The Public Health 12 framework: interpreting the ‘Meadows 12 places to act in a system’ for use in public health

Abstract

Background Systems science approaches have demonstrated effectiveness in identifying underlying drivers of complex problems and facilitating the emergence of potential interventions that are locally tailored, feasible, sustainable and evidence informed. Despite the potential usefulness of system dynamics simulation modelling and other systems science modelling techniques in guiding implementation, time and cost constraints have limited its ability to provide strong guidance on how to implement complex interventions in communities. Guidance is required to ensure systems interventions lead to impactful systems solutions, implemented utilising strategies from the intersecting fields of systems science and implementation science. To provide cost-effective guidance on how and where to implement in systems, we offer a translation of the ‘Meadows 12 places to act in a system’ (Meadows 12) into language useful for public health. Methods This translation of Meadows 12 was informed by our experience in working with 31 communities across two complex large scale randomised control trials and one large whole of community case study. These research projects utilised systems science and implementation science to co-create childhood obesity prevention interventions. The team undertaking this translation comprised research academics, implementation specialists and practitioners, practice-based researchers and a systems dynamicist. Our translation of each of the Meadows 12 levels to act in the system maintains the fidelity and nuance of the 12 distinct levels. We provide examples of each level of the Public Health 12 framework (PH12) drawn from 31 communities. All research was conducted in Victoria, Australia between 2016 and 2020. Results PH12 provides a framework to guide both research and practice in real world contexts to implement targeted system level interventions. PH12 can be used with existing implementation science theory to identify relevant strategies for implementation of these interventions to impact the system at each of the leverage points. Conclusion To date little guidance for public health practitioners and researchers exists regarding how to implement systems change in community-led public health interventions. PH12 enables operationalisation Meadows 12 systems theory into public health interventions. PH12 can help research and practice determine where leverage can be applied in the system to optimise public health systems level interventions and identify gaps in existing efforts. Trial registration WHO STOPS: ANZCTR: 12616000980437. RESPOND: ANZCTR: 12618001986268p.

COVID‐19: A systems perspective on opportunities for better health outcomes

“…To test my analysis, I discussed it with the broader project’s research team, all of whom who were familiar with the data. Themes were then considered against Meadows’ ( 1999 ) idea that there are places to intervene in a system, which Bolton et al ( 2022 ) have tailored for use in public health.…”

“…Understanding a system’s behaviour by consciously using systems thinking and perspectives can help actors identify leverage points to shift the system and produce sought‐for outcomes (Bolton et al, 2022 ). However, distinct leverage points have different levels of effectiveness.…”

Systems science approaches to cardiovascular disease prevention and management in the era of COVID-19: A Humpty-Dumpty dilemma?

“…The argument to prioritize prevention (i.e., proactive approach) over management (i.e., reactionary approach) may be framed as a “Humpty-Dumpty” dilemma since failure to prevent will have catastrophic consequences due to the disease-related burdens as well as the proportions of the populations affected. 35 , 36 Sustaining cardiovascular population health under complex post-pandemic conditions will necessitate decision-making to be informed with a systems science approach, in which interventions, goals, outcomes and features of complex systems are carefully aligned.…”

“… 39 , 40 More recently, a specific translation of the Meadows framework was created for public health: the Public Health 12 Framework. 35 4 Apply data and iteratively develop, refine, or improve upon initial, more simplified versions. 5 Do not limit simulations to a single model.…”

Mapping and analysis of laws influencing built environments for walking and cycling in Australia

“…Understanding the legal environment is an important component of understanding the existing system for PA, why it may not be generating the desired outcomes for PA, and potential opportunities for improvement. In order to achieve maximum system impact, the ‘rules’ of the system (which includes laws), must be addressed as one of the levers for systems change [ 43 ]. Legislative objectives provide a powerful signal about what issues should be prioritised and considered by decision makers, thus playing a role in shifting the ‘goals’ of a system, a key leverage point for systems impact [ 36 ].…”