Pathways for Strengthening Lived Experience Leadership for Transformative Systems Change: Reflections on Research and Collective Change Strategies.

INTRODUCTION: The Activating Lived Experience Leadership (ALEL) project was a South Australian participatory action research project that aimed to improve the ways lived experience is recognised, valued and integrated across mental health and social sector systems. ALEL was completed during 2019-2021, where it engaged 182 participants in generating community action and research knowledge. OBJECTIVE: Our paper discusses the project's processes of building a collective partnership among lived experience leaders and other leaders from within the sector, so that the actions and strategies identified through research could be implemented by systems-level impact. We describe the collaborative process and key learnings that resulted in eight key action areas for transformative systems change in South Australia. METHODS: The project invited a diverse range of self-identified lived experience and other leaders to be involved in a PAR process featuring formal qualitative research (focus groups, surveys and interviews) as well as community development activities (leaders' summit meetings, consultations, training and community of practice meetings). These processes were used to help us describe the purpose, achievements and potential of lived experience leadership. Project priorities and systems-level analysis was also undertaken with lived experience sector leaders and project advisors across two leaders' summit meetings, integrating research outcomes with sector planning to define high-level actions and a vision for transformational change. RESULTS: Participatory action research as informed by systems change and collective impact strategies assisted the project to generate detailed findings about the experiences and complexities of lived experience leadership, and collective responses of how systems could better support, be accountable to and leverage lived experience perspectives, experience and peer-work approaches. CONCLUSION: Systems change to define, value and embed lived experience leadership benefits from collective efforts in both formal research and sector development activities. These can be used to generate foundational understandings and guidance for working together in genuine ways for transforming mental health and social sector systems, experience and outcomes. PUBLIC CONTRIBUTION: Members of lived experience communities codesigned the project, and contributed to project governance and the development of all findings and project reports.

Development and testing of the capacity of organisations for system practices scale.

BACKGROUND: Systems change approaches are increasingly adopted in public health to address complex problems. It is important that measures of systems change be developed so that the effects of systems change on health outcomes can be evaluated. Organisational practices are potential levers for systems change. However, robust measures of organisational capacity to engage in these practices are lacking. Informed by the Theory of Systems Change, we developed and tested the Capacity of Organisations for System Practices (COSP) scale. The COSP scale comprises four inter-related system practices within organisations-adaptation, alignment, collaboration and evidence-driven action and learning. METHODS: We applied a three-stage process: (1) Item generation; (2) Scale pre-testing; and (3) Structural analyses. Item response theory tests and semantic review, together with factor analytic techniques, were applied to refine the item set and determine the scale structure. RESULTS: An initial pool of 97 items was generated and pre-tested with six content experts and four target audience representatives. Modifications resulted in 60 items. In total, 126 participants provided data for the structural analysis. A second-order hierarchical four-factor model fit the data better than the more basic correlated factor model (Δχ2 = 1.758, p = .415). The fit indices for the final 31-item model were acceptable (RMSEA = .084, TLI = .819). CONCLUSIONS: The COSP scale is ready for further testing to ensure construct validity, stability and utility. SO WHAT?: Once validated, the Capacity of Organisations for System Practices (COSP) scale has the potential to advance the theory and practice of systems change approaches.

Five ways 'health scholars' are complicit in upholding health inequities, and how to stop.

Health scholars have been enthusiastic in critique of health inequities, but comparatively silent on the ways in which our own institutions, and our actions within them, recreate and retrench systems of oppression. The behaviour of health scholars within academic institutions have far reaching influences on the health-related workforce, the nature of evidence, and the policy solutions within our collective imaginations. Progress on health equity requires moving beyond platitudes like 'equity, diversity and inclusion' statements and trainings towards actually being and doing differently within our day-to-day practices. Applying complex systems change theory to identify, examine and shift mental models, or habits of thought (and action), that are keeping us stuck in our efforts to advance health equity is a promising approach. This paper introduces five common mental models that are preventing meaningful equity-oriented systems transformation within academia and offers ideas for shifting them towards progressively more productive, and authentic, actions by health scholars to advance health equity across systems.

Can improvement in delivery of smoking cessation care be sustained in psychiatry inpatient settings through a system change intervention? An analysis of statewide administrative health data.

