How to do (or not to do)…Using Causal Loop Diagrams for Health System Research in Low- and Middle-Income Settings

Strategizing towards the future hospital: a systems thinking approach

BACKGROUND

The complex systemic nature of Future Hospital design in the rapidly ageing city-state of Singapore calls for systems thinking. We apply this approach to answer two research questions: (i) What are the variables that drive the present and future dynamics of the Future Hospital system? (ii) How are these driving variables related?

METHODS

Causal loop diagrams (CLDs) were developed collaboratively by a cross-functional system modelling team through group modelling discussions and reviews, totalling 20 sessions. Network analysis of the resulting CLDs was used to identify dominant variables.

RESULTS

Seven interlocking CLDs (national view, cluster view, and study hospital top level, outpatient, emergency department, inpatient and surgeries and procedures views) were created to serve as "boundary objects" for different Future Hospital stakeholders, as well as researchers and planners of other Future Hospital systems. Important feedback loops and 15 interventions for redesign were identified. In all the modelled services (outpatient, emergency, inpatient and surgeries and procedures), capacities are subject to positive feedback loops. Alternative models of care are needed to restrain ever-increasing demand. Need for agility (the need for ability to quickly deploy and pivot capacity in responses to crises) is the variable with the highest betweenness centrality in the combined network of seven CLDs.

CONCLUSIONS

We address the need for greater openness on Future Hospital initiatives by making our resulting logic maps public. Due to their qualitative nature, the CLDs are insightful for Future Hospital strategic planning exercises globally.

Understanding healthcare demand and supply through causal loop diagrams and system archetypes: policy implications for kidney replacement therapy in Thailand

BACKGROUND

Systems thinking approaches can determine system interdependencies to guide effective policymaking but have been underutilised in health policymaking, particularly for policies related to access and delivery of health services. In Thailand, a policy changing access to dialysis services for patients with kidney failure in 2022 had resulted in an unexpected surge in patients, mortality rate, and budget overspend. This study applied systems thinking to characterise the dynamics underlying the unforeseen impact of the 2022 policy, in order to propose context-specific policy interventions.

METHODS

We developed a causal loop diagram through iterative stakeholder engagement, to understand the drivers for supply and demand of dialysis under the 2022 policy in Thailand. Since systems thinking was considered a new tool for policymaking, we used system archetypes as a means by which to collapse down the complexity of causal loop diagrams into simple narratives for policymakers. Confidence-building (validation) was conducted through triangulation across data sources and steps to facilitate stakeholder critique throughout the process.

RESULTS

Chronic underinvestment in peritoneal dialysis had failed to capitalise on improvements in expertise and quality of services, while a series of short-term measures to overcome constraints in haemodialysis supply had unintentionally increased haemodialysis demand in the long-term, increasing strain on the healthcare system. By applying generic solution archetypes, we identified a series of measures to balance demand for services with system capacity, including better alignment of incentives with health system goals, proactive planning to anticipate future supply needs, and regulatory mechanisms to moderate demand according to available supply.

CONCLUSIONS

A major implication of this research is that changes to healthcare access and delivery require multi-stakeholder engagement and whole system thinking, as even small changes can have potentially vast consequences. Applying a systems thinking lens not only communicated the reasons for unintended impact of the 2022 policy, but also identified interventions absent from the literature that were unique to the drivers of demand and supply in Thailand.

A co-designed conceptual model for implementing falls prevention programmes for community-dwelling older adults in Singapore: a systems thinking approach

INTRODUCTION

Implementing falls prevention programmes in the community presents numerous challenges. We sought to understand the dynamics between the determinants influencing implementation to develop a common conceptual model describing the complexities of implementing falls prevention programmes in Singapore.

METHODS

A full-day group model building workshop with a series of structured activities was organised with 31 multidisciplinary stakeholders. Stakeholders who attended include healthcare professionals of different specialities (i.e. geriatrics, rehabilitation medicine, physiotherapy, nursing), community-based voluntary welfare organisations, researchers and policymakers.

