A systems perspective on place-based approaches to community health and wellbeing

Preventing chronic diseases is a global public health priority because of the significant health, social, and economic impacts these diseases have on individuals, communities, and society more broadly. The factors that contribute to the prevalence of chronic diseases are complex, and traditional approaches by diverse stakeholder groups involved in prevention efforts have largely failed to grapple with this complexity. Systems thinking approaches that account for place may be a promising alternative to those traditional approaches; yet there is a need for more evidence on their application and effectiveness. It is accepted that local governments in Western democracies have a key part in supporting place-based efforts to reduce the prevalence of chronic diseases, which is often described as improving community health and wellbeing. Yet, there is limited research on such matters in many sub-national jurisdictions, including the Australian state of Tasmania, which has among the poorest health and wellbeing outcomes in the country and among the best opportunities to change that situation.
In this thesis, a systems thinking perspective is used to consider places as complex adaptive systems comprising many interacting parts, including people and context-specific factors that interact as a dynamic whole and contribute to the prevalence of chronic disease. This perspective stems from systems thinking and complexity sciences, interdisciplinary fields that offer many theories, methods, tools, and practices that can help researchers, policymakers, and community members to better understand places as complex systems and decide where change might occur to get better outcomes. Since 2000, there has been growing interest from members of the public health community in systems thinking approaches to engage more effectively and efficiently with the complexities of preventing chronic diseases. To advance the application of systems thinking in public health research and practice and to gain a better understanding of local government’s roles in community health and wellbeing, one central question is asked in this research: From a systems perspective, what factors shape local government’s role in place-based approaches to community health and wellbeing, and what opportunities exist or could be made to strengthen such approaches to improve community health and wellbeing?
I applied systems thinking in two ways to address that question, which was informed by systems and complexity theories and methods, findings from literature reviews, and my senior health policy role in the Tasmanian Government public service. First, to determine key forces and patterns that affect place-based approaches to community health and wellbeing in Tasmania and gauge where opportunities for better outcomes might exist, two methods of data collection were used with local government personnel in Tasmania: an online survey (n=135) and semi-structured interviews with some survey respondents (n=10). Second, to consider how a place-based systems approach might be implemented to address context-specific factors that affect health and wellbeing outcomes in practice, a participatory systemic inquiry encompassing mixed systems methods was tested with stakeholders (n=19) in the West Coast local government area in Tasmania.
Data collection occurred during the COVID-19 pandemic, between October 2020 and July 2022, which highlighted the importance of research that helps scholars, policymakers, and members of diverse communities to understand context- and time-specific factors that impact health and wellbeing outcomes. My findings show that study participants want health and wellbeing to be more highly prioritised—an aspiration amplified during the pandemic. Furthermore, they want the local government sector to have a greater role in supporting efforts to improve place-based health and wellbeing outcomes, although more support from other tiers of governments and communities is needed. Specifically, participants identified funding, collaboration, a mandate in legislation, and building systems thinking capacity as key opportunities that could enhance the sector’s contribution. Findings also reveal system parts that are fostering spatial inequalities among Tasmanian local governments, which are likely exacerbating health and wellbeing inequities and therefore must be addressed. Finally, there was broad support for the systems approach tested in the West Coast local government area. Study participants thought the approach increased their systems thinking capacity, collaboratively revealing systemic issues, and identifying opportunities to address those issues.
Such evidence suggests significant opportunities exist that could strengthen local government’s role and approach to improve community health and wellbeing in Tasmania. Among them are local government reforms, the development of a statewide wellbeing framework, and the implementation of the Healthy Tasmania strategic plan. Together, the findings highlight that a common, multi-scalar, and intersectoral systems goal that considers future generations and strives towards equitable wellbeing on a healthy planet would help reorient efforts towards the systems changes that are required to improve health and wellbeing outcomes for all.
Overall, then, this research highlights the importance of understanding context-specific factors that impact local government’s roles and subsequent opportunities to enhance contributions to improve community health and wellbeing outcomes. The research demonstrates how systems thinking provides a useful theoretical framework, perspective, methods, and tools that can help uncover context-specific macro and micro systems that affect local government’s roles in supporting efforts to improve community health and wellbeing. While the insights from this research that are specific to Tasmania are not representative or generalisable, they may be beneficial in comparable jurisdictional settings around the world. On that understanding, elements of the systems approach used are replicable and can be used to help gain deeper understandings of place-based systems elsewhere. There is a need to continue to build evidence of systems thinking approaches in public health over the longer term.