OBJECTIVE: This study evaluated maintenance of improved delivery of smoking cessation assistance in adult acute psychiatry inpatient units 3 years post statewide implementation of a system change intervention through analysis of a statewide administrative health dataset. METHOD: Rates of documenting smoking status and providing a brief smoking cessation intervention (the Smoking Cessation Clinical Pathway) in all eligible Queensland public adult acute psychiatry inpatient units (N = 57) during the implementation phase (October 2015-September 2017) of a system change intervention were compared to the maintenance phase (October 2017-October 2020) using interrupted time series analysis. RESULTS: Across implementation and maintenance phases, the percentage of discharges from psychiatry inpatient units that had a smoking status recorded remained high with the statewide average exceeding 90% (implementation phase 93.2%, 95% confidence interval = [92.4, 93.9]; and maintenance phase 94.6%, 95% confidence interval = [94.0, 95.2]). The percentage of discharges statewide with a completed Pathway stabilised during the maintenance phase (change in slope -3.7%, 95% confidence interval = [-5.2, -2.3]; change in level 0.4%, 95% confidence interval = [-7.0, 7.9]). CONCLUSION: An evidence-based smoking cessation intervention implemented with a system change intervention resulted in sustained improvement in addressing smoking in adult inpatient psychiatry units up to 3 years post implementation.

Family Engagement at the Systems Level: A Framework for Action.

While family engagement at the individual level of health care, such as families partnering with providers in decision-making about health care for an individual child has been well studied, family engagement in systems-level activities (e.g., participation in advisory and other decision-making groups, or creation and revision of policies) that impact the health services families and children receive has not. This note from the field presents a framework that describes the information and supports that help families partner with professionals and contribute to systems-level activities. Without attention to these components of family engagement, family presence and participation may be only token. We engaged an expert Family/Professional Workgroup whose members represented key constituencies and diverse geography, race/ethnicity, and areas of expertise; conducted a review of peer-reviewed publications and grey literature; and conducted a series of key informant interviews to identify best practices for supporting meaningful family engagement at the systems level. Based on an analysis of the findings, the authors identified four action-oriented domains of family engagement and key criteria that support and strengthen meaningful family engagement in systems-level initiatives. Child- and family-serving serving organizations can use this Family Engagement in Systems framework to support meaningful family engagement in the design of policies, practices, services, supports, quality improvement projects, research, and other systems-level activities.

Assessing County-Level Behavioral Health and Justice Systems with the Sequential Intercept Model Practices, Leadership, and Expertise Scorecard.

The Sequential Intercept Model has helped conceptualize interventions for people with serious mental illness in the criminal/legal system. This paper operationalizes the Sequential Intercept Model into a 35-item scorecard of behavioral health and legal practices. Using interviews, survey, and observational methods, the scorecard assesses an exploratory sample of 19 counties over 27 independent data collections. A series of ordinary least squares regression models assessed the predictor scores on four jail outcomes: prevalence of serious mental illness, length of stay, connections to treatment, and recidivism. Increases in pre-booking scores showed significant decreases in jail prevalence of serious mental illness at the p < 0.05 level, and post-booking scores and overall scores showed significant positive associations with connections to treatment at the p < 0.05 level, though these were non-significant after correcting for multiple comparisons. Preliminary findings suggest a combination of practices across the Sequential Intercept Model could have synergistic impacts on key jail diversion outcomes.

Implementation Strategies to Support Built Environment Approaches in Community Settings.

BACKGROUND: Built environment approaches are recommended to improve population physical activity levels. Implementation strategies are needed to improve uptake, but little is known about effective strategies to translate research to practice in community settings. PURPOSE: Inform implementation strategies through understanding delivery agents' perceptions of (1) built environment approaches, (2) a toolkit developed to support implementation, and (3) other required implementation strategies. METHOD: A toolkit was developed to detail the process of partnering to change the built environment and provide examples of built environment approaches (e.g., walking paths, traffic calming). Data were collected through focus groups (N = 3) with Extension Agents (n = 46) in 2020. The semi-structured focus group script was based on the Consolidated Framework for Implementation Research and the Technology Acceptance model. Rapid content analysis techniques and a deductive, grounded theory approach were used to interpret the data. Results. Focus groups generated meaning units coded into themes of perceptions of the intervention (subthemes: barriers, resources needed, and facilitators) and perceptions of the toolkit (subthemes: components to add, positive perceptions, and helpful components). The most common resources needed were coalition guidance and funding. CONCLUSION: Agents experience barriers and facilitators to implementing built environment approaches and have specific needs for support. Based on the results, we created implementation strategies: (1) Places for Physical Activity toolkit, (2) Coalition Coaching, and (3) Mini-Grants. Future work is needed to investigate the effectiveness of these implementation strategies.

