively high for all nine domains of the HLQ. In the five domains rated from one to four the lowest score was 2.8 for 'appraisal of information' and the highest was 3.2 for 'feeling understood and supported by healthcare providers'. In the four domains rated from one to five; the lowest score was 3.7 for 'navigating the healthcare system' and the highest was 4.1 for 'understand health information well enough to know what to do'.  Prioritised action ideas recommended increases in practitioners to meet local needs and training General Practitioners and other health staff in culturally sensitive and trauma informed health care. The survey findings and field notes from the GMB were used to construct personas embodied in vignettes highlighting general themes identified in the workshops including those relevant to local areas.

CONCLUSIONS

There are many possibilities for health care and local governments to work together to bring services to community members disengaged from the health system. Bringing together people from diverse backgrounds and organisations created synergies that resulted in novel and feasible potential strategies to improve community health.

Systems Mapping of the New Zealand Free and Healthy School Lunch Programme: Perspectives from Lunch Providers

As part of the COVID-19 economic recovery package, the Aotearoa New Zealand Government rolled out a universal free and healthy lunch programme to the 25% least advantaged schools nationwide. This study explored experiences of school lunch providers in the Hawke’s Bay region. The aim was to create a systems map identifying points of intervention through which the lunch programme could be improved to meet the goal of reducing child food insecurity. Twelve lunch providers were interviewed to generate casual loop diagrams which were examined and integrated to form a single systems map. Seven themes arose during analysis: teacher support, principal support, nutrition guidelines and government support, supply chain, ingredient suppliers, student feedback and food waste. Teacher support was important for getting students to try new foods and eat the nutritious lunches. Principal support was a strong theme impacting opportunities for broader student engagement. This study employed systems science to highlight the importance of support from different stakeholders within the lunch programme to achieve the goal of reduced child food insecurity. Further work is needed to ensure the programme meets the wider goals of the government and community, and to determine the potential broader benefits of the programme.

Utilizing Causal Loop Diagramming to Explore a Research and Evaluation Capacity Building Partnership

The capacity to engage in research, evaluation and evidence-informed decision-making supports effective public health policy and practice. Little is known about partnership-based approaches that aim to build capacity across a system or how to evaluate them. This study examines the impacts of a research and evaluation capacity building partnership called the Western Australian Sexual Health and Blood-borne Virus Applied Research and Evaluation Network (hereafter, SiREN). SiREN aims to strengthen capacity across a system of clinical and medical services and government and non-government organizations. These organizations are connected through their shared aim of preventing and managing sexually transmissible infections and blood-borne viruses. To examine SiREN, systems concepts and methods were used. Data were collected from SiREN organizational documents (n = 42), a survey tool (n = 104), in-depth interviews (n = 17), a workshop and three meetings with SiREN stakeholders and used to develop two causal loop diagrams. Findings show engagement with SiREN was influenced by a complex interplay of contextual (e.g., organizational capacity) and process (e.g., presence of trusting relationships) factors. SiREN contributed to system level changes, including increased resources for research and evaluation, the development of networks and partnerships that led to more efficient responses to emerging health issues, evidence sharing, and sustainable research and evaluation practice. The use of causal loop diagrams enabled the identification of key leverage points that SiREN can use for continuous improvement or evaluation. The focus on how contextual factors influenced SiREN's ability to create change provides valuable information for researchers, policymakers or practitioners seeking to develop a similar partnership.

Pathways to suicide or collections of vicious cycles? Understanding the complexity of suicide through causal mapping

Suicide is the second leading cause of death among youth ages 10-19 in the USA. While suicide has long been recognized as a multifactorial issue, there is limited understanding regarding the complexities linking adverse childhood experiences (ACEs) to suicide ideation, attempt, and fatality among youth. In this paper, we develop a map of these complex linkages to provide a decision support tool regarding key issues in policymaking and intervention design, such as identifying multiple feedback loops (e.g., involving intergenerational effects) or comprehensively examining the rippling effects of an intervention. We use the methodology of systems mapping to structure the complex interrelationships of suicide and ACEs based on the perceptions of fifteen subject matter experts. Specifically, systems mapping allows us to gain insight into the feedback loops and potential emergent properties of ACEs and youth suicide. We describe our methodology and the results of fifteen one-on-one interviews, which are transformed into individual maps that are then aggregated and simplified to produce our final causal map. Our map is the largest to date on ACEs and suicide among youth, totaling 361 concepts and 946 interrelationships. Using a previously developed open-source software to navigate the map, we are able to explore how trauma may be perpetuated through familial, social, and historical concepts. In particular, we identify connections and pathways between ACEs and youth suicide that have not been identified in prior research, and which are of particular interest for youth suicide prevention efforts.

