Strengthening complex systems for chronic disease prevention: a systematic review

Collaborative capacity and having a collaborative mindset was discussed in all literature reviewed. Some was particularly strong in this regard [14, 19, 28, 37, 54, 56‐75] while other literature made mention of the need for collaboration. Having a capacity building mindset was described as having a systematic approach to continually assess existing collective system capacity [76] and Manson et al. [14] argued that this mindset was especially needed among leaders in the public sector. There were plentiful and broad descriptions regarding critical success factors of multisectoral collaboration or partnerships [47‐50, 54, 77, 78]. It is beyond the scope of this paper to elaborate in detail on success factors, however, the need for effective mechanisms, structures, processes, and facilitative infrastructure for coordination, collaboration, and relationship building were widely discussed [16, 19, 28, 74, 77, 79‐82]. Woulfe et al. [77] maintained that collaborative partnerships were in essence the system for CDP.

Some literature focused on the unique challenges of building collaborative capacity in public – private partnerships for CDP [28, 45, 54, 83]. The need for rules of engagement, resolution of conflicts of interest and governance mechanisms to protect public health policies from industry interference were particularly discussed [31, 35, 39, 58, 64, 84].

Another theme regarding collaborative capacity was the need for active participation and collaboration with community members [55, 81, 85‐89]. The term ‘community’ was often used to broadly describe the importance of collaborating with and empowering people at the local level [51, 75, 90]. Some literature was detailed in reporting that community-level governance is necessary [91] and that good governance requires “active citizenship and participation in deliberative democracy to form social consensus” [92]. This theme was reinforced through discussions of community capacity building, empowerment approaches and community-based participatory action research [38, 52, 93].

A frequently discussed attribute of effective systems for CDP was not only leadership but linked dimensions of governance and accountability. In terms of leadership, there was considerable emphasis on the need for demonstrated political will to ensure CDP actions are embedded in policy agendas [14, 15, 94‐96]. For example, Swinburn [97] stated that “the impetus for change needs a critical level of political leadership and some defined policy directions” (p4). The links to policy leadership for CDP were abundant [14, 34, 46, 51, 98, 99]. High-level leadership - people who can influence change at the policy level - was described as necessary to establish legitimacy [54] and priority or buy in for CDP [43, 100, 101]. Furthermore, the need for high-level support for action on the social determinants of health was a very common theme [19, 43, 68, 95, 102, 103]. Academic leadership [104, 105] and political champions or leaders in civil society [95] were also highlighted. However, it was leadership from within the health sector that was most emphasized [70, 96, 106‐109].

Leadership at multiple levels was also identified. Although global [37, 94], state [82, 104] and local levels [40] were discussed, it was national- level leadership that was most frequently reported as important to effective systems for CDP [17, 44, 45, 54, 76, 97, 110, 111]. National leadership was considered critical to oversee and integrate strategic policy frameworks [5, 44, 74], align vision, strategy and mission [19, 83] in integrated plans and joined up governance structure [46, 51, 58, 65, 67, 69, 74, 76, 79, 112‐116]. Leadership at many levels in many sectors was often reported as essential [98, 117], for example, public sector leadership at all jurisdictional levels was emphasized by Manson et al. [14] and Swinburn [97].

Regarding governance, the following elements were described as important to effective systems for CDP: transparent structures and processes, strategic frameworks, multisectoral coordination, coalitions and partnerships, policy development and planning [5, 19, 54, 69, 74]. Discussion of planning and the development of policy, regulations and laws were closely linked to the need for systems of integrated and multilevel governance [95, 99, 118], health in all policies [101, 115] and multisectoral public health policy [32, 42, 63, 80, 119‐123]. Abernethy [75] specifically discussed the need for a paradigm shift to complex socio-ecological systems governance that “includes social justice, gender equity, inclusive participatory engagement and transparency in deliberative processes” (p457). The critical connections or relationships between collaborative capacity, national leadership for joined up governance, and a health equity paradigm (discussed below) were evident in the literature.

Finally, accountability was mostly discussed in terms of the critical leadership and governance role in system for CDP. For example, Gostin et al. [58] discussed multisectoral accountability in governance mechanisms and Beaglehole et al. [38] identified the need for multilevel (national and international) governance and accountability for CDP. The focus was largely on monitoring and evaluation of outcomes in CDP and this is discussed below as a dimension of the information attribute. Thus, more connections between attributes such as leadership and information emerged from the literature review.