RESULTS

A causal loop diagram was developed to illustrate the determinants influencing implementation of community-based fall prevention programmes. It revealed factors driving key implementation and service outcomes in supply and demand of such programmes. Determinants of these outcomes were synthesised into four themes: (i) structural factors affecting the management and resource allocation for community-based falls prevention programmes, (ii) participation in programmes affected by older adults' willingness and ability to participate, (iii) perceived value as a composite of costs and benefits, and (iv) social support and exercise self-efficacy motivating long-term adherence. Furthermore, in our analysis of feedback relationships, two organisational behaviours were identified: unsustainable growth due to resource constraints (Limits to Growth) and tensions between executing symptomatic or fundamental solutions (Eroding Goals). Stakeholders also explored strategies for effective implementation.

CONCLUSIONS

A conceptual model describing the dynamics of implementing community-based fall prevention programmes was developed. This informed the formulation of a National Falls Prevention Framework, a priority action step for the effective implementation of these programmes in Singapore.

Converging perspectives on the processes exacerbating adolescent obesity: An integrative systems approach

Adolescent obesity is a complex public health challenge with steadily increasing and variable prevalence among countries. This paper synthesises the driving feedback mechanisms of adolescent obesity studied in the CO-CREATE project, furthering our understanding of the complexity of this issue. Using systems thinking principles and causal loop diagramming, we integrated the following knowledge and perspectives derived from diverse sources into a causal loop diagram (CLD): a systems map generated by adolescents through participatory modelling workshops, a comprehensive literature review, and input from subject-matter experts during validation workshops. We used a structured and iterative approach to include drivers and to identify feedback loops exacerbating adolescent obesity. The CLD identified 27 key feedback loops across four themes: twelve related to the commercial food environment, six to the physical activity environment, four to mental wellbeing and five to social norms. These loops indicate not only diet and physical activity as drivers of obesity but also stress and other emotional and social pressures. Recognising the imperative need to integrate the perspectives and experiences of adolescents into our analysis, this work advocates for the synthesis of experiential insights with empirical research. The integrated CLD can be used as a visual tool that fosters collaboration among stakeholders and engenders a more comprehensive and inclusive system understanding that can provide holistic intervention considerations to tackle adolescent obesity. Additionally, the CLD lays a foundation for subsequent quantitative modelling works to further address this issue and develop context-based approaches to prevention and evaluation of adolescent obesity.

Opportunities in Programs and Policies to Address the Underlying Drivers of Sugary Drink and Water Consumption in the Washington, DC, Metro Area: A Qualitative Community-Based System Dynamics Approach

BACKGROUND

Although the Dietary Guidelines for Americans recommend that individuals drink water instead of sugar-sweetened beverages (SSBs), this behavior is influenced and reinforced by a complex network of structures and systems.

OBJECTIVE

The objectives of this study were to develop a shared understanding among multiple stakeholders about the structural and underlying, interconnected drivers of SSB and water consumption in the Washington, DC, metro area and to have them identify feasible and influential policy levers.

DESIGN

A community-based system dynamics approach was used during a 2-day group model building workshop where stakeholders engaged to develop a shared visual representation of the underlying, interconnected drivers of SSB and water intake and to identify what they believed were influential and feasible policy levers.

PARTICIPANTS/SETTING

Stakeholders were purposively recruited from diverse sectors (early childhood education [n = 6], nutrition assistance programs [n = 2], food policy council and advocacy groups [n =4], city government officials including municipal water [n = 4], and food and beverage retail [n = 1]) to participate in a group model building workshop during July 2022 in Washington, DC.

STATISTICAL ANALYSIS

Using member checking and iterative feedback, the research team synthesized the outputs from the workshop into 1 causal loop diagram and ranked policy levers.

