Integrating One Health into Systems Science

One Health Systems Science. The three subsystems of One Health (ecosystem, human and animal health) are integrated in the Systems Science concept, where objects or adaptive agents (circles) interact with a dynamic environment, and Systems Thinking can lead it intervations (Systems Design) generating a change in One Health outcomes. Real-time genomic data retrieved from the three subsystems porvide information fo Systems Thinking and Systems Design.Unlabelled Image.

From urban ecology to urban enquiry: How to build cumulative and context-sensitive understandings

This paper positions urban ecology as increasingly conversant with multiple perspectives and methods for understanding the functions and qualities of diverse cities and urban situations. Despite progress in the field, we need clear pathways for positioning, connecting and synthesising specific knowledge and to make it speak to more systemic questions about cities and the life within them. These pathways need to be able to make use of diverse sources of information to better account for the diverse relations between people, other species and the ecological, social, cultural, economic, technical and increasingly digital structures that they are embedded in. Grounded in a description of the systemic knowledge needed, we propose five complementary and often connected approaches for building cumulative systemic understandings, and a framework for connecting and combining different methods and evidence. The approaches and the framework help position urban ecology and other fields of study as entry points to further advance interdisciplinary synthesis and open up new fields of research.

A qualitative study to explore experiences of anti-racism teaching in medical residency programs across the United States and subsequent creation of the SPOC (Support - Pipeline - Outcomes - Community) Model to guide future curricula design

BACKGROUND

Racism contributes to health disparities and is a serious threat to public health. Teaching physicians about racism, how to address it in medical practice, and developing high quality and sustainable curricula are essential to combating racism.

OBJECTIVE

This study aimed to (1) describe the experience of racism and anti-racism teaching in residency programs, and elicit recommendations from key informants, and (2) use these data and formative research to develop recommendations for other residencies creating, implementing, and evaluating anti-racism curricula in their own programs.

METHODS

From May to July 2023, 20 faculty and residents were recruited via convenience sampling for key informant interviews conducted via Microsoft Teams. Interviews were audio recorded, transcribed, and coded. An initial list of themes was developed using theoretical frameworks, and then refined using a grounded-theory approach. A brief online optional anonymous demographic survey was sent to participants in August of 2023.  RESULTS: Eighty percent (20/25) of participants approached were interviewed. Seventy-five percent (15/20) answered a brief optional demographic survey. Seven themes emerged: (1) Racism in medicine is ubiquitous; (2) Anti-racism teaching in medicine varies widely; (3) Sustainability strategies should be multifaceted and include recruitment, resource allocation, and outcome measures; (4) Resources are widely available and accessible if one knows where to look; (5) Outcomes and metrics of success should include resident- faculty-, patient- community-, and system-focused outcomes; (6) Curricular strategies should be multilayered, longitudinal, and woven into the curriculum; and (7) Self-reflection and discomfort are necessary parts of the process.  CONCLUSIONS: This study is one of the first to qualitatively examine perspectives of key stakeholders invested in anti-racism teaching for residents. The Support - Pipeline - Outcomes - Community (SPOC) Model, that was developed using information collected during this study, can be used in the future as a guide for others working to design and implement sustainable and high quality anti-racism curricula for residents.

Exploring challenges and opportunities in detecting emerging drug trends: A socio-technical analysis of the Canadian context

OBJECTIVES

This study aimed to apply a systems thinking approach to explore factors influencing the detection of emerging drug trends in Canada's provinces and territories to better understand how the local context can influence the design and performance of a pan-Canadian (i.e., national) substance use early warning system (EWS). This study also presents a set of actionable recommendations arising from the results. METHODOLOGY AND METHODS: Semi-structured interviews were conducted with 13 purposively recruited Medical Officers of Health and epidemiologists from across Canada working in the field of substance use. Thematic and social network analysis guided by the socio-technical systems framework were subsequently employed.

RESULTS

Barriers and facilitators for detecting emerging drug trends in provinces and territories are a product of the collective linkages and interactions between social (objectives, people, culture), technical (tools, practices, infrastructure), and external environmental (financial, regulatory frameworks, stakeholders) factors. Shortcomings in several of these areas shaped the system's behaviour and together contributed to fragmented operations that lacked strategic focus, poorly designed cross-sector partnerships, and unactionable information outputs. Participants' experiences shaped perceptions of a national substance use EWS, with some voicing potential opportunities and others expressing doubts about its effectiveness.

CONCLUSION

This study highlights interconnected social, technical, and external environmental considerations for the design and implementation of a national substance use EWS in Canada. It also demonstrates the value of using the socio-technical systems framework to understand a complex public health surveillance issue and how it can be used to inform a path forward.

Transitioning towards more plant-based diets: sharing expert knowledge through a system lens

Transitioning towards more plant-based protein diets is essential for public and planetary health. Current research about consumption practices of protein sources provides limited insight in the multidisciplinary nature and interconnectivity of the food environment. This study aimed to collect mental models of review authors by synthesizing both their implicit and explicit system views into an overarching system view. Published reviews were used to select participants and identify variables that explain the protein transition in relation to the food environment. To overcome differences in disciplines and scale levels (e.g. individual, interpersonal, environmental), variables were organized according to the Determinants of Nutrition and Eating Framework. Eight review authors shared their mental models in an interview. Participants were asked to construct a causal loop diagram (CLD), a tool proven valuable in making one's ontology explicit to others. Implicit system views in narrative were converted into CLDs using a coding framework. The overarching system view suggests that a multitude of feedback loops sustain current consumption patterns of protein sources, for example by reinforcement through habit, availability and peer support. Several aspects require further research, such as variable relationships that were subject to disagreement and the lack of reciprocity between the physical and social elements of the food environment. In addition, knowledge gaps were exposed, including long-term behaviour and interaction of multiple variables. As a boundary object, the overarching system view can facilitate the direction of future research. The findings underscore the interconnected nature of many disparate elements within the food environment, stressing the need for holistic methods like systems thinking. These are essential in developing a systemic understanding and facilitating the transition towards more plant-based diets.

A review of implementation and evaluation frameworks for public health interventions to inform co-creation: a Health CASCADE study

BACKGROUND

By including the needs and perspectives of relevant stakeholders, co-creation is seen as a promising approach for tackling complex public health problems. However, recommendations and guidance on how to plan and implement co-creation are lacking. By identifying and analysing existing implementation and evaluation frameworks for public health, this study aims to offer key recommendations for professional stakeholders and researchers wanting to adopt a co-creation approach to public health interventions.

METHODS

Firstly, PubMed and CINAHL databases were screened for articles introducing original implementation and evaluation frameworks for public health interventions. Backwards snowballing techniques were applied to the included papers. Secondly, identified frameworks were classified and relevant data extracted, including steps and constructs present in the frameworks. Lastly, recommendations were derived by conducting thematic analysis on the included frameworks.

RESULTS

Thirty frameworks were identified and data related to their nature and scope extracted. The frameworks' prominent steps and constructs were also retrieved. Recommendations related to implementation and evaluation in the context of co-creation were included.

CONCLUSION

When engaging in co-creation, we recommend including implementation considerations from an early stage and suggest adopting a systems thinking as a way to explore multiple levels of influence, contextual settings and systems from an early planning stage. We highlight the importance of partnering with stakeholders and suggest applying an evaluation design that is iterative and cyclical, which pays particular attention to the experience of the engaged co-creators.

