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6 August 2021

From Understanding to Impactful Action: Systems Thinking for Systems Change in Chronic Disease Prevention Research

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Menzies Centre for Health Governance, School of Regulation and Global Governance (RegNet), Australian National University, Canberra, ACT 0200, Australia
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The Australian Prevention Partnership Centre, The Sax Institute, Glebe, NSW 2037, Australia
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Menzies Centre for Health Policy, School of Public Health, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2006, Australia
4
School of Health and Social Development, Faculty of Health, Deakin University, Geelong, VIC 3125, Australia
Systems2021, 9(3), 61;https://doi.org/10.3390/systems9030061
This article belongs to the Special Issue Systems Practice in Public Health
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Abstract

Within the field of chronic disease prevention, research efforts have moved to better understand, describe, and address the complex drivers of various health conditions. Change-making is prominent in this paper, and systems thinking and systems change are prioritised as core elements of prevention research. We report how the process of developing a theory of systems change can assist prevention research to progress from understanding systems, towards impactful action within those systems. Based on Foster-Fishman and Watson’s ABLe change framework, a Prevention Systems Change Framework (PSCF) was adapted and applied to an Australian case study of the drivers of healthy and equitable eating as a structured reflective practice. The PSCF comprises four components: building a systemic lens on prevention, holding a continual implementation focus, integrating the systemic lens and implementation focus, and developing a theory of change. Application of the framework as part of a systemic evaluation process enabled a detailed and critical assessment of the healthy and equitable eating project goals and culminated in the development of a theory of prevention systems change specific to that project, to guide future research and action. Arguably, if prevention research is to support improved health outcomes, it must be more explicitly linked to creating systems change.

1. Introduction

Population-level chronic disease prevention efforts are typically anchored in one or more of implementation science, knowledge mobilisation, or evidence-based practice [1,2,3,4]. More recently, chronic disease prevention research is applying systems thinking methods and tools to understand and address complexity [5,6]. These efforts are well described for research design, though description of real-world systems change is less clear. This paper describes the adaptation of a framework that can be used to apply systems thinking within chronic disease prevention research.
Many prevention researchers see societal change to prevent chronic disease as having broader impacts to reduce inequities and promote sustainable population health and wellbeing. Within programs of work or individual projects, intended goals become more specific (e.g., reducing nutrition-related inequities through policy change; lowering rates of cardiovascular disease within a population; and creating built environments that support healthy and active living [7,8,9,10]). High impact, long term change is difficult particularly without a clear concept of the complex system of interest, a clearly articulated theory of change, or shared understanding across stakeholders of different perspectives [8,11,12,13,14,15,16,17].
This paper set out to: (i) apply and adapt a complex systems change framework for prevention research, and (ii) explore the utility of the adapted framework using a case study of healthy and equitable eating (the HE2 project) [10,18,19]. Foster-Fishman and Watson’s ABLe change framework (ACF) [13] was selected and adapted for the Prevention Systems Change Framework (PSCF) and piloted to develop a theory of systems change for prevention. This iterative process of adapting and exploring was aligned with systemic evaluation practice characterised by in-depth and ongoing empirically-based reflection [20,21].