RESULTS

Stakeholders visualized 7 subsystems that drive water and SSB consumption, then identified and ranked 5 policy levers by potential impact and ease of implementation, including increase public health spending (high impact/hard to do); invest in new and updated infrastructure for public water (high impact/hard to do); implement coordinated public health campaigns to promote drinking safe, palatable water as an alternative to SSB (low impact/easy to do); provision of tap water filters (low impact/easy to do); and limits on SSB marketing (high impact/debated easy or hard to do).

CONCLUSIONS

This participatory approach allowed stakeholders to envision multiple places to intervene in the system simultaneously to both decrease SSB and increase water consumption in the specific context of their community.

Using qualitative systems mapping to analyze the linkages between the behavioral and social (BeSD) determinants of routine childhood immunization in LMICs

BACKGROUND

Designing effective immunization programs requires a strong understanding of how the factors affecting vaccine uptake interplay. In this review, we analyze the relationships between the Behavioral and Social Drivers (BeSD) of routine immunization using qualitative systems mapping (QSM).

METHODS

In this review, we analyzed 92 experimental and quasi-experimental impact evaluations (IEs) from 11 LMICs that were published between 2010 and 2020. Secondary literature on the study context or the intervention was also included. The WHO's behavioral and social determinants (BeSD) framework was used to code the determinants identified in these IEs, and their relationships were mapped using qualitative systems mapping. We computed the in-degree (influenced by other determinants) and out-degree scores (influencing other determinants) to assess the extent of the influence of the BeSD determinants on one another.

RESULTS

The results identified that knowledge regarding immunization, trust in the health system and quality of immunization services, and community engagement by the health workers was influenced by several other determinants and had a high in-degree score. Caregivers perceptions of quality of immunization services, health provider availability, religious leaders, community engagement by health workers, and physical accessibility had a high out-degree score. We also identified two feedback loops between health provider availability and physical accessibility, and trust and perceptions of immunization quality.

CONCLUSIONS

QSM analysis shows that the determinants of immunization uptake were interlinked with each other in complex ways. Our research identified BeSD drivers that affected multiple factors and can be viewed as key leverage points. Programs for improving vaccination uptake need to account for the strong role that caregivers' experience of immunization services and their trust in the health system play in indirectly affecting immunization uptake. There is also a need to acknowledge that fear of vaccination is fear of the opportunity and monetary costs associated with vaccine side-effects. The results from this review can inform discussion and form the basis for context specific research on the factors affecting immunization.

Qualitative system dynamics modelling to support the design and implementation of tuberculosis infection prevention and control measures in South African primary healthcare facilities

Tuberculosis infection prevention and control (TB IPC) measures are a cornerstone of policy, but measures are diverse and variably implemented. Limited attention has been paid to the health system environment, which influences successful implementation of these measures. We used qualitative system dynamics and group-model-building methods to (1) develop a qualitative causal map of the interlinked drivers of Mycobacterium tuberculosis (Mtb) transmission in South African primary healthcare facilities, which in turn helped us to (2) identify plausible IPC interventions to reduce risk of transmission. Two 1-day participatory workshops were held in 2019 with policymakers and decision makers at national and provincial levels and patient advocates and health professionals at clinic and district levels. Causal loop diagrams were generated by participants and combined by investigators. The research team reviewed diagrams to identify the drivers of nosocomial transmission of Mtb in primary healthcare facilities. Interventions proposed by participants were mapped onto diagrams to identify anticipated mechanisms of action and effect. Three systemic drivers were identified: (1) Mtb nosocomial transmission is driven by bottlenecks in patient flow at given times; (2) IPC implementation and clinic processes are anchored within a staff 'culture of nominal compliance'; and (3) limited systems learning at the policy level inhibits effective clinic management and IPC implementation. Interventions prioritized by workshop participants included infrastructural, organizational and behavioural strategies that target three areas: (1) improve air quality, (2) improve use of personal protective equipment and (3) reduce the number of individuals in the clinic. In addition to core mechanisms, participants elaborated specific additional enablers who would help sustain implementation. Qualitative system dynamics modelling methods allowed us to capture stakeholder views and potential solutions to address the problem of sub-optimal TB IPC implementation. The participatory elements of system dynamics modelling facilitated problem-solving and inclusion of multiple factors frequently neglected when considering implementation.

