Addressing Complexity in Chronic Disease Prevention Research

Abstract

There is wide agreement on the need for systems thinking to address complexity in chronic disease prevention but there is insufficient understanding of how such approaches are operationalised in prevention research. Ison and Straw propose that to address complexity, the right balance must be struck between ‘systemic’ and ‘systematic’ paradigms. We examined the nature and characteristics of this relationship in a series of six qualitative case studies of prevention research. Data comprised 29 semi-structured interviews with 16 participants, and online documents. The analysis combined inductive methods from grounded theory with a theoretically informed framework analysis. Systemic and systematic ways of working varied across each case as a whole, and within the dimensions of each case. Further, the interplay of systemic and systematic approaches was described along a dynamic continuum of variable proportions, with greater emphasis on systemic aspects balanced by less focus on the systematic, and vice versa. By expanding the boundaries for exploring prevention research, we gained empirical understanding of the potential and scope of systemic and systematic paradigms for addressing complexity in prevention research. There is inherent value in being more explicitly conscious and bilingual in both systemic and systematic paradigms so that their respective value and strengths may be utilised. Our findings propose a coherent theoretical frame to better understand existing approaches for addressing complexity in prevention research.

1. Introduction

In the past decade, there have been calls for systems-based approaches to study and address chronic disease. This shift is a response to the understanding that chronic disease can be understood as a result of the complex interactions between social, economic, and environmental forces [1,2,3,4,5]. The evidence demonstrating the likely value of systems-based responses for tackling population-level chronic disease continues to grow [6,7,8].

Yet despite wide agreement in public health literature on the importance of addressing complexity, the lack of working examples of how research does address complexity is an important gap in knowledge, and more understanding is needed of the operationalisation and impact of different approaches [9]. Systems theories, methods, and tools are not yet universally adopted, nor embedded at scale in public health research and practice, although some notable examples exist, e.g., [10,11,12,13], including the Australian Prevention Partnership Centre [14] that applies and funds systems approaches to the study of chronic disease prevention.

In this paper we present an empirical analysis from the Prevention Centre’s Systems Case Studies project, spanning cases related to food and nutrition policy, obesity prevention, liveability, and health services research. We sought to explore different ways in which complexity is addressed in chronic disease prevention research, and whether and how systems-based approaches were used to inform or guide that work. The goals of the research were to (1) draw on a series of empirical case studies undertaken under the auspices of, or aligned with, the Prevention Centre to explore and understand how research teams address complexity in prevention research; and (2) contribute knowledge about operationalising systems-based approaches in chronic disease prevention research to empirically inform the reflective practice, capacity building, and future planning of researchers and policy partners.

We propose that understanding existing approaches from the common vantage point of a coherent theoretical frame offers a basis to better understand the existing approaches to complexity in prevention research, and empirically advance our efforts in the prevention of chronic disease. Ison and Straw [15] proposed that to address complexity, the right balance must be struck between ‘systemic’ and ‘systematic’ paradigms and approaches. Systemic broadly refers to approaches that explore the bigger picture, with a focus on whole systems comprising dynamic relationships between interconnected parts, while systematic broadly refers to a focus on step-by-step, linear processes, details, and examining selected parts within a system [15]. We draw on the work of Ison and Straw [15] to examine the relationship between systemic and systematic ways of working in the case studies, and present how this was operationalised across different forms of prevention research. We also present an expansion of Ison and Straw’s heuristic to further describe and illustrate the multi-layered interplay that was observed.

2. Materials and Methods

2.1. Research Context and Design

This research was conducted under the auspices of the Australian Prevention Partnership Centre [14] which was established in 2013 to apply systems thinking and systems science to the study of chronic disease prevention [16,17,18,19]. There was also provision to learn from the growing experience of those affiliated with the Centre by conducting a process of empirically derived reflexive learning based on a series of prevention research systems case studies [20]. This research applied a comparative case study design using semi-structured qualitative interviews to explore similarities, differences, and patterns with respect to systemic and systematic approaches across six cases [21]. See

Table 1. Methodological pathway.