The common drivers of children and young people's health and wellbeing across 13 local government areas: a systems view

BACKGROUND

System dynamics approaches, including group model building (GMB) and causal loop diagrams (CLDs), can be used to document complex public health problems from a community perspective. This paper aims to apply Social Network Analysis (SNA) methods to combine multiple CLDs created by local communities into a summary CLD, to identify common drivers of the health and wellbeing of children and young people.

METHODS

Thirteen community CLDs regarding children and young people health and wellbeing were merged into one diagram involving three steps: (1) combining variable names; (2) CLD merging, where multiple CLDs were combined into one CLD with a set of unique variables and connections; (3) paring, where the Decision-Making Trial and Evaluation Laboratory (DEMATEL) method was used to generate a cut-point to reduce the number of variables and connections and to rank the overall importance of each variable in the merged CLD.

RESULTS

Combining variable names resulted in 290 variables across the 13 CLDS. A total of 1,042 causal links were identified in the merged CLD. The DEMATEL analysis of the merged CLD identified 23 common variables with a net importance between 1.0 and 4.5 R + C values and 57 causal links. The variables with the highest net importance were 'mental health' and 'social connection & support' classified as high net receivers of influence within the system.

CONCLUSIONS

Combining large CLDs into a simple diagram represents a generalisable model of the drivers of complex health problems.

Assessing a potential conflict associated with the production of Moringa oleifera in the Limpopo Province of South Africa: A systems thinking approach

The increased movement of humans throughout the world allowed the transportation of several species, such as Moringa oleifera Lam. (moringa), into biomes far away from their native habitation. Native to India, moringa is a versatile, drought-tolerant, and fast-growing tree that is easily adaptable to wide-ranging tropical and sub-tropical conditions around the world. It is used in cosmetics, as food and medicine for humans, livestock feed, crop biostimulant, and green manure. Even though moringa is an alien species to South Africa, its production is increasing, and its numerous uses are recognised by communities. Moringa forms part of a highly complex (social, ecological, and economic) system. This is because it is on the Species Under Surveillance for Possible Eradication or Containment Targets (SUSPECT) list under the National Environmental Management Biodiversity Act (NEM:BA) of South Africa. Listing species that are regarded as beneficial to communities on national regulations can cause conflicts and uncertainties among various stakeholders (i.e., environmental policymakers, farmers, rural communities, and government bodies). In this paper, a systems thinking approach was applied to address complex and conflicting issues linked to the production and overall status (economic, ecological, legal, and social) of moringa in South Africa. The Causal Loop Diagram (CLD) was developed to present a broad insight into the complexity of moringa in South Africa and assist in underscoring the feedback mechanisms within the system. Moreover, the CLD indicated that the position of moringa within the country comprised a variety of interdependent variables of government policies, environment, and society, which are interconnected into a multifaceted system. The potential conflict dimensions and types associated with allocating moringa an impact category within the South African context were identified, and this may serve as a useful tool for facilitating engagements and decision-making processes among stakeholders in resolving the status of moringa in South Africa.

Development of an action programme tackling obesity-related behaviours in adolescents: a participatory system dynamics approach

System dynamics approaches are increasingly addressing the complexity of public health problems such as childhood overweight and obesity. These approaches often use system mapping methods, such as the construction of causal loop diagrams, to gain an understanding of the system of interest. However, there is limited practical guidance on how such a system understanding can inform the development of an action programme that can facilitate systems changes. The Lifestyle Innovations Based on Youth Knowledge and Experience (LIKE) programme combines system dynamics and participatory action research to improve obesity-related behaviours, including diet, physical activity, sleep and sedentary behaviour, in 10-14-year-old adolescents in Amsterdam, the Netherlands. This paper illustrates how we used a previously obtained understanding of the system of obesity-related behaviours in adolescents to develop an action programme to facilitate systems changes. A team of evaluation researchers guided interdisciplinary action-groups throughout the process of identifying mechanisms, applying the Intervention Level Framework to identify leverage points and arriving at action ideas with aligning theories of change. The LIKE action programme consisted of 8 mechanisms, 9 leverage points and 14 action ideas which targeted the system's structure and function within multiple subsystems. This illustrates the feasibility of developing actions targeting higher system levels within the confines of a research project timeframe when sufficient and dedicated effort in this process is invested. Furthermore, the system dynamics action programme presented in this study contributes towards the development and implementation of public health programmes that aim to facilitate systems changes in practice.

The need for systems thinking to advance Alzheimer's disease research

Despite extensive research efforts to mechanistically understand late-onset Alzheimer's disease (LOAD) and other complex mental health disorders, curative treatments remain elusive. We emphasize the multiscale multicausality inherent to LOAD, highlighting the interplay between interconnected pathophysiological processes and risk factors. Systems thinking methods, such as causal loop diagrams and systems dynamic models, offer powerful means to capture and study this complexity. Recent studies developed and validated a causal loop diagram and system dynamics model using multiple longitudinal data sets, enabling the simulation of personalized interventions on various modifiable risk factors in LOAD. The results indicate that targeting factors like sleep disturbance and depressive symptoms could be promising and yield synergistic benefits. Furthermore, personalized interventions showed significant potential, with top-ranked intervention strategies differing significantly across individuals. We argue that systems thinking approaches can open new prospects for multifactorial precision medicine. In future research, systems thinking may also guide structured, model-driven data collection on the multiple interactions in LOAD's complex multicausality, facilitating theory development and possibly resulting in effective prevention and treatment options.

Calculation of carbon emissions in wastewater treatment and its neutralization measures: A review

As the pursuit of "carbon neutrality" gains momentum, the emphasis on low-carbon solutions, emphasizing energy conservation and resource reuse, has introduced fresh challenges to conventional wastewater treatment approaches. Precisely evaluating carbon emissions in urban water supply and drainage systems, wastewater treatment plants, and establishing carbon-neutral operating models has become a pivotal concern in the future of wastewater treatment. Regrettably, limited research has been devoted to carbon accounting and the development of carbon-neutral strategies for wastewater treatment. In this review, to facilitate comprehensive carbon accounting, we initially recognizes direct and indirect carbon emission sources in the wastewater treatment process. We then provide an overview of several major carbon accounting methods and propose a carbon accounting framework. Furthermore, we advocate for a systemic perspective, highlighting that achieving carbon neutrality in wastewater treatment extends beyond the boundaries of wastewater treatment plants. We assess current technical measures both within and outside the plants that contribute to achieving carbon-neutral operations. Encouraging the application of intelligent algorithms for the multifaceted monitoring and control of wastewater treatment processes is paramount. Supporting resource and energy recycling is also essential, as is recognizing the benefits of synergistic wastewater treatment technologies. We advocate a systematic, multi-level planning approach that takes into account a wide range of factors. Our goal is to offer valuable insights and support for the practical implementation of water environment management within the framework of carbon neutrality, and to advance sustainable socio-economic development and contribute to a more environmentally responsible future.

Planning, implementing and governing systems-based co-creation: the DISCOVER framework

BACKGROUND

Increasingly, public health faces challenges requiring complex, multifaceted and multi-sectoral responses. This calls for systems-based approaches that facilitate the kind of collective and collaborative thinking and working required to address complexity. While the literature on systems thinking, system dynamics and the associated methodologies is extensive, there remains little clear guidance on how to plan, govern and implement participatory systems approaches within a co-creation process.