Systems mapping: a novel approach to national lung cancer screening implementation in Australia

Background

Lung cancer screening with low-dose computed tomography has been started in some high-income countries and is being considered in others. In many settings uptake remains low. Optimal strategies to increase uptake, including for high-risk subgroups, have not been elucidated. This study used a system dynamics approach based on expert consensus to identify (I) the likely determinants of screening uptake and (II) interactions between these determinants that may affect screening uptake.

Methods

Consensus data on key factors influencing screening uptake were developed from existing literature and through two stakeholder workshops involving clinical and consumer experts. These factors were used to develop a causal loop diagram (CLD) of lung cancer screening uptake.

Results

The CLD comprised three main perspectives of importance for a lung cancer screening program: participant, primary care, and health system. Eight key drivers in the system were identified within these perspectives that will likely influence screening uptake: (I) patient stigma; (II) patient fear of having lung cancer; (III) patient health literacy; (IV) patient waiting time for a scan appointment; (V) general practitioner (GP) capacity; (VI) GP clarity on next steps after an abnormal computed tomography (CT); (VII) specialist capacity to accept referrals and undertake evaluation; and (VIII) healthcare capacity for scanning and reporting. Five key system leverage points to optimise screening uptake were also identified: (I) patient stigma influencing willingness to receive a scan; (II) GP capacity for referral to scans; (III) GP capacity to increase patients' health literacy; (IV) specialist capacity to connect patients with timely treatment; and (V) healthcare capacity to reduce scanning waiting times.

Conclusions

This novel approach to investigation of lung cancer screening implementation, based on Australian expert stakeholder consensus, provides a system-wide view of critical factors that may either limit or promote screening uptake.

Adopting a systems-thinking approach to optimise dietary and exercise referral practices for cancer survivors

PURPOSE

Service referrals are required for cancer survivors to access specialist dietary and exercise support. Many system-level factors influence referral practices within the healthcare system. Hence, the aim of this study was to identify system-level factors and their interconnectedness, as well as strategies for optimising dietary and exercise referral practices in Australia.

METHODS

A full-day workshop involving national multidisciplinary key stakeholders explored system-level factors impacting dietary and exercise referral practices. Facilitated group discussions using the nominal group technique identified barriers and facilitators to referral practices based on the six World Health Organisation (WHO) building blocks. The systems-thinking approach generated six cognitive maps, each representing a building block. A causal loop diagram was developed to visualise factors that influence referral practices. Additionally, each group identified their top five strategies by leveraging facilitators and addressing barriers relevant to their WHO building block.

RESULTS

Twenty-seven stakeholders participated in the workshop, including consumers (n = 2), cancer specialists (n = 4), nursing (n = 6) and allied health professionals (n = 10), and researchers, representatives of peak bodies, not-for-profit organisations, and government agencies (n = 5). Common system-level factors impacting on referral practices included funding, accessibility, knowledge and education, workforce capacity, and infrastructure. Fifteen system-level strategies were identified to improve referral practices.

CONCLUSION

This study identified system-level factors and strategies that can be applied to policy planning and practice in Australia.

