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Applied Systems Thinking for Health Systems Research: A Methodological Handbook
Abstract
Patient safety in health systems has become more and more important as a theme in health research, and so it is not surprising to see a growing interest in applying systems thinking to healthcare. However there is a difficulty – health systems are very complex and constantly adapting to respond to core drivers and fit needs. How do you apply systems thinking in this situation, and what methods are available? National health authorities, international donors and research practitioners need to know the “how-to” of conducting health systems research from a systems thinking perspective.
This book will fill this gap and provide a range of tools that give clear guidance of ways to carry out systems thinking in health, with real-world examples. These methodologies include:
• System dynamics and causal loops
• Network analysis
• Outcome mapping
• Soft systems methodology
And many more.
Written by an international team of experts in health research, this handbook will be essential reading for those working in or researching public health, health policy, health systems, global health, service improvement and innovation in practice.
... 19 20 Process mapping has been highlighted as a methodology useful for applying systems thinking to health systems research and shedding light onto complex systems. 21 It has utility for describing a system's boundaries, analysing stakeholder relationships and engagement and identifying problems and their solutions. 21 Process mapping is credited with being a versatile, simple technique, 22 which is low cost and requires limited training to facilitate, 23 consistent with rapid assessment principles. ...
... 21 It has utility for describing a system's boundaries, analysing stakeholder relationships and engagement and identifying problems and their solutions. 21 Process mapping is credited with being a versatile, simple technique, 22 which is low cost and requires limited training to facilitate, 23 consistent with rapid assessment principles. ...
... The approach helped to breakdown complexity to understand reality 34 which easily incorporated the Three Delays framework as 'lanes' within the process map structure. 21 Investigations undertaken, lab and radiological 4 ...
Objectives
We used the process mapping method and Three Delays framework, to identify and visually represent the relationship between critical actions, decisions and barriers to access to care following injury in the Karonga health system, Northern Malawi.
Design
Facilitated group process mapping workshops with summary process mapping synthesis.
Setting
Process mapping workshops took place in 11 identified health system facilities (one per facility) providing injury care for a population in Karonga, Northern Malawi.
Participants
Fifty-four healthcare workers from various cadres took part.
Results
An overall injury health system summary map was created using those categories of action, decision and barrier that were sometimes or frequently reported. This provided a visual summary of the process following injury within the health system. For Delay 1 (seeking care) four barriers were most commonly described (by 8 of 11 facilities) these were ‘cultural norms’, ‘healthcare literacy’, ‘traditional healers’ and ‘police processes’. For Delay 2 (reaching care) the barrier most frequently described was ‘transport’—a lack of timely affordable emergency transport (formal or informal) described by all 11 facilities. For Delay 3 (receiving quality care) the most commonly reported barrier was that of ‘physical resources’ (9 of 11 facilities).
Conclusions
We found our novel approach combining several process mapping exercises to produce a summary map to be highly suited to rapid health system assessment identifying barriers to injury care, within a Three Delays framework. We commend the approach to others wishing to conduct rapid health system assessments in similar contexts.
... Instead, it requires valuing a staged approach to implementation research, one starting with observation and interpretation. Thus, rather than starting a research effort with a predefined, single "silver bullet" implementation strategy or bundle of strategies to be tested through a variety of pragmatic or hybrid trial designs, we start with an embedded systems approach to understand the context, the actors, their interactions, and the boundaries which constrain the system in which the cancer control intervention will be delivered (15,16). ...
... Novel scientific methods are needed as well to support this work. Emphasizing the scientific value of the use of methodologies such as systems approaches (16)(17)(18), participatory group model building (19), and implementation mapping (20) to ensure that implementation strategies are co-designed (involving scientists and implementers) with context and complexity in mind. The challenging, but critical, role of the IS academic in this endeavor is as an astute observer, equipped with the knowledge of IS concepts-to take the observations from the "rich experience" of embedded IS (21,22) and develop the critical theories on the mechanisms by which the cancer control interventions, the implementation strategies, and the implementation agents interact to drive core implementation outcomes (14). ...