METHODS

We used a three-step process to develop DISCOVER, a framework for implementing, and governing systems-based co-creation: Stage 1: We conducted a literature analysis of key texts to identify well-documented methods and phases for co-creation using a systems approach, as well as areas where gaps existed. Stage 2: We looked for the most appropriate methods and approaches to fill the gaps in the knowledge production chain. Stage 3: We developed the framework, identifying how the different tools and approaches fit together end-to-end, from sampling and recruiting participants all the way through to responding with an action plan.

RESULTS

We devised DISCOVER to help guide researchers and stakeholders to collectively respond to complex social, health and wider problems. DISCOVER is a strategic research planning and governance framework that provides an actionable, systematic way to conceptualise complex problems and move from evidence to action, using systems approaches and co-creation. In this article, we introduce the eight-step framework and provide an illustrative case study showcasing its potential. The framework integrates complementary approaches and methods from social network analysis, systems thinking and co-creation literature. The eight steps are followed sequentially but can overlap.

CONCLUSIONS

DISCOVER increases rigour and transparency in system approaches to tackling complex issues going from planning to action. It is being piloted in environmental health research but may be suitable to address other complex challenges and could be incorporated into research proposals and protocols for future projects.

Producing knowledge together: a participatory approach to synthesising research across a large-scale collaboration in Aboriginal and Torres Strait Islander health

BACKGROUND

Despite that stakeholder participation in evidence synthesis could result in more useful outcomes, there are few examples of processes that actively involve them in synthesis work. Techniques are needed that engage diverse stakeholders as equal partners in knowledge co-production. The aims of this paper are to describe an innovative participatory process of synthesising a large body of academic research products and compare the findings of the participatory process against two traditional approaches to synthesis: a rapid review and a structured review.

METHODS

First, a rapid synthesis of all research outputs (n = 86) was conducted by researchers with in-depth knowledge of the collaboration's research. Second, a team of researchers and service providers conducted a structured synthesis of seventy-eight peer-reviewed articles and reports generated by the collaboration. Fifty-five publications were brought forward for further synthesis in part three, a facilitated participatory synthesis. Finally, we explored the value added by the participatory method by comparing findings generated across the three synthesis approaches.

RESULTS

Twelve researchers and 11 service providers/policy partners-8 self-identified as Aboriginal and/or Torres Strait Islander-participated in two facilitated workshops (totalling 4 h). Workshop activities engaged participants in reviewing publication summaries, identifying key findings, and evoked review, discussion and refinement. The process explicitly linked experiential knowledge to citations of academic research, clearly connecting the two knowledge types. In comparing the findings generated across all three methods we found mostly consistencies; the few discrepancies did not contradict but gave deeper insights into statements created by the other methods. The participatory synthesis generated the most, detailed, and unique findings, and contextual insights about the relevance of the key messages for practice.

CONCLUSION

The participatory synthesis engaged stakeholders with diverse backgrounds and skillsets in synthesising a large body of evidence in a relatively short time. The participatory approach produced findings comparable to traditional synthesis methods while extending knowledge and identifying lessons most relevant for the participants who, ultimately, are the end users of the research. This process will interest other large-scale research collaborations seeking to engage stakeholders in evidence synthesis.

A conceptual model of the continuous glucose monitoring integration process for older adults with diabetes developed using participatory systems science methods

AIMS

Continuous glucose monitoring (CGM) use remains low in older adults. We aimed to develop a conceptual model of CGM integration among older adults with type 1 and type 2 diabetes.

METHODS

We previously engaged older adults with type 1 diabetes using participatory system science methods to develop a model of the system of factors that shape CGM integration. To validate and expand the model, we conducted semi-structured interviews with 17 older adults with type 1 and type 2 diabetes and 3 caregivers. Vignettes representing each integration phase were used to elicit outcomes and strategies to support CGM use. Data were analyzed using team-based causal loop diagraming.

RESULTS

The model includes six phases spanning (1) CGM uptake; (2) device set-up; acquisition of (3) belief in oneself to use CGM effectively; (4) belief that CGM is preferable to blood glucose monitoring; (5) belief in future CGM benefits CGM; and (6) development of a sense of reliance on CGM. Causal loop diagrams visualize factors and feedback loops shaping outcomes at each phase. Participants proposed support strategies spanning clinical, educational, and behavioral interventions.

CONCLUSIONS

The model underscores the complex transition of learning new technology and provides opportunities for tailored support for older adults.

Towards planetary oral health

It is time to consider the protection of our environment as a major public health issue in oral medicine. Evidence shows that activities related to dental practice, such as patient transportation, use of rare materials and chemicals, or energy consumption, affect our ecosystems and contribute to the global degradation we are increasingly observing. The degradation of our environment is considered the greatest threat to our health. Exposure of oral tissues to multiple environmental factors can lead to pathological conditions. In addition to these direct effects, there are more complex phenomena, leading to co-deficits in the health of populations. The example of the sugar industry illustrates the systemic failures resulting in the double degradation of the environment and the health of individuals. Face with these dynamically interacting phenomena, human communities must consider systemic responses such as those described in this article. The dental community will need to do its part and consider global oral health as a central issue. This conceptual work will help define the innovations and action needed to ensure equitable practice that respects planetary limits.

Developing a Tool for Monitoring and Evaluating a Network Approach to Innovation: Lessons from Year 1 of the SexEdVA Disability-Inclusive Sexual Health Network (DSHN)

Disparities in sexual health outcomes for youth with disabilities require new and creative approaches to address the complex and often individualized barriers facing this diverse population. The Disability-inclusive Sexual Health Network (DSHN) establishes, funds, coordinates, and supports a multidisciplinary network of partners to explore, develop, test, refine, and evaluate innovative interventions that will improve optimal health, prevent teen pregnancy, and address sexually transmitted infections (STIs) for youth with disabilities in Virginia. DSHN developed the Monthly Reporting Instrument (MRI) to support communication, coordination, monitoring, and evaluation of the project, and shares findings from data collected using this tool. A mixed method analysis was conducted on data collected in year 1 using the MRI. A total of 67 MRI submissions were collected across eight DSHN Partners between March 2021 and March 2022. Analysis of the year 1 MRI data gives a rich understanding of the common barriers faced, accomplishments and progress achieved in the face of those challenges, and Partners' relationships to the Network and each other. This paper proposes solutions to common barriers in implementing Network support and coordination activities in year 2 and reflects on the utility of the MRI as a multi-purpose tool for communication and engagement as well as monitoring and evaluating DSHN as a systems-level intervention.

Systems thinking based approaches to engage with health inequities shaping Antimicrobial Resistance in low and lower-middle-income countries

This paper argues for 'systems thinking' as a conceptual framework to address antimicrobial resistance, especially focusing on the context of low and lower middle-income countries (LLMICs), which are plagued with health inequities that magnify the AMR threat. Systems thinking provides two avenues to enhance these mitigation efforts: i) it helps go beyond a purely biomedical approach to incorporate considerations of the social and informational; ii) particularly relevant as is it helps to understand the role of health inequities in shaping AMR related prevention and care processes.

Minding our futures: Understanding climate-related mental wellbeing using systems science

INTRODUCTION

Climate change impacts mental wellbeing through complex pathways and young people are among the most vulnerable to climate-related anxiety. Minding our Futures used methods from systems science to explore this issue and identify actions to promote mental wellbeing for young Australians (18-24 years).

METHODS

This qualitative study used Group Model Building via three online facilitated workshops recruiting health, youth and climate practitioners and researchers engaged with young people around climate change and/or mental wellbeing (N = 14). Analysis created a systems map and rich description of the relationships between causal factors and their impact on young people.