There was a strong theme that effective systems for CDP need a health equity paradigm as a foundation. This was discussed as relating to a social justice or human rights approach through action on the social determinants of health [14, 32, 39, 75, 90, 102, 114, 118, 124]. A human rights approach was described as requiring a paradigm shift focused on the structural determinants of chronic disease [14, 19, 34, 46, 75, 101, 118, 122, 125]. Shifting the paradigm was reported in such terms as increasing the value of health as a public good and of collective action [88, 126]. Some literature focused on action on the social determinants of health with little discussion of health equity [41, 44, 45]. Furthermore, there was little in the literature that explicitly described how this would be realized in practice (e.g., priority setting for health equity). As noted above, a health equity paradigm was linked to system leadership and governance in some literature.

There was a theme that CDP suffers from a lack of effective implementation of desired action and that continued focus on planning is problematic [19, 25, 90, 93, 127, 128]. The reasons for the lack of implementation were not clearly articulated. There were rich and recurrent descriptors of the type of actions needed. Coordinated, integrated and intersectoral actions were highlighted most frequently and this was well stated by Catford and Cateson [129]: “A complex web of action is needed to address the underlying social, cultural, physical, and economic determinants … A combination of approaches is required, delivered in a coordinated way, with the input of a range of different sectors and organisations.” (p579). Coordinated, integrated planning and implementation of action was discussed as requiring a shared foundation of values, principles and accountability [27, 52, 93]. These three requirements may form a good basis for studying and understanding the lack of implementation. Furthermore, similar to the discussion about diverse entities as inherent in systems for CDP, there was a significant discussion about coordination of intersectoral action involving non-health sectors [32, 42, 62, 95, 111, 119, 123, 125, 130‐132]. The key is the synergistic effects from coordinated actions [52] and system integration that could result [29].

Effective CDP actions were also discussed in terms of multifaceted, comprehensive and knowledge-based approaches. For example, multifaceted actions include efforts to change individual behaviour, strengthen community and environments for health, as well as the implementation of health promoting policy [45, 63, 85, 110, 133]. These are clearly aligned with the Ottawa Charter [134] strategies however this document did not surface as a foundation in the literature reviewed. Comprehensiveness was not only reported in terms of multiple strategies or actions but also in terms of comprehensive implementation of plans that include monitoring targets and responsibilities among entities [27, 93]. Furthermore, evidence informed or knowledge-based actions were discussed as a critical dimension [29, 52, 76, 89, 116, 135] and these dimensions are closely linked and discussed below with respect to information as an attribute of effective system for CDP.

In addition, actions at multiple levels were consistently reported as fundamental [17, 32, 59, 61, 71, 109, 122, 124, 126, 133, 135] and this is in keeping with the description of effective systems for CDP above. An increased focus on the complexity of implementing several strategies at multiple levels and tailored to changing contexts was reported as important [5, 74].

There was considerable attention to the leadership role of the health care sector, particularly primary health care, in implementing actions for CDP [2, 32, 81, 85, 126]. Key recommendations included increasing the priority on CDP action [73, 74], targeting patient, provider, and system level factors [122, 127], improving services and community programs [68, 133], and enhancing organizational capacity in health systems [96]. Following this, the need for leadership [108] and particularly increased primary health care coordination of programs or services within health departments was deemed necessary [37, 68, 113, 133, 135]. There was, however, a tendency in the literature to retreat to discussion of chronic disease management [106, 133].

Lastly, some literature focused on the relationships among diverse actions [51, 68, 70, 89, 109, 122]. Gortmaker et al. [27] reported that addressing these types of relationships requires complex systems thinking to conceptualise systemic causes and to organise evidence needed to plan and implement action. Further, a systems approach was described as addressing the relationships among multiple, heterogeneous interdependent factors (i.e., actors, entities and actions) that interact dynamically across levels of action [17, 55, 136]. Overall, the connections among attributes such as collaborative capacity, leadership, information and implementation of action were clearly evident.

Three themes are combined to form information as an attribute of effective systems for CDP: surveillance of chronic diseases and monitoring of system performance, research and evaluation, and knowledge exchange. Some literature, however, discussed information more broadly in terms of multicomponent monitoring systems examining policy, environments, health system responses, capacity building, innovation, and accountability [16, 71, 104].

Sensitive and context- specific surveillance of the epidemiology of chronic disease was deemed vital to CDP [14, 15, 54, 55, 113, 121]. There was ample discussion of the need to embed surveillance in CDP goals and to ensure accountability mechanisms are in place [14, 15, 33, 39, 94, 121, 130, 132, 133]. Similar to calls for broad monitoring systems, Baum et al. discussed the need for embedded health equity goals that require the production of relevant data and evidence not simply the monitoring of chronic disease. Thus, connections became clear as to the links between surveillance and monitoring, leadership, governance and accountability, and health equity paradigms. Overall, building accountability mechanisms and capacity to monitor progress towards goals and measureable targets were emphasized [67, 68, 73, 85, 117, 121, 123, 131, 132].