Leveraging global investments for polio eradication to strengthen health systems' resilience through transition

Since the launch of the Global Polio Eradication Initiative in 1988, more than US$20 billion has been invested globally in polio eradication. The World Health Organization and its partners are currently supporting Member States to transition the functions used to eradicate polio to strengthen their health systems. This study analyses global polio activities through the lens of health systems and the Common Goods for Health (CGH). Polio activities include key health system functions such as surveillance and response systems and immunization, which are essential to maintaining resilient health systems. They also support essential functions such as policy development, planning, training and capacity building, which are often underfunded in many countries. To improve overall resilience, it is critical to continue to integrate these functions into local health systems so that the capacity built through the polio eradication programme can be used for broader public health purposes. It is vital that this integration process be tailored to each country's unique health system context, rather than using a one-size-fits-all approach. While integration of all polio activities into local health systems is ideal, the transition to domestic financing may be coordinated with other global health financing mechanisms. This would reduce funding fragmentation and transaction costs, and allow for a focus on health system functions as a whole rather than just disease-specific efforts. The transition to domestic financing of polio activities could be staggered, prioritizing the transition to domestic funding for activities with limited global externalities, while seeking longer-term external funding for those that are global CGH.

Constructing causal loop diagrams from large interview data sets

"Tackling the Root Causes Upstream of Unhealth Urban Development" is a trans-disciplinary research project seeking to map and understand urban development decision-making, visualise stakeholder mental models and codevelop improvement interventions. The project's primary data was gathered through 123 semistructured interviews. This article applies, compares, and discusses four variations on a method for constructing causal loop diagrams to illuminate mental models and collective decision-making, based on manual and semiautomated processes applied to individual interview transcripts and datasets collected by thematic analysis. It concludes that while semiautomated approaches offer some time saving over manual approaches when applied to large data sets, care is required in interpreting and including peripheral contextual variables at the boundaries of the thematic analysis. Decisions regarding automation depend on the purpose of the modelling. Finally, the article recommends future applications record quantitative descriptors characterising the process of constructing CLDs from large qualitative data sets.

Unveiling Maternal Health Insights During the COVID-19 Pandemic in Pakistan: Using Causal Loop Diagrams to Illuminate and Prevent Unintended Policy Effects

The authors explain that using causal loop diagrams can visualize retrospectively the unintended negative consequences of COVID-19 related policies on maternal health and has potential to be used prospectively to foster decision-making to prevent those consequences.

Developing an integrated model of care for vulnerable populations living with non-communicable diseases in Lebanon: an online theory of change workshop

INTRODUCTION

The Syrian crisis, followed by a financial crisis, port explosion, and COVID-19, have put enormous strain on Lebanon's health system. Syrian refugees and the vulnerable host population have a high burden of Non-communicable Diseases (NCD) morbidity and unmet mental health, psychosocial and rehabilitation needs. The International Committee of the Red Cross (ICRC) recently introduced integrated NCD services within its package of primary care in Lebanon, which includes NCD primary health care, rehabilitation, and mental health and psychosocial support services. We aimed to identify relevant outcomes for people living with NCDs from refugee and host communities in northern Lebanon, as well as to define the processes needed to achieve them through an integrated model of care. Given the complexity of the health system in which the interventions are delivered, and the limited practical guidance on integration, we considered systems thinking to be the most appropriate methodological approach.

METHODS

A Theory of Change (ToC) workshop and follow-up meetings were held online by the ICRC, the London School of Hygiene and Tropical Medicine and the American University of Beirut in 2021. ToC is a participatory and iterative planning process involving key stakeholders, and seeks to understand a process of change by mapping out intermediate and long-term outcomes along hypothesised causal pathways. Participants included academics, and ICRC regional, coordination, and headquarters staff.

RESULTS

We identified two distinct pathways to integrated NCD primary care: a multidisciplinary service pathway and a patient and family support pathway. These were interdependent and linked via an essential social worker role and a robust information system. We also defined a list of key assumptions and interventions to achieve integration, and developed a list of monitoring indicators.

DISCUSSION

ToC is a useful tool to deconstruct the complexity of integrating NCD services. We highlight that integrated care rests on multidisciplinary and patient-centred approaches, which depend on a well-trained and resourced team, strong leadership, and adequate information systems. This paper provides the first theory-driven road map of implementation pathways, to help support the integration of NCD care for crises-affected populations in Lebanon and globally.