Whole systems approach

Background: Unlike traditional linear models targeting individuals and specific health problems, community-wide initiatives aim to foster healthy lifestyles by modifying policies, physical environments, and engaging local stakeholders. In Sweden, public health responsibilities are shared among municipalities, regions, and the state. Generation Pep, is a non-profit organization with a vision that all children and young people should have good opportunities to lead an active and healthy life.

Program Delivery: The Pep Initiative, including 6 municipalities in the pilot phase (2021-23) and 25 municipalities from 2024, is inspired by ISPAHs; Eight investment that work for physical activity. The overall initiative is characterised as a multi-level community-wide programmes (8) and including five other ISPAH investments; Whole-of-school programmes, Active transport, Active urban design, Health care, Sports and recreation for all. And two additional themes; the food environment and the children’s perspective (based on The UN Convention on the Rights of a Child).
Our work is based on four key complementary forms of knowledge and a conceptual model has been developed to describe knowledge about; ”the issue”, ”interventions”, ”context”, “implementation”. Visually represented by a four-leaf clover mode, used in the planning and development of the initiative.

Evaluation: The qualitative evaluation are currently being compiled and will be presented.

Conclusions: The Pep initiative involves actions by, and interactions among, a wide range of local actors in the municipalities, which is necessary to work with the seven cross-boundary themes that form the core of the initiative. Insights from the presented studies can guide the successful implementation of The Pep Initiative in various municipality settings and inform the implementation of other public health initiatives.

Practical implications: The initiative tackles governance and convergence issues associated with intersectoral collaboration. The Pep Initiative also serves as an exemplary research-informed community-wide approach to influence physical activity and dietary habits among children.

Funding:

Background: The prevalence of overweight and obesity is 20% higher in the regional Queensland, compared to the state and national averages. Purpose: The aim of this participatory research study was to use systems mapping to develop a multi-sectorial approach and strategy to address obesity in regional communities. Methods: Stakeholders (n=29) and community members (n=30) were recruited via emails using existing networks and snow-ball sampling. Online workshops (n=5) were conducted with stakeholders using miro software. In person workshops (n=3) were conducted with community members. After a brief introduction, participants were asked to post ‘sticky notes’ reflecting their perceptions of the determinants of obesity in their region. This was followed by a short discussion where they provided more insight into the determinants listed. Next, participants drew connection circles illustrating links between determinants. Kumo software was used to develop the collated systems map. Results: All the determinants and the causal links between them were collated to create a systems map. The main themes that emerged included lack of supportive environments for physical activity, and costs associated with better food choices and physical activity. Being time-poor was associated with less healthy lifestyle choices and participants noted that extended family support and networks could assist with improving these behaviours. Local and State governments were consistently identified as actors that should play a role in addressing various determinants. The importance of local organisations such as community groups, sports clubs, schools, and the media were highlighted. Conclusions: The systems map generated illustrates the potential actions that can be implemented by various organisations, addressing the determinants of obesity in the region. Practical Implications: The next phase includes workshops with community members to co-design interventions for the priority actions identified. Funding: This research was funded by the Darling Downs Health Innovation and Research Collaborative and The Manna Institute, Australia

Background: We Can Move (WCM) is a large systems approach that works with local communities and organisations to improve the physical activity environments across Gloucestershire, England.

Purpose: Evaluating such a complex approach is challenging. Here, we aim to bring to life a selection of innovative methods used to understand how WCM influenced the physical activity system.

Methods: Nine participatory systems mapping (PSM) workshops were carried out with 100 stakeholders to understand the factors influencing population level physical activity. Social Network Analysis (SNA) determined which stakeholders, and organisations, were engaged in WCM over time (n=2599). Lastly, 15 Ripple Effects Mapping (REM) workshops were conducted with 25 stakeholders to explore how WCM impacted the physical activity system. Findings were triangulated, centred around the systems map.

Results: The WCM systems map included 198 factors spanning 12 themes, from school and workplace influences, to physical activity opportunities, to political and systems leadership. The SNA identified that most stakeholders were able to influence physical activity opportunities (45%) and the school environment (22%). Those categorised as “co-owners” were predominantly seen to influence the political and systems leadership theme. These findings were largely mirrored through the REM analyses, indicating that some areas of the system, such as the workplace and transportation options, were yet to be substantially targeted.
Conclusions: The evaluation of WCM provided a noteworthy opportunity to test, develop, and triangulate a series of innovative methods, the findings from which enabled a comprehensive and nuanced understanding for how this complex systems approach functioned.

Practical implications: The triangulation of PSM, SNA, and REM provided detailed insight around system functioning, enabling future intervention and policy modification.

Funding: The evaluation of WCM was commissioned by Active Gloucestershire and supported by the NIHR ARC West.