Putting the system in systemic racism: A systems thinking approach to advancing equity.

Generations of scholars and activists have argued that racial inequities emerge not only because of racist ideologies but also from a hierarchical system of racial oppression. This theoretical tradition has highlighted numerous ways in which systemic racism manifests itself, from racist policies to differential access to material conditions and power. However, given that by definition systemic racism is focused on systems, theories of systemic racism would be more comprehensive and actionable by drawing on scholarship related to systems thinking. Systems thinking is a conceptual orientation that aims to understand how different types of systems function over time. This paper builds on the work of previous scholars to propose a systems thinking approach to understand and strategically disrupt racist systems. We provide a typology of system characteristics (organized into the categories of paradigms, structures, elements, and feedback loops) that together can be used to help understand the operation of systemic racism in different system contexts. The paper also provides an approach to identify and strategically target multiple system leverage points to simultaneously disrupt the status quo of racial inequity and promote the emergence of conditions enabling racial equity. This systems thinking approach can be used to guide learning and action within an ongoing process of antiracist praxis.

The C-CAP Process: A Comprehensive Approach to Community Resource Mapping.

INTRODUCTION: Place-based systems change approaches are gaining popularity to address the complex problems associated with locational disadvantage. An important stage of place-based systems change involves understanding the context that surrounds (re)produces a target problem. Community resource mapping can be used to establish the context and identify the strengths of a community that might be leveraged through systems change efforts. Approaches to community resource mapping draw on a range of philosophical assumptions and methodological frameworks. However, comprehensive, practical guidance for researchers and practitioners to conduct community resource mapping is scarce. METHOD: Drawing on the learnings from a literature review, scoping workshops, and reflective practice sessions, we developed a flexible, methodologically robust process called the Contextualize, Collect, Analyze, and Present (C-CAP) process: a four-phase approach to preparing for, conducting, and reporting on community resource mapping. The C-CAP process was co-developed by researchers and practitioners and was tested and refined in two different communities. RESULTS: The C-CAP process provides robust guidance for conducting and reporting on a community resource mapping project. The C-CAP process can be applied by public health practitioners and researchers and adapted for use across different communities, problems, and target groups. We encourage others guided by differing theoretical perspectives to apply C-CAP and share the learnings. CONCLUSION: Application of the C-CAP process has the potential to improve the comparability and comprehensiveness of findings from community resource mapping projects and avoids duplication of effort by reducing the need to design new processes for each new community resource mapping activity.

Cultivating a Healthier Policy Landscape: The Building Healthy Communities Initiative.

OBJECTIVE: To identify effective methods for local public health departments to secure policy and systems changes that will achieve health equity and improve health outcomes across diverse populations. METHODS: We reviewed 220 documents from a philanthropic initiative that funded collaborative efforts to improve conditions for health and equity in 14 California communities from 2010 to 2020. We examined the role of factors associated with movement-building approaches-such as organizing, base-building, investing in organizational capacity, and forming alliances-in securing policy and systems changes that foster more equitable community conditions. RESULTS: All 14 sites made progress in implementing policies and systems to improve the social determinants of health, including neighborhood conditions and the built environment, health care access, social and community context, economic stability, and education access. All 14 also shifted processes to be more inclusive of and responsive to community members, who in turn gained capacity to advocate for change and build collective power. CONCLUSION: Local public health leaders can make progress toward health equity by drawing on movement-building approaches to change policies and systems that affect social determinants of health.

Applying a Social Determinants of Health Approach to the Opioid Epidemic.

Ohio is one of the hardest-hit states in the United States when it comes to opioid overdose deaths. Confronted with over 4,000 opioid overdose deaths in 2017, the Ohio Department of Mental Health and Addiction Services launched the Community Collective Impact Model for Change (CCIM4C) initiative to encourage 12 Ohio counties to think more deeply about primary prevention. By moving upstream and taking a look at the causes of the opioid crisis, the counties involved in the CCIM4C initiative were able to expand the range of potential partners and potential solutions, moving from emergency response alone to broader efforts to support social connection, economic security, and other social determinants of health. Each county brought together a wide array of partners, including local employers, community colleges, health care organizations, faith leaders, youth-serving organizations, first responders, librarians, school board members, public health officials, parks and recreation staff, and people with lived experience. This article focuses on the efforts of three counties-Ashtabula, Lorain, and Lawrence-to take on the community conditions that increase the risk of unhealthy substance use and addiction. It describes what they learned as they went beyond a sole focus on preventing opioid overdoses and deaths-as critically important as that is-to transforming their communities to support health and well-being in the first place.