Understanding the Influence of Community-Level Determinants on Children's Social and Emotional Well-Being: A Systems Science and Participatory Approach

Healthy social and emotional development and longer-term outcomes for children are shaped by factors across the multiple levels (micro, meso, exo, macro) of a child’s environment. By employing a novel systems science and participatory approach, we were able to co-produce a series of causal loop diagrams that detail the complex relationships between variables operating at the community or neighborhood environment level (e.g., features of the built environment such as: housing type, access, availability, and location; parks and greenspace, facilities such as community services, and other service infrastructure such as transit), and highlight the individual and collective impacts these relationships can have on the subsystem surrounding a child’s social and emotional well-being. Our approach provides a unique lens of knowledge through which communities can identify key leverage points for action and (re)design of community spaces, practices, and policy.

A Theory of Change for Community-Based Systems Interventions to Prevent Obesity

INTRODUCTION

Applying systems science in public health trials is a recent innovation in childhood obesity prevention. This paper aims to use systems science conventions to propose a theory of change for community-based interventions aiming to build capacity and use exemplars from systems science for obesity prevention to describe how this approach works.

METHODS

Participants were community-based researchers. A dynamic hypothesis was created in workshops conducted in 2020 and 2021 by identifying variables critical to building community capacity for systems thinking. These were used to develop stock and flow diagrams representing individual causal relationships, feedback loops, and the overall theory of change.

RESULTS

The resultant model identified 9 stocks and 4 pairs of central balancing and reinforcing feedback loops. These represented building commitment through relationships, mutual learning, strengthening collaboration, and embedding capacity. The model is described using examples from 3 trials involving 25 communities across Victoria, Australia.

CONCLUSIONS

This nonlinear and practice-based model illustrates the process of community-based obesity prevention. The model integrates >20 years of community-based intervention implementation experience, providing an overarching theory of how such interventions work to create change and prevent obesity.

Critical factors that affect the functioning of a research and evaluation capacity building partnership: A causal loop diagram

Introduction

Public health policy and practice is strengthened by the application of quality evidence to decision making. However, there is limited understanding of how initiatives that support the generation and use of evidence in public health are operationalised. This study examines factors that support the internal functioning of a partnership, the Western Australian Sexual Health and Blood-borne Virus Applied Research and Evaluation Network (SiREN). SiREN aims to build research and evaluation capacity and increase evidence-informed decision making in a public health context.

Methods

This study was informed by systems concepts. It developed a causal loop diagram, a type of qualitative system model that illustrated the factors that influence the internal operation of SiREN. The causal loop diagram was developed through an iterative and participatory process with SiREN staff and management (n = 9) via in-depth semi-structured interviews (n = 4), workshops (n = 2), and meetings (n = 6).

Results

Findings identified critical factors that affected the functioning of SiREN. Central to SiREN’s ability to meet its aims was its capacity to adapt within a dynamic system. Adaptation was facilitated by the flow of knowledge between SiREN and system stakeholders and the expertise of the team. SiREN demonstrated credibility and capability, supporting development of new, and strengthening existing, partnerships. This improved SiREN’s ability to be awarded new funding and enhanced its sustainability and growth. SiREN actively balanced divergent stakeholder interests to increase sustainability.

Conclusion

The collaborative development of the diagram facilitated a shared understanding of SiREN. Adaptability was central to SiREN achieving its aims. Monitoring the ability of public health programs to adapt to the needs of the systems in which they work is important to evaluate effectiveness. The detailed analysis of the structure of SiREN and how this affects its operation provide practical insights for those interested in establishing a similar project.

Tools for Supporting the MCH Workforce in Addressing Complex Challenges: A Scoping Review of System Dynamics Modeling in Maternal and Child Health

Objectives

System Dynamics (SD) is a promising decision support modeling approach for growing shared understanding of complex maternal and child health (MCH) trends. We sought to inventory published applications of SD to MCH topics and introduce the MCH workforce to these approaches through examples to support further iteration and use.

Methods

We conducted a systematic search (1958–2018) for applications of SD to MCH topics and characterized identified articles, following PRISMA guidelines. Pairs of experts abstracted information on SD approach and MCH relevance.

Results

We identified 101 articles describing applications of SD to MCH topics. Approach: 27 articles present qualitative diagrams, 10 introduce concept models that begin to quantify dynamics, and 67 present more fully tested/analyzed models. Purpose: The most common purposes described were to increase understanding (n = 55) and support strategic planning (n = 26). While the majority of studies (n = 53) did not involve stakeholders, 40 included what we considered to be a high level of stakeholder engagement – a strength of SD for MCH. Topics: The two Healthy People 2020 topics addressed most frequently were early and middle childhood (n = 30) and access to health services (n = 26). The most commonly addressed SDG goals were “End disease epidemics” (n = 26) and “End preventable deaths” (n = 26).

Conclusions for Practice

While several excellent examples of the application of SD in MCH were found, SD is still underutilized in MCH. Because SD is particularly well-suited to studying and addressing complex challenges with stakeholders, its expanded use by the MCH workforce could inform an understanding of contemporary MCH challenges.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10995-022-03376-8.