Background: Systems approaches to physical inactivity are commonplace. It is argued that their focus on dynamic influences and emergent outcomes may help address issues of inequalities, and sustainability and scalability of physical activity interventions. However, few studies have considered the underlying behavioural implications of systems approaches for actors of change. There is uncertainty as to what roles and associated needs better support change efforts across different levels of the system. Purpose: This qualitative study explored how to advance systems approaches to physical activity policy. Methods: Twenty-eight researchers, policymakers and practitioners participated in a half-day Zoom workshop, which was underpinned by action-orientated research principles. Using a flipped-class design, participants received videos before the workshop, which informed breakout/plenary discussions on: i) everyday experiences of systems working; ii) stimulating changes in practices and cultures; iii) mobilising knowledge of systems. Data were captured using Padlet, and analysed using a realist-informed thematic approach. Results: Findings indicated that the physical activity policy environment may be unconducive to systems approaches. Three propositions to mobilise the emerging idea of systems entrepreneurship were developed: 1) identifying a role in creating policy change can support system activation; 2) creating connections supports systems awareness, empowerment and belonging, and facilitates transdisciplinarity; 3) increasing focus on agency can support those trying to change systems. Findings transcended individuals to raise ideas about the ‘health’ of collective systems. Conclusions: Systems approaches to physical activity promotion may be further optimised by critical behaviourally-informed reflections. Systems entrepreneurship provides a clear role to enhance transdisciplinarity and co-produce solutions for opportune moments, while galvanising systems in needs supportive ways. Practical implications: Systems approaches are challenging to implement. People involved in system change efforts should be supported motivationally, and trained to identify and act upon windows of opportunity to change the system architecture. More action-informed research is required. Funding: UKRI-ESRC

Background: There is growing interest in system approaches to increasing physical activity. However, there are currently few examples of interventions taking this approach described in the literature. Purpose: To report the process of developing a whole system physical activity intervention for children, and to describe the resulting intervention which has been implemented in Bradford, UK, an ethnically diverse city with high levels of deprivation. Methods: There were three phases of intervention development. The initial phase included: i) review of published literature, ii) analysis of local population data, iii) community, partner, and local leader consultations, iv) asset mapping, vi) co-development of a theory of change and implementation plan. During the feasibility phase, the intervention was implemented for 18 months focused on three neighbourhoods; Driscoll’s reflection cycle underpinned a mixed-methods process evaluation to understand feasibility and acceptability. Stakeholder workshops reflected on findings and refined the intervention. During the evolution phase, the intervention was implemented for 2-years focused on five additional neighbourhoods. Reflection cycles continued and data was used to further refine and evolve the intervention to changing circumstances. Results: The resulting intervention, the JU:MP Programme, aims to increase physical activity in children aged 5-14 working through five themes: community, organisations, environment, families, and policy and strategy. Fifteen interacting work-streams sit within the themes (e.g. green space development, creating active schools, active faith settings). A neighbourhood approach to delivery is adopted and concurrently, local leaders are supported to build physical activity into policy and strategy. Flexibility is integral to the design, allowing community ownership of Programme elements; this aims to foster sustainable behavioural change. Reflection cycles support the Programme to continually refine and evolve. Conclusion and practical implications: This development approach and intervention could be adapted to other populations and localities wanting to adopt a whole system approach to increasing physical activity.

Background: Much remains unknown about how complex community-based programmes can successfully achieve long-term impact. Additional insight is needed to understand the key mechanisms through which these programmes work. Purpose: to explore potential working mechanisms of the Healthy Youth, Healthy Future (JOGG) approach, a Dutch community-based programme for promoting physical activity and healthy nutrition. Therefore we identified the outcomes and long-term impacts as perceived by local stakeholders and causal pathways to impact. Methods: we studied five JOGG communities using Ripple Effects Mapping (REM), a qualitative participatory method to map outcomes and causal pathways with stakeholders. We involved 26 stakeholders – professionals and policymakers affiliated with the local JOGG approach – in eight REM sessions and conducted 24 additional interviews. We comparatively analysed causal pathways across communities. Results: over the long term (5-9 years) participants perceived that JOGG had improved stakeholder ownership, policy, intersectoral collaboration and the social norms towards promoting healthy lifestyles. Although the exact actions that were implemented varied widely between communities, we identified five common working mechanisms: 1) creating a positive connotation with JOGG, 2) mobilising stakeholders to participate in the JOGG approach, 3) facilitating projects to promote knowledge and awareness among stakeholders and create success experiences with promoting healthy lifestyles, 4) connecting stakeholders, stimulating the intersectoral collaboration that is needed to effectively promote healthy lifestyles, and 5) sharing successes from stakeholders that promote healthy lifestyles, which over time created a social norm of participation. Conclusions: the identified key working mechanisms appeared essential in activating initial stakeholder participation and bolstering the process towards ownership, policy change and intersectoral collaboration for promoting healthy lifestyles. Analysing REM output across communities enabled us to uncover common working mechanisms. Practical implications: results can inform further development of the JOGG approach and other community-based prevention programmes. Funding: the national JOGG organisation