Recruitment	Case selection
	Selected a convenience sample of known chronic disease prevention projects that addressed complexity on a range of prevention research topics and study designs.
Data collection	Conducted qualitative semi-structured interviews using two-part interview schedule, plus analysis of case study documents available online
	Interview 1 explored the background, context, and purpose of the work in each case study, while Interview 2 explored further details of working with complexity and the role of systems approaches. Questions informed by Foster-Fishman et al. [22].
Data analysis	Developed codes and categories with analysis combined with deductive and inductive processes
	Open coding analysis in Word using the comments function and memo writing; drew on systems literatures to inform theoretical sensitivity, and inductive methodology informed by grounded theory for empirically derived concepts. Structured framework analysis used to develop higher order categories and their relationships. Data managed in Google sheets. All categories further explored in relation to the core social process of ‘addressing complexity’ as identified in the research question.
	Explored the operationalisation of systems approaches within each case study
	Described elements of systems approaches for addressing complexity within each case study articulated across a range of dimensions. The dimensions were derived from the framework analysis above. These identified explicit uses of systems science, methods, and tools, plus examples of implicit systemic approaches. Analysis explored how these were operationalised. Identified systematic methods embedded in systemic work, and systemic approaches incorporated into systematic work; described how these relationships played out in varying forms and proportions.
	Incorporated the systematic paradigm to represent the whole (Ison and Straw [15])
	Comparative descriptive synthesis conducted for each case study to identify how systemic and systematic aspects were operationalised within the core dimensions. Building on Ison and Straw’s [15] work contrasting systemic and systematic paradigms, further analysis explored their relational properties as a continuum with variable proportions. Key considerations: All case studies had operationalised both systemic and systematic paradigms; The Ison and Straw [15] relational paradigms could be further explored through a number of different dimensions; The relative proportions of these systemic and systematic paradigms varied between case studies, and between the dimensions within the case studies; Some of the dimensions identified as systemic were not explicitly described as such by the participants; Even work that did not explicitly apply systems science or theory was often found to be systemic in how it was conceived and operationalised; The dimension of ‘data and evidence’ was the most consistently difficult to delineate into systemic and systematic dimensions.
Reflexive practice
The core team on this project were LR and MP; LR was also the Co-Director of the Prevention Centre and MP a Senior Research Fellow supported through the Centre at the Australian National University (ANU). Throughout the project, our analysis, interpretations, and writing were also guided by our co-authors in conversations (in person and virtually) and via feedback on working documents and draft manuscripts. We convened bi-monthly Chief Investigator meetings (SA, SF, MJI); and a quarterly Systems Advisory Group (RI, DTF, TR, HR). Our data collection and analysis were also informed through wider reading of the systems literature, but particularly the following: [8,15,22,23,24,25]. The study was conducted in the context of a Prevention Centre project, itself conceived as reflexive practice (i.e., to explore what can be learned from research case studies affiliated with the Centre that seek to address the complexity of chronic disease prevention). We acknowledge that our data and interpretations are partly formed by our research question and study design; our team’s worldviews, assumptions, and beliefs; and the overall goals of the Prevention Centre. We have, however, sought to provide an explicit audit trail to maximise the replicability of our methods, and propose that the concepts and theory emerging from our analysis will likely hold true for many examples of prevention research seeking address complexity.

for an overview of the study stages, processes, and analytical decisions.

Our overarching research question was: how do prevention researchers address complexity in their work? The intention was to produce generalisable lessons from the cases as they pertain to their common goal of chronic disease prevention [26]. Case study research is appropriate when “a how or why question is being asked about a contemporary set of events over which the investigator has little or no control” (p. 9) [27]. Cases are also useful when the implementation of methods or techniques are being explored and events are complex, involving change over time [26].

Ethical clearance for the study was granted from the Australian National University human research ethics committee—ref no. 2019/653.

2.2. Recruitment

2.2.1. Case Selection

A convenience sample was selected of known chronic disease prevention projects actively addressing complexity and covering a range of prevention research topics and study designs. In total, we examined six case studies using qualitative interviews and related materials available online. The case studies comprised three projects and one program of work that had been fully or partly funded through the Prevention Centre, and two other affiliated programs of work (i.e., related prevention research led by chief investigators within the Centre).

2.2.2. Data Collection

Data collection comprised two sets of semi-structured interviews and gathering of online data sources. All study participants were recruited via personalised email invitations with an attached participant information letter and consent form. Interviews were conducted via Zoom video calls or phone and transcribed verbatim by a professional transcription service. The interviews were conducted approximately 4–6 weeks apart and involved 29 interviews with 16 participants. The online data collection pertaining to the case studies included project information on the Prevention Centre and/or other websites, study findings briefs, reports, and peer-reviewed publications. To assist with triangulation, these data were used to complement the interview data and compile a fuller picture of the program of work relating to each case study.

The purpose of the first set of interviews was to sensitise participants to the study, take a deep dive into the background and context of their work, and explore how they approached and conducted their research. These interviews made limited reference to systems language or theory, unless raised by the participants themselves. The second set of interviews delved deeper into how the participants and their team responded to complexity within their project, or program of work, and explored whether and how the case studies applied a systemic lens. The guide for the second interviews was informed by Foster-Fishman et al.’s [22] framework for understanding and changing organisational and community systems. Foster-Fishman et al.’s framework was selected for its theoretical breadth and depth, spanning literature from the organisational change field, systems thinking, and community change, and its previous practical applications to enable a deeper understanding of how complexity was being addressed. The framework was adapted to our context to explore how teams respond to complexity in prevention research [13,22].

2.3. Data Analysis

Data analysis took place in an iterative manner over an 18-month period. A staged series of in-depth analyses were conducted within and across case studies to identify the approaches and explanations of how each project, or program of work, responded to complexity, as per our research question [21]. Both deductive and inductive processes were used throughout; we drew upon our wide reading of systems literatures to inform theoretical sensitivity and used inductive principles to allow for new empirically derived concepts to arise [27]. The core analytical steps are summarised as a methodological pathway (Table 1).

2.3.1. Open Coding and Framework Analysis

Every interview transcript was individually coded by at least two authors (i.e., MP, and LR or MJI) using the comments function in Word, followed by detailed memo writing. Memos were written about each interview, each case (first and second interviews, plus online data), and as reflections across cases. We then conducted a structured framework analysis in Google sheets comprising categories along the vertical and horizontal axes. These were empirically derived as pertinent to the research question of addressing complexity in prevention research. The vertical framework categories were as follows: case study goals, case study narrative, addressing complexity, achieving impact, change making, systems approaches, systems thinking worldview, use of theories, soft systems practices, and systems science methods. Additional vertical categories added during the synthesis process were for our reflections and developing ideas to inform reporting/writing up. The horizontal framework categories pertained to each case and the interview participants within each case. An additional horizontal category for synthesising key learnings from each vertical column was also added. This stage of the analysis was primarily conducted by MP and LR in an iterative series of online dialogues to review, discuss, and generate joint reflections on the empirical data.

