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BACKGROUND: The physical and the social environment are important predictors of healthy weight, especially in low socioeconomic position (SEP) neighborhoods. Many Dutch municipalities have implemented a healthy weight approach (HWA). Yet, there is room for improvement. This system science study examined what influences the utilization of HWA facilities and activities, and what aspects can help to achieve a desired systems change (also called leverage point themes (LPTs)) in the HWA system as perceived by citizens living in low SEP neighborhoods. METHOD: All research phases were performed with four citizens co-researchers. Forty-seven citizens living in low SEP neighborhoods were semi-structurally interviewed about the neighborhood HWA facilities and municipal HWA activities. A rapid coding qualitative analysis approach was applied per topic. The topics were citizens' healthy living description, personal circumstances, and satisfaction with foot and cycle paths, sports facilities, playgrounds, green spaces, museums and theaters, community centers, churches, healthcare, school, food supplies, contact with neighborhood, unfamiliar and/or unused activities, familiar and used activities, unavailable but desired (lacking) activities, and reaching citizens. RESULTS: The utilization of HWA facilities and activities was influenced by the overarching themes of social cohesion, familiarity, reaching citizens, maintenance, safety, physical accessibility, financial accessibility, social accessibility, fit with personal context, and fit with the neighborhood's specific needs. Different overarching themes stood out across different facilities and activities. LPTs indicated the overarching themes needed in combination with one another for a specific activity or facility to increase utilization. For example, the LPT regarding foot and cycle paths was "accessible, safe, and maintained foot and cycle paths". The LPTs regarding familiar and used activities were "customized activities; information provision (e.g., about possibilities to join without paying); social contact, meeting others, and everyone feels included". CONCLUSION: Conducting inclusive qualitative research from a systems perspective among citizens living in low SEP neighborhoods has contributed valuable insights into their needs. This enables practical implementation of HWAs by providing a deeper understanding of the LPTs within the HWA system. LPTs can help HWA stakeholders to further develop current HWAs toward systems approaches. Future research could study the leverage points that may contribute to LPT implementation.

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BACKGROUND: Effective mentorship is an important contributor to academic success. Given the critical role of leadership in fostering mentorship, this study sought to explore the perspectives of departmental leadership regarding 1) current departmental mentorship processes; and 2) crucial components of a mentorship program that would enhance the effectiveness of mentorship. METHODS: Department Division Directors (DDDs), Vice-Chairs, and Mentorship Facilitators from the Department of Medicine at the University of Toronto Temerty Faculty of Medicine were interviewed between April and December 2021 using a semi-structured guide. Interviews were audio-recorded and transcribed verbatim, then coded. Analysis occurred in 2 steps: 1) codes were organized to identify emergent themes; then 2) the Social Ecological Model (SEM) was applied to interpret the findings. RESULTS: Nineteen interviews (14 DDDs, 3 Vice-Chairs, and 2 Mentorship Facilitator) were completed. Analysis revealed three themes: (1) a culture of mentorship permeated the department as evidenced by rigorous mentorship processes, divisional mentorship innovations, and faculty that were keen to mentor; (2) barriers to the establishment of effective mentoring relationships existed at 3 levels: departmental, interpersonal (mentee-mentor relationships), and mentee; and (3) strengthening the culture of mentorship could entail scaling up pre-existing mentorship processes and promoting faculty engagement. Application of SEM highlighted critical program features and determined that two components of interventions (creating tools to measure mentorship outcomes and systems for mentor recognition) were potential enablers of success. CONCLUSIONS: Establishing 'mentorship outcome measures' can incentivize and maintain relationships. By tangibly delineating departmental expectations for mentorship and creating systems that recognize mentors, these measures can contribute to a culture of mentorship.

