To investigate: (1) the injury epidemiology in an Australian academy; (2) how athletes transition through the high-performance sport (HPS) pathway; and (3) why athletes leave this HPS program. This retrospective cohort study was conducted at an Australian HPS academy over a 4-year period. Medical attention injuries were prospectively recorded. Injury incidence rates (IIR) and burden were calculated per 365 athlete-days, according to sport, sex, and pathway level. Athlete pathway levels were mapped to the Foundations, Talent, Elite, and Mastery (FTEM) framework. Reasons for athletes transitioning out were reported. Four hundred and eighty-one injuries were reported across 124 athletes at an IIR of 2.09 injuries per 365 athlete-days (95% CI = 1.91-2.29). Most athletes (103, 83.1%) were injured at least once over the 4-year period. IIRs increased (IRR = 1.17, 95% CI = 1.06-1.29, p = 0.001) as athletes progressed through the pathway. The most common reason for athlete attrition was deselection due to performance (n = 18), with 55.6% of these athletes sustaining an injury in the season prior to deselection. Injury burden was highest at E2 (119.5 days absence per 365 athlete-days (95% CI = 62.18-229.67)) and lowest at T4 (30.47 days absence per 365 athlete-days (95% CI = 21.98-42.24)). Injury occurrence is common across HPS, with IIRs increasing as athletes progressed to higher talent levels. Deselection due to poor performance was the main attrition factor, with more than half the deselected athletes impacted by injury prior to deselection. This study highlights an increased risk of deselection, following injury, and indicates the need for further development of prevention strategies targeting pathway athletes.

OBJECTIVE: This study investigates how a hospital can increase the flow of patients through its emergency department by using benchmarking and process improvement techniques borrowed from the manufacturing sector.
METHODS: An in-depth case study of an Australasian public hospital utilises rigorous, multi-method data collection procedures with systems thinking to benchmark an emergency department (ED) value stream and identify the performance inhibitors.
RESULTS: High levels of value stream uncertainty result from inefficient processes and weak controls. Reduced patient flow arises from senior management\'s commitment to simplistic government targets, clinical staff that lack basic operations management skills, and fragmented information systems. High junior/senior staff ratios aggravate the lack of inter-functional integration and poor use of time and material resources, increasing the risk of a critical patient incident.
CONCLUSIONS: This research is limited to a single case; hence, further research should assess value stream maturity and associated performance enablers and inhibitors in other emergency departments experiencing patient flow delays.
CONCLUSIONS: This study illustrates how hospital managers can use systems thinking and a context-free performance benchmarking measure to identify needed interventions and transferable best practices for achieving seamless patient flow.
CONCLUSIONS: This study is the first to operationalise the theoretical concept of the seamless healthcare system to acute care as defined by Parnaby and Towill (2008). It is also the first to use the uncertainty circle model in an Australasian public healthcare setting to objectively benchmark an emergency department\'s value stream maturity.

BACKGROUND: The Aotearoa New Zealand COVID-19 pandemic response has been hailed as a success story, however, there are concerns about how equitable it has been. This study explored the experience of a collective of Māori health and social service providers in the greater Wellington region of Aotearoa New Zeland delivering COVID-19 responses.
METHODS: The study was a collaboration between a large urban Māori health and social service provider, Tākiri Mai Te Ata whānau ora collective, and public health researchers in Aotearoa New Zealand. Two online workshops were held with staff of the Māori service provider, collectively developing a qualitative causal loop diagram and generating systemic insights. The causal loop diagram showed interactions of various factors affecting COVID-19 response for supporting whānau (Māori family/households) at a community level. The iceberg model of systems thinking offered insights for action in understanding causal loop diagrams, emphasizing impactful changes at less visible levels.
RESULTS: Six interacting subsystems were identified within the causal loop diagram that highlighted the systemic barriers and opportunities for effective COVID-19 response to Māori whānau. The medical model of health service produces difficulties for delivering kaupapa Māori services. Along with pre-existing vulnerability and health system gaps, these difficulties increased the risk of negative impacts on Māori whānau as COVID-19 cases increased. The study highlighted a critical need to create equal power in health perspectives, reducing dominance of the individual-focused medical model for better support of whānau during future pandemics.
CONCLUSIONS: The study provided insights on systemic traps, their interactions and delays contributing to a relatively less effective COVID-19 response for Māori whānau and offered insights for improvement. In the light of recent changes in the Aotearoa New Zealand health system, the findings emphasize the urgent need for structural reform to address power imbalances and establish kaupapa Māori approach and equity as a norm in service planning and delivery.