2.3.2. Exploring How Systemic Approaches Were Operationalised

To synthesise the findings from the framework analysis in relation to the core social process of addressing complexity, two authors (MP and LR) distilled the key dimensions of each case study into further memos and summary tables. This stage of the analysis also focused on identifying whether, where, and how systems approaches, theories, and methods were used—and how these interacted and aligned with other aspects of the research. The analysis examined instances of systems thinking, methods, and tools that were explicitly reported, as well as our own interpretations of a systems-based approach based on the representations in the data. A brief summary of our own roles and reflexive practice in the context of this research are outlined within Table 1. We described some of the core dimensions of systems-based approaches, including some that were implicit as well as others that were explicit (e.g., systems science and systems methods and tools). There were also core systematic components within the systems-led work (e.g., methodological protocols used within systemic community workshops).

2.3.3. Representing the Whole

We drew on Ison and Straw’s [15] systemic–systematic duality to more explicitly incorporate and explore both the systemic and systematic paradigms to represent the whole. Ison and Straw [15] suggest the two paradigms exist in complement rather than opposition to one another and that one cannot exist without the other [15]. We describe and contrast systemic and systematic approaches, and consider their relative proportions within our case studies and the dimensions (empirically derived from the open coding and framework analysis) within each case study. Systemic and systematic paradigms as identified by the work of Ison and Straw [15] and Swinburn et al. [1] are defined in

Table 2. Systemic and systematic paradigms.

Systemic	Systematic
Exploring the bigger picture; Focus on whole systems composed of interconnected parts; Natural experiments; A non-linear focus; Supporting change and change-agents in leveraging systems; Non-dualistic thinking (embracing the continuum); “What works for what systems in what contexts?”; A focus on strengthening existing systems.	A focus on details; Methodical; Examining the parts within a system; A more linear focus; Duality (black and white, night and day, inhale and exhale, yin and yang, etc.); Randomised controlled trials and cluster randomised controlled trials; “What intervention works?”; A focus on fidelity in program delivery.

.

Overall, our intention was not to evaluate or rate projects on the degree to which they incorporated and adopted a systemic paradigm, but rather to explore how the two paradigms manifested within these case studies, and what we could learn from exploring empirically their various dimensions and interactions.

3. Results

3.1. Addressing Complexity through Systemic and Systematic Paradigms—Case Study Summaries

The Systemic and Systematic Paradigms Took Different Forms and Played out in Different Proportions within the Cases of Prevention Research

Our study found significant diversity in how the systemic and systematic paradigms are embodied and operationalised within and across different types of prevention research, and the case studies illustrate varying combinations of these paradigms within their work. The systematic paradigm was embraced most obviously via controlled study designs and highly methodical means such as randomised controlled trials, systematic reviews, and other strict replicable research processes and an adherence to fidelity. Overall systems thinking and systemic approaches were also valued and sometimes applied through explicit adoption of systems theories, methods, and tools. However, the systemic paradigm was also embraced to address complexity through other means such as governance models, relationship-based process and infrastructure, co-design approaches, a focus on systems change, and the ‘soft systems’ approaches embodied in the way that people work. Significantly, these systemic dimensions were identifiable even when the use of systems approaches was not explicitly reported by the study participants.

We present below a brief summary of each case study, with the key manifestations of both the systemic and systematic paradigms observed within that work, e.g., problem framing, ways of working, or adoption of methods and tools. Also provided are tables with further illustrative details.

Table 3. Case study descriptions.

