Whole systems approaches: what's the evidence in public health?
The concept of a whole systems approach has seen a dramatic rise in popularity in recent years. Five years ago, you would have struggled to find this terminology, yet today its use seems ubiquitous. Defined as a 'strategic integrated approach to planning and delivering services', a quick internet search demonstrates examples in patient safety, acute kidney injury, public financial management, active lifestyles, youth justice, asthma management, homelessness, dementia care and poverty, to name but a few.
But what is the evidence from the scientific literature to support this approach to tackle obesity and other public health issues, and how can they be implemented in practice? This was the question we set out to answer in a recently published review, commissioned by Public Health England (PHE) as part of the Whole Systems Obesity programme.
What we did
Seven electronic databases were searched from 1995 to 2018 for studies where there had been an effort to implement a whole systems approach, defined as those that:
- considered, in concert, the multifactorial drivers of overweight and obesity;
- involved transformative co-ordinated action (including policies, strategies, practices) across a broad range of disciplines and stakeholders;
- operated across all levels of governance, including the local level;
- identified and targeted opportunities throughout the life course.
What we found
From an initial 9,777 records screened at title and abstract stage, 860 were retrieved in full and a total of 65 included in the review (33 about obesity). In general, we found that where programmes demonstrated features of whole systems working, there was evidence of a positive impact on a variety of outcomes, including health behaviours, body mass index and nutrition and physical activity environments. Process evaluations also demonstrated that ownership and commitment, strong relationships between stakeholders, and allowing sufficient time to build relationships, trust and community capacity are all key to building a successful whole systems approach.
However, programmes tended to focus on strong community engagement and partnership working rather than a comprehensive systems approach involving the whole local system. There was limited evidence of systems science or systems practice embedded in included studies. Few programmes explicitly recognised the public health issue in question as a being part of a wider system, meaning they rarely approached implementation from a perspective encapsulating a systems approach.
Why it was important to undertake the review
Learning from the systematic review, in conjunction with broader systems science literature and national and international practice, helped build the foundations of the Whole Systems Obesity programme. It informed the programme’s co-production work with pilot local authorities to develop resources to support local areas with the process of implementing a whole systems approach to tackling obesity.
The Whole Systems Obesity programme is directly addressing some of the specific recommendations of the review through developing a workable definition of a local whole systems approach that is relevant to obesity and developing a practical guidance on how to implement a whole systems approach at a local level.
Duncan Radley, Margie Van Dijk, Ellen Lithgow, Anne-Marie Bagnall
Pinki Sahota is a former Professor of Nutrition and Childhood Obesity at Leeds Beckett and a Core Member of the Institute for Health and Wellbeing. Her expertise and research interests include the development, implementation and evaluation of interventions addressing nutrition.
Anne-Marie Bagnall is Professor of Health & Wellbeing Evidence and Director of the Centre for Health Promotion Research at Leeds Beckett University. Her research aims to improve people's health and wellbeing and reduce health inequalities.