Diverse Approaches to Creating and Using Causal Loop Diagrams in Public Health Research: Recommendations From a Scoping Review

Objectives: Complex systems thinking methods are increasingly called for and used as analytical lenses in public health research. The use of qualitative system mapping and in particular, causal loop diagrams (CLDs) is described as one promising method or tool. To our knowledge there are no published literature reviews that synthesize public health research regarding how CLDs are created and used. Methods: We conducted a scoping review to address this gap in the public health literature. Inclusion criteria included: 1) focused on public health research, 2) peer reviewed journal article, 3) described and/or created a CLD, and 4) published in English from January 2018 to March 2021. Twenty-three articles were selected from the search strategy. Results: CLDs were described as a new tool and were based upon primary and secondary data, researcher driven and group processes, and numerous data analysis methods and frameworks. Intended uses of CLDs ranged from illustrating complexity to informing policy and practice. Conclusion: From our learnings we propose nine recommendations for building knowledge and skill in creating and using CLDs for future public health research.

Implementing Group Model Building With the Shape Up Under 5 Community Committee Working to Prevent Early Childhood Obesity in Somerville, Massachusetts

OBJECTIVE

To describe our process of using group model building (GMB) with the Shape Up Under 5 Committee; measure the effects on Committee members; and describe the community-wide health messaging campaign that resulted from the process.

DESIGN

Pilot study.

SETTING

Somerville, Massachusetts.

PARTICIPANTS

Members of the Shape Up Under 5 Committee, a multisector group of professionals.

INTERVENTION

Research team convened the Committee and facilitated GMB from October 2015 to June 2017.

MAIN OUTCOME MEASURES

Boundary objects produced during GMB activities; committee members' perspectives on early childhood obesity in their community; and Committee members' knowledge, engagement, and trust at the conclusion of each meeting.

RESULTS

Working together using GMB activities and with support from the research team, the Committee created a community-wide campaign that provided evidence-based messages to reach an entire city that emphasized diversity and reaching immigrants and community members who spoke languages other than English. More than 80% of Committee members reported changes in their perspectives related to early childhood obesity at the conclusion of the pilot test. Six perspective shift themes emerged from interviews and open-ended survey items: exposure to new perspectives about challenges community members face; increased awareness of others working on similar issues; increased knowledge about early childhood obesity; seeing value in creating a space to work across sectors; appreciating complexity and linkages between early childhood obesity prevention and other community issues; and how participation in committee influences members' priorities in their own work. Knowledge of and engagement with early childhood obesity prevention varied at the conclusion of each meeting, as did increases in trust among Committee members.

CONCLUSION

Group model building is a promising approach to support multisector groups working to address early childhood obesity in their community. Meeting activities may have had differential impacts on members' knowledge of and engagement with early childhood obesity.

Mapping the Complexity of Suicide by Combining Participatory Modeling and Network Science

Suicide rates are steadily increasing among youth in the USA. Although several theories and frameworks of suicide have been developed, they do not account for some of the features that define suicide as a complex problem, such as a large number of interrelationships and cycles. In this paper, we create the first c omprehensive m ap o f a dverse c hildhood experiences (ACEs) and suicide for youth, by combining a participatory approach (involving 15 subject-matter experts) and network science. This results in a map of 946 edges and 361 concepts, in which we identify ACEs to be the most important factor (per degree centrality). The map is openly shared with the community to support further network analyses (e.g., decomposition into clusters). Similarly to the high-impact Foresight Map developed in the context of obesity, the largest map on suicide and ACEs to date presented in this paper can start a discussion at the crossroad of suicide research and network science, thus bringing new means to address a complex public health challenge.

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

Systems thinking is increasingly applied to understand and address systemic drivers of complex health problems. In Australia, group model building, a participatory method from systems science, has been applied in various locations to engage communities in systems-based health promotion projects. To date there is limited evidence regarding GMB use with Australian Aboriginal communities. This study aimed to determine the value and acceptability of group model building (GMB) as a methodological approach in research with Aboriginal communities and identify any adaptations required to optimise its utility. Semi-structured interviews were undertaken with 18 Aboriginal health and university staff who had prior experience with a GMB research project. Interview transcripts were inductively analysed using thematic analysis and key themes were organised using an Indigenous research framework. Participants reported that GMB methods generally aligned well with Aboriginal ways of knowing, being, and doing. Participants valued the holistic, visual and collaborative nature of the method and its emphasis on sharing stories and collective decision-making. Group model building was viewed as a useful tool for identifying Aboriginal-led actions to address priority issues and advancing self-determination. Our findings suggest that by bringing together Aboriginal and non-Aboriginal knowledge, GMB is a promising tool, which Aboriginal communities could utilise to explore and address complex problems in a manner that is consistent with their worldviews. In adapting group model building methods, non-Aboriginal researchers should aspire to move beyond co-design processes and enable Aboriginal health research to be entirely led by Aboriginal people.