Case Study 1—The Healthy and Equitable Eating (HE2) Study Case Study
Data	Two interviewees, two interviews each
Study link	https://preventioncentre.org.au/our-work/research-projects/healthy-public-policy-to-support-healthy-and-equitable-eating/ (accessed on 26 April 2023).
Focus	Structural/policy level
Project	Discrete project
Academic/Policy/Practice	Academic-led with policy focus genesis, academic-led and policy research implementation
The study: what happened?	The team explored what is required to create a healthy and equitable system of eating in Australia. A key piece of work was a causal loop diagram developed as a collaborative effort between academics and policy makers, and depicting the drivers of inequities in healthy-eating-spanning domains—including housing and the built environment, health literacy, transport, employment, food supply and environment, food taste preferences, and social protection. A systems-based policy framework was also developed suggesting plausible policy actions that could be implemented across each of the domains. An additional piece of work used an existing Australian policy case study to explore the potential value of public policy attention given to inequities in obesity.
Rationale	When working to address the complex problem that is addressing inequities in healthy eating, a typical response has been to oversimplify both the problem and the solution instead of paying attention to the multiple interacting variables affecting the consumption of a healthy diet across social groups. Evidence was required to guide coherent policy development and implementation spanning a broad range of policy areas which affect nutrition-related inequities.
Outcome	An evidence base was produced showing what can be done to improve healthy and equitable eating (HE2) in Australia via federal and state cross-government policies and programs.
Case study 2—Food environment policy index (Food-EPI) study case study
Data	Four interviewees, two interviews with two participants and one paired interview where only one interview was conducted
Study link	https://preventioncentre.org.au/our-work/research-projects/benchmarking-obesity-policies-in-australia/ (accessed on 26 April 2023).
Focus	Structural/policy level
Project	Program of work
Academic/Policy/Practice	Academic-led with policy focus genesis, academic-led and policy research implementation, for public policy advocacy
The study: what happened?	The Healthy Food Environment Policy Index (Food-EPI) was developed by INFORMAS (International Network for Food and Obesity/NCDs Research, Monitoring and Action Support) to assess government policy across 14 areas for action in relation to food environments. This approach was replicated and applied in this Australian case study in which diet-related aspects of obesity prevention policies at state, territory, and federal level were assessed and compared to international best practice. There was extensive engagement between researchers and policy makers, including in the extensive process of collating government policy data, verifying it, and reviewing and prioritising recommendations. Government also had input into the way in which results were presented as part of final reports. An important goal of the project was to increase accountability of governments around obesity prevention. The ratings were conducted in workshops engaging all of the participating policy agencies.
Rationale	While it is recognised that in order to address obesity a comprehensive approach is required, the development and implementation of recommended policies has not moved quickly within Australia and elsewhere. Australia’s performance when it comes to obesity prevention had not been systematically benchmarked and monitored. The study design was also informed by former successful campaigns establishing competition and accountability, i.e., the Dirty Ashtray and Couch Potato Awards benchmarking the States and Territories against best practice and each other.
Outcome	An assessment was made as to the degree to which policies in Australian met best practice for creating healthy food environments and priority areas for action to improve food environments were identified. The findings were published in and published in public reports.
Case study 3—NSW childhood obesity modelling project addressing complexity
Data	Five interviewees, two interviews each
Study link	https://preventioncentre.org.au/wp-content/uploads/2017/03/1702_FB_ATKINSON_PremObesity.pdf (accessed on 26 April 2023).
Focus	Structural/policy level
Project	Discrete project, but it has produced spin-off projects
Academic/Policy/Practice	Primarily policy-led genesis, academic-led and policy research implementation, for local policy decision making
The study: what happened?	In NSW, as part of the Premier’s Priorities, the Ministry of Health approached the Prevention Centre to test how different interventions and combinations of interventions could help achieve a 5% reduction in child overweight and obesity over a 10-year period. A dynamic simulation model was used to provide insights into what combination of interventions would be required to meet the target.
Rationale	When it comes to addressing overweight and obesity in Australian children, population-level interventions that create sustained change have been lacking. The impact of these interventions being implemented simultaneously has also been unclear.
Outcome	A participatory approach was employed to build and test the model. This engaged multiple stakeholders central to decision making in relation to addressing overnight and obesity in NSW children. The combination of interventions required to meet the target included actions to improve the built environment, food policy interventions, school and childcare interventions, and clinical service delivery.
Case study 4—Hunter New England region program of work addressing complexity
Data	Three interviewees, two interviews each
Study link	https://preventioncentre.org.au/blog/youve-heard-of-clinician-scientists-were-applying-the-same-model-to-public-health/ (accessed on 26 April 2023).
Timeframe	Ongoing
Focus	Structural/policy/community level
Project	Program of work
Academic/Policy/Practice	Practice-based genesis, practice-led and academic research implementation, for quality improvement of service delivery
The study: what happened?	This case relates to the research–practice partnership set up between Hunter New England Population Health (a population health service delivery unit in Australia) and the University of Newcastle and was included as a case study of an embedded model for prevention and health services research. A single-integrated governance structure means that researchers are embedded within the health service delivery unit. Senior leadership roles are filled by staff holding appointments at both the health service and university.
Rationale	Health research is much more likely to be used if the research questions are derived from the proximal service delivery needs of the end users.
Outcome	Research and service delivery work is co-conceived, co-designed, co-evaluated, and co-disseminated by both practitioners and researchers. This optimises research co-production via greater knowledge exchange and alignment of research with the needs of the health service. Thus, research and evaluation findings are readily available to end users. Both academic and health service resources are simultaneously leveraged to meet scientific and service delivery goals.
Case study 5—Liveability program of work addressing complexity
Data	Two interviewees, two interviews each
Study links	https://preventioncentre.org.au/our-work/research-projects/creating-liveable-and-healthy-communities/ (accessed on 24 June 2023). https://preventioncentre.org.au/our-work/research-projects/developing-the-tools-to-map-and-measure-urban-liveability-across-australia/ (accessed on 26 April 2023). https://preventioncentre.org.au/our-work/research-projects/benchmarking-monitoring-modelling-and-valuing-the-healthy-liveable-city/ (accessed on 26 April 2023).
Focus	Structural/policy level
Project	Program of work
Academic/Policy/Practice	Academic-led with policy focus genesis, academic and policy-led research implementation, for public policy decision making and system change
The study: what happened?	A range of policies related to the liveability domains have been validated to provide evidence for how they contribute to chronic disease risk factors. These have also been benchmarked and are being monitored to track the progress of communities towards healthier and more equitable living. Furthermore, agent-based modelling is being used to explore the efficacy and economic benefits of possible interventions relating to the indicators to improve walking, cycling, and public and private transport usage.
Rationale	Eleven domains of liveability have been identified by Billie Giles-Corti’s research team relating to the social determinants of health. Neighbourhoods have huge impacts on many aspects of health and wellbeing.
Outcome	The liveability indicators are being used by a range of stakeholders to inform the creation of healthier built environments.
Case study 6—Community-based childhood obesity strategies case study addressing complexity
Data	One interviewee, two interviews
Study link	https://iht.deakin.edu.au/global-centre-for-preventive-health-and-nutrition/stream/community-collaboration/ (accessed on 26 April 2023).
Focus	Community level
Project	Discrete projects across many communities as part of broad program of work
Academic/Policy/Practice	Academic-led with community focus genesis, community-led and academic research implementation, for local community action
The study: what happened?	Informed by system dynamics theory, communities are empowered to create informal maps as well as contribute to formal simulation models to understand, address, and communicate dynamic complexity. Systems science methods including Agent Based modelling, System Dynamics, Social Network Analysis and Causal Loop Diagrams are used in this program of work spanning numerous and diverse communities in Australia and internationally.
Rationale	Successful population-level interventions for addressing child obesity and other non-communicable diseases require a shared understanding of the systemic drivers of these problems and an understanding of how to strengthen existing systems to promote good health and reduce disease burden. The ability of communities to apply systems thinking is crucial to the success of such interventions.
Outcome	Capacity is built within communities and communities are empowered to solve their problems as a collective and engage in sustainable change.