There was considerable discussion of research and evaluation in effective systems for CDP. A key theme was the importance of building research capacity [14, 27, 54, 65, 66, 76, 77] and as Huang et al. [17] pointed out this requires multilevel research involving leadership among researchers and policy makers, public-private sectors, and national governments. Ali et al. [15] emphasized the participation of decision- makers in research and Manson et al. [14] indicated linking research with political agendas to be vital. Some literature indicated that participatory action research methods are aligned well with complex systems approaches particularly with respect to bringing diverse perspectives together to address the complexity of CDP [52, 75]. Thus, the interdependence of collaborative capacity, leadership and research in effective systems for CDP was recognized.

The increased need for evaluation of implemented CDP actions was commonly identified in the literature. This was discussed in terms of demonstrated commitment to and funding for evaluation of policies and programs [27, 42, 54, 55, 93] and linking these to quality improvement [89]. One area not commonly reported was economic evaluation. As Gortmaker [27] stated, “a systems approach reminds us of the importance of structural or cross-cutting interventions that support direct actions, but for which cost-effectiveness evidence is not available” (p842).

There was some discussion of the challenges to evaluation from a complex systems perspective for example, accounting for the complexity of urban planning [93], measuring outcomes of CDP networks [72] and evaluating the impact of advocacy activities [109]. In keeping with how systems for CDP are conceptualized in this paper, Matheson et al. (2017) highlight that evidence is context specific therefore factors such as history, resources, and organization of the system needs to be examined and considering different perspectives on the criteria that should be applied in evaluation is part of understanding complex systems.

Finally, structures and processes for knowledge exchange or the translation of existing research evidence to purposeful action for diverse audiences (i.e., public, health providers, and policy makers) was commonly identified as critical to effective systems for CDP [42, 49, 52, 57, 59, 60, 65, 75, 89, 93, 109, 115]. Wutzke et al. [74] described this in broad terms including increasing demand for prevention through improved communication about effective systems for CDP, learning from global and national evidence regarding best practices and ensuring feedback-learning cycles are supported.

Much of the literature utilized resources as a catchall term, for example, Bloch et al. [52] listed material, financial, time, expertise, and creative thinking as vital resources for CDP. Supportive infrastructure was another term used to encapsulate diverse resources [55]. These conceptualizations are different from the health system building block framework [6] where financing and workforce are discrete building blocks.

Resource development figured prominently in terms of the need to mobilize core, adequate or appropriate resources and long-term investment [27, 32, 37, 42, 54, 65, 80, 101, 129, 137]. Beyond discussing resources for the implementation of desired actions and research [74] resources to build collaborative capacity were called for to facilitate synergistic effects of linked actions [30, 82], shared or leveraged cross sectoral assets [42, 59, 89] and system integration and coordination [29].

With respect to financial resources, the literature clearly emphasized that stable, sustained and flexible funding was required to support CDP [5, 14, 15, 82]. Similar emphasis with respect to human resources was found and there was also considerable discussion of the need for workforce development. For example, skill and competency development among practitioners was advocated [14, 40, 137] in areas such as health in all policies [101, 107], working in multidisciplinary teams [10, 51, 59, 105, 138] and cross-sectoral collaboration [15, 75, 80, 105, 107, 124]. Finally, technological resources for CDP were discussed to a very limited extent. When specified as important these resources were discussed in terms of technology to aggregate and use information [60, 89] and to enable communication [81].

As per the study design, having an overarching complex systems perspective or paradigm was identified as an attribute of effective systems for CDP in some literature [74, 139]. This perspective was viewed as holistic, ecological or whole system thinking [52, 139] that required a paradigm shift [5, 75] to address the complexity of systems for CDP [55, 136, 140]. A complex systems paradigm was also described in terms of strategic [139], intelligent and high level system design [15, 120, 139] to help identify “enablers, accelerants, synergies, and interconnectedness of multiple influences” [76] and facilitate context sensitive and cross cutting actions and strategies to strengthen systems for CDP [52]. Further, complex systems perspectives were reported to be complimentary to socioecological models but they specifically aim to advance understanding of dynamic interaction among such things as the heterogeneity and relationships among individuals, entities and subsystems, nonlinear and overlapping interdependencies among entities and actions at multiple levels, and feedback mechanisms and delays [136].