Background

The limited improvements in chronic disease outcomes to date, including cardiovascular disease, some cancers, and type II diabetes, have been attributed to a lack of engagement with the complex nature of the causes of chronic disease [17]. In addition, the commentary for a number of years around public health research is that it is focused too much on problem description rather than evaluating actions for creating change [22]. Engaging in ‘systems thinking’ in a meaningful way, has been shown to be an effective approach to understanding and acting on many intractable and complex public health challenges, including nutrition-related inequities, alcohol consumption, tobacco smoking, and obesity [6,7,8,9,10,23,24,25,26].
Systems thinking, defined for the purposes of this paper, is a mindset whereby complex phenomena are perceived as dynamic wholes comprised of numerous interconnected and interdependent parts, which, through their interactions, produce emergent products that are different to the sum of the parts combined [27,28]. There has been a significant increase in approaches that conceive of systems in different ways in prevention research, including social network analysis, agent-based and system dynamic simulation models, and participatory approaches to intervention design, like group model building, to better understand the complex drivers of chronic disease and possible solutions [10,29,30,31,32,33].
While the need for chronic disease prevention to be informed by systems science has been widely expressed [17], there are few examples of this translating into impact and change [6]. Framing prevention research within the context of systems thinking for systems change is different to formulating usual study aims and research questions. It draws attention towards understanding the systems within which prevention-researchers work, their roles within those systems, identifying specific changes, and how they can take action to make them a reality [12,13,34].
There are many disciplines and bodies of literature that discuss the concept of change making and how to do it effectively, such as the implementation field [35], change management [36], leadership [37], evaluation [38], and systems change [39]. Such theories suggest how a given series of activities or interventions will have impact within a system to create change [40,41,42]. A theory of systems change can be developed for complex interventions where change may occur in a progressive manner, and the system and people adapt as new issues emerge [41]. Furthermore, a theory of systems change can speak to aspects beyond external factors, such as prevailing epistemologies, how we position ourselves as researchers, and the data we collect [43].
Foster-Fishman and Watson developed and successfully applied the ABLe change framework (ACF), incorporating theories of change, to facilitate change making in the field of community psychology [13]. Their framework was developed specifically for facilitating systems change in local communities and provides a platform to guide systemic inquiry applying a systems approach [13,20]. It has been successfully applied in the United States to the design and implementation of a system of care effort in early childhood, cradle-to-career initiatives, health reform, and comprehensive community planning [44]. With a few notable exceptions [8] formal theories of systems change have yet to be meaningfully applied in prevention research. We argue that creating a theory of systems change for prevention research strengthens the bridge that connects understanding and intervention, that is, to move from descriptions of complex systems more explicitly towards efforts focused on systems change for real and lasting impact [12,45,46].
In this paper we report how we adapted Foster-Fishman and Watson’s ACF to apply the prevention systems change framework (PSCF) through the case study of the existing HE2 project (Box 1). We present our empirically derived findings and discuss their implications for change-making, focused prevention research.
Box 1. Healthy and Equitable Eating (HE2) Project.
The Healthy and Equitable Eating project (HE2), conducted between 2014–2017, was one of the first projects supported through the Australian Prevention Partnership Centre (https://preventioncentre.org.au/ (accessed on 4 August 2021)). The Prevention Centre is a national research-policy collaboration aimed at applying systems approaches to the study of chronic disease prevention; it was first funded in 2013–2018 and funded for a further 5 years in 2018 [47]. The HE2 Project examined the drivers of inequities in healthy eating relevant to the Australian context, applied a systems lens and methodology, and took place in three stages (i.e., the HE2 diagram, the HE2 policy framework, and the HE2 qualitative study) [10]. Soft systems conceptual modelling workshops were conducted using a participatory approach. Seven sub-systems were identified within the HE2 system: food supply and environment, transport, housing and the built environment, employment, social protection, health literacy, and food preferences. The HE2 diagram set the groundwork for understanding and planning how to address inequities in healthy eating.
The HE2 policy framework emerged from the diagramming work and extended previous conceptualisations of policy responses addressing nutrition-related inequities, by including the social determinants of healthy eating along with the seven sub-systems identified in the HE2 System Diagram [18]. It presents a call to action to populate the framework with evidence-based actions that can be implemented to tackle inequities that constrain healthy eating. This piece of work also included a systems-informed qualitative study exploring the level of public policy attention given to addressing inequities in obesity in an Australian jurisdiction [19]. The findings from the qualitative study highlighted the importance of understanding local needs and institutional contexts, as well as fostering a shared understanding and concerns for tackling inequities in obesity. The overall project provided a means for exploring and articulating the relationships between various sociological, political, economic, and philosophical tensions within the broader system. These are key to navigating healthy eating and its social distribution as a complex problem—one that cannot be dealt with in a siloed manner nor by health departments alone.
The short-term change making goals of the HE2 study included enhancing capacities in core knowledge and understanding of the intersectoral causes of inequities in healthy eating, and shifting prevention research, policy and practice mindsets towards a systems orientation. The longer-term change making goals are articulated as part of the theory of systems change in the Results section of this paper.

