Case Study 2
Using the Child Health System Map as a teaching aid

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Target audiences

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The following guidance is based on teaching students at postgraduate level on public health courses in England. Use of the maps in teaching could be supported through a focus on the following topics.

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Introduction to systems thinking

Adapted from Jessiman P, Powell K, Williams P, Fairbrother H, Crowder M, Williams J & Kipping R (2021) A systems map of the determinants of child health inequalities in England at the local level. PLoS ONE, 16(2).

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The following points are important when understanding the relevance of systems thinking to current public health practice in the UK.

• Systems thinking has become a popular approach to addressing complex public health issues.

• In systems thinking, poor health and health inequalities are seen as outcomes of many elements that interdependent and can be seen as connected in a system [1].

• Systems thinking encourages people to look at how different actors (individuals, populations, or organisations) relate to each another and how activities in one part of a system may affect another.

• Applying a systems lens to thinking about public health challenges can support the evaluation of policy and programmes, and the development of interventions which recognise wider system influences [2-4].

• In public health practice, systems thinking has been applied to consider the range of stakeholders, including partners outside traditional health sectors that affect an issue  [5]. 

Suggested reading:

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1. Rutter H, Savona N, Glonti K, Bibby J, Cummins S, Finegood DT, et al. The need for a complex systems model of evidence for public health. Lancet. 2017;390(10112):2602–4. pmid:28622953

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2. Public Health England. Whole systems approach to obesity: A guide to support local approaches to promoting a healthy weight. 2019. [Cited 2020 June 19]. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/820783/Whole_systems_approach_to_obesity_guide.pdf.

3. Egan M, McGill E, Penney T, Anderson de Cuevas R, Er V, Orton L, et al. NIHR SPHR Guidance on Systems Approaches to Local Public Health Evaluation. Part 1: Introducing systems thinking. 2019. [Cited 2020 June 19]. https://sphr.nihr.ac.uk/wp-content/uploads/2018/08/NIHR-SPHR-SYSTEM-GUIDANCE-PART-1-FINAL_SBnavy.pdf.

4. Allender S, Brown AD, Bolton KA, Fraser P, Lowe J, Hovmand P. Translating systems thinking into practice for community action on childhood obesity. Obes Rev. 2019;20 Suppl 2(Suppl 2):179–84. pmid:31359617

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5. Bagnall AM, Radley D, Jones R, Gately P, Nobles J, Van Dijk M, et al. Whole systems approaches to obesity and other complex public health challenges: a systematic review. BMC Public Health. 2019;19(1):8. pmid:30606173

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Explaining the context: the relevance of systems maps to child health

Adapted from Jessiman P, Powell K, Williams P, Fairbrother H, Crowder M, Williams J & Kipping R (2021) A systems map of the determinants of child health inequalities in England at the local level. PLoS ONE, 16(2).

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The following issues may be worthy of discussion when introducing the relevance of systems thinking to the topic of child health.

• The landscape for children and young people’s health policy in England is complex, comprising a large number of organisations with different organisational structures, professional cultures and priorities.

• It is also a dynamic landscape, with many organisations having recently experienced restructuring and budgetary changes. 

Suggested reading:

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Jessiman P, Powell K, Williams P, Fairbrother H, Crowder M, Williams J & Kipping R (2021) A systems map of the determinants of child health inequalities in England at the local level. PLoS ONE, 16(2).[KP4]

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Learning activities

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To support critical thinking in relation to public health practice, the map can be used by students in the following way.

After introducing the map and what it shows (see more here), activities can be undertaken:

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Activity 1: To design an intervention

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1. Ask students to select a public health problem or issue affecting child health.

2. Ask them to identify this issue on the map using the search function, noting that the wording might be different on the map. This is their ‘primary factor of interest’ for the purpose of this activity.

3. Ask students to identify ‘level 1 connections’ to the primary factor of interest.

4. Ask students to identify ‘level 2 connections’ to the primary factor of interest (factors that are connected to the primary factor via one other factor).

Invite students to reflect on the following questions:

• Which domains have most influence on the primary factor of interest? Please consider the number of factors per domain as well as HOW they connect to your factor of interest.

• Which groups of stakeholders have influence on your primary factor of influence?

• Which factors would you target if you were trying to influence the primary factor of interest (these will be your priority factors)?

• What interventions are you aware of that target your priority factors?

• How might these interventions be adapted to address your priority factors?

Ask students what they learned about the influences on their chosen public health issue and how it might be addressed.

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Activity 2: To design an evaluation

1. Ask your students to identify a current public health intervention in the field of child health. They should choose an intervention for which they have good understanding (from any source) of the aims and activities of the intervention.

2. Which factor on the map is the primary target of the intervention (if a large number of factors are specified as target outcomes for the intervention, please identify the primary factor)?

3. Which factors are related to the primary factor (level 1 connections)?

4. Invite students to reflect on the following questions:

5. Which routinely available datasets might you use to monitor changes to the primary factor?

6. What other data might you generate to monitor changes to this factor?

7. How does the current intervention target level 1 connections (if at all?)

8. Which level 1 factors would you wish to monitor for changes?

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Ask students what they learned about the influences on their chosen public health issue and how attempts to address it should be evaluated.

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Suggested reading for students

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Introduction to systems thinking

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Rutter H, Savona N, Glonti K, Bibby J, Cummins S, Finegood DT, et al. The need for a complex systems model of evidence for public health. Lancet. 2017;390(10112):2602–4. pmid:28622953

Egan M, McGill E, Penney T, Anderson de Cuevas R, Er V, Orton L, et al. NIHR SPHR Guidance on Systems Approaches to Local Public Health Evaluation. Part 1: Introducing systems thinking. 2019. [Cited 2020 June 19]. https://sphr.nihr.ac.uk/wp-content/uploads/2018/08/NIHR-SPHR-SYSTEM-GUIDANCE-PART-1-FINAL_SBnavy.pdf.

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Methodological guidance on participatory systems mapping

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Kane M, Trochim WMK. Concept mapping for planning and evaluation: Thousand Oaks, CA: Sage Publications; 2007.

Burke JG, O’Campo P, Peak GL, Gielen AC, McDonnell KA, Trochim WM. An introduction to concept mapping as a participatory public health research method. Qualitative Health Research. 2005;15(10):1392–410. pmid:16263919

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• PubMed/NCBI

• Google Scholar

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Trochim WM. An introduction to concept mapping for planning and evaluation. Evaluation and Program Planning. 1989;12(1):1–16.

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• Google Scholar

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Penney T, Adams J, Briggs A, Cummins S, Harrington R, Monsivais P, et al. Evaluation of the impacts on health of the proposed UK industry levy on sugar sweetened beverages: developing a systems map and data platform, and collection of baseline and early impact data. 2018. National Institute for Health Research (NIHR). [Cited 2020 June 19]. https://fundingawards.nihr.ac.uk/award/16/49/01.