BACKGROUND: Racism contributes to health disparities and is a serious threat to public health. Teaching physicians about racism, how to address it in medical practice, and developing high quality and sustainable curricula are essential to combating racism.
OBJECTIVE: This study aimed to (1) describe the experience of racism and anti-racism teaching in residency programs, and elicit recommendations from key informants, and (2) use these data and formative research to develop recommendations for other residencies creating, implementing, and evaluating anti-racism curricula in their own programs.
METHODS: From May to July 2023, 20 faculty and residents were recruited via convenience sampling for key informant interviews conducted via Microsoft Teams. Interviews were audio recorded, transcribed, and coded. An initial list of themes was developed using theoretical frameworks, and then refined using a grounded-theory approach. A brief online optional anonymous demographic survey was sent to participants in August of 2023.  RESULTS: Eighty percent (20/25) of participants approached were interviewed. Seventy-five percent (15/20) answered a brief optional demographic survey. Seven themes emerged: (1) Racism in medicine is ubiquitous; (2) Anti-racism teaching in medicine varies widely; (3) Sustainability strategies should be multifaceted and include recruitment, resource allocation, and outcome measures; (4) Resources are widely available and accessible if one knows where to look; (5) Outcomes and metrics of success should include resident- faculty-, patient- community-, and system-focused outcomes; (6) Curricular strategies should be multilayered, longitudinal, and woven into the curriculum; and (7) Self-reflection and discomfort are necessary parts of the process.  CONCLUSIONS: This study is one of the first to qualitatively examine perspectives of key stakeholders invested in anti-racism teaching for residents. The Support - Pipeline - Outcomes - Community (SPOC) Model, that was developed using information collected during this study, can be used in the future as a guide for others working to design and implement sustainable and high quality anti-racism curricula for residents.

BACKGROUND: By including the needs and perspectives of relevant stakeholders, co-creation is seen as a promising approach for tackling complex public health problems. However, recommendations and guidance on how to plan and implement co-creation are lacking. By identifying and analysing existing implementation and evaluation frameworks for public health, this study aims to offer key recommendations for professional stakeholders and researchers wanting to adopt a co-creation approach to public health interventions.
METHODS: Firstly, PubMed and CINAHL databases were screened for articles introducing original implementation and evaluation frameworks for public health interventions. Backwards snowballing techniques were applied to the included papers. Secondly, identified frameworks were classified and relevant data extracted, including steps and constructs present in the frameworks. Lastly, recommendations were derived by conducting thematic analysis on the included frameworks.
RESULTS: Thirty frameworks were identified and data related to their nature and scope extracted. The frameworks\' prominent steps and constructs were also retrieved. Recommendations related to implementation and evaluation in the context of co-creation were included.
CONCLUSIONS: When engaging in co-creation, we recommend including implementation considerations from an early stage and suggest adopting a systems thinking as a way to explore multiple levels of influence, contextual settings and systems from an early planning stage. We highlight the importance of partnering with stakeholders and suggest applying an evaluation design that is iterative and cyclical, which pays particular attention to the experience of the engaged co-creators.

BACKGROUND: Vocational school students exhibit significant risk behaviors in terms of poor diet, frequent use of nicotine products, inadequate fruit and vegetable intake, low levels of physical activity, and poor mental health. This makes vocational students vulnerable to the development of noncommunicable diseases. Therefore, effective health promotion programs targeting vocational students are required.
OBJECTIVE: The Danish study \"Data-driven and Systems Approach to Health Promotion Among Vocational Students\" (Data Health) aims to develop, implement, and evaluate a systems approach to support vocational schools, municipalities, and local communities in implementing locally relevant health promotion actions among and for vocational students. This paper describes the Data Health program and how implementation and preliminary effectiveness will be evaluated.
METHODS: The Data Health program offers an iterative 5-step process to develop changes in the systems that shape health behavior and well-being among vocational students. The program will be implemented and evaluated in 8 Danish vocational schools in 4 municipalities. The implementation of the process and actions will be explored using a systems-based evaluation design that assesses contextual differences and the mechanisms through which the program leads to changes in the systems. Preliminary effectiveness at the individual level (students\' self-reported health behavior and well-being) and organizational level (school organizational readiness reported by school staff) will be assessed using a quasi-experimental design, and cross-sectional data will be collected at all 8 schools simultaneously 4 times during the 2-year study period.
RESULTS: This study was launched in 2021, and data collection is expected to be completed in June 2024. The first results are expected to be submitted for publication in January 2024.
CONCLUSIONS: We expect that the Data Health study will make significant contributions to complex intervention research by contributing to the paucity of research studies that have used systems approaches in school settings. The study will also provide evidence of successful elements for systems change and effectiveness to determine whether a national scale-up can be recommended.
BACKGROUND: ClinicalTrials.gov NCT05308459; https://clinicaltrials.gov/study/NCT05308459.
UNASSIGNED: DERR1-10.2196/52571.

Implementing ethics is a complex issue and should engage stakeholders. Yet, ensuring a fair, transparent, and meaningful participatory process contributes to the complexity. This qualitative study explores how to engage with stakeholders about a COVID-19 AI app following principles of Critical Systems Thinking. The study is set to explore both process and outcomes of stakeholder engagement and draw recommendations for both.