The theme for the 11th Annual Symposium on Global Cancer Research, co-convened with partners by the U.S. NCI Center for Global Health is "Closing the Research-to-Implementation Gap." Here, we reflect on the evolving role of implementation science from the lens of the needs of low- and middle-income countries. We highlight the importance for stronger and sustained engagement of implementation scientists and cancer control and prevention practitioners to enable more context-relevant co-design of implementation plans and strategies. We argue that deep learning from embedded implementation research through inductive analytic approaches is a critical first step to acceleration of evidence-to-practice translation and suggest an important role for systems approaches to facilitate this transition.
... 11 Although there is a wealth of theoretical applications of ST in health systems, there is a gap between the conceptual use of ST and its actual application in the real world. [12][13][14] Kwamie et al 15 suggest that the application of ST needs to be documented better to build a stronger evidence base. 15 One practical application of ST in health has been the Systems Thinking for District Health Systems (ST-DHS) initiative, which supported countries and health districts, to apply ST tools and practices to understand and intervene in their local health systems. ...
... The aim of the framework was to close the gap between ST theory and application. [12][13][14] Stave and Hopper's Taxonomy of Systems Thinking Objectives was used as the starting point of the framework. JT, DCM and CSF adapted the taxonomy based on the results of the systematised literature review and developed the first draft of the STHA framework. ...
Background
Systems thinking is an approach that views systems with a holistic lens, focusing on how components of systems are interconnected. Specifically, the application of systems thinking has proven to be beneficial when applied to health systems. Although there is plenty of theory surrounding systems thinking, there is a gap between the theoretical use of systems thinking and its actual application to tackle health challenges. This study aimed to create a framework to expose systems thinking characteristics in the design and implementation of actions to improve health.
Methods
A systematised literature review was conducted and a Taxonomy of Systems Thinking Objectives was adapted to develop the new ‘Systems Thinking for Health Actions’ (STHA) framework. The applicability of the framework was tested using the COVID-19 response in Pakistan as a case study.
Results
The framework identifies six key characteristics of systems thinking: (1) recognising and understanding interconnections and system structure, (2) identifying and understanding feedback, (3) identifying leverage points, (4) understanding dynamic behaviour, (5) using mental models to suggest possible solutions to a problem and (6) creating simulation models to test policies. The STHA framework proved beneficial in identifying systems thinking characteristics in the COVID-19 national health response in Pakistan.
Conclusion
The proposed framework can provide support for those aiming to applying systems thinking while developing and implementing health actions. We also envision this framework as a retrospective tool that can help assess if systems thinking was applied in health actions.
... Outside the health sector, several attempts were made to create a resilience index, sometimes measured as fragility or readiness indexes: in agriculture and livelihood with the United Nations Resilience Index Measurement and Analysis (RIMA) (FAO, 2016) In health systems research, the trend appears to be on developing adapted research methods based on systems thinking methodologies (de Savigny, Blanchet and Adam, 2017) rather than investing in developing a health system resilience index. The current level of data quality and availability does not satisfy the needs of decision-makers to rely on accurate and time-sensitive information for their decisions, particularly when dealing with resource-constrained countries. ...
This chapter describes the main concepts and common theories of health system resilience. The chapter introduces the origins of resilience as a concept, including the resilience of complex adaptive systems, and describes the major milestones and debates as resilience developed in the field of health systems. The chapter also describes the current different perspectives of resilience as a process, an ability, and an outcome, and the difficulties associated with researching resilience from each perspective, including measuring resilience. Finally, the chapter summarizes current gaps and opportunities for health system resilience research.
... Additionally, it also provides the possibility to analyse policy-level and strategic decisions (Vanderby et al., 2015). Several authors have reviewed the use of SD in healthcare (Cassidy et al., 2019;Chang et al., 2017;Kunc et al., 2018), and defended the need for a systems thinking perspective to analyse HCSs (De Savigny et al., 2017), as well as studied how to restructure HCSs via SD (Homer & Hirsch, 2006;Mitropoulos et al., 2022), or applied it for resource planning and policy development in HCS via SD (Faeghi et al., 2021;Vanderby et al., 2015). In the review by Cassidy et al. (2019), an analysis of different healthcare settings modelled using SD is presented, these being cardiology care, elderly care or long-term care services, emergency or acute care, hospital waste management, accountable care organisation and health insurance schemes, maternal, and child health, as well as orthopaedic care. ...