2. Materials and Methods

2.1. The ABLe Change Framework (ACF)

The ACF has three components that guide the user through a series of reflective questions that: (1) apply a systemic lens to a problem (this incorporates an examination of the policy landscape, systems interconnections, power and control dynamics, systems regulations, values and norms, and systems interdependencies); (2) consider issues related to the implementation of change; and (3) integrate the systemic lens and implementation focus to plan systems change. We selected the ACF for this study as it provides a strong theoretical framework which builds on seminal pieces of work in systems science, offers a deep and comprehensive set of questions to guide transformative systems change informed by a broad body of literatures spanning systems thinking, organisational change, community change, and implementation theory, and explicitly incorporates a theory of systems change [8,12,13].
The HE2 project (Box 1) was chosen for retrospective application and adaptation of the ACF to produce the PSCF for a number of reasons: (1) three of the co-authors, including the lead author worked on the HE2 project and thus could reflect together on this piece of work, (2) the HE2 project took a systems-based approach to addressing the complex problem of nutrition-related inequities, and (3) a focus on change making was an important aspect of this work.
This work was conducted as part of a larger study examining the role of systems approaches in responding to complexity in chronic disease prevention research (reviewed by the Australian National University human research ethics committee-ref. no 2019/653).
As the ACF had been specifically developed for use within the field of community psychology, it was necessary to make a number of context-specific changes to the framing and wording of its components so that it would better suit the prevention research context. Through the iterative process of applying and adapting the ACF using the historical, empirical case study of the HE2 Project, we produced the adapted Prevention Systems Change framework (PSCF). In terms of adaptations across the ACF to create the PSCF, the majority of changes were made within the systemic lens component. While some changes were also made to the Implementation component, most questions remained similar. The Integration component in the ACF was not in table format but rather in the main text of the original publication. This text was paraphrased and incorporated into the new PSCF table, adding to the systematic process for working through the content. We also added a fourth component to develop an explicit theory of prevention systems change. A summary of the steps for adapting the ACF to create the new PSCF are provided in Table 1, and examples of the changes made are included in Table 2. The final PSCF is included in Table 3.
Table 1. Steps for adapting and applying the ACF to produce the Prevention Systems Change Framework (PSCF).
Table 2. Examples of changes to the ACF to produce the PSCF.
Table 3. Prevention Systems Change Framework (PSCF) Adapted from ACF [13].
The iterative process of adapting the ACF and applying the PSCF was primarily conducted as a dialogue between two of the co-investigators of the original HE2 Project (MP and SF). They met on two separate occasions to discuss each component of the PSCF, consider the relevance and utility of the questions (adapting as required), and to record their reflections about the HE2 Project. The results were then reviewed in detail by LR, leading to further refinements before discussion with the remaining authors of this paper.

2.2. The Prevention Systems Change Framework (PSCF)

The PSCF has four components (Table 3). The first component examines the systemic context of prevention systems change efforts and enquires about the policy landscape, systems interconnections, power and control dynamics, systems regulations, values and norms, and systems interdependencies. The second component examines the facilitators of prevention change implementation, including readiness to change, capacity within the system, how changes will spread throughout the system, and sustainability of implemented changes. The third component integrates the systemic and implementation focus, and considers the need to engage with multiple and diverse perspectives, the importance of agile teams who can adapt quickly to address issues as they emerge within the system, and the need for small wins to foster momentum. The guiding questions in the first three components are posed for consideration as one designs, implements, and improves prevention systems change efforts. The fourth component combines the learnings from the first three components to formulate an explicit theory of prevention systems change to support explicit reflection of one’s hypothesis and assumptions, and/or for planning future actions.