Nursing homes (also referred to as residential aged care facilities, or long-term care facilities) cater for older people on a respite or long-term basis for those who are no longer able to live independently at home. Globally the sector struggles to meet societal expectations since it is torn between three competing agendas-meeting the needs of residents, meeting the demands of regulators, and meeting the financial imperatives of nursing home proprietors. Competing demands indicate that the system lacks a clear understanding of its purpose-without a clearly understood purpose any system will become dysfunctional overall and across all its levels of organisation. This scoping study aims to summarise and synthesise what is already known about the systemic function and failures in the nursing home system, and the impact this has on the wider health and aged care system.
METHODS: MEDLINE, EMBASE, PSYCHINFO, CINAHL and SCOPUS were searched using the terms: (nursing home care OR residential aged care OR nursing home) AND (organisational failure OR institutional failure OR systemic failure), limited to English language articles, including all years up to the end of February 2021. In addition, we used snowballing of article references and Google searches of the grey literature. System-focused articles were defined as those that explored how an issue at one system level impacted other system levels, or how an issue impacted at least two different agents at the same system level.
RESULTS: Thirty-eight articles addressed systemic issues as defined in four different contexts: United States (14), Canada (2), Australia (11) and European countries (11). Only four studies reported whole-of-system findings, whereas the remaining 34 more narrowly addressed systemic features of specific nursing home issues. The thematic analysis identified 29 key systemic issues across five system layers which consistently appear across every country/health system context. The negative outcomes of these systemic failings include: high rates of regulatory reprimands for unacceptable or unsafe practices; dissatisfaction in care experiences on the part of residents, families, and care staff-including a fear of being sent to a nursing home; and the perception amongst staff that nursing homes are not preferred places to work.
CONCLUSIONS: The key issues affecting nursing home residents, and the care home sector more generally, are systemic in nature arising from two key issues: first, the lack of shared agreement on the care home system\'s purpose; and second, the lack of clear governance and accountability frameworks for system regulation and performance at a national level. Addressing these two key issues must be the starting point for any \'real\' nursing home system redesign that can achieve a seamlessly integrated system that delivers the outcomes nursing home residents and their families expect. \'Systems thinking\' is required to simultaneously improve care quality and outcomes for residents, strengthen regulation and accountability, and enable financial viability.

BACKGROUND: Hand hygiene (HH) is a proven low-cost means to curtail the problem of hospital-acquired infection (HAI). However, a low HH compliance rate of 17.1% was found among surgical health workers at Ahmadu Bello University Teaching Hospital (ABUTH) in Zaria, Nigeria.
METHODS: This was an intervention study conducted utilizing mixed methods to investigate the effectiveness of the World Health Organization (WHO) multimodal strategy to improve the HH compliance rate of doctors at ABUTH Zaria. The study was conducted between June and August 2022 and included delivering a behavioural change HH workshop to doctors followed by data collection in the surgical wards that had received environmental modification through the provision of an alcohol-based hand rub (ABHR), HH posters and nurses for visual and/or verbal reminders.
RESULTS: The cumulative HH compliance rate was 69% (n=1774) and was significantly different from the baseline HH compliance rate of 17.1% (confidence interval 45.5 to 57.7, p<0.001). Observed HH was highest in the ward with both visual and verbal reminders (78%) and lowest (59%) where neither visual nor verbal reminders were provided (n=444 per ward). All respondents reported motivation to perform HH with the presence of ABHR.
CONCLUSIONS: The WHO multimodal strategy is good for enhancing HH among health workers in the context of low- and middle-income countries. More research is needed to understand how much of a reduction in HAI is directly associated with efficient HH by health workers.

Scale-up and sustainability are often studied separately, with few studies examining the interdependencies between these two processes and the implementation contexts of innovations towards malaria prevention and control. Researchers and implementers offer much more attention to the content of innovations, as they focus on the technological dimensions and the conditions for expansion. Researchers have often considered innovation a linear sequence in which scaling up and sustainability represented the last stages. Using systems thinking in this manuscript, we analyze complex scaling and sustainability processes through adopting and implementing seasonal malaria chemoprevention (SMC) in Burkina Faso from 2014 to 2018.
We conducted a qualitative case study involving 141 retrospective secondary data (administrative, press, scientific, tools and registries, and verbatim) spanning from 2012 to 2018. We complemented these data with primary data collected between February and March 2018 in the form of 15 personal semi-structured interviews with SMC stakeholders and non-participant observations. Processual analysis permitted us to conceptualize scale-up and sustainability processes over time according to different vertical and horizontal levels of analysis and their interconnections.
Our results indicated six internal and external determinants of SMC that may negatively or positively influence its scale-up and sustainability. These determinants are effectiveness, monitoring and evaluation systems, resources (financial, material, and human), leadership and governance, adaptation to the local context, and other external elements. Our results revealed that donors and implementing actors prioritized financial resources over other determinants. In contrast, our study clearly showed that the sustainability of the innovation, as well as its scaling up, depends significantly on the consideration of the interconnectedness of the determinants. Each determinant can concurrently constitute an opportunity and a challenge for the success of the innovation.
Our findings highlight the usefulness of the systemic perspective to consider all contexts (international, national, subnational, and local) to achieve large-scale improvements in the quality, equity, and effectiveness of global health interventions. Thus, complex and systems thinking have made it possible to observe emergent and dynamic innovation behaviors and the dynamics particular to sustainability and scaling up processes.