RESULTS

Three themes emerged; "Government, Services and Structures" highlighted underlying structural issues including capitalism and political powerlessness; "Social Norms, Communication and Taking Action" reflected social media and misinformation; and "Personal Experience of Environmental Disasters" described the impact of climate-related disasters and importance of nature and place connection. Participants specified connections between the themes and mental health outcomes.

CONCLUSION

This novel applied translational research process supported key informants to design structural responses to a complex and critical public health issue. Their vision was a multi-faceted approach, co-led with young people, drawing on Indigenous knowledges and change-focused policy, community empowerment and nature-based interventions.

Using systems thinking to understand the scale-up and sustainability of health innovation: a case study of seasonal malaria chemoprevention processes in Burkina Faso

BACKGROUND

Scale-up and sustainability are often studied separately, with few studies examining the interdependencies between these two processes and the implementation contexts of innovations towards malaria prevention and control. Researchers and implementers offer much more attention to the content of innovations, as they focus on the technological dimensions and the conditions for expansion. Researchers have often considered innovation a linear sequence in which scaling up and sustainability represented the last stages. Using systems thinking in this manuscript, we analyze complex scaling and sustainability processes through adopting and implementing seasonal malaria chemoprevention (SMC) in Burkina Faso from 2014 to 2018.

METHODS

We conducted a qualitative case study involving 141 retrospective secondary data (administrative, press, scientific, tools and registries, and verbatim) spanning from 2012 to 2018. We complemented these data with primary data collected between February and March 2018 in the form of 15 personal semi-structured interviews with SMC stakeholders and non-participant observations. Processual analysis permitted us to conceptualize scale-up and sustainability processes over time according to different vertical and horizontal levels of analysis and their interconnections.

RESULTS

Our results indicated six internal and external determinants of SMC that may negatively or positively influence its scale-up and sustainability. These determinants are effectiveness, monitoring and evaluation systems, resources (financial, material, and human), leadership and governance, adaptation to the local context, and other external elements. Our results revealed that donors and implementing actors prioritized financial resources over other determinants. In contrast, our study clearly showed that the sustainability of the innovation, as well as its scaling up, depends significantly on the consideration of the interconnectedness of the determinants. Each determinant can concurrently constitute an opportunity and a challenge for the success of the innovation.

CONCLUSION

Our findings highlight the usefulness of the systemic perspective to consider all contexts (international, national, subnational, and local) to achieve large-scale improvements in the quality, equity, and effectiveness of global health interventions. Thus, complex and systems thinking have made it possible to observe emergent and dynamic innovation behaviors and the dynamics particular to sustainability and scaling up processes.

The Connections Matter: Bi-Directional Learning in Program Evaluation and Practice-Oriented Research

Intended for researchers and clinical leaders, this article suggests that embedded program evaluation is a good fit with the desired features of practice-oriented research. The systematic nature of evaluation that is built into the operational workflow of a practice setting may increase the diversity of methods available to explore processes and outcomes of interest. We propose a novel conceptual framework that uses a human-centered systems lens to foster such embedded evaluation in clinical routine. This approach emphasizes the evaluator-practitioner partnership to build confidence in the bi-directional learning of practice-based evidence with evidence-based practice. The iterative cycles inherent to design thinking are aimed at developing better evaluation questions. The attention to structure and context inherent to systems thinking is intended to support meaningful perspectives in the naturally complex world of health care. Importantly, the combined human-centered systems lens can create greater awareness of the influence of individual and systemic biases that exist in any endeavor or institution that involves people. Recommended tools and strategies include systems mapping, program theory development, and visual facilitation using a logic model to represent the complexity of mental health treatment for communication, shared understanding, and connection to the broader evidence base. To illustrate elements of the proposed conceptual framework, two case examples are drawn from routine outcome monitoring (ROM) and progress feedback. We conclude with questions for future collaboration and research that may strengthen the partnership of evaluators and practitioners as a community of learners in service of local and system-level improvement.

Group Model Building on causes and interventions for falls in Singapore: insights from a systems thinking approach

BACKGROUND

Falls in older adults are the result of a complex web of interacting causes, that further results in other physical, emotional, and psychological sequelae. A conceptual framework that represents the reciprocal dynamics of these causal factors can enable clinicians, researchers, and policymakers to clarify goals in falls intervention in older adults.

METHODS

A Group Model Building (GMB) exercise was conducted with researchers and clinicians from academic units and public healthcare institutes in Singapore. The aim of the exercise was to produce a shared visual representation of the causal structure for falls and engage in discussions on how current and future falls intervention programmes can address falls in the older adults, especially in the Asian context. It was conducted in four steps: 1) Outlining and prioritising desirable patient outcomes, 2) Conceptual model building, 3) Identifying key intervention elements of effective falls intervention programmes, 4) Mapping of interventions to outcomes. This causal loop diagram (CLD) was then used to generate insights into the current understanding of falls causal relationships, current efforts in falls intervention in Singapore, and used to identify gaps in falls research that could be further advanced in future intervention studies.

RESULTS

Four patient outcomes were identified by the group as key in falls intervention: 1) Falls, 2) Injurious falls, 3) Fear of falling, and 4) Restricted mobility and life space. A CLD of the reciprocal relationships between risk factors and these outcomes are represented in four sub-models: 1) Fear of falling, 2) Injuries associated with falls, 3) Caregiver overprotectiveness, 4) Post-traumatic stress disorder and psychological resilience. Through this GMB exercise, the group gained the following insights: (1) Psychological sequelae of falls is an important falls intervention outcome. (2) The effects of family overprotectiveness, psychological resilience, and PTSD in exacerbating the consequences of falls are not well understood. (3) There is a need to develop multi-component falls interventions to address the multitude of falls and falls related sequelae.

CONCLUSION

This work illustrates the potential of GMB to promote shared understanding of complex healthcare problems and to provide a roadmap for the development of more effective preventive actions.

Double burden of vulnerability for refugees: conceptualization and policy solutions for financial protection in Iran using systems thinking approach

INTRODUCTION

Iran is host to one of the world's largest and longest-standing refugee populations. Although Iran has initiated a basic health insurance scheme for refugees throughout the country since September 2015, the population coverage of this scheme is very low, and various factors have caused a significant percentage of refugees to still lack insurance coverage and often face financial hardships when receiving health services. In response, this study aimed to understand barriers to insurance coverage among refugees in Iran and propose effective policies that can address persistent gaps in financial protection.

METHODS

This qualitative study was conducted in two phases. First, a review of policy documents and interviews with participants were conducted to investigate the common barriers and facilitators of effective insurance coverage for refugees in Iran. Then, a systems thinking approach was applied to visualize the common variables and interactions on the path to achieving financial protection for refugees.

RESULTS

Findings showed that various factors, such as (1) household-based premium for refugees, (2) considering a waiting time to be eligible for insurance benefits, (3) determining high premiums for non-vulnerable groups and (4) a deep difference between the health services tariffs of the public and private service delivery sectors in Iran, have caused the coverage of health insurance for non-vulnerable refugees to be challenging. Furthermore, some policy solutions were found to improve the health insurance coverage of refugees in Iran. These included removing household size from premium calculations, lowering current premium rates and getting monthly premiums from non-vulnerable refugees.

CONCLUSIONS

A number of factors have caused health insurance coverage to be inaccessible for refugees, especially non-vulnerable refugees in Iran. Therefore, it is necessary to adopt effective policies to improve the health financing for the refugee with the aim of ensuring financial protection, taking into account the different actors and the interactions between them.