describes what each case entailed as a piece of research. Appendix A is a more detailed summary of how each case addressed complexity overall (the overview), and delineation of how systemic and systematic approaches were operationalised within eight dimensions, i.e., Theory, Methods, Data and Evidence, Relationships, Capacity Building, Learning Orientation, Multi-perspectivity, and Knowledge Mobilisation/Translation. Note: it was not logical to delineate the two paradigms for the dimension of ‘Data and Evidence’ and so the columns are combined.

Summary of systemic and systematic dimensions in case study 1: Healthy and equitable eating (HE2) project

This case study examined a project [28] focused on expanding the conceptualisation and understanding, including among prevention researchers and policy partners, of the system-wide drivers of healthy and equitable eating (Table 3). How the systemic paradigm was operationalised in this work included a participatory systems-based methodology (collaborative conceptual modelling [29]) used to develop a comprehensive causal loop diagram of the Australian food system [10]. This systems diagram was co-produced through a series of collaborative workshops of researchers and health sector-based policy and program partners. There was an explicit goal to develop shared understanding and language to support future collaboration on addressing the leverage points within the system. The systematic, process-driven qualities within the work included the strict adherence to a structured methodology for developing the CLD. The project also included a discrete qualitative evaluation conducted through semi-structured interviews (Appendix A).

The way the systemic paradigm was operationalised in this work included the focus on food environments (rather than dietary behaviours) and an analysis of state and federal government policy systems (comprising food composition, food labelling, food promotion, food provision, food prices, food retail, leadership, governance, monitoring and intelligence, funding and resources, and support for communities) (Appendix A). There was also an emphasis on both internal and external capacity building and reflexive learning. The investigators also prioritised establishing and maintaining trusting relationships with government officials/policy participants. The highly systematic qualities in this work included the focus on fidelity to the rigorous and clearly prescribed methodology, with strict policy rating criteria, an emphasis on the independence of the researchers and the reporting of findings, and reference to competitive benchmarking as part of the strategy to effect change (note this strategy also had an explicit focus on knowledge development and enhancing collaboration which reflected more systemic work).

Summary of systemic and systematic dimensions in case study 2: Food environment policy index (Food-EPI) project

This case study examined a project [30] that replicated an existing methodology developed by INFORMAS (International Network for Food and Obesity/NCDs Research, Monitoring and Action Support) in the Australian context to assess government policies related to the food environment (Table 3). How the systemic paradigm was operationalised in this work included the focus on food environments (rather than dietary behaviours) and an analysis of state and federal government policy systems (comprising food composition, food labelling, food promotion, food provision, food prices, food retail, leadership, governance, monitoring and intelligence, funding and resources, and support for communities) (Appendix A). There was also an emphasis on both internal and external capacity building and reflexive learning. The investigators also prioritised establishing and maintaining trusting relationships with government officials/policy participants. The highly systematic qualities in this work included the focus on fidelity to the rigorous and clearly prescribed methodology, with strict policy rating criteria, an emphasis on the independence of the researchers and the reporting of findings, and reference to competitive benchmarking as part of the strategy to effect change (note this strategy also had an explicit focus on knowledge development and enhancing collaboration which reflected more systemic work).

Summary of systemic and systematic dimensions in case study 3: State-level childhood obesity prevention modelling project

This case study examined a policy-driven dynamic simulation modelling project [31] that was used to forecast what combination of interventions would be required to achieve a state-level target of a 5% reduction in child overweight and obesity over a specified time period (Table 3). The systemic paradigm was operationalised in this work through a whole-of-system, state-wide focus; how the research was policy-led and embedded within the government system that it sought to inform; and system dynamic theory, methods, and tools were explicitly applied to interact with the end-users and develop the model (Appendix A). For example, these included participatory group model building (qualitative) with clinical, program, and policy partners; dynamic simulation modelling (quantitative); and the development of an interactive interface to support engagement and knowledge mobilisation. The relational aspects of the work were emphasised throughout, prioritising deliberative methods that incorporated multiple perspectives, empowerment and capacity building, and priority research questions arising from real-world policy decisions. The systematic aspects of the work included the rigorous synthesis, appraisal, and incorporation of systematic reviews; international and local data and other forms of evidence; and validation of the model outputs against historical data.

Summary of systemic and systematic dimensions in case study 4: Embedding prevention research within health services—program of work

This case study examined an embedded model of health services led prevention research through a long-term partnership between the Local Health District’s (LHD) population health service and the local University [32]—a partnership built over several decades (Table 3). The systemic paradigm is reflected in this work through its organisational structures, governance and relational aspects, and prioritising research to inform systems change (Appendix A). All of these aspects support an integrated program of work comprising research, research translation and program implementation across the population health service, and the wider LHD prevention system. Research questions are regularly derived from the program delivery needs of the LHD and/or its affiliated government, non-government, and community partners. Other systemic qualities were the focus on understanding and changing the prevention system, and capacity building and quality improvement across that system. There were also strong systematic dimensions to this case study, including the methodological focus on evidence-based practice, intervention effectiveness and routine use of randomised controlled trials (RCTs), and other epidemiological and qualitative study designs and methods.