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Failure of governments across the world to address climate change has fuelled social movements focused on climate-related policy and action. Research analysing these movements has focused mainly on the types of strategies employed including blockades and occupations, marches and petitions, divestment, boycotts and litigation as well as how groups are framing climate change as a problem. What has been largely missed are the ways these groups are framing the change they want to see, that is their demands to governments. Not all demands and actions have the same potential to create the changes needed to mitigate climate change. Used in public health and health promotion, the systems science Intervention Level Framework (ILF) is a tool that can help analyse to what extent different demands have the leverage to create change in a system. We use the ILF to analyse 131 demands from 35 different climate-related advocacy groups in Australia. Results show demands are more focused on lower system leverage points, such as stopping particular projects, rather than on more impactful leverage points, such as the governance structures that determine climate-related policy and decision-making mechanisms. Further, the results highlight the lack of attention on public health related topics of transport and food systems. This paper shows how a systems science framework used in health promotion, the ILF, could enable climate advocacy groups to more effectively target demands to achieve more impactful outcomes from governments, corporations and the public.

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Transformative change can help achieve the 2050 vision of biodiversity, but concrete ways to achieve it are only being discovered. To contribute to the understanding of the practical options for concrete action to foster, accelerate and maintain the transformative change, we assessed the leverage potential of existing conservation actions using the Meadows' Leverage points framework. We took the actions from the Conservation Actions Classification by the Conservation Measures Partnership. The outcome is a scheme that evaluates at which leverage points, from simple parameters to paradigms, the different conservation actions have potential to make an impact, and thus impact systemic change. We found that all conservation actions have potential to leverage systemic transformative change, with varying coverage of the leverage points. All leverage points were addressed by several actions. The scheme could be used both as an interim tool for evaluating transformative potential in different broad datasets, but also help with planning of new conservation policies, interventions and projects. We hope our work could be a first step toward standardization and broader adoption of assessing leverage in conservation research and practice, achieving broader socio-ecological system leverage with conservation tools. Supplementary Information: The online version contains supplementary material available at 10.1007/s10531-023-02600-3.

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As we cross the 2030 deadline to achieve the Sustainable Development Goals (SDGs), there is a growing sense of urgency around the need to accelerate the necessary transformations. These encompass a broad range of systems and require fundamental changes in system goals and design. In this paper, we undertake a narrative review of the literature relating to the acceleration of transformations and offer a framework for unlocking and accelerating transformations to the SDGs. While there is no blueprint for acceleration, there is an expanding knowledge base on important dynamics, impediments and enabling conditions across diverse literatures which can help to inform strategic interventions by actors. The emerging literature on positive tipping points and deep leverage points identifies opportunities to rewire systems design so that important system feedbacks create the conditions for acceleration. Transformation takes time and actors will need to build momentum to reorient systems around new goals, informed by knowledge of common policy, technology and behavioural feedbacks that govern system dynamics. Where resistance is strong, actors can seek to augment system design in ways that weaken balancing feedbacks that stabilise existing system configurations and strengthen reinforcing feedbacks that promote emerging system configurations oriented towards the SDGs. Well-designed and sequenced interventions can promote innovation and behaviour change and build and maintain political support. This can build critical enabling conditions and push systems towards large-scale tipping points, paving the way for decisive policy action that is crucial for triggering acceleration. We conclude by highlighting gaps and priorities for further research.

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Game changers in public health are traditionally seen as specific in(ter)ventions, but contemporary public health challenges warrant acknowledging complexity instead. Our game changer is a compass to deal with this complexity. In our vision of 2030, system beliefs, goals, structures and events line up to create a society that balances health, climate, social cohesion and economy. To reach this desired system, a resilient public health sector actively interacts with public discourse, political windows of opportunity are seized for institutionalizing health for all policies, and research is intertwined with the policy process, without the merging of the two.

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Entrepreneurship has emerged as a key element for experimentation and niche innovation in sustainability transitions. Yet, its contributions beyond this initial stage and the multi-pronged role that entrepreneurs can play in transformation processes remain elusive. In response, we conceptualize and empirically illustrate how entrepreneurs can contribute to innovations within firms and to city-wide processes of change. With insights from small- and medium-sized enterprises in European and North American cities, we develop a framework encompassing eight intervention types through which entrepreneurs shape urban sustainability transformations. We propose avenues for future research to better understand the distributed role of entrepreneurship and how it can contribute to shaping and accelerating change toward sustainability across integrated levels of urban transformations.