3. Results

3.1. Reflections on the HE2 Project Derived from Applying the PSCF

We used the PSCF to both reflect on the research work that took place within the HE2 Project, and to consider what will be necessary to create systems change through future work. The results are discussed under the four key components of the PSCF, with details of the specific reflections that informed the results narrative provided in Table 4, Table 5 and Table 6. The retrospective review process of working through the PSCF culminated in the development of a theory of systems change specific to the HE2 project, which can be used to guide future research on addressing inequities in healthy eating.
Table 4. Key questions for embedding systems change into prevention research work using the HE2 Project.
Table 5. Key components for strengthening implementation processes into prevention research work using the HE2 Project.
Table 6. Key components for bringing together the systemic lens and implementation focus using the HE2 Project.
Overall, the retrospective HE2 project reflection process revealed how much additional work is needed over an extended period in order to create systems change. While it was apparent that we had applied a systemic lens to the study of healthy and equitable eating, the implementation aspects of this type of work will require explicit and focused attention. In considering the integration of the systemic and implementation components, we identified that while some aspects had been addressed in the HE2 Project (i.e., as part of simple rules in terms of pursuing social justice, thinking systemically, and engaging diverse perspectives), others, such as leveraging small wins and systemic action learning teams, offer valuable potential for future work. Other noteworthy findings included the need for core skills and capabilities that facilitate systemic analysis and implementation, the importance of influence and agency, and the value of shared understanding and common purpose to produce transformative change. All of these reflections informed the development of a theory of systems change to address nutrition-related inequities.

3.1.1. Component 1: Building a Systemic Lens for Prevention

The first stage in reviewing the HE2 Project was to apply a systemic lens to the work (Table 4). In terms of policies for healthy and equitable eating, it was apparent that to create systems change it will be necessary to address the gaps in current policies, programs, and procedures. In terms of connections and boundaries, our review suggests a need to expand the range of actors involved by including more government departments, NGOs, industry, and community groups. It is also important to build connections between these actors across the system. With respect to power and control dynamics, we will need to involve those with intersectoral influence within the system, as well as the voices of community members who are experiencing nutrition-related inequities. It will also be beneficial to explore the possibilities for shared power in decision-making to improve intersectoral work. When it comes to system regulations, the lack of institutional mechanisms to enable intersectoral collaboration will need to be addressed, and generating shared understanding will be a necessary for enabling intersectoral work to begin. In considering values and norms around equity, it will be important to distinguish between implicit and explicit theories of systems change, and where and how to achieve it. While many publicly agree that equity matters, there is a tendency to not prioritise it; thus, it will be helpful to create more opportunities for those involved in the system to discuss the kinds of procedures and policies needed to ensure equity is front and centre. In addressing system interdependencies, all the leverage points identified within the HE2 System Diagram [10] will need to be considered and appropriately prioritised as part of the change effort.

3.1.2. Component 2: Continual Implementation Focus

The second component involved the application of an ongoing implementation focus to the work (Table 5). In addressing readiness for systems change to support healthy and equitable eating, the system in its current form was constraining desired changes due to an unwillingness, or inability, by policy and program leaders to promote intersectoral working. Thus, future programs of work need to include new actors with a remit and desire to enact such change. When it comes to contingent capacities, the skills and knowledge of those involved in our study were appropriate, but only a small handful were equipped to implement the changes required; this will also need to be addressed moving forward. Furthermore, ties across sectors were weak and require significant strengthening. In terms of diffusion of the intended systems changes, we need stronger accountability mechanisms to make healthy and equitable eating a possibility, and we need to explore new and appropriate diffusion mechanisms across the system. Ensuring the sustainability of changes was not emphasised as part of our initial piece of work; thus, being mindful of the sustainability of policies and practices throughout the HE2 system will need to be a key feature of systems change in future iterations of this work.

3.1.3. Component 3: Bringing Together the Systemic Lens and Implementation Focus

To bring together the systemic lens and implementation focus, we explored the potential value of simple rules, systemic action learning teams, and small wins (Table 6). The concept of Simple rules is broken down into six key features, namely, engaging diverse perspectives, thinking systemically, incubating change, effectively implementing change, adapting quickly, and pursuing social justice. While we engaged diverse perspectives in our work, overall, the perspectives across the project participants were more convergent than divergent, except within the qualitative sub-study, where there was more diversity of views. Future research could aim to explore this divergence more explicitly and include a more diverse mix of disciplines and sectors, as well as insights from communities experiencing nutrition-related inequities. Thinking systemically must continue to be the overarching paradigm for addressing nutrition-related inequities and be emphasized at all stages of the work. Incubating change could be emphasized, which can be realised by leveraging key opportunities and feedback loops. For example, within the food supply and environment sub-system, an important feedback loop exists between food labelling and the impact that labelling has on the marketing and reformulation of food [10]. Monitoring and evaluation will also need to be key features of future work, to support an ability to learn from the evidence and adapt quickly to effectively implement change. To use systemic action learning teams, we would seek to design such teams at multiple levels of government, as well as spanning industry, the not-for-profit sector, academic, and community level to expand the focus on equity across the system. Finally, leveraging small wins can also be an effective way of incubating change over time, and future systems change work would benefit by more explicitly identifying and incorporating these into program communications. One of the key insights from undertaking this reflective process was the importance of considering the role of one small study as part of a broader program of work.