•

Group model building is a promising method for research with Aboriginal communities that is generally consistent with Aboriginal worldviews.

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Group Model Building may be a useful tool for identifying actions to address priority issues and advancing Aboriginal self-determination.

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Capacity building is required so that Group Model Building workshops, and ideally entire research projects, can be led by Aboriginal people.

An action-oriented framework for systems-based solutions aimed at childhood obesity prevention in US Latinx and Latin American populations

Childhood obesity in US Latinx and Latin American populations is a persistent, complex public health issue and, as such, requires solutions grounded on systems science theory and methods. In this paper, we introduce an action-oriented framework to design, implement, evaluate, and sustain whole-of-community systems changes for childhood obesity prevention in US Latinx and Latin American populations. Our framework covers six action steps: (1) foster multisectoral team; (2) map the system, its context, and drivers; (3) envision system-wide changes; (4) effect system-wide changes; (5) monitor, learn, and adapt; and (6) scale and sustain. We also propose 10 principles that put human and environmental rights and systems thinking at the center of these systems-based solutions. For each action step, we provide a list of concrete activities, methods, approaches, and examples that can be used to guide and inform the work needed to achieve the expected outputs. Finally, we discuss how a wider adoption of systems science for childhood obesity prevention among US Latinx and Latin American populations can be encouraged and sustained.

Four-Year Behavioral, Health-Related Quality of Life, and BMI Outcomes from a Cluster Randomized Whole of Systems Trial of Prevention Strategies for Childhood Obesity

OBJECTIVE

This study aimed to test the effectiveness of the Whole of Systems Trial of Prevention Strategies for Childhood Obesity (WHO STOPS Childhood Obesity) for behavioral, health-related quality of life (HRQoL), and BMI outcomes.

METHODS

This was a cluster randomized trial of 10 communities randomly allocated (1:1) to start intervention in 2015 (step 1) or in 2019 (after 4 years) in South West Victoria, Australia. Data were collected from participating primary schools in April to June of 2015 (73% school participation rate), 2017 (69%), and 2019 (63%). Student participation rates were 80% in 2015 (1,792/2,516 invited), 81% in 2017 (2,411/2,963), and 79% in 2019 (2,177/2,720). Repeat cross-sectional analyses of measured height and weight (grades two, four, and six [aged approximately 7 to 12 years]), self-reported behavior, and HRQoL (grades four and six) were conducted.

RESULTS

There was an intervention by time interaction in BMI z scores (P = 0.031) and obesity/overweight prevalence (P = 0.006). BMI z score and overweight/obesity prevalence decreased between 2015 and 2017 and increased between 2017 and 2019 in intervention communities. The intervention significantly reduced takeaway food consumption (P = 0.034) and improved physical (P = 0.019), psychosocial (P = 0.026), and global (P = 0.012) HRQoL. Water consumption increased among girls (P = 0.033) in the intervention communities, as did energy-dense, nutrient-poor snack consumption among boys (P = 0.006).

CONCLUSIONS

WHO STOPS had a positive impact on takeaway food intake and HRQoL.

A systems map of the determinants of child health inequalities in England at the local level

Children and young people in the UK have worse health outcomes than in many similar western countries and child health inequalities are persistent and increasing. Systems thinking has emerged as a promising approach to addressing complex public health issues. We report on a systems approach to mapping the determinants of child health inequalities at the local level in England for young people aged 0-25, and describe the resulting map. Qualitative group concept mapping workshops were held in two contrasting English local authorities with a range of stakeholders: professionals (N = 35); children and young people (N = 33) and carers (N = 5). Initial area maps were developed, and augmented using data from qualitative interviews with professionals (N = 16). The resulting local maps were reviewed and validated by expert stakeholders in each area (N = 9; N = 35). Commonalities between two area-specific system maps (and removal of locality-specific factors) were used to develop a map that could be applied in any English local area. Two rounds of online survey (N = 21; N = 8) experts in public health, local governance and systems science refined the final system map displaying the determinants of child health inequalities. The process created a map of over 150 factors influencing inequalities in health outcomes for children aged 0-25 years at the local area level. The system map has six domains; physical environment, governance, economic, social, service, and personal. To our knowledge this is the first study taking a systems approach to addressing inequalities across all aspects of child health. The study shows how group concept mapping can support systems thinking at the local level. The resulting system map illustrates the complexity of factors influencing child health inequalities, and it may be a useful tool in demonstrating to stakeholders the importance of policies that tackle the systemic drivers of child health inequalities beyond those traditionally associated with public health.