A Community Profile of Walking and Cycling for Exercise or Transportation in a Rural County in the Southeastern United States.

People living in rural areas of the United States, especially in the southern region, are much less likely to walk or cycle for leisure time or transportation. The purpose of this study is to provide a more detailed community-level estimate of walking and cycling behaviors and attitudes among adults living in a rural county (Hardeman County, TN) participating in a High Obesity Program (HOP) from the Centers for Disease Control and Prevention. Telephone interviews and online surveys regarding walking and cycling behaviors, attitudes, and perceptions of the built environment were completed by 634 adults. Questions originated from the 2002 National Survey of Bicyclist and Pedestrian Attitudes and Behavior. Respondents were classified as walkers, cyclists, or both. Chi-square and logistic regression were used for data analysis. Of adults in this county, 67.2% were walkers and 16.2% cyclists. Both forms of active living tended to decrease with age, especially after 50 years. Walking was associated with younger ages, 2-person households, positive perceived health, and a feeling that walking was good for them. Cycling was only associated with age. Most people felt that their communities were safe places to walk or bike. Walking was most often done on roads or road shoulder. Social support and intrinsic motivators may also play a role in walking and bicycling in rural areas. Interventions that promote walking and cycling in rural areas should provide a means for social support, creating activity-friendly routes perceived to be safe, and enhanced destinations for places to be physically active.

Paddling Together: Water Trails as Innovative Public Health Strategies.

BACKGROUND: Blueways can help improve health and quality-of-life by providing places for exercise, recreation, and community gatherings. The Rouge River Watershed is an industrialized region in Southeast Michigan with high rates of chronic disease and historic disinvestment in social and environmental conditions. The purpose of this article is to describe the process taken to develop an equitable, community-driven vision and approach for developing a water trail along the Lower Rouge River and to identify the key elements that emerged. METHODS UTILIZED TO CREATE A COMMUNITY-DRIVEN APPROACH: Project leaders incorporated community-driven planning, community outreach, and community ownership strategies. The Rouge River Water Trail Leadership Committee engages the public, those affected by decisions, with a transparent, fact-based process. The public is given equal status and shares decision-making authority. INITIAL RESULTS: This approach led to the development of a Water Trail Strategic Plan, community-informed recommendations for capital improvements, development of key relationships, and coalitions that provide a vehicle for ongoing community engagement and ownership. Five main elements, considered through an equity lens, go into building a water trail: (1) creating access points, (2) water quality monitoring, (3) woody debris management, (4) signage, and (5) developing a safety plan. IMPLICATIONS FOR PRACTICE, POLICY, AND RESEARCH: Water trail development should consist of (1) environmental change through the creation of access points and safe, navigable waterways and (2) opportunities to utilize the infrastructure through programming and initiatives to make the trail accessible to all communities.

Feasibility of Healthy Beverages Policies in American Samoa and Federated States of Micronesia: Water and Coconut Water Only Community Interventions.

American Samoa and the Federated States of Micronesia (FSM) are two small Pacific Island nations that have some of the highest noncommunicable disease (NCD) mortality rates in the world. Supported by church leaders to address obesity as an NCD risk factor, American Samoa, and Chuuk and Kosrae States of FSM selected the implementation of healthy beverages as a nutrition intervention through a water- and coconut water-only pledge in church events. The consumption of water and coconut water was tracked. Across 105 church events in the three jurisdictions, the count of water bottles before and after events decreased from 142.8 to 22.3, the number of coconuts before and after events decreased from 19.6 to 1.2, and cups of water before and after events decreased from 52.9 to 7.6. The promotion of healthy beverages in church settings holds promise in the Pacific as a feasible, accessible, and culturally responsive nutrition approach, given limited access to other nutritional alternatives, e.g., fresh fruits and vegetables. Supplemental health promotion messaging to maintain knowledge and attitudes about healthy is recommended for future scaling up.

Perspectives From Extension Staff on Building and Sustaining Community Wellness Coalitions.

