OBJECTIVE: Service referrals are required for cancer survivors to access specialist dietary and exercise support. Many system-level factors influence referral practices within the healthcare system. Hence, the aim of this study was to identify system-level factors and their interconnectedness, as well as strategies for optimising dietary and exercise referral practices in Australia.
METHODS: A full-day workshop involving national multidisciplinary key stakeholders explored system-level factors impacting dietary and exercise referral practices. Facilitated group discussions using the nominal group technique identified barriers and facilitators to referral practices based on the six World Health Organisation (WHO) building blocks. The systems-thinking approach generated six cognitive maps, each representing a building block. A causal loop diagram was developed to visualise factors that influence referral practices. Additionally, each group identified their top five strategies by leveraging facilitators and addressing barriers relevant to their WHO building block.
RESULTS: Twenty-seven stakeholders participated in the workshop, including consumers (n = 2), cancer specialists (n = 4), nursing (n = 6) and allied health professionals (n = 10), and researchers, representatives of peak bodies, not-for-profit organisations, and government agencies (n = 5). Common system-level factors impacting on referral practices included funding, accessibility, knowledge and education, workforce capacity, and infrastructure. Fifteen system-level strategies were identified to improve referral practices.
CONCLUSIONS: This study identified system-level factors and strategies that can be applied to policy planning and practice in Australia.

In this paper, we review the progress on developing sustainability-related content in the Bachelor of Nursing curriculum in Aotearoa New Zealand and engage with Planetary Health. Sustainability in nurse education is explored and the concept of sustainability-practising graduates is promoted. THE ISSUE: We have seen ambivalence towards sustainability persisting amongst nurse educators and students, and sustainability-related content discarded. Despite this, we continue to recognise that sustainability is closely related to climate change which is the greatest threat to planetary, human, and animal health and as such is an essential component of nurse education and practice. Never has there been a timelier reminder of nurses\' responsibility to recognise we are ideally placed to contribute to, and help lead, the health response to climate change and champion sustainability. A SYSTEMS-THINKING APPROACH: This response includes a systems-thinking approach to understanding climate change and the impact on health, nursing\'s responsibility to address climate change, promote health, and respond to health needs. As we revise our current Bachelor of Nursing curriculum, it is timely to review how our sustainability content and thinking has progressed since our previous review in 2017. We are mindful of the need to continue championing this topic, ensuring it is situated at the forefront of nurse education. We propose that a gradual and purposeful shift towards a Planetary Health focus will help to counter the sustainability fatigue and ambivalence we have noted amongst our colleagues and students, ensuring our revised Bachelor of Nursing curriculum is future proofed.

BACKGROUND: This case study details the experience of the Proyecto Precancer in applying the Integrative Systems Praxis for Implementation Research (INSPIRE) methodology to guide the co-development, planning, implementation, adoption, and sustainment of new technologies and screening practices in a cervical cancer screening and management (CCSM) program in the Peruvian Amazon. We briefly describe the theoretical grounding of the INSPIRE framework, the phases of the INSPIRE process, the activities within each phase, and the RE-AIM outcomes used to evaluate program outcomes.
METHODS: Proyecto Precancer iteratively engaged over 90 stakeholders in the Micro Red Iquitos Sur (MRIS) health network in the Amazonian region of Loreto, Perú, through the INSPIRE phases. INSPIRE is an integrative research methodology grounded in systems thinking, participatory action research, and implementation science frameworks such as the Consolidated Framework for Implementation Research. An interrupted time-series design with a mixed-methods RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) evaluation framework was used to examine the adoption of human papillomavirus (HPV) testing (including self-sampling), with direct treatment after visual inspection with portable thermal ablation, at the primary level.
RESULTS: This approach, blending participatory action research, implementation science, and systems-thinking, led to rapid adoption and successful implementation of the new cervical cancer screening and management program within 6 months, using an HPV-based screen-and-treat strategy across 17 health facilities in one of the largest public health networks of the Peruvian Amazon. Monitoring and evaluation data revealed that, within 6 months, the MRIS had surpassed their monthly screening goals, tripling their original screening rate, with approximately 70% of HPV-positive women reaching a completion of care endpoint, compared with around 30% prior to the new CCSM strategy.
CONCLUSIONS: Proyecto Precancer facilitated the adoption and sustainment of HPV testing with subsequent treatment of HPV-positive women (after visual inspection) using portable thermal ablation at the primary level. This was accompanied by the de-implementation of existing visual inspection-based screening strategies and colposcopy for routine precancer triage at the hospital level. This case study highlights how implementation science approaches were used to guide the sustained adoption of a new screen-and-treat strategy in the Peruvian Amazon, while facilitating de-implementation of older screening practices.