Understanding the dynamics of obesity prevention policy decision-making using a systems perspective: A case study of Healthy Together Victoria

INTRODUCTION

Despite global recommendations for governments to implement a comprehensive suite of policies to address obesity, policy adoption has been deficient globally. This paper utilised political science theory and systems thinking methods to examine the dynamics underlying decisions regarding obesity prevention policy adoption within the context of the Australian state government initiative, Healthy Together Victoria (HTV) (2011-2016). The aim was to understand key influences on policy processes, and to identify potential opportunities to increase the adoption of recommended policies.

METHODS

Data describing government processes in relation to the adoption of six policy interventions considered as part of HTV were collected using interviews (n = 57), document analyses (n = 568) and field note observations. The data were analysed using multiple political science theories. A systematic method was then used to develop a Causal Loop Diagram (CLD) for each policy intervention. A simplified meta-CLD was generated from synthesis of common elements across each of the six policy interventions.

RESULTS

The dynamics of policy change could be explained using a series of feedback loops. Five interconnected balancing loops served to reduce the propensity for policy change. These pertained to an organisational norm of risk aversion, and the complexity resulting from a whole-of-government policy approach and in-depth stakeholder consultation. However, seven virtuous reinforcing loops helped overcome policy resistance through policy actor capabilities that were improved over time as policy actors gained experience in advocating for change.

CONCLUSION

Policy processes for obesity prevention are complex and resistant to change. In order to increase adoption of recommended policies, several capabilities of policy actors, including policy skills, political astuteness, negotiation skills and consensus building, should be fostered and strengthened. Strategies to facilitate effective and broad-based consultation, both across and external to government, need to be implemented in ways that do not result in substantial delays in the policy process.

Community Group Model Building as a Method for Engaging Participants and Mobilising Action in Public Health

Group model building (GMB) is a qualitative method aimed at engaging stakeholders to collectively consider the causes of complex problems. Tackling inequities in community nutrition is one such complex problem, as the causes are driven by a variety of interactions between individual factors, social structures, local environments and the global food system. This methods paper describes a GMB process that utilises three system mapping tools in a study with members of a multicultural, low-income community to explore declining fruit and vegetable intake in children. The tools were: 1) graphs over time, which captures the community's understanding of an issue; 2) cognitive mapping, which enables participants to think systemically about the causes and consequences of the issue; 3) causal loop diagrams, which describe feedback loops that reinforce the issue and identify potential actions. Cognitive mapping, a tool not usually associated with GMB, was added to the research process to support the gradual development of participants' thinking and develops the skills needed to tackle an issue from a systems perspective. We evaluate the benefits and impact of these three tools, particularly in engaging participants and increasing understanding of systems thinking in order to develop and mobilise action. The tools could be adapted for use in other community-based research projects. Key learnings were the value of genuine partnership with a local organisation for longevity of the project, recruitment of key decisionmakers from the community early in the process, and allowing time to create sustainable change.

Process evaluation of a whole-of-community systems approach to address childhood obesity in western Victoria, Australia

Background

SEA Change Portland is a systems-based approach implemented in Portland, Victoria that utilises local community resources to sustainably prevent and reduce the prevalence of childhood obesity. Action is implemented by community-led task teams with differing priority areas, and supported by a steering committee representative of four collaborating organisations. This study examines the SEA Change Portland process to identify significant events, enablers and barriers of its development and implementation to date as reported by key stakeholders involved in implementation during the first 12 months.

Methods

Semi-structured interviews were conducted with eight steering group members and three community task team members. Data was collected utilising open ended interview questions to gather in-depth information regarding program implementation, and the individual attitudes, beliefs and experiences of key stakeholders.

Results

Data were analysed under three key themes: collective impact, systems thinking and asset based community development (ABCD). Participants gave perceptions of significant events; factors positively and negatively affecting the process; reasons for becoming involved in the process; perceived efficacy of task teams, principles of diversity and areas of concern. Themes emerged from participant responses allowing were categorisation of their responses into four key process stages: initial lead up; process development; establishing community ownership of the obesity system; and community action.

Conclusion

Collective impact was a crucial element in applying the systems thinking. Strong and equitable relationships between steering organisations and topic experts provided the initiative with a sustainable foundation, and ABCD promotes community ownership and future sustainability. Understanding the process of implementing a new whole-of-community systems approach to childhood obesity prevention such as SEA Change Portland has provided vital knowledge for other communities regarding enablers and barriers of this promising approach.

Developing a strategic understanding of telehealth service adoption for COPD care management: A causal loop analysis of healthcare professionals

BACKGROUND

Telehealth services can improve the quality of health services for chronic obstructive pulmonary disease (COPD) management, but the clinical benefits for patients yet not clear. It is crucial to develop a strategy that supports the engagement of healthcare professionals to promote the sustainable adoption of telehealth services further. The aim of the study was to show how variables related to the perception of telehealth services for COPD by different healthcare professionals interact to influence its adoption and to generate advice for future telehealth service implementation.