Summary of systemic and systematic dimensions in case study 5: Liveability—program of work

This case study examined a program of work [33] that focused on developing and evaluating a series of indicators to measure the liveability of neighbourhoods and the association between these indicators and health outcomes (see Table 3). The operationalisation of the systemic paradigm in this work included examining the interacting dimensions of liveability within the system of a local neighbourhood (or city) that combine and impact on health (Appendix A). Research-policy relationships have been key to framing the research, and it is underpinned by the long-term partnerships between the lead investigators and their urban planning policy partners. The embedded relationships between prevention researchers and policy partners outside the health sector are relatively novel—they focus on the co-benefits of health and planning—and have been strategically developed to ensure relevance to those most able to influence systemic changes within the system being studied. The systematic, detail-driven dimensions in this case study include the focus on fidelity, generating replicable indicators for benchmarking and monitoring liveability, and statistical modelling.

Summary of systemic and systematic dimensions in case study 6: Community-based childhood obesity prevention—program of work

This case study examined a growing body of work [34] that applies systems science theories and methods to develop, implement, and study childhood obesity prevention initiatives in partnership with communities and/or governments at local, regional, and state-levels (Table 3). The explicitly systemic aspects of this work include the application of system dynamics theory to conceptualise, understand, and address complex problems, and implementing co-designed solutions focused on creating sustainable systems change (Appendix A). The community-based interventions seek to communicate complexity in digestible forms and empower local agents for change. The STICKE software platform used for group model building [35] and to support communities to develop their own causal loop diagrams (CLDs) is widely available through a low-cost licence. Other research methods employed throughout include an integrated network of local, national, and international projects include social network analysis, agent-based modelling, and dynamic simulation modelling. The systematic dimensions of the work include the CLD group model building workshops; these follow clearly defined guidelines, with strict rules about governance mechanisms, group process, as well as precise scripts to guide facilitation. The projects also routinely employ RCTs to evaluate intervention effectiveness.

3.2. Expanding the Boundary: Comparing the Relative Proportions of Systemic and Systematic Paradigms

The Balance between the Systemic and Systematic Paradigms Appears to Vary When One Considers a Case as a Whole, When Examining the Individual Dimensions within That Work, and When Comparing across Case Studies

As outlined above and in Appendix A, there was variability in the relative proportions of systemic and systematic paradigms within and across the different case studies and their dimensions. For example, both the obesity modelling project (#3) and the community-based childhood obesity program (#6) may be holistically described as highly systemic due to the explicit use of systems science theory and methods. However, each case study also demonstrated a core dimension of more systematic, process-driven, and detail-focused public health research methodologies, including the principles of evidence-based practice, a highly systematic collection and synthesis of evidence reviews and other data, and using an RCT design to demonstrate intervention effectiveness.

Conversely, when considering the food policy environment project (#2) or the prevention in health services program (#4), both could be described as highly systematic in their use of underpinning theories, research designs, and data collection methods. Yet such a categorisation alone would not be a true reflection of the overall program of work as there are other dimensions that are also clearly systemic, including a focus on systems change, multi-perspectivity, systems leadership, and their approaches to capacity building. To understand how systemic and systematic dimensions manifested within a case study, it was necessary to explore each of its composite dimensions.

A key finding from this research is the importance of avoiding surface-level judgements about the paradigms operating within different types of prevention research projects and programs of work. For example, within the health services case study #4, the methods were viewed as primarily systematic while their knowledge mobilisation efforts were primarily systemic in nature. Other dimensions were a combination of systemic and systematic aspects such as the use of theory dimension. Furthermore, within the methods dimension of the community-based childhood obesity strategies (#6), both systemic and systematic tools were utilised, i.e., a systems science method stemming from Hovmand [25] was used to understand and mobilise community systems change, while systematic RCTs were used to evaluate intervention effectiveness. Collectively, the distribution across each dimension determined the overall balance of systemic–systematic dimensions making up the case as a whole. Therefore, unless we expand our boundaries, most notably beyond theory and methods, we may not notice if we are making surface-level judgements and we may not notice the true degree to which something is systemic or systematic. Thus, by expanding the boundary, our perception of each case study will change.

Adoption of systemic vs. systematic approaches, and their relative balance, were influenced by many variables. Reported factors underpinning enhanced systemic dimensions (explicit or implicit) included at least one (or more) of the following: strong orientation towards achieving real-world impact and creating systems change; professional training and personal belief in the value of systems thinking and systems science; sociological, structural orientations to public health; or inherent valuing of relational and other soft systems practices. Meanwhile, factors enhancing the systematic paradigm included methodological training, and/or expectations and requirements of funding bodies; requirements to articulate strict study timeframes and milestones; and siloed structures, expectations, or hierarchies within health and other partnering organisations. Furthermore, some discomfort with overt use of systems science methods and/or terminology was also reported by some, although this had diminished over time as it mainly related to initial unfamiliarity with methods or theories.