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Antimicrobial resistance (AMR) decreases the effectiveness of antimicrobials to treat bacterial infections in humans and animals. The increased occurrence of AMR in bacterial population in humans, animals, and the environment requires the measures to combat a rising global health crisis. The aim of this research was to present current knowledge on AMR in a system map and to identify potential explanations of former identified variables significantly associated with AMR. This study applies a systems thinking approach and uses feedback loops to visualize the interconnections between human, animal, and environmental components in a circular AMR system map model. First, a literature review focusing on AMR and socioeconomic factors, wicked problem, and system change was carried out, which was then processed in a system map to conceptualize the present core challenges of AMR via feedback loops. Second, to investigate possible underlying values of the society and those that influence humans' behavior in the present AMR system, an iceberg model was established. Third, leverage points were assessed to estimate which kinds of interventions would have the greatest effect to mitigate AMR in the system. The present AMR system map implies the potential to identify and visualize important risk factors that are direct or indirect drivers of AMR. Our results show that the tool of system mapping, which interconnects animals, humans, and environment in one model, can approach AMR holistically and be used to assess potential powerful entry points for system wide interventions. This study shows that system maps are beneficial as a model to predict the relative effect of different interventions and adapt to rapidly changing environments in a complex world. Systems thinking is considered as a complementing approach to the statistical thinking, and further research is needed to evaluate the use of such tools for the development and monitoring of interventions.

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Forests are key components of European multifunctional landscapes and supply numerous forest ecosystem services (FES) fundamental to human well-being. The sustainable provision of FES has the potential to provide responses to major societal challenges, such as climate change, biodiversity loss, or rural development. To identify suitable strategies for the future sustenance of FES, we performed a solution scanning exercise with a group of transdisciplinary forest and FES experts from different European regions. We identified and prioritized fifteen major challenges hindering the balanced provision of multiple FES and identified a series of potential solutions to tackle each of them. The most prominent challenges referred to the increased frequency and impacts of extreme weather events and the normative mindset regarding forest management. The respective solutions pointed to the promotion of forest resilience via climate-smart forestry and mainstreaming FES-oriented management through a threefold strategy focusing on education, awareness raising, and networking. In a subsequent survey, most solutions were assessed as highly effective, transferable, monitorable, and with potential for being economically efficient. The implementation of the solutions could have synergistic effects when applying the notion of leverage points. Seven emerging pathways towards the sustainable supply of FES have been identified. These pathways build on each other and are organized based on their potential for transformation: (1) shifting forest management paradigms towards pluralistic ecosystem valuation; (2) using integrated landscape approaches; (3) increasing forest resilience; (4) coordinating actions between forest-related actors; (5) increasing participation in forest planning and management; (6) continuous, open, and transparent knowledge integration; and (7) using incentive-based instruments to support regulating and cultural FES. These pathways can contribute to the implementation of the new EU Forestry Strategy to support the balanced supply of multiple FES. Supplementary Information: The online version contains supplementary material available at 10.1007/s11625-022-01111-4.

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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 .

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Contrary to the expectations of promoters of organic agriculture, the adoption of the technology by smallholder farmers in Africa has been low and slow, for reasons not well understood. Existing studies on the topic mostly estimated the effect of some variables on the adoption of the technology. But adoption is characterized by complex and dynamic interactions of many interconnected factors, which existing studies overlooked. The underlying causal structures and feedback mechanisms that dynamically interact to affect the adoption of organic farming in urban and rural Africa are also not well known. To bridge these gaps, we used a system dynamics tool called participatory causal loop diagraming to map the underlying causal factors and feedback mechanisms driving the adoption of organic farming in rural and urban Nigeria. We conducted loop and network analyses of the group causal loop diagrams, which were created during the participatory system dynamics modeling workshops with the organic farmers in our study areas. Our findings underscore the importance of the knowledge of organic farming, demand- and supply-side-oriented awareness creation, and the economic viability of organic farming for widespread adoption of the technology. We suggested the potential leverages around which interventions can be built to boost the adoption rates of the technology.