METHODS

Data was thematically synthesized from published qualitative studies to create causal loop diagrams, further validated by expert interviews. These diagrams visualize dependencies and their polarity between different variables.

RESULTS

Adoption of telehealth services from the nurse's perspective is directly affected by change management and autonomous decision making. From the physician's perspective, perceived value is the most important variable. Physical activity management and positive user experience are considered affecting perceived value for physiotherapists. There is no consensus where self-management services should be positioned in the COPD care pathway.

CONCLUSION

Our results indicate how complex interactions between multiple variables influence the adoption of telehealth services. Consequently, there is a need for multidimensional interventions to achieve adoption. Moreover, key variables were identified that require attention to ensure success of telehealth services. Furthermore, it is necessary to explore where self-management services are best positioned in the care pathway of COPD patients.

Building a systems thinking prevention workforce

ISSUE ADDRESSED

Healthy Together Victoria (HTV) was a large-scale intervention that adopted a systems approach to prevention. It established the capability of an inexperienced workforce by cultivating their understanding of systems theories, tools and practice. This paper explores how this capacity was developed and what helped and hindered the process.

METHODS

This qualitative research included 31 primary semi-structured interviews that focused on participants' understanding of systems thinking. Deductive thematic analysis was undertaken. A workforce development framework informed the coding that was used to create a causal loop diagram.

RESULTS

The findings display the multiple influencers on capacity-building. Practice change was enabled with training-although it lacked coordination and participation was limited. Yet, the systems approach was strengthened with governance arrangements, policies, funding, team support and leadership that empowered practitioners to trial systems methods. Capacity-building was hindered by HTV's unspecified theory that made it harder for novice practitioners to grasp. Funding cuts due to political changes reduced the initiative's duration and prompted resignations, causing the newfound experience to exit the workforce.

CONCLUSION

Capacity-building for systems practice requires a holistic approach of simultaneous, complimentary actions that address the individual and environmental influences of workforce development, especially the drivers of organisational culture that facilitate new practice. SO WHAT?: Effective training methods should specifically teach skills and knowledge that help practitioners to implement systems thinking. The workforce development requirements of other contributors also need to be considered, in addition to the policies, opportunities and resources that embed practice change.

Bayesian strategy selection identifies optimal solutions to complex problems using an example from GP prescribing

Complex health problems require multi-strategy, multi-target interventions. We present a method that uses machine learning techniques to choose optimal interventions from a set of possible interventions within a case study aiming to increase General Practitioner (GP) discussions of physical activity (PA) with their patients. Interventions were developed based on a causal loop diagram with 26 GPs across 13 clinics in Geelong, Australia. GPs prioritised eight from more than 80 potential interventions to increase GP discussion of PA with patients. Following a 2-week baseline, a multi-arm bandit algorithm was used to assign optimal strategies to GP clinics with the target outcome being GP PA discussion rates. The algorithm was updated weekly and the process iterated until the more promising strategies emerged (a duration of seven weeks). The top three performing strategies were continued for 3 weeks to improve the power of the hypothesis test of effectiveness for each strategy compared to baseline. GPs recorded a total of 11,176 conversations about PA. GPs identified 15 factors affecting GP PA discussion rates with patients including GP skills and awareness, fragmentation of care and fear of adverse outcomes. The two most effective strategies were correctly identified within seven weeks of the algorithm-based assignment of strategies. These were clinic reception staff providing PA information to patients at check in and PA screening questionnaires completed in the waiting room. This study demonstrates an efficient way to test and identify optimal strategies from multiple possible solutions.

Taking a systems approach to explore the impacts and outcomes of a research and evaluation capacity building partnership: a protocol

INTRODUCTION

Partnership models that bring researchers, policymakers and service providers closer together are gaining traction as a strategy to improve public health practice. Yet, there is little evidence of how these models work, or indeed if they do work. The Sexual Health and Blood-borne Virus Applied Research and Evaluation Network (SiREN) is one such model. SiREN is a partnership between researchers, policymakers and service providers that aims to develop the research and evaluation capacity and evidence-informed decision making capability of professionals working to address sexual health and bloodborne virus issues in Western Australia. This study will use a systems approach to identify the mechanisms of action, impacts and outcomes of SiREN and inform the development of evaluation tools.

METHODS AND ANALYSIS

Data will be collected from organisational documents, surveys, in-depth interviews and a workshop. It will be analysed using a complex adaptive systems lens and findings will be used to inform the development of a type of qualitative systems model called a causal loop diagram. The causal loop diagram will illustrate the: contextual factors influencing engagement; mechanisms of action; and impacts and outcomes of SiREN. Evaluation tools will then be developed that can be used to assess the indicators identified in the causal loop diagram.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Curtin University Human Research Ethics Committee (approval number: HRE2017-0090). Participants will be free to withdraw from the study at any point and confidentiality will be maintained by de-identifying participant responses in any published or shared data. The findings from this study will be shared in conference presentations, reports, peer-reviewed journals and online through websites and social media.