3.1.4. Component 4: Developing a Theory of Systems Change

Theories of systems change are highly variable and can take many forms, including as a hypothesis and series of assumptions or framed in terms of a series of intended actions, anticipated reactions/responses, and predicted outcomes. Theories of change can also be presented in the form of a sentence, series of statements, simple logic model, complex series of logic steps in the form of a diagram, or dynamic simulation models [40,41,42,48,49]. Theories of change are also highly context specific and are ideally devised as part of a co-production process with those who are focused on their implementation [41].
For the sake of illustration, the following retrospective theory of systems change was drafted as part of the final stage of the reflective process using the PSCF. Typically, this would be done at the beginning, and revised throughout the life of a project (or body of work) by combining the first three components. Because we examined the HE2 Project as part of a reflective process to adapt and apply the ACF to prevention research, we have produced a draft retrospective theory of systems change. It considers what is likely to be required to create systems change in the future and could be used to inform further dialogue and planning.
A draft theory of systems change for the health and equitable eating (HE2) Project could look like this:
Theory of systems change: Longer-term and sustained change is supported by thinking and acting systemically. Coordinated actions by those with agency, authority, and remit to lead and implement systems change across the HE2 system domains will foster healthy and equitable eating in the population. Systemic change should be informed by diverse points of view that include disciplinary and sectoral experts, and the insights of communities experiencing nutrition-related inequities.
Positioning equity and intersectoral working front and centre in all dialogues will build shared understanding of the problem and alignment on the solutions. Continued cycles of reflection and learning that are underpinned by monitoring and evaluation to incubate change, and acknowledging small wins to foster momentum, will help to produce sustained action across sectors.
Articulating this theory of systems change highlighted for us that the HE2 Project was an important initial step, and that an extensive program of work needs to happen over an extended period to change the system that impacts on health and equitable eating. One research project can rarely achieve large-scale systems change, and, indeed, this would not be appropriate. The next step for an active prevention research project focused on impact and creating change would be to engage with relevant stakeholders to develop a long-term program of work underpinned by an explicit theory of systems change. The theory of prevention systems change for healthy and equitable eating, as articulated above, can be seen as a hypothesis to inform such ongoing dialogue, and as something to review, adapt, or develop further across the life of any future project or program of work.