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BACKGROUND: Systems thinking is integral to working effectively within complex systems, such as those which drive the current population levels of overweight and obesity. It is increasingly recognised that a systems approach - which corrals public, private, voluntary and community sector organisations to make their actions and efforts coherent - is necessary to address the complex drivers of obesity. Identifying, implementing and evaluating actions within complex adaptive systems is challenging, and may differ from previous approaches used in public health. METHODS: Within this conceptual article, we present the Action Scales Model (ASM). The ASM is a simple tool to help policymakers, practitioners and evaluators to conceptualise, identify and appraise actions within complex adaptive systems. We developed this model using our collective expertise and experience in working with local government authority stakeholders on the Public Health England Whole Systems Obesity programme. It aligns with, and expands upon, previous models such as the Intervention Level Framework, the Iceberg Model and Donella Meadows' 12 places to intervene within a system. RESULTS: The ASM describes four levels (synonymous with leverage points) to intervene within a system, with deeper levels providing greater potential for changing how the system functions. Levels include events, structures, goals and beliefs. We also present how the ASM can be used to support practice and policy, and finish by highlighting its utility as an evaluative aid. DISCUSSION: This practical tool was designed to support those working at the front line of systems change efforts, and while we use the population prevalence of obesity as an outcome of a complex adaptive system, the ASM and the associated principles can be applied to other issues. We hope that the ASM encourages people to think differently about the systems that they work within and to identify new and potentially more impactful opportunities to leverage change.

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The sustainability challenges the world faces today call for concerted and immediate action. Complementing problem-oriented, descriptive-analytical research with solution-oriented research could strengthen sustainability science's contribution to address these challenges. We introduce different types of solution-oriented sustainability research to structure the discourse, outline opportunities to advance this research trajectory, and close with recommendations on how to support particularly students and early career researchers in getting involved with solution-oriented sustainability research.

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HIV drug resistance (HIVDR) is a complex problem with multiple interconnected and context dependent causes. Although the factors influencing HIVDR are known and well-studied, HIVDR remains a threat to the effectiveness of antiretroviral therapy. To understand the complexity of HIVDR, a comprehensive, systems approach is needed. Therefore, a local systems map was developed integrating all reported factors influencing HIVDR in the Dar es Salaam Urban Cohort Study area in Tanzania. The map was designed based on semi-structured interviews and workshops with people living with HIV and local actors who encounter people living with HIV during their daily activities. We visualized the feedback loops driving HIVDR, compared the local map with a systems map for Sub-Saharan Africa, previously constructed from interviews with international HIVDR experts, and suggest potential interventions to prevent HIVDR. We found several interconnected balancing and reinforcing feedback loops related to poverty, stigmatization, status disclosure, self-esteem, knowledge about HIVDR and healthcare system workload, among others, and identified three potential leverage points. Insights from this local systems map were complementary to the insights from the Sub-Saharan systems map showing that both viewpoints are needed to fully understand the system. This study provides a strong baseline for quantitative modelling, and for the identification of context-dependent, complexity-informed leverage points.