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.

Ethical enactivism for smart and inclusive STEAM learning design

Current global challenges of the 21st century promote STEAM (science, technology, engineering, arts and mathematics) education and digitalization as a means for humans to be the central actors in the construction of a sustainable society that favors a sense of worth and global wellbeing. In this scenario, new educational technology tools and immersive learning affordances (possibilities), offer unprecedented potential for the design of smart and dynamic learning systems and contexts that can enhance learning processes across varied audiences and educational settings. However, current STEAM education practice lacks attention to equipping all citizens with the necessary skills to use digital technologies in an ethical, critical and creative way. This gap calls for attention in design processes, principles and practices that are attentive to ethical considerations and values-based approaches. On the other hand, in its formulation STEAM as an educational approach is framed in four fundamental pillars: creativity, inclusion, citizenship and emerging technologies, which also put attention on the inclusion of disadvantaged and underrepresented social groups during STEAM education design. Following an apparent need to explore ethical and inclusive design in STEAM education, and inspired in the 4E cognition framework, ethical enactivism and embodied and ecosomaesthetics experience design, here we propose a theoretical framework grounded on systems thinking for the design of smart and dynamic STEAM learning systems and settings. The framework is aimed at STEAM educational psychologists, educational technologists, learning designers and educational practitioners who wish to address the global challenges of 21st century education by means of creative, innovative and inclusive education design.

Developing an integrated model of care for vulnerable populations living with non-communicable diseases in Lebanon: an online theory of change workshop

INTRODUCTION

The Syrian crisis, followed by a financial crisis, port explosion, and COVID-19, have put enormous strain on Lebanon's health system. Syrian refugees and the vulnerable host population have a high burden of Non-communicable Diseases (NCD) morbidity and unmet mental health, psychosocial and rehabilitation needs. The International Committee of the Red Cross (ICRC) recently introduced integrated NCD services within its package of primary care in Lebanon, which includes NCD primary health care, rehabilitation, and mental health and psychosocial support services. We aimed to identify relevant outcomes for people living with NCDs from refugee and host communities in northern Lebanon, as well as to define the processes needed to achieve them through an integrated model of care. Given the complexity of the health system in which the interventions are delivered, and the limited practical guidance on integration, we considered systems thinking to be the most appropriate methodological approach.

METHODS

A Theory of Change (ToC) workshop and follow-up meetings were held online by the ICRC, the London School of Hygiene and Tropical Medicine and the American University of Beirut in 2021. ToC is a participatory and iterative planning process involving key stakeholders, and seeks to understand a process of change by mapping out intermediate and long-term outcomes along hypothesised causal pathways. Participants included academics, and ICRC regional, coordination, and headquarters staff.

RESULTS

We identified two distinct pathways to integrated NCD primary care: a multidisciplinary service pathway and a patient and family support pathway. These were interdependent and linked via an essential social worker role and a robust information system. We also defined a list of key assumptions and interventions to achieve integration, and developed a list of monitoring indicators.

DISCUSSION

ToC is a useful tool to deconstruct the complexity of integrating NCD services. We highlight that integrated care rests on multidisciplinary and patient-centred approaches, which depend on a well-trained and resourced team, strong leadership, and adequate information systems. This paper provides the first theory-driven road map of implementation pathways, to help support the integration of NCD care for crises-affected populations in Lebanon and globally.

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.

Applying Systems Thinking to Inform Decentralized Clinical Trial Planning and Deployment

Recently, there has been a growing interest in understanding how decentralized clinical trial (DCT) solutions can mitigate existing challenges in clinical development, particularly participant burden and access, and the collection, management, and quality of clinical data. This paper examines DCT deployments, emphasizing how they are integrated and how they may impact clinical trial oversight, management, and execution. We propose a conceptual framework that employs systems thinking to evaluate the impact on key stakeholders through a reiterative assessment of pain points. We conclude that decentralized solutions should be customized to meet patient needs and preferences and the unique requirements of each clinical trial. We discuss how DCT elements introduce new demands and pressures within the existing system and reflect on enablers that can overcome DCT implementation challenges. As stakeholders look for ways to make clinical research more relevant and accessible to a larger and more diverse patient population, further robust and granular research is needed to quantify the impact of DCTs empirically.

Thinking in Terms of Change over Time: Opportunities and Challenges of Using System Dynamics Models

Understanding the world around us is a growing necessity for the whole public, as citizens are required to make informed decisions in their everyday lives about complex issues. Systems thinking (ST) is a promising approach for developing solutions to various problems that society faces and has been acknowledged as a crosscutting concept that should be integrated across educational science disciplines. However, studies show that engaging students in ST is challenging, especially concerning aspects like change over time and feedback. Using computational system models and a system dynamics approach can support students in overcoming these challenges when making sense of complex phenomena. In this paper, we describe an empirical study that examines how 10th grade students engage in aspects of ST through computational system modeling as part of a Next Generation Science Standards-aligned project-based learning unit on chemical kinetics. We show students' increased capacity to explain the underlying mechanism of the phenomenon in terms of change over time that goes beyond linear causal relationships. However, student models and their accompanying explanations were limited in scope as students did not address feedback mechanisms as part of their modeling and explanations. In addition, we describe specific challenges students encountered when evaluating and revising models. In particular, we show epistemological barriers to fruitful use of real-world data for model revision. Our findings provide insights into the opportunities of a system dynamics approach and the challenges that remain in supporting students to make sense of complex phenomena and nonlinear mechanisms.

Impacts of Systems Thinking on Mission When Environmental Nonprofit Organizations Encounter the Complex Systems Problem of Homelessness

The article examines how nonprofit organization staff navigate organizational mission as they encounter complex systems problems outside their area of expertise, focusing on environmental organizations encountering homelessness in river watersheds. Drawing on surveys from seventy-three individuals from forty-three organizations and interviews with seventeen nonprofit staff, I find that staff who demonstrate systems thinking are more likely to describe integrating complex systems problems into their mission and activities in meaningful ways. Not interacting with systems issues due to lack of skill is most often explained with language of mission adherence and avoiding mission drift.

Indigenous trans-systemics: changing the volume on systems

This paper emerged as a result of Anishinabe and non-Indigenous scholars discussing the basic principles behind systems thinking. By asking the question "what is a system?", we uncovered that our very understanding of what makes a system was vastly different. As scholars working in cross-cultural and inter-cultural environments, these differing worldviews can create systemic challenges in unpacking complex problems. Trans-systemics offers language to unearth these assumptions by the recognition that the dominant, or "loudest", systems are not always the most appropriate or equitable. It goes beyond critical systems thinking to identify that tackling complex problems requires the recognition that there are multiple, overlapping systems and worldviews at play. We identified three key takeaways from Indigenous trans-systemics for socio-ecological systems thinkers: (1) trans-systemics is a call to humility, asking us to critically examine our patterns of thought and behavior; (2) by exploring humility, trans-systemics allows us to move past the autopoiesis of Eurocentric systems thinking to consider interdependence; and (3) to utilize Indigenous trans-systemics, we need to fundamentally reconsider how we understand the systems around us and bring in outside tools and concepts to enact meaningful systems change.