Huang et al. [17] stated that “faced with the continued lack of effective and sustainable prevention strategies” systems perspectives are needed to address issues such as obesity (p7). Calls for systems approaches were linked with calls for increased attention to the implementation of actions, for example, Gortmaker et al. [27] stated that complex systems thinking is useful to conceptualise and organise evidence needed for implementing CDP action. Further to this, Wutzke et al. [5, 74] explained that a systems perspective shifts thinking regarding traditional prevention strategies because the focal points are the numerous actors, paradigms, processes, actions, contexts, structures and the dynamic interactions between them that either facilitate or hinder CDP.

Some complex systems thinking methods and tools were described in the selected literature however there was no synthesis nor consensus. System mapping was discussed most frequently and there were several different approaches reported. For example, Maclean et al. [141] mapped system entities at various levels and key influences to CDP in a flow chart type diagram while Bloch et al. [52] and Willis et al. [83] created word and arrow type diagrams to illustrate the interactions of factors that influenced the system for CDP. There was attention to system mapping to assess various attributes of systems (some discussed in this paper) and identify leverage points to strengthen systems change. Assessing and building collaborative capacity among diverse entities through system mapping was the most described approach. For example, Contandriopoulos [24] contended that “chronic disease prevention should not be conceived as the sum of discrete CDP-active organizations’ capacities, but rather as a more complex ecology of interconnected organizations whose overall influence is shaped by the ways in which they are interconnected and collaborate” (p112). Other literature discussed system mapping in order to support the identification of structures and processes to build participation and group learning about context, synergies, interactions and collaboration [15, 30, 33, 52, 75, 139]. System mapping was also used to assess resources, for example, determine diverse and valuable resources [52], identify strategic and well connected organizations as “vectors” to transfer resources [24], leverage cross sectoral assets [89] and understand human resources in terms of roles in diverse entities [15]. Finally, systems mapping was used for identifying the infrastructure to build effective knowledge exchange processes and structures, enhance cultures of learning, and highlight potential measures for monitoring and accountability [24, 30].

Rating and comparing various attributes of systems for CDP was also a method reported in the selected literature. Martin et al. [25] used a benchmarking tool to rate nine domains or desirable actions (e.g., regulations, policies) to address obesity and presented findings in a graphical radar chart. Other examples included the use of tables to convey ratings of domains of organizational capacity domains [47], a healthy city [19], and of monitoring accountability systems for CDP [71].

Further to these approaches, there were examples of causal loop diagrams to map or illustrate feedback in systems. Waqa et al. [139] described these diagrams as a “grounded logic model of the complex drivers that help to illustrate interdependent cause-effect relationships that either facilitate or hinder the underlying infrastructure of the system” (p2). Here, the causal loop diagram was a product of framing the dynamic problem, creating connection circles, and group model building using systems dynamics approaches. This system dynamics tool brought a complexity-focused lens to system mapping that went beyond the linear word and arrow diagrams.

Concept mapping as a method was described in two articles. Wutzke et al. [74] contended that this method (i.e., qualitative brainstorming and quantitative cluster analysis) was useful for gathering diverse perspectives on the most important and feasible multi-stakeholder and multi-component CDP actions. Concept mapping was also used by Manafo et al. [33] and they too identified many actions across numerous clusters and took these forward to consultation workshops to determine collaborative opportunities and strategic investment in actions.

Only Contandriopoulos et al. [24] discussed the application of social network analysis. They used this method “to map interorganizational collaborative networks”, “measure the structural properties of the network” and “present visually the patterns of connections used for sharing resources and information” (p.e110). Thus, this method appeared to be useful for assessing not only potential collaborative capacity but also other attributes such as resources and information.

Document review was used to analyze policies that addressed obesity through the lens of a systems-based intervention-level framework (i.e., paradigm, goals, system structure, feedback and delays and structural elements) [136]. The framework was considered valuable to identify interventions “that range from targeting specific groups of people and a specific behavior to affecting the deeply held beliefs that underlie the actions of actors throughout the system” (p. 1277). This framework was useful to assess CDP actions in terms of the degree to which they could potentially leverage system change.

Finally, although computational or quantitative modelling was recommended there were no applications discussed in the selected literature. For example, Huang et al. [17] and Gortmaker et al. [27] simply called for studies of this type and Lowe et al. [93] explained the usefulness in terms of “simplifying reality into a conceptual model, which can then be used to predict the potential effects of a policy or plan on a range of inter-related health risk factors” (p.16).