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Fluvial systems are particularly sensitive to changes in the terrestrial ecosystems where they are embedded, receiving simultaneously the impact of multiple stressors. The design of adequate management policies requires analyzing fluvial systems as social-ecological systems, because the decoupling of natural and social systems can lead to a severe mismatch between maintaining ecological integrity and the pursuit of human well-being. Pampean streams are especially prone to the impact of human activities because they are located in a region that provides almost half of the agricultural production of Argentina and concentrates 66% of the whole population of the country. In the present work, we conceived a general social-ecological framework that links the occurrence of multiple stressors and their impacts on ecosystem services, with changes in environmental perception of streams, which in turn feedback over institutional actions at the watershed's governance. We identified four current key drivers of the dynamics in Pampean streams: a dominant agro-industrial model for the region, a command-and-control governance regime mainly based on an engineering hydraulic perspective, the real estate market speculation of surrounding lands, and the persistence of structural poverty in urban areas. The resulting dynamics resembles the occurrence of different kinds of social-ecological traps, i.e., a highly stable but undesirable state of the system that is difficult to escape. Based on this analysis, we provide a leverage point perspective to avoid this trap. Together, this approach could be applied to other fluvial systems of the world to link the ecological and social domains to multiple stressors analysis, and to improve institutional fit for the sustainability of fluvial social-ecological systems.

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Human-wildlife conflicts (HWC) are complex conservation challenges that impair both wildlife populations and human livelihood. Research on HWC, however, has traditionally approached ecological and human components separately, hampering a broader understanding of connections between ecological drivers and human dimensions of conflicts. We developed a model that integrates ecological and human components of HWC to investigate how the amount of remaining native forest (forest cover, a key ecological variable known to influence species occurrence and abundance) affects human experiences with wildlife (contact with species and attacks on livestock) and how such experiences influence tolerance via beliefs, emotions, and attitudes. We tested the model with piecewise structural equation modeling and data on human interactions with 3 mammals with different rarity and body size: opossum (Didelphis aurita), crab-eating fox (Cerdocyon thous), and puma (Puma concolor). Data were obtained by interviewing 114 landowners across 13 Atlantic Forest landscapes (10-50% forest cover). Forest cover was associated with high chance of attacks on livestock, and thus with low tolerance, only in the case of the puma. Effects of distinct experiences with wildlife on beliefs and emotions varied across species. Beliefs and emotions toward wildlife influenced tolerance toward all species, but negative emotions affected tolerance toward only with the puma. Conflicts with large carnivores, such as pumas, can then be understood as disservices provided by forests, indicating the relevance of framing HWC more broadly to consider trade-offs with ecosystems services. For some species, positive experiences with wildlife may counteract the negative effects of attacks on livestock in shaping tolerance. Models such as ours-that link ecological and human dimensions-can help identify more effective leverage points to improve HWC mitigation.

Vinculación de componentes humanos y ecológicos para entender los conflictos humano-fauna a nivel paisaje y especies Resumen Los conflictos humano-fauna (CHF) son retos complejos para la conservación pues perjudican tanto a las poblaciones de fauna como al sustento humano. Sin embargo, las investigaciones sobre los CHF por tradición han manejado a los componentes humanos y ecológicos de manera separada, dificultando un entendimiento más amplio de las conexiones entre los conductores ecológicos y las dimensiones humanas de estos conflictos. Desarrollamos un modelo que integra a los componentes ecológicos y humanos de los CHF para investigar cómo la cantidad de bosque nativo remanente (la cobertura de bosque, una variable ecológica importante que se sabe influye sobre la presencia y abundancia de las especies) afecta a las experiencias que las personas tienen con la fauna (contacto con especies y ataques al ganado) y cómo dichas experiencias influyen en la tolerancia por medio de creencias, emociones y actitudes. Probamos el modelo con un modelado de ecuación estructural por partes y datos sobre las interacciones humanas con tres mamíferos de diferente tamaño y rareza: la zarigüeya (Didelphis aurita), el zorro cangrejero (Cerdocyon thous) y el puma (Puma concolor). Los datos se obtuvieron por medio de entrevistas realizadas a 114 terratenientes distribuidos en 13 paisajes de bosque atlántico (10-50% de cobertura de bosque). La cobertura de bosque estuvo asociada con una alta probabilidad de ataques al ganado, y por lo tanto con una baja tolerancia, sólo para el caso del puma. Los efectos de las distintas experiencias con la fauna sobre las creencias y las emociones variaron con cada especie. Las creencias y las emociones hacia la fauna influyeron en la tolerancia hacia todas las especies, aunque las emociones negativas afectaron la tolerancia solamente hacia el puma. Los conflictos con los grandes carnívoros, como el puma, pueden entenderse como servicios negativos proporcionados por los bosques, lo que indica la relevancia de enmarcar a los CHF de manera más amplia para considerar las compensaciones con los servicios ambientales. Para algunas especies, las experiencias positivas con la fauna pueden contrarrestar los efectos negativos de los ataques al ganado en cuanto a la formación de la tolerancia. Los modelos como el nuestro - que conectan las dimensiones ecológicas y humanas - pueden ayudar a identificar puntos de ventaja más efectivos para mejorar la mitigación de los CHF.