3.3. The Continuum: Changing the Relative Proportions of Systemic and Systematic Paradigms in Prevention Research

3.3.1. The Proportional Interplay between the Systemic and Systematic Paradigms Is not Fixed, and Variations Can Be Described along on a Continuum (see Figure 1)

Our analysis led us to conclude that the interplay between the systemic and systematic qualities coded in the data was most appropriately described as manifesting at points along a continuum (Figure 1) rather than as distinct categories. For example, there was much variability along the continuum of whether and how participants self-identified with a systems thinking worldview and practice, i.e., ranging from extensive to partial applications of systems theory, systems science, and systems methods. There were also degrees of systemic approaches embedded within knowledge mobilisation from dissemination of descriptive analyses to more interventionist framing oriented to creating system change. All of the case study dimensions had dynamic qualities that may evolve over time.

Figure 1. Continuum representing different degrees of emphasis between systemic and systematic paradigms [15].

Figure 1. Continuum representing different degrees of emphasis between systemic and systematic paradigms [15].

We anticipate that most prevention research projects and programs of work are inherently dynamic and thus will evolve over time based on contextual factors such as funding, team members, skillsets, and learning opportunities. Notably, the relative balance between systemic–systematic dimensions of the case studies is an analytical interpretation of the data, not directly reported by the study participants. Further, the perception of a dynamic interplay between systemic and systematic paradigms along a continuum, and analytical placement of a case study along that continuum, is dependent on what dimensions are taken into account. The movement along the continuum may occur through boundary expansion (or contraction) in terms of which dimensions are (or not) taken into account. We propose that all prevention research is likely to change over time in terms of the relative distribution of systemic and systematic dimensions.

3.3.2. The Concept of a (Dynamic) Continuum of Systemic–Systematic Paradigms in Prevention Research Can Be Conceived as a Repeating Pattern Occurring on Different Scales (i.e., the Case as a Whole and within Cases Explored along Different Dimensions) (Figure 1 and Figure 2)

To visually represent these findings as a heuristic tool, we commissioned an artist to adapt and expand the original diagram from Ison and Straw [15]. Our goal was to illustrate how the differing proportional distributions between the systemic and systematic paradigms can be represented along a spectrum (Figure 1). Thus, Figure 1 depicts a graphic illustration of the following points:

• The relative proportions of systemic and systematic dimensions play out along a continuum of variable proportions.
• There is potential for movement (up and down via the ladder) between the systemic and systematic dimensions, which results in movement (left to right) along the sliding scale of the continuum. Of note, however, is that position along the continuum can be supported or constrained by contextual factors and what dimensions are included in the assessment.
• The detailed images on the two levels illustrate the descriptive characteristics of the two paradigms (as articulated in the methods Table 1); they do not have deeper meanings other than for illustration.

Figure 2, a hypothetical case study of prevention research, depicts the increasing boundary scope moving from looking at the case as a whole to looking at the case in terms of its component dimensions. Looking at Figure 2, we can see that if we judge a case by its theory and methods alone then we will see it as more systematic in nature. However, if we bring in the additional dimensions, we can see that it is overall more systemic. By widening our perspective of each prevention research case, we can deepen our understanding of the range of systemic and systematic dimensions comprising the work.

Figure 2. Example of research responses to complexity as a repeating pattern and the importance of boundary scope for ascertaining systemic and systematic paradigms.

Figure 2. Example of research responses to complexity as a repeating pattern and the importance of boundary scope for ascertaining systemic and systematic paradigms.

4. Discussion

In this paper, we present findings from a series of prevention research case studies that offer insights into how the study of complex problems may be operationalised through a duality of systemic and systematic paradigms. We highlight the diversity of how prevention research embodies both systemic and systematic ways of working; describe how that duality is enacted along a continuum; and how it plays out across different dimensions, i.e., Theory, Methods, Relationships, Capacity Building, Learning Orientation, Multi-perspectivity, and Knowledge Mobilisation/Translation. We note that one category for which it is difficult to distil and articulate these relationships is ‘Data and Evidence’, and surmise that this is because these are primarily determined by the purpose for what it was collected and how it was to be used. We illustrate the many ways that systems approaches are embedded in prevention research and identify how a systemic lens is both explicitly and implicitly employed. Finally, we propose a coherent theoretical frame (Figure 1 and Figure 2) to inform conversations about the nature and value of understanding both systemic and systematic paradigms in prevention research. To operationalise systems-based approaches in chronic disease prevention research, it is important for researchers to be able to describe how they are working to address complexity and be explicit about where their work sits along the dynamic continuum of the relative proportions of systemic and systematic paradigms.

Traditionally in public health research, the systematic paradigm has predominated, with limited attention paid to enhancing and operationalising the systemic paradigm—including in health care and public health research [15,26]. Typically, systems-based approaches have been adopted implicitly without clear reference to their systemic nature [36]. Strengthening systemic approaches in prevention research will also enhance the broader public health goals of enabling and supporting systems change [4,20]. This has implications for addressing chronic disease yet, as several authors on this paper have previously proposed, when research teams seek to incorporate systemic dimensions into their work, they often experience constraints such as restrictive funding arrangements and unsupportive contextual factors including a lack of management support [15,37,38].