The onset and impacts of COVID-19 have prompted attention to national health system preparedness for, and capacity to adapt in response to, public health emergencies and other shocks. This preparedness and adaptive capacity are often framed as \'health system resilience\' a concept previously associated more with assessments of health systems in conflict-affected and fragile states. Yet health system resilience remains a slippery concept, defined and applied in multiple ways. Reflecting on the Hodgins and colleagues\' study \"the COVID-19 system shock framework: capturing health system innovation during the COVID-19 pandemic,\" this article restates the limitations of health systems resilience as a concept capable of anchoring evaluative assessments of health system performance but stresses its value in the context of explanatory research investigating how and why health systems adapt, with due attention to the power of actors\' whose choices inform the nature and direction of change.

UNASSIGNED: This case study details the experience of the Proyecto Precancer in applying the Integrative Systems Praxis for Implementation Research (INSPIRE) research methodology to guide the co-development, planning, implementation, adoption, and sustainment of new technologies and screening practices in a cervical cancer screening and management program in the Peruvian Amazon. We briefly describe the theoretical grounding of the INSPIRE framework, the phases of the INSPIRE process, the activities within each phase, and the RE-AIM outcomes used to evaluate program outcomes.
UNASSIGNED: Proyecto Precancer iteratively engaged over 90 stakeholders in the Micro Red Iquitos Sur (MRIS) health network in the Amazonian region of Loreto, Perú through the INSPIRE phases. INSPIRE is an integrative research methodology grounded in systems thinking, participatory action research, and implementation science frameworks such as the Consolidated Framework for Implementation Research. An interrupted time-series design with a mixed-methods RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) evaluation framework was used to examine the adoption of molecular-based primary cervical cancer screening using HPV-testing (including self-sampling), with direct treatment after visual inspection with portable thermal ablation at the primary level.
UNASSIGNED: The participatory and system-thinking-oriented approach led to rapid adoption and successful implementation of the new cervical cancer screening and management program within 6 months, using an HPV-based screen-and-treat strategy across 17 health facilities in one of the largest public health networks of the Peruvian Amazon. Monitoring and evaluation data revealed that, within 6 months, the MRIS had surpassed their monthly screening goals, tripling their original screening rate, with approximately 70% of HPV-positive women reaching a completion of care endpoint, compared with around 30% prior to the new CCSM strategy.
UNASSIGNED: Proyecto Precancer facilitated the adoption and sustainment of molecular-based primary cervical cancer screening using HPV-testing (including self-sampling), with direct treatment after visual inspection with portable thermal ablation at the primary level and the de-implementation of existing visual inspection-based screening strategies and colposcopy for routine precancer triage at the hospital level. This case study shows how PP used implementation science approaches to guide the adoption of a new screen-and-treat strategy in the Peruvian Amazon, while facilitating de-implementation of older screening practices.

Benefit cost analysis (BCA) is frequently used to evaluate potable water infrastructure (PWI) investments. However, a limitation raised by BCA researchers is the narrow view of analysts in identifying investment impacts. In this paper, we propose a systems-thinking framework, supported by data from the literature, interviews, and macroeconomic data, to provide analysts with a more systematic and comprehensive view of investment impacts. The framework, once built, can be applied to any PWI investment question, to identify the prominent impacts that an analyst should consider taking forward through the quantification stages of the BCA process. We validate our method for identifying impacts using data from New Zealand. Our method identifies impacts that are typically not valued in BCA of PWI investments, but that are a common impact of many types of PWI investment decision. Household costs, for example, score in the Top 10 investment outcomes, but are only typically valued in ex post analyses of outbreaks. These impacts warrant attention in future benefit cost analyses. An additional contribution is the development a new betweenness importance rating, which we call flow betweenness, to evaluate each impact\'s prominence within the PWI socio-economic system.

Health care lies at the forefront of the impacts of climate change. Since the health sector is a major polluting and emission intensive sector, it remains a crucial challenge to address sustainability. The English National Health System (NHS) aims to be the first in the world to achieve net zero in all emission classes (Scope 1-3). In Germany, sustainability in health care is being driven bottom-up, while the Federal Ministry of Health at the time of the research in early 2021 takes no active stance on a net zero health care system. This article analyses the approaches to sustainability in the two different health care systems, explores common challenges, and draws recommendations to support the transition of the sector to a net zero future. An exploratory mixed method approach was taken applying qualitative and quantitative methods. This includes high-level expert interviews and an online survey from the United Kingdom (UK) and Germany. Results reveal the complex nature of health care systems and the need for engraining a systems-thinking approach. The findings call for the legal embedding of sustainability into the key principles of health care in Germany, endorses the ambition of the national health care systems in the UK, recommends collaborative cross-sector approaches for sustainability, and highlights the need for increased public awareness on the interrelation between human and planetary health to enable governance for sustainable health care.