Advancing Systems Citizenship in Colleges and Schools of Pharmacy

The pharmacy academy works collectively to serve the educational needs of diverse stakeholders by promulgating expectations for professional programs to achieve standards for both practice and professional development. Building systems thinking into the learning process, with its associative benefits to postgraduate preparation and lifelong practice, offers a pathway to achieve this educational mission. The concept of systems citizenship has been suggested as a process for helping health professional students incorporate a meaningful professional identity and responsibly seek out an understanding of the connections between patients, communities, and the larger institutions and environments that affect each. Drawing on the discipline of systems thinking, the student and pharmacist learn to be effective locally by thinking globally. Systems thinking, a basis for effective citizenship, is a proactive and shared approach to problem-solving that integrates professional identity with the goal of closing gaps in care. Pharmacy colleges/schools provide an opportune forum for educating professional students and postgraduates with the knowledge, skills, and abilities critical to becoming valuable and contributing systems citizens.

Using systems thinking-based risk assessment methods to assess hazardous manual tasks: a comparison of Net-HARMS, EAST-BL, FRAM and STPA

Formal risk assessment is a component of safety management relating to hazardous manual tasks (HMT). Systems thinking approaches are currently gaining interest for supporting safety management. Existing HMT risk assessment methods have been found to be limited in their ability to identify risks across the whole work system; however, systems thinking-based risk assessment (STBRA) methods were not designed for the HMT context and have not been tested in this area. The aim of this study was to compare the performance of four state-of-the-art STBRA methods: Net-HARMS, EAST-BL, FRAM and STPA to determine which would be most useful for identifying HMT risks. Each method was independently applied by one of four analysts to assess the risks associated with a hypothetical HMT system. The outcomes were assessed for alignment with a benchmark analysis. Using signal detection theory (SDT), overall STPA was found to be the best performing method having the highest hit rate, second lowest false alarm rate and highest Matthews Correlation Coefficient of the four methods.Practitioner summary: A comparison of four systems thinking risk assessment methods found that STPA had the highest level of agreement with the benchmark analysis and is the most suitable for practitioners to use to identify the risks associated with HMT systems.

A whole system approach to childhood obesity: how a supportive environment was created in the city of Brighton and Hove, United Kingdom

Childhood obesity is a growing global challenge, and no country has yet reversed the upward trend in prevalence. The causes are multifaceted, spanning individual, societal, environmental, and political spheres. This makes finding solutions complex as traditional linear models of treatment and effect have proven only minimally successful or unfeasible at the population level. There is also a paucity of evidence of what works, and few examples of intervention that operate on a 'whole systems' level. The city of Brighton in the United Kingdom has experienced a downward trend in child obesity rates compared to national figures. The aim of this study was to explore what has led to successful change in the city. This was done through a review of local data, policy and programs, and thirteen key informant interviews with key stakeholders involved in the local food and healthy weight agenda. Our findings highlight key mechanisms that have plausibly contributed to a supportive environment for obesity reduction in Brighton according to key local policy and civil society actors. These mechanisms include; a commitment to early years intervention such as breastfeeding promotion; a supportive local political context; the ability to tailor interventions to community needs; governance structures and capacity that enable cross-sectoral collaboration; and a citywide framing of obesity solutions in the context of a 'whole system' approach. However, substantial inequalities persist in the city. Engaging families in areas of high deprivation and operating in an increasingly difficult context of national austerity are persistent challenges. This case study sheds light on some mechanisms of what a whole systems approach to obesity looks like in practice in a local context. This is of relevance to both policymakers and healthy weight practitioners across a spectrum of sectors who need to be engaged to tackle child obesity.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12571-023-01361-9.

Developing an agent-based model to minimize spreading of malicious information in dynamic social networks

This research introduces a systematic and multidisciplinary agent-based model to interpret and simplify the dynamic actions of the users and communities in an evolutionary online (offline) social network. The organizational cybernetics approach is used to control/monitor the malicious information spread between communities. The stochastic one-median problem minimizes the agent response time and eliminates the information spread across the online (offline) environment. The performance of these methods was measured against a Twitter network related to an armed protest demonstration against the COVID-19 lockdown in Michigan state in May 2020. The proposed model demonstrated the dynamicity of the network, enhanced the agent level performance, minimized the malicious information spread, and measured the response to the second stochastic information spread in the network.

Effect of improvement measures in reducing interruptions in a Japanese hospital pharmacy using a synthetic approach based on resilience engineering and systems thinking

BACKGROUND

Workflow interruptions in pharmacies contribute to dispensing errors, a high-priority issue in patient safety, but have rarely been studied from a systemic perspective partly because of the limitations of the conventional reductionistic approach. This study aims to identify a mechanism for the occurrence of interruptions in a hospital pharmacy and find interventional points using a synthetic approach based on resilience engineering and systems thinking, and assess implemented measures for reducing them.

METHODS

At a Japanese university hospital, we gathered information about performance adjustments of pharmacists in the inpatient medication dispensing unit for oral and topical medicines (IMDU-OT) and nurses in the inpatient wards (IPWs) in the medication dispensing and delivery process. Data about the workload and workforce of pharmacists were collected from hospital information systems. Telephone inquiries and counter services in the IMDU-OT, the primary sources of interruptions to pharmacists' work, were documented. The feedback structure between the IMDU-OT and the IPWs was analyzed using a causal loop diagram to identify interventional points. The numbers of telephone calls and counter services were measured cross-sectionally before (February 2017) and four months after implementing measures (July 2020).

RESULTS

This study found that interruptions are a systemic problem emerging from the adaptive behavior of pharmacists and nurses to their work constraints, such as short staffing of pharmacists, which limited the frequency of medication deliveries to IPWs, and lack of information about the medication dispensing status for nurses. Measures for mitigating cross-system performance adjustments-a medication dispensing tracking system for nurses, request-based extra medication delivery, and pass boxes for earlier pick-up of medicines-were introduced. Following their implementation, the daily median number of telephone calls and counter services was significantly reduced (43 to 18 and 55 to 15, respectively), resulting in a 60% reduction in the total number of interruptions.

CONCLUSION

This study found interruptions in the hospital pharmacy as a systemic problem that can be reduced by mitigating difficulties being compensated for by clinicians' cross-system performance adjustments. Our findings suggest that a synthetic approach can be effective for solving complex problems and have implications for methodological guidance for Safety-II in practice.

Pursuitworthiness in urgent research: Lessons on well-ordered science from sustainability science

Urgent and complex sustainability problems are redefining the conditions for success of science and instigating novel methodologies and new roles of values in science. At the same time, sustainability research, mostly under the umbrella of sustainability science, is abundant with dubious methods and dubious aims of research, contributing to the already widespread crisis of the quality control mechanisms in science. This paper identifies some of these dubious methods (non-systemic thinking and specific contractual funding mechanisms) and dubious aims (unclear aims and undisclosed value assumptions), and argues that, with proper expert evaluation, it is possible to predict the type of content (and the scientific value) these forms of research will result in. Identifying the forms of research with predictably dubious results has practical implications for doing and evaluating research in sustainability science, on the one hand, while on the other, it contributes to the discussion on the ideal of well-ordered science by concretizing the ideal and developing a criterion for ordering science in the case of sustainability science. Finally, the paper provides a connection of sustainability science with the meta-science discussions on the crisis in the quality of science and on science organization, what at the same time more closely connects the philosophy of science with problems encountered in research practice tackling urgent, complex and value-laden problems.