Activating a Community: An Agent-Based Model of Romp & Chomp, a Whole-of-Community Childhood Obesity Intervention

OBJECTIVE

Successful whole-of-community childhood obesity prevention interventions tend to involve community stakeholders in spreading knowledge about and engagement with obesity prevention efforts through the community. This process is referred to by the authors as stakeholder-driven community diffusion (SDCD). This study uses an agent-based model in conjunction with intervention data to increase understanding of how SDCD operates.

METHODS

This agent-based model retrospectively simulated SDCD during Romp & Chomp, a 4-year whole-of-community childhood obesity prevention intervention in Victoria, Australia. Stakeholder survey data, intervention records, and expert estimates were used to parameterize the model. Model output was evaluated against criteria derived from empirical data and experts' estimates of the magnitude and timing of community knowledge and engagement change.

RESULTS

The model was able to produce outputs that met the evaluation criteria: increases in simulated community knowledge and engagement driven by SDCD closely matched expert estimates of magnitude and timing.

CONCLUSIONS

Strong suggestive evidence was found in support of a hypothesis that SDCD was a key driver of the success of the Romp & Chomp intervention. Model exploration also provided additional insights about these processes (including where additional data collection might prove most beneficial), as well as implications for the design and implementation of future interventions.

Improving low fruit and vegetable intake in children: Findings from a system dynamics, community group model building study

Many children globally do not meet government guidelines for daily fruit and vegetable intake, and in New Zealand, adherence to the vegetable intake recommendation is declining. This study aimed to identify systemic barriers to children meeting fruit and vegetable (FV) guidelines and generate sustainable actions within a local community to improve children's FV intake. A qualitative system dynamics method of community group model building was used. The research team partnered with Healthy Families Waitākere, a Ministry of Health funded prevention initiative, to recruit 17 participants (including students, parents, teachers, community leaders, local retailers and health promoters) from a low-income, ethnically-diverse community in West Auckland, New Zealand. Three group model building workshops were held during which a systems map was created and used to identify actions by considering causal pathways and reinforcing loops in the system. Barriers to children's FV intake identified by participants were the saturation of fast-food outlets in the community and ubiquitous marketing of these products, the high cost of fresh produce compared to fast food, and parents having little time for food preparation plus declining cooking skills and knowledge. Several actions to improve children's FV intake by improving the local food environment were identified, which will be co-designed further and tested by a collaborative group involving community leaders. This project highlights the effectiveness of group model building for engaging a local community in systems change to improve child nutrition, and supplies a blueprint for future qualitative system dynamics research.

Process evaluation of the healthy primary School of the Future: the key learning points

Background

While schools have potential to contribute to children’s health and healthy behaviour, embedding health promotion within complex school systems is challenging. The ‘Healthy Primary School of the Future’ (HPSF) is an initiative that aims to integrate health and well-being into school systems. Central to HPSF are two top-down changes that are hypothesized as being positively disruptive to the Dutch school system: daily free healthy lunches and structured physical activity sessions. These changes are expected to create momentum for bottom-up processes leading to additional health-promoting changes. Using a programme theory, this paper explores the processes through which HPSF and the school context adapt to one another. The aim is to generate and share knowledge and experiences on how to implement changes in the complex school system to integrate school health promotion.

Methods

The current study involved a mixed methods process evaluation with a contextual action-oriented research approach. The processes of change were investigated in four Dutch primary schools during the development year (2014–2015) and the first two years of implementation (2015–2017) of HPSF. The schools (each with 15–26 teachers and 233–389 children) were in low socio-economic status areas. Measurements included interviews, questionnaires, observations, and analysis of minutes of meetings.

Results

Top-down advice, combined with bottom-up involvement and external practical support were key facilitators in embedding HPSF within the schools’ contexts. Sufficient coordination and communication at the school level, team cohesion, and feedback loops enhanced implementation of the changes. Implementation of the healthy lunch appeared to be disruptive and create momentum for additional health-promoting changes.

Conclusions

Initiating highly visible positive disruptions to improve school health can act as a catalyst for wider school health promotion efforts. Conditions to create a positive disruption are enough time, and sufficient bottom-up involvement, external support, team cohesion and coordination. The focus should be on each specific school, as each school has their own starting point and process of change.

Trial registration

The study was retrospectively registered in the ClinicalTrials.gov database on 14 June 2016 (NCT02800616).

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6947-2) contains supplementary material, which is available to authorized users.