4. Discussion

To address chronic disease prevention, there is an imperative for research to articulate what action is required within a complex system to generate change [17]. Systems approaches have a growing profile in prevention research, but an often-missed key aspect of addressing complexity is the underlying purpose of systems change [12,13]. This aspect requires further exploration as an explicit function of systems-informed prevention research [2,17,24]. To this end, in this paper we explored the value of applying a systems change framework to existing prevention research, seeking to understand the role of such an approach in articulating the types of action required to generate change.
Based on an adaptation of the ABLe change framework (ACF), we used the new Prevention Systems Change framework (PSCF) to review the healthy and equitable eating (HE2) research project. The review process entailed contemplating the questions within the first three components of the PSCF, namely: (i) applying a systemic lens, (ii) considering issues related to the implementation of change, and (iii) integrating the systemic lens and implementation focus, to (iv) develop a theory of systems change. The systematic consideration of the questions outlined in the PSCF enabled a comprehensive and evidence-informed research review and reflection process to unfold. These reflections generated new guidance on how research could progress from understanding the systems drivers of healthy and equitable eating towards impactful action within those systems. The PSCF could also be extended further by adding another column whereby specific actions for change are listed along with the names of actors and institutions with remit and responsibility to create change in these areas. This would act to create a sense of shared and collective accountability across the system of interest [50].
Articulating a systems theory of change is an important part of any ongoing social learning process focused on creating change [13,21] and has significant potential to guide the incorporation of a systemic lens in prevention research, to guide future research and action. Within public health, intervention and evaluation studies, and translation research have assisted to shift the field beyond understanding and description in the direction of change through the evidence-based movement [51,52]. The impact of evaluation research and quantifying person-centred outcomes was enabled through knowledge translation/mobilisation [3]. By incorporating systems thinking, we take a step further to consider the role of systems change [11,13,53]. If we are to advance the field of chronic disease prevention and have greater impact, embedding a structured reflective process and practice that applies a systems change framework will be essential [12].
It has been argued that when engaging with complex systems, what is learnt must be acted upon and because systems are dynamic, they will continue to change and evolve over time [20]. Therefore, when engaging in research designed to create change, processes of reflection, action, and feedback must be ongoing [13,20]. Further, engaging in reflective practice is a hallmark of becoming a skillful practitioner and must include both self-reflection and reflection on the research project itself [21]. The formulated PSCF has potential as a tool for retrospective review of existing work, and as a precursor for planning more impactful research. We thus contend that undergoing the type of reflective process enabled through the PSCF is valuable to do both retrospectively and as part of a research intervention planning process (Figure 1). Ideally, such cycles become a continuous process whereby reflection and planning become synonymous and feed into further research [20,21]. The development of the PSCF from the ACF was based on a single retrospective study. In line with systems practice, it is intended that the adapted PSCF may be further modified through considering other prevention research projects spanning different contexts, content, and scales.
Figure 1. Cycle of reflection for creating systems change in prevention research.
The PSCF was adapted from the ACF to provide a framework to better suit the prevention research context. While the ACF provides an excellent framework for understanding and planning for systems change, there are several advantages of the PSCF over the ACF. These include its greater focus on policy, changes in language to suit the prevention context, removal of redundant questions within the prevention research context, the addition of questions to add more depth to the exploration process, and a specific focus on a theory of systems change in both prospective and retrospective settings.

5. Conclusions

To conclude, the Prevention Systems Change Framework was adapted from the ABLe Change Framework to suit the prevention research context. The PSCF supports a guided and comprehensive systemic analysis of prevention research from which to create a theory of prevention systems change and, thus, more explicitly connect research that generates understanding of complex systems with actionable systems change efforts.

Author Contributions

Conceptualization, M.P., L.R. and S.A.; formal analysis, M.P., L.R. and S.F.; funding acquisition, M.P., L.R., S.A. and S.F.; investigation, M.J.I., D.T.F., T.R., R.I. and H.R.; methodology, M.P., L.R., S.A. and S.F.; project administration, M.P. and L.R.; supervision, L.R. and S.F.; writing—original draft, M.P., L.R. and M.J.I.; writing—review and editing, M.P., L.R., S.A., M.J.I., D.T.F., T.R., R.I., H.R. and S.F. All authors have read and agreed to the published version of the manuscript.

Funding

This research was funded by The Australian Prevention Partnership Centre, which is supported through the NHMRC partnership centre grant scheme (Grant ID: GNT9100003) with the Australian Government Department of Health, ACT Health, Cancer Council Australia, NSW Ministry of Health, Wellbeing SA, Tasmanian Department of Health, and VicHealth. It is administered by the Sax Institute.

Institutional Review Board Statement

The study was approved by the Ethics Committee of the AUSTRALIAN NATIONAL UNIVERSITY (protocol code 2019/653 on 1 October 2019).

Data Availability Statement

The data supporting this study are available on The Australian Prevention Partnership Centre website in the form of peer-reviewed publications, reports, findings briefs, and project pages. See The Australian Prevention Partnership Centre. Available online: https://preventioncentre.org.au/ (accessed on 4 August 2021).

Conflicts of Interest

The authors declare no conflict of interest. The funders had no role in the design of the study, in the collection, analyses, or interpretation of data, in the writing of the manuscript, or in the decision to publish the results.

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