Fostering engineering and science students' and teachers' systems thinking and conceptual modeling skills

As science and technology create an ecosystem that is becoming increasingly more knowledge-intensive, complex, and interconnected, the next generation science standards include systems thinking and systems modeling among 21st skills that should be fostered. We examined the effect of an online cross-disciplinary learning process on the development of systems thinking and modeling skills among engineering students and engineering and science teachers. The study, which used quantitative and qualitative tools, included 55 participants who performed four food-related learning assignments and created conceptual models in Object-Process Methodology. Their responses to online assignments were analyzed along with their perceptions, captured via a reflection questionnaire. The online learning process in this study effectively enhanced systems thinking and modeling skills of all learners, including those with no relevant background. One main conclusion that extends beyond the online learning was that imparting the basics of systems thinking and conceptual modeling skills can be achieved even within a short period of time-less than one semester. The contribution of the study is the formation of theoretical and practical frameworks for the integration of an cross-disciplinary model-based systems engineering online assignments into engineering and science curricula.

Ways of thinking in STEM-based problem solving

This article proposes an interconnected framework, Ways of thinking in STEM-based Problem Solving, which addresses cognitive processes that facilitate learning, problem solving, and interdisciplinary concept development. The framework comprises critical thinking, incorporating critical mathematical modelling and philosophical inquiry, systems thinking, and design-based thinking, which collectively contribute to adaptive and innovative thinking. It is argued that the pinnacle of this framework is learning innovation, involving the generation of powerful disciplinary knowledge and thinking processes that can be applied to subsequent problem challenges. Consideration is first given to STEM-based problem solving with a focus on mathematics. Mathematical and STEM-based problems are viewed here as goal-directed, multifaceted experiences that (1) demand core, facilitative ways of thinking, (2) require the development of productive and adaptive ways to navigate complexity, (3) enable multiple approaches and practices, (4) recruit interdisciplinary solution processes, and (5) facilitate the growth of learning innovation. The nature, role, and contributions of each way of thinking in STEM-based problem solving and learning are then explored, with their interactions highlighted. Examples from classroom-based research are presented, together with teaching implications.

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.

Integrated twitter analysis to distinguish systems thinkers at various levels: a case study of COVID-19

Systems Thinking (ST) has become essential for practitioners and experts when dealing with turbulent and complex environments. Twitter medium harbors social capital including systems thinkers, however there are limited studies available in the extant literature that investigate how experts' systems thinking skills, if possible at all, can be revealed within Twitter analysis. This study aims to reveal systems thinking levels of experts from their Twitter accounts represented as a network. Unraveling of latent Twitter network clusters ensues the centrality analysis of their follower networks inferred in terms of systems thinking dimensions. COVID-19 emerges as a relevant case study to investigate the relationship between COVID-19 experts' Twitter network and their systems thinking capabilities. A sample of 55 trusted expert Twitter accounts related to COVID-19 has been selected for the current study based on the lists from Forbes, Fortune, and Bustle. The Twitter network has been constructed based on the features extracted from their Twitter accounts. Community detection reveals three distinct groups of experts. In order to relate system thinking qualities to each group, systems thinking dimensions are matched with the follower network characteristics such as node-level metrics and centrality measures including degree, betweenness, closeness and Eigen centrality. Comparison of the 55 expert follower network characteristics elucidates three clusters with significant differences in centrality scores and node-level metrics. The clusters with a higher, medium, lower scores can be classified as Twitter accounts of Holistic thinkers, Middle thinkers, and Reductionist thinkers, respectfully. In conclusion, systems thinking capabilities are traced through unique network patterns in relation to the follower network characteristics associated with systems thinking dimensions.

A problem-bound evaluation approach

Traditional modes of evaluation can be constraining when seeking to improve persistent societal problems within complex systems. Frameworks that assume stability and predictability may not match the system dynamics within which a program resides. This paper seeks to further evaluators' understanding of how to improve problems in complex systems by offering a "problem-bound" evaluation approach. This model is grounded in theoretical concepts from complexity science, complex adaptive systems, systems thinking, and improvement science. As such, it provides an agile and flexible framework for continually learning from emergent findings related to the problem. By offering this model, we seek to contribute to the limited knowledge base on how to apply systems change theoretical ideas in evaluation practice, along with practical implications regarding the evaluator's role.

Development of Systems and Futures Thinking Skills by Primary Pre-service Teachers for Addressing Epidemics

Science educators highlight the importance of developing systems thinking (ST) and futures thinking (FT) for students to make decisions and to be active citizens that address socioscientific problems. The dimensions related to FT take in this study were three implied in ST and two in the appropriation of the future. The aim of this study is to analyse the level of FT-related dimensions developed by a group of pre-service elementary teachers and how far different activities designed to foster them were effective. Written explanations presented by the participants about the origin of pandemics and possible ways to prevent them, as well as videos developed by small groups with the goal to present a campaign for avoiding future pandemics, were analysed. Based on the literature, five dimensions and up to four levels of performances were identified. After completing the activities, participants were able to relate the three spheres of the "One Health" notion to explain the causes of pandemics. Moreover, they established complex cause-effect relationships between the different factors, although they only constructed monocausal relationships when proposing measures. Participants improved their performance in anticipating the future and identifying themselves as agents of change. The elaboration of concept maps facilitated the development of components and behaviour ST dimensions, and the design of the campaign allowed participants to identify themselves as agents of change. The use of these strategies in science education can contribute to the development of a citizenry capable of understanding and acting on systems.

From evidence to implementation of lifestyle behaviour in cancer prevention and control: A Preventive Medicine Golden Jubilee Commentary

Preventive interventions targeting tobacco, alcohol, healthy diets and physical activity are key strategies to tackle the most pressing health challenges in modern society. A major gap remains in how to translate research evidence into population-level behaviour change to reduce the disease burden. We use the case for the role of physical activity-related behaviour and cancer to illustrate the iterative, multidirectional, and transdisciplinary nature of translational research. The issues we address in this context are generalizable and applicable to other behavioral risk factors and non-communicable diseases. There is now solid evidence that physical activity reduces cancer risk and improves outcomes after cancer diagnosis. Here we provide a framework for how to implement this knowledge into real-world settings. We provide the rationale for combining systems, causal and design thinking to develop interventions that can be implemented for this type of behaviour change. The proposed model is iterative, multidirectional and transdisciplinary. We identify major knowledge gaps in epidemiology and science of behaviour change on physical activity and cancer control and propose approaches to suggest priorities for future research.

Development of a system model to predict flows and performance of regional waste management planning: A case study of England

Significant loss of valuable resources and increasing burdens on landfills are often associated with a lack of proper planning in waste management and resource recovery strategy. A sustainable waste management model is thus urgently needed to improve resource efficiency and divert more waste from landfills. This paper proposes a comprehensive system model using stock-and-flow diagram to examine the current waste management performance and project the future waste generation, treatment and disposal scenarios, using England as a case study. The model comprises three integrated modules to represent household waste generation and collection; waste treatment and disposal; and energy recovery. A detailed mass and energy balance has been established and waste management performance has been evaluated using six upstream and downstream indicators. The base case scenario that assumes constant waste composition shows that waste to landfills can be reduced to less than 10% of the total amount, by 2035. However, it entails greater diversion of waste to energy-from-waste facilities, which is not sustainable and would incur higher capital investment and gate fees. Alternative case scenarios that promote recycling instead of energy recovery result in lower capital investment and gate fees. Complete elimination of the food and organic fraction from the residual waste stream will help meet the 65% recycling target by 2035. In light of the need for achieving a more circular economy in England, enhancing material recovery through reuse and recycling, reducing reliance on energy-from-waste and deploying more advanced waste valorisation technologies should be considered in future policy and planning for waste management.