... Each cycle had three components: 'engage/observe' , 'analyse/plan' and 'act/ reflect' (Fig. 2). The design was rooted in health policy and systems research (HPSR), focussing on how societies organise to protect and promote health, and health systems as complex, adaptive, human, and relational [61,62]. The research was based at the MRC Wits/Agincourt Health and Socio-Demographic Surveillance System (HDSS). ...
Background
While community participation is an established pro-equity approach in Primary Health Care (PHC), it can take many forms, and the central category of power is under-theorised. The objectives were to (a) conduct theory-informed analysis of community power-building in PHC in a setting of structural deprivation and (b) develop practical guidance to support participation as a sustainable PHC component.
Methods
Stakeholders representing rural communities, government departments and non-governmental organisations engaged through a participatory action research (PAR) process in a rural sub-district in South Africa. Three reiterative cycles of evidence generation, analysis, action, and reflection were progressed. Local health concerns were raised and framed by community stakeholders, who generated new data and evidence with researchers. Dialogue was then initiated between communities and the authorities, with local action plans coproduced, implemented, and monitored. Throughout, efforts were made to shift and share power, and to adapt the process to improve practical, local relevance. We analysed participant and researcher reflections, project documents, and other project data using power-building and power-limiting frameworks.
Results
Co-constructing evidence among community stakeholders in safe spaces for dialogue and cooperative action-learning built collective capabilities. The authorities embraced the platform as a space to safely engage with communities and the process was taken up in the district health system. Responding to COVID-19, the process was collectively re-designed to include a training package for community health workers (CHWs) in rapid PAR. New skills and competencies, new community and facility-based alliances and explicit recognition of CHW roles, value, and contribution at higher levels of the system were reported following the adaptations. The process was subsequently scaled across the sub-district.
Conclusions
Community power-building in rural PHC was multidimensional, non-linear, and deeply relational. Collective mindsets and capabilities for joint action and learning were built through a pragmatic, cooperative, adaptive process, creating spaces where people could produce and use evidence to make decisions. Impacts were seen in demand for implementation outside the study setting. We offer a practice framework to expand community power in PHC: (1) prioritising community capability-building, (2) navigating social and institutional contexts, and (3) developing and sustaining authentic learning spaces.
... Each cycle had three components: 'engage/observe' , 'analyse/plan' and 'act/ reflect' (Fig. 2). The design was rooted in health policy and systems research (HPSR), focussing on how societies organise to protect and promote health, and health systems as complex, adaptive, human, and relational [61,62]. The research was based at the MRC Wits/Agincourt Health and Socio-Demographic Surveillance System (HDSS). ...
Background
While community participation is an established pro-equity approach in Primary Health Care (PHC), it can take many forms, and the central category of power is under-theorised. The objectives were to (a) conduct theory-informed analysis of community power-building in PHC in a setting of structural deprivation and (b) develop practical guidance to support participation as a sustainable PHC component.
Methods
Stakeholders representing rural communities, government departments and non-governmental organisations engaged through a participatory action research (PAR) process in a rural sub-district in South Africa. Three reiterative cycles of evidence generation, analysis, action, and reflection were progressed. Local health concerns were raised and framed by community stakeholders, who generated new data and evidence with researchers. Dialogue was then initiated between communities and the authorities, with local action plans coproduced, implemented, and monitored. Throughout, efforts were made to shift and share power, and to adapt the process to improve practical, local relevance. We analysed participant and researcher reflections, project documents, and other project data using power-building and power-limiting frameworks.
