摘要：Objectives . Awareness of and support for systems thinking and modeling in the public health field are growing, yet there are many practical challenges to implementation. We sought to identify and describe these challenges from the perspectives of practicing public health professionals. Methods . A systems-based methodology, concept mapping, was used in a study of 133 participants from 2 systems-based public health initiatives (the Initiative for the Study and Implementation of Systems and the Syndemics Prevention Network). This method identified 100 key challenges to implementation of systems thinking and modeling in public health work. Results . The project resulted in a map identifying 8 categories of challenges and the dynamic interactions among them. Conclusions . Implementation by public health professionals of the 8 simple rules we derived from the clusters in the map identified here will help to address challenges and improve the organization of systems that protect the public’s health. Modern public health practice encompasses a complex, loosely coupled system 1 of actors including governmental entities at the international, national, regional, and local levels; a diverse conglomeration of nongovernmental organizations (such as foundations, advocacy and special interest groups, coalitions and partnerships, for-profit and nonprofit medical systems, and businesses); and citizens in the public at large. The broad array of threats to well-being, ranging from obesity and tobacco use to violence and infectious diseases, can be most aptly portrayed from a complex and adaptive system perspective. Systems thinking and modeling are broad classes of intellectual endeavors that are being incorporated increasingly into contemporary public health. Research has proven both the general potential of systems thinking 2 – 14 and applications in specific areas. 15 – 28 Empirical studies related to complex systems have appeared of late in notable medical journals, including the Journal of the American Medical Association, Lancet , and the New England Journal of Medicine . 29 – 35 The authors of an Institute of Medicine report, Crossing the Quality Chasm: A New Health System for the 21st Century , 11 (pp8–9) used a systems perspective to delineate 10 “simple rules to guide the redesign of the health care system” and described the entire health care system as a complex adaptive system: A health care system can be defined as a set of connected or interdependent parts or agents—including caregivers and patients—bound by a common purpose and acting on their knowledge. Health care is complex because of the great number of interconnections within and among small care systems. 11 (p64) Systems thinking encompasses and is consonant with ecological models 36 – 38 familiar to public health practitioners, including the ideas of human ecology, population health, and the social determinants of public health. But it goes beyond these models, incorporating advances over the past decades, particularly in fields such as system dynamics and complexity theory. It is relatively easy to identify examples of public health issues that can be understood accurately only by examining the complex and dynamic part-and-whole interactions that make up systems. For instance, consider the area of tobacco control. At the policy level, it is reasonable to argue that the 1964 surgeon general’s report on smoking 39 had profound effects on the policy debate with consequences for smoking prevalence and consumption to this day. The report itself was the product of a complex series of events that led to its production. In turn, it set off a cascade of events and changes. It is virtually impossible to determine the effects of that important event in isolation, as a part that is separable from the whole. For instance, the report was most likely an important catalyst in creating a public policy climate that enabled the litigation that led to the Tobacco Settlement Agreement several decades later, to increased taxation of cigarettes by states, to legal restrictions on smoking in public places, and to tobacco counteradvertising. By the same token, the report may have led to unanticipated “negative” consequences by spurring the tobacco industry to adapt its product, marketing, lobbying, and public relations and perhaps indirectly contributed to the creation of front groups and covert efforts to undermine tobacco control research. 40 There are countless other examples. Smokers may react to fears about the harmful effects of smoking by switching to so-called “light” cigarettes (i.e., low tar and nicotine formulations as determined by machine smoking tests). Yet, despite their manufacturers’ claims, “light” cigarettes may actually increase the prevalence of a more lethal type of lung cancer, probably because of the way their ventilated filters alter the physical act of smoking. 41 , 42 Or consider the way the industry responds to youth advertising restrictions. Billboard advertising was outlawed by the Master Settlement Agreement. In response, the tobacco companies increased advertising and promotion in retail stores, effectively saturating the retail environment with product images. 43 Thus, banning billboard advertising has led to even more children being exposed to protobacco messages as they go about their daily lives. Even the cigarette itself is a complex system, a highly engineered product designed for extreme elasticity of delivery. 44 And tobacco control as a public endeavor can be viewed as a set of systems challenges regarding how we might best balance the complex configurations of individuals, government agencies, and organizations that are engaged in fighting tobacco use. In tobacco control, as in all other areas of public health work, systems problems are legion, and the need for systems thinking and modeling is ubiquitous. Despite the growing cognizance of and support for “systems thinking” in public health, implementation of effective systems approaches remains challenging. 12 , 13 , 45 , 46 We sought to identify and describe the challenges that must be addressed by public health leaders in implementing effective systems-based approaches. Here we address 3 major topics. First, we discuss systems thinking and modeling and their most recent developments. Second, we provide an overview of public health initiatives that are exploring and using systems thinking and modeling, particularly the Initiative for the Study and Implementation of Systems (ISIS). 1 Finally, we present the results of an initial empirical study in which we used a systems-based method (concept mapping) with a self-selected group of public health professionals in an attempt to identify the challenges facing those who support systems thinking and modeling in public health.