Applying systems thinking to improve the safety of work-related drivers: A systematic review of the literature

INTRODUCTION

Light vehicles (<4.5 tons) driven for work purposes represent a significant proportion of the registered motor vehicles on our roads. Drivers of these vehicles have significant exposure to the dangers of the road transport environment. To optimize safety for these workers, it is critical to understand the factors contributing to risk of being involved in an incident. This information can then be used to inform the review and revision of existing risk controls and the development of targeted prevention activities.

METHOD

The aim of the study was to undertake a systematic review of the literature to identify the factors associated with work-related driving incidents. The factors identified in the review were represented within an adapted version of Rasmussen's risk management framework (Rasmussen, 1997). Fifty studies were analyzed following data screening and review of full text. The highest proportion of risk factors were categorized at the lower levels of the system, including the 'Drivers and Other Road Users' level (n = 20, 44.4%) and the 'Equipment, Environment, and Meteorological Surroundings' level (n = 19, 42.2%). There were no risk factors identified at the 'Regulatory and Government Bodies' levels of the framework, confirming the narrow investigative scope of past research and the need to acknowledge a broader range of factors within and across higher levels of the system.

CONCLUSIONS

The findings of this study inform the direction of future research and design of targeted prevention activities capable of creating system change for the safety of work-related drivers.

Complex Problems and Dealing with them on a Research Methods Course in a Business School

This study offers a conceptual explanation of a holistic methodology that has utility in how we engage with complex situations. This is the VIPLAN Methodology developed by Raul Espejo and first published in 1988. A case is presented that evaluates whether this methodology has impact when tacitly embedded in a postgraduate research methods course. The underlying argument is that research can be usefully viewed as a form of engagement in complex problem situations, with one challenge being to make sense of situational complexity and establish the question. Thus, it becomes appropriate to introduce the principles underpinning this methodology into a research methods course in order to develop student understanding of how to move from making sense of the situation to a clearly defined problem that is then handled. The study examines a research methods course delivered annually over a period of three years, but drawing upon data from the previous two years, permitting a five year perspective. The evidence from this study in the form of marks attained and proposal - dissertation topics, indicates that this more holistic approach to a research methods course has a positive impact, especially in terms of establishing a research question. It is concluded that the introduction of the principles underpinning this methodology into a research methods course does enhance the student ability to handle complex situations.

'Just Right' job design: A conceptual framework for sustainable work in rail driving using the Goldilocks Work Paradigm

Excessive physical demand at work has traditionally been connected with adverse health outcomes, but excessive sitting is now also being recognised as an occupational hazard and emerging work-related risk. Traditional preventive occupational health and ergonomics programs are useful but limited through reliance on individual behaviour change and time-diversion from productive work. A new 'Goldilocks Work Paradigm' aims to optimise health and productivity by using movements of productive tasks. Using rail driving as a specific case of a highly sedentary and inflexible working environment, we construct a conceptual framework for designing better jobs, arguing that a theoretical amalgamation of the new Goldilocks Work Paradigm with System Thinking, Participatory Ergonomics, and a Risk Management Framework, is needed, for establishing a unified, strategic approach-a 'just right' job design model. We extend this by outlining a practical process of designing better jobs with tools that can be used to achieve it.

Weaving a new blanket together: lessons on compassionate leadership and engagement from a virtual regional summit on early childhood wellness in northern communities of British Columbia, Canada

BACKGROUND

Early childhood is a critical period of development for infants, young children, and their families. An array of services, programs, and interventions exist to support families during this life stage, often delivered by a diverse range of professionals. Overlap in early years services exists between healthcare, social care, childcare, education, and not-for-profit organizations. Such diversity in services has the potential to add a rich experience to early childhood development, or without collaboration, widen service gaps, risking providers' ability to meet the needs of families.

METHODS

In northern British Columbia (BC), Canada, a group of individuals came together to approach building relationships and engagement across sectors in early years services using compassionate systems leadership (CSL). A virtual summit was hosted with early childhood service providers including peer support workers and parents/caregivers using a hybrid model of pre-recorded asynchronous sessions combined with a live workshop. The purpose of the event was to find common ground, celebrate local success, and build understanding of how to work collaboratively across the region to identify and address early years priorities.

RESULTS

The event was successful in engaging 121 providers across early years services from a broad geographic region. Applying CSL principles for engagement allowed the team to examine how all partners could address silos in early years services across northern BC. Using a reflexive thematic approach, four key themes were identified at the Summit: (1) early years services are a patchwork but there are dreams of weaving a new blanket together, (2) an ideal model of service is family-centred and inclusive, (3) all sectors are needed at the table, and (4) compassion is the thread that weaves this work together.

CONCLUSIONS

The application of CSL principles can be used to guide engagement and develop supportive spaces for open conversation about creating systems change. In facilitating a space that allowed for vulnerability and relational ways of engaging across sectors we discovered commitment and a willingness for those present to consider new ideas and partnerships that would allow for greater integration of early years services in northern BC.

Parity of esteem and systems thinking: a theory informed qualitative inductive thematic analysis

BACKGROUND

Parity of Esteem (PoE) is about equality between mental and physical health but is a term lacking definition and clarity. The complexity of the field of mental health and the conversations around PoE add to its opacity. Therefore, the aim of this study is to use systems thinking to explore the strengths and challenges of using PoE.

METHODS

This is a secondary analysis of descriptive qualitative data, from 27 qualitative interviews, utilising the World Health Organisation (WHO) system domains as a framework for the inductive thematic analysis.

RESULTS

Examining the current strengths and challenges of systems in mental and physical healthcare using the WHO domains and macro, meso and micro levels, identifies specific actions to redress inequity between mental and physical health provision.

CONCLUSION

The evidence suggests that moving PoE from rhetoric towards reality requires new configurations with a systems orientation, which uses macro, meso and micro levels to analyse and understand the complexity of relations within and between domain levels and reorienting funding, training and measurement. This requires embedding new competencies, infrastructures and practices within an effective learning healthcare system.

Analyzing the wastewater treatment facility location/network design problem via system dynamics: Antalya, Turkey case

Wastewater treatment facility location selection and network design issues have become attractive topics in the field of wastewater management due to increasing human population, resource scarcity, environmental concerns, and rise of necessity for sustainable solutions for future policy designs. Especially in areas where the demand for wastewater treatment increases dramatically over the years because of reasons such as high migration levels, rapid industrialization, and tourism activities, the problem turns out to be more critical and dynamic. The existing studies try to deal with the issue through mathematical modeling approaches based on optimization perspectives, which require significant computational effort. In this study, an alternative approach based on system dynamics (SD) method is proposed to examine the complex dynamic and nonlinear structure of wastewater treatment facility location selection and network design problems. The proposed SD simulation model is designed for a densely populated industrial and tourism spot, the city of Antalya, located on the Mediterranean coast of Turkey. The model is capable of determining where and when to build a new wastewater treatment facility as well as generating the generic wastewater network structure to be built for the five districts situated in the city center based on cost issues for 2015-2040 period. In addition, the impacts of demand level changes for wastewater treatment due to population variations are analyzed via several scenarios to help decision makers to develop sustainable and cost-efficient management policies. Although SD is a frequently utilized approach in the water/wastewater management arena, to the best of our knowledge, this study is the first attempt to examine the complex and dynamic nature of wastewater treatment facility location selection and network design problems through SD approach.