Further, previous empirical studies of systems thinking in public health have commonly assessed and rated intervention research to determine how much, and/or how well, it had applied the systems theories and methods of complexity science, e.g., [39]. Some have further explored the relationship between such normative ratings of a systems-based approach and intervention effectiveness, e.g., [8]. We recognise the importance of such work for generating evidence of the value-add of a systemic lens. While also drawing on existing systems frameworks, our study adopted a notably different and more inductive and exploratory approach. Thus, rather than apply a normative stance, we sought to explore how prevention research addressed complexity—and if a systemic lens was applied, where and how this occurred—irrespective of an explicit use of systems theory, methods, and language. We propose that this theoretically sensitive and grounded theory approach enabled us to observe and elaborate upon a broad range of systemic dimensions of prevention research, as outlined in the results and Tables. Jebb and colleagues [37] conceptualise systems-based approaches as existing on a continuum that moves from a low-to-high consideration of complex systems principles. As the consideration of complex systems principles increases, so does the application of systems thinking. We extend this work by adding in the systematic paradigm to the systemic (systems-based approaches) and demonstrate how the two paradigms exist as a duality.

We found a relatively even balance between the systemic and systematic paradigms in the case studies examined, but with substantial variability across different dimensions. This balance may partly reflect the fact that the work was conducted under the auspice of the Prevention Centre, with its explicit focus on capacity building in systems approaches, or by affiliated researchers who purposefully apply systems science to inform their work. Other examples of prevention research may look quite different, and on the surface appear more systematic than systemic in its approach. As demonstrated in this study, however, such work may also reflect implicit systemic approaches across multiple domains.

Our study also suggests that if prevention research is examined primarily on its theories and methods, then unless these are explicitly derived from systems science the work may be judged as systemically deficient or lacking. However, different forms of prevention research embodies both systemic and systematic paradigms across a number of other important dimensions. Thus, rating projects, programs of work, or researchers on the degree to which they do, or do not, use systems methods may be counterproductive if there is an assumption that there is a ‘correct’ balance. By elaborating on the duality proposed by Ison and Straw [15], and by describing how that is operationalised in prevention research along a continuum across many dimensions and as a whole, our results broaden and deepen understanding of the range of options in how prevention research does, and can, address complexity through a systemic lens. We propose that as long as it is fit-for-purpose, prevention research may legitimately sit anywhere along the systemic–systematic continuum and still be ‘right’. Further research is however required to assess the practical application of this work as well as the roles and impact of the interplay between systemic and systematic dimensions within prevention research. By exploring intervention effectiveness, researchers may also build the empirical evidence base required to support or challenge the need for a balanced approach. Future research may identify new important dimensions and assess the relative proportions of the systemic and systematic approaches, both overall and within their dimensions, and understand the impact of any interplay between those approaches. Our heuristic is important for ensuring the boundary is broad enough to capture all of the systemic and systematic dimensions, or as many as possible, especially when quantifying or rating prevention research case studies.

It is our intention that application of this tool should enable teams to consider and explore prevention research along our proposed continuum. This may be conducted both for a case or program of work overall and also as a more detailed, and potentially cumulative assessment, within each of the related dimensions. That is, Figure 1 is to be applied to explore a repeating pattern that is self-similar across different scales, and thus may be conceived as ‘fractal’ [40]; a simple example of an object in nature with fractal features is a fern whereby the same shape is repeated in its leaves (including the veins inside each leaf), fronds, and branches. Figure 2 presents a visual example of the fractal concept as applied to a hypothetical case study of prevention research. The heuristic can also be used as a synthesis tool whereby multiple systemic and systematic dimensions are considered at once, analysed, and then synthesised as a collective ‘whole’ case study.

In using our heuristic, we propose that researchers will be better able to:

• Gain a deeper understanding of the paradigm from which they predominantly work;
• Describe how they are working both systemically and systematically and to what extent (this is important for articulating given our field has called for more systemic approaches to addressing complex problems (see [2]);
• Produce better evidence about the value of systemic and systematic dimensions through the expansion of the boundaries within which these dimensions exist;
• Identify opportunities for how to become more systemic in their practice, especially if this paradigm is lacking beyond the application of systemic theories and methods.

Thus, a key aspect of addressing complexity is the capacity to practice being conscious of the paradigms that are guiding your research efforts and what these paradigms bring to the research. While there are many tools to help research to be systematic and appraisal tools to assess rigour and quality based on systematic principles (e.g., the CONSORT checklist for randomised trials or the PRISMA checklist for systematic reviews), there are fewer tools for guiding the application of a systemic approach within prevention research. Some exceptions include the Prevention Systems Change Framework [20] and a systems thinking mindset guide for enhancing knowledge mobilisation in prevention research [41]. Other examples include the Intervention Level Framework [24] and the iceberg model [42].

Our conclusion derived from the empirical literature and these case studies is that prevention research does address complexity using both systemic and systematic dimensions, and the manifestation of these proportions are themselves highly dependent on individual, contextual, structural, and systemic factors. We propose therefore, that there is inherent value in researchers being explicitly ‘bilingual’ in both systemic and systematic ways of thinking and terminology in order to ensure that the relative value and strengths of these paradigms may be utilised. Our overall goal is to support and inform conversations about where and how prevention research could and should manifest the systemic–systematic duality across different dimensions. We also propose that that the balance between these paradigms may be modified through reflexivity. Explicit reviews of prevention research, utilising the key summary points in our findings and employing Figure 1 and Figure 2 will help to ensure that the systemic–systematic duality of a study or program of research is purposeful relative to the goals, priorities, and context of that work.

In summary, we endorse the importance and value of systemic and systematic theories, methods, and tools in addressing complexity in prevention research. Our goal is to support more explicit reflexive practice to ensure that choices about the adoption of systemic and systematic paradigms are consciously made and clearly described, and so that the nature and balance of the adopted duality is well-informed, transparent, and truly fit for purpose.