Dr Melanie Pescud, The Australian National University, and Professor Lucie Rychetnik, The Australian Prevention Partnership Centre
The Difficulties of the Search for Solutions
Research about chronic disease prevention can fall short of achieving positive change – not because it isn’t relevant, but because it too often describes problems, rather than charting a path towards effectual action. Implementation science and theories of systems change provide a way to move beyond rhetoric to create sustainable change on public health issues.
Addressing complex problems such as chronic disease, reducing inequity, and promoting sustainable population health and wellbeing cannot be done without a clear understanding of the complex systems we are trying to influence.
Systems thinking means considering all the interconnected and interdependent parts of a system as a dynamic whole. Systems methods include:
- Social network analysis
- Group modelling
- Agent-based models
- System dynamic simulation models
These help us to better understand the complex drivers of chronic disease and where we can nudge the system to achieve possible solutions.
Still, many of us researchers get stuck at the point of describing systems rather than articulating how to create change within them. And, even when the evidence tells us what is needed, we sometimes feel hamstrung to act or are not sure about our role or responsibility in creating systems change.
Moving from Understanding to Application
Our recently published paper outlines how prevention researchers can develop a pathway for creating system change through deep systems analysis and reflective learning, followed by the development and implementation of a theory of systems change.
We have drawn on the work of prominent systems thinkers Pennie Foster-Fishman and Erin Watson, whose ABLe change framework presented a new approach to the design and implementation of community change efforts in the United States.
The work incorporates systems theory, implementation theory and organisational change theory into a framework that prompts users towards deep systems analysis and reflective learning, then to develop and implement a plan for systems change.
The Prevention Systems Change Framework
The Prevention Systems Change Framework (PSCF) provides a tool to explore a complex system and articulate the types of action needed to help us generate change. It can be used to guide systems-based research planning, monitoring, study team reflective learning, and research evaluation processes.
The PSCF illustrates how to work through four iterative steps:
(1) Applying a systemic lens to the prevention problem being studied
(2) Holding an implementation focus
(3) Integrating the systems lens and the implementation focus, and
(4) Developing a theory of systems change
Users are prompted through a series of questions to think beyond increasing awareness of a problem to trying to change mindsets and practices – to gently urge all the actors in the system to move along the same path to create change. These questions are a guide only, and users should modify the questions to suit their own context and needs.
We have shown that when the PSCF (as part of a systemic evaluation process) is applied retrospectively to a project, it enabled a detailed and critical assessment of the project’s goals and how to meet them.
By evaluating the project through a systems lens, we were able to undertake a comprehensive and evidence-informed research review and reflection process that suggested how we could progress from understanding the system towards driving effectual action.
Becoming Comfortable with Being Uncomfortable
The framework will be useful for anyone planning a change within a complex system – from advocates, policy makers and health promotion practitioners thinking about implementing a program, policy or intervention, to those grappling with larger scale change that involves numerous interventions.
We all need to be willing to reflect on our own roles within the systems we are studying, and to look for our potential blind spots with openness and receptivity. From our own experience, this is often confronting and uncomfortable. But such reflexivity can be supported by purposeful and sustained questioning, and an ongoing process of reflection, action and feedback from new and diverse perspectives.
Arguably, if prevention research is to support improved health outcomes, it must be more explicitly linked to creating systems change. Incorporating systems thinking for systems change into our work is an important step in advancing the field of chronic disease prevention.