BACKGROUND: Community wellness coalitions are an important part of functioning program infrastructure and have been effective in promoting policy, systems, and environmental (PSE) change, especially when paired with technical support by a community champion or Extension staff. PSE strategies are critical to support long-lasting behavior change but can be challenging to implement. Extension is an established and equipped organization that has potential to help community overcome those challenges. The aim of this article was to identify and describe experiences of Extension staff working as community coaches. METHODS: A mixed-methods design to assess the impact of Extension staff working with Community Champions included a quantitative Extension Coaching Confidence Scorecard and an Extension Key Informant Interview. RESULTS: The total Extension Coaching Confidence score significantly increased from pre- to post-intervention (55.1 ± 35.3 vs. 81.7 ± 37.7, p = .03). Five facilitators and two barriers to wellness coalition development were identified by Extension staff. DISCUSSION: The results of this study indicate that the model of community coaching used was effective at addressing the foundational components of the Component Model of Infrastructure (CMI). However, comprehensive training for Extension staff in the CMI and technical assistance are needed in order to build capacity, achieve outcomes, and promote sustainability. IMPLICATIONS FOR PRACTICE: Individuals seeking to transition to PSE work should be provided with a foundation of specific, targeted training in the CMI and evidence-based technical assistance methods. Practitioners should recognize the essential role of community champions in PSE work. Completing the Extension Coaching Confidence Scorecard periodically can inform evolving training needs.

Facilitating Nutrition and Physical Activity-Focused Policy, Systems, and Environmental Change in Rural Areas: A Methodological Approach Using Community Wellness Coalitions and Cooperative Extension.

Obesity prevalence is higher among rural populations than urban, which may be related to differences in environments. Rural counties face barriers to accessing healthy foods and physical activity opportunities including isolation, transportation distances, and lack of facilities. As part of the Centers for Disease Control and Prevention Division of Nutrition, Physical Activity, and Obesity High Obesity Program, community-based wellness coalitions were established in six South Dakota counties with adult obesity prevalence >40%. The community coalitions were charged with improving access to healthy foods and safe and accessible places to participate in physical activity within their rural, underserved communities. Coalitions were created and members were recruited by Cooperative Extension staff who had existing relationships with key stakeholders within the community. Within these coalitions, champions were identified to provide leadership and ensure project implementation. Ongoing support and technical assistance were provided to the community coalitions by Cooperative Extension staff as they completed a community needs assessment, disseminated results of the needs assessment with the community, created action plans based on needs assessment data, implemented evidence-based interventions to support nutrition and physical activity policy, system and environmental changes, and assessed impact within their community. Overall, the purpose of this article is to share the project methodology, which capitalized on using Cooperative Extension, to build capacity to improve the nutrition and physical activity environment in rural, unserved communities. Sustainability of this work, along with lessons learned, is also discussed.

A Comprehensive Program to Reduce Tobacco-related Cancers Through Actions by a National Cancer Institute-designated Cancer Center.

Tobacco use accounts for 30% of all cancer-related deaths worldwide and 20% in the US, despite effective, evidence-based interventions for reducing tobacco use and tobacco-related cancers and deaths. In 2012, to reduce the burden of tobacco-related cancer and associated population-level risks across Texas, The University of Texas MD Anderson Cancer Center initiated the EndTobacco® program to promote statewide cancer control activities. We created evidence-based initiatives, established selection criteria, and implemented actions involving policy, education, and tobacco treatment services. As a result, EndTobacco has supported, educated, and convened local and state coalitions in policymaking; provided tobacco treatment education to health professionals; implemented Texas' only certified tobacco treatment training program; and led an initiative to enhance the tobacco-free culture of the state's publicly funded university system. Supported by commitments from MD Anderson, we developed and implemented evidence-based actions for tobacco control tailored to the center's mission, values, expertise, resources, and partnerships. By 2021, the adult smoking rate in Texas dropped from 19.2% (2014) to 13.2%. Contributors to this drop include state tobacco control policies, programs and services from multiple agencies and associations, and EndTobacco activities that complement the statewide effort to prevent youth smoking initiation and increase quit attempts among youth and adults.

Transformational Change in maternity services in England: a longitudinal qualitative study of a national transformation programme 'Early Adopter'.