Results
Co-constructing evidence among community stakeholders in safe spaces for dialogue and cooperative action-learning built collective capabilities. The authorities embraced the platform as a space to safely engage with communities and the process was taken up in the district health system. Responding to COVID-19, the process was collectively re-designed to include a training package for community health workers (CHWs) in rapid PAR. New skills and competencies, new community and facility-based alliances and explicit recognition of CHW roles, value, and contribution at higher levels of the system were reported following the adaptations. The process was subsequently scaled across the sub-district.
Conclusions
Community power-building in rural PHC was multidimensional, non-linear, and deeply relational. Collective mindsets and capabilities for joint action and learning were built through a pragmatic, cooperative, adaptive process, creating spaces where people could produce and use evidence to make decisions. Impacts were seen in demand for implementation outside the study setting. We offer a practice framework to expand community power in PHC: (1) prioritising community capability-building, (2) navigating social and institutional contexts, and (3) developing and sustaining authentic learning spaces.
... Following current trends in systems thinking for health that draws on multi-, inter-and transdisciplinary approaches (de Savigny et al., 2017), the commentary on social prescriptions is informed by researchers in psychology, exercise sciences, health sciences, environmental health, food systems, sustainability, landscape architecture and education. We hope this can provide a fair starting point to open further discussions and inputs from other disciplines and practitioners to provide a comprehensive and inclusive approach to appropriate healthcare with respect to social prescriptions. ...
Social prescriptions are one term commonly used to describe non-pharmaceutical approaches to healthcare and are gaining popularity in the community, with evidence highlighting psychological benefits of reduced anxiety, depression and improved mood and physiological benefits of reduced risk of cardiovascular disease and reduced hypertension. The relationship between human health benefits and planetary health benefits is also noted. There are, however, numerous barriers, such as duration and frequencies to participate in activities, access, suitability, volition and a range of unpredictable variables (such as inclement weather, shifting interests and relocating home amongst others) impeding a comprehensive approach to their use on a wider scale. From a multidisciplinary perspective, this commentary incorporates a salutogenic and nature-based approach to health, we also provide a range of recommendations that can be undertaken at the patient level to assist in shifting the acknowledged systemic barriers currently occurring. These include using simple language to explain the purpose of health empowerment scripts, ensuing personal commitment to a minimum timeframe, enabling ease of access, co-designing a script program, providing ongoing motivational support and incorporating mindfulness to counter unexpected disruptions.
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.
BACKGROUND: While community participation is an established pro-equity approach in Primary Health Care (PHC), in practice it can take many forms, and the central category of power is under-theorised. The objectives of this paper were to (a) conduct theory-informed analysis of community power-building in PHC in a setting of structural deprivation and (b) develop practical guidance.
METHODS: Stakeholders representing rural communities, government departments and non-governmental organisations engaged through a participatory action research (PAR) process in a rural sub-district in South Africa. Three reiterative cycles of collective evidence generation, analysis, action, and reflection were progressed. Local health concerns were raised and framed by rural community stakeholders, who generated new data and evidence with researchers. Dialogue and learning were developed between the authorities and communities, with local action plans coproduced, implemented, and monitored. Throughout, efforts were made to shift and share power, and to adapt the process to improve practical and local relevance. We analysed participant and researcher reflections, project documents, and other project data using power-building and power-limiting frameworks.
RESULTS: Co-constructing evidence among community stakeholders in ‘safe spaces’ for dialogue and cooperative action built collective capabilities. The authorities embraced the platform as a space to safely engage with communities and the process was taken up in the district health system. Responding to COVID-19, the process was collectively re-designed to include a training package for community health workers (CHWs) in rapid PAR. New skills and competencies, new community and facility-based alliances and explicit recognition of CHW roles, value, and contribution at higher levels of the system were reported following the adaptions. The process was subsequently scaled across the sub-district.
CONCLUSIONS: Community power-building in rural PHC was multidimensional, non-linear, and deeply relational. Collective mindsets and capabilities for joint action and learning were built through a pragmatic, cooperative, adaptive process creating spaces where people could create and use evidence to make decisions. Impacts were seen in demand for implementation in outside the study setting. We offer a practice framework to expand community power in PHC: (1) prioritising community capability-building, (2) navigating social and institutional contexts and (3) developing and sustaining authentic learning spaces.
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