Table 3 Studies categorised as ‘high use of a systems approach’ (n = 5)

Conte et al. (2017) [44]

Physical activity and diet (for the prevention of obesity)

Recognised health care settings as complex adaptive systems and that they should act consistently with this theory for quality improvement purposes. Recognised that practice occurs as part of a social system, and practitioners have agency and multiple accountabilities within the system(s). System also referred to in context of ‘monitoring systems’ for implementation of health promotion

No framework to guide scaling up reported in paper. Social network analysis was used to quantify how connected practitioners were with each other, how central/or isolated some players were, and why it was easier to diffuse information across some groups

Joyce et al. (2018) [48]

Physical activity, tobacco use, alcohol consumption and diet (for the prevention of obesity)

Systems thinking used to inform implementation. Systems science described as a broad class of analytical approaches that aim to uncover the behaviour of complex systems. Applied systems thinking practice, systems mapping to draw connections with staff from other stakeholder organisations and discuss common concerns, look for common interests and potential strategies to align as many community groups as possible, decide on which issues to prioritise

Systems thinking allowed practitioners to act as ‘practice entrepreneurs’, a concept developed in the paper to describe the more reactive and flexible approach in practice. Systems mapping was used to explore common practice, concerns, interests, and values of other organisations. Identified interrelationships between key attributes of the system (such as programs, practitioners, networks and organisations), and leverage points that could produce action across these multiple actors. Engaging key organisations and people linking them was a key indicator of success. Outcomes included levels of population reach and engagement

Malakellis et al. (2017) [51]

Diet (for the prevention of obesity)

Systems thinking informed implementation and the intervention, and the intervention targeted different systems points across the whole food system

Analysis Grid for Element Linked to Obesity (ANGELO) (Swinburn et al. 1999) workshop, which includes WHO systems building blocks. Schools leveraged existing health-promoting activities and introduced initiatives informed by ANGELO. Systems mapping identified and prioritised the key determinants while considering gaps in knowledge, capacity, needs and existing health promotion initiative

Matheson et al. (2019)

Physical activity, tobacco use, alcohol consumption and diet

This study targeted different points in the system, used systems thinking to inform implementation, and focussed on system change. It distinguished systems thinking from linear, siloed approaches

Context- and complexity-oriented. For example, interventions are described as ‘events in a system’ and need to be able to adapt to the specific social, economic, cultural, and geographic circumstances of a community

Through Strategic Leadership Groups (SLGs), guided by the WHO’s building blocks for a strong health system (WHO, 2007). A dedicated systems thinking and acting health promotion workforce and activating local leadership to influence change

The study developed criteria for two outcomes of systems change: First, Prevention Infrastructure, requiring evidence of an increase in local organisations focusing on prevention and healthier practices, including through policy changes, changes in the built environment and additional resources dedicated to prevention. Second, Prevention Attitudes and Paradigm, requiring evidence of an increased commitment to prevention or seeking out opportunities to collaborate with other organizations for the purpose of prevention

Tong et al. (2020) [56]

Tobacco use

This study targeted different systems points, and systems thinking was used to inform implementation

The systems framework (the Cancer Care Continuum) was used to facilitate viewing plans, progress, and priorities. It helps identify research gaps, and where collaboration with others is needed to have an impact, including where more resources may be needed. The Consolidated Framework for Implementation Research (CFIR) (Damschroder et al. 2009) was used to describe and evaluate implementation