The international increase in the prevalence of childhood obesity has hastened in recent decades. This rise has coincided with the emergence of comorbidities in childhood-such as type II diabetes, non-alcoholic fatty liver disease, metabolic syndrome, sleep apnoea and hypertension-formerly only described in adulthood. This phenomenon suggests global social and economic trends are impacting on health supportive environments. Obesity prevention is complex and necessitates both long-term and systems approaches. Such an approach considers the determinants of health and how they interrelate to one another. Investment in the early years (from conception to about 5 years of age) is a key life stage to prevent obesity and establish lifelong healthy habits relating to nutrition, physical activity, sedentary behavior and sleep. In Australia, obesity prevention efforts are spread across national and state/territory health departments. It is not known from the literature how, with limited national oversight, state and territory health departments approach obesity prevention in the early years.
We conducted a qualitative study including policy mapping and interviews with senior officials from each Australian state/territory health department. A series of questions were developed from the literature to guide the policy mapping, drawing on the World Health Organisation Ending Childhood Obesity Report, and adapted to the state/territory context. The policy mapping was iterative. Prior to the interviews initial policy mapping was undertaken. During the interviews, these policies were discussed, and participants were asked to supply any additional policies of relevance to obesity prevention. The semi-structured interviews explored the approaches to obesity prevention taken in each jurisdiction and the barriers and enablers faced for policy implementation. Thematic analysis was used to analyse the data, using NVivo software.
State and territory approaches to obesity prevention are eclectic and while there are numerous similarities between jurisdictions, no two states are the same. The diversity of approaches between jurisdictions is influenced by the policy culture and unique social, geographic, and funding contexts in each jurisdiction. No Australian state/territory had policies against all the guiding questions. However, there are opportunities for sharing and collaborating within and between Australian jurisdictions to establish what works, where, and for whom, across Australia\'s complex policy landscape.
Even within a single country, obesity prevention policy needs to be adaptable to local contexts. Opportunities for jurisdictions within and between countries to share, learn, and adapt their experiences should be supported and sustained funding provided.

Childhood routine immunization (RI) is a highly effective public health intervention for the prevention of infectious diseases. Despite high immunization rates, a 2018 Knowledge, Attitudes, and Practices (KAP) study by the United Nations Children\'s Fund (UNICEF) noted a growing practice of vaccine refusal among parents and primary caregivers as well as clusters of significantly lower immunization coverage in some provinces. Moreover, a 2018 Joint Appraisal report by GAVI (Global Vaccine Alliance) has highlighted a decrease in immunization rates among children under 1 year of age from 96.1% to 92% for some vaccines. As a result, UNICEF is spearheading a national communication initiative to increase the rates of RI in Kyrgyzstan. This initiative includes strengthening interpersonal communication skills of local healthcare workers, improving the quality and accuracy of media coverage via a tailored outreach to the Kyrgyz media, as well as fostering community engagement to give voice to local champions and engage hesitant parents and vaccine refuters. UNICEF has also partnered with a research team for the design phase of a suitable evaluation framework. Grounded in the socio-ecological model (SEM) of health, the framework recognizes the interconnection of behavioral, social, and policy change, and includes not only activity-specific indicators (process indicators) but also progress, outcome, and impact indicators to document results among key groups and stakeholders at different levels of the SEM, and, ultimately, on immunization rates in Kyrgyzstan. The framework reflects the importance of an integrated and multilevel approach to intervention and communication design, and integrates the SEM with a logic model that connects different components of the initiative. This paper introduces this evaluation framework, including implications for the evaluation of child health programs, and other public health, communication, and international development interventions.

Managing current and future urban flood risks must consider the connection (i.e. interoperability) between existing (and new) infrastructure systems to manage stormwater (pluvial flooding). Yet, due to a lack of systematic approaches to identify interoperable flood management interventions, opportunities are missed to combine investments of existing infrastructure (e.g. drainage, roads, land use and buildings) with blue-green infrastructure (e.g. sustainable urban drainage systems, green roofs, green spaces). In this study, a spatial analysis framework is presented combining hydrodynamic modelling with spatial information on infrastructure systems to provide strategic direction for systems-level urban flood management (UFM). The framework is built upon three categories of data: (i) flood hazard areas (i.e. characterize the spatial flood problem); (ii) flood source areas (i.e. areas contributing the most to surface flooding); (iii) the interoperable potential of different systems (i.e. which infrastructure systems can contribute to water management functions). Applied to the urban catchment of Newcastle-Upon-Tyne (UK), the study illustrates the novelty of combining spatial data sources in a systematic way, and highlights the spatial (dis)connectivity in terms of flood source areas (where most of the flood management intervention is required) and the benefit areas (where most of the reduction in flooding occurs). The framework provides a strategic tool for managing stormwater pathways from an interoperable perspective that can help city-scale infrastructure development that considers UFM across multiple systems. This article is part of the theme issue \'Urban flood resilience\'.