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This study aims to investigate acceptance of vaginal self-sampling for high-risk human papilloma virus (HPV) among long-term screening non-attenders at increased cervical cancer risk and to identify leverage points to promote screening adherence among these women. Forty-three long-term screening non-attenders performed home vaginal self-sampling for HPV, had positive HPV results, and subsequently attended gynecologic examination. Sixteen (37.2%) had high-grade cervical intraepithelial neoplasia (CIN2 or 3), and two had invasive cervical cancer. Forty-one of these women completed a questionnaire concerning Specific Knowledge about HPV, CIN, and cervical cancer, potential barriers to screening and views about self-sampling. Results were compared with 479 women treated for CIN2+ who attended gynecologic follow-up and also performed self-sampling. Significant multivariate predictors of long-term non-attender status compared with referents were low Specific Knowledge, high confidence in self-sampling, and potential barriers-refraining from activity to attend gynecologic examination, needing another's help to attend, and long travel time. Non-attenders citing fear/refraining from gynecologic examination as why they preferred self-sampling significantly more often had lowest Specific Knowledge compared with other non-attenders. All non-attenders could envision themselves doing self-sampling again while only 74% of referents endorsed this statement (p = 0.0003). We conclude that HPV self-sampling is an acceptable option for women at increased cervical cancer risk who have been long-term screening non-attenders. Educational outreach to enhance Specific Knowledge about HPV, CIN and cervical cancer is critical. Those non-attenders who explicitly avoid gynecologic examinations need special attention. Trial Registry: Clinicaltrials.gov NCT02750124.

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In the context of continuing ecosystem degradation and deepening socio-economic inequality, sustainability scientists must question the adequacy of current scholarship and practice. We argue that pre-occupation with external phenomena and collective social structures has led to the neglect of people's 'inner worlds'-their emotions, thoughts, identities and beliefs. These lie at the heart of actions for sustainability, and have powerful transformative capacity for system change. The condition of people's inner worlds ought to also be considered a dimension of sustainability itself. Compassion, empathy and generosity, for example, are personal characteristics that mark individual expressions of sustainability. Sustainability science must take inner life more seriously by considering how language shapes and is shaped by paradigms about the world, prioritising enquiry into how spirituality, contemplation and sustainability transformation relate, and encouraging scholars and practitioners to intentionally cultivate their inner worlds to strengthen inner resources necessary for addressing sustainability challenges.

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Transformational research frameworks provide understanding and guidance for fostering change towards sustainability. They comprise stages of system understanding, visioning and co-designing intervention strategies to foster change. Guidance and empirical examples for how to facilitate the process of co-designing intervention strategies in real-world contexts remain scarce, especially with regard to integrating local initiatives. We suggest three principles to facilitate the process of co-designing intervention strategies that integrate local initiatives: (1) Explore existing and envisioned initiatives fostering change towards the desired future; (2) Frame the intervention strategy to bridge the gap between the present state and desired future state(s), building on, strengthening and complementing existing initiatives; (3) Identify drivers, barriers and potential leverage points for how to accelerate progress towards sustainability. We illustrate our approach via a case study on sustainable development in Southern Transylvania. We conclude that our principles were useful in the case study, especially with regards to integrating initiatives, and could also be applied in other real-world contexts.