BACKGROUND: Large system transformation in health systems is designed to improve quality, outcomes and efficiency. Using empirical data from a longitudinal study of national policy-driven transformation of maternity services in England, we explore the utility of theory-based rules regarding 'what works' in large system transformation. METHODS: A longitudinal, qualitative case study was undertaken in a large diverse urban setting involving multiple hospital trusts, local authorities and other key stakeholders. Data was gathered using interviews, focus groups, non-participant observation, and a review of key documents in three phases between 2017 and 2019. The transcripts of the individual and focus group interviews were analysed thematically, using a combined inductive and deductive approach drawing on simple rules for large system transformation derived from evidence synthesis and the findings are reported in this paper. RESULTS: Alignment of transformation work with Best et al's rules for 'what works' in large system transformation varied. Interactions between the rules were identified, indicating that the drivers of large system transformation are interdependent. Key challenges included the pace and scale of change that national policy required, complexity of the existing context, a lack of statutory status for the new 'system' limiting system leaders' power and authority, and concurrent implementation of a new overarching system alongside multifaceted service change. CONCLUSIONS: Objectives and timescales of transformation policy and plans should be realistic, flexible, responsive to feedback, and account for context. Drivers of large system transformation appear to be interdependent and synergistic. Transformation is likely to be more challenging in recently established systems where the basis of authority is not yet clearly established.

Increasing Human Papillomavirus Vaccination in a Federally Qualified Health Center Organization Using a Systems-Based Intervention Integrating EHR and Statewide Immunization Information System.

Public acceptance of the HPV vaccine has not matched that of other common adolescent vaccines, and HPV vaccination rates remain below the Healthy People 2020 target of 80% compliance. The purpose of this study was to evaluate the capacity of nine pediatric clinics in a Federally Qualified Health Center organization to implement a systems-based intervention targeting office staff and providers using EHRs and a statewide immunization information system to increase HPV vaccination rates in girls and boys, ages 11 to 16 over a 16-month period. System changes included automated HPV prompts to staff, postcard reminders to parents when youths turned 11 or 12 years old, and monthly assessment of provider vaccination rates.During the intervention, 8960 patients (11-16 yo) were followed, with 48.8% girls (n = 4370) and 51.2% boys (n = 4590). For this study period, 80.5% of total patients received the first dose of the HPV vaccine and 47% received the second dose. For the first dose, 55.5% of 11 year old girls and 54.3% of 11 year old boys were vaccinated. For ages 12 to 16, first dose vaccination rates ranged from the lowest rate of 84.5% for 14 yo girls up to the highest rate of 90.5% for 13 yo boys. Logistic regression showed age was highly significantly associated with first dose completion (OR 1.565, 95% CI 1.501, 1.631) while males did not have a significant association with first dose completion compared to females. The intervention increased overall counts of first and second HPV vaccination rates.

A scoping review of systems approaches for increasing physical activity in populations.

INTRODUCTION: The past decade has increasingly seen systems approaches as a featured theme in public health studies and policy documents. This trend is evident in the area of physical activity, which is a significant global health risk factor that is addressed in WHO's Global Action Plan on Physical Activity. We undertook a comprehensive scoping review to characterize the application of systems approaches to physical activity, to develop a typology of the objectives, themes and methods of research papers that purported to apply systems thinking to this issue. METHODS: We searched electronic databases (PubMed, Web of Science, Scopus and PsycINFO) for studies published during the period 2010-2021 that explicitly applied systems approaches or methods to investigate and/or address population physical activity. A framework using systems-based methodological approaches was adapted to classify physical activity studies according to their predominant approach, covering basic descriptive, complex analytical and advanced forms of practice. We selected case studies from retained studies to depict the current "state of the art". RESULTS: We included 155 articles in our narrative account. Literature reporting the application of systems approaches to physical activity is skewed towards basic methods and frameworks, with most attention devoted to conceptual framing and predictive modelling. There are few well-described examples of physical activity interventions which have been planned, implemented and evaluated using a systems perspective. There is some evidence of "retrofitted" complex system framing to describe programmes and interventions which were not designed as such. DISCUSSION: We propose a classification of systems-based approaches to physical activity promotion together with an explanation of the strategies encompassed. The classification is designed to stimulate debate amongst policy-makers, practitioners and researchers to inform the further implementation and evaluation of systems approaches to physical activity. CONCLUSION: The use of systems approaches within the field of physical activity is at an early stage of development, with a preponderance of descriptive approaches and a dearth of more complex analyses. We need to see movement towards a more sophisticated research agenda spanning the development, implementation and evaluation of systems-level interventions.