Systems science and systems thinking for public health: a systematic review of the field The Harvard community has made this article openly available. Please share how this access benefits you. Your story matters Citation Carey, Gemma, Eleanor Malbon, Nicole Carey, Andrew Joyce, Brad Crammond, and Alan Carey. 2015. “Systems science and systems thinking for public health: a systematic review of the field.” BMJ Open 5 (12): e009002. doi:10.1136/bmjopen-2015-009002. http:// dx.doi.org/10.1136/bmjopen-2015-009002. Published Version doi:10.1136/bmjopen-2015-009002 Citable link http://nrs.harvard.edu/urn-3:HUL.InstRepos:24984033 Terms of Use This article was downloaded from Harvard University’s DASH repository, and is made available under the terms and conditions applicable to Other Posted Material, as set forth at http:// nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of- use#LAA Open Access Research Systems science and systems thinking for public health: a systematic review of the field Gemma Carey,1 Eleanor Malbon,2 Nicole Carey,3 Andrew Joyce,4 Brad Crammond,5 Alan Carey6 To cite: Carey G, Malbon E, ABSTRACT et al Strengths and limitations of this study Carey N, . Systems Objectives: This paper reports on findings from a science and systems thinking systematic review designed to investigate the state of ▪ for public health: a This study provides a systematic review of the systems science research in public health. The systematic review of the field. application of systems science and systems BMJ Open 2015;5:e009002. objectives were to: (1) explore how systems thinking to the field of public health. doi:10.1136/bmjopen-2015- methodologies are being applied within public health ▪ The review identified critical shortcomings in the 009002 and (2) identify fruitful areas of activity. use of systems methodologies being used. Design: A systematic review was conducted from ▪ The review showed that public health is currently ▸ Prepublication history and existing literature that draws on or uses systems not engaging with the full range of systems additional material is science (in its various forms) and relates to key public methodologies. available. To view please visit health areas of action and concern, including tobacco, ▪ The sample of articles is representative but not the journal (http://dx.doi.org/ alcohol, obesity and the social determinants of health. comprehensive, which is a limitation of the 10.1136/bmjopen-2015- Data analysis: 117 articles were included in the study. 009002). review. An inductive qualitative content analysis was used for data extraction. The following were 12 Received 6 June 2015 behaviour of complex systems. A general systematically extracted from the articles: approach, Revised 23 October 2015 distinction is made between ‘hard’ systems methodology, transparency, strengths and weaknesses. Accepted 11 November 2015 methodologies which refer to quantitative These were then organised according to theme (ie, commonalities between studies within each category), dynamic model building (ie, system dynam- ‘ ’ in order to provide an overview of the state of the field ics) and soft systems methodologies which as a whole. The assessment of data quality was refer to qualitative, action-based research intrinsic to the goals of the review itself, and therefore, methodologies (ie, critical systems heuris- was carried out as part of the analysis. tics). As a whole, systems methodologies are Results: 4 categories of research were identified from thought to enable researchers and decision the review, ranging from editorial and commentary makers to examine system components, and pieces to complex system dynamic modelling. Our the dynamic relationships between them, at analysis of each of these categories of research multiple levels, from cell to society.1 highlighted areas of potential for systems science to 1Regulatory Institutions Taking a systems approach encourages a strengthen public health efforts, while also revealing a Network Australian National rethinking of organisations and system issues, number of limitations in the dynamic systems University, Canberra, including how actors behave in relation to Australia modelling being carried out in public health. 2 them and are involved in their diagnosis and The Australian Prevention Conclusions: There is a great deal of interest in how 2–5 Partnership Centre, Sax the application of systems concepts and approach treatment. Here, the emphasis is placed ‘ ’ Institute, Sydney, Australia might aid public health. Our analysis suggests that soft on understanding the whole system, rather 3 Self-organizing Systems systems modelling techniques are likely to be the most than focusing exclusively on individual com- 2–46–8 Research Group School of useful addition to public health, and align well with ponents. engineering and applied current debate around knowledge transfer and policy. While a range of systems methodologies sciences Harvard University However, the full range of systems methodologies is 4Centre for Social Impact, exist (or are in the process of being devel- Swinburne University, yet to be engaged with by public health researchers. oped and refined within a public health Melbourne, Victoria, Australia context), the most advanced systems method- 5Centre for Epidemiology and ologies seek to model systems and/or subsys- Preventive Health. Monash tems, in order to identify potential points for University, Melbourne, i Australia INTRODUCTION intervention and change. Modelling and 6Maths Science Institute In the past 5–10 years, there has been rapidly Australian National University growing interest in the applicability of i ‘systems science’ to public health. Systems This paper does not provide an overview of systems Correspondence to theories or methods. These are provided in many of the Dr Gemma Carey; science is a broad class of analytical papers reviewed, and comprehensive introductions can [email protected] approaches that aim to uncover the be found elsewhere.910 Carey G, et al. BMJ Open 2015;5:e009002. doi:10.1136/bmjopen-2015-009002 1 Open Access simulations are thought to have significant potential for which discussed a system (ie, the health system) but improving decision-making in health policy, planning were not drawing on ‘systems science’. A list of papers and implementation by highlighting unintended conse- included in the review is provided in online supplemen- quences.11 It is argued that ‘by replicating the real world tary appendix 1. Owing to limitations associated with in important ways—simplifying where possible while using key search terms (within abstracts and titles) to retaining the critical aspects relevant to the problem identify literature, we do not suggest that this is an under study—we can better understand the structural exhaustive list of published work in the field. We do, complexity of real-world problems that results from the however, argue that it is a broadly representative sample. interaction of specific phenomena and their As Williams and Hummelbrunner9 note, holism is environments’.12 ‘somewhat of an ideal. In reality, all situations, all inquir- The introduction of systems science to public health ies are bounded in some way’. has been met with considerable interest. A plethora of In total, 341 articles, reports and reviews were identi- articles now argue for the applicability of systems meth- fied. A further two were sourced from reference lists. odologies and perspectives to a wide range of public After reviewing abstracts, 124 were excluded on the basis health problems, from obesity to tobacco and the social of the aforementioned exclusion criteria and the removal – determinants of health.261317 What remains unclear, of duplicates. A further 12 were excluded after more however, is whether the reality has lived up to this rhet- in-depth examination (on the basis of the same exclusion oric. This paper reports on findings from a systematic criteria). In total, 117 articles were included in the review, review designed to investigate the state of systems with the far majority from peer-reviewed journals (see science research in public health. The objectives were online supplementary appendix 1 and figure 1). to: (1) explore how systems methodologies are being Articles were categorised by three of the authors (for applied within public health and (2) identify fruitful inter-rater reliability). An inductive qualitative approach areas of activity. to analysis was used. As Dixon-woods et al18 note, system- atic reviews can be integrative or interpretive. With inte- grative reviews, the categories and concepts are set prior METHODS to conducting literature searches. With an interpretive Search strategy approach, concepts and categories arise inductively from The search strategy and analysis was informed by: the the content after the searches are conducted.18 This study’s aims, previous systematic reviews using qualitative approach to analysis is otherwise known as an inductive data, and best practice recommendations in the research qualitative content analysis.20 literature.18 19 Data extraction followed a number of stages. After pre- A systematic review of the literature was conducted by liminary categorisation, categories were divided among a single research assistant. Searches for peer-review lit- the authors according to expertise. Each category was erature were conducted in major databases: ProQuest, reviewed in depth by at least one author and the lead Sociological Abstracts, PubMed, Web of Science, Science author: Citation