An integrated understanding of the complex drivers of emergency presentations and admissions in cancer patients: Qualitative modelling of secondary-care health professionals' experiences and views

The number of cancer-related emergency presentations and admissions has been steadily increasing in the UK. Drivers of this phenomenon are complex, multifactorial and interlinked. The main objective of this study was to understand the complexity of emergency hospital use in cancer patients. We conducted semi-structured interviews with 42 senior clinicians (20 doctors, 22 nurses) with diverse expertise and experience in caring for acutely ill cancer patients in the secondary care setting. Data analysis included thematic analysis and purposive text analysis to develop Causal Loop Diagrams. Our Causal Loop Diagrams represent an integrated understanding of the complex factors (13) influencing emergency hospital use in cancer patients. Eight factors formed five reinforcing feedback loops and therefore were high-leverage influences: Ability of patients and carers to self-care and cope; Effective and timely management of ambulatory care sensitive conditions by primary and community care; Sufficient and effective social care for patients and carers; Avoidable emergency hospital use; Bed capacity; Patients accessing timely appropriate specialist inpatient or ambulatory care; Prompt and effective management and prevention of acute episode; Timely and safe discharge with appropriate support. The loops show that reduction of avoidable hospital use helps relieve hospital bed pressure; improved bed capacity then has a decisive, positive influence on patient pathway and thus outcome and experience in the hospital; in turn, better in-hospital care and discharge help patients and carers self-care and cope better back home with better support from community-based health and social care services, which then reduces their future emergency hospital use. To optimise acute and emergency cancer care, it is also essential that patients, carers and other clinicians caring for cancer patients have prompt access to senior cancer specialists for advice, assessment, clinical decision and other support. The findings provide a useful framework and focus for service planners aiming to optimise care.

Systemic Barriers and Equitable Interventions to Improve Vegetable and Fruit Intake in Children: Interviews with National Food System Actors

Fruit and vegetable (FV) intake is declining in New Zealand, and over half of New Zealand's children do not meet the recommendation of two serves of fruit and three serves of vegetables daily (with even lower adherence among children in high-deprivation neighbourhoods). The aim of this study was to map the potential causal pathways explaining this decline and possible actions to reverse it. Semi-structured interviews were held in April-May 2018 with 22 national actors from the produce industry, food distribution and retail sector, government, and NGO health organisations. The qualitative systems dynamics method of cognitive mapping was used to explore causal relationships within the food system that result in low FV intake among children. Barriers and solutions identified by participants were analysed using thematic analysis and according to a public health intervention framework. Participants were in agreement with the goal of improving FV intake for health and economic outcomes, and that health promotion strategies had been ineffectual to date due to multiple systemic barriers. Common barriers discussed were poverty, high food prices, low skills/knowledge, unhealthy food environments, climate change, and urbanization. Solutions with the strongest evidence of efficacy identified by the participants were subsidizing FVs and early childhood interventions to improve FV exposure.

Grappling With Complex Food Systems to Reduce Obesity: A US Public Health Challenge

Despite 2 decades of effort by the public health community to combat obesity, obesity rates in the United States continue to rise. This lack of progress raises fundamental questions about the adequacy of our current approaches. Although the causes of population-wide obesity are multifactorial, attention to food systems as potential drivers of obesity has been prominent. However, the relationships between broader food systems and obesity are not always well understood. Our efforts to address obesity can be advanced and improved by the use of systems approaches that consider outcomes of the interconnected global food system, including undernutrition, climate change, the environmental sustainability of agriculture, and other social and economic concerns. By implementing innovative local and state programs, taking new approaches to overcome political obstacles to effect policy, and reconceptualizing research needs, we can improve obesity prevention efforts that target the food systems, maximize positive outcomes, and minimize adverse consequences. We recommend strengthening innovative local policies and programs, particularly those that involve community members in identifying problems and potential solutions and that embrace a broad set of goals beyond making eating patterns healthier. We also recommend undertaking interdisciplinary research projects that go beyond testing targeted interventions in specific populations and aim to build an understanding of the broader social, political, and economic context.

Comparing complex perspectives on obesity drivers: action-driven communities and evidence-oriented experts

INTRODUCTION

The Foresight obesity map represents an expert-developed systems map describing the complex drivers of obesity. Recently, community-led causal loop diagrams have been developed to support community-based obesity prevention interventions. This paper presents a quantitative comparison between the Foresight obesity systems map and a community-developed map of the drivers of obesity.

METHODS

Variables from a community-developed map were coded against the thematic clusters defined in the Foresight map to allow comparison of their sizes and strength of adjoining causal relationships. Central variables were identified using techniques from network analysis. These properties were compared to understand the similarities and differences between the systems as defined by the two groups.

RESULTS

The community map focused on environmental influences, such as built physical activity environment (18% of variables) and social psychology (38%). The Foresight map's largest cluster was physiology (23%), a minimal focus in the community map (2%). Network analysis highlighted media and available time within both maps, but variables related to school and sporting club environments were unique to the community map.

CONCLUSION

Community stakeholders focus on modifiable social and environmental drivers of obesity. Capturing local perspectives is critical when using systems maps